aDVANCED hEALTH ASSESSMNET uNIT 4

Symptoms to Inquire About

(please see page 54–56 in Jarvis textbook)

Document pertinent negatives and/or positives

The first system is addressed to provide a guide

General

Wgt Δ; weakness; fatigue; fevers

Pertinent Negatives: No weight gain or losses; no weaknesses, fatigue, or fevers

Pertinent Positives: Positive weight gain over past 2 months with fatigue and weakness; no fevers

Skin

Rash; lumps; sores; itching; dryness; color change; Δ in hair/nails

Head

Headache; head injury; dizziness or vertigo

Eyes

Vision Δ; eye pain, redness or swelling, corrective lenses; last eye exam; excessive tearing; double vision; blurred vision; scotoma

Ears

Hearing Δ; tinnitus; earaches; infections; discharge, hearing loss, hearing aid use

Nose/

Sinuses

Colds; congestion; nasal obstruction, discharge; itching; hay fever or allergies; nosebleeds; change in sense of smell; sinus pain

Throat/

Mouth

Bleeding gums; mouth pain, tooth ache, lesions in mouth or tongue, dentures; last dental exam; sore tongue; dry mouth; sore throats; hoarse; tonsillectomy; altered taste

Neck

Lumps; enlarged or tender nodes, swollen glands; goiter; pain; neck stiffness; limitation of motion

Breasts

Lumps; pain; discomfort; nipple discharge, rash, surgeries, history of breast disease; performs self-breast exams and how often, last mammogram; any tenderness, lumps, swelling, or rash of axilla area

Pulmonary

Cough—productive/non-productive; hemoptysis; dyspnea; wheezing; pleuritic pains; any H/O lung disease; toxin or pollution exposure; last Chest X-RAY, TB skin test

Cardiac

Chest pain or discomfort; palpitations; dyspnea; orthopnea; edema, cyanosis, nocturia; H/O murmurs, hypertension, anemia, or CAD

G/I

Appetite Δ; jaundice; nausea/emesis; dysphagia; heartburn; pain; belching/flatulence; Δ in bowel habits; hematochezia; melena; hemorrhoids; constipation; diarrhea; food intolerance

GU

Frequency; nocturia; urgency; dysuria; hematuria; incontinence

Females: Use of kegal exercises after childbirth; use of birth control methods; HIV exposure; Menarche; frequency/duration of menses; dysmenorrhea; PMS symptoms: bleeding between menses or after intercourse; LMP; vaginal discharge; itching; sores; lumps Menopause; hot flashes; post-menopausal bleeding;

MALES: caliber of urinary stream; hesitancy; dribbling; hernia, Sexual habits; interest; function; satisfaction; Discharge from or sores on penis; HIV exposure; testicular pain/masses; testicular exam and how often

Peripheral Vascular

Claudication; coldness, tingling, and numbness; leg cramps; varicose veins; H/O blood clots, discoloration of hands, ulcers

Musculo-skeletal

Muscle or joint pain or cramps; joint stiffness; H/O arthritis or Gout; limitation of movement; H/O disk disease

Neuro

Syncope; seizures; weakness; paralysis; stroke, numbness/tingling; tremors or tics; involuntary movements; coordination problems; memory disorder or mood change; H/O mental disorders or hallucinations

Heme

Hx of anemia; easy bruising or bleeding; blood transfusions or reactions; lymph node swelling; exposure to toxic agents or radiation

Endo

Heat or cold intolerance; excessive sweating; polydipsia; polyphagia; polyuria; glove or shoe size; H/O diabetes, thyroid disease; or hormone replacement; abnormal hair distribution

Psych

Nervousness/anxiety; depression; memory changes; suicide attempts; H/O mental illnesses

General:

Skin:

HEENT & Sinuses:

Neck & Regional Lymph Nodes:

Breasts:

Lungs & Thorax:

Heart:

Gastrointestinal:

Genitourinary:

Extremities (Peripheral Vascular):

Musculoskeletal:

Neurological: