Comprehensive Medical Assessment: Cultural, Neuro, HEENT, Breast, and Reproductive

What is culture?

Knowledge, belief, art, morals, laws, customs, and any other capabilities and habits acquired by a person as a member of society.

What is cultural awareness?

Understanding the characteristics that a group may share, such as geographic origin, race, language, religious beliefs, traditions, and symbols.

What is ethnic awareness?

Characteristics that a group may share, including common geographic origin, race, language, religious beliefs, and shared traditions.

What is spirituality?

Religious systems of beliefs and values, life meaning, purpose, connection with others, and nonreligious systems of beliefs.

What is spiritual awareness?

Knowledge about spirituality and religious beliefs.

What are personal barriers to assessing spiritual needs?

Viewing assessment as a private matter, feeling embarrassment or discomfort about one's own spirituality, and discomfort with spiritual distress.

What are knowledge barriers to assessing spiritual needs?

Lack of knowledge about spirituality and minimal education related to spiritual assessment.

What is added to the assessment process for a patient with a nasal cannula?

Note respiratory effort and oxygen saturation, inspect skin of nares and behind ears for irritation.

What is added to the assessment process for a patient with an oxygen mask?

Use of accessory muscles, inspect facial skin for redness or indentation from the mask.

What is added to the assessment process for a patient with a tracheostomy?

Assess respiratory effort and secretions suctioned, inspect skin around the tube for redness or breakdown.

What is added to the assessment process for a patient with a chest tube?

Inspect pain, dressing around the tube, and color and amount of drainage.

What is added to the assessment process for a patient with a gastrostomy tube?

Inspect oral mucous membranes and skin around the G tube for redness and drainage.

What is added to the assessment process for a patient with a nasogastric tube?

Inspect skin of naris for redness and assess for nausea/vomiting and bowel sounds.

What is added to the assessment process for a patient with a wound drain?

Inspect wound for color, size, drainage, and assess nutrition.

What is added to the assessment process for a patient with an ostomy?

Inspect stoma and under ostomy appliance for intactness and describe output characteristics.

What is added to the assessment process for a patient with a urinary catheter?

(Information not provided in the notes.)

What is added to the assessment process for a patient with a cast?

Assess circulation, movement, sensation of toes/fingers, and capillary refill.

What is added to the assessment process for a patient with an external fixator?

Assess pin site for redness, swelling, warmth, tenderness, and monitor for pain.

What is added to the assessment process for a patient who is unconscious?

Assess Glasgow coma scale, breathing pattern, pupil size, eye movements, and motor responses.

What mental health problems are commonly assessed during an initial patient admission?

Depression, anxiety, suicidal ideation, substance use, interpersonal violence, cognitive status.

How can mental health impact physical assessment?

(Information not provided in the notes.)

What physical assessment findings may be present in a patient suffering from depression?

Poor eye contact, slow speech/movements, poor hygiene, weight loss or gain, fatigue.

What physical assessment findings may indicate drug/alcohol abuse?

Tremors, sweating, dilated or pinpoint pupils, slurred speech, unsteady gait, track marks, poor nutrition, signs of withdrawal.

What physical assessment findings may suggest interpersonal violence?

Bruises in different stages of healing, injuries inconsistent with the story, frequent 'accidents', fearful/anxious behavior, avoids eye contact, partner refusing to leave room, delay in seeking care.

What are some risk factors for depression and suicide?

Gender, age, substance abuse, genetics, psychosocial environment, personal characteristics.

What screening tool is commonly used to assess depression?

PHQ-9.

What screening tool is commonly used for substance abuse?

CAGE questionnaire.

What screening tool is used for alcohol addiction?

AUDIT tool.

What question can be asked regarding interpersonal violence?

'Many people are dealing with this problem, you may talk to me about it safely.'

What follow-up is required if a patient screens positive for depression or suicidal thoughts?

Further assessment, ensure safety, notify provider/interdisciplinary team, initiate referrals, mandatory reporting, document everything.

What are the components of a neurologic exam?

Mental status, speech, cranial nerve function, motor and sensory function, deep tendon reflexes.

What does 'alert' mean in terms of level of consciousness?

Answers and is aware.

What does 'lethargic' mean in terms of level of consciousness?

Aroused by saying their name and touching them, responds appropriately but returns to 'sleep' once stimuli ceases.

What does 'obtunded' mean in terms of level of consciousness?

Requires louder verbal stimuli and vigorous shaking to prompt a response.

What does 'stuporous' mean in terms of level of consciousness?

Requires painful stimuli to respond; response is usually withdrawal from pain.

What does 'semicomatose' mean in terms of level of consciousness?

Requires painful stimuli and responds with abnormal flexion or extension.

What does 'comatose' mean in terms of level of consciousness?

Does not respond to any stimuli, even central pain.

How do you assess orientation?

Ask for name and date of birth, location, and current date.

What is the definition of a 0 grade in tendon reflexes?

No response (absent).

What is the definition of a 1+ grade in tendon reflexes?

Diminished/low normal.

What is the definition of a 2+ grade in tendon reflexes?

Normal.

What is the definition of a 3+ grade in tendon reflexes?

Higher than average.

What is the definition of a 4+ grade in tendon reflexes?

Hyperactive, clonus present (possible CNS issue).

Where would you test for the biceps reflex?

Tap biceps tendon in antecubital space; arm flexion.

Where would you test for the triceps reflex?

Tap above elbow; arm extension.

Where would you test for the patellar reflex?

Tap patellar tendon; normal leg kicks out.

What is a positive finding for the plantar/Babinski reflex in adults?

Toes curl down; positive is abnormal in adults.

What is proprioception?

Kinesthetic sensation that allows identification of body position.

How is proprioception tested?

Move finger/toe up or down, ask to identify direction.

What is stereognosis?

The ability to identify an object by touch.

How is stereognosis tested?

Place an object in hand (like a coin or key) and ask to identify it.

What is graphesthesia?

The ability to recognize writing on the skin.

How is graphesthesia tested?

Draw a number or letter on the palm and have the patient identify it.

What is extinction in sensory testing?

The inability to perceive stimuli on one side of the body when both sides are stimulated.

How is extinction tested?

Touch both sides of the body at the same time; the patient should feel both.

What is 2-point discrimination?

The ability to distinguish two points of touch.

How is 2-point discrimination tested?

Touch the skin with two points simultaneously.

What is the Glasgow Coma Scale?

A scale used to assess consciousness and responsiveness.

What does the motor response in the Glasgow Coma Scale assess?

Whether the patient follows commands or responds to pain.

What does the verbal response in the Glasgow Coma Scale assess?

Whether the patient responds verbally or shows no response.

What does the eye opening in the Glasgow Coma Scale assess?

Whether the patient opens eyes spontaneously or not.

What are common findings in elderly patients?

Memory loss, slower processing, depression, incontinence, increased risk of falls.

What is dementia?

A condition characterized by memory loss and slower processing.

What is the significance of increased medication use in elderly patients?

Higher risk for drug interactions, side effects, and toxicity.

What is normocephalic?

A term describing a normal shape and size of the head.

What is the difference between dizziness and vertigo?

Dizziness is lightheadedness; vertigo is the sensation of room spinning.

What is epistaxis?

Nosebleeds.

What does PERRLA stand for?

Pupils Equal, Round, and Reactive to Light and Accommodation.

What is myopia?

Nearsightedness, the inability to see far.

What is hyperopia?

Farsightedness, the inability to see near.

What is presbyopia?

Age-related deterioration of near vision.

What is astigmatism?

Blurred or distorted vision due to an irregular cornea.

What is strabismus?

A condition where the eyes are not aligned (crossed eyes).

What is nystagmus?

Involuntary eye movement.

What is the purpose of the cover/uncover test?

To assess eye alignment.

What is the significance of a lump in breast examination?

It requires assessment of size, shape, consistency, mobility, tenderness, and location.

What is gynecomastia?

Enlargement of male breast tissue.

What are the risk factors for breast cancer?

Older age, female gender, family history, hormonal exposure, alcohol consumption.

What is breast awareness?

Knowing the normal look and feel of breasts to report changes.

What are the recommendations for mammography screening in the U.S.?

Start at age 40-50, every 2 years.

What is the role of family history in breast cancer risk?

Having a first-degree relative significantly increases risk.

What is the role of reproductive history in breast cancer risk?

Early onset of menstruation, late menopause, and no pregnancies increase risk.

What is the role of alcohol consumption in breast cancer risk?

Higher alcohol intake is associated with higher estrogen levels and increased risk.

What is the significance of hypothyroidism?

Characterized by weight gain, fatigue, cold intolerance, dry skin, and bradycardia.

What is the significance of hyperthyroidism?

Characterized by weight loss, heat intolerance, anxiety, tachycardia, and possible exophthalmos.

What are the characteristics of fibrocystic changes in breast tissue?

Lumpy, tender, and cyclical changes.

What is ductal ectasia?

A condition characterized by sticky discharge from the nipple.

What is mastitis?

An infection of the breast that is red and painful.

What are risk factors for cervical cancer?

HPV, multiple partners, smoking, early sexual activity.

What is a major risk factor for testicular cancer?

Cryptorchidism (undescended testicle).

What are risk factors for ovarian cancer?

Age, family history, BRCA genes, nulliparity.

What are risk factors for prostate cancer?

Age, African American race, family history.

What should be inspected in a scrotal examination?

Color, swelling of the scrotum.

What should be palpated in a testicular examination?

Testes (smooth, oval, firm), epididymis (soft, posterior), vas deferens (cord-like).