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Advanced Health Assessment > Exam 1 > Flashcards

Exam 1 Flashcards

1
Q

Hair

A

quantity
distribution
texture
pattern of loss

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2
Q

Scalp

A

scaliness
lumps
nevi
lesions

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3
Q

Skull

A

deformities
depressions
lumps
tenderness

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4
Q

Face

A 
facial expressions 
contours
asymmetry
involuntary movements
edema
masses
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5
Q

Skin

A 
color
pigmentation
texture
thickness
hair distribution
lesions
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6
Q

Eyebrows

A

fullness
hair distribution
scaliness

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7
Q

Eyelids

A 
position of lids in relation to eyeballs
width of palpebral fissures
edema
color
lesions
condition/direction of lashes
adequacy of lid closure
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8
Q

Lacrimal Apparatus

A

inspect lacrimal gland & lacrimal sac for swelling

excessive tearing or dryness of eye may require referral to ophthalmology

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9
Q

Conjunctiva/Sclera

A

have patient look up while depressing lower lids simultaneously

  • inspect sclera & conjunctiva for color
  • note vascular pattern
  • look for nodules/swelling
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10
Q

Cornea/Lens

A

inspect for opacities

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11
Q

Iris

A

inspect both iris simultaneously

  • markings should be clearly defined
  • with light shining from the temporal side, look for crescentic shadow on the medial side of iris
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12
Q

Pupil

A

dim light

  • inspect size, shape, symmetry
  • measure both pupils
  • test light reaction
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13
Q

Extraocular Muscles

A
  • assess for conjugate movements, nystagmus, and lif lag

- test the 6 EOM by having patient follow pen/finger

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14
Q

Opthalmoscopic Exam

A
  • instruct patient to keep both eyes open and look beyond your ear/shoulder while gazing into the distance
  • shine light into pupil and look for orange glow in the pupil known as red reflex
  • done in NB screen & regular routine eye exams
  • note opacities interrupting red reflex
  • optic disc
  • Retina
  • Disturbance in vision
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15
Q

Absence of red reflex

A

cataracts

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16
Q

Optic Disc

A

round, yellowish-orange to creamy pink structure with pink rim and central depression

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17
Q

Retina

A
  • inspect arteries and veins
  • identify any lesions and note their size, shape, and color
  • flashing light mean vitreous detachment from retina
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18
Q

Disturbance in Vision

A

flashing light mean vitreous detachment from retina

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19
Q

AV Nicking

A
  • damage to capillaries due to DM or HTN

- least expected finding in a normal eye

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20
Q

Chalazion

A
  • chronic inflammation of the UPPER eyelid due to NON-TENDER nodule blocking the meibomian gland.
  • PAINLESS
  • c/o GRADUAL onset of small superficial nodule that feels like a bead, is discrete, and moveable.
  • may resolve in 2-8 weeks
  • can slowly enlarge, press on the cornea, and cause blurred vision
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21
Q

Hordeolum (stye)

A
  • external: abscess of a hair follicle on the upper OR lower lid
  • internal: inflammation of the meibomian gland
  • PAINFUL and TENDER
  • c/o ACUTE onset of a swollen, red, warm abscess on the lids involving 1 hair follicle that gradually enlarges
  • usually UNILATERAL
  • may spontaneously rupture and drain purulent exudate.
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22
Q

Subconjunctival hemorrhage

A

blood shot eyes d/t the rupture of small eye vessels caused by sneezing, coughing, and straining.

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23
Q

Blepharitis

A
  • chronic condition caused by inflammation of the oil glands of the inner eye
  • associated with seborrheic dermatitis, rosacea, or allergies
  • c/o itching, irritation, gritty sensation, eye redness, and crusting dryness
  • intermittent exacerbations
  • lid may be colonized by staph
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24
Q

Allergic Conjunctivitis

A
  • chronic, seasonal condition caused by hypersensitivity reaction to a specific allergen.
  • HALLMARK: itching and tearing disproportionate to findings
  • watery, non-purulent, or mucoid discharge BILATERALLY
  • painless
  • conjunctiva has cobblestone appearance
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25
Q

Viral Conjunctivitis

A
  • occurs in young people most commonly
  • watery discharge
  • gradual onset; may be UNILATERALLY
  • slight crusting along eyelid margins
  • may be seen with upper resp. tract infections (adenovirus, picornavirus, rhinovirus, and HSV
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26
Q

Bacterial Conjunctivitis

A
  • gradual onset, usually starts unilaterally but become bilateral d/t touching/rubbing eye
  • most commonly d/t S. aureus, H influenzae, and N. Gonorrhoeae
  • least commonly d/t E.coli
  • purulent or mucopurulent discharge, matted eyes
  • c/o scratchy instead of painful
  • no photophobia, no fever
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27
Q

Conjunctivitis vs. Corneal Abrasion

A
  • pain w. corneal abrasion; no pain with conjunctivitis
  • treat corneal abrasion rapidly to prevent permanent scarring
  • NO STEROIDS for corneal abrasion
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28
Q

Glaucoma

A
  • can cause blindness if left untreated; early detection saves lives
  • c/o interocular pressure and pain
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29
Q

Exophthalmos

A
  • bulging, or unusual protrusion of eyes related to thyroid hormone production (
  • seen in 60% of hyperthyroidism/Grave’s disease patients
30
Q

Diabetic retinopathy

A
  • initially asymptomatic or only mild vision problems
  • can cause blindness eventually
  • AKA: AV nicking
31
Q

Normal Ear

A
  • visible bony landmarks
  • greyish/pearl TM
  • honey colored cerumen
  • visible cone of light (absence of cone of light is abnormal)
32
Q

Weber Test

A
  • place base of a vibrating tuning fork above head or on midforehead to test for unilateral conductive hearing loss.
  • sound is heard best in the IMPAIRED ear
33
Q

Rhinne Test

A
  • used primarily to evaluate loss of conductive hearing in one ear
  • AC > BC = normal
  • BC > AC = abnormal conductive loss
34
Q

Sensorineural Hearing loss

A
  • permanent.

- difficult to to speak appropriately and understand

35
Q

Otitis Externa (Swimmer’s Ear)

A
  • bacterial infection of the skin in the external ear canal d/t Pseudomonas aeruginosa (gram negative) and S. aureus (gram positive)
  • common during warm and humid weather
  • c/o external ear pain, swelling, purulent green discharge, pruritus, and hearing loss, red canal
  • ear pain with manipulation of the tragus or external ear
  • may not be able to visualize the TM
36
Q

Dacrocystitis

A
  • blocked tear duct d/t deviated septum
37
Q

Infant ear infection

A
  • common in 3 month infant
  • teach to not bottle prop to prevent
  • high risk of recurring infections if less than 3 mo
38
Q

TM immobility

A

excessive cerumen

39
Q

Otitis Media

A
  • most commonly in childhood
  • acute bacterial infection of middle ear cavity d/t trapped mucus, secondary to eustachian tube dysfunction.
  • c/o of otalgia (ear pain), ear popping, MUFFLED HEARING/HEARING LOSS
  • TM bulging or retracted and erythematous, with DISPLACED LIGHT REFLEX, may look opaque
  • DECREASED MOBILITY with flat line tracing on tympanogram
  • SEROUS EFFUSION: amber fluid behind the ear drum
  • may be accompanied by ruptured TM with relief, or blood/pus.
40
Q

Mastoiditis

A
  • symptoms are similar to ear infection

- drainage, ear pain, fever, headache

41
Q

Nose Exam

A
  • insert otoscope speculum into turbinate/vestibule of each nostril, AVOID CONTACT WITH SEPTUM (sensitive)
  • normal: moist & pink
42
Q

Allergic Rhinitis

A

nasal mucosa/turbinate is PALE/blusih & BOGGY

43
Q

Acute Sinusitis

A
  • fever, HA, tender sinuses w. palpitation, purulent nasal secretions, TOOTH PAIN, post nasal drip, sore throat.
  • EPISTAXIS an uncommon s/s
44
Q

Tongue Cancer

A

risk factor: men > 50 yo & previous cancer hx

45
Q

Peritonsillar Abscess

A
  • ASYMMETRIC SWELLING of uvula, tonsils, or posterior pharynx
  • redness, swelling edema, hx of tonsillitis, inability to swallow, negative strep
46
Q

Step Pharyngitis

A
  • sore throat w. tonsillar exudate, anterior cervical adenopathy, elevated & persistent temp >101.5, no asymmetry,
47
Q

Viral Pharyngitis

A
  • fever, cough, malaise

- no tonsillar exudate

48
Q

Laryngitis

A
  • sore throat, loudness/quality of voice is affected
  • redness & edema of vocal chords
  • whispering worsens
  • anterior cervical adenopathy
49
Q

Thrush/Candida

A
  • common in patients with asthma, steroid use, or chronic dairy product exposure
  • infants with patches on tongue=normal; patches on cheek= TREAT
  • educate to rinse after inhaler use
  • white patches/candida don’t scrape off without bleeding. (not exudate)
50
Q

Chief Complaint

A

in patients own words

51
Q

S-subjective

A 
history of present illness reported by patient in their own words
OLDCART
pertinent past Hx
pertinent preventative hx 
ROS
pertinent social hx
pertinent family hx
52
Q

OLDCART

A 
onset
location
duration
characteristics
aggravating factors
relieving factors
treatment
53
Q

Social History

A

caffeine intake
alcohol use
substance/drug use
tobacco use

54
Q

O-objective

A

information observed by clinician:

  • general: VS, ht, wt, BMI, description of clinical presentation
  • HEENT,
  • neck
  • Respiratory
  • Cardiovascular
  • Abdominal
  • GU/GI
  • Musculoskeletal
  • Neuro
  • Integumentary
  • Diagnostics: pertinent diagnostic test (webber, rhinne)
55
Q

A-assessment

A
  • working diagnosis

- differential diagnoses

56
Q

P-plan

A
  • prescriptions

- education

57
Q

Predictive Value

A

dependent on prevalence

58
Q

Sensitivity

A
  • true positive rate (probability that patient with positive actually has the disease)
  • high sensitivity=reliable and trustworthy
59
Q

Specificity

A
  • true negative rate (probability that patient with negative test doesn’t actually have the disease)
60
Q

SnOUT

A

a sensitive test with negative results rules out a disease

61
Q

SpPIN

A

a specific test with a positive result rules in a disease

62
Q

Clinical reasoning

A

why you make a decisions

63
Q

Differential Diagnosis

A

list of most likely to least likely causes

64
Q

Early screening

A

saves lives in absence of s/s

better outcomes

65
Q

Establish rapport

A

eye contact, avoid looking at screen

if another person in the room, ask permission to conduct interview

66
Q

Guided Questions

A

help narrow open-ended questions
offer multiple reasons/explanations
help understand and confirm facts by repeating what patient says and means
can help prevent misinterpretation and avoid confusion/frustration with interview process

67
Q

Pediatric Physical Exam

A
  • DEVELOPMENTAL assessment (emotional, mental, social)
  • LEAST INVASIVE to MOST INVASIVE
  • when examining ear, be gentle and quick to examine TM
  • temp >101.5 in and infant 2 months or younger=septic work up
  • beware of legal aspects of adolescent reprorductive care and resources for pregnant adolescents
68
Q

6th Vital Sign

A

functional assessment is unique to geriatric population

  • assess ADLS/mobility/safety
  • what holds them back from independence
  • are environmental modifications needed (ramp, shower chair)
69
Q

Amsler Grid

A

eye exam to test for macular degeneration

70
Q

Hearing Loss

A

impacted wax vs conductive/sensorineural hearing loss.

use Webber test for true conductive hearing loss if wax is ruled out

71
Q

Sports Physicals

A
  • comprehensive cardiac hx (exertional symptoms, heart murmur, Marfan Syndrome, family hx of premature or sudden death d/t cardiac condition)
  • EKG may not be beneficial unless an abnormal irregularity finding is present on exam.
72
Q

Marfan Syndrome

A

genetic disorder of the connective tissue that can cause heart problems

Advanced Health Assessment (5 decks)

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