Aggravating factorsAssociated Symptoms Relieving factors

Aggravating factorsassociated symptoms relieving

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Aggravating factors/Associated Symptoms Relieving factors Treatment/Medications/Remedies PMH _____1. Major childhood illnesses _____5. Immunizations _____2. Major adult illnesses _____6. Allergies to medications, foods and environment _____3. Surgeries _____7. Medications (including RX, OTC, herbal) _____4. Hospitalizations FAMILY HISTORY _____1. Asks about both parents _____2. Siblings SOCIAL HISTORY _____1. Occupation _____2. Relationship status _____3. Children HABITS _____1. Tobacco _____2. ETOH/Illegal Drug Use ROS _____1. Constitutional _____4. Cardiovascular/Lungs
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Chamberlain College of Nursing NR509 Advanced Physical Assessment _____2. HEENT _____5. GI _____3. Neck/Lymphatic Sub-total Correct History Items: _______ /23 EPISODIC PHYSICAL EXAMINATION (Items in bold are not included in the final immersion evaluation) GENERAL _____1. Note gait, appearance, position, posture, demeanor, level of distress HEENT _____1. Inspect, note swelling, facial symmetry _____2. Inspect the ears, note the TMs _____3. Inspect the eyes, Conjunctiva (color, drainage) lids, sclera, pupils note: PERRL (pupils equal round reactive to light), and the red reflex _____4. Inspect the lips, buccal mucosa, gingivae, teeth, tongue, floor of the mouth, hard and soft palates, and salivary glands _____5. Inspect the nose, note the turbinates and mucosal surfaces _____6. Inspect the pharynx, note and grade the tonsils _____7. Palpate frontal and maxillary sinuses for tenderness NECK/LYMPHATIC _____1. Inspect the neck _____2. Palpate neck/face lymph nodes _____3. Palpate the Thyroid _____4. Palpate Carotid Pulse CARDIOVASCULAR/LUNGS _____1. Auscultates heart in all 5 areas [aortic, pulmonic, Erb’s point, tricuspid, mitral] _____2. Auscultates breath sounds anterior lung fields _____3. Auscultates breath sounds posterior lung fields _____4. Palpates for symmetry of lung expansion by respiratory excursion _____5. Palpates for tactile fremitus (have patient say ninety nine while palpating posterior thorax) Sub-total Physical Exam Items : ______/17 Student Comments:
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  • Fall '15
  • Physical examination, Palpation

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