Hea lth Assessment Exam 1
N urs607 Page 1 of 104
1
a. Health hx: includes systematic collection of data about the patienl's current &
past heahh history. It is divided into subjective & objective dala.
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"'l'he com ponents ola HH include all ofthe
followin except hich one?
i. ROS
ii. Thorrx & 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. "l have a headache that started yesterday."
ii. "I feel dizzy when I stand up."
Mr. M has SOB that has persisted for the past l0 days; it is rvorse with activity and relieved by
Y rest. Srbi.a'*ird f,iaia
ii. Objective Data:
1. Observable and measurable findings by the clinician.
2. Signs that are assessed during the physical exam.
a. Examples:
i. Blood pressue reading: 140/90 mmHg
ii. Skin is pale and diaphoretic.
Mr. M has a RR of32 and a PR of t20. gili
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 t}le patient's words.
1. Exampl e: "I've had chest nain for 3 days."
b ner: \\t\g frn fiq/,* \\\i',,t'''-
i. A detailbd aE co unt ofthe CC: organized in chronological order
ii. Utilizes "OLD CARTS":
l. Qnset
2. Location
, Health Assessment Exam 1 (,LD CANM:
Nu rs607 Page 2 of lO4
3. Duration
4. Character
5. Aggravatingl Alleviating Factors
6. Radiation
7. - Timins
t,
8. Severity l-llr
'.{,rrr\
l\ '
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,
&tP:Ic!9rYl
I . 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's1glgtrg4 based on the HPI, ROS, & Exam findings.
ii. May include differential osis or definitive sis.
l Example: "Angina ctoris
f. Plan:
i. The next steps in patient care, including diagnostic testing, treatments,
refenals, & follow-up.
l. Example:
a. Prescribe nitroglycerin for chest pain.
b. Order an EKG & Stress Test
f c. Follow-up in I week.
The following information is recorded in the HH: "The patient has had abdominal pain for I
week. l he pain lasts for 30 minutes at a time; it comes and goes. Tire severity is 7-9 on a scale ol'
l -10. It is accompanied by N,A/. lt is located in the mid-epigastric area." Wtrich of the categories
doesitbelongto?ffi{relatesdirectlytothecomplaint}
\\f\ r
^ - /^,4\.^'
\\\i' '
, Health Assessment Exam 1
Nurs607 Page 3 of 104
1'he 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
lackrry during the week." Which category does it belong to?
x 'l
he tbllorving inlbrmation is recorded in the HH: "I feel really
belong to? CiL$j6if
CEI, {quoting the pts own words}
tired." Which category does it
f l. following information is recorded in the HH: "Patient denies chest pain. palpitations,
{
onhopnea, & paroxysmal nocturnal dyspnea." Which category does it belong to? SlXm&&
Wl;{documents the present or absence of common symptoms; major body symptoms; ex:
cardiovascular I
All ol'the follorving are a corrrmon or conceming symptom in a health history for a respiratory
assessment EXCEPT?
. S188fltr& {chest pain, blootl-streaked sputum, & snoring are all common or
conceming symptoms in a HH for Resp. assessment)
o Blood-stre aked sputum
. Chest pain . .ir rl
. . [ (/- f4\ 1[ t {,' r-.c I
Snoring \J
ry'a S+yo pt tells the NP that he thinks he must have lJlcerative Colitis. He has been having "black
stools" for the last 24 hours. How would the NP best document the FAC'IS fbr his reason for
seeking care'? JM is a 59vo male here for havins (black stools" for the nast 24 hours {CC:
the reason the pt is seeking care. Make every effort to quote the pts own words)
'[ he nurse is taking family hx. Important diseases or problems to ask the pt about include:
a
mental illness
\:) L-
4 ffi )
No stlructural or functional abnormalities
'
a. Common in healthy individuals, particularly CJi/dffi.
'1
I
i\r,,r\ i.
Characteristics:
, ,\.\ r' 1 Timing: ofien Systolic (occurs during a contraction)
t.\'ri,'\lS i['ri.i'
r'
2 Sound
.J
blowing, or musical quality.
Grade: Typically Grade I ot 2 (LOll/ intensity)
") r(+ b\ LtLltnc\
(n.) Location: Commonly heard al the LL sterual bonler or(APEX
I
^t
na L" rD\',+u^6fiq 6
Changes wilh position: May become quieter or disapprur#rn
lhe Dalienl slands uD.
A w"h,m a\-drdrn\ Associated Conditions :
r.ffir,
2. Can occur temporarily in adults during high-output states (fever,
pregnancy)
i, r(
\(r'i :-an
,ll\ \)
, Health Assessment Exam 1
N urs607 Page 4 of 104
iii. Clinical Importance
I . No further worhup is usually needed unless other symptoms
presenl.
5 : caused by INCREASED bloodllow across a normal valve, ofien d/t
p hy s i o I o gi c al c ondit i ons.
. a. Characteristics:
{Vtti \' i. Timing: typically, Systolic
\i,, ,,, r. ii. Sound: similar to Innocent Murmur- sofi & blowing.
:lt\u '__ iii. Grade: LOW-MODERTE intensiry, usually Grade 1-3
', \' ' \ ''-\f- iv. Locarion; Best heard at the LEFT sternal border.
b.
r
I
Causes:
Fever
T.
\.
It. Anemia
\,t rl'l r)i'- \ itt[.\''-
Ilt. Hyperthyroidism Ir
iv. Pregnancy
c Key Distinction:
i. Unlikz Innocenl Murmurs )
d. Clinical Importance:
i. Resolves when the underlying cause is trealed.
ii. Further investigation may be needed if murmurs persisl, or olher
symptoms arise.
How to differcntiotc b/w Innocent ll Functionol lAut:murs: , )r.f& -\w
. Borh ore benien. urt ru*tion$il?1,lffirtot*"iif* ,o o
physiologicol cousc thot moy need oddrcssirg (trcoting onemio).
a Innocent murmurs orc NOT ossociated with pothology.
Which of these findings would the nurse expect to notice during o cordia Crt
// i 1\L
(innocent (
ossessment on o 4yo child? murmur
is heond ot the ?nd ICS & disoppeors with sitting, ond the young person hos no
associoted signs of cordioc dysfunction)
)<-Wt
, i\- ouscultoting heort sounds on a 7yo child for o routine physicol exam, the
"n
nurse heors on 53, o soft murmur ot the LEFT midsternol border, & o Venous Hum
when the child is stonding. Whot would be o correct interpretotion of these
f indings? td (physiologic 53 is
common in children. Venous Hum: coused by turbulence of blood flow in the Jugulor
i1 /{ [i ll" i\r - I
I
ttv yJ
rl \l I
N urs607 Page 1 of 104
1
a. Health hx: includes systematic collection of data about the patienl's current &
past heahh history. It is divided into subjective & objective dala.
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"'l'he com ponents ola HH include all ofthe
followin except hich one?
i. ROS
ii. Thorrx & 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. "l have a headache that started yesterday."
ii. "I feel dizzy when I stand up."
Mr. M has SOB that has persisted for the past l0 days; it is rvorse with activity and relieved by
Y rest. Srbi.a'*ird f,iaia
ii. Objective Data:
1. Observable and measurable findings by the clinician.
2. Signs that are assessed during the physical exam.
a. Examples:
i. Blood pressue reading: 140/90 mmHg
ii. Skin is pale and diaphoretic.
Mr. M has a RR of32 and a PR of t20. gili
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 t}le patient's words.
1. Exampl e: "I've had chest nain for 3 days."
b ner: \\t\g frn fiq/,* \\\i',,t'''-
i. A detailbd aE co unt ofthe CC: organized in chronological order
ii. Utilizes "OLD CARTS":
l. Qnset
2. Location
, Health Assessment Exam 1 (,LD CANM:
Nu rs607 Page 2 of lO4
3. Duration
4. Character
5. Aggravatingl Alleviating Factors
6. Radiation
7. - Timins
t,
8. Severity l-llr
'.{,rrr\
l\ '
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,
&tP:Ic!9rYl
I . 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's1glgtrg4 based on the HPI, ROS, & Exam findings.
ii. May include differential osis or definitive sis.
l Example: "Angina ctoris
f. Plan:
i. The next steps in patient care, including diagnostic testing, treatments,
refenals, & follow-up.
l. Example:
a. Prescribe nitroglycerin for chest pain.
b. Order an EKG & Stress Test
f c. Follow-up in I week.
The following information is recorded in the HH: "The patient has had abdominal pain for I
week. l he pain lasts for 30 minutes at a time; it comes and goes. Tire severity is 7-9 on a scale ol'
l -10. It is accompanied by N,A/. lt is located in the mid-epigastric area." Wtrich of the categories
doesitbelongto?ffi{relatesdirectlytothecomplaint}
\\f\ r
^ - /^,4\.^'
\\\i' '
, Health Assessment Exam 1
Nurs607 Page 3 of 104
1'he 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
lackrry during the week." Which category does it belong to?
x 'l
he tbllorving inlbrmation is recorded in the HH: "I feel really
belong to? CiL$j6if
CEI, {quoting the pts own words}
tired." Which category does it
f l. following information is recorded in the HH: "Patient denies chest pain. palpitations,
{
onhopnea, & paroxysmal nocturnal dyspnea." Which category does it belong to? SlXm&&
Wl;{documents the present or absence of common symptoms; major body symptoms; ex:
cardiovascular I
All ol'the follorving are a corrrmon or conceming symptom in a health history for a respiratory
assessment EXCEPT?
. S188fltr& {chest pain, blootl-streaked sputum, & snoring are all common or
conceming symptoms in a HH for Resp. assessment)
o Blood-stre aked sputum
. Chest pain . .ir rl
. . [ (/- f4\ 1[ t {,' r-.c I
Snoring \J
ry'a S+yo pt tells the NP that he thinks he must have lJlcerative Colitis. He has been having "black
stools" for the last 24 hours. How would the NP best document the FAC'IS fbr his reason for
seeking care'? JM is a 59vo male here for havins (black stools" for the nast 24 hours {CC:
the reason the pt is seeking care. Make every effort to quote the pts own words)
'[ he nurse is taking family hx. Important diseases or problems to ask the pt about include:
a
mental illness
\:) L-
4 ffi )
No stlructural or functional abnormalities
'
a. Common in healthy individuals, particularly CJi/dffi.
'1
I
i\r,,r\ i.
Characteristics:
, ,\.\ r' 1 Timing: ofien Systolic (occurs during a contraction)
t.\'ri,'\lS i['ri.i'
r'
2 Sound
.J
blowing, or musical quality.
Grade: Typically Grade I ot 2 (LOll/ intensity)
") r(+ b\ LtLltnc\
(n.) Location: Commonly heard al the LL sterual bonler or(APEX
I
^t
na L" rD\',+u^6fiq 6
Changes wilh position: May become quieter or disapprur#rn
lhe Dalienl slands uD.
A w"h,m a\-drdrn\ Associated Conditions :
r.ffir,
2. Can occur temporarily in adults during high-output states (fever,
pregnancy)
i, r(
\(r'i :-an
,ll\ \)
, Health Assessment Exam 1
N urs607 Page 4 of 104
iii. Clinical Importance
I . No further worhup is usually needed unless other symptoms
presenl.
5 : caused by INCREASED bloodllow across a normal valve, ofien d/t
p hy s i o I o gi c al c ondit i ons.
. a. Characteristics:
{Vtti \' i. Timing: typically, Systolic
\i,, ,,, r. ii. Sound: similar to Innocent Murmur- sofi & blowing.
:lt\u '__ iii. Grade: LOW-MODERTE intensiry, usually Grade 1-3
', \' ' \ ''-\f- iv. Locarion; Best heard at the LEFT sternal border.
b.
r
I
Causes:
Fever
T.
\.
It. Anemia
\,t rl'l r)i'- \ itt[.\''-
Ilt. Hyperthyroidism Ir
iv. Pregnancy
c Key Distinction:
i. Unlikz Innocenl Murmurs )
d. Clinical Importance:
i. Resolves when the underlying cause is trealed.
ii. Further investigation may be needed if murmurs persisl, or olher
symptoms arise.
How to differcntiotc b/w Innocent ll Functionol lAut:murs: , )r.f& -\w
. Borh ore benien. urt ru*tion$il?1,lffirtot*"iif* ,o o
physiologicol cousc thot moy need oddrcssirg (trcoting onemio).
a Innocent murmurs orc NOT ossociated with pothology.
Which of these findings would the nurse expect to notice during o cordia Crt
// i 1\L
(innocent (
ossessment on o 4yo child? murmur
is heond ot the ?nd ICS & disoppeors with sitting, ond the young person hos no
associoted signs of cordioc dysfunction)
)<-Wt
, i\- ouscultoting heort sounds on a 7yo child for o routine physicol exam, the
"n
nurse heors on 53, o soft murmur ot the LEFT midsternol border, & o Venous Hum
when the child is stonding. Whot would be o correct interpretotion of these
f indings? td (physiologic 53 is
common in children. Venous Hum: coused by turbulence of blood flow in the Jugulor
i1 /{ [i ll" i\r - I
I
ttv yJ
rl \l I
