Health Assessment and Diagnostic Tests

Health Assessment and Diagnostic Tests

Health History

Purpose and Correlation to Physical Examination
  • Initiates the client-clinician relationship: Establishing a rapport to facilitate trust and open communication.
  • Identifies client's main concerns: Helps the clinician understand what issues the client prioritizes.
  • Provides information on social determinants of health: Understanding factors such as socioeconomic status, education, and community influences on the client's health.
  • Informs risk assessment and health promotion: Identifying risks allows for targeted interventions and preventive measures.
  • Focuses physical examination and diagnostic tests: Guides the clinician in what areas to focus on during the assessment.
  • Reveals cultural variations in health beliefs and practices: Acknowledges the influence of culture on health behaviors and perspectives.
Health History Communication Principles
  1. Use Inclusive Language:
    • Prefer terms like "partner" or "spouse" over gender-specific labels.
    • Respect client-preferred pronouns for individuals who are transgender, gender nonconforming, or gender queer.
    • Include options for gender identity on forms, allowing identification as transgender or providing a space for other identities.
  2. Assess Health Literacy:
    • Evaluate the client's ability to understand health information and services.
    • Use accessible written materials, patient navigators, and medical interpreters as needed.
  3. Active Listening:
    • Start with open-ended questions to encourage client dialogue.
    • Reflect on responses for mutual understanding; allow time for silence for client contemplation.
  4. Address Sensitive Issues Respectfully:
    • Approach delicate subjects while ensuring confidentiality and respect.
  5. Cultural Humility:
    • Acknowledge the limits of one's knowledge regarding the client's context.
    • Avoid generalizing assumptions about clients based on their background.
    • Recognize and address one's own biases during interactions.
    • Utilize patient-centered communication techniques.
Components of the Health History
  1. Reason for Visit/Chief Concern:
    • A succinct statement in the client’s words about why they are seeking care.
  2. Presenting Problem/Illness:
    • A chronological history of presenting issues, described using the OLD-CARTS mnemonic:
      • Onset: When did the problem start?
      • Location: Where is the problem?
      • Duration: How long does it last?
      • Characteristics: What are the symptoms like?
      • Aggravating/Associated factors: What makes it worse or better?
      • Relieving factors: What helps alleviate the symptoms?
      • Temporal factors: Timing of the symptoms (e.g., constant, intermittent).
      • Severity: How bad is the problem, on a scale of 1 to 10?
    • Include pertinent negatives: Document absence of symptoms that eliminate possibilities for the condition.
    • Impact on client's lifestyle: Describe how the problem affects daily life.
    • Current Health Status Summary: If no presenting problem, summarize current health and promotion needs.
  3. Past Health History:
    • General perception of the client’s health status.
    • Account of childhood illnesses, major adult illnesses, psychiatric conditions, accidents, surgeries/hospitalizations, and blood transfusions including dates and units.
  4. Current Health Status:
    • Detail current medications including prescriptions, over-the-counter drugs, and herbal remedies (medication reconciliation).
    • Document allergies including names and reactions.
    • Gather information on substance use (tobacco, alcohol, drugs), nutrition (24-hour dietary recall), screening test results, immunization dates, sleep patterns, leisure activities, environmental hazards, safety measures, and functional disabilities if applicable.
  5. Family Health History:
    • Detail the health status or causes of death for immediate family members (parents, siblings, children, spouse).
    • Ask about specific health conditions including:
      • Heart disease, hypertension, stroke, diabetes, cancer, epilepsy, kidney disease, thyroid disease, asthma, arthritis, blood diseases, tuberculosis, alcoholism, allergies, congenital anomalies, mental illness, genetic disorders.
    • Evaluate risk for hereditary conditions like breast and ovarian cancer syndromes.
    • Note if the client is adopted or lacks knowledge of family history.
  6. Psychosocial History:
    • Discuss living situation, access to care, support systems, domestic violence issues, stressors, coping mechanisms, and any relevant cultural practices.
  7. Obstetric History:
    • Note details of all pregnancies, including:
      • Gravidity: Total pregnancies.
      • Parity: Pregnancies reaching 20 weeks or beyond, differentiating between term, preterm, stillbirth.
      • GTPAL: Gravida, Term, Preterm, Abortion, Living children notation.
  8. Menstrual History:
    • Information about age at menarche, menstrual cycle regularity, last period, use of menstrual products, and any menstrual problems.
  9. Sexual History/Contraceptive Use:
    • Document age at first sexual intercourse, sexual orientation, current relationships, and any STI risks.

Physical Examination

Purpose and Correlation to Health History
  • Findings during the physical exam may necessitate additional health history inquiries.
  • Understand the normal variations across different age, racial, and ethnic groups.
Techniques of Examination
  1. Inspection:
    • Visual observation and sometimes use of smell; it’s continuous throughout the exam.
    • Includes assessing the overall appearance of the client and each body system specifically.
  2. Auscultation:
    • Using a stethoscope to listen to various body sounds:
      • Diaphragm: Best for high-pitched sounds (e.g., heart sounds).
      • Bell: Best for low-pitched sounds (e.g., larger blood vessels).
  3. Percussion:
    • Tapping on body surfaces to create vibrations to determine the density of underlying tissues, and to elicit tenderness.
    • Different sounds indicate conditions:
      • Tympany: Loud, high-pitched (e.g., gas-filled bowel).
      • Hyperresonance: Very loud, low-pitched (e.g., emphysema).
      • Resonance: Loud, low-pitched sound (e.g., healthy lungs).
      • Dullness: Moderate-pitched sound (e.g., liver).
      • Flatness: Soft, high-pitched dull sound (e.g., muscle).
  4. Palpation:
    • Using hands to examine body tissues and organs:
      • Light Palpation: About 1 cm depth to identify tenderness.
      • Deep Palpation: About 4 cm depth for identifying less obvious masses.
General Appearance Assessment
  • Observe aspects like posture, grooming, hygiene, body odors, and facial expressions.
Anthropometric Measurements
  1. Height and Weight:
    • Regular measurements to assess the client's size and growth pattern.
  2. Body Mass Index (BMI):
    • Calculated as extweight(kg)/extheight(m2)ext{weight (kg)}/ ext{height (m}^2).
      • Underweight: BMI < 18.5
      • Normal weight: BMI 18.5 - 24.9
      • Overweight: BMI 25.0 - 29.9
      • Obesity: BMI 30.0 - 39.9
      • Extreme obesity: BMI ≥ 40
  3. Waist Circumference:
    • Important for assessing abdominal fat and its related diseases:
      • In female, increased risk at > 35 inches (88 cm).
Examination of Skin, Hair, and Nails
  • Inspect skin color, texture, temperature, moisture, hair distribution, color, nails for abnormalities, lesions, and overall health.
  • Use the ABCDES mnemonic for assessing melanoma risk:
    • A: Asymmetry
    • B: Borders irregular
    • C: Color variations (blue/black, variegated)
    • D: Diameter >6 mm
    • E: Elevation
Examination of Head, Eyes, Ears, Nose, and Throat
  1. Head and Neck:
    • Examine skull for masses, facial symmetry, and thyroid function.
  2. Eyes:
    • Use a Snellen chart for visual acuity, check pupillary reactions, and inspect ocular structures using an ophthalmoscope.
  3. Ears:
    • Perform hearing assessments and examine external ear structures and tympanic membrane.
  4. Nose and Sinuses:
    • Inspect for symmetry and patency of nasal passages.
  5. Mouth and Oropharynx:
    • Examine the mouth’s structure and assess tonsils for size and color.
Respiratory System Assessment
  1. Chest Examination:
    • Evaluate chest symmetry, respiratory rate, and use of accessory muscles.
  2. Auscultate Lung Fields:
    • Listen for breath sounds and any adventitious sounds.
Cardiovascular System Examination
  1. Vital Signs:
    • Assess blood pressure, pulse rate, and rhythm.
  2. Heart Sounds:
    • Check heart sounds and identify any abnormalities including murmurs.
  3. Neck Vessels:
    • Examine carotid arteries for strength and symmetry.
  4. Extremities:
    • Inspect for color, temperature, capillary refill, and peripheral pulses.
Abdominal Examination
  1. Inspect, Auscultate, Palpate:
    • Evaluate shape, sounds, and tenderness of the abdomen.
  2. Special Maneuvers:
    • Assess for signs of appendicitis and peritonitis.
Musculoskeletal and Neurologic Assessment
  1. Musculoskeletal System:
    • Check for alignment, symmetry, range of motion, and tenderness in joints.
  2. Neurologic Function:
    • Test cranial nerves, reflexes, and sensory responses to assess neurological health.
Mental Status Examination
  • Evaluate the client's appearance, cognitive functioning, emotional stability, and speech.
  • Use standardized screening tools for cognitive status (e.g., Mini Mental Status Examination).
Detailed Female Reproductive Examination
  • Include breast and pelvic exams guiding each assessment with attention to potential sensitivity or prior trauma, employing trauma-informed care as appropriate.
Diagnostic Tests/Studies
  1. Complete Blood Count (CBC):
    • Measurement of RBC, Hct, Hgb, and WBC with differential to assess overall health and detect a variety of disorders.
  2. Blood Clotting Studies:
    • Evaluates factors involved in coagulation.
  3. Comprehensive Metabolic Panel (CMP):
    • Provides information on metabolism and functions of kidneys/liver.
  4. Blood Glucose Tests:
    • Key tests to monitor and diagnose diabetes.
  5. Lipid Profile:
    • Evaluates cardiac risk factors through cholesterol and triglyceride levels.
  6. Thyroid Function Tests:
    • Measures TSH, FT4, and T4 to diagnose thyroid issues.
  7. Urinalysis:
    • Assesses for infections or diseases affecting urinary systems.
  8. Vaginal Cultures/Tests:
    • Detects infections and assesses health of the vaginal microbiome.

Imaging Studies

  1. Pelvic Ultrasonography:
    • High-frequency sound waves evaluate pelvic organs, confirming gestation, and assessing uterine conditions.
  2. Mammography:
    • Screening for breast cancer through X-ray images under various techniques.
  3. Bone Densitometry:
    • Evaluates risk for osteoporosis by assessing bone density.
Conclusion
  • The integration of thorough health history, physical examination, and appropriate diagnostic tests is vital in the assessment and promotion of health.