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Advanced Health Assessment Test 1
Define Chief Complaint (CC) and how to document it the reason for the encounter; symptom, problem, condition, physician recommended return. ex: "I have had a runny nose & sore throat for 5 days" Two types of exams Comprehensive and focused How to document a physical exam Subjective data, Objective data, assessment, and plan Subjective Data things a patient tells you about that you cannot observe through your senses; symptoms Objective data what the health professional observes by inspecting, palpating, percussing, and auscultating during the physical examination Assessment
The evaluation that pulls subjective and objective data together to form a diagnosis. Plan Outlines the treatment related to the CC, current morbidities, and additional problems that have become evident during the exam Past Medical History (PMI) The past hx should include previous illness, hospitalizations, surgeries, injuries, allergies, medications, and immunizations. For females, LMP should be recorded EX: if a patient has hx of hypertension check that off and indicates the yr of diagnosis or # of years patient had it. Differential Diagnosis the process of differentiating between two or more conditions that share similar signs or symptoms. Physical findings related to neurofibromatosis 6 of more Cafe-au-lait spots or macule, tumors growth Otits media inflammation of the middle ear, effusion,perforations, unilateral conductive hearing loss , and possible fluid Otitis externa
otoscope instrument used for visual examination of the ear, pull ear back and up for adults and down and back for kids. Should see TM structures, shiny gray light reflex. opthalmoscope Instrument used to examine the eyes, Darken room, right eye to right eye of exmainer. Dial at 0. 15- degree angle and observe red reflex. What is a red reflex Red or orange glow over the patient's pupil created by light illuminating the retina. Risk factor for skin cancer personal or family HX, greater than 50 yrs of age, moles, an sun exposure A,B,C,D,E Asymmetry compare to sides of moles Border Irregular? ragged? blurred? Color- variation ( blue or black) Diameter- Greater than 6mm Evolution- has it changed? Macule discoloration, flat, only noticed visually (Freckle)
Papule Raised area, no fluid (raise nevi) Used to measure inteocular Tonometer Normal interlocutor pressure 10-22 mmhg Plaque Flat topped, raised lesion, scaly& itchy (Psoriasis) Vesicle Raised bomb filled with clear liquid or air. less than 1 cm ( varicella) Pustule Small bump w/ pus ( impetigo/ acne) bullae similar to vesicle but larger than 1 cm ( blister w/ second degree burn)
Cranial nerve for sight CN II optic nerve Cranial nerve for hearing Vestibulocochlear CN VIII What do enlarged supraclavicular lymph nodes suggest? A possible chest or abdominal malignancy Drusen Spots on the retina usually indicate what? Age related macular degeneration Where is the development assessment in a SOAP note in the subjective section under social history How do optic fundal arteries appear Small and light in color how do optic fundal veins appear large and dark red
Strep Throat Diagnosis Pharyngeal swab samples, Strep species A, bacteria cause inflammation because of toxins being released. If strep is negative send to culture. Primary lesions lesions arising from previously normal skin. Macule, papule, patch vesicle, plaque, bullae Secondary lesion Any lesion associated w primary lesion but evolved due to injury or change. ( ulcer, scale,erosion, fissure) Actinic Keratosis a pre-malignant growth of thick, scaly patches of skin from long exposure to the sun, bleeds when scraped, appears yellow/ brown. most common in Caucasians. What is the snellen chart? an eye chart that can be used to measure visual acuity 20/20 is perfect. 20/200 suggest significant visual impairment. Subject must stand 20 feet from the chart while reading letters. Assess Cranial nerve I With eyes closed, the pt is asked to identify familiar odors. Test each nostril separately. Cranial Nerve II
Cranial Nerve X Vagus - senses aortic blood pressure & slows heart rate & stimulates digestive organs & taste Cranial Nerve XI spinal accessory Cranial Nerve XII hypoglossal nerve Which cranial nerve is being assessed is instructed to shrug shoulders CN XI spinal Accessory which cranial nerve is evaluated when cotton is lightly brushed against corner of eye? CN V trigeminal nerve which cranial nerve is being assessed when Rinne test is being done Acoustic nerve CNVIII Which cranial nerves innervate extra occular muscles of the eye? CN II occulomotor, IV trochlear, VI abducens
Rinne and Weber test are used to assess which cranial nerve CNVIII acoustic nerve
