Introduction to Elements of Assessment

Vocabulary-style flashcards covering key concepts from the Health History and Physical Examination notes.

Health History

The interview portion of the assessment; builds the patient–provider relationship and gathers subjective (qualitative) data to guide focused assessment and identify patient priorities.

Physical Examination

The objective, quantitative data collection phase using inspection, palpation, percussion, and auscultation.

Therapeutic communication

Techniques used to support patient comfort, trust, and openness during the interview and exam.

Active listening

Concentrated, reflective listening that shows understanding and encourages the patient to share more information.

Qualitative data

Descriptive information obtained from the patient about feelings, perceptions, and health status.

Objective, quantitative data

Measurable findings obtained from examination and testing.

Biographical Data

Identifying information such as name, age, date of birth, address, contact information, emergency contact, and usual source of care.

Chief Concern (CC)

The reason the patient seeks care, documented in the patient’s own words (often in direct quotes).

History of Present Illness (HPI)

Description and chronology of current symptoms and events.

Past Medical History (PMH)

Childhood illnesses, immunizations, adult illnesses, communicable diseases, surgeries/injuries, medications, allergies, and disabilities.

Family History (FH)

Health status and diseases among relatives; often documented over two generations and may be shown with a pedigree diagram.

Current Health Status / Personal & Social History (CHS)

Personal status, occupation, habits, daily living, sexual practices, hobbies, travel, health habits and check-ups.

Review of Systems (ROS)

Systematic review of symptoms by body system to relate the chief complaint to overall health.

OLD CARTS

Mnemonic for describing symptoms: Onset, Location, Duration, Character, Aggravating factors, Relieving factors, Temporal factors, Severity.

Onset

When the symptom began.

Location

Where the symptom is located.

Duration

How long the symptom lasts.

Character

Quality or nature of the symptom (e.g., dull, sharp).

Aggravating factors

Factors or activities that worsen the symptom.

Relieving factors

Factors or actions that alleviate the symptom.

Temporal factors

Time pattern of the symptom (frequency, timing).

Severity

Intensity of the symptom.

Immunizations

Vaccinations; a patient’s history may include more than just being up to date.

Childhood illnesses

Illnesses experienced during childhood as part of the PMH.

Adult medical illnesses

Medical conditions diagnosed in adulthood.

Communicable diseases

Infectious diseases that can be transmitted to others.

Surgeries/injuries

Past surgical procedures and injuries.

Medications

Drugs the patient is currently taking or has taken in the past.

Allergies

Hypersensitivities with reactions; important to document substances (medications, foods, etc.).

Disabilities

Any physical or cognitive limitations affecting health or daily living.

Pedigree diagram

A diagram used to record hereditary health information across generations.

Personal status

Individual life circumstances that may affect health.

Occupation

Job or work status and potential health risks related to work.

Habits

Lifestyle practices such as smoking, alcohol use, and other routines.

Daily living

Activities of daily living and routines essential for self-care.

Travel

Recent travel history relevant to health status or exposure risk.

Health habits and check-ups

Routine health maintenance and preventive care patterns.

Inspection

Visual observation of the patient; uses all senses; involves exposing areas and preserving privacy.

Palpation

Use of hands and fingers to feel tissues and structures; pressure is controlled; warm hands and short nails are preferred; palpate painful areas last.

Light palpation

Palpation to a depth of about 1 cm.

Deep palpation

Palpation to a depth of about 4 cm.

Areas of hand used in palpation

Palmer and finger pads (position/texture/size), ulnar surface (vibrations), dorsal surface (temperature).

Percussion

Striking one object against another to produce vibrations and sound waves.

Tympanic

Drumlike sound (e.g., gastric bubble) on percussion.

Hyperresonance

Booming sound (e.g., emphysematous lungs).

Resonance

Hollow sound typical of healthy lungs.

Dull

Thud-like sound (e.g., over liver).

Flat

Soft, dull sound (e.g., over muscle).

Direct percussion

Percussion directly with the striking hand on the surface.

Indirect percussion

Percussion using the finger of one hand as the hammer and the other hand as the striking surface.

Auscultation

Listening to body sounds; assess symmetry; use a stethoscope on bare skin; choose bell or diaphragm for different frequencies.

Stethoscope

Instrument used to listen to internal body sounds; should be placed on bare skin.

Bell

The small, concave part of the stethoscope used for low-frequency sounds.

Diaphragm

The flat, larger part of the stethoscope used for high-frequency sounds.

Vital signs

Basic physiologic measures used to assess general status: blood pressure, pulse, and respirations.

Blood Pressure (BP)

Pressure exerted by circulating blood; measured on the correct arm and at the proper position.

Pulse

Heart rate and rhythm as observed or palpated.

Respirations

Breathing rate, depth, and effort; assessment of breathing pattern.

Privacy

Respecting patient modesty and ensuring privacy during the exam.

Sequence of history and physical examination

Following an orderly order to perform assessment for consistency and completeness.

Objective terms

Descriptive, observable terms used to report findings.

Exposure during exam

Exposing only what is necessary to inspect and assess, while maintaining privacy.