NURS 680B DQ The Physical Examination and Health Assessment
NURS 680B DQ The Physical Examination and Health Assessment
Select one of the following case studies to address. In the subject line of your post, please identify which prompt you are responding to, for example, choice #2 19-year old male.
A 23-year old female complains of severe left lower abdominal/pelvic pain for 6 hours. States her last menstrual period was “about 3 or 4 weeks ago”. She is sexually active and denies using any contraceptive method.
A 19-year old male complains of “burning sometimes, when I pee”. Is sexually active and denies using any contraceptive method.
A 32-year old male complains of severe pain to the left flank pain for approx. 2 hours. Was playing volleyball at the beach when it occurred. Admits to drinking 5-6 cans of beer throughout the day and denies other fluid intake.
For the case you have chosen, post to the discussion:
Discuss what questions you would ask the patient, what physical exam elements you would include, and what further testing you would want to have performed.
In SOAP format, list:
Pertinent positive and negative information
Differential and working diagnosis
Treatment plan, including: pharmacotherapy with complementary and OTC therapy, diagnostics (labs and testing), health education and lifestyle changes, age-appropriate preventive care, and follow-up to this visit.
Use at least one scholarly source other than your textbook to connect your response to national guidelines and evidence-based research in support of your ideas.
In your peer replies, please reply to at least one peer who chose a different case study.
About Health Assessments
Many people who visit the doctor or healthcare provider’s office wonder: “What are they doing?
What are they looking for?” During a physical examination, there are many things that your healthcare provider may be looking for as they are gathering cues and clues, during the short time you are in the office. Some of the clues are based on the spoken information that you provide, or they may be based on physical examination findings.
During a health assessment, diagnosing an illness, disorder or a condition is like a puzzle. Diagnosis often includes laboratory studies, radiology studies to look at certain organs, and the physical exam itself. This process is called data collection. Before modern technology, it was important for healthcare providers to perfect their physical examination techniques, because x-ray machines, scanners, and echocardiograms were non-existent.
In a physical examination, there are many things that your healthcare provider can find out by using their hands to feel (palpate), stethoscope and ears to listen, and eyes to see. Findings that are present on the physical exam may by themselves diagnose, or be helpful to diagnose, many diseases. The components of a physical exam include:
Your examiner will look at, or “inspect” specific areas of your body for normal color, shape and consistency. Certain findings on “inspection” may alert your healthcare provider to focus other parts of the physical exam on certain areas of your body. For example, your legs may be swollen. Your healthcare provider will then pay special attention to the common things that cause leg swelling, such as extra fluid caused by your heart, and use this information to help them make a diagnosis. Common areas that are inspected may include:
- Your skin – to look for bruising, cuts, moles or lumps
- Your face and eyes – to see if they are even and “normal”
- Your neck veins – to see if these are bulging, distended (swollen)
- Your chest and abdomen (stomach area)- to see if there are any masses, or bulges
- Your legs – to see if there are any swelling
- Your muscles- to check for good muscle tone
- Your elbows and joints – check for swelling and inflammation, if any deformities are present
This is when the examiner uses their hands to feel for abnormalities during a health assessment. Things that are commonly palpated during an exam include your lymph nodes, chest wall (to see if your heart is beating harder than normal), and your abdomen. He or she will use palpation to see if there are any masses or lumps, anywhere in your body.
This is when the examiner uses their hands to “tap” on an area of your body. The “tapping” produces different sounds. Depending on the kind of sounds that are produced over your abdomen, on your back or chest wall, your healthcare provider may determine anything from fluid in your lungs, or a mass in your stomach. This will provide further clues to a possible diagnosis.
This is an important physical examination technique used by your healthcare provider, where he or she will listen to your heart, lungs, neck or abdomen, to identify if any problems are present. Auscultation is often performed by using a stethoscope. The stethoscope will amplify sounds heard in the area that is being listened to. If there is an abnormal finding on your examination, further testing may be suggested.
- The neck: When your doctor or healthcare provider is listening to your neck, they are often listening for a “swishing” sound in your arteries. This may suggest that there is a narrowing of the arteries, which would increase the sound of blood flow.
- The Heart: Normally, your heart produces a “lub-dub” sound, when the heart valves are opening and closing during the flow of blood. Your healthcare provider will listen to see if your heart is beating regularly, or if there are any murmurs (extra sounds with every heart beat). Heart murmurs may be “innocent”, meaning they are normal, and non-life threatening, or they may signify a problem may be present. To diagnose this, your healthcare provider may listen with their stethoscope to many areas around the heart, instead of just one area, and suggest further testing, if necessary.
- The Lungs: Your doctor or healthcare provider may listen to your lungs with their stethoscope, anywhere on your back (posterior), or on the front of your chest wall (anterior). He or she may be able to tell if air is moving to the bottom of your lungs, by listening to the airflow in and out of your lungs with each breath. These are called normal lung sounds. If there is a blockage, constriction or narrowing of your lung tubes, or fluid in your lungs, this can be heard by the examiner.
- The Abdomen: The abdomen will be examined using a stethoscope, to listen for any “swishing” sounds of blood through the arteries near your stomach (such as the aorta), or abnormal bowel sounds.
- Other locations: Auscultation may be used anywhere your healthcare provider wants to listen
The Neurologic Examination:
- During a physical examination by the health care professional, a neurologic examination may be performed. This can be very brief or more detailed depending on concerns and findings. In general the physical examination is divided into 4 parts; cranial nerve assessment, motor function assessment, sensory function assessment, and assessment of reflexes.
- Cranial nerve assessment: There are 12 cranial nerves and these arise from the brain. Each nerve has its own function and the assessment of the nerves is done by evaluating each function. For example, testing the gag reflex with the tongue depressor is testing the 9th and 10th cranial nerves.
- Motor function assessment is checking a person’s gait, muscle strength and coordination. The test where a person is asked to touch their nose then the finger of the examiner, with eyes open then with eyes closed is an example of how coordination may be evaluated.
- Sensory function assessment is checking sensations such as pain, temperature, position sense, crude and fine touch along certain pathways. A test that may used to evaluate this is asking the person to close their eyes and then using a wisp of cotton, ask the person if they can feel the cotton brushed on the skin.
- During a physical examination, testing reflexes helps to assess the status of the central nervous system, this indicates whether the pathway from the spinal cord to the area stimulated and back is intact. The briskness of response is evaluated.