Physical Assessment
Study Guide
Exam One
6PM in Room HP220
Consists of:
Matching Pictures
50 Multiple Qs
Know:
O COMPLETE HEALTH HISTORY
1. Biographic data, ex: demographics, age, name, address, occupation, marital status, primary
language, etc.
2. Reason for seeking care, ex: chief complaint, could be chest pain for 2 hours, or sore throat for3
days which is getting worse
3. Present health or history of present illness, ex:
a. Location (where is it, point to the location.)
b. Character or quality (descriptive terms.)
c. Quantity or severity (profuse, less, double, how does it affect daily activities?)
d. Timing, (onset, duration, frequency, cycle of remission or exacerbation)
e. Aggravating or relieving factors, (is it worsened by activity, time of day, food, or fatigue? is
it relieve with rest or medication?)
f. Associated factors, (is the system accompanied by anything else, i.e., fever, chills, or
shortness of breath?)
g. Patients perception, (how does this affect you? What does it mean to you)
Use PQRST for pain assessment,
I. P- provocative or palliative: what set it off, what makes it better or worse
II. Q-quality or quantity: look, feel, sound? Intensity/ severity?
III. R-region or radiation: where is it? Does it spread anywhere?
IV. S-severity scale: how bad is it on a scale of 0 to 10? Is it getting better or worse, or same?
V. T- timing: onset (when did it start) duration (how long does it last? Frequency how often does it occur
VI. U- understand: what do you think it means?
4. Past history, ex:
- past health events that affect current health
- childhood illnesses
- accident or injuries
- serious or chronic injuries
- hospitalizations
- surgeries
- obstetric history (gravida, number of pregnancies), (para- # of deliveries of viable fetuses) (AB-
number of spontaneous abortions)
- immunizations
- last examination date
- allergies
5. Medication reconciliation, ex:
, ● Comparison of a list of current medications with previous list to reduce errors and promote
patient safety
● Nonprescription OTC
● Herbal medications
● Other substances- smoking tobacco, street drugs
6. Family history, ex:
- Pedigree or genogram
● Graphic family tree and its associate health data, age, cause of death
- Specific medical conditions to ask about:
● Coronary heart disease
● High blood pressure
● Stroke
● Diabetes
● Obesity
● Blood disorders
● Breast/ ovarian cancer
● Colon cancer
● Sickle- cell anemia
● Arthritis
● Allergies
● Alcohol or drug addiction
● Mental illness
● Seizure disorder
● Kidney disease
● Tuberculosis
7. Review of systems, ex:
1) General Status
● Vital signs
● Heart rate
● Blood pressure
● Temperature
● Pulse oximetry
● Respiratory rate
● Pain
2) Head, Ears, Eyes, Nose, Throat
● Observe color of lips and moistness
● Inspect teeth and gums
● Assess buccal mucosa and palate
● Examine Tongue
● Examine at uvula
● Examine tonsils
● Palpate nose and assess symmetry
● Check Septum and inside nostrils
● Verify patency of nares
● Check patient’s sense of smell
● Palpate sinuses
● Assess patient hearing with whisper test
● Tuning Fork test (Weber’s test, Rinne test)
● Look inside ear
● Assess ear discharge and tympanic membrane