Advanced Health Assessment Final

BMI Classifications

Underweight: <18.5
Normal: 18.5-24.9
Overweight: 25.0-29.9
Obesity class
� I: 30.0-34.9
� II: 35.0-39.9
� III: at or over 40

How do you calculate BMI?

Stages of HTN

Normal: under 120/80
Prehypertension: 120-139/80-89
Stage 1: 140-159/90-99
Stage 2: over 160/100
If diabetes or renal disease: goal is under 130/80

Waist Circumference

Risk if over 35in for women
Risk if over 40in for men

Cranial Nerves

1. Olfactory: Sensory
2. Optic: Sensory
3. Occulomotor: Motor
4. Trochlear: Motor
5. Trigeminal: Both
6. Abducens: Motor
7. Facial: Both
8. Acoustic: Sensory
9. Glossopharyngeal: Both
10. Vagus: Both
11. Spinal Accessory: Motor
12. Hypoglossal: Motor

Romberg Test

Stand with hands to the sides and eyes closed, observe swaying

Pronator Drift

Stand with arms out, eyes closed, and hands supine -- watch for hands pronating.

Graphesthesia

The inability to recognize numbers written on the hand. Suggests a lesion in the sensory cortex.

Astereognosis:

Inability to recognize objects placed in the hand

Kernig

Flex patient's leg at hip and knee, then straighten the knee. Discomfort behind the knee during full extension should not cause pain.

Brudzinski

Pt supine, your hands behind pt's head and flex the neck forward, until chin touches the chest if possible. Neck stiffness with resistance and flexion of hips and knees is a positive sign. May be a sign of acute bacterial meningitis or subarachnoid hemorrhage

Straight Leg Raising

Lift the straight leg, if pt has low back pain with nerve pain that radiates down the leg = sciatica from compression of the spinal nerve root as it passes through the vertebral foramen

Plantar (Babinski) Reflex

Dorsiflexion of the big toe is a positive Babinski response from a CNS lesion in the corticospinal tract

Finkelstein Test

Pt grabs thumb with hand and you pull down to see if there is tendon tenderness - if positive, might mean tendonitis

Tinel's Sign

Tap on the Median Nerve

Phalen's Test

Bend wrists at 90 degrees and put back of hands against each other for 1 minute and see if there is numbness/tingling

Ballotment

Leg extended, compress the suprapatellar pouch and then push the patella sharply against the femur, watching for fluid returning to the pouch

Bulge Sign

Knee extended, hand on knee above the patella and milk downward. Apply medial pressure and tap laterally. Watch for a fluid wave

Drawer Sign

Pt supine with knee flexed, your thumbs at the medial/lateral joint line and fingers wrapped around. Then sharply push/pull, watching for laxity

McMurray Test

Pt supine with knee flexed, one hand medial knee and the other medial ankle. Extend the leg and laterally rotate, watching for clicking

Directions for Self-Breast Exam

5-7 days after period OR same time every month for menopausal women. Lawn Mower pattern

What Abdominal locations do you listen for bruits with the Bell of the stethoscope?

Aoritc, Illiac, Femoral

What Abdominal locations do you listen for bruits with the diaphragm of the stethoscope?

Epigastric and Renal

Murphey's Sign

Assessing gallbladder, pt will stop breathing d/t pain when pushing up on the liver if positive.

Rovsing's Sign

Pressure on LLQ causes referred pain in RLQ

Rebound Tenderness

Pain in RLQ increases when pressure is released quickly

Psoas Sign

Place hand just above right knee and ask pt to raise that thigh against your hand and turn onto the left side. then extend the right leg at the hip.Flexion of th leg at the hip makes the psoas muscle contract; extension stretches it. Increased abd pain with either maneuver constitutes a positive sign

Obturator Sign

Flex pt's right thigh at the hip, with knee bent, and rotate the leg internally at the hip. It stretches the internal obturator muscle. Right hypogastric pain = positive sign

Normal size of aorta

under 3 cm

Spleen percussion/palpation

Normally the lowest interspace in the left anterior axillary line is tympanitic. After a deep breath, if percussion changes from tympanitic, enlargement is suspected and you'll need to palpate the spleen, but be careful not to cause rupture

Feeling the liver edge

Normally feels smooth, soft, sharp, and regular. Normally about 3 cm below the right costal margin in the midclavicular line

Grading of Heart Murmurs

�Grade I -barely audible
�Grade 2-clearly audible but faint
�Grade 3-moderately loud, easy to hear
�Grade 4- Loud, associated with thrill
�Grade 5- Very loud- partly off chest
�Grade 6- Loudest can be heard with stethoscope lifted off chest

S3

low frequency heard best at the apex, use bell and lay on the left side. Ventricular gallop - means that ventricular compliance is low. Heard at the beginning of diastole. Blood flowing into overfilled non-compliant left ventricle rapidly decelerates. Sound of it "popping" open quickly. Ken-tuc-ky

S4

low frequency, heart best at the apex, use bell and lay on left side. Atrial gallop, pericardial friction rub. Heard at the end of diastole. Atrial contraction trying to push blood to the ventricle, but it is stiff. Ten-ness-ee.

Murmurs

Caused by a flow of blood across a partial obstruction (valve stenosis) or valve irregularity (leaks...) or increased flow through normal structures (pregnancy and anemia), flow into a dilated chamber (aneurysm), backward flow, shunting of blood out of a high pressure area through a hole

Heart conditions that accompany systolic murmurs

�Aortic Stenosis: pressure or gradient that the blood has to flow through due to a smaller valve. Increased pumping pressure of Left ventricle
�Pulmonary Stenosis: same as above, heard with diaphragm at 2nd and 3rd intercostal space, medium or rough quality, radiates to left shoulder and neck
�Tricuspid Insufficiency: supposed to be closed during systole, so causes a backward flow of blood. Diaphragm at 5th intercostal space at the sternal border, radiates to left anterior sternal line
�Mitral Insufficiency: loudest at the apex, 5th intercostal space, high pitched and blowing quality

Heart conditions that accompany Diastolic murmurs

�Aortic Insufficiency: most common, Marfan syndrome, retrograde blood flow into left ventricle. Diaphragm at 2nd and 4th intercostal along sternal border, sit up and lean forward and hold breath
�Pulmonary Insufficiency: high pitched, diaphragm, 2nd or 3rd intercostal, enhanced during inspiration.
�Mitral Stenosis: most common, bell at 5th intercostal, low pitched rumbling, left lateral position
�Tricuspid Stenosis: forward blood flow from right atrium though stenosed tricuspid valve, bell at 4th intercostal along sternal border.

Allen Test

Occlude radial and ulnar arteries and then release one and visualize blood return

Presbycusis

Hearing loss associated with age

Sarcopenia

loss of lean body mass and strength with aging

Axillary Lymph Nodes

Lateral
Pectoral (Anterior)
Subscapular (Posterior)
Supraclavicular
Infraclavicular

Self Breast Exam Instructions

5-7 days after period for women still menstruating or can choose a time of month if menopausal.

Vaginal Speculum Exam

lubricate with water so that sample is not contaminated, insert two fingers first and then speculum vertically, putting pressure on the posterior vaginal wall

Obtaining Vaginal Specimens

Pap Smear: Rotate 5X and obtain sample before any other test samples
Then any swabs for infection

Skene's Glands

Near urethra- can milk to see if there is discharge.

Bartholin's Glands

5 and 7

Do you listen for Epigastric and Renal Bruits with the bell or the diaphragm?

Diaphragm

Do you listen for aortic, illiac, and femoral bruits?

Bell

Shifting Dullness

Shifting Dullness: Indicates ascites - fluid shifts dependently when the patient lies supine vs laying on the side. Percuss to determine or look for fluid wave

Do you listen for carotid Bruits with the bell or the diaphragm?

Both

Cardiac Landmarks

Epitrochlear Nodes

Inguinal Nodes

Ankle-Brachial Index

Arterial Vs. Venous

Cervical Lymph Nodes

Pre-auricular
Post-auricular
Tonsillar
Occipital
Submental
Submandibular
Posterior cervical
Superficial cervical
Deep cervical chain
Supraclavicular

Retinal Structures

Macula/Fovea
Optic Disc
Red Reflex
Vessels

Convergence

Eye converge symmetrically at the nose

Accommodation

Look far away and then close up, pupils will constric

Direct light reflex

Light goes into the eye and that eye's pupil constricts

Corneal Light reflex

Light shone from the side, and watch for shadowing on the iris - shadowing might mean lesions

Consensual light reflex

Light goes into one eye and the opposite eye's pupil constrict

Weber Test

Place base of tuning fork on top of the head and see if the patient hears it equally in both ears. If not, this is considered conductive hearing loss and they will hear the sound in the impaired ear.

Rinne Test

Base of the tuning fork is placed on the mastoid bone, count how long they hear it. Then move it in front of the ear and count how long they hear that. Normally the sound is heard longer through air than through bone. In conductive hearing loss, sound is heard through bone as long as or longer than it is through air (BC>AC). In sensorineural hearing loss, sound is heard longer through air (AC>BC).

Tonsil Grades

Parotid Glands- Stenson's Duct

Side of cheek

Submaxillary- Wharton's duct

Under the tongue

Diaphragmatic excursion

percuss after breathing in and holding it, then same for breathing out and holding it - then look at the distance between the two. Normal is 3-5.5cm

Dullness on respiratory percussion

fluid or solid tissue replaces air containing lung or occupies the pleural space beneath your fingers

Generalized hyperresonance on respiratory percussion

hyperinflated lungs of COPD or asthma

Vesicular Sounds

soft, low pitched. Heard through inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration

Bronchovesicular Sounds

with inspiratory and expiratory sounds about equal in length, at times separated by a silent interval. Detecting differences in pitch and intensity is often easier during expiration.

Bronchial Sounds

louder, harsher, and higher in pitch, with a short silence between inspiratory and expiratory sounds. Expiratory sounds last longer than inspiratory sounds..

Egophony

ee" sounds like "A". This sound is present with consolidation/pneumonia

Bronchophony

ninety-Nine" - if louder than normal

Whispered pectoriloquy

whisper "ninety-nine" or "one-two-three" and if louder, clearer whispered sounds, then whispered pectoriloquy

Light palpation

use one hand and press 1cm - think kneading dough

Deep palpation

use two hands and press 2-3cm

Methods for assessing cognitive functioning

�A&O: person, time, place
�Remote, immediate, and recent memory
�Cognitive function: tell me what a proverb means, "if you found an envelope on the ground, what would you do", calculations

ABCDE of skin assessment

�A: Asymmetry
�B: Irregular Borders
�C: changes in color
�D: Diameter over 1/4in or 6mm
�E: evolving/changing

How do you interpret a Snellen Chart?

Vision of 20/200 means that at 20 ft the pt can read print that a person with normal vision could read at 200ft. The larger the second number, the worse the vision.

Exopthalamus

protrusion of the eyeball, a common feature of Graves', triggered by autoreactive T lymphocytes.

Xanthelasma

slightly raised, yellowish, well-circumscibed plaques that appear along the nasal portions of one or both eyelids. May accompany lipid disorders

Lid Lag

the eyelid should follow the eye if it moves down, almost always covering a little bit of the iris.

Perforated ear drum

-Central perforation: don't extend to the margin of the drum
-Marginal perforations: involve the margin
-Reddened internal ear, might have drainage, no cone of light

Serous effusion of the ear

-Usually caused by viral URI or by sudden changes in atmospheric pressure as from flying or diving. Eustachian tube can't equalize the air pressure in middle ear and outside air. Air absorbed from middle ear into the bloodstream, and serous fluid accumulated there instead.
-Symptoms: fullness and popping sensation in the ear, mild conduction hearing loss, ,and sometimes pain
-Amber fluid behind the eardrum. Air bubbles can be seen, but not always

Acute otitis media with purulent effusion-ear

-Commonly caused by bacterial infection with S. penumoniae and H. influenza
-s/s: earache, fever, hearing loss. Eardrum reddens, loses its landmarks, and bulges laterally toward the examiner
-hearing loss is conductive

Bullous Myringitis

-Painful hemorrhagic vesicles appear on TM or ear canal or both
-s/s earache, blood-tinged discharge from the ear and conductive hearing loss
-caused by mycoplasma, viral, or bacterial otitis media

Torus Palatinus

Midline bony growth in hard palate that is fairly common in adults. Size and lobulation vary. Harmless

Kaposi's sarcoma in AIDs

Deep purple lesions. A low grade vascular tumor associated with human herpesvirus 8. Lesions may be raised or flat. Antiretroviral therapy can reduce prevalence

Thrush on the palate

Yeast infection. Thick, white plaques are somewhat adherent to underlying mucosa. Predisposing factors: prolonged Tx with antibiotics or corticosteroids and AIDS

Diptheria

-Acute infection caused by Corynebacterium diptheriae; rare
-Throat is dull red and grey exudate is present on uvula, pharynx, and tongue. Airway may become obstructed.

Pharyngitis

-Redness and vascularity of pillars and uvula
-s/s sore, scratchy throat - no fever, exudate or enlargement of cervical lymph nodes
-causes: viral and bacterial

Exudative tonsillitis

-Red throat with white exudate on tonsils
-Fever, enlarged cervical nodes = Group A strep or mono

Nummular Lesions

Round (coin-shaped) lesions. Also known as discoid.

Linear Lesions

A linear shape to a lesion often occurs for some external reason such as scratching. Also striate.

Target Lesion

Concentric rings like a dartboard. Also known as iris lesion

Gyrate Rash

A rash that appears to be whirling in a circle.

Annular Lesions

Lesions grouped in a circle

Lichenification

Lichenification is caused by chronic rubbing, which results in palpably thickened skin with increased skin markings and lichenoid scale. It occurs in chronic atopic eczema and lichen simplex.

Crusting

Crust occurs when plasma exudes through an eroded epidermis. It is rough on the surface and is yellow or brown in color. Bloody crust appears red, purple or black.

Excoriation

An excoriation is a scratch mark. It may be linear or a picked scratch (prurigo). Excoriations may occur in the absence of a primary dermatosis.

Erosion

Erosion is caused by loss of the surface of a skin lesion; it is a shallow moist or crusted lesion.

Fissure

A fissure is a thin crack within epidermis or epithelium, and is due to excessive dryness.

Ulcer

An ulcer is full thickness loss of epidermis or epithelium. It may be covered with a dark-coloured crust called an eschar

Hypertrophy

Some component of the skin such as a scar is enlarged or has grown excessively. The opposite is atrophy or thinned skin.

Percussion Sounds for Respiratory

Murmur Grades