Ethical Principles and Clinical Practices in Healthcare, Exams of Nursing

Download Ethical Principles and Clinical Practices in Healthcare and more Exams Nursing in PDF only on Docsity! NR509 Midterm Advanced Physical Assessment Study Sequence of Clinical Encounter Initiate encounter Gather information Perform ohysical exam Explain and planning Closing the encounter FIFE model Feelings Ideas effects on Function Expectations Mnemonic used to explore the patient perspective on the illness. ***the combination of concerns and expectations that has shown to have a major influence on the patient’s decision to seek help from the clinician Identifying gender pronouns Done during "initiating encounter." "What pronouns do you use?" Setting stage for medical care -Prepare for interview. -Check your appearance. -Make sure patient is comfortable, and environment is conducive to very personal information that is to be shared. -review biases (implicit, explicit) implicit bias A set of unconscious, beliefs or associations that lead to a negative evaluation of a person on the basis of their perceived group identity. Example - a patient assuming a female doctor is a nurse upon meeting or a doctor audibly sighing in frustration about a patient's substance use disorder. These unconscious biases can permeate the patient encounter through nonverbal behavior such as poor eye contact, speech errors, and other subtle avoidance behaviors that convey distrust or dislike. explicit bias The conscious or deliberate decisions or preferences founded on beliefs, stereotypes, or associations on the basis of a perceived group identity. Example - a patient who refuses to see a African-American doctor because they "want a qualified doctor" or a clinician who believes that all gay males are at risk of HIV. 5 R's of cultural humility Reflection Respect Regard NR509 Midterm Advanced Physical Assessment Study Sequence of Clinical Encounter Initiate encounter Gather information Perform ohysical exam Explain and planning Closing the encounter FIFE model Feelings Ideas effects on Function Expectations Mnemonic used to explore the patient perspective on the illness. ***the combination of concerns and expectations that has shown to have a major influence on the patient’s decision to seek help from the clinician Identifying gender pronouns Done during "initiating encounter." "What pronouns do you use?" Setting stage for medical care -Prepare for interview. -Check your appearance. -Make sure patient is comfortable, and environment is conducive to very personal information that is to be shared. -review biases (implicit, explicit) implicit bias A set of unconscious, beliefs or associations that lead to a negative evaluation of a person on the basis of their perceived group identity. Example - a patient assuming a female doctor is a nurse upon meeting or a doctor audibly sighing in frustration about a patient's substance use disorder. These unconscious biases can permeate the patient encounter through nonverbal behavior such as poor eye contact, speech errors, and other subtle avoidance behaviors that convey distrust or dislike. explicit bias The conscious or deliberate decisions or preferences founded on beliefs, stereotypes, or associations on the basis of a perceived group identity. Example - a patient who refuses to see a African-American doctor because they "want a qualified doctor" or a clinician who believes that all gay males are at risk of HIV. 5 R's of cultural humility Reflection Respect Regard Components of the comprehensive adult health history Initial information Chief complaints History of present illness Past medical history Family history Personal and social history Review of systems mnemonic for characterizing chief complaint OLD CARTS Onset Location Duration Character Aggravating/Alleviating Radiating Timing Setting Reasons for a comprehensive assessment -New patients in office or hospital -If it provides fundamental and personalize knowledge about the patient -Improves provider-patient relationship -establishes a baseline for future assessments -Create a platform for health promotion through education and counseling -Develops proficiency in the essential skills of physical examination Reasons for a focused patient assessment -for establish patients, especially during routine or urgent care visits -addresses focus concerns are symptoms -Assess his symptoms restricted to a specific body system -Applies examination methods, relevant to assessing the concern or problem as thoroughly and carefully as possible Modifying clinical interview for various clinical settings (ambulatory clinic and ED) Ambulatory care clinic: Patients are more likely to be mobile and independent with CC of lower acuity. Exam rooms tend to be quieter, more private, and have minimal distractions. They are more ideal for conducting a health hx. Since patients are seen on a regular basis, focus info gathering not only on the CC but also on chronic health issues and any changes to those since last visit. Ask about routine health care maintenance. Emergency Care: High acuity & fast paced. Ensure patient clinically stable before initiating detailed but FOCUSED interview. Ask about symptoms related to possible causes of the patient’s problem to quickly route life-threatening illnesses. Info gathering may be interrupted intermittently so may have to complete at later time. AMS may warrant health hx from caregivers, clinicians, or records, if available. Modifying clinical interview for various clinical settings (ICU and nursing home) ICU: Limited ability to communicate d/t illness, AMS, sedation, vent-gather info from others and EHR. Comprehensive health hx focused on events that led to icu. If transferring from another unit to ACU, prior, clinician should document events leading up to Icu transfer. If patient is able to communicate, gather information about advanced directives and resuscitation wishes, including use of life-sustaining interventions, if required. Nursing home: Patients are called residents. Attempt to obtain history from resident first but if there is cognitive deficits, may need to confirm with family or staff. Include ADLs, IADLs. Can come back over multiple visits to get a complete comprehensive history. The four classic techniques of the physical exam: 1. Inspection 2. Palpation 3. Percussion 4. Auscultation Percussion Technique Use the striking or plexor finger, usually the third, to deliver a rapid tap or blow against the distal pleximeter finger, usually the distal third finger of the left hand laid against the surface of the chest or abdomen to evoke a sound wave such as resonance or dullness from the underlying tissue or organs. This sound wave also generates a tactile vibration against the pleximeter finger Head to toe assessment Clinical reasoning process: hypotheticodeductive A more tempered, controlled thought process. Is subject to conscious judgments and attitudes, and uses logic and probabilities to come to a conclusion. The process is time and resource intensive and requires more cognitive effort. anchoring bias Tendency to perceptually lock onto salient features in the patient's initial presentation too early in the diagnostic process and failure to adjust in light of later information availability heuristic Assumption that a diagnosis is more likely or more frequently occurring, if it more readily comes to mind confirmation bias Seeking support of evidence for a diagnosis at the exclusion of more persuasive information refuting it Diagnostic momentum Prioritizing a diagnosis made by prior clinicians, discounting evidence of alternative explanations framing effect Interpretation of information is influenced heavily by the way, in which information about the problem are presented Representation error Failure to take prevalence into account, when estimating a probability of a diagnosis Ex: clinician who often sees older patients places diverticular bleed high on her differential diagnosis when evaluating rectal bleeding in an adolescent patient Visceral bias Visceral arousal (negative and positive feelings toward patients) lead to poor diagnostic decisions problem list Summarizes all related problems that support a differential diagnosis. List the most active/serious problems first. Differential Diagnosis (DDx) List of possible diagnoses supported by the problem list. Pertinent positives = abnormal findings that support diagnosis Pertinent negatives = normal findings that rule out diagnosis summary statement -Makes the case for the working diagnosis. -Written in the patient’s health record as a summary statement, and often starts the assessment section of the clinical record. -Should not simply recite facts. -includes restated patient’s CC and its clinical context with salient historical information, physical exam findings, and study data results. -The goal is for the summary statement to elicit the dx in the mind of the reader by aligning with the illness script. -2-3 sentences Constitutional symptoms Broad symptoms affecting a patient's physical state with regard to vitality, health, and strength. May include fatigue, weakness, fever, chills, night sweats, weight, loss, weight gain, and pain. Fatigue is a common symptom of... Depression, anxiety, infections (hepatitis, mononucleosis, tuberculosis), endocrine disorders (hypothyroidism, adrenal, insufficiency, diabetes), heart failure, chronic diseases of the lungs, kidneys, or liver, electrolyte, imbalances, moderate to severe anemia, malignancies, nutritional deficits, and medications. Extreme shaking chills suggests suggests... More extreme swings in temperature in systemic bacteremia. Symptoms that a company arising temperature. Feeling cold, goosebumps, and shivering Feelings that accompany a falling temperature Feeling hot and sweating Symptoms that often accompany fever Malaise, headache, and pain in the joints and muscles Immunocompromise patients with sepsis may have what in regard to their temperature? Fever may be absent, low-grade, or drop it below normal (hypothermia) Clinically significant weight loss Loss of 5% or more of usual body weight over a six month. Causes of clinically significant weight loss Decreased food intake due to anorexia, depression, dysphasia, vomiting, abdominal pain, or financial difficulties; defective G.I., absorption, or inflammation; and increased metabolic requirements Ask about abuse of alcohol, cocaine, amphetamines, or opiates, or withdrawal from marijuana. Heavy smoking also suppresses appetite. Diagnoses associated with weight loss G.I. disease, diabetes, hyperthyroidism, adrenal insufficiency, chronic infections, HIV/AIDS, malignancy, chronic cardiac/pulmonary/renal failure, depression, anorexia nervosa, or bulimia Medication is associated with weight loss -Press the arm on a table a little above the patient's waist, or at the level of the fourth interspace at the junction with the sternum -if standing, I support the patient's arm at mid chest level Normal blood pressure range <120 and <80 Elevated BP 120-129 / <80 Stage 1 HTN 130-139 or 80-89 Stage 2 HTN >/=140 or >/=90 Low BP Interpret relatively low levels of blood pressure in the light of past readings and the patient's clinical state Orthostatic BP measurements A sustained reduction in SBP of at least 20 mmHg or in DBP of at least 10 mmHg within 3 minutes of standing. white coat hypertension >= 140/90 in medical settings, and mean awake ambulatory readings <135/85. Masked, hypertension low clinic blood pressure, but elevated ambulatory/home blood pressure Office BP <140/90 but elevated daytime BP >135/85. Consider home or ambulatory BP monitoring . fever pyrexia Pyrexia Extreme elevation of temperature, above 41.1°C or 106°F. Hypothermia Abnormally low temperature, below 35°C or 95°F rectally Gold standard for core body temperature Blood temperature in the pulmonary artery acute pain -Physiological response to chemical, thermal, mechanical stimulus -Typically lasts less than 3 to 6 months -Commonly associated with surgery, trauma, an acute illness -Symptoms can last hours, days, or weeks, but gradually resolve as injured tissue heals chronic pain -pain not associated with cancer or other medical conditions that persist for more than 3 to 6 months -pain lasting more than one month beyond the course of an acute illness or injury, or pain, recurring at intervals of months or years Leading cause of disability, and impaired work performance Chronic pain Dietary changes for patients with hypertension Increase foods high in potassium: baked white or sweet, potatoes, white beans, beet greens, soy beans, spinach, lentils, kidney beans, yogurt, tomato products, bananas, plantains, dried fruits, OJ Decrease foods high in sodium: Canned foods, pretzels, potato chips, pizza, pickles, olives, processed foods, batter-fried foods, table salt incidence of depression -Twice as common in women -Affects 13% of postpartum mothers -Frequently accompanies chronic medical illness -Often coexists with anxiety and substance abuse -vulnerable group: young, female, single, divorced or separated, seriously or chronically ill, bereaved, or have psychiatric disorders, including substance abuse. Personal our family history of depression. Screening question for depressed mood "Over the past two weeks, have you felt down, depressed, or hopeless?" Screening question for anhedonia "Over the past two weeks, have you felt little interest or pleasure and doing things?" Key components of Mental Status Exam -Appearance and behavior -Speech and language -Mood -Thoughts and perceptions -Insight and judgment -Cognition/ Cognitive function Dysarthria Defective articulation of speech aphasia Disorder of language dysphonia Impaired quality, volume, or pitch of the voice If a person can write a correct sentence.... Perseveration occurs in schizophrenia and other psychotic disorders Hallucinations •perception-like experiences that seem real •Lack external stimulation • person may or may not recognize experiences as false • May be auditory, visual, olfactory, gustatory, tactile, or somatic NOT associated w/ false perceptions of falling asleep, dreaming, and awakening Illusions Misinterpretations of real external stimuli, such as mistaking rustling leaves for the sound of voices Hallucinations may occur in delirium, dementia (less commonly), posttraumatic stress disorder, schizophrenia, and substance use. illusions may occur in grief reactions, delirium, acute and posttraumatic stress disorders, and schizophrenia. insight An awareness that symptoms or distorted behaviors are normal or abnormal assessing abstract thinking ask to interpret a proverb -average patient should give abstract or semi abstract responses -concrete responses are common in people with intellectual disability, delirium, or dementia -bizarre, personal, or concrete responses by schizophrenic ——————————————— Similarities -ask the patient to tell you how to things are alike Serial 7 Test instruct the patient to start from 100 and subtract 7. ask them to do that 5 times Tests for attention attention tests digit span, serial 7s, spelling backwards Higher cognitive functions tests Informations and vocabulary Calculating ability Abstract thinking Constructional ability (copy shapes/draw clock face) Who should be screened for substance abuse, alcohol use, and miss use of prescription drugs? Every patient Unsafe drinking habit Women: >3 drinks/day and >7 drinks/week binging= 4+ on one occasion Men: >4 drinks/day and >14 drinks/week binging= 5+ on one occasion Melanoma risk factors -personal or family history of previous melanoma -50+ common moles -Atypical or large moles, especially if dysplastic -Red or light hair -Solar lentigines (acquired brown macules on sun exposed areas) -UV radiation from heavy smoke exposure, sun lamps, or tanning booths -light eye or skin color, especially that freckles or burns easily - severe blistering sunburns in childhood -immunosuppression from HIV or chemotherapy -Personal history of nonmelanoma skin cancer ABCDE-EFG of melanoma screening Asymmetric Border irregularity Color variation Diameter >6mm/pencil eraser Evolving or changing rapidly Elevation -Unilateral and dermatomal vesicles with erythematous base that do not cross midline Herpes zoster with eye involvement Herpes zoster opthalmicus (HZO) Considered an ophthalmology emergency Layers of skin (Superficial to deep) epidermis, dermis, hypodermis (subcutaneous) Nevi small, dark skin growths that develop from melanocytes in the skin; also known as moles skin cancer health promotion •Avoid or reduce exposure to sun or tanning beds •Sunscreen 30 spf + •Wear hats and opaque clothing •Sunglasses •Monthly skin checks •Report skin changes •ABCDE guide for melanoma eccrine sweat glands Widely distributed, open directly onto skin surface, and helps control body temperature by their sweat production apocrine sweat glands Found chiefly in the axillary and genital regions, and usually open into hair follicles. Bacterial decomposition of these are responsible for adult body odor. 1- postauricular 2- posterior auricular 3- tonsillar 4- occipital 5- superficial cervical 6- posterior cervical 7- supraclavicular 8- deep cervical chain 9- submandibular 10- submental When a lymph node is enlarged or tender, look for a source where? And it's nearby drainage area Enlarged tender lymph nodes, commonly a company... Pharyngitis A persistent neck mass in an adult older than 40 years should raise suspicion of.... Malignancy Group of lymph nodes that are deep in the SCM muscle and often inaccessible to examination Deep cervical chain lymph node group How normal lymph nodes feel Small, mobile, discrete, nontender Lymph nodes suggestive of information Tender and enlarged Lymph nodes associated with malignancy Hard or fixed nodes - fixed two underlying structures, and not movable on palpation Generalized lymphadenopathy as seen in.... Multiple infectious, inflammatory, or malignant conditions, such as HIV/AIDS, infectious mononucleosis, lymphoma, leukemia, sarcoidosis. Thyroid attributes in Graves Soft, may be nodular May hear localized systolic or continuous bruit over lateral lobes with stethoscope Thyroid attributes in Hashimoto's thyroiditis Firm (Tender in thyroiditis) Diagnostics for abnormal findings of thyroid For palpable, solitary nodules, ultrasound, impossible, fine needle aspiration advise. Ultrasound usually reveals multiple additional nonpalpable nodules - but only 5% of nodules are malignant JVD hallmark of Heart failure (right) Screening for thyroid cancer USPSTF recommends against screening for thyroid cancer, stating potential harm related to over diagnosis and over treatment Nodules that are greater than or equal to 2 cm, firm, and fixed two adjacent tissues are concerning for malignancy. Ultrasound imaging is recommended to further evaluate thyroid nodules to determine whether biopsy is indicated. S/S of hypothyroidism Fatigue/lethargy Weight gain with anorexia Dry and course skin Cold intolerance Swelling a face, hands, legs Constipation EOM cranial nerves 3, 4, 6 hyperopia farsightedness Myopia nearsightedness presbyopia impaired vision as a result of aging Hyphema Blood in anterior chamber of the eye Gradual vision loss arises from... Cataracs, glaucoma, or macular degeneration Sudden, visual loss is unilateral and painless, consider... Hemorrhage from diabetes or trauma, macular degeneration, retinal detachment, retinal vein, occlusion, or central retinal artery occlusion If sudden unilateral visual loss is painful, causes are usually in the ... Cornea and anterior chamber -such as corneal ulcer, uveitis, traumatic, hyphema, and acute angle closure glaucoma Miosis constricted pupils Test visual acuity of central vision by using Snellen eye chart Position the patient 20 feet from the chart Patients who wear glasses, other than for reading, should put them on. What does 20/100 vision mean? At 20 feet the patient can read a print that a person with normal vision could read at 100 feet. The larger the second number, the worst division. The first number indicates the distance from the chart. Cranial nerve associated with visual acuity CN II- optic legally blind vision 20/200 How does optic neuritis present? Sudden visual loss that is unilateral and can be painful associated with multiple sclerosis How does retinal detachment present? Sudden painless vision loss that is unilateral sudden onset of photopsia (flashes of light) and floaters. Most classic description is "curtain coming down over my eyes" What conditions could absence of a red reflex indicate? Suggestive of an opacity of the lens (cataract), or possibly the vitreous (or even an artificial eye). Less commonly, a detached retina, or in children it could be a retinoblastoma that can obscure this reflex. cotton wool patches Irregular patches, seen a diabetic and hypertensive retinopathy usually between 11 and 12 o'clock. 1 to 2 disc diameter from the disc. Each measures about 1/2 by 1/2 disc diameter. nystagmus An involuntary, jerking movements of the eyes with quick and slow components Seen in cerebellar disease especially with: -Gait ataxia -Dysarthria (increases with retinol fixation) -Vestibular disorder (decreases with retinal fixation) -Internuclear ophthalmoplegia Testing for nystagmus Ask the patient to fix his or her vision on a distant object, and observe if nystagmus increases or decreases Nystagmus is named for the direction of the quick component Testing visual fields Static finger wiggle test Confrontation visual field testing mydriasis dilation of the pupil EOM assessment conjugate movements Nystagmus Lid lag (upper lid should overlap iris slightly) in hyperthyroidism there is proptosis- rim of sclera and protrusion Wide H Convergence Opthalmoscopic (Funduscopic) Examination -bacterial, viral, or other infection - highly contagious -can be allergy or irritation -causes conjunctival injection that tends to be worse peripherally -Vision not affected except for when drainage interferes -Discharge = watery, mucoid, or mucopurulent Pupil and cornea not affected subconjunctival hemorrhage -can result from trauma, bleeding disorders, or sudden increase in venous pressure (cough) -Leakage of blood outside of the vessels, producing a homogenous, sharply demarcated, red area that resolves over 2 weeks. -No plain, no vision loss, no discharge - Pupil and cornea not affected CN responsible for hearing AND sense of balance CN VIII (vestibulocochlear) Otitis Externa (Swimmer's Ear) An infection of the outer ear, with severe painful movement of the pinna and tragus, redness and swelling of pinna and canal, scanty purulent discharge otitis media inflammation of the middle ear causes tenderness behind the ear Can occasionally progress to acute mastoiditis, which presents with postauricular swelling, fluctuance, erythema, and significant tenderness. tinnitus perceived sound with no external stimuli -can be musical, ringing, rushing, roaring, popping more common with age vertigo a spinning sensation accompanied by nystagmus and ataxia usually from peripheral vestibular dysfunction ask about triggers, check for nystagmus, and ask to describe without using word "dizzy" rhinorrhea drainage from the nose and is often associated with nasal congestion, a sense of stuffiness or obstruction frequently accompanied by sneezing; watery eyes; throat discomfort; and itching in the eyes, nose, and throat Acute bacterial sinusitis (rhinosinusitis) unlikely until viral URI symptoms persist more than 7 days; both purulent drainage and facial pain should be present for diagnosis (sensitivity and specificity are above 50%) sensorineural hearing loss (causes, attributes, Weber, Rinne) inner ear disorder involves cochlear nerve and neuronal impulse transmission to the brain. Causes include loud noise exposure, inner ear infections, trauma, acoustic neuroma, congenital and familial disorders, and aging. Higher registers are lost, so sound may be distorted Hearing worsens in noisy environment Voice may be loud because hearing is difficult Weber = Sound lateralizes to good ear—inner ear or cochlear nerve damage impairs transmission to affected ear Rinne= AC longer than BC (AC > BC) vertigo and tinnitus together Meniere disease conductive hearing loss External or middle ear disorder impairs sound conduction to inner ear. Causes include foreign body, otitis media, perforated eardrum, and otosclerosis of ossicles. -Assess for red or white patches (leukoplakia or thrush), nodules, or ulcers -Carcinoma common on sides and under tongue Assess pharynx and uvula Cranial nerve tested by having patient stick tongue out and move side to side CN XII: Hypoglassal jugular venous pressure A measurement of the highest oscillation point (meniscus) of the jugular venous pulsations. Reflects right atrial pressure, which in turn equals central venous pressure and right ventricular end-diastolic pressure Best estimated from right IJ vein, which has the most direct channel into the right atrium oropharyngeal cancer Risk factors: Men, alcohol, tobacco, HPV. Commonly found tonsils, oropharynx, base of tongue. Respiratory exam Inspection: Asymmetric expansion/retractions Palpation: -Chest expansion (thumbs at 10th rib, pt inhale, check if even) -Palpate for fremitus (vibrations in chest wall while pt speak[norma]; absent in high pitched voices, thick chest wall, an obstructed bronchus, COPD, pleural effusion, fibrosis, air (pneumothorax), or an infiltrating tumor. -Crepitus Percussion: -Healthy lungs = resonant -Consolidation/pna = dull -pleural effusion = flat - COPD/pneumothorax/asthma = hyperresonant - Lg pneumothorax = tympanitic Auscultation: -have pt cough before listening to lungs to clear secretions -listen with diaphragm on direct skin -check ego phony, bronchophony, whispered pectoriloquy Egophony listen with stethoscope pt say E over and over If E sound changes to A sound its positive and indicative of consolidation Bronchophony Positive if "99" sounds abnormally loud with stethoscope when whispered - indicating presence of consolidation whispered pectoriloquy Ask the patient to whisper "ninety-nine" or "one-two-three." The whispered voice is normally heard faintly and indistinctly, if at all. Louder, clearer whispered sounds are called whispered pectoriloquy and heard over areas of lung consolidation asthma Widespread, usually reversible, airflow obstruction with bron- chial hyperresponsiveness and underlying inflammation. During attacks, as air flow decreases lungs hyperinflate. asthma percussion sound resonant to diffusely hyper resonant asthma breath sounds wheezes, possibly crackles added asthma tactile fremitus and transmitted voice sounds decreased partial lobar obstruction (atelectasis) When a plug (from mucus or a foreign object) obstructs bronchial air flow, affected alveoli collapse and become airless. percussion with atelectasis dullness over airless area Atelectasis breath sounds Usually absent when bronchial plug persists. Exceptions include right upper lobe atelectasis, where adjacent tracheal sounds may be transmitted. COPD Slowly progressive disorder in which the distal air spaces enlarge and lungs become hyperinflated. Chronic bronchitis may precede or follow the development of COPD. COPD percussion Diffusely hyperresonant COPD breath sounds Decreased to absent, with delayed expiration - may have crackles, wheezes or rhonchi if they also have chronic bronchitis Lobular pneumonia (consolidation) Alveoli fill with fluid, as in pneumonia percussion of pneumonia dullness over airless area Pneumonia/consolidation breath sounds elevated JVP correlated with both acute and chronic heart failure. It is also seen in tricuspid stenosis, chronic pulmonary hypertension, superior vena cava obstruction, cardiac tamponade, and constrictive pericarditis How to measure JVP pt at 30 degrees head slightly turned to left find highest point of oscillation in IJ make right angle between that point and ruler coming up from suprasternal notch Measure that number and round to whole number Interpreting JVP results Hypovolemia = point of oscillation can be as low as suprasternal angle Hypervolemia = JVP elevated above normal when 3-4 cm above sternal angle with HOB 30 or more OR 7-8 cm in total distance from right atrium 1st degree HB and sound change S1 diminished aortic stenosis and S2 S2 diminished Heaves sustained impulses that rhythmically lift your fingers, usually produced by an enlarged right or left ventricle (depending on the location of the heave) and occasionally by ventricular aneurysms Screening for CV risk factors 1) Screen for: (9) family history, smoking, diet, physical inactivity, obesity, HTN, dyslipidemia (WDL- fasting lipid panel Q5yr ages 40-75), diabetes (WDL - A1C Q3yr at age 45 or more frequently if warranted), cardia rhythm (a. fib) 2) Calculate 10-Year and Lifetime Global CVD Risk Using a Web-Based Calculator (ages 40-79) 3) Address Individual Risk Factors—Hypertension, Diabetes, Dyslipidemias, Metabolic Syndrome, Smoking, Family History, and Obesity Lipid screening Obtain baseline fasting lipids at age 21. Measure fasting lipids in average risk adults every 5 years from ages 40 to 75 start low-mod statin if for aged 40 to 75 years who have one or more CVD risk factors (dyslipidemia, diabetes, hypertension, or smoking) and a 10-year calculated CVD event risk ≥10% left heart failure/CHF causes systemic HTN LV MI LV hypertrophy aortic SLV or bicuspid damage right sided HF left sided HF/CHF symptoms fatigue decreased UO rapid, irreg HB congestion/SOB pink tinged sputum orthopnea wt gain Crackles Right sided heart failure/ Cor pulmonale causes inability of RV to provide adequate blood flow thru pulmonary circulation pulmonary disease/pulm HTN RV MI RV hypertrophy pulmonary semilunar valve or tricuspid damage Left heart failure clear lungs Right heart failure s/s JVD hepatosplenomegaly peripheral edema nocturia tired/fatigue palpitations complication of carotid artery palpation the dislodgment of an atherosclerotic plaque, which could result in stroke.