HEALTH ASSESSMENT Flashcards
[1]
GENERAL SURVEY OF PHYSICAL ASSESSMENT
- Introduce self (0.5pt)
- Note orientation (person/place/time) (0.5pt)
- Observe for eye contact (0.5pt)
- Inspect personal hygiene (0.5pt)
____________________________
— “looks her chronologic stated age, demeanor is calm, well dressed/groomed for the weather, making eye contact.”
- “Patient is oriented to person, place and time”
- “Eye contact is present when speaking”
- “Patient has proper hygiene and wearing appropriate clothing for winter weather.”
[2]
SKIN, HAIR, AND NAILS ASSESSMENT
- Inspect skin color; check for bruising, lesions
- Palpate for edema, moisture, temperature, turgor
- Inspect nails for shape, contour, capillary refill
- Inspect hair for dryness, dandruff texture (thick or thin), even distribution
- Palpate scalp for lesions, tenderness
[2]
Findings for Skin, Hair and Nails Assessment
INSPECT
—“Skin appropriate for ethnicity, no erythema”
PALPATION
— “skin is warm, dry, elastic” (temp = back of hand; moisture = palm of hand)
— “no tenting with skin turgor check” (check on forearm)
— “nails are pink and translucent, clean, smooth, no cracks; profile is <180, no clubbing noted”
—“cap refill <2sec, brisk”
HAIR
— “hair is evenly distributed, no alopecia noted, lesions. No dry skin/dandruff, no tenderness noted.”
— “no pitting noted on pretibial area”
[3]
HEAD, FACE, NECK, LYMPH NODES ASSESSMENT
- Inspect face for symmetry, for expression (smile, frown, lift eyebrows, puff checks, note equal air dispersion
- Palpate temporal artery
- Plapate TMJ w/ opening and closing mouth (smooth movement, limited ROM, crepitation, tenderness)
- Test mastication muscles by clenching teeth (symmetrical strength, push down on chin)
- Inspect neck symmetry (midline?), [full] ROM, strength
- Palpate carotid pulse + listen with bell
- Palpate and identify neck are lymph nodes
[3]
Findings for HEAD, NECK, FACE, NECK, LYMPH NODES
Head
— “Head is erect. — “Head is normocephalic. No lesions or tenderness noted. Skull feels symmetric and smooth”
— “
Face
— “facial features appropriate size for head. No swelling noted. Able to raise eyebrows. Nasolabial folds symmetrical and in tact.
— “Palpebral fissures are symmetrical and align up with ears
— “Pulses present, regular rhythm in temporal arteries.”
— TMJ: “No clicking noted.”
Neck
— “Full ROM noted.” turn L/R, shrug shoulders up/down
— “Mastication: full ROM for mastication. No crepitus noted”
— “Neck, is midline. No involuntary movements noted”
— “Pulse present (carotid), no bruit noted.”
Lymph nodes
— Know all 10 — “No pain noted”
Name the TEN (10) lymph nodes that you must feel for?
- Preauricular
- Posterior auricular
- Occipital
- Submental
- Submandibular
- Jugulodigastric
- Superficial cervical
- Deep cervical chain
- Posterior cervical
- Supraclavicular
[4]
EYES ASSESSMENT
- Inspect pupils: measure resting pupil size and shape
- Inspect conjunctival (moist, pink), sclera (color-white, red, yellow)
- Inspect eyebrows, pale real fissures for symmetry, eyelashes evenly distributed, curved out
- Inspect corneal smoothness/opacitites
- Test peripheral vision by confrontation
- Test extraocular muscles: diagnostic positions test
- Test extraocular muscles: corneal light reflex
- Test pupillary light reflex (direct light reflex & consensual light reflex)
- Test accommodation for constriction and convergence *(PERRLA)**
[4]
Findings for EYE assessment
—Use penlight to shine on the side of eye
— Shine across the eyes to ensure pupils are brisk
Note: Range b/w 3-5mm
— Inspect anterior eyeball structure [look from side + shine light on side]
— “Anterior structure is flat w/ no opacity noted smooth, clear, translucent, color is even.”
— “Eyebrows and lashes present, curving upward.”
— “Palpebral fissures symmetrical. Eyes are aligned with ears. No swelling, draining, lesions, or redness noted.”
— “Eyeball and conjunctivae on lower lid looks moist and glossy. No color change or lesions noted. Lower lids are pink, sclera are white.”
— “Resting pupils sizes are 5mm and they are brisk on the R/L. No exothalamous noted.”
— Confrontation test [cover eye, cover same side then move top, bottom, side] — “Peripheral vision is in tact. I will repeat test on the other eye.”
— Diagnostic positions test [follow pen in middle focus w/ eyes] — “parallel tracking noted with no/slight nystagmus noted” (checking extraocular muscle)
— Corneal light reflex [looking for symmetry when shining in MIDDLE of eyes; muscle strength]— “corneal light reflex is in tact symmetrical, eye corneal noted”
— Pupillary light reflex [shine light in ONE eye + other will follow]— “Direct light and consensual light reflexes are in tact”
— Accommodation [focus far then focus near] — “Eyes will converge and pupils constrict OR pupillary constriction noted”
PERRLA — “Eyes are PERRLA: pupils are equal, round, reactive to light and accommodation.”
[5]
EARS ASSESSMENT
— Inspect ears for symmetrical size, swelling, alignment with eyes (1pt)
— Move pinna and push tragus for tenderness, firmness, palpate mastoid process (1pt) Inspect external ear for swelling, redness, discharge, foreign object (1pt)
— Test hearing: whispered voice test, 2 syllables (2pts)
Cone of light on ear: right = 5; left = 7
[5]
Findings for EARS assessment
— “Ears appropriate size for facial features, no redness, foreign objects, or discharge noted. Pinna is non tender, no pain with palpation. No pain, tenderness noted in tragus
– “No pain or tenderness on the mastoid process (bone behind ear) noted.”
— [will say 2 syllable word]: “Whisper test is in tact, and I would perform the same test on the opposite ear.”
[6]
NOSE ASSESSMENT
— Inspect external nose (midline, deformity, lesions, in proportion to facial features) (0.5pt)
— Palpate gently for pain (0.5pt)
— Inspect nasal mucosa with penlight for redness, smooth, swelling, discharge, bleeding, foreign object (1pt)
— Inspect septum for deviation or perforation (0.5pt) —
— Perform sniff test to check for nasal patency (0.5pt) — findings “Sounds are equal/no nasal obstruction noted”
[6]
Findings for nose assessment
Inspect
— “Nose is midline, symmetric, and in proportionate to facial features. No swelling, deformities/lesions noted.”
— “No pain or tenderness noted upon palpation of nose”
— “No perforation, bleeding, nor deviated septum noted.”
— “Nasal patency is in tact. Nasal mucosa is pink, smooth, moist, with no swelling, discharge, bleeding, no foreign objects with polyps and growths noted.”
— “Sounds are equal/no nasal obstruction noted when performing sniff test.”
[7]
MOUTH ASSESSMENT
— Inspect lips (color, moisture, cracking, lesions) (0.5pt)
— Inspect teeth (straight, abnormally positioned, loose, absent, evenly spaced, clean, patient’s bite for alignment) (0.5pt)
— Inspect gums (pink/discolored, swelling, retraction from teeth, bleeding) (1pt)
— Inspect tongue (pink, roughened papillae, moisture, white patches, lesions, protrudes midline without tremors or deviations) (1pt) Uvula rises midline when patient says “aah” (1pt) — “blood vessels present under tongue”
— Inspect buccal mucosa (pink, smooth, moist, lesions) (1pt)
— Observe clear distinct speech- have patient say “light, tight, dynamite” (1pt)
[7]
Findings for mouth assessment
— “Lips are present. There is no lesions noted on the lips. Nasolabial folds are symmetrical. NO cracks, lips are pink, no dryness noted.”
— [need tongue depressor] “Tongue is midline, no tremors, roughened papillae noted. Smooth, shiny, and BVs noted. Teeth is spaced evenly, no missing teeth, no under/overbite. No retraction to the gums or swelling. Buccal cavity in tact, no bite marks, drainage noted.”
— “Uvula = midline, and rises when saying, “ahh” Tonsils are 1+“ | “tonsils absent”
— “Speech is clear and distinct.”
[8]
THORAX + LUNGS ASSESSMENTS
— Inspect Posterior chest shape (elliptical/barrel), configuration
(AP: T=1:2) (1pt)
— Inspect symmetry and color (1pt)
— Palpate for lumps and tenderness (1pt) Palpate for tactile fremitus (1pt)
— Palpate the length of spinous processes (1pt);
— Percuss posterior lung fields (1pt)
— Auscultate and identify breath sounds
(T, B, BV, V) (resonance, clear and no adventitious sounds) (2pt)
— Test costovertebral angle tenderness-perform kidney punch (1pt)
— Inspect Anterior symmetry (1pt)
— Palpate lumps and tenderness (1pt)
— Palpate tactile fremitus (1pt)
— Percuss anterior lung fields (1pt)
— Auscultate and identify breath sounds (1pt)
[8]
Findings for Thorax + Lungs
—No stress when breathing noted, no barrel chest noted. AP:T 1:2.
— Chest expansion is symmetrical
Palpate
— no pain or tenderness noted
— tactile fremitus (4): equal vibrations noted
Percussion
— Equal resonance noted
Auscultation
—[11] Tracheal, Bronchial, B, BV, V, BV— “breath sounds are clear throughout for anterior”
—POSTERIOR—
—“Spinous process noted, midline”
—“Symmetrical chest expansion noted”
—“No pain or tenderness noted upon palpation.”
— “Equal vibration noted throughout”
— “Percussion, resonance is equal bilaterally”
— “Vesicular, vesicular, BV x8, V x6” – “Bilateral breath sounds are clear and equal.”
—Costovertebral tenderness Kidney punch— “no costovertebral pain or tenderness noted/negative.”
– Then I would perform the kidney punch on the other side.”
[9]
HEART + NECK ASSESSMENTS
— Inspect for jugular distention (0.5pt)
— Inspect precordium for any heaves, pulsations (turned to side and feel) (0.5pt)
— Palpate precordium for abnormal thrill, apical impulse (0.5pt)
— Auscultate apical rate and rhythm (0.5pt)
– Auscultate heart sounds with diaphragm, identify sounds heard (site, S1, S2, valve) (10pts)
— Palpate brachial (0.5pt), radial (0.5pt), ulnar (0.5pt) pulses, noting presence and amplitude
[9]
Findings for heart + neck assessment
— “Neck is midline, skin is appropriate for ethnicity, no swelling, lesions noted.”
— “Carotid medial to sternomastoid muscle in neck”— “No swelling noted. Skin is warm and dry.”
— “Checking for jugular vein distention [please lay down with HOB 30° and turn head to side, shine light]. It is full when laying down then flat with no JVD noted.”
— “Carotid artery is 2+, bounding upon palpating.”
— “No bruit noted upon auscultating neck in neutral position” (Make sure to have them hold their breath to avoid tracheal breath sounds)
— “No thrills, heaves, or lifts noted when inspecting the -precordium (non present) anterior apical impulse. No abnormal thrill noted[touch them].”
Heart sounds
— “2nd ICS, RSB — S2 is louder — aortic valve is closing”
— “2nd ICS, LSB — S2 is louder — pulmonic valve is closing”
— “3rd ICS, LSB — S1/S2 sounds are equal at the Erbs point”
— “4th ICS, LSB — S1 is louder — the tricuspid valve is closing”
— “5th ICS, MCL — S1 is louder — mitral valve is closing” “This is where I would find my apical for a full minute. It should be b/w 60-100bpm”
— “Brachial/Radial/Ulnar pulses all present, rhythms is regular rhythm, 2+, on both sides.
— Allen test: “hand is now white, let go of ulnar, the hand will pink up, collateral circulation is in tact, therefore Allen test is positive.”
[10]
ABDOMEN ASSESSMENT
— INSPECTION: contour (round/flat); “Skin appropriate for ethnicity. No lesions, no bruises, symmetry. Contour is round/flat.”
— AUSCULTATION: “bowels sounds heard and equal in all 4 quadrants”
– “I’m listening to the aorta, L renal, L illiac, femoral. No bruit noted in all 4 sounds [with bell].”
— PERCUSSION: “tympany present/noted in all 4 quadrants”
— PALPATION: light (1/2”) to deep (2-3”); “no pain or tenderness noted. No masses palpated.”
zig-zag pattern, begin at RLQ
_______________________________
“LOOK. LISTEN. FEEL (LIGHT TO DEEP).”
Inspect contour (flat, round, scaphoid, protuberant) (0.5pt)
Inspect symmetry, skin lesions, pulsations (0.5pt)
Inspect umbilicus (midline, clean) (1pt)
Auscultate bowel sounds (1pt)
Auscultate vascular sounds: aorta (0.5pt), renal (0.5pt), iliac (0.5pt), femoral (0.5pt) Percuss all quadrants for tympany (for tummy)(1pt) Palpate all quadrants lightly (half inch depth) (1pt), then deeply (2-3 inches deep) (1pt)
Palpate liver (1pt)
Palpate spleen (1pt)
[10]
Findings for ABDOMEN ASSESSMENT
— “Tone is even. Abdomen is rounded, no scarring (healed?) no masses noted, as symmetry noted, umbilicus is clean midline, no drainage noted.”
— “Starting from RLQ, I will listen in a zig-zag manner. Bowel sounds are present in all 4 quadrants.”
— Listen to vascular sounds (switch to bell). Aorta, no bruit, L renal R renal, L illiac, R iliac, R femoral, L femoral, no bruit noted.
— “Check pulse: femoral, popliteal, dorsal pedalis, posterior tibial. Regular rhythm, 2+”
— “ Starting at RLQ, I will percuss. Equal tympani noted in all 4 quadrants.”
— “Light palpation in 1/2’ (circular). No pain or tenderness noted.”
— “Deep 3-5”. No pain/tenderness noted.”
— “With my nondominant hand to displace liver, dominant on rib cage. No liver edges noted/palpable on fingers.”
— “No spleen palpated.”
[11]
PERIPHERAL VASCULAR SYSTEM ASSESSMENT
Inspect shoulders, elbows, wrists, hands for contour (0.5pt)
Palpate shoulders, elbows, wrists, and hands for spasm, swelling, heat, tenderness (0.5pt) Test ROM and muscle strength of shoulders, elbows, wrists, and hands (0.5pt)
Phalen’s test (0.5pt)
Tinel’s sign (0.5pt)
Modified Allen Test (0.5pt)
Inspect symmetry of legs, skin color, lesions, hair distribution (0.5pt)
Palpate for temperature of legs (0.5pt)
Palpate popliteal (0.5pt), dorsalis pedis (0.5pt), posterior tibial (0.5pt)
Test ROM and muscle strength of hips, knees, ankles, and feet (0.5pt)
[11]
Findings: Peripheral Vascular System Assessment
UPPERS
Checking joints and strength
— “Upon inspection, the shoulders aligned properly, no deformity, swelling noted.”
— “No pain/tenderness on shoulders upon palpaiting. Elbow, wrist (open/close). Elbow extension/flexion (non noted), supination/pronation.
— “Touch fingers with thumb. Open hand and make a fist, pronation, supinate hands…FULL ROM noted on hands, wrists, and elbows.”
— “Shoulder pain/injuries? Bring hand back, front, up, sides, rotate and bring it back, behind the head. FULL ROM noted on shoulders, elbows, wrists.”
— “Bring hands together to perform Phalen’s test. I would ask them to hold for 60 seconds. No pain/tenderness.”
— “Tinel test to tap on nerve. No carpel tunnel noted.”
LOWERS
– Modified Allen’s test: hold radial and ulnar, ask to pump fist, release ulnar, wait for pink to return. “+ for collateral circulation.”
— “Any surgeries on hips/knees? No. Extension/Flexion/External rotation, Internal rotation. No pain noted.”
—“Check for pretibial edema. Appropriate hair growth for legs”
—“Inversion/Eversion, dorsiflexion (up), plantar flexion (toes down); full ROM noted on ankle”
—“Abbduction/Adduction: no pain/tenderness noted with ROM.”
[12]
NEUROLOGIC ASSESSMENT
— Test finger to nose test (1pt), finger to finger test (1pt)
— Test rapid alternating movement test (1pt)
— Stereognosis (1pt)
— Graphesthesia (1pt)
[12]
Findings: Neurological Assessment
— “Finger-finger test to check your coordination. Do it faster. Nose to finger test is in tact.”
— “Close eyes, spread out arms, touch finger to nose as fast as you can. Coordinated movements are noted.”
— “Coordinated rapid hand movements noted [tapping on legs]”
— “Let me know what do you feel in your hand…Stereognosis is in tact”
— “I’m going to write a letter, let me know what you feel…Graphesthesia is in tact.”
— Graphesthesia [eyes closed] “I’m going to write a letter on the palm of your hand. Tell me what it is.”
— Stereognosis [recognize objects, eyes closed] “i”m going to place an object in your hand. Tell me what it is.”
“Graphesthesia + Stereognosis are present.”
[13]
MUSCULOSKELETAL ASSESSMENT
— Inspect posture (1pt)
— Test ROM of spine (bend sideways, twist shoulders to one side, then other side) (1pt)
— Gait: normal and tandem (1pt)
— Walk on heels, walk on toes (1pt)
— Romberg test (1pt)
Findings for Musculoskeletal Assessment [13]
— “Posture is erect.”
—“Twist shoulders without moving hips…no pain/tenderness noted…move sideways…no pain/tenderness noted.”
— “Full ROM of spine noted when bending sideways, twisting shoulders to one side then the other side.”
— “Gait and balance are steady. Arms swinging in opposite to steps.”
— “Toes planting to floor is plantar flexion” Plantar flexion
– “Walk in your heels.” Dorsiflexion noted
—Gait is steady, and arms are opposite to hand
—Able to maintain her balance with heel to toe
—Plantar flexion is in tact (walk on toes)
—Dorsiflexion is tact (walk on heels); (toes to the nose)
—“No swaying noted, balance in tact. Romberg test is negative.”
—“Spinous process is midline, not pain/tenderness noted
—“Touch your toes, no clicks or scoliosis noted.”
— “Coordinated, quick rhythmic pace noted”
— “Balance is noted, so negative Romberg test noted.”
Palpating Pattern for Posterior Thorax
Palpating Pattern for Anterior Thorax
Pattern for Palpating Tactile Fremitus
Percussion Pattern in Anterior Thorax
Percussion Pattern in Posterior Thorax
Auscultation Pattern in Posterior Thorax
Auscultation Pattern in Anterior Thorax
Percussion Pattern of Abdomen
PERCUSSION OF BREATH SOUNDS
