The Complete Health Assessment

Recording the Data

Record the data from the history and physical examination as soon after the event as possible. Memory fades as the day develops, especially when you are responsible for the care of more than one person.

It is difficult to strike a balance between recording too much data and recording too little. It is important to remember that, from a legal perspective, if it is not documented, it was not done. Data important for the diagnosis and treatment of the person’s health should be recorded, as well as data that contribute to your decision-making process. This includes charting relevant normal or negative findings.

On the other hand, a listing of every assessment parameter described in this text yields an unwieldy, unworkable record. One way to keep your record complete yet succinct is to study your writing style. Use short, clear phrases. Avoid redundant introductory phrases such as “The patient states that….” Avoid redundant descriptions such as “No inguinal, femoral, or umbilical hernias.” Just write, “No hernias.”

Use simple line drawings to describe your findings. You do not need artistic talent; draw a simple sketch of a tympanic membrane, breast, abdomen, or cervix, and mark your findings on it. A clear picture is worth many sentences of words.

Ellen K. is a 23-year-old single white female cashier at a tavern, currently unemployed for 6 months.

Source. Ellen, seems reliable.

Reason for Seeking Care. “I’m coming in for alcohol treatment.”

History of Present Illness. First alcoholic drink, age 16. First intoxication, age 17, drinking one or two times per week, a 6-pack per occasion. Attending high school classes every day, but grades slipping from A−/B+ average to C− average. At age 20, drinking two times per week, six to nine beers per occasion. At age 22, drinking two times per week, a 12-pack per occasion, and occasionally a 6-pack the next day to “help with the hangover.” During this year, experienced blackouts, failed attempts to cut down on drinking, was physically sick the morning after drinking, and was unable to stop drinking once started. Also, incurred three driving-under-the-influence (DUI) legal offenses. Last DUI 1 month PTA; last alcohol use just before DUI, 18 beers that occasion. Abstinent since that time.

Ellen is second youngest child, parents divorced 8 years, father has chronic alcoholism. See Family genogram below.

Review of Systems

General Health. Reports usual health “OK.” No recent weight change; no fatigue, weakness, fever, sweats.

Skin. No change in skin color, pigmentation, or nevi. No pruritus, rash, lesions. Has bruise now over right eye, struck by boyfriend 1 week PTA. No history skin disease. Hair: no loss, change in texture. Nails: no change. Self-care: Stays in sun “as much as I can.” No use of sunscreen. Goes to tanning beds at hair salon twice/week during winter.

Head. No unusually frequent or severe headaches; no head injury, dizziness, syncope, or vertigo.

Eyes. No difficulty with vision or double vision. No eye pain, inflammation, discharge, lesions. No history glaucoma or cataracts. Wears no corrective lenses.

Ears. No hearing loss or difficulty. No earaches; no infections now or as child; no discharge, tinnitus, or vertigo. Self-care: No exposure to environmental noise; cleans ears with washcloth.

Nose. No discharge; has two or three colds per year; no sinus pain, nasal obstruction, epistaxis, or allergy.

Mouth and Throat. No mouth pain, bleeding gums, toothache, sores or lesions in mouth, dysphagia, hoarseness, or sore throat. Has tonsils. Self-care: Brushes teeth twice/day, no flossing.

Neck. No pain, limitation of motion, lumps, or swollen glands.

Breasts. No pain, lump, nipple discharge, rash, swelling, or trauma. No history breast disease in self, mother, or sister. No surgery. Self-care: Does not do breast self-examination.

Respiratory. No history of lung disease; no chest pain with breathing; no wheezing or shortness of breath. Colds sometimes “go to my chest”; treats with over-the-counter cough medicine and aspirin. Occasional early-morning cough, nonproductive. Smokes cigarettes 2 PPD × 2 years; prior use 1 PPD × 4 years. Never tried to quit. Works in poorly ventilated tavern; “Everybody smokes.”

Cardiovascular. No chest pain, palpitation, cyanosis, fatigue, dyspnea with exertion, orthopnea, paroxysmal nocturnal dyspnea, nocturia, edema. No history of heart murmur, hypertension, coronary artery disease, or anemia.

Peripheral Vascular. No pain, numbness or tingling, swelling in legs. No coldness, discoloration, varicose veins, infections, or ulcers. Legs are unequal in length as sequelae of accident age 12. Self-care: Usual work as cashier involves standing for 8-hour shifts; no support hose.

Gastrointestinal. Appetite good with no recent change. No food intolerance, heartburn, indigestion, pain in abdomen, nausea, or vomiting. No history of ulcers, liver or gallbladder disease, jaundice, appendicitis, or colitis. Bowel movement 1/day, soft, brown; no rectal bleeding or pain. Self-care: No use of vitamins, antacids, laxatives. Diet recall—see Functional Assessment.

Genitalia. Menarche age 11. Last menstrual period April 18. Cycle usually q 28 days, duration 4 to 5 days, flow moderate, no dysmenorrhea. No vaginal itching, discharge, sores, or lesions.

Sexual health. In relationship now that includes intercourse. This boyfriend has been her only sexual partner for 2 years; had one other partner before that. Uses birth control pills to prevent pregnancy; partner uses no condoms. Concerned that boyfriend may be having sex with other women but has not confronted him. Not aware of any STI contact. Never been tested for AIDS. History of sexual abuse by father from ages 12 to 16 years; abuse did not include intercourse. Ellen is unwilling to discuss further at this time.

Musculoskeletal. No history of arthritis, gout. No joint pain, stiffness, swelling, deformity, or limitation of motion. No muscle pain or weakness. Bone trauma at age 12; has sequela of unequal leg lengths, right leg shorter, walks with limp. Self-care: No walking or running for sport or exercise “because of leg.” Able to stand as cashier. Uses lift pad in right shoe to equalize leg length.

Neurologic. No history of seizure disorder, stroke, fainting. Has had blackouts with alcohol use. No weakness, tremor, paralysis, problems with coordination, difficulty speaking or swallowing. No numbness or tingling. Not aware of memory problem, nervousness or mood change, depression. Had counseling for sexual abuse in the past. Denies any suicidal ideation or intent during adolescent years or now.

Hematologic. No bleeding problems in skin, no excessive bruising. Not aware of exposure to toxins, never had blood transfusion, never used needles to shoot drugs.

Endocrine. Paternal grandmother with diabetes. No increase in hunger, thirst, or urination; no problems with hot or cold environments; no change in skin or appetite; no nervousness.

Head-To-Toe Examination

Skin. Uniformly tan-pink in color, warm, dry, intact; turgor good. No lesions, birthmarks, edema. Resolving 2-cm yellow-green hematoma present over right eye; no swelling; ocular structures not involved. Hair: normal distribution and texture, no pest inhabitants. Nails: no clubbing, biting, or discolorations. Nail beds: pink and firm with prompt capillary refill.

Head. Normocephalic, no lesions, lumps, scaling, parasites, or tenderness. Face: symmetric, no weakness, no involuntary movements.

Eyes. Acuity by Snellen chart: right eye 20/20; left eye 20/20−1. Visual fields full by confrontation. EOMs intact, no nystagmus. No ptosis, lid lag, discharge, or crusting. Corneal light reflex symmetric; no strabismus. Conjunctivae clear. Sclerae white; no lesion or redness. Pupils: 3 mm resting, 2 mm constricted, and = bilaterally. PERRLA.

Fundi: discs flat with sharp margins. Vessels present in all quadrants without crossing defects. Background has even color, no hemorrhage or exudates.

Ears. Pinna: no mass, lesions, scaling, discharge, or tenderness to palpation. Canals clear. Tympanic membrane: pearly gray, landmarks intact, no perforation. Whispered words heard bilaterally.

Nose. No deformities or tenderness to palpation. Nares patent. Mucosa pink, no lesions. Septum midline, no perforation. No sinus tenderness.

Mouth. Mucosa and gingivae pink, no lesions or bleeding. Right lower 1st molar missing, multiple dark spots on most teeth, gums receding on lower incisors. Tongue symmetric, protrudes midline, no tremor. Pharynx pink, no exudate. Uvula rises midline on phonation. Tonsils 1+. Gag reflex present.

Neck. Neck supple with full ROM. Symmetric; no masses, tenderness, lymphadenopathy. Trachea midline. Thyroid nonpalpable, not tender. Jugular veins flat @ 45 degrees. Carotid arteries 2+ and = bilaterally; no bruits.

Spine and Back. Normal spinal profile; no scoliosis. No tenderness over spines; no CVA tenderness.

Thorax and Lungs. AP < transverse diameter. Chest expansion symmetric. Tactile fremitus equal bilaterally. Lung fields resonant. Diaphragmatic excursion 4 cm and = bilaterally. Breath sounds diminished. Expiratory wheeze in posterior chest at both bases, scattered rhonchi in posterior chest at both bases, do not clear with coughing.

Breasts. Symmetric; no retraction, discharge, or lesions. Contour and consistency firm and homogeneous. No masses or tenderness, no lymphadenopathy.

Heart. Precordium: no abnormal pulsations, no heaves. Apical impulse at 5th ICS in left MCL, no thrills. S₁–S₂ are not diminished or accentuated, no S₃ or S₄. Systolic murmur, grade ii/vi, loudest at left lower sternal border, no radiation, present supine and sitting.

Abdomen. Flat, symmetric. Skin smooth with no lesions, scars, or striae. Bowel sounds present, no bruits. Tympany predominates in all quadrants. Liver span 7 cm in right MCL. Abdomen soft, no organomegaly, no masses or tenderness, no inguinal lymphadenopathy.

Musculoskeletal. Temporomandibular joint: no slipping or crepitation. Neck: full ROM, no pain. Vertebral column: no tenderness, no deformity or curvature; full extension, lateral bending, rotation. Arms symmetric, legs measure as described, extremities have full ROM, no pain or crepitation. Muscle strength: able to maintain flexion against resistance and without tenderness.

Neurologic. Mental status: Appearance, behavior, speech appropriate. Alert and oriented to person, place, time. Thought coherent. Remote and recent memories intact. Cranial nerves II through XII intact. Sensory: Pinprick, light touch, vibration intact. Stereognosis: Able to identify key. Motor: No atrophy, weakness, or tremors. Gait: Has limp, able to tandem walk with shoes on. Negative Romberg’s sign. Cerebellar: Finger-to-nose smoothly intact. DTRs: See stick gram.

Genitalia. External genitalia: no lesion, discharge. Internal genitalia: vaginal walls pink, no lesion. Cervix: pink, nulliparous os, no lesions, small amount nonodorous clear discharge. Specimens for Pap test, GC/chlamydia, trichomoniasis, moniliasis obtained. Swabbing mucosa with acetic acid shows no acetowhitening.

Bimanual: no pain on moving cervix; uterus midline; no enlargement, masses, or tenderness. Adnexa—ovaries not enlarged, no tenderness. Anus—no hemorrhoids, fissures, or lesions. Rectal wall intact, no masses or tenderness. Stool soft, brown; hematest negative.

Assessment

Alcohol dependence, severe, with physiologic dependence

Nicotine dependence with physiologic dependence

Hypertension

Systolic heart murmur

Ineffective airway clearance R/T tracheobronchial secretions and obstruction

Right orbital contusion (resolving)

Risk for trauma

Self-care deficit: oral hygiene R/T lack of motivation

Deficient knowledge about alcoholism disease process, treatment options, support systems R/T lack of exposure

Deficient knowledge about balanced diet R/T lack of exposure and substance abuse

Dysfunctional family processes: alcoholism