Exam 2 Flashcards
Components of health history
biographic data, reason for seeking care, presetn health, past health, family history, review of systems, functional assessment
Biographic data
name, age, birthdate, address, gender, race, occupation
reason for seeking care
one or two symptoms and the duration
present health
OLD CARTs
onset, location, duration, characteristics, aggrevating factors, releiving factors, time
past health
childhood illnesses, accidnts, chronic illness, hospitalizations, operations, immunization, last examination date, allergies
medication reconcilliation
current vs previous medications
family history
conditions for which the patient may be at an increased risk
review of systems
collection of subjective data of body systems, limited to patient statements
functional assessments
self care ability, alcohol, and tobacco use
Important subjective questions to ask for the ABDOMEN
appetite
dysphagia
food intolerance
pain
nausea/vomiting
bowel habits
medications
bowel habits
melena, hematochezia, past abdominal history including surgies
nutritional assessment
what have you eaten in the last 24 hours
physical assessment abdominal order
-inspection
-auscultation
-percussion
-palpation
Preparing pt for abd assessment
adequate lighting, empty bladder, lie supine wiht arms at side, small pillow under the knees, assess areas of pain last
Landmarks
umbilicus
RLQ pain
rebound tenderness with appendix
RUQ pain
liver should not be palpable before the liver
Abd inspection
overall demeanor
bulging/masses
skin
striae, moles, surgical scars
umbilicus
cullen’s sign
contour
symmertry
Cullen’s sign
bluish discoloration around umbilicus, symptom of intraperitoneal bleeding
Coutour
flat, scaphoid, rounded, protuberant
-stand on right side and look across the abdomen
-contour helps describe nutritional state
Symmertry
usually symmetrical, note any bulding, masses, or asymmetry
Asucultation
bowel sounds, borborgymi, hyperactive, vascular sounds
-warm stethescope
-record character and frequency
-norma, hypoactive, hyperactive
absent if not sounds in 2 minutes
Bowel sound auscultation order
start at RLQ move to RUQ to LUQ to LLQ
Vascular sounds
bruit, hypoactive, hyperactive
Bruit
over aorta, renal arteries, iliac arteries, femoral arteries, splenic arteries
-abnormal swishing and rushing
-use the bell
Hypoactive
diminished or absent bowel sounds signals decreased motility
occurs in: peritonitis, paralytic ileus from abdominal surgery, late bowel obstruction, pnemonia
Hyperactive
loud gurgling sounds “borborygmi” hunger sounds
singals IN motility
Occurs in: early bowel obstruction, gastroenteritis, brisk diarrhea, laxative use, subsiding paralytic ileus
What bowel sounds do you listen for in the diaphram
hypo and hyperactive bowel sounds
Percussion
tympany
dullness over soild organs
-move clockwise around stomach
-generalized tympany: air in intestines, rises when supine
-hyperresonace
-CVA tenderness
hyperresonance
IN air or gas
CVA tenderness
indirect percussion at 12th rib, pain show renal inflammation
Where to palpate for liver
under pts right rib cage and lift to support abd
-under right costal margin
-client exhale, move fingers up 1-2 cm
-liver edge feels like firm ridge with smooth surface
RLQ
cecum, appendix (mcburney’s point, rovsings sign, psoas sign, obturator sign), ileum, ascending colon, right ovary, right uterine tube, right spermatic cord, uterus if enlarged, bladder
RUP
liver, gallbladder, stomach, duedenum, pancrease, right suprarenal gland, right kidney, ascending colon, transverse colon
LUP
liver left lobe, spleen, stomach, jejunum/ilum, pancreas, left kidney, left suprarenal gland, left colic flexure, transverse colon, descending colon
LLP
signmoid colon, descending colon, left ovary, left uterine tube, left ureter, left permatic cord, uteus, bladder
Ascites
abd fluid build up
-fluid waves
-shifitng dullness
Fluid waves
-stand of right side of pt
- place pt own hand firmly on the midline
-place left hand on pts right flank
- reach across the abdomen
- give the left flank a firm shake
Positive: blow generates a fluid wave and feel tap or virbation on the RIGHT side
Shifting dullness
percuss flank to midline, note changes from tympany to dull, fluid settles in flank when ascites pt is supine
-pt turn to side and percuss
-note change from where tympany to dullness occurs
Newborns abd
-umbilical cord shows on abd, contains 2 arteries and 1 vein
-liver takes up more space than later in life
-orangs are easier to palpate
-abdomen is protuberant
-umbilical stump dries within one week: hardens, falls off by 10-14 days, skin overs area by 3-4 weeks
Umbilical hernia
-abd shows respriatory movement
umbilical hernia
appears at 2-3 weeks and especially prominent when infant cries, disappears by 1 year. Normal, should not continue to get bigger
Abd Infants
-ascultation: only bowel sounds, metallic tinkling of peristalsis
-percussion: same as adults
-palpation: liver, spleen, bladder normal to palpate
-note newborn’s first meconium stool
-under 4 years old protuberant abd is normal
-liver is easily palpable
Abd aging
-easier to feel organs
-abd wall msuculature relaxes
-DE salivation
-esophagela emptying and gastric acid secretion are delayed
-IN gallstones
-Liver size DE, fxn remains (drug metabolism DE)
- report constipation
-Inspection: IN fat, muscles thinner, organs easier to palpate
- Distened lungs are dpressed diaphragm, liver can be palpated lower
Constipation causes
DE physical activity, DE water, low fiber diet, side effects of medications
-bristol stool chart to measure consistency
Nutrtional status
the degree of balance between nutrient intake and nutrient requriements
optimal nutrtional status
acheived when suffiencet nutrients are consumed to support day to day body needs and increased metabolic demand d/t growth, pregnancy, illness
under nutrtional status
occurws when nutrtional reserves are depleted or when nutrient intake is inadequate to meet day to day needs to added metabolic demanedsds
over nutrtional status
caused by consumption of nutrients, too many calories, sodium, fat in excess of body needs
nutrtion screening
quick 1st step method to obtain data, weight/weight history, conditions associated with increased nutrtional risk, diet information, and routine lab data
comprehensive nutrtional assessment
individuals identified at nutrtional risk during screening should undergo, includes health history, physical exam, lab tests
Metabolic syndrome
3-5 biomarkers
waist cirumference
glucose level
high densitiy lipoprotein
triglyceride level
hypertension
Inguinal area
iliac crest area, hypogastric section, location of hernias
perineum
patch of sensitive skin around genitals
polyuria
over production of urine
oliguria
low production of urine
dysuria
painful urination
hydrocele
fluid build up in scrotum
hernia
buldge or lump when organ pushes through tissue
hypospadias
abnormally low urethra opening on penis
epispadias
urethra does not fully develop correctly, urine comes out an abnormal place
phimosis
difficult to retract penis foreskin
paraphimosis
foreskin becomes trapped under corona
cremasteric reflex
contraction that elevates the testicles
cryptorchidism
one or both testicles don’t descend to scrotum
encopresis
toilet trained child has trouble passing bowel movements in inappropriate places
dyschezia
difficulty passing stool
prostate
gland of the male reproductive system
benign prostatic hypertrophy
prostate larger than norma, can cause blockages in urinary tract
lithotomy
postion to expose perineum
menstrual history
hisotyr of woman’s periods
dysmenorrhea
pain ni menstruation
amenorrhea
absence of periods
menopause
stopping of periods
GU questions to ask about health history
pain with urination?
what color is your urine?
what color are your bowel movements?
how often do you have a bowel movement?
what are currently in a relationship involving sexual intercourse?
what is your sexual preference?
ask first about menstruation history, then urination
general GU subjective
skin changes
urination
sexual practices
bowel changes
self care behavoirs
subjective male GU
penile issues: pain, lesions, discharge
scrotum issues
sexual behavoirs
red flags
circumcisions
elective surgical procedure to remove part of all the foreskin
-give unbiased education with rsks and benefits
-Benefits: reduced UTIs, cancer, HV, reduce STDs for women
Risks: minor and treatable, pain, bleeding, swelling
subjective female GU
menstrual history
obestetic history
menopause
self care
vaginal discharge
past history
contraceptive use
Observe GU
catheter, ileal condiut, nephrostomy tubes, suprapubic catheter, condom catheter
color, presence, nature of odor, vl of urine
irritation? skin integrity, ooze?
STI lesions
Palpate GU
subrapubic abdomen to assess for pain, possible urinary retention
Physical exam male
inspection, palpation, penis, hernia, urine assessment
inspection and palpation
penis, scrotum, hernias, lymph nodes
hair distribution
lesions or redness
penis
discharge or tenderness
foreskin: philmoisis, paraphimosis
scrotum
testes
epiddymis
phimosis
narrow opening
cannot retract foreskin
paraphimosis
foreskin is retracted and cannot return to normal position
scrotum
have pt hold penis to the side, use back of hand
-spread rugae
-life sac, inspect for symmertry and size
-asymmetircal is normal
testes
oval, firm, smooth
abnormal: hard, bumpy, pain
epeiddymis
non tender
hernia
bear down
inguinal and femoral cannula
normal= no buldge
abnormal = buldge
urine assessment
abnormalies, color, character, ph, specific gravity, glucose, ketones, proteins, bilirubin, blood, nitrates, leukocytes, bacteria
physical GU exam female
exam positioning
inspect/palpate
normal skin findings
exam positioning
supine or modifed lithomy
inspect/palpate female Gu
external: color, edema, lesions, tenderness, discharge, inflammation, SMR
itneral: cervis and vaginal wall
palpate internal: uterus and ovaries, rectovaginal exam
colecrectal cacner
colonscopy 5-75 ya
annual fecal occult blood testing
prostate cancer
physical exam with DRE
PSA- prostate specfic antigen blood test
testicular cancer
no routine screening
ovarina cancer
yearly pelvic exam, no screening tools, routine screening not recommended
cervical cancer
pap, HPV cotesting and pelvic exam
meconium stool
first stool of a newborn
male position for GU exam
standing
female position for GU exam
external gentialia: supine or modifeid lithotomy
interal vaginal exam: lithotomy, HOB 45 degrees, feet in stirrups, knees apart, butt to edge of table
modified lithotomy if needed and can’t have head up
rectal: thotomy or left lateral
Cardiac assessment landmarks
-clavicle
-intercostal space
-ribs
-sternum
Subjuective cardiac questions
chest pain?
flutter?
nutrtion?
alcohol use?
smoking?
Apical impulse
left ventricle rotation
-4th/5th intercostal space
MCL line
ask pt to exhale and hold
point of max impulse
how is blood flow?
Z pattern
aortic area
pulmonic area
erbs point
tricuspid area
mitral area
aortic area
second right intercostal space
-oxygen rish blood passes through before exiting the heart and coursing through the rest of the body
-valve prevents blood from flowing back to the left ventricle
- S1 < S2 (S1 quieter)
pulmonic area
second left intercostal space
-pulmonic vlave has deoxygenated blood that flow through it . Closes off the right ventricle and opens to allow the blood to flow to the lungs
-S1<S2
Erb’s point
third left intercostal space
-not truly a heart sound because not reflective of a specific valve closure
S1 =S2
Triscuspid area
fourth intercostal space
left lower sternal border
-named because of its 3 flaps called cusps, blood flow through this valve after leaving the righ atrium
S1 >S2
mitral
fifth left intercostal space on the midclavicular line
-closes off the left atrium, allowing oxygenated blood form the lungs to flow through to the left ventricle
-S1>S2
Carotid artery
palpate and ausculate- only one side at a time because both can cause dizziness
-listen for bruit with bell side
-keep neck neutral, listen with bell
- angle jaw, mid cervical area, base of the neck
S1
lub
apex
low
systolic
S2
dub
base
high
diastole
murmurs
timing, loudness, pitch, pattern, quality, location, radiation, posutre, variation, innoncent, function
timing murmur
systolic or diastolic
distole always indicates heart disease
loudness
grades
pitch
high
medium
low
pattern
crescendo
decrescendo
quality
blowing
harsh
rumbling
loction
where is ti best heard at
radiation
heard in neck, back, axilla
variation
with respiratory phase
innocent murmur
no vavlular defect, crescendo-decrescendo, healthy childern normally have IN BF
function murmur
caused by IN BF to heart with fever, pregnancy, or anemia,
normal variation
murmur grade 1
barely audible
heard only in a quiet room and then with difficulty
murmur grade 2
clearly audible
but faint
murmur grade 3
moderatly loud
easy to hear
murmur grade 4
associated with a thrill palpable on chest wall
murmur grade 5
very loud
heard with 1 corner of stethescope lifted off chest wall
thrill
murmur grade 6
loudest
still heard with entire stethoscope lifted just of chest wall, thrill
cardiac inspection
apical impulse, pulsations
-jugular venous pulsations? heave or lift? color?
cardiac palpate
apical impulse- left ventricle rotation
ausculation cardiac
APE To Man
rate and rhtym
S1 and S2
pericardium
membrane enclosing the heart
mediastinum
chest pocket that contains the heart
systel
heart cotracts
diastole
heart relaxes
murmurs
extra sound between heart beats
preload
how much the heart ventricles stretch to contain blood
afterload
pressure the heart has to overcome to pump blood
angina
symptom of reduced blood flow that can manifest as chest pain, pressure, or discomfort
pulse deficit
difference between heart rate and pulse rate
heart sounds
created by blood flwoing through heart chambers and ventricles closing a nd opening
aortic valve
left ventricle to the aorta
aortic area is where sound is heard
S1 quiet S2 heard
pulmonic valve
heart to lungs
S1 quiet
S2 heard
pulmonic area
tricuspid valve
right atrium to right ventricle
S1 louder than S2
tricuspid area
mitral valve
left atrium to left ventricle
mitral area
S1 >s2
jugular vein assessment
pulsations? visible?
central venous pressure
blood pressure in the vena cava
Aortic stenosis
aortic valve narrows and doesn’t let enough blood flow through
aortic regurg
aortic valve doesn’t close properly
Cardiac emergent signs
6/6 murmur, fhx hypertension, new hypertension, irregular heart rate, tachycardia during rest, bradycardia, chest pain, jugular vein distention, cyanosis, fatigue, SOB, cough, orthopnea
venous assessmetn
-carries blood back to the heart
-low pressure system
-erythema
-DVT: swelling, redness, warmth
- Edema
- Warming
- Ulcers
Arterial assessment
-carry blood away from the heart
-high pressure system
-cyanosis, pallor, cold
- numb
- weak pulses or no pedal pulses
- cold
- ulvers- pain
cardiac risk factors
lifestyle, smoking, diet, alcohol use, exercise patterns, and stress have an inflence on coronary artery disease
Cardiac critical characteristics
past medical history
ROS
fhx
functional history
subjective data
- arm or leg pain
- skin changes
- swelling
arm or leg pain questions
-describe pain
-aggravated by activity or walking
- how many blocks does it take to produce this pain
- is pain worse with elevation or cool temperature
- does pain wake you up at night
- SOB
- changes in exercises
- what relieves pain
history?
venous put legs up
better
arteriol put legs up
worse
skin changes questions
-any skin changes in arms or legs? redness, pallor, blueness, brown?
- any change in temperature?
- do your leg veins look bulding and crooked?
- use support hose?
- leg sores or ulcers?
swelling cardiac questions
-swelling bilatera
-start
time of day it is worse?
- what brings it out
-what releives it
- pain, heat, ulceration, hardned skin
-swollwen lymph nodes
Cardiac pregnancy changes
- BV IN by 30-40% during pregnancy
- functional murmur
- IN CO, arterial BP DE d/t peripheral vasodilation
- vital signs IN in resting pulse rate of 10-15 bpm and drop BP from normal level
- apical pulse: moves higher
- mammary souffle: muffle during lactation
aging adult cardiac considerations
-closely interrealted with lifestyle, habits, and disease
-gradual rise in systolic blood pressure
-orthostatic hypotension
-left ventricular wall thickness increase
- presence of supraventricular and ventricular dysrhythmias increases with age
-age releated ECG changes occur due to histologic changes in teh conduction system and dysrhtmias
Lung landmarks
-supraclavicular fossa
-clavicle
-intraclaviular fossa
-xiphoid process
-subrasternal notch
-sternal angle
-anterior axillary line
-mediastinum
-pleural cavities
apex of lung
highest lung tissue
3-4 cm above clavicles
base of lung
lowest border of lung tissue
rest of diaphragm
lobes and fissures
anterior chest
fissures
posterior chest
lateral chest wall
anterior chest
mostly upper and middle lob with very little lower lobe
fissures
oblique (major or diagnoal), horizontal (minor fissure)
posterior chest
contains all lower lobes
lateral chest wall
right and left lateral
inspection lungs
postion to breath, clubbing, cyanosis or pallor, pursing lips, flaring nostrils, retractions, shape of chest wall, rate and rhytm
shape of chest wall
anterioir/postior length (AP)
transverse should be greater than width (otherwise barrel chest)
1:2
rate and rhtym concerning signs
cyanosis, pallor, tripod position, use of accessory muscles, nasal flaring
palpatation
symmetric chest expansion
hands should move up and down on posterior as patient inhales and exhales
tactile fremitus
IN fremitus- consolidation of lung tissue, pnemonia (will IN vibration if consolidated pnemonia), say 99 or blue moon and feel for pt vibration
Tactile fremtitus DE
thick barrier, obstructed bronchus, pleural effusion, or thickening
check for temperature, tenderness, lumps, masses, and skin
lungs percussion
hyperresonance
resonance
dullness
flatness
lungs auscultation
vesiculr, bronchovesicular, bronchial, tracheal
vesicular
2 seconds in, 1 seconds out
-inspriatory
-soft
- low pitch
- heard over most of the lungs
bronchovesicular
inpriatory and expriatroy sounds are equal, intermediate sound and pitch, head in teh 1/2 interspcaes anterioirly and between the scapulae
bronchial
expiratory sounds lasts longer than inspiratory ones, loud sound, high pitch, heard over the manubrium
tracheal
inspiratory and expiratory sounds are about equal, expiratory sound very loud, pitch is relatively high, heard over the trachea in the neck
voice sounds
egophony, bronchophony, whispered pectoriloquy
normal lung sounds
soft, muffled, and indistinct
bronchophy
pt says 99
abnormal is more clear than normal
egophony
EE
whispered pectoriloquy
1-2-3
abnormal sounds
wheesing, crackles, rhonci, friction rub, stridor
crackles
discontious popping heard over inspiration
-fine: stand of hair between fingers near your ear
-Coarse: sounds like velcro
rhonchi
low pitch snore
wheeze
high pitch musical sound or wheeze
-asthma
stridor
sounds like a crowing sound
-anaphylaxis
pleural friction rubt
sounds like leather rubbing together, caused by inflammed, roughed surfaces rubbing together
what parts of the exam are simultaneous
assessment and diagnosis
step 1
introduction
door, introduce yourself, hand hygiene, provide privacy, verify name/dob/allergies, provide reason you are examining the pt and brief plan of care
step 2
general survery and measurements
-snellen eye exam
-screenings
step 3
VS, pain, AOx4, temperature, radial pulse, respriatrions, blood pressure, pulse ox, pain, orientation
step 4
head to toe, head/trunk/extremities, skin, head, PERRLA, facial movements
step 5
lungs, cardiac, abdomen, options
