 Interview  Physical Examination › Functional › Spiritual › Cultural › Physical characteristics

 Inspection  Auscultation  Palpation  Percussion

FIGURE 7-2 Touch or palpation is used during the health assessment. (From Bonewit-West K, Hunt S, Applegate E: Today’s medical assistant: clinical & administrative procedures, St. Louis, 2009, Saunders.)

FIGURE 7-3 Assessment by percussion involves evaluating the sound produced by tapping the patient. (From Bonewit-West K, Hunt S, Applegate E: Today’s medical assistant: clinical & administrative procedures, St. Louis, 2009, Saunders.)

Appearance Hair General health Weight Posture Communication skills Physical appearance Developmental milestones Color Texture Cleanliness Distribution

Nails Skin  Color  Texture  Markings  Size  Shape  Color  Temperature  Turgor  Lesions  Mucous membranes  Injury  Edema

Neurological Musculoskeletal  Pupil reaction › PERRLA  Motor & verbal responses  Range of motion  Gait  Posture  Injury

Cardiovascular Respiratory  Heart rate, rhythm, character  Peripheral pulses  Temperature  Respiratory rate, rhythm, character  Breath sounds › Wheezes › Stridor › Rhonchi (crackles) › Rales  Sputum production  cough

Gastrointestinal Genitourinary  Abdominal contour  Bowel sounds  Nausea/vomiting (n/v)  Defecation frequency & consistency  Urine color › Normal  Yellow  Straw  Amber › Abnormal  Red  Blue  Orange  Cloudy  Brown  Amount › Liters Frequency Odor Sweet Ammonia offensive Clarity clear

 Mouth › Alcohol › Halitosis › Fruity, sweet › Feces › Acid breath › Rotten eggs, garlic › Ammonia  Rectal › Feces-incontinent  Urine › Ammonia › Foul › Sweet  Vomit › feces  Wound › Feces › Sweet, heavy

 Measure changes in body function, general health, & response to treatment  Vitals we measure  Blood Pressure  Temperature  Pulse  Respiration  Oxygen Saturation  Skin Color

 Measures the force of the blood against walls of arteries  Systolic-maximum amount of pressure  Diastolic- minimum amount of pressure

 Normal Value 120/80 mmHg  Prehypertension /80-89  Hypertension 140/90 or above

Yes you will have to spell it on the test!!

 Diameter & flexibility of blood vessels  Force of heart contraction  Amount of blood in vessels  Pressure brain that controls BP

 measures the balance between the heat produced & lost by the body  Oral  Axillary  Rectal  Temporal  Tympanic

 Glass with an expandable liquid filling › Oral  Red tip › Rectal  Blue tip  Bulb is rounded to prevent injury to rectum tissue  Electronic  Disposable chemical thermometers

 heartbeat that can be palpated on surface arteries as the artery walls expand  usually assessed using the radial artery  Infant are significantly faster than an adults  Assess rate, rhythm, & character

b located on the side of the head at the “ temple.” b place the index and middle fingertips lightly against the skin.

b main pulse site- the heart. b Can be osculated. b Remember “ Apical” because you would be in a “ pickle “ without it.

b throat next to the “ Adams apple” b index and middle finger pressed lightly against the skin. b ONLY ONE SIDE AT A TIME !

b between the base of the thumb in the wrist b Usually the most assessed

b Antecubital space of the arm, the medial aspect. b Remember this way-”right where the arm breaks.”

b inguinal/femoral area of the groin. b We find this one in the shower.

b posterior aspect of the knee. b palpate by placing two fingers behind the knee above the calf. b Remember, you hold a can of “pop” on your knee.

b dorsal aspect of the foot midway between the big toe and the ankle. b Remember this way- the pedal pulse is in the foot, the thing you “ pedal “ a bike with.

 Inspiration/inhalation › Breath in  Expiration/exhalation › Breath out  One respiration › Count 1 inspiration and expiration  Watch rise & fall of chest  Normal rate is more rapid in infants than in adults  Assess rate, rhythm, & character

Pulse Respirations  Normal Ranges › Adult   <60-bradycardia  >100-tachycardia › School age  › Infant  › Newborn   Adult Normal Ranges › Rate  › Rhythm  Regular › Character  Effortless, deep, quiet

 Eupnea › normal breathing  Apnea › stop breathing  Orthopnea › can’t breath laying flat  Tachypnea › too fast  Bradypnea › to slow  Dyspnea › difficulty breathing  Hyperpnea › increased depth of breathing  Hypopnea › decreased depth  Cheyne stokes › Usually seen at end of life  Kussmual respirations › Usually seen with elevated blood sugars

 Insurance companies determine at which weight for a specific height an individual is predicted to live the longest.  The National Heart, Lung, and Blood Institute defines an ideal weight as having a body mass index (BMI) between 18.7 and 24.9.