INDEX

S.No. Contents Page No.

1 Acknowledgment 2
2 Introduction – Health Assessment 3
3 Nursing/Health History Taking 4-5
4 Performing Physical Examination – 6-7
 General
 Body System
5 Use Of Various Methods of Physical Examination – 8-10
 Inspection
 Palpation
 Percussion
 Auscultation
 Olfaction
6 Identification of System Wise Deviations – 11-15

 Documentation of Findings 16-22

 Questionnaire 23-30

7 Summary 31
8 Conclusion 32
9 Bibliography 33

10 Multiple Choice Questions with Answer- 34-40

 25 Questions

[1]
 Acknowledgement
I would like to express my heartfelt gratitude to all the individuals who
contributed to the development of this module on Health assessment.
Special thanks to our respected Principal for their continuous support,
encouragement, and vision in promoting such important educational topics.

Their leadership has been a driving force behind the creation of this
module, ensuring that students are equipped with essential life-saving
knowledge.

I am also deeply grateful to the medical professionals whose expertise,

advice, and insights have significantly enriched the content and practical
relevance of this module. Their dedication to healthcare and their willingness
to share valuable information have made this resource both informative and
impactful.

Additionally, I would like to thank the faculty members who provided

valuable guidance during the preparation of this module and the students
whose feedback and participation were essential to improving its quality.
This module would not have been possible without the collective efforts of
everyone involved.

Suman Yadav
BSc Nursing
1 st year
2 nd semester

[2]
Introduction: Health Assessment
Health assessment is the first
and most important step in
understanding a patient's
condition. It helps healthcare
professionals gather detailed
information about a person's
physical, mental, emotional,
and social health.
The process begins with taking
the patient's health history, followed by a physical
examination using different techniques like inspection,
palpation, percussion, auscultation, and olfaction. These
methods help in identifying any signs of illness or
abnormalities in the body systems.
Health assessment is not just about finding diseases — it
helps in building trust, planning treatment, and giving the
right care at the right time. A proper assessment ensures that
no small detail is missed and that the patient’s health is fully
understood.
In short, health assessment is the foundation of effective
patient care.
It also improves communication between patients and
healthcare professionals, leading to better outcomes and
satisfaction.
[3]
Nursing / Health History Taking
Health history taking is the first step in the nursing
assessment process. It involves collecting detailed and
structured information about the patient’s health to
understand their current condition, past illnesses, and
lifestyle.
Purpose:
 To identify health problems or
risks early
 To plan safe and effective
nursing care
 To establish a good nurse-
patient relationship
Key Components:
1. Personal Information
– Name, age, gender, occupation, marital status
2. Chief Complaints
– Main reason for the visit, in the patient’s own words
3. History of Present Illness
– Details about symptoms (onset, duration,
severity, etc.)
[4]
4. Past Medical History
– Previous illnesses, surgeries, hospitalizations,
allergies
5. Family History
– Diseases running in the family (e.g., diabetes,
hypertension)
6. Lifestyle and Habits
– Diet, exercise, sleep pattern, smoking, alcohol,
etc.
7. Psychosocial History
– Mental health, emotional well-being, support
systems
8. Medication History
– Current medications, dose, duration,
compliance
9. Immunization Status
– Vaccinations received or pending
Importance:
 Helps in early diagnosis
 Builds trust and communication
 Forms the base for physical examination
[5]
Performing Physical Examination
Physical examination is a step-by-step process used by nurses
and doctors to assess a patient's body for signs of disease. It
helps confirm findings from the health history and detect any
abnormalities.
1. General Physical
ExaminationThis is done to
get an overall idea of the
patient's health.Steps
include:
 Appearance: Level of
consciousness, posture,
body build, hygiene
 Vital Signs:
o Temperature
o Pulse
o Respiration
o Blood Pressure
 Height and Weight: For
BMI calculation
 Skin: Color, texture,
turgor, lesions
 Mobility: Gait, balance, coordination
[6]
 2. System-wise Physical Examination
Each body system is
examined using four
techniques: Inspection,
Palpation, Percussion,
Auscultation

System What to Check

Cardiovascular Heart sounds, pulse rate, rhythm,
blood pressure
Respiratory Chest expansion, breath sounds, signs
of distress
Gastrointestinal Abdominal shape, bowel sounds,
tenderness
Nervous System Reflexes, muscle strength, sensory
responses
Musculoskeletal Joint movement, posture, deformities
Integumentary Rashes, wounds, colour changes
(Skin)
Genitourinary Urinary output, tenderness, swelling (if
applicable)
Endocrine & Observe for signs of hormonal
Others imbalance

[7]
Various Methods of Physical Examination

Physical examination is a crucial part of diagnosing a

patient's condition. It involves a systematic
assessment using various methods to observe, feel,
and listen to the body. Here are the main methods of
physical examination:
1. Inspection
Definition: The process of
visually examining a patient’s
body for signs of illness,
abnormalities, or changes in
appearance.
Purpose: To identify any
visible signs such as swelling,
deformities, asymmetry, skin
color changes, scars, or signs
of infection.
Example: Observing the skin
for rashes or jaundice, or
looking for abnormal
posture or gait.

[8]
2. Palpation
Definition: Using the hands to touch
and feel the body for abnormalities,
tenderness, or changes in texture.
Purpose: To detect lumps, swelling,
temperature changes, or abnormalities in organs.
Example: Palpating the abdomen to check for tenderness,
mass, or enlarged organs like the liver or spleen.
3. Percussion
Definition: Tapping on the body’s
surface (usually the chest or
abdomen) to assess the condition of
underlying tissues and organs.
Purpose: To detect fluid accumulation,
air in organs, or solid masses.
Example: Percussing the chest to check for signs of fluid
(pleural effusion) or checking for dullness or resonance in
the lungs.
4. Auscultation
Definition: Listening to the internal
sounds of the body, typically using a
stethoscope.

[9]
Purpose: To evaluate the heart, lungs, abdomen, and other
internal organs by listening for abnormal sounds like heart
murmurs, lung crackles, or bowel sounds.
Example: Auscultating the heart for murmurs or listening
to the lungs for wheezing or crackling sounds.
Detect murmurs, crackles, or abnormal rhythms
5. Olfaction (Smelling)
Definition: Olfaction in physical examination refers to using the
sense of smell to detect unusual odors that may indicate a
medical condition.
Purpose: To identify abnormal smells that can signal specific
diseases or disorders.
Example:
Fruity smell (acetone) in diabetic ketoacidosis.
Ammonia odor in chronic kidney failure.
Foul smell from a wound indicating infection.

Each method provides unique clues. When used together,

they help in forming a complete and accurate
understanding of the patient's health.

[10]
Identification of system-wise derivations

Identification of system-wise
derivations in clinical
practice refers to recognizing
and understanding the
different signs, symptoms,
and diagnostic results that
point to abnormalities in
specific body systems. Each
body system (e.g.,
cardiovascular, respiratory,
digestive, etc.) has a set of
characteristic clinical
manifestations when
affected by a disease or disorder. Here’s how you can
approach system-wise derivations:
1. Cardiovascular System
 Common Derivations:
o Chest pain: Could indicate myocardial
infarction (heart attack) or angina.
o Shortness of breath: May point to heart failure
or pulmonary embolism.
[11]
 o Edema: Suggests heart failure, often in the
lower limbs.
 Diagnostic Tests: ECG, echocardiogram, and blood
tests (e.g., cardiac troponin).

2. Respiratory System
 Common Derivations:
o Cough: Can indicate infections (e.g.,
pneumonia), chronic conditions (e.g., asthma),
or malignancy.
o Wheezing: Suggestive of asthma, chronic
obstructive pulmonary disease (COPD).
o Cyanosis: Indicates hypoxia or poor
oxygenation of tissues, as seen in respiratory
failure or severe asthma.
 Diagnostic Tests: Chest X-ray, pulmonary function
tests, arterial blood gases.
3. Gastrointestinal System
 Common Derivations:
o Abdominal pain: Can arise from conditions like
appendicitis, ulcers, or gallbladder disease.
[12]
 o Vomiting: Could be due to infections, food
poisoning, or gastrointestinal obstruction.
o Jaundice: Suggests liver dysfunction, as seen in
hepatitis, cirrhosis, or bile duct obstruction.
 Diagnostic Tests: Abdominal ultrasound, liver
function tests, endoscopy.
4. Neurological System
 Common Derivations:
o Headache: Could be a sign of tension
headache, migraine, or brain tumors.
o Seizures: Suggestive of epilepsy, brain injury,
or infections like meningitis.
o Weakness or paralysis: Indicates a possible
stroke, multiple sclerosis, or spinal cord injury.
 Diagnostic Tests: CT scan, MRI, EEG
(electroencephalogram).
5. Renal System
 Common Derivations:
o Hematuria (blood in urine): Could point to
kidney stones, infection, or malignancy.

[13]
 o Oliguria (low urine output): Suggests kidney
failure or dehydration.
o Edema: Can be seen in conditions like
nephrotic syndrome or chronic kidney disease.
 Diagnostic Tests: Urinalysis, kidney function tests
(e.g., creatinine, GFR), ultrasound.
6. Endocrine System
 Common Derivations:
o Fatigue, weight changes: May indicate thyroid
dysfunction (hypothyroidism or
hyperthyroidism).
o Polydipsia and polyuria: Could suggest
diabetes mellitus.
o Increased thirst and hunger: Often related to
diabetes or adrenal disorders.
 Diagnostic Tests: Blood glucose, thyroid function
tests, hormone levels.
7. Musculoskeletal System
 Common Derivations:
o Joint pain: May be related to arthritis
(osteoarthritis, rheumatoid arthritis).
[14]
 o Muscle weakness: Could indicate conditions
like muscular dystrophy or neuropathy.
o Deformities or swelling: Often seen in
fractures or joint diseases.
 Diagnostic Tests: X-rays, MRI, bone scans.
8. Integumentary System (Skin)
 Common Derivations:
o Rashes: Could indicate allergic reactions,
infections (e.g., chickenpox), or autoimmune
conditions.
o Ulcers or sores: May suggest poor circulation,
infection, or pressure ulcers.
o Changes in skin color: Can be a sign of
jaundice, cyanosis, or anemia.
 Diagnostic Tests: Skin biopsy, culture tests, blood
tests.
By recognizing these system-wise derivations,
clinicians can narrow down the potential causes of
symptoms, helping in diagnosis and treatment
planning.

[15]
 Documentation of Findings
Documentation of Findings in clinical practice is a
critical part of patient care. It involves recording all
relevant information gathered during the physical
examination, patient history, diagnostic tests, and any
other clinical assessments. Proper documentation
ensures continuity of care, legal protection, and
effective communication between healthcare
providers. Here’s a structured approach to
documenting clinical findings:
1. Patient Information
 Name: Full name of the
patient.
 Age: The patient's age.
 Gender: Male/Female/Other.
 Date of Examination: The date when the
examination took place.
 Presenting Complaint: The main issue the patient
is seeking medical help for.
 History of Present Illness (HPI): A detailed
description of the patient’s symptoms, onset,

[16]
 duration, and any factors that make the condition
better or worse.
2. Medical History
 Past Medical History: Includes
any chronic conditions,
previous surgeries, or ongoing
treatments (e.g., diabetes, hypertension, asthma).
 Family History: A record of any genetic or
hereditary diseases within the family.
 Social History: Information regarding the patient’s
lifestyle, smoking, alcohol consumption, drug use,
and occupational factors.
 Medications: List of current medications, including
over-the-counter drugs and herbal supplements.
3. Physical Examination
 General Appearance: The
patient’s overall state (e.g., well-
nourished, distressed, pale, etc.).
 Vital Signs:
o Temperature
o Pulse rate
[17]
 o Respiratory rate
o Blood pressure
o Oxygen saturation
 Inspection: Findings from visual examination (e.g.,
skin color, deformities, posture).
 Palpation: Notes on any tenderness, swelling, or
abnormalities found when palpating the body.
 Percussion: Sounds noted during percussion (e.g.,
dullness over the liver, tympany in the abdomen).
 Auscultation: Findings from listening to the heart,
lungs, and abdomen (e.g., heart murmurs, lung
crackles, bowel sounds).
4. System-wise Examination Findings
Document findings under each specific body system:
 Cardiovascular System: Heart sounds (murmurs,
regular rhythm), peripheral pulses, edema, etc.
 Respiratory System: Breath sounds (wheezes,
crackles), cough, signs of distress, etc.
 Gastrointestinal System: Abdominal tenderness,
bowel sounds, masses, etc.

[18]
  Neurological System: Reflexes, motor strength, cranial
nerve assessment, etc.
 Musculoskeletal System: Joint range of motion,
deformities, muscle strength.
 Integumentary System: Skin lesions, rashes, ulcers,
pallor.
5. Diagnostic Tests & Results
 Lab Results: Document blood tests,
urine tests, imaging (X-rays, MRI,
etc.), and any other relevant
diagnostic tests.
 Findings from Imaging: Describe what was noted (e.g.,
presence of a tumor, fracture, infection).
 Other Tests: EKG/ECG, echocardiogram, spirometry,
etc.
6. Impression/Diagnosis
 Working Diagnosis: Based on the findings, provide an
initial diagnosis or a differential diagnosis list.
 Differential Diagnosis: Include conditions that could
also explain the symptoms if the diagnosis is uncertain.
7. Plan of Care
 Investigations: Any further tests or studies that need
to be conducted.
[19]
  Treatment Plan: Medications,
therapy, surgery, or interventions
recommended.
 Follow-up: Instructions for the
patient to return for further evaluation or treatment.
 Patient Education: Guidance on lifestyle changes,
medication adherence, or coping strategies.
8. Signature & Date
 Clinician’s Signature: The healthcare
professional documenting the
findings must sign the note.
 Date and Time: The date and time the findings were
documented.
Example of Documentation
Patient Information:
 Name: John Doe
 Age: 45
 Gender: Male
 Date of Examination: 14th April 2025
 Presenting Complaint: Persistent chest pain for 2 days.
Medical History:

[20]
  Past Medical History: Hypertension, Type 2 Diabetes
Mellitus, No prior heart conditions.
 Family History: Father had a myocardial infarction at
age 50.
 Social History: Smokes 10 cigarettes/day, occasional
alcohol use.
 Medications: Metformin 500mg daily, Amlodipine 5mg
daily.
Physical Examination:
 General Appearance: Alert, anxious, in mild distress
due to pain.
 Vital Signs:
o Temperature: 98.6°F
o Pulse: 88 bpm, regular
o Blood Pressure: 140/90 mmHg
o Respiratory Rate: 18 breaths/min
o Oxygen Saturation: 97%
 Cardiovascular System: Normal S1, S2; no murmurs or
gallops, peripheral pulses intact.
 Respiratory System: Clear breath sounds bilaterally, no
wheezes or crackles.

[21]
  Gastrointestinal System: Soft, non-tender abdomen,
no masses.
 Neurological System: Alert, oriented, normal reflexes.
 Integumentary System: No rashes or lesions.
Diagnostic Tests:
 ECG: Normal sinus rhythm, no ST changes.
 Chest X-ray: No signs of pneumothorax or cardiomegaly.
 Cardiac Enzymes: Troponin levels within normal range.
Impression:
 Likely non-cardiac chest pain due to musculoskeletal
strain. Differential includes angina or gastrointestinal
reflux disease.
Plan of Care:
 Investigations: Refer for stress test if pain persists.
 Treatment Plan: Prescribe ibuprofen 400mg for
pain relief. Advise dietary modifications and
lifestyle changes.
 Follow-up: Return in 1 week for re-evaluation.
Signature:
 Dr. Suman Yadav, MBBS
 Date: 14th April 2025

[22]
 questionnaire
A questionnaire in the medical or clinical
context is a tool used to collect
information from patients or study
participants. It can be used to assess
symptoms, medical history, lifestyle
habits, and more. Below is an example of a patient
intake questionnaire and a health assessment
questionnaire to help guide clinical data collection:
1. Patient Intake Questionnaire
This questionnaire is typically used when a patient
first visits a healthcare facility to collect essential
personal and medical information.
Personal Information:
 Full Name: ________________________
 Date of Birth: ________________________
 Gender: Male / Female / Other
 Address: ________________________
 Phone Number: ________________________
 Emergency Contact Name:
________________________
[23]
  Relationship to Emergency Contact:
________________________
 Emergency Contact Number:
________________________
Insurance Information (if applicable):
 Insurance Provider: ________________________
 Policy Number: ________________________

Medical History:
 Do you have any chronic conditions? (e.g.,
diabetes, hypertension, asthma)
☐ Yes ☐ No
If yes, please specify:
________________________
 Have you had any surgeries in the past?
☐ Yes ☐ No
If yes, please list: ________________________
 Are you currently taking any medications?
☐ Yes ☐ No
If yes, please list: ________________________

[24]
  Do you have any allergies to medications, food, or
environmental factors?
☐ Yes ☐ No
If yes, please specify:
________________________
 Do you have a family history of any medical
conditions? (e.g., heart disease, cancer, diabetes)
☐ Yes ☐ No
If yes, please specify:
________________________

Lifestyle and Social History:

 Do you smoke?
☐ Yes ☐ No
If yes, how many cigarettes per day?
_______________
 Do you drink alcohol?
☐ Yes ☐ No
If yes, how many drinks per week?
_______________
 Do you use recreational drugs?
☐ Yes ☐ No
[25]
 If yes, please specify:
________________________
 How often do you exercise?
☐ Daily ☐ Weekly ☐ Rarely ☐ Never
 What is your diet like?
☐ Healthy ☐ Unhealthy ☐ Balanced ☐ Special
Diet (please specify): _____________
Current Symptoms or Concerns:
 What is the main reason for your visit today?
_______________________________________
 Have you experienced any of the following
symptoms recently? (Check all that apply) ☐
Chest pain ☐ Shortness of breath ☐ Abdominal
pain ☐ Headache
☐ Fatigue ☐ Dizziness ☐ Nausea ☐ Joint pain ☐
Cough ☐ Fever ☐ Other (please specify):
___________
2. Health Assessment Questionnaire
This questionnaire is more focused on assessing a
patient’s health and understanding their risk factors
for certain conditions.
[26]
General Health:
 How would you rate your general health?
☐ Excellent ☐ Good ☐ Fair ☐ Poor
 Do you feel fatigued often?
☐ Yes ☐ No
 Have you noticed any weight changes recently?
☐ Yes ☐ No
If yes, how much? _______________
Cardiovascular System:
 Do you experience chest pain or discomfort?
☐ Yes ☐ No
 Do you experience palpitations or irregular
heartbeats?
☐ Yes ☐ No
 Do you have a family history of heart disease or
stroke?
☐ Yes ☐ No
Respiratory System:
 Do you have shortness of breath or difficulty
breathing?
☐ Yes ☐ No
[27]
  Do you experience wheezing or coughing?
☐ Yes ☐ No
 Have you ever been diagnosed with asthma,
bronchitis, or other lung disease?
☐ Yes ☐ No
Gastrointestinal System:
 Do you have frequent heartburn or indigestion?
☐ Yes ☐ No
 Do you have abdominal pain or bloating?
☐ Yes ☐ No
 Have you experienced changes in your bowel
movements (constipation, diarrhea, etc.)?
☐ Yes ☐ No
Musculoskeletal System:
 Do you experience joint pain or stiffness?
☐ Yes ☐ No
 Do you have muscle weakness or cramps?
☐ Yes ☐ No

[28]
Endocrine System:
 Do you experience excessive thirst or urination?
☐ Yes ☐ No
 Do you feel overly tired or fatigued frequently?
☐ Yes ☐ No
 Have you ever been diagnosed with thyroid
problems, diabetes, or other endocrine disorders?
☐ Yes ☐ No
Neurological System:
 Do you experience headaches or migraines?
☐ Yes ☐ No
 Have you ever had a seizure?
☐ Yes ☐ No
 Do you experience dizziness or fainting?
☐ Yes ☐ No
Psychological Health:
 Do you often feel anxious or stressed?
☐ Yes ☐ No
 Do you feel depressed or have trouble sleeping?
☐ Yes ☐ No
[29]
3. Follow-up Section
 What are your main concerns about your health
today?
________________________________________
 Any additional information you'd like to share
with your healthcare provider?
________________________________________

These questionnaires can be adapted to fit specific

needs depending on the nature of the visit, the
clinical setting, or the patient population. They're vital
in creating a comprehensive patient profile and assist
in making well-informed decisions about diagnosis
and treatment.

[30]
 Summary – Health Assessment
Health assessment is the first sacred touch of care —
where observation meets intuition, and science holds
hands with service.
It begins with nursing history taking — not just names and
numbers,
but stories whispered through symptoms, lifestyles etched
in words.
Then comes the physical examination,
both general (the body's rhythm and tone)
and system-wise (from head to toe, from heart to
hormones).
Nurses become detectives of the body, using the five
ancient tools:
Inspection – the art of seeing what others miss.
Palpation – feeling the silent messages of skin and organ.
Percussion – tapping out secrets from within.
Auscultation – listening to the body’s inner music.
Olfaction – the nose knows when something’s wrong.
In each step, nurses don’t just sense — they document.
From deviations in systems to subtle shifts in health,
everything is written with care — the findings, the
questionnaire responses,
so the story continues with clarity and continuity.
[31]
 Conclusion – Health Assessment
Health assessment is more than a checklist —
it is the first conversation between a caregiver and a
life in need.
Through skillful observation, tender touch, and
mindful listening,
nurses unveil the silent stories the body tries to tell.
From history taking to the five senses of examination
—
inspection, palpation, percussion, auscultation, and
olfaction —
each method is a bridge between signs and solutions.
By identifying system-wise deviations and
documenting findings with precision,
nurses become both protectors of truth and pioneers
of healing.
In the ever-evolving rhythm of healthcare,
a thorough health assessment remains the foundation
—
ensuring that every treatment, every plan,
begins not with assumption, but with understanding.

[32]
 Bibliography
1. Potter, P. A., Perry, A. G., Stockert, P., & Hall,
A. (2021). Fundamentals of Nursing (10th ed.).
Elsevier Health Sciences.
2. Bickley, L. S. (2020). Bates' Guide to Physical
Examination and History Taking (13th ed.).
Wolters Kluwer.
3. Kozier, B., Erb, G., Berman, A., Snyder, S. J., &
Levett-Jones, T. (2018). Kozier and Erb’s
Fundamentals of Nursing (Vol. 1–3, 4th Australian
ed.). Pearson Australia.
4. Swearingen, P. L. (2016). All-in-One Care
Planning Resource: Medical-Surgical, Pediatric,
Maternity, and Psychiatric Nursing Care Plans
(4th ed.). Elsevier.
5. World Health Organization. (2023). Health
topics: Health assessment. Retrieved from
https://www.who.int/

[33]
Multiple Choice Questions with Answer

1–5: Methods of Physical Examination

1. Which of the following is a method of physical
examination that involves visually observing the
body?
A) Palpation
B) Percussion
C) Inspection
D) Auscultation
2. What does palpation help the clinician assess?
A) Smell of the body
B) Size, shape, and texture of organs
C) Heart rhythm
D) Emotional state
3. Which method involves tapping the body to
evaluate the underlying structures?
A) Inspection
B) Percussion
C) Palpation
D) Olfaction
4. Which technique is used to listen to internal
body sounds like the lungs and heart?
[34]
 A) Percussion
B) Auscultation
C) Palpation
D) Olfaction
5.Which physical examination method uses the
clinician's sense of smell?
A) Inspection
B) Palpation
C) Percussion
D) Olfaction
6–9: Olfaction – Definition, Purpose, Examples
6. What is olfaction in the context of a clinical
examination?
A) Touch
B) Hearing
C) Sense of smell
D) Visual observation
7. What is the purpose of olfaction in physical
examination?
A) To measure blood pressure
B) To detect visual abnormalities
C) To identify unusual body or breath odors

[35]
 indicating disease
D) To examine neurological reflexes
8. A sweet, fruity breath odor is a sign of:
A) Kidney failure
B) Diabetic ketoacidosis
C) Anemia
D) Appendicitis
9. A foul-smelling discharge from a wound may
indicate:
A) Dehydration
B) Local infection or gangrene
C) Liver cirrhosis
D) Fracture healing
10–16: System-wise Identification of Derivations
10. Clubbing of fingers is most commonly
associated with:
A) Liver failure
B) Chronic respiratory disease
C) Renal failure
D) Gallstones
11. A patient presenting with bilateral pedal
edema likely suffers from:
[36]
 A) Liver cancer
B) Bronchitis
C) Congestive heart failure
D) Appendicitis
12. Yellowing of the skin and eyes is called:
A) Cyanosis
B) Jaundice
C) Pallor
D) Erythema
13. Neurological symptoms like loss of
coordination and reflexes point to issues in:
A) Cardiovascular system
B) Central nervous system
C) Digestive system
D) Urinary system
14. Crackles or rales in lung auscultation suggest:
A) Liver disease
B) Pulmonary edema or pneumonia
C) Bone fracture
D) Stroke
15. Palpable liver edge below the right costal
margin is an indication of:
A) Normal anatomy
[37]
 B) Hepatomegaly
C) Splenomegaly
D) Diaphragmatic hernia
16. A patient complains of tingling and numbness
in hands and feet. This could be:
A) Muscle strain
B) Peripheral neuropathy
C) Sinus infection
D) Hepatitis
17–21: Documentation of Findings
17. Why is proper documentation of physical
findings crucial?
A) For statistical purposes
B) For continuity of care and legal validity
C) For billing codes
D) For academic reporting
18. Which of the following should be recorded in
patient documentation?
A) Favorite food
B) Physical exam findings, vitals, and complaints
C) Political views
D) Instagram profile

[38]
19. The term SOAP in documentation stands for:
A) Standard Order And Procedure
B) Subjective, Objective, Assessment, Plan
C) Signs Of Abnormal Pathology
D) Symptoms Of Ailment Progress
20. A complete physical examination report must
include:
A) Only vital signs
B) History, examination findings, and impression
C) Lab reports only
D) Prescription details only
21. What does the assessment section in clinical
documentation reflect?
A) Vital signs
B) Medications
C) Clinical impression or diagnosis
D) Insurance details
22–25: Clinical Questionnaires
22. What is the main goal of a health
questionnaire?
A) Entertainment
B) Advertising
C) Gathering relevant clinical and lifestyle
[39]
 information
D) Booking appointments
23. A questionnaire asking about smoking,
alcohol, or drug use relates to:
A) Family history
B) Social history
C) Surgical history
D) Physical examination
24. In a general medical questionnaire, a question
like "Do you have chest pain during exertion?"
targets which system?
A) Digestive
B) Cardiovascular
C) Integumentary
D) Reproductive
25. Questionnaires are particularly useful in:
A) Blood transfusion
B) Surgery
C) Early screening and case history collection
D) Discharge planning

[40]