General Appearance, Vital Signs, Skin, Hair, Nails, Head, Neck, and Mental Status

Question 1

General review of systems

Answer 1

Weight loss or gain
Fatigue
Fever or chills
Muscle weakness
Night sweats

Question 2

Skin

Answer 2

Skin changes
Rashes
Lumps
Itching
Dryness
Color Change

Change in nevi (moles)
Color
Shape
New

Question 3

weight gain caused by

Answer 3

Excess body fat
Edema
Ascites
Endocrine disorders
Medication side effects

Question 4

what do you do when a patient has gained weight?

Answer 4

Diet?
Physical activity?
Weight loss attempts?
Psychological conditions?

Screen for endocrine disorders
Take a medication history

ALWAYS determine the time frame
for weight gain voluntary or involuntary?

Question 5

Anorexia-

Answer 5

Loss of desire to eat, could be a sick patient w/ a terminal illness

Question 6

Anorexia nervosa

Answer 6

Disorder marked by extremely low body weight and distorted body image.

Question 7

Bulimia-

Answer 7

Disorder characterized by recurrent binge eating and compensatory behaviors to prevent weight gain such as excessive exercise or vomiting

Question 8

weight loss follow up questions?

Answer 8

Has your appetite increased or decreased?
How long have you been losing weight?
How do you feel about the way you look?
What is your typical diet?

Question 9

fatigue

Answer 9

common symptom of illness is a Lack of energy to complete tasks, exhaustion, tiredness May signify underlying medical (anemia, thyroid disorder, cardiac ischemia) or psychiatric disease (depression

Affected everyday activities?
Time course?
Modifying factors? 
Personal and social issues? 
was there anything else going on at this time or feel similar?

Question 10

fatigue differential diagnosis

Answer 10

Anxiety/depression
Systemic diseases
Infections
Cancer
Medications 
And others!

Question 11

Persistent fatigue

Chronic fatigue

Idiopathic fatigue

Answer 11

persists for more than 1 month

for 6 months or more

not attributed to a psychiatric or medical illness

Question 12

muscle weakness

Answer 12

Categorized according to anatomic location causing the weakness
Muscle
Spinal nerve root
Peripheral nerves
Brain or spinal cord
Upper/lower motor neurons disease

Primary muscle or neurologic disorders
Other systemic
diseases

Duration of symptoms? 
Evolution of symptoms?
Distribution of symptoms?
Associated signs and symptoms?
Risk factors?

Question 13

Functional weakness

Answer 13

• No true muscle weakness, but this interferes with completing activities of daily living.

Question 14

True motor weakness

Answer 14

• Difficulty or inability to perform certain tasks. Example: patient that has difficulty rising from a chair.

Question 15

Normal Temperature

Answer 15

Average oral temperature:
37°C or 98.6°F
Diurnal variation: 35.8°C (96.4°F) to 37.3°C (99.1°F)
temperature lower during sleep

Question 16

Fever-

Fever of unknown origin (FUO)

Chills-

Answer 16

Temperature over 99 °F during the day and over 100 °F in the evening

• Temperature over 100.9 °F for 3 weeks with no clear etiology.

Involuntary muscle contractions with violent shivering and teeth chattering.

Question 17

Fevers/chills caused by

Answer 17

Infection
Malignancy (can cause night sweats)
Inflammation
Medications
Post-op (chills after anesthesia because of changes in body temp. 
Endocrine disorders (hypothyroidism)

Question 18

When someone has fevers/chills ask about?

Answer 18

Alarm symptoms- Rash, SOB (meningitis), chest pain, change in mental status.
Sick contact
Time course (how long has this been going on for)
Associated symptoms

Question 19

Flushing-

Hot flashes

Hyperhydrosis

Night sweats

Answer 19

Acute onset of cutaneous vasodilation. ex. steroid reaction found in torso or head and can be found in periphery

• Sudden feelings of warmth, sweating. feels like flushing or may accompany it ex. menopause
• Increased sweating beyond necessary to maintain thermal homeostatis. ex. usually caused by medication
• Drenching sweating occurring during sleep requiring the patient to change clothes or bedding in absence of fever or environmental factors. Serious until proven otherwise if… New, Accompanied by Systemic Symptoms (weight loss, lymphadenopathy, cough). Clinical context is crucial! Ask about known co-morbid illnesses, travel/ exposure history.
  ex. women going into menopause, red flag for undiagosed malignancy around once a week or once a month, hyperthyroidism, can be caused by medication taken at odd times

Question 20

Night sweats are caused by

should be asked about?

Answer 20

Hormonal changes
GERD
Sleep disorders
Medications
Infection
Malignancy 
inflammation

Alarm symptoms- Weight loss, lymphadenopathy, new symptoms in any organ system.
Bedding , night clothes, medications
Social history that might indicate TB, HIV, hepatitis

Question 21

what are you looking for in general appearance?

Answer 21

Level of consciousness
Apparent state of health
Signs of distress
Height (stature) and build (habitus) [weight]
Skin
Dress, grooming, and personal hygiene
Facial Expression
Odors of body and breath
Posture, gait and motor activity

Question 22

Level of Consciousness factors

Answer 22

Alert- Eyes open; responds appropriately.
Lethargic- Appears drowsy; can open eyes; makes eye contact, responds then may fall asleep.
Obtunded- Can open eyes; responds slowly but is confused; decreased interest in environment.
Stupor- Arouses from sleep only after painful stimuli is utilized; slow to no responses; lapses into unresponsiveness when stimuli is removed.
Comatose- Remains unresponsive to external stimuli.

Question 23

General appearance

Answer 23

Well appearing
Acute or chronically ill 
Frail
Robust
vigorous

Question 24

signs of distress include

Answer 24

clutching chest (cardiac or respiratory)
guarding (indicating pain)
frazzled (anxiety/depression)

Question 25

Height (stature) and build (habitus) [weight]:

Answer 25

``` Is the patient unusually short or tall? Is the build slender and lanky, muscular, or stocky? Note general body proportions and look for deformities ``` - short stature (turner syndrome, renal failure, achondroplastic and hypopituitary dwarfism, long limbs in proportion to trunk in hypognoadism and marfan syndrome height loss in osteoporoisis and vertebral issues; truncal fat w/ thin limbs suggests cushing syndrome

Question 26

marfan syndrome

Answer 26

connective tissue disorder ex. causing fatal aneurysm from lack of tissues and is very lax

Question 27

Cushing syndrome

Answer 27

C6-C7 vertebrae with fat pad buffalo hump, facial hair, lines on abdomen, osteoporosis ex-or-endogenous cortisol, when take prednisone a lot, something that develops, pituitary or adrenal adenoma. skinny arms and truncal fat - increased adrenal cortisol production of cushing syndrome produces round moon face w/ red check w/ excessive hair growth in mustache, sideburn areas, and chin.

Question 28

general appearance

Answer 28

``` Skin color and obvious lesions: Brief inspection of exposed skin. Full integument exam later. Looking for: pallor cyanosis Jaundice (icterus) rashes bruises ```

Question 29

facial expression

Answer 29

Observe at rest, during conversation, during the physical exam, and during interaction with others Note eye contact Look for appropriate changes in facial expression (mask facies is parkinson disease symptom) natural eye contact, sustained or unblinking, averted quickly or absent? stare of hyperthyroidism, immobile of parkinsonian, flat or sad of depression;

Question 30

Posture, gait, and motor activity functions

Answer 30

gait steady or unsteady, unassisted? how fast are they moving, involuntary movements w/ preferred posture posture-sit as if in pain or uncofmroatble, gait & motor activity-tremors, involuntary movement, smooth or self confidence walking w/ balance?

Question 31

``` Gaits: spastic scissors propulsive steppage waddling ```

Answer 31

upper neuron issues after stroke for spastic and scissors propulsive- spinal stenosis parkinson hurts to go straight steppage- can't dorsiflex foot usually w/ a lesion of L5 waddling- hip issue or duck gait

Question 32

Palpating temperature –

Answer 32

better accuracy using dorsum of examiner’s hands if it is cold and clammy how does it compare to other areas

Question 33

Places to get a temperature

Answer 33

Axillary (least accurate hold thermometer for 5-10 minutes least accurate Oral-most commonly used Temporal Artery- common higher than normal Rectal Membrane- best and most accurate way to measure temperature inserting toward umbilicus Tympanic- common higher than oral clean out wax

Question 34

Hyperthermia Hyperpyrexia- Hypothermia- Fever-

Answer 34

Elevation in body temperature due to loss of homeostatsis with inability to increase heat loss. Extreme elevation in temperature above 106 degrees F. excessively high temperature above 106F severe illness, crush injury, malignancy, drug reactions, and immune disorders (collagen and vascular diseas) Abnormally low temperature; below 95 degrees F when taken rectally. abnormally low temperature caused by exposure to cold, paralysis, sepsis alcohol starvation, hypothyroidism, and hypoglycemia Elevated temperature 38 degrees C (100.4 degrees F) Rectally.

Question 35

Arterial Pulse Measurement

Answer 35

``` An assessment of heart rate Radial or other locations Palpate for pattern (rhythm) Regular or irregular Palpate for intensity (strength) Weak, brisk (normal strong), or bounding If regular rhythm and normal rate count for 30 seconds and multiply by 2. If abnormal or irregular, count for a full 60 seconds. do early beats appear in a basically regular rhythm? does irregularity vary consistency w/ respiration? is is irregularly irregular Normal adult range: 60-100 beats/minute ```

Question 36

Respiratory Rate

Answer 36

``` Count the respirations by watching the chest rise and fall. can have retractions It is more accurate if the patient does not know you are counting. expiration prolonged COPD Observe Rate: Normal 12 to 20 breaths/minute Rhythm: Regular, Irregular Depth: Shallow, Deep Effort: Gasping, Labored ```

Question 37

Blood Pressure Cuff Measurement

Answer 37

Width of bladder: 40% of upper arm circumference Length of bladder: 80% of upper arm circumference. arrows of arm width must fall in range for proper measurement. If the cuff is too narrow, the reading will be high If the cuff is too wide, the reading will be low on a small arm and high on a large arm

Question 38

Optimal conditions for taking blood pressure

Answer 38

higher in first thing in the morning, do both arms, must do after multiple visits and if high double check before leaving. Preparation is vital! Avoid smoking, caffeine, exercise 30 minutes prior to measurement. (increases rate, cause inflammation in vessels) Quiet examination room with comfortable temperature. Arm free of clothing. Ask the patient which arm they prefer. Avoid using side with a fistula, lymphedema, lymph node excision, extensive scarring or other abnormality. Patient should sit quietly in a chair for at least 5 minutes prior; back supported and feet on the ground.

Question 39

List the steps for obtaining an accurate blood pressure, and describe the consequences if proper technique is not observed.

Answer 39

Palpate the brachial artery (antecubital crease; medial to the biceps tendon) Position the arm so that the brachial artery is at heart level Rest the arm on a table a little above the patient’s waist OR support the patient’s arm with your own at their mid-chest level Proper cuff location (2.5 cm above antecubital crease) Secure the cuff – snug, not tight. Palpate the radial pulse and inflate the cuff until it disappear Remember this number (systolic BP by palpation). Deflate the cuff; wait 15-30 seconds. Place your stethoscope lightly over the brachial artery Hold arm at level of patient’s heart, and reinflate the cuff 30 mm Hg higher than the systolic number obtained by palpation. Deflate the cuff at a rate of 2-3 mmHg/second First sound = systolic blood pressure two consecutive sounds Disappearance of sound = diastolic blood pressure except when there is an auscultatory gap

Question 40

Orthostatic blood pressure

Answer 40

Measure blood pressure and heart rate in two positions 1) Check BP with patient supine after resting 3-10 minutes 2) Wait three minutes 2) Check BP immediately when patient stands up patient usually gets dizzy Normal: systolic ≤ initial ; diastolic rises slightly Orthostasis: systolic BP drops ≥ 20 mmHg or diastolic BP drops ≥ 10 mmHg, pulse increases ≥ 20 beats/min *In some settings it is routine to do this in 3 positions (supine, sitting, standing). drop in systolic blood pressure of at least 10 mmHg w/in 3 minutes of standing caused by drugs, blood loss, bed rest, and ANS diseases caused by Medications; Polypharmacy Moderate or severe blood (or other fluid) loss dehydration Prolonged bed rest Autonomic and cardiovascular disorders

Question 41

Types of hypertension

Answer 41

White Coat- Elevated BP in a clinical setting but not elsewhere. blood pressure >14090 in medical settings and mean awake home readings of 135/85 caused by stress of being in a medical environment Masked- Normal office BP; but BP elevated when ambulating and at home. Increased risk of cardiovascular disease and organ damage. ex. if you have headache, dizziness, and other common signs of HBP have pt check home or have moving pressure. office blood pressure <140/90 elevated daytime blood pressure above 135/85 at home 10-30% of population w/ increased risk of cardiovascular disease and end organ damage

Question 42

Nocturnal hypertension

Answer 42

Normally a physiologic dipping of BP occurs when shifting from wakefulness to sleep. With this type of HTN, a nocturnal fall of less than 10% of daytime values is associated with significant risk of cardiovascular disease and organ damage. Only identified by 24 hour monitoring. caused by vascular changes in eyes, headache, and dizziness

Question 43

Blood pressure measurement

Answer 43

Measurement of BP in both arms at least once Difference of pressure should be no more than 10 mm Hg per side Diagnosis of Hypertension: Two or more properly measured BP readings taken on two or more office visits and verified in contralateral arm.

Question 44

auscultatory gap

Answer 44

start to hear systolic pressure, disappears and then it comes back, at risk for cardiovascular instance, buildup of plague or aneurysm check doing BP while arm is raised and lower while you deflate, or have them make a fist

Question 45

why do we check both arms for blood pressure?

Answer 45

check both sides if there is a difference of more than 10 mmhm can be caused by aneurysm or stenosis

Question 46

pain is...

Answer 46

subjective with pain feeling different to each person. find out more by OPQRST when did it start, at what point is it worse or better, associated sensory loss, other neurological symptoms setting in which it occurs (environmental, emotional) remitting or exacerbating factors what makes it better or worse, associated manifestations

Question 47

Idiopathic Neuropathic Nocioceptive (somatic) Psychogenic

Answer 47

– Without identifiable etiology – Direct consequence of lesion or disease affecting somatosensory system ex. disc hernia – Linked to tissue damage but sensory system is intact – Associated with psychological factors ex. if patient states 10/10 and is not in distress could be psychogenic

Question 48

somatic visceral neuropathic

Answer 48

Sharp, stabbing, localized Deep, achy, poorly localized Burning, hot, distribution of nerve

Question 49

actue pain chronic pain

Answer 49

short lived lasting at least 12 weeks

Question 50

4. Compare and contrast different methods of obtaining a patient’s temperature.

Answer 50

Oral- most commonly used and for adults correlate more closely w/ correct pulmonary artery temperature are generally lower than core body temperature and lower than core body temperature by (0.7-0.9F) higher than axillary by 1 problems caused by breathing Rectal- most closely and more reliable because closer to core and not affected by breathing Temporal- for adults correlate more closely w/ pulmonary artery temperature but are about 0.5C lower, using temporal artery Axillary- take 5-10 inutes to register and are much less accurate than other measurements Tympanic- more variable than oral or rectal, better used for children reliable but does it close to hypothalamus where temperature regulation occurs

Question 51

Pain | 1. Describe components of the patient history that are useful in the evaluation of pain.

Answer 51

LOPQRST

Question 52

tolerance dependence addiction

Answer 52

reduced physiological reaction to a drug following repeated use physical condition in which the body has adapted to the presence of the drug. withdrawal symptoms are eminent chronic, relapsing disease marked by compulsive drug seeking and use despite harmful consequences

Question 53

high vmi in men and women and assess for

Answer 53

if bmi greater than 35 if circumference is greater than 35in in men 40 in women. bmi>25 assess for risk factors of hypertension, high LDL,, low HDL, high triglycerides, high BG, heart disease, cigarette an inactivity

Question 54

major functions of the skin

Answer 54

``` keep the body in homeostasis Provides boundaries for body fluid Protects underlying tissues from microorganisms, harmful substances, and radiation Modulates body temperature Synthesizes vitamin D ```

Question 55

Three Layers of Skin

Answer 55

``` Epidermis Outer Layer- Stratum Corneum Inner (cellular) Layers- Stratum Basale and Stratum Spinosum Dermis Subcutaneous tissue ```

Question 56

Epidermis

Answer 56

Horny Layer (keratinized layer of dead cells aka stratum corneum) and cellular layer (stratum lucidium, stratum granulosum, stratum spinous, and stratum basal)

Question 57

dermis-

Answer 57

contains connective tissue, sebaceous glands, hair follicle, and sweat glands and provides nourishment to the epidermis

Question 58

hypodermis

Answer 58

contains nerves, vein, artery and mostly fat adipose cushioning

Question 59

sweat glands two kinds and variety

Answer 59

eccrine (widely distributed, open directly onto skin surface, help control body temperature through sweat production) apocrine (axxilary and genital open to genitals during stress providing body odor).

Question 60

sebaceous glands

Answer 60

(found everywhere except palms soles secretes fatty, oily substance (sebum) secreted onto skin through hair follicles)

Question 61

structure of nail

Answer 61

nail bed-tissue under nail nail plate-fingernail cuticle-seals space between nail fold and plate nail root where nail grows from

Question 62

structure of nail

Answer 62

nail bed-tissue under nail causing plate to be pink nail plate-fingernail cuticle-seals space between nail fold and plate or lateral nail fold nail root where nail grows from lunula- white area proximal nail fold- covers nail root clubbing more convex angle greater than 180 degrees caused by hypoxia

Question 63

Concerning symptoms associated w/ skin

Answer 63

Hair loss (alopecia) Rash Moles Nail changes

Question 64

hair loss caused by

Answer 64

Systemic/chronic illness Infection (systemic or local) Medication exposure or serious illness in past 3-4 months Psychiatric disorder Physical stress or life-threatening psychological stress Tight braids or “pulled-back” hairstyle – traction alopecia Hormonal due to systemic/chronic illness, infection (systemic or local), medication exposure or serious illness in past 3-4 months, psychiatric disorder, physical/psychological life-threatening stress, tight braids, hormones. Alopecia = Hair loss. May be diffuse or patchy, Telogen effluvium = Excessive hair shedding, Male-pattern baldness = Androgenic alopecia. Thinning crown, receding hairline. Trichotillomania = Urge to pull out one’s own hair. Can be diffuse, patchy, or total. Focal patches lost suddenly in alopecia areata w/ scarring alopecia need to refer to dermatology, sparse hair in hypothyrodism and fine silky hair inhyperthyroidism. Inspect for erythema, scaling, pustules, tenderness, bogginess, and scarring (need refferal right away). Pull on hair and if they have telogen bulbs most liekly have telogen effluvium, see if they break off

Question 65

Alopecia Telogen effluvium Male-pattern baldness Trichotillomania

Answer 65

= Hair loss. May be diffuse or patchy = Excessive hair shedding = Androgenic alopecia. Thinning crown, receding hairline. = Urge to pull out one’s own hair

Question 66

rash? | what is it caused by caused by

Answer 66

``` inflammatory skin eruption caused by: Drug reactions Infections (bacterial, viral, fungal)/infestations pregnancy Autoimmune (polycyhtemia vera and thyroid disease) Idiopathic Allergic Neoplastic (lymphomas and leukemia) ```

Question 67

macule

Answer 67

primary lesion circumscribed, flat discoloration of only the top layer of horny epidermis of skin less than 1cm w/ a patch is more than 1cm. if a flat spot is larger than >1cm can be blue, red, or hypopigmented from a number of causesfreckle is a type of macule. can be brown, blue, red, or hypo pigmented any color can be associated w/ problems. if a flat spot is small <1cm it is a macule, can be brown, blue, red, or hypopigmented by a number of causes see powerpoint

Question 68

plaque

Answer 68

primary lesion circumscribed palpable solid lesion 1 cm or larger often formed by confluence of papuples caused by many disease appear red, raised, and dry patchy affecting only horny layer of epidermis raised spot >1cm psoriasis, atopic dermatisis, or rosea

Question 69

papule

Answer 69

primary lesion a palpable lesion effecting full thickness of epidermis and dermis <1cm in diameter coloration varies from skin color, yellow, white, brown, red, blue or violaceous with variations from benign to associated w/ a disease - lesion that is palpable above skin being raised if <1cm, color varies felsh, yellow, white, brown, red, bblue can become confluent and form plaques can be benign or cancerous

Question 70

nodule/cyst

Answer 70

primary lesion a circumscribed often round, solid lesion larger and deeper than a papule w/ a large one referred to as tumor located completely below the epidermis fully floating in the epidermis almost always associated w/ something that needs treatment mobile or fixed encapsulated collections of fluid or semisolid - circumscribed, often round, solid lesion larger and deeper than papule w/ a large one being a tumor ex. BCC, wart

Question 71

wheal

Answer 71

primary lesion. a firm edematous papule or plaque, resulting from infiltration of the dermis with fluid wheals are transient and may last a few hours to a few days. A wheal is a red, swollen mark or white that can be individual bumps or large connected areas, that is often itchy and changes shape. They usually occur in response to a stimulus like a bug bite or food allergies. causing by increased inflammation of cellularly layer in skin and redness in the horny layer. firm edematous papule or plaque, resulting from infiltration of dermis w/ fluid transient w/ dermal edema lasting few hours to days ex. hives, urticara

Question 72

vesicle

Answer 72

primary lesion circumscribed collection of free fluid less than 1cm in height that is located between horny and cellular layer of epidermis ranging from benign to indicator of herpes if lesion is raised, filled w/ fluid and small <1cm it is a vesicle ex. herpes simplex or shingles

Question 73

pustule

Answer 73

primary circumscribed collection of leukocytes and free fluid that varies in size and is located under horny layer of epidermis dividing cellular epidermis and comes in contact w/ dermis ex. acne, chicken pox,

Question 74

burrow

Answer 74

primary Burrows are tunnels formed in the skin that appear as linear marks. They are a result of an infestation of the skin by parasites such as scabietic mites. small linear or semipiginous pathways in epidermis created by scabies mites

Question 75

crust

Answer 75

secondary lesion is a collection of dried serum and cellular debris, scab caused from damage

Question 76

lichenification

Answer 76

secondary skin has become thickened and leathery caused from continual rubbing or scratching skin caused by chronic eczema

Question 77

scar

Answer 77

secondary an abnormal formation of connective tissue implying dermal damage after injury or surgery are initially thick and pink but become white and atrophic forming a bump in cellular layer that increases the size of the horny layer w/ no issue

Question 78

keloid

Answer 78

secondary abnormal proliferation of scar tissue that forms at the site of cutaneous injury (eg, on the site of a surgical incision or trauma); it does not regress and grows beyond the original margins of the scar

Question 79

erosion

Answer 79

secondary a focal loss of epidermis. do not penetrate below the dermoepidermal junction and therefore heal without scarring from inflammatory or infectious disease

Question 80

excoriation

Answer 80

secondary lesion that is a scratch caused from ones own compulsion to pick at skin causing red raised bumps and scratches to surface.

Question 81

fissure

Answer 81

secondary a linear loss of epidermis and dermis with sharply defined nearly vertical walls caused by chapping or eczema

Question 82

ulcer

Answer 82

secondary focal loss of epidermis and dermis ulcers heal with scarring caused by physical trauma and infection

Question 83

scale

Answer 83

excess dead epidermal cells of horny layer that are produced by abnormal keratinization and shedding with genetic components or some bacterial causes

Question 84

moles or nevi

Answer 84

Most moles are harmless, but in some cases, moles may become cancerous. Monitoring moles and other pigmented patches is an important step in detecting malignant melanoma. Clusters of pigmented cells Can come in a range of colors and can develop virtually anywhere on your body. nevi use ABCDEEFG to describe and characterize could become cancer

Question 85

7. Describe the ABCDE method of screening for melanoma, and describe the skin findings associated with malignant melanoma.

Answer 85

Any two of these factors should be sent to a dermatologist for an assessment. screen anyone w/ >50 moles, and >5-10 atypical moles A- asymmetry of one side of mole compared to other, B- border irregularity especially if ragged, notched, or blurred, C-color variations w/ more than two colors especially, blue=black, white (loss of pigment due to regression), or red (inflammatory reaction to abnormal cells except of homogenous blue color in blue nevus. the blue or black color w/in a larger pigmented lesion is especially concerning for melanoma. D- diameter >6mm normal one should be approximately the size of a pencil eraser. E- evolving or changing rapidly in size, symptoms, or morphology and is the most sensitive of these criteria. E- elevated. F-firm to palpation. G-growing progressively over several weeks

Question 86

basal cell carcinoma

Answer 86

Comprises 80% of skin cancers Shiny and translucent, they grow slowly and rarely metastasize. raised pearly reddish most common cancer in world, rarely spreads to other parts of body, invdde and destroy local tissues immature cells to basal layer

Question 87

squamous cell carcinoma

Answer 87

Comprises 16% of skin cancers Crusted, scaly, and ulcerated, they can metastasiz. roughened hyperkeratotic lesions sun exposed areas begn usually by acitinic keratosis feeling rough or keratotic arises form sun-damaged skin of head, neck, and dorsal arms and ahnds and can metastasize if left untreated consisting of more mature cells found on scalp, lips, and ears

Question 88

melanoma

Answer 88

Comprises 4% of skin cancers | Tend to spread rapidly

Question 89

when examining skin quality what do you look for

Answer 89

color (hyper or hypopigmentatioN, redness/erythema), yellow/jaundice), ecchymosis/bruising, cyanosis) moisture (Dryness, sweating (moist), and oiliness) temperature (Identify warmth or coolness of skin) texture (Rough or smooth) turgor (Lift fold of skin over back of hand Note ease with which it lifts up (mobility) and speed with which it returns to place (turgor)) lesions

Question 90

what do you do differently of people of color

Answer 90

Melanin may obscure changes | Therefore inspect conjunctivae, buccal mucosa, nail beds, and palms to assess color changes.

Question 91

cyanosis and its location

Answer 91

- indicating severe lack of oxygen forcing areas like extremities to shunt oxygen elsewhere and turn blue ex. COPD exacerbation Blue coloration of the skin and mucous membranes due to the presence of deoxygenated hemoglobin in blood vessels near the skin surface. Central cyanosis is often due to a circulatory or ventilation problem (cardiopulmonary failure) low oxygen levels in blood cause lips, fingers, and toes to turn blue central due to circulatory or ventilation problem (cardiopulmonary failure, Peripheral - Peripheral cyanosis is the blue tint in fingers or extremities, due to inadequate circulation.

Question 92

what do you look at in scalp

Answer 92

Look at distribution and quantity of hair | Look for any scalp lesions

Question 93

what do you look for in nail beds

Answer 93

Look for color and deformity | Clubbing (mostly caused by lung issues or cancers)

Question 94

lesion characteristics

Answer 94

``` Anatomic location and distribution Patterns and shapes (morphology) Type of lesion (macules, papules, nevi, vesicles) Color Size ```

Question 95

describing a rash what do you look for?

Answer 95

Morphology of lesions - What is the color? Primary or secondary lesions? Are the lesions all the same or variable? Is there any exudate? Size, number? Texture? Pattern – Shape, round, oval, annular (ring-shaped), iris (target-shaped), serpiginous (snake-like) Anatomic distribution – localized, generalized, symmetrical, acral (hands and feet), light-exposed areas, intertriginous (skin folds), clustered, dermatomal

Question 96

pityriasis rosea

Answer 96

Scaly, patchy rash sometimes seen in a Christmas tree pattern Hearld Patch may appear initially then symmetric spreading Unknown etiology but may be related to viral infection single oval, flat-topped superficial erythematous to skin colored plaque or multiple round to oval scaling violaceous plaques contagious infection

Question 97

dermatomyositis

Answer 97

``` Inflammatory myopathy Muscle weakness and rash Red/purple patches Unknown etiology, most likely autoimmune - uncommon inflammatory disease w/ rash ad muscle weakness slightly raised reddish scaly rash ```

Question 98

athlete's foot (tinea pedis)

Answer 98

Fungal infection Usually begins between the toes, but can spread - fungal infection beginning between toes occurs in people who feet are sweaty in tightfitting shoes scaly rash cuasing itching, stinging, and burning contagious and can be spread

Question 99

tinea versicolor

Answer 99

Common fungal infection Discolored patches hypopigmented, hyperpgimented or tan round to oval macules on upper neck and back, upper chest, and arm w/ slight inducible scale on scraping

Question 100

small pox

Answer 100

Firm Well circumscribed vesicles or pustles May be umbilicated Caused by viral (variola) infection

Question 101

erythema infectiosum

Answer 101

“Slapped cheek” rash “Lace like” rash on extremities Caused by Parvovirus B19

Question 102

pigments of skin

Answer 102

melanin- brown skin tone determined by sunlight carotene- golden yellow pigment subcutaneous fat palms and soles hemoglobin- RBC oxygen of blood oxyhemoglobin vs. deoxyhemoglobin w/ or without oxygen (causing bluish cast cyanosis best assessed where horny layer is thinnest under fingernails, mouth and mucus membrane, and in mouth

Question 103

velus hair

Answer 103

short fine, incosncipuous unpigmented

Question 104

terminal

Answer 104

coarser, thicker, conspicuous, more pigments scalp and eyebrows

Question 105

jaundice

Answer 105

yellow in sclera, liver disease or excessive hemolysis, palpebral conjunctive, lips hard pallet, yympanic membrane skin,. blanch out color by lips of slide. caused by the increased amount of bilirubin a pigment involved in the breakdown of RBCs associated w/ liver failure or disease caused by the

Question 106

INTERTRIGENOUS

Answer 106

area where two skin areas of skin may come and rub together

Question 107

patterns of skin lesions

Answer 107

linear, clustered, annular (ring), arciform (arc), dermatomal covering skin band sensory nerve root

Question 108

signs of cardiac or respiratory distress

Answer 108

clutching of chest, pallor, diaphoresis, labored breathing, wheezing, or coughing

Question 109

signs of pain

Answer 109

wincing, diaphoresis, protectiveness of a painful area, grimacing, unusual posture

Question 110

signs of psychological distress

Answer 110

anxious facial expressions, fidgety movements, cold moist palms, inexpressive or flat affect, poor eye contact, yshomotor slowing

Question 111

posture of someone w/ left sided CHF

Answer 111

leaning forward w/ arms braced COPD

Question 112

how can a clinician handle a difficult patient?

Answer 112

hard trials and tribulations show your worth like an olympian clinician should identify many variables associated w/ encounters, identify own underlying negative emotions, adapt approach and redirect encounter exploring why

Question 113

What are common functional syndromes?

Answer 113

IBS, fibromyalgia, chronic fatigue, TMJ, fatigue, sleep distrubance, musculoskeletal pain, headache, and gastrointestinal problems, overlap or comobrid w/ functional impairment psychiatric comorbitis if chronic more than 6 weeks highly likely it is psych medical symptoms with a mental health component – patients are not “faking.” clusters of common sysmptoms caused by psychological reasonsing such as IBS, fibromyalgia, chronic fatigue, TMJ, and multiple chemical sensitivity Conversion disorder, psychogenic non-epileptic seizures

Question 114

Mental health disorders can be masked by other conditions

Answer 114

Depression Multiple somatic (body-wide) complaints, aches, pains, fatigue Hypothyroidism Anxiety Palpitations, chest pain Panic attack Diaphoresis, paresthesias of extremities, shortness of breath, chest pain, tunnel vision Delirium presents with psychiatric symptoms but is a medical diagnosis with a medical etiolog

Question 115

Common or concerning symptoms:

Answer 115

Changes in attention Changes in mood Changes in speech Changes in insight Changes in orientation Changes in memory Anxiety (excessive worrying that interferes with ability to function) Panic Ritualistic Behavior (counting, checking) Delirium (confusion, altered level of consciousness) Dementia (forgetfulness)

Question 116

Conversion disorder-

Answer 116

neurological symptoms w/out neuro problems history of abuse or trauma to childhood, recent stressor need to treat underling health depression Cognitive behavioral therapy and physical therapy Psychogenic non-epileptic seizures- patients w/ epilepsy can have psychogenic

Question 117

How do you approach a psych patient

Answer 117

Safety Create an environment that is safe for both yourself and the patient Examiner’s behavior Eye contact Interpersonal space Posture Verbal interventions: Report and reflect to patient periodically Accept what the patient says Express concern and desire to protect patient’s safety Acknowledge patient’s power to make decisions Comfort measures So it sounds like you’ve been feeling… is that accurate? Resisting writing reflex, instead of writing it off ask what they like and what they don’t like about it and ask why it can be bad

Question 118

agitated depression

Answer 118

tense posture, restlessness, and anxious fidgeting; crying, pacing, and hand wringing of agitated depression; hopeless slumped posture and slowed movements of depression; agitated and expansive movements of manic disorder

Question 119

opposite parental cortex

Answer 119

one sided neglect of grooming may result form lesion in opposite partial cortex usually nondominat side

Question 120

facial expressions seen in psych patients

Answer 120

anger, hostility, suspiciousness, or evasiveness of patients w/ paranoia; elation and euphoria fo mania; flat affect and remoteness of schizophrenia; apathy (dulled affect w/ detachment and indifference) of dementia and anxiety or depression. hallucinations occur in schizophrenia, alcohol withdrawal, and systemic toxicity.

Question 121

aphasia-

Answer 121

from cerebrovascular infraction can be receptive (impaired comprehension w/ fluent speech) or expressive (preserved comprehension and slow confluent speech) hesitancies and gaps in flow and rhythm of words, disturbed inflections like monotone, circumlocution phrases or sentences are substituted for a word a person cannot think of paraphasia in which words are malformed wrong or invented

Question 122

test for aphasia

Answer 122

word comprehesnion (ask patient to follow one-stage command) repetition )repeat a phrase of one-syllable words) naming- ask patient to name something reading comprehension- have them read something writing- have them write something

Question 123

amnestic disorders

Answer 123

impair merry or new learning ability and reduce social or occupational function, lack global features of delirium or dementia

Question 124

1. Discuss the following common or concerning symptoms as part of the initial assessment. change in weight-

Answer 124

rapid changes over a few days suggest body fluid not tissue, edema from extracellular luid retention found inCHF, nephrotic syndrome, liver failure, and venous stasis. weight gain caused by many drugs, weight loss or loss of 5% or more of usual body weight over 6 month period w/ ddysphagia, vomiting, abdominal pain caused by gastrointestinal diseases, endocrine disorders (diabetes, hyperthyroidism, adrenal insufficianty, chronic infections, HIV/ADS, malignancy, CHF, COPD, renal failure, depression, anorexia or bulimia

Question 125

Discuss the following common or concerning symptoms as part of the initial assessment. List possible causes for these symptoms (i.e. – differential diagnosis): fatigue

Answer 125

- feeling tired all the time common symptom of depression and anxiety, also caused by infections (hepatitis, mono, and tb), endocrine disorders (hypothyroidism, adrenal insufficiency, diabetes mellitus), heart failure, COPD, kidney or liver disease, electrolyte imbalance, anemia, nutritional deficits and mediation

Question 126

Describe the use of the stethoscope

Answer 126

The large structure is the diaphragm, the smaller opposite side is a pediatric diaphragm and can be used for a bell, but to fully make it a bell you must remove the top in order to listen to high pitched sounds and things like heart sounds etc.

Question 127

1. Discuss the following common or concerning symptoms as part of the initial assessment. List possible causes for these symptoms (i.e. – differential diagnosis): weakness-

Answer 127

denotes demonstrable loss of muscle power, if localized in a neuroanatomical pattern suggests neuropathy or myopathy

Question 128

1. Discuss the following common or concerning symptoms as part of the initial assessment. List possible causes for these symptoms (i.e. – differential diagnosis): fever-

Answer 128

abnormal elevation in body temperature usually caused by acute or chronic illness feeling hot correlates to a falling temperature

Question 129

1. Discuss the following common or concerning symptoms as part of the initial assessment. List possible causes for these symptoms (i.e. – differential diagnosis): chills-

Answer 129

recurrent shaking chills suggest more extreme swings in temperature and systemic bacteremia. usually characterized with shivering throughout body, feeling cold, goosebumps and shivering accompany rising temperature

Question 130

1. Discuss the following common or concerning symptoms as part of the initial assessment. List possible causes for these symptoms (i.e. – differential diagnosis): night sweats-

Answer 130

fever exagerrate the swing of body temperature rising during day and falling during night causing pt to sweat during nighttime caused by tb and malignancy

Question 131

2. Define and describe the components of the general survey.

Answer 131

``` apparent state of health level of consciousness signs of distress skin, color,r and obvious lesions, dress, grooming & personal hygiene facial expression odors of body and breath gait and motor activity height and weight ```

Question 132

dress grooming & personal hygiene,

Answer 132

- are they dressed? (neglected appearance suggest depression or dementia) overdressed? (hypothyroidism cold intolerance) underdressed? dressed appropriately?, worn down shoes or slipper (gout, bunions, edema, painful foot conditions causing foot or back pain;

Question 133

; odors of body and breath-

Answer 133

presence of alcohol or acetone (diabetes), pulmonary infections, uremia, or liver failure, drugs or alcohol;

Question 134

Diaphoresis

Answer 134

-excessive sweating caused by menopause, hyperthyroidism, diabetes, withdrawal, medications heart attack, anaphylaxis, cancers, and pain

Question 135

Facial grimacing-

Answer 135

painful facial expression caused by injury

Question 136

Flat affect

Answer 136

- severe reduction in emotional expressiveness caused by depression, schizophrenia appearing apathetic

Question 137

Immobile face

Answer 137

-facial muscles of face paralyzed or unable to move caused by bells palsy, stroke, or parkinsons

Question 138

Involuntary movements-

Answer 138

caused by tremor, tics, chorea, mycoclonus, athetosis, dystonia, hemiballismus

Question 139

Labored breathing-

Answer 139

someone who was having apparent respiratory distress caused by COPD includes trippoding retractions belly breathing

Question 140

Pallor-

Answer 140

pale whitish color indicating sickness or lack of oxygen due to repiratory distress

Question 141

Psychomotor slowing

Answer 141

- slow movements caused by schizophrenia

Question 142

Tremors-

Answer 142

caused by withdrawal, drugs, hyperthyroidism and hypoglycemia

Question 143

Unkempt-

Answer 143

persons appearance not kept up can be lifestyle, depression, dementia

Question 144

Wheezing-

Answer 144

caused by respiratory distress and infection associated w/ narrowing of airways

Question 145

Wincing –

Answer 145

facial expression in response to pain

Question 146

aortic dissection-

Answer 146

inner layer of aorta, tears w/ blood surging through tear, causing inner and middle layers to separate can be deadly commonly caused by age weakening muscle and CAD can cause death

Question 147

arrhythmias-

Answer 147

heart beats w/ irregular or abnormal rhythm caused by CAD, electrolyte imbalance

Question 148

auscultatory gap

Answer 148

- silent interval that may be present between systolic and diastolic pressures can lead to underestimation of systolic pressure from arterial stiffness and atherosclerosis

Question 149

bradycardia- tachycardia-

Answer 149

low heart rate can be caused by infection coarctation of the aorta- narrowing of thoracic aorta, distal to origin of left subclavian artery w/ systolic hypertension greater in arms than legs fast heart rate can be caused by physical activity, distress, or

Question 150

coarctation of the aorta-

Answer 150

narrowing of thoracic aorta, distal to origin of left subclavian artery w/ systolic hypertension greater in arms than legs

Question 151

isolated systolic hypertension

Answer 151

- systolic blood pressure is >140 and distaloic is <90.

Question 152

Korotkoff sounds-

Answer 152

sounds that you listen to while taking BP

Question 153

Activities of daily living

Answer 153

- what activities do you need to do daily or weekly to survive and are they hindered

Question 154

Acute pain

Answer 154

- pain lasting less than 3-6 months usually related to soft tissue damage feeling sharp and severe

Question 155

Addiction- Physical dependence- Tolerance-

Answer 155

physical condition in which the body has adapted to the presence of the drug. withdrawal symptoms are eminent body’s requirement for something reduced physiological reaction to a drug

Question 156

Analgesia-

Answer 156

inability to feel pain caused by nerve damage, long term use of pain meds, damage of kidney

Question 157

Chronic pain

Answer 157

- pain not associated w/ cancer or other medical conditions that persist for more than 3-6 months, pain lasting more than 1 month beyond course of an acute illness or injury, or recurring at intervals of months or years

Question 158

Faces pain scale-

Answer 158

using facial expressions to describe pain used for children and people with language barriers

Question 159

Idiopathic- Neuropathic

Answer 159

pain without an identifiable etiology - consequence of a lesion or disease affecting somatosensory system can become independent of injury, burning, lancinating, or shock-like and can persist after healing ex. CNS brain or spinal cord injury from stroke or trauma PNS disoarders trapping or prssing on nerves

Question 160

Nocioceptive-

Answer 160

somatic pain linked to tissue damage to the skin, musculoskeletal system, or viscera ex. arthritis acute or chronic using anti-inflammatory mediators or psychological neurotransmitters

Question 161

Numeric rating scale Visual analog scale-

Answer 161

- scale using facial numbers to rate pain scale from 1-10 on symptoms how they affect you and how you would describe it

Question 162

Opioid-

Answer 162

doses correlate w/ sleep disordered breathing and sleep apnea prescriptions have increased correlating w/ overdoses particularly in those 65+ depression, substance abuse, and benzodiazepine treatment

Question 163

Pain management-

Answer 163

analysis and tools used to help a patient have their pain relieved weighing consequences of addiction and personal comfort

Question 164

Psychogenic-

Answer 164

anxiety or depression, personality and coping style, cultural norms, and social support systems

Question 165

nail changes-

Answer 165

include paronychia (causing redness ad irritation infection of lateral folds of nail plate from S. aureus and streptococcus can surround nail plate because of trauma from nail biting, manicuring, or frequent hand immersion in water), clubbing, habit tic deformity (depression of central nail w/ xmas tree appearance from small horizontal depressions, resulting from repetitive trauma from rubbing index finger over them), melanoychia increased pigmentation in nail matrix causing a streak can be caused by nevus if small or subungula melanoma in nail or ethnic variation in multiple), onycholysis (painless separation of whitened opaque nail plate from pinker translucent nail bed goes from distal to proximal due to trauma from excess manicuring, psoriasis, fungal infection, allergic reaction, diabetes, anemia, photosensitive drug reactions, hyperthyroidism, peripheral ischeia, bronchiectasis, and syphilis). onyxhomycosis (from bacertia and mold or nail thickening and subungual debris), terry nails (nail plate turns white w/ ground glass appearcance, no lunula, liver disease, cirrhosis, CHF, and diabetes), transverse linear depressions(from temporary disruption of proximal nail growth from systemic illness, can measure size to determine illness), pitting (punctate depressions of nail palte because of defective layering of superifical nail plate by proximal nail matrix w/ psoriasis, reiter syndrome sarcoidosis, alopecia areata, and localized atopic or chemical dermatitis

Question 166

rash-

Answer 166

inflammatory skin eruption caused by a Drug reactions, Infections (bacterial, viral, fungal)/infestations, Autoimmune, Idiopathic, Allergic, Neoplastic

Question 167

Adipose tissue

Answer 167

- subcutaneous fat the skin layer below the dermis that is highly vascularized, w/ major nerves, and provides the cushion for the skin and body

Question 168

Bulla

Answer 168

–raised, filled w/ fluid, and larger than 1cm ex. herpes

Question 169

Clubbing

Answer 169

bulbous swelling of soft tissue at nail base w/ loss of normal angle between nail and proximal nail fold increasing it 180 degree, nail bed feels spongy or floating due to vasodilation with increased blood flow to distal portion of digits and changes in connective tissue from hypoxia, innervation, genetic or platelet derived growth factor from fragments of platelet clumps in CAD, lung disease and lung cancer, IBS, and malignancies

Question 170

Cuticle-

Answer 170

extends from nail fold covering nail root and functioning as a seal protecting it from moisture

Question 171

Dermis-

Answer 171

provides nutrition to epidermis and is a dense layer of interconnecting collagen and elastic fibers containing sebaceous glands, sweat glands, hair follicles, and terminals of cutaneous nerves

Question 172

Epidermis-

Answer 172

superficial layer of skin, thin avascular keratinized epithelium consisting of outer horny stratum corneum (dead keratinized cells)and inner cellular layer (stratum basale and spinosum where melanin and keratin are formed

Question 173

Fine textured hair-

Answer 173

short, fine, inconspicuous vellus hair around body | Induration-inflammation causing loss of elasticity and fibers

Question 174

Nail bed- Nail plate

Answer 174

vascular plate attaches to it - firm rectangular and curving gets pink color from vascular nail bed where it attaches

Question 175

Sebaceous glands- Sweat glands- eccrine glands apocrine glands

Answer 175

produce fatty substance secreted onto skin surface through hair follicles present on all skin surfaces except palms and soles eccrine and appocrine (widely distributed open directly onto skin and control body temperature) and (found in axillary and genital regions opening onto hair follicles causing adult body odor.

Question 176

Turgor-

Answer 176

measure of elasticity of skin, reflecting a patient’s state of hydration (change w/ age)

Question 177

Acne-

Answer 177

most common cutaneous disorder in US, pilosebaceous unit involving proliferation of keratinocytes at opening of follicle increased production of sebum, w/ androms and keratinocytes lug follicular opening cosmetics, humidity, heavy sweating and stress dividing comedonal, inflammatory, and nodulocstic in chest, neck, face, upper back and arms

Question 178

Dermatomyositis

Answer 178

- uncommon inflammatory disease w/ rash ad muscle weakness slightly raised reddish scaly rash

Question 179

Psoriasis-

Answer 179

condition speeding up life cycle of skin cells building up rapidly on surface w/ extra forming scales and red patches itchy and sometimes painful chornic

Question 180

Small pox-

Answer 180

face arms and legs filled w/ clear fluid, pus, then crusts and falls off also have flu like symptoms

Question 181

Vitiligo-

Answer 181

large confluent completely depigmented patches on dorsal hands and distal forearms

Question 182

Headache-

Answer 182

ask about severeity, sudden or gradual, increase over time, come in waves, chronic or recurring, recent change, any other symptoms. if it has an aura can be a stroke or CAD,. primary headaches include migraine, tension, cluster, and chronic daily headaches. secondary headaches arise from underlying structural, systemic, or infectious causes such as minenigits or subarachnoid hemorrhage and may be life-threateneing

Question 183

Head injury/trauma-

Answer 183

sensistivity to light? drowsiness, poor concentration, confusion, memory loss, blurred vision, dizziness, irritability, restlessness fatigure could be concussion up to a brain bleed or vertebral or skull fracture

Question 184

Neck mass (goiter) –

Answer 184

enlargement of the thyroid gland to twice its normal size can be simple, without nodules, or multinodular and usually euthyroid can cause stridor or upper airway blockage

Question 185

Swollen glands (lymphadenopathy)

Answer 185

- commonly means pharyngitis palpate to find

Question 186

Temporomandibular (TMJ) pain

Answer 186

can palpate and see if there is swelling in the jaw muscles or pain upon palpation commonly from gridning teeth

Question 187

tension headache

Answer 187

- episodic and tend to peak over several hours. new and persisting, progressively severe headaches raise concerns of tumor, abscess or mass lesion, arise in temporal areas, cluster headaches may be retro-orbital

Question 188

migraine headache

Answer 188

- episodic and tend to peak over several hours. new and persisting, progressively severe headaches raise concerns of tumor, abscess or mass lesion. unilateral headache occurs. nausea and vomiting are common have have symptom prodome prior to onsetflash of light, fortifications, scotomas areas of visual loss.

Question 189

meningitis

Answer 189

- if headache is severe and sudden of onset consider subarachnoid hemorrhage thunderclap headaches- reaching maximal intensity over several minutes occur in 70% of patients w/ subarachnoid hemorrhage and are often preceded by sentinel leak headache from vascular leak into subarachnoid space

Question 190

Acromegaly

Answer 190

-pronounced cheekbones, forehead bulges, jaw is enlarged, facial lines are prominent because of pituitary gland gland producing too much growth hormone increased growth hormone produces enlargement of both bone and soft tissue w/ an elongated head, bone prominence of forehead, nose, and lower jaw soft tissues of nose, lips, and ears are large and features coarsened

Question 191

Bruit-

Answer 191

vibrations resulting from turbulence in intracranial or extracranial vessels. systolic in timing can extend into diastole or even be continuous originate in cranium or can be transmitted from arteries in neck causing seizures, headaches, stroke syndromes, intracranial mass lesions, or carotid bruits.

Question 192

Goiter/Multinodular goiter-

Answer 192

goiter enlarged thyroid, multinodular where there are multiple nodules can be toxic making too much thyroid hormone and cause hyperthyroidism Multinodular goiter- toxic Diffusely enlarged thyroid gland- goiter

Question 193

Great vessels-

Answer 193

deep to the sternocleidomastoids in the neck, carotid artery artery and internal jugular vein, external jugular vein passing diagonally over surface of sternocleidomastoid helpful when trying to identify jugular venous processes.

Question 194

Hirsutism

Answer 194

-condition of unwanted male pattern hair growth in women resulting in excessive amounts of dark course hair on body areas where men typically grow hair face chest and back

Question 195

Hyper/hypo-thyroidism | Lymphadenopathy

Answer 195

- disease of the lymph nodes, in which they are abnormal in size, number caused by infections, autoimmune diseases,

Question 196

Mechanism of injury

Answer 196

- what causes an injury or trauma

Question 197

Moon face-

Answer 197

medical sign in which face develops rounded appearache due to fat deposits on sides of face because of Cushing’s syndrome or steroid treatment

Question 198

Myxedema-

Answer 198

caused by severe hypothyroidism showing expressionless face, puffines around eyes and pallow in severe hypothyroidism mucopolysaccharide deposition in dermis leads to dull, puffy faces. edema pronounced around eyes does not pit w/ pressure and hair and eyebrows are dry, coarse and thinned w/ loss of lateral third of eyebrows and dry skin

Question 199

Normocephalic-

Answer 199

referring to a head of normal shape and size for a person’s age

Question 200

Parotitis- Parotid gland

Answer 200

inflammation of parotid gland ex. mumps. chronic bilateral asymptomatic parotid gland enlargement may be associated w/ obesity, diabetes, cirrhosis, and other conditions w/ swelling in earlobes and above jaw. unilateral enlargement suggest neoplasm and acute in mumps - superficial to behind the meandible (both visible and palpable when enlarged)

Question 201

Periorbital edema-

Answer 201

swelling and fluid filled around eyes

Question 202

TMJ syndrome-

Answer 202

temporomandibular joint acts like sliding hinge connecting jawbone to skill w/ one on each side and with a disorder of TMJ pain commonly due to grinding teeth or clenching can be arthritis, injury or genetics while you sleep causes pain in jaw joint and in muscles that control jaw movements

Question 203

Anterior triangle-

Answer 203

mandible, sternocleidomastoid laterally and midline of neck medially

Question 204

Carotid artery- exteneral jugular vein Internal jugular vein

Answer 204

artery going up on either side of neck next to trachea splits at the thyroid cartilage empties blood from back of head and neck on the outside of sternocleidomastoid near the carotid carrying blood from head and neck to superior vena cava on inside of sternocleidomastoid

Question 205

Cricoid cartilage

Answer 205

- just below the thyroid cartilage protecting the airway

Question 206

Frontal bone Hyoid bone- Occipital bone Parietal bone- Temporal bone- Vertex of the head-

Answer 206

- bone located at the forehead top bone above thyroid cartilage, horseshoe shaped bone in anterior midline of neck between chin and thyroid cartilage at mandible - bone in the back of the head covering the occipital part of brain and cerebellum bone on the top of the skull bone by your temple upper surface of head formed by frontal bone, parietal bones and occipital bone

Question 207

Posterior triangle-

Answer 207

sternocleidomastoid muscle, trapexius, and clavicle portion of omohyoid in lower part of triangle

Question 208

Thyroid cartilage- Thyroid isthmus- Thyroid lobe-

Answer 208

have notch on superior edge covering thyroid spans the second, third, and fourth tracheal rings below cricoid cartilage lobes of thyroid curve posteriorly around sides of trachea, esophagus

Question 209

anterior cervical occipital- posterior cervical- preauricular- submandibular- submental- supraclavicular- tonsillar-

Answer 209

- contain superficial and deep cervical chain (deep to sternocleidomastoid and often inacccessibble to examination hook thumb and fingers around either side of sternocleidomastoid muscle to find them at base of skull posteriorly postauricular- superficial to mastoid process behind ear lobe along anterior edge of trapezius in front of ear midway between angle and tip of mandible, smaller and smoother than lobulated submandibular gland against which they lie in midline few centimeters behind tip of mandible deep in angle formed by clavicle and sternocleidomastoid enlargement of this node on left suggest possible metastasis from thoracic or abdominal malignancy at angle of mandible

Question 210

• Assess the hair, scalp, skull, face and skin-

Answer 210

note hair’s quantity, distribution, texture, an any pattern of loss (fine hair causes hyperthyroidism coarse hair hypothyroidism, white ovoid granules adhering to nails may be lice eggs); scalp part hair in several places and look for scaliness, lumps, nevi or other lesions (redness and scaling can indicate dermatitis or psoriasis soft lumps pilar cysts pigmented nevi may be elanoma), observe general size and contour of skull w/ any deformtities depresssions lumps or tendernessw/ enlarged skull hydrocephalus or paget disease w/ palpable tenderness and bony step offs from head trauma; no patients facial expression and contours observe for asymmetry, involuntary movments, edema, and masses. skin observing on face, head, noting color pigmentation, texture, thickness, hair distribution and any lesions (w/ acne, hirsutism/excessive facial hair appearing in polycystic ovary syndrome in woman.

Question 211

Inspect & palpate the TMJ-

Answer 211

• palpate jaw beginning in front of ear asking them to open mouth check for smooth range of motion, swelling or tenderness or redness

Question 212

• Inspect and palpate the lymph nodes in the neck-

Answer 212

use pads of index and middle finger press gently on skin w/ patient neck relaxed but slightly flexed forward examining both sides at once for asymmetry swelling tenderness

Question 213

• Assess range of motion of the neck-

Answer 213

hold the patients head and move it around in all directions, have them resist against you

Question 214

• Inspect and palpate the thyroid gland-

Answer 214

tip the patient’s head slightly back, using tangential lighting directed diwonward from tip of chin, inspect region below cricoid cartilage to identify contours of gland and observe patient swallowing

Question 215

• Assess the trachea, the cervical spine, and the cervical muscles-

Answer 215

touch down front of throat, swallowing reflex for swelling etc., have patient flex, extend, rotate, and bend neck by having them look and move their head in all directions noting any tenderness, loss of sensation or weakness

Question 216

7. Describe the indications for listening for a thyroid bruit, and demonstrate appropriate technique.

Answer 216

if thyroid is enlarged listen over lateral lobes w/ stethoscope to detect a bruit, sound similar to cardiac mrurmur heard in cases of hyperthyroidism from graves disease or multinodular goiter

Question 217

Nephrotic syndrome-

Answer 217

glomerular disease causes excess albumin excretion, which reduces intravascular colloid osmotic pressure, causing hypovolemic, then sodium and water retention w/ face becoming edematous and pale. swelling around eyes in morning making them slits eventually.

Question 218

Paget’s disease-

Answer 218

enlarged skill of bone

Question 219

Parkinson’s disease-

Answer 219

neurodegenerative disorder linked to loss of neurotransmitter dopamine, decreased facial mobility and masklike facies w/ dereased blinking and characteristic stare. since neck and upper trunk flex forward pat. seems to peer upward toward observer face becomes oily and drooling occur

Question 220

Hard fixed lymph node

Answer 220

- not a node but in fact the styloid process

Question 221

Parotid gland enlargement-

Answer 221

chronic bilateral asymptomatic parotid gland enlargement may be associated w/ obesity, diabetes, cirrhosis, and other conditions w/ swellings anterior to ear lobes and above angles of jaw. gradual unilateral enlargement suggests neoplasm and acute is mumps

Question 222

Thyroid nodules

Answer 222

- lumps that arise mostly benign in woman but can be cancerous

Question 223

Discuss the approach to history taking and the significance of findings for the following common or concerning symptoms:• Anxiety

Answer 223

- things like palpitations and chest pain mask it. Need to know that OCD is a type of anxiety disorder. Generalized anxiety disorder- worry about everything and anything not a trigger or particular thing. Panic disorder- chest pain, palpitations, numbness and tingling of fingers sense of impending doom having it more than once. Agoraphobia- fear of leaving house or enclosed space wont wanna leave house for fear of panic attack. OCD- obsessive thinking about same thought over and over and have to carry out compulsion or counting to help relieve obsessive thinking

Question 224

Discuss the approach to history taking and the significance of findings for the following common or concerning symptoms: • Confusion

Answer 224

- rule out medical causes first UTI ex. I WATCH DEATH infections, withdrawal, acute metabolic, trauma, CNS disease, hypoxia, deficiencies, environmental, acute vascular, toxins, heavy metals

Question 225

Discuss the approach to history taking and the significance of findings for the following common or concerning symptoms: • Depression-

Answer 225

can be masked by multiple somatic (body-wide) complaints, stomach aches, pain, fatigue, hypothyroidism, look for particularly vulnerable patients who are young, female, single, divorced or separated, seriously or chronically ill, bereaved or have other psychiatric disorders or substance abuse

Question 226

Discuss the approach to history taking and the significance of findings for the following common or concerning symptoms:• Memory loss-

Answer 226

rule out medical causes first UTI ex. I WATCH DEATH infections, withdrawal, acute metabolic, trauma, CNS disease, hypoxia, deficiencies, environmental, acute vascular, toxins, heavy metals

Question 227

Cognitive function-

Answer 227

orientation, attention, memory, attention and vocuabulary calculations, abstract thinking and constructional ability

Question 228

Difficult patient-

Answer 228

frequent users of health care system unexplained somatic symptoms most of these patients that seem difficult to deal with or give you a hard time have underlying psychiatric conditions. people w/ depression and anxiety increase difficulty 3X w/ somatization 9X

Question 229

Medically unexplained symptoms

Answer 229

- 30% of somatic symptoms single complaints that persist longer than other like back pain, headache, or musculoskeletal pain and have no medical causes usually psychological. range from impairment to behaviors for mood and somatic symptoms disorders. 2/3 w/ depression have physical unexplained

Question 230

Overlap symptoms-

Answer 230

many paitnets have both medical and psychiatric symptoms fatigue, sleep disturbance, musculoskeletal pain, headache, and gastrointestinal problems

Question 231

Somatic-

Answer 231

70% self limited resolving in 6 weeks, 25% recurring physical symptoms or physical symptoms such as pain, fatigue, or palpitations gastrointestinal sexual or reproductive and neurological symptoms like dizziness or loss of balance that are caused because of psychological causes. distressing somatic symptoms plus abnormal, thoughts, feelings, and behaviors in response to symtpoms w/ somatic symptom and related disorder based on how patient determines them

Question 232

``` 2. Compare and contrast personality disorders, somatoform disorders, anxiety disorders, disorders of mood, and psychotic disorders, and give examples of each. personality disorder somatoform disorders anxiety disorder disorders of mood psychotic ```

Answer 232

Difficult patient w/ strong response form you have personality disorder. personality disorders: when fixed, rigid, interferes w/ not able to function enduring pattern of inner experience and behavior that deviates markedly from expectations of individual’s culture is pervasive and inflexible has early onset of child or adult stable over time and leads to distress or impairment w/ dysfunctional coping styles disrupting and destabilizing relationships. ex. odd and eccentric (paranoid-distrust suspiciousness or delusion-specific to one thing aka gov., schizoid-detachment from social w/ restricted emotional, schizotypal- magical thinking quirky eccentric behavior and cognitive distortions), dramatic emotional or erratic (antisocial-disregard for or violation of rights of others no enoathy remorse , borderline-black/white thinking unstable relationships and impulsive surrounding them ex. Self harm cutting impulsive behavior, histrionic-excessive emotionality and attention seeking, narcissitic-need for admiration, lack of empathy), anxious and fearful (avoidant-social inhibition hypersensitive to negative evaluatoin, dependent-clingy, submissive, needs to be taken care of, OCPD-oderiliness perfectionism control )common w/ alcohol and substance abuse or other of them

Question 233

anxiety disorder

Answer 233

respond to things w/ fear or dread w/ anxiety, panic, increased heartbeat and sweating if response is more drastic and cannot be controlled interfering w/ normal functioning ex. generalized, panic, agoraphobia, OCD.

Question 234

disorders of mood

Answer 234

affective inolve persisiten feeling of sadness or periods of feeling overly happy fluctuating from extremes ex. major depressive disorder, bipolar disorder feel tired insomnia if manic don't feel tired.

Question 235

psychotic disorders.

Answer 235

– distorted awareness and thinking sucha s hallucinations w/ images or sounds that are not real like hearing voices and delusions false fixed beliefs that they accept as true despite evidence. ex. schizophrenia, brief psychotic disorder (resolves within a month, undergone immense amount of stress in refugee population, asylum seekers), delusional disorder (fixed false belief and paranoid thinking ex. Grandiose president or done all these things)

Question 236

Identify and discuss patient characteristics that may indicate a need for mental health screening.

Answer 236

medically unexplained physical symptoms (1/2 have depression or anxiety), multiple physical or somatic symptoms or “high symptom count,” high severity of presenting somatic symptom, chronic pain, symptoms for more than 6 weeks, phsyycian rating as “difficult,” recent stress, low self rating of overall health, frequent use of health care services, substance abuse

Question 237

Compare and contrast components of the mental status examination with components of the general survey.

Answer 237

General survey looks specifically at the appearance, motor activity, and general expressions but the MSE looks much more in depth at all of those not just looking for the symptoms of a medical issue but asks questions regarding neurological and psychological reasoning.

Question 238

5. Identify and describe components of the mental status examination.

Answer 238

Complete assessment of cognitive (knowledge-related) ability, appearance, emotional mood, speech, thought patterns at the time of the evaluation. Includes observations about the patient’s cooperativeness and ability to answer specific questions. Psychiatry’s physical examination: Assessment of a patient’s overall cognitive and societal functioning, Diagnostic tool, May suggest areas for further testing, Done periodically to monitor or document changes in a patient’s condition, The mental status exam starts as soon as you enter the patient’s room

Question 239

Appearance

Answer 239

- Overall appearance, Level of consciousness, Wakefulness, awareness, “Awake and alert”, Hygiene, dress (Poor personal hygiene or grooming may reflect a loss of interest in self-care of physical inability to bathe or dress oneself,” “Appropriately dressed for the weather”

Question 240

Motor behavior and posture-

Answer 240

Gait, posture, coordination, involuntary movements, abnormal movements; Psychomotor slowing (depression) or agitation (mania), Facial expressions, Eye contact (MAD), Attitude, Cooperative/uncooperative, Guarded (surface level answer question but just don't want to tell you about it), Irritated , Indifferent

Question 241

Speech and language:

Answer 241

able to assess expression, receiving, and comprehending words, Quantity (Talkative, silent), Rate (Fast, slow, Pressured-fast to the extreme super quick losing breath in the middle of saying it and you cant interrupt or redirect symptom of mania), Volume (Loud, soft), Articulation (Clear, distinct words, Dysarthric (slurred)), Fluency (Rate, flow, melody of speech (cadence), Stuttering, hesitancies) Evaluation of aphasia (loss of ability to understand or express speech, Components of MMSE – word comprehension, repetition, naming, reading comprehension, writing

Question 242

Mood =

Answer 242

how the patient is feeling, Refers to the underlying emotional “atmosphere” or tone of the person’s answers (Ex: euthymic-normal, dysphoric-sad), Internal emotional state, May use patient’s own words (Ex: sad, angry, worried)

Question 243

Affect -

Answer 243

your observation of the patient’s outward appearance, Outwardly observable emotional reactions (what mood appears to be) (Ex: Flat – no emotional expression (constricted or blunted- not totally flat but some facial expression), Ex: Labile – wide range of emotions, Comment on appropriateness and congruence-euthymic mood but facial expression flat so opposing to stated mood)

Question 244

Before asking questions of psych patients what do you tell them?

Answer 244

tell them Normalize it that they ask everyone what you are doing stating you will be asking very personal questions etc.

Question 245

Thought process:

Answer 245

logic, coherence, and relevance of patients though flow of thought; formulation of thoughts – how is the patient thinking? Logical vs. illogical, Organized vs. disorganized, Circumstantial (long list of other thing and they finally can come to the thing obsessions, speech w/ unecesary detail, indirection and delay in reaching point), tangential (can never answer questions just talk about other things shifting topics loosely connected or unrelated in schizophrenia, manic episodes, and psychotic), flight of ideas, perseveration (same thought over and over common w/ autism)

Question 246

Thought content:

Answer 246

what is the patient thinking?, Obsessions/Compulsions (repritive behaviors feels driven in response to obsession to reduce anxiety or dreaded even phobias and anxieties), Suicidal ideation, Homicidal ideation

Question 247

Perception-

Answer 247

sensory awareness of objects in enivornment and internal or external relationship Hallucinations – lack external stimulation auditory/visual/command (worrisome voices telling patient to do something psychosis hurting people or themselves always ask o they tell you to do anything) PTSD, schizophrenia and alcoholism, Delusions, Ex: paranoia, illusions in grief ractions delirium acute and PTSD and schizophrenia

Question 248

Insight-

Answer 248

Patient’s awareness of situation/abnormality, Note: does not always correlate with the severity of disease lack insight

Question 249

Judgement-

Answer 249

Patient’s decision-making skills, If you found an envelope that was sealed, stamped, and addressed, what would you do with it? poor in delirium, dementia, intellectual disability, and psychotic states, anxiety, mood disorders, intelligence, education, income, and cultural all influence

Question 250

Orientation-

Answer 250

requires memory and attention. impaired in delirium. Ability to locate self, Personal identity + place + time (day of week/date – day month year) specifying what questions were asked

Question 251

Attention-

Answer 251

ability to focus over time on stimulus can have difficulty giving history so use Serial 7’s cont down from 100, Spell “world” backwards ex. delirium, dementia, intellectual disability, and performance anxiety ex. poor performance for dementia, intellectual disability, anxiety, or depression

Question 252

Memory

Answer 252

– process of registering or recording info. for asking immediate repetition following storage or retention. Remote – birthdays, anniversaries, names of schools attended, SSN ex. difficult for end stage dementia, , Recent – events of the day, current medications, today’s weather, anxiety, depression, and intellectual disability impairs it New learning ability – 5 minute 3-word recall

Question 253

Information and Vocabulary-

Answer 253

Current events, “name last 4 presidents.” only problematic in severe cases life-long intellectual impairment from mild or moderate dementia get background information

Question 254

Calculating-

Answer 254

Ask patient to add, multiply poor performance from dementia or aphasia based on knowledge and education

Question 255

Abstract thought-

Answer 255

Similarities: Apple/orange; fruit = abstract thinking; round = concrete thinking. Proverbs ( how would you describe what this means interpreting it) : Don’t judge a book by it’s cover, Squeaky wheel gets the grease. concrete responses in people w/ intellectual disability, delirium, or dementia or limited education schizophrenia can respond concretely.

Question 256

Constructional ability

Answer 256

Copy a figure / Clock draw Be aware of patient’s cultural background and level of education as you are testing. MMSE- higher level of education can score higher than correct can compensate w/ lower level of education can score unusually lower ex. dementia, parietal, lob damage, and intellectual diability

Question 257

Identify components of the Mini-Mental Status Exam (MMSE), and discuss the indications for using this tool.

Answer 257

Assesses cognitive functioning only, Specific dementia screen. include orientation to time, registration (repetition), naming, reading and doing command

Question 258

Identify components of the CAGE, and discuss indications for using this tool.

Answer 258

Asking the patient if they have ever felt the need to cut down on their drinking? Have you ever felt annoyed by criticism of your drinking?Have you ever felt guilty about your drinking? Have you ever had a morning eye opener? two or greater of these answers suggests alcohol use problem, cannot be used for other substances