How would you assess someone with heartburn?

Ask patient onset (after eating =GERD)

if pain is worse when lying down- assess for GERD
hiatial hernia
ask type of pain- Angina/indigestion may indicate MI
ask what relieves pain
palpate abdomen (HH)
check for ulcers (Left epigastrium pain)

What would a cardiovascular assessment look like on a healthy individual?

Pulse 60-100
Heart sounds heard at all sites (APETM)
patient breathes normally and then holds breath in expiration
S1 louder at apex & S2 louder at base
nail beds pink w/ angle 160 degrees
jugular pulsations visible without distention (pg.239)

What are the risk factors for someone with hypertension?

select all that apply Family history
age, race (African American)
lack of physical activity
poor diet (salt)
overweight
alcohol
tobacco (pg. 213)

What other signs and symptoms would someone have with elevated jugular
distension?
Right sided heart failure
Fluttering or oscillating pulsations
irregular rhythms, elevated BP
discrepancies in measurements of BP between arms (pg.220-221)

What conditions would cause you to hear an S4 sound?

**Normal in children and young adults**
Indicates a non-compliant or "stiff" ventricle
Hypertrophy of the ventricle precedes a non-compliant ventricle
Coronary artery disease [major cause] (pg.231)

How would you open an interview with a patient?

Phase 1: Introduce self
describe purpose of interview
describe the interview process
Establish rapport
describe what to expect
how long interview will take
How would you respond to a patient who says they do not take many meds?
What drugs do you take?
Inquire about prescriptions
over the counter preparations
herbal treatments in addition to any home remedies

What kind of patient would get a focused assessment?

Specific problem or condition
most common in walk in or clinic or emergency dept. (urgent care) pg. 3

How do you assess for abdominal fluid?

Percuss abdomen when fluid is suspected
Marked dullness in a localized area
––may indicate distension, fluid, or an abdominal mass (pg.259)

How do you assess for kidney tenderness?

Percuss kidneys for costovertebral angle pain:
––Use direct percussion to tap each costovertebral angle (CVA)
with the ulnar surface of the dominant fist.
Palpate for contour and pain:
––left hand at posterior costal angle and right hand at anterior costal margin
––ask patient to take a deep breath
––elevate left flank & palpate deeply with right hand (pg. 263)

What is tympany?
One of five percussion tones
Tympany is normally heard over
––abdomen [stomach & gas bubbles in intestines] (pg.25)

When do you use the bell of the stethoscope? The diaphragm?

Valves of heart APETM
––use diaphragm with firm pressure then bell with light pressure
Murmurs:
––Diaphragm for high pitched sounds
aortic, pulmonic, and mitral regurgitation
––Bell for low pitch sounds
carotid bruits, Mitral and tricuspid stenosis (pg. 234/pg.28)

What makes a BP reading inaccurate? Too high? Too low?

Wide cuff= too low
narrow cuff= too high
If stethoscope is longer than 18 inches sound may become distorted (pg.28)
What do you use a Doppler for?
When you are unable to palpate a pulse (pg.220)

How would you confirm an irregular radial pulse in a patient?

Auscultate apical pulse for 60 seconds
Palpate both radial pulses at the same time to assess for equality
Palpate ulnar pulse if radial is difficult to find/injured
Note whether there is a pattern to the irregularity

What are the normal vitals across the lifespan?

Newborn:
––HR 140
––BP 60/20-90/60
––RR 30-60
Toddler:
––HR 110
––BP 80/50-112/80
––RR 24-40
School age:
––HR 85
––BP 84/54-120/80
––RR 18-30
Adolescent:
––HR 70
––BP 94/62-139/88
––RR 12-16
Adult:
––HR 70
––BP 110/60-139/79
––RR 12-20 (pg. 41)

What are you hearing during systolic BP? Diastolic BP?

Systolic: Pressure against blood vessel walls when ventricles contract
––you hear sound of blood rushing back from arteries
Diastolic: Pressure against blood vessel walls when ventricles relax
––you hear lack of sound because artery is open

How do you care for someone with different values?

Assess your own values

What is malignant pain?

Type of chronic pain associated with cancer
pain caused by the invasion of the tumor on surrounding tissues (pg. 55)

How can someone with an amputated limb still feel pain?

Phantom Pain
If a nerve pathway from an amputated extremity is stimulated anywhere along it's
pathway
the nerve impulses ascend to the cerebral cortex (pg. 55)

What is pain tolerance?

Duration or intensity of pain a person endures or tolerates before responding outwardly
(tolerance decreases w/ exposure to pain) (pg. 58)

What are the signs and symptoms of pain? - select all that apply
Low to moderate acute pain:
Increase in respiratory rate
Palpitations
Diaphoresis
?High? BP may occur briefly.
Severe/Deep pain:
Pallor
rapid irregular breathing
nausea
vomiting (pg.60)

How do you access for pain? - select all that apply

Present health status
how patient manages pain
OLDCARTS
pain scales
Examination:
––observe facial expression
––listen for sounds pt makes
––measure BP & palpate pulse
––assess RR and pattern
––inspect site for appearance
––palpate for tenderness (pg. 58, 62)

What kinds of patients and scenarios might cause anxiety?

Sleep deprivation
psychosocial environment
trauma
excessive stress
financial
health
relationships
genetic predisposition
illness/other mental health disorders
substance abuse (pg.69)

What would cause an A, D, K vitamin deficiency in a patient?

Lack of essential fatty acids
nutritionally based diseases
malabsorption
malnutrition
eating disorders

What kinds of questions would you ask a patient who has gained or lost weight?
Onset
Duration
Extent of weight loss/gain
If it was sudden or gradual
Any associated symptoms

What is a good tool to assess dietary intake?

24-hour recall

If you hear crackles during auscultation in the morning and they disappeared
later, what sounds did you actually hear?
Vesicular sounds

What are bronchovesicular sounds? How do they sound? Where do you hear
them?
Expected sounds heard over the central area of anterior thorax around sternal border
posteriorly between spine & scapula

If someone has a pleural effusion and decreased fremitus what other signs and
symptoms might you see?
Accumulation of serous fluid in pleural space
might show signs of fever
tachypnea
dyspnea
absent breath sounds on affected side
diminished chest wall movement
shifted trachea

What is air in the subcutaneous tissue called? How does it feel? What does it
sound like?
Pneumothorax
will cause chest pain & respiratory distress
breath sounds absent in affected area
decreased chest wall movement
crackling feeling in fingers
narrow leak from respiratory tree

If someone is complaining of chest pain and nausea, what other signs and
symptoms might they have?
Patient is likely having an MI
Men:
Sweating
shortness of breath
squeezing or pressure
Women:
Sharp or burning pain
epigastric pain
dyspnea
diaphoresis
fatigue

How can you tell if someone has venous insufficiency?

Lower leg edema
capillary refill < 3 seconds
ulcers may appear as crater like legions near medial malleolus
skin
thick
hardened
indurated
warm

What is the Weber test?

Uses lateralization to test for hearing loss
tuning fork placed on midline of skull and activated
ask patient to indicate in which ear the sound is heard louder
should be equal

What are the different types of hearing loss? How do you test them?
Conductive and Sensorineural
Use Weber test or Rhine test
Weber:
lateralization of sound to affected ear suggests conductive hearing loss
lateralization of sound to unaffected ear suggests sensorineural hearing loss

What is nystagmus?
Condition in which the eyes move involuntarily and rapidly from side to side

How do you test accommodation?

Test by asking the patient to focus on a far object
then a near object
& observe for dilation/constriction

How do you test for eye movement?

Six cardinal fields of vision
Nasal drainage that is purulent, green, and yellow is a sign of what?
Bacterial infection

The patient reports that they vomited an hour ago, what other data do you need to
collect?
If vomiting preceded abdominal pain (infection)
or abdominal pain preceded vomiting (appendicitis)
what did vomit look like
nausea without vomiting (pregnancy or metastatic disease)
food in last 24 hours
other associated symptoms

The patient reports a change in urination, what other data would you need to
collect?
Pain or burning
Frequency
Urgency
color/if blood is present
weight gain
associated symptoms
––back pain, fever, chills could indicate stones

What kinds of questions would you ask a patient with edema?

What does an abdominal assessment look like on a healthy individual?

Expected findings:
umbilicus is centrally located
striae scars
faint vascular network may be present.
Abdominal contour is flat, rounded, or scaphoid

What would you hear in the upper epigastric region of a healthy patient?
Nothing

When do you hear dull sounds? When do you hear tympanic sounds?
Dull sounds:
liver, spleen
Tympany:
stomach, lower intestines

What are the risk factors for esophageal cancer?

Age & gender
Barrett's esophagus
Smoking and/or alcohol
Diet and/or obesity
Workplace exposures
Injury to esophagus

What are the risk factors for colon cancer?

Diet and/or obesity
Age and/or physical activity
smoking and/or alcohol
colorectal polyps or
history of:
cancer
adenomatous polyps
chronic inflammatory bowl disease
family history
inherited gene defects

What is a pustule? What does it look like?

Vesicle greater then 1 cm in diameter
blister pemphigus vulgaris
lupus erythematous
impetigo
drug reaction

What are the different stages of a pressure ulcer? Be able to distinguish them.
Stage 1: intact skin with non-blanching redness
usually over bony prominence
Stage 2: partial thickness loss of dermis
shiny or dry shallow open ulcer
Stage 3: full thickness skin loss
involving damage to or necrosis of subcutaneous tissue
Stale 4: full thickness tissue loss with exposed bone, tendon or muscle
slough or eschar present

The patient reports that they have a rash. What other data would you need to
collect?
Where did you first notice the rash?
Does it itch or burn?
Allergies
Aggravating factors
Related symptoms
Measures of self-treatment

Describe what the oral and nasal mucosa look like on a normal patient.
Oral:
Pink and moist
buccal mucosa pale or coral pink
Nasal:
slightly darker red then oral mucosa
no lesions or drainage

What is the normal ROM for the neck?

Flexion 45 degrees
Extension 55 degrees
Lateral 40 degrees

What are the risk factors for oral cancer?

Age- increases after 40
gender (m)
race (African American highest incidence)
tobacco and/or alcohol
sun exposure
history of cancer
immunosuppression

What does a head and neck assessment look like on a healthy patient? select all
that apply
Head: Symmetrical and proportioned
scalp is clean
??intact with with male-pattern baldness??
Temporal arteries palpable 2+
Neck: centered with full ROM
no palpable thyroid smooth soft
no palpable lymph nodes

How do you assess tricep and bicep muscle strength?

Tricep:
Ask patient to extend arm while you resist by pushing it into a flexed position
Bicep:
Ask patient to flex arm while you try to extend the forearm

How do you test ROM in the shoulder?

Abduction
Adduction
Circumvention
External rotation
Internal rotation

What does rheumatoid arthritis look like? What are the signs and symptoms?
Ligaments and tendons around inflamed joints become fibrotic and shortened causing
contractures and partial dislocation
Stiffness in mornings <30 min
S&S:
Pain, edema, stiffness of fingers, wrists, ankles, feet, and knees.
Systemic:
 low grade fever and fatigue

How do you assess for lumbar nerve compression?

Perform straight leg raises with patient supine
Raise one leg keeping knee straight

How do you assess ROM in the ankle?

Dorsiflexion 20º
Plantar flexion 45º
Eversion 20º
Inversion 30º
Abduction 10º
Adduction 20º

How do you assess ROM in the hips?

What are the risk factors for osteoporosis?

Age and/or gender
Race (Caucasian/Asian)
Bone structure and/or body weight
Family history and/or lifestyle
Medications
Sex hormones (estrogen)

What are the signs and symptoms of a CVA?

Sudden unilateral numbness or weakness of face, arm, leg
Trouble walking, dizziness, loss of balance or coordination
Sudden severe headache
Confusion
Dysphagia
Aphasia
Partial vision loss

How do you test the brachioradialis deep tendon reflex?

Ask patient to let their relaxed arm fall into your hand
Hold arm with hand slightly pronated
Strike brachioradialis tendon directly about 1-2 inches above the wrist
Expected response: pronation of forearm, flexion of elbow.

A patient has recently had a seizure, what other assessment findings do you
need?
Focal or Generalized seizure?
Triggers or warning signs (aura)
medications to prevent seizures
urination during seizure
length of loss of consciousness

What are the risk factors for a stroke?

Age, gender(m), family history, race, smoking, alcohol, high blood cholesterol, obesity,
hypertension, DM, previous CVA or heart attack, atrial fibrillation