El Camino College

Associate DegreeNursing Program

Nursing 155

Health Assessment

1.0 unit

Fall 2007/SPRING 2008

PRINTED EXCLUSIVELY FOR THE EL CAMINO COLLEGE BOOKSTORE

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N 155 HEALTH ASSESSMENT

N 155 COURSE DESCRIPTIONStudents will develop and utilize health assessment skills necessary to care for clients. The focus will be on describing normal findings and common abnormalities observed in physical assessments of clients. Students will perform physical assessments, explain the pathophysiology of common abnormalities, and document assessment findings.

N 155 ENTRY COMPETENCIESStudents should enter N155 with knowledge of the normal pathophysiology of cardiac, respiratory, musculoskeletal, and peripheral vascular systems. Students should be familiar with the physical assessment and physical assessment techniques taught in N150.

N 155 STUDENT LEARNING OUTCOMESAt the end of N155 the student will be able to complete a physical assessment of a client identifying normal and common abnormal findings. The student will be able to document their findings in a concise and accurate format.

N 155 COURSE OBJECTIVES1. Gather data for a health history from an adult client.2. Perform a physical assessment on an adult client incorporating the cardiac, respiratory,

peripheral vascular, abdominal, musculoskeletal, lymphatic, head, eyes, ears, nose, and throat (HEENT), and neurological systems.

3. Identify normal body landmarks that correspond to underlying structures on the anterior and posterior chest wall of a client.

4. Identify common abnormal assessment findings.5. Compare and contrast the pathophysiology of normal and abnormal assessment findings.6. Evaluate the impact of abnormal assessment findings on a client.7. Document assessment findings utilizing a problem-based format.8. Formulate a priority nursing diagnosis based upon assessment findings.9. Complete a comprehensive health history (in the clinical setting).

N 155 UNIT OBJECTIVES:At the end of each Module the student will:

Module One1. Explain the purpose and components of the health history.2. Describe effective and ineffective interviewing techniques.3. Gather appropriate data for each health history component: biographic data, health and

illness patterns, health promotion patterns, role and relationship patterns, and a summary of health history data.

4. Describe modifications needed to accommodate the client’s structural variables and basic needs.

5. Document a health history utilizing AIE format.6. Identify the steps in the nursing process and how they are used in collecting data for a

history and physical.7. Explain how the subjective and objective data gathered during assessment relate to the

nursing process.

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8. Identify methods of collecting and organizing nursing assessment data: interviewing and observation.

9. Identify the steps of the Mini Mental State Exam

Module II1. Discuss the purpose and components of the physical assessment.2. Describe the equipment required to perform the physical assessment and demonstrate its

use.3. Identify the purpose of the following physical exam techniques: inspection, auscultation,

palpation, and percussion.4. Demonstrate the techniques of inspection, auscultation, palpation, and percussion.5. Describe how to perform a general survey on an adult client.6. Utilize an adult simulator to perform a health assessment.7. Identify the normal anatomy and physiology of the Integumentary system.

Module III1. Identify the normal anatomy and physiology of the head, eye, ears, nose and throat

(HEENT). 2. Identify common abnormal findings (TMJ). 3. Document normal and abnormal findings of the HEENT exam using appropriate

terminology.

Module IV1. Identify the anatomic structures and physiologic functions of the respiratory system.2. Describe the mechanics of respiration.3. Demonstrate how to inspect, auscultate, palpate, and percuss respiratory system structures. 4. Describe the normal findings of the respiratory system detected by inspection,

auscultation, palpation, and percussion. 5. Describe the most common abnormal findings of the respiratory system (rales, rhonchi,

wheezes, nasal flaring, clubbing, position for breathing, pursed-lip breathing, use of accessory muscles, sternal retractions) detected by inspection, auscultation, palpation, and percussion.

6. Document normal and abnormal findings of the respiratory system using appropriate terminology.

Module V1. Identify the anatomic structures and physiologic function of the heart (chambers and

valves).2. Trace the blood flow through the pulmonary and coronary and systemic circulation. 3. Explain the events of the cardiac cycle (systole and diastole).4. Differentiate between normal and abnormal findings of the cardiovascular system during

inspection and auscultation (lifts, heaves, pulsations, S1, S2, Split S25. Demonstrate auscultation of the aortic, pulmonic, tricuspid and mitral areas and describe

heart sounds normally auscultated at each site.6. Describe common abnormal findings on auscultation of the heart (murmurs)7. Document normal and abnormal findings of the CV system using appropriate terminology.8. Identify the anatomic location of all peripheral pulses.9. Review rate, rhythm, and strength of pulses.10. Assess for jugular venous distention (JVD).

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11. Describe common abnormal findings of the peripheral vascular system (bruits and JVD) detected by inspection, auscultation and palpation.

Module VI1. Demonstrate how to perform an abdominal assessment on an adult client.2. Identify and locate (by inspection, auscultation, palpation and percussion) the organs of

the gastrointestinal system (liver).3. Differentiate between normal and abnormal findings detected on physical assessment of

the GI system (contour, pulsations, Borborygmi, ascites, rebound tenderness, guarding, hypo/hyperactive sounds, and solid mass).

4. Document normal and abnormal findings of the GI systems using appropriate terminology.

5. Identify normal breast tissue.6. Perform a breast examination on a simulator7. Describe common abnormal findings (orange peel, dimpling) on inspection and palpation

of breast tissue.8. Describe Testicular Self Exam

Module VII1. Describe the normal anatomy and physiology of the musculoskeletal system.2. Identify developmental musculoskeletal system variations (scoliosis, lordosis, kyphosis,

and TMJ).3. Explain overall body symmetry, gait, posture, and muscle and joint functions. 4. Describe systematic palpation of muscles, bones, joints, ROM, and muscle strength.5. Document normal and abnormal findings of the musculoskeletal system using appropriate

terminology.6. Identify the major components of the central nervous system (CNS).7. Identify the function and assess the 12 cranial nerves.8. Explain the difference between a neurologic screening test, a complete neurologic

assessment, and a neuro check.9. Describe how to assess a client’s level of consciousness.10. Compare and rate deep tendon reflexes (DTR’s) of the biceps, triceps, brachioradialis,

patellar and Achilles.11. Document common findings on inspection, palpation, percussion and auscultation of the

Musculoskeletal and Nervous Systems using appropriate terminology.

N 155 UNIT HOURS:This is a one unit nursing course, consisting of lecture and lab.

N 155 PREREQUISITES:Successful completion of N150, N151, and N152.

N 155 COURSE PLACEMENT:This course is offered during the second eight weeks of the second semester of the nursing program.

N 155 REQUIRED TEXTS/EQUIPMENTJarvis, C. (2004). Physical examination and health assessment (4th ed.). Philadelphia: W.B. Saunders Co.A dual head or single head (cardiac) stethoscope is required for lab and pen light.

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N 155 RECOMMENDED TEXTSAny pocket edition for Physical Assessment is acceptable.

N 155 METHODS OF INSTRUCTION:Case StudiesLectures and demonstrations of a sequenced basic physical exam and a cognitive status examDiscussion of typical findings in a basic adult assessmentGroup projects focused on use of assessment skillsHandouts related to various aspects of course contentHands on physical examination practice

N 155 LEARNING ACTIVITIESReading (Reading list will be provided).Assigned or recommended content in texts and references related to normal and abnormal findings in basic physical assessment of the adult.Documentation of history and physical findings on a sample client recordDemonstration of a timed, observed comprehensive basic physical examinationObserve, interpret and analyze client behaviorDemonstration of use of clinical assessment skillsPractice skills in the lab on student colleagues.

N 155 FACULTY RESPONSIBILITIES:Faculty will be prepared and present to assist students in the learning lab.Faculty will present weekly lectures. Faculty will be available to students during office hours.

N 155 STUDENT RESPONSIBILITIES:Students will be responsible for arriving to lecture and lab on time, having completed reading assignments. Students will be responsible for reviewing previously learned material for class. Students will provide their own stethoscopes, penlight and wrist watch with second hand. The student is responsible for demonstrating all behavioral objectives of the course. Clinical evaluation is based on demonstrated ability to achieve all course objectives by the last day of classes. Course expectations include attendance and experiential learning. N 155 STUDENT-FACULTY COMMUNICATION:Faculty office hours will be posted on faculty offices. Lab faculty should provide their availability to students. For the didactic component of the course, students should communicate with the lecturer. For the lab component of the course, students should communicate with the lab instructor(s).

*All students and faculty have El Camino College e-mail addresses which will be utilized throughout this course. Students are required to check their El Camino College email address routinely in that course information and updates will be sent via email periodically throughout the semester. Students are responsible for all information sent to them via their El Camino account.

N 155 ATTENDANCE POLICY:Course expectations include attendance and experiential learning. Students must successfully pass the final practical examination to complete the course.

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N 155 GRADING POLICY:The standard nursing criteria will be utilized in the calculation of all grades. The minimum grade points are as follows

92-100% A 83-87% B 77-78% C 65-72% D90-91% A- 81-82% B- 75-76% C- 63-64% D-88-89% B+ 79-80% C+ 73-74% D+ 62% or less F

N 155 METHODS OF EVALUATION:QuizzesFour short 10 point quizzes will be given at the beginning of specified labs. The content of each quiz will relate to the readings assigned for that day. Students who arrive late will not be able to make up missed quizzes. Each quiz will be worth 10 points (10% of grade).

Lab activity documentation: Complete and accurate documentation of assessment findings completed during clinical labs. There will be a total of 8 (eight) documentation assignments each worth 5 points for a total of 40 points (40% of grade).

Final Practicum (Pass/Fail): This consists of performing a head to toe exam within 15 minutes. Students must pass this in order to pass the class.

Grading:Quizzes 4 40% Health History 20%Weekly lab documentation 40%Total 100%

N155 WRITTEN HOMEWORK: HEALTH HISTORYStudents are required to complete a health history on an adult client in their clinical setting (see paper format example on the course website). You will be given a Health History form for this assignment by one of the course lecturers. If you are not in a clinical setting during this semester, please notify your instructor.

Grading for the Health History: 20 PointsSubjective data gathered 10 PointsIdentify 3 relationships between structural variables and basic needs

based on subjective data gathered with rationale and references 6 PointsIdentify 1 Actual and 1 ‘Risk for’ NANDA approved Nursing Diagnosis

(must be written properly) 2 PointsAPA Format/Grammar (see below) 2 PointsTotal 20 Points

NOTE: You must follow APA guidelines when writing this paper. This includes format, spelling, and grammar written at a college level. If you do not follow these guidelines and/or have an unacceptable number of grammatical/spelling errors, you will receive an automatic 50% (10 points) on this assignment. NO second chance will be granted after the due date.

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Final Practicum

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N155 Health AssessmentOutline Lecture 1

Kim Baily RN, MSN, PhD Health Assessment

o Purpose Assessment Nursing Assessment

Interviewingo What is an interview?

Factors affecting the interviewo Internal factors

Liking others Empathy Active Listening

o External Factors Privacy Interruptions Physical environment Dress Note taking

o Stages of the Interview Orientation

Introductions Purpose of interview Length of interview Developing therapeutic relationship

Working Phase Termination Working Phase

Gathering data Open-ended questions Close ended questions Therapeutic Communication Techniques Facilitation Paraphrasing Restating Reflections Focusing Clarifying Silence Confrontation Summarizations One question at a time

Ten Traps of Interviewing False reassurance Giving unwanted advice Using authority Using avoidance language Distance Using medical jargon Using leading or biased questions Talking too much! Interrupting Asking “why”

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Check your non/verbal body language Yawning Body turned away Facial expression Lack of eye contact Gesticulations Touching

o Termination of Interview Summarize important findings Check with client if there is anything else they would like to discuss Explain what the next step will be Provide information

Cross Cultural Communicationo Etiquetteo Proxemics

Intimate space – within 6 inches Personal space – 6 inches to 4 feet Social space – 4 to 12 feet Public space – more than 12 feet Comfort zone

The Complete Health Historyo Biographical datao Reason for seeking care (Was called “Chief Complaint” but this has negative connotation)o Present health or history of present illnesso Past historyo Family historyo Review of systemso Functional assessment or activities of daily living

Terminology Reviewo Symptom – Subjective sensationo Sign – Objective observations

Sources of Datao Primaryo Secondary

Biographical Data Reason for Seeking Care

o Want the client to describe their problem in their own wordso Do not interpret or rephrase complainto Do not use “Chief Complaint”

Present Health or History of Present Illnesso Chronological record of why pt seeking careo Characteristics of symptom:

Location Character or quality Quantity or severity Timing Setting Aggravating or relieving factors Associated factors Patient’s perception

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o Analysis of Symptomso PQRST Mnemonic o P: Provocative or palliativeo Q: Quality or quantityo R: Region or radiationo S: Severity scaleo T: Timingo U: Understand patient’s perception

Past Healtho List of past problems,o Childhood illness o Chronic illness – dm 1, congenital heart dx, o Accidents and injurieso Hospitalizations and Operations: o Obstetric historyo Immunizations o Last examination dateo Allergieso Current medications

Family Historyo Genogram

Review of Systems (ROS)o Done to ensure no significant data was overlooked o Also asks about health promotion practiceso Series of “yes” or “no” questionso Begins with general health (weight loss, fatigue, weakness, fever, chills present weight)o Remember, if your client has an acute problem, every other body system will be affected o If any positive findings from ROS, always do an analysis of the symptom (PQRSTU) on that

finding Functional Assessment

o ADLs and self care ability; o Activity/exerciseo Sleep/resto Nutrition/eliminationo Interpersonal relationships/resourceso Coping and stress managemento Personal habits

Alcohol Street drugs

o Environment/hazardso Occupational health

Perception of Healtho How do you define health?o How do you view your situation now?o What do you think will happen in the future?o What are your health goals?o Self-esteem, self-concepto What are your concerns/goals?o What do you expect from your health care providers?

Mental Status Examination

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o Examination - ABCTo Appearance

Posture, body movement, dress, grooming and hygieneo Behavior

Level of consciousness Alert- awake or easily aroused Lethargic- not fully alert, drifts off when not stimulated Obtunded- sleeps most times, difficult to arouse (loud noise, vigorous shaking

or pain) Stupor- need persistent loud noise or pain for arousal; responds to stimuli Coma- no response Acute confusional state (delirium)

Facial expression Speech Mood and affect

o Cognition Orientation (Person, time, place and purpose) Attention span Recent memory Remote memory New learning—the four unrelated words test Judgment

o Thought processes Thought processes Thought content Perceptions Screen for suicidal thoughts

Mini Mental State Examo Orientationo Registrationo Attention and calculationo Recallo Language

Glascow Coma Scaleo Eye openingo Best Verbal responsiveness o Best Motor responsiveness

Reminders - Reviewo Cultural Assessment Page 48-49o Developmental Considerations for adult and older adult in Chapter 2.

Note: All remaining lecture outlines will be found at http://www.elcamino.edu/faculty/kbaily/index.htmlOutlines should be printed out each week before lecture.

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N155 WEEK 1 – LAB 1. INTERVIEW TO OBTAIN A HEALTH HISTORY (SEE HEALTH HISTORY FORM)

Work in groups of threeo Student 1 – Interviewer

“Interview” patient. Remember interviewing techniques, therapeutic communication and body language”

Analyze any symptoms using PQRSTU mnemonic Document interview findings on below: Pick one problem and write a SOAP note on this form – hand into both

documents to lab instructoro Student 2 – Interviewee (client)

Pretend to be a patient with a new medical condition and a chronic health problem (do not discuss with Student 1 or 3)

o Student 3 Recorder Silently observe “nurse” and ‘patient”. Make notes on interview technique,

including types of questions asked and body language of both nurse and client. You will provide constructive feedback to the “nurse” regarding interview technique.

Each student should attempt each role and hand in Health Form and SOAP note.

DOCUMENTATION:Summarize findings using SOAP note:Subjective:

Objective:

Assessment:

Plan

Nursing DiagnosisBased on the subjective data collected above, identify one applicable nursing diagnosis and/or collaborative problems. Write a complete nursing diagnosis using the PES format. If you need help writing a correct nursing diagnosis please ask lab faculty.

2. COMPLETE MINI-MENTAL STATE EXAM Work in pairs to complete Mini-Mental State Exam

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Name of Interviewer (Nurse): ________________________Date: _______________________

EL CAMINO COLLEGEN155 HEALTH HISTORY

Biographical Data: (Do not fill in grey areas)

Name (Initials): Gender: M/F Date of Birth: Age: Race:Address: Telephone:Marital Status: Contact Person:Occupation: Source of Data:

Reason for Seeking Care:

Present Health History:

Current medical conditionsChronic medical conditionsMedicationsFood allergiesCurrent medical treatments

Past Health History:Chronic illnesses (circle all that apply)

Measles Mumps Rubella Chicken pox PertussisEar infections Throat infections Other:Previous Medical conditions

Previous hospitalizations/surgeriesAccidents/Injuries

Immunizations: (Circle) Tetanus Diptheria Pertussis Mumps RubellaPoliomyelitis Hepatitis B Influenza Varicella Other:

Date of last exams – Physical, dental, visionWomen Date last pap smear: LMP: Date last

mammogram:

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Family History:(Indicate age and current health. If deceased, indicate age and cause of death.)

Mother and father:Maternal grandparents:Paternal grandparents:Parents’ siblings:Client’s siblings:Spouse and children:

Personal and Psychosocial History:Family/Social Relationships (significant others, individuals in home, role within family, etc)

Diet/Nutrition (include appetite, typical food intake, etc):

Functional Ability (indicate ability to independently perform following self-care activities

Mental Health (anxiety, depression, irritability, stressful events, personal coping strategies):

Person Habits:Tobacco use: ____________________ Alcohol intake: _____________________Illicit drug use: _______________________________________________

Health PromotionExercise (type/frequency):

Self-examination (type/frequency):

Oral hygiene practice (frequency of brushing/flossing):

Environment (including living and work environment)

Review of Systems: (circle all symptoms that apply, and comment below). Use PQRSTU symptom evaluation. Remember this is not a physical exam but information which the client reports to nurse (subjective information.)

General Symptoms:

Pain Fatigue Weakness FeverProblems sleeping Weight changesComments:

Integumentary System:

Changes in skin/color/texture

Excessive bruising Itching Skin lesions

Sores that do not heal

Change in mole Recent hair loss Sun exposure

Comments:Head: Headaches Head Injury Dizziness Fainting spells

Comments:

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Eyes: Change in vision Discharge Excessive tearing

Eye pain

Sensitivity to light

Halos around lights

Difficulty reading

Correct lenses Y/N

Eyeglasses Y/N Contact Lenses Y/N

Comments:Ears: Ear pain Drainage Tinnitus Excessive wax

Changes in hearing

Recurrent infections

Sensitivity to noises

Hearing devicesY/N

Comments:Nose, Nasopharynx, Sinuses

Nasal discharge Frequent nosebleeds

Sneezing Nasal obstruction

Sinus pain Postnasal drip Change in smell SnoringComments:

Mouth/Oropharynx Sore throat Sore in mouth Bleeding gums Change in tasteTrouble swallowing/chewing Dental prothesis Change in voiceComments:

Neck Lymph nodes Swelling/mass Neck pain StiffnessComments:

BreastsRespiratory System

Frequent colds SOB Wheezing CoughPain w breathing Cough up blood Night sweatsComments:

Cardiovascular System

Chest pain Palpitations Dyspnea Dyspnea w sleepEdema Cold extremities Discoloration Varicose veinsLeg pain w activity ParathesiaComments:

GI System Pain Heartburn Nausea/Vomiting Vomiting bloodJaundice Change appetite Diarrhea ConstipationFlatus Change in bowel habitsComments:

Urinary System Hesitancy Frequency Change in stream NocturiaPain w urination Flank pain Blood urine Inc/dec urine volComments:

ReproductiveMusculoskeletal Muscle pain Weakness Joint Swelling Joint pain

Stiffness Limited ROM Limited mobility Back painComments:

Neurologic System Pain Seizures Fainting TremorSpasms Change in sensation, cognition, memory, coordinationComments:

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MINI-MENTAL STATUS QUESTIONNAIRE

Question

Max Score

Score on

Date:

Score on

Date:

Score on

Date:

ORIENTATION1) What is the (year) (season) (date) (day) (month)?

2) Where are we? (state) (country) (town) (hospital) (floor)

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5REGISTRATION3) Repeat (immediately) 3 objects: garbage, tree, airplane. 3ATTENTION / CALCULATION4) Serial 7's or spell WORLD backwards 5RECALL5) Remember 3 objects at 2 minutes 3LANGUAGE6) Name a pencil and a watch.

7) Repeat "No ifs, ands, or buts."

8) Three stage command: “Take a paper in your right hand, fold it in half, and put it on the floor.”

9) Written command: Please read the following “Close your eyes”

10) Write a sentence.

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1

3

2

1

VISUAL-SPATIAL

11) Copy a design: 1

LEVEL OF CONSCIOUSNESS (circle one) Alert Drowsy Stupor Coma

Total Score: 30INTERPRETATION OF TOTAL SCORE:

25-30 Normal21-24 Mild intellectual impairment16-20 Moderate intellectual impairmentunder 15 Severe intellectual impairment

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Review of Systems: Problem Analysis.

If any problem emerges complete a more in depth assessment using the PQRSTU mnemonic: Page 86

P: Provocative or palliative Q: Quality or quantity R: Region or radiation S: Severity scale T: Timing U: Understand patient’s perception

Work in pairs Each student should spend a few minutes creating a health problem (don’t let other

student know what problem is).o Either use a past health problem (nothing likely to cause embarrassment) or

invent a problem Take turns being interviewer

P: Ask: o What were you doing when the problem started?o Does anything make it better? (meds, positioning)o Does anything make it worse? (movement or breathing)

Q: Asko Can you describe the symptom? o What does it feel like, look like or sound like? o To what degree does it affect your usual daily activities?

R: Asko Can you point to where the problem is? Does it occur or spread anywhere else?

(Take care not to lead your client – e.g. Does it radiate to your left arm?)o Do you have any other symptoms? Depending of CC- ask about related symptoms

– ex. If cc is CP, ask about nausea, sweating, SOB etc. S: Ask

o Is the symptom mild, moderate, or severe? Grade it on a scale of 0-10 (0 being no symptom and 10 being the most severe)

o Timing: Asko When did the symptom start? How often does it occur? How long does it last?

U: Asko What do you think these symptoms mean?

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Name of Interviewer (Nurse): ________________________Date: _______________________

EL CAMINO COLLEGEN155 HEALTH HISTORY

Biographical Data: (Do not fill in grey areas)Use this form for term paper.

Name: Gender: M/F Date of Birth: Age: Race:Address: Telephone:Marital Status: Contact Person:Occupation: Source of Data:

Reason for Seeking Care:

Present Health History:

Current medical conditionsChronic medical conditionsMedicationsFood allergiesCurrent medical treatments

Past Health History:Chronic illnesses (circle all that apply)

Measles Mumps Rubella Chicken pox PertussisEar infections Throat infections Other:Previous Medical conditions

Previous hospitalizations/surgeriesAccidents/Injuries

Immunizations: (Circle) Tetanus Diptheria Pertussis Mumps RubellaPoliomyelitis Hepatitis B Influenza Varicella Other:

Date of last exams – Physical, dental, visionWomen Date last pap smear: LMP: Date last

mammogram:

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Family History:(Indicate age and current health. If deceased, indicate age and cause of death.)

Mother and father:Maternal grandparents:Paternal grandparents:Parents’ siblings:Client’s siblings:Spouse and children:

Personal and Psychosocial History:Family/Social Relationships (significant others, individuals in home, role within family, etc)

Diet/Nutrition (include appetite, typical food intake, etc):

Functional Ability (indicate ability to independently perform following self-care activities

Mental Health (anxiety, depression, irritability, stressful events, personal coping strategies):

Person Habits:Tobacco use: ____________________ Alcohol intake: _____________________Illicit drug use: _______________________________________________

Health PromotionExercise (type/frequency):

Self-examination (type/frequency):

Oral hygiene practice (frequency of brushing/flossing):

Environment (including living and work environment)

Review of Systems: (circle all symptoms that apply, and comment below). Use PQRSTU symptom evaluation. Remember this is not a physical exam but information which the client reports to nurse (subjective information.)

General Symptoms:

Pain Fatigue Weakness FeverProblems sleeping Weight changesComments:

Integumentary System:

Changes in skin/color/texture

Excessive bruising Itching Skin lesions

Sores that do not heal

Change in mole Recent hair loss Sun exposure

Comments:Head: Headaches Head Injury Dizziness Fainting spells

Comments:

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Eyes: Change in vision Discharge Excessive tearing

Eye pain

Sensitivity to light

Halos around lights

Difficulty reading

Correct lenses Y/N

Eyeglasses Y/N Contact Lenses Y/N

Comments:Ears: Ear pain Drainage Tinnitus Excessive wax

Changes in hearing

Recurrent infections

Sensitivity to noises

Hearing devicesY/N

Comments:Nose, Nasopharynx, Sinuses

Nasal discharge Frequent nosebleeds

Sneezing Nasal obstruction

Sinus pain Postnasal drip Change in smell SnoringComments:

Mouth/Oropharynx Sore throat Sore in mouth Bleeding gums Change in tasteTrouble swallowing/chewing Dental prothesis Change in voiceComments:

Neck Lymph nodes Swelling/mass Neck pain StiffnessComments:

BreastsRespiratory System

Frequent colds SOB Wheezing CoughPain w breathing Cough up blood Night sweatsComments:

Cardiovascular System

Chest pain Palpitations Dyspnea Dyspnea w sleepEdema Cold extremities Discoloration Varicose veinsLeg pain w activity ParathesiaComments:

GI System Pain Heartburn Nausea/Vomiting Vomiting bloodJaundice Change appetite Diarrhea ConstipationFlatus Change in bowel habitsComments:

Urinary System Hesitancy Frequency Change in stream NocturiaPain w urination Flank pain Blood urine Inc/dec urine volComments:

ReproductiveMusculoskeletal Muscle pain Weakness Joint Swelling Joint pain

Stiffness Limited ROM Limited mobility Back painComments:

Neurologic System Pain Seizures Fainting TremorSpasms Change in sensation, cognition, memory, coordinationComments:

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