Advanced Health Assessment Flashcards
In general, if you find that the clients symptoms are not psychiatrically based, you should
refer them out
Which part of the physical assessment should an NP be especially good at
the neuro exam
Components of the neuro exam
Reflexes
Cranial Nerves
Coordination and fine motor
Sensory
Motor
Neurological soft signs
Components of the neuro exam: Reflexes
Normal reflexes: Check biceps, triceps, brachioradialis, patellar, Achilles, plantar
Grade reflexes and note symmetry
Primitive reflexes (head lag, flexion, rooting, grasping, Moro, glabellar, Babinski)
Babinski
A positive Babinski is fanning the of the toes. It’s normal up to 2 years old
Neuro exam: CN1
Close your eyes an occlude each nostril one at a time and test your smell
Neuro exam: CN2
Snellen chart
Opthalmoscope
Peripheral vision test
Neuro exam: CN3
Check the 5 eye movements
Check PERLA
Corneal light reflex (shining a light at the bridge of the nose to see if the light is symmetrical in both eyes)
Neuro exam: CN4
Check eye movements
Neuro exam: CN5
Trigeminal
Clench your teeth, feel to see if one side of the face is weaker
Look for lip tremor or random mouth movements
Test their sense of touch in their face and mouth
Corneal reflex!
Neuro exam: CN6
eye movements
Neuro exam: CN7
Look at the face for drooping/paralysis
Wrinkle forehead, close eyes, frown, smile, puff cheeks
Sense of taste
Neuro exam: CN8
Hearing, webber, rinne
Neuro exam: CN9
Glossopharyngeal
Same test as CN10 vagus nerve
Neuro exam: CN 10
Open and say “ah” (check the uvula)
Gag reflex
Neuro exam: CN11
Accessory spinal
Try to raise your shoulders while I hold them done
Neuro exam: CN12
Hypoglossal
Stick out your tongue and look for tremors
Neuro exam: Coordination and fine-motor skills
Equilibrium- Use the Romberg test, they stand on one leg and look for swaying
Diadochokinesia- Are they able to perform rapid alternating movements
Dyssynergia- Finger-to-nose, heel-to-knee
Handwriting
Gait
Neuro exam: Sensory functions
Can they feel pain, temperature, light touch, two point discrimination, stereogenesis (what’s in your hand?), graphesthesia
Neuro exam: Motor functions
Muscle mass- is there atrophy? Hypertrophy?
Muscle tone- is there tension even when resting?
Muscle strength
Choreiform movements
Rapid, jerking tics
Peds BMI
If they’re BMI is over the 85th percentile, they are at risk for being overweight
Adult BMI
20 to 25 is normal
25 to 29 is overweight
30 to 35 is obese
In addition to the obvious things, high BMI is a risk for
OA and some types of cancer
If a patient has a high temperature, which 2 meds might they be taking?
Carbamazepine and clozapine (which cause agranualocytosis, which causes fever)
Which 2 meds causes SJS
lamotrigine and carbamazepine
Evaluate moles with ABCDE
Asymmetry Borders irregular Color variation Diameter greater than 6mm Elevation
If they have cataracts, which med might they be on
Quetiapine
How should the tympanic membrane appear
Pearly, translucent, no bulging or retractions
Palpating the thyroid
You usually cannot feel it unless the person is thin
What are the 2 classes of drugs where we see ECG changes (in general)
antipsychotics and TCAs
What medication and what disorder often cause peripheral edema
Lithium, anorexia
Palpating the liver
Often not palpable, except for in thin clients
Normal value of thyroxine T4
0.8 to 2.8
Diseases that have increased thyroid levels
Grave’s
Hashimoto’s
Thyrotoxicosis due to T4
Acute thyroiditis
Diseases that have decreased thyroid levels
Cushing’s
Thyrotoxicosis due to T3
Renal failure
Cirrhosis
Things that can increase thyroid levels
Heparin, aspirin, propranolol
Things that can decrease thyroid levels
Furosemide (lasix), methadone
Normal value of thyroid stimulating hormone
2 to 10
Things that can decrease TSH
T3, aspirin, steroids, heparin
Things that can increase TSH
Lithium
Hypothyroid symptoms
Everything is slower Confusion Headaches Syncope Fluid retention Muscle aches and stiffness Sensory disturbance (hearing) Ataxia Loss of amplitude in ECG
Hyperthyroid symptoms
Labile
Abdominal pain
Dysrhythmias
Calcium levels
Normal value 8.8 to 10.5
Low calcium = tetany/muscle excitability, alkalosis, hypoparathyroid, renal failure, pancreatitis, confusion, paresthesias of the mouth and digits, convulsions, prolonged QT interval, stomach cramps, hyperactive bowel sounds
High calcium = hyperthyroidism, hyperparathyroidism, coma, metastatic cancer, acidosis, Addison’s disease, fatigue, weakness, anorexia, nausea, constipation, behavioral change, renal impairment, Shortened QT interval, depressed T waves, bradycardia, heart block
Calcium functions
Enzyme cofactor for blood clotting Hormone secretion Cell receptors Plasma membrane stability and permeability Nerve impulses and muscle contraction
How is calcium mediated
It’s mediated by 3 things: parathyroid, vitamin D, and calcitonin
Things that increase or decrease calcium levels
High calcium is caused by growth in children, drinking too much milk, lithium, thiazide diuretics, antacids, and vitamin D
Low calcium is caused by anticonvulsants, aspirin, calcitonin, steroids, heparin, laxatives, diuretics, albuterol, and birth control
Sodium levels
135 to 145
Sodium functions
acid-base balance
membrane transport
retaining/excreting water
Too much sodium can be caused by
hypervolemia, dehydration, diabetes insipidous, gastroenteritis, too much salt, adrenocorticosteroids, methyldopa, hydralazine, cough medication
Too little sodium can be caused by
addison’s disease, renal disorder, vomiting/diarrhea, lithium, vasopressin, diuretics
Having not enough sodium can cause
lethargy, headache, confusion, anxiety, seizures, come, hypotension, tachycardia, decreased urine, weight gain, edema, JVD
Having too much sodium can cause
convulsions, pulmonary edema, thirst, fever, dry membranes, tachycardia, restlessness
Magnesium level
1.3 to 2.1
Magnesium functions
Cofactor in intracellular enzyme reactions
It’s regulated by the kidney
Things that increase magnesium
Addison's Adrenalectomy Renal failure Diabetic ketoacidosis Dehydration Hypothyroidism Hyperthyroidism Antacids, salicylates, lithium
Things that decrease magnesium
Hyperaldosteronism Hypokalemia Diabetic ketoacidosis Malnutrition Alcoholism Pancreatitis Gi loss Malabsorption pregnancy induced HTN thiazide diuretics, calcium, insulin, neomycin, aldosterone, ethanol
Effects of hypomagnesemia
depression confusion irritability increased reflexes but with muscle weakness ataxia nystagmus tetany convulsions
Effects of hypermagnesemia
N/V muscle weakness and depressed contractions hypotension bradycardia respiratory depression depressed nerve functioning
Chloride level
98 to 106
the level changes according to how much sodium there is
Increased chloride is caused by
acidosis hyperkalemia Hypernatremia dehydration renal failure Cushing's Hyperventilation Anemia Potassium chloride, acetazolamide, methyldopa, diazoxide, and guanethidine
Decreased chloride is caused by
aalkalosis hypokalemia hyponatremia GI loss Diuresis Overhydration Addison's Burns Elevated triglycerides Ethacrynic acid Furosemide thiazide diuretics bicarbonate
Potassium level
3.5 to 5
Potassium functions
Regulates the intracellular environment Glycogen deposits in the liver and muscles Maintains resting membrane potential Conducts impulses Cardia rhythms muscle contractions
Too much K is caused by
acidosis insulin deficiency Addison's Acute renal failure Hypoaldosteronism Infection Dehydration amphotericin tetraacycline heparin epinephrine K sparring diuretics isoniazid
vigorously pumping the hand
hemolysis
High platelet count
Too little Potassium is caused by
Alkalosis too much insulin GI loss laxative abuse burns trauma surgery cushing's hyperaldosteronism thyrotoxicosis anorexia Not eating enough meat and veggies furosemide, ethacrynic acid, thiazide, insulin, aspirin, prednisone, cortisone, gentamycin, lithium, laxatives
Sample left at room temp
Hyperkalemia causes
muscle weakness paralysis tingling of lips and fingers restlessness intestinal cramping diarrhea Narrow/tall T waves Shorten T wave Depressed ST segment, prolonged PR interval, wide QRS complex leading to heart attack
Hypokalemia causes
impaired carb metabolism impaired renal function polyuria polydipsia weakness and no muscle tone dysrhythmias paralysis and respiratory arrest
ALT
Normal level = 5 to 35
Liver cancer, hepatitis, mono = Over 300
Many things can cause, like severe burns, pancreatitis = 100 to 300
Uremia and hemodialysis can falsely elevate the level
These meds can truly elevate ALT:
Acetaminophen, allopurinol, aspirin, ampicillin, carbamazepine, cephalosporins, codeine, digitalis, indomethacin, heparin, isoniazid, methotrexate, methyldopa, OC, phenothiazines, propranolol, tetracylcine, verapamil
AST
Normal value = 5 to 40
2 to 3 times elevated = DTs, pericarditis, pulmonary infraction
3 to 5 times elevated = Biliary obstruction, arrhythmias, liver tumor, chronic hepatits
5 times elevated = Acute liver damage, acute pancreatitis, MI, shock, mono
AST can be elevated by: exercise, HTN drugs, cholinergics, anticoagulants, digitalis, erythromycin, isoniazid, methyldopa, OC, opiates, salicylates
GGT values
Normal = 10 to 38
We check the values to see if someone abuses alcohol.
It can be elevated with alcohol, liver problems, heart problems, pancreas problems, DM, seizures
High levels of GGT can be caused by alcohol, barbituates, and phenytoin
Low levels can be caused by late pregnancy, OC, and clofibrate
