cardiac assessment

1. ASSESSMENT
ANANYA BISWAS

2. RESPIRATOR
Y
ASSESSMENT

3. ASSESSMENT
ON
RESPIRATORY SYSTEM
 History
 Physical examination
 Investigation and diagnostic tests

4. History
 Identification data
 Current health
 Past health history
 Family health history
 Psycho-social history
 Review of system

5.  Identification data :
Name
Age
Gender
Living situations

6.  Current health :
o Chest pain -
1. may associated with pulmonary, cardiac, gastrointestinal problem
2. determine location, duration, intensity of chest pain
3. Pleuritic pain – sharp, stabbing pain that occur at one site on chest wall and increase
the chest wall movement and deep breathing.
4. Angina pectoris – an aching, heavy, squeezing sensation with pressure or tightness in
the substernal area and radiate into the neck or arm.
o Dyspnea -
1. difficulty in breathing.
2. shortness of breathing, suffocation, tightness, being breathless

7. o Cough -
1. note when and how cough begun,
2. how long the cough been present,
3. characteristic – dry, hoarse, congested, wheezy,
4. Sputum – color, consistency, odour, amount
5. hemoptysis - is simply a medical term for coughing up blood.
Causes of hemoptysis include chronic bronchitis, bronchiectasis,
pulmonary embolism, pneumonia, lung cancer, lung abscesses.
o Wheezing-
1. sound produces when air passes through partially obstructed or narrowed
airway.
2. complain of chest tightness or chest discomfort.

8. o Shortness of breathing -
1. Onset
2. Duration
3. Severity
4. Characteristic
o Other complaints -
1. Sweating
2. Dizziness
3. Limb pain
4. Exercise intolerance

9. Past medical history
1. data regarding common childhood diseases, congenital history and vaccinations
2. any history of Tuberculosis, Bronchitis, Influenza, Asthma, Pneumonia
 Smoking history
 Alcohol use- frequency and amount
 Allergies history
precipitating and aggravating factors –such as foods, medications, pollens, smoke,
fumes, dust
 Surgical history - history of any surgical procedure
 Medication

10. Family history
1. history of hereditary disease
2. living with person with infectious disease
Psycho-social history
1. Environment
2. Work environment
3. Occupation
4. Dietary habits
5. Exercise

11.  Physical examination
 Inspection-
1. general inspection :
- evidence of respiratory distress at rest or when walking, talking,
-evidence of other respiratory symptoms
2. Hands :
-finger clubbing
-cyanosis
-tremor
3. Nose : -patent
4. Neck :
- lymph node
- Goitre, jugular vein

12. Chest
Chest shape – normal; Barrel chest; Pectus carinatum (pigeon's chest); Pectus excavatum (funnel chest);
Scoliosis; lordosis; kyphosis
 Chest movement – paradoxical movement
 Respiration rate, rhythm, pattern, depth.
 Pursed lip breathing
 Tripod position - a patient who is seen taking the tripod position on their own is an indication that the
patient may be in respiratory distress.
 Nature of breathing -
Kussmaul's breathing- deep & laboured breathing; associated with the metabolic acidosis
Cheyne-stokes breathing- progressively deeper breathing

16.  Palpation -
1. Lymph node
2. Air entry – bilaterally equal / unequal
3. Tactile fremitus - ( use ulnar side of the hand, place it at various levels over the back, each time asking
patient to say ninety-nine. Note the sound transmitted.
If fremitus is increased indicates inflamed lung tissue caused by pneumonia
If it is decreased that suggest air or fluid in the pleural spaces, )

17. 

18.  Auscultation
Lung sound – normal / abnormal
Normal-
1. Bronchial - heard over the tracheal area, sound is high pitched and loud. Inspiration slightly
shorter than expiration.
2. Broncho-vesicular – heard over bronchi, sound is medium pitch. Inspiration is equal for
inspiration.
3. Vesicular – heard through peripheral lung fields, sound is soft with the low pitch. Inspiration
slightly greater than expiration.

20. 
6. Stridor- a harsh, vibrating, shrill sound is produced during respiration as heard in upper airway
obstruction. Eg- laryngitis.
7. Stertorous- noisy breathing,snorings sound are made by the air passage through the secretion as seen in
acute alcoholism

21.  INVESIGATION -

22. CARDIO-
VASCULAR
ASSESSMENT

23. ASSESSMENT
ON
CARDIO-VASCULAR SYSTEM
 History
 Physical examination
 Investigation and diagnostic tests

24. HISTORY COLLECTION
 data
 Current health history
 Past health history
 Family health history
 Psycho-social history

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26.  Cough -
 1. note when and how cough begun,
 2. how long the cough been present,
 3. characteristic – dry, hoarse, congested, wheezy,
 4. Sputum – color, consistency, odour, amount
 5. hemoptysis - is simply a medical term for coughing up blood.
 Causes of hemoptysis include chronic bronchitis, bronchiectasis, pulmonary embolism,
pneumonia, lung cancer, lung abscesses.
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27.  Dyspnea -
 1. difficulty in breathing.
 2. shortness of breathing, suffocation, tightness,
 3. being breathless I middle of night.
 Wheezing-
 1. sound produces when air passes through partially obstructed or
narrowed airway.
 2. complain of chest tightness or chest discomfort.
 Other complaints -
 1. Sweating
 2. Dizziness
 3. Limb pain
 4. Exercise intolerance

28.  Past medical history
 1. data regarding common childhood diseases, congenital history and vaccinations
 2. any history of Tuberculosis, Bronchitis, Influenza, Asthma, Pneumonia
 Smoking history
 Alcohol use- frequency and amount
 Allergies history
 precipitating and aggravating factors –such as foods, medications, pollens, smoke, fumes,
dust
 Surgical history - history of any surgical procedure
 Medication

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 is when the increased pressure of the superior vena cava
causes the jugular vein to bulge, making it most visible on the right side of a person's neck
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34. GASTRO-
INTESTINAL
ASSESSMEN
T

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36. HISTORY
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Abdominal pain-

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42. PHYSICAL EXAMINATION
 INSPECTION -
 General inspection-
1. Wasting
2. Jaundice
 System specific- Hands :
1.Nails ( clubbing / leuconychia )
2.Palmar erythema
3.Dupuytren's contracture
4.Hepatic flap
 Arms :
1.Spider naevi
2.Brusing
3.Wasting
4.Scratch marks (chronic cholestasis)

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48. GENITO-
URINARY
ASSESSMEN
T

49. ASSESSMENT OF GU SYSTEM
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