Health Assessment Exam 1
Nurs607 Page 1 of 77
1. Components of Health History:
a. Health hx: includes systematic collection of data about the patient’s current &
past health history. It is divided into subjective & objective data.
b. For which of the following patients would a comprehensive HH be
appropriate? A new patient with the CC of “I am here to establish care”
c. The components of a HH include all of the following except which one?
i. ROS
ii. Thorax & Lungs
iii. Present Illness
iv. Personal & Social Items
2. Subjective vs Objective Data:
a. Give Examples:
i. Subjective Data:
1. Information provided by the patient.
2. Symptoms the patient experiences or describes.
a. Examples:
i. "I have a headache that started yesterday."
ii. "I feel dizzy when I stand up."
iii. Mr. M has SOB that has persisted for the past 10
days; it is worse with activity and relieved by
rest. Subjective Data
ii. Objective Data:
1. Observable and measurable findings by the clinician.
2. Signs that are assessed during the physical exam.
a. Examples:
i. Blood pressure reading: 140/90 mmHg.
ii. Skin is pale and diaphoretic.
iii. Mr. M has a RR of 32 and a PR of 120. Objective
Data
3. Know what components of H&P belong in what portion of the chart:
a. CC:
i. The primary reason the patient is seeking medical attention
ii. Recorded verbatim in the patient’s words.
1. Example: “I’ve had chest pain for 3 days.”
b. HPI:
i. A detailed account of the CC: organized in chronological order.
ii. Utilizes “OLD CARTS”:
1. Onset
2. Location
3. Duration
4. Character
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5. Aggravating/Alleviating Factors
6. Radiation
7. Timing
8. Severity
a. Example: “The chest pain started 3 days ago, feels like
pressure, and worsens with activity.”
c. ROS:
i. System-by-system review of symptoms reported by the patient.
ii. Includes general symptoms (fatigue, fever) & specific symptoms (CV,
Respiratory)
1. Example:
a. General: No recent weight changes.
b. Cardiovascular: Reports chest pain, denies palpitations
d. Exam: “Physical Exam Findings”
i. Objective findings gathered during the physical examination.
ii. Includes VS, Inspection, Palpitation, Auscultation, & Percussion results.
1. Example:
a. BP: 138/88 mm/Hg.
b. Lungs: Clear Bilaterally
e. Diagnosis:
i. The clinician’s assessment based on the HPI, ROS, & Exam findings.
ii. May include differential diagnosis or definitive diagnosis.
1. Example: “Angina pectoris suspected.”
f. Plan:
i. The next steps in patient care, including diagnostic testing, treatments,
referrals, & follow-up.
1. Example:
a. Prescribe nitroglycerin for chest pain.
b. Order an EKG & Stress Test
c. Follow-up in 1 week.
The following information is recorded in the HH: “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 7-9 on a
scale of 1-10. It is accompanied by N/V. It is located in the mid-epigastric area.” Which of
the categories does it belong to? Present Illness {relates directly to the complaint}
The following information is recorded in the HH: “The pt 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? Personal &
Social History
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The following information is recorded in the HH: “I feel really tired.” Which category does
it belong to? Chief Complaint {quoting the pts own words}
The following information is recorded in the HH: “Patient denies chest pain, palpitations,
orthopnea, & paroxysmal nocturnal dyspnea.” Which category does it belong to? Review of
Systems {documents the present or absence of common symptoms; major body symptoms;
ex: cardiovascular}
4. Innocent Murmur: harmless ♥ murmur NO structural or functional abnormalities
a. Common in healthy individuals, particularly children.
i. Characteristics:
1. Timing: often Systolic (occurs during ♥ contraction)
2. Sound: Soft, blowing, or musical quality.
3. Grade: Typically Grade 1 or 2 (LOW intensity)
4. Location: Commonly heard at the LL sternal border or APEX
5. Changes with position: May become quieter or disappear when
the patient stands up.
ii. Associated Conditions:
1. Seen in normal growth phases in children
2. Can occur temporarily in adults during high-output states (fever,
pregnancy)
iii. Clinical Importance:
1. No further workup is usually needed unless other symptoms
present.
5. Functional Murmur: caused by INCREASED blood flow across a normal valve, often d/t
physiological conditions.
a. Characteristics:
i. Timing: typically, Systolic
ii. Sound: similar to Innocent Murmur- soft & blowing.
iii. Grade: LOW-MODERTE intensity, usually Grade 1-3.
iv. Location: Best heard at the LEFT sternal border.
b. Causes:
i. Fever
ii. Anemia
iii. Hyperthyroidism
iv. Pregnancy
c. Key Distinction:
i. Unlike Innocent Murmurs Functional murmurs are r/t REVERSIBLE
or TREATABLE conditions.
d. Clinical Importance:
i. Resolves when the underlying cause is treated.
, Health Assessment Exam 1
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ii. Further investigation may be needed if murmurs persist, or other
symptoms arise.
How to differentiate b/w Innocent & Functional Murmurs:
Both are benign, but Functional Murmurs are linked to a physiological cause that may need
addressing (treating anemia).
Innocent murmurs are NOT associated with pathology.
Which of thee findings would the nurse expect to notice during a cardiac assessment on a 4yo child? Murmur
at the 2nd ICS when supine {innocent murmur is heard at the 2nd ICS & disappears with sitting, and the young
person has no associated signs of cardiac dysfunction}
When auscultating heart sounds on a 7yo child for a routine physical exam, the nurse hears an S3, a soft
murmur at the LEFT midsternal border, & a Venous Hum when the child is standing. What would be a correct
interpretation of these findings? These findings can all be NORMAL in a child. {physiologic S3 is common in
children. Venous Hum: caused by turbulence of blood flow in the Jugular Venous System; common in children.
Heart murmurs that are innocent (or functional) in origin are very common through childhood.}
Murmur Locations on the Chest
This diagram represents the key locations where murmurs are typically auscultated with a stethoscope:
Auscultation Areas Valve Heard Landmark
Aortic Valve Systolic murmurs 2nd Right Intercostal Space, sternal border
Pulmonic Valve Systolic murmurs 2nd Left Intercostal Space, sternal border
Tricuspid Valve Holosystolic murmurs Lower Left Sternal Border
Mitral Valve Systolic or diastolic Apex of the Heart (5th Intercostal Space, midclavicular line)
2. Grading of Murmurs
Murmurs are graded on a scale from 1 to 6, depending on their intensity:
Grade 1: Barely audible; heard only under ideal conditions.
Grade 2: Soft but clearly audible.
Grade 3: Moderately loud; no palpable thrill.
Grade 4: Loud with a palpable thrill.
Nurs607 Page 1 of 77
1. Components of Health History:
a. Health hx: includes systematic collection of data about the patient’s current &
past health history. It is divided into subjective & objective data.
b. For which of the following patients would a comprehensive HH be
appropriate? A new patient with the CC of “I am here to establish care”
c. The components of a HH include all of the following except which one?
i. ROS
ii. Thorax & Lungs
iii. Present Illness
iv. Personal & Social Items
2. Subjective vs Objective Data:
a. Give Examples:
i. Subjective Data:
1. Information provided by the patient.
2. Symptoms the patient experiences or describes.
a. Examples:
i. "I have a headache that started yesterday."
ii. "I feel dizzy when I stand up."
iii. Mr. M has SOB that has persisted for the past 10
days; it is worse with activity and relieved by
rest. Subjective Data
ii. Objective Data:
1. Observable and measurable findings by the clinician.
2. Signs that are assessed during the physical exam.
a. Examples:
i. Blood pressure reading: 140/90 mmHg.
ii. Skin is pale and diaphoretic.
iii. Mr. M has a RR of 32 and a PR of 120. Objective
Data
3. Know what components of H&P belong in what portion of the chart:
a. CC:
i. The primary reason the patient is seeking medical attention
ii. Recorded verbatim in the patient’s words.
1. Example: “I’ve had chest pain for 3 days.”
b. HPI:
i. A detailed account of the CC: organized in chronological order.
ii. Utilizes “OLD CARTS”:
1. Onset
2. Location
3. Duration
4. Character
,Health Assessment Exam 1
Nurs607 Page 2 of 77
5. Aggravating/Alleviating Factors
6. Radiation
7. Timing
8. Severity
a. Example: “The chest pain started 3 days ago, feels like
pressure, and worsens with activity.”
c. ROS:
i. System-by-system review of symptoms reported by the patient.
ii. Includes general symptoms (fatigue, fever) & specific symptoms (CV,
Respiratory)
1. Example:
a. General: No recent weight changes.
b. Cardiovascular: Reports chest pain, denies palpitations
d. Exam: “Physical Exam Findings”
i. Objective findings gathered during the physical examination.
ii. Includes VS, Inspection, Palpitation, Auscultation, & Percussion results.
1. Example:
a. BP: 138/88 mm/Hg.
b. Lungs: Clear Bilaterally
e. Diagnosis:
i. The clinician’s assessment based on the HPI, ROS, & Exam findings.
ii. May include differential diagnosis or definitive diagnosis.
1. Example: “Angina pectoris suspected.”
f. Plan:
i. The next steps in patient care, including diagnostic testing, treatments,
referrals, & follow-up.
1. Example:
a. Prescribe nitroglycerin for chest pain.
b. Order an EKG & Stress Test
c. Follow-up in 1 week.
The following information is recorded in the HH: “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 7-9 on a
scale of 1-10. It is accompanied by N/V. It is located in the mid-epigastric area.” Which of
the categories does it belong to? Present Illness {relates directly to the complaint}
The following information is recorded in the HH: “The pt 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? Personal &
Social History
,Health Assessment Exam 1
Nurs607 Page 3 of 77
The following information is recorded in the HH: “I feel really tired.” Which category does
it belong to? Chief Complaint {quoting the pts own words}
The following information is recorded in the HH: “Patient denies chest pain, palpitations,
orthopnea, & paroxysmal nocturnal dyspnea.” Which category does it belong to? Review of
Systems {documents the present or absence of common symptoms; major body symptoms;
ex: cardiovascular}
4. Innocent Murmur: harmless ♥ murmur NO structural or functional abnormalities
a. Common in healthy individuals, particularly children.
i. Characteristics:
1. Timing: often Systolic (occurs during ♥ contraction)
2. Sound: Soft, blowing, or musical quality.
3. Grade: Typically Grade 1 or 2 (LOW intensity)
4. Location: Commonly heard at the LL sternal border or APEX
5. Changes with position: May become quieter or disappear when
the patient stands up.
ii. Associated Conditions:
1. Seen in normal growth phases in children
2. Can occur temporarily in adults during high-output states (fever,
pregnancy)
iii. Clinical Importance:
1. No further workup is usually needed unless other symptoms
present.
5. Functional Murmur: caused by INCREASED blood flow across a normal valve, often d/t
physiological conditions.
a. Characteristics:
i. Timing: typically, Systolic
ii. Sound: similar to Innocent Murmur- soft & blowing.
iii. Grade: LOW-MODERTE intensity, usually Grade 1-3.
iv. Location: Best heard at the LEFT sternal border.
b. Causes:
i. Fever
ii. Anemia
iii. Hyperthyroidism
iv. Pregnancy
c. Key Distinction:
i. Unlike Innocent Murmurs Functional murmurs are r/t REVERSIBLE
or TREATABLE conditions.
d. Clinical Importance:
i. Resolves when the underlying cause is treated.
, Health Assessment Exam 1
Nurs607 Page 4 of 77
ii. Further investigation may be needed if murmurs persist, or other
symptoms arise.
How to differentiate b/w Innocent & Functional Murmurs:
Both are benign, but Functional Murmurs are linked to a physiological cause that may need
addressing (treating anemia).
Innocent murmurs are NOT associated with pathology.
Which of thee findings would the nurse expect to notice during a cardiac assessment on a 4yo child? Murmur
at the 2nd ICS when supine {innocent murmur is heard at the 2nd ICS & disappears with sitting, and the young
person has no associated signs of cardiac dysfunction}
When auscultating heart sounds on a 7yo child for a routine physical exam, the nurse hears an S3, a soft
murmur at the LEFT midsternal border, & a Venous Hum when the child is standing. What would be a correct
interpretation of these findings? These findings can all be NORMAL in a child. {physiologic S3 is common in
children. Venous Hum: caused by turbulence of blood flow in the Jugular Venous System; common in children.
Heart murmurs that are innocent (or functional) in origin are very common through childhood.}
Murmur Locations on the Chest
This diagram represents the key locations where murmurs are typically auscultated with a stethoscope:
Auscultation Areas Valve Heard Landmark
Aortic Valve Systolic murmurs 2nd Right Intercostal Space, sternal border
Pulmonic Valve Systolic murmurs 2nd Left Intercostal Space, sternal border
Tricuspid Valve Holosystolic murmurs Lower Left Sternal Border
Mitral Valve Systolic or diastolic Apex of the Heart (5th Intercostal Space, midclavicular line)
2. Grading of Murmurs
Murmurs are graded on a scale from 1 to 6, depending on their intensity:
Grade 1: Barely audible; heard only under ideal conditions.
Grade 2: Soft but clearly audible.
Grade 3: Moderately loud; no palpable thrill.
Grade 4: Loud with a palpable thrill.
