health assessment midterm study

COLDSPA

• Character: Describes the nature of the pain (e.g., sharp, dull, or burning).

• Onset: Addresses when and how the pain began, whether suddenly or gradually.

• Location: Identifies the specific area where the pain is felt.

• Duration: Refers to how long the pain persists, whether it's constant or comes and goes.

• Severity: Assesses the intensity of the pain, often rated on a scale from 1 to 10.

• Pattern: Does pain come & go or is consistent

• Associated Symptoms: what causes the pain to start

PQRST

A comprehensive method for assessing pain that includes:

• Provocation or Palliation: What causes the pain

• Quality: Describes the type of pain (e.g., sharp, dull, burning, throbbing)

• Region/Radiation: Is pain localized or spread to other areas

• Severity: Pain on a scale of 1-10

• Timing: When it occurs, how long it lasts

SBAR

A communication tool in healthcare for sharing critical information: Situation (issue)

Background (history)

Assessment (evaluation findings)

Recommendations (next steps)

GCS

Glasgow Coma Scale, a scoring system used to assess consciousness in a patient. (E4,V5,M6)

Dementia

Loss of brain function. A chronic or progressive syndrome affecting memory, thinking, and social abilities.

Delirium

A sudden change in mental status marked by confusion and disorientation.

ABCDE

A systematic approach for skin cancer self-examination:

• Asymmetry: Uneven shape of moles or growths, indicating potential malignancy if one half doesn't match the other.

• Border: Irregular, scalloped, or poorly defined edges that may suggest a cancerous lesion.

• Color: Variation in color within a mole, such as shades of brown, black, or tan, and the presence of red, white, or blue hues.

• Diameter: Moles larger than 6mm (about the size of a pencil eraser) should be evaluated, as larger growths can be more concerning.

• Evolving: Any change in size, shape, color, or elevation of a mole, or new symptoms such as bleeding, itching, or crusting should be assessed.

ROS (review of systems): Cardiovascular System

• subjective Data: Patient may report chest pain, palpitations, fatigue, shortness of breath.

• Objective Data: Blood pressure, heart rate, ECG findings, and auscultation of heart sounds.

• Clinical Tips: Monitor for signs of heart failure; evaluate risk factors for cardiovascular disease.

ROS (review of systems): Respiratory System

• Subjective Data: Patients may describe cough, wheezing, chest tightness, difficulty breathing.

• Objective Data: Respiratory rate, oxygen saturation, lung auscultation, and potential imaging results.

• Clinical Tips: Be aware of patient history with asthma or COPD; assess for signs of hypoxemia.

ROS: Gastrointestinal System

• Subjective Data: Inquire about appetite changes, nausea, vomiting, abdominal pain.

• Objective Data: Abdominal exam findings, bowel sounds, imaging studies like ultrasound or CT scan.

• Clinical Tips: Follow up on any changes in bowel habits; consider dietary assessments for nutritional status.

ROS: Neurological System

• Subjective Data: Ask about headaches, dizziness, memory loss, or changes in mood.

• Objective Data: Neurological exam results, GCS (Glasgow Coma Scale) scores, imaging like MRI or CT.

• Clinical Tips: Assess for signs of stroke or seizure activity; probe into family history of neurological diseases.

ROS: Musculoskeletal System

• Subjective Data: Patients may report joint pain, stiffness, or difficulty with mobility.

• Objective Data: Range of motion testing, strength assessments, visual inspections for swelling.

• Clinical Tips: Check for signs of inflammation; use scales for joint pain severity assessment.

ROS: Integumentary System

• Subjective Data: Questions regarding skin changes, itching, rashes, or lesions.

• Objective Data: Skin inspection notes, description of lesions, temperature, and moisture levels.

• Clinical Tips: Regular skin assessments to identify changes that could indicate malignancy; educate on skin protection.

ROS: Endocrine System

• Subjective Data: Inquire about weight changes, fatigue, heat or cold intolerance, and skin changes.

• Objective Data: Blood glucose levels, hormone level assessments, and vital signs.

• Clinical Tips: Monitor for signs of hypo- or hyperglycemia; assess for symptoms related to thyroid abnormalities.

ROS: Urinary System

• Subjective Data: Ask about urination frequency, pain during urination, or changes in urine appearance.

• Objective Data: Urinalysis results, abdominal ultrasound for kidneys, and bladder assessments.

• Clinical Tips: Be aware of urinary tract infection symptoms and risk factors; assess hydration status.

ROS: Reproductive System

• Subjective Data: Gather information about menstrual cycles, sexual health issues, or changes in libido.

• Objective Data: Pelvic exams, lab tests for hormone levels, imaging if needed (like ultrasound).

• Clinical Tips: Discuss contraception options and sexual health openly; educate on STIs.

Physical Examination Techniques in order

inspection - look for symmetry, appearance of skin, size, location, odors

palpation - feel for texture, temperature, size/shape, consistency

percussion - tap to assess underlying structures; determines location, size & shape of organ; views reflexes

auscultation - listen to sounds produced by body to assess heart, lungs, bowel functions

• Diaphragm - listen to high pitch sounds (hold firm against body)

• Bell - listen to low pitch sounds (hold lightly against body)

Types of Palpation

• Light palpation: Gently move one hand in circles on the skin’s surface, pressing less than 1 cm deep. Used to check things like pulse, temperature, and moisture.

• Moderate palpation: Press slightly deeper (1–2 cm) with one hand in circular motions to feel organs or lumps.

• Deep palpation: Use both hands, with one on top of the other, pressing 2.5–5 cm deep to feel deep organs.

• Bimanual palpation: Use both hands on opposite sides of the body—one hand presses while the other feels the organ or structure.

Types of percussion

• Direct: Tap a body part directly with one or two fingers to check for pain or tenderness.

• Blunt: Place one hand flat on the body and use a fist to tap the back of that hand to check for organ pain.

• Indirect: Place one finger on the body and use the other hand’s finger to tap it, helping to detect sounds from deeper inside the body.

Vital Signs Pulse

normal range - 60-100bpm

tachycardia - greater than 100bpm

bradycardia - less than 60bpm

Vital Signs Respiratory

normal range: 12-20 breathes per min

observe: rate, rhythm, depth

Vital Signs Blood Pressure

Ideal range: 120/80 mmHg

elevated bp: 120-129 & 80 or less diastolic

Hypertention:

• Stage 1: 130-139; diastolic 80-89

• Stage 2: 140+; diastolic 90+

• hypertensive crisis: systolic over 180; diastolic over 120

Orthostatic hypotension - SUDDEN drop of 20mmhg diastolic or systolic within 3 min of sitting/laying down to standing

Vital Signs Temperature

Normal temp: 36.5-37.7 C (96-99 F)

hypothermia: less than 36.5 C (96 F)

hyperthermia: more than 38 C (100.4 F)

Temp can be taken: oral, temporal, axillary, tympanic, rectal

• Psychological Pain:

• Pain linked to emotional issues.

• Psychosomatic Pain:

• Pain affected by mental state, with no clear physical cause.

• Nociceptive Pain:

• Pain from tissue damage or injury.

• Neuropathic Pain:

• Pain caused by nerve damage, often described as burning or tingling.

• Inflammatory Pain:

• Pain due to swelling and inflammation, like in arthritis.

• Somatic Pain:

• Sharp pain from muscles or body tissues, easy to locate.

• Visceral Pain:

• Diffuse pain from internal organs, hard to pinpoint.

• Radicular Pain:

• Pain that radiates from a nerve root, like sciatica.

• Phantom Pain:

• Pain in a limb that has been amputated, as if the limb is still there.

• Cancer Pain:

• Pain from cancer or its treatments.

• Referred Pain:

• Pain felt in a different place from where it actually comes from.

Underweight BMI

less than 18.5

Normal BMI

18.5 - 24.9

Overweight BMI

25-29.9

Obese BMI

30+

Nutritional disorders on general body:

• Weight loss, weakness, fatigue

  • Can be from anemia, electrolyte imbalance, lack of nutrients

Nutritional disorders on skin, hair, nails:

• Dry skin, ecchymosis, dry thinning hair, brittle nails

  • Can be from Vitamin A,B,C,K,Zinc deficiency, dehydration, lineolic acid deficiency

Nutritional disorders on eyes:

• Night blindness, red conjunctiva

  • Can be from vitamin A deficiency, riboflavin deficiency

Nutritional disorders of throat & mouth:

• Cracks @ corner of mouth, magenta tongue, beefy red tongue, soft sponges bleeding gums, swollen neck (goiter)

  • Can be from riboflavin/niancin, B12, C, iodine deficiency

Nutritional disorders on cardiovascular:

• Edema, tachycardia, hypotension

  • Can be from protein deficiency, fluid volume deficit

Nutritional disorders on gastrointestinal:

• Ascites (excess abdominal fluid)

  • Can be from protein deficiency

Nutritional disorders on musculoskeletal:

• Bone pain & bow leg, muscle wasting

  • Can be from vitamin D, calcium, protein, fat, carbohydrates deficiency

Nutritional disorders on neurologic:

• Altered mental status, paresthesia (tingling sensation)

  • Can be from dehydration, B12, thiamine, pyridoxine deficiency

Skin Lesions: primary lesions - Macule

a flat, well-circumcised lesion up to 1 cm in diameter

Skin lesions: primary lesions - papule

a raised bump up to 1 cm in diameter

Skin lesions: primary lesions - nodule

an elevated, firm, circumscribed, and palpable area greater than 5 mm in diameter

Skin lesion: primary lesion - Cyst

an elevated, circumscribed area filled with liquid or semisolid
fluid

Skin lesion: primary lesion - plaque

an elevated, flat-topped, firm, rough, superficial papule greater than 1 cm in diameter

Skin lesion: primary lesion - wheal

an elevated, irregularly shaped area of cutaneous edema;
wheals are solid, transient, and changeable, with a variable
diameter; can be red, pale pink, or white.

Skin lesion: primary lesion - vesicle

a clear, fluid-filled blister up to 1 cm in diameter

Skin lesion: primary lesion - bulla

a vesicle greater than 1 cm in diameter

Skin lesion: primary lesion - postule

an elevated, pus-filled lesion up to 1 cm in diameter

Skin lesion: secondary lesion - scale

• Flaky skin made up of dead cells

  • flakey exfoliation

  • irregular, thick/thin, dry/oily, can be white or tan

Skin lesion: secondary lesion - crust

• Raised area with dried fluid or pus.

Skin lesion: secondary lesion - fissure

• A deep crack in the skin.

Skin lesion: secondary lesion - ulcer

• Open sore that damages deeper skin layers.

Skin lesion: secondary lesion - scar

• Permanent mark on the skin from healing.

Skin lesion: secondary lesion - atrophy

• shrinking of skin in one area

Skin lesion: secondary lesion - excoriation

• Scratches on the skin surface.

Skin lesion: secondary lesion - lichenification

• Thick, rough skin from constant rubbing/scratching (ex: eczema)

Pressure injuries

prolonged pressure that restricts blood flow.

Commonly seen on: heels, sacrum, back of head, elbows

braden scale helps predict the risk for pressure injuries

Prevention:

• reposition every 30 min or 2 hours (depends)

• keep head of bed elevated at 30 degrees

• use special mattress

Pressure injury stages

• Stage 1: Red area that does not turn white when pressed (nonblanchable).

• Stage 2: Partial skin loss with exposed dermis; may include blisters.

• Stage 3: Full thickness skin loss affecting deeper layers.

• Stage 4: Very deep injury exposing bone, muscle, or tendons.

• Hypothyroidism:

• Patients may report fatigue, weight gain, cold intolerance, dry skin, and hair loss.

• abnormal findings: Enlarged thyroid (goiter), decreased metabolic rate, potential bradycardia observed.

• Hyperthyroidism:

• Symptoms to inquire about include weight loss, heat intolerance, increased appetite, anxiety, and tremors.

• abnormal findings: Enlarged thyroid, increased heart rate, tremors, warmth, and moist skin may be noted.

• Goiter:

• Ask about visible swelling in the neck or any difficulty swallowing or breathing.

• abnormal findings: Visible swelling in the neck.

• Headache:

• Inquire about headache characteristics (e.g., onset, duration), types (e.g., tension, migraine, cluster), locations, and associated symptoms (nausea, light sensitivity).

• abnormal findings: Identify patterns indicating migraines or tension headaches.

• Traumatic Brain Injury (TBI):

• Assess history of head trauma and related symptoms such as confusion, balance issues, or changes in consciousness.

• abnormal findings: Changes in consciousness, imbalance, or neurological deficits may be seen.

• Acromegaly:

• Enlarged hands and feet, facial changes (prominent jaw), potential glucose intolerance.

• Cushing Syndrome:

• Weight gain, hypertension, facial puffiness, and purple striae may be present.

• Scleroderma:

• Tight skin, joint pain, difficulty swallowing, and Raynaud's phenomenon observed.

• Bell's Palsy:

• Sudden weakness in one side of the face, drooping mouth, and inability to close one eye.

• Parkinson's Disease:

• Bradykinesia (slow movement), resting tremor, rigidity, and postural instability noted in the examination.

• Epicanthic Folds:

• Commonly observed in individuals of Asian descent and in some individuals with Down syndrome of non-Asian descent.

• Protrusion of Eyes:

• Slightly more prevalent in African Americans, with less occurrence in Hispanic populations.

• Freckles on Sclera:

• More frequently seen in darker-skinned individuals.

• Optic Disc Size:

• Typically larger in African Americans compared to other ethnic groups.

• Common visual disorder Glaucoma:

• More prevalent in African Americans.

• Common visual disorder Age-Related Macular Degeneration (AMD):

• Higher rates found in Non-Hispanic Whites than in African Americans and Hispanics.

• Common visual disorder Cataracts:

• Higher incidence rates in Hispanic populations.

• Common visual disorder Diabetic Retinopathy:

• Lower rates in Non-Hispanic Whites compared to African Americans and Hispanics.

• Common visual disorder Trachoma and Corneal Diseases:

• Vary by geographic and socioeconomic status.

• Common visual disorder Children's Visual Diseases:

• Include cataracts, retinopathy of prematurity, and vitamin A deficiency.

Causes of Visual Impairment by Ethnic Groups

• Non-Hispanic Whites: Display lower rates of diabetic retinopathy and glaucoma but higher rates of AMD.

• Hispanics: More frequently diagnosed with cataracts compared to Non-Hispanic Whites.

• African Americans: Show a higher prevalence of glaucoma compared to other ethnic groups.

• Snellen Chart:

• Measures visual acuity, determining how well a person can see at a distance. A higher number indicates better vision.

• E Chart:

• This chart is like the Snellen Chart but is made for people who can't read letters. It helps to check how well someone can see by using different pictures instead of letters.

• Jaeger Test:

• Assesses near vision, commonly used for determining reading and close-up vision capabilities; the smallest readable print size indicates the level of near vision acuity.

Glaucoma

• Causes:

• Glaucoma usually happens when the pressure inside the eye gets too high, which can hurt the optic nerve. Age, family history, and health issues like diabetes can increase your chances of getting it.

Glaucoma Signs:

In the early stages, there may be no obvious signs. As it gets worse, you might notice problems with your side vision and, in severe cases, can go blind.

Glaucoma Symptoms:

Common symptoms include blurry vision, seeing halos around lights, and difficulty seeing in dim light.

Glaucoma Screening:

It's important to have regular eye check-ups for early detection. These exams often include checking eye pressure, looking at the health of the optic nerve, and testing side vision. People over 40, especially with risk factors, should get screened regularly.

Glaucoma Risk Factors:

• Being over 40 years old

• Family history of glaucoma

• Having health problems like diabetes or high blood pressure

• Being of African descent

• Injuries or surgeries to the eye

• Long-term use of steroids.

Macular Degeneration

• Causes:

• Macular degeneration occurs when the central part of the eye (macula) gets damaged, often due to aging, genetics, or other health problems.

Muscular Degeneration Signs:

Look for blurred vision in the center, problems seeing details, and straight lines looking wavy.

Muscular Degeneration Symptoms:

Common signs include blurry vision, dark spots in the center of sight, and difficulty recognizing faces or reading.

Muscular Degeneration Screening:

It's important to have regular eye exams. Eye doctors can use special tools to look for early signs.

Muscular Degeneration Risk Factors:

being over 50, having a family history of the condition, smoking, being overweight, and having high blood pressure.

Cataracts

• Causes:

• Cataracts often happen with age when the eye lens gets cloudy. They can also be caused by diabetes, long-term steroid use, and too much sunlight.