Health Assessment Final

mental status exam

* level of alertness, appropriate responses, orientation to place and time
* completed throughout entire exam
* general survey
* cognition

oral temperature range

94\.6-99.1

rectal temperature range

97\.1-100.1

bradycardia

HR < 50

tachycardia

HR > 95

elevated BP

120-129/

HTN stage 1

130-139/80-89

HTN stage 2

> 140/>90

Hypertensive crisis

>180/>120

bradypnea

8-12 respirations

tachypnea

>25 respirations

Health history sequence

1. biographic data
2. reason for seeking care
3. H&P: time of first symptoms to now
4. PMH
5. Med reconciliation
6. Family history
7. review of symptoms
8. ADLs

frontal lobe

* Primary Motor Cortex, personality, behavior, emotion, intellect, skilled movement
* **Broca's area**(left side of frontal lobe): speech & motor function

parietal lobe

process sensory data

occipital lobe

Visual cortex & interpretation of visual data

temporal lobe

* __**SOUNDS**__ (Perception & Interpretation)
* __**SMELL**__
* **Wernicke's area:** left side of temporal lobe → language comprehension

Wernicke area damage

* **receptive aphasia**- person hears sound but it has no meaning, like hearing foreign language
* left side of temporal lobe

Broca’s area damage

* When injured: **expressive aphasia**- person can understand language and knows what they want to say but only produces garbled sound
* Region in the frontal lobe of the dominant hemisphere

CN VII, facial testing

Facial (m): Tests ability to make facial expressions:

* Note mobility and facial symmetry as patient smiles, frowns, closes eyes tightly while resisting your attempt to open them, raises eyebrows, shows teeth, puffs out cheeks (air should escape equally from both sides)

CN VIII, vestibulocochlear Testing

hearing (vestibular = balance; cochlear = hearing)

* Whisper Test
* Conductive vs Sensorineural Hearing: air vs bone: tuning fork test
* Weber & Rinne

whisper test

* Stand 45 degrees behind patient about 2-3 feet away from their uncovered ear and have patient cover opposite ear
* Whisper three numbers a word and ask patient to repeat

Webber & Rhinne testing

Conductive vs. Sensorineural Hearing - Air vs. Bone conduction - Tuning Fork Test

* Weber: (tests for localization) sound should be equally loud in both ears
* Rinne: (tests for conduction) sound should be heard 2x as long by air conduction than by bone conduction
* Bone > air = abnormal - conductive hearing loss)

CN XII Hypoglossal Testing

Test Tongue Strength:

* Have pt stick tongue out
* Observe for deviation (weak muscles)
* Hold tongue to cheek against resistance
* Check speech and ability to clearly speak and pronounce words/letters

PERRLA

__**P**__upils

__**E**__qual

__**R**__ound

__**R**__eactive to

__**L**__ight and

__**A**__ccommodating

* use pen light to test

Palpating PMI

Have patient lay on lateral left side and palpate beneath nipple

* any lifts or heaves?

Rating muscle strength

* 5/5 = normal, complete ROM/ full resistance
* 4/5 = good, complete ROM/ moderate resistance
* 3/5 = fair, complete ROM
* 2/5 = poor, complete ROM with joint support, cannot perform against gravity
* 1/5 = trace, muscle contraction detectable, no movement of joint
* 0/5 = zero, no visible muscle contraction

changes in HEENT with aging

* Nose more prominent bc of loss of fat
* Decrease in smell >60 (decrease in olfactory fibers)
* Decrease in salivary production, loss of taste
* Increase risk for malignant lesions
* Dental changes (tooth loss, receding gums)
* Hearing aids

changes in GI with aging

* Motility and perstalsis slows→ increased constipation
* Salivation decreases → dry mouth, dysphagia
* Liver size decreases with age → metabolism of drugs slowed
* Potbelly

Clubbed fingernails

decreased oxygenation over time

capillary refill

identifying skin cancer

__**A**__symmetrical

__**B**__order irregularity

__**C**__olor differences

__**D**__iameter > 6mm

__**E**__volving

__**F**__unny looking

basal cell carcinoma

* Small pink or red papule, eventually looks like a large pore
* Most common skin cancer
* Usually on face, ears, scalp and shoulders

squamous cell carcinoma

* Arise from actinic keratinosis
* Erythematous scaly patch
* Usually on hands or head, bald scalps at higher risk
* Less common than basal cell, but grows rapidly

malignant melanoma

* brown/mixed pigment; irregular borders
* May arise from preexisting moles

auscultating abdominal aorta

Slightly left of midline, listen with bell for bruits

* No sound=normal

auscultating carotid

Exhale and hold breath and use diaphragm & bell

* Any bruits, blowing, or swishing sound?

DVT

* Symptoms: Unilateral edema, warmth, redness, and tenderness
* DO NOT: massage area, use SCDs, or have patient walk: could cause pulmonary embolism

flexion

* Bending the limb at the joint
* Decreasing the angle between bones

Extension

\
* Straightening of the limb at the joint
* Increases the angle between bones

rotation

Turning of a joint around an axis

abduction

Movement AWAY from the center of the body

adduction

\
Movement TOWARD the center of the body

circumduction

Conical movement of a limb extending from the joint at which the movement is controlled (circle) \n • Combines flexion, extension, abduction, and adduction

inversion

Movement of the sole towards the median plane so that the sole faces in a medial direction (ankle in)

eversion

Movement of the sole away from the median plane so that the sole faces in a lateral direction (ankle out)

protraction

Movement of body part FORWARD & parallel to the ground

retraction

Movement of body part BACKWARD & parallel to the ground

elevation

Raising a body part

* Movement in a superior direction

depression

Lowering a body part

* Movement in an inferior direction

opposition

Approximation of the thumb and 5th digit

pronation

Turning the forearm so the palm is DOWN

suppination

\
Turning the forearm so the palm is UP

dorsiflexion

Dorsum of the foot, Flexion of the ankle

(toes moving up to sky)

plantar flexion

plantar aspect of foot, Extension of the ankle

* **Step on the gas**

stress incontinence

leakage of small amount of urine during physical movement

urge incontinence

leakage of large amount of urine during unexpected times, including sleep

overflow incontinence

unexpected leakage of small amounts of urine because bladder is full

menopause

end of menses

* **rapid** decrease in female hormones
* age __48-51__
* Effects: vaginal infections (pH alkaline), UTIs, dyspareunia (painful intercourse), lowered libido

perimenopause

* __age 40-55__
* hot flashes- sudden feeling of intense heat/warmth
* mood swings
* menstrual irregularity

polymenorrhea

menstruation less than 21 days; frequent, short menstrual cycles

oligomenorrhea

infrequent bleeding; irregular/ inconsistent menstrual blood flow

metorrhagia

intermenstrual bleeding; abnormal bleeding between regular periods

postcoital bleeding

spotting or bleeding during/after sex (not related to menstruation)

postmenopausal bleeding

vaginal bleeding that occurs a year or more after last menstrual period

atelectasis findings

Partial or complete collapse of a lung or lobe of a lung.

Findings:

* cough
* increased RR
* dull percussion
* decreased/absent breath sounds
* occasional crackles

acute bronchitis findings

Acute infection of the trachea and larger bronchi. Caused by viruses/ exposure to smoke, air pollution, dust.

Findings:

* SOB, wheezing, chest tightness


* cough > 3 weeks
* larger airways narrowed
* increased mucous production
* loss of cilia
* swelling

chronic bronchitis findings

Inflammation of the bronchi persisting over a long time. Usually caused by smoking.

Findings:

* SOB, wheezing, chest tight
* dyspnea
* fatigue
* possible clubbing of fingers
* __crackles and possible wheeze__

Emphysema findings

Hyperinflated lungs, permanent enlargement of alveoli with destruction of septa (alveolar walls).

Findings:

* __decreased breath sounds__
* prolonged expiration, airway resistance increased
* barrel chest, AP = 1:1
* accessory muscle use

pleural effusion findings

Excessive fluid in pleural cavity

Caused by: CHF, fluid overload, infections

Findings:

* decreased or absent sounds over effusion (because of fluid)
* crackles, pleural rub
* increased RR
* dyspnea
* possible __asymmetric expansion__

Testing convergence

As a object moves closer to the patients nose, their pupils will move towards the nose

testing accomidation

As an object moves closer to the nose, the pupils will constrict

Greatest influence on health status

poverty

Social determinants of health

* **Economic stability** (greatest influence)
* education
* social & community context
* neighborhood and build environment
* health care access

Documentation of abuse

* Detailed, nonbiased notes
* Injury “maps”
* Photographs (if needed) \*\*Check with your \n facility as consent may be required
* Written histories: when recording the patient’s history, do not sanitize the words utilized – verbatim documentation is appropriate.
* Always ask for clarification, if you are unsure of what the abused personnel means.

joints

site of articulation of two or more bones

* needed for mobility, needed for ADLs

synovial joints

* **Freely movable**
* Lined with synovial membrane
* Supported by ligaments
* Swivel/pivot/ball & socket/hinge/saddle/planar/condyloid

non synovial joints

* Fibrous joints
* Cartilaginous
* **Immovable or slightly moveable**

tendons

connects muscle to bone

* ex: achilles to calcaneous

ligaments

connect bone to bone

* ACL, MCL, LCL, PCL

TMJ assessment

hand in front of tragus, have patient open and close jaw

* inspect: symmetry, swelling, redness
* Assess for grinding, pain, swelling, symmetry, smoothness, crepitus
* AROM: protrusion, retraction, lateral deviation

Elbow assessment

* Inspect: Olecranon bursa for swelling and bruising
* Palpate: support forearm and flex to 70deg, identify condyles, evaluate for pain or tenderness
* AROM: flexion, extension, pronation, supination
* Strength: flex and extend against resistance

Wrist and hand assessment

* Inspect: fingers, joint alignment, scars, deformity


* Palpate: feel joints using thumbs while hold patients hand


* AROM: flexion, extension, ulnar/radial deviation, finger abduction/adduction, opposition


* Strength: ROM against resistance, grip strength

knee assessment

* Inspect: swelling, tenderness, deformity, symmetry, tension
* Palpate: patella, tibia, clicking, crepitus
* AROM: flexion, extension, hyperextension
* Strength: squat and rise, strength against resistance

Osteoarthritis

* Deterioration of joint cartilage and new bone
* Localized
* Progressive
* Noninflammatory
* Rest relieves pain
* Worse throughout the day
* Onset >40

Rheumatoid Arthritis

* Chronic inflammation of the synovial membrane leads to thickening and fibrosis
* Onset 20-40
* Systemic, inflammatory disorder
* Inflammatory
* Bilateral and symmetrical
* Stiffness worse in the morning

alert

patient can look and fully respond to stimulil

lethargy

drowsy but open eyes, responds to questions then falls asleep

obtunded

open eyes, responds slowly and is somewhat confused

stuporous

arouses from sleep afer painful stimuli, verbal responses are slow or absent. Lapses into unresponsive state

comatose

remains unrousable with eyes closed when painful stimuli

Mongolian spots

Blue-black-to-purple macular area at the sacrum or buttocks but sometimes on the abdomen, thighs, shoulders, or arms.

* common variation of hyperpigmentation in Black, Asian, Native American, and Latino newborns
* caused by deep dermal melanocytes. It gradually fades during the first year, by adulthood these spots are lighter but are frequently still visible.

BPH

enlargement of prostate

* 80% of men > 60
* can create risk for urine obstruction
* increased cell proliferation with decreased programmed cell death
* s/s: hematuria, dysuria. weak or interrupted urine flow

S1

closure of AV valves, lub sound, __beginning of systole__, NORMAL

S2

closure of SL valves, dub sounds, end of systole, NORMAL

S3

immediately after S2, __when AV valves open and atrial blood goes into ventricles__

* ABNORMAL
* lub dubPA

S4

just before S1, at end of diastole, ventricle resistant to filling,

* ABNORMAL
* DAlub dub

Pack year smoking history

\#of packs per day x # of years smoking

presumptive signs of pregnancy

what patient feels:

* breast tenderness
* nausea
* fatigue
* urinary frequency

probable signs of pregnancy

what provider observes:

* positive pregnancy test
* enlarged uterus

positive signs of pregnancy

test confirmation, direct evidence:

* auscultation of fetal heart sounds
* cardiac activity on u/s