Health Assessment Test #2

Musty odor breath

with liver disease

** Rhinorrhea

(runny nose) occurs with colds, allergies, sinus infection, trauma.

Objective Data: Palpate Precordium

-Palpate across the precordium using the palmer aspects of your four fingers -gently palpate the apex, the left sternal border and the base, searching for any other pulsations. -Normally none occur. ***If they are present note the timing, use the carotid artery pulsation as a guide or Auscultate as you palpate.

Abnormal pulses: Small weak pulse-

-diminished pulse pressure, weak and small on palpation. -Graded as 1+ **Causes: Any conditions causing a decreased stroke volume: -Heart failure -Hypovolemia -Severe aortic stenosis -hypothermia

Subjective Data: Ears

1. Earache? Any earache or other pain in ears? Any accompanying cold symptoms or sore throat? Any problem with sinus or teeth? Ever been hit on ear or on side of head? Trauma from a foreign body? **may be referred pain from problem in teeth or oropharynx or directly due to ear disease. Virus or bacteria from URI may migrate up Eustachian tube to involve middle ear. Trauma may rupture tympanic membrane. 2. Infections- any ear infections? History of chronic ear problems alert you to possibility of sequelae. 3. Discharge- what does it look like- pus, bloody. Discharge suggests infection, it may come from canal or may indicate perforated eardrum. Examples: external otitis- purulent, or watery, sanguineous. Acute otitis media (AOM)- with perforation- purulent discharge. **typically with perforation- ear pain occurs first, stops with a popping sensation, then drainage occurs. 4. Hearing loss?- ever had trouble hearing? Slowly or acute? **Presbycusis gradual onset over years, whereas hearing loss to trauma is often sudden. Refer any sudden loss in one or both ears not associated with URI. Note to examiner- during history, note these clues from normal conversation which indicate possible hearing loss: Person lip reading or watching your face and lips closely Frowning or straining forward to hear Posturing to catch sounds with better ear Misunderstands or frequently asks you to repeat Inappropriately loud voice 5. Environmental noise- any loud noises at home or on the job? 6. Tinnitus- ever felt ringing, crackling or buzzing in your ears? When did this occur? Taking any meds? **Tinnitus accompanies some hearing loss or ear disorders. Tinnitus seems louder when no competition from environment noise exists. Many meds. Have ototoxic sequelae- example- streptomycin, vancomycin. 7. Vertigo- ever felt that the room is spinning or you are spinning? Ever felt dizzy, like you are not quite steady, like falling or losing your balance? 8. Self care behaviors- how do you clean your clean your ears? Last time hearing checked?- assess potential trauma from invasive instruments.

Heart and Neck Vessels: Position and Surface Landmarks: Pulmonary Circulation and the Systemic Circulation

**Blood vessels are arranged in two continuous loops, the pulmonary circulation and the systemic circulation. When the heart contracts it pumps blood simultaneously into both loops.

Heart and Neck Vessels: Position and Surface Landmarks: Cardiovascular (CV) system

**consists of the heart, a muscular pump and blood vessels.

Auscultation: Identify S1 and S2

***S1: -start of systole -first Lub -ventricular contraction -aortic and pulmonic valves (semilunar valves) are open -tricuspid and mitral valves are closed (AV Valves) ***S2: -second (Dub) -ventricular relaxation -tricuspid and mitral valves are open (AV Valves) -aortic and pulmonic valves (semilunar valves) are closed ***Guidelines to help you distinguish the two:. 1. S1 is louder than S2 at the apex; 2. S2 is louder than S1 at the base 3. S1 coincides with the carotid artery pulse. Feel the carotid gently as you Auscultate at the apex, the sound you hear as you feel each pulse is S1. S1 is caused by closure of the AV valves and signals the beginning of systole. You can hear it over the entire precordium , although it is loudest at the apex. 4. A split S1 is normal , but it occurs rarely. A split means you are hearing the mitral and tricuspid components separately. The split is audible in the tricuspid valve area, the left lower sternal border. 5. S2 is associated with closure of the semilunar valves. You can hear it over the entire precordium, although it is loudest at the base. A split S2 is a normal phenomenon that occurs toward the end of inspiration in some people. A split S2 is heard only in the pulmonic valve area, the 2nd interspace.

Peripheral vascular system: Arteries

**Arteries carry blood away from the heart. Nearly all arteries carry oxygen rich blood from the heart throughout the rest of the body. The only exception is the pulmonary artery, which carries oxygen-depleted blood to the lungs.

Photophobia

inability to tolerate light

Dyspnea

shortness of breath

cheeks

side walls of the oral cavity.

Each tooth has three parts:

the crown, the neck and the root.

Objective data: Mouth- Teeth and Gums

**Begin with the anterior structures and move Posteriorly. **Use a tongue blade to retract structures and a bright light for optimal visualizatio -the condition of teeth is an index of the clts. general health. Note any diseased, absent, loose, or abnormally positioned teeth. - normally look white, straight and evenly spaced and clean and free of debris or decay. Ask the clt. to bite as if chewing something and note alignment. -Normal occlusion in the back is the upper teeth resting directly on the lowers; in the front, the upper incisors slightly override the lower incisors. -Normally the gums look pink or coral with a stippled (dotted) surface. -Gum margins at the teeth are tight and well defined. -Check for swelling; retraction of gingival margins and spongy, bleeding or discolored gums. Black clts. normally may have a dark melanotic line along the gingival margin. **Gums bleed with slight pressure-indicates gingivitis. ** Dark line on gingival margins occurs with lead poisoning.

Objective Data: Mouth- Tongue

**Begin with the anterior structures and move Posteriorly. **Use a tongue blade to retract structures and a bright light for optimal visualization -check the color, surface characteristics and moisture. -The color is pink and even. The dorsal surface is normally roughened from the papillae. A thin white coating may be present. -Ask the clt to touch the tongue to the roof of the mouth. Its ventral surface looks smooth, glistening and shows veins. Salvia is present. -With a glove, hold the tongue using a cotton gauze pad for traction and swing the tongue out and to each side. -Inspect for any white patches or lesions - normally none are present. If any occur, palpate these lesions for induration. -Inspect carefully the entire U shaped area under the tongue. Oral malignancies are most likely to develop here. -Note any white patches, nodules, or ulcerations. -If lesions are present, or with any clt. over 50 or with a positive history of smoking or alcohol use, use your gloved hand to palpate the area. Place the other hand under the jaw to stabilize the tissue and to "capture" any abnormality. Note any induration. ** Any lesion or ulcer persisting for more than 2 weeks must be investigated. ** any indurated area may be a mass and must be investigated.

Objective Data: Mouth- Palate

**Begin with the anterior structures and move Posteriorly. **Use a tongue blade to retract structures and a bright light for optimal visualization -shine your light up to the roof of the mouth. -The more anterior hard palate is white with irregular transverse rugae. -The posterior soft palate is pinker, smooth, and upwardly movable. -A normal variation is a nodular bony ridge down the middle of the hard palate, a torus palatinus. This benign growth arises after puberty and is present normally in 25% of whites and 20% of blacks. **It is more common in Native Americans and Asians. -Observe the uvula, it normally looks like a fleshy pendant hanging in the midline. Ask the clt. to say "ahh" and note the soft palate and uvula rise in the midline. This tests one function of cranial nerve X- the Vagus nerve. ** The hard palate appears yellow with jaundice. ** A bifid uvula looks like it is spit in two ** Any deviation to the side or absent movement indicates nerve damage, which also occurs with polio and diphtheria.

Objective Data: Mouth- Buccal Mucosa

**Begin with the anterior structures and move Posteriorly. **Use a tongue blade to retract structures and a bright light for optimal visualization 4. Buccal Mucosa: - Hold the cheek open with a wooden tongue blade, and check the buccal mucosa for color, nodules or lesions. -It looks pink, smooth, and moist although patchy -Hyperpigmentation is common and normal in dark skinned clt.s -an expected finding is Stensen's duct, the opening of the parotid salivary gland. It looks like a small dimple opposite the upper second molar. -You may also see a raised occlusion line on the buccal mucosa parallel with the level the teeth meet due to the teeth closing against the cheek. -A larger patch also may be present along the buccal mucosa. This is Leukoedema, a benign grayish opaque area, more common in blacks and east Indians. When it is mild, the patch disappears as you stretch the cheeks. The severity of the condition, increases with age, looking grayish white and thickened. The cause is unknown. Do not mistake Leukoedema for oral infections such as candidiasis (thrush). -Fordyce's granules are small isolated white or yellow papules on the mucosa of cheek, tongue, and lips. These little sebaceous cysts are painless and not significant. **Orifice of Stensen's duct looks red with mumps. **Kopliks spots- a prodromal sign of measles ** The chalky white raised patch of leukoplakia is abnormal.

Objective data: Mouth- Lips

**Begin with the anterior structures and move Posteriorly. **Use a tongue blade to retract structures and a bright light for optimal visualization. -inspect the lips for color, moisture, cracking or lesions. Retract the lips and note their inner surface as well. Black clts. normally may have bluish lips. -asymmetrical smile= could mean an cranial nerve problem

Direction of blood flow

**Circulation is a continuous loop. **Blood is kept moving along by continually shifting pressure gradients. **Blood flows from an area of higher pressure to one of lower pressure. Direction of flow RIGHT SIDE= DEOXYGENATED BLOOD **Superior vena cava drains venous blood from the head, neck, arms, and upper trunk; inferior vena cava drains venous blood from the liver, abdomen and lower extremities; Both lead to RA RA-->tricuspid valve --> RV--> pulmonic valve--> pulmonary artery--> lungs LEFT SIDE= OXYGENATED BLOOD Lungs -->Pulmonary veins-->LA--> mitral valve--> LV-->aortic valve--> aorta **Aorta delivers oxygenated blood to body and veins

Six grades describe the intensity of a murmur:

**Grade 1: very faint, heard only after the listener has "tuned in". **Grade 2: Quiet but heard immediately. **Grade 3: Moderately loud **Grade 4: Loud **Grade 5; very loud. May be heard with the stethoscope partly off the chest. **Grade 6: may be heard with the stethoscope entirely off the chest.

Heart and Neck Vessels: Position and Surface Landmarks:

**Inside the body, the heart is rotated so that its right side is anterior and its left side is mostly posterior. **right ventricle (RV) forms the greatest area of anterior cardiac surface. **left ventricle (LV) lies behind the right ventricle and forms the apex and slender area of the left border. **right atrium (RA) lies to the right and above the right ventricle and forms the right border. **left atrium (LA) is located posteriorly, with only a small portion, the left atrial appendage, showing anteriorly.

Objective Data: Palpate the Sinus Areas

1. Using your thumbs, press over the frontal sinuses below the eyebrows and over the maxillary sinuses below the cheekbones. Take care not to press directly on the eyeballs. The clt. should feel firm pressure but no pain. **Sinus areas are tender to palpation in clts. with chronic allergies and acute infection (sinusitis) 2. Transillumination- use this technique when you suspect sinus inflammation, although it is of limited usefulness. a. Darken exam room. Hold a penlight under the superior orbital ridge against the location of the frontal sinus area. b. Cover with your hand. A diffuse red glow is a normal response. It comes from the light shining through the air in the healthy sinus. c. Use the same technique with the maxillary sinus. Ask the clt to tilt the head back and open the mouth. Shine the light on each cheek just under the inner corner of the eye. Note a dull glow inside the mouth on the hard palate as the light transmits through the sinuses. **Healthy sinuses contain air and may light up symmetrically. But be aware that asymmetry is not a reliable sign of sinus inflammation because many healthy sinuses normally will not transilluminate. ** An inflamed sinus filled with fluid does not transilluminate. ** A significant finding is one sinus illuminated and the other clouded. If one has fluid, it looks darker then the healthy one.

Angina

Chest pain

Characteristics of Venous Insufficiency

Pain: Aching, cramping Pulses: Present but may be difficult to palpate because of edema Skin:Thickened and rough; may be reddish-blue in color; moderate to severe leg edema. Ulcers: medial malleolus; usually superficial, minimal pain; granulation tissue -beefy red to yellow;

***Decreased fremitus occurs when

anything obstructs transmission of vibrations -EXs: obstructed bronchus, pleural effusion or thickening, pneumothorax and emphysema.

When injury/trauma to head occurs..

discharge in eyes/ears/nose could be cerebral spinal fluid (CSF); test for glucose, if present=CSF clt. will usually be unconscious if CSF is present

***Left ventricular dilation (volume overload)

displaces the apical impulse down and to the left and increases size more than one space.

Fatigue due to decreased cardiac output is worse

in the evening

**Scleral icterus

is an even yellowing of the sclera extending up to the cornea, indicating jaundice.

Ototoxic

toxic to ear causes deafness

**Pallor with

vasoconstriction

Ammonia breath

with uremia (A condition involving abnormally high levels of waste products in the blood.)

Characteristics of Arterial Insufficiency

**Pain: intermittent claudication (pain and/or cramping in the lower leg due to inadequate blood flow to the muscles) to sharp unrelenting constant **Pulses: Diminished or absent **Skin: 1. Dependent rubor (dependent position but not when it's elevated above the heart.) 2. when foot is elevated pallor occurs 3. Dry, shiny skin 4. Cool to touch 5. Loss of hair 6. Ulcers: top of toes, heel or other pressure areas if confined to bed; very painful; very deep; circular, pale black to dry and gangrene base; minimial leg edema

Heart and Neck Vessels: Position and Surface Landmarks: Heart

**The heart extends from the second to the fifth intercostal space and from the right border of the sternum to the left midclavicular line. ** "top" of the heart is the broader base, and the "bottom" is the apex, which points down and left.

When examining ear, pull pinna

**Up and back for adults **down for infant- children 3 younger allows for better visualization

Peripheral vascular system: Veins

**Veins carry blood toward the heart. Nearly all veins carry oxygen depleted blood, the sole exception being the pulmonary vein, which carries oxygenated blood from the lungs to the heart.

Semilunar (SL) valves

**are set between the ventricles and the arteries. **Each valve has three cusps. **SL valves are the pulmonic valve in the right side of the heart **SL valves are the aortic valve in the left side of the heart. **They open during pumping, or systole to allow blood to be ejected from the heart **the pulmonic valve ejects blood into the lungs via the pulmonary arteries, and the aortic valve ejects blood to the body via the aorta

Heart and Neck Vessels: Position and Surface Landmarks: Great Vessels

**are the major arteries and veins connected to the heart. **The heart and great vessels are located between the lungs in the middle third of the thoracic cage, called the mediastinum. **lie bunched above the base of the heart. **Superior and inferior vena cava return unoxygenated venous blood to the right side of the heart **Pulmonary artery leaves the right ventricle, bifurcates and carries the venous blood to the lungs. **Pulmonary veins return the freshly oxygenated blood to left side of the heart **Aorta carries it out to the body. The aorta ascends from the left ventricle, arches back at the level of the sternal angle, and descends behind the heart.

Anatomy Review: Posterior Thoracic Landmarks

**counting ribs and intercostals spaces on the back is a bit harder due to the muscles and soft tissue surrounding the ribs and spinal column. 1. Vertebra prominens- start here. Flex your head and feel for the most prominent bony spur protruding at the base of the neck- this is the spinous process of C7. If two bumps seem equally prominent, the upper one is C7 and lower one is T1. 2. Spinous process. Count down these knobs on the vertebrae, which stack together to form the spinal column. Note that the spinous processes align with their same numbered ribs only down to T4. After T4, the spinous processes angle downward from their vertebral body and overlie the vertebral body and rib below. 3. Inferior border of scapula- the lower tip is usually at the seventh or eighth rib. 4 Twelfth rib- palpate midway between the spine and the clts side to identify its free tip

Subjective Data: Thorax and Lungs: Smoking history

**do you smoke cigarettes or cigars? ***HAVE YOU EVER SMOKED? At what age did you start? How many packs per day do you smoke? For how long? Have you ever tried to quit? What helped? Live with someone who smokes or work in a smoke filled environment such as a nightclub? If not currently smoking- Have you ever smoked, if yes, when did you quit, how many packs per day and for how long? ***State number of packs per day and the number of years smoked. ***Most clients already know that smoking is bad for them. Instead of admonishing assess smoking behavior and ways to modify daily smoking activities.

Valves

**four chambers are separated by valves, whose main purpose is to prevent backflow of blood. The valves are unidirectional. They can only open one way. The valves open and close passively in response to pressure gradients in the moving blood. **There are four valves in the heart.

Heart and Neck Vessels: Position and Surface Landmarks: Precordium

**is the area on the anterior chest overlying the heart and great vessels.

Two atrioventricular (AV) valves

**that separate the atria and the ventricles. **right AV valve is the tricuspid **left AV valve is the bicuspid or mitral valve. **The AV valves open during the hearts filling phase, or diastole to allow the ventricles to fill with blood. **During the pumping phase, or systole the AV valves close to prevent regurgitation of blood back up into the atria. There are no valves present between the vena cava and the RA, or between the pulmonary veins and the left atrium. For this reason, abnormally high pressure in the left side of the heart gives person symptoms of pulmonary congestion, and abnormally high pressure in the right side of the heart shows in the neck veins and abdomen.

Chambers

**the right side of the heart pumps blood into the lungs, and the left side of the heart simultaneously pumps blood into the body **two pumps are separated by an impermeable wall, the septum **Each side has an atrium and a ventricle **atrium is a thin walled reservoir for holding blood **ventricle is thick walled and is the muscular pumping chamber.

Reference Lines: Thorax

**use the reference lines to pinpoint a finding vertically on the chest Anterior Reference Lines: 1. Midsternal line 2. Midclavicular line 3. Anterior axillary line Posterior Reference Lines 1. Vertebral line 2. Scapular line Lateral Reference lines 1. Anterior axillary line 2. Midaxillary line 3. Posterior axillary line

Objective Data: Eyes Inspect External Ocular Structures

- Begin with the most external points, and logically work your way inward. a. General - Note the clts. Ability to move around the room, with vision functioning well enough to avoid obstacles, and to respond to your directions. b. Eyebrows- normally eyebrows are present bilaterally, move symmetrically as facial expression changes and have no scaling or lesions. ** Absent lateral third of brow with hypothyroidism **Unequal or absent movement with nerve damage. c. Eyelids and lashes- the upper lids normally overlap the superior part of the iris, and approximate completely with the lower lids when closed. The skin is intact without redness, swelling, discharge or lesions. **lid lag with hyperthyroidism **incomplete closure creates risk for corneal damage. Note that the eyelashes are evenly distributed along the lid margins and curve outward. d. Eyeballs - aligned normally in their sockets with no protrusion or sunken appearance. e. Conjunctiva and sclera- ask the clt to look up. Using your thumbs, slide the lower lids down along the bony orbital rim. Take care not to push against the eyeball. Inspect the exposed area. The eyeball should look moist and glossy. Numerous small blood vessels normally show through the transparent conjunctiva. Otherwise the conjunctiva are clear and show the normal color to the structure below- pink over the lower lids and white over the sclera. Note any color change, swelling or lesions. **pallor may indicate anemia **can indicate jaundice **Sclera is china white although some dark skinned clts. occasionally have a gray blue or "muddy" color to the sclera. Also in dark skinned clts, you may normally see small brown macules (like freckles) on the sclera, which should not be confused with foreign bodies or petechiae. f. Eversion of the upper lid- OMIT this test on classmate and clt. unless clt. c/o of pain or you suspect foreign body. This maneuver is not part of the normal exam, but is useful when you inspect the conjunctiva of the upper lid, as with eye pain or suspicion of foreign body. g. Lacrimal apparatus-ask the clt. to look down. With your thumbs, slide the outer part of the upper lid along the bony orbit. Inspect for any redness or swelling. **Swelling of the Lacrimal gland may show as a visible bulge in the outer part of the upper lid. Presence of excessive tearing may indicate blockage of the nasolacrimal duct. -Check this by pressing the index finger against the sac, just inside the lower orbital rim, not against the side of the nose. Pressure will slightly evert the lower lid, but there should be no other response. **Puncta red, swollen, tender to pressure. Watch for any regurgitation of fluid out of the puncta, which confirms duct blockage.

Auscultation: Valve Areas

- Identify the Ausculatory areas where you will listen. -The four traditional valve areas are not over the actual anatomic location of the valves but are at the sites on the chest wall where sounds produced by the valves are best heard. See textbook. 1. Aortic valve area- 2nd right interspace 2. Pulmonic valve area- 2nd left interspace 3. Erbs point-3rd left interspace 4. Tricuspid valve area- left lower sternal border 5. Mitral valve area- 5th interspace at around left midclavicular line. ***Use the mnemonic ape to man to remember sites.( the e stands for erbs point which is in the 3rd left interspace) -Do not limit your auscultation to only four locations because sounds produced by valves may be heard all over precordium. -Learn to inch your stethoscope in a Z pattern, from the base of the heart across and down, then over to the apex or start at the apex and go up. See attachment -Begin with the diaphragm and then switch to the bell noting the following: Rate and Rhythm- **Review Vital signs handout. Remember normal rate 60-100 beats per minute. Rhythm should be regular. If you notice any irregularity, check for a pulse deficit( auscultating apical beat while simultaneously palpating radial pulse.

Paroxysmal nocturnal dyspnea (PND)

- SOB when laying down or supine (associated with congestive heart failure and classically the clt. awakens two hours after sleep and flings open the window with the perception of needing fresh air)

** Rhinitis

- Stuffy nose; nasal mucosa is swollen and bright red with an URI.

Extra heart sounds: Fourth heart sound

- The S4 occurs at the end of diastole, at pre systole, when the ventricle is resistant to filling. -The atria contract and push blood into a non-compliant ventricle. This creates vibrations that are heard as S4. -The S4 occurs just before S1. S4 is an adventitious sound called an atrial gallop that heard over the tricuspid or mitral areas. -You may hear S4 in elderly clt. Or in clts with a previous MI.

tonsils

- a mass of lymphoid tissue -same color as the surrounding mucous membrane, although they look more granular, and their surface shows deep crypts -tissue enlarges during childhood until puberty, then involutes. -posterior pharyngeal wall is seen behind these structures -Some small blood vessels may show on it.

Auscultation: Murmurs

- a murmur is a blowing, swooshing sound that occurs with turbulent blood flow in the heart or great vessels. **a systolic murmur may occur with a normal heart or with heart disease; ****a diastolic murmur is always indicative of valvular heart disease.

Miosis

- constricted and fixed pupils. - Occurs with use of certain eye drops for glaucoma, narcotic use, with iritis, and brain damage of pons.

Mydriasis

- dilated and fixed pupils. -Occurs with certain eye drops, acute glaucoma, trauma and herald central nervous system injury, circulatory arrest or deep anesthesia.

Ptosis

- drooping of upper lid due to neuromuscular weakness -oculomotor cranial nerve III damage or sympathetic nerve damage. -Gives person sleepy appearance and impairs vision.

Conductive loss

- impacted cerumen is most common cause. Others foreign body, OM. -With conductive (middle ear) loss during the Weber test- the sound lateralizes to the bad ear or the one with the conductive loss ; Rinne test- AC = BC or BC> AC. -With sensorineural (inner ear) loss during the Weber test- the sound lateralizes to the good ear or the one without the loss ;Rinne test AC> BC but reduced overall. AC= air conduction BC= bone conduction

Abnormal pulses: Large bounding pulse

- increased pulse pressure, strong and bounding on palpation. -Graded as 3+ or 4+. -Causes: conditions that cause a increased stroke volume or decreased peripheral resistance: 1. Fever 2. Anemia 3. Hyperthyroidism 4. Complete heart block 5. Conditions resulting in decreased compliance of the aortic walls: a. Aging b. Atherosclerosis (plaque build up in arteries)

Otis media

- inflammation of the middle ear and TM. -Drum immobility is an early sign, then absence of light reflex, redness and bulging in superior part of drum along with earache and fever. Then lastly, fiery red bulging of entire drum occurs, deep throbbing pain and transient hearing loss.

Uvula

- is the free projection hanging down from the middle of the soft palate. -should move

Macular degeneration

- loss of central vision and visual acuity -Most common cause of blindness. -Person is unable to read fine print, sew or do fine work and has difficulty distinguishing faces. -Peripheral vision is not affected.

Myopia

- nearsightedness - impaired far vision

Objective data: Inspect and palpate the Nose: External Nose

- normally the nose is symmetric, in the midline, and in proportion to other facial features. -Inspect for any deformity, asymmetry, inflammation or skin lesions. -If any injury is reported or suspected, palpate gently for any pain or break in contour. -Test the patency of the nostrils by pushing each nasal sing shut with your finger while asking the clt. to sniff inward through the other naris. This reveals any obstruction, which late is explored using the nasal speculum. -The sense of smell, mediated by cranial nerve I, is usually not tested in a routine exam. **Absence of sniff indicates obstruction- nasal polyps, rhinitis.

Heart Sound: Normal heart sounds: First heart sound (S1)

- occurs with closure of the AV valves and thus signals the beginning of systole. -The mitral component of the first sound (M1) slightly precedes the tricuspid component (T1)- but you usually hear the two components fused as one sound. -You can hear S1 over all of the precordium but usually it is loudest at the apex.

Exophthalmos

- protruding eyes occurs with hyperthyroidism. "Lid lag"- the upper lid rests well above the limbus and white sclera is visible.

Paradoxical pulse

- pulse strength varies with respiration. -Decreases with inspiration and becomes stronger with expiration. -One cause is obstructive lung disease.

Ventricular impulse abnormalities: Laterally displaced Apical impulse

- the apical impulse is displaced laterally and found over a wider area. -Sign of volume overload. -Caused by Ventricular dilation.

Anisocoria

- unequal pupil size. -Exists is 5% population.

Ventricular impulse abnormalities: Lift

-A diffuse lifting noted on inspection. -occurs with right ventricular hypertrophy, as found in pulmonic valve disease, pulmonic hypertension, and chronic lung disease -feel lifting impulse in systole at lower left sternal border -may be ass. with retraction of apex because the left ventricle is rotated posteriorly by the enlarged right ventricle

Auscultation: Change Position

-After auscultating in the supine position: 1. roll the clt. towards his left side. Listen with the bell at the apex for the presence of any diastolic filling sounds. **S3 and S4 and the murmur of mitral stenosis may only be heard when the clt. is on the left side. 2. ask the clt. to sit up, lean forward slightly and exhale. Listen with the diaphragm firmly pressed at the base, right, and left sides. Check for the soft, high pitched early systolic murmur of aortic or pulmonic regurgitation. **murmur of aortic regurgitation sometimes may be heard only when the person is leaning forward in the sitting position.

Heart Rate:

-Although heart muscle has innate pattern of contractility, is also influenced by the autonomic nervous system to respond to changing needs: 1. Sympathetic impulses increase heart rate and therefore, increase CO 2. Parasympathetic impulses decrease heart rate and therefore, decrease CO

Objective Data: Neck vessels: Carotid Artery Auscultation

-Auscultate the carotid artery for persons middle aged or older clts. Who show signs or symptoms of CV disease. -Auscultate each carotid artery for the presence of a bruit -None should be present. ***A bruit is present when the lumen is occluded by ½ to 2/3. When the lumen is completed occluded - the bruit disappears. Thus absence of bruit, is not a sure indication of absence of carotid lesion.

Olfactory Nerve

-CN I (1) -sense of smell

Oculomotor Nerve

-CN III -Ptosis, drooping if upper eyelid

Glossopharyngeal Nerve

-CN IX (4) Touching the posterior wall with the tongue blade elicits the gag reflex

Vagus Nerve

-CN X (5) -tested by Ask the clt. to say "ahh" and note the soft palate and uvula rise in the midline. -also tested by touching the posterior wall with the tongue blade elicits the gag reflex

Hypoglossal nerve

-CN XII (7) -tested by asking the clt. to stick out the tongue. It should protrude in the midline. Note any tremor, loss of movement or deviation to the side. -With damage to cranial nerve XII, the tongue deviates toward the paralyzed side.

Optic Nerve

-CN ll -Scotoma a blind spot in the visual field surrounded by are area of normal or decreased vision can be caused by CN ll damage

Functions of the lymphatic system are:

-Conserve fluid and plasma proteins that leak out of the capillaries -Form a major part of the immune system that defends the body against disease -Absorb lipids from the intestinal tract.

Heart and Neck Vessels: Position and Surface Landmarks: Apical Pulse

-During contraction, the apex beats against the chest wall, producing an apical impulse. This is palpable in most people, normally at the fifth intercostal space, 7-9 cm from the midsternal line.

Objective Data: Cardiovascular(CV)

-First a general survey begins the moment you meet the clt: 1. Person's facial expression- should be relaxed and benign. Not tense, or strained 2. LOC- should be alert, awake, and cooperative- 3. Skin color- lips and nail beds should be pink and free of cyanosis and pallor and clubbing. Clubbing is a sign of chronic hypoxia caused by lengthy CV or respiratory disorder ex. cystic fibrosis.) -When performing a regional CV assessment use this order: 1. pulse and BP 2. extremities 3. neck vessels 4. precordium

Objective Data: Inspection of the Arms

-Inspect the arms at the very beginning when you are checking the vital signs. -Lift both the clt's arms in your hands. Inspect, then turn the clt.'s hands over, noting color of skin and nail beds; temperature, textures and turgor of skin and presence of any lesions, edema, or clubbing( if not noted earlier). -Compare one arm with the other- they should be symmetrical in size. -Check capillary refill- this is an index of peripheral perfusion and cardiac output. Depress and blanch the nail beds; release and note the time for color return. Usually the vessels refill within a fraction of a second. Consider it normal if the color returns in less than 1-2 seconds. **Refill lasting more than 2 seconds signifies vasoconstriction or decreased cardiac output. The hands are cold, clammy and pale. Note any scars on hands or arms. Ex: needle tracks- IVDA (IV drug abuse), suicide attempts from slashing wrists, tattoos etc.

Objective Data: Palpation Apical Pulse

-Localize the apical impulse precisely using one finger pad. -Asking the clt. to exhale and then hold it aids the examiner in locating the pulsation. You may need to roll the clt. midway to the left to find it, note that this also displaces the apical impulse farther to the left. Note: 1. location- Apical impulse should occupy only one interspace. The 4th or 5th , and be at or medial to the midclavicular line. 2. size- normally 1 cm X 2cm. 3. amplitude- normally a short, gentle tap 4. duration- short, normally occupies only first half of systole. ***The apical impulse is not palpable in: 1. about half of adults 2. obese persons or those with thick chest walls. 3. high cardiac output states (anxiety, fever, anemia) the apical impulse increases in amplitude and duration.

Subjective Data: Thorax and Lungs: Cough and mucous production

-PQRST -Do you cough up any phlegm or sputum? Cough seem to come with anything- activity, position(lying), fever, congestion, talking, anxiety? -Some conditions have a characteristic timing of cough: **continuous throughout the day- is associated with acute illness. **Afternoon/evening- may be due to irritants at work. **Night- postnasal drip, sinusitis. **Early morning-chronic bronchial inflammation of smokers. **chronic bronchitis is characterized by history of productive cough for 3 months of the year for 2 years in a row. -some conditions have a characteristic sputum production: **white or clear= colds, bronchitis, viral infections, **yellow or green= bacterial infections, **rust=TB, pneumonia, **pink, frothy= pulmonary edema.

Objective Data: Palpation of Arm

-Palpate both the radial, ulnar, and brachial arteries- noting equal rate, rhythm, and force. -Grade the force (amplitude on the four point scale, 4+ bounding, 3+ increase, 2+ normal, 1+ weak, 0 absent) -Palpate both epitrochlear lymph nodes in the depression above and behind the medial condyle of the humerus. Do this by "shaking hands" with the clt. and reaching your other hand under the clt's elbow to the groove between the biceps and triceps muscle. This node is not palpable normally. **An enlarged epitrochlear node occurs with infection of the hand or forearm. See textbook -Perform the modified Allen test to evaluate the adequacy of collateral circulation. by: 1. Firmly occlude both the ulnar and radial arteries of one hand while the clt. makes a fist several times. This causes the hand to blanch. 2. Ask the clt to open the hand without hyperextending it; then release pressure on the ulnar artery while maintaining pressure on the radial artery. Adequate circulation is suggested by a return to the hands normal color in approximately 2-5 seconds*** This test is useful but it is subject to error. To check the radial circulation. Repeat as above but release pressure on the radial artery instead. See textbook.

Objective Data: Neck vessels: Jugular Venous Pulse Inspection

-Position the clt. supine with the torso elevated anywhere from a 30-45 degree angle. Remove pillow and turn clts. Head slightly away from the examined side, and direct a strong light tangentially onto the neck to highlight pulsations and shadows -Note the external jugular veins overlying the sternomastoid muscle. In some individuals, the veins are not visible at all; whereas in others, they are full in the supine position. -As you raise the clt. to a sitting position, these external jugulars should flatten and disappear, at 45 degrees- this is normal. They should be symmetrical. -Now look for pulsations of the internal jugular veins in the area of the suprasternal notch or around the origin of the sternomastoid muscle around the clavicle.(although the external jugular vein is easier to see, the internal (especially the right) jugular vein is attached more directly to the superior vena cava and thus is more reliable for assessment. You cannot see the internal jugular vein itself, but you can see its pulsation). ***Do not confuse the internal jugular vein pulsation from that of the carotid artery. See textbbook.

Neck Vessels: Jugular Venous pulse and pressure

-The jugular veins empty unoxygenated blood directly into the superior vena cava. -Since no cardiac valve exists to separate the superior vena cava from the right atrium, the jugular veins give information about activity on the right side of the heart. -Specifically they reflect filling pressure and volume changes. -Since, volume and pressure increase when the right side of the heart fails to pump efficiently, the jugular veins expose this. -Two jugular veins are present on each side of the neck. The larger internal jugular lies deep and it is usually not visible. The external jugular vein is more superficial; it lies lateral to the sternomastoid muscle, above the clavicle.

Objective data: Inspect the Throat

-Using your light, observe the oval, rough surfaced tonsils behind the anterior tonsillar pillar. Their color is the same pink as the oral mucosa, and their surface is peppered with indentations, or crypts. -In some clts. the crypts collect small plugs of whitish cellular debris. This does not indicate infection. However, there should be no exudates on the tonsils. Tonsils are graded in size as follows: 1+ visible 2+ halfway between tonsillar pillars and uvula 3+ Touching the uvula 4+ touching each other **You may normally see 1-2+ tonsils in healthy clts, especially in children, because lymphoid tissue is proportionately enlarged until puberty. **Tonsils are enlarged to 2+ - 4+ with an acute infection. ** With an acute infection, tonsils are bright red, swollen and may have exudates or large white spots. ** a white membrane covering the tonsils may accompany infectious mono., leukemia and diphtheria. -Enlarge your view of the posterior pharyngeal wall by depressing the tongue with a tongue blade. Push down halfway back on the tongue; if you push on its tip, the tongue will hump up in back. Press slightly off center to avoid eliciting the gag reflex. -You can help the clt. whose gag reflex is easily triggered by offering a tongue blade to depress his or her own tongue. -Scan the posterior wall for color, exudates, or lesions. When finished, discard the tongue blade. During the exam, notice any breath odor. ** Halitosis, Diabetic ketoacidosis, Ammonia, Musty odor, Foul odor

Tongue

-a mass of striated muscle arranged in a crosswise pattern so that it can change shape and position. -has papillae are the rough, bumpy elevations on its dorsal surface. -Note the larger vallate papillae in an inverted V shape across the posterior base -Underneath the ventral surface is smooth and shiny and has prominent veins. -frenulum is a midline fold of tissue that connects the tongue to the floor of the mouth. - ability to change shape and position enhances its functions in mastication, swallowing, cleansing the teeth, and the formation of speech. also functions in taste sensation.

Ventricular impulse abnormalities: Thrill

-a murmur that is palpable. -Feels like the throat of a cat purring. -Usually associated with a grade IV or higher murmur. -Many causes.

Kiesselbach's plexus

-anterior part of the septum holds a rich vascular network -the most common site of nosebleeds.

cyanosis

-appears in light skinned clts.; blue lips -occurs with hypoexemia (low O2 levels in blood) and chilling

circumoral pallor

-appears in light skinned clts.; pale lips -occurs with shock and anemia

palate

-arching roof of the mouth -it is divided into two parts: 1. anterior hard palate is made up of bone and is a whitish color. 2.Posterior soft palate, an arch of muscle that is pinker in color and mobile.

paranasal sinuses

-are air filled pockets within the cranium -lighten the weight of the skull bones -serve as resonators for sound production -provide mucus, which drains into the nasal cavity. -The sinus openings are narrow and easily occluded (obstructed), which may cause inflammation or sinusitis.

Sinuses that are not accessible to examination-

-are smaller and deeper: - ethmoid sinuses between the orbits, -sphenoid sinuses deep within the skull in the sphenoid bone.

Objective data: Inspect and palpate the Nose: Nasal Cavity

-attach the short wide tipped speculum to the otoscope head and insert this into the nasal vestibule, avoiding pressure on the nasal septum. -Gently lift up the tip of the nose with your finger before inserting. -View each nasal cavity with the clts. head erect, then with the head tilted back. -Inspect the nasal mucosa, noting its normal red color and smooth moist surface. Note any swelling, discharge, bleeding or foreign body. **Discharge is common with rhinitis and sinusitis, varying from watery and copious to thick, purulent and green yellow. Observe the nasal septum for deviation. -A deviated septum is common and is not significant unless airflow is obstructed. Note any perforation or bleeding in septum. ** For hospitalized clt. , document deviated septum in event clt. needs nasal suctioning or a nasogastric tube for feeding. **A deviated septum looks like a hump or shelf in one nasal cavity. **Perforation is seen as a spot of light from penlight shining in other naris. **Epistaxis commonly comes from anterior septum. Inspect the turbinates, the bony ridges curving down from the lateral walls: -The superior turbinate will not be in your view, but the middle and inferior turbinates appear the same light red color as the nasal mucosa. Note any swelling but do not try to push the speculum past it. Turbinates are quite vascular and tender if touched. Note any polyps, which are benign growths that accompany chronic allergy and distinguish them from the normal turbinates. **Polyps are smooth, pale gray, avascular, mobile and nontender.

Halitosis

-bad breath -common and usually is due to local cause, such as: poor oral hygiene, consumption of certain foods, alcohol consumption, heavy smoking or dental infection.

polyps

-benign growths that accompany chronic allergy -smooth, pale gray, avascular, mobile and nontender.

Objective Data Inspection of the legs

-both legs must be completely visible 1. Inspect both legs together noting skin color, hair distribution, venous pattern, size or swelling or atrophy and any skin lesions or ulcers. **Pallor, erythema, any cyanosis. Normally hair covers the legs. If legs are shaved, you will note hair on the dorsa of the toes. ***Note any- thin, shiny atrophic skin, thick ridged nails, loss of hair, ulcers, gangrene. Malnutrition, pallor and coolness occur with arterial insufficiency. **In the presence of skin discoloration, ulcers, or gangrene- note the size and exact location. Ex: brown discoloration occurs with chronic venous statis. Venous ulcers occur usually at medical malleolus because of bacterial invasion of poorly drained tissues. With arterial deficit, ulcers occur of tips of toes, metatarsal heads, and lateral malleoli. 2.The venous pattern normally is flat and barely visible. Note any varicosities, although these are best assessed while standing. 3. Both legs should be symmetric in size without any swelling or atrophy. If the lower legs look asymmetric or if deep vein thrombosis (DVT) is suspected, measure the calf circumference at the widest point, taking care to measure the other leg in exactly the same place. If lymph edema is suspected, measure also at the ankle, distal calf, knee and thigh. Record your findings in centimeters.

**Lymphatic obstruction

-can be unilateral or bilateral. -feels hard and non-pitting

Inspection of Anterior Chest

-clt. can be sitting or supine and anterior chest must be visible: not covered with gown 1. note shape and configuration of chest wall 2. note skin color and condition-any lesions 3. note respiratory effort and any use of accessory muscles 4. observe the costal angle- increased with emphysema ** Barrel chest has horizontal ribs and costal angle >90 degrees.

Hyperopia

-farsightedness - impaired near vision. -Globe of eye is shorter than normal.

Objective data: Inspect the posterior chest

-female: the clt is sitting with gown opened in back -male: gown opened in back or shirtless Note: 1. Shape and configuration of the chest wall: observe for any skeletal abnormalities: scoliosis, kyhposis-may limit thoracic excursion. 2. The anteroposterior (AP) diameter should be less than the transverse diameter. The ratio of AP to transverse diameter is from 1:2 ***AP=transverse diameter is called "barrel chest"(ribs are horizontal and chest appears as if held in continuous inspiration.) and this occurs with COPD due to hyperinflation of the lungs. 3. Neck muscles and trapezius muscles should be developed normally for age and occupation. ** Neck muscles are hypertrophied in COPD from aiding in forced respirations 4. Position the person takes to breath- should be relaxed with the ability to support one's own weight with arms comfortably at sides or in lap. ***People with COPD often sit in a tripod position, leaning forward with arms braced against their knees, chair or bed. This gives them leverage so that their accessory muscles all can aid in expiration. 5. Inspect the skin color and condition- should be consistent with clt. genetic background. Any lesions and inquire about any change in nevus on the back where most clts. will have difficulty monitoring skin lesions

Peripheral vascular system and Lymphatics:

-form a completely separate vessel system, which retrieves excess fluid form the tissue spaces and returns it to the bloodstream. -During circulation of the blood, somewhat more fluid leaves the capillaries than the veins can absorb. -Without lymphatic drainage, fluid would build up in the interstitial spaces and produce edema. -vessels drain into two main trunks, which empty into the venous system at the subclavian veins: 1. The right lymphatic duct empties into the right subclavian vein. It drains the right side of the head and neck, right are, right side of thorax, right lung, and pleura, right side of the heart, and right upper section of the liver 2. The thoracic duct drains the rest of the body. It empties into the left subclavian vein.

Presbycusis

-gradual loss of hearing due to nerve degeneration from aging and ototoxic drugs. -Accentuated when background noise is present. -High tone frequency loss. -Person is unable to hear whispered words because a whisper is a high frequency sound. -Form of sensorineural loss.

**unilateral swelling in legs

-indicates a local acute problem. -Asymmetry of calves of 1 cm or more is abnormal. -With lymph edema asymmetry can be: -mild 1-3cm -3-5cm with moderate - +5cm with severe

Otitis externa

-infection of outer ear and ear canal with severe painful movement of pinna and tragus -Redness and swelling of pinna and canal. -Scanty purulent discharge, scaling and itching and enlarged cervical lymph nodes. -Called swimmers ear. Hearing is normal or slightly diminished.

**Crepitus

-is a coarse crackling sensation palpable over the skin surface. -It occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as following surgery or from pathology. -Feels like palpating "puffed rice".

Pulsus Alternans

-is a regular rhythm but changes in amplitude or strength from beat to beat. -Caused by left ventricular failure

Nasopharynx

-is continuous with the oropharynx, although it is above the oropharynx and behind the nasal cavity. -Pharyngeal tonsils (adenoids) and the Eustachian tube openings are located here.

oropharynx

-is separated from the mouth by a fold of tissue on each side, the anterior tonsillar pillar.

Cardiac output(CO)

-is the amount of blood pumped by ventricles during a given period of time(usually 1min) -determined by stroke volume(SV) X heart rate. -Normal adult CO is 5-6L/Min.

Nose

-is the first segment of the respiratory system -warms, moistens and filters the inhaled air, and it is the sensory organ for smell.

Objective Data: Eyes- systemically inspect the structures in the fundus: Optic disc

-is the most prominent landmark, located on the NASAL side of the retina. -Explore these characteristics: a. color- creamy yellow-orange to pink b. shape-round or oval c. margins- distinct and sharply demarcated, although the nasal edge may be slightly fuzzy d. cup-disc ratio- distinctness varies. When visible, physiologic cup is a brighter yellow-white than rest of the disc. Its width is not more than one half the disc diameter. **Two normal variations may be present around the disc margins: 1. Scleral crescent is a gray white new moon shape. It occurs when pigment is absent in the choroids layer and you are looking directly at the sclera. 2. Pigment crescent is black and it is due to accumulation of pigment in the choroid ** The diameter of the disc or DD is a standard of measure for other fundus structures. To describe a finding note its clock- face position as well as its relationship to the disc in size and distance. Ex. at 4:00, 2 DD from the disc. ***See textbook

Orthopnea

-is the need to assume a more upright position to breath. -Ask how many pillows do you use when sleeping or lying down? Does the SOB interrupt with the clts. ADLs or IADLs?(PQRST)

parotid gland

-largest -lies within the cheeks in front of the ear extending from the zygomatic arch down to the angle of the jaw - Its duct, Stensen's duct, runs forward to open on the buccal mucosa opposite the second molar

Peripheral vascular system: Femoral Artery, Popliteal Artery, Tibial Artery, Plantar Artery

-major artery in the leg, passing under the inguinal ligament; the femoral artery travels down the thigh. At the lower thigh it courses posteriorly; then it is termed the popliteal artery. -Below, the knee, the popliteal artery divides. The anterior tibial artery travels down the front of the leg on to the dorsum of the foot, where it becomes the dorsalis pedis. -In back of the leg, the posterior tibial artery travels down behind the medial malleolus and in the foot forms the plantar arteries.

Peripheral vascular system: brachial artery and radial arteries

-major artery supplying the arm - runs in the biceps -triceps furrow of the upper arm and surfaces at the antecubital fossa in the elbow medial to the biceps tendon. -Immediately below the elbow, the brachial artery bifurcates into the ulnar and radial arteries. The radial pulse lies just medial to the radius at the wrist; the ulnar artery is in the same relation to the ulna, but is deeper and often difficult to feel.

Auscultation: Identify S3 and S4

-occur in diastole -S3: ventricular gallop; heard immediately after S2 -S4: atrial gallop; heard immediately after S1 -either may be normal or abnormal. **A pathologic S3 ventricular gallop occurs with heart failure and volume overload; normal in kids and young adults, ventricular resistance to filling **a pathologic S4 atrial gallop occurs with Coronary artery disease, MI, noncompliant ventricle when atria contracts

Heart Sound: Normal heart sounds: Second heart sound (S2)

-occurs with closure of the semilunar valves and signals the end of systole. -aortic component of the second sound (A2) slightly precedes the pulmonic component (P2). -Although it is heard over all the precordium, S2 is loudest at the base.

Neck vessels: Carotid Artery Palpation

-palpate each carotid artery medial to the sternomastoid muscle in the neck. -Avoid excessive pressure on the carotid sinus area higher in the neck; excessive vagal simulation here could slow down the heart rate, especially in older adults. -Palpate gently and palpate only one carotid artery at a time to avoid compromising arterial blood flow to the brain. -Feel the contour and amplitude of the pulse. **Normally the contour is smooth with a rapid upstroke and slower down stroke, and normal strength is 2+. Should be symmetrical. **1+--> Diminished pulse feels small and weak **2+--> Normal **3+--> Increased pulse feels full and strong **4+--> Bounding

Bigeminal pulse

-regular, irregular rhythm (one regular beat followed by a premature contraction). -Alternates in amplitude also from one strong pulse followed a quicker weaker one. -Caused by premature ventricular contractions

Cardiac Cycle:

-rhythmic movement of blood through the heart is the cardiac cycle. -It has two phases: diastole and systole -In diastole the ventricles relax and fill with blood. -The hearts contraction is systole.

oval cavity

-short passage bordered by the lips, palate, cheeks, and tongue. -contains the teeth and gums, tongue, and salivary glands.

submandibular gland

-size of a walnut. -lies beneath the mandible at the angle of the jaw -Wharton's duct runs up and forward to the floor of the mouth and opens at either side of the frenulum.

sublingual gland

-smallest, the almond shaped -lies within the floor of the mouth under the tongue. It has many small openings along the sublingual fold under the tongue. -glands secrete salvia, the clear fluid that moistens and lubricates the food bolus, starts digestion and cleans and protects the mucosa.

Enophthalmos

-sunken eyes -occurs with dehydration or wasting illnesses.

Periorbital edema Bilateral

-swelling around eyes - systemic disease- CHF, renal failure, hypothyroidism, allergic reaction.

Periorbital edema Unilateral

-swelling around eyes . -local inflammation, infection.

Objective Data: Precordium Inspection

-the clt. is supine with the precordium exposed -Inspect the anterior chest looking for pulsations and heaves. -Arrange tangential lighting to accentuate any flicker of movement. You may or may not be able to see the apical impulse, the pulsation created as the left ventricle rotates against the chest wall during systole. When visible it occupies the 4-5 intercostal space, at or inside the midclavicular line. It is easier to see in kids and in those with thinner chest walls.

Auscultate the Posterior Chest: Voice sounds or vocal resonance

-the spoken voice can be auscultated over the chest wall just as it can be felt in tactile fremitus. -Ask the person to repeat a phrase while you listen over the chest wall. **Normal voice transmission is soft, muffled, and indistinct, you can hear sound through the stethoscope but cannot distinguish exactly what is being said. Eliciting voice sounds is not usually done unless pathology is suspected. When performed you are testing for: 1. bronchophony( abnormal transmission of sounds from the lungs or bronchi)- say "99" 2. egophone(increased resonance of voice sounds heard when auscultating the lungs,)- say "e" 3. whispered pectoriloguy- whisper "1-2-3" ** Abnormal voice sounds indicate pathology and indicate that the normally air- filled lungs have become airless, ex: consolidation.** See textbook.

In diastole

-the ventricles are relaxed, and the AV valves (the tricuspid and mitral) are opened (opening of normal valves is acoustically silent) -Blood pours into the ventricles from the atria. -This first passive filling is called early or protodiastolic filling. -During the end of diastole, the atria contract and push the last amount of blood (about 25% of stroke volume) into the ventricles. This active filling is called presystole or atrial systole or atrial kick. -Now so much has been pumped into the ventricles that ventricular pressure is finally higher than that in the atria, so the mitral and tricuspid valves swing shut. -This closure of the AV valves contributes to the first heart sound -S1 and signals the beginning of systole. The AV valves close to prevent regurgitation of blood back up into the atria during contraction. -For a very brief moment all four valves are closed. -The ventricular walls contract. This contraction against a closed system works to build pressure inside the ventricles to a high level. Consider first the left side of the heart. -When the pressure in the LV exceeds pressure in the aorta, the aortic valve opens and blood is ejected rapidly. -After the ventricles contents are ejected, its pressure falls. When pressure falls below pressure in the aorta, some blood flows backward toward the ventricle, causing the aortic valve to swing shut. This closure of the semilunar valves causes the second heart sound -S2. -Now all four valves are closed and ventricles relax. The atria have been filling with blood delivered from the lungs ( on the left) and the venous systemic circulation( on the right) Atrial pressure is now higher than the relaxed ventricular pressure . -The mitral valve drifts open and the tricuspid valve opens also and diastolic filling begins again. -Pressures in the right side of the heart are much lower than those of the left side because less energy is needed to pump blood to its destination, the pulmonary circulation. -Also, events occur just slightly later in the right side of the heart due to the route of myocardial depolarization. As a result, two distinct components to each of the heart sounds exist, and sometimes you can hear them separately. -In the first heart sound, the mitral component (M1) closes just before the tricuspid component (T1). And with S2, aortic closure (A2) occurs slightly before pulmonic closure (P2).

Objective Data: Palpate the entire chest wall

-using your fingers note any areas of tenderness, skin temperature and moisture and detect any lumps, masses. Note any crepitus. There should be none.

Peripheral vascular system: Anatomy Review

-vascular system consists of the vessels in the body that transport fluid, such as blood or lymph. -heart pumps freshly oxygenated blood and nutrients through the arteries to all body tissues. The pumping heart makes this a high-pressure system.

varicosities

-veins that have become enlarged and twisted. - best assessed when standing

Extra heart sounds: Third heart sound

-ventricular filling creates vibrations that can be heard over the chest. These vibrations are S3. The S3 occurs when the ventricles are resistant to filing during the early rapid filling phase. -This occurs immediately after S2, when the AV valves open and atrial blood first pours into the ventricles. -This third heart sound is frequently heard in children and in clt.s with high cardiac output. -Called ventricular gallop when it occurs in adults. S3 may be a cardinal sign of CHF. -S3 is best heard at the apex when the clt. Is lying on his back.

Subjective Data: Thorax and Lungs: Shortness of breath(SOB)

-when- at rest or walking up hill, etc. Is it affected by position, like lying down? Occur at specific time of day or night? **Determine how much activity precipitates the SOB- state specific number of blocks walked, or stairs or if at rest.

Glaucoma (increased ocular pressure)

- Involves loss of peripheral vision -Halos around lights occur with acute narrow angle glaucoma.

Presbyopia

- impaired near vision found in middle aged and older people due to lens losing elasticity and decreasing its ability to change shape in order to accommodate for near vision

Nystagmus

- involuntary rapid oscillating movement of the eyeball -occurs with disease of the semicircular canals in the ears, a paretic eye muscle, multiple sclerosis or brain lesion.

Auscultate the Posterior Chest: Adventitious sounds

-are added sounds that are not normally heard in the lungs. -They are classified s continuous and discontinuous. -Continuous sounds are: 1. wheezes (high pitched)- they are high pitched, musical squeaking sounds which predominate in expiration but may also be heard in inspiration. Here air is squeezed through narrow almost closed passages. 2. wheeze low pitched (rhonchi)- low pitched, musical snoring, moaning sounds, hear throughout cycle but more prominent on expiration, may clear somewhat by coughing. Ex. Bronchitis, obstruction from tumor. -Discontinuous sounds: 1. crackles (rales.) - discontinuous crackling sounds. **See text book.

Lymph nodes

-are small oval clumps of lymphatic tissue located at intervals along the vessels. -Most nodes are arranged in groups, both deep and superficial in the body. -Nodes filter the fluid before it is returned to the bloodstream and filter out microorganisms that could be harmful to the body. -The pathogens are exposed to lymphocytes in the lymph nodes. -With local inflammation the nodes in that area become swollen and tender. -The superficial groups of nodes are accessible to inspection and palpation and give clues to the status of the lymphatic system.

gums (gingivae)

-collar the teeth -thick fibrous tissues covered with mucous membrane -different from the rest of the oral mucosa because of their pale pink color and stippled (markings) surface.

lateral walls of each nasal cavity

-contain three bony projections- the turbinates (superior, middle, and inferior) . -They increase the surface area so that more blood vessels are available to warm, humidify and filter the inhaled air. -Underlying each turbinate is the cleft, the meatus, which is named for the turbinate above

Neck Vessels: Carotid artery pulse

-is a central artery- that is close to the heart. Its timing closely coincides with ventricular systole.

Pulses/ Pulse Scale

-normal pulse has a smooth, rounded wave. -Pulse should feel strong and regular and is graded as 2+. -is usually a 3 or 4 point scale depending upon facility. (0-3+ or 0-4+) **** 0=absent 1+=Weak 2+=Normal 3+= increased 4+=bounding

Neck vessels: Carotid Artery Inspection

-the clt. may be sitting up with the neck exposed. The clt. is in a gown with the opening in the back.. The examiner is standing on the clt's right side. **Inspect the neck for pulsations - carotid pulsations may be visible just medial to the sternomastoid muscles. A tortuous and kinked carotid artery may produce a unilateral pulsatile bulge.

Ventricular impulse abnormalities: Accentuated Apical impulse

-very strong and bounding apical impulse. -Increased force is noted. -This is a sign of pressure overload.

Percuss Anterior Chest

1. Begin per cussing the apices and down the lungs comparing one side to the other avoid the female breast, shift breast over slightly using edge of stationary hand or ask the clt. to displace it. -Note borders of cardiac dullness and the upper border of liver dullness (located in the fifth intercostal space in the right midclavicular line). On the left, tympany is evident over the gastric space. ** Lungs are hyperinflated with emphysema, resulting in Hyperresonance where you would expect cardiac dullness.

Objective Data: Palpation of the legs: Temperature

1. Palpate for temperature along the legs down to the feet, comparing symmetric spots. The skin should be warm and equal bilaterally

Adults have 1.______ permanent teeth- _____in each arch.

32 permanent teeth 16 in each arch

Objective Data: Check for pretibial edema

5. Firmly depress the skin over the tibia for 5 seconds and release. Normally your fingers should leave no indentation, although it may be seen if the person has been standing all day or is pregnant. **IF the clt. Is confined to bed be sure to check the sacrum for swelling.

Murmurs

1. Blood circulating through normal cardiac chambers and valves usually makes no noise. -However, some conditions create turbulent blood flow and collision currents. This results in murmur. -A murmur is a gentle, blowing, swooshing sound that can be heard on the chest wall. Conditions resulting in murmurs: 1. Velocity of blood increases (flow murmur). Ex: in exercise, in thyrotoxicosis 2. Viscosity of blood decreases ex. Anemia 3. Structural defects in the valves (narrowed valve, incompetent valve) or unusual openings occur in the chambers (dilated chamber, wall defect). -Are typically characterized by longer duration due to turbulent blood flow which creates a swooshing or blowing sound. -Heart murmurs are assessed to various characteristics including timing. -A heart murmur can occur during systole or diastole. -A systolic murmur can be normal or pathological -A diastolic murmur always indicates valvular heart disease.

Subjective Data: Cardiovascular(CV)

1. Chest pain or tightness (PQRST) 2. Irregular heartbeat or palpitations 3. Dyspnea (on exertion, lying down, or at night or at rest all the time.) 4. Cough? (PQRST). Is there mucous? What color and amount? 5. Fatigue? 6. Cyanosis or pallor-Ever noticed your skin turn blue or ashen? 7. Edema- any swelling of your feet, arms and legs?. 8.Nocturia 9. Past cardiac history- HTN, elevated cholesterol or triglycerides, heart murmur, congenital heart disease.- Ever had heart disease? Heart surgery? Last ECG, etc.? 10. Leg pain or cramps? 11. Skin changes on arms or legs? Any redness, pallor, blueness or brown discoloration? Any temp. change? Any leg sores or ulcers? Do your veins look bulging and crooked? Ex. coolness is associated with arterial disease. 12. Lymph node enlargement- any swollen glands? 13. Family cardiac history- Any family history of HTN, MI, coronary artery disease(CAD), sudden death at younger age? 14. Personal habits- cardiac risk factors a. Nutrition- Please describe your usual daily diet? (note if it represents all basic food groups) b. Smoking-how many packs per day and for how many years? c. Alcohol- d.Exercise e. Drugs- prescription- including hormone replacement, OTC, illicit.

Objective Data: Eyes Inspect the ocular fundus:

1. Darken the room to help dilate the pupils. Dilating eye drops are not needed during a screening exam. When indicated, they dilate the pupils for a wider look at the fundus background and macular area. Eye drops are used only when glaucoma can be completely r/o(ruled out) , because dilating the pupils in glaucoma can precipitate an acute episode. 2. Remove eyeglasses from yourself and the clt. Contact lenses may be left in. You can compensate for eyeglass correction by using the diopter setting. 3. Select the large round aperture with a white light for the routine exam. If pupils are small, use the smaller white light. **Although the instrument has other shape and colored apertures, these are rarely used in a screening exam. 4. Tell the clt. to look at a mark(such as picture, light switch etc.) on the wall across the room. Staring at a fixed distant object helps to dilate the pupils and to hold the retinal structures still. 5. Match sides with the clt. That is holding the instrument in your right hand up to your right eye to view the clts. right eye and vice versa. Do this to avoid bumping noses during the exam and to be not as intimate with the clt. as nose to nose is. Place your free hand on the clts. Forehead over the eye you are viewing. This helps to orient you in space. Your thumb can anchor the upper lid in place and help prevent blinking. **See textbook. 6. Begin about 10 inches away from the clt at about 15 degrees lateral to the clts. Line of vision. Note the red glow filling the clt.s. pupil. This is the red reflex, caused by the reflection of the instrument light off the inner retina. Keep sight of the red reflex, and steadily move closer to the eye. If you lose the red reflex, the light has wandered off the pupil and onto the iris or sclera. Adjust your angle to find it again. **cataracts appear as opaque black areas against the red reflex. 7. Progress toward the clt. until your foreheads almost touch. Adjust the diopter setting to bring the fundus into sharp focus. If you and the clt. have normal vision, this should be at 0. Moving the diopter compensates for nearsightedness or farsightedness. Use the red lenses (negative diopter) for nearsighted eyes (myopia) and the black (Positive diopter) for farsighted eyes (hyperopia). **See textbook 8. Moving in on the lateral line should bring your view just to the optic disc. If the disc is not in sight, track a blood vessel as it grows larger and it will lead you to the disc.

Subjective Data: Nose

1. Discharge 2. Frequent colds- any unusually frequent or severe colds (URI- Upper respiratory infections)? 3. Sinus pain- 4. Trauma- **Trauma may cause deviated septum, which may cause nares to be obstructed. 5. Epistaxis( nosebleeds)- **Epistaxis occurs with trauma, vigorous nose blowing, foreign body. **Clt. should sit up with head tilted forward, pinch nose between thumb and forefinger for 5- 15 minutes. 6. Allergies- **Seasonal rhinitis(stuffy nose) if due to pollen; perennial if allergen is dust. *** Misuse of OTC nasal meds. Irritates the mucosa, causing rebound swelling a common problem. 7. Altered smell- experienced any change in sense of smell? **sense of smell diminished with smoking or chronic allergies.

Objective Data: Percuss the Posterior Chest

1. Find predominant note- start at apices and percuss in the interspaces, make a side-to-side to comparison all the way down the lung region. Avoid the damping effect of the scapulae and ribs. Avoid the vertebrae. ***Resonance predominates in the health lung. ***Small and deep lesions will not be noted by percussion ***See textbook 2. Diaphragmatic excursion- ask the clt. to "exhale and hold it briefly" while you percuss down the scapular line until the sound changes from resonant to dull on each side. Mark the spot with ink. Now ask clt. to "take deep breath and hold it briefly". Continue percussing down from your first mark and mark the level where the sound changes to dull on deep inspiration. Mark this spot. Measure the difference. This estimates the level of the diaphragm separating the lungs from the abdominal viscera. It may be somewhat higher on the right side due to the presence of the liver. Perform this procedure on both sides. They should be about 3-5 cm (can be up to 7-8 cm in athletes) and equal bilaterally. ** An abnormal high level on one side can occur with a large pleural effusion of the lower lobe. **See textbook

Anatomy Review: Lungs

1. In the anterior chest, the apex or highest point of lung tissue is 3-4 cm above the inner third of the clavicles 2. The base or lower border, rests on the diaphragm at the about the 6th rib in the midclavicular line. 3. Laterally, the lung tissue extends from the apex of the axilla down to the 7th or 8th rib. 4. Posteriorly, the location of C7 marks the apex of lung tissue, and T10 corresponds to the base. Deep inspiration expands the lungs and their lower border drops to the level of T12. 5. The lungs are paired but not precisely symmetric structures. The right lung is Shorter than the left lung because of the underlying liver. The left lung is narrower than the right lung because the heart bulges to the left. 6. The right lung has three lobes, and left lung has two lobes. 7. The pleurae form a thin slippery envelope between the lungs and chest wall. 8. Visceral pleura line the outside of the lungs. 9. Parietal pleurae line the inside of the chest wall and diaphragm. Inside of this envelope is called the pleural cavity or space and is filled with only a few milliliters of lubricating fluid. It normally has a vacuum or negative pressure, which holds the lungs tightly against the chest wall.

Palpate Anterior Chest

1. Palpate symmetric chest expansion: -place your hands on the anterolateral wall with the thumbs along the costal margins and pointing toward the xiphoid process. Ask clt to take deep breath. Watch your thumbs move apart symmetrically and note smooth chest expansion with your fingers. Any limitation is easier to detect to the anterior chest because greater range of motion exists with breathing here **Note any lag in expansion or unequal chest expansion which occurs with pneumonia, thoracic trauma such as fractured ribs or other pathology such as pneumothorax. 2. Assess tactile fremitus: -begin over apices in the supraclavicular areas. Compare vibrations from one side to the other as the clt. -repeats ninety-nine. Avoid female breast tissue which normally dampens sounds. 3. Palpate the anterior chest wall to note any tenderness and detect any lumps. Note temperature and moisture

Subjective Data: Thorax and Lungs: Chest pain with breathing; Past history of respiratory infections

1. Please point to exact location. When did it start? Constant or intermittent? Describe pain. PQRST. 2. any past history of breathing trouble or lung diseases like bronchitis, emphysema, asthma, pneumonia? Any unusually frequent or unusually severe colds? Any family history of allergies, TB, or asthma? .

Stroke volume is influenced by:

1. Preload- which is the degree of stretch of heart muscle before contraction. Increased preload= Increased stroke volume. 2. Afterload- pressure which heart muscle has to eject blood during contraction.Increased afterload=Decreased stroke volume. 3. Synergy of contraction. Conditions that cause an asynchronous contraction= decreased stroke volume 4. Compliance of ventricles or distensibility of ventricles. Decreased compliance= Decreased stroke volume 5. Contractility or force of contractions. Increased contractility= Increased stroke volume

Objective Data Inspection - first general survey of clts.

1. Respiratory status- begins the moment you meet the clt. 2. Persons facial expression- should be relaxed and benign. Not tense, strained. **The clt. with COPD may purse the lips in a whistling position 3. Level of consciousness- should be alert, awake and cooperative- cerebral hypoxia may be reflected by excessive drowsiness, anxiety, and irritability 4. Skin color and condition- lips and nail beds should be pink and free of cyanosis and clubbing. Clubbing indicates long standing chronic respiratory or cardiac disease. Assess the quality of respirations- should be automatic, effortless, regular and Even and produce no noise. Noisy breathing occurs with severe asthma or chronic bronchitis. Observe for nasal flaring- there should be none. 5. RR is WNL for the person's age and the pattern of breathing is regular. ** For an adult the normal RR is 10-20 breaths per minute. 6. No accessory muscles should be used for breathing except after very heavy exercise, when they are used momentarily. Accessory muscles are used in acute respiratory distress

Subjective Data: Throat

1. Sores and lesions- ** History helps to determine if oral lesions have infectious, traumatic, immunologic or malignant etiology- Remember history of smoking and heavy alcohol use associated with Head and neck Cancers- throat, tongue, etc. 2. Sore throat- 3. Hoarseness- **Disorders of the larynx are due to many causes- overuse of voice, URI, chronic inflammation, lesions or Cancer. 4. Dysphagia- any difficulty swallowing? How long? Food gets stopped at certain point? Any pain? 5. Smoking, alcohol consumption? Cage questionnaire. **Chronic tobacco use is associated with tooth loss, and periodontal disease in older adults. **CHRONIC USE OF TOBACCO IN ANY FORM AND HEAVY ALCOHOL USE- INCREASE RISK OF ORAL AND PHARYNGEAL CANCERS.

Subjective Data: Mouth

1. Sores and lesions- any sores or lesions in the mouth, tongue, or gums? ** History helps to determine if oral lesions have infectious, traumatic, immunologic or malignant etiology- Remember history of smoking and heavy alcohol use associated with Head and neck Cancers- throat, tongue, etc. 2. Bleeding gums- how long? Any treatment? 3. Toothache- any toothache? Teeth sensitive to hot/cold? Have you lost any teeth? 4. Hoarseness- any hoarseness, voice change? 5. Altered taste- any change in sense of taste? 6. Smoking, alcohol consumption? Cage questionnaire. **Chronic tobacco use is associated with tooth loss, and periodontal disease in older adults. 7. Self care behaviors- daily dental care? **Assess self care behaviors for oral hygiene. **periodic dental screening is necessary to note caries. ** lesions may arise from ill fitting dentures or the presence of dentures may mask the eruption of new lesions.

Anatomy Review: Anterior Thoracic Landmarks

1. Supersternal notch- feel this hollow U-shaped depression just above the sternum in between the clavicles. 2. Sternum- breastbone has three parts- manubrium, body and xiphoid process.CONTAINS bone marrow. Walk your fingers down the manubrium a few centimeters until you feel a distinct bony ridge the manubriosternal angle or the Angle of Louis, or the sternal angle. 3. Angle of Louis also called the sternal angle- this is the articulation of the manubrium and body of sternum, and it is continuous with the second rib. The angle of Louis is a useful place to start counting ribs. Identify the angle of Louis, palpate lightly to the 2nd rib, and slide down to the second intercostal space. Each intercostal space is numbered by the rib above it. Count down the ribs in the middle of the hemi thorax, not close to the sternum where the costal cartilages lie too close together to count. You can palpate easily down to the 10th rib. Angle of Louis also marks the site of tracheal bifurcation into the right and left main bronchi, it corresponds with the upper border of the atria of the heart 4. Costal angle- the right and left costal margins from an angle where they meet at the xiphoid process. Usually 90 degrees or less, this angle increases when the rib cage is chronically over inflated, as with COPD and emphysema.

Objective data: Palpate the posterior chest

1. Symmetric expansion- confirm symmetric chest expansion by placing your warmed, cleaned hands on the posterilateral chest wall with thumbs at the level of T9-T10. Slide your hands medially to pinch up a small fold of skin between your thumbs. Ask clt. to take deep breath. As the clt. inhales deeply, your thumbs should move apart symmetrically. **Note any lag in expansion or unequal chest expansion which occurs with pneumonia, thoracic trauma such as fractured ribs or other pathology such as pneumothorax (collapsed lung) 2. Tactile fremitus- use the palmer base (the ball) of the fingers and touch the clt's chest while he repeats the words "ninety-nine". Start over lung apices and palpate down, comparing one side with another. Fremitus varies among clts. **But symmetry is most important. Fremitus should be symmetrical. Note ay areas of abnormal fremitus. Sound is conducted better through a dense structure than through a porous one, thus any conditions that increase the density of lung tissue make a better conducting medium for sound vibrations and increase tactile fremitus.

Anatomy Review: Thorax

1. The thoracic cage is a bony structure with a conical shape, which is narrower at the top. 2. It is defined by the sternum, 12 pairs of ribs and 12 thoracic vertebrae. 3. It's floor is the diaphragm (a musculotendinous septum that separates the thoracic cavity from the abdomen) 4. The first seven ribs attach directly to the sternum via their costal cartilages. 5. Ribs 8, 9, 10 attach to the costal cartilage above. 6. Ribs 11 and 12 are floating with free palpable tips. 7. The costochondral junctions are the points at which the ribs join their cartilages. They are not palpable.

DVT

Deep vein thrombosis

Heart Sounds

Events in the cardiac cycle generate sounds that can be heard through a stethoscope over the chest wall. These include normal heart sounds and extra heart sounds and murmurs.

**Dysphagia occurs with

GERD (gastroesophageal reflux disease, pharyngitis, stroke and other neurological diseases, and esophageal cancer.

**CHRONIC USE OF TOBACCO IN ANY FORM AND HEAVY ALCOHOL USE

INCREASE RISK OF ORAL AND PHARYNGEAL CANCERS.

Objective Data: Additional Tests of Legs for suspected abnormalities- Manual Compression Test for Varicose Veins.

Now have the clt. stand. Test the length of the varicose vein to determine if its valves are competent. Place one hand on the loser part of the varicose vein, and compress the vein with your other hand about 15-20 cm higher. Competent valves will prevent a wave transmission and your distal fingers will fee no change. ** a palpable wave occurs when the valves are incompetent.

Objective Data: Additional Tests of Legs for suspected abnormalities- Color Changes

See textbook 6. if you suspect an arterial deficit, raise the legs about 12 inches off the table and ask the clt. to wag the feet to drain off venous blood. The skin color now reflects only the contribution of arterial blood. A light skinned clt.s feet normally will look a little pale but still should be pink. A dark skinned clts. Feet are more difficult to evaluate, but the soles should reveal extreme color change. Now have the clt. sit up with the legs over the side of the table. Compare the color of both feet. Note the time it takes for the color to return to the feet. Normally 10 seconds or less. Note also the time it takes for the superficial veins around the feet to fill - normally 15 seconds. ***Dependent rubor (deep blue-red color)occurs with severe arterial insufficiency. **Chronic hypoxia produces a loss of vasomotor tone and a pooling of blood in the veins. **Delayed venous filling occurs with arterial insufficiency.

Objective Data: Ears-Vestibular apparatus

The Romberg test assesses the ability of the vestibular apparatus in the inner ear to help maintain standing balance. Remember it also assesses intactness of the cerebellum and proprioception.

**Scotoma

a blind spot in the visual field surrounded by area of normal or decreased vision, occurs with glaucoma, with optic nerve and visual pathway disorders.

Cultural considerations in nose, mouth, and throat: 2. Torus palatinus

a bony ridge running in the middle of the hard palate, is more common in Native Americans, and Asians.

Cultural considerations in nose, mouth, and throat: 1. Bifid uvula

a condition in which the uvula is split either completely or partially occurs in 18% of Native Americans and in 10% of Asians. Cleft lip and palate are most common in Asians and Native Americans.

Cultural considerations in nose, mouth, and throat: 3. Leukoedema

a grayish white benign lesion occurring on the buccal mucosa, is present in 70-90% of blacks but in only 43% of whites.

Objective Data: Ears-Inspect and palpate the external ear

a, Size and shape- ears should be of equal size bilaterally with no swelling or thickening. Ears of unusual size and shape may be a normal familial trait with no clinical significance. b. Skin condition- color should be consistent with clts. Facial skin color. The skin should be intact, with no lumps or lesions. **Reddened, ,excessively warm skin indicates inflammation. Crusts and scaling occur with otitis externa, eczema, contact dermatitis. c. Tenderness- move the pinna and push on tragus. They should feel firm and movement should produce no pain. Palpating the mastoid process should also produce no pain. ** Pain with movement occurs with otitis externa. Pain at the mastoid process may indicate mastoiditis d. External auditory meatus- note the size of the opening to direct your choice of speculum for the otoscope. No swelling, redness or discharge should be present. **a sticky yellow discharge accompanies otitis externa or may indicate otitis media if the drum has ruptured. ** Some cerumen is usually present. The color varies from gray-yellow to light brown and black and texture varies from moist and waxy to dry. **Impacted cerumen is a common cause of conductive hearing loss.

Objective Data: Eyes Test visual fields

a. ***Confrontation test- this is a gross measure of peripheral vision. It compares the clt.s peripheral vision with your own, assuming yours is normal. Position yourself at eye level with the clt. about 2 feet away. Direct the clt. to cover one eye with an opaque card and with the other eye to look straight at you. Cover your own eye opposite to the clts. Covered one. Hold your flicking finger as a target midline between you and the clt. and slowly advance it in form the peripherary in several directions. Ask the clt. to say 'now" as the target is first seen, this should be just as you see the object also. With the temporal direction, start the object somewhat behind the person. **If the clt. is unable to see your finger as examiner does, the test suggests peripheral field loss. OR alternatively, imagine a glass bowl that encircles the front of the clts. Head. Ask the clt to look with both eyes into your eyes. While your return the clts. Gaze, place your hands about 2 feet apart, lateral to the clts. Ears. Instruct the clt to point to your fingers as soon as they are seen. Then slowly move the wiggling fingers of both our hands along the imaginary bowl and toward the line of gaze until the clt. identifies them. Repeat this pattern in the upper and lower fields. **Normally, the clt. should see both sets of fingers at the same time.

Objective Data: Eyes Inspect Anterior Eyeball Structures

a. Cornea and lens- shine a light from the side across the cornea, and check for smoothness and clarity. This oblique view highlights any abnormal irregularities in the corneal surface. There should be no opacities (cloudiness) in the cornea, the anterior chamber or the lens behind the pupil. **A corneal abrasion causes irregular ridges in reflected light, producing a shattered look to light rays. b. Iris and pupil- the iris normally appears flat, with a round regular shape and even coloration. Note the size, shape and equality of the pupils. **Normally the pupils appear round, regular and of equal size in both eyes. In the adult, resting size is from 3-5mm. A small number of people (5%) normally have pupils of two sizes, which is termed anisocoria. **Although they may be normal, all unequally sized pupils call for a consideration of central nervous system injury. Check pupils for size, regularity, equality, direct and consensual light reaction and accommodation. **To check pupillary light reflex, darken the room and ask the clt to gaze into the distance (this dilates the pupils). Advance the light in from the side and note the response. Normally you should see: Constriction of the same- sided pupil- DIRECT LIGHT REFLEX AND simultaneous constriction of the other pupil-CONSENSUAL LIGHT REFLEX ** Abnormal response is dilated pupils, dilated and fixed pupils and constricted pupils or one pupil responds and the other does not. **To test for accommodation- ask the clt. to focus on distant object (this dilates the pupils). Then have the clt. shift the gaze to a near object, such as your finger held about 3 inches from the nose. **A normal response includes: 1. Pupillary constriction 2. Convergence of the axes of the eyes. **Record the normal response to all these maneuvers as **PERRLA or pupils equal, round, react to light and accommodation.

Objective Data: Eyes Inspect Extraocular Muscle Function

a. Corneal light reflex (The Hirschberg test): -Assess the parallel alignment of the eye axes by shining a light toward the clts. Eyes. Direct the clt. to stare straight ahead as you hold the light about 12 inches away. -Note the reflection of light on the corneas; it should be in exactly the same spot on each eye. **Asymmetry of the light reflex indicates deviation in alignment due to eye muscle weakness or paralysis. If you see this perform the cover test. b. Cover test: **performed if abnormal response to corneal light reflex - detects small degrees of deviated alignment by interrupting the fusion reflex that normally keeps the two eyes parallel. Ask the clt. to stare straight ahead at your nose even though the gaze may be interrupted. -With a card, cover one eye. As it is covered, note the uncovered eye. **A normal response is a steady fixed gaze. If muscle weakness exists, the covered eye will drift into a relaxed position. -Now uncover the eye and observe it for movement. It should stare straight ahead. If it jumps to reestablish fixation, eye muscle weakness exists. Repeat with other eye. c. Diagnostic positions test: -assess extraocular movements by the cardinal positions of gaze - leading the eyes through the six cardinal positions of gaze will elicit any muscle weakness during movement. -Ask the clt. to hold the head the steady and to follow the movement of your finger, pen or penlight only with the eyes. Hold the target back about 12 inches so the clt can focus on it comfortably and move it to each of the six positions, hold it momentarily, then back to center. Progress clockwise or make a large capital "H". **A normal response is parallel tracking of the object with both eyes. In addition, to parallel movement -note any Nystagmus (**Mild Nystagmus at extreme lateral gaze is normal. Nystagmus at any other position is not) **Note Strabismus **Note "lid lag"

Objective Data: Eyes Test Central Visual Acuity

a. Snellen eye chart- the Snellen alphabet chart is the most commonly used and **accurate measure of central visual acuity. Position the clt. 20 feet from the well-lit chart. Clts. Who use glasses other than reading should wear them. Ask the clt. to cover one eye with a card ( to prevent peeking through the fingers). And to read the smallest line of print possible. A clt. who cannot read the largest letter should be positioned closer to the chart, with the distance form it noted. Determine the smallest line of print form which the clt. can identify more than half the letters. Record the visual acuity designated at the side of this line, along with the use of glasses, if any. **Use the Snellen E chart for clts. Who cannot read. **Visual acuity is expressed as two numbers (ex. 20/30) in which the first indicates the distance of the clt. from the chart and the second the distance at which a normal eye can read the line of letters. **Vision of 20/ 200 means that at 20 feet the clt. can read print that a clt with normal vision could read at 200 feet. The larger the second number, the worse the vision. 20/40 corrected means the clt. could read the 40 line with glasses. b. Near vision- for clts. Over 40 or for those who report increasing difficulty reading, test near vision using a handheld vision screener with various sizes of print- this helps to identify the need for reading glasses or bifocals in clt. over age 40. Hold the card in good light about 14 inches from the eye. Test each eye separately with glasses on. A normal result is "14/14" in each eye, read without hesitancy and without the clt. moving the card closer or farther away. When no vision-screening card is available, ask the clt. to read from a newspaper or magazine. **IN the USA a clt. is usually considered legally blind when vision in the better eye, corrected by glasses is 20/200 or less. Legal blindness also results from a constricted field of vision, 20 degrees or less in the better eye.

Objective Data: Ears- Inspect using the otoscope

a. as you inspect the external ear, note the size of the auditory meatus. Then choose the largest speculum that will fit comfortably in the ear canal, and attach it to the instrument. b. Tilt the clts. Head away from you toward the opposite shoulder. This method brings the sloping eardrum into better view. c. Pull the pinna up and back on an adult or older child to straighten the canal . (pull pinna down on an infant and a child under 3 years of age) hold pinna gently but firmly. Do not release traction on the ear until you have finished the exam and the otoscope is removed. d. Insert the speculum slowly and carefully along the axis of the canal. Watch the insertion; then put your eye up to the otoscope. Avoid touching the inner "bony" section of the canal wall, which is covered by a thin epithelial layer and sensitive to pain. Have the dorsa of your hand along the clts. Cheek braced to steady the otoscope. Sometimes you cannot see anything but canal wall. If so try to reposition clt.s head and re angle the instrument forward toward the clt.s nose. BE GENTLE. 1. External canal- note any redness and swelling, lesions, foreign bodies or discharge. If discharge present, note color and odor and Also, change the speculum before examing the other ear to avoid contamination with possibly infectious material. **Redness and swelling occur with otitis externa; canal may be completely closed with swelling. Frank blood or clear, watery drainage (cerebrospinal fluid (CSF) following trauma suggests basal skull fracture and warrants immediate referral . CSF feels oily and is positive for glucose) 2. tympanic membrane (TM) a. color and characteristics- systemically explore its landmarks. **The normal eardrum is shiny and translucent, with a pearl gray color. The cone shaped light reflex is prominent is thee the anterinferior quadrant(5 o'clock right drum, 7 o'clock left drum). This is the reflection of your otoscope light. Sections of the malleus are visible through the translucent drum, the umbo, manubrium and short process. **yellow amber drum color- serous otitis media (OM) **Red color- acute OM **Air/fluid level or air bubbles behind drum - serous OM **pink/cloudy=inner ear infection **if doesn't vibrate= hearing issue b. position- eardrum is flat, slightly pulled in at the center and flutters when the person performs the Valsalva maneuver or holds the nose and swallows. You may elicit these maneuvers to assess drum mobility. Avoid them with an aging person because they may disrupt equilibrium. Also avoid in a clt. with URI because it could propel infectious matter into middle ear. Also avoid on classmate. *** Retracted drum due to vacuum in middle ear with obstructed Eustachian tube. Bulging drum from increased pressure in otitis media. Drum hypo mobility is an early sign of otitis media. c. Integrity of membrane- inspects the eardrum and entire circumference of the annulus for perforations. The normal tympanic membrane is intact. Some adults may show scarring, which is a dense white patch on drum. This is a sequelae of repeated ear infections. **Perforation shows as a dark oval area or as a larger opening on drum.

**Floaters

are common with myopia or after middle age due to condensed vitreous fibers. Usually not significant, but acute onset of floaters may occur with retinal detachment. in younger age= medical emergency could be a detached retina

**Disorders of the larynx

are due to many causes- overuse of voice, URI, chronic inflammation, lesions or Cancer.

Unilateral cold foot or leg occurs with

arterial deficit.

Nocturia

awaken at night with an urgent need to urinate - laying down at night promotes fluid re-absorption and excretion - this occurs with heart failure in the person who is ambulatory during the day.

Nasal mucosa appears redder than oral mucosa

because of the rich blood supply present to warm the inhaled air.

During systole

blood is pumped from the ventricles and fills the pulmonary and systemic arteries.

***Increased fremitus occurs with

consolidation of lung tissue EX: lobar pneumonia.

Strabismus

deviated gaze or limited movement crossed eye deviation in the anteroposterior axis of the eye.

Diplopia

double vision

mouth

first segment of the digestive system and an airway for the respiratory system

With the ophthalmoscope: Use black lenses(positive diopter)

for farsightedness

With the ophthalmoscope: use red lenses (negative diopter)

for nearsightedness

Diabetic ketoacidosis

has a sweet, fruity odor, this acetone smell also occurs in kids with malnutrition or dehydration.

**Bilateral pitting edema occurs with

heart failure, diabetic neuropathy and hepatic cirrhosis.

Full bounding pulse (3-4+) occur with

hyerkinetic states such as fever, anemia, hyperthyroidism.

** Full-distended bilateral external jugular veins above 45 degrees signify

increased CVP (central venous pressure) as with heart failure. (inspection jugular venous pulse)

***Left ventricular hypertrophy

increased force and duration occur but no change in location occurs.

After the general survey, you will begin the physical examination of the thorax and lungs. The lung assessment always begins with

inspection, palpation, percussion and last auscultation.

diopter setting

instrument contains a set of lenses that control the focus. unit of strength of each lens is the diopter. **black numbers indicate a positive diopter; they focus on objects nearer in space to the ophthalmoscope. **red numbers show a negative diopter and are for focusing on objects farther away. **Use the red lenses (negative diopter) for nearsighted eyes (myopia) ** use black lens (Positive diopter) for farsighted eyes (hyperopia).

tears from the nasolacrimal duct drain

into the inferior meatus.

sinuses drain

into the middle meatus

a thrill

is a palpable vibration. It feels like the throat of a purring cat. It signifies turbulent blood flow and accompanies loud murmurs. (Palpation of Precordium)

** a heave or lift

is a sustained forceful thrusting of the ventricle during systole. This is abnormal and should not be seen. ***It occurs with ventricular hypertrophy due to increased workload. (inspection precordium)

Cheilitis

is cracking at the corners.

***Hyperresonance

is found when too much air is present=COPD or pneumothorax. **Lungs that are hyperinflated with emphysema, result in hyperresonance where you would expect cardiac dullness.

***Dull note

is found with abnormal density=pneumonia, tumor.

**a heave or lift LV

is seen at apex.

**a heave or lift of RV

is seen at sternal border

Stroke volume(SV)

is the amount of blood pumped from the heart with each contraction.

Cataracts

lens thickening/ becoming cloudy; lens is removed artificial one put in can be caused by trauma in young people =steroids/ immunotherapy

**Unilateral distention of external jugular veins above 45 degree is due to

local cause ex. kinking or aneurysm (inspection jugular venous pulse)

What sinuses are present at birth

maxillary and ethmoid sinuses

** untreated strep

may lead to complications of rheumatic fever.

Auscultate the Posterior Chest: Increased Breath Sounds

mean that sounds are louder than they should be or heard where they should not be. Ex. Bronchial sounds heard over peripheral lung fields. They occur when consolidation (pneumonia) enhances the transmission of sound from the bronchi.

Appearance of nasal cavity in chronic allergy,

mucosa looks swollen, boggy, pale and gray.

**Unilateral edema occurs with

occlusion of a deep vein.

fatigue due to anxiety, depression

occurs all day or is worse in the morning, ex. too tired to get out of bed in am.

**Night blindness

occurs with optic atrophy, glaucoma, or vit. A deficiency.

cherry red lips

occurs with with carbon monoxide poisoning, acidosis from aspirin OD or ketoacidosis.

diuretic (EX: lasix)

oral/IV NEVER give more than 1mL at a time give 1mL wait 5 minutes VERY HIGHLY OTOTOXIC in clt. with CHF, their heart hold more fluid, is managed with a diuretic if tinnitus occurs stop meds!!

Nares

oval openings at the base of the nose

Accommodation

pupillary constriction of the eye when looking at near object and convergence of axes of eyes.

Precordium

region or the thorax immediately in front of the heart.

Tinnitus

ringing, crackling, buzzing of ears

CO=

stroke volume X heart rate

***Emphysema

the apical impulse is not palpable due to hyper inflated lungs that override the heart.

pharynx (throat)

the area behind the mouth and nose

Objective Data: Eyes- systemically inspect the structures in the fundus: General Background

the color normally varies from light red to dark brown-red, generally corresponding with the clts. skin color. your view of the fundus should be clear; no lesions should obstruct the retinal structures. **abnormal lesions, hemorrhages, exudates, micro aneurysms.

nasal septum.

the columella divides the two nares;

Objective Data: Eyes- systemically inspect the structures in the fundus: Macula

the macula is 1 DD in size and located 2 DD temporal to the disc. Inspect this area last in the exam. A bright light on this area of central vision causes some watering and discomfort and pupillary constriction. Note that the normal color of the area is somewhat darker than the rest of the fundus but is even and homogenous. Clumped pigment may occur with aging, trauma or retinal detachment. Within the macula you may note the foveal light reflex. This is a tiny white glistening dot reflecting your instrument light.**Hemorrhage or exudates in the macula occurs with macular degeneration.

Auscultate the Posterior Chest: Normal Breath Sounds

the passage of air creates a characteristic set of noises that are audible through the chest wall. These noises may be modified by obstruction within the respiratory passages or by changes in the lung, pleura, or chest wall. 1. Evaluate the presence of normal breath sounds. The clt. should be sitting, leaning forward slightly, with arms crossed resting on opposite shoulders (this helps to move the scapulae out of the way). Instruct clt. to breath deep through mouth but to stop if feels dizzy. Use flat end of diaphragm and hold it firmly against skin. Listen to at least one full respiration in each location. Begin with apices and proceed to bases comparing one-side with another all the way down. *See textbook. You should expect to hear three types of normal breath sounds. *See textbok ***Decreased or absent breath sounds occur when the bronchial tree is obstructed at some point by secretions, mucous plug or foreign body, in the emphysema due to loss of elasticity in lungs ad decreased force of inspired air, and when anything obstructs transmission of sound such as air(pneumothorax) or fluid (pleural effusion) in pleural space

bruit

this is a blowing, swishing sound indicating blood flow turbulence due to local vascular cause such as atherosclerotic narrowing (auscultation of carotid artery)

Objective Data: Eyes- systemically inspect the structures in the fundus: Retinal vessels

this is the only place in the body where you can view blood vessels directly. Many systemic diseases that affect the vascular system show signs in the retinal vessels. Follow a paired artery and vein out to the peripherary in the four quadrants, noting these points: a. number- a paired artery and vein pass to each quadrant . vessels look straighter at the nasal side. **Absence of vessels is abnormal b. color- arteries are brighter red than veins. Also they have the arterial light reflex, with a thin stripe of light down the middle. **Abnormal dilated veins or abnormal constricted arteries. c. A: V ratio- the ratio comparing the artery to vein width is 2:3 or 4:5. d. Caliber(diameter)- arteries and veins show a regular decrease in caliber as they extend to periphery.**any abnormal neovascularization e. A-V crossing- an artery and vein may cross paths. This is not significant if within 2 DD of disc and if no sign of interruption in blood flow is seen. These should be no indenting or displacing of vessel. f. Tortuosity- mild vessel twisting when present in both eyes is usually congenital and not significant.. g. Pulsations- present in veins near disc as their drainage meets the intermittent pressure of arterial systole-OFTEN HARD TO SEE.

entropion

turned inward of eyelashes.

**Ectropion

turned outward of eyelashes

***Erythema with

vasodilatation

A coarse tremor of the tongue occurs

with Cerebral palsy (cp) and alcoholism.

Cyanosis or pallor occurs

with MI or low cardiac output stated due to decreased tissue perfusion.

Foul odor breath

with dental or respiratory infection

A fine tremor of the tongue occurs

with hyperthyroidism;

Weak thready pulses occur

with shock and peripheral arterial disease.

Subjective Data: Eyes

1. Vision difficulty? (Decreased acuity, blurring, blind spots). Any difficulty seeing or any blurring? 2. Pain- Any eye pain? Please describe. ***Consider sudden onset of eye symptoms or vision change (pain, floaters, blind spot, loss of peripheral vision) as a possible emergency. REFER IMMEDIATELY. **Note that some common eye diseases cause no pain ex. refractive errors, cataract, glaucoma. 3. Strabismus, diplopia- Any history of crossed eyes? Now or in the past? Does this occur with eye fatigue? Ever see double? Constant, or intermediate? One eye or both? 4. Redness, swelling? Any infections, now or in past? When occur? Particular time of year? Seasonal? 5. Watering, discharge? **Lacrimation (tearing) and epiphora (excessive tearing) are due to irritants or obstruction in drainage of tears. **Purulent thick discharge is thick and yellow. Crusts form at night. 6. Past history of ocular problems- any history of injury or surgery to eye? Allergies? **Allergens may cause irritation of conjunctiva or cornea ex. make up, contact lens solution. 7. Glaucoma? Macular Degeneration? Cataracts? 8. Use of glasses or contact lenses- Wear glasses or contact lenses? Last time prescription checked? How do you care for contacts? 9. Self care behaviors- last vision test. By whom? Any environmental conditions at home or work that may affect eyes? Examples- flying sparks, metal bits, smoke, dust, chemical fumes? Do you wear goggles to protect eyes? **Assess self-care behaviors. Ocular diseases or injuries may be work related- auto mechanic with foreign body from metal working. 10. Medications? What meds. Are you on? Any specific meds. For eyes? **Some meds. Have ocular side effects- prednisone may cause cataracts. 11. If experienced vision loss, how do you cope? **Assess if maintain living environment the same to ease navigation and decrease injury.

Auscultate Anterior Chest

1. breath sounds- Auscultate from apices in the supraclavicular areas down. Listen to one full inspiration in each location and compare one side with another. Displace the female breast and listen over chest wall. Assess for voice sound: **Normal voice transmission is soft, muffled, and indistinct, you can hear sound through the stethoscope but cannot distinguish exactly what is being said. Eliciting voice sounds is not usually done unless pathology is suspected. When performed you are testing for: 1. bronchophony( abnormal transmission of sounds from the lungs or bronchi)- say "99" 2. egophone(increased resonance of voice sounds heard when auscultating the lungs,)- say "e" 3. whispered pectoriloguy- whisper "1-2-3" ** Abnormal voice sounds indicate pathology and indicate that the normally air- filled lungs have become airless, ex: consolidation.** See textbook.

Two pairs of sinuses are accessible to examination-

1. frontal sinuses in the frontal bone above and medial to the orbits 2. maxillary sinuses in the maxilla (cheekbone) along the side walls of the nasal cavity.

1. Edema is dependent in... 2. is worse

1. heart failure 2. at evening and better in morning after elevating legs all night.

The mouth contains three pairs of salivary glands.

1. parotid gland 2. submandibular gland 3. sublingual gland **in order largest-smallest

Subjective Data: Thorax and Lungs: Environmental exposure; Self care behaviors

1. work and at home. Are there any environmental conditions that may affect your breathing? Where do you work? At a factory, chemical plant, outdoors in heavy traffic, after 9/11 at ground zero. Do you live with someone with TB? 2. last TB skin test and results, chest x-ray, pneumonia and influenza immunization

The nodes that are assessed in the peripheral vascular assessment are:

1.The epitrochlear node is in the antecubital fossa and drains the hand and lower arm. 2.The inguinal nodes in the groin drain most of the lymph of the lower extremity, the external genitalia and the anterior abdominal wall.

Objective Data: Ears-Test Hearing Acuity

1.test hearing acuity by the ability: a. To hear normal conversation during the interview and by the whispered voice test- test one ear at a time while masking hearing in the other ear to prevent sound transmission around the head. This is done by placing one finger on the tragus and rapidly pushing it in and out of the auditory meatus. Shield your lips so the clt. cannot compensate by lip reading. With you head 1-2 feet from the clt. ear, whisper slowly some two syllable words, such as Tuesday, baseball and fourteen. Normally, the clt. repeats each word correctly after you say it. ** A whisper is a high frequency sound and is used to detect high tone loss. b. Tuning fork tests: measure hearing by air conduction (AC) or bone conduction (BC), in which the sound vibrates through the cranial bones to the inner ear. To activate the tuning for, hold it by the stem and strike it softly on the back of your hand. **See textbook 1. Weber test - place the vibrating tuning fork in the middle of the clts. Skull and ask if tone sounds the same in both ears or better in one. The clt. should hear the tone by bone conduction through the skull and it should sound equally loud in both ears. 2. Rinne test - compares air conduction and bone conduction sound. Place the stem of the vibrating tuning fork on the clts. Mastoid process and ask him to signal when the sound goes away. Quickly invert the fork so the vibrating end is near the ear canal. The clt. should still hear a sound. Normally the sound is heard twice as long by air conduction (next to ear canal ) as by bone conduction ( through the mastoid process). A normal response is a positive Rinne test or AC>BC. Repeat with other ear. **See textbook

Objective Data: Palpation of the legs: Homans sign

2. Flex the clt.s knee, then gently compress the calf muscle anteriorly against the tibia, no tenderness should be present or you may sharply dorsiflex the foot toward the tibia. Normally this does not cause pain. ***calf pain with these maneuvers is a positive Homans sign, which occurs in about 35% of DVT. It also occurs with superficial phlebitis (inflammation of a vein) and other conditions such as Achilles tendonitis.

Objective Data: Palpate the inguinal lymph nodes

3. It is not unusual to find palpable nodes that are small, movable and nontender. **Usually tender movable nodes indicate infection, nontender enlarged fixed nodes are often suggestive of Ca(cancer).

Objective Data: Palpate the peripheral arteries in both legs

4. : femoral, popliteal, dorsalis pedis, and posterior tibial. Grade the force on the four point scale. a. Locate femoral arteries just below the inguinal ligament halfway between the pubis and anterior superior iliac spines. To help expose the femoral area, ask the clt to bend his knee to the side in a froglike position. Should this pulse be weak or diminished, Auscultate the site for a bruit. ** a bruit occurs with turbulent blood flow indicating partial occlusion. See textbook.

Characteristics of Sound

All heart sounds are described by: 1. Frequency (pitch) heart sounds are ddiscirbed as high pitched or low pitched 2. intensity- loudness- loud or soft 3. duration- very short for heart sounds. Silent periods are longer 4. timing- systole or diastole.