Health Assessment & Clinical Physical Examination Flashcards
Subjective vs. Objective Data and Database Types
Subjective Data: Information reported directly by the patient, including subjective feelings, perceptions, or self-reported symptoms such as pain.
Objective Data: Observable and measurable findings obtained through physical examination, laboratory testing, diagnostic studies, or direct observation by the healthcare provider (e.g., vital signs, posture, skin color).
Complete (Total Health) Database: Baseline evaluation including a complete health history and full physical examination to establish a patient's overall health state.
Episodic (Problem-Centered) Database: Mini-database focused primarily on a short-term, acute problem or a single body system.
Follow-Up Database: Assessment conducted at regular intervals to evaluate the status of previously identified health problems.
Emergency Database: Rapid collection of crucial clinical data gathered concurrently with lifesaving interventions.
Validation of Data Definition & Process: Involves verifying that subjective reports match objective findings, confirming facts through corroborating sources or repeated assessments, and clearing up inconsistencies prior to making clinical judgments.
Interview Communication Techniques
Open-Ended Questions: Asks for narrative information, allowing the patient to express themselves fully and set the direction of the response.
Closed-Ended Questions: Asks for specific, targeted information leading to a forced choice (e.g., "yes" or "no" answers).
Facilitation: Encourages the patient to say more or continue talking (e.g., nodding, saying "go on").
Silence: Directed attentiveness that gives the patient time to think, organize thoughts, and process feelings without interruption.
Clarification: Used when the patient's word choice is ambiguous or confusing; asks for confirmation or agreement to ensure accurate understanding.
Reflection: Echoes or repeats part of what the patient just said to help them elaborate or clarify the meaning of their statement.
Empathy: Recognizes and names a feeling, validating the patient's emotion and allowing its expression.
Interpretation: Links events, makes associations, or identifies causes based on clinical inference.
Explanation: Shares factual and objective clinical information with the patient.
Summary: Provides a final review or conclusion of what was learned during the interaction to signal the end of the interview.
10 Traps of Interviewing:
Providing false assurance or reassurance
Giving unwanted advice
Using authority
Using avoidance language
Engaging in distancing
Using professional jargon
Using leading or biased questions
Talking too much
Interrupting
Using "why" questions
Communication Modes and Physical Environment
Verbal Communication: Includes spoken words, vocalizations, and the tone used in conversation.
Non-Verbal Communication: Encompasses unconscious or conscious body language, posture, gestures, facial expressions, eye contact, and physical touch. When non-verbal cues conflict with verbal messages, non-verbal communication is viewed as the truer reflection of a patient's feelings.
Optimizing the Physical Environment:
Ensure geographic and psychological privacy.
Limit external interruptions.
Maintain equal-status seating with both provider and patient at eye level.
Reduce physical distance between provider and patient.
Maintain a comfortable room temperature and adequate lighting.
Keep note-taking or Electronic Health Record (EHR) usage to a strict minimum to preserve eye contact and rapport.
Functional Assessment and Health Promotion
Functional Assessment (FHP / ADLs):
Definition: Measures a person’s self-care ability in daily life (Activities of Daily Living or ADLs) and lifestyle factors.
Evaluated Domains: Self-esteem, activity and exercise, sleep, nutrition and elimination, interpersonal relationships, spiritual resources, stress management, personal habits, substance use, and environmental or work hazards.
Health Promotion Principles:
Definition: Proactive questions integrated into the Review of Systems (ROS) or functional assessment to evaluate disease prevention and healthy behaviors.
Targeted Health Behaviors: Usage of sun protection, seatbelts, exercise routine, date of last dental or eye exam, and immunization status.
General Survey Components
Definition: An objective evaluation of the patient as a whole initiated upon first impression.
Four Major Parameters:
Physical Appearance: Assessment of age, sex, level of consciousness, skin color, facial features, and overall appearance.
Body Structure: Assessment of stature, nutrition, symmetry, posture, body position, and physical deformities.
Mobility: Assessment of gait, range of motion, and absence of involuntary movements.
Behavior: Assessment of facial expression, mood and affect, speech clarity and pace, dress, and personal hygiene.
Assessment Techniques and Hand Mechanics
Four Primary Assessment Techniques:
Inspection: Close, careful scrutiny of the patient as a whole and then of each individual body system. Always performed first in the physical examination standard sequence.
Palpation: Applying the sense of touch to evaluate texture, temperature, moisture, organ size, swelling, rigidity, masses, and tenderness.
Percussion: Tapping the skin with short, sharp strokes to assess underlying structures by evaluating sound density, location, and organ boundaries.
Auscultation: Listening to sounds produced by the body using a stethoscope.
Parts of the Hand Used for Palpation:
Fingertips: Used for fine tactile discrimination (such as skin texture, swelling, pulsation, and presence of lumps).
Fingers and Thumb: Used for detecting position, shape, and consistency of an organ or mass.
Dorsa (Back) of Hands and Fingers: Used for evaluating skin temperature, as the skin is thinner here than on the palms.
Base of Fingers / Ulnar Surface of Hand: Used for detecting vibration.
Distinction Between Palpation and Percussion:
Palpation Execution: Assesses texture, temperature, moisture, organ location/size, swelling, vibration, pulsation, crepitation, rigidity/spasticity, lumps/masses, and tenderness. Begins with light palpation and proceeds to deep palpation.
Percussion Execution: Assesses the location, size, and relative density of underlying organs, detects superficial abnormal masses (penetrates approximately deep), elicits pain over inflamed structures, and tests deep tendon reflexes.
Sequencing of Assessment Techniques:
Standard Physical Assessment Sequence: Inspection, Palpation, Percussion, Auscultation.
Abdominal Assessment Sequence: Inspection, Auscultation, Percussion, Palpation. Palpation and percussion are performed after auscultation in the abdominal exam so as not to alter natural bowel sounds.
Adaptations for Sick or Distressed Patients: Examination steps may be altered or focused based on patient comfort or immediate clinical distress, collecting a focused "mini-database" initially before completing the remainder of the assessment later.
Infection Control, Safety, and Stethoscope Mechanics
Gloves and Standard Precautions:
Indications for Glove Use: Gloves must be worn whenever there is potential for contact with blood, infectious materials, mucous membranes, non-intact skin, body fluids, or contaminated equipment (Standard Precautions).
Procedure: Gloves must be put on immediately before patient contact and removed with hand hygiene performed immediately after removal.
Nosocomial Infections / Healthcare-Associated Infections (HAIs):
Definition & Prevention: Infections acquired during hospital stays or medical treatment.
Primary Prevention: Strict hand hygiene (washing with soap and water or using an alcohol-based hand rub before and after patient contact) is the single most effective prevention measure.
Additional Precautions: Standard precautions, appropriate personal protective equipment (PPE), thorough cleaning of medical equipment between patients, and proper cough etiquette are essential.
Stethoscope Mechanics:
Mechanism: Transmits body sounds directly to the ear while blocking extraneous ambient noise; it does not amplify sound.
Diaphragm: Flat edge used for listening to high-pitched sounds (such as breath, bowel, and normal heart sounds).
Bell: Deep, cuplike shape used for listening to soft, low-pitched sounds (such as extra heart sounds, murmurs, and bruits).
Tubing and Earpieces: Earpieces should fit snugly and slope forward toward the nose; thick-walled tubing reduces external acoustic interference.
Pain Assessment, Categorization, and Scales
PQRSTU Pain Assessment Framework:
P (Provocation/Palliation): What makes the pain better or worse?
Q (Quality/Quantity): What does the pain feel like (e.g., burning, stabbing, aching)?
R (Region/Radiation): Where is the pain located, and does it spread to other areas?
S (Severity): How severe is the pain on a scale from ?
T (Timing): What is the onset, duration, and frequency of the pain?
U (Understand Patient Perception): How does the pain affect the patient's daily living and activities?
Self-Report Rule: Always collect self-report data first as it is the gold standard of pain assessment, and systematically reassess pain following any intervention.
Acute vs. Chronic Pain:
Acute Pain: Short-term and self-limiting; follows a predictable trajectory and dissipates after an injury heals (e.g., surgical procedures, acute trauma). Clinical signs include guarding, grimacing, moaning, diaphoresis, and elevated vital signs.
Chronic (Persistent) Pain: Pain lasting . Does not stop when an injury heals and outlasts its protective purpose. Clinical signs are variable as the body adapts over time, and may include bracing, rubbing, diminished activity, sighing, and changes in appetite or sleep patterns.
Classifications of Pain:
Visceral Pain: Originates from large interior organs (triggered by stretching, ischemia, or distention).
Deep Somatic Pain: Comes from blood vessels, joints, tendons, muscles, and bones.
Cutaneous Pain: Derived from the skin surface and subcutaneous tissues.
Referred Pain: Felt at a particular site but originates from another anatomical location innervated by the same spinal nerve.
Neuropathic Pain: Caused by a lesion or disease affecting the somatosensory nervous system, resulting in abnormal processing of pain signals.
Pain Assessment in Older Adults:
Pain is prevalent in older adults due to comorbidities (e.g., osteoarthritis, angina), but it is not a normal part of aging.
Older adults may deny pain due to fear of dependency, fear of invasive diagnostic procedures, or fear of drug addiction.
In patients with advanced dementia who cannot communicate verbally, behavioral pain scales such as the PAINAD scale must be used (evaluating breathing, vocalization, facial expression, body language, and consolability).
Mental Status, Consciousness, and Orientation
Levels of Consciousness (LOC):
Alert: Fully awake, oriented, aware of environmental stimuli, and responds appropriately.
Lethargic (Somnolent): Drifts off to sleep when not actively stimulated; can be aroused when called by name in a normal voice, but looks drowsy.
Obtunded: Sleeps most of the time; difficult to arouse (requires a loud shout or vigorous shake); acts confused when aroused.
Stupor (Semi-Coma): Spontaneously unconscious; responds only to persistent and vigorous shaking or painful stimuli; groans or mumbles.
Coma: Completely unconscious; exhibits no response to pain or external stimuli.
Affect Parameters:
Definition: A temporary, objective expression of feelings or state of mind observed through external behavior and facial expressions.
Appropriate Affect: Affect matches the topic being discussed or the current environment.
Inappropriate Affect: Affect is clearly discordant with the content of the conversation (e.g., laughing while discussing a serious illness).
Flat / Blunted Affect: Complete or partial lack of emotional response, reactivity, or facial expression.
Orientation Assessment:
Evaluates the ability to recognize and state person, place, and time:
Time: Day of week, date, year, season.
Place: Present location, city, state, building.
Person: Own name, age, examiner’s role.
Mental Status Considerations in Aging Adults:
Sensory impairments (vision, hearing) must always be assessed and ruled out before assuming cognitive decline.
Normal age-related changes may cause slower response times or minor decline on formal memory tests like the Four Unrelated Words Test, but orientation remains intact if basic time parameters (month/year) are provided.
Mini-Cog: Quick clinical screening tool consisting of a 3-item recall test and a clock-drawing test.
Differential Diagnosis: Distinguish between Delirium (an acute, reversible confusional state) and Dementia (a chronic, progressive cognitive loss).
Components of Mental Status Exam (ABCT Framework):
A (Appearance): Posture, body movements, dress, grooming, and hygiene.
B (Behavior): Level of consciousness, facial expression, speech quality/pace, and mood/affect.
C (Cognitive Functions): Orientation, attention span, recent memory, remote memory, and new learning evaluated via the Four Unrelated Words Test.
T (Thought Processes): Thought processes, thought content, perceptions, judgment, and screening for anxiety, depression, or suicidal ideation.