Health Assessment Test 2

Primary Lesion

Arise from previously healthy or unaltered skin as a result of a specific triggering agent or disease process.

Macule

Flat, circumscribed area of color change <1 cm (e.g., freckle).

Papule

Elevated, firm, circumscribed area <1 cm (e.g., mole, wart).

Vesicle

Elevated, circumscribed, fluid-filled <1 cm (e.g., chickenpox, shingles).

Patch

Flat, non-palpable, irregular-shaped macule greater than 1 cm in diameter (e.g., mongolian spots, vitiligo).

Plaque

Elevated, firm, and rough lesion with a flat top, with a surface area greater than 1 cm in diameter (e.g., psoriasis, eczema).

Wheal (Urticaria)

Elevated, irregular-shaped area of cutaneous edema; solid, transient, with a variable diameter (e.g., allergic reaction, insect bite).

Nodule

Elevated, firm, circumscribed lesion that extends deeper into the dermis than a papule; 1 to 2 cm in diameter (e.g., melanoma).

Tumor

Elevated and solid lesion; deeper in the dermis; greater than 2 cm in diameter (e.g., lipoma).

Bulla

Larger than 1 cm, superficial, thin-walled (e.g., drug reactions, blisters from severe burns).

Pustule

Elevated, superficial lesion similar to a vesicle, but filled with purulent fluid (pus) (e.g. acne, impetigo).

Cyst

Elevated, circumscribed, encapsulated lesion located in the dermis or subcutaneous layer; filled with liquid or semisolid material (e.g., cystic acne).

Secondary Lesion

Result from changes over time, evolution of a primary lesion, trauma, or healing

Scale

Heaped-up, keratinized cells; flaky skin; irregular; thick or thin; dry or oily; variable size (e.g., psoriasis, eczema).

Lichenification

Rough, thickened epidermis secondary to persistent rubbing, itching, or skin irritation (e.g., chronic dermatitis, psoriasis).

Keloid

Irregular-shaped, elevated, progressively enlarging scar that grows beyond the boundaries of the original wound caused by excessive collagen formation during healing (e.g., following surgical incisions or piercings).

Scar

Thin-to-thick fibrous tissue that replaces normal skin following an injury or laceration to the dermis (e.g., healed surgical wound or traumatic laceration).

Excoriation

Loss of the epidermis; linear, hollowed-out, crusted area (e.g., abrasions, scratches)

Fissure

Linear crack or break extending from the epidermis into the dermis; may be moist or dry (e.g., athlete’s foot, chapped hands).

Erosion

Loss of part of the epidermis; depressed, moist, glistened area; follows the rupture of a vesicle or bulla (e.g., candidiasis).

Ulcer

Loss of epidermis and dermis; concave shape; varies in size (e.g., pressure injuries).

Crust

Dried exudate, blood, or pus on the skin surface; slightly elevated; variable size; red-black, brown, tan, or yellow-mixed color (e.g., scabs on abrasions, impetigo).

Striae

Silver/pink "stretch marks" from rapid skin stretching.

Vascular Lesions

Result from blood leaking from blood vessels into the dermis/subcutaneous tissues or from dilated blood vessels

Petechiae

Tiny, flat, reddish-purple, non-blanchable spots in the dermal layer; 1 to 3 mm (or <0.5 cm) in size (e.g., bleeding disorders, tiny capillary hemorrhages due to infection)

Purpura

Flat, reddish-purple, non-blanchable skin discoloration greater than 0.5 cm (or >3 mm) in diameter (e.g., infection, bleeding disorders).

Ecchymosis (Bruise)

Reddish-purple, non-blanchable patch of variable size caused by trauma or bleeding under the skin; changes color (blue, green, yellow, brown) as it heals (e.g., trauma, physical injury).

Cherry Angioma (Angioma)

Small, smooth, slightly raised, bright red benign vascular lesion; ranges from tiny pinpoint up to 1–3 cm (e.g., benign tumor of small blood vessels)

Telangiectasia

Permanent dilation of preexisting small blood vessels (capillaries, arterioles, or venules) producing fine, irregular red line (e.g., rosacea, sun damage)

Spider Angioma (Vascular Spider)

Small, central red spot with radiating spider-like capillary legs; characteristically blanches when pressure is applied to the central core (e.g., pregnancy, liver disease)

Capillary Hemangioma (Port-Wine Stain)

Vascular lesion involving capillaries that produces an irregular, flat or raised patch ranging from light red to dark purple (e.g., congenital vascular malformation of capillaries).

Venous Star

Non-blanching, bluish vascular star-shaped lesion that can be linear or irregularly shaped (e.g., increased pressure in superficial veins).

Stage 1 Pressure Injury

Intact skin with a localized area of non-blanchable erythema (redness that does not turn white when gentle pressure is applied).

Stage 2 Pressure Injury

Partial-thickness loss of skin with exposed dermis.

Stage 3 Pressure Injury

Full-thickness loss of skin; adipose (subcutaneous fat) tissue is visible in the ulcer, with granulation tissue and rolled wound edges (epibole) frequently present. Slough and/or eschar may be visible.

Stage 4 Pressure Injury

Full-thickness skin and tissue loss with directly visible or palpable bone, tendon, cartilage, ligament, or muscle.

Unstageable Pressure Injury

Full-thickness skin and tissue loss in which the extent of tissue damage cannot be confirmed because it is obscured by slough or eschar.

Deep Tissue Pressure Injury (DTPI)

Intact or non-intact skin with localized area of persistent, non-blanchable, deep red, maroon, or purple discoloration, or epidermal separation revealing a dark wound bed or blood-filled blister.

Braden Scale

Analyzes:

1. Sensory Perception 2. Moisture 3. Activity 4. Mobility 5. Nutrition 6. Friction and Shear.

Significance: Total score ranges from 6 to 23. A lower score indicates a higher risk for pressure ulcer development.

Melanoma Screening

• A - Asymmetry: One half does not match the other half.

• B - Border: Ragged, notched, or blurred edges.

• C - Color: Variation in shades (brown, black, tan, red, or blue).

• D - Diameter: Greater than 6 mm (size of a pencil eraser).

• E - Evolving: Changing in size, shape, or color over time.

Color Variations Across Skin Tones

Pallor, Cyanosis, Erythema, Jaundice

Pallor

Light Skin Tone: ghostly white/pale

Dark Skin Tone: ashen/grey; check mucous membranes or conjunctiva

Cyanosis

Light Skin Tone: blueish tinge (lips, nail beds)

Dark Skin Tone: grayish/dull; check palms, soles, and oral mucosa

Erythema

Light Skin Tone: red/bright pink

Dark Skin Tone: purplish tinge; palpate for increased warmth/edema

Jandice

Light Skin Tone: yellow skin and sclera

Dark Skin Tone: yellowing most visible in hard palate and sclera

Lesion Shapes and Patterns

Annular: Circular (e.g., ringworm).

Zosteriform: Linear arrangement following a nerve dermatome (e.g., Herpes Zoster).

Polycyclic: Annular lesions that grow together (e.g., psoriasis).

Physical Exam Checklist of Skin

Inspection: Observe for color (congruency with genetic background), texture, moisture, and integrity (lesions/breakdown).

Palpation:

• Temperature: Use the dorsal aspect of the hands.

• Moisture: Diaphoresis vs. dehydration.

• Texture: Smooth and firm.

• Mobility/Turgor: Tested over the clavicle; "tenting" indicates dehydration.

Normal v. Abnormal Findings Nails

Normal Findings: Capillary refill <3 seconds; 160-degree nail base angle.

Abnormal Findings:

• Clubbing: Angle >180 degrees. Indicates chronic hypoxia (COPD, congenital heart disease).

• Beau's Lines: Transverse depressions (systemic illness/trauma).

• Konylochia: "Spoon nails" (iron deficiency).

Hair Physical Exam

Normal Findings: Vellus (fine, faint body hair) vs. Terminal (darker, thicker scalp/axillary hair).

Abnormal Findings:

• Alopecia: Significant hair loss.

• Hirsutism: Excessive hair growth in women, often following male-pattern distribution.

Head Terminology

Normocephalic: Round, symmetric skull proportionate to body.

Hydrocephalus: Fluid accumulation causing head enlargement.

Microcephaly: Abnormally small head

Macrocephaly: Abnormally large head.

Facial Muscle Abnormalities

Bell’s Palsy (CN VII): Lower motor neuron lesion; total paralysis of half the face (cannot wrinkle forehead on affected side).

Stroke (CVA): Upper motor neuron lesion; paralysis of lower face only (can still wrinkle forehead due to bilateral innervation).

Red Flags: Lumps (potential malignancy), "Worst headache of life" (aneurysm/hemorrhage), and nuchal rigidity (meningitis).

Normal v. Abnormal Findings Lymph Nodes

Normal Lymph Nodes	Abnormal (Lymphadenopathy)
Nonpalpable (often)	Large (>1 cm)
Soft, mobile	Hard, fixed (suggests malignancy)
Nontender	Tender (suggests infection)

Thyroid & Neck Assessment

Technique: Use posterior or anterior approach. Ask patient to take a sip of water; the thyroid should move up with swallowing.

Hyperthyroidism: Symptoms include tachycardia, weight loss, heat intolerance, exophthalmos (bulging eyes).

Hypothyroidism: Symptoms include bradycardia, weight gain, cold intolerance, periorbital edema.

Visual Clinical Tests

Snellen Chart: Standardized at 20 feet. "20/40" means the patient sees at 20 feet what a normal eye sees at 40 feet. Used for far vision.

Rosenbaum: Used for near vision (14 inches).

Hirschberg (Corneal Light Reflex): Light should reflect in the same spot on both corneas. Asymmetry indicates muscle weakness.

6 Cardinal Fields of Gaze: Tests CN III, IV, and VI for conjugate movement and nystagmus.

Cover/Uncover Test: Detects small degrees of deviated alignment. If the uncovered eye jumps to fixate, it was previously out of alignment (tropia/phoria).

PERRLA Guide

1. P - Pupils: Observe shape and size (mm).

2. E - Equal: Compare left and right pupils.

3. R - Round: Ensure circularity.

4. RL - Reactive to Light:

   • Direct: Pupil constricts in eye with light.

   • Consensual: Other pupil constricts simultaneously.

5. A - Accommodation: Ask patient to focus on a distant object, then shift to a near object. Pupils should constrict and eyes should converge.

Normal v. Abnormal Findings Eyes

Structure	Normal Findings	Abnormal Findings
Sclera	White	Yellowing (Icterus)
Cornea	Clear, smooth	Cloudy, abraded (steamy)
Pupils	3-5mm, symmetric	Anisocoria (unequal size)
Eyelids	Symmetrical	Ptosis (drooping), Lid lag
Nystagmus	None	Oscillating movement (Red Flag if not lateral)

Eye Abnormalities

Miosis: Constricted/fixed pupils.

Mydriasis: Dilated/fixed pupils.

Anisocoria: Naturally occurring unequal pupil size (found in ~5% of population).

Conditions: Cataracts (lens opacity), Glaucoma (increased intraocular pressure), Conjunctivitis (pink eye/erythema).

Tympanic Membrane Normal Findings

Tympanic Membrane (TM): Should be Pearly Gray. Landmarks include the Umbo, Malleus, and the Cone of Light (5 o'clock in right ear, 7 o'clock in left)

Hearing Tests

Whisper Test: High-frequency sound check.

Weber: Tuning fork on midline skull; sound should be equal bilaterally.

Rinne: AC (Air Conduction) should be > BC (Bone Conduction) 2:1.

Ear Conditions

Otitis Media: Middle ear infection (red, bulging TM).

Otitis Externa: "Swimmer's ear" (pain with movement of pinna/tragus).

Equilibrium Test

Romberg Test: Stand with feet together, eyes closed. Minimal swaying is normal. Significant loss of balance is a positive Romberg (indicates vestibular/proprioception issues).

Tonsil Grading Scale

1+: Visible.

2+: Halfway between tonsillar pillars and uvula.

3+: Touching the uvula.

4+: Touching each other ("kissing" tonsils)

Rhinologic Assessment

Nose: Check patency of nares.

• Allergic Rhinitis: Pale, boggy, gray turbinates.

• Common Cold: Bright red, swollen turbinates.

Sinuses: Palpate Frontal (above eyebrows) and Maxillary (cheekbones).

Palpation & Auscultation of Respiratory System

Tactile Fremitus: Palpate "99"; vibrations should be symmetric.

Ladder Pattern: Systematically move from side-to-side to compare lobes.

• 10 posterior sites, 8 anterior sites, 7 lateral sites.

Adventitious Sounds & Disease Exemplars

Crackles (Rales): Discontinuous popping (Pneumonia, Heart Failure).

Wheezes: High-pitched musical squeaking (Asthma, Emphysema).

Rhonchi: Low-pitched "snoring" sound (Bronchitis; may clear with cough).

Stridor: High-pitched crowing (Upper airway obstruction - Emergency).

Pleural Friction Rub: low-pitches, grating sound (Pericarditis)

Diminished: quieter (COPD)

CN I

Name: Olfactory

Type: Sensory

Assessment: Smell identification

CN 2

Name: Optic

Type: Sensory

Assessment: Snellen Chart

CN 3

Name: Oculomotor

Type: Mixed

Assessment: PERRLA; EOM (up, middle, down)

CN 4

Name: Trochlear

Type: Motor

Assessment: EOM (down and inward)

CN 5

Name: Trigeminal

Type: Mixed

Assessment: Clench teeth; light touch to face

CN 6

Name: Abducens

Type: Motor

Assessment: EOM (lateral movement)

CN 7

Name: Facial

Type: Mixed

Assessment: Smile, frown, puff cheeks

CN 8

Name: Vestibulocochlear

Type: Sensory

Assessment: Whisper test; Weber/Rinne

CN 9

Name: Glossopharyngeal

Type: Mixed

Assessment: Gag reflex; “Ahhh” (uvula rise)

CN 10

Name: Vagus

Type: Mixed

Assessment: Swallowing and speech quality

CN 11

Name: Accessory

Type: Motor

Assessment: Shrug shoulders; turn head against resistance

CN 12

Name: Hypoglossal

Type: Motor

Assessment: Stick out tongue

Bradypnea

Rate & Depth Characteristics: Regular rhythm with a rate slower than 12 breaths per minute

Clinical Significance: Can be caused by neurological injury, medication/sedation, or respiratory depression

Tachypnea

Rate & Depth Characteristics: Rapid, shallow breathing at a rate greater than 20 breaths per minute

Clinical Significance: Occurs with fear, fever, exercise, acute respiratory distress, or hypoxemia

Hyperventilation

Rate & Depth Characteristics: Rapid, deep breathing at a rate greater than 20–24 breaths per minute

Clinical Significance: Expels excessive CO2 leading to hypocarbia and respiratory alkalosis; caused by exertion, anxiety, pain, or metabolic disorders

Hypoventilation

Rate & Depth Characteristics: Irregular, shallow respirations at a rate below expected limits

Clinical Significance: Leads to carbon dioxide retention (hypercarbia); caused by overdose, airway obstruction, or sedation

Sighing

Rate & Depth Characteristics: Frequently interspersed deeper breaths within a normal pattern

Clinical Significance: Occasional sighing expands alveoli; frequent sighing indicates hyperventilation or altered emotional/respiratory status

Cheyne-Stokes

Rate & Depth Characteristics: Cyclic pattern of gradually increasing depth, followed by decreasing depth, and periods of apnea

Clinical Significance: Indicates severe CNS hypoxia, brain damage, or end-of-life respiratory failure

Kussmaul

Rate & Depth Characteristics: Rapid, deep, labored breathing without expiratory pauses

Clinical Significance: Compensatory mechanism for severe metabolic acidosis, most commonly diabetic ketoacidosis

Biot (Ataxic)

Rate & Depth Characteristics: Disorganized pattern with irregular depths and unpredictable periods of apnea

Clinical Significance: Caused by severe brain injury, meningitis, or profound CNS depression

Air Trapping

Rate & Depth Characteristics: Pattern of increasing difficulty in exhaling air

Clinical Significance: Caused by chronic airway resistance in conditions like COPD and emphysema

Normal Adult Thorax

Anteroposterior to Transverse Ratio 1:2

Barrel Chest

1:1 Ratio; caused by hyperinflation of lungs

Funnel Chest

Sunken or depressed sternum; congenital structure

Pigeon Chest

Forward protrusion of the sternum; congenital structure

Scoliosis

Lateral S-shaped curvature of the thoracic and lumbar spine; restricts chest expansion

Kyphosis

“hunchback” ; common in older adults

Infant Thorax

1:1

Acute Bronchitis

Etiology: Inflammation of bronchial mucous membranes

Clinical Signs: Coughing progressing to green/yellow sputum

Assessment Findings: Rhonchi or wheezes on auscultation, which often clear or shift after coughing

Emphysema/COPD

Etiology: Permanent destruction of alveolar walls leading to decreased gas exchange

Clinical Signs: underweight, barrel chest, SOB, pursed-lip breathing, tripod position

Assessment Findings: Diminished breath sounds, wheezes, prolonged expiration, hyperresonance on percussion

Asthma

Etiology: Hyperreactive airway disease causing bronchoconstriction, airway inflammation, and edema

Clinical Signs: dyspnea, tachycardia, tachypnea with prolonged expiration, wheezes, accessory muscle use, cough, diminished breath sounds

Assessment Findings: High-pitched musical wheezes

Pneumonia

Etiology: Infection of terminal bronchioles and alveoli causing exudative consolidation

Clinical Signs: Fever, chills, dyspnea, tachypnea, tachycardia, pleuritic chest pain, cough producing yellow/green or rust-colored sputum

Assessment Findings: Fine/coarse crackles, increased tactile fremitus, dullness to percussion

Pneumothorax

Etiology: Air accumulation in the pleural space causing partial or complete lung collapse

Clinical Signs: Absent breath sounds, sudden sharp chest pain, tachycardia, tracheal displacement

Pleural Effusion

Etiology: Accumulation of serous fluid in the pleural space

Clinical Signs: Dyspnea, sharp pleuritic chest pain (worse with deep inspiration/cough), tachypnea, tachycardia

Clinical Sings: Absent or decreased breath sounds over fluid level, dullness to percussion, decreased tactile fremitus, pleural friction rub

Lung Cancer

Etiology: Malignant tumor growth within lung tissue

Clinical Signs: Persistent cough, hemoptysis, dyspnea, chest pain, unintended weight loss, fatigue, hoarseness

Assessment Findings: Localized wheezing, diminished or absent breath sounds distal to tumor obstruction