Comprehensive Physical and Mental Health Assessment Techniques

Four primary techniques in physical examination

Inspection, Palpation, Percussion, and Auscultation.

Purpose of inspection in physical assessment

To visually examine the patient for any signs of abnormalities such as skin changes, posture, facial expression, and overall appearance.

Palpation in a physical assessment

Palpation involves using the hands to feel body parts for abnormalities, such as tenderness, swelling, or irregularities in texture or temperature.

Two types of palpation

Light palpation (used to assess surface characteristics) and deep palpation (used to assess underlying organs or structures).

What does percussion assess during a physical exam?

Percussion is used to assess the size, density, and location of organs and to detect fluid or air within body cavities.

How does auscultation contribute to a physical assessment?

Auscultation involves listening to the sounds produced within the body, such as heartbeats, lung sounds, and bowel sounds, using a stethoscope.

Common equipment used in a physical examination

Stethoscope, thermometer, sphygmomanometer (blood pressure cuff), otoscope, ophthalmoscope, reflex hammer, tape measure, and thermometer.

Purpose of a thermometer in a physical examination

It is used to measure the patient's body temperature to detect fever, hypothermia, or normal temperature.

What does a sphygmomanometer measure?

It measures blood pressure by occluding the brachial artery and recording systolic and diastolic pressures.

Normal ranges for adult blood pressure

Systolic: 90-120 mmHg, Diastolic: 60-80 mmHg.

Use of an otoscope

An otoscope is used to inspect the ear canal and tympanic membrane (eardrum) for signs of infection, wax buildup, or injury.

What is an ophthalmoscope used for?

It is used to examine the retina, optic disc, and blood vessels of the eye, detecting conditions like retinal disease or glaucoma.

What does a reflex hammer assess?

It is used to test deep tendon reflexes (e.g., patellar reflex) to assess neurological function.

How is mental status assessed during a health exam?

Mental status is assessed through orientation (person, place, time), memory, mood, cognition, and behavior using structured tools like the Mini-Mental State Examination (MMSE) or Montreal Cognitive Assessment (MoCA).

Key components of cognitive function in a mental status assessment

Orientation, memory, attention, calculation, language, and abstract thinking.

What is the Mini-Mental State Examination (MMSE) used for?

The MMSE is used to assess cognitive impairment and screen for conditions like dementia by evaluating memory, attention, language, and visuospatial skills.

What is the Montreal Cognitive Assessment (MoCA) used for?

The MoCA is a screening tool for mild cognitive dysfunction, evaluating memory, attention, language, and executive function.

Why is nutrition assessed in a health examination?

Nutritional assessment helps identify deficiencies or excesses in the patient's diet, which could lead to health problems such as malnutrition, obesity, or deficiencies in vitamins and minerals.

Common methods to assess a patient's nutritional status

Methods include dietary recall, 24-hour food diary, calorie count, and anthropometric measurements (e.g., BMI, waist-to-hip ratio).

How is Body Mass Index (BMI) calculated?

BMI is calculated using the formula: BMI = weight (kg) / height (m²).

What BMI range is considered normal weight?

A BMI between 18.5 and 24.9 is considered normal weight.

What is a 24-hour dietary recall?

A method used to assess an individual's dietary intake over the past 24 hours.

Dietary Assessment Tool

A dietary assessment tool where the patient recalls everything they have eaten and drunk in the past 24 hours, which is then analyzed for nutrient intake.

Pain Assessment

Pain is assessed in terms of intensity, location, duration, quality (e.g., sharp, dull), and factors that alleviate or exacerbate the pain.

Numeric Rating Scale (NRS)

The NRS is a commonly used pain assessment tool where patients rate their pain on a scale from 0 (no pain) to 10 (worst pain imaginable).

Faces Pain Scale - Revised (FPS-R)

It assesses pain in patients, particularly children or those with communication difficulties, by showing faces depicting varying levels of pain intensity.

Pain Severity Assessment

Pain severity is typically assessed using scales like the NRS or VAS, where the patient rates their pain level from 0 to 10 or on a visual scale.

McGill Pain Questionnaire

A tool used to assess pain quality and intensity through a list of descriptors, allowing patients to describe their pain's sensory, affective, and evaluative aspects.

Skin Inspection

You should check for color, temperature, moisture, texture, and the presence of rashes, lesions, or wounds.

Palpation of Skin

Palpation helps assess skin temperature, texture, moisture, turgor, and the presence of lumps or masses.

Percussion of Lungs

Percussion of the chest can help detect abnormalities such as fluid in the lungs or consolidation of lung tissue.

Auscultation of Heart

It helps assess heart sounds, including the presence of murmurs, extra heart sounds (S3 or S4), and the rate and rhythm of heartbeats.

Normal Heart Sounds

The normal heart sounds are S1 ('lub') and S2 ('dub'). S1 corresponds with the closure of the atrioventricular valves, and S2 corresponds with the closure of the semilunar valves.

Respiratory Rate Assessment

Respiratory rate is assessed by counting the number of breaths per minute, observing for any irregularities, and noting the depth and effort of breathing.

Normal Respiratory Rates

Normal adult respiratory rate is 12-20 breaths per minute, while normal rate for infants is 30-60 breaths per minute.

Joint Mobility Inspection

Inspection involves observing for signs of joint deformities, asymmetry, swelling, or redness, and noting the patient's ability to move the joint.

Mental Status

Mental status refers to a patient's cognitive function, emotional state, and ability to interact with their environment. It is important for diagnosing mental health disorders and guiding treatment.

Glasgow Coma Scale (GCS)

The GCS is a scale used to assess a patient's level of consciousness, with scores based on eye, verbal, and motor responses. A lower score indicates a more severe impairment of consciousness.

ABCD Approach to Mental Status

A (Appearance), B (Behavior), C (Cognition), and D (Thinking/Orientation).

Pupil Assessment

Pupils should be equal, round, and reactive to light (PERRLA).

Orientation in Mental Status

It assesses the patient's awareness of person, place, and time. A patient who is disoriented may have cognitive dysfunction or mental health issues.

Short-term Memory

Short-term memory refers to the ability to recall information immediately or within a short time frame, typically within minutes to hours.