Exam 2 Flashcards
Health History Goals
- Gather info: provide subjective database
- Identify actual and potential health problems
- Identify teaching and referral needs
- Negotiate management
- Support emotional and spiritual needs
- Contract for: positive behavioral change, disease prevention
Traditional Health History
- Start with general survey
- Review chart/records
- Understand where things go in chart
- CC: chief complaint in patient’s own words
- HPC/HPI: history of present concern/illness
- PMH: past medical history
- FH: family history
- SH: social/lifestyle history
Importance of Genogram
- Useful if patient is concerned about genetic risk or interaction of genetic/environmental factors
- Helps patient/provider determine risk for developing a condition, understanding the reason for developing a condition, understanding if they will pass on the risk to children
- Contains 3 generations - gender, age, dates of death
- Only contains medical history
CN I
Olfactory
* test with familiar aromatic odors, one nare at a time with eyes closed
CN II
Optic
* Test distant and near vision
CN III
Oculomotor
* Allows EOM to move inward, lateral, upward
* Responsible for upper eyelid symmetry
CN IV
Trochlear
* Allows EOM to move eye inward and downward towards nose
CN VI
Abducens
* Allows EOM to move eye laterally to ear
* Inspect pupils’ size for equality and their direct and consensual response to light and accommodation (PERRLA)
CN V
Trigeminal
* Palpate jaw muscles for tone and strength when patient clenches teeth
CN VII
Facial
* Inspect symmetry of facial features with various expressions
* Smile, frown, puffed cheeks, wrinkles forehead
CN VIII
Acoustic
* Whisper neat patient’s ear and have them repeat
* If deafness suspected: use Rinne’s Test and Weber’s Test
* Test vestubular action: Romberg Test
CN IX and X
Glossopharyngeal and Vagus
* Test gag reflex and ability to swallow
* Inspect palate and uvula for symmetry and gag reflex
* If both are fully functioning - intact gag reflex
CN XI
Accessory Spinal Nerve
* Have patient shrug shoulders or turn head side to side for function
CN XII
Hypoglossal
* Have patient stick out tongue and assess for midline
External Ear Exam
Inspection
* Note level of the ears
* Inspect auricles and moce them around gently to assess tenderness
* Inspect auditory canal (cerumen, discharge, redness, tenderness)
Palpation
* Palpate mastoid process for tenderness or deformity
* Palpate tragus since tenderness can be sign of infection
Internal Ear Exam
- Hold otoscope so ulnar aspect of hand makes contact with patient
- Have patient tilt head slightly toward opposite shoulder
- Pull ear back and up fro adult, back and down for child
- Insert Otoscope under direct vision to point just beyonf protective hairs angled toward nose
- Use shortest and largest speculum that will fit comfortable
Ptosis
Drooping of upper eyelid
Exophthalmos
Bulging of eyes (indicative of Grave’s Disease)
Xanthelasma
Regular, slightly raised/yellow lesions
Suggests lipid disorder
Anisocoria
Unequal pupils
Presbiopia
Near focus ability more difficult
Hard to see small print clearly
Increases with age and need reader glasses
Strabismus
Cross-eyed
Mitosis
Pupils <2mm from opiates
Mydriasis
> 6mm from cocaine or THC
Snellen Chart
Record smallest print successfully read at 100%
* 20/40: what normal eye can read at 40ft, tested eye can read at 20ft
* 20/200 = legal blindness
Cataracts
Progressive clouding of the eye due to age
Glaucoma
Damage to ocular nerve, can be due to increased ocular pressure
Can cause vision loss, peripheral vision loss, and blindness
Macular Regeneration
Causes loss in center of field of vision
* Dry: center of retina deteriorates
* Wet: leaky blood vessels grow under retina
Retinal Detachment
Retina separates in back of eye
Lose vision, painless
Can be corrected with surgery
Tympanic Membrane Findings
Normally shiny, translucent, pearly gray
* Left ear: cone of light at 7
* Right Ear: cone of light at 5
* Fluid in ear can alter where cone of light goes - indicated infection
Normal Lymph Nodes
Movable, discrete, soft, non-tender
Abnormal Lymph Nodes
Large, tender
* Acute infection: enlarges, bilateral, tender, firm, freely movable
* Malignancy: hard, >3cm, unlateral, matted/fixed to structues
Assessing Lymph Nodes
- Gentle circular motion using finger pads
- Start with preauricular nodes
- Gentle pressure, use both hands to assess symmetrically except for submental gland under chin
- Deep cervical chain - have patient turn head towards examined side
Cardiac Physiology
4 chambers separated by valves to prevent backflow
* 2 AV: Tri and Mi
* 2 SL: P and A
* open and close passively
Landmarks for Auscultation
- Aortic: 2 ICS RSB / S2>S1
- Pulmonic: 2 ICS LSB / S2>S1
- Erb’s: 3 ICS LSB / S1 = S2
- Tricuspid: 4 ICS LSB / S1>S2
- Mitral (Apical): 5 ICS MCL / S1>S2
Inspection of CVS
- Look for scars, prior cardiac surgery, chest deficiencies (barrel/pigeon)
- Look for pulsations, lift/heave
- Apical Impulse: pulsation created at 5th ICS and left MCL as a result of L ventricle moving outward during systole
- Displacement of apical pulse to left = enlarged heart
- Lift/heave: pulsation that is not apical, considered abnormal, forceful thrusting as result of increased heart workload (ventricular hypertrophy)
Palpation of CVS
- Palpate carotid - note strength and compare with apical pulse
- Position patient supine with head of bed/table slightly elevated
- Use palm of hand, go from apex to LSB to base
- Thrill: palpable vibration; signifies turbulent blood flow - can help identify murmur location
Auscultaion of CVS
- Carotids with bell, listen for bruit - can be sign of atherosclerosis or TIA/ischemic stroke
- Asks patient to hold breath momentarily
- 3 positions: sitting up, lying on side (listen with bell), lying on back, head is raised 30-45 degrees
- Zig-zag pattern starting at base then going downwards
- S1: loudest at apex, S2: loudest as base
Cardiac Murmur Causes
Main sign of valvular heart disease
Causes
* High rate of blood flow through either normal or abnormal valve
* Valve opening problem - stenosis: valve tissues (leaflets) are stiffer/hardened which narrows the valve opening
* Closing - Insufficiency/Regurgitation: leaflets do not
close completely, blood flows backward, heart may enlarge to compensate and lose elasticity/efficiency, pooling can cause stroke or PE
Grading Murmurs I-VI
I: barely audible with stethoscope in quiet room
II: quiet but clearly audible with stethoscope
III: moderately loud like S1/2
IV: loud, associated with thrill
V: very loud, easily palpable
VI: extremely loud, audible with stethoscope not in contact with chest, thrill palpable and visable
Heart Murmur Descriptions
- disruption of blood flow through heart: blowing/swishing sound
- innocent murmur: healthy children and adolecents
- timimg: where in cardiac cycle
- loudness: intensity
- pitch: low, medium, high
- pattern: crescendo, decrescendo across cardiac cycle
- quality: blowing, musical, harsh, rumbling
- location: heard best
- radiation
S1 Heart Sound
- Closure of AV valves - signals beginning of systole
- Mitral component of first sound (M1) slightly precedes tricuspid (T1)
- Usually hear these two components fused as one sound
- Can hear S1 all over precordium, but loudest at apex
S2 Heart Sound
- Closure of semilunar valves - signals end of systole
- Aortic component of second sound (A2) slightly precedes pulmonic (P2)
- Although heard all over precordium, S2 loudest at base
ECG Reading
- Poor placement can result in misinterpretation
- Help diagnose heart arrhythmias and alert ST elevation
- Consider: warm/dry skin, extremity electrodes should point posteriorly
- Patient supine with HOB slightly raised
- Stay still, no shivering
Mental Status and LOC
- Change in MS or LOC = first clue to deteriorating condition
- First signs of neurological deterioration are subtle - can be best detected by family members & conversation w/ patient
- Consciousness is the degree of wakefulness or ability to arouse the patient. Not the same as orientation, a patient may be conscious but not oriented.
Motor Assessment Significance
- Note any voluntary/involuntary movement: tics/tremors
- Movements should be smooth and coordinated
- Coordination, fine motor skills, balance can only be performed when patient is awake & alert & can respond to verbal stimuli
Sensory Assessment Significance
- Majority of neuropathy issues begin distally (start assessing at the feet then move to the hands)
- Use safety pin to test superficial pain
Posturing
Associated with head trauma
* Decorticate Rigidity: rigid flexion, preserves brainstem function, arms like a C
* Decerebrate Rigidity: arms are pronated outwards, indicates brainstem damage, arms like an E
Deep Tendon Reflexes
- Testing for muscle contraction in response to direct/indirect percussion of a tendon
- Clonus: foot is dorsiflexed & taps multiple times (sign of neurological condition)
Cerebellar Assessment Significance
- Test coordination, fine motor skills, and balance
- Assess patient’s gait - should have smooth, rhythmic cadence with equal amount of time in swing/stance phase, opposite arm movements
Cerebellar Assessment
Balance
* Tandem: heel-toe walking
* Romberg test: feet together, eyes closed, look for swinging - lesion present, patient able to compensate by opening eyes
Coordination
* Rapid alternating movements
* Finger to nose to finger test - inability could indicate cere dysfunction
* Heel down shin - loss of coordination is abnormal
Gait Disturbances
* Could indicate spastic hemiparesis, cerebellar ataxia, parkinsonian gait
Glasgow Coma Scale
- Used to quantify LOC/Neurological impairment (usually for patients with trauma and other hypoxic effects)
- Based on: Eye opening, Motor Response, Verbal response
- Patient receives score for best response in each of these areas (score added together)
- Score range 3-15 = higher the better
- <8 indicates coma, lower scores indicate greater degree of damage
- Infants and children are slightly different
Nystagmus
Abnormal, involuntary, rapid eye movements
Strabismus
Involuntary drifting of one eye out of alignment with the other eye - lazy eye
Senile Letingines
Hyperpigmented macules of skin that occur in irregular shapes, appearing most commonly in the sun-exposed areas of the skin such as on the face and back of the hands
Bruit
The sound of blood flowing through a narrowed portion of an artery. The sound means that the blood flow may be partially blocked; artery blockage is most often due to atherosclerosis
Typically heard over the aorta, renal arteries, iliac arteries, and femoral arteries
Which respiratory sound indicates an upper airway obstruction?
Stridor: abnormal, high-pitched, musical breathing sound
