CM exam 2 Flashcards
what are the seven attributes of a symptom?
location (where is it? where does it radiate?), quality (what is it like?), quantity or severity (how bad is it? 1-10), timing (when did this start, how long does it last, how often does it come?), setting in which it occurs, remitting or exacerbating factors (is there anything that makes it better or worse?), associated manifestations (anything that accompanies it?)
common or concerning symptoms?
headache, change in vision, double vision, hearing loss, earache, tinnitus, vertigo, epistaxis, sore throat, swollen glands, trauma
where must a patient go if they fall from a height equal to their height or higher?
a level 1 trauma center due to hidden injuries
what are some things to assess with head trauma?
is the patient awake/oriented? how did they get hurt? time of injury? loss of consciousness immediately post-injury? subsequent levels of alertness? amnesia (retrograde, anterograde)?, headache (mild, moderate, severe), double or blurred vision? bleeding from ears, nose, mouth, eyes?
concussion
a disturbance in brain function caused by a direct or indirect force to the head; do not have to be knocked out to have a concussion
what clues you into a possible concussion?
headache, physical unsteadiness, impaired brain function, confusion (person, place, time; inadequate answers are suspicious), abnormal behavior
what is the sports concussion tool used in iowa?
sport concussion assessment tool-2
how do you disqualify an athlete based on a concussion?
the screen after a head injury does not match the baseline following injury
when can a high school athlete return to sports?
they may not go back the same day as the injury; may only return after medical practice; RTP (return to practice)
classic migraine
70% unilateral; pulsating or throbbing; hours to days; females have it more often; nausea/vomiting are common; caused by missing meals, menses, BCP, stress, certain foods
cluster
rare, but has classical characteristics; occurs in adulthood, unilateral, 1/2-2 hours, intense burning, searing, knife-like, several nights for several days and then gone, males are more likely to get them, increased tearing/nasal discharge that is almost always unilateral
tension
occurs in adulthood, unilateral or bilateral (if unilateral, do not automatically think classic migraine), hours to days, anytime it can start, band-like and constricting, no prodrome (a “tip off” to the patient they will get one), stress, anger, and teeth grinding can cause them
medication rebound
diffuse, hours at a time, hours or days of last dose, dull or throbbing pain, daily analgesics are a clue, abrupt analgesic stops will cause them
hyperparathyroidism
“speed up”; the following symptoms do not begin at the same time; nervousness, weight loss, excessive sweating, heat intolerance, warm/smooth/moist skin, Grave’s disease, tachycardia
hypothyroidism
“slow down”; fatigue, lethargy, modest weight gain, dry coarse skin, cold intolerance, swelling of face, hands, and legs, bradycardia, impaired memory
what do you exam on the head?
symmetry, presence of hair, scalp (lesions, bugs, bumps, lumps, cysts), face (CN VII), palpation, bony irregularities, oral mucosa (number of teeth, look at tongue), facial sensation, carotid and temporal arteries
what do you check on the TMJ?
alignment and palpate for clicking or crepitus
what do you inspect on the neck?
the general appearance in bright and tangential light, symmetry, lesions, masses, tracheal position, jugular venous distention, range of motion (assess strength), auscultation carotids and thyroid, palpation, nuchal rigidity (stiffness to the neck; check infants and children where this is classic in meningitis), cervical spinous processes, paravertebral musculature, cricoid and thyroid cartilage, position of trachea, thyroid, carotids, lymphatics
what do you always check from birth to 24 months?
head circumference!
why do you transilluminate the skull?
to look for excess fluid accumulation
how do the heads of an adult and an infant compare?
head at birth is 1/4 of body length (adult is 1/8) and the head at birth is 1/3 of the weight (adult is 1/10)
why do infants need to be placed backwards in carseat for first 2 years of life?
because the head is heavy and fairly unstable - not held up by much! in the event of a motor vehicle accident, the head will go into the seat which is safer than forwards
sutures
separate the bones; membranous tissues
fontanelles
areas where sutures intersect
when does the anterior fontanelle close?
18 months (9-24); measures 4-6 cm at birth
when does the posterior fontanelle close?
2 months
why would a fontanelle bulge?
as a result of increased intercranial pressure
why would a patient present with a sunken fontanelle?
dehydration
microencephaly
the head is small due to the brain not growing
hydrocephalus
increased intracranial pressure from deficient CSF circulation (or excess production) that causes the calvaria to become enlarged before the sutures are closed
why would you have overlapping of sutures?
due to molding, or the movement of bones at sutures that occurs during vaginal delivery
caput succedaneum
swelling of scalp during delivery; transluminates; usually occurs over the occipitoparietal area
cephalohematoma
collection of blood underneath the periosteum of the skull; does not cross over suture lines, does not transilluminate
what do the heads of C/S infants look like?
more rounded
plagiocephaly
occurs when an infant lies on one side constantly; due to subsequent flattening, mishapen head; self resolves with age
cranioynostosis
premature closure of sutures that can lead to assymetry; brachycephaly is known as premature closer of coronal cells
bracycephaly
premature closure of coronal suture; typically need a procedure to fix this
lymph nodes (infants)
“shotty”: small, movable, round lymph nodes; not worrisome, not tender, not warm
how do you palpate the neck of an infant?
use 1-2 fingers; the neck is short and thin
congenital muscular torticollis
injury and possible bleed into the SCM at birth that shortens the muscle at birth; treatment is stretching exercises; patient presents with misshapen head, normal fontanelles, flat head on posterior right occipitoparietal area with neck rotated left, sidebent right
what questions should you ask about the ear?
how is your hearing? do you have difficulties understanding people when they talk? what happens in a noisy environment? earache? vertigo? medications (some can mess with hearing over time), resent URI? discharge? tinnitus
tinnitus
ringing in ears
rhinorrhea
runny nose/ discharge
why should you be concerned about unilateral congestion in children?
could have stuck something up their nose
epistaxis
nosebleed; could be caused by trauma, anticoagulants, NSAIDS
what do you check for on the external ear?
deformities, lesions, placement on head, characteristics
what do you palpate for pain before inserting otoscope?
the pinna and tragus; this helps differentiate between otitis externa and otitis media; if either pinna or tragus hurt, could be otitis externa
how do you adjust the ear for an adult while doing an otoscope exam?
pull the pinna lateral, superior, and posterior
how do you adjust the ear for a child while doing an otoscope exam?
pull pinna lateral, inferior, and posterior
what finger is held out during an otoscope exam?
5th digit
what hand do you use to do otoscope exam?
if on the patients left side, use your left hand; if on the patient’s right side, use you right hand
erythema
redness and inflammation of mucous membrane
cerumen
ear wax
why do you use an insufflation bulb?
to test for mobility of TM when air is put into the ear; if there is fluid behind the ear or an infection, the TM will be stuck
what is the biggest mistake with a otoscope?
holding it with your entire fist around it; you should hold it with the first couple fingers and thumb so that your 4th and 5th digits can act as shock absorbers
what do you look for externally on the nose
deformities, lesions; check nares for symmetry
true or false: both nares are the same side
false; it is common for one nare to be larger than the other; this is important for when placing a NG tube on the side that will be most comfortable
what do you check for on the inside of the nose?
polyps, evidence of recent epitaxis, debris, color, and consistency of discharge
how do you check for nasal patency?
occlude one nare and have the patient breathe in; if they can’t breathe out of one nostril, they may have a deviated septum
how do you check CN I?
have them smell with each nostril; this is done when athletes hit their heads really hard
how does weight loss related to smell?
when you lose smell, you can lose taste as well. a patient can lose weight as a result of losing taste.
how do you test the sinuses?
palpation (may feel warm), percussion (for tenderness, not sound; do not do it if the patient says they have pain), transillumination (inspecting for fluid under the flashlight; if fluid present you wont see light)
true or false: hitting the septum will cause epitaxis?
true
polyps
fleshy swellings; can occur in the nose
whisper test
stand behind and to the side 1-2 ft away from patient, have the patient put their finger in the ear not being tested and move it around, exhale fully and whisper 3 letters or numbers, ask the patient to repeat what they heard; do for both ears
weber test
assesses hearing and helps differentiate between neurosensory and conductive hearing loss; vibrate the tuning fork and place in the middle of the patient’s vertex; ask them where they hear the sound (one side, both sides, not at all?)
what frequency tuning fork do you use for the weber test?
512 Hz
if you hear the tuning fork during a weber test on the side of hearing loss, what kind of hearing loss do you have?
conductive because you received input of vibrations via fork
rinne test
helps determine whether each ear detects sounds better through air or bone; use vibrating fork and place on mastoid process, asking the patient to tell them you when they can no longer hear the ringing; next move the tuning fork to 2.5 cm away from patient’s ear and ask the patient when they stop hearing the ringing
what is a normal test result for rinne test?
normally you hear sounds through the air longer; should be a 2:1 ratio; if the hearing is prolonged, you could have neurological issues
conductive hearing loss
external or middle ear disorder caused by foreign body in the ear, otitis media, perforated eardrum, or otosclerosis; sound lateralizes to impaired ear (weber test); bone conduction longer than or equal to air conduction
sensorineural loss
inner ear disorder involving the cochlear nerve; caused by loud noise exposure, inner ear infections, trauma, acoustic neuroma, aging, familial disorders; sound lateralizes to good ear (weber test); air conduction longer than bone conduction
where are the ears positioned on an infant?
upper portion of auricle joins the scalp at or above the level of line drawn from the inner and outer canthus of the eye
true or false: there is a relationship between ear tags and the renal system
true
why is it difficult to see the TM in the first few days of life?
presence of vernix caseosa
where should the child sit during a toddler exam>
on the parent’s lap, facing you; to look at the ears, have parent turn head of child to one side and hug with one arm around the arms and one on the forehead
pneumatic otoscopy
uses insufflator bulb; puffs burst of air into TM to check for movement; if there is no movement, there is fluid behind the ear drum. if there is no fluid (no movement) then you can rule out otitis media
how do newborns breathe?
obligate nose breathers; this makes nasal congestion or obstruction a problem
