Health Assessment Exam 1 PDF

Health History and SOAP documentation SOAP- subjective, objective, assessment, plan Old carts - onset, location, duration, characteristics, alleviating factors, aggravating factors, radiation or relieving pain, timing, severity HPI - history of present illness Acronyms to remember all compone...

Health History and SOAP documentation SOAP- subjective, objective, assessment, plan Old carts - onset, location, duration, characteristics, alleviating factors, aggravating factors, radiation or relieving pain, timing, severity HPI - history of present illness Acronyms to remember all components PQRST - precipitation, quality, radiation, severity, timing Client outcomes - character, location, impact, expectation, neglect, timing, other, understanding/beliefs, treatment, complementary, options, modulating, exposure, spirituality SOAP notes Subjective data is given from the patient, even ROS. Objective data is taken by the practitioner aka assessment. Past medical history means that it doesn\'t pertain to this visit. Even if the patient currently suffers from a comorbidity, it is past. Skin: Common Geriatric Lesions: Xerosis: Impaired keratinocyte formation, which results in abnormal epidermal cell turnover, is responsible for xerosis, the most common cause of itch in the elderly Stasis Dermatitis: Dry, itchy skin of the lower extremities warrants special evaluation for advancing vascular changes. Superficial varicose veins with the underlying vascular impediments of edema and pressure manifest as an eruption of the lower leg seen in stasis dermatitis. The inflamed, sometimes ulcerated skin of acute stasis dermatitis may be accompanied by the chronic changes of stasis dermatitis including hyperpigmentation, lichenification, and scars of healed ulcers. Rosacea: While not limited to the geriatric population, rosacea is an underdiagnosed and misdiagnosed inflammatory condition, which is chronic and progressive. The hallmark of rosacea in the geriatric population is in the bulky tissue (phymatous) and dilated telangiectatic vessels commonly seen after years of persistent redness and flushing. Another common variant of rosacea in the elderly is ocular rosacea, often overlooked in the ocular examination. **Common Geriatric Skin Tumors:** **Seborrheic Keratosis** location: Face, trunk Hallmark features: stuck-on appearance, varying color and degrees of dryness, waxy with pebbly or verrucous surface. Differential diagnosis: Pigmented basal cell and squamous cell carcinomas, malignant melanoma, lentigo, wart, actinic keratosis. **Cherry angioma (senile angioma)** Location: Trunk Hallmark Features: smooth, firm, deep red, few or hundreds, increasing with age. Differential Diagnosis: Petechiae **Acrochordon (skin tag)** Location: neck, axillary, groin, eyelids Hallmark features: soft compressible, pedunculated, or projectile Differential Diagnosis: seborrheic keratosis, dermal nevi, warts **Venous lake** Location: vermillion border of lip, ear Hallmark features: compression collapses lesions Differential Diagnosis: Blue nevus, malignant melanoma, tattoo **Sebaceous hyperplasia** Location: face\_glabella Hallmark: 1-2 mm soft, dome-shaped, pale yellow with central umbilication. Differential Diagnosis: basal sale carcinoma, HSV, Molluscum **Chondrodermatitis nodularis chronica helicis** Location: lateral surface of the helix, antihelix Hallmark features: single, firm 2 to 6 mm painful, red to white nodule Differential diagnosis: Actinic keratosis, keratoacanthoma Eye Exam Eye Assessment - A good mnemonic for an eye history is to ask "RSVP" questions. If all answers are YES = urgent ophthalmology consult required. ○ Redness Sensitivity to light Vision Loss Pain ○ Any sudden loss of vision = ocular emergency Pupils ○ Arcus senilis - white or gray ring at corneal margin seen in older adults. Caused by fat deposits in the cornea or hyaline degeneration. See Photo Below. ○ Pterygium - Wedge-shaped and raised conjunctival growth, usually extending from nasal side. May be related to chronic irritation. Eyelids ○ Endotropion - inward turning of lid margin and lashes toward eye surface (incidence increases with age) ○ Exotropion - outward turning of the lid margin and lashes outward, away from eye (incidence increases with age ○ Eyelid malignancy - most common is basal cell carcinoma: Hordeolum (Stye) and Chalazion -- **Hordeolum(Stye)** Location: most commonly found at or near an eyelash follicle Cause: bacterial infection either at the root of the eyelash follicle or in the oil gland of the lids Symptoms: tenderness, swelling Treatment: spontaneous drainage, warm compresses **Chalazion** Location: most commonly found above the eyelashes on the upper lid Cause: a blocked oil gland Symptoms firm, painless lump Treatment: warm compresses, antibiotic eye drops, surgery Cranial nerve III (oculomotor) is responsible for transmitting visual images to the brain Cranial nerve III (oculomotor), IV (trochlear), and VI (abducens) are responsible for the movements of the eye Vertical diplopia is caused by an issue with Cranial nerve IV while horizontal diplopia is caused by Cranial nerve VI Visual Acuity test: expressed as two numbers. The first number describes the patient's distance from the chart (20 feet); the second describes the distance at which a normal eye can read print that a person with normal vision could read at 30 feet. The negative number documents the number of errors made by the patient. I.e. 20/30-1 Corneal Reflex test: Lightly touch the cornea with a wisp of cotton. The lids of both eyes will normally close when either eye is touched. Failure of both eyes to close indicated increased ICP which impairs the sensory branch (CN V) and motor branch (CN VII). Typically done on unconscious pts. Eyelid Eversion: If the pt complains of eye pain/foreign body sensation, evert the upper lid. Gently grasp upper eyelashes and pull downward. Place a cotton swab midway on the upper lid. Using slight pressure, evert lid over the applicator. Examine the lid for swelling, tenderness, and foreign bodies Fluorescein Stain Technique: Ask if pt has relevant allergies first. Inspect cornea and sclera prior to staining. Administer ocular anesthetic. Moisten the tip of the stain strip with sterile saline after 1 minute. Hold lids open with thumb/index finger and apply stain strip to lower conjunctiva. Ask pt to blink with eyelid closed to disperse stain. Inspect cornea/conjunctiva beneath upper and lower lids using UV light. Areas of stain uptake will light up fluorescent bright green indicating corneal abrasion. Remove foreign body if visible and/or superficial. Flush stain with sterile saline solution. Corneal Light Reflex test (aka Hirschberg Test): Instruct the pt to focus their gaze on your light source. Light reflections should appear symmetrically in both pupils. When an imbalance is found in the corneal light reflex, perform the cover-uncover test Cover/Uncover test: If the covered eye moves to focus after its cover is removed, it is the weaker eye. EAR Ear Is responsible for balance and hearing Outer ear - pinna (auricle), and the ear canal. The ear canal extends intward, forward and \*downward\* for anyone above 3, and inward forward and \*upward\* for those under 3. So for children under three when examining their ears pull downward, outward and backward. Middle ear - tymp anic membrane to the oval window. Consists of bones that transmit sound waves to the cochlear organs Inner ear - consist of end organs for hearing. Responsible for balance. Otalgia - ear pain, primary (infection or inflammation of the middle ear) or secondary (tmj, dental, periodontal pain, sinus infection, lesions of the tongue). Additionally neuralgia of the cranial nerves, V VII, IX, and X nerve. As well as cervical nerves I, II, III. Hearing loss - chronic health problem. Gradual or sudden. \- Tympanic membrane light reflex should be seen in the anterior inferior quadrant. On the left side it will be noted at 7 o clock and on the right at 5 o clock. \- An opaque tympanic membrane can indicate chronic otitis without perforation, repetitive perforation with healing, or tympanosclerosis. \- Air bubbles behind the tympanic membrane can indicate acute otitis media and serous otitis. \- Yellow tinged tympanic membrane can be a infection with puss \- Lack of tympanic membrane flexibility can cause conductive hearing loss. \- Weber test - this tests for bone conduction. Place the tuning fork on the patient forehead in the middle and ask if the sound is heard evenly. If the tone is equal, that is a desired finding. If the tone is heard louder in one ear that indicates conductive hearing loss, if it is heard softer that is sensorineural hearing loss. \- Rinne test - this test compares air conduction to bone conduction. This tests one ear at a time. Apply the tuning fork to the mastoid process of the patient\'s chosen ear and ask the patient to identify when the sound is no longer heard. Without hitting the tuning fork again, place it 1 inch from the patient ear and ask when the patient no longer hears the sound. Note which one is longer. If the air conduction is longer, note if it is twice as long as this is a positive test result. A positive test is a good result, meaning that air conduction should be louder then bone conduction. AC\>BC. A negative test that would indicate conductive hearing loss would be if the fork tone intensity became louder or heard longer than air conduction. BC\>AC. Sensorineural hearing loss manifests when AC is equal to or less than half as long as BC. \- Whisper test - tests for hearing acuity. Cover your mouth and exhale. Whisper a series of numbers or words from two feet away. The tester should use one vowel sounds or two vowel sounds that are similar. If the patient gets 50% of the words correct it is a normal result. If less than 50% repeat the test with a louder sound until the patient passess. A result less than 50% indicates either conductive or sensorineural hearing loss. \- Romberg test. Have the patient close their eyes with their arms at their side. If they can stay still an not sway they passed. This tests for inner ear organ function. \- In pediatric patient wait till the end of the assessment to do the internal exam \- In adult patients it iEAR Ear Is responsible for balance and hearing Outer ear - pinna (auricle), and the ear canal. The ear canal extends intward, forward and \*downward\* for anyone above 3, and inward forward and \*upward\* for those under 3. So for children under three when examining their ears pull downward, outward and backward. Middle ear - tymp anic membrane to the oval window. Consists of bones that transmit sound waves to the cochlear organs Inner ear - consist of end organs for hearing. Responsible for balance. Downloaded by betty crane (bettycrane606\@gmail.com) lOMoARcPSD\|46401444 Otalgia - ear pain, primary (infection or inflammation of the middle ear) or secondary (tmj, dental, periodontal pain, sinus infection, lesions of the tongue). Additionally neuralgia of the cranial nerves, V VII, IX, and X nerve. As well as cervical nerves I, II, III. Hearing loss - chronic health problem. Gradual or sudden. \- Tympanic membrane light reflex should be seen in the anterior inferior quadrant. On the left side it will be noted at 7 o clock and on the right at 5 o clock. \- An opaque tympanic membrane can indicate chronic otitis without perforation, repetitive perforation with healing, or tympanosclerosis. \- Air bubbles behind the tympanic membrane can indicate acute otitis media and serous otitis. \- Yellow tinged tympanic membrane can be a infection with puss \- Lack of tympanic membrane flexibility can cause conductive hearing loss. \- Weber test - this tests for bone conduction. Place the tuning fork on the patient forehead in the middle and ask if the sound is heard evenly. If the tone is equal, that is a desired finding. If the tone is heard louder in one ear that indicates conductive hearing loss, if it is heard softer that is sensorineural hearing loss. \- Rinne test - this test compares air conduction to bone conduction. This tests one ear at a time. Apply the tuning fork to the mastoid process of the patient\'s chosen ear and ask the patient to identify when the sound is no longer heard. Without hitting the tuning fork again, place it 1 inch from the patient ear and ask when the patient no longer hears the sound. Note which one is longer. If the air conduction is longer, note if it is twice as long as this is a positive test result. A positive test is a good result, meaning that air conduction should be louder then bone conduction. AC\>BC. A negative test that would indicate conductive hearing loss would be if the fork tone intensity became louder or heard longer than air conduction. BC\>AC. Sensorineural hearing loss manifests when AC is equal to or less than half as long as BC. \- Whisper test - tests for hearing acuity. Cover your mouth and exhale. Whisper a series of numbers or words from two feet away. The tester should use one vowel sounds or two vowel sounds that are similar. If the patient gets 50% of the words correct it is a normal result. If less than 50% repeat the test with a louder sound until the patient passess. A result less than 50% indicates either conductive or sensorineural hearing loss. \- Romberg test. Have the patient close their eyes with their arms at their side. If they can stay still an not sway they passed. This tests for inner ear organ function. \- In pediatric patient wait till the end of the assessment to do the internal exam \- In adult patients it is not uncommon to have presbycusis which is a gradual hearing loss due to nerve degeneration.. \- Cerumen impaction can be a cause of hearing losss not uncommon to have presbycusis which is a gradual hearing loss due to nerve degeneration. \- Cerumen impaction can be a cause of hearing loss Oh Oh Oh To Touch And Feel Very Good Velvet AH mnemonic? The mnemonic, Oh Oh Oh To Touch And Feel Very Good Velvet AH, refers to the cranial nerves: olfactory (I) which controls smell; optic (II) which controls vision; oculomotor (III) for eye movement and pupil constriction; trochlear (IV) controlling downward and inward rotation of the eye; trigeminal (V) for facial sensation and chewing; abducens (VI) for lateral eye movement; facial (VII) for facial expressions and taste; vestibulocochlear (VIII) for hearing and balance; glossopharyngeal (IX) for taste and swallowing; vagus (X) controlling speech, swallowing, and heart rate; spinal accessory (XI) for neck and shoulder movement; and lastly, hypoglossal (XII) for tongue movement.