Health And Assessment Final

Front 1

Neuro Assessment

Back 1

1. Mental status/speech/language
2. CN
3. Motor System
4. Sensory System
5. Reflexes

Front 2

Neuro Assessment(2)

Back 2

CN I: olfactory-smell
CN II: optic-vision
CN III: oculomotor-PERRLA, opening eyelid, EOM
CN IV: trochlear-downward, internal rotation of eye
CN V: trigeminal-clench jaw/facial sensation
CN VI: abducens-lateral deviation of the eye
CN VII: facial-expression(raise eyebrows, frown, close eyes tight, show teeth, smile, puff out cheeks)
CN VIII: acoustic-hearing/balance
CN IX: glossopharyngeal-swallow
CN X: vagus-gag reflex
CN XI: spinal accessory-shrug shoulders, turn face against provider hand
CN XII: hypoglossal-stick out tongue

Front 3

Neuro Assessment(3)

Back 3

Rapid alternating movement: striking hands(front then back) on thigh/tap distal joint of thumb with tip of index finger/tap with foot against provider hand w ball of each foot

Point-to-point movement: finger-to-nose test/heel-to-shin test

Gait: walk/heal-to-toe/on toes/on heels/hop in place/shallow knee bend

Stance: Romberg-stand with feet together, close eyes, open eyes, stay upright/Pronator drift-arms out, palms up, eyes closed

Front 4

Neuro Assessment(4)

Back 4

Pain: broken tongue blade/cotton swab and dull end, ask pt to determine if sharp or dull

Temperature: touch w hot and cold test tubes

Light touch: wisp of cotton, touch skin lightly

Vibration: tuning fork, tap on provider palm, place over distal interphalangeal joint on finger and interphalangeal joint of big toe

Proprioception: grab pt big toe, ask if up or down

Discriminative sensations: labeling objects felt in hand(stereognosis)/draw number on hand of pt(number id)/two-point discrimination/touch part of pt's body, ask to open their eyes and point to area touched(point localization)/simultaneously stimulate areas on both sides of body and ask pt to point to areas(extinction)

Front 5

Neuro Assessment(5)

Back 5

Deep tendon reflexes:
(4+ very brisk/hyperactive, 3+ brisker than average, 2+ average/normal, 1+ somewhat diminished, 0 no response

Knee reflex

Biceps reflex: pt arm flexed at elbow, palm down, place provider finger or thumb on biceps tendon, tap hammer on finger(look for flexion at elbow and contraction of biceps muscle)

Triceps reflex: sitting or supine, flex pt's arm at elbow, palm toward body, pull across chest, strike triceps tendon above elbow(watch for extension at elbow and contraction of the triceps muscle)

Brachioradialis relfex: pt's hand in lap, forearm partially pronated, strike radius 1-2 in above wrist(watch for flexion and supination of forearm)

Ankle reflex: strike achilles tendon(watch for plantar flexion at the ankle)

Plantar response: stroke w tongue blade from heel up bottom of foot toward small toe curving medially across ball of foot(watch for downward contraction of toes)

Front 6

Neuro Assessment(LOC)

Back 6

LOC:
-Alertness: speak to pt normally
-Lethargy: speak to pt in a loud voice(appears drowsy, but opens eyes looks at your responds to questions and then falls asleep)
-Stupor: apply painful stimuli(arouses from sleep only after painful stimuli, lapses into unresponsive state when stimuli ceases)
-Obtundation: shake the pt gently as if awakening a sleeper(opens eyes and looks at you but responds slowly and is somewhat confused)
-Coma: apply repeated painful stimuli(no response)

Front 7

Neuro Assessment(meningeal signs)

Back 7

Neck mobility: flex neck forward(resistance=positive)
Brudzinski sign: neck flexed, watch hips and knees in reaction to maneuver(flexion=positive)
Kernig sign: flex pt's leg at hip and knee, straighten knee, (pain=positive)

Front 8

GI/GU Assessment(quadrants)

Back 8

RUQ: ascending colon, duodenum, gallbladder, right kidney, liver, pancreas(head), transverse colon, ureter(right)

LUQ: descending colon, left kidney, pancreas(body and tail), spleen, stomach, transverse colon, ureter(left)

LLQ: bladder, descending colon, ovary, uterus, fallopian tube(female), prostate and spermatic cord(male), small intestine, sigmoid colon, ureter(left)

RLQ: appendix, ascending colon, bladder, cecum, rectum, ovary, uterus, and fallopian tube(female), prostate and spermatic cord(male), small intestine, ureter(right)

Front 9

GI/GU Assessment(Physical Exam)

Back 9

Inspection

Auscultation(all 4 quadrants)/if pt has high BP listen for bruits

Percussion(all 4 quadrants)/lower anterior chest, between the lungs(right will be dull on liver, left will be tympany on intestine)

Palpation: feel gently for tenderness/deep palpation-push down 2-3 in for masses

Assessment for periotoneal inflammation: ask pt to cough and show where pain, palpate gently w one finger to map tender area, look for rebound(press fingers down firmly and slowly then release quickly, watch for signs of pain)

Front 10

Skin Assessment

Back 10

Inspect and palpate the skin: color(increased pigmentation, loss of pigmentation, cyanosis, pallor, yellow of jaundice)/moisture(excessive dryness, sweating, or oiliness)/temperature(use back of hand against pt skin)/texture(roughness or smoothness)/mobility and turgor(lift a fold of skin and let go)/edema(excess fluid in the interstitial space)/lesions(location, pattern, shape, type, color, elevation)

Front 11

Musculoskeletal Assessment

Back 11

Inspect: size and contours of muscle

Look for symmetry of involvement

Note crepitus during movement of tendons or ligaments

Test ROM: TMJ, shoulder(flexion, extension, adduction, abduction, internal rotation, external rotation), elbow, wrist, fingers, spine, hips, knees, ankles/feet

Test muscle strength

Front 12

Thorax/Lungs Assessment

Back 12

Observe rate, rhythm, depth, and effort of breathing/facial expression/LOC/color

Listen to breathing

Inspect the neck

Observe shape of chest: from behind place hands on back and measure chest expansion/from front place hands below breasts

Feel w ball of hand for fremitus("ninety-nine") on front and back

Front 13

Cardiovascular

Back 13

Health Assessment:
Chest pain
Pain or discomfort to neck, left shoulder or arm, and back
Nausea
Diaphoresis
Arrhythmias
Dyspnea
Orthopnea
Cough
Edema
Nocturia
Fatigue
Cyanosis or pallor

Lifestyle habits?

FHx?

PMH?

Front 14

Cardiovascular(Great vessels of the neck)

Back 14

Carotid artery pulse

JVP