Table of Contents
Chapter 1. Intro to Health Assessment and Social Determinants of Health 1
Chapter 2 Critical Thinking and Clinical Judgement in Health Assessment 4
Chapter 3 Interviewing and Communication 10
Chapter 4 The Health History 17
Chapter 5 Cultural and Spiritual Assessment 24
Chapter 6 Physical Examination-Let’s Get Started 30
Chapter 7 Beginning the Physical Examination-General Survey, Vital Signs, and Pain 36
Chapter 8 Nutrition and Hydration 41
Chapter 9 The Integumentary System 47
Chapter 10 The Head and Neck 53
Chapter 11 The Eyes 62
Chapter 12 Ears, Nose, Mouth, and Throat 69
Chapter 13 The Respiratory System 74
Chapter 14 The Cardiovascular System 84
Chapter 15 The Peripheral Vascular System 90
Chapter 16 The Gastrointestinal and Renal Systems 96
Chapter 17 The Breasts and Axillae 107
Chapter 18 The Musculoskeletal System 114
Chapter 19 Mental Status and Mental Health Assessment 122
Chapter 20 The Nervous System 129
Chapter 21 Reproductive Systems 138
Chapter 22 Putting the Physical Examination All Together 148
Chapter 23 Assessing Children-Infancy Through Adolescence 157
Chapter 24 Assessing Older Adults 166
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Chapter 1 Intro to Health Assessment and Social Determinants of Health
MULTIPLE CHOICE
1. For which of the following patients would a comprehensive health history be appropriate?
a. A new patient with the chief complaint of “I sprained my ankle”
b. An established patient with the chief complaint of “I have an upper respiratory
infection”
c. A new patient with the chief complaint of “I am here to establish care”
d. A new patient with the chief complaint of “I cut my hand”
ANS: C
Page and Header: 4, Patient Assessment: Comprehensive or Focused This patient is here to
establish care, and because she is new to you, a comprehensive health history is appropriate.
2. The components of the health history include all of the following except which one?
a. Review of systems
b. Thorax and lungs
c. Present illness
d. Personal and social items
ANS: B
The thorax and lungs are part of the physical examination, not part of the health history. The
others answers are all part of a complete health history.
3. Is the following information subjective or objective?
WWW.TBSM.WS
Mr. M. has shortness of breath that has persisted for the past 10 days; it is worse with
activity and relieved by rest.
a. Subjective
b. Objective
ANS: A
This is information given by the patient about the circumstances of his chief complaint. It
does not represent an objective observation by the examiner.
4. Is the following information subjective or objective? Mr. M. has a respiratory rate of 32 and
a pulse rate of 120.
a. Subjective
b. Objective
ANS: B
This is a measurement obtained by the examiner, so it is considered objective data. The
patient is unlikely to be able to give this information to the examiner.
5. The following information is recorded in the health history: “The patient has had abdominal
pain for 1 week. The pain lasts for 30 minutes at a time; it comes and goes. The severity is 7
to 9 on a scale of 1 to 10. It is accompanied by nausea and vomiting. It is located in the mid-
epigastric area.” Which of these categories does it belong to?
a. Chief complaint
b. Present illness
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c. Personal and social history
d. Review of systems
ANS: B
This information describes the problem of abdominal pain, which is the present illness. The
interviewer has obtained the location, timing, severity, and associated manifestations of the
pain. The interviewer will still need to obtain information concerning the quality of the pain,
the setting in which it occurred, and the factors that aggravate and alleviate the pain. You
will notice that it does include portions of the pertinent review of systems, but because it
relates directly to the complaint, it is included in the history of present illness.
6. The following information is recorded in the health history: “The patient completed 8th
grade. He currently lives with his wife and two children. He works on old cars on the
weekend. He works in a glass factory during the week.” Which category does it belong to?
a. Chief complaint
b. Present illness
c. Personal and social history
d. Review of systems
ANS: C
Personal and social history information includes educational level, family of origin, current
household status, personal interests, employment, religious beliefs, military history, and
lifestyle (including diet and exercise habits; use of alcohol, tobacco, and/or drugs; and
sexual preferences and history). All of this information is documented in this example.
7. The following information is recorded in the health history: “I feel really tired.” Which
category does it belong to? WWW.TBSM.WS
a. Chief complaint
b. Present illness
c. Personal and social history
d. Review of systems
ANS: A
The chief complaint is an attempt to quote the patient's own words, as long as they are
suitable to print. It is brief, like a headline, and further details should be sought in the
present illness section. The above information is a chief complaint.
8. The following information is recorded in the health history: “Patient denies chest pain,
palpitations, orthopnea, and paroxysmal nocturnal dyspnea.” Which category does it belong
to?
a. Chief complaint
b. Present illness
c. Personal and social history
d. Review of systems
ANS: D
Review of systems documents the presence or absence of common symptoms related to
each major body system. The absence of cardiac symptoms is listed in the above example.
9. The following information is best placed in which category? “The patient has had three
cesarean sections.”
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a. Adult illnesses
b. Surgeries
c. Obstetrics/gynecology
d. Psychiatric
ANS: B
A cesarean section is a surgical procedure. Approximate dates or the age of the patient at the
time of the surgery should also be recorded.
10. The following information is best placed in which category? “The patient had a stent placed
in the left anterior descending artery (LAD) in 1999.” A) Adult illnesses
a. Surgeries
b. Obstetrics/gynecology
c. Psychiatric
ANS: A
The adult illnesses category is reserved for chronic illnesses, significant hospitalizations,
significant injuries, and significant procedures. A stent is a major procedure but does not
involve a surgeon.
11. The following information is best placed in which category? “The patient was treated for an
asthma exacerbation in the hospital last year; the patient has never been intubated.”
a. Adult illnesses
b. Surgeries
c. Obstetrics/gynecology
d. Psychiatric
ANS: A WWW.TBSM.WS
This is information about a significant hospitalization and should be placed in the adult
illnesses section. If the patient is being seen for an asthma exacerbation, you may consider
placing this information in the present illness section, because it relates to the chief
complaint at that visit.
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Chapter 1. Intro to Health Assessment and Social Determinants of Health 1
Chapter 2 Critical Thinking and Clinical Judgement in Health Assessment 4
Chapter 3 Interviewing and Communication 10
Chapter 4 The Health History 17
Chapter 5 Cultural and Spiritual Assessment 24
Chapter 6 Physical Examination-Let’s Get Started 30
Chapter 7 Beginning the Physical Examination-General Survey, Vital Signs, and Pain 36
Chapter 8 Nutrition and Hydration 41
Chapter 9 The Integumentary System 47
Chapter 10 The Head and Neck 53
Chapter 11 The Eyes 62
Chapter 12 Ears, Nose, Mouth, and Throat 69
Chapter 13 The Respiratory System 74
Chapter 14 The Cardiovascular System 84
Chapter 15 The Peripheral Vascular System 90
Chapter 16 The Gastrointestinal and Renal Systems 96
Chapter 17 The Breasts and Axillae 107
Chapter 18 The Musculoskeletal System 114
Chapter 19 Mental Status and Mental Health Assessment 122
Chapter 20 The Nervous System 129
Chapter 21 Reproductive Systems 138
Chapter 22 Putting the Physical Examination All Together 148
Chapter 23 Assessing Children-Infancy Through Adolescence 157
Chapter 24 Assessing Older Adults 166
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______________________________________________________________________________________________
Chapter 1 Intro to Health Assessment and Social Determinants of Health
MULTIPLE CHOICE
1. For which of the following patients would a comprehensive health history be appropriate?
a. A new patient with the chief complaint of “I sprained my ankle”
b. An established patient with the chief complaint of “I have an upper respiratory
infection”
c. A new patient with the chief complaint of “I am here to establish care”
d. A new patient with the chief complaint of “I cut my hand”
ANS: C
Page and Header: 4, Patient Assessment: Comprehensive or Focused This patient is here to
establish care, and because she is new to you, a comprehensive health history is appropriate.
2. The components of the health history include all of the following except which one?
a. Review of systems
b. Thorax and lungs
c. Present illness
d. Personal and social items
ANS: B
The thorax and lungs are part of the physical examination, not part of the health history. The
others answers are all part of a complete health history.
3. Is the following information subjective or objective?
WWW.TBSM.WS
Mr. M. has shortness of breath that has persisted for the past 10 days; it is worse with
activity and relieved by rest.
a. Subjective
b. Objective
ANS: A
This is information given by the patient about the circumstances of his chief complaint. It
does not represent an objective observation by the examiner.
4. Is the following information subjective or objective? Mr. M. has a respiratory rate of 32 and
a pulse rate of 120.
a. Subjective
b. Objective
ANS: B
This is a measurement obtained by the examiner, so it is considered objective data. The
patient is unlikely to be able to give this information to the examiner.
5. The following information is recorded in the health history: “The patient has had abdominal
pain for 1 week. The pain lasts for 30 minutes at a time; it comes and goes. The severity is 7
to 9 on a scale of 1 to 10. It is accompanied by nausea and vomiting. It is located in the mid-
epigastric area.” Which of these categories does it belong to?
a. Chief complaint
b. Present illness
______________________________________________________________________________________________
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c. Personal and social history
d. Review of systems
ANS: B
This information describes the problem of abdominal pain, which is the present illness. The
interviewer has obtained the location, timing, severity, and associated manifestations of the
pain. The interviewer will still need to obtain information concerning the quality of the pain,
the setting in which it occurred, and the factors that aggravate and alleviate the pain. You
will notice that it does include portions of the pertinent review of systems, but because it
relates directly to the complaint, it is included in the history of present illness.
6. The following information is recorded in the health history: “The patient completed 8th
grade. He currently lives with his wife and two children. He works on old cars on the
weekend. He works in a glass factory during the week.” Which category does it belong to?
a. Chief complaint
b. Present illness
c. Personal and social history
d. Review of systems
ANS: C
Personal and social history information includes educational level, family of origin, current
household status, personal interests, employment, religious beliefs, military history, and
lifestyle (including diet and exercise habits; use of alcohol, tobacco, and/or drugs; and
sexual preferences and history). All of this information is documented in this example.
7. The following information is recorded in the health history: “I feel really tired.” Which
category does it belong to? WWW.TBSM.WS
a. Chief complaint
b. Present illness
c. Personal and social history
d. Review of systems
ANS: A
The chief complaint is an attempt to quote the patient's own words, as long as they are
suitable to print. It is brief, like a headline, and further details should be sought in the
present illness section. The above information is a chief complaint.
8. The following information is recorded in the health history: “Patient denies chest pain,
palpitations, orthopnea, and paroxysmal nocturnal dyspnea.” Which category does it belong
to?
a. Chief complaint
b. Present illness
c. Personal and social history
d. Review of systems
ANS: D
Review of systems documents the presence or absence of common symptoms related to
each major body system. The absence of cardiac symptoms is listed in the above example.
9. The following information is best placed in which category? “The patient has had three
cesarean sections.”
______________________________________________________________________________________________
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a. Adult illnesses
b. Surgeries
c. Obstetrics/gynecology
d. Psychiatric
ANS: B
A cesarean section is a surgical procedure. Approximate dates or the age of the patient at the
time of the surgery should also be recorded.
10. The following information is best placed in which category? “The patient had a stent placed
in the left anterior descending artery (LAD) in 1999.” A) Adult illnesses
a. Surgeries
b. Obstetrics/gynecology
c. Psychiatric
ANS: A
The adult illnesses category is reserved for chronic illnesses, significant hospitalizations,
significant injuries, and significant procedures. A stent is a major procedure but does not
involve a surgeon.
11. The following information is best placed in which category? “The patient was treated for an
asthma exacerbation in the hospital last year; the patient has never been intubated.”
a. Adult illnesses
b. Surgeries
c. Obstetrics/gynecology
d. Psychiatric
ANS: A WWW.TBSM.WS
This is information about a significant hospitalization and should be placed in the adult
illnesses section. If the patient is being seen for an asthma exacerbation, you may consider
placing this information in the present illness section, because it relates to the chief
complaint at that visit.
______________________________________________________________________________________________
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