Interview Cardiac
Intro: NOD| Identify| Explain| Consent | Any questions?
HH: What brings you here | Felt this pain before | Cardiac problems |Family
history? | Any medications? | Any fatigue, shortness of breath? LOPQRSTU
Physical Assessment (Cardiac)
Inspect: JVD | Colour | Bulges/masses/pacemaker | Symmetry| Varicose
Veins | Atrophy | Hair Distribution |
Palpate: Precordium (heaves) | Apical | Radial |Brachial | Dorsalis| Tibialis|
Auscultate: Carotid (then palpate) | Heart (No murmur or galloping)
Gastro Inspect: Colour | Contour| Masses | Umbilicus |Auscultate: Bowel
sounds (Clockwise) |Palpate| Last BM | Void | Vomit | Weight change | Diet
Respiratory Inspect: Position | Colour| Accessory use | Respirations|
audible | Auscultate: 2 each side | In & out |Crackles, wheezes, or stridor
Skin: Cap Refill (toes & hands) |Turgor| Edema |Temp
Neuro: PERRLA *Dim Light* | Strength (Bilaterally)
MSK: CSMT, ROM, Joint Pain? Difficulty w/ ADL? Sensory Aids?
Vitals: BP, O2, Temp, Resp, Pulse, Pain
Mental Health: Covid Restrictions? Coping Mechanisms? Support systems?
Patient Teaching:
- Lessen vigorous activity or heavy lifting until you are seen by your
doctor & we figure out what is happening
- Take a break from exercising when you feel increased chest pain
- Come to hospital or call 911 if you notice if it is getting worse
Interview Gastro
Intro: NOD| Identify| Explain| Consent | Any questions?
HH: What brings you here | Pervious abdominal pain | Digestive problems? |
Any medications? | Vomiting/ Nausea | Last BM| Void | Weight loss/gain|
Diet| LOPQRSTU
Physical Assessment (Gastro)
Inspect: Colour | Contour| Masses |Lesions | Umbilicus| Pulsations
Auscultate: Bowel sounds (Counter-clockwise) | Aorta, Renal Iliac (USE BELL)
Percuss: Tympany is expected, Hyperresonance = gas, Dull = dense organ
Palpate: Tender area last, ask & assess for pain
Inspect: JVD | Colour | Masses| Symmetry| Varicose Veins | Atrophy | Hair
Palpate: Precordium (heaves) | Radial | Dorsalis| Tibialis| Auscultate:
Carotid (then palpate) | Heart (No murmur or galloping)
Respiratory Inspect: Position | Colour| Accessory use | Respirations|
audible | Auscultate: 2 each side | In & out |Crackles, wheezes, or stridor
Skin: Cap Refill (toes & hands) |Turgor| Edema |Temp
Neuro: PERRLA *Dim Light* | Strength (Bilaterally)
MSK: CSMT, ROM, Joint Pain? Difficulty w/ ADL? Sensory Aids?
Vitals: BP, O2, Temp, Resp, Pulse, Pain
Mental Health: Covid Restrictions? Coping Mechanisms? Support systems?
Patient Teaching:
- Avoid intake of greasy foods until you see your doctor and we
figure out what is going on (Give resources to balanced nutrition
intake)