Assessment Flashcards
Eyes
Blurred vision, glasses, contacts, photophobia, excessive tearing, night blindness, diplopia, drainage, pain, blind spots, flashing lights, halos, glaucoma or cataracts.
Ears
Hearing deficits, hearing aid, discharge, vertigo, tinnitus, earaches, infection.
Musculoskeletal
Muscle pain, joint stiffness, cramps, back pain, limited movement in affected area, redness swelling, weakness, bony deformity, broken bones, dislocations, sprains, gout, arthritis, osteoporosis, herniated disc.
Cortical Sensation/Neuro
- Stereognosis (familiar object placed in hand)
- Graphesthesia (number or letter drawn in hand)
- Two-point discrimination (at what point can two points no longer be felt)
Throat/Neck
Hoarseness, change in voice, frequent sore throat dysphagia, pain/stiffness, nodularities, goiter, lymphadenopathy.
Female Reproductive
Discharge, change in libido, sterility, pain during intercourse, menses, LMP, start of menarche, regularity, duration, amount of bleeding, premenstrual symptoms, menopause/age of onset/duration/bleeding.
Obstetrical: number of pregnancies, births, types of delivery, complications, birth control
Mental Status /Neuro
Assess Orientation
• Identifies self, place and date (A&O x 3)
Assess Memory
• Immediate: Give the patient three things to remember (example: cat, cloud, ball). Asks the patient to repeat them to the examiner at a later point during the examination.
• Recent: What did you have for breakfast?
• Remote: Where were you born?
Assess abstract reasoning
• Have the patient explain the meaning of a parable “If I say its raining cats and dogs, what does that mean?”
Assess judgment
• Provide the patient with a hypothetical situation and ask: “What they would do if your house was on fire?”
Assess general knowledge
• Who is the president?
Assess Attention
• Serial calculations: subtract by 2s from 20
Neck Assessment
Inspect for masses or deformity
Inspect trachea for position
Assess neck ROM (active followed by resistance)
Palpate the thyroid gland
Assess Cranial Nerve XI (Spinal Accessory)
• ROM head against resistance
• Shrug shoulders against resistance
Assess lymph nodes (naming each of the chains correctly)
Hips
- Inspect hips for erythema, deformity & symmetry
- Palpate for heat, tenderness, edema, and crepitation
- Assess active ROM of the hips (abduction/adduction, flexion/extension, internal/external rotation)
- Assess strength of hips (abduct/adduct)
Adams Test - unlevel hips
Ear Assessment
Inspect the ears for size, alignment, configuration, skin color, lesions, and discharge.
Palpate the external ear, bilaterally
Inspect the auditory canal
Perform otoscopic exam describing structures visualized
Assess Cranial Nerve VIII (Vestibulocochlear/Acoustic)
• Whispered voice test at 1-2 feet on non-occluded ear
• Weber & Rinne Test
Assessment of Head
Inspect head for size, contour, obvious deformities
Inspect hair for distribution, color, condition
Inspect hair for infestations
Palpate head for depressions, masses, pain
Palpate hair for texture
Psychological
Irritability, nervousness, tension, stress, increased stress, suicidal/homicidal thoughts, anxiety or sleep disturbances, difficulty in concentrating, mood changes or depression.
PVD
Inspect the upper extremities
• Temperature, color, & hair distribution
• Condition of skin and presence of edema, ulcers, capillary refill
Inspect the lower extremities
• Temperature, color, & hair distribution
• Condition of skin and presence of edema, ulcers, capillary refill
Palpate upper extremity pulses
• External brachial and radial
Palpate lower extremity pulses
• Femoral, popliteal, dorsalis pedis, posterior tibial
Demonstrate how to assess the Ankle Brachial Index and calculate the value (one side)
• Verbalize normal and abnormal scores and if this patient is normal
Pulmonary
Inspect thorax for symmetry, posture, and deformity
Inspect thorax for AP – Transverse diameter
• Verbalize what they should be and if today’s findings are normal
-Palpate intercostal spaces for tenderness & pain (anterior) (minimum of 6 ICS)
-Palpate intercostal spaces for tenderness & pain (posterior and lateral) (minimum of 6 ICS posteriorly and 4 ICS laterally)
Palpate costal angle
• verbalize if finding is normal
-Palpate tactile fremitus (anterior and posterior)
-Assess and report thoracic expansion (posterior)
Percuss anterior and posterior thorax
• At least 6 areas each
Auscultate anterior and posterior thorax
• At least 6 areas each
Assess and demonstrate diaphragmatic excursion (posterior)
• Verbalize findings
Demonstrate one technique: bronchophony (99-scope)
Coordination/Neuro
- Upper extremities (finger-thumb/ pronate-supinate)
- Lower extremities (toe tap/heel-shin)
- Assess Romberg (protects patient safety) close eyes place hands on each side and have patient stand there.
Cardiovascular
Inspect the Precordium (Aortic, Pulmonic Tricuspid, & Mitral)
• Pulsations, lifts, heaves
Palpate the Precordium (A,P,T,M)
• Pulsations, thrills
Auscultate the Precordium (A,P,T,M)with patient sitting upright: Diaphragm
• Repeat with bell
Auscultate the Precordium (A,P,T,M)with patient supine: Diaphragm
• Repeat with bell
Auscultate the Precordium (A,P,T,M) with patient in left lateral position: Diaphragm
• Repeat with the bell
Report the location and quality S1, S2
- Compare the apical pulse via auscultation with the radial pulse via palpation
Report presence or absence of: Murmurs, rubs, arrhythmia, gallop, clicks
Auscultate the carotid arteries
• Then palpate the carotid arteries (one at a time)
Chief Complaint
O- onset L- location D-duration C- character A- associated/aggravating R- reliving T- timing S- severity
Male Reproductive
Change in Libido, infertility, sterility, impotence, pain during intercourse, onset puberty, testicular pain, penile discharge, erections, hernias, enlarged prostate, urine stream.
General
Fever, Chills, change in energy, night sweats, weight changes
Focused Health History
Biographical Data Chief Complaint History of Present Illness Past Medical History Family History Social History Select Review of Systems
Neurological
Headaches, change in coordination, loss of movement, tics or tremors, change in smell, taste, or speech, forgetfulness, tremors, seizures or loss of consciousness, involuntary movements, weakness, head injury, vertigo, balance, or syncopal episodes.
