Chapter 2 Health Assessment and Diagnostic Tests

A client with cholecystitis would most likely have increased direct bilirubin because an elevated direct (conjugated) bilirubin level occurs with gallstones and obstruction of the extrahepatic duct.

Increased tactile fremitus would be an expected finding in a client with lobar pneumonia. Tactile fremitus refers to the palpable transmission of vibrations through the bronchus to the chest wall when the client is speaking. There is an increased transmission through consolidated tissue, as is found with lobar pneumonia.

HBsAg

HBsAb

HBeAg

HBeAb

🧪 HBsAg – Hepatitis B Surface Antigen

• What it is: A protein on the surface of the virus.

• Positive means: The person is currently infected (acute or chronic).

• Memory hook: “Ag” = Antigen = Active infection.

🛡 HBsAb (Anti-HBs) – Hepatitis B Surface Antibody

• What it is: Antibody against the surface antigen.

• Positive means: The person is immune—either from recovery or vaccination.

• Memory hook: “Ab” = Antibody = Bye-bye virus.

🔥 HBeAg – Hepatitis B e-Antigen

• What it is: A marker of viral replication.

• Positive means: High infectivity—virus is actively replicating.

• Memory hook: “e” = Explosive replication.

🧤 HBeAb (Anti-HBe) – Hepatitis B e-Antibody

• What it is: Antibody against the e-antigen.

• Positive means: Lower infectivity—replication is slowing down.

• Memory hook: “Ab” = Antibody = Easing off the gas.

🧠 Quick Summary Table

🧨 IgM – “I’m the First Responder”

• What it is: The first antibody your body makes when it detects a new infection.

• Positive means: Recent or acute infection—your immune system just rang the alarm.

• Memory hook: “M” for “Moment of infection”.

🛡 IgG – “I’ve Got Your Back Long-Term”

• What it is: The antibody that kicks in later and sticks around for long-term protection.

• Positive means: Past infection or immunity (possibly from vaccination).

• Memory hook: “G” for “Gone but remembered.”

🧠 Quick Interpretation Table

A false-negative TB PPD test may be the result of immunosuppression. The test must be administered intradermally.

this one’s all about understanding how the immune system responds (or doesn’t) to the tuberculin skin test (PPD).

🧬 The Science Behind the PPD Test

The PPD test relies on a delayed-type hypersensitivity (DTH) reaction, which is a cell-mediated immune response:

• T-cells that have been previously sensitized to Mycobacterium tuberculosis antigens react to the injected tuberculin.

• This reaction causes localized skin induration (not just redness) within 48–72 hours.

🚫 Why Immunosuppression Can Cause a False-Negative

In immunosuppressed individuals (e.g., HIV/AIDS, corticosteroids, chemotherapy, transplant meds):

• Their T-cell function is impaired.

• Even if they’ve been exposed to TB, their immune system may fail to mount a visible response to the PPD.

• This phenomenon is called anergy—a lack of immune reactivity despite infection.

So the test result appears negative, but it’s not truly reflective of their TB status.

🩺 Clinical Implications

• A negative PPD in an immunocompromised patient does NOT rule out TB.

• In these cases, clinicians often prefer interferon-gamma release assays (IGRAs) like QuantiFERON-TB Gold or T-SPOT.TB, which are less affected by immune suppression3.

• Additional workup (e.g., chest X-ray, sputum cultures) may be needed if TB is suspected.

A pregnant client presents with a recent-onset rash. Which of the following laboratory results would be reassuring that this is not likely to be rubella? HAI titer of 1:10 at her initial visit 1 month earlier. The HAI test is used to detect immunity to rubella and to diagnose rubella infection. Titers of 1:10 or greater indicate immunity to rubella. High titers (1:64 or greater) may indicate current rubella infection.

The HAI titer stands for Hemagglutination Inhibition titer, and while it’s not the most commonly used test for rubella today (IgG/IgM serologies are more standard), it’s still worth knowing for boards and historical context.

🧬 HAI Titer – Hemagglutination Inhibition Titer

• What it tests: Measures the level of antibodies in the blood that can inhibit viral hemagglutination—a process where viruses clump red blood cells together.

• In rubella, the rubella virus has surface proteins that can cause hemagglutination. If a person has antibodies (from past infection or vaccination), those antibodies will block this clumping.

• Titer meaning: The highest dilution of serum that still prevents hemagglutination is the HAI titer. A higher number = stronger immunity.

🧠 How to interpret it:

The bell of the stethoscope should be used when listening for carotid bruits and low-pitched sounds such as those heard over large blood vessels.

Osteopenia -1 to -2.5 and Osteoporosis is -2.5+

Obtaining a Z-score on a bone mineral density test might be appropriate for evaluating a premenopausal woman to an age-, gender-, and ethnicity-matched reference population to evaluate for secondary causes of osteoporosis. For example, a 40-year-old female with a nontraumatic hip fracture.

Gravida denotes the total number of pregnancies, including a current pregnancy. Para denotes the total number of pregnancies reaching 20 weeks or longer gestation.

Normal values of a urinalysis are as follows:

    Specific gravity 1.005 to 1.030

    pH 4.6 to 8.0

    WBCs 0 to 4 per HPF

    Protein 0 to 8 mg/dL

A laboratory test finding of increased immature neutrophils (shift to the left) is consistent with an acute bacterial infection. Neutrophils are increased in acute bacterial infections and trauma. Increased immature neutrophil forms (band and stab cells), referred to as a “shift to the left”, are seen with ongoing acute bacterial infection.

BUN is an indirect measure of renal and liver function. Increased levels may be seen with hypovolemia, dehydration, reduced cardiac function, GI bleeding, starvation, sepsis, and renal disease.

A fasting glucose of 126 mg/dL or greater in a non-pregnant woman is diagnostic for diabetes. Repeat testing should be done on a subsequent day to confirm the diagnosis.

The CDC-recommended test for Trichomonas is the NAAT. It is more sensitive than a wet mount or culture. Which stands for

When auscultating lung sounds, the normal finding over most of the lung fields is vesicular. The lung sound over most of the lung fields is vesicular, with inspiratory sounds lasting longer than expiratory sounds.

The squamocolumnar junction is the area where the squamous epithelium (pink) and columnar epithelium (dark red) of the cervix meet. The junction may be inside the cervical os so that only squamous epithelium is visible, or a ring of columnar tissue may be visible to a varying extent around the os.

The glands located posteriorly on each side of the vaginal orifice are the Bartholin’s glands.

Tests for cerebellar function include the Romberg test for balance. The cerebellum coordinates motor activity, maintains equilibrium, and helps to control posture.

An example of information that goes into the review of systems section of the health history would include occasional loss of urine with coughing. The review of systems is used to assess common symptoms for each major body system to avoid missing any potential or existing problems.

A positive PPD result in an individual from the high-risk population is a PPD skin test resulting in a 5-mm or greater area of induration, which is a positive reaction.

A client who had HBV 6 months ago has no symptoms but has a positive test for HbsAg. This most likely indicates that she is a chronic carrier of HBV. HBsAg rises before the onset of clinical symptoms, peaks during the first week of symptoms, and returns to normal by the time jaundice subsides. An individual is considered to be a carrier (remains infectious) if HBsAg persists.

A client reports having sex with someone who disclosed afterwards that they have a history of genital herpes. Is there a test that can be done at this visit to see if they have been infected? She can have a blood test in 1-2 months to determine if she has herpes antibodies. Type-specific serologic tests detect HSV-1 and HSV-2 antibodies. It may take 4-12 weeks for seroconversion to occur.

A premenopausal woman with which of the following conditions would be most likely to have a low FSH and low estradiol level? Anorexia nervosa.

This is a great question that dives into the physiology of the hypothalamic-pituitary-ovarian (HPO) axis. Let’s break it down so it feels intuitive, not just memorized.

🧠 The Core Concept: HPO Axis Suppression

In a healthy premenopausal woman:

• The hypothalamus secretes GnRH (gonadotropin-releasing hormone),

• Which stimulates the pituitary to release FSH and LH,

• These then act on the ovaries to produce estradiol and progesterone.

If any part of this axis is disrupted, hormone levels shift accordingly.

✅ Why B. Anorexia Nervosa Is Correct

In anorexia nervosa:

• Severe caloric restriction and low body fat lead to hypothalamic suppression.

• The hypothalamus reduces GnRH pulses → ↓ FSH and LH from the pituitary → ↓ estradiol from the ovaries.

• This is called functional hypothalamic amenorrhea—a reversible condition if nutritional status improves.

So both FSH and estradiol are low, because the signal from the top (hypothalamus) is weakened.

❌ Why the Other Options Don’t Fit

Both C and D are examples of primary ovarian failure, where the pituitary is trying to compensate by increasing FSH.

🩺 Clinical Pearl

In anorexia, the body is in survival mode. It downregulates reproductive function to conserve energy. That’s why you see low FSH and low estradiol—the system isn’t broken, it’s paused.

A pertinent negative that needs to be documented is the description of presenting symptoms. Symptoms suggesting that an abnormality may exist or may develop in that area include documentation of the absence of symptoms that may help eliminate some of the possibilities. For example, a 40-year-old female with depression, past history of suicidal attempt, is not considered pertinent negative as a 25-year-old female with abdominal pain, no nausea, vomiting, or diarrhea. The 2nd example displays a pertinent negative symptom that can indicate an underlying health issue or something that may develop.

The following statement regarding testing for strep throat in an adult client with sore throat, fever, and tonsillar exudate is correct: A positive rapid streptococcal antigen test indicates the presence of GABHS requiring antibiotic treatment. A negative test indicates that the infection is more likely viral. A culture is not needed to confirm a negative test.

Which lab values are not normally affected by pregnancy? Cholesterol, MCV, T4, or triglycerides? MCV is the correct answer. The MCV is the average volume or size of a single RBC. Although the Hgb/Hct levels may be lower during pregnancy, the size of the RBCs should not change unless the woman has iron-deficiency anemia, thalasemia, vitamin B12 deficiency, or folic acid deficiency. Cholesterol and triglyceride levels may be elevated during pregnancy. T4 levels are affected by the amount of TBG, which is increased during pregnancy.

A woman who states she may be pregnant because her period is 12 days late. The best initial pregnancy test to obtain is a qualitative sensitive urine hCG test. Sensitive urine hCG tests may detect pregnancy as early as 28 days from the last menstrual period. Cross-reactions with other hormones are not a problem. A qualitative (positive/negative) test is the appropriate pregnancy test choice.

In a nulliparous woman, the uterus is 5.5 to 8 cm long and pear-shaped. In the reproductive years, the ovaries are approximately 3 cm x 2 cm x 1 cm.

The sound heard over the cardiac area if the client has pericarditis is most likely to be a friction rub, which sounds like a grating sound throughout the cardiac cycle when inflammation of the pericardium is present.

A laboratory test finding of increased immature neutrophils indicates an acute bacterial infection and trauma.

A client with an increased WBC count related to infectious hepatitis would most likely have an elevated level of lymphocytes. The WBC count with differential provides information useful in evaluating an individual with infection, neoplasm, allergy, or immunosuppression. Lymphocytes and monocytes are increased in acute viral infections and chronic bacterial infections.

Spenic dullness may be percussed at the 6th to 10th IS just posterior to the midaxillary line on the left side, with he client in the supine position. Splenic dullness at the anterior axillary line is indicative of an enlarged spleen.

The cranial nerve that can be tested for both motor and sensory function is the CN V-trigeminal nerve. The cranial nerves with both motor and sensory functions are CN V (trigeminal), CN VII ( facial), CN IX (glossopharyngeal), and CN X (vagus). Routinely, the only cranial nerve in which you test both motor and sensory function is CN V.

The blood type in which an individual has no antigens on their RBCs is O-. Blood types are grouped according to the presence or absence of antigens A, B, and Rh on RBCs. Blood type O negative has no antigens.

Z scores are used to compare bone density in a premenopausal woman to an age, gender, population, and ethnicity-matched reference population to evaluate for secondary causes of osteoporosis.

A client who was sexually assaulted 3 weeks ago by an individual known to be infected with HIV has a nonreactive rapid EIA test result using an oral mucosal transudate specimen. The next appropriate step would be to order an HIV-1 p24 antigen test. The HIV-1 p24 antigen test detects HIV-1 antigen as early as 2-6 weeks after infection; levels of this antigen decline once HIV antibodies develop. HIV antibodies are detectable in 95% of individuals within 6 months of infection. A combined HIV antibody and p24 antigen test is available.

Increased tactile fremitus is a medical exam to assess the vibration of the chest wall when a patient speaks. It is the palpable transmission of vibrations through the bronchus to the chest wall when the client is speaking. There is increased transmission through consolidated tissue, which would be an expected finding in a client with lobar pneumonia.

Somatic mutations are acquired and occur after conception. A DNA copying mistake may occur during cell division or from exposure to ionizing radiation, chemicals, or viruses during gestation or later in life.

An abnormal finding on ophthalmoscopic examination would be a tapering of the veins. The normal retinal artery wall is transparent except for the column of blood going down the middle, so a vein crossing beneath the artery can be seen up to the column of blood on either side (arteriovenous crossing). When narrowing of the retinal artery occurs ( as in hypertension), the arterial wall thickens and becomes less transparent. The vein crossing under the narrowed artery appears to taper down on either side of the artery.

Increased direct (conjugated) bilirubin level occurs with gallstones and obstruction of the extrahepatic duct.

The sickle cell preparation is used to screen for sickle cell disease and trait. A positive test indicates the presence of Hgb S, indicating either sickle cell disease or trait. Hgb electrophoresis is the definitive test performed if the screening test is positive, as it identifies Hgb type and quantity.

Autosomal recessive inheritance of a genetic disorder occurs when both parents are unaffected but are carriers of the mutated gene. The affected individual has two mutated copies of the responsible gene in each cell. The affected individual usually has unaffected parents (carriers), each of whom carries a single copy of the mutated gene.

The following heart sound may be a normal finding in the third trimester of pregnancy S3. An increased S3 may be audible in late pregnancy. This heart sound is heard only in diastole during rapid ventricular filling!

The S2 sound is heard best at the base of the heart using the diaphragm of the stethoscope.

Nontreponemal tests (VDRL, RPR) usually become nonreactive with time after treatment. Treponemal tests (FAT-ABS, TPI) usually remain positive indefinitely after treatment.

Evaluation of EOM movement includes the 6 cardinal fields of gaze. It assesses symmetry, lid lag, and nystagmus as the client holds her head still and follows your finger through the 6 cardinal fields of gaze.

The best position for palpating the axilla is with the woman sitting up with her arm down on the side you are examining. The examiner palpates the axillary lymph nodes and the breast tissue that extends in the axillary area (tail of Spence) with the woman sitting with arms relaxed at her side. The examiner supports the lower arm and uses the palmar surface of the fingers to palpate the entire area.

Increased TSH = primary hypothyroidism and thyroiditis

Decreased T4 = hypothyroidism

Microcytic (abnormally small) and Hypochromic (pale) RBCs = iron deficiency anemia

Adding KOH to a wet mount slide before viewing it under the microscope is useful in the detection of Candida pseudohyphae and buds.

Somatic mutations may occur at any time in a person’s life. They are acquired and occur after conception. A DNA copying mistake may occur during cell division or from exposure to ionizing radiation, chemicals, or viruses during gestation or later in life.

Different types of anemias

Vaginal glands

    Bartholin’s glands- located posteriorly on each side of the vaignal orifice are the Bartholin’s glands.

    Bulbar glands

    Nabothian glands

    Skene’s glands

🧭 Gland Locations & Functions

🧠 Clinical Pearls

• Bartholin’s abscess: Painful swelling near the vaginal opening, often in younger women.

• Nabothian cysts: Common incidental findings on pelvic exams or ultrasounds — usually benign.

• Skene’s glands: Can become infected (Skene’s duct cyst or abscess), sometimes mistaken for a UTI.

🧪 Thyroid Function Test Findings

🧠 Clinical Pearls

• TSH is the most sensitive screening test — always interpret it in context with free T4/T3.

• In central hypothyroidism (pituitary origin), TSH may be low or normal despite low T4.

• Subclinical states:

  • Subclinical hyperthyroidism: ↓ TSH, normal T4/T3

  • Subclinical hypothyroidism: ↑ TSH, normal T4/T3

🧪 Common Labs Ordered for Suspected Cholecystitis

These help assess inflammation, infection, and biliary obstruction:

1. Complete Blood Count (CBC)

• WBC count: Often elevated due to inflammation or infection.

  • Think: leukocytosis with a left shift (↑ neutrophils).

2. Liver Function Tests (LFTs)

• AST & ALT: May be mildly elevated if there's hepatic inflammation.

• Alkaline Phosphatase (ALP): Can be elevated if there's biliary obstruction.

• Total & Direct Bilirubin: May be elevated if bile flow is impaired.

3. Amylase & Lipase

• Usually normal, but ordered to rule out pancreatitis, which can mimic cholecystitis.

4. CRP (C-reactive protein) or ESR

• Elevated as markers of systemic inflammation.

5. Blood Cultures

• If the patient is febrile or septic — to check for bacteremia.

🔍 What Would Be Abnormal or High?

🧠 Clinical Pearl:

If you see elevated WBC + RUQ pain + fever + positive Murphy’s sign, and LFTs suggest biliary stasis, you’re likely dealing with acute cholecystitis. Imaging (ultrasound) confirms it, but labs give you the inflammatory and hepatic picture.

🧠 First, what do low FSH and low estriol suggest?

• FSH (Follicle Stimulating Hormone) is released by the pituitary to stimulate ovarian follicle development.

• Estriol is a form of estrogen, primarily produced during pregnancy, but in non-pregnant women, estradiol is more dominant. Still, low estriol implies low estrogen activity.

So if both are low, we’re likely dealing with a central (hypothalamic or pituitary) suppression — not ovarian failure (which would cause high FSH due to lack of feedback).

🔍 Let’s analyze each option:

A. Adrenal tumor

• Could cause hormonal imbalance, but not typically associated with low FSH and estriol.

• Not the best fit.

B. Anorexia nervosa

• YES. This is a classic cause of hypothalamic amenorrhea.

• Malnutrition suppresses GnRH → ↓ FSH/LH → ↓ estrogen.

• So both FSH and estriol would be low.

• ✅ Most likely answer.

C. Premature ovarian failure

• Ovaries fail early → ↓ estrogen → ↑ FSH (due to lack of negative feedback).

• So FSH would be high, not low.

D. Turner’s syndrome

• Gonadal dysgenesis → ↓ estrogen → ↑ FSH.

• Again, FSH would be high, not low.

✅ Correct answer: B. Anorexia nervosa

This reflects central suppression of the hypothalamic-pituitary-ovarian axis, leading to low FSH and low estriol.

A normal finding in the third trimester of pregnancy is S3, which is caused by an increased audible sound in late pregnancy. This heart sound is heard early in diastole during rapid ventricular filling. 

Adding KOH to a wet mount slide before viewing it under the microscope is useful in the detection of pseudohyphae. KOH on a vaginal wet mount slide facilitates visualization of Candida pseudohyphae and buds. 

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