Midterm Study Guide

Health Assessment (South University)

WEEK 1

Know the definition of a chief complaint

The CC or presenting complaint is the term used to describe the primary

problem or condition of the patient prompting the clinician visit (reason for
visit). The primary symptom or concern causes the patient to seek care. It
may be one or two concerns and rarely more than that.
Know what each letter of 'SOAP' represents and definitions

Subjective - documentation of data from patients' experiences (history of

illness, symptoms experienced, pain and anxiety, etc)
Objective - data as assessed by the clinician (physical
examination findings, diagnostic testing, and radiologic examinations)
Assessment- documents the synthesis of subjective and objective evidence
to arrive to a diagnosis. Details the differential diagnosis and may include
some risk/benefit trade-offs in decision making.
Plan- details the needs for additional testing and consultation with other
clinicians to address the patients' illnesses in addition to the steps being
taken to treat the patient.
Know what is documented in each of the sections of the SOAP note,
like the subheadings

Subjective: source and reliability, chief complaint, HPI, PMH, family history,
personal and social history, ROS, allergies

Objective: General survey, vital signs, skin, HEENT, thorax and lungs,
cardiovascular, breasts, abdomen, genitalia, rectal, extremities, peripheral
vascular, musculoskeletal, neurological mental status, labs,
Assessment: differential diagnosis

Plan: treatment

Know what needs to be documented in the History of Present Illness

(HPI)

Amplifies the Chief Complaint; describes the chronology of events as to how

each symptom developed (onset of symptoms). Includes patient’s
thoughts and feelings about the illness. Pulls in relevant portions of the
Review of Systems, called “pertinent positives and negatives” (see p. 86).
Ex: “My asthma gets worse at night”
OLDCARTS: Onset, Location, Duration, Character, Aggravating or Alleviating
factors, Radiation, Timing, Setting
Know the difference between subjective and objective data

Subjective information: includes symptoms which are health concerns that

the patient tells you. Examples: the patient tells you (sore throat, headache,
pain); feelings, perceptions and concerns
Objective information: is the physical examination findings or signs you
detect during the examination. All laboratory and diagnostic testing results
are also considered objective information.

Know examples of subjective and objective data

Subjective examples include complaints of a sore throat, headache, or pain.

It also includes feelings, perceptions, and concerns obtained from the clinical
interview.
Objective example, “chest pain” is subjective information while “tenderness
on palpation of anterior chest” is an objective one.

Know what the Review of Systems (ROS) is and how to document it

here
The review of systems (ROS) includes existing symptoms related to the body
systems.

For a patient who is new to you, include constitutional/general, HEENT,

respiratory, cardiovascular, gastroenterology, genitourinary, musculoskeletal,
hematology, skin and breasts, endocrine, neurological, and psychiatric. Make
note of any positive comments by the patient and follow through with
additional questions. If the patient is already established with you and has a
problem-specific visit, the ROS would only be pertinent to the presenting
problem.
For example, a patient presents with a complaint of a sore throat. You would
do a constitutional, HEENT, respiratory, and possibly gastrointestinal (GI)
ROS. Why? Is there any weight loss, fever, or malaise with the presentation?
What other symptoms does the patient have with the pharyngitis? Is there
any sinus congestion, drainage, headache, earache, adenopathy, dental or
mouth pain, cough, or shortness of breath? Why ask about GI symptoms?
Your patient presented with pharyngitis. It may be as simple as an upper
respiratory infection or allergic rhinitis, or it could be nocturnal reflux disease
that is causing overflow to the larynx and into the lungs. Look for horses but
don't forget about the zebras.

Know the definition and examples of differential diagnoses

pertinent positives and negatives; the list of different possible diagnoses,

from the most to least likely, and the thought process behind the list; this is
where the decision-making process is explained in depth; include the
possibility of other diagnoses that may harm the patient, but are less likely

Know where to document the medical diagnoses in the SOAP note:

The assessment section.

Know the difference in documentation between comprehensive,

focused, and episodic SOAP note:

Focused - specifically refer to concise, targeted, and centered on a specific

issue or complaint

Know about skilled interviewing and its components:

Use of global communication and interpersonal techniques active listening,

guided questioning, empathic responses, summarization, transitions,
partnering, validation, reassurance, empower the patient, use
understandable language, use, non-stigmatizing language, use appropriate
nonverbal communication,
Know cultural humility: Self awareness

Mitigates implicit bias, promotes empathy, and helps respond to individuality

engage in self-reflection and self-critique examining cultural beliefs and
systems self-awareness, respectful communication, collaborative
partnerships. 5R- reflections, respects, regard, relevance, resiliency.
Spirituality, medical ethics, clinical documentation including the EHR.
Know how to interview patients about sexual health and substance
use
Includes any history of tobacco, alcohol, or recreational drug use. Describes
sexual history. Describes educational level, family of origin, current
household, personal interests, and lifestyle. Use specific language.
The single most important rule is to be nonjudgmental. Use opening
questions for sensitive topics, consciously acknowledge whatever discomfort
you are feeling. Your role is to learn from the patient and help the patient
achieve better health. Acceptance is the best way to reach this goal. Explain
why you need to know certain information. This makes patients less
apprehensive. For example, say to patients, “To help me take better care of
you, I need to ask you some questions about your sexual health and
practices.” Find opening questions for sensitive topics and learn the specific
kinds of information needed for your shared assessment and plan.
Consciously acknowledge whatever discomfort you are feeling. Denying your
discomfort may lead you to avoid the topic altogether.
WEEK 2

Examination of the Head

• Inspect the head for size, shape, symmetry, and deformities.

• Palpate for tenderness, masses, and irregularities.
• Assess facial symmetry and muscle strength (cranial nerve VII, facial
nerve).
• Evaluate temporomandibular joint (TMJ) function and tenderness.

Use of Otoscope and Ophthalmoscope

• Otoscope:
o Select the appropriate speculum size.
o Hold the otoscope like a pencil and use the opposite hand to pull the auricle
upward and back (adults) or downward and back (children) to straighten the
canal.
o Insert the otoscope gently into the ear canal and examine for cerumen,
inflammation, discharge, foreign bodies, and the tympanic membrane’s color and
integrity.
o Identify landmarks such as the cone of light and malleus.
• Ophthalmoscope:
o Dim the room lights to enhance visualization.
o Set the ophthalmoscope to 0 diopters initially.
o Approach the patient from 15 degrees to the side while focusing on the red reflex.
o Move closer to examine the optic disc, retinal vessels, and macula.
o Assess for abnormalities such as papilledema, hemorrhages, or retinal exudates.

Parts of the Eye and Examination

• Structures: Sclera, cornea, conjunctiva, iris, pupil, lens, retina, optic

disc, macula.
 • Examination: Inspect eyelids, conjunctiva, sclera, and cornea; assess
pupil size, shape, and reaction to light.
• Lacrimal glands

Definitions

• Accommodation: The eye’s ability to adjust focus from far to near.

• Consensual Reaction: Pupil constriction in the opposite eye when
light is shined in one eye.
• Direction: The ability of the eyes to track movement smoothly.
• PERRLA: Pupils Equal, Round, Reactive to Light and Accommodation.

Eye Examination Findings

• Normal: Clear cornea, equal pupils, red reflex present, normal visual
fields.
• Abnormal: Cloudy cornea (cataract), unequal pupils (anisocoria),
absence of red reflex (retinoblastoma), hemorrhages or exudates in the
retina (hypertension, diabetes).
• Scotoma

Snellen Chart

• Purpose: Tests visual acuity at a standardized distance (20 feet).

• Documentation: Recorded as a fraction (e.g., 20/20, 20/40);
numerator = distance from chart, denominator = distance a normal
eye can read the same line.

Corneal Abrasion Examination

• Use fluorescein staining and cobalt blue light to detect abrasions.

• Assess pain, photophobia, and foreign body sensation.

Subjective Data

• Patient-reported symptoms and history, including pain, vision changes,

tinnitus, hearing loss.
Parts of the Ear and Examination

• External: Auricle (pinna), external auditory canal.

• Middle: Tympanic membrane, ossicles (malleus, incus, stapes).
• Inner: Cochlea, vestibule, semicircular canals.
• Not part of assessment: mastoid

Ear and Hearing Assessment

• Inspection: External ear for deformities, lesions, and discharge.

• Otoscope: Evaluate tympanic membrane for color, position, and
perforations.
• Hearing Tests: Whisper test, Weber and Rinne tests.

Weber and Rinne Tests

• Weber: Tuning fork on forehead; normal = equal sound in both ears;

abnormal = lateralization to one ear (conductive or sensorineural loss).
• Rinne: Tuning fork on mastoid, then near ear; normal = air conduction
> bone conduction.

Oropharynx Examination Findings

• Normal: Pink mucosa, midline uvula, intact soft palate movement.

• Abnormal: Erythema (infection), white patches (thrush), enlarged
tonsils (tonsillitis).

Tympanic Membrane Examination

• Normal: Pearly gray, translucent, visible cone of light.

• Abnormal: Bulging (infection), retraction (eustachian tube
dysfunction), perforation.

Lymph Nodes of HEENT

• Palpate: Preauricular, postauricular, occipital, submental,

submandibular, tonsillar, cervical (anterior, posterior, deep),
supraclavicular.
(Axillary is not part of it)

lymph nodes of the neck are:

 o Preauricular, located in the front of the ear
o Posterior auricular or mastoid, above the mastoid process and behind the ear
o Occipital, at the base of the skull
o Submental, midline, behind the tip of the mandible
o Submandibular, midway under the mandible
o Jugulodigastric, under the angle of the mandible
o Superficial cervical, lying over the sternomastoid muscle
o Deep cervical, under the sternomastoid muscle
o Supraclavicular, just above and behind the clavicle
(Posterior cervical lymph node for the question about a pt w fever
etc)

Thyroid Examination

• Inspect for enlargement; palpate for nodules, tenderness, consistency;

assess for goiter and bruit (auscultation).

Types of Headaches and Red Flags

• Tension: Bilateral, band-like pressure.

• Cluster: Unilateral, severe, periorbital pain with autonomic symptoms.
• Migraine: Unilateral, throbbing, associated with nausea and
photophobia.
• Rebound: Due to overuse of analgesics.
• Red Flags: Sudden onset, "thunderclap" headache, neurological
deficits, fever, stif f neck (possible meningitis, hemorrhage).Started
over 50yo F

Definitions and Causes

• Epistaxis: Nosebleed (trauma, anticoagulants, hypertension).

• Allergic Rhinitis: Inflammation due to allergens (pollen, dust);
symptoms include sneezing, nasal congestion.
• Bacterial Rhinitis: Infection with purulent nasal discharge, fever.
• Tinnitus: Ringing in ears (sensorineural loss, ototoxic drugs, noise
exposure).
• Scotoma: Blind spots in vision (retinal disease, optic neuritis).
• Rhinorrhea: Nasal discharge (allergies, viral infections, CSF leak).

WEEK 3
Normal and Abnormal Respiratory/Pulmonary/Lung Exam
Findings

Normal Findings:

• Inspection:
o Symmetrical chest expansion
o No use of accessory muscles for breathing
o Respiratory rate: 12-20 breaths per minute (eupnea)
o Quiet, unlabored breathing
o Normal anteroposterior (AP) diameter (1:2 ratio)
• Palpation:
o Equal tactile fremitus bilaterally
o No tenderness or masses
o Symmetrical chest wall movement on deep inspiration
• Percussion:
o Resonant sound over lung fields
o Dullness over the heart and liver
o Tympany over the gastric bubble
• Auscultation:
o Clear breath sounds bilaterally
o Normal breath sounds:
▪ Vesicular (soft, low-pitched, heard over most lung fields)
▪ Bronchovesicular (moderate intensity, heard over major
bronchi)
▪ Bronchial (loud, high-pitched, heard over trachea)
o No adventitious sounds

Abnormal Findings:

• Inspection:
o Asymmetrical chest expansion (pneumothorax, pleural effusion)
o Use of accessory muscles (respiratory distress)
o Barrel chest (COPD)
o Cyanosis (hypoxia)
o Clubbing of fingers (chronic hypoxia)
• Palpation:
o Increased tactile fremitus (pneumonia, lung consolidation)
 o Decreased tactile fremitus (pleural effusion, pneumothorax)
o Crepitus (subcutaneous emphysema)
• Percussion:
o Hyperresonance (pneumothorax, emphysema)
o Dullness (pneumonia, pleural effusion, tumor)
• Auscultation:
o Adventitious sounds:
▪ Crackles (rales): Fluid in alveoli (pneumonia, pulmonary
edema, CHF)
▪ Wheezes: Narrowed airways (asthma, COPD, bronchitis)
▪ Rhonchi: Mucus or secretions in airways (chronic
bronchitis, pneumonia)
▪ Stridor: Upper airway obstruction (croup, foreign body)
▪ Pleural friction rub: Inflamed pleura rubbing together
(pleuritis, pleurisy)
o Diminished or absent breath sounds:
▪ Pneumothorax
▪ Pleural effusion
▪ Severe emphysema
▪ Atelectasis

Know what objective and subjective data related to the

respiratory/lungs is
Subjective data:

Does patient have a cough? Onset abrupt or gradual? How long? Frequency?
Worse at certain times, day or bedtime? Awake you at night? Productive? If
so, color and consistency? SOB? Chest pain when breathing?
Last CXR, TB test, exposure to irritants. Always assess for TB even in children
(High risk: weakened immune system or who have a condition that can cause
a weakened immune system, or recent TB infection). Environmental concerns
such as workplace.
Current medications. Smoker?

Objective Data: positive rhonchi

Patient appearance/position, RR, pulse ox, lung sounds, chest expansion,

tactile
Diagnostics: labs, xrays, CT scans
Know the findings associated with auscultation, palpation, and
percussion of the respiratory/pulmonary/lung exam - what is normal
and abnormal

1. Auscultation

Normal Findings:

• Vesicular Breath Sounds:

o Heard over most lung fields
o Soft, low-pitched
o Inspiration > Expiration
• Bronchovesicular Breath Sounds:
o Heard over mainstem bronchi
o Moderate intensity and pitch
o Inspiration = Expiration
• Bronchial Breath Sounds:
o Heard over trachea
o Loud, high-pitched
o Expiration > Inspiration
• No adventitious (abnormal) sounds

Abnormal Findings:

• Crackles (Rales):
o Discontinuous, nonmusical, popping sounds
o Heard during inspiration
o Associated with pneumonia, pulmonary edema, CHF, fibrosis
• Wheezes:
o Continuous, high-pitched, musical sounds
o Heard during expiration (sometimes inspiration)
o Associated with asthma, COPD, bronchitis
• Rhonchi:
o Low-pitched, coarse, snoring-like sounds
o Heard during expiration
o Associated with mucus in large airways (chronic bronchitis,
pneumonia)
• Stridor:
o Harsh, high-pitched sound
 o Heard over upper airway
o Associated with airway obstruction (croup, foreign body)
• Pleural Friction Rub:
o Grating, creaky sound
o Heard during inspiration and expiration
o Associated with pleuritis, pleural effusion
• Diminished or Absent Breath Sounds:
o Seen in pneumothorax, severe emphysema, pleural effusion,
atelectasis

2. Palpation

Normal Findings:

• Chest Expansion: Symmetrical expansion of the chest

• Tactile Fremitus: Normal vibration intensity (felt when patient says
"99")
• No tenderness, masses, or crepitus

Abnormal Findings:

• Asymmetrical Chest Expansion:

o Seen in pneumothorax, pleural effusion, pneumonia, atelectasis
• Increased Tactile Fremitus:
o Seen in lung consolidation (pneumonia, lung mass)
• Decreased or Absent Tactile Fremitus:
o Seen in pleural effusion, pneumothorax, COPD
• Crepitus:
o Crackling sensation under skin (subcutaneous emphysema)

3. Percussion

Normal Findings:

• Resonance:
o Low-pitched, hollow sound over normal lung tissue
• Dullness Over Organs:
o Expected over liver (right lower thorax) and heart (left anterior
chest)
 • Tympany Over Gastric Bubble:
o Expected over stomach

Abnormal Findings:

• Hyperresonance:
o Heard in pneumothorax, emphysema (trapped air in lungs)
• Dullness:
o Heard in pneumonia, pleural effusion, tumor, atelectasis (fluid or
solid replacing air)
• Flat Percussion:
o Seen over massive pleural effusion

Know the order of the exam techniques

Inspect

1. Thoracic cage
2. Respiration: quality, quantity, effort, depth, use of accessory muscles,
or abdominal effort
3. Skin color and condition
4. Patient's choice of position
5. Facial expression
6. Level of consciousness

Palpate

1. Symmetric expansion
2. Tactile fremitus
3. Lumps, masses, and tenderness

Percuss

1. Overall lung fields

2. Diaphragmatic excursion

Auscultate

1. For normal breath sounds

2. For whether there are any abnormal or adventitious breath sounds

Know the different breath sounds - normal and abnormal

Normal: bronchial, bronchovesicular, vesicular

Abnormal (adventitious): rhonchi, crackles, friction rub, stridor, wheezing

Know the definition, signs and symptoms, and the associated exam
findings for
COPD

COPD is most caused by smoking, with the onset of symptoms typically

beginning in middle age usually related to and often coexisting problems
such as chronic bronchitis and emphysema.

S/S: chronic cough, SOB, barrel chest (AP chest diameter > lateral diameter),

Asthma,

Asthma is a chronic condition that involves inflammation of the airways, with

varying degrees of airway obstruction and hyperresponsiveness.

S/S: wheezing, SOB, cough, chest tightness

Chronic Bronchitis,

Pneumonia
Pneumonia involves inflammation and consolidation of lung tissue.
Pneumonia is broadly categorized by whether it occurs outside of the
hospital (community-acquired pneumonia) or within the hospital (nosocomial,
or hospital-acquired, pneumonia). The cause is most often Streptococcus
pneumoniae, Haemophilus influenzae, or Staphylococcus aureus. Atypical
pneumonia involves infection of mycoplasma, legionella, or chlamydia.
S/S: couhg, fever, malaise, chills, rigors, chest discomfort. The patient often
appears ill. Abnormal vital signs include tachycardia and tachypnea and
fever. There is uneven fremitus, and the area over the consolidation
percusses dull. On auscultation, there are bronchial breath sounds, often with
crackles. Bronchophony, egophony, and whispered pectoriloquy are often
present.
Cough,

Cough is an extremely common and potentially nonspecific complaint

foreign body aspiration,

Aspiration of a solid or semisolid object can be life-threatening

S/S: sudden difficulty of breathing, inability to talk, cyanosis, stridor,
diminished lung sounds, loss of consciousness
pulmonary embolism

Pulmonary emboli (PE) are life-threatening events stemming from venous

thrombi. The symptoms associated with PE range from very dramatic to
nonspecific, making them sometimes difficult to diagnose.
S/S: sudden onset severe dyspnea, cough, chest pain, possible hemoptysis

VQ scan, CT pulmonary angiogram

costochondritis,
Costochondritis is pain at a costosternal cartilage site. It can lead to trauma
to the chest wall, but the cause is often not identifiable. The symptoms may
follow a period of strenuous exercise or coughing.
Not PNA

sleep apnea

S/S: snoring, fatigue, obese

Know about tobacco use and smoking cessation in adults and
adolescents

Pack year history. Number of pack years= packs smoked per day x years as a
smoker or number of pack years= (number of cigarettes smoked per day x
years smoked)/ 20

Know vaccine recommendations and populations for influenza,

pneumonia

Vaccinations up to date? Especially children and the elderly. Refer to CDC for
most up to date immunization schedule. Spring and fall are the highest risk
times. PNA Adults 50 years and older and children younger than 5 years old.
FLU everyone 6 months old or older annually.
WEEK 4

Note general know the subjective, objective, ROS data of the cardiac
system (heart)

Subjective:

• Investigate complaints of chest pain, pressure, or heaviness; left arm

or jaw pain or numbness; dyspnea on exertion; cough; paroxysmal
dyspnea; hemoptysis; syncope; palpitations; fatigue; or edema.
 • Complaints indicating PVD, such as claudication, skin changes
especially in the lower extremities, dependent edema, or pain, also
should be investigated.
• Determine the date of the last chest x-ray and electrocardiogram
(EKG).
• Inquire about comorbid conditions or other factors that may increase
the patient’s risk for heart disease and PVD
• PMH
• Family Hx
• Social Habits: smoking, physical inactivity, high-fat diet, drug or alcohol
abuse, and stress

Objective:

• appearance and measure blood pressure and heart rate.

• Estimate the level of jugular venous pressure.
• Auscultate the carotids (bruit) one at a time.
• Palpate the carotid pulse including carotid upstroke (amplitude,
contour, timing) and presence of a thrill.
• Inspect the anterior chest wall (apical impulse, precordial movements).
• Palpate the precordium for any heaves, thrills, or palpable heart
sounds.
• Palpate and locate the PMI or apical impulse.
• Palpate for a systolic impulse of the right ventricle, pulmonary artery,
and aortic outflow tract areas on the chest wall.
• Auscultate S1 and S2 in six positions from the base to the apex.
• Identify physiologic and paradoxical splitting of S2.
• Auscultate and recognize abnormal sounds in early diastole, including
an S3 and OS of mitral stenosis and an S4 later in diastole.
• Distinguish systolic and diastolic murmurs, using maneuvers when
needed. If present, identify their timing, shape, grade, location,
radiation, pitch, and quality
Pulses

• The femoral artery just below the inguinal ligament, midway between
the anterior superior iliac spine and the symphysis pubis
• The popliteal artery, an extension of the femoral artery that passes
medially behind the femur, palpable just behind but deep in the knee
• The posterior tibial (PT) artery that lies behind the medial malleolus
of the ankle; an interconnecting arch between its two chief arterial
branches protects circulation to the foot
 • The dorsalis pedis (DP) artery on the dorsum of the foot just lateral to
the extensor tendon of the big toe

know how to assess the heart - locations of auscultation and

palpation points

Know normal and abnormal heart sounds

S1: heard louder at the apex

S2: heard louder at the base

S3

You will detect physiologic S3 frequently in children and young adults to the
age of 35 or 40 years, and often during the last trimester of pregnancy.
Occurring early in diastole during rapid ventricular filling, it is later than an
OS, dull and low in pitch, and heard best at the apex in the left lateral
decubitus position. The bell of the stethoscope should be used with very light
pressure.
S4

An S4 (atrial sound or atrial gallop) occurs just before S1. It is dull, low in
pitch, and best heard at the apex with the bell. Listen at the lower left sternal
border for a right ventricular S4 (or in the subxiphoid area if obstructive lung
disease). An S4 is occasionally normal, especially in trained athletes and
older age groups. More commonly, it is due to ventricular hypertrophy or
fibrosis causing stiffness and increased resistance (or decreased compliance)
during ventricular filling following atrial contraction.2,
Know how the body should be positioned when assessing
differences of the cardiac system

For the precordial examination, stand at the patient’s right side. The patient
should be supine, with the upper body and head of the bed or examining
table raised to about 30°.
JVD- Patient lying down. Adjust HOB down enough to see JVD
extended/pulsating.

***Know normal and abnormal exam findings and symptoms related

to the cardiac system
Not be considered a cardiac concern in ROS: + Homans sign

Chest pain

Palpitations

Shortness of breath: dyspnea, orthopnea, or paroxysmal nocturnal dyspnea

Swelling (edema)

Fainting (syncope)
Know the definition of:

Orthopnea is dyspnea that occurs when the patient is supine and improves
when the patient sits up.
Syncope- Fainting, blacking out, or syncope, is a transient loss of
consciousness followed by recovery.

Homan- Homan sign, discomfort behind the knee with forced dorsiflexion on
the foot, is neither sensitive nor specific, and discredited by Homan himself
Dyspnea- Shortness of breath: dyspnea, orthopnea, or paroxysmal nocturnal
dyspnea

Know the cardiac murmurs - grading system and sounds, etc...

classifications

Midsystolic Ejection Murmurs

• Aortic stenosis: Loud, harsh, midsystolic murmur with crescendo-

decrescendo notes. It is loudest at the second right intercostal space.
This murmur radiates to the carotid arteries, and down the left sternal
border. Patients with severe aortic stenosis generally need surgery to
 correct the issue. If left untreated serious heart conditions may occur
due to the limited amount of blood the heart can pump which may
weaken the heart muscle.
• Pulmonic stenosis: A medium pitch, coarse, midsystolic murmur, with
crescendo-decrescendo notes. It is best heard at the left second
intercostal space. This murmur radiates to the neck and the left chest
wall. People with mild pulmonic stenosis may not have symptoms but
those with severe pulmonic stenosis may present, along with the
murmur, shortness of breath, chest pain, fainting, fatigue, and
palpitations. If an adult or child patient presents with shortness of
breath, chest pain, or fainting then prompt evaluation and treatment
will reduce the risk of complications.
• Mitral regurgitation: May be pansystolic, blowing murmur, best heard
at the apex with radiation to the left axilla possible. This murmur may
be soft or loud. In some cases surgery is required to repair the mitral
valve. Treatment depends on severity of the patient’s condition.
• Tricuspid regurgitation: A soft, blowing, pansystolic murmur that
increases upon inspiration. This murmur is best auscultated at the left
lower sterna border. Treatment may not be necessary if there are few
or no symptoms associated with the murmur. If symptoms are present
then treatment will depend on the presenting symptoms.
Diastolic murmurs

• Mitral stenosis: A low-pitched murmur best heard at the apex when

patient is in the left lateral side lying position. This murmur does not
radiate. The primary cause of mitral stenosis is rheumatic fever.
• Tricuspid stenosis: A rumble-like sound that increases with inspiration.
This is best heard at the left lower sterna border. This murmur usually
does not require treatment.
• Aortic regurgitation: This soft, high pitched, blowing murmur begins
with the S2 sound. It has a decrescendo sound; being heard best at the
left third intercostal space with the patient in an upright, sitting
position, leaning forward. This murmur should radiate down the chest
wall. Patients should seek medical attention if they have fatigue,
shortness of breath, or swollen ankles and feet.
• Pulmonic regurgitation: This murmur is very similar to aortic
regurgitation and most likely cannot be determined on physical exam
alone. A 2-D echo is suggested for diagnosis. Treatment is
management of the cause of the pulmonic regurgitation.
Pediatric Murmur

• Still's Murmur: This innocent murmur was first described by Dr. George
Still in 1909. It is commonly found in children ages two to eight years
old and up to 30 percent of this population. The Still’s murmur is a low
to medium frequency, midsystolic murmur, Grade II-III of VI intensity.
The murmur can be best auscultated near the apex, described as a
vibratory, harmonic, musical, twanging, or groaning noise. The murmur
is louder when the patient is in a supine position, experiencing fever,
or is anemic.
A. Identify the beginning of systole and diastole.

a. S1

b. S2

Timing

A. Determine the timing of the murmur.

a. Systolic

b. Diastolic

B. Determine if the murmur is early, middle, or late in the interval.

Severity

A. Grade 1/6: barely audible

B. Grade 2/6: just audible, heard without straining

C. Grade 3/6

D. Grade 4/6

E. Grade 5/6: louder than previous levels, heard with a stethoscope

F. Grade 6/6: Heard without the stethoscope on the chest wall

Location

A. Identify which valve area is involved in the murmur.

Pattern

A. Uniform or constant
B. Crescendo or increasing
 C. Decrescendo or decreasing; diminuendo

D. Crescendo-decrescendo: Diamond-shaped murmur

Pitch

A. Low pitched

a. Best auscultated with the bell of the stethoscope with only

light pressure being applied if any

B. High pitched

a. Best auscultated with the diaphragm of the stethoscope with

firm pressure being applied
Know how to calculate CVD risk
HTTP://[Link]/ASCVD-RISK-ESTIMATOR-PLUS/#!/CALCULATE/ESTIMATE

Age (40-79), sex, race, BP (sys/dia), total cholersterol, HDL, LDL, hx of DM,
smoker, HTN treatment, on statin?, aspirin?

Know the signs and symptoms of acute coronary syndrome in young

and older adults

Epidemiology/Patho: Older age, risk factors include diabetes, hypertension,

dyslipidemia, family history, tobacco use
Time course: Acute onset, not necessarily preceded by exertional angina

Clinical Presentation: Chest pain, with crescendo to maximal pain; often dull
and substernal, radiating to arms/shoulders; diaphoresis; dyspnea;
nausea/vomiting, diaphoresis; tachycardia on examination
Diagnostics: Elevated cardiac biomarkers; ST elevation/depression, T-wave
changes on ECG; regional wall motion abnormality on echocardiogram
Know the definitions, physical exam findings, symptoms, risk
factors, lifestyle modifications

• aortic stenosis,
o Aortic stenosis is heard best in the second right intercostal space
with the client leaning forward. The murmur is harsh, loud, and
often associated with a thrill. It may radiate to the neck, left
sternal border, and, in some cases, to the apex.
o S/S: Syncope, angina, and dyspnea (remembered with the
acronym SAD) on exertion
• aortic dissection: A life-threatening condition where there is a tear in
the intimal layer of the aorta, allowing blood to enter the aortic wall
and create a false lumen. This can lead to rupture, compromised blood
flow to vital organs, and death if untreated.
o S/S: -Sudden onset of severe, tearing chest pain, often radiating
to the back or between the shoulder blades
o Unequal pulses or blood pressure in the upper extremities
o Possible signs of shock, stroke, or myocardial ischemia
o May present with a new diastolic murmur (if involving the aortic
valve)

• atrial fibrillation: A common cardiac arrhythmia characterized by

disorganized and rapid electrical impulses in the atria, leading to
ineffective atrial contractions and an irregularly irregular ventricular
rate.
o S/S: -Irregularly irregular pulse (no consistent rhythm)
o May be asymptomatic or present with palpitations, dizziness,
fatigue, shortness of breath
o Risk of thromboembolic events, particularly stroke
o Detected on EKG by absence of P waves and irregular R-R
intervals

• Angina: Chest pain or discomfort caused by transient myocardial

ischemia (reduced blood flow to the heart muscle) without infarction.
o S/S: -Described as pressure, squeezing, tightness, or heaviness
in the chest
o Often precipitated by exertion or emotional stress and relieved
by rest or nitroglycerin
o May radiate to the jaw, neck, shoulder, or left arm
o Stable angina occurs predictably with exertion; unstable angina
is new, worsening, or at rest (a red flag for acute coronary
syndrome)

• mitral valves prolapse

o MVP, also termed click-murmur syndrome, is a variant of mitral
regurgitation and occurs in approximately 10% of young women.
MVP generally is hemodynamically insignificant and
characterized by normal heart size and dynamics, although the
 process can progress to hemodynamically significant mitral
regurgitation.
• Pericarditis
o inflammation of the pericardium is usually not a solo disease
process but is seen in conjunction with other diseases or
conditions. Pericarditis may occur as a complication of MI
(Dressler’s syndrome) or coronary artery bypass surgery. It is
also more commonly seen in patients with connective tissue
disorders such as rheumatoid arthritis, systemic lupus
erythematosus (SLE), scleroderma, and sarcoidosis. Bacterial,
viral, or fungal infections, including HIV, are risk factors for
pericarditis.
o S/S: sharp and stabbing; it may worsen with inspiration or when
lying flat or leaning forward. Associated symptoms may include
shortness of breath, fever, chills, and malaise.
• metabolic syndrome
o When occurring together, a cluster of risk factors known as
syndrome X, or metabolic syndrome, seem to dramatically
increase the risk for CAD, diabetes, and stroke. Lack of physical
activity and poor dietary habits lead to a positive energy
balance, increased body fat, and insulin resistance.
o Risk factors
▪ Abdominal Obesity
• Men >40in
• Women >35in
▪ Triglycerides >150mg/dl
▪ HDL Cholesterol
• Men <40mg/dl
• Women <50mg/dl
▪ Blood Pressure >130/85
▪ Fasting Glucose >100
o Weight loss, through diet and exercise, is the most important
factor in preventing the progression of this syndrome.
• primary hypertension
o The pathophysiology of primary HTN is varied. Genetic factors
are significant contributors, especially if both parents have HTN.
Other factors include sympathetic nervous system
hypersensitivity, decreased ability to balance sodium and
calcium, and a renin-angiotensin-aldosterone imbalance.
 o Factors that may exacerbate the predisposition to develop HTN
include a sedentary lifestyle, obesity, smoking, alcohol use,
sodium intake in some individuals, low potassium intake,
polycythemia, and long-term use of NSAIDs.
o S/S: elevated BP otherwise asymptomatic, some throbbing
headache, hear their own heartbeat in ears at bedtime
• secondary hypertension
o Only 5% or less of patients have specific, identifiable causes of
HTN, particularly those who develop HTN at an early age with no
family history, those whose previously controlled HTN suddenly
becomes uncontrolled, and those who first develop HTN after age
50.
o S/S: nervousness, diaphoresis, palpitations, dyspnea, tremor,
muscle weakness, polyuria, nocturia, nausea, or vomiting.
• diabetes
***Know the vaccination schedule for the different vaccines and age
groups
Hepatitis A at 1 year and people with high risk factors. Refer to below.

Hepatitis B: The ACIP recommends universal vaccination for all infants

beginning at birth as well as for previously unvaccinated children younger
than 19 years. For adults, vaccine recommendations target high-risk groups.

• Hepatitis A (HAV):
o Recommended at age 1 year.
o Also for people with chronic liver disease or high-risk behaviors
(travelers to endemic areas, MSM, illicit drug users, occupational
exposure).
• Hepatitis B (HBV):
o Universal vaccination beginning at birth.
o Catch-up for all unvaccinated individuals under 19 years.
o Adults at high risk: healthcare workers, dialysis patients, those
on immunosuppressive therapy, MSM, IV drug users, and
pregnant women.
• Hepatitis C (HCV):
o No vaccine currently available.
o Screening recommended for high-risk populations and all adults
at least once in their lifetime.
Know what the definitions of and the indication of:

Murphy sign: or inspiratory arrest. During palpation of the liver, hold your
fingers under the ribs and therefore the liver border; ask the patient to take a
deep breath. If pain is elicited, consider cholecystitis or other liver/gall
bladder functions. RUQ
Rovsing sign: Rovsing sign (indirect tenderness) and referred rebound
tenderness. With the patient supine, press deeply and evenly in the LLQ.
Then quickly withdraw your fingers. Pain in the RLQ during left-sided
pressure is a positive Rovsing sign.
Obturator sign: Flex the patient’s right thigh at the hip, with the knee bent,
and rotate the leg internally at the hip. Right hypogastric pain is a positive
obturator sign, from irritation of the right obturator internus muscle by an
inflamed appendix located in the pelvis. This sign has very low sensitivity.
RLQ

Psoas sign: With the patient supine, place your hand just above the
patient’s right knee and ask the patient to raise that thigh against your hand.
Alternatively, ask the patient to turn onto the left side. Then extend the
patient’s right thigh at the hip. Flexion of the thigh at the hip makes the
psoas muscle contract; extension stretches it. Increased abdominal pain on
either technique is a positive psoas sign, suggesting irritation of the right
psoas muscle by an inflamed retrocecal appendix. RLQ

Polyuria: refers to a significant increase in 24-hour urine volume, roughly

defined as exceeding 3 L.
Polyphagia: excessive hunger

Polydipsia: excessive thirst

urge incontinence: urgency is followed by involuntary leakage due to

uncontrolled detrusor contractions that overcome urethral resistance. Ask
about any related fever or chills; blood in the urine; or any pain in the
abdomen, flank, or back.

stress incontinence: increased abdominal pressure causes bladder

pressure to exceed urethral resistance—there is poor urethral sphincter tone
or poor support of bladder neck. urinart leakage associated w coughing
laughing
uterine prolapse: Descent of the uterus into the vaginal canal due to
weakened pelvic floor support.

Know the organs/structures located in the four abdominal quadrants

-

RUQ: These include the liver, gallbladder, duodenum, head of the pancreas,
right kidney and adrenal gland, hepatic flexure of the colon, and part of the
ascending and transverse colon.
LUQ: These include the stomach, spleen, left lobe of the liver, body of the
pancreas, left kidney and adrenal gland, splenic flexure of the colon, and part
of the transverse and descending colon.

RLQ: These include the cecum, appendix, right ovary and tube, right ureter,
and right spermatic cord.

LLQ: These include the part of the descending colon, sigmoid colon, left
ovary and tube, left ureter, and left spermatic cord.

Midline: These include the aorta, the uterus if enlarged, and the bladder if
distended.

Know how to examine the gastrointestinal system/abdomen

Subjective Data

Appetite: Is there any change in your appetite? Is this a loss or increase in

appetite? Have you experienced a weight change recently? Is this due to a
specific diet or other problem?
Do you have abdominal pain? Where? Ask the patient to point to the pain.
Does the pain move about or stay in one place? How does it start? How long
does it last? When did you first notice the pain? Is the pain intermittent or
constant? What does the pain feel like (cramping, wringing, burning,
bloating, dull, aching, or stabbing)?
Nausea and vomiting: Any recent nausea and vomiting? What is the
frequency and volume? Ask about color and odor, especially presence of
blood. Any associated pain, diarrhea, constipation, fever, or chills?
Bowel habits: How often do you have a bowel movement? Do you consider
this pattern normal? What is the color and consistency of the stool? Do you
have any issues with diarrhea or constipation? How long have you had this
problem? Have you experienced a recent change in your bowel habits?
Past abdominal history: Do you have any previous problems with ulcers,
gallbladder, hepatitis or jaundice, appendicitis, colitis, or hernia? Describe
your abdominal operations. Were there any post-operative problems from
these surgeries? Any previous abdominal X-rays? What were the results?

Pain characteristics (location, onset, duration, quality)

Pain Types

• Visceral: Poorly localized; from distention/stretch of hollow organs.

• Parietal (Somatic): Localized, intense; from peritoneal inflammation.
• Referred: Pain perceived at distant sites sharing spinal innervation.

Objective Data

Inspection:

• The abdomen may be rounded, flat, protuberant, or scaphoid (sunken).

Is the abdomen symmetric bilaterally?
• The umbilicus should be midline, inverted, clear, or flesh colored,
without bruising, inflammation, discoloration, or hernia.
• The skin should be even in texture and color. The skin surface should
be smooth to touch. Moles or nevi are usually brown papule or macules
on the abdomen. Note any surgical scars, including position, length,
and color.
• Note any signs of infection or inflammation

Auscultation:

• Listen before you feel. Palpation and percussion can increase bowel
sound activity; therefore, you should always auscultate first.
 • Use the diaphragm of the stethoscope; place it lightly on the skin of
the abdomen, starting at the RLQ. Bowel sounds are most likely to be
present here at all times unless there is an underlying problem.
• Listen for vascular sounds, such as a bruit. Use a firmer pressure over
the aorta than you did with bowel sound auscultation.

Percussion:

• Use percussion to identify and measure organs and any masses or fluid
that might be present. Percuss all four quadrants with the expected
finding to be tympany.
• Start on the right sternal wall and percuss down until you hear the
tympanic sound change to dullness. This is the top of the liver border
and should be approximately at the fifth intercostal space.

Palpation:

• Palpation can be used to locate and measure certain organs as well as

a means to screen for masses or tenderness.
• Begin with light palpation across the four quadrants. Light palpation is
to screen for tenderness and any masses or skin changes.
• Deep palpation is conducted in a similar fashion to light palpation but
with depressing the hand 5 to 8 cm.

***Know normal and abnormal findings of the gastrointestinal

system/abdomen in the young adult, adult, and older adult

Visceral pain occurs when hollow abdominal organs such as the intestine or
biliary tree contract unusually forcefully or are distended or stretched (Fig.
19-8). Solid organs such as the liver can also become painful when their
capsules are stretched. Visceral pain is typically nonspecific and difficult to
localize.
Somatic or parietal pain originates from inflammation of the parietal
peritoneum, called peritonitis, which can be localized or diffuse. It is a
steady, aching pain that is usually more severe than visceral pain and more
precisely localized over the involved structure. It is typically aggravated by
movement or coughing. Patients with parietal pain usually prefer to lie still.
Referred pain is felt in more distant sites that are innervated at
approximately the same spinal levels as the disordered structures. Referred
pain often develops as the initial pain becomes more intense and seems to
radiate or travel from the initial site. Palpation at the site of referred pain
often does not result in tenderness.
WEEK 5

Know the definition, signs and symptoms, risk factors, and lifestyle
modifications (if applicable) for

Hepatitis A

• Transmission: Fecal-oral
• S/S: Fatigue, nausea, abdominal pain, jaundice
• Prevention: Hand hygiene, vaccine at age 1 or for high-risk
individuals

HAV infection is rarely fatal; it does not cause a chronic hepatitis, and deaths
usually occur only in those with other liver diseases. Viral transmission is
primarily person to person through the fecal–oral route and can be reduced
by handwashing with soap and water after using the bathroom or changing
diapers and before preparing or eating food.
The Advisory Committee on Immunization Practices (ACIP) recommends
hepatitis A vaccination for all children at age 1 year, for persons with chronic
liver disease, and for groups at increased risk of acquiring HAV—persons
traveling to or working in countries with high endemic rates of infection, men
who have sex with men, injection and illicit drug users, persons with
occupational risk for infection, and persons who have clotting-factor
disorders.
Hepatitis B

• Transmission: Blood and body fluids

• S/S: Often asymptomatic, jaundice, fatigue, abdominal discomfort
• Risk Factors: IV drug use, sexual contact, healthcare exposure
• Prevention: Vaccination at birth and for high-risk groups

HBV is spread by the blood, semen, or other bodily fluids of an infected

person; sexual contact, injection drug use, and perinatal transmission are the
most common pathways.
Risk of chronic HBV infection is highest when the immune system is
immature; chronic infection occurs in up to 90% of infected infants and 30%
of children infected before age 6 years.

The ACIP recommends universal vaccination for all infants beginning at birth
as well as for previously unvaccinated children younger than 19 years.43 For
adults, vaccine recommendations target high-risk groups (Box 19-7).

The CDC also recommends screening persons on hemodialysis or who are

receiving immunosuppressive therapy.45 The USPSTF (grade A) and ACIP
recommend screening all pregnant women.43,46 Chronic liver disease not at
high risk? Pregnant women

Hepatitis C

• Transmission: Primarily bloodborne (IV drug use, needlesticks)

• S/S: Often asymptomatic; fatigue, liver dysfunction signs in chronic
cases
• Treatment: Antiviral therapy; no vaccine available

Hepatitis C virus (HCV), is the most prevalent chronic bloodborne pathogen

in the United States. Anti-HCV antibody is detectable in just under 2% of the
population, although prevalence is markedly increased in high-risk groups.
HCV is mainly transmitted by percutaneous exposures, particularly injection
drug use, health care workers with needlestick injury or mucosal exposure to
HCV-positive blood, long-term hemodialysis, getting an unregulated tattoo,
and birth from an HCV-positive mother; sexual transmission is uncommon,
although it occurs among HIV-positive persons, particularly among men who
have sex with men.
Antiviral treatment regimens can achieve high rates of sustained virologic
response (aviremia 24 weeks or more after completing treatment) and
improve clinical outcomes.

Colorectal cancer

• Risk Factors: Age, polyps, IBD, family history. Not a risk factor: female
gender
 • Screening: Begin at age 50 (or earlier with risk factors)
• Prevention: Healthy diet, physical activity, avoid tobacco/alcohol

Colorectal cancer is the third most frequently diagnosed cancer among both
men and women and the third leading cause of cancer death (around 50,000
deaths) in the United States.

Prevention: decreased tobacco use; increased uptake of screening, which

both prevents cancers and increases detection of early-stage curable
cancers; and improved treatments.
Risk Factors: increasing age; personal history of colorectal cancer,
adenomatous polyps, or longstanding inflammatory bowel disease (IBD); and
family history of colorectal neoplasia—particularly with diagnoses in multiple
first-degree relatives, a single first-degree relative diagnosed before age 60,
or a hereditary colorectal cancer syndrome.
A recommendation for colorectal cancer screening in average-risk adults
from the ages of 50 to 75, suggests multiple screening options (Box 19-8).
Performing digital rectal examination to test for fecal occult blood is not
recommended for colorectal cancer screening.
GERD

• S/S: Heartburn, regurgitation

• Risk Factors: Obesity, delayed gastric emptying, hiatal hernia
• Management: Lifestyle changes, PPIs, avoiding triggers

If patients report heartburn and effortless regurgitation together more than

once a week, the accuracy of diagnosing GERD is over 90%. These
symptoms or mucosal damage on endoscopy are the diagnostic criteria for
GERD.

Risk factors include reduced salivary flow, which increases mucosal acid
exposure by dampening the actions of the bicarbonate buffer; obesity;
delayed gastric emptying; selected medications; hiatal hernia and increased
intraabdominal pressure
Cholecystitis

• S/S: RUQ pain, nausea, vomiting, positive Murphy’s sign

• Etiology: Usually gallstones blocking the cystic duct

Pancreatitis
 • S/S: Severe epigastric pain radiating to back, nausea, vomiting
• Risk Factors: Alcohol use, gallstones

Appendicitis

S/S: RLQ pain (McBurney's point), nausea, vomiting, fever, positive psoas,
obturator, Rovsing signs

Irritable Bowel Syndrome

• S/S: Abdominal discomfort, bloating, alternating diarrhea/constipation

• More common in women
• Management: Diet modification (FODMAP), stress reduction

Peptic Ulcer Disease

• Etiology: H. pylori, NSAID use

• S/S: Epigastric burning pain, worse with fasting or certain foods
• Complications: Bleeding, perforation