1: History and Physical Assessment

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Part 1 History and Physical Assessment

HEALTH HISTORY

Information

Identifying Information

1. Name

2. Address

3. Telephone number

4. Age

5. Birth date

6. Race/ethnic group

7. Gender

8. Religion/spiritual beliefs

9. Nationality

10. Date of interview

11. Informant

Chief Complaint (CC).

To establish the specific reason for the individual seeking professional health attention

Present Illness (PI)

To obtain all details related to the chief complaint

1. Onset

a. Date of onset
b. Manner of onset (gradual or sudden)
c. Precipitating and predisposing factors related to onset (emotional disturbance, physical exertion, fatigue, bodily function, pregnancy, environment, injury, infection, toxins and allergens, therapeutic agents)

2. Characteristics

a. Character (quality, quantity, consistency, or other)
b. Location and radiation (e.g., pain)
c. Intensity or severity
d. Timing (continuous or intermittent, duration of each, temporal relationship to other events)
e. Aggravating and relieving factors
f. Associated symptoms

3. Course since onset

a. Incidence
1. Single acute attack
2. Recurrent acute attacks
3. Daily occurrences
4. Periodic occurrences
5. Continuous chronic episode
6. Recent travel outside the U.S.
b. Progress (better, worse, unchanged)
c. Effect of therapy

Past history (PH)

To elicit a profile of the individual’s previous illnesses, injuries, or operations

1. Pregnancy (maternal)

a. Number (gravida)
1. Dates of delivery
b. Outcome (parity)
1. Gestation (full-term, near-term, preterm, postterm)
2. Stillbirths, abortions
c. Health during pregnancy
d. Medications taken

2. Labor and delivery

a. Duration of labor
b. Type of delivery
c. Place of delivery
d. Medications

3. Perinatal period

a. Weight and length at birth
b. Time of regaining birth weight
c. Condition of health immediately after birth
d. Apgar score
e. Presence of problems including congenital anomalies
f. Date of discharge from nursery or NICU

4. Previous illnesses, operations, or injuries

a. Onset, symptoms, course, termination
b. Occurrence of complications
c. Incidence of disease in other family members or in community
d. Emotional response to previous hospitalization
e. Circumstances and nature of injuries

5. Allergies

a. Hay fever, asthma, or eczema
b. Unusual reactions to foods, drugs, animals, plants, latex products, or household products

6. Current medications

a. Name, dose, schedule, duration, and reason for administration

7. Alternative remedies

a. Herbs, natural products, special foods, drinks

8. Pain

a. Previous experiences
b. Reactions
c. Effective management
d. Cultural influences

9. Immunizations

a. Name, number of doses, age when given
b. Occurrence of reaction
c. Administration of horse or other foreign serum, gamma-globulin, or blood transfusion

10. Growth and development

a. Weight at birth, 6 months, 1 year, and present
b. Dentition
1. Age of eruption/shedding
2. Number
3. Problems with teething
c. Age of head control, sitting unsupported, walking, first words
d. Present grade in school, scholastic achievement
e. Interaction with peers and adults
f. Participation in organized activities, such as scouting, sports

11. Habits

a. Behavior patterns
1. Nail biting
2. Thumb sucking
3. Pica
4. Rituals, such as security blanket
5. Unusual movements (head banging, rocking)
6. Temper tantrums
b. Activities of daily living
1. Hour of sleep and arising
2. Duration of nighttime sleep/naps
3. Age of toilet training
4. Pattern of stools and urination; occurrence of enuresis or encopresis
5. Type of exercise
c. Use/abuse of drugs, alcohol, coffee (caffeine), tobacco, vitamins/supplements, or alternative therapies
d. Usual disposition; response to frustration

12. Nutrition

a. Infant
1. Breast fed or bottle fed
2. Frequency and amount
3. Duration
4. Supplements
b. Preschool and older
1. 24-hour diet recall

Family Medical History

To identify the presence of genetic traits or diseases that have familial tendencies; to assess family habits and exposure to a communicable disease that may affect family members

Familial diseases, such as heart disease, hypertension, cancer, diabetes mellitus, obesity, congenital anomalies, allergy, asthma, tuberculosis, seizures, sickle cell disease, depression, mental retardation, mental illness or other emotional problems, syphilis, or rheumatic fever; indicate symptoms, treatment, and sequelae.

REVIEW OF SYSTEMS

General—Overall state of health, fatigue, recent and/or unexplained weight gain or loss (period of time for either), contributing factors (change of diet, illness, altered appetite), exercise tolerance, fevers (time of day), chills, night sweats (unrelated to climatic conditions), frequent infections, general ability to carry out activities of daily living, behavior

Integument—Pruritus, pigment or other color changes, acne, moles, birthmarks, discoloration, eruptions, rashes (location), tendency toward bruising, petechiae, excessive dryness, general texture, disorders or deformities of nails, hair growth or loss, hair color change (for adolescent, use of hair dyes or other potentially toxic substances such as hair straighteners)

Head—Headaches, dizziness, injury (specific details)

Eyes—Visual problems (ask about behaviors indicative of blurred vision, such as bumping into objects, clumsiness, sitting very close to the television, holding a book close to the face, writing with head near desk, squinting, rubbing the eyes, bending the head in an awkward position), cross-eye (strabismus), nystagmus, eye infections, edema of lids, excessive tearing, use of glasses or contact lenses, date of last optic examination

Nose—Nosebleeds (epistaxis), constant or frequent running or stuffy nose, nasal obstruction (difficulty in breathing), alteration or loss of sense of smell

Ears—Earaches, discharge, evidence of hearing loss (ask about behaviors such as need to repeat requests, loud speech, inattentive behavior), results of any previous auditory testing, pulling or rubbing ear

Mouth—Mouth breathing, gum bleeding, toothaches, toothbrushing, use of fluoride, difficulty with teething (symptoms), last visit to dentist (especially if temporary dentition is complete), response to dentist

Throat—Sore throats, difficulty in swallowing, choking (especially when chewing food—may be from poor chewing habits), hoarseness or other voice irregularities

Neck—Pain, limitation of movement, stiffness, difficulty in holding head straight (torticollis), thyroid enlargement, enlarged nodes or other masses

Chest—Breast enlargement, discharge, masses, enlarged axillary nodes (for adolescent female, ask about breast self-examination)

Respiratory—Chronic cough, frequent colds (number per year), wheezing, shortness of breath at rest or on exertion, difficulty in breathing, sputum production, infections (pneumonia, tuberculosis), date of last chest x-ray examination, and skin reaction from tuberculin testing

Cardiovascular—Cyanosis or fatigue on exertion, cold extremities, history of heart murmur or rheumatic fever, anemia, date of last blood count, blood type, recent transfusion

Gastrointestinal—nausea, vomiting (not associated with eating, may be indicative of brain tumor or increased intracranial pressure), jaundice or yellowing skin or sclera, belching, flatulence, recent change in bowel habits (blood in stools, change in color, diarrhea, and constipation)

Genitourinary—Pain on urination, frequency, hesitancy, urgency, hematuria, nocturia, polyuria, unpleasant odor to urine, force of stream, discharge, change in size of scrotum, date of last urinalysis (for adolescent, sexually transmitted disease, type of treatment; for male adolescent, ask about testicular selfexamination)

Gynecologic—Menarche, date of last menstrual period, regularity or problems with menstruation, vaginal discharge, pruritus, date and result of last Pap smear (include obstetric history as discussed under birth history when applicable); if sexually active, type of contraception

Musculoskeletal—Weakness, clumsiness, lack of coordination, unusual movements, back or joint stiffness, muscle pains or cramps, abnormal gait, deformity, fractures, serious sprains, activity level, redness, swelling, tenderness

Neurologic—Seizures, tremors, dizziness, loss of memory, general affect, fears, nightmares, speech problems, any unusual habit

Endocrine—Intolerance to weather changes, excessive thirst and urination, excessive sweating, salty taste to skin, signs of early puberty

Lymphatic—History of frequent infections, enlarged lymph nodes in any region, swelling, tenderness, red streaks

CULTURAL ASSESSMENT

1. Communication

a. What language is spoken at home?
b. How does the family demonstrate respect or disrespect?
c. How well does the family understand English (spoken and written)?
d. Is an interpreter needed?

2. Health beliefs

a. How are health and illness defined by the family?
b. How are feelings expressed regarding illness or death?
c. What are the attitudes toward sickness?
d. Who makes the decisions regarding health practices in the family?
e. Are there cultural practices that would restrict the type of care needed?
f. Is a health professional of a specific gender or ethnic background an issue for the family?

3. Religious practices and rituals

a. What is the family’s religious preference?
b. To whom does the family turn for support and counseling?
c. Are there special practices or rituals that may affect care?
d. Are there special rituals or ceremonies when a patient is ill or dying?
e. Are special rituals or ceremonies attached to birth, baptism, puberty, or death?

4. Diet practices

a. Are some foods restricted by the family’s culture?
b. Are there cultural practices in observance of certain occasions or events?
c. How is food prepared?
d. Who is responsible for food preparation?
e. Do certain foods have special meaning to the family or child?
f. Are special foods believed to cause or cure an illness or disease?
g. Are there times of required food fasting?
h. How are the periods of fasting defined, and who fasts in the family?

5. Family characteristics

a. Who makes the decisions in the family?
b. How many generations are thought to be a single family?
c. Which relatives compose the family unit?
d. When are children disciplined or punished?
e. How is affection demonstrated in the family?
f. How are emotions exhibited in the family?
g. What is the attitude toward children?

6. Sources of support

a. What ethnic or cultural organizations does the family belong to?
b. How do the organizations influence the family’s approach to health care?
c. Who is most responsible for influencing the family’s health beliefs?
d. Is there a specific cultural group with which the family identifies?
e. Is the specific cultural group identified by where the child was born and has lived?

SUMMARY OF PHYSICAL ASSESSMENT OF THE NEWBORN

Usual Findings

1. General measurements

a. Head circumference—33-35 cm (13-14 inches); about 2-3 cm (1 inch) larger than chest circumference
b. Chest circumference—30.5-33 cm (12-13 inches)
c. Crown-to-rump length—31-35 cm (12.5-14 inches); approximately equal to head circumference
d. Head-to-heel length—48-53 cm (19-21 inches)
e. Birth weight—2700-4000 g (6-9 pounds)

2. Vital signs

a. Temperature
b. Axillary—36.5°-37° C (97.9°-98.6° F)
c. Heart rate
d. Apical—110-160 beats/min
e. Respirations
f. 30-60 breaths/min
g. Blood pressure (BP)
h. Oscillometric—65/41 mm Hg (average) in arm and calf

3. General appearance

a. Posture—Flexion of head and extremities, which rest on chest and abdomen

4. Skin

a. At birth, puffy, smooth
b. Second to third day, pink, flaky, dry
c. Vernix caseosa
d. Lanugo
e. Edema around eyes, face, legs, dorsa of hands, feet, and scrotum or labia
f. Acrocyanosis—Cyanosis of hands and feet
g. Cutis marmorata—Transient mottling when infant is exposed to stress, decreased temperature, or overstimulation

5. Head

a. Anterior fontanel—Diamond-shaped, 2.5-4 cm (1-1.75 inches)
b. Posterior fontanel—Triangular, 0.5-1 cm (0.2-0.4 inch)
c. Fontanels should be flat and firm.
d. Widest part of fontanel measured from bone to bone, not suture to suture

6. Eyes

a. Lids usually edematous
b. Iris color—slate gray, dark blue, brown; absence of tears
c. Presence of red reflex
d. Corneal reflex in response to touch
e. Pupillary reflex in response to light
f. Blink reflex in response to light or touch
g. Rudimentary fixation on objects and ability to follow to midline

7. Ears

a. Position—Top of pinna on horizontal line with outer canthus of eye
b. Startle reflex elicited by a loud, sudden noise
c. Pinna flexible, cartilage present

8. Nose

a. Nasal patency
b. Nasal discharge—Thin, white mucus
c. Sneezing
d. Milia

9. Mouth and throat

a. Intact, high-arched palate
b. Uvula in midline
c. Frenulum of tongue
d. Frenulum of upper lip
e. Sucking reflex—Strong and coordinated
f. Rooting reflex
g. Gag reflex
h. Extrusion reflex
i. Absent or minimal salivation
j. Vigorous cry

10. Neck

a. Short, thick, usually surrounded by skin folds
b. Tonic neck reflex

11. Chest

a. Anteroposterior and lateral diameters equal
b. Slight sternal retractions evident during inspiration
c. Xiphoid process evident
d. Breast enlargement

12. Back and rectum

a. Spine intact; no openings, masses, or prominent curves
b. Trunk incurvation reflex
c. Anal reflex
d. Patent anal opening
e. Passage of meconium within 48 hours

13. Extremities

a. Ten fingers and ten toes
b. Full range of motion
c. Nail beds pink, with transient cyanosis immediately after birth
d. Creases on anterior two thirds of sole
e. Sole usually flat
f. Symmetry of extremities
g. Equal muscle tone bilaterally, especially resistance to opposing flexion
h. Equal bilateral brachial and femoral pulses

14. Neuromuscular system

a. Extremities usually maintain some degree of flexion.
b. Extension of an extremity followed by previous position of flexion
c. Head lag while sitting, but momentary ability to hold head erect
d. Able to turn head from side to side when prone
e. Able to hold head in horizontal line with back when held prone

PHYSICAL ASSESSMENT SUMMARY

1. Growth measurements

a. Measure weight and height/length, chest and head circumference (see Tables 1-3 and 1-6).

2. Physiologic measurements

a. Obtain vital sign measurements.

3. General appearance

a. Observe the following during the assessment:
1. Face
2. Posture
3. Body movement
4. Hygiene
5. Nutrition
6. Behavior
7. Development
8. State of awareness

4. Skin

a. Observe skin in natural daylight or neutral artificial light.
b. Color

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