Health assessment Exam Review Cards

What is the purpose of the health history in a physical assessment?

To begin the relationship with the patient and gather essential information for focused assessments.

What skills are required for conducting a health history interview?

Good communication skills, active listening, and therapeutic communication.

What are the main components of a health history?

Biographical Data, Chief Concern (CC), History of Present Illness (HPI), Past Medical History (PMH), Family History (FH), Current Health Status (CHS), Review of Systems (ROS).

What does Chief Concern (CC) refer to in a health history?

The reason for seeking care, stated in the patient's own words.

What is included in the History of Present Illness (HPI)?

A chronological account of the Chief Concern, including specifics like location, character, quality, timing, setting, associated manifestations, and impact on the patient.

What types of childhood illnesses should be noted in Past Medical History (PMH)?

Measles, mumps, chickenpox, pertussis, strep throat, rheumatic fever, scarlet fever, polio, smallpox, diphtheria, chronic ear infections.

What immunizations should be documented in the Past Medical History (PMH)?

MMR, polio, DPT, flu, pneumococcal, varicella, hepatitis B, meningitis, PPD, Td.

What adult medical illnesses are relevant in the Past Medical History (PMH)?

Myocardial infarction (MI), cerebrovascular accident (CVA), diabetes mellitus (DM), hypertension (HTN), cancer (CA), peripheral vascular disease (PVD), angina, stroke, COPD, asthma, GERD, renal failure, liver disease, thyroid problems, chronic sinus infections, and mental illness.

What should be included in the Family History (FH) section?

Age, health status, relationship of blood relatives, history of diseases, and hereditary disorders.

What does Current Health Status (CHS) encompass?

Personal and social history including birthplace, ethnic background, education, marital status, occupation, habits, daily living characteristics, stress management, recent travel history, and health habits.

What is the purpose of the Review of Systems (ROS)?

To determine if there is a relationship between the Chief Concern and each major system by asking relevant questions.

What is the first step in the physical examination?

Inspection, which involves using observation and all senses to gather information.

What are the components of inspection during a physical examination?

Gait, stance, ease of movement, appropriateness of dress, eye contact, body language, skin presentation, and symmetry of body parts.

What is palpation in the context of a physical examination?

Using touch to gather objective information about the patient, including light and deep palpation techniques.

What types of sounds are produced during percussion in a physical examination?

Tympanic, hyperresonance, resonance, dull, and flat.

What is the significance of using quotes in documenting the Chief Concern (CC)?

To accurately capture the patient's own words regarding their reason for seeking care.

What should be assessed regarding the patient's pain during the History of Present Illness (HPI)?

Location, character, quality, severity, timing, setting, associated manifestations, and factors affecting the pain.

Why is it important to document the patient's medications in the Past Medical History (PMH)?

To understand the patient's current treatment regimen, including prescription, OTC, and herbal medications.

What information should be gathered about allergies in the Past Medical History (PMH)?

Types of allergies (medications, foods, environmental) and the reactions or treatments associated with them.

What aspects of the patient's lifestyle should be included in the Current Health Status (CHS)?

Habits such as caffeine and alcohol use, daily living characteristics like sleep patterns, diet, exercise, and stress management.

What is the role of privacy during the physical examination?

To ensure the patient feels comfortable and secure while undergoing the examination.

What are the two types of percussion?

Direct percussion, where the hand or finger strikes the surface directly, and indirect percussion, where one finger acts as a hammer and the other as the striking surface.

What is auscultation?

Listening to sounds produced by the body, often using a stethoscope.

What is the function of the epidermis?

It is the outermost layer of skin, providing protection and undergoing turnover every 3 to 4 weeks.

What are the main functions of the skin?

Protection from injury, barrier to fluid loss, wound repair, sensory organ, temperature regulation, vitamin D production, and emotional indicator.

What is the role of sebaceous glands?

They produce sebum to lubricate the skin and are connected to hair follicles.

What are the two types of sweat glands?

Eccrine glands, which are throughout the body for temperature regulation, and apocrine glands, which become functional during puberty.

What is the significance of melanin in hair color?

Melanin in the hair shaft determines the color of the hair.

What are the characteristics of vellus hair?

Vellus hair is short, fine, and faint, covering most of the body.

What changes occur in the skin during pregnancy?

Increased body heat, sweat, and sebaceous gland activity, along with hormonal changes and dark pigmentation.

What are common skin changes in older adults?

Thinning epidermis, reduced collagen, decreased subcutaneous tissue, and grey hair due to decreased melanocyte function.

What does the ABCDE rule assess?

It assesses moles for signs of melanoma: Asymmetry, Border irregularity, Color variation, Diameter greater than 6mm, and Evolving changes.

What is a macule?

A flat, non-palpable change in skin color less than 1 cm in size, such as a freckle.

What is a papule?

A palpable, elevated, solid mass less than 1 cm in size, such as a wart or mole.

What is a cyst?

A solid mass located deeper in the skin that is harder to palpate.

What is the difference between a vesicle and a bulla?

A vesicle is a fluid-filled blister less than 1 cm, while a bulla is greater than 1 cm.

What is a pustule?

A vesicle or bulla filled with pus, commonly seen in acne.

What is the active growing part of a nail called?

The matrix.

What are the characteristics of basal cell carcinoma?

It is the most common skin cancer, spreads locally, and rarely metastasizes.

What is the significance of the dermis layer?

It contains blood vessels, nerve fibers, hair follicles, and glands, and is composed of collagen and elastin.

What are the signs of impaired skin integrity?

Wounds, injuries, and surgical incisions.

What factors can increase the risk for skin cancer?

Male gender, age over 50, family history of skin cancer, extensive sun exposure, and fair skin tone.

What is the role of the subcutaneous tissue?

It provides insulation, adheres skin to underlying structures, and contains mast cells.

What are common skin conditions to note in health history?

Eczema, psoriasis, skin cancer, infections, and rashes.

What is the purpose of inspecting skin characteristics?

To assess color, symmetry, hygiene, and characteristics of lesions.

What does the term 'excoriation' refer to?

Loss of the epidermal layer, often due to scratching.

What is a keloid?

A scar that forms from past wounds, often raised and thickened.

What is the primary function of the lymphatic system?

To move fluid within a closed circuit, produce lymphocytes, antibodies, perform phagocytosis, and absorb fats from the intestinal tract.

What is the expected nail base angle in a healthy individual?

160 degrees

What does clubbing of the nails indicate?

A nail base angle greater than 180 degrees, often associated with respiratory or cardiovascular conditions.

What are the two main lymphatic drainage pathways?

The right lymphatic duct and the thoracic duct.

What does the right lymphatic duct drain?

The right jugular and subclavian areas, right lung, right head, arm, and thorax.

What does the thoracic duct drain?

Lymph from all other areas of the body into the left subclavian vein.

What are the characteristics of easily palpated lymph nodes in healthy adults?

They are generally small (less than 1 cm), non-tender, and freely movable.

What are abnormal findings when palpating lymph nodes?

Enlarged, hard, tender, or immobile nodes.

What should be assessed when lymph nodes are palpated?

Location, size, shape, consistency, tenderness, movability, warmth, and signs of inflammation or malignancy.

What is the significance of supraclavicular lymph nodes?

Enlargement may indicate malignancy.

What are common symptoms associated with lymphatic system issues?

Enlarged nodes, pain, warmth, fatigue, and anorexia.

How does the lymphatic system change with age in infants?

It begins to develop at 20 weeks gestation, with an inability to produce antibodies at birth, increasing vulnerability to infection.

What hormonal changes occur in the lymphatic system during pregnancy?

Altered immune function due to hormonal changes.

What changes occur in the lymphatic system of older adults?

A decrease in the number of lymphocytes and an increased likelihood of fibrotic and fatty changes, impairing infection response.

What is the role of lymph nodes in the immune response?

They provide early clues to the presence of infection or malignancy.

What is the normal size of inguinal nodes?

Less than 2 cm is considered a normal variation.

How does lymph drainage differ between males and females?

Males drain lymph from the testes into the abdomen, while females drain internal genitalia into pelvic nodes.

What are the key areas to inspect during a lymphatic system assessment?

Head, neck, supraclavicular, axillary, elbows, and inguinal areas.

What are the signs of inflammation or infection in lymph nodes?

Enlarged, warm, and tender nodes.

What is the palpation technique for assessing lymph nodes?

Use pads of the 2nd, 3rd, and 4th fingers with gentle to firmer pressure in a circular pattern.

What are the three main functions of the digestive system?

Eat, absorb, eliminate.

How long is the esophagus?

10 inches long.

What are the three main parts of the stomach?

Fundus, body, pylorus.

What is the total length of the small intestine?

21 feet long.

What are the lengths of the three sections of the small intestine?

Duodenum: 12 inches, jejunum: 8 feet, ileum: 12 feet.

Where is the appendix located?

At the base of the cecum.

What is the length of the large intestine (colon)?

4.5 to 5 feet long.

Name the four sections of the large intestine.

Ascending, transverse, descending, sigmoid.

What organs are located in the right upper quadrant (RUQ)?

Liver, gallbladder, pylorus, duodenum, head of pancreas, right adrenal gland, top of right kidney, portions of ascending and transverse colon.

What organs are located in the left upper quadrant (LUQ)?

Sliver of liver, spleen, stomach, body of pancreas, left adrenal gland, top of left kidney, portions of transverse and descending colon.

What organs are located in the right lower quadrant (RLQ)?

Bottom of right kidney, cecum, appendix, portion of ascending colon, distended bladder, right ureter, right ovary, right spermatic cord.

What organs are located in the left lower quadrant (LLQ)?

Bottom of left kidney, sigmoid colon, distended bladder, left ureter, left ovary, left spermatic cord.

What are common abdominal assessment findings in infants and children?

Round bellies, thin skin, umbilical hernia, feeding patterns every 2 to 3 hours.

What gastrointestinal changes may occur during pregnancy?

Decrease in bowel sounds, constipation, hemorrhoids, nausea, vomiting, skin changes like stretch marks.

What are common gastrointestinal issues in older adults?

Constipation, decreased liver size, decreased taste, decreased activities of daily living (ADLs).

What are some risk factors for colon cancer?

Over age 50, family history, diet lacking fruits and vegetables, obesity, inactivity, smoking, personal history of polyps or IBD.

What is the significance of rebound tenderness during a physical exam?

It indicates that letting go is more painful than pushing, suggesting possible peritoneal irritation.

What does the term 'borborygmi' refer to?

Growling sounds in the abdomen, audible outside of the stethoscope.

What is the purpose of using the diaphragm and bell of a stethoscope during auscultation?

The diaphragm is used for bowel sounds, while the bell is used for vascular sounds.

What is ascites?

Accumulation of fluid in the peritoneal cavity.

What is the normal range for active bowel sounds?

Gurgling sounds occurring 5-35 times a minute.

What does a hypoactive bowel sound indicate?

Decreased motility, often associated with constipation or little to no bowel sounds.

What should be assessed last during palpation of the abdomen?

Pain areas.