Assessment Question

[bayouchick02]

Just wondering:

I have always been curious, and now that I am still a student, I figured I could ask and not get laughed at! :rotfl: When you have a patient who presents to the clinic for a UTI or tinea corporis, for example, do you listen to the heart and lungs to include in your assessment as well? Someone told me you don't have to, but I wasn't sure.....

Thanks!! I'm graduating soon, and I feel like there is soooooo much that I still do not know!

[ROLO]

If I understand your question, you want to know if you HAVE to (as in “required”) listen to heart and lungs, and then include them in your H&P when dealing with a possible UTI (or something or low acuity), for example....

1) YES

2) YES

3) YES

[bayouchick02]

Yes, that's exactly what I was asking.........thank you for your response, that's what I thought too!

[sailornurse]

The answer is no, you do a focused exam. For UTI, focus on the Abd/GI/GU system. Skin: describe. But before you even touch the patient, you need to get the complete history for the symptoms they are presenting with, The history is what guides your physical exam. Working urgent care you see one patient every 15 minutes, that includes the entire visit, PE, writing scripts and documenting, so no need to listed to cardiac/respiratory if they present with UTI sx

[ROLO]

I just wanted to throw this out there for the student. As you know, there are several types of assessments, and the one you choose is ultimately up to you. I work in a busy ER, but I almost always include the heart and lung with my assessments. They only take a moment to assess. Mind you, I am not talking about measuring JVD, finding the point of maximal impulse, and grading dependent edema. Your question was sort of general, but I can just hear my program director from school telling me, “If you have a little old lady, with CHF and COPD, YOU BETTER LISTEN TO HER HEART AND LUNGS!"

[reddgirl]

I would say yes! I was always taught to ALWAYS listen to your heart and lungs at each and every visit then tailor the rest of your PE to what the CC/HPI is! This came from MDs alll the way to NPs that I have rounded with. You will be surprised of what you may stumble upon just by listening! I am in my last rotation in Women's Health and eventhough I am doing a quick pap, I always listen and check the thyroid! Good luck!

[pedspnp]

Unless they have a chronic condition I just focus on cc, but then again I only see children, but one day I did have a kid come in for a wart and something told me to look in his ear and I found a bunch of candy sprinkles stuck in his ear canal lol

[FNPdude74]

I would hate to say yes, you should, but then it could open up a can of worms totally unrelated to the visit. If you're using the patient centered medical home model then yeah you can go ahead and open up the can of spam all you want lol... But I'm guilty of listening to heart and lungs a lot even if it's just knee pain, sometimes it adds more credit to the visit if you're working for RVUs. If I'm a rush because I had a lot of "oh by the way" visits then I would do focus exams such as if they came in for a wart on their hand and wants it frozen off.

[toasterboy85]

From what I have picked up in clinical, every patient needs to be thoroughly assessed. I am about to be complete with FNP school and my preceptors have tole me after being "comfortable" in your role you can start slimming down to a brief assessment. You hate to miss something big. A few weeks ago we had a pt who complained of simple cellultitis ended up having pneumonia, was admitted to the hospital and with no complaints of SOB or respiratory complains/fever/chills ect...