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N270: Advanced Health Assessment [Fall 2016] > For Midterm > Flashcards

Flashcards in For Midterm Deck (361):
1

normal adult heart rate

60-80 (60-100)

2

Nodularity (breasts)

think fine curd cottage cheese - fine mass of small little bumps, no discrete mass among the background

 

in the upper outer quadrant of many young women's breasts you might find fine or medium nodularity

3

Systolic ejection murmur possible diagnoses:

Normal, pulmonic, or aortic stenosis

hypertrophic obstructive cardiomyopathy

ASD

tetralogy of Fallot

4

Otorrhea

drainage from the ear

5

Whispered pectorliloquy

Whispered words easily heard

suggests lung consolidation

6

How do you distinguish between dimer and perforation?

use pneumatic otoscope

7

Squamocolumnar junction

area where the columnar junction of the endocervical canal meets the squamous cells of the external cervix

causes an irregular, deeper red area - usually symmetrical

NORMAL

on younger adolescence, it's on the outside

later, it regresses

it's where most HPV lesions occur (cancer)

8

What would you think of to cause unilateral nasal congestion? Bilateral?

unilateral: nasal mass

bilateral: allergic rhinitis, nasal polyps

9

Normal PMI is how wide and usually located where?

1-2 cm

medial to the mid-clavicular line at 5th ICS

10

When doing physical assessment of popliteal artery, remember what 2 things?

- bend knee slightly

- push fingers into popliteal fossa

11

Should imperforate hymen in prepubertal exam be referred?

yes

12

Physiological splitting of S2 (normal) heard where/when?

at pulmonic area

during PEAK inspiration

13

Epistaxis - where do most people commonly bleed?

Kisselbach’s plexus (juncture of all the arteries)

14

Positive Romberg test (swaying, can't stand straight with arms out and eyes closed) means

problem with proprioception or ear balance function

15

"Natural" pacemaker is

SA node

16

vaginal fornix

space around cervix tucked in the back of vaginal canal

important because things can get lost up there

17

Odynophonia

pain when speaking

18

Expected diaphragmatic excursion

5-6cm

19

What would the patient complain of if they were hyperventilating during your auscultation?

feeling dizzy

20

Are fallopian tubes normally felt?

No

21

An 85-year-old female presents with chest pain and dyspnea that is worsen x 3 months. She had a presyncopal episode last week. What type of murmur is this?

• Timing? Systolic

• Location? Left sternal border (LSB) that radiates to apex and carotids

• Shape? Crescendo-decrescendo

• Pitch? Harsh

aortic stenosis

22

Murmur (5 key etiologies)

- caused by turbulent flow

- flow across partial obstruction of abnormal valve

- backwards through leaky valves

- across shunts like septal defects

- increased flow across normal valve

23

What should ovaries be like?

2-3 cm, smooth, firm, ovoid, mobile, sensitive to touch

24

Diastolic murmur grade I out of IV

barely audible

25

Older adults: be mindful that they may have ___ pulse pressure and ___ hypotension

widened

orthostatic

26

Rinne test

Always done after Weber

Strike tuning fork and place it on the mastoid bone. (Here, the sound is bypassing external anatomy and being conducted through skull base directly into cochlea. They’ll be able to hear that.) Then, hold the tuning fork in front of their ear, right in the opening of the ear canal. You ask which one is greater.

27

Mallampati grading 1-4

(tongue extended, mouth open): has to do with the obstruction of the airway in the oropharynx, closely correlated with obstructive sleep apnea

Grade 1: you can see all of the tonsillar pillars, full uvula, all of soft palate (all visible)

Grade 2: can’t see end of uvula or tonsils

Grade 3: root of uvula and end of soft palate

Grade 4: tongue base obstructing all of the posterior oropharynx

28

Pediatric murmurs are often ___ in children age 3-8

innocent systolic flow murmurs and Grade III or less

29

Systolic murmur grade II (out of VI) - volume/thrill?

audible but soft no thrill

30

most cervixes are in what position

midline or downwards

31

Is tachycardia common during pregnancy? When might you have it?

yes

- 10-20bpm above baseline esp near term

32

systolic or diastolic? pulmonic stenosis

systolic

33

PDA continuous murmur sounds like what? Is it a diastolic, systolic, or continuous murmur?

harsh "machinery" murmur

continuous

34

CN VII

facial nerve

responsible for movement on one side of the face

35

What do Wheezes represent? Quality?

– obstruction of small airways

– High-pitched musical type sound during inspiration and/or expiration

– A “continuous sound”

36

Secondary sex characteristics (puberty) appear between ages ___ with breast buds

8-13

37

Common Cervical Findings: Polyps

Usually friable (crumble/bleed easily), should be removed

38

Systolic murmur grade IV (out of VI) - volume/thrill?

easily audible with thrill

39

retrouterine pouch

opens into abdominal cavity

40

Non-cyclic breast pain

No relationship to menses, post-menopausal

Calcification and ductal dilatation

more common in women 35+

41

Expected RR for Adult

12-20

42

uterine fundus

top of the uterus

43

Systolic murmur grade V (out of VI) - volume/thrill?

easily audible with thrill, heard with stethoscope partially off chest

44

severe aortic stenosis can radiate where

along the whole precordium/chest

45

problem-oriented or focused health history

◆ Used when comprehensive history has already been done

◆ Addresses acute or focused problems

◆ Only the need of the moment given full attention

◆ Will include PMH, PSH, FH, as relevant to the presenting complaint or problem.

◆ Most commonly used in reality of clinical practice

46

pectus carinatum

pigeon chest

47

How many lobes in right and left lungs?

right: 3

left: 2

48

Dix-Hallpike test

Test for benign proxismal positional vertigo (stones in the balance canal that spin)

Lay patient down, turn head to one side --

if present you get obvious rotational nystagmus (eye twitching towards the downwards side)

49

uterus has ___ openings

2

external and internal

50

Should you be able to palpate ovary in post-menopausal women?

No

51

Location of PVD symptoms: Buttock, hip - what is the associated artery?

Aortoiliac

52

Basic principle of vocal resonance: Voice transmission enhanced (improved) if underlying lung field is ____

consolidated (such as in pneumonia)

53

Expected RR for Newborn

30-60

54

Diastolic murmur grade III out of IV

easily audible

55

Location of PVD symptoms: Erectile dysfunction - what is the associated artery?

Iliac-pudendal

56

What 2 valves are Semilunar?

Aortic, Pulmonic

57

Late diastolic murmur possible diagnoses:

Tricuspid or mitral stenosis

58

Breast self exam should be done which day of menstrual cycle?

Day 4-7 of menstrual cycle

59

Systolic murmur grade III (out of VI) - volume/thrill?

easily audible no thrill

60

Edema is most commonly a sign of what?

decreased cardiac function leading to decreased capillary flow

increased fluid perfusion, especially in the gravity dependent areas

61

In primary care, Problem 1 should usually be

“Health Care Maintenance”

62

Is audible splitting of heart sounds normal during pregnancy?

yes

63

Tinnitus is often an early sign of

hearing loss

64

Pectoral/anterior nodes: where are they located? What do they drain/where do they drain into?

- Lower border of pectorals major inside anterior axillary fold

- Drains anterior chest wall and most of breast

- Drains into central axillary nodes

65

S4 may be physiologic in ___ and ____ and _____

infants, small kids, adults over 50

66

Extra Heart Sounds in Systole

• Clicks – usually MVP

• Ejection sound (click)

67

Diastolic murmur grade IV out of IV

loud

68

Rounding in child's chest should be gone by age

1

69

S3 correlates with time of what?

rapid ventricular filling (diastole)

70

Breast lifespan changes: Pregnancy (4)

- increase in size

- pigmented areas darken

- fat replaced by functional ducts

- Montgomery glands lubricate

71

Neonates vs adult signs of respiratory distress

Neonates: nasal flaring, retractions, paradoxical mvmts., stridor or grunting

Adults: pursed lip breathing (COPD - this is actually helpful for these patients because it allows more time for expiration)

72

Aortic area murmurs (2nd ICS, right sternal border) - what could they potentially be?

aortic stenosis

aortic regurgitation

73

S3

Low-pitched vibration occurring in early diastole after S2

74

What does Friction rub represent? quality?

– Indicates inflammation of pleural surfaces

– Low-pitched, grating sound

– Occurs on inspiration and expiration

75

A ____ murmur may reflect the increased flow across AV valves in pregnancy, but is much less common and organic disease should be ruled out

innocent diastolic flow murmur

76

4 components of the "Plan" portion of the health history

  1. Diagnostic Tests/Consultation
  2. Therapeutic Interventions
  3. Client Education
  4. Follow up

77

Supernumerary breasts

Non-functional embryonic milk line from groin to axilla

Glandular tissue and /or pigmented lesion

78

Turbulence in the great veins can cause an ___ in very small children

innocent venous hum

79

Systolic click with late systolic murmur possible diagnosis:

Mitral valve prolapse

80

What are contributing factors to tinnitus? (6)

  1. TMJ 
  2. Cervical spine 
  3. Iatrogenic - meds (Aspirin, NSAIDS, chemo agents) 
  4. Insomnia 
  5. Psychiatric (depression, anxiety will worsen tinnitus)
  6. Caffeine and sodium intake

81

Diastolic murmur grade II out of IV

audible but soft

82

Bronchophony

When there is increased voice clarity and volume

suggests lung consolidation

83

What do Rhonchi represent? Quality?

– represent secretions in large airways

– snoring type of sound

– low pitched

– during insp. and/or exp;

– a “continuous breath sound”***

– may change or clear with coughing

84

For women 30-65 years, what are the pap recommendations?

Pap every 3 years

or

Pap and co-testing with HPV every 5 years if both initial tests negative.

85

Otalgia

pain in ear

86

ACS mammography recommendations:

age 45-54 yearly >55 every two years, as long as in good health or 10+ years life expectancy

87

S1 should be consistent with ____ and ____

carotid pulse and PMI

88

S4 is common in ___ patients

HTN

89

If the sound from the Weber test is louder in one side, it means either of 2 things?

they could have a conductive hearing loss in the side that’s hearing the sound LOUDER

Or it could be that’s the better sensory hearing side, so it could be a sensory hearing loss on the softer side

90

chronic poor oxygen delivery to the peripheral tissues of the hands and feet

cyanosis

91

S1

systole Closure of the mitral (tricuspid) valve (M before T)

92

systolic or diastolic? mitral valve prolapse

systolic

93

What do these tuning fork tests results indicate?

AC>BC bilaterally; Weber lateralized to the Right

sensory hearing loss in the left ear

94

Systolic murmur grade I (out of VI) - volume/thrill?

barely audible no thrill

95

Adults: Anterior-posterior (A- P) diam. should be what in relation to transverse diem?

less than

96

Expected RR for 10 years

16-20

97

4 important questions to take for history of hearing loss

1. Laterality (most important)

2. Onset

3. Fluctuations

4. communication function

98

Is increase in intensity of S1 normal during pregnancy?

yes

99

One of the most common forms of vertigo is

benign paroxysmal positional vertigo

Lays down rolls over in bed and spins

100

What position should patients be in for cardiac auscultation

Supine at 30-45 degrees

101

Venous vs. arterial phase of epistaxis

Lesser quantity: venous phase

More quantity: arterial phase

102

2 speculum names and sizes - what's the difference between the two?

Pedersen: small, medium (S-XL)

Graves: medium, large (S-XL)

difference: width of the beaks

103

Bronchial/tracheal (tubular) breath sounds: where are they heard? Quality?

– heard over manubrium/ trachea/ large airways (abnormal in other locations)

– relatively loud

– expiratory phase somewhat longer than inspiratory phase or about equal

104

Location of PVD symptoms: Thigh - what is the associated artery?

Common femoral or aortoiliac

105

Any time you hear a click, it only refers to

mitral valve prolapse

106

After initial pap smear at 21 years, they should be done every ___ years until what age?

every 3 years under age 29

107

Where do you palpate Bartholin's glands? Is pain normal

5 and 7 o'clock downwards

no pain

108

Central axillary nodes: where are they located? where do they drain into?

- Palpable high in axilla, close to ribs

- Drains into infra and supraclavicular nodes

109

Location of PVD symptoms: Upper calf - what is the associated artery?

Superficial femoral

110

How can slapping someone against the head lead to hearing loss?

Slapping someone alongside the head can form a column of air through ear canal and perforate the eardum, leading to hearing loss

111

If you note Xanthelasmas (yellowish plaques that occur most commonly near the inner canthus of the eyelid, more often on the upper lid than the lower lid) during eye assessment, what might this indicate?

hyperlipidemia

112

Pregnant women have a ____ costal angle

widened

113

Left lateral decubitus position when auscultating accentuates what 3 things?

  1. left-sided S3
  2. S4
  3. mitral murmurs (stenosis)

114

Otalgia (ear pain) could be referred pain from what 3 areas?

1. jaw (bruxism aka teeth grinding)

2. cervical spine (sleeping position)

3. throat (lesions)

115

to palpate cervix during bimanual exam, where should abdominal hand be?

midway between umbilicus and pubic bone, applying downward pressure

116

S1 best heard where?

at the apex with bell

117

7 components of Pediatric History: SUBJECTIVE DATA

◆ Identification and client profile

◆ Chief Complaint (CC)

◆ Present Concerns/Illness (HPI)

◆ Past Medical History (PMH): including birth, feeding, growth and development, ADLs (diet, sleep, elimination, childcare arrangements, safety practices)

◆ Current development level, including school history

◆ Social and family history, including discipline practices

◆ Review of Systems

118

systolic or diastolic? mitral stenosis

diastolic

119

What breath sounds represent opening of small airways or air bubbling through secretions?

Crackles/rales

120

What position accentuates left sided S3, S4, mitral murmurs like stenosis for auscultation?

Left lateral decubitus

121

What do these tuning fork tests results indicate?

AC>BC bilaterally; Weber is midline

normal

122

With head bending forward, ___ usually most prominent vertebrae

C7

123

Sinuses (4 sets)

1. frontal (sometimes - not everyone has them)

2. ethmoid

3. sphenoid

4. maxillary

124

Some types of xanthoma are indicative of lipid metabolism disorders which indicate increased risk of what?

coronary artery heart disease

125

Lateral nodes: where are they located? What do they drain/where do they drain into?

- On upper humorous

- Drains most of arm

- Drains into central axillary nodes

126

During pregnancy, there is an increase in what 3 things?

  1. plasma volume (50% above baseline by 2nd trimester)
  2. maternal cardiac output (during early pregnancy)
  3. uterine blood flow (10x normal)

127

Problem in inner ear like age-related hearing loss, hair cell deterioration would qualify as ___ hearing loss

sensory

128

When auscultating older adults, especially those who have a cognitive impairment or something like Parkinson's, where is it best to begin auscultating?

at the bottom - work up

you may only get 1 or 2 breaths out of them

may hear basilar crackles

129

Majority of cervical cancers and HPV lesions appear in what area?

Squamocolumnar junction aka transformation zone, ectropian, squamous metaplasia

130

Vestibulo-ocular reflex

signal sent from your ear about where you’re moving in space and allowing eyes to keep focused as you’re moving - when you’re driving in car you can read a sign

131

Why do you massage parotid and submandibular glands from front to back?

to get saliva production and therefore assess patency of ducts

132

Weber screening test

Done first

Strike the tuning fork on the end, then put it in the center of the patient’s forehead.

Can they hear it? Is it louder in one ear or the other?

133

Most common GYN concerns (6)

1. Vaginal discharge

2. Abnormal bleeding

3. Pelvic pain

4. Urinary problems

5. Sexual dysfunction

6. Infertility

134

tonsillar grading 0-4

0 - tonsils removed, not present

1 - most people in here, tonsils tucked into pillars

2 - extend beyond pillars

3 - at least halfway to the uvula

4 - airway issue, the tonsils are touching

135

Vocal Resonance: normal

Normally voice/spoken words heard through stethoscope should be muffled and difficult to understand

136

Exam: External Neck - when assessing the salivary gland, why do you need to pay attention to parotid tail

tucks behind the ear, where a lot of tumors come from

137

How does Pneumatic otoscope work? What will you see if eardrum is intact? What will you see if fluid behind TM?

Pushes air up into the ear canal and against the tympanic membrane

If eardrum is intact, you’ll see mobility - if there’s a hole in the eardrum, you the air will go right through and you won’t see the effect at all

If fluid is present behind the TM, you won’t get any movement either

138

Tricuspid area murmurs (4th and 5th ICS, left sternal border) - what could they potentially be?

tricuspid stenosis, insufficiency, or regurgitation

139

Is displaced apical impulse common during pregnancy?

yes - rotated axis to left

140

Should speculum be closed or open when removing?

closed

141

thrills

vibrations of loud cardiac murmurs

142

Which is louder, S1 or S2?

S2

143

What do these tuning fork tests results indicate?

Left BC>AC; Right AC>BC; Weber lateralized to the Left

left conductive hearing loss

144

Is fertility/ability to get pregnant affected by uterine position?

no

145

S3 may be physiologic in ___ and ____

children and pregnancy

146

Pelvic examinations should begin at age

21 years

147

What do each of the following indicate? 4 parts of the plan: DX:

RX:

Pt. Ed.

F/U:

DX: diagnostic test

RX: therapeutic interventions

Patient education

Follow up

148

5 key things to note on bimanual exam of cervix

1. position related to axis of uterus

2. consistency (firm, soft, patency)

3. wag cervix for CMT (cervical motion tenderness)

4. surface characteristics

5. fornices

149

Sequence from Tanner stage 2-5 takes on average __ years

4 (1.5 to 6 years)

150

most common cause of hemoptysis is ____

bronchitis

151

CDC advises ____ screening of sexually active adolescents and women ≤25 years for gonorrheal and chlamydial infection and HIV

annual

152

PVD: arterial disorders (3)

  1. Atherosclerosis
  2. Acute Arterial Occlusion
  3. Raynaud’s Disease

153

Opening snap with diastolic rumble murmur possible diagnosis:

Mitral stenosis

154

hernia of intestines into vaginal wall

enterocele bulging in posterior fornix

155

Pulmonic area murmurs (2nd and 3rd ICS, left sternal border) - what could they potentially be?

pulmonic stenosis or pulmonic insufficiency

156

4 major types of pelvic organ prolapse

1. anterior comportment prolapse

2. posterior compartment prolapse

3. enterocoele

4. uterine prolapse (apical compartment prolapse)

157

Most common site for men to get basal cell carcinoma is on where? Where for women?

on the helix of the ear

for women it’s the bridge of the nose

158

What type of health history is most commonly used in reality of clinical practice?

problem-oriented or focused health history

159

Breast exam: positions for inspection (4)

1. arms at sides

2. arms raised

3. hands pressed on hips or against temples (Elicits dimpling if mass has infiltrated suspensory ligament)

4. leaning forward (with large pendulous breasts reveals asymmetry of breast)

160

Systole - 4 main points

• Ventricular contraction with increasing pressure

• Mitral/tricuspid valves close (S1) “lubb”

• Ventricular pressure opens aortic and pulmonary valves (silent)

• Ejection

161

Sexual maturity rating with pubic development - keep in mind that hair development usually follows ___ of breast development

within a few months

162

Systolic murmur grade VI (out of VI) - volume/thrill?

easily audible with thrill, heard with stethoscope fully off chest

163

Patient should be in what position when measuring JVP? What side of the neck are you checking?

at 30-45 degrees right side because it corresponds to right atrium

measure at the highest point of pulsations

164

What is often an early presenting sign of hearing loss?

Tinnitus

165

Widened pulse pressure in pregnancy is due to

uterine contraction and endogenous hormones resulting in decline in peripheral vascular resistance

166

Fakuda step test

Patient marching in place, have them close eyes, and they’ll rotate towards the side where there’s ear damage

167

Just because sputum is discolored, it doesn't necessarily indicate bacterial infection - what does the discoloration represent?

inflammatory cells which could be either bacterial or viral

168

Axillary adenopathy

Due to arm or breast infection

169

Main local causes of edema

• Deep Vein Thrombosis

... Or Infection, trauma, lymphatic obstruction

170

4 Objective Components of the Pediatric Health History

◆ Physical exam

◆ Laboratory findings

◆ Developmental assessment

◆ Direct observations including parent-child interaction

171

there are __ pneumonia vaccines recommended in adults

2

prevnar 13 (age 50 and up)

pneumovax (65 and up)

172

chronic poor oxygen perfusion to the distal tissues of the hand and feet (congenital heart disease)

clubbing

173

When palpating for tactile fremitus, remember that vibraton is greatest where?

over the large airways

diminishes peripherally

174

Auricular hematoma

cauliflower ear - wrestling

175

systolic or diastolic? aortic stenosis

systolic

176

Normal weber screening test

hearing it equally in both ears

177

When doing physical assessment of femoral artery, remember what 2 things?

- identify femoral pulse

- listen with diaphragm for bruits

178

Problem with bones of hearing/TM/external anatomy would quality as ___ hearing loss

conductive

179

Pertinent history for Rhinology (5)

1. nasal congestion

2. epistaxis

3. rhinorrhea

4. sinus pressure

5. sense of smell

180

In the presence of blood, which pap technique is more sensitive?

liquid-based

181

Innocent murmurs:

- what grade are the normally?

- systolic or diastolic?

- is there radiation?

- where heard best?

- in what position?

• Grade I or II, rare III

• Mid-systolic

• Little or no radiation

• Heard at 2nd-4th LICS

• When patient recumbent – decreases or goes away when sitting

182

When you're doing auscultation posteriorly, how should patient hold their arms?

crossed

183

S2 best heard where?

Heard at base (R and L 2nd ICS) with diaphragm

184

Squatting / handgrip position accentuates what?

mitral valve prolapse (increased afterload and increased ventricular volume)

185

A 60-year-old male presents with increasing shortness of breath x 6 months. What type of murmur is this?

• Timing? Systolic

• Location? Apex

• Shape? Holosystolic

• Pitch? Harsh

mitral regurgitation

186

Extra Heart Sounds in Diastole (3)

• S3

• S4

• OS – Opening Snap

187

interim health history

◆ A Follow-up approach

◆ Often used for management of chronic disease i.e – every 6 mo for DM client

◆ Detail events since the last meeting with the client

◆ Presumes an intact complete history

188

Venous PVD:

  • - pain
  • - mechanism
  • - pulses
  • - color
  • - temperature
  • - edema
  • - skin changes
  • - ulceration
  • - gangrene

Venous PVD:

  • pain: often painful
  • mechanism: venous hypertension
  • pulses: normal
  • color: normal or cyanotic on dependency; petechiae
  • temperature: normal
  • edema: present
  • skin changes: brown pigmentation around ankle, stasis dermatitis and thickening of leg as scarring develops
  • ulceration: if present, think medial sides of ankles
  • gangrene: none

189

systolic or diastolic? tricuspid stenosis

diastolic

190

If split S2 is heard on expiration, this is what?

paradoxical (pathologic)

191

Aortic area is where

2nd ICS, right sternal border

192

lifts/heaves

forceful cardiac contractions

193

S3 possible diagnosis

Normal in children; occurs in heart failure

194

Malignant neoplasm

May be solitary, unilateral, firm, fixed, non-tender, + dimpling, edema, scaling, retraction

195

Which murmur grades do NOT have a thrill?

I, II, III

196

A ___ murmur occurs in greater than 90% of pregnant women.

Grade II systolic murmur at pulmonary area

197

Location of PVD symptoms: Foot - what is the associated artery?

Tibial or peroneal

198

What breath sounds have long inspiratory phase, short expiratory phase?

Vesicular (Soft and whispery quality, low pitched)

199

Tricuspid area is where?

4th and 5th ICS, left sternal border

200

are cervical bruits innocent in adults?

NO

201

systolic or diastolic? tricuspid regurgitation

systolic

202

pectus excavatum

Funnel chest

203

Peripheral edema, palmar erythema, and spider telangectasias are all normal or not during pregnancy

normal

204

Expected RR for 1 year

20-40

205

11 lymph nodes of external neck

  1. Pre-auricular 
  2. Post-auricular 
  3. Occipital 
  4. Parotid  
  5. Tonsillar  
  6. Submandibular  
  7. Submental  
  8. Superficial cervical  
  9. Deep cervical 
  10. Posterior cervical 
  11. Supraclavicular

206

Vestibular symptoms is an umbrella term for

vertigo, vestibular rocking

207

hernia of posterior vaginal segment often associated with descent of rectum

posterior compartment prolapse

208

systolic or diastolic? VSD

systolic

209

Most common benign solid tumor in <25 years

fibroadenoma

210

> 40 years old, S3 is ___, S4 is ____

S3 abnormal

S4 common

211

3 Objective Components of the Adult Health History

 

  1. physical exam
  2. lab findings
  3. direct observations

212

If vibration symmetry is decreased or absent upon palpation for tactile fremitus:

trapped air in lungs;

thick pleura;

effusion;

obstruction;

massive pulmonary edema

213

physical assessment of dorsalis pedis artery: where is it located? technique tips?

- lateral to extensor tendon of great toe

- use pads of 2-3 fingers, push gently, grade 0 to 2+

214

S4

Soft, low-pitched sound in late diastole before S1, therefore an "atrial" sound

215

Diastole - 4 main points

• Pressure falls aortic &amp; pulmonary valves close – (S2, A2/P2) “dubb”

• Mitral/tricuspid valves open with filling (S3)

• Atrial contraction (S4)

• Ventricles are relaxed

216

All certifying bodies recommend first pap is at age

21

217

Key 5 cardiac risk factors

1. HTN

2. Hyperlipidemia

3. Smoking

4. Family history

5. Obesity

218

Ptotic (sagging) submandibular gland is part of

normal aging

219

What's more concerning, unilateral or bilateral hearing loss?

unilateral hearing loss (One-sided, you might think tumor)

220

According to ACOG, pelvic exams should be performed only when indicated by the medical history for patients under __ years

21

221

Breast lifespan changes: Menopause (3)

- glandular tissue replaced by fat

- inframammary ridge thickens

- relaxation of suspensory ligament

222

Arterial PVD:

  • pain 
  • mechanism
  • pulses
  • color
  • temperature
  • edema
  • skin changes
  • ulceration
  • gangrene

Arterial PVD:

  • pain: intermittent claudication
  • mechanism: tissue ischemia
  • pulses: decreased/absent
  • color: pale on elevation, dusky/red on dependency
  • temperature: cool
  • edema: absent/mild
  • skin changes: thin, atrophic skin, loss of hair, thick nails
  • ulceration: if present, toes or point of trauma on feet
  • gangrene: may develop

223

2 portions of inner ear anatomy

1. Cochlea (hearing) Arranged in frequencies from high to low - we hear from 200-20,000 hz

2. semicircular canals (balance input) - 3 planes - sense rotational movement

224

Which female population is HPV more transient in? 21-29 or 30-65?

more transient in 21-29

225

Subscapular/posterior nodes: where are they located? What do they drain/where do they drain into?

- Lateral border of scapula in posterior axillary fold

- Drains posterior chest wall and portion of arm

- Drains into central axillary nodes

226

Bronchovesicular breath sounds: where are they heard? Quality?

– Heard over bronchus and upper right posterior lung field; med. pitch

– Inspiratory and expiratory phases are equal

– Abnormal if heard over peripheral lung fields

– Normal child: Bronchovesicular BS throughout is normal

227

Main systemic causes of edema

• Heart failure

• Venous stasis 

.. Or pulmonary, kidney, or liver disease

228

If wheezes are fixed/localized, think about

possible airway obstruction (foreign body, tumor)

229

most cervical cancers happen where

squamocolumnar junction in the canal area between the external and internal cervical os - esp in young women (cervical canal)

230

Are labial adhesions common in prepubertal exam

YES - usually resolves with estrogen exposure in puberty

231

Normal child percussion:

Hyperresonant (very loud intensity, lower pitched, longer duration, “boom like quality”)

232

Fibroadenoma - peak incidence? where located? other key characteristics

- Common benign solid tumor in <25 years

- Commonly UOQ, non-tender

- Mobile, smooth, rubbery-firm

233

Summary statement includes: (4)

◆ Patient Profile

◆ Chief Complaint

◆ Concurrent Illnesses

◆ Positive and pertinent negative findings from history and PE

234

HPI - OLDCARTS

  • Onset
  • Location
  • Duration
  • Character/quality
  • Aggravating factors/associated symptoms
  • Relieving factors
  • Temporal factors
  • Severity (scale 1-10)

235

CN I how do you test?

Olfactory

• University of Pennsylvania Smell Identification Test – UPSIT

• In clinic exam and takes 30-40 minutes to complete

• Objective data for sense of smell

236

Mitral area murmurs (5th ICS, mid-clavicular line) - what could they potentially be?

mitral stenosis, insufficiency, regurgitation

237

hernia of anterior vaginal wall often associated with descent of bladder

anterior compartment prolapse

238

When assessing CN VII, if patient can't close their eye, that's automatically what grade on the House-Brackmann Scale?

4

239

S1 immediately precedes what?

carotid upstroke

240

systolic or diastolic? mitral regurgitation

systolic

241

If vibration symmetry is decreased or absent upon palpation for tactile fremitus:

Lung consolidation/ compression/mass;

excess fluids or non-obstructive secretions

242

Menarche usually occurs at Tanner stage ___, about __ years after bud development

3-4

2

243

Early diastolic murmur possible diagnoses:

Aortic or pulmonary regurgitation

244

Delay of pulmonic valve closure will ____ splitting

increase

245

systolic or diastolic? ASD

systolic

246

Pericardial friction rub continuous murmur sounds like what? Is it a diastolic, systolic, or continuous murmur?

scratchy

continuous

247

Is S3 normal during pregnancy?

yes

248

when you hear opening snap, think of what?

mitral stenosis

249

Venous hum continuous murmur sounds like what? Is it a diastolic, systolic, or continuous murmur?

low hum

continuous

250

Xanthomas

yellowish plaques / skin lesions caused by the accumulation of fat in macrophage immune cells

251

How do you assess the nasal valve?

inhale and look to see if it's hypermobile

- stent valve with stick then do Cottle maneuver

- stretch their cheek to the side and see if breathing improves

252

S3 best heard where?

Ventricular sound, at apex, use bell in LLD position kentucky

253

Expected RR for 3 years

20-30

254

Fluid cysts - peak incidence? where located? other key characteristics

- Peak incidence age 35-50 years

- Commonly UOQ, tenderness with menses

- Rapid development, firm or fluctuant

255

How can retroverted, retroflexed uterus be palpated?

rectally or via retrouterine pouch

256

Normal adult percussion:

Resonant (loud intensity, low pitch, long duration, “hollow quality”)

257

comprehensive health history

The client’s entire story

258

If you note Ophthalmitis and petechial / subconjunctival hemorrhages on eyelids, what might this indicate?

bacterial endocarditis

259

Egophony:

When the spoken “e” sounds like “a”

suggests lung consolidation

260

Mitral area is where?

5th ICS, mid-clavicular line

261

Do electrical impulses happen before or after the mechanical actions of the heart?

before

262

Gynecomastia - more common in what age?

- Enlarged breast in male

- Palpation of glandular tissue instead of fat

- Common in adolescents due to decreased ratio of androgens to estrogens

263

Pap specimen collection - does order of samples affect the results?

no

264

Normal JVP

6-8 cm H2O

JVP is distance up from angle to top of pulse wave

265

systolic or diastolic? pulmonic regurgitation

diastolic

266

If PMI is shifted to L of mid-clavicular line, what does that indicate?

Increased LV dimension

267

timing and quality of crackles/rales

Timing: early, mid or late inspiration

Quality: fine, medium or coarse

268

Holosystolic (pansystolic) murmur possible diagnoses:

Tricuspid or mitral regurgitation

269

What 2 valves are Atrioventricular?

Tricuspid, Mitral

270

Symptoms of Chronic Venous Insufficiency (CVI) - 3

• Persistent swelling of the lower legs

• Edema improves with raising legs; worsens later in the day

• Leg pain, dull aching, heaviness or cramping

271

3 types of health histories

1. comprehensive

2. problem-oriented or focused

3. interim

272

S3 is considered pathological in what age?

>40 y.o.

273

Largest area of glandular tissue in the breast; Majority of breast tumors occur here

Tail of spence

274

molluscum

viral infection that causes little pock-like lesions, often on inner thighs/buttocks

275

A 15-year-old male presents with shortness of breath over the past 2 weeks. You elicit a recent history of severe sore throat that was not treated with antibiotics. What type of murmur is this? What is the etiology?

• Timing? Systolic and diastolic

• Location? Loudest at 2nd RICS

• Shape? Crescendo-decrescendo

• Pitch? Harsh

Trick question: it's rheumatoid fever

276

systolic or diastolic? aortic regurgitation

diastolic

277

Vestibulo-spinal reflex

efferent motor nerve response that happens automatically when your ear turns to the right and head follows, it gives tone to your neck to support your balance

278

ACOG recommends first reproductive health visit between ___ yrs. Scope of exam depends on patient need. Often education.

13-15

279

Internal jugular pulsations/auscultation - what is normal? is the level of pulsations changed by position or affected by respirations?

- normal: rarely palpable, soft, 2 elevations per heartbeat

- Level of pulsations DOES change with position

- DROPs with inspiration

280

Examining the posterior oropharyngeal wall: what is cobblestoning?

lymphoid tissue in little pockets that line the throat - white, gray, yellowish bumps which can be related to anything that would activate the immune system

281

physical assessment of posterior tib artery: where is it located? technique tips?

- posterior to medial malleolus

- use pads of 2-3 fingers, push gently, grade 0 to 2+

282

Cyanosis in the skin, nails, lips is a ___ sign

late

283

Why do you need to be aware of hx of skull base surgery with rhinorrhea?

spinal fluid can leak through the surgery site even years afterwards

284

physiologic murmurs associated with what 4 conditions? and remember that they have ___ to innocent murmurs

  1. pregnancy
  2. fever
  3. anemia
  4. hyperthyroidism

 

similar characteristics

285

Location of PVD symptoms: Lower calf - what is the associated artery?

Popliteal

286

Superior mediastinum; largest at puberty, then involutes

Thymus

287

GRBAS voice grading

Grade

Raspy-ness

Breathiness

Asthenia - weakness, can’t project or get volume

Strain

Total is 0-15; 15 is severe vocal disability

288

S3 can be heard in patients who are in ___ failure and are overloaded

heart

289

Carotid neck pulsations/auscultation - what is normal? is the level of pulsations changed by position or affected by respirations?

- normally vigorous upstroke

- level of pulsations NOT changed by position or affected by respirations

290

Ejection sound possible diagnosis:

Aortic valve disease

291

CN VIII how to test?

Cochlear nerve aka Vestibulocochlear

rubbing

Weber, Rinne

292

one of the leading causes of COPD worldwide is ____

exposure to products of combustion during cooking (cooking over an open flame)

293

2 major precipitating factors for otorrhea (drainage) which is the hallmark of otitis media

1. respiratory infection (URI)

2. water exposure

294

descent of apex of vagina into lower vagina, to the hymen, or beyond vaginal introitus

uterine prolapse (apical compartment prolapse)

295

Pulmonic area is where?

2nd and 3rd ICS

296

3 components of vestibular exam

  1. Oculomotor testing (eye movement)
  2. Cerebellar testing (neurology lecture)
  3. Basic balance function

297

PVD: venous disorders (3)

  1. Chronic Venous Insufficiency (CVI)
  2. Deep Vein Thrombosis
  3. Superficial Thrombophlebitis

298

What's the best way to hold the pediatric handheld otoscope?

Brace with fifth finger against child's temple/face

299

9 components of Adult History: Subjective Data

◆ Informant

◆ Patient Profile (PP)

◆ Chief Complaint (CC)

◆ History of Present Illness (HPI)

◆ Past Medical History (PMH)

◆ Family History (FH)

◆ Occupational History (OH)

◆ Personal and Social History (PSH)

◆ Review Of Systems (ROS)

300

In children, AP diameter and transverse diameter should be

equal

301

If you note Corneal arcus in <40 y.o. during eye assessment, what might this indicate?

hyperlipidemia

302

adnexa of uterus

ovaries and fallopian tubes

303

during pregnancy, there is an initial ___ in BP up to 16 weeks, then what happens?

increase

then back to pre-pregnancy level

304

Physical Findings of CVI (3)

• Edema (dependent on position)

• Bluish discoloration of the skin at the ankles

• With prolonged swelling, venous ulcers can develop at the ankles and these often become infected

305

Always ask about what 6 things when taking an otology history?

1. Hearing loss

2. Otorrhea

3. Otalgia

4. Tinnitus

5. Aural fullness

6. Vestibular symptoms

306

When is the Thymus largest?

puberty

307

An innocent murmur in pregnancy is only ___. IT may change with ____

systolic

posture

308

Proprioception

your body’s sense of self in space

309

Common Cervical Findings: Nabothian cysts

Common, 1 cm, smooth, round, yellow lesion

Obstruction of cervical gland with squamous metaplasia

310

How do you test CN VII? The House-Brackmann Scale for CN VII - what does I indicate? What does VI indicate?

I - normal

VI - complete paralysis

311

Space between lungs; houses heart, large airways, large blood vessels, lymphatics

Mediastinum

312

Pertinent history for Laryngology and Head/Neck (6)

1. throat pain

2. dysphonia

3. dysphagia

4. neck masses

5. oral lesions

6. facial pain/numbness

313

___ could occur with pneumothorax. This is called subcutaneous emphysema

Crepitus like bubble wrap

314

Lingula

(not a lobe) - area that's adjacent to left heart border

315

Components of health history for GU (6)

1. Menstrual history

2. Sexual/contraceptive history

3. Obstetrical history

4. Cervical cytology history

5. Screening for intimate partner violence

6. Gynecological history

  • Current symptoms or history of pelvic, vaginal, or vulvar infections
  • Symptoms of pelvic organ prolapse or urinary or anal incontinence
  • History of gynecologic procedures

316

Synkinesis

automatically level II on House-Brackmann scale

mis-wiring of facial nerve post-trauma, like after Bells Palsy

317

Expected RR for 6 years

16-22

318

S4 is best heard where?

at apex in LLD position with bell Tennessee

319

What is happening when the mitral and tricuspid valves close? Is the heart in systole or diastole?

systole

320

85% of uteruses are in what position?

Anteverted, anteflexed

321

AP diameter ____ with age

increases

322

CN V

Trigeminal Nerve

- has 3 branches supplies sensation to face

- examine via light touch, using Filament or other fine instrument

– Compare touch from side to side in each of the three branches

– Rate by percentage i.e. 80% R V2 intact

323

1/3 of older adults have ___ murmur

systolic aortic

324

If adult is Hyperresonant, think about?

pneumothorax or emphysema

325

Sit up, lean forward, exhale completely and hold breath – this accentuates what?

aortic murmurs (regurg)

326

What is normal S2 splitting caused by

increased blood flow

327

Is the heart right or left dominant?

Right (70%)

328

paroxysmal nocturnal dyspnea (PND) could be sign that someone's having problems with ____

heart failure

329

Is bounding pulse common during pregnancy?

yes

330

Is pain normal when milking skene's glands?

no

331

S2

Closure aortic (pulmonic) valve (A before P)

332

Cranial nerves:

  • I
  • II
  • III
  • IV
  • V
  • VI
  • VII
  • VIII
  • IX
  • X
  • XI
  • XII

  • I Olfactory (Smell)

  • II Optic (Sight)

  • III Oculomotor (Moves eyelid and eyeball and adjusts the pupil and lens of the eye)

  • IV Trochlear (Moves eyeballs)

  • V Trigeminal (Facial muscles incl. chewing; Facial sensations)

  • VI Abducens (Moves eyeballs)

  • VII Facial (Taste, tears, saliva, facial expressions)

  • VIII Vestibulocochlear (Auditory)

  • IX Glossopharyngeal (Swallowing, saliva, taste)

  • X Vagus (Control of PNS e.g. smooth muscles of GI tract)

  • XI Accessory (Moving head & shoulders, swallowing)

  • XII Hypoglossal (Tongue muscles - speech & swallowing)

333

Purpose of the bimanual exam?

assess vaginal tone and cervical motion tenderness (CMT) in case of pelvic inflammatory disease

 

also to palpate the uterus and ovaries through the abdomen

334

3 components of the past medical history

1. childhood illnesses

2. adult illnessess

3. health maintenance behaviors including immunizations and screening test

335

An elderly patient with history of smoking 2 packs of cigarettes/day for 50 years complains of progressive shortness of breath. On cardiac exam, the most prominent PMI is in the xiphoid area. This is most likely result of what condition?

pulmonary HTN

336

A 77-year-old man is experiencing shortness of breath and dizziness. After cardiac catheterization, systolic BP in left ventricle is measured at 180 but systolic BP in aorta is 140. This is most likely caused by what valvuar condition?

aortic stenosis

337

Patients with aortic stenosis often experience what 3 symptons? What kind of BP discrepancy does it cause?

  1. dyspnea with exertion
  2. chest pain
  3. dizziness

BP in left ventricle will be higher than aorta

338

Where is the best place to auscultate the splitting of a second heart sound?

Left second and third interspace

339

20 year old college student experiencing dyspnea on exertion and palpitations. On auscultation, the second heart sound is split and fixed on both inspiration and expiration.  What is the most likely cardiac condition associated with this finding?

ASD (atrial septal defect)

340

Fixed splitting of the second heart sound that does not vary with respiration occurs in ___ defects and also in ____

ASD (atrial septal defects) and right sided heart failure

341

A 70 year old retired businessman presents to ED with progressive SOB and 2-pillow orthopnea. BP 140/90, JVD present, lower extremity pitting edema to knee, blowing holosystolic murmur heard best at LLSB. What intervention will best help him?

*Removal of intravascular volume with diuresis*

these symptoms are consistent with heart failure

murmur is indicative of tricuspid regurgitation

342

343

Normal QRS duration? What would it be after MI with left bundle branch block?

Normal = 100 miliseconds

With block = extended (longer)

344

Atrial enlargement would cause changes in what portion of the electrocardiogram?

P wave

345

Cardiac output = HR x stroke volume. So if HR decreases by 20%, how much would cardiac output change if stroke volume is consistent? 

20%

346

39 y/o with 2-day hx of fever, chills, cough with green sputum, dyspnea. Temp is 101.2. Late inspiratory crackles on auscultation of left lower lung posteriorly. "EE" sounds like "AA." What is this condition? What sound most likely heard on percussion of lungs

pneumonia

dullness

347

What breath sounds are most consistent with asthma?

wheezes on expiration

348

Depression of lower part of sterum would be what?

Pectus excavatum

349

Tingling around the lips can be a symptom of

anxiety

350

Patient with SOB - dullness to percussion over right lung base. Breath sounds absent at right lung base. No crackles, wheezes, or ronchi. These findings are characteristic of ___ or ____.

Atelectasis or pleural effusion

351

If needing to put a chest tube in 4th ICS, how does the provider determine where this is?

Find the sternal angle then move finger laterally to second rib. Then walks down from there. 4th ICS is below the 4th rib.

352

Sensitivity of screening for breast cancer increases with breast MRI at the expense of ____

specificity 

353

35 y/o G0P0 presents to clinic with biateral nipple discharge. Started several weeks ago, occurs irregularly. no symptoms other than slightly irregular period. On exam, the discharge is found to be breast milk, no pus or blood. Normal other labs. What would this be?

Prolactinoma - tumors that secrete prolactin, which causes production of breast milk and suppressing of menstruation

354

Symptoms: elderly, "tearing" chest pain, asymmetric BP in arms. ECG, cardiac enzymes and chest x-ray normal. This is most likely

dissecting aortic aneurysm

355

Where is the most important area to obtain cells for a Pap smear?

Transformation zone

356

Which muscle group is responsible for support of the pelvic floor?

levatori ani

357

On manual BP testing, what indicates true diastolic pressure?

disappearance of Korotkoff sounds following initial muffling

358

If heart sound/murmur is heard at the right 2nd interspace to the apex, what would be the typical origin valve?

aortic

359

If heart sound/murmur is heard at the left 2nd and 3rd interspace close to the sternum, but also at higher or lower leves, what would be the typical origin valve?

Pulmonic

360

If heart sound/murmur is heard at or near the lower left sternal border, what would be the valve of origin?

Tricuspid

361

If heart sound/murmur is heard at and around the cardiac apex, what is typically the origin valve?

mitral