Health assessment exam 2

Left of midline, above diaphragm, behind sternum. 3rd to 6th costal cartliages

Right side is more forward, enlarges in anterioposterior direction

12cm length x 8cm width x 6cm AP diameter

• Tricuspid - between R atrium and R ventricle
• Mitral - between L atrium and L ventricle

• Pulmonic - separates R ventricle from pulmonic artery
• Aortic - separates L ventricle from aorta

• 1st heart sound (lub), sound is caused by closure of atrioventricular valves, signifies systole
• Best heard at mitral and tricuspid precordial sites

• Second heart sound (dub), sound is created by the closure of the semilunar valves, signifies diastole (ventricular filling).
• Sound is louder at the aortic and pulmonic sites

• to the left of the LMCL
• in 2 ICS in the same phase of respiration

• chest pain - men under sternum, women more general
• shortness of breath when supine/ on exertion; nocturnal
• ankle edema/neck vein distention
• easily fatigued
• cough, hemoptysis
• tachycardia, palpatations
• hepatomegaly
• weight gain

• Mitral - 5th LICS, slightly medial to the LMCL
• Tricuspid - 4th LICS at L sternal border
• Erb's Point - 3rd LICS at LSB
• Pulmonic - 2nd LICS at LSB
• Aortic - 2nd LICS at RSB

The cardiac apex - the PMI will be seen here

murmurs

At the 5 precordial sites

turbulent blood flow, often across a valve

When valve leaflets are thickened and bloods passage is narrowed so forward blood flow is restricted

when a valve fails to close (the leaflets lose competency) and the slack openings allow backward flow of blood

timing, frequency, location, intensity, radiation, quality, effect of respiration, effect of position

• I - barely audible
• II - quiet but clear
• III - moderately loud
• IV - louder
• V - very loud, heard with stethoscope partially off chest
• VI - very loud, heard with stethoscope fully off chest

IV - VI

• External carotid - anterior to sternocleidomastoid along fold of jaw
• Carotid sinus - above thyroid cartilage
• Brachial - medial arm above anticubital fossa
• Radial - medial and ventral side of wrist (thumb side)
• Ulnar - lateral and ventral side of wrist (pinky side)
• Femoral - below inguinal ligament
• Popliteal - behind knee
• Dorsalis pedis - top of foot
• Posterior tibial - behind and inferior to medial malleolus of ankle

• 0 - absent
• 1+ - diminished, barely palpable
• 2+ - normal
• 3+ - increased, full volume
• 4+ - hyperactive, bounding

• intermittent claudication
• severe advanced perepheral artery disease
• arterial pulses diminished or absent
• color pale
• temperature cool
• skin thin and shiny
• no/mild edema
• hair loss on legs/toes/feet
• nails thickened brittle and ridged
• ulceration
• gangrene

• no pain/dull achy pain
• edema
• temp. normal
• normal or cynotic color
• brawny pigmentation
• ulceration (esp. at medial malleolus)

Pain in calf, thigh or buttocks with activity and relieved with rest progressing to pain at rest. Caused by ischemia (decrease of O2 to muscle).

Inspection, ascultation, percussion, palpation

right lower, right upper, left upper, left lower

R&L hypochondriac, R&L lumbar, R&L inguinal, Epigastric, umbilical, hypogastric. Helps difine location of pain

Symmetry and contour, umbilicus midline and inverted, peristalsis down and to the right, pulsation of abdominal aorta, venous network towards head above umbilicus, toward feet if below

IV drug use, tattoos, unprotected sex, incarceration

• Reducible - contents of hernial sac easily replaced
• Nonreducible/incarcerated - strangulated, if blood supply to protruded contents obstructed becomes medical emergency

• Normoactive - irregular, high pitched clicks and gurgles every 5-15 seconds
• Hypoactive - low pitched, >every 15 seconds
• Hyperactive - high pitched, <every 5 seconds

a lack of motion in the bowel, when no bowel sounds are heard for 10 minutes

Overall tympany with dullness over organs

6-12cm in RMCL, 4-8cm in MSL

sharp pain with kidney or paranephric inflammation

It descends below the right costal margin

porous bones, loss of bone density

• female
• caucasian/asian
• small frame
• short stature
• family history
• diet deficient in CA++ and vitamin D
• hyperthyroid
• prolonged corticosteriod usage
• sedentary lifestyle
• postmenopausal
• smoking
• chemo or breast cancer

• Osteoarthritis - degeneration of movable joints causing deterioration of articular tissue and new bone formation, asymmetrical, crepitus, joint enlargement
• Rheumatoid - chronic inflammatory disease, symmetrical, constitutional symptoms, swelling

hunchback. often occurs with osteoporosis

Swayback - accentuation of concavity in lower back

lateral deviation of the spine, assessed with forward flexion

• 0 - no contraction
• 1 - contraction but no movement
• 2 - passive ROM without gravity
• 3 - AROM
• 4 - AROM with light to moderate resistance
• 5 - AROM with full resistance

put hands on shoulders and have patient shrug (checks trapezius muscle)

• active
• passive
• active assistive
• full

abnormal joint mobility and consolidation

• ball and socket - shoulder, hip
• hinge - elbow, ankle, knee
• saddle - thumb
• gliding - foot
• pivot - neck
• slightly movable - vertebral

warm up, exercise at least 150min/week in 20 min intervals, cool down

mental status, sensory system, motor system, reflexes, 12 pairs of cranial nerves

• sensory, motor, autonomic - bowel, bladder, sexual.
• Recovery if effective occurs in reverse order

• attention
• remembering
• feeling
• language
• thinking
• spatial perception

• carelessness
• indifference
• inability to sense emotions in others
• loss of sympathetic reactions
• unusual docility
• rage reactions
• excessive irritability

• State of conciousness
• memory
• attention span
• judgement
• abstract reasoning
• arithmetic calculations
• thought processes and content

• alert and oriented to time place and person
• awake (may sleep more or be somewhat confused when first awakened)
• Lethargic (drowsy but able to follow simple commands)
• Stuporous (very hard to arouse, inconsistantly may follow simple commands or speak short words/phrases)
• Semicomatose (movements purposeful when stimulated, does not follow commands or speak clearly)
• Comatose (reflexive posturing or no response)

• orientation to person
• orientation to place
• orientation to time
• short term memory of facts
• short term recall

• significant memory loss
• difference in personality
• hazardous behavior
• getting lost in familiar places
• agitation
• suspiciousness
• impaired communication
• nocturnal confusion
• personal self care difficulties
• rambling speech
• catastrophic reactions (rage)

side to side, distal to proximal with patient's eyes closed

Cranial nerve V

• Light touch with a wisp of cotton
• sharp and dull sensation
• temperature
• proprioception
• vibratory sensation

• stereogenesis (ability to recognize familiar objects by feel)
• graphesthisia (ability to id shapes, # or letters traced onto palm)
• two point discrimination

• tests motor system (cerebellar) function
• heel to toe walk

• patient stands, feet together with arms at sides, with eyes open and then closed for 20-30 seconds
• + with staggering or loss of balance

tricep, bicep, brachioradialis, pateller, achilles

C 5,6

C 6,7

C 5,6

L 2,3,4

S 1,2

• 0 - no response
• 1+ - sluggish, diminished response
• 2+ - active or expected
• 3+ - slightly hyperactive
• 4+ brisk, hyperactive

superficial, tests L 4,5, S1,2

• A response to the plantar reflex
• Expected in adult - all toes curl down
• Positive in adult - big toe dorsiflexes and other toes fan
• Expected in children under 2 - big toe dorsiflexes and all other toes fan