N210 Review: Physical Examination and Health Assessment

ABCDE

A mnemonic representing asymmetry, border, colour, diameter, elevation and evolution.

Pallor

Cause of color change anemia, shock, arterial insufficiency.

Erythema

Cause of color change fever, polycythemia (too many RBCs cancer), venous stasis (veins can’t return blood to heart).

Cyanosis

Cause of color change shock, heart failure, chronic bronchitis (inflammation of airway).

Jaundice

Causes of color change hepatitis (inflammation of liver), cirrhosis (scarring of liver tissue).

Brown-tan

Causes of color changes addisons disease (adrenal glands don’t produce enough hormones).

Pitting Edema 1+

Mild pitting, slight indentation, no leg swelling noted.

Pitting Edema 2+

Moderate pitting, indentation rapidly subsides.

Pitting Edema 3+

Deep pitting, indentation remains for a short period of time, swelling of the leg noted.

Pitting Edema 4+

Very deep pitting, indentation lasts a long time, major swelling with distortion of the leg noted.

Profile Sign

The practical nurse views the index finger at its profile.

Nail Base Angle

Normally, the angle of the nail base is 160 degrees and it feels spongy on palpation.

Milia

Tiny, white papules on the cheeks, forehead, nose and chin of infants.

Erythema Toxicum

A common rash that occurs in the first 3-4 days of life.

Senile Lentigines

Small, flat, brown macules that are a common variation in hyperpigmentation in the older adult.

Confluent Lesions

Lesions that merge together.

Gyrate Lesions

Twisted, coiled, snake-like lesions.

Discrete Lesions

Distinct individual lesions that remain separate.

Zosteriform Lesions

Linear lesions along a nerve route.

Grouped Lesions

Cluster of lesions.

Macule

Primary skin lesion.

Cyst

Primary skin lesion.

Ulcer

Secondary skin lesion.

Fissure

Secondary skin lesion.

Keloid

Secondary skin lesion.

Wheal

Primary skin lesion.

Pustule

Primary skin lesion.

Normocephalic

Describes a round, symmetrical skull that is appropriate to body size.

Parotid Gland

Swollen in cases of mumps.

Trachea

A normal finding is for the trachea to be midline with the space symmetrical on both sides.

Lymph Node Assessment

If lymph nodes are palpable, note the location, size, shape, delimitation, mobility, consistency, and tenderness.

Periorbital Edema

Edema in the faces first occurs around the periorbital area and the cheeks.

Cephalohematoma

An infant with cephalohematoma is at an increased risk for jaundice.

Fontanelles

Upon palpation, fontanelles should feel firm, slightly concave, and well-defined against the edges of the cranial bones.

Lymph Node Palpation Sequence

1. Preauricular, 2. Posterior auricular, 3. Occipital, 4. Subvmental, 5. Submandibular, 6. Jugulodigastric, 7. Superficial cervical, 8. Deep cervical chain, 9. Posterior cervical, 10. Supraclavicular.

Rhinitis

Nasal mucosa appear swollen and bright red.

Chronic Allergies

Mucosa appear swollen, boggy, pale, and gray.

Turbinates

The superior turbinate is not visible upon inspection.

Chelitis

Cracking noted at the corners of the lips.

Malocclusion

Protrusion of the upper or lower incisors.

Oral Malignancies

Most likely to develop in the U-shaped areas under the tongue behind the teeth.

Bifid Uvula

Looks as if it is split in two.

Tonsil Size Grading 1+

Visible.

Tonsil Size Grading 2+

Halfway between tonsillar pillars and uvula.

Tonsil Size Grading 3+

Touching uvula.

Tonsil Size Grading 4+

Touching each other.

Superior turbinate

Not visible when inspecting the turbinates.

Tonsil grading 1+

Visible.

Tonsil grading 2+

Halfway between tonsillar pillars and uvula.

Tonsil grading 3+

Touching uvula.

Tonsil grading 4+

Touching each other.

Musculoskeletal examination purpose

To assess function for ADLs and to screen for abnormalities.

Joint swelling

Presence suggests joint irritation.

Joint warmth and tenderness

Indicates inflammation.

Thickened synovial joint

Feels doughy/boggy.

Normal ROM of a joint

Should be the same in both active and passive ROM.

Ortolani manoeuvre

Check the hips for congenital dislocation at every clinic visit until an infant reaches 1 year old.

Genu valgum

Characterized by a span of more than 2.5 cm between the medial malleoli when the knees are together.

Muscle strength grading 1

Slight contraction.

Muscle strength grading 2

Full ROM with gravity eliminated.

Muscle strength grading 5

Full ROM against gravity with full resistance.

Dislocation

One or more bones in a joint being out of position.

Crepitation

Audible and palpable crunching with movement.

Subcutaneous Nodules

Overlying the skin, non tender, raised, firm.

Ulnar Deviation

Fingers deviate toward the ulnar side of the hand.

Dupuytren's Contracture

Flexion contracture of one or more fingers.

Subluxation

Partial dislocation of a joint.

Contracture

Shortening of a muscle, leads to limited ROM of joint.

Temporomandibular joint ROM movements

Vertical, lateral, protrusion.

Cervical Spine ROM movements

Flexion, hyperextension, lateral bending, rotation.

Shoulder ROM movements

Flexion, extension, abduction, adduction, internal rotation, external rotation.

Elbow ROM movements

Flexion, extension, pronation, supination.

Wrist and Hands ROM movements

Flexion, extension, ulnar deviation, radial deviation, abduction.

Hip ROM movements

Flexion, extension, internal rotation, external rotation, abduction, adduction.

Knee ROM movements

Flexion, extension, hyperextension.

Ankle ROM movements

Flexion, extension, inversion, eversion.

Spine ROM movements

Flexion, extension, hyperextension, rotation, lateral bending.

Cervical spine flexion expected range

45 degrees.

Shoulder external rotation expected range

90 degrees.

Shoulder abduction expected range

180 degrees.

Elbow flexion expected range

160 degrees.

Hip adduction expected range

30 degrees.

Spine flexion expected range

90 degrees.

Spine rotation expected range

30 degrees.

Complete musculoskeletal examination requirement

Needed when the client has: 1. history of musculoskeletal symptoms 2. articular disease 3. problems with ADLs.

Assessing spinal curvature

Ask the client to touch their toes, mark a dot on each spinous process, then observe if the dots form a straight vertical line.

Olfactory Nerve (I)

Patency first then presenting a familiar aromatic substance to each nostril while the other is occluded.

Optic Nerve (II)

Visual acuity, visual fields by confrontation, assessment using ophthalmoscope.

Oculomotor, Trochlear, Abducens Nerves (III, IV, VI)

Inspect palpebral fissures, PERRLA, cardinal positions of gaze, assess for nystagmus.

Trigeminal Nerve (V)

Motor: Assess muscles of mastication, try to separate jaws by pushing down on the chin. Sensory: with client's eyes closed assess light touch in three locations on the client's face (forehead, cheeks, and chin). Client says 'now' when touch is felt.

Facial Nerve (VII)

Motor: Mobility and symmetry assessed as client frowns, lifts eyebrows, closes eyes tightly against examiner attempt to open them, shows teeth, puffs cheeks. Press client's puffed cheeks and note whether air escapes equally from both sides.

Acoustic Nerve (VIII)

Whispered Voice Test.

Glossopharyngeal & Vagus Nerves (IX, X)

Motor: Depress tongue with tongue blade - ask client say 'Ahhh'. Note uvula and soft palate rise in midline, tonsillar pillars should move medially.

Spinal Accessory Nerve (XI)

Examine sternomastoid and trapezius muscles for equal size. Strength testing: against resistance ask client to rotate head and shrug shoulders.

Hypoglossal Nerve (XII)

Inspect tongue, ask client to stick out tongue, ask client to say 'light, tight, dynamite'.

Deep Tendon Reflexes

The examiner should stimulate the reflex by giving a short, snappy blow of the reflex hammer onto the muscle's insertion tendon.

Clonus

A set of rapid rhythmic contractions of the muscle.

Reinforcement

A technique used to relax the muscles and enhance the response.

Reflex response grading scale

4+: very brisk, hyperactive with clonus; 3+: brisker than average; 2+: average, normal; 1+: low normal, diminished; 0: no response. On the five-point scale, 4+ is indicative of disease and 3+ may indicate disease.

Identify the five deep tendon reflexes that the examiner can test…

Biceps reflex, triceps reflex, brachioradialis reflex, quadriceps reflex, Achilles reflex.