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How to Use Symptom Analysis Tables

INTRODUCTION
When you encounter patients with positive symptoms, you will need to perform a symptom analysis to thoroughly
assess your patient’s presenting symptoms. Although many questions come to mind, your patient’s condition and
time constraints may preclude you from going into too much detail. If so, you’ll need to zero in on several key areas
to evaluate your patient’s symptoms.

As you perform the symptom analysis, try to determine how disabling this problem is for your patient. Also ask if he
or she has any medical problems related to the current problems and if he or she is taking any medications for this
current problem.

WHAT IS PQRST?
The helpful mnemonic PQRST provides key questions that will give you a good overview of any symptom. Although
you can ask additional questions, the following ones provide a thorough analysis of any presenting symptom:

P = Precipitating/Palliative Factors

Ask: What were you doing when the problem started? Does anything make it better, such as medications
or certain positions? Does anything make it worse, such as movement or breathing?

Q = Quality/Quantity

Ask: Can you describe the symptom? What does it feel like, look like, or sound like? How often are you
experiencing it? To what degree does this problem affect your ability to perform your usual daily activities?

R = Region/Radiation/Related Symptoms

Ask: Can you point to where the problem is? Does it occur or spread anywhere else? (Take care not to
lead your patient.) Do you have any other symptoms? (Depending on the chief complaint, ask about
related symptoms. For example, if the patient has chest pain, ask if she or he has breathing problems
or nausea.)

S = Severity

Ask: Is the symptom mild, moderate, or severe? Grade it on a scale of 0 to 10, with 0 being no symptom
and 10 being the most severe. (Grading on a scale helps objectify the symptom.)

T = Timing

Ask: When did the symptom start? How often does it occur? How long did it last?

The symptom analysis tables below will help you in assessing your patients with positive symptoms using the
PQRST method.

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Assessing the Integumentary System

SYMPTOM ANALYSIS: CHANGE IN MOLE OR LESION

QUESTIONS TO ASK SIGNIFICANCE


P Do you have a history of skin disorders Helps identify if this is new occurrence or reoccurrence.
or a family history of skin cancer? Positive family history of skin cancer is a risk factor.
Do you have excessive sun exposure? Excessive sun exposure is a risk factor for all types of
Severe sunburns? skin cancers.
Work outdoors? May identify teaching needs.
Use sunscreen? Cancerous lesions do not respond to self-treatment.
Does anything make the mole or lesion May identify teaching needs.
better?
Do you put anything on it?

Q What does the mole or lesion look like? Basal cell carcinoma is often a pink, pearly, translucent, smooth
How big is it? papule with telangiectasis.
Can you show me? Squamous cell carcinoma is often a scaly plaque or ulceration
with an irregular translucent border.
Melanoma depends on type:
Lentigo maligna: Flat, hyperpigmented, variegated, with
irregular border.
Superficial spreading: Irregular border and color, found close
to existing nevi.
Nodular: Papular, arises in nevus; blue, black, or gray nodule
with discrete, sharp borders.
Acral lentiginous: Similar to lentigo maligna but with one or
more dark papules against an uneven, pigmented, speckled
background.
R Where is the mole or lesion? Basal cell carcinoma is usually found on sun-exposed areas
of the face and ears.
Squamous cell carcinoma is usually found on sun-exposed
areas of the face, ears, arms, and hands.
Melanoma depends on type:
Lentigo maligna: Sun-exposed areas, especially face and neck.
Superficial spreading: Men’s backs, women’s legs, trunk of
both sexes.
Nodular: On or within a nevus.
Acral lentiginous: Palms, soles, subungual areas. and
mucous membranes.

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Assessing the Integumentary System

S Is the mole or lesion getting worse, staying Helps determine progression.


the same, or getting better? Basal cell carcinoma grows locally, rarely metastasizes.
Squamous cell carcinoma rarely metastasizes.
Melanoma depends on type:
Lentigo maligna may be present for 5 years before
invading dermis.
Superficial spreading exists 1 to 7 years before nodule
develops and deep penetration occurs.
Nodular: Invasive from onset.
Acral lentinginous: Early diagnosis imperative to prevent
metastasis.
T When did you first notice the change Helps determine onset and progression of disease.
or the lesion?

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Assessing the Integumentary System

SYMPTOM ANALYSIS: NONHEALING SORE OR CHRONIC ULCERATION

QUESTIONS TO ASK SIGNIFICANCE


P Do you have any history of recent injury or Many explain cause of sore.
trauma? Diabetes is associated with poor wound healing.
Do you have any medical problems, such Vascular disease may result in a venous stasis ulcer.
as diabetes or vascular disease, Arterial insufficiency may cause leg ulcers.
malignancy, or immunological disorders? Malignancies and immunological disorders may affect
Did anything make it better? wound healing.
Do you have limited mobility, paralysis, Helpful in determining extent of self-treatment and may
decreased sensation? identify learning needs.
Decreased mobility and sensory loss may
contribute to development of a pressure ulcer.
Q What does it look like? A thorough description of the ulcer is essential
Can you show me? How big is it? to establish a baseline and to stage the ulcer.
R Can you show me where the sore is? Ulcers from arterial insufficiency usually occur on pressure
Does the sore hurt? points and bony prominences or areas vulnerable to minor
Is there any swelling? trauma, such as toes, feet, and heels.
Have you noticed any changes in the Venous stasis ulcers usually develop on the ankle above
color in or around the sore? the medial malleolus.
Have you noticed a change in the Pressure ulcers, as indicated by their name, develop on
skin temperature? pressure points.
Is there any drainage? If yes, does it Ulcers associated with arterial insufficiency are usually painful
have an odor? and have intermittent claudication (pain in leg when walking).
Venous stasis ulcer and pressure ulcer are usually not painful,
but legs may have dull ache or heaviness when dependent
that is relieved when elevated.
Ulcers associated with arterial insufficiency have minimal
to no edema.
Venous stasis ulcers have associated edema.
Ulcers associated with arterial insufficiency often turn black
and necrotic. Affected extremity is often reddish in color when
dependent and pale when elevated.
Extremity with a venous stasis ulcer is usually brown from
release of hemoglobin, which changes to hemosiderin, resulting
in the brown pigmentation, and cyanotic when dependent.
Extremity with an ulcer from arterial insufficiency is cool.
Extremity with a venous stasis ulcer is warm.
Extremity with any type of ulcer with increased warmth may
indicate an infection or cellulitis.
Drainage from a sore or ulcer, especially if associated with
a foul odor, may indicate infection.

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Assessing the Integumentary System

S Does it seem to be getting worse, getting Helps determine progression of ulcer and its impact on
better, or staying the same? patient’s activities of daily living (ADLs).
Has it affected your ability to do what you
usually do?
T When did you first notice the sore? Helps determine an acute vs. a chronic problem.
How long has it been there?

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Assessing the Integumentary System

SYMPTOMS ANALYSIS: PRURITUS

QUESTIONS TO ASK SIGNIFICANCE


P Do you have any allergies to food, drugs, Positive history of allergies could cause allergic dermatitis
or environmental factors? and itching.
Do you have any medical problems? Environmental exposure includes heat, fiberglass, pets,
Are you on any prescribed or over-the-coun- plants, insects.
ter (OTC) medications? Several systemic diseases—such as renal disease, diabe-
Have you been in contact with anyone tes, Graves’ disease, liver disease with obstructive jaundice,
with a similar problem? Hodgkin’s disease, lymphoma, polycythemia vera, human
Are you pregnant? immunodeficiency virus (HIV), and psychiatric disorders—
Does anything make it worse? may cause pruritus.
Medication—especially opiates, amphetamines, quinidine,
aspirin, B vitamins, and niacinamide—may cause itching
as an adverse effect.
Scabies and pediculosis cause itching.
Pruritus may occur during the last trimester of pregnancy.
Anything that causes vasodilation—such as heat, coffee,
spices, alcohol—precipitates itching.
Q Does the itching interfere with what you Pruritus tends to be worse at night and may interfere with
usually do? sleep; however, dermatoses usually don’t interrupt sleep.
Pruritus associated with scabies interrupts sleep patterns.

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Assessing the Integumentary System

R Is the itching generalized or confined to a Generalized itching is more likely systemic in origin
specific area? Eyes: Allergic, viral, bacterial, or fungal conjunctivitis.
If confined to a specific area where? Head: Tinea capitis, pediculosis capitis.
Do you have a rash? Genitals: Vaginitis, tinea cruris, pediculosis pubis.
Do you have a runny nose, tearing of eyes, Chest: Tinea corporis, pediculosis corporis, herpes zoster,
itching of nose and eyes? pityriasis rosea.
Have you noticed any changes in your skin Extremities: Pityriasis rosea, herpes zoster, psoriasis.
color? Ankles, lower legs: Cimex lectularius (bedbugs) or fleas.
Do you have nausea and vomiting, loss of Feet: Tinea pedis.
appetite? The distribution of a rash often helps to identify its source:
Do you have abdominal pain? Generalized rash: More likely systemic in origin.
Is there pain or burning along with the itch- Burrowing-induced skin lesions: Scabies.
ing? Christmas tree pattern on trunk: Pityriasis rosea.
Have you noticed a change in your energy Vesicles in a linear pattern: Herpes.
level? Are you nervous or “hyper?” Or do Transient rash/wheal: Urticaria.
you have decreasedenergy and fatigue? The lesion characteristics also help to identify the source:
Vesicles: Herpes.
Patches: Pityriasis rosea.
Papules: Pediculosis corporis.
Red elevated plaques with silver scales: Psoriasis.
Scales and blisters: Tinea pedis.
Sinus pressure and nasal congestion suggest allergies.
Yellow: Renal disease, liver disease, other systemic problems
associated with itching.
Redness: Infection or inflammatory process.
Pallor: Anemia.
If anorexia, nausea, and/or vomiting, must consider hepatitis or
other form of liver disease.
Right upper quadrant (RUQ) pain is seen in some liver diseas-
es with bile obstruction disorders and with increased bilirubin
levels. The elevated bilirubin causes itching.
Herpes zoster.
If energy is altered, consider thyroid disease or .
diabetes.
Fatigue may also be associated with anemia, malignancy, HIV,
renal or liver disease.

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Assessing the Integumentary System

S How severe is the itching? (Grade it on a Severity may help determine the progression of the problem.
scale of 0 to 10, with 10 being the most se-
vere.) Is it worse, the same, or better?
T When did it start? Determining acute vs. chronic onset may help identify underly-
ing cause. For example, allergies usually have an acute onset;
pruritus associated renal disease or liver disease may be more
insidious.
Is it worse at certain times? Pruritus associated with xerosis (dry skin), common in elderly
people, is worse in the winter months.

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Assessing the Integumentary System

SYMPTOMS ANALYSIS: RASHES

QUESTIONS TO ASK SIGNIFICANCE


P Do you have any allergies to food, drugs, or Allergies can result in urticaria (hives)—temporary, immune-
environmental factors? mediated, well-circumscribed, erythematous wheals.
Do you have any medical problems? Are Rashes may result from systemic problems, such as:
you taking any prescription or OTC medica- Infectious mononucleosis: Maculopapular rash.
tions? Have you used any new soaps or Kaposi’s sarcoma: Purple/blue macules or papules.
detergents? Lupus: Butterfly rash.
Have you had any insect bites? Scarlet fever, rubella, rubeola, viral infections: Red,
pinpoint rashes.
Herpes zoster: Vesicles.
Fungal infections: Tinea capitis, tinea pedis, tinea corporis.
Lyme disease from deer tick may cause bull’s-eye rash.
Q Can you describe the rash? A description of the rash may help determine the type of
lesion. For example:
Pinpoint rash: Infectious mononucleosis.
Raised papular rash: Pityriasis rosea, plaques
of psoriasis.
R Can you show me the rash? Is it generalized Generalized rashes are often systemic in origin.
or localized? Localized rashes are often dermatological in origin, such as
Do you have a fever? contact dermatitis, or related to insect bite.
Have you noticed any lumps (node enlarge- Fever suggests infectious disorder.
ment) in your neck or under your arms? Lymphadenopathy with rash suggests viral syndrome.
Do you have nasal discharge; achy, scratchy Upper respiratory infection (URI) symptoms with rash suggest
or raw throat; frontal or maxillary head pain? an infectious cause.
Do you have any joint pain? Rash with painful joints may indicate Reiter’s syndrome or
lupus erythematosus.
S On a scale of 0 to 10, with 10 being the Helps determine progression of the problem.
worst, how would you rate the rash? Is it
better, the same, or worse?
T When did it start? Was the onset acute or Helps identify underlying cause. For example:
gradual? Acute onset: Allergic dermatitis, contact dermatitis.
Insidious onset: Lupus or a more chronic disorder.
Several skin disorders associated with rashes are seasonal.

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Assessing the Integumentary System

SYMPTOM ANALYSIS: HAIR LOSS

QUESTIONS TO ASK SIGNIFICANCE


P Do you have any medical problems? Thyroid disease, iron deficiency, lupus erythematosus, infec-
Are you on any prescribed or OTC tious diseases with persistent high fevers such as pneumonia,
medications? critical illnesses, and fungal infections such as tinea capitis
Do you have history of trauma or burns? may cause hair loss.
How do you style your hair? Do you use a Many medications may cause alopecia.
curling iron or hot comb; get permanents; Burns or radiation may cause scarring alopecia.
or dye or braid your hair? Hot combs and curling irons can lead to burning and fibrosis.
Are you or have you been recently Permanents/dyes can damage hair. Braids and rollers can lead
pregnant? to traction alopecia.
Transient hair loss can occur during postpartum period.
Are you under a lot of stress? Stress can cause hair loss.
Are you on any special diets? Excessive dieting may result in hair loss.
Do you have a family history of hair loss? Genetic link to male/female-pattern baldness (androgenetic
alopecia).
Do you play with or pull at your hair? Trichotillomania is self-induced hair loss.
Q How much hair have you lost? More than 100 strands/day is abnormal.
R Is the hair loss generalized or localized? Generalized: Medications, thyroid disease.
Do you have any itching or Localized: Tinea capitis, alopecia aerata (patchy alopecia),
rashes? trichotillomania.
Female-pattern baldness more diffuse than male-pattern, with-
out complete baldness.
Fungal infection such as tinea capitis.
S On a scale of 0 to 10, with 10 being the Helps determine impact on patient’s self-image.
worst, how bad is this problem?
T When did it start? How long have you had Determining onset may help determine underlying cause.
it?

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Assessing the Integumentary System

SYMPTOM ANALYSIS: NAIL CHANGES

QUESTIONS TO ASK SIGNIFICANCE


P Do you have any medical problems? Cardiopulmonary problems and Raynaud’s disease may cause
cyanosis of nailbeds. Serious medical problems may affect nail
growth, resulting in Beau’s lines (transverse lines).
Psoriasis can cause nail pitting.
What is your usual nail care? Iron deficiency anemia can cause spoon nails.
Bacterial endocarditis can cause splinter hemorrhages.
Hyperthyroidism causes brittle nails.
False nails increase risk for fungal infections.
Do you smoke? Smoking causes yellow discoloration of nails.
Have you had recent nail trauma? Leukonychia (white spots) often result from trauma.
Q What do your nails feel like? Brittle nails: Hyperthyroid disease, malnutrition, calcium or iron
deficiency.
Transverse ridges (Beau’s lines): Serious illness.
Longitudinal ridges are usually benign.
R Have you noticed any color changes? Blue nails (cyanosis): Cardiopulmonary problem or peripheral-
Are you losing the nail? vascular constriction.
White spots (leukonychia): Trauma.
Green nails: Pseudomonas.
Yellow nails: Fungus infection.
Onycholysis (separation of the nail): Thyrotoxicosis, psoriasis,
eczema, mycosis.
Paronychia (inflammation of perionychium): Fungal infection.
S On a scale of 0 to 10, with 10 being the Helps determine progression.
worst, how bad is the problem?
T When did it start? How long has it been Helps determine onset:
going on? Acute onset: Problem may be local in origin.
Insidious onset: May indicate underlying systemic problem.

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Assessing the Head, Face, and Neck

SYMPTOM ANALYSIS: HEAD PAIN

QUESTIONS TO ASK SIGNIFICANCE


P What were you doing when the pain Helps to identify triggers. For instance, chewing may trigger
started? Have you ever had trauma to your temporomandibular joint (TMJ) discomfort; extensive reading
head? When? Any other injury? or computer work may cause head pain or eye strain. Trauma
Has anything made the pain better? is an important clue to head pain, suggesting the potential for
serious problems associated with intracranial hemorrhage or
fracture.
Factors that relieve the pain may suggest the cause; for ex-
ample, heat and rest may relieve a tension headache.
Q How would you describe the pain? Migraine headaches are generally moderate to severe and
Throbbing? Sharp? On a scale of 0 to 10, have a throbbing or pulsating quality. Tension headaches are
with 10 being the worst, how bad is it? also moderate to severe, but are more steady and viselike and
may feel like a band around the head. Trigeminal neuralgia
causes a very sharp, lancing pain, whereas temporal arteritis
pain is generally more like tenderness, but may be throbbing in
quality. Vascular headaches usually cause throbbing, unilateral
pain that is unrelieved by analgesics. Explosive, very severe
pain may signal an intracranial hemorrhage. Headaches from
brain tumors are often intermittent, deep-seated, and more
intense in the morning.
R Where is the pain? On one or both sides? Pain from migraine, temporal arteritis, and trigeminal neuralgia
In your temples? Circling your head? Over is often unilateral and temporal. Tension headache pain may
your cheeks or above your eyes? Extend- extend in a bandlike pattern from the occiput around the brow
ing up from your neck? Along one side of or may start in the neck and extend upward. Sinus tenderness
your forehead, cheek, and chin (trigeminal is often a sign of sinusitis. Severe pain around the eye may
dermatome)? indicate acute glaucoma. Facial pain radiating up from the neck
may be cardiac in origin. Trigeminal distributed pain may signal
herpes zoster (shingles).

Do you have other symptoms along Migraines often occur with nausea, vomiting, or visual dis-
with the pain? turbances. Nasal discharge and fever occur with sinusitis.
Sensory changes may accompany intracranial hemorrhage or
temporal arteritis, which often causes unilateral vision loss.

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Assessing the Head, Face, and Neck

S How severe is the pain at its worst? At its Migraine is usually quite severe, whereas tension headache
least severe? varies from mild to severe. Headache with meningitis is very
severe. Trigeminal neuralgia pain is also very severe. The
“worst headache ever” may indicate subarachnoid bleeding.
T Was the onset of pain sudden or gradual? Sudden-onset pain may be caused by injury or hemorrhage.
Was the pain an isolated event, or does it Migraines and tension headaches often evolve over minutes
recur? Does anything seem to trigger it? or hours and are recurrent. Trigeminal neuralgia pain often
occurs with eating or smiling, is paroxysmal, and causes recur-
rent episodes of extreme pain. Temporal arteritis pain may be
most evident when the temporal area is palpated.

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Assessing the Head, Face, and Neck

SYMPTOM ANALYSIS: JAW TIGHTNESS AND/OR PAIN

QUESTIONS TO ASK SIGNIFICANCE


P Is there anything that seems to cause the Pain on chewing is suggestive of TMJ. When the jaw hurts with
pain? What were you doing when you first physical exertion and pain eases when exertion stops, explore
noticed it? Have you had any trauma to the potential for referred cardiovascular pain. Jaw pain that
your head or jaw? Does anything lessen or follows a blow to the head or other injury may indicate fracture
relieve the discomfort? or dislocation.
Q How would you describe the pain? TMJ pain may be sharp with chewing or cause an aching
Is it a tightness? sensation. Dental pain often causes a throbbing or severe
A sharp pain? An aching sensation? aching discomfort.
R Where is the pain? Is it along the jawline? Pain along the mandible may be dental in origin.
At the TMJ? Pain and tenderness at the site of the TMJ is commonly TMJ
Does the pain radiate anywhere else? syndrome. Jaw pain that also radiates to the neck or arm can
Have you noticed any other symptoms? indicate cardiovascular disease.
For instance, shortness of breath (SOB), Pain associated with SOB, chest pain, nausea, weakness, or
chest pain, nausea, fever, enlarged lymph other symptoms may signal ischemic heart disease. Pain with
nodes, tooth decay, or jaw cracking fever and/or swollen cervical nodes is likely to be related to
or popping? infection. Decayed teeth may indicate that the pain is referred
dental pain. Associated jaw clicking, popping, or cracking
indicates TMJ syndrome.
S How severe is the problem at its worst? The severity of the pain may be proportional to the acuity of
At its least severe? the problem.

T Is the tightness or discomfort constant? Constant jaw discomfort may be associated with dental pain,
Intermittent? whereas intermittent pain related mostly to chewing action may
How has it progressed since you first be associated with TMJ syndrome.
noticed it?

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Assessing the Head, Face, and Neck

SYMPTOM ANALYSIS: NECK PAIN AND STIFFNESS

QUESTIONS TO ASK SIGNIFICANCE


P Have you had any recent injuries, falls, or Neck pain after a motor vehicle accident may reflect neck
accidents? strain and/or “whiplash” injury. A fall can cause neck strain or
Have you done any recent heavy lifting, fracture. Strain is a common cause of neck pain after unusual
carrying, or sustained physical exertion involving the upper extremities
or other physical activity? or an activity requiring a sustained neck position. Neck pain
What were you doing when you first noticed associated with meningeal irritation is increased with neck
the pain? flexion. Neck pain after an illness or URI may indicate
Does anything provide relief or make it meningeal irritation associated with meningitis.
worse?
Have you recently been acutely ill?
Q How would you describe the pain? A sense of neck tightness is common to fibromyalgia and other
Is it a sense of tightness? myofascial problems, as well as with
Is it sharp or spasmodic? cervical strain and acceleration injuries. Sharp pain with
intermittent spasms may occur in strain syndromes.
R Where, exactly, does your neck hurt? Neurologic, radicular symptoms and/or shoulder and arm pain
Does the pain radiate anywhere else? with neck pain may signal osteoarthritis. Neck pain with
Have you noticed any other symptoms? headache may be caused by tension. Neck pain associated
For instance, headache, fever, photophobia, with tenderness at specific points is seen with myofascial pain
neurologic symptoms, shoulder/arm pain, or fibromyalgia. When other joints also have pain, the cause
neck stiffness, or pain in other joints? may be osteoarthritis or another form of arthritis.
Consider meningeal irritation when neck pain and/or stiffness
is associated with headache, fever, and photophobia. Neck
pain with headache and neurologic symptoms may indicate
cervical strain or acceleration injury, such as that caused by a
motor vehicle accident.
S How severe is the pain at its worst? Very severe pain is associated with meningitis.
At its least severe?
T Was the onset of pain sudden or gradual? Sudden neck pain that is not preceded by injury may indicate
Is this an isolated event or has the symptom meningeal irritation. Pain that is gradual in onset may be
been recurrent? caused by viral illness or overuse strain. Recurrent neck pain
may be caused by
arthritic changes, work strain, or fibromyalgia.

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Assessing the Head, Face, and Neck

SYMPTOM ANALYSIS: NECK MASS

QUESTIONS TO ASK SIGNIFICANCE


P Has anything made the enlarged area seem Generally, thyroid disease or malignancy leads to slowly
larger or smaller? Do you have a family his- progressive enlargements. The patient is unable to identify a
tory of malignancies? Of thyroid disease? particular factor that causes the mass to become dramatically
Do you have a URI? A rash? Any other larger or smaller. With infectious disease, the patient may
illness? notice that the swelling or enlargement occurred relatively
rapidly. A family history of malignancy or thyroid disease
increases the likelihood that the patient might have a similar
disorder.
Q How large is the mass? Is the area of swell- The size of a neck mass is an important consideration but is
ing or enlargement hard, soft, or tender? best assessed during the physical exam. However, it is im-
portant to learn the patient’s perception of the problem. The
texture and mobility of the mass are important. For instance,
a nonmalignant thyroid mass often feels meaty but can have
a nodular surface. Malignancies may present as hard, immo-
bile masses. Lymph nodes enlarged by an infection are often
tender.
R Where is the mass or enlargement? Enlarged lymph nodes along the areas of distribution were
Have you noticed any similar masses discussed earlier. Thyroid enlargements occur in the anterior
anywhere else? and anterolateral lower third of the neck, but can extend with
Have you noticed any other time. Enlarged salivary glands are seen with parotitis.
symptoms recently? Malignancies can occur in any area.
For instance, weight change, altered energy Weight gain can be a sign of hypothyroidism, which may be
level, nervousness, fever, malaise, or URI accompanied by goiter. Weight loss is associated with both
symptoms? hyperthyroidism (with goiter or nodule) and various malignancies.
Increased energy or nervousness may occur with hyperthyroidism.
Fatigue and decreased energy may be found with hypothyroidism
and malignancies. Fever can also accompany malignancies
and thyroiditis. Fever, URI symptoms, and malaise may
accompany various infectious disorders, which may be
reflected through lymphadenopathy (enlarged lymph nodes).
If bleeding gums, low-grade fever, or malaise is present with
enlarged nodes, the cause may be leukemia. Enlarged cervical
nodes, malaise, fluctuating temperature, and sore throat are
common with mononucleosis.
S How big is the mass? Is it getting bigger, A mass increasing in size may correlate with the progression
smaller, or staying the same? of the disease.
T How has the mass changed since you first Neck masses from malignancies, thyroid disease, and infections
noticed it? Has it remained the same or gotten may all increase in size over time. If the cause is infection with
larger? Has it been constant or intermittent? lymphadenopathy, the mass may fluctuate in size.

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Assessing the Head, Face, and Neck

SYMPTOM ANALYSIS: NASAL CONGESTION

QUESTIONS TO ASK SIGNIFICANCE


P Is the congestion worse in certain settings Allergy is a common cause of nasal congestion. Discussing
or situations? For example, when you are these factors helps the patient identify what triggers allergy
outside, around pets, or exposed to any symptoms and learn how to minimize exposures to them. It
particular scents? also tells you what self-treatments the patient has tried, what
Have you recently been around anyone worked and what didn’t, and how well he or she understands
who you suspect was sick? Have you found how to treat and prevent symptoms. Because nasal congestion
anything that relieves the congestion? Any is also associated with URIs, knowing about recent exposures
decongestants? Antihistamines? Antibiotics? to illness is important.
Removing yourself from specific settings?
Have you had similar congestion before?
Q How bad is the congestion at its worst? Do Knowing the extent of congestion will tell you whether it
you sense a complete blockage of the nasal compromises the patient’s ability to move air or sleep at night.
passage?
R When you have nasal congestion, do you A sense of congestion or tightness that also occurs in the
sense swelling, tightness, or congestion throat or mouth may be caused by angioedema or another
anywhere else (e.g., mouth or throat)? severe allergic response that requires immediate treatment.
Have you had any other related symptoms, Nasal discharge is common in disorders with an allergic,
such as nasal discharge; allergy symptoms, bacterial, or viral source. Allergies and viral infections usually
such as sneezing or watery or itching eyes; have clear drainage. Bacterial infections have purulent drainage.
or URI symptoms, such as sore throat, Congestion caused by allergies is often accompanied by
cough, or fever? sneezing; tearing of eyes; itching of eyes, nose, and throat;
and headache. Infectious causes are more likely to be
associated with fever, malaise, and specific URI symptoms,
including sore throat, hoarseness, sinus or ear pain, and cough.
S Is the congestion better at some times than Determines the degree to which symptoms fluctuate, which
others? can indicate exacerbations with exposures.
T Was the onset sudden or gradual? How has Sudden onset of nasal congestion may be associated with
the congestion progressed since you first allergen exposure. Onset over hours or days may have a viral
noticed it? Has it gotten worse or stayed the or bacterial cause, with viral infections generally having quicker
same? Is it constant or intermittent? onset than bacterial ones. When symptoms are intermittent or
recurrent, allergies are often the cause. When congestion is
constant, a possible source could be a tumor in the nasopharynx
or enlarged adenoids.

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Assessing the Head, Face, and Neck

SYMPTOM ANALYSIS: NOSEBLEED

QUESTIONS TO ASK SIGNIFICANCE


P Have you noticed anything that seems to Nosebleed caused by dry mucosa may occur more often in
make the bleeding occur? Have you had any the winter, when air is heated and dry. Children may trigger
trauma or surgery to the face or nose? How nosebleeds by nose picking. Bleeding associated with URI
do you stop the bleeding? Do you have a symptoms may be caused by sinusitis. Trauma to the nose,
personal or family history of bleeding followed by a nosebleed, suggests fracture or soft tissue injury.
disorder or high blood pressure? Many nosebleeds occur suddenly without a known precipitating
event. If the patient has been able to stop the bleeding with
nose pinching or pressure, the bleeding site is probably in the
anterior nose; posterior bleeding is more difficult to control. If
the cause is superficial mucosal irritation, lubricating or coating
the mucosa with ointment may limit or avoid the bleeding.
Uncontrolled hypertension (HTN) can cause nosebleed.
Q How severe has the bleeding been? It is important to know whether the bleeding has been mild or
Describe a typical episode. Is there nasal severe. Deep red, pumping blood from the nose can indicate a
discharge other than blood? Is the bleeding maxillofacial injury with arterial bleeding, whereas blood-tinged
more like blood-tinged nasal mucus or deep nasal discharge is more likely to be found with sinusitis.
red blood?
R Have you noticed bleeding from the ears, Bleeding from the ears, pharynx, or conjunctiva, along with
conjunctiva, pharynx, or another area? nose bleeding, may indicate a skull fracture. If the cause of
Have you had any other symptoms, such as nosebleed is related to a coagulation disorder, aplastic anemia,
URI symptoms, easy bruising, headache, leukemia, or similar disease, the patient may have noticed
eye pressure, facial pain, weakness or bleeding of the gums or bruising of other areas.
fainting, altered level of consciousness, or Bleeding with head pain, eye pressure or displacement, and/or
seizures? facial pain may reflect a nasal or sinus tumor. Symptoms
associated with skull fractures include headache, altered level
of consciousness, and seizures.
S How bad is the bleeding? Sinus infections sometimes cause bloody nasal drainage.
Headache/sinus pain and other symptoms of viral or bacterial
infection may also occur.
Although high blood pressure is generally a “silent” disorder,
it may be associated with an occipital headache and could
account for nasal bleeding. Severe bleeding can cause
hypotension with weakness or syncope.
T Was the bleeding sudden or abrupt in Sudden, abrupt onset is typical of nasal bleeding. Recurrent
onset? Is this the only episode of bleeding, episodes may be associated with self-inflicted trauma to the
or is it recurrent? If recurrent, when was the mucosa or allergies. Bleeding that occurs seasonally may be
first episode? associated with a dry environment.

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Assessing the Head, Face, and Neck

SYMPTOM ANALYSIS: MOUTH LESIONS

QUESTIONS TO ASK SIGNIFICANCE


P Have you had any recent trauma or injury Trauma can cause breaks in the oral mucosa. Several
to the mouth area? Have you recently taken medications, including chemotherapeutic agents, cause
any medications or been ill? Do you have a stomatitis as a side effect or allergic reaction. Several illnesses,
history of tobacco or alcohol use? Have you including syphilis, herpes, and candidiasis, can cause mouth
tried any self-treatment for the sore? Have sores. Tobacco use (smoking or chewing) and excessive use
you found anything that has made the sore of alcohol are both associated with oral malignancies. It is
better? What do you think caused the sore? important to know what self-treatments the patient has tried
because she or he might be applying agents or taking
medications that are confounding the problem.
Q How would you describe the sore? The characteristics of the lesion can give clues to its cause.
Has it gotten smaller or larger? Single or multiple vesicles may be related to herpes. A white
lesion that resists being scraped off may represent leukoplakia,
lichen planus, or early squamous cell lesion. Ulcerations can
indicate various types of stomatitis, aphthous sores, or oral
syphilis.
R Where, exactly, is the sore? Have you Traumatic sores are most likely to appear on the tongue and
noticed similar sores in other areas? buccal mucosa; squamous cell lesions most often appear on
Does the sore hurt? Have you noticed any the lower lip. However, most causes of mouth lesions can result
other associated symptoms? Have you had in mucosal changes on the lips, buccal mucosa, tongue,
a rash elsewhere? A fever? Swollen nodes? palates, gingiva, and other tissues. If the cause is herpes
simplex, there may be other lesions on the face. If the lesion
represents secondary syphilis, lupus, or erythema multiforme,
a rash may appear on other parts of the body.
If the lesion is associated with an infectious cause, there may
be a history of fever, malaise, swollen nodes, sore throat, or
other symptoms.
S Has the sore caused any specific distress? Determine the severity of discomfort associated with a mouth
Does it make it hard to eat or talk? lesion, because it can affect hydration, nutrition, and
Is it painful? communication. The most common types of mouth lesions
are painful. Painful lesions may indicate herpes simplex,
aphthous ulcers, or primary syphilis. Candidiasis is associated
with pain. When oral lesions are painless, they may be caused
by secondary syphilis, leukoplakia, (a precancerous lesion),
or a malignancy.

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Assessing the Head, Face, and Neck

T Has the sore progressed at all since you Most lesions—including those associated with various types
first noticed it? Did it gradually reach its of stomatitis, herpes, syphilis, or trauma—tend to develop and
current size and state, or did it form heal rather abruptly.
abruptly? Is this the first sore you’ve had, However, there may be some early symptoms, such as a
or have they been recurrent? prodromal period of discomfort or progression from nodular
area to vesicles and ulcers that might be present with herpes
simplex or herpes zoster. Recurrent episodes could be related
to herpes simplex, allergies to foods or medications, or trauma,
such as might occur with tongue biting. Persistent nonhealing
lesions are often associated with malignancy.

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Assessing the Head, Face, and Neck

SYMPTOMS ANALYSIS: MOUTH AND DENTAL PAIN

QUESTIONS TO ASK SIGNIFICANCE


P Have you recently had dental treatment? Tooth pain can be a sign of dental disease, gingival disease,
Have you had trauma to your mouth or or even cardiovascular disease. Trauma can cause tooth
teeth? Have you recently taken medications dislocations or soft tissue damage that causes pain. Eating
or been ill? Does anything seem to make the or drinking something extremely hot can burn the oral mucosa,
pain better? Worse? Does the pain occur in causing pain. Mouth or tooth pain triggered by physical
certain situations more than in others? For exertion and then relieved with rest suggests a
example, have you noticed any relationship cardiovascular origin.
between the pain and exercise? Do you
have a personal or family history of cancer
or heart disease?
Q Has the pain caused you to limit activities? The type of pain may provide clues about the source. Dental
Which ones? Can you describe the pain? Is pain is aching or throbbing, whereas gingival pain is sharper.
it sharp? Throbbing? Aching?
R Can you show me exactly where it hurts? Pain along a dermatome may indicate the prodromal neuralgia
Have you had pain in other areas? Where? of herpes zoster. Pain in a specific tooth suggests a dental
Have you noticed any other symptoms? source. Pain poorly localized to the teeth and associated with
SOB, chest tightness or pain, swelling or pain in the neck, arm, or chest should increase suspicion of
sores in your mouth, decaying teeth? Have cardiovascular cause.
you had nasal congestion, nasal discharge, Associated mouth lesions or swelling suggests parotitis or
or other sinus symptoms? herpes. Dental caries associated with mouth pain indicates a
dental abscess. Tooth pain associated with other symptoms
of angina suggests ischemia. Pain in the maxillary teeth can
be a sign of sinusitis.
S On a scale of 0 to 10, how bad is the pain at Limitations in eating, chewing, or exercise give information
its worst? At its least severe? about the severity of the pain and its impact on the patient.
Be aware that ischemic cardiac pain can be referred and
perceived as tooth pain.
T When, exactly, did the pain start? Has it Ischemic pain is intermittent, whereas pain following a
progressed or changed since you first noticed mucosal burn or dental abscess is constant.
it? Does it come and go, or is it constant?

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Assessing the Head, Face, and Neck

SYMPTOM ANALYSIS: SORE THROAT

QUESTIONS TO ASK SIGNIFICANCE


P Does anything make the pain worse? Pain from a foreign body lodged in the throat is most severe
What have you done to relieve it? Did it during swallowing. Many conditions that cause sore throat—
help? Have you recently been ill? Have including tonsillitis, inflammatory pharyngitis, and even referred
you been exposed to anyone who had a pain from the ear—result in pain that is worse while swallowing,
sore throat or was ill? Have you ever had Recent illnesses or exposure suggests sources of infectious
a sexually transmitted disease (STD)? sore throat. Gonorrhea and chlamydia can both cause severe
pharyngitis.
Q Has the pain interfered with your ability Determine whether the pain causes dysphagia. A patient who
to swallow or speak? What does the pain has an infectious sore throat and who has trouble swallow-
feel like? ing can easily become dehydrated. The type of pain helps to
identify the source. Thyroid enlargement or tumor may cause a
sense of difficulty swallowing rather than frank pain. A scratchy
or itchy throat may be caused by an allergic disorder and/or
postnasal drainage.
R Can you show me where the pain is? Is it Laryngeal and pharyngeal malignancy pain may radiate to the
generalized or is it limited to a specific area, ears. Generalized pain is common with tonsillitis, strep throat,
like the back of the throat? Does it radiate and epiglottitis. Postnasal drainage tends to cause pain in
to the ear region? the posterior pharyngeal wall. Pain from otitis media can be
Are you having other URI symptoms, such referred to the throat.
as cough, congestion, drainage, malaise, Most bacterial and viral forms of pharyngitis occur along with
or fever? Have you had allergy symptoms malaise, nasal congestion or drainage, fever, and/or swollen
such as itching nose and eyes, clear nodes. An exception is streptococcal pharyngitis, which rarely
drainage, or sneezing? Is it hard to swallow involves cough or nasal symptoms. Throat discomfort caused
or speak? Have you been drooling? by an allergy often presents with other symptoms of allergy.
Severe throat pain associated with dysphagia, difficulty with
speech, and drooling may indicate epiglottitis or severe
tonsillitis/peritonsillar abscess. Epiglottitis is a medical
emergency.
S On a scale of 0 to 10, how would you rate Identifies how the patient perceives the pain’s severity. Both
the pain at its worst? At its least severe? bacterial and viral infections can cause severe sore throat. Viral
and most bacterial causes of pharyngitis are usually accompanied
by mild to moderate pain, whereas mononucleosis, streptococcal
pharyngitis, epiglottitis, and tonsillitis pain is typically very
severe.
T When, exactly, did the sore throat start? Sore throats that recur frequently may be associated with
Was the onset sudden or gradual? Has it allergies but may also indicate chronic tonsillitis. Chronic throat
been intermittent, recurrent, or constant? pain is associated with chronic tonsillitis.
Most infectious forms of pharyngitis have a sudden onset.

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Assessing the Head, Face, and Neck

SYMPTOM ANALYSIS: HOARSENESS

QUESTIONS TO ASK SIGNIFICANCE


P Does anything make the hoarseness better Overusing the voice may lead to hoarseness that improves
or worse? Have you recently had trauma, with significant voice rest. Trauma to the throat area and
surgery, or other procedures to your throat? procedures and surgeries that involve endotracheal tubes can
Have you been ill or exposed to others who damage the larynx and result in loss of the voice. Hoarseness
were ill? Do you smoke or drink alcohol is also commonly caused by a wide spectrum of bacterial and
regularly? Do you have a personal or family viral illnesses. Other causes include a tumor in the throat, on
history of cancer or throat disease? the larynx, or in a bronchus, which makes the patient’s smoking
and alcohol intake history important.
Q How would you describe the typical “Hoarseness” can mean different things to different people, so
hoarseness? Do you lose your voice or determine whether your patient is talking about alterations in
does it just sound different? Does your pitch or loudness. A raspy voice can stem from polyps on the
voice get raspy? vocal cords, whereas general voice weakness may indicate
unilateral vocal cord paralysis from trauma, a tumor, or a
neuromuscular disease. A sudden complete loss of voice is
common with acute laryngitis.
R Have you noticed any other symptoms, Hoarseness can be associated with laryngeal irritation from
such as heartburn or belching? Have you gastroesophageal reflux, acute infections, and allergies.
had a scratchy or sore throat, postnasal Chronic hoarseness, along with dyspnea or dysphagia, can
drainage, cough, sneezing, fever, difficulty indicate laryngeal cancer, as well as some autoimmune
swallowing, or sensation of a foreign body diseases such as rheumatoid arthritis (RA) or Sjögren’s
in your throat? syndrome.
S How severe is the hoarseness at its worst? Determine the severity of the voice change and its impact on
Does it improve from time to time? Has it communication. Some patients are embarrassed by real or
affected your ability to communicate? perceived voice changes and avoid speaking.
Has it affected any of your usual activities?
T When did you first become aware of the Determine the length of time the hoarseness has existed.
hoarseness? Has it changed since you first Chronic hoarseness suggests a tumor, vocal cord paralysis,
noticed it? How? Does it come and go, or polyps, or autoimmune causes, whereas intermittent
is it persistent? hoarseness might be found with allergies or other causes
of postnasal drainage. Acute infectious diseases generally
cause hoarseness of sudden onset.

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Assessing the Eye and the Ear

SYMPTOM ANALYSIS: VISION LOSS

QUESTIONS TO ASK SIGNIFICANCE


P What precipitated the decrease or loss of Severe blows can dislodge the lens or lead to retinal
vision? Do you have a history of trauma to detachment.
the eye or bony orbit?
Q Was your loss of vision painless or painful? Painless: Retinal detachment, diabetic retinopathy, occlusion
of retinal blood vessel, primary open-angle glaucoma (POAG).
Painful: Primary angle-closure glaucoma (PACG).
R Did you experience nausea or vomiting with These symptoms are associated with PACG.
your vision loss?
S How severe is your vision loss on a scale of Partial vision loss: Able to see size, shape, and position of
0 to 10? Are you able to see the size, shape, objects but with less precision than normal.
or position of objects? Can you distinguish More severe vision loss: Able only to distinguish light from
light from dark? dark.
T When did you first notice the vision loss? Sudden loss: Retinal detachment, occlusion of retinal vessel,
Was it sudden or gradual? PACG.
Gradual loss: POAG, retinitis pigmentosa, diabetic retinopathy.

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Assessing the Eye and the Ear

SYMPTOM ANALYSIS: EYE PAIN

QUESTIONS TO ASK SIGNIFICANCE


P Does anything make the eye pain better? Pain with light exposure is often caused by inflammation of the
Worse? For example, is the pain iris or choroid layer.
associated with exposure to light?
Have you had recent trauma or irritation to Caused by foreign body or corneal abrasion.
your eyes?
Is the eye pain associated with eye Often caused by optic neuritis of inflammatory origin.
movement?
Is the pain associated with blinking? Common in conjunctivitis, foreign body, or corneal abrasion.
Q How would you describe your eye pain? Sandy/gritty: Conjunctivitis or conditions such Sjögren’s
Sandy or gritty? A burning sensation or syndrome in which the eyes are dry.
headache? Burning sensation/headache: Refractory error, such as
nearsightedness or farsightedness, or eyestrain.
R Do you have drainage from Drainage is associated with conjunctivitis. Nausea/vomiting
your eyes? Nausea or vomiting? may be associated with glaucoma.
S On a scale of 0 to 10, how severe is your Pain with corneal abrasion or glaucoma, severe pain with
eye pain? closed-angle glaucoma.
T How long have you had eye pain? Is it Provides baseline assessment data for evaluating future
constant or does it come and go? changes.

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Assessing the Eye and the Ear

SYMPTOM ANALYSIS: DIPLOPIA

QUESTIONS TO ASK SIGNIFICANCE


P Does your double vision worsen with fatigue May indicate eye muscle weakness, systemic diseases
or improve after resting? Does anything (e.g., thyroid abnormalities or diabetes), neurologic diseases
make it better or worse? (e.g., myasthenia gravis [MG] or multiple sclerosis [MS]),
aneurysm, tumor, or head injury.
Q Can you describe your vision, Accurately identifies patient’s perception of vision problem.
what you see?
R Is your double vision associated with Headache: Head injury or brain tumor.
a headache? Weakness or tremor: MS.
With weakness or tremor in your arms
or legs?
S What activities does your double vision Increased severity of double vision may prevent safe participa-
prevent you from doing? tion in ADLs or engaging in school, work, or social activities.
Is the severity of the double vision staying Gradual worsening may occur in strabismus.
the same, improving, or getting worse?
T How long have you had double vision? Did it Duration, onset, and constancy of symptoms influence the
start suddenly or gradually? Is it constant, or person’s ability to adjust to changes. Fear may be increased
does it come and go? If it comes and goes, by sudden onset or long duration of worsening symptoms.
how long does it last?

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Assessing the Eye and the Ear

SYMPTOM ANALYSIS: TEARING

QUESTIONS TO ASK SIGNIFICANCE


P Did you injure your eyes? Have you been Associated with allergies, viral infections, ectropion, foreign
exposed to any substances that can irritate body, corneal abrasion, exposure to chemical irritants, or
them, such as chemicals or pollen? obstruction of the nasolacrimal duct.
Q Is the tearing painless or painful? Painless: Often associated with exposure to environmental
allergens.
Painful: Associated with foreign body, chemicals, corneal
abrasion, or infection.
R Is the tearing associated with headache? Unilateral headache pain with unilateral eye tearing often
Is the tearing associated with a cough, sore indicates cluster headache pattern.
throat, or nasal congestion? Associated with URI.
S How severe would you rate the tearing Greater severity score affects ability to read, watch TV,
on a scale of 0 to 10? or pursue other activities.
T How long has the tearing been a problem? Duration relates to the cause. For example, corneal abrasion
Is it constant or intermittent? has acute onset and limited duration, and allergies continue
during exposure to allergens.

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Assessing the Eye and the Ear

SYMPTOM ANALYSIS: DRY EYES

QUESTIONS TO ASK SIGNIFICANCE


P Do you have a history of trauma to the Trauma to eye surfaces, obstructed lacrimal gland, medications,
surface of your eyes? Corneal abrasion? Sjögren’s syndrome, or wearing contact lenses may result in
Burns? Do you wear contact lenses? decreased moisture.
Is the dryness worse when you do not get Sleep provides time for restoring eye lubrication. Atropine
enough sleep or with the use of certain dries secretions, including those of the eyes.
medications?
Q How do your eyes feel when you blink? This description confirms dryness of eyes.
Gritty or sticky?
R Can you show me how you do these things: Asymmetry of movements indicates involvement of cranial
Raise your eyebrows, frown, and smile? nerves, possibly as a result of Bell’s palsy, trigeminal
Is your mouth dry? neuralgia, or stroke.
Medication effect or possible Sjögren’s syndrome.

S How severe is the sensation on a scale Provides a baseline assessment for evaluating improvement
of 0 to 10? or worsening of condition.
T How long have you had the dryness in your Constant dryness is more common with advanced age or
eyes? Is it constant or does it come and go? systemic disease, such as Sjögren’s syndrome or disease
of the lacrimal gland.

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Assessing the Eye and the Ear

SYMPTOM ANALYSIS: EYE DRAINAGE

QUESTIONS TO ASK SIGNIFICANCE


P Have you recently been exposed to anyone Possible source of infection.
with pink eye (conjunctivitis)? Differentiates possible cause of drainage.
Any recent eye trauma or irritation of the
surface of the eyes?
Q What does the drainage look like? Drainage that is thick, cream colored, not translucent, and
located around eyelid margins and along conjunctiva is
associated with bacterial infections or conjunctivitis. Clear or
whitish, mucoid, thin drainage is associated with allergic or
viral conjunctivitis.
R Do you have a fever? May indicate bacterial or viral conjunctivitis.
Is there any swelling or redness of the orbit? May indicate orbital cellulitis.
S N/A N/A
T How long has the drainage been a Provides baseline data for evaluating change.
problem?

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Assessing the Eye and the Ear

SYMPTOM ANALYSIS: EYE APPEARANCE CHANGES

QUESTIONS TO ASK SIGNIFICANCE


P Have you had a recent eye infection? Can indicate source of problem.
Q How has the appearance of your eyes Iris cloudy or red with visible blood vessels: Iritis.
changed? Cornea cloudy: Vitamin A deficiency or corneal ulcer.
Increase in gold color pigment: Defect in copper metabolism
seen in Wilson’s disease.
White ring at outer edges of the cornea: Normal effect of
aging called arcus senilis. In people under age 40, indicates
hyperlipidemia.
Unequal pupils: Normal finding (anisocoria) or can indicate
increased intracranial pressure (ICP) in the presence of severe
head trauma or stroke.
Blue sclera: Normal variant in newborns. May indicate
osteogenesis imperfecta, a genetic condition manifesting in
fragile and easily fractured bones.
Grayish blue sclera or brown spots (“muddy sclera”): Common
in dark-skinned people.
Yellow sclera: Elevated bilirubin levels. Seen in hepatitis,
gallbladder disease, and physiological jaundice of the
newborn.
R Do you have eye pain? Associated with eye trauma. Results in collection of blood in
the anterior chamber, which appears as a fluid line in the iris.
Pain may also indicate closed-angle glaucoma.
S N/A N/A
T How long have you noticed the change in Helps to differentiate an acute vs. a chronic problem.
the appearance of your eyes?

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Assessing the Eye and the Ear

SYMPTOM ANALYSIS: BLURRED VISION

QUESTIONS TO ASK SIGNIFICANCE


P Does the blurred vision worsen with eye Can occur with overuse of eyes from doing detailed work for
fatigue and improve with rest? long periods of time.
Do you wear corrective lenses?
Q Has your distance vision decreased? Decreased distance vision: Uncorrected refractory error.
Your near vision? Decreased near vision: Commonly associated with aging
When was your last eye exam? (called presbyopia, hyperopia, or farsightedness).
Are all images hazy? “Cloudy cornea,” which sometimes occurs in glaucoma, or
Do objects appear wavy or cloudy lens caused by cataract.
Irregular? Astigmatism (irregularly shaped cornea) prevents light rays
from being focused on a single point on the retina.
R Do you have muscle weakness or tremor? MS or MG.
Lack of sensation in the skin?
S What activities does your blurred vision Indicates actual or potential problems in performing ADLs or
prevent you from doing or make it difficult taking part in school, occupational, or social activities.
for you to do?
T How long have you had blurred vision? Is it Can help determine the underlying cause.
constant or intermittent?

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Assessing the Eye and the Ear

SYMPTOM ANALYSIS: HEARING LOSS

QUESTIONS TO ASK SIGNIFICANCE


P Have you had an ear infection or head Rupture of the tympanic membrane during an acute infection
injury recently? Are you or have you ever or as a result of trauma prevents hearing by air conduction.
been exposed to continuous loud noise? Damage to the vestibulocochlear nerve or the temporal area
Have you ever taken the antibiotics of the brain may cause to sudden hearing loss. Excessive
gentamycin or streptomycin? exposure to loud noise can cause damage to hearing
Does anything improve your hearing? structures. Some antibiotics can cause permanent hearing
loss. Provides information about self-care and treatment
effectiveness.
Q Are certain sounds more difficult to hear? Common in persons with age-related hearing loss
For example, high-pitched sounds or (presbycusis).
conversations when other people are Occurs in otitis media and serous otitis or after exposure to
speaking in the background? loud noises.
Are sounds muffled or distant?
R Is your hearing loss associated with Occurs with ear infections such as otitis media.
ear pain? Ear infection with rupture of the tympanic membrane.
Is it associated with sudden relief of Symptoms of URI often occur with ear infections.
ear pain?
Have you recently had a cough, sore
throat, fever, or nasal congestion?
S Is your hearing loss in one or both ears? Inability to hear can negatively affect self-esteem,
How has your hearing loss affected your self-confidence, and social interaction.
ability to function at school or work?
T How long have you noticed your hearing Sudden hearing loss occurs in ear infections and ruptured
loss? Did it occur suddenly or gradually? tympanic membrane. Gradual loss occurs with aging,
ototoxicity, and cerumen accumulation.

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Assessing the Eye and the Ear

SYMPTOM ANALYSIS: VERTIGO

QUESTIONS TO ASK SIGNIFICANCE


P Does the dizziness get worse if you get up May occur with postural hypotension.
from a lying position? Associated with multiple diseases, including Ménière’s disease
Does it get worse when you lift your head? and acoustic neuroma as well as vestibulotoxic drugs.
Have you recently had treatment with High doses, prolonged treatment with or rapid infusion of
intravenous antibiotics, diuretics, or high ototoxic drugs may produce vertigo.
doses of aspirin or nonsteroidal
anti-inflammatory drugs (NSAIDs)?
Q Do you feel as though your body is Referred to as subjective vertigo.
spinning or swaying? Referred to as objective vertigo.
Do you feel as though stationary objects
are moving?
R Do you have other symptoms, such as nau- Nausea, vomiting, and low-buzz tinnitus in one ear associated
sea, vomiting, or ringing in your ears? with Ménière’s disease.
S What activities does your dizziness Provides baseline data for future comparison of progress.
prevent you from doing or make it difficult Supports nursing diagnoses Injury, risk for and Home
for you to do? Maintenance, impaired.
T How long have you been feeling dizzy? Duration and predictability influence patient’s ability to cope
Is it constant, or does it come and go? with condition. Unpredictable occurrences increase the risk
of injury.

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Assessing the Eye and the Ear

SYMPTOM ANALYSIS: TINNITUS

QUESTIONS TO ASK SIGNIFICANCE


P What makes the ringing in the ears better? Provides information about self-care and self-treatment
Worse? measures that have or have not been effective.
Have you been treated with aspirin or Possible cause of tinnitus in high doses.
quinine recently?
Q How would you describe the sound? Provides a baseline description for future comparison.
Does it pulsate?
R Have you ever had nausea, vomiting, May occur with Ménière’s disease.
or profuse sweating along with ringing
in the ears?
S Does ringing in the ears interfere with your Provides baseline data useful for evaluating improvement.
ability to go to school or work?
T How long have you had tinnitus? Is it Intermittent: Associated with prolonged, high-dosage therapy
intermittent or continuous? with salicylates, NSAIDS, aminoglycosides, or antineoplastic
agents. May also be a normal occurrence.
Continuous: Damage to inner ear structures associated
with the drugs listed above.

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Assessing the Eye and the Ear

SYMPTOM ANALYSIS: OTORRHEA

QUESTIONS TO ASK SIGNIFICANCE


P Have you had a recent head or ear injury? Determines likely cause of drainage and directs nurse to
Ear infection? Throat infection? explore for other injuries or URI symptoms.
Q Is the drainage thick? Does it have an odor? Acute or chronic middle ear infection, ruptured otitis media,
Is the drainage watery, clear, thin, and or severe otitis externa.
transparent? Cerebrospinal fluid leaking through basilar skull fracture.
Is the drainage red to dark red and thicker Associated with bleeding caused by head or ear trauma or
than water? carcinoma.
R Do you have any hearing loss or symptoms Hearing loss in affected ear with symptoms of URI suggests
of a URI? ear infection.
S Is the drainage continuous? Provides baseline data for evaluating changes in condition.
T How long have you noticed the drainage? Provides baseline data for evaluating changes in condition.

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Assessing the Eye and the Ear

SYMPTOM ANALYSIS: OTALGIA

QUESTIONS TO ASK SIGNIFICANCE


P What makes your earache better? Worse? Provides baseline data for evaluating changes in condition
Have you had a recent URI or head or ear and information about the effectiveness of self-care
injury? treatments. Differentiates possible causes of the earache.
Q How would you describe the pain? Provides a baseline for evaluating further changes.
Dull? Sharp?
Throbbing?
R Are you having dizziness or difficulty with Related to Ménière’s disease, ear infections, or severe
balance? Do you have a cough? head injury.
Sore throat? Fever?
Do you have ear drainage? If so, what color
is it, and does it have an odor?
Do you have hearing loss?
S On a scale of 0 to 10, how intense is your Provides baseline data for evaluating improvement.
ear pain? Provides a baseline assessment for evaluating future
How long have you had the ear pain? Is it change in condition.
constant, or does it come and go?
T Did the pain occur suddenly? Sudden onset, usually unilateral, associated with diminished
hearing and infection: Acute or chronic middle ear infection
(otitis media) or severe otitis externa.
Sudden onset, usually unilateral, not associated with hearing
loss or infection: Referred pain from teeth, throat, or
cervical spine.

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Assessing the Respiratory System

SYMPTOM ANALYSIS: COUGH

QUESTIONS TO ASK SIGNIFICANCE


P Do you smoke? If so, how much and for Smoking, exposure to other inhaled chemical irritants, or
how long? allergies may contribute to or cause cough.
Are you exposed to chemical irritants? Do Cough may indicate a cardiopulmonary complication
you have allergies? associated with recent health problem.
Have you had a recent illness, surgery, or Determines self-treatment and its effects.
trauma? Nocturnal cough: Often associated with angiotensin-converting
Does anything make the cough worse or enzyme (ACE) inhibitors.
better—for example, medication or changing Cough that worsens with supine position: Gastroesophageal
position? reflux disease (GERD) related to nocturnal aspiration,
postnasal drip, bronchiectasis, bronchitis, and heart failure.
Q What does the cough sound like? Whooping, dry: Pertussis.
Barking, honking: Croup.
Wheezing: Narrowed or reactive airways from asthma or
obstruction.
Moist, congested: Bronchitis, pneumonia, asthma.
Dry, hacking: Asthma, cardiac problems, nervous cough.

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Assessing the Respiratory System

R Do you have mucus with your cough? If so, Small amount, thin, clear-to-white, odorless, tasteless: Normally
what is the mucus like? present to maintain patent airway and remove debris.
What color is it? Increased amount, thin, clear, or white: Postnasal drip, allergy,
What does it smell/taste like? sinus
What other symptoms do you have? inflammation, viral cold or flu, bronchitis/asthma without infection
(emphysema does not have sputum).
Thick, tenacious: Usually related to dehydration or inadequate
fluid intake. If difficult to expectorate, may develop mucus plugs.
Gray or tan: Smoking, bronchitis.
Yellow or green: Bacterial infection, Pseudomonas: Infection with
emphysema or chronic bronchitis. With asthma, mucus may be
from increased eosinophils rather than infection.
Apple green, thick: Haemophilus influenzae, pneumonia.
Rust colored: Pneumococcal pneumonia, pulmonary infarction,
tuberculosis (TB), lung cancer.
Pink, either thin, streaked, or frothy/bubbly: Streptococcal or
staphylococcal pneumonia, pulmonary edema.
“Red currant jelly” appearance: Klebsiella pneumoniae.
Blood-streaked mucus or frank bleeding (hemoptysis): Violent
coughing, TB, pneumonia, lung cancer, lung abscess with infarc-
tion, pulmonary emboli, bronchiectasis, coagulation disorders,
sarcoidosis.
HELPFUL HINT
If patient reports hemoptysis, determine if source of bleeding
is from lungs or stomach. Hematemesis (bloody emesis from
stomach) is usually dark red or coffee ground colored if blood is
partially digested. Blood tests positive for acid in a litmus test.
Bright red, thick blood is usually from ruptured esophageal vari-
ces (dilated esophageal blood vessels). Hemoptysis (coughed-
up blood) is usually light to bright red, thin, and possibly mixed
with mucus.
ALERT
Persistent hemoptysis in a middle-aged smoker usually indicates
bronchial carcinoma.
Foul odor or taste: Bacterial infection, especially anaerobic
bacteria. “Tickle” in throat: Cough localized above or below larynx.
Sneezing, nasal blockage: Rhinitis. Hoarseness: Laryngitis.
Ineffective cough, hoarse voice: Recurrent laryngeal nerve palsy.
Dry, painful cough: Tracheiti
S Is the cough getting worse? Persistent cough for more than 3 weeks is considered chronic
and warrants investigation.

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Assessing the Respiratory System

T How long have you had the cough? More than 3 weeks: Often associated with smoking.
When does it occur? Upon arising: Bronchitis or cigarette smoking.
Late afternoon: Allergies or occupational exposure to irritants.
After eating: GERD.
Evening or after going to bed: Postnasal drip, sinusitis, GERD
with nocturnal aspiration.
During the night: Asthma, pulmonary edema.
After exercise: Asthma.
No specific time: COPD, lung cancer, pneumonia, TB.

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Assessing the Respiratory System

SYMPTOM ANALYSIS: DYSPNEA

DESCRIPTION SIGNIFICANCE
P What precipitates the SOB? Dyspnea on exertion (DOE) with little or no SOB at rest: Physi-
Activity or exercise? cal decompensation (being out of shape), inadequate ventila-
What makes it better? tion and perfusion, inefficient breathing mechanism, slowly
Sitting upright? Sleeping propped on pil- progressive lung disorders in early stages.
lows? Resting? Paroxysmal nocturnal dyspnea (awakening at night with SOB):
Pulmonary edema secondary to cardiac disorders/failure or
advanced chronic lung disease (cor pulmonale).
Orthopnea (must be in upright position to breathe comfortably):
Pulmonary edema, asthma, pulmonary HTN.
Nonrespiratory causes: Obesity, high spinal cord injury, pain.
Q How would you describe your breathing Helps determine degree of functional disability.
problem? (Often described as SOB, inabil- “Tight chest”: Associated with pain, as with angina or pleurisy.
ity to “catch breath,” feeling short-winded, Dyspnea is the result of pain, as with angina or pleurisy.
“tight chest,” inability to do housework.)
Does it keep you from performing your
usual activities?
R Aside from the SOB, do you have any other Chest pain: Angina, myocardial infarction (MI), pulmonary
symptoms? embolus.
Dyspnea with deep inspiration: Associated with pleuritic pain or
abdominal surgery.
S On a scale of 1 to 4, how would you rate If patient with COPD is compensating, dyspnea may be mild
your shortness of breath (1 = mildly dis- (1–2). If patient has decompensated, with decreased PaO2 or
abling; 4 = very disabling)? increased PaCO2 levels, dyspnea will be disabling (3–4).
Can also assess severity by functional
measure.
T When did the SOB start? Onset/duration:
How long does it last? Immediate (minutes): Pulmonary edema, pulmonary emboli,
pneumothorax, or acute asthma.
Short (hours to days): Pulmonary edema, pneumonia, asthma,
pleural effusion, anemia.
Long (weeks to years): Chronic lung disease, restrictive lung
disease, anemia, chronic congestive heart failure (CHF).
When duration is prolonged, gradual changes in functional
ability often occur.
Note if accompanied by pain, anxiety/panic, or change in level
of consciousness. Changes in level of consciousness may
indicate hypoxia.

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Assessing the Respiratory System

SYMPTOM ANALYSIS: CHEST PAIN

DESCRIPTION SIGNIFICANCE
P Have you had recent respiratory prob- Pneumonia, pulmonary infarction from pulmonary emboli, and
lem? pneumothorax can cause pleuritic pain.
Is the pain worse with deep breathing Pleuritic pain intensifies with breathing, coughing, muscle strain,
and coughing? With movement? or rib fractures.
ALERT
Pleuritic pain that subsides does not
necessarily indicate an improvement, but
may indicate that an effusion has devel-
oped.
Q What does the pain feel like? Aching: Muscle tenderness, possibly cardiac in origin.
HELPFUL HINT
When distinguishing chest pain of respiratory origin from cardiac
pain, be sure to rule out cardiac pain first. (See Chapter 12 for
more information.)
Sharp, stabbing: Spontaneous pneumothorax, pulmonary infarc-
tion, pleurisy, especially with deep breath.
Dull: Lung cancer, from pressure on mediastinal structures.
Localized chest-wall tenderness: Infection; inflammation of chest
wall, intercostal nerves or muscles; fractured ribs.
Referred pain: Possible cardiac or abdominal causes, depending
on pattern of referral.
R Can you point to where it hurts? Localized: Pleural pain, fractured ribs, muscle strain.
Poorly localized: Lung cancer.
S How severe is the pain on a scale of 0 to Severity associated with breathing: Pleuritic pain.
10, with 0 being no pain and 10 being the Severity associated with movement: Musculoskeletal pain.
worst possible pain? Severe, constant pain unrelated to breathing and interfering with
sleep: Malignant disease involving chest wall.
T When does the pain occur? Pain associated with breathing: Pleuritic pain.
Pain with movement: Musculoskeletal pain.
Continual pain: Malignancy of chest wall.

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Assessing the Cardiovascular System

SYMPTOM ANALYSIS: CHEST PAIN

QUESTIONS TO ASK SIGNIFICANCE


P What were you doing before the pain Angina, MI.
started? Does anything make it worse, such Dissecting aortic aneurysm.
as emotional stress, extreme temperatures, Coughing, deep breathing? Postmyocardial syndrome, pericar-
big meals, physical exertion, or sexual ditis, pulmonary emboli, pneumothorax, rib fracture.
intercourse? Esophageal reflux, esophageal rupture.
Heavy lifting?
Coughing, deep breathing
Using alcohol, caffeine, aspirin?
Drinking cold liquids, exercising, Esophageal spasm.
swallowing? Pulmonary HTN.
Do you have a history of anemia, hypox-
emia, or carbon monoxide poisoning? Do
you live at a high altitude?
Does anything make the pain better, Angina.
such as: Pericarditis, pulmonary emboli.
Rest or nitroglycerine (NTG)? Gastrointestinal (GI) disorders such as hiatal
Sitting up or leaning forward? hernia or peptic ulcer.
Diet, antacids, and NTG? Musculoskeletal problems.
Rest and limited movement? Hyperventilation (anxiety).
Controlled breathing?
Q What does the pain feel like? MI, angina, GI disorders, cholecystitis.
Pressure, burning or tightness?
Tearing, excruciating? Dissecting aortic aneurysm, esophageal rupture.

Tearing, pleuritic? Pneumonia, pneumothorax.


Stabbing, knifelike? Pericarditis, postmyocardial syndrome.
Sharp, crushing, squeezing? Angina, MI, pulmonary HTN, esophageal rupture,
GI problems such as esophageal spasm.
Vague? Musculoskeletal problems such as degenerative disc disease.
R Can you point to where it hurts? Substernal chest: Hyperventilation, MI, angina, postmyocardial
Does the pain radiate anywhere else? syndrome, pericarditis, pulmonary HTN.
Do you have nausea or vomiting? Are you Back: Dissecting aortic aneurysm, degenerative disc problems.
breathless? Retrosternal: Pneumonia, esophageal spasm.
Lateral side of chest: Pneumothorax.
Epigastric: GI problems.
Left shoulder, arm, jaw: Angina, MI, pericarditis, postmyocardial
syndrome (but not down arm), pulmonary emboli, GI problems.

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Assessing the Cardiovascular System

S On a scale of 0 to 10, with10 being the Mild to severe: MI, angina, pericarditis, pulmonary emboli,
worst, how severe is the pain? pneumothorax, pneumonia, esophageal reflux, esophageal
spasm.
Severe: Dissecting aortic aneurysm, pulmonary HTN,
esophageal rupture.
T When did the pain start? Cardiac origin:
How long did it last? Sudden onset lasting 30 minutes to 1 hour, may not have
Have you had this before? precipitating factor: Acute MI.
Sudden onset lasting a few minutes, usually with a precipitating
factor: Angina pectoris.
Acute onset: Dissecting aortic aneurysm.
Acute or variable onset: Pericarditis.
Respiratory origin:
Acute onset: Pulmonary emboli, pneumothorax, pleurisy,
pneumonia, bronchitis, asthma.
Insidious onset: Lung cancer, lung abscess.
Musculoskeletal origin:
Acute: Degenerative disc disease in cervical or thoracic spine,
costochondritis.
GI origin:
Acute: Pancreatitis, cholecystitis peptic ulcer, esophageal
reflux disease.
Neurologicl origin:
Acute: Herpes zoster, nerve root compression.
Psychogenic origin:
Acute: Anxiety or panic attack resulting in hyperventilation.

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Assessing the Cardiovascular System

SYMPTOM ANALYSIS: PALPITATIONS

QUESTIONS TO ASK SIGNIFICANCE


P Do you have a history of cardiac problems? Coronary artery disease, mitral valve prolapse, sick sinus syn-
Do you have any other medical problems? drome, Wolff-Parkinson-White syndrome and other
Are you taking any prescribed or OTC arrhythmias.
medications? Do you use street drugs? Thyroid disease, diabetes, anxiety.
Caffeine; alcohol; amphetamines; cocaine; and cardiovascular
medications such as digitalis, beta-blockers, and calcium
channel blockers.
Q What do the palpitations feel like? Various cardiac arrhythmias.
Skipped beats, fluttering, racing,
irregular heartbeat?
R Do you have any other symptoms? Dizziness, chest pain: Depending on the arrhythmia, if
circulation is compromised, additional symptoms may result.
S Are the palpitations getting worse? If palpitations are becoming progressively worse, may correlate
Better? with progression of underlying disease process.
T When did the palpitations start? Helpful in determining the onset and progression of disease.
How long do they last?

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Assessing the Cardiovascular System

SYMPTOM ANALYSIS: SYNCOPE

QUESTIONS TO ASK SIGNIFICANCE


P What were you doing before you felt dizzy? Change of position: Postural hypotension.
Do you have any medical problems? Cardiovascular causes include: Valvular disorders,
dysrhythmias, vascular insufficiency, angina, MI, CHF,
hypotension, pacemaker failure, emphysema.
Are you on any medications? Medications that cause dizziness include: Antianxiety drugs,
central nervous system (CNS) depressants, narcotics,
decongestants, antihistamines, antihypertensives, vasodilators.
Q What does the dizziness feel like? It is important to differentiate dizziness from vertigo. Dizziness
is a sensation of imbalance or light-headedness. Vertigo is a
sensation that you or the surroundings are revolving. Vertigo
is often accompanied by nausea, vomiting, and nystagmus,
whereas dizziness is not.
R Do you have any other symptoms? Blurred vision, headache: HTN, transient ischemic
attacks (TIAs).
Palpitations: Cardiac arrhythmias.
Pallor and fatigue: Anemia.
S Have the dizzy spells gotten worse? Have May indicate impending stroke.
you ever fainted or blacked out?
T When did the dizzy spells start? 1 to 2 weeks after a head injury: Postconcussion syndrome.
How often do the dizzy spells occur? Increased frequency: May indicate impending stroke.
How long do they last? Cardiac arrhythmias can cause dizziness. If arrhythmia per-
sists, fainting may occur.

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Assessing the Cardiovascular System

SYMPTOM ANALYSIS: EDEMA

QUESTIONS TO ASK SIGNIFICANCE


P Have you gained weight? Do your ankles Right CHF HTN, vascular disease.
swell? Are your shoes tight? Prolonged sitting or standing (nonpathological).
Does the swelling go down when you el-
evate your legs?
Q How would you describe the swelling? Pitting edema: CHF or nonpathological conditions such as
prolonged sitting or standing.
Brawny edema (associated with thick, hard tissue): Chronic
venous insufficiency.
R Is the swelling in one leg or both? Localized or unilateral: Leg trauma, osteomyelitis, thrombo-
Do you have any other symptoms? phlebitis.
Bilateral: CHF, venous insufficiency.
Pain, fever: Osteomyelitis.
Pain, fever, redness, warmth: Thrombophlebitis.
Painless: Venous insufficiency.
S How bad is the edema? Mild to moderate: Osteomyelitis, thrombophlebitis.
Mild to severe or progressive: Venous insufficiency, advanced
heart failure.
T When did the edema start? Acute onset: Leg trauma, osteomyelitis, thrombophlebitis.
Insidious, gradual onset: CHF, venous insufficiency.

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Assessing the Cardiovascular System

SYMPTOM ANALYSIS: FATIGUE

QUESTIONS TO ASK SIGNIFICANCE


P Do you feel tired after activity, take naps Fatigue associated with activity and improving with rest usually
during the day, or feel as though you don’t has a physical origin.
have enough energy to get through the day? Fatigue not affected by activity and unrelieved by rest usually
Do you feel re-energized after resting? has a psychological origin.
Do you have any medical problems? Fatigue of cardiac origin is often associated with CHF.
Are you taking any medications? Noncardiac causes of fatigue include depression, infection,
cancer, anemia, hypothyroid disease, lung disease, and
fibromyalgia.
Antihypertensives and sedatives may cause fatigue.
Fatigue is a symptom of digitalis toxicity.
Q How would you describe the fatigue? Incapacitating: Chronic fatigue syndrome.
R Do you have any other symptoms? Fever: Acquired immunodeficiency syndrome (AIDS),
Lyme disease.
Weight loss: Cancer, diabetes mellitus.
Dyspnea: COPD, CHF, valvular heart disease.
Pallor: Anemia.
Sleep disturbance: Hypercortisolism.
Forgetfulness, cold intolerance, weight gain: Hypothyroidism.
Butterfiy rash: Lupus erythematosus.
Muscle weakness: MG.
S On a scale of 0 to 10, with 10 being the Mild to severe: Anemia.
worst, how severe would you say your Persistent: CHF, COPD.
fatigue is? Progressive: Valvular disease.
T When did the fatigue begin? Early onset: Cancer, anemia, COPD.
Sudden: Acute renal failure.
Insidious: Diabetes mellitus.

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Assessing the Cardiovascular System

SYMPTOM ANALYSIS: EXTREMITY CHANGES

QUESTIONS TO ASK SIGNIFICANCE


P What were you doing when the extremity Pain or cramping in calf while walking: Intermittent claudication,
changes started? associated with arterial insufficiency.
Do you have any medical problems? The following may cause paresthesia: Peripheral-vascular
Does anything make the problem worse? disease (PVD), coronary artery disease, cerebral vascular
disease, diabetes mellitus, herniated disc, and neurologic
problems such as MS, brain tumor, peripheral neuropathy, and
seizures.
Exposure to cold can precipitate attacks of Raynaud’s and
Buerger’s diseases.
Smoking can trigger an attack of Buerger’s disease.
The following medications may cause paresthesia: Phenytoin,
chemotherapeutic agents (such as vincristine, vinblastine, and
procarbazine), isoniazid, D-penicillamine, nitrofurantoin,
chloroquine, and gold therapy.
Q What does it feel like? Numbness and tingling: PVD, arteriosclerosis obliterans,
cerebrovascular disease.
Burning: Diabetic neuropathy, herpes zoster.
R Does it affect one side or both? Contralateral: Stroke, TIA, brain tumor.
Do you have any other symptoms? Bilateral: Buerger’s disease, Guillain-Barré syndrome,
Raynaud’s disease, PVD.
One or both: Arterial occlusion, arteriosclerosis obliterans,
peripheral neuropathy.
Cold: Arterial occlusion, Buerger’s disease, Raynaud’s
disease.
Muscle weakness, paralysis: Stroke, peripheral neuropathy,
Guillain-Barré syndrome, MS.
Pain: Arterial occlusion, arteriosclerosis obliterans, herpes
zoster.
S If you have numbness, how bad is it? Progressive: Arterial occlusion, peripheral neuropathy,
Guillain-Barré syndrome.
T When did the numbness start? Insidious onset: Diabetes mellitus, vascular disease.
How long does it last? Acute: Arterial occlusion, head trauma, stroke.
Transient: TIAs, MS.

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Assessing the Cardiovascular System

SYMPTOM ANALYSIS: DYSPNEA

QUESTIONS TO ASK SIGNIFICANCE


P When do you notice SOB? All the time? Constant dyspnea: Pneumothorax, pulmonary emboli,
When you exercise? At night? When you lie CHF, MI.
down? Can you breathe more easily when Dyspnea on exertion, paroxsymal nocturnal dyspnea,
you are sitting or standing erect? orthopnea: Left-side CHF that results in pulmonary congestion.
S Do you have a cough? Productive cough: Left-side CHF.
If so, how would you describe it? Bloody sputum: Pulmonary emboli.
Bloody, frothy sputum: Pulmonary edema.
Brassy cough: Thoracic aortic aneurysm.

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Assessing the Peripheral-Vascular and Lymphatic Systems

SYMPTOM ANALYSIS: SWELLING

QUESTIONS TO ASK SIGNIFICANCE


P Does anything make the swelling worse, Edema worsened by prolonged standing or sitting and relieved
such as sitting for long periods? by rest or elevation is called orthostatic edema.
Does anything reduce the History of CHF or renal disease may account for edema.
swelling, such as elevating your feet or High-sodium or low-protein diets may cause edema.
using support hose? Steroids can cause edema.
Do you have any other medical problems?
Are you on a special diet? Does eating salty
foods make the swelling worse?
Are you taking any medications?
Q How would you describe the swelling? Do Soft, pits on pressure: Orthostatic edema from prolonged
you have an imprint of a sock line or shoe standing or sitting, pregnancy, menopause.
when you take your shoes and socks off? Soft early, then becomes hard and nonpitting: Lymphatic
obstruction.
Soft, pitting, then brawny: Venous insufficiency.
R Where is the swelling located? Does it affect Bilateral: Orthostatic edema, venous insufficiency, heart
both arms or legs? Does it involve the entire failure, excessive renal retention of sodium water, kidney
extremity failure.
or just a certain area? How far up the Pain, warmth, redness: Deep vein thrombosis (DVT),
extremity does the swelling go? thrombophlebitis.
Is the swelling associated with pain, warmth, Unilateral: Cellulitis, osteomyelitis, venous obstruction
redness? from thrombus, tumor.
Do you have any other symptoms, Breathing difficulties with edema may occur with heart failure.
such as SOB? ALERT
Dyspnea associated with edema may indicate CHF and
requires immediate attention.
S Have you gained weight? Is the swelling Weight gain over a short time period usually reflects fluid
marked or slight? Has it occurred before? changes. Severity of edema may reflect progression of a
If so, is it more or less severe this time? disease. Anasarca (severe generalized body edema) is
seen with CHF.
T When did the swelling start? When does it Onset helps differentiate whether problem is acute or chronic.
occur—on awakening or at the end of the Generalized edema is usually chronic and progressive.
day? Is it constant or intermittent? How long Localized edema may be more acute and self-limiting with
does it last? treatment.

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Assessing the Peripheral-Vascular and Lymphatic Systems

SYMPTOM ANALYSIS: LIMB PAIN

QUESTIONS TO ASK SIGNIFICANCE


P What were you doing when the pain Calf pain with walking (intermittent claudication): Arterial
started? Does it occur after walking long insufficiency.
distances? When walking up and down Pain when feet are elevated: Arterial insufficiency caused by
stairs? After decreased blood flow to legs.
repetitive movements? Only at night?
Does anything make it better or worse?

Q What does the pain feel like? Cramping: Thrombophlebitis, occlusive vascular disease.
Is it deep or superficial? Dull aching: Varicose veins.

R Where does it hurt? Does it radiate to Localized: Thrombophlebitis.


another location? Bilateral: Arterial insufficiency, venous insufficiency.
Do you have any other symptoms? Paresthesia: Peripheral neuropathy.
Color/temperature changes:
• Cold extremity: Arterial insufficiency, occlusion.
• Warm, red, edematous extremity: Thrombophlebitis.
• Bluish discoloration: Venous insufficiency.
• Dependent rubor: Arterial insufficiency.
S On a scale of 0 to 10, with 0 being no pain Mild to severe: Varicose veins.
and 10 being the worst pain, how would Increasing in severity: Progressive arterial insufficiency.
you rate your pain? Severe: Arterial embolism.

T When did the pain start? Was it sudden or Gradual onset: Venous or arterial insufficiency.
gradual? Is it intermittent or continuous? Sudden onset: Thrombophlebitis, acute arterial occlusion.
How long does it last? ALERT
Sudden onset of pain with cold extremity and absent pulse may
indicate acute arterial occlusion, a surgical emergency.

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Assessing the Peripheral-Vascular and Lymphatic Systems

SYMPTOM ANALYSIS: PARESTHESIA

QUESTIONS TO ASK SIGNIFICANCE


P Do you have a history of vascular problems Vascular disease and diabetes frequently cause paresthesia.
or diabetes? Cold: Raynaud’s disease, Buerger’s disease (an inflammatory
Does anything make the sensation better occlusive disease).
or worse? Elevating legs: Occlusive vascular disease; causes loss of
sensation or burning, prickling sensation caused by
diminished blood flow.
Smoking: Buerger’s disease.
Q What does the problem feel like? How Prickling sensation with legs elevated: Occlusive disease.
intense is it?
R Where is the sensation? In just one part of Cold extremity: Arterial occlusion, Buerger’s disease,
the extremity, in the entire extremity, in one Raynaud’s disease.
or both extremities? Do you have any other Paresis (paralysis): Arterial occlusion, peripheral neuropathy.
symptoms, such as color changes? Cyanosis or pallor: Buerger’s and Raynaud’s diseases,
arterial insufficiency.
S How bad is the numbness? Is it the same, Helps determine acuity and progression of problem.
better, or worse?
T Did the problem occur suddenly or Sudden onset: Acute arterial occlusion.
gradually? Gradual, intermittent: Arterial insufficiency.
Is it intermittent or progressive? Progressive: Peripheral neuropathy.

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Assessing the Peripheral-Vascular and Lymphatic Systems

SYMPTOM ANALYSIS: FATIGUE

QUESTIONS TO ASK SIGNIFICANCE


P What have you been doing? Physiological fatigue: Prolonged physical activity, overwork,
Is your fatigue related to exertion? inadequate sleep, dieting, pregnancy and having recently
Have you been overburdened with job given birth, sedentary lifestyle.
or family commitments? Acute organic: Viral or bacterial infections, anxiety, depression,
Have you been sleeping well? anemia, hypothyroidism, CHF, cancer, AIDS.
How many hours do you sleep a night? Functional fatigue: Depression, anxiety, emotional stress.
Do you have trouble getting to sleep or
staying asleep?
Do you have any other medical problems?
Q How often are you tired? How would you Constant, incapacitating fatigue: Chronic fatigue and
describe your fatigue? immune dysfunction syndrome.
Easy fatigability: MG (an autoimmune disorder),
protein-deficient malnutrition.
R Do you have any other Fever, night sweats: AIDS.
symptoms? Weight loss: AIDS, cancer, type 1 diabetes.
Weight gain: Hypothyroidism.
Dyspnea: Anemia, CHF, COPD.
Muscle weakness: MG.
S Is the fatigue better, worse, or the same? Helps determine progression of problem.
T When did you first notice the fatigue? Sudden onset: Acute renal failure.
Did it occur suddenly or gradually? Progressive: Valvular heart disease.
Is it progressive? Do you wake up tired, or
do you become tired during the day?

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Assessing the Breasts

SYMPTOM ANALYSIS: LUMP OR MASS

QUESTIONS TO ASK SIGNIFICANCE


P How have you been feeling? Vague unwell feelings: May be associated with underlying
malignancy.
Has your weight changed Recent weight gain may account for a feeling of breast
recently? thickening. Weight loss associated with breast mass:
May reflect metastatic breast cancer.
Have you had a fever? Elevated temperature: Mastitis, abscess, or hematoma.
Have you had recent trauma to the breast? May cause hematoma or scar tissue.
Do you have any breast problems such as Lumps may be related to fibrocystic disease.
fibrocystic breast disease?
Have you had breast surgery or implants? Breast surgeries and implants may cause adhesions or
scar tissue.
Q What does the lump feel like? Helps identify type of mass.
Have you ever had a similar lump before? Hard: Cancer.
Firm, rubbery: Fibroadenoma.
Nodular: Fibrocystic breast disease.
R Is the lump localized? Where is it? Well-defined, movable, occurring singularly: Fibroadenomas.
Is there more than one lump or are there Not well defined, not movable: Cancer.
“mirror” lumps in the opposite breast? One or more, round or oval, movable: Fibrocystic breast
Is the lump easily movable or fixed? disease.
Has the contour of your breast changed Asymmetrical changes, dimpling, nipple retraction: Cancer.
(e.g., dimpling or redness)? Redness: Mastitis.
Do you have breast pain or tenderness? Nontender: Early breast cancer, fibroadenomas.
Cyclic pain/tenderness: Fibrocystic disease.
S Has the lump gotten larger or smaller? Rapidly enlarging mass may indicate a cyst.
T When did you first notice the lump? After ovulation, breasts become tender and swollen with fluid.
Is there a relationship to the menstrual cycle? Enlargement or lump before or during menstruation may be
caused by fluid changes, not a mass.
Fibrocystic breast masses are cyclical in occurrence.

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Assessing the Breasts

SYMPTOM ANALYSIS: BREAST PAIN OR TENDERNESS

QUESTIONS TO ASK SIGNIFICANCE


P Have you ever injured your May cause pain.
breast?
Do you have fibrocystic breast disease? Usually causes pain or tenderness.
Do you have breast cancer? Pain is not associated with early breast cancer but may occur
with late, metastatic disease.
Are you nursing? Mastitis often occurs with nursing.
Does anything make the pain or tenderness Fibrocystic breast tenderness is cyclical.
better or worse (e.g., removing bra, cessa- Cyclical mastalgia (breast pain) coincides with menstrual cycle.
tion of menses)?
Have you done anything to try to get rid of Identifying what relieves symptoms has diagnostic value.
the pain? If so, what?
How well did it work?
Q What does the pain or tenderness feel like? Discomfort from fibrocystic breast disease ranges from
tenderness to pain.
R Where does it hurt? Pain may be directly over affected area or referred to
Is the pain in both breasts? another area.
Do you have any other symptoms, Malignant lesions are generally painless; however, pain may
for example: Fever? occur as a result of compression of a vessel, nerve, or lymph
Breast swelling? node.
Nipple discharge or bleeding? Pain may also indicate mastitis, infection or abscess,
or hematoma.
Indicates infectious process.
Mastitis, infection, abscess.
Infection, malignancy, mastitis.
S On a scale of 0 to 10, with 0 being no pain Helps determine patient’s perception of pain.
and 10 being the worst possible pain, how
would you rate
the pain?
T When did the pain start, and how long Slight tenderness during pregnancy and before menstruation
does it last? is normal.
Did it happen suddenly or gradually? Cyclical pain: Fibrocystic breast disease.
Breast pain occurs in 70 percent of women and in most cases
is cyclical, lasting 2 to 3 days.
Pain in a lactating breast or in woman who recently
gave birth: Mastitis.
Abscess or rapidly enlarging cyst can cause acute pain.

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Assessing the Breasts

SYMPTOM ANALYSIS: NIPPLE DISCHARGE

QUESTIONS TO ASK SIGNIFICANCE


P Does anything make the discharge better May help explain cause of discharge.
or worse? Normally causes discharge, for example:
Are you pregnant? May be cause of discharge.
Do you have fibrocystic breast disease? Identifying what relieves symptoms has diagnostic value.
Have you had recent breast trauma?
Have you tried to relieve this problem?
If so, how? How did it work?
Q How much discharge is there? May reflect progression of problem.
Is it from both breasts? Yellow: Discharge of colostrum occurs late in pregnancy and
What color is the discharge? immediately after delivery.
White, milky: Normal in lactating women.
Galactorrhea (inappropriate lactation) may occur as a result of
drug therapy or endocrine or neural disorder.
Milky yellow or green or yellow-greenish purulent: Fibrocystic
breast disease.
Bloody: Trauma or breast cancer.
Thick, gray: Ductal ectasis.
Serous, serosanguineous, or bloody: Intraductal papilloma.
Yellowish-greenish purulent: Mastitis, infection.
R Do you have any other symptoms? Pain can be caused by obstruction of a duct or fibrocystic
For example, breast or nipple pain? breast disease.
S Is the discharge getting better or worse? May reflect status of problem.
T Does the discharge occur spontaneously, or An occasional, minimal amount of clear fluid that is expressed
is it expressed? may be a normal finding.
When did the discharge start?
How often does it occur?

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessing the Abdomen

SYMPTOM ANALYSIS: ABDOMINAL PAIN

QUESTIONS TO ASK SIGNIFICANCE


R Can you point to where it hurts? Does the Pain may be directly over affected organ or referred to another
pain stay in one place or radiate? If so, area. Note location of pain by quadrant or region.
where? Pain in shoulder: Ruptured spleen, ectopic pregnancy, Pancreatitis.
Do you have a fever? Pain in scapula: Cholelithiasis, MI, angina, biliary colic, Pancreatitis.
Do you have abdominal bloating? Pain in thighs, genitals, lower back: Renal problems, ureteral colic.
Do you have vaginal or penile discharge, Pain in lower and middle back: Abdominal aortic aneurysm.
bleeding? Indicates infectious process.
Do you have blood in your urine? Caused by gas, ascites, liver problems, or cancer.
Have you lost weight? If so, how much and Infection, STDs, vaginal bleeding associated with ruptured ectopic
over what time period? Have you had any pregnancy, urinary tract infection (UTI), renal calculi.
changes in bowel habits, such as diarrhea Peptic ulcer, stomach and pancreatic cancer, pancreatitis,
or cholecystitis, appendicitis.
constipation? Stomach and pancreatic cancer.
Diarrhea can cause cramping pain; constipation can cause
full/pressure sensation.
T When did the pain start? Acute-onset pain may signal these life-threatening problems:
What were you doing when it started? How Bowel or gastric perforation, intestinal obstruction, ruptured
long did it last? (An instant, minutes, hours, appendix, ruptured spleen, ruptured tubal pregnancy, ruptured
days, months?) When was your last men- aortic aneurysm, MI; assess for signs of shock.
strual period (LMP)? Gradual-onset pain may signal these non–life-threatening
problems: Cholelithiasis (gallbladder stones) and nephrolithia-
sis (kidney stones), infections, cancer, gastritis, ulcers, colitis,
Crohn’s disease, prostatitis, paralytic ileus.
Q What does the pain feel like? Sharp? Dull? Sharp pain (arises from parietal irritation): Perforated ulcer.
Aching? Burning? Colicky? Crampy? Dull or aching: Visceral pain over affected organ or early
How often does the pain occur? stages of appendicitis.
Burning: Problems with esophagus (e.g., esophagitis, GERD).
Colicky: Problems with colon or stomach; UTI, food poisoning,
intestinal obstruction, cholecystitis.
Crampy: Crohn’s disease, colitis, viral infection,
gastroenteritis.
Intermittent pain: Typical of cholelithiasis or nephrolithiasis.
S On a scale of 0 to 10, with 0 being no pain Intense pain: Strangulated hernia, dissecting abdominal aortic
and 10 being the worst, how would you rate aneurysm, adrenal crisis, cholelithiasis, Crohn’s disease, peri-
your pain? tonitis, perforated ulcer.

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Assessing the Abdomen

P Does anything make the pain worse? Eating fatty foods: Precipitates gallbladder symptoms.
Does anything make it better? Changing body position: Intensifies parietal pain associated
HELPFUL HINT with appendicitis or perforated ulcer.
Identifying what relieves symptoms has Deep inspiration: Worsens RUQ pain in acute cholecystitis
diagnostic value. and peritonitis.
Eating: Improves symptoms of gastric ulcer.
Sitting up after eating: Improves symptoms of hiatal hernia
and GERD.

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Assessing the Abdomen

SYMPTOM ANALYSIS: WEIGHT CHANGE

QUESTIONS TO ASK SIGNIFICANCE


P How have you been feeling? Vague feelings of not feeling well may be associated with
malignancy and account for weight loss.
Have you been ill recently? Recent illness may account for weight loss or gain.
Are you on a special diet? Diets may explain weight loss.
Do you have any medical problems, such Cardiac or renal disease may cause fluid retention and
as cardiac or renal disease? weight gain.
Q What is your usual weight? If you have lost Unintentional weight loss: Loss of appetite with decreased
weight, how much? intake, impaired absorption, increased rate of elimination,
Are you trying to lose weight? What have endocrine problem, malignant processes, depression.
you eaten in the last 24 hours? Do you ever Intentional weight loss: In a normal-weight or underweight
eat large amounts of food at one time? person, a drive to lose weight could be pathological and indi-
If you have gained weight, how much? cate an eating disorder.
Weight gain: Pregnancy, accumulation of fluids, constipation,
overeating, endocrine problem, tumor, fibroid tumor.
R Is the weight gain or loss in a certain part of Weight gain/fluid retention in extremities or abdomen (ascites).
your body? CHF causes weight gain from edema, with loss of muscle and
Have you had changes in your appetite? fat resulting in an underlying weight loss that becomes appar-
Nausea or vomiting? Changes in bowel ent once edema subsides.
habits or diarrhea? Anorexia, nausea, and vomiting may cause weight loss. This
is often seen with underlying malignancy. Diarrhea may also
explain weight changes.
S Have the weight changes gotten better or Severity of weight loss may relate to progression of an
worse or stayed the same? underlying disease.
T When did you first notice the weight Weight changes of 2 to 3 lb (1 to 1.4 kg) within 48 hours
change? How long has this been occurring? usually reflect fluid changes, not body mass.

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Assessing the Abdomen

SYMPTOM ANALYSIS: CHANGES IN BOWEL ELIMINATION PATTERNS

QUESTIONS TO ASK SIGNIFICANCE


P Are you taking any medications? What Frequent and prolonged use of some antacids, opioids,
do you usually eat? What did you eat in antidepressants, anticholinergics, and antihistamines
the last 24 hours? Has your diet changed causes constipation. Low-fiber diets are also associated
recently? Have you noticed any foods that with constipation.
upset your stomach or cause changes in Helps identify dependency on laxatives.
your bowel movements?
Have you done anything to relieve the
constipation; for example, have you taken
laxatives or stool softeners?
If so, how often do you take them?
Q How often do you have a bowel movement? Large amounts of diarrhea indicate possible problem in small
How big or small in volume are your bowel intestine. Infrequent, small amounts of stool indicates
movements? constipation.
What is the shape and odor of your bowel Hard, small balls: Constipation.
movements? Hard, formed movements alternating with semiliquid:
What color are your bowel movements? Bowel impaction.
Watery: Reflects process in small bowel.
Greasy, foul-smelling, fatty (steatorrhea): Intestinal
malabsorption diseases.
Containing mucus: Irritable bowel disease.
Food and medicines affect stool color.
Black, tarry (melena): Digested blood from below duodenum;
bleeding in the GI system.
Maroon, tarry-colored stool with positive guaiac: Digested
blood, indicating upper GI bleeding.
Black, nontarry: Iron ingestion.
Gray/clay: Absence of bile in stool, possibly caused by
hepatitis or other liver ailments.
Red blood on stool surface: Anal/rectal bleeding.
Bright red blood: Hemorrhage (lower GI bleeding) or
hemorrhoids.
Dark, tarry stools or hematemesis (blood in vomitus) causes
a decrease in complete blood count (CBC) from blood loss.
The extent of the effect on the CBC will be determined by
the amount of blood loss.
R Do you have pain during bowel move- Pain, fullness, diarrhea, and constipation: Intestinal obstruction
ments? How about bloating or gas? from diverticulitis or cancer.
Pain, bloating, gas: Irritable bowel disease.
S Is the constipation getting better or worse? May reflect status of problem.

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Assessing the Abdomen

T When was your last bowel movement? May identify onset and duration of problem.
How often do you have them? Normal frequency of bowel movements is from 2/day
What is your usual bowel pattern? to 2 to 3/wk.
Has it changed? How long have you had
constipation problems?

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessing the Abdomen

SYMPTOM ANALYSIS: DIARRHEA

QUESTIONS TO ASK SIGNIFICANCE


P Do you drink alcohol or smoke? Can precipitate irritable bowel syndrome.
Are you under a lot of stress? High amounts of lactose (in enteric feedings) cause diarrhea
Are you receiving tubal/enteral feedings? in some people. Some foods, such as onions, wheat, cabbage,
What foods do you eat every day? and diary products can cause diarrhea.
Have you recently been on antibiotics? Antibiotics cause GI upset, cramping, and diarrhea and are
Are you taking any other medications? associated with pseudomembranous colitis. Antacids
Have you recently traveled outside the containing magnesium, digitalis, potassium supplements,
country? cholestyramine, anticoagulants, and laxative abuse may
cause diarrhea.
Unsafe food handling practices and contaminated water
supplies increase the risk of GI infection. The risk of GI
infection (giardiasis, salmonella, cryptopsporidium, shigella).
Q Can you describe your bowel movements Indicates intestinal location of problem.
as to amount and consistency? Large amounts of diarrhea indicate possible problem in small
Shape? Color? Frequency? Amount? intestines.
Oily, frothy, foul-smelling: Chronic pancreatitis, biliary
obstruction, malabsorption problems.
Changes in the stool’s diameter may indicate a problem with
the colon’s diameter. Signifies tumor or inflammation.
Gray/clay-colored: Reflects bilirubin content.
Red or black/tarry: Presence of blood.
Large amounts of frequent diarrhea may indicate a severe
problem and lead to fluid and electrolyte imbalance and
dehydration.
R Do you have a fever? Indicates infection.
Do you have cramping and malaise? Lactose intolerance, gastroenteritis.
Pain? Crohn’s disease.
Pain with distension? Irritable bowel syndrome.
Pain, rectal bleeding? Ulcerative colitis.
Weight loss? Malabsorption diseases such as celiac disease.
S Is the diarrhea getting better or worse? Reflects the course of the problem.
T When did it start? How long did it last? Prolonged diarrhea increases the risk for electrolyte
imbalance.

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Assessing the Abdomen

SYMPTOM ANALYSIS: INDIGESTION

QUESTIONS TO ASK SIGNIFICANCE


P Does anything seem to cause the Lying flat: Worsens indigestion or problems related to hiatal
indigestion? hernia.
Does anything relieve it? Make it worse? Eating too fast: Precipitates indigestion.
Antacids: Relieve discomfort of indigestion and peptic ulcer.
Food: Relieves duodenal ulcer pain but increases gastric ulcer
pain. Spicy and fatty foods increase indigestion.
Rest: Improves angina but does not affect indigestion.
Duodenal ulcer pain often awakens person from sleep.
Q What does the indigestion feel like? Burn- Burning: Reflects indigestion, possible esophageal erosions.
ing, crushing, pressure? Is it constant or Crushing/pressure: Cardiac in nature.
intermittent?
R Where do you feel the indigestion (point Upper epigastric area localized to left of midline: Gastric ulcer.
with your finger)? Right epigastric area: Duodenal ulcer.
Does it radiate or stay in one place? Substernal, retrosternal radiating upward to neck or jaw or
Do you have pain anywhere else? referred to back: GERD.
Do you have gas or belching? Belching (eructation) associated with GERD, cholecystitis.
Does the pain make you break out in Flatulence associated with cholecystitis.
a sweat? Diaphoresis may indicate cardiac problems.
S Is the indigestion getting better or worse? Degree of severity and number of symptoms relate to
How would you rate it on a scale of 0 to 10, seriousness of GI problem.
with 0 being no indigestion and 10 being
the most severe?

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessing the Abdomen

SYMPTOM ANALYSIS: NAUSEA

QUESTIONS TO ASK SIGNIFICANCE


P Are you taking any medications? Nausea is a side effect of many medications.
Do offensive odors make you nauseated? Odors can trigger nausea during pregnancy.
Is there any chance that you are pregnant?
Do you have any GI problems? Appendicitis, cholecystitis, cirrhosis, gastritits, gastroenteritis,
intestinal obstruction, peptic ulcer, and peritonitis can cause
nausea.
Do you have diabetes? Gastroparesis diabeticorum, a complication of diabetes, causes
delayed gastric emptying and can cause nausea.

Do you have ear problems such as Mé- Inner ear problems may cause nausea.
nière’s disease?
Do you have motion sickness? Nausea is associated with motion sickness.
Do you have a history of heart failure? Nausea can be associated with heart failure, especially
right-sided heart failure.
What have you done to relieve the nausea? Depending on the cause, helps determine if medication or
How has it worked? other interventions will be effective at relieving nausea.
Q How would you describe the nausea? Does Description of nausea depends on cause.
it come over you in a wave and then dis-
sipate, or is it constant?
R Do you have any other symptoms, such as Associated with food poisoning.
fever, chills, cramps, vomiting, or diarrhea?
Vomiting and headache? Typical of migraine headaches.
Malaise and joint pain (arthralgia)? Associated with glomerulonephritis.
Malaise, anorexia, pain in RUQ, and jaun- Associated with hepatitis.
dice?
Anorexia, pain in umbilical region or right Associated with appendicitis.
lower quadrant (RLQ)?
Weight loss? Associated with malabsorption disorders, cancer, food intoler-
ance.
S Is the nausea getting better or worse? Reflects the progression of the problem. For example, nausea
Has the nausea prevented you from doing associated with pregnancy usually subsides by the second
your regular activities? trimester.
Nausea associated with underlying malignancy does not
subside.
Identifies the impact of symptom on patient’s life.

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Assessing the Abdomen

T When does the nausea occur? Morning nausea occurs in pregnancy.


What did you eat during the last 24 hours? Identifies possibility of foodborne pathogens.
Have you been around anyone who has Identifies possibility of contagious illness.
been sick with the same symptoms?
Did it come on gradually? Insidious onset associated with liver disease.

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessing the Abdomen

SYMPTOM ANALYSIS: VOMITING

QUESTIONS TO ASK SIGNIFICANCE


P Do you have GI problems? Appendicitis, cholecystitis, cirrhosis, gastritis, gastric cancer,
Did you have a head injury? and gastroenteritis cause vomiting.
Has anyone else in your family been Head injuries cause vomiting.
vomiting? Many GI diseases are contagious and can be spread to other
Do you have ear problems? family members.
What did you eat during the last 24 hours? Labyrinthitis causes nausea and vomiting.
Are you on any medications? Food poisoning, such as salmonella, causes nausea and
Does anything make the vomiting better vomiting.
(e.g., lying still, eating crackers) or worse Many medications, such as antineoplastic agents, can cause
(e.g., eating)? vomiting.
Morning sickness often relieved by eating crackers.
Nausea and vomiting associated with motion sickness are
often relieved by being still.
Q What did the vomit look and smell like? Coffee-ground color: Digested blood in stomach from slow
Was the vomit ejected with great force? gastric or duodenal bleeding.
How much and how often are you vomiting? Contains bright red blood: Upper GI bleeding from gastritis
or peptic ulcer.
Contains dark red blood: Usually caused by esophageal
bleeding.
ALERT
Vomiting of blood (hematemesis) requires immediate
treatment.
Green: Presence of bile, reflecting an obstruction below the
pylorus.
Brown with fecal odor: Intestinal obstruction.
Projectile vomiting without nausea is associated with
increased ICP. It is also seen in infants with pyloric stenosis.
Vomiting large amounts can lead to fluid and electrolyte
problems.

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Assessing the Abdomen

R Do you have any pain? Abdominal discomfort is associated with gastric cancer. Epi-
gastric pain is associated with gastritis.
Periumbilical pain progressing to RLQ pain is associated with
appendicitis.
Do you have diarrhea? Associated with food poisoning and gastroenteritis.
Do you have a fever? Associated with hepatitis, gastroenteritis, and pancreatitis.
Have you lost weight? Associated with gastric cancer.
Are you dizzy? Associated with motion sickness and labyrinthitis.
Are your eyes sensitive to light Associated with migraines.
(photophobia)?
Do you have a headache and stiff neck? Associated with meningitis.
Is your abdomen swollen? Associated with bowel obstruction.
S Is the vomiting getting better or worse? Determining the severity will reflect the progression and acuity
Have you been able to keep any food or of the symptom.
fluids down?
T When did the vomiting start? Identifying the duration of the problem is important in
identifying possible electrolyte imbalance.

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessing the Female Genitourinary System

SYMPTOM ANALYSIS: VAGINAL DISCHARGE

QUESTIONS TO ASK SIGNIFICANCE


P Do you have an STD? Vaginal discharge is a typical complaint of women with
Do you have any other medical problem, vaginitis. Most common presenting symptom in women with
such as diabetes? STDs is vaginal discharge.
Are you on any medications, such as Presenting symptoms and characteristics of discharge may
antibiotics or oral contraceptives? signal candidiasis. Precipitating factors include increased
Do you have an unusual amount of stress emotional stress, oral contraceptive use, diabetes mellitus,
in your life? and recent antibiotic use.
Q What color is the discharge? How much is Heavy, white, curdlike, odorless discharge; pruritus, vaginal
there? soreness; possible dysuria: Candidiasis.
Does it have an odor? Gray or white, thin, homogeneous, malodorous, unpleasant
fishy or musty odor: Bacterial vaginosis, caused by a common
bacteria that invades the vagina.
Yellowish-green, thick: Suggests gonorrhea.
Yellowish-green or gray; possibly frothy; often profuse and
pooled in vaginal fornix; possibly malodorous; may be
accompanied by pruritus, dysuria, dyspareunia: Bacterial
vaginitis. Suspected organism is Trichomonas vaginalis, a
protozoa.
Vaginitis and/or vulvitis often occur with immobilization, poor
hygiene, poor nutrition, obesity, and medication use. Atrophic
changes increase risk for inflammation or aggravate existing
inflammation.
R Do you have pain with intercourse Bartholin’s gland infection, urethritis, possible
(dyspareunia)? atrophic vaginitis.
Do you have genital itching?
S How bad do you consider this? Severity of symptoms may correlate with progression
of disease.
T When did the problem start? Establishing timing helps determine stage of disease
How long have you had it? progression.

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Assessing the Female Genitourinary System

SYMPTOM ANALYSIS: LESIONS

QUESTIONS TO ASK SIGNIFICANCE


P Are you sexually active? Do you have an Lesions are often seen with STDs. Immunosuppression
STD? If so, what? Does your sex partner increases susceptibility to HIV. Stress can trigger recurrence
have similar symptoms? of herpes.
Do you have HIV or are you taking any
immunosuppressive drugs?
Are you under stress?
Q What does the lesion look like? Small, firm, round nodule in labia: Sebaceous cyst.
Sometimes yellowish in color.
Ulcerated or raised red vulvar lesion: Vulvar carcinoma.
Firm, painless ulcer: Chancre of primary syphilis.
Slightly raised, flat, round or oval papules covered by gray
exudate (condylomata): Secondary syphilis.
Warty lesions on labia and within vestibule (condylomata
acuminata): Human papillomavirus (HPV).
Shallow, small, painful ulcers on red bases: Genital herpes.
R Where are the lesions? Vulva, vagina, Location depends on sexual activity.
perineum, anorectal area, mouth? Painful: Chancroid and genital herpes.
Are they painful? Painless: Syphilitic lesions and condylomata acuminata.
S How extensive are the lesions? Scattered, Scattered: Leukoplakia vulvae are thick, gray patches
single, multiple, diffuse? scattered over vulva and perineum. Precancerous lesions.
Single chancre: Appears 4 weeks after initial syphilis infection.
Multiple: Genital warts.
Diffuse: Associated with allergies, Candida, or allergy to latex.
T When did you first notice the lesions? Tells progression of disease.

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Assessing the Female Genitourinary System

SYMPTOM ANALYSIS: VAGINAL BLEEDING

QUESTIONS TO ASK SIGNIFICANCE


P Are you sexually active? Amenorrhea: May be caused by pregnancy, strenuous
When was your last period? exercise, or stress.
Do you participate in strenuous exercise? Menorrhagia: Associated with intrauterine devices (IUDs)
Are you under stress? and anticoagulants.
Do you use contraceptives? Breakthrough bleeding: Associated with oral contraceptives
If so, what type? and medications such as psychotrophics and
Are you on any other medications? antihypertensives.
Q What is your usual menstrual flow like? Is it Excessive/prolonged/painful periods: May be related to
excessive or prolonged? How many pads/ hormonal influences or conditions such as cervical cancer,
tampons do you use a day? endometrial cancer, fibroid tumors, and endometriosis.
Are your periods painful? Do you have a Scant breakthrough bleeding: May indicate hormonal
history of menstrual problems? imbalance.
R Do you have pain with excessive bleeding? Pain before, during, and after menstrual period: Endometriosis.
Is intercourse painful (dyspareunia)? Fibroid tumor.
Do you have abdominal pain, urinary fre-
quency, or constipation?
S Is bleeding about the same, getting worse, Helps determine acuity of problem.
or getting better?
T When did the problem start? How long have Helps determine acuity and progression of problem.
you had it? How often do you have it?

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Assessing the Female Genitourinary System

SYMPTOM ANALYSIS: PAIN

QUESTIONS TO ASK SIGNIFICANCE


P Where are you in your menstrual cycle? Primary dysmenorrhea and pain related to endometriosis begin
Are you sexually active? 1 to 2 days before onset of menses.
If yes, do you practice safe sex? STDs can cause pelvic inflammatory disease (PID).
What type of contraception do you use? IUDs can cause dysmenorrhea. Oral contraceptives may
relieve pain.
Do you have any other medical problems, Renal calculi can cause back/flank pain; UTIs can cause lower
such as renal or GI problems? abdominal pain; diverticulitis can cause lower abdominal pain.
Does anything make the pain better? Antibiotics provide relief from pain associated with PID.
Are you on any medications?
Q What does the pain feel like? Cramplike pain: Primary dysmenorrhea, premenstrual
syndrome, and diverticulosis.
Aching pain before menses: Endometriosis.
Sharp pain: Ruptured ovarian cyst, ectopic pregnancy,
and renal calculi.
R Can you point to where it hurts? Patient is often able to localize pain with secondary
Does the pain radiate, that is, spread to dysmenorrhea and endometriosis.
another place? Back: Prolapsed uterus.
Do you have a fever with the pain? Back/flank: Renal problems.
Do you have nausea and vomiting Lower abdomen: Ruptured ovarian cyst and
with the pain? ectopic pregnancy.
Radiating to shoulder/neck: Ruptured ectopic pregnancy.
Do you have pain during intercourse? Associated with PID and ruptured ovarian cyst.
Associated with primary dysmenorrhea, ruptured ovarian
cyst, ruptured ectopic pregnancy, and appendicitis.
PID may cause dyspareunia.
S How would you rate the pain on a scale of 0 Moderate to severe abdominal/pelvic pain, not related to
to 10, with 0 being no pain and 10 being the pregnancy: Infection, menstrual difficulties, endometriosis,
worst possible pain? adhesions, pelvic masses, ovarian cysts, endometrial cancer.
Moderate to severe abdominal/pelvic pain or cramping,
pregnancy related: Surgical emergencies, such as ectopic
pregnancy, threatened or incomplete abortion, corpus
luteum cyst.
T When did the pain start? 1 to 2 days before menses: Primary dysmenorrhea.
5 to 7 days before menses: Endometriosis.
How long have you had it? Acute onset: PID, ruptured ovarian cyst, ectopic pregnancy.

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessing the Female Genitourinary System

SYMPTOM ANALYSIS: AMENORRHEA

QUESTIONS TO ASK SIGNIFICANCE


P What is your menstrual history? Primary amenorrhea: Patient has not yet had menses.
Are you sexually active? If so, do you use Secondary amenorrhea: May be caused by pregnancy, meno-
contraceptives? What kind? pause, excessive exercise, rapid weight loss, pituitary tumor,
Do you exercise every day? If so, what type anorexia, stress, hypothalamic dysfunction, thyroid problems,
and for how long? and medications.
What are your eating habits?
Do you use prescription or OTC drugs? If
so, what?
Can you describe any emotional stresses
you have?
Q Can you describe the change in flow? Change in menstrual flow may help determine cause. For
example, in menopause, cycles may become irregular and flow
decreased until complete cessation.
R Have you noticed any other symptoms, Secondary amenorrhea associated with pregnancy.
such as weight gain, breast tenderness,
increased skin pigmentation?
Have you had headache, breast discharge, Might indicate an endocrine disorder.
change in body hair patterns?
S If you have secondary amenorrhea, has Helpful in determining progression of amenorrhea.
flow continued to decrease or totally
ceased?
T When was your LMP? Date of LMP is important in pregnant patients to estimate due
When did the change start? date.
Onset is important to determine if underlying problem exists.

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessing the Female Genitourinary System

SYMPTOM ANALYSIS: URINARY SYMPTOMS

QUESTIONS TO ASK SIGNIFICANCE


P Do you have an STD? STDs such as gonorrhea and chlamydia are
Do you have any gynecological problems? frequently associated with UTIs.
What was the date of your LMP? Vaginal fistulas may affect urinary patterns.
Are you pregnant? Pregnancy often results in urinary frequency during the
How many children have you given birth to? first and third trimesters.
Are you taking any medications? If so, what? Multiple childbirths; medications—such as tranquilizers,
Do you drink alcohol? If so, how much? sedatives, diuretics, and antihistamines—and alcohol
Do you take showers or tub baths increase risk for urinary incontinence.
(bubble baths)?
Q What color is your urine? Cloudy urine: Infection.
Is it bloody? Bloody urine (hematuria): Cystitis or renal damage.
R Is it painful to urinate? Dysuria: UTI.
Do you have bank or back pain? Back/flank pain: May indicate that kidneys are involved.
S How severe is the problem? Acuity of symptom may correlate with progression of problem.
T When did the problem start? How long has it Acute onset and urinary frequency usually associated
been going on? Did it occur suddenly? with infection.
How often do you urinate?
How many times do you get up at night?

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Assessing the Male Genitourinary System

SYMPTOM ANALYSIS: GENITAL PAIN

QUESTIONS TO ASK SIGNIFICANCE


P Have you had any recent trauma to the Trauma can precede testicular torsion or epididymitis.
genital area? Penile discharge: STD (STDs, especially gonorrhea and
Do you have an STD? Penile discharge? chlamydia, can cause epididymitis).
Do you have a UTI? Pain, burning, or UTIs frequently cause prostatitis.
frequency during urination? Pain, burning, or frequency during urination: UTI, gonorrhea.
Q What does the pain feel like? Excruciating? Excruciating pain in testicular area: Testicular torsion.
Dull or aching? ALERT
Testicular torsion is a surgical emergency.
HELPFUL HINT
Urinary complaints, fever, and elevated white blood count
(WBC) are not associated with testicular torsion.
Dull, aching pain in testicular area: Epididymitis (common
infection, usually unilateral).
Dull ache or feeling of heaviness: Prostatitis.
R Where does it hurt? Groin? Penis? Scro- Local pain in testicular area: Testicular torsion.
tum? Testicular area? Between scrotum Other symptoms of testicular torsion include swelling, nausea,
and anus (perineal area)? and vomiting.
Do you have swelling, redness, painful uri- Edema, dysuria, scrotal erythema: Epididymitis.
nation, discharge, or any other symptoms? Prostatitis can be bacterial or nonbacterial in origin. Gentle
palpation of the prostate usually results in a urethral discharge
high in WBCs.
S How severe is the pain? Rate it on a scale Excruciating pain: Testicular torsion.
of 0 to 10, with 0 being no pain and 10
being the worst pain.
T When did the pain first begin? Did it start Sudden pain: Testicular torsion.
suddenly or gradually? Sudden or gradual onset: Epididymitis, prostatitis.

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Assessing the Male Genitourinary System

SYMPTOM ANALYSIS: GENITAL LESIONS

QUESTIONS TO ASK SIGNIFICANCE


P Do you have an STD? Lesions are often seen with STDs.
Do you have HIV/AIDS or are you on Immunosuppression increases susceptibility to HPV.
any immuno suppressive drugs?
Have you been under stress? Stress can trigger recurrence of herpes.
Have you been intimate with anyone
who has an STD?
Q What does the lesion look like? Is it Indurated: Chancre associated with syphilis.
hardened (indurated)? Wart (condylomata): Genital warts (HPV)
Is it wartlike? Small, ruptured: Genital herpes.
Is it a small ulcer?
Has the appearance of the lesion changed?
For example, did it rupture?
R Where are the lesions? Location depends on sexual activity.
Penis, scrotum, rectal area, mouth? Painful/recurring: Genital herpes.
Are the lesions painful? Painless: Syphilitic lesions and penile cancer.
Do you have painful lesions that heal and Dysuria: Genital herpes.
recur?
Is urination painful or difficult (dysuria)?
S How extensive are the lesions? Single small lump or nontender ulcer: Carcinoma of the penis.
Are they single? Two or more? Two or more: Syphilitic chancres.
Multiple? Rashlike (diffuse)? Multiple: Genital warts.
Diffuse: Allergy (e.g., latex), Candida.
T When did you first notice the lesion? Chancre (stage 1 syphilis) lasts 3 to 8 weeks.
How long have you had it? Genital herpes incubation period is 1 to 45 days.
HPV incubation period is 1 to 6 months.

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Assessing the Male Genitourinary System

SYMPTOM ANALYSIS: GENITAL SWELLING

QUESTIONS TO ASK SIGNIFICANCE


P Have you had a recent injury to your Trauma to genitals can cause edema.
genital area? STDs or UTIs are associated with prostatitis or epididymitis
Do you have an STD or a UTI? with subsequent scrotal edema.
Do you have any other medical problems? Medical problems such as CHF and liver disease may cause
Does position affect the swelling? scrotal edema.
Scrotal edema associated with CHF may decrease when
scrotum is elevated.
Q How much swelling is there? Degree of swelling may correlate with the disease.
Do you have a heavy or dragging feeling in Scrotal heaviness: Possible testicular cancer.
your scrotum? Slight dragging feeling: Varicocele.
R Where is the swelling? Scrotal area: May be local problem, such as prostatitis,
epididymitis, or hydrocele; or a systemic problem, such as
CHF, liver disease, or testicular cancer.
Unilateral swelling: Hernia, tumor, or local infection of
epididymis.
Inguinal area: Hernia.
Bilateral scrotal edema: Systemic problems such as CHF.
S How severe is it? Severity may correlate with the disease.
T When did it start? How long have you had Sudden scrotal swelling: Acute or chronic inflammatory
it? Did it occur gradually or suddenly? process, hydrocele, scrotal edema, indirect scrotal hernia,
systemic disease such as CHF or liver disease.
Sudden inguinal area swelling: Hernia.

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Assessing the Male Genitourinary System

SYMPTOM ANALYSIS: PENILE DISCHARGE

QUESTIONS TO ASK SIGNIFICANCE


P Do you have an STD? STDs are a common cause of penile discharge.
Have you had recent trauma to your Genital trauma may cause bloody discharge.
genital area?
Q What color is the discharge? Copious, thick, yellow: Gonorrhea.
How much is there? Mucopurulent: Chlamydia.
What consistency is it? Thin, watery: Prostatitis.
Is it bloody? Bloody: Infection, trauma, or cancer.
Does it have a foul odor? Foul odor: Infection.
R Does your penis hurt? Infections usually associated with pain and dysuria.
Is urination difficult or painful?
S How painful is it? Rate it on a scale of 0 to Severity of pain may correlate with progression of disease.
10, with 0 being no pain and 10 being the
worst possible pain.
T When did the pain start? Establishing timing helps determine stage of disease
How long have you had it? progression.

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Assessing the Male Genitourinary System

SYMPTOM ANALYSIS: URINARY PROBLEMS

QUESTIONS TO ASK SIGNIFICANCE


P Do you have an STD? STDs such as gonorrhea and chlamydia are frequently
Do you have prostate problems? associated with UTIs.
Prostate enlargement may affect urinary patterns.
Q What color is your urine? Cloudy urine: Infection.
Is it bloody? Bloody urine (hematuria): Cystitis or renal damage.

R Is urinating painful or difficult? Dysuria: UTI.


Do you have flank/back pain? Back/flank pain: May indicate that kidneys are involved.
Do you have dribbling? Dribbling/awakening often to void: Possible enlarged prostate.
Do you awaken more than once during
night to void?
S How severe is the pain? Rank it on a scale The acuity of the symptom may correlate with progression of
of 0 to 10, with 0 being no pain and 10 being the problem.
the worst possible pain.
T When did the problem start? Gradual change in urinary patterns: Often seen in older men
Did it start suddenly or gradually? with benign prostatic hypertrophy.
How long has it been going on? Acute onset: Usually associated with infection.

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Assessing the Motor-Musculoskeletal System

SYMPTOM ANALYSIS: PAIN

QUESTIONS TO ASK SIGNIFICANCE


P Is the pain associated with activity? Bone pain is generally not related to movement unless a
Have you had a recent injury? fracture is present.
Have you had a recent illness? It can occur with or without trauma.
Migratory polyarthritis—in which one joint is affected, the
disease subsides, and then another joint becomes involved—
is often caused by acute rheumatic fever, leukemia,
sarcoidosis, or juvenile arthritis.
Do you have any other medical problems? Viral illnesses are commonly associated with muscle aches
and pains. TB and other chronic infections can be present
for years before pain becomes evident.
Q What does the pain feel like? Bone pain is typically described as deep, dull, throbbing, or
intense.
Does it interfere with sleep? Sleeping may be difficult or impossible. Complaints of
cramping or soreness for short or long time periods are
generally associated with muscle pain.
Cramping/muscle pain in lower extremities when walking:
Possible PVD secondary to ischemia of calf or hip muscles.
Muscle pain/weakness: Possible muscular disorder (needs
further evaluation).
Joint pain is usually felt around or in the joint, can be extremely
tender, and is usually worsened by movement. Joint pain
associated with RA usually decreases with movement.
R Can you point to where it hurts? Does the Certain diseases are more prevalent in certain joints (e.g., gout
pain occur anywhere else? in toes and degenerative joint disease [DJD]) in weight-bearing
joints like the hip and knee).
Do you have any other symptoms? Related symptoms give clues to underlying cause (e.g.,
sciatica suggests herniated disc and fever suggests systemic
infection).
S On a scale of 0 to 10, how severe is the Scaling pain may indicate severity and progression of
pain? the problem.
T When did the pain start? Sudden onset in a metatarsophalangeal joint: Suggests gout.
How long have you had it? Pain lasting for several years generally rules out acute
infections and malignancy.
Is it worse at different times of the day? Time of day when pain is worse can help identify disorder.
Worse in morning: Rheumatic disorders.
Worse in morning and lessens by mid-day: Tendinitis.
Worsens as day progresses: Osteoarthritis.

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Assessing the Motor-Musculoskeletal System

SYMPTOM ANALYSIS: WEAKNESS

QUESTIONS TO ASK SIGNIFICANCE


P What were you doing when you first noticed Spinal injury can cause muscle weakness.
the weakness? Pain associated with DJD, RA, and herniated disc can lead
Do you have any other medical problems? to disuse and weakness. Anemia can lead to generalized
Are you taking any medications? weakness. Hypokalemia can cause muscle weakness.
Steroids and digitalis toxicity can cause muscle weakness.
Q Is the weakness interfering with your ability Helps determine effect that weakness has on patient’s life.
to perform daily activities?
R Is the weakness generalized or localized? Generalized weakness: MG, MS.
Brain tumor and stroke can cause weakness; extent
depends on affected area of brain.
Spasticity: MS.
Do you have any related symptoms? Loss of sensation: Peripheral neuropathy.
Pill-rolling tremors, sciatica: Parkinson’s disease,
herniated disc.
S Is the weakness getting worse, better, or Progressive weakness starting in one hand, then moving to the
staying the same? arm, then the other arm, chest, neck, tongue, larynx, and legs
is seen in amyotrophic lateral sclerosis (ALS).
Weakness starting distally and working proximally (feet and
hands) is seen in Guillain-Barré syndrome.
T When did you first notice the weakness? Gradual progression: Peripheral neuropathy, MG, and MS.
Is the weakness constant or temporary? Acute rapid progression: Guillain-Barré syndrome.
Temporary muscle weakness: Seizures and hypokalemia.
Is the weakness better or worse at certain Constant, progressive weakness: MG, MS, peripheral
times of the day? neuropathy.
Weakness associated with MG is worse as day progresses.

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Assessing the Motor-Musculoskeletal System

SYMPTOM ANALYSIS: STIFFNESS

QUESTIONS TO ASK SIGNIFICANCE


P What were you doing before experiencing Stiffness from arthritis occurs after rest and improves with
stiffness? movement.
Does anything make it better? Worse? Humidity and falling barometric pressure increase symptoms
associated with DJD.
Q Does the stiffness prevent you from per- Helps determine effect on patient’s life and identifies possible
forming any daily activities? need for assistive devices or referrals.
R Can you point to areas of stiffness? Identifies joint involvement.
Do you have any other symptoms? Pain/crepitus: DJD.
S Is the stiffness getting better, worse, or Helps determine progression of problem.
staying the same?
T When does the stiffness occur? Stiffness on arising is associated with arthritis.

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Assessing the Motor-Musculoskeletal System

SYMPTOM ANALYSIS: BALANCE AND COORDINATION PROBLEMS

QUESTIONS TO ASK SIGNIFICANCE


P Do you have any medical problems? Parkinson’s disease: Propulsive gait.
If so, what are they? MS, Huntington’s chorea, cerebral palsy: Ataxic gait.
Stroke: Hemiplegic gait.
Diabetic neuropathies and herniated disc: Steppage gait.
Ear problems? Inner ear problems can cause balance disturbances
Are you taking any medications? Toxic levels of phenytoin (Dilantin), tricyclics, and
Have you been exposed to chemicals? anticholinergics can cause ataxia. Chlorpromazine (Thorazine)
If so, what? can cause tremors and ataxia. Arsenic and mercury can
cause ataxia.
Do you drink alcohol? Wernicke’s encephalopathy (thiamine deficiency), often
seen with chronic alcoholism, causes ataxia and may
reverse with treatment.
Have you had a head injury? Head trauma with increased ICP can cause ataxia.
Q What is the balance or coordination An accurate description of the problem may help pinpoint
problem like? the cause.
R Are both your arms and your legs affected? Ataxia can affect both upper and lower extremities.
Do you have any other symptoms? Gait disorders caused by neuropathies or herniated disc
are likely to be more localized.
Associated symptoms depend on cause (e.g., stroke causes
slurred speech, changes in level of consciousness, weakness).
S Has the problem affected your ability Helps determine degree of disability and potential need for
to do everyday tasks? referrals.
T When did you first notice that you were Many chronic neurologic disorders have an insidious onset;
having trouble walking or maintaining some, such
balance? as MS, have periods of remission,
ALERT
Sudden onset of ataxic movements may signal increased ICP
and impending herniation and requires immediate attention.
Check for additional signs of increased ICP, such as vital sign,
papillary, and level of consciousness (LOC) changes.

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Assessing the Sensory-Neurologic System

SYMPTOM ANALYSIS: HEADACHE

QUESTIONS TO ASK SIGNIFICANCE


P What were you doing before the headache Tension headaches associated with stress.
began? Head trauma in past 4 weeks can cause headache from
Are you under a lot of stress? increased ICP or subdural or epidural hematoma.
Have you had a recent head injury? Auras—especially visual—often precede migraines.
Have you had any visual changes? Headache associated with meningitis.
Have you had a recent infection? Uncontrolled HTN with diastolic pressures > 120 mm Hg
Do you have other medical problems, can cause headache.
such as HTN? Hemorrhagic stroke can cause headache.
Have you recently stopped drinking Vascular headaches are associated with caffeine withdrawal.
caffeinated coffee or tea? Do you ever get Chocolate, cheese, and foods containing monosodium
a headache after eating certain foods? glutamate (MSG) can cause headaches.
Are you on any medications? Headaches are a side effect of nitrates.
Does anything make the headache better? Benign tension headaches are usually relieved by rest,
Does anything make the headache worse? OTC analgesics, and stress reduction.
Vascular headaches usually relieved with rest or the drugs
methysergide, propanolol, and ergot or serotonin-receptor drugs.
Headaches from increased ICP improve when person is
standing (compared with being supine).
Headaches associated with increased ICP worsen with
Valsalva’s maneuver.
Q What does it feel like? “Worst headache ever”: Acute onset of cerebral hemorrhage.
Throbbing: Migraine, temporal arteritis.
Tight band around head: Tension headache.
Dull, deep-seated: Brain tumor.
R Can you point to where it hurts? Tight band around head, neck, occipital, and temporal areas:
Have you had changes in LOC? Do you Tension headache.
have any visual changes? Nausea and Pain above, below, and around eyes: Sinus headaches.
vomiting? Occipital pain: HTN.
Have you had weakness, numbness, or Pain localized at abscess or tumor site: Brain abscess or
paralysis? tumor. With tumor, pain becomes more generalized as tumor
Have you had fever or sensitivity to light? grows.
Generalized headache: Meningitis, encephalitis.
Changes in vision or LOC, nausea, and vomiting:
Increased ICP.
Associated with stroke.
Associated with meningitis.

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Assessing the Sensory-Neurologic System

S How bad is the headache? Rate it on a Severe: Intracranial bleeding.


scale of 0 to 10, with 0 being no headache Severe, constant: Meningitis.
and 10 being the
worst-possible headache.
T When did the headache occur? On awakening, decreases during day unless diastolic
How long did it last? > 120 mm Hg: HTN.
Intensifies over few days: Brain abscess.
Fluctuates over weeks and months: Chronic subdural
hematoma.
Rapid onset: Intracranial bleeding.
5 to 15 minutes forewarning, lasts 4 to 6 hours: Migraine.
Sudden onset: Meningitis.

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Assessing the Sensory-Neurologic System

SYMPTOM ANALYSIS: MENTAL STATUS CHANGES

QUESTIONS TO ASK SIGNIFICANCE


P Do you have (or does the patient have): Sepsis and meningitis can cause varying degrees of confusion.
Any medical problems? Confusion can also follow seizures and be caused by fluid and
Any psychiatric problems? electrolyte imbalance.
Change in mental status is an early indicator of hypoxia.
A recent head injury? Concussions, contusions, and hemorrhages can cause
confusion, memory loss, and loss of consciousness.
Use of drugs or alcohol? Use of and withdrawal from drugs and alcohol can cause
confusion.
Are you (or is the patient) on any Lidocaine, digitalis, indomethacin, cycloserine, chloroquine,
medications? atropine, cimetidine, and CNS depressants can cause mental
status changes.
Q How would you describe what you are Accurate descriptions, for example, memory loss, forgetful-
(or the patient is) experiencing? ness, and inability to concentrate, may give clues about
progression.
R Do you (or does the patient) have a fever? Associated with meningitis.
Have nausea and vomiting occurred? Associated with increased ICP.
S How bad is the problem? Is it getting better Mild confusion is an early symptom of hypoperfusion.
or worse? Mild confusion is also an early symptom of brain tumor;
then progresses as tumor grows.
Subtle, progressive memory loss: Alzheimer’s disease.
T When did you first notice the changes? Helps determine acute or insidious onset.
Infection, metabolic imbalances, and hypoxia usually have
acute onset and may reverse with treatment.
Gradual onset: Brain tumors, Alzheimer’s disease.

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Assessing the Sensory-Neurologic System

SYMPTOM ANALYSIS: DIZZINESS, VERTIGO, AND SYNCOPE

QUESTIONS TO ASK SIGNIFICANCE


P What were you doing before you felt Orthostatic hypotension is caused by position change from
dizzy or passed out? supine to upright and can result in dizziness and syncope.
Do you have any cardiovascular or Cardiac arrhythmias can cause dizziness and syncope.
cerebrovascular problems? Dizziness or syncope associated with other neurological
Any respiratory problems? changes can be a sign of TIA or impending stroke.
Are you on any medications? Hypoxia can cause dizziness or syncope.
Have you had any recent head trauma? Some antihypertensives can cause orthostatic hypotension
Does anything make the problem better? with dizziness or syncope.
Antianxiety drugs, antihistamines, narcotics, and vasodilators
can cause dizziness.
Can cause dizziness, vertigo, and syncope.
Persistent vertigo: Temporal bone fracture.
Dizziness occurring 1 to 3 weeks after concussion:
Postconcussion syndrome.
Dizziness or syncope associated with postural hypotension
is relieved by lying down.
Q What does the problem feel like? Helps differentiate vertigo from dizziness.
R Do you have any other symptoms Nausea and vomiting often occur with vertigo.
along with dizziness and vertigo? Visual, motor, and sensory deficits along with
Do you black out? dizziness/vertigo: MS, head trauma, stroke.
S How bad is the problem? Progressive episodes of dizziness or syncope may indicate
TIA or impending stroke.
T When did the problem first occur? How often Establishes progression of problem.
does it happen? How long does it last? TIAs can last from a few minutes to 24 hours.
Postconcussion syndrome occurs 1 to 3 weeks after injury.

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Assessing the Sensory-Neurologic System

SYMPTOM ANALYSIS: PARESTHESIA

QUESTIONS TO ASK SIGNIFICANCE


P Do you have a history of vascular Arterial occlusion, arterial obliterans, Buerger’s disease,
problems? Raynaud’s disease, and diabetic neuropathies can cause
Have you had a recent traumatic injury to paresthesia.
your head or spine? Paresthesia is associated with TIAs and stroke.
Are you taking any medications? Diabetic neuropathies cause paresthesia.
Spinal cord injuries and head trauma can cause paresthesia.
Phenytoin, intravenous gold chemotherapeutic drugs,
isoniazid, nitrofurantoin, D-penicillamine, and chloroquine
can cause paresthesia. Effects reverse when drugs are
discontinued.
Q Is the paresthesia getting better or worse? Establishes progression of problem and possible
Are you able to perform daily tasks? need for referral.
R Where does the paresthesia occur? Hands: Raynaud’s disease.
Hands? Arms? Legs? Feet: Buerger’s disease.
Are you having weakness? Leg: Herniated lumbar disk.
Arm: Cervical disc.
Bilateral: Spinal cord trauma or tumors.
Unilateral: TIA, stroke.
Hemiparesis: Stroke.
Weakness: Peripheral neuropathy.
T When did the weakness start? Sudden onset: Stroke, trauma.
How long has it been going on? Gradual onset: Peripheral neuropathies.
How often do you have it? Progressive contralateral: Brain tumor.
Transient: TIA, MS.

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Assessing the Sensory-Neurologic System

SYMPTOM ANALYSIS: VISION CHANGES

QUESTIONS TO ASK SIGNIFICANCE


P What were you doing before your vision Head or eye trauma can cause visual deficits.
changed? HTN, stroke, diabetes, MS, and temporal arteritis can cause
visual deficits.
Have you had any recent eye or head Visual auras often precede migraine headaches.
trauma? Meningitis can cause photosensitivity.
Do you have any medical problems? Visual changes can be caused by specific eye diseases such as
Have you had headaches? glaucoma or macular degeneration (see Chapter 12, Assessing
Have you had a recent infection? the Eye and the Ear).
Do you have any eye problems? Chloroquine, digitalis, indomethacin, ethambutol, quinine sulfate,
Are you on any medications? cycloplegics, guanethidine, resperine, chlomiphene,
phenylbutazone, thiazides, antihistamines, anticholinergics,
and phenothiazines can cause visual changes.
Q Can you describe the vision change? An accurate description of visual deficit is helpful in identifying
Is it getting better or worse? problem.
R Have you had any confusion or changes Change in LOC: Brain tumors, stroke, concussion.
in your LOC?
S How bad is the vision problem? Severity may correlate with progression of problem
Are there visual field cuts or total loss of (e.g., brain tumor).
vision?
T When did the vision problem start? Time of onset is important. Visual deficits may be temporary
How long did it last? or permanent depending on cause.
Temporary vision changes: TIA, stroke, migraine, concussion.
Permanent vision changes: Retinal arterial occlusion, macular
degeneration, brain tumor.

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Assessment Checklist: Integumentary System

HISTORY
Remember to look at each history component as it relates to the integumentary system. Ask the patient the following:
Do you have:
Changes in moles or other lesions? Nonhealing sore or chronic ulceration?
Pruritus/itching? Rashes?
Changes in skin, hair, or nails?
Do you have any food, drug, or environmental allergies?
Do you have any medical problems?
Are you on any medications, prescribed or over the counter (OTC)?

PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Gloves Penlight
Ruler Marker
Magnifier

POSITION
Assess all areas, changing position as needed.

TECHNIQUE
First, scan your patient, checking for specific signs of diseases affecting other organ systems that might
alter the skin, hair, or nails.

INSPECTION/PALPATION
Skin
Inspect:
Color Odor
Integrity Lesions, if any (if found, describe morphology,
distribution, pattern, and location).
Palpate:
Temperature Turgor
Texture Moisture
If lesions found on inspection, palate them for texture, tenderness, pulsations, blanching.
Hair
Inspect:
Color Quantity
Distribution Condition of scalp
Lesions Pediculosis
Palpate:
Texture Scalp for tenderness, mobility

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Assessment Checklist: Integumentary System

Nails
Inspect:
Color Condition
Shape Angle of attachment
Palpate:
Texture Capillary refill

DOCUMENTATION
Document your findings.

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Assessment Checklist: Head, Face, and Neck

HISTORY
Remember to look at each history component as it relates to the head, face, and neck. Ask the patient the following:
Do you have:
Head pain/headaches? Jaw tightness and pain?
Neck pain and stiffness? Neck mass?
Nasal congestion? Nosebleed?
Mouth and dental pain? Sore throat?
Hoarseness?
Do you have problems or complaints related to your head, face, nose, mouth, throat, or neck?
Do you have allergies to any medications, foods, or environmental factors?
Do you have any health problems?
Are you taking any medications, prescribed or OTC?

PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Glove Penlight
Tongue blade Gauze
Stethoscope Otoscope
Transilluminator Cup of water

POSITION
Sitting

TECHNIQUE
First, scan your patient from head to toe, checking for specific signs of diseases affecting other organ
systems that might alter the head, face, and neck.

INSPECTION, PALPATION, PERCUSSION, AUSCULTATION


Head
Inspect:
Size, shape, and symmetry
Facial appearance, symmetry of facial features, lesions, hair distribution, and abnormal movements
Palpate
Tenderness, masses Temporomandibular joint (TMJ)
Sinuses
Inspect:
Edema Transilluminate sinuses
Palpate:
Tenderness
Percuss:
Tenderness

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Assessment Checklist: Head, Face, and Neck

Nose
Inspect:
Position, septal deviation, discharge, flaring
Nasal mucosa color, intact septum, turbinates, polyps
Palpate:
Patency
Mouth And Throat
Inspect:
Lips: Color, lesions, purse-lip, odor Oral mucosa: Color, lesions
Gingivae: Color, bleeding, retraction, Teeth: Occlusion, number, condition, color
hypertrophy
Tongue: Color, lesions, texture, Oropharynx/soft and hard palate/tonsils: Color,
position, mobility condition lesions, drainage, exudates
Palpate:
Lips and tongue: Tenderness, muscle tone, lesions
Oropharynx: Test gag reflex
Neck
Inspect:
Neutral position, hyperextended, and as patient swallows
Note range of motion (ROM), symmetry, condition of skin.
Palpate:
Cervical lymph nodes: Occipital, postauricular, preauricular, tonsillar, submandibular, submental,
superficial, deep, posterior, supraclavicular, infraclavicular
Thyroid gland: Anterior or posterior approach
Auscultate:
Thyroid: If palpable, listen for bruits with the bell over the thyroid.

DOCUMENTATION
Document your findings and develop your plan of care.

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Assessment Checklist: Eyes

HISTORY
Remember to look at each history component as it relates to the eyes. Ask the patient the following:
Do you have:
Vision loss? Eye pain?
Double vision? Eye tearing?
Dry eyes? Eye drainage?
Eye appearance changes? Blurred vision?
Have you noticed any changes in your vision?
Do you wear glasses or corrective lenses?
Have you ever had eye surgery? Injury?
Have you ever seen spots or floaters, flashes of light, or halos around lights?
Do you have a history of recurrent eye infections, styes?
When was your last eye exam?
Do you have a history of diabetes or hypertension (HTN)?
What medications are you currently taking?
Do you take any prescribed or OTC eye drops?

PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Visual acuity chart (Snellen) Color vision chart
Ophthalmoscope Penlight
Cotton swab/ball Gloves if indicated

POSITION
Sitting
TECHNIQUE
First, scan your patient from head to toe, checking for specific signs of diseases affecting other organ
systems that might alter the eyes.

INSPECTION, PALPATION, OPHTHALMOSCOPY

Visual Acuity
Test far (distant) vision. Test near vision.
Test peripheral vision. Test color vision.
Extraocular Muscles
Check parallel alignment and corneal Check for lid lag.
light reflex.
Test six cardinal fields. Perform cover-uncover test.

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Assessment Checklist: Eyes

External Structures
Inspect:
General appearance Eyelids and lashes: Position and distribution
Eyeballs: Protrusion Lacrimal glands and ducts: Swelling, redness,
or drainage
Conjunctiva (bulbar and palpebral): Sclera: Color
Color, foreign objects
Cornea: Clarity, abrasions, corneal reflex Iris: Color, size, equality
Pupils: Size, equality, reaction to light,
and accommodation
Palpate:
Eyeballs: Consistency
Lacrimal glands and ducts: Tenderness
Ophthalmoscopy
Inspect:
Red light reflex Optic disc: Color, shape, borders
Physiological cup: Color, size Vessels (arteries and veins): Color, size, crossings
Retina (fundus): Color, lesions Macula: Color, fovea centralis, lesions

DOCUMENTATION
Document your findings and develop your plan of care.

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Ears

HISTORY
Remember to look at each history component as it relates to the ears. Ask the patient the following:
Do you have:
Hearing loss? Vertigo?
Tinnitus? Ear drainage?
Earache?
Do you have problems with your ears, such as ringing? Do you have hearing problems?
Do you have balance problems?
Do you have drainage from your ears? If yes, how much and what color?
Have you had recent head trauma?
Do you have any health problems?
Are you exposed to noise pollution at work or in your home environment?
Are you on any prescribed or OTC medications?
Do you have allergies?

PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Tuning fork Otoscope with pneumatic attachment
Thermometer Watch
Gloves if indicated

POSITION
Sitting for adult; supine for infant or toddler to stabilize head

TECHNIQUE
First, scan your patient from head to toe, checking for specific signs of diseases affecting other organ
systems that might alter the ear.

INSPECTION, PALPATION, OTOSCOPIC EXAM, HEARING TESTS


External Ear
Inspect:
Angle of attachment Size, shape, symmetry
Condition of skin, drainage
Palpate:
Consistency, tenderness, nodules Helix, tragus, mastoid process

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Ears

Otoscopic Exam
External Ear Canal
Inspect:
Color, drainage, foreign objects, lesions
Tympanic Membrane
Inspect:
Color, position of landmarks, integrity of tympanic membrane ™, mobility of TM
Hearing Tests (Test Each Ear Separately)
Whisper Voice Test Ticking Watch Test
Weber Test Rinne Test

DOCUMENTATION
Document your findings and develop your plan of care.

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Respiratory System

HISTORY
Remember to look at each history component as it relates to the respiratory system. Ask the patient the following:
Do you have:
Cough? Dyspnea?
Chest pain? Related symptoms, such as edema and fatigue?
Do you have any history of respiratory disease? If so, are you taking any medication? What are they,
and why are you taking them?
Do you have any other medical problems?
Do you use tobacco? If so, what kind? How much tobacco do you use? How long have you been using it?
What is your occupation?
Where do you live?
When was your last purified protein derivative (PPD)? What was the result?
Have you ever had a chest x-ray? If so, what were the results?
Have you ever been immunized for influenza or pneumonia?

PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Stethoscope Marker
Ruler

POSITION
Sitting

TECHNIQUE
First, scan your patient from head to toe, checking for specific signs of diseases affecting other organ
systems that might alter the respiratory system.
INSPECTION, PALPATION, PERCUSSION, AUSCULTATION
Apply techniques:
Anterior, posterior, lateral Side to side
Apex to base
Chest
Inspect:
Shape and symmetry Muscles for breathing
Anteroposterior:lateral ratio Respiratory rate, rhythm
Costal angle Spinal deformities
Condition of the skin
Palpate:
Tenderness, masses, crepitus Excursion
Fremitus

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Respiratory System

Percuss:
Identify percussion sound. Note diaphragmatic excursion.
Auscultate:
Note breath sounds. Note abnormal sounds.
Notes adventitious sounds. Note abnormal voice sounds.
Trachea
Palpate:
Position

DOCUMENTATION
Document your findings and develop your plan of care.

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Cardiovascular System

HISTORY
Remember to look at each history component as it relates to the cardiovascular (CV) system. Ask the patient the following:
Do you have:
Chest pain? Palpitations?
Syncope? Edema?
Fatigue? Extremity changes?
Dyspnea and cough?
Are you having any chest discomfort? If yes, when did it start?
What were you doing before the pain started? Did anything make it better or worse?
Have you ever had this pain before? What does it feel like? Where does it hurt? On a scale from 1 to 10,
with 10 being the worst, how severe is the pain?
Do you have a history of CV disease? If yes, are you taking any medications? If yes, what are you taking
and why?
Do you have any other medical problems?
Are you having any breathing difficulties?
Do you have any allergies? If, yes, describe reaction.

PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Stethoscope with the ability to detect Sphygmomanometer
high- and low-pitched sounds
Marker Ruler

POSITION
Supine, sitting, left lateral recumbent

TECHNIQUE
First, scan your patient from head to toe, looking for signs related to the CV system.

INSPECTION, PALPATION, PERCUSSION, AUSCULTATION


Neck
Inspect:
Locate carotid and jugular pulsations and differentiate.
Measure jugular venous pressure (JVP).
Palpate:
Carotid arteries Jugulars
Test abdominojugular reflex.
Auscultate (With Diaphragm and Bell):
Bruits or venous hums

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Cardiovascular System

Precordium
Inspect:
Apex for pulsations Precordium for pulsations or movement
Palpate:
Locate point of maximum impulse (PMI; left ventricular impulse [LVI]).
Pulsations, lifts, heaves, thrusts, thrills
Percuss: Cardiac dullness
Auscultate (With Diaphragm and Bell):
Each auscultatory site: apex, left lower sternal border, base left, base right
Apex
Auscultate (With Diaphragm and Bell):
Rate, rhythm, S1, S2, extra sounds

DOCUMENTATION
Document your findings and develop your plan of care.

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Peripheral-Vascular And Lymphatic Systems

HISTORY
Remember to look at each history component as it relates to the peripheral-vascular (PV) and lymphatic systems.
Ask the patient the following:
Do you have:
Swelling? Limb pain?
Changes in sensation? Fatigue?
Have you noticed pain, pallor, pulselessness, polar sensation (coldness), paresthesias, or paralysis in
an extremity (the “six Ps” of acute occlusion)?
Do you have aching, heaviness, throbbing or burning pain, itching, or cramping in your legs?
Are your ankles swollen? Is it difficult to fit into your shoes or wear your wedding band lately?
Do you have leg pain when walking or at rest? What makes the leg pain better?
Have you noticed any sores or ulcers on your feet or legs? How long have they been there? What have
you used to treat them?
Do you have a history of high blood pressure, high cholesterol, CV or PV disease, or diabetes mellitus?
Do you smoke? If so, how long and how much?
Have you noticed any swelling in your neck, armpits, or groin? If so, are the swollen areas sore, hard, or red?
Do they appear on both sides of your body?
Are you unusually tired? If so, are you tired all the time or only after exertion? Do you need frequent naps,
or do you sleep an unusually long time at night?
Have you had a fever recently? If so, how high was it? Was it constant or intermittent? Did it follow a pattern?
Do you ever have joint pain? If so, which joints are affected? Does swelling, redness, or warmth accompany
the pain? Do your bones ache?
Have you noticed any sores that heal slowly?
Do you have a history of blood transfusions?
Have you ever been diagnosed with a chronic infection?

PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Stethoscope with the ability to detect Sphygmomanometer
high- and low-pitched sounds
Marker Ruler

POSITION
Supine, sitting, standing

TECHNIQUE
Remember to scan your patient from head-to-toe, looking for signs related to the PV/lymphatic systems.

INSPECTION, PALPATION, AUSCULTATION


Inspect:
Upper extremities: Color, condition of skin; capillary refill
Abdomen: Shape, pulsations, veins

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Peripheral-Vascular And Lymphatic Systems

Lower extremities: Color, condition of skin; hair growth; veins; edema


Palpate:
Pulses: Note rate, rhythm, contour, elasticity, equality, amplitude
Temporal Carotid
Brachial Radial
Ulnar Femoral
Popliteal Dorsalis pedis
Posterior tibialis
Lymph nodes
Cervical Epitrochlear
Inguinal
Auscultate:
Arteries for bruits Blood pressure

DOCUMENTATION
Document your findings and develop your plan of care.

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Breasts

HISTORY
Remember to look at each history component as it relates to the breasts. Ask the patient the following:
Do you have:
Lump or mass? Pain or tenderness?
Nipple discharge?
Do you have a lump or thickening in or near your breast or under your arm that persists through the
menstrual cycle?
Is the skin on your breast or nipple red, dimpled, puckered, scaly, or inflamed?
Do you have nipple changes? For example, a change in the direction in which one nipple points,
inversion, eversion, or discharge?
Has your breast changed in size, shape, or contour?

PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Small pillow Mirror
Gloves Ruler
Specimen slide and culture swab

POSITION
Supine with small pillow under shoulder of breast being examined.
Sitting arms at side, arms over head, hands on hips, leaning forward.

TECHNIQUE
Remember to scan your patient from head-to-toe, looking for signs related to the breasts.

INSPECTION, PALPATION
Breasts
Inspect (Different Positions):
Size, shape, symmetry Condition of skin, lesions, venous pattern
Palpate (Vertical Strip, Pie Wedge, or Concentric Circles Methods):
Consistency Tenderness
Masses
Nipple
Inspect:
Inversion/eversion Direction
Discharge Axilla
Condition of skin Lesions
Palpate:
Elasticity Tenderness
Discharge

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Breasts

Axilla And Nodes


Palpate:
Central, lateral, posterior, anterior, epitrochelar, and clavicular nodes

DOCUMENTATION
Document your findings and develop your plan of care.

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Abdomen

HISTORY
Remember to look at each history component as it relates to the abdomen. Ask the patient the following:
Do you have:
Abdominal pain? Change in bowel patterns?
Nausea? Indigestion?
Vomiting? Weight changes?
Have you ever had the following: stomach ulcer, hemorrhoids, hernia, bowel disease, cancer, hepatitis,
cirrhosis, or appendicitis?
Have you had abdominal surgery? If so, when, what type, and were there any subsequent problems?
Do you have a family history of ulcer, gallbladder disease, bowel disease, or cancer?
Do you have any problems with swallowing, heartburn, yellowing of your skin, gas, or bloating?
Do you have any food allergies or lactose intolerance?
What is your usual weight and height?
How is your appetite? What did you eat in the last 24 hours?
How is your health usually?
Are you currently being treated for a health problem? If so, what?
How often do you usually have a bowel movement?
Are you having problems with diarrhea, constipation, hemorrhoids, or fecal incontinence? Have you
ever noticed blood in your stool or had black, tarry stools?
How often do you urinate? Do you have incontinence or burning when you urinate?
When was your last menstrual period?
Do you smoke? How many packs a day? (Calculate pack-years.)
Do you drink alcohol? If so, how often? Do you use street drugs?
How many cups of coffee, tea, or caffeinated soda do you drink every day?
Have you been exposed to an infectious disease recently?
What is your occupation?
Have you been immunized against hepatitis B?
Have you ever had a blood transfusion? If so, when?
Do you take any prescribed medications? What are they?
Do you have any allergies to medications?
What OTC medicines or herbal preparations do you use?
Do you use antacids, laxatives, enemas, nonsteroidal anti-inflammatory drugs (NSAIDs), or aspirin?
What home remedies do you use?

PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Stethoscope with the ability to detect Marker
high- and low-pitched sounds
Ruler Reflex hammer or tongue blade

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Abdomen

POSITION
Supine

TECHNIQUE
Remember to scan your patient from head-to-toe, looking for signs related to an abdominal assessment.

INSPECTION, AUSCULTATE, PERCUSSION, PALPATION


Inspect (From Several Different Angles):
Abdomen
Size, shape, symmetry Movements (respiratory, pulsations, peristalsis)
Condition of skin, lesions Hernias
Umbilicus
Inverted/everted, position
Auscultate:
Abdomen
Bowel sounds: Frequency Vascular sounds: Bruits, venous hums
Friction rubs
Percuss:
Abdomen Liver (scratch test)
Spleen Costovertebral angle (CVA) tenderness
Palpate (Light):
Abdomen for tenderness Surface characteristics
Lymph nodes
Palpate (Deep):
Abdomen for tenderness or masses Organs (liver, spleen, kidneys, aorta, bladder)

ADDITIONAL ABDOMINAL ASSESSMENT TECHNIQUES


Testing for ascites
Shifting dullness Fluid wave
Measuring abdominal girth and weight
Abdominal reflexes
Ballottement
Kehr’s sign
Ballance’s sign
Murphy’s sign
Signs for appendicitis
Rebound tenderness Obturator test
Rovsing’s sign Cutaneous hypersensitivity
Iliopsoas Sign

DOCUMENTATION
Document your findings and develop your plan of care.

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Female Genitourinary System

HISTORY
Remember to look at each history component as it relates to the female genitourinary (GU) system. Ask the patient
the following:
If premenopausal, when as your last menstrual period?
Do you have any pain? Location?
Can you describe your menstrual cycle? What as your age of menarche? What was age at menopause?
Do you have any abnormal vaginal bleeding?
What are your sexual practices? How many partners have you had? What type of sexual activity, oral,
genital, anal? What is your sexual preference, heterosexual, homosexual, or bisexual? Do you practice safe
sex? What do you use? Do you use contraceptives? If, yes, type?
What is your obstetrical history? Have you ever been pregnant? Number of live deliveries? Number of
miscarriages? Abortions? Age of first full-term pregnancy?
Do you have any vaginal discharge? If so, can you describe it?
Do you have a history of GU surgery, sexually transmitted diseases (STDs), or cancer?
Are you currently taking any medications? Hormone replacement therapy (HRT)? Birth control pills (BCP)?
Do you have any urinary symptoms, such as burning, frequency, or dysuria?

PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Gloves Drape
Lightening Vaginal speculum
Cytological materials for Pap test Culture plates
Reagents Hemoccult test
Warm water Water-soluble lubricant
POSITION
Lithotomy

TECHNIQUE
Remember to scan your patient from head-to-toe, looking for signs related to the female GU system.

INSPECTION, PALPATION, SPECULUM EXAM


Inspect:
External genitalia
Hair distribution Skin
Clitoris Urethral meatus
Vaginal introitus Perineum and anus
Internal genitalia
Cervix Obtain specimens
Vaginal wall

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Female Genitourinary System

Palpate:
External genitalia
Labia Bartholin’s and Skene’s glands
Vaginal introitus Perineum
Internal genitalia
Vaginal wall Cervix
Fornices Uterus
Adnexa Rectovaginal exam: Obtain specimens,
hematest stool if present.

DOCUMENTATION
Document your findings and develop your plan of care.

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Male Genitourinary System

HISTORY
Remember to look at each history component as it relates to the GU system. Ask the patient the following:
Do you have penile pain? Do you have any lesions? If yes, please describe.
Could you tell me about your sexual practices? Do you practice oral, genital, or anal sex?
How many partners have you had? What is your sexual preference: heterosexual, homosexual, or bisexual?
Do you practice safe sex? What do you use?
Do you have any discharge? Type?
Did you have a history of GU surgery, STDs, or cancer?
Are you taking any medications? If, yes, what are the medications?
Do you have any medical problems, such as diabetes mellitus, HTN, or PV disease?
Do you have any problems with urination, such as burning, frequency, dysuria, or hematuria?

PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Gloves Penlight
Stethoscope Cotton swab or gauze
Urogenital alginate swabs and Hemoccult test
Thayer-Martin plate
Water-soluble lubricant

POSITION
Supine or standing for genitalia assessment; side-lying or leaning over exam table for rectal exam

TECHNIQUE
Remember to scan your patient from head-to-toe, looking for signs related to male GU assessment

INSPECTION, PALPATION, AUSCULTATION


Inspect:
Genitalia Hair distribution
Penis Scrotum
Urethral meatus Inguinal area
Palpate:
Penis Scrotum and testes
Horizontal and vertical lymph nodes Hernias (inguinal, femoral)
Rectum Prostate
Auscultate:
Scrotum, if hernia present
Obtain Specimens for Diagnostic Tests:
Hematest stool if present.

DOCUMENTATION
Document your findings and develop your plan of care.

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Motor-Musculoskeletal System

HISTORY
Remember to look at each history component as it relates to the motor-musculoskeletal system. Ask the patient
the following:
Do you have:
Pain? Weakness?
Stiffness? Balance or coordination problems?
Other related symptoms?
Do you have a history of musculoskeletal problems, pain, or disease? If yes, are you taking any medications
or undergoing any treatments?
Do you have any other medical problems?
Are you taking any medications, either prescribed or OTC?
Have any accidents or trauma ever affected your bones or joints?
Do your joint, muscle, or bone problems limit your usual activities?
Do you have any occupational hazards that could affect your muscles and joints?
Have you been immunized for tetanus and polio?
Do you smoke or consume alcohol or caffeine? If yes, how much and how often?

PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Tape measure Goniometer

POSITION
Standing, sitting, supine

TECHNIQUE
Remember to scan your patient from head-to-toe, looking for signs related to a motor musculoskeletal
assessment.
INSPECTION, PALPATION, PERCUSSION
Inspect and Palpate:
Posture
Normal spinal curves (cervical, thoracic, lumbar, sacral)
Test for spinal deformities (kyphosis, scoliosis, lordosis)
Gait
Cerebellar function
Balance (gait, tandem walk, heel-and toe-walk, deep knee bend, hop in place, Romberg test)
Coordination (rapid alternating movements [RAM], finger-thumb opposition, toe tapping, heel down shin)
Accuracy of movements (finger to nose, point-to-point localization)
Measurements
Arm lengths from acromion process to tip of middle finger
Arm circumferences
Leg lengths from anterior superior iliac crest to medial malleolus
Leg circumferences

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Motor-Musculoskeletal System

Muscles
Tone (relaxed and contracted state) of upper and lower extremities
Muscle strength
Joints
ROM, edema, redness, tenderness, crepitus, deformities, stability
Additional tests
Carpal tunnel syndrome: Phalen test or Tinel test
Arm weakness: Pronator drift
Spinal problems: Straight leg raise
Hip problems: Thomas test, Trendelenburg test
Knee problems: Bulge sign, Lachman test, draw sign, McMurray’s test, Apley’s test
Percuss:
Knee for fluid (patellar tap)

DOCUMENTATION
Document your findings and develop your plan of care.

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Sensory-Neurologic System

HISTORY
Remember to look at each history component as it relates to the sensory-neurologic system. Ask the patient
the following:
Do you have:
Headache? Mental status change?
Dizziness, vertigo, and syncope? Numbness or loss of sensation?
Deficits in the five senses?
Do you have any neurologic problems?
Do you have any other medical problems?
Are you taking any medications?
Do you have a history of head trauma, loss of consciousness, dizziness, headaches, or seizures?
Do you have memory problems or changes in your senses?
Do you have weakness, numbness, or paralysis?
Do you have problems walking or performing activities of daily living (ADLs)?
Do you have mood problems or depression?
Do you use drugs or alcohol?
Do you have allergies?
Have you ever been treated for a neurologic or psychiatric problem?
When did your symptoms start?

PHYSICAL EXAM
EQUIPMENT
Gather equipment needed for the exam:
Stethoscope Blood pressure cuff
Penlight Gloves
Cotton Tooth pick
Coin Substances to test smell and taste
Tongue blade Reflex hammer
POSITION
Sitting

TECHNIQUE
Remember to scan your patient from head-to-toe, looking for signs related to sensory-neurologic
system assessment.

ASSESSING CEREBRAL FUNCTION


Behavior
Level of consciousness (LOC), orientation to time, place, and person
Mental status and cognitive function
Memory (immediate, recent, remote) Mathematical and calculative ability
General knowledge and vocabulary Thought process
Abstract thinking Judgment
Communication

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Assessment Checklist: Sensory-Neurologic System

ASSESSING CRANIAL NERVES I THROUGH XII


Sensory
Superficial sensations: Light touch, pain, temperature
Deep sensations: Vibration and kinesthetics
Discriminatory sensations: Stereognosis, graphesthesia, two-point discrimination, extinction,
point-to-point localization
Reflexes
Deep tendon reflexes: Biceps, triceps, brachioradialis, patellar, Achilles
Superficial reflexes: Abdominal, plantar, cremasteric, anal, bulbocavernous
Primitive
Meningeal Signs

DOCUMENTATION
Document your findings and develop your plan of care.

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Abduction - Akinesia

A
Abduction
Movement away from the midline.
Acne Vulgaris
Inflammation of the sebaceous glands and hair follicles characterized by papules, pustules, or comedones;
common acne.
Acoustic Neuroma
Benign tumor that grows into the auditory canal involving CN VIII.
Acrochordons
Small, benign polyp growths; skin tags.
Acrocyanosis
Peripheral cyanosis caused by thermoregulation adjustments in newborns.
Acromegaly
Chronic disease in middle-aged adults marked by enlargement of facial bones caused by hyperfunction of the
anterior pituitary, resulting in increased growth hormone.
Actinic Keratosis
Horny, precancerous lesion caused by sun exposure.
Actual Nursing Diagnosis
Identifies an occurring health problem.
Addison Disease
Disease that results in adrenal insufficiency.
Adduction
Movement toward the midline.
Adie’s Pupil
Tonic pupil that responds slowly or not at all with impaired accommodation; affected pupil is frequently larger
than the normal.
Adnexa
Pertaining to the ovaries and fallopian tubes.
Afterload
Volume of blood remaining in the ventricle after contraction; end-systolic pressure.
Agnosia
Inability to recognize an object by sight (visual agnosia), touch (tactile agnosia), or hearing (auditory agnosia).
Agnostic
Person who does not believe in God.
Akathisia
Restlessness, urgent need to move; an extrapyramidal side effect of some antipsychotic medications.
Akinesia
Complete or partial loss of voluntary muscle movement.

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Alopecia - Apley’s Test

Alopecia
Hair loss. Alopecia can be cicatricial (caused by scarring) or noncicatricial (caused by hormonal changes,
medications, infections, or thyroid disease).
Alopecia Areata
Patchy loss of hair.
Alzheimer’s Disease
Chronic, progressive disorder, accounts for 50 percent of all dementias.
Amaurosis Fugax
Temporary loss of vision in one eye, as if a “shade is being pulled down.”
Amenorrhea
Absence or suppression of menstruation.
Anagen
Growth phase of hair development.
Analgesia
Absence of the normal response to pain.
Aneurysm
Abnormal dilatation of a blood vessel.
Angioedema
Development of urticaria and edema of the skin, mucous membranes, or viscera; usually benign.
Angiomas
Vascular spiders, dilated capillaries on the skin, usually seen on neck, chest, face, and arms.
Anisocoria
Inequality in pupil size.
Anorexia Nervosa
Eating disorder characterized by a preoccupation with being thin and dieting, leading to excessive weight loss.
Anosmia
loss of the sense of smell.
Anoxia
Absence of oxygen.
Anthropometry
Measurements of the human body, such as height, weight, skin folds, craiometry, and osteometry.
Apgar
System for evaluating an infant’s physical condition at birth; includes heart rate, respirations, muscle tone,
response to stimuli, and color.
Aphasia
Absence or the impairment of ability to communicate through speech, writing, or signs.
Aphthous Ulcer
A painful oral lesion related to stomatitis cause unknown fever, stress, certain foods may precede lesion.
Apley’s Test
Test for torn meniscus of the knee.

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Apnea - Ballance Sign

Apnea
Absent breathing.
Apneustic Breathing
Prolonged gasping inspirations followed by extremely short, inefficient expiration.
Appendicitis
Inflammation of the appendix.
Apraxia
Inability to carry out learned sequential movements or commands.
Arcus Senilis
White ring around the cornea from fat deposits; seen in older adults.
Arthritis
Inflammation of the joints, accompanied by pain, swelling, and deformity.
Ascities
Accumulation of serous fluid in the peritoneal cavity.
Assessment
Data collection phase of the nursing process.
Asthma
Reactive airway disease causing inflammation and obstruction of the airways.
Astigmatism
Corneal irregularity causes diffuse refraction of light rays.
Ataxia
Poor muscle coordination with voluntary movements.
Atheist
Person who denies the existence of God.
Atopic Dermatitis
Inflammation and itching of the skin of unknown cause.
Atrophy
Wasting or decrease in size.
Auscultation
Physical assessment technique that uses the sense of hearing to collect data. Auscultation may be direct or
indirect with use of a stethoscope.
Automaticity
Unique property of cardiac muscle tissue to contract without nervous stimulation.

B
Babinski Reflex
Dorsiflexion of the great toe when the sole of the foot is stimulated.
Ballance Sign
Dullness and tenderness when percussing left upper quadrant is a positive sign of peritoneal irritation or
injury to spleen.

Copyright 2007 © F.A. Davis Company, www.fadavis.com


Ballottement - Bris

Ballottement
Physical assessment technique that involves bimanual palpation of a partially free-floating object. Deep
palpation is applied in one area, causing the partially attached object to become palpable in another area.
Barlow-Ortalini’s Maneuver
Test for congenital dislocation of the hip.
Barrel Chest
Chest shape in which the anteroposterior-to-lateral diameter ratio is 1:1 rather than the normal 1:2 in an adult;
usually associated with chronic lung disease.
Basal Cell Carcinoma
common form of skin cancer; flesh-colored with rolled borders; usually seen on sun-exposed areas.
Beau’s Lines
White, transverse lines across the nail.
Bell’s Palsy
unilateral facial paralysis involving the facial (VII) cranial nerve.
Benign Prostatic Hypertrophy (BPH)
Benign enlargement of the prostate gland.
Biot’s Breathing
Breathing pattern marked by short breaths followed by long, irregular periods of apnea.
Bipolar Disorder
Disorder marked by manic and depressive episodes.
Blepharoconjunctivitis
Inflammation of the eyelids and conjunctiva.
Blunt or Fist Percussion
Percussion technique used to identify organ tenderness by directly or indirectly striking a body surface with
the ulnar surface of the fist.
Body Mass Index (BMI)
Accurate indicator of body fat; calculated from height and weight measurements.
Bouchard’s Nodules
Bony enlargements or nodules on the proximal interphalangeal joints.
Boutonnière deformity
Flexion of the proximal interphalangeal joint and hyperextension of the distal interphalangeal joint.
Bradypnea
Respiratory rates below normal.
Braxton-Hicks contractions
Probable sign of pregnancy; painless, irregular uterine contractions that start after the fourth month of
pregnancy and last through the remainder of the pregnancy.
Bris
Jewish religious ceremony for circumcision of the male that usually occurs 8 days after birth.

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Bronchial Breath Sound - Callus

Bronchial Breath Sound


Normal breath sound with a shorter inspiratory phase and longer expiratory phase; high-pitched, loud intensity;
heard over the trachea.
Bronchitis
Type of obstructive lung disease with excessive mucous production producing a recurrent, persistent cough.
Bronchophony
Abnormal voice sound; clearer transmission of spoken voice sounds over the affected area.
Bronchovesicular Breath Sound
Normal breath sound with equal inspiratory and expiratory phases; medium pitch and intensity; heard over
the mainstem bronchi.
Brudzinski’s Sign
Flexion of the hip when the neck is flexed from a supine position; sign of meningitis.
Bruit
Abnormal, low-pitched, vascular sound heard best over narrowed arteries.
Brushfield Spots
Gray or pale yellow speckling of the iris; may be seen in children with Down syndrome.
Buerger’s Disease
Chronic, recurring inflammatory vascular occlusive disease of the peripheral arteries and veins of the extremities.
Buffalo Hump
Deposit of fat on the midcervical and upper thoracic area of the back; usually caused by excessive adrenocortical
hormone production or therapy.
Bulbar Conjunctiva
Conjunctiva that covers the eyeball up to the edge of the cornea.
Bulge Test
test for fluid in the patellar space.
Bulimia Nervosa
Eating disorder characterized by uncontrollable binge eating of excessive amounts of foods alternated with
purging in an attempt to lose weight.
Bulla
Pprimary lesion; fluid-filled lesion greater than 1 cm in size.
Bunions
Inflammation and thickening of the bursa of the joint of the great toe.
Bursitis
Inflammation of the bursa sac.

C
Café-Au-Lait Spots
Pale brown areas of increased melanin on the skin; appear during infancy but often fade with age.
Callus
Painless thickening of the skin over pressure points.

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Candidiasis - Cheyne-Stokes Breathing

Candidiasis
Infection of the skin or mucous membranes caused by candida.
Capillary Hemangiomas
Stork bites; benign tumor of dilated blood vessels.
Caput Medusa
Plexus of dilated veins around the umbilicus due to portal vein obstruction; seen in cirrhosis (Cruveilhier-
Baumgarten syndrome).
Caput Succedaneum
Edema of the soft scalp tissue from birth trauma.
Cardiomegaly
Enlarged heart.
Carotenemia
Benign yellow discoloration of the skin caused by carotene.
Carpal Tunnel Syndrome
Compression of the median nerve causing numbness and tingling of the fingers.
Cataract
Opacity of the lens of the eye, the capsule, or both.
Cephalohematoma
Hematoma between the periosteum and the skull.
Cerumen
Ear wax.
Chadwick’s Sign
Bluish discoloration of the cervix; seen at 6 to 8 weeks of pregnancy; probable sign of pregnancy.
Chalazion
Hard cyst on the eyelid; meibomian cyst.
Chancre
Hard, syphilitic, primary, painless ulcer; the first sign of syphilis; appearing 2 to 3 weeks after infection; heals
without leaving a scar.
Chancroid
Highly infectious, painful, nonsyphilitic venereal ulcer; heals leaving a scar.
Chandelier’s Sign
Cervical movement tenderness.
Charcot’s Joint
Deformity, instability, and bony overgrowth of the joint.
Chelitis
Inflammation of the lip.
Cheyne-Stokes Breathing
Breathing pattern marked with gradually increasing then decreasing depth of respirations followed by periods
of apnea.

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Cholasma - Conductive Hearing Loss

Cholasma
Mask of pregnancy; increased areas of pigmentation on the face associated with the hormonal changes that
occur during pregnancy.
Cholecystitis
Inflamed gallbladder.
Cholesteatoma
Cystlike sac of keratin caused by a congenital defect or chronic otitis media that may affect hearing.
Chordee
Ventrally curved penis.
Circadian Rhythms
Biological events that occur over a 24-hour period of the sleep-wake cycle of humans.
Circumcision
Surgical removal of the end of the prepuce of the penis.
Circumlocution
Inability to name object verbally, so patient talks around object or uses gesture to define it.
Circumstantiality Thinking
Excessive, irrelevant detail, but eventually gets to the point.
Clang Association
Association of words by sound.
Cleft Lip
Congenital condition, resulting in incomplete fusion of the median nasal process and lateral maxillary processes.
Cleft Palate
Congenital fissure in the palate forming a passageway between the mouth and the nasal cavity.
Clonus
Spasms of alternating muscle contractions between muscle groups caused by hyperactive stretch reflex from
an upper motor neuron lesion.
Clubbing
Condition affecting the fingers and toes; characterized by an increased angle of attachment 180 degrees or
greater and an enlargement of the finger pad.
Colitis
Inflamed colon.
Collaborative Nursing Diagnosis
Identifies a potential medical complication that warrants both medical and nursing intervention.
Colostrum
breast fluid; thin, yellowish fluid that contains proteins, calories, and immunoglobulins.
Concrete Thinking
Unable to abstract; thinks in concrete terms.
Conductive Hearing Loss
Sound transmission through air is affected; caused by a problem with the external or middle ear.

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Condylomata Acuminatum - Cystourethrocele

Condylomata Acuminatum
Venereal warts caused by the HPV virus. White, dry, painless lesions.
Conjunctivitis
Inflammation of the conjunctiva.
Contact Dermatitis
Inflammation of the skin due to contact with an irritating substance.
Corns
Horny induration and thickening of the skin extending down into the dermis, causing pain and irritation.
Cor Pulmonale
Hypertrophy or right-sided heart failure due to lung disease.
Crackles
Popping, crackling, discontinuous abnormal breath sound; more predominant on inspiration; more in the
periphery of the lung. Formerly referred to as rales caused by atelectasis, pneumonia, CHF, or interstitial fibrosis.
Craniosynostosis
Premature closure of the sutures.
Crepitus
Crackling sound created when air leaks into tissue, or joint movement with little support.
Crisis
Acute event that stresses a person’s resources and ability to cope or a perceived threat to self.
Critical Thinking
Complex thinking process that involves inquiry, interpretation, analysis, and synthesis.
Crohn’s Disease
Inflammatory bowel disease; regional ileitis.
Cryptorchidism
Undescended testicles; absence of testes and epididymis in the scrotal sac.
Cushing’s Triad
Increase in systolic pressure, widened pulse pressure, and bradycardia seen with increased intracranial pressure.
Cutis Marmorata
Mottled skin.
Cyanosis
Bluish discoloration. Types include central cyanosis, a bluish discoloration due to hypoxia, and peripheral
cyanosis, a bluish discoloration due to vasoconstriction.
Cyst
Primary encapsulated lesion that extends into the dermis; filled with fluid or solid material; less than 2 cm in size.
Cystitis
Inflammation of the bladder.
Cystocele
Prolapse of the bladder into the vagina.
Cystourethrocele
Prolapse of the bladder and urethra of the female.

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Dacryocystitis - Dupuytren Contracture

D
Dacryocystitis
Inflammation of the lacrimal sac.
Decerebrate Posturing (extension)
Extension of the arms with hands clenched and hyperpronated resulting from midbrain (brainstem) lesion.
Decorticate Posturing (flexion)
Arms flexed to chest with hands clenched and internally rotated resulting from a lesion in, at, or above the
brainstem in the cerebral cortex.
Degenerative Joint Disease
Type of arthritis due to “wear and tear” of joints; marked by progressive cartilage deterioration in synovial joints,
also known as osteoarthritis.
Delirium
Acute state of mental confusion and excitement marked by disorientation to time and place, usually with
illusions and hallucinations.
Delusions
False belief (grandiose/persecution/reference/somatic) associated with psychosis.
Dementia
Chronic condition with cognitive deficits, including memory impairment.
Depersonalization
Altered perception or experience that causes temporarily loss of self or personal identity.
Depression
Lowering a body part.
Desquamation
Peeling of the skin.
Dexascan
Scan that tests bone density; screens for osteoporosis.
Dextrocardia
Heart located on the right side of the chest.
Diastasis Recti
Separation of the two halves of the rectus abdominis muscles in the midline at the linea alba.
Diopters
Refractive power of a lens.
Dowager’s Hump
Cervical lordosis with dorsal kyphosis due to slow, painless loss of bone (ostoporosis).
Dullness
Percussion sound that is high-pitched, soft, and short in duration heard over organs.
Dupuytren Contracture
Contracture of the palmar fascia causing contraction of the ring and little finger so they cannot be extended.

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Dysarthria - Ejection Click

Dysarthria
Defective speech; inability to articulate words; impairment of the tongue and other muscles needed for speech.
Dysmenorrhea
Painful menstruation.
Dyspareunia
Painful sexual intercourse.
Dyspepsia
Indigestion.
Dysphagia
Difficulty swallowing.
Dysphasia
Impaired or difficulty with speech.
Dysphonia
Difficulty with quality of voice; hoarseness.
Dysplasia
Abnormal growth of tissue.
Dyspnea
Difficulty breathing.

E
Ecchymosis Bruise
A bluish-black skin discoloration due to bleeding (hemorrhage) into the skin.
Echolalia
Repetition of words spoken by another.
Eclampsia
Coma and convulsive seizures that occur between the 20th week of pregnancy and the end of the 1st week
postpartum.
Ectropion
Eversion of the edge of the eyelid.
Eczema
Acute or chronic inflammation of the skin with erythema, papules, vesicles, pustules, scales, or crusts.
Edema
Local or generalized; the body contains excessive amounts of tissue fluid.
Egophony
Abnormal voice sound; “ee” to “aa” change over affected area.
Ejection Click
Abnormal sound; opening of the aortic or pulmonic valves are heard or a prolapse of the mitral valve, high-
pitched, systolic sound.

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Elevation - Erythema Toxicum Neonatorum

Elevation
Raising a body part.
Embolism
Occlusion of a blood vessel by a foreign object or a blood clot within the vessel.
Emphysema
Type of obstructive lung disease with permanent enlargement of the alveoli and destruction of the aveolar wall,
leading to overinflated lungs.
Endocarditis
Inflammation of the endocardium.
Endometriosis
Inflammation of the endometrium.
Enopthalmos
Recession of the eyeball into the orbit.
Entropion
Inversion of the edge of the lower eyelid.
Epicodylitis
Inflammation of the epicondyle of the humerus and the surrounding tissue.
Epididymitis
Inflammation of the epididymis.
Epidural Hematoma
Hematoma above the dura; usually an arterial bleed.
Episcleritis
Inflammation of the sclera.
Epispadias
Male urethral meatus opens on the dorsal side of the glans penis.
Epistaxis
Nosebleed.
Epstein’s Pearls
Small, white, pearl-like epithelial cysts on the palate of newborns that disappear within a few weeks after birth.
Epulis
Raised, red nodules on the gums.
Erectile Dysfunction
Difficulty achieving, maintaining, or completing an erection; inability to achieve satisfactory sexual performance.
Erosion
Secondary lesion; loss of superficial epidermis.
Erythema
Diffuse redness of the skin.
Erythema Toxicum Neonatorum
Firm, red macules and papules on newborns; are benign and resolve without treatment.

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Esotropia - Fissure

Esotropia
Convergent strabismus.
Eupnea
Normal respiratory rates.
Eversion
Turning outward.
Excoriation
Secondary lesion; abrasion of the epidermis.
Excursion
Expansion or movement of the chest.
Exopthalmus
Protrusion of the eyeball.
Exotropia
Divergent strabismus.
Expressive Aphasia (motor aphasia)
Inability to express language even though the person knows what he or she wants to say. Inability to
coordinate the muscles controlling speech. Also called Broca’s aphasia. Frontal lobe affected.
Extension
Straightening, increasing the joint angle.
External Rotation
Turning away from the midline.
Extinction
Tested by simultaneously touching opposite sides of patient’s body and having patient identify points where
she or he was touched.
Extravasation
Escape of fluid into surrounding tissue.

F
Fasciculation
Involuntary contraction or twitching of muscle fibers.
Fetal Alcohol Syndrome
Birth defects in an infant born to a mother whose chronic alcoholism persisted during pregnancy; physical and
mental deficits are noted.
Fibrocystic Disease
Tender, thick, nodular areas in the breast influenced by hormones and diet.
Fibroidadenoma
Benign, well-defined adenoma of fibrous tissue.
Fissure
Secondary lesion; linear break in the skin.

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Flaccidity - Goodell’s Sign

Flaccidity
Loss of muscle tone.
Flat
Percussion sound that is very high pitched, very soft, and very short in duration; heard over soft tissue.
Flexion
Bending; decreasing the joint angle.
Flight of Ideas
Rapidly going from one topic to another.
Fluent Aphasia
Words can be spoken but are used incorrectly.
Fluorosis
Chronic fluorine poisoning causing mottling of the tooth enamel.
Fontanel
Unossified space or soft spot lying between the cranial bones of the infant’s skull.
Fordyce’s Granules
Enlarged ectopic sebaceous glands on the oral mucosa or genitalia that appear as small yellow spots.
Fremitus
Palpable vibration created by the movement of air when the patient speaks.
Friction Rub
High-pitched, scratchy sound caused by inflamed layers rubbing together as with a pleural friction rub of
pleuritis or a pericardial friction rub of pericarditis.

G
Genogram
Visual depiction of a family history identifying family members’ health status; a family tree.
Genu Valgum
Knock –knees.
Genu Varum
Bowlegs.
Glaucoma
Group of eye diseases characterized by increased intraocular pressure that leads to pressure on the optic
nerve and can result in blindness.
Glossitis
Inflammation of the tongue.
Goniometer
Instrument used to measure the angle of joint range of motion.
Goodell’s Sign
Probable sign of pregnancy; palpated at 8 weeks; softening of the cervix.

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Graphesthesia - Hepatitis

Graphesthesia
Ability to recognize numbers, letters, or symbols traced or written on the skin.
Gravidity
Total number of a woman’s pregnancies.
Grunting
Loud abnormal expiratory sound heard over larger airways resulting from retention of air in the lungs.
Guillain-Barré Syndrome
Acute autoimmune inflammatory destruction of the myelin sheath leading to rapid, progressive, symmetrical
loss of motor function with no sensory loss; usually triggered by a viral infection.
Gynecomastia
Enlarged breast tissue in a male.

H
Hallucination
False perception having no relation to reality; can be auditory, visual, or tactile.
Hallux Valgus
Displacement of the great toe toward the other toes.
Harlequin Sign
Positional color changes seen in infants; dependent side red, nondependent side pale.
Heave
Abnormal, diffuse, lifting precordial impulse.
Hegar’s Sign
Probable sign of pregnancy; appears at 6 weeks; softening of the lower uterine segment.
Hemangioma Simplex
Strawberry marks; collection of dilated blood vessels.
Hematoma
Vascular lesion; a collection of blood in a confined space.
Hemianopsia
Blindness of half the visual field.
Hemimelia
Absence of distal part of an extremity.
Hemiparesis
Weakness on one side of the body.
Hemiplegia
Paralysis on one side of the body.
Hemotympanum
Dark blue tympanic membrane caused by bleeding in the middle ear.
Hepatitis
Inflamed liver.

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Hepatomegaly - Hyperthermia

Hepatomegaly
Enlargement of the liver.
Herbeden’s Nodules
Bony enlargements or nodules on the distal interphalangeal joints.
Hernia
Protrusion of an organ through the wall of a cavity that usually contains it.
Herniated Disc
Prolapse of the nucleus pulposus of a ruptured intravertebral disc into the spinal canal.
Herpes
Vesicular eruptions caused by a virus. Herpes simplex type 1 or 2; commonly called cold sores or fever
blisters. Genital Herpes with herpes simplex type 2; Herpes zoster, shingles.
Hesselbach’s Triangle
Slitlike opening in the groin bounded by the Poupart ligament, the edge of the rectus muscle, andthe deep
epigastric artery; the external inguinal ring.
Hiatal Hernia
Protrusion of the stomach upward into the mediastinal cavity through the esophageal hiatus of the diaphragm.
Hirsutism
Abnormal, excessive hair growth in unusual places, especially in women.
Homen’s Sign
Test for DVT; positive sign if patient complains of calf pain upon dorsiflexion of the foot.
Homeothermic
Ability to stabilize body temperature within a small range.
Homonymous Hemianopsia
Half a visual field cut in the same side on both eyes.
Hordeolum
Sty; inflammation of the sebaceous glands of the eyelid.
Horner’s Syndrome
Contraction of the pupil, partial ptosis of the lid, enopthalmos, and sometimes, loss of sweating on one side
of the face owing to paralysis of the cervical sympathetic nerve trunk.
Hydrocele
Accumulation of serous fluid in a saclike cavity; the tunica vaginalis testis.
Hydrocephalus
Increased accumulation of cerebrospinal fluid within the ventricles of the brain.
Hyperalgesia
Excessive sensitivity to pain.
Hyperresonance
Percussion sound that is very low pitched, very loud, and very long in duration; heard over overinflated lungs.
Hyperthermia
Body temperature elevation above normal.

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Hypertonia - Inotropes

Hypertonia
Increased tone, tightly flexed arms, and stiffly extended legs with quivering.
Hypertrophy
Increase in size.
Hyperventilation
Increase in the depth of respirations.
Hyphema
Blood in the anterior chamber, in front of the iris.
Hypoalgesia
Decreased sensitivity to pain.
Hypogeusia
Decreased or blunted sense of taste.
Hyponosmia
Decrease in the sense of smell.
Hypopyon
Pus in the anterior chamber of the eye in front of the iris behind the cornea; seen with corneal ulcer.
Hypospadia
Abnormal congenital opening of the urinary meatus on the ventral, undersurface, of the penis in males, in the
vagina in females.
Hypothermia
Body temperature below normal.
Hypotonia
Decreased tone; floppy, limp extremities.
Hypoxia
Oxygen deficiency.

I
Icthyosis
Dry, scaly skin, resembling fish skin.
Iliopsoas Test
Abdominal pain as the patient attempts to raise right thigh against resistance; sign of appendicitis.
Illusions
Misperception of a real external stimuli; common with dementia of Alzheimer’s and schizophrenia.
Imperforated Anus
No anal opening
Impetigo
Inflammatory skin disease with pustules that rupture, then develop crusts.
Inotropes
Influencing the force of muscular contractility.

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Insensible Water Loss - Kinesthesia

Insensible Water Loss


Water loss that cannot be measured, such as via lungs and skin.
Inspection
Physical assessment technique that uses the sense of sight to collect data. Inspection can be direct or indirect,
use of equipment to enhance visualization.
Intention Tremor
Involuntary movement when attempting coordinated movements.
Intermittent Claudication
Pain in the legs while walking.
Internal Rotation
Turning toward the midline.
Intertrigo
Superficial dermatitis in the folds of the skin.
Intertriginous
Folds of the skin.
Intuition
Problem-solving method developed through experience, combining theory and practice.
Inversion
Turning inward.
Iritis
Inflammation of the iris.

J
Jaundice
Yellow discoloration of the skin, sclera, and mucous membranes that can result from impaired bile excretion.

K
Kaposi Sarcoma
Vascular malignancy that often first appears on the skin and mucous membranes. Currently, the most common
AIDS-related tumor.
Kehr’s Sign
Referred pain to the left shoulder; sign of splenic rupture. Keloids Hypertropied scar tissue.
Keratoconjunctivitis
Inflammation of the cornea and the conjunctiva.
Kernig’s Sign
Reflex contraction and pain in hamstrings when flexed leg is extended; sign of meningitis.
Kinesthesia
Ability to perceive extent, direction, or weight of movement.

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Koran - Linea Nigra

Koran
Sacred book of Islam regulating faith and practices; written by Mohammed.
Korotkoff Sounds
Sounds heard when auscultating the blood pressure.
Kussmaul Breathing
Rapid and deep breathing associated with diabetic acidosis.
Kwashiorkor
Protein deficiency caused by inadequate dietary protein, malabsorption, cancer, or AIDS.
Kyphosis
Accentuated thoracic curve of the spine; hunch back.

L
Lachman’s Test
Test for stability of the collateral cruciate ligaments.
Lacto-Ovovegetarian
Vegetarian diet that includes eggs and dairy products.
Lactovegetarian
Vegetarian diet that includes dairy products.
Lanugo Hair
Fine, downy hair on face, shoulders, and back of newborns.
Lasegue Test
Sstraight-leg test; test for herniated disc; positive if patient has pain with straight-leg rise.
Lentigines
Hyperpigmented macular lesions; liver spots.
Leopold’s Maneuvers
Four steps used to palpate the uterus to determine the position and presentation of the fetus.
Leukonychia
White spots or streaks on the nail.
Leukoplakia
White spots or patches on the mucous membranes or tongue; considered a precancerous lesion.
Lichenification
Cutaneous thickening and hardening from continued irritation.
Lift
Abnormal lifting precordial impulse.
Linea Alba
White line of connective tissue in the middle of the abdomen from the sternum to the pubis.
Linea Nigra
Darkening of the linea alba due to increased pigmentation during pregnancy.

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Lipoprotein - Melanoma

Lipoprotein
Conjugated proteins composed of simple proteins and lipids.
Loose Association
Loose connection between thoughts that are unrelated.
Lordosis
Accentuated lumbar curve of the spine.
Lymphadenopathy
Disease of the lymph nodes.
Lymphedema
Abnormal accumulation of lymphatic fluid in the interstitial space.

M
Macular Degeneration
Degeneration of the macular area of the retina, the area of most acute vision.
Macule
Primary lesions; area of color change less than 1 cm in size.
Macrosomic
Infant large for gestational age.
Mammary Souffle
Murmur that occurs during pregnancy resulting from increased blood flow through the mammary artery.
Mania
Type of bipolar disorder in which the predominant mood is elevated, expansive, or irritable. Motor activity is
frenzied and excessive.
Marasmus
Protein-calorie malnutrition; a severe protein and calorie deficiency leading to tissue breakdown to supply
energy needs; caused by dietary deficiency, severe infections, burns, eating disorders, chronic liver disease,
cancer, and AIDS.
Mastalgia
Breast pain.
Mastitis
Inflammation of the breast.
McBurney’s Sign
Tenderness and rigidity at McBurney’s point (above anterosuperior spine of the ileum, on a line between
the ilium and umbilicus); sign of appendicitis.
McMurray’s Test
Test for torn meniscus of the knee.
Melanoma
Malignant, darkly pigmented mole or tumor of the skin.

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Menarche - Naegele’s Rule

Menarche
Age at the onset of menstruation.
Ménière’s Disease
Chronic progressive disease of the inner ear that leads to permanent hearing loss.
Meningitis
Inflammation of the meninges of the brain and spinal cord; may be viral or bacterial.
Menorrhagia
Excessive menstrual bleeding.
Migraine
Vascular headache, usually temporal and unilateral.
Milia
White, pinhead-sized, keratin-filled cysts.
Molding
Shaping of the fetal head to accommodate the pelvic inlet during delivery.
Mongolian Spots
Bluish colored spot in the sacral area; may be seen at birth in Asian, American Indians, African American, and
Southern European infants; usually disappears during childhood.
Monotheistic
One who believes in one God.
Morphology
Classification of organisms by form and structure.
Multigravida
Woman that has had more than one pregnancy.
Multiparous
Having borne more than one child.
Munchausen Syndrome by Proxy
Fabrication of symptoms or physical evidence of another’s illness, or deliberately causing another’s illness,
to gain medical attention.
Murmur
Abnormal heart sound caused by turbulent flow.
Murphy Sign
Sign for an inflamed gallbladder if pain at right midclavicular line under costal angle.

N
Nabothian Cysts
Small, round, yellow, benign lesions on the cervix due to obstruction of the cervical glands.
Naegele’s Rule
System used to estimate the date of onset of labor by counting back exactly 90 days from the onset of last
period and adding 7 days to the date.

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Nasolabial Fold - Nonfluent Aphasia

Nasolabial Fold
Distance from the corner of the nose to the edge of the lip; smile crease.
Neglect Syndrome
Unilateral inattention in which a patient is unaware of the existence of the affected side of the body, as with
right stroke with left-sided paralysis.
Neologisms
Made-up, meaningless, nonsense words.
Neuralgia
Severe, sharp pain occurring along a nerve.
Neuritis
Inflammation of a nerve.
Neuroleptic Malignant Syndrome
Rare but potentially fatal complication of treatment with neuroleptic drugs. Symptoms include severe muscle
rigidity, high fever, tachycardia, fluctuations in blood pressure, diaphoresis, rapid deterioration of mental status
to coma.
Neuropathic Pain
Pain serves no adaptive purpose and therefore is “pathological” pain.
Neuropathy, Peripheral
Characterized by weakness, paresthesia, ataxia, and decreased deep tendon reflexes with decrease in or loss
of sensation.
Nevus
Mole; congenital discoloration of a circumscribed area of the skin owing to pigmentation.
Nevus Flammeus
Port-wine stain; a large reddish-purplish discoloration on the face or neck.
Nightmare
Frightening dream; bad dreams.
Night Terrors
Type of nightmare from which the child awakens screaming.
Nociceptive Pain
Pain that results from exposure to noxious (painful) stimuli.
Nociceptors
Receptors that respond to painful stimuli found in the skin, subcutaneous tissue, joints, walls of arteries, and
most internal organs, with the highest concentration found in the skin and the least in internal organs.
Nocturia
Excessive urination during the night.
Nocturnal Enuresis
Involuntary loss of bladder control while sleeping; bed wetting.
Nonfluent Aphasia
Slow, deliberate speech; few words.

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Nulligravida - Otorrhea

Nulligravida
Woman who has never conceived a child.
Nulliparous
Never having borne a child.
Nursing Diagnosis
Second phase of the nursing process; an actual or potential health problem or response to life process.
Nursing diagnosis can be actual, potential, possible, collaborative, or wellness focused.
Nursing Process
Systematic problem-solving method that has five steps: assessment, nursing diagnoses, planning,
implementation, and evaluation.
Nystagmus
Involuntary, cyclic movement of the eyeball.

O
Obturator Test
Abdominal pain on inward rotation of the hip; sign of appendicitis.
Onycholysis
Loosening or detachment of the nail from the nailbed.
Opening Snap
Abnormal heart sound; opening of the mitral or tricuspid valves is heard, high-pitched, diastolic sound.
Ophthalmoplegia
Paralysis of the extraocular muscles.
Opisthotonic
Arched back.
Opposition
Movement of thumb to finger.
Orchitis
Inflammation of the testes, causing pain, swelling, and warmth of the scrotum.
Osteoporosis
Loss of bone mass density.
Otalgia
Ear pain.
Otitis Externa
Inflammation of the external ear canal.
Otitis Media
Inflammation or infection of the middle ear.
Otorrhea
Inflammation of the ear with purulent drainage.

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Ototoxic - Parity

Ototoxic
Having detrimental effects on the inner ear or the eighth cranial nerve.

P
Palmar Erythema
Pinkish-red, diffuse mottling over the palms of the hands.
Palpation
Physical assessment technique that uses the sense of touch to collect data. There are two types of palpation:
light, indenting the skin less than ½ inch, best for assessing surface characteristics; and deep palpation.
indenting the skin more than ½ inch, best for assessing organs and masses.
Palpebral Conjunctiva
Conjunctiva that covers the eyelids.
Palpebral Fissure
Distance between the upper and the lower eyelids; the opening of the eyes.
Pancreatitis
Inflamed pancreas.
Pantheistic
Polytheistic; one who believes in many gods.
Papilledema
Edema and inflammation of the optic nerve at the entrance of the eyeball, the optic disc, often caused by
increased intracranial pressure.
Papules
Primary lesion; raised macules.
Paralytic Ileus
Paralysis of the intestines.
Paranoia
Extreme suspiciousness.
Paraphimosis
Strangulation of the glans penis due to retraction of a narrowed or inflamed foreskin.
Paraphrasia
Loss of ability to use words correctly and coherently; words are jumbled or misused.
Paraplegia
Paralysis on lower half of the body.
Paresthesia
Sensation of numbness or tingling; heightened sensitivity.
Parity
Number of pregnancies carried to viability, regardless of outcomes.

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Parkinson’s Disease - Perseveration

Parkinson’s Disease
Chronic nervous system disease characterized by a fine, slowly spreading tremor, muscular weakness and
rigidity, and shuffling gait.
Paronychia
Acute or chronic infection of or around the nail.
Parotitis
Inflammation of the parotid glands; the mumps.
Patellar Tap
Test for fluid in the patellar space.
Pathological Jaundice
Jaundice that occurs within the first 24 hours after birth; caused by destruction of the newborn’s red blood cells
by the mother’s antibodies.
Pectus Carinatum
Pigeon breast shape of chest.
Pectus Excavatum
Funnel shape of chest.
Pediculosis
Genus of parasitic insects; lice.
Pedunculated
Possessing a stalk or stem.
Perceptive Hearing Loss
Sound transmission through bone is affected; caused by a problem with the inner ear.
Percussion
Physical assessment technique that involves striking or tapping a body surface to determine the density
of underlying tissue, identify areas of tenderness, or test reflexes. Types include direct (immediate), directly
tapping on body surface, and indirect (mediate), tapping a hand placed over a body surface or using an
instrument to elicit a response.
Pericarditis
Inflammation of the pericardium.
Peridontitis
Inflammation or degeneration of the periosteum, bone and adjacent gingivae.
Peristalsis
Is the wavelike movement of the intestinal tract caused by contraction and relaxation of the circular muscles
that moves the contents forward through the tract.
Peritonitis
Inflammation of the peritoneum, the serous membrane lining of the abdominal cavity.
Perseveration
Involuntary, excessive repetition of a single response to different questions.

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Pes Planus - Pneumothorax

Pes Planus
Flat feet.
Petechiae
Macule; hemorrhagic spot that results from capillary fragility.
Phalen Test
Test for carpal tunnel syndrome; positive if patient complains of numbness of fingers with flexion at the wrist.
Phimosis
Stenosis of the preputial orifice so that the foreskin cannot return over the penis.
Phobia
Irrational fear.
Phocomelia
Hands and feet attached close to the chest.
Physiological Jaundice
Nonpathological jaundice that occurs in newborns after 24 hours of birth; usually appears 48 to 72 hours after
birth, lasts for a few days, and resolves with no treatment.
Pica
Unusual cravings to ingest material that is not food.
Pinguecula
Yellow triangular thickening of the bulbar conjunctiva on the inner and outer margins of the cornea.
Piskacek’s Sign
Probable sign of pregnancy; palpated at 4 to 6 weeks; asymmetry of the uterus with soft prominence on
implantation side.
Pityriasis Rosea
Acute inflammatory skin condition, cause unknown; herald patch precedes fawn-colored, scaly rash on trunk.
Placenta Abruptio
Premature detachment of a normally positioned placenta after the 20th week of gestation.
Placenta Previa
Placenta that is implanted in the lower uterine segment.
Plaque
Primary lesion; palpable, raised, and superficial; greater than 1 cm in size.
Pleural Effusion
Collection of fluid in the pleural space.
Pleuritis
Inflammation of the pleura.
Pneumonia
Inflammation of the alveoli, interstitial tissue, and bronchioles of the lung due to bacteria, virus, other
pathogens, or irritation from chemicals or other agents.
Pneumothorax
Collection of air or gas in the pleural cavity.

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Point of Maximum Impulse (PMI) - Pruritus

Point of Maximum Impulse (PMI)


Ventricular pulsation, apical pulsation, or left ventricular impulse.
Polydactyly
Extra digits.
Polyhydramnios
Excess of amniotic fluid in the bag of waters in pregnancy.
Port-Wine Stain
Nevus flammeus.
Possible Nursing Diagnosis
Identifies a likely health problem, but more data are needed to define and support the problem.
Postural Hypotension
Orthostatic hypotension; a drop in blood pressure with change in position from supine to sitting. A 10 to 20 mm
Hg drop in systolic pressure is seen with a 20 BPM increase in pulse and a feeling of dizziness.
Potential Nursing Diagnosis
Identifies a high-risk health problem that most likely will occur unless preventive measures are taken.
Pre-Eclampsia
Complication of pregnancy characterized by hypertension, proteinuria, and edema.
Preload
End-diastolic volume or pressure; the volume of blood in the ventricles at the end of diastole.
Presbycusis
Diminished hearing of high-pitched sound in older adults.
Presbyopia
Diminished near vision in older adults.
Priapism
Abnormal, painful, sustained erection without sexual pleasure.
Primary Malnutrition
Inadequate intake of proper nutrients in the diet.
Pronation
Turning downward; palms down.
Pronator Drift
Test for muscle weakness; positive if patient’s arm pronates and drifts when eyes are closed.
Proprioception
Sense of awareness, posture, and position and resistance of objects in relation to the body.
Prostatitis
Inflammation of the prostate gland.
Protraction
Moving forward.
Pruritus
Itching.

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Pseudofollicultis - Rales

Pseudofollicultis
Inflammation of beard follicles when tightly coiled hairs become ingrown.
Psoriasis
Chronic skin disorder characterized by erythematous papules that coalesce to form plaques; silvery-white
in color.
Psychosis
Psychiatric disorder characterized by disorganization of personality, disturbance in reality testing, and
impairment of interpersonal functioning and relationship to the external world.
Pterygium
Triangular thickening of the bulbar conjunctiva from the inner canthus to the border of the cornea.
Ptosis
Drooping of an organ or body part.
Ptyalism
Excessive salivation.
Pulsus Alternans
Weak pulse alternating with a strong one.
Pulsus Bigeminus
Irregular pulse rhythm with premature beats alternating with sinus beats.
Pulsus Bisferiens
Pulse with a strong upstroke, downstroke, and second upstroke.
Pulsus Paradoxus
Pulse amplitude decreases with inspiration.
Purpura
Hemorrhage into the skin, mucous membranes, internal organs, or other tissue, usually red to dark purple
in color.
Pustule
Primary lesion; pus-filled papule.
Pyrosis
Heartburn.

Q
Quadriplegia
Paralysis of all four extremities.
Quickening
Perception of fetal movement.

R
Rales
Also known as crackles.

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Rapid Eye Movement - Rhonchi

Rapid Eye Movement (REM) Sleep


Cyclic movement of closed eyes during sleep.
Raynaud’s Disease
Idiopathic, intermittent spasms of the arterioles in the digits in response to cold or stress. The fingers become
pale thEn cyanotic, and ulcers may develop.
Rebound Tenderness
Examiner presses deeply in one area, if patient experiencee pain upon release, positive test for appendicitis.
Receptive Aphasia (sensory)
Inability to comprehend spoken or written words. Also known as Wernicke’s aphasia. Temporal lobe affected in
auditory-receptive aphasia; parieto-occipital lobe affected in visual-receptive aphasia.
Rectocele
Prolapse of the rectum into the posterior vaginal wall.
Referred Pain
Pain felt at a site other than the site of origin.
Reflexive Thinking
Automatic thinking without conscious deliberation and comes from experience.
Regurgitation
Backflow.
Reinforcement Techniques
Techniques, clenching teeth or interlocking hands, to enhance reflex response.
Reposition
Returning thumb to original position.
Resonance
Percussion sound that is low-pitched, loud, and long in duration; heard over healthy lung tissue.
Retinitis Pigmentosa
Degeneration of the retina that begins in childhood and may lead to blindness.
Retinopathy
Disorders of the retina.
Retraction
Moving backward.
Retrograde Amnesia
Amnesia of events that occurred prior to the precipitating event that caused amnesia.
Rheumatoid Arthritis
Type of arthritis; a chronic, progressive, systemic inflammatory disease primarily affecting the synovial joints;
resulting in destruction, pain, and deformity of the joint.
Rhonchi
Snore, gurgle, rattle; continuous sound more predominant on expiration in the larger airways; caused by a nar
rowing of the airways.

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Romberg Test/Sign - Sensible Water Loss

Romberg Test/Sign
Test of inner ear vestibular function and cerebellar function. Positive if the person loses balance when feet are
together and eyes are closed.
Rosacea
Chronic skin disease of the face; occurring in middle- and older-aged persons. Characterized by erythema,
papules, pustules, telangiectasis, and hyperplasia.
Rovsing’s Sign
Positive test for appendicitis; patient complains of pain as examiner presses left lower quadrant.

S
S1
first heart sound; created by the closing of the mitral and tricuspid valves.
S2
second heart sound; created by the closing of the aortic and pulmonic valves.
S3
third heart sound; low-pitched; heard best with the bell; early diastolic sound. May be normal in children and
young adults, but is a sign of CHF in patients over 30 years.
S4
Fourth heart sound; low-pitched; heard best with the bell; late diastolic sound. May be normal in children and
young adults, but is a sign of a stressed heart in patients over 30 years.
Scale
Secondary lesion; shedding; dead skin cells.
Scientific Method
Systematic, critical-thinking approach to problem solving. The steps of the scientific method include problem
identification, data collection, hypothesis formulation, planning, implementing, and evaluating plan.
Sclera Icterus
Jaundice; yellow discoloration of the sclera.
Scoliosis
Lateral “s” curve of the spine.
Seborrheic Keratosis
Benign skin lesion of immature epithelial cells; common in the elderly.
Secondary Malnutrition
Impaired bioavailability of nutrients to the body owing to deficient breakdown, assimilation, or utilization
of the food.
Senile Ectasias
Red-purple macule or papule lesions (senile or cherry angiomas).
Senile Pruritus
Itching in older adults with degenerative skin changes.
Sensible Water Loss
Measurable water loss, such as urine and gastrointestinal secretions.

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Sjögren’s Syndrome - Supination

Sjögren’s Syndrome
Immunologic disorder characterized by decreased production of tears and saliva.
Sleep Latency
Increased amount of time needed to fall asleep.
Smegma
Sebaceous gland secretions that are thick, white, cheesy, odoriferous; found under the labia minora of the
female or the male prepuce.
Somnambulism
Sleepwalking.
Spermatocele
Nontender, well-defined cyst on the epididymis containing spermatozoa.
Spider Angioma
Type of telangiectasis that looks like spider, with central body and radiating legs.
Spirituality
Belief in something greater than oneself and in a faith that affirms life.
Sprue
Intestinal tract disease characterized by malabsorption, weight loss, abdominal distension, bloating, diarrhea,
and steatorrhea.
Stenosis
Narrowing.
Stereognosis
Ability to identify an object by touch.
Stomatitis
Inflammation of the mouth.
Stork Bites
Flat hemangiomas, reddish in color, at the nape of the neck in newborns.
Strabismus
Axis of eye deviates and cannot fixate; crossed or wall eye; caused by weak extraocular muscles or oculomotor
nerve damage.
Striae
Stretch marks; pinkish-white to gray in color.
Stridor
High-pitched, harsh inspiratory abnormal sound; caused by obstruction of upper airways or spasms of trachea
or larynx.
Stroke Volume
Amount of blood ejected from the heart with each contraction.
Subdural Hematoma
Hematoma located beneath the dura; results from a venous bleed.
Supination
Turning upward; palms up.

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Syncope - Tic Douloureux

Syncope
Transient loss of consciousness resulting from inadequate blood flow to the brain.
Syndactyly
Webbed digits.

T
Tachypnea
Respiratory rates above normal.
Talipes
Clubfoot.
Tangential Thinking
Digresses from topic to topic, never getting to the point.
Tardive Dyskinesia
Bizarre facial and tongue movements, a stiff neck, and difficulty swallowing; an adverse effect of long-term
antipsychotic medication use.
Telangiectasis
Vascular lesion of dilated blood vessels frequently seen on face.
Telogen
Resting phase of hair growth.
Tendinitis
Inflammation of the tendon.
Testicular Torsion
Twisting of the testes; a surgical emergency.
Tetany
Intermittent tonic spasms caused by a calcium or magnesium deficiency.
Thomas Test
Test for hip flexure contraction.
Thrill
Palpable vibrations created by turbulent blood flow.
Thrombophlebitis
Inflammation of a vein in conjunction with the formation of a blood clot.
Thrombosis
Formation, development, or existence of a blood clot in the vascular system.
Thrust
Palpable precordial rocking movement.
Tic
Involuntary muscle spasm, usually involving the face, mouth, eyes, head, neck, or shoulders.
Tic Douloureux
Degeneration or pressure on the trigeminal nerve, causing neuralgia.

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Tinea - Vaginitis

Tinea
Fungal infection of the skin. Versicolor, causing yellow or fawn-colored patches; pedis, involving the feet; cruis,
involving the male genitalia; corporis, involving the body; capitis, involving the head.
Tineal Test
Test for carpal tunnel syndrome; positive if patient has numbness and tingling of fingers when wrist
is percussed.
Torah
First five books of the Bible; written on scrolls.
Torus Mandibularis
Exostosis, a benign bony growth, that develops on the lingual aspect of the body of the mandible.
Torus Palatinus
Exostosis, a benign bony growth, that develops on the hard palate.
Toxoplasmosis
Infectious disease caused by protozoan.
Tremor
Involuntary movement of body parts.
Trendelenburg Test
Test for dislocated hip and gluteal medius muscle strength.
Triceps Skin Fatfold Measurements
Measurement of skin fold and subcutaneous tissue of the dominant arm to estimate body fat.
Tumor
Primary encapsulated lesion that extends into the dermis; filled with fluid or solid material; greater than 2 cm in size.
Turgor
Elasticity, or resilience, of the skin.
Tympany
Percussion sound that is medium-pitched, medium intensity and duration, with a distinct musical quality; heard
over the stomach or intestines with gastric air.

U
Ulcer
Secondary lesion; loss of tissue to or through the dermis.
Uremic Frost
Excretion of urea through the skin owing to renal insufficiency or failure.
Urticaria
Hive; temporary primary lesion.

V
Vaginitis
Inflammation of the vagina.

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Varicocele - Word Salad

Varicocele
Varicose veins of the spermatic cord; “bag of worms.”
Varicose Veins
Irregular, tortuous veins with incompetent valves; usually affecting the lower extremities.
Vegan
Vegetarian diet that avoids all animal products.
Vegetarian
Diet that consists primarily of plant foods.
Vena Caval Syndrome
Supine hypotension due to compression of the vena cava and aorta by abdominal contents when a pregnant
women is supine; causes 30 mm Hg drop in blood pressure with reflex tachycardia.
Venous Hum
Low-pitched vascular sound; continuous sound due to increased or turbulent venous flow.
Venous Lake
Bluish-black papular vascular lesion.
Venous Stasis Ulcer
Poor-healing ulcer, usually located on the ankle, due to poor venous return.
Vernix Caseosa
White, cheesy substance of sebum and desquamated epithelium seen in the folds of full-term babies.
Vesicle
Primary lesion; fluid-filled papule less than 1 cm in size.
Vesicular Breath Sound
Normal breath sound with a long inspiratory phase and a short expiratory phase; low-pitched, soft intensity;
heard in most of the lung fields.
Vitiligo
Patchy loss of pigmentation; seen as white patches on the skin.

W
Wellness Nursing Diagnosis
Identifies areas that promote or enhance a client’s level of wellness.
Wheal
Primary lesion; temporary raised area.
Wheezes
High-pitched, musical abnormal breath sound caused by a narrowing of an airway, as heard with asthma.
Whispered Pectoriloquy
Abnormal voice sound; clearer transmission of whispered voice sounds over the affected area.
Word Salad
Combination of words that have no meaning.

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Xanthomas - Xerostomia

XYZ
Xanthomas/Xanthelasma
Flat or raised yellow plaques, usually around the eyes; usually resulting from lipid deposits.
Xerosis
Excessive dryness of the skin, mucous membranes, or conjunctiva.
Xerostomia
Dry mouth.

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