PD block 1 Flashcards
1
Q
otoscope
A
provides illumination for examining the external auditory canal and the tympanic membrane.
2
Q
ophthalmoscope
A
has system of lenses and mirrors to visualize the interior structures of the eye.
3
Q
ophthalmoscope apertures large
A
large aperture – (most commonly used) produces a large round beam
4
Q
sphygmomanometer
A
a device used to manually measure blood pressure with the use of a stethoscope. The inflatable bladder restricts blood flow, measurements of pressure are recorded when blood flow is just starting and when it ceases to be unimpeded.
5
Q
thermometers
A
used to measure body temperature which can be a clue to a pt’s illness/current state
6
Q
oral temp
A
oral – placed under the tounge (98.6) (abnormal >100)
7
Q
rectal temp
A
rectal – commonly used for infants for accurate reading. (99.6) (abnormal >101)
8
Q
axillary temp
A
axillary – held between body and arm. (97.6)
9
Q
tympanic temp
A
tympanic – used in the ear – tympanic membrane shares blood supply with hypothalamus. (99.6) (abnormal >101)
10
Q
stethoscope
A
can be acoustic, magnetic, or electronicb. Bell – Low pitched sounds – light pressure (harder to hear sounds)c. Used to listen to heart and adnominal sounds Diaphragm – high pitched sounds – firm pressure
11
Q
Snellen visual acuity
A
a. Used for screening and examination of far vision for literate, English, verbal adults and school aged childrenb. Recorded as a fraction – numerator = # of feet between chart and pt. and denominator = distance from which a normal person can read the lettering
12
Q
Rosenbaum visual acuity charts
A
used to test near vision at distance of 14 in.
13
Q
512 tuning fork
A
auditory evaluation via estimating hearing loss in the range of normal speech. This is the lowest intensity of sounds at which an auditory stimulus can be heard.
14
Q
128 tuning fork
A
vibratory sensation applied to bony prominence the patient should feel the vibration/tingling.
15
Q
percussion hammer
A
used to test deep tendon reflexes, tap should be brisk and direct
16
Q
tape measure
A
used to determine circumference, length, diameter. Pull tape tightly without causing depression in skin.
17
Q
transilluminator
A
strong light source with narrow beam directed into body cavity to differentiate between various media present in that cavity (air, fluid, tissue). Place beam of light directly against area to observe the presence or absence of illumination and any irregularities.
18
Q
palmar surface palpation
A
used for distinguishing size and texture. Any examination that requires fine detail/texture should be done with palmar surface. More nerve endings on this portion of the hand.
19
Q
ulnar surface palpation
A
used for detection of vibration
20
Q
dorsal surface palpation
A
used for detection of temperature. better than palmar surface because your own body heat does not interfere.
21
Q
Diaphragm sounds
A
best for high-pitched sounds (heart sounds and abdominal/bowel sounds)with firm pressure skin converts bell to a diaphragm end piece
22
Q
Bell Sounds
A
best for low-pitched sounds when light pressure is used
23
Q
bruits -
A
turbulent blood flow through artery & heart
24
Q
murmurs
A
turbulent blood flow through heart valve)
25
normal pulse
Normal: 60-100 beats per minute
26
resting pulse
number of heart beats per minute while at complete rest; generally 60-100 beats per minute; average 70 bpm; this can vary widely based on general health and fitness, age, underlying medical conditions
27
Tachycardia pulse
pulse rate>100 beats per minutefever, anxiety, drugs, anemia, exercise, HYPERthryroidism
28
Bradycardia: pulse
rate<60 beats per minuteHYPOthyroidismdrugs, physical shape, hypothermia
29
tachycardia
If oxygen demand or metabolic activity increases, blood volume decreases, the body is working, or the sympathetic nervous system is activated (stress, certain drugs), this can induce tachycardia
30
bradycardia
While the body is at rest there is less oxygen demand and metabolic activity, so the pulse rate decreases. Parasympathetic stimulation and certain drugs can decrease the heart rate significantly below a normal resting heart rate.
31
Korotkoff sounds. (Seidel/Mosby pg 54-55)
Low-pitched sounds produced by turbulence of blood flow in the artery
32
ausculatory gap
Korotkoff sounds may disappear 10-15 mmHg below first systolic reading = this is normal and called the ausculatory gap
33
First and Second Korotkoff sounds
First two audible consecutive beats indicate systolic pressure reading and beginning of Korotkoff soundswhen the Korotkoff sounds disappear, this is the second diastolic sound
34
Guarding
: protective behavior, distorted posture, reluctance to be moved
35
Facial mask of pain:
| physical pain behavior
lackluster eyes, wrinkled forehead, tightly closed or opened eyes, fixed or scattered movement
36
Vocalizations:
| physical pain behavior
grunting, groaning, crying, talkative patient becomes quiet
37
Body movements
| physical pain behavior
:head rocking, pacing or rubbing; an inability to keep the hands still
38
Changes in vital signs: Pain
blood pressure, pulse, respiratory rate and depth, with acute onset of pain. Fewer changes in vital signs are found in patients with persistent pain or after they adapt to acute pain.
39
Facies:
expression or appearance of the face and features of the head and neck indicating a clinical condition or syndromecertain conditions impart a “classic” physical appearance to the face indicating an underlying disease or syndrome. In GA, facies can be used to diagnose condition or syndrome (most often an endocrine disorder, but could be congenital or infectious disease). (PKM lecture on GA)
40
Hyperthyroid disease
exopthalamos (prominent eyes, lid retraction)
41
Sclera
The outer layer of the posterior eye, which is a dense, avascular structure. It supports the internal structure of the eye. It also encases the Optic nerve
42
optic nerve
Optic nerve, which passes through the optic foramen along with the ophthalmic artery and vein, sends signals to the CNS.
43
cornea
The Cornea is the outer layer of the anterior eye. It is continuous with the Sclera. It is optically clear, has rich sensory innervations, and is also avascular.
44
Uveal Tract
The Uveal tract consists of the Iris, Ciliary body, and Choroids. T
45
Iris
(the color of the eye) is a circular, contractile muscular disc that controls the amount of light that is able to reach teh retina.
46
pupil
The central aperture of the iris is the pupil, which light travels to the retina.
47
ciliary body
The ciliary body produces the aqueous humor (fluid that circulates between the lens and cornea) and contains the muscles that control accommodation.
48
Choroid
The Choroid is a pigmented, richly vascular layer that supplies oxygen to the outer layer of the retina.
49
lens
The Lens is a biconvex, transparent structure located behind the iris. It is supported by fibers that come from the ciliary body. It is highly elastic, and contraction or relaxation of the ciliary body changes its thickness, allowing images of various distances to be focused by the retina.
50
Retina
The Retina is the sensory network of the eye. It transforms light impulses into electrical impulses, which are transmitted through the optic nerve, optic tract and optic radiation to the visual cortex of the brain, the cerebral cortex. Other landmarks of the retina include the optic disc, where the optic nerve originates, together with the central retinal artery and vein. The Macula, or fovea is the site of central vision.
51
eyelid
The eyelid is composed of skin, striated muscle, the tarsal plate and conjunctivae. Meibomian glands provide oils to the tear film. The tarsus provides a skeleton to the lid. The eyelid distributes tears over the surface of the eye, limits the amount of lights entering it, and protects the eye from foreign bodies.
52
The Conjunctiva
is a clear, thin mucous membrane. The palpebral conjunctiva is the part of the conjunctiva that coats the inside of the eyelid. The bulbar conjunctiva is the part that covers the outer surface of the eye. The conjunctiva should be observed for erythema and exudate.
53
Eye Muscles
superior, inferior, medial, and lateral rectus muscles. superior and inferior oblique muscles, which allow you to move your eyes at an angle.
54
The Lacrimal Gland
is located in the temporal region of the superior eyelid and is responsible for tear production.
55
Head Bones
made up of 7 bones: frontalx2, parietalx2, occipital, temporalx2;
56
Face Bones
mandible, maxilla, zygomatic, sphenoid, lacrimal, and nasal bones.
57
Externally visible head tissue
Eyes (inner&outer canthus), nose (ala, nares, philtrum, nasal bridge), Ears (tragus, pinna)
58
landmarks on face
palpebral fissures, eyelids, eyebrows, nasolabial fold, mouth
59
neck location
begins at base of skull, ends at clavicles/sternum.
60
neck formed by
cervical vertebrae, ligaments, sternocleidomastoid muscle, and trapezius muslce
61
neck contains
trachea, esophagus, jugular veins, carotids, and thyroid.
62
cyanosis:
bluish; lack of oxygen or circulation
63
pallor:
unhealthy/pale skin;
64
leukonychia:
white spots on the nail plate; cuticle manipulation or mild trauma
65
paronychia:
infection or disease around the nail; pain, swelling, redness
66
koilonychia:
“spoon nail”; nail takes on a spoon-like appearance; can be due to anemia, hypothyroidism
67
nail pitting:
small pock-mark type indentations in the nail; psoriasis
68
peau d’orange:
on the breast; skin puckers and resembles an orange peel; lymphatic blockage or advanced breast cancer
69
edema/dependent edema:
swelling/ extracellular fluid accumulation; in dependent edema, the fluid remains in low points (i.e. the lower extremities); can be due to cardiac insufficiency
70
striae:
skin irregularity that resembles stripes; many causes and presentations (stretch marks, endocrine disorders, etc.)
71
alopecia:
hair loss
72
onycholysis:
spontaneous painless separation of the nail from the bed; trauma, medications, infection, many causes
73
varicosities:
varicose (enlarged, twisted) veins; due to failure of the valves to prevent backflow; often seen in superficial veins in lower extremities
74
Beau's lines:
horizontal/transverse grooves on nail plate; infection, trauma, systemic disease, many causes
75
hirsutism:
(females) the growth of terminal hair in patterns normally associated with male hair distribution (facial hair, increased body hair); associated with endocrine disorder
76
clubbing:
instead of growing (relatively) flat and straight, the nail angle increases, leading to a club-like appearance; can be due to prolonged cardiac or respiratory disease or can be idiopathic
77
sensorineural hearing loss
-PERMANENT-Associated with damage to cochlear hair cells or auditory nerve-EX: old age, noise-induced hearing loss, trauma, chemotherapy, radiation, genetics, etc.-Typically addressed with hearing aids
78
conductive hearing loss
-NOT TYPICALLY PERMANENT-Associated with any obstruction of sound transmission-EX: fluid in middle ear, ear infections, holes in TM, abnormal bone growth, cerumen impaction, etc.-Typically addressed with medical intervention or surgery (most cases are NOT permanent)
79
Normal respiration range for adults
12 to 20 breaths per minute
80
Wood's light
used to dx fungal infections(epidermal hypo and hyper pigmented lesions, distinguish fluorescing lesions)
81
Diascopy
blanchabilty of a lesion - differentate between vascular (inflammation), nonvascular (nevi), or hemorrhagic (petechia)
82
Direct microscopy
samples of flaked skin (scales) - used to determine if fungal infection is present
83
4 types of biopsy
shave, punch, incisional, excisional
84
Type of test used for allergy testing
patch or prick test
85
Wood's light
used to dx fungal infections(epidermal hypo and hyper pigmented lesions, distinguish fluorescing lesions)
86
Diascopy
blanchabilty of a lesion - differentate between vascular (inflammation), nonvascular (nevi), or hemorrhagic (petechia)
87
Direct microscopy
samples of flaked skin (scales) - used to determine if fungal infection is present
88
4 types of biopsy
shave, punch, incisional, excisional
89
I P P A
InspectionPalpation Percussion Auscultation
90
5 types of notes produced by percussion:
1) Tympanic2) Hyperresonant3) Resonant4) Dull5) Flat
91
Tympanic percussion tone:
Loud, drumlike, gastric bubble
92
Hyperresonant percussion tone:
Abnormal, very loud, boomlike, Emphysematous lungs
93
Resonant percussion tone:
Loud, Hollow, Healthy lung tissue
94
Dull percussion tone:
Thudlike, Over liver
95
Flat percussion tone:
soft, Over muscle
96
3 phases of hair growth:
I. Anagen: the phase of active growth. Last approximately 3-4 years. Approximately 84% of the scalp follicles are in anagen growth.II. Catagen: the phase that marks follicular regression. Last approximately 2-3 weeks. 1-2% of scalp follicles are in catagen phase.III. Telogen: the phase that represents a resting period. Lasts approximately 3 months. 10-15% of scalp follicles are in telogen phase.
97
Traditions of PE
--Usually conducted from pt's R side --Pt usually seated or supine-- Reposition yourself and pt as neededlet pt talksit downexercise a chaperone
98
Pattern of PE
IPPA:InspectionPalpationPercussionAuscultation(specifics are discussed on other cards)
99
Epidermis
Topmost, thin layer of skin, made of 3 sub-layers:--Stratum corneum (horny layer): sheds dead keratinocytes from below; keratin is waterproof, protects--Cellular stratum: melanocytes (pigment) + keratinocytes (makes protective keratin)--Basal layer/basement membrane: continually makes new keratinocytes that migrate upward every 4 weeks
100
Dermis
--Middle of 3 layers--Richly vascular and innervated, hair follicles, sweat glands--Supports and separates epidermis from cutaneous adipose--Elastin, collagen, reticulum : strength, stretchiness
101
Hypodermis (aka subcutis, aka subcutaneous)
Deepest of 3 layers--Collagen + fat: shock absorber, generates heat/insulation
102
Hair shaft
The section of hair that protrudes above the level of the skin (from follicle up)
103
Apocrine glands
--Larger and deeper than eccrine glands--Found only in the axillae, nipples, areolae, anogenital area, eyelids, external ears--Secrete odorless white fluid (“apocrine sweat”) w/ protein, carbohydrates, etc (not stinky in and of itself; it’s bacterial metabolism that makes BO)
104
Eccrine glands
--Sweat glands that open directly onto surface of skin--Regulate body temperature by secreting water
105
Nail plate
--The hard, visible part of the nail --Made of keratin--What you apply polish to when you paint your nails
106
Three segments of hair follicle
--Lower = bulb and suprabulb(from the base of follicle to insertion of erector pili muscle)--Middle = isthmus(short section that extends from insertion of erector pili muscle to entrance of sebaceous gland duct)--Upper = infundibulum(from entrance of sebaceous gland duct to follicular orifice)
107
Paronychium
--Skin at the lateral edges of the nail plate--Like eponychium, but laterally instead of at the base of nail--Infection = paronychia
108
Sebaceous gland
Secrete sebum (lipid-rich, keeps skin from drying out)
109
Hair root
--Round area at base of hair shaft--Houses the hair matrixNote: Follicle = root + its covering
110
Hair follicle
--The root and its covering--Three segments:-Lower = bulb and suprabulb, from the base of follicle to insertion of erector pili muscle-Middle = isthmus, short section that extends from insertion of erector pili muscle to entrance of sebaceous gland duct-Upper = infundibulum, from entrance of sebaceous gland duct to follicular orifice
111
Three segments of hair follicle
--Lower = bulb and suprabulb, from the base of follicle to insertion of erector pili muscle--Middle = isthmus, short section that extends from insertion of erector pili muscle to entrance of sebaceous gland duct--Upper = infundibulum, from entrance of sebaceous gland duct to follicular orifice
112
amastia
absence of breast tissue. May be due to rare congenital abnormality, or more often a bilateral mastectomy.
113
lactation
production and release of milk by mammary glands.
114
polymastia
The condition of having more than two breasts
115
galactorrhea
Lactation not associated with childbearing. Often due to a disruption of communication between the hypothalamus and pituitary glands which leads to elevated levels of prolactin, a hormone that stimulates milk production.
116
mastalgia
pain in the breast. May be due to hormonal fluctuations (e.g. menstrual cycle), trauma, cyst, infection.
117
inverted nipple(s)
nipple(s) that are retracted/tucked inward. May affect one or both nipples and can be congenital or acquired. If acquired, can be suggestive of inflammatory or malignant tissue.
118
everted nipple(s)
nipple(s) that point outward; most nipples have this appearance
119
gynecomastia
enlargement of breast tissue in males. May occur briefly at birth, briefly around puberty, or in adults >50 years old. Causes include hormonal stimulation (e.g. maternal hormones in newborns), pituitary or testicular tumors, excess body fat (causes increased estrogen production), medications.
120
Montgomery's tubercles
sebaceous glands in the areola that produce oily secretions to lubricate and protect the nipple
121
supernumerary nipple
congenital accessory breast tissue, that may or may not contain glandular tissue. Located along the “milk line” an embryonic ridge that stretches from the from the axilla to the groin; most frequently found inferior to the “normal” breast. More common in black women than white women.
122
Physiologic factors influencing arterial blood pressure.
BP is affected by three factors:
a. stroke volume (amount of blood pumped by left ventricle in one contraction)
b. heart rate (beats per minute)
c. peripheral vascular resistance (resistance to expansion of vessel walls by circulating blood)
Conditions that affect one of the above factors influence blood pressure: exercise, diet (e.g. sodium), alcohol/drugs, caffeine, stress/anxiety, weight, pain, fever, vascular resistance (e.g. atherosclerosis).
123
diaphragmatic respirations
synonymous with "abdominal respirations", "belly breathing"; the diaphragm does most of the work while the chest wall muscles are mostly a rest; normal, quiet breathing
124
abdominal respirations
synonymous with "diaphragmatic respirations", "belly breathing"; the diaphragm does most of the work while the chest wall muscles are mostly a rest; normal, quiet breathing
125
thoracic respirations
performed entirely by expansion of the chest by using the chest wall muscles; the abdomen does not move
126
paradoxic breathing
a portion of the chest wall sinks inward with each inspiration, common with chest trauma; also a condition seen in diaphragm paralysis when the diaphragm ascends during inspiration
127
hyperpnea
rapid and deep respirations >20 breaths per minute
128
apnea
literally "no breathing", the absence of spontaneous respiration
129
tachypnea
literally "rapid breathing", faster than normal respirations >20 breaths per minute
130
bradynea
literally "slow breathing", slower than normal
131
hyperventilation
can be due to tachypnea, hyperpnea or both; an increased amount of air enters the lungs, which results in lowered CO2 levels
132
Cheyne-Stokes repirations
periodic breathing; repetitive pattern of apnea followed by gradual increasing depth and frequency of respirations
133
Kussmaul breathing
rapid, very deep, labored and gasping respirations associated with metabolic acidosis
134
7 dimension of a complaint
LocationqualitySeverityTimingContextmodifying factorsassociated symptoms
135
IPPA Inspection
use all sensesassess for shape, color, size, symmetry, moisture, intactuse appropriate lighting
136
IPPA Palpation palmar
fine details/textures, mobility
137
IPPA Palpation Dorsal
temperature
138
IPPA Palpation Ulnar
vibrations
139
IPPA Percussion
increased density, decreased sound
140
IPPA Percussion Plexor and Pleximeter
Plexor dominate hand, Pleximeter - hand that gets struck
141
IPPA Ausculation
quiet room, bare skin, ID Characteristics of each sound. Always last exp for ABD.
142
Heart Rate
radial pulse15x4irregular do for 1 mincheck amplitude 0-4, 2 is normal.
143
heart rate can identify
distress, anxiety, drugs, cardio and neuro state, psychogenic
144
temp can indicate
illness or infection
145
respiration can indicate
signs of distress, brady/tachy, use of accessory muscles
146
respiration normal
12-20 /min
147
blood pressure can indicate
peripheral measurement of cardiovascular disease
| Represents force of blood against arterial wall
148
heigh/weight
development
149
BMI normal
18-24
150
Hypothermia
radiation, conduction, vaporization (sweating), respiratoryLess than 95
151
Hyperthermia
fever, metabolic process, environment, activity, hot drinksgreater than 100
152
Pulse rate
of contractions/min
153
pulse rhythm
regular (predictable pattern) irregular (not) assess for 1 min
154
Pulse deficit
absence of palpable pulse for 1+ heartbeatsweaker pulse on one sidedifference btwn apical and radial pulse
155
Apical Pulse
pulse at Apex (bottom) of heart5-6 intercostal space
156
Pulse amplitude
force which bolus of blood moves through artery 0-4, 2 is normal
157
pulse pressure
difference btwn systolic and diastolic S-D=force generated with each contractionnormal - 30-50 mmhg
158
Pulse paradoxus
exaggerated decrease in amplitude of pulsation with inspirationincrease during expiration
159
Purpose of taking heart rate (pulse)
Number of cardiac cycles/minute may give clues to cardiovascular or neurologic status, psychogenic factors, or drug use
160
Adult average pulse
60-90 bmp
161
Standard "normal" temperature range for adults
97.3 - ~99.5 (oral)
162
Most average (oral) temperature
98.6F/37C (decreases with age)
163
Average rectal temperature
99.6
164
Average axillary temperature
97.6
165
Average tympanic membrane temperature
99.6
166
Most accurate temperature measurement method
rectal
167
How to take respiratory rate
Without patient’s knowledge, observe rise and fall of chest for 15 seconds. Multiply x 4. May be performed while still holding wrist after taking pulse.
168
Normal respiratory rate range for adults
12-20 respirations/minute
169
4 parameters to assess for respiration
(1) respiratory rate (2) respiratory pattern (3) respiratory depth (4) signs of distress
170
Signs of distress in respiration
nasal flaring, cyanosis, labored breathing, tensed accessory muscles, wheezing, tachypnea or bradypnea
171
Adult blood pressure range
<90
172
Systole
Maximal ventricular contraction (top number)
173
Diastole
Maximal ventricular relaxation (bottom number)
174
Cardiac outout
Stroke volume x heart rate
175
Stroke volume
Blood pumped by left ventricle in 1 contraction
176
How to measure cuff size for BP
Bladder length must cover 80% circumference of upper arm, width should be ⅓ - ½ circumference
177
How to take BP
Locate brachial artery and center cuff (arrow toward) arteryWhile palpating radial pulse, inflate cuff until pulse disappears, deflate cuffRe-inflate cuff to 20-30 mm Hg above reading when pulse disappeared (this is the auscultatory gap)Deflate cuff slowly, note mm Hg when Korotkoff sounds start and stopRepeat in other arm (right tends to be higher)
178
What can affect BP?
Anxiety, hyper/hypotension, vascular resistance, pain, fever, weight, lifestyle, caffeine, alcohol, drugs
179
BMI formula
weight (kg) / height (m^2)
180
Describe the auscultatory gap, method for obtaining it, and the clinical usefulness of it
The auscultatory gap is the period of silence between the Korotkoff sounds Phase 1 and Phase 2. It's obtained by palpating the blood pressure and adding 20-30 mm Hg to the systolic number. This is useful because it prevents providers from being misled into underestimating the systolic or overestimating the diastolic
181
What is the most appropriate time in the female menstrual cycle to perform a breast exam?
The week after menses. hormonal changes are least noticeable during this time (breast enlargement, tenderness, increased nodularity)
182
Korotkoff sounds
Low-pitched sounds produced by turbulence of blood flow in the artery
183
T/F: Korotkoff sounds are best heard with the bell of a stethoscope.
True, they are LOW-pitched (light pressure with "tunable" stethoscope)
184
Stated Age vs. Apparent Age
Stated age is the patient’s chronological age.Apparent age is based off appearance, may be older, younger or equal to stated age.
185
Level of toxicity
Most important in assessing an ill patient. Only mention if the patient is ill; not mentioned if patient is not ill. How sick does the patient appears to you; toxic vs nontoxic appearing.
186
Acutely ill vs. chronically ill
Acute: sudden, temporary onset of symptoms.Chronic: longer, more generalized pain.
187
Affect appropriate for situation
Assessing a patient’s mood and behavior. Behavior should usually be cooperative and friendly.
188
Level of alertness
Patient's ability to interact and respond to you.
189
Orientation
Patient’s ability to recognize where the pt is, who the pt is and what time it is.
190
Tanner Stage
Stages of sexual development in males and females beginning with the adolescent stage through adult stage. Breast development is measured from M1-M5. Pubic Hair development in both males and females is measured from P1-P6. Testes/Scrotum development is measured from G1-G5.
191
What BMI is considered obese?
30-39.9
192
What does cachectic mean?
Looks like pt is at the end of his/her lifetime; physical wasting
193
Weber test- purpose?
Helps to assess unilateral hearing loss
194
Weber test- procedure?
Place a vibrating tuning fork on the middle of the patient’s head, ask the patient if the sound is heard, ask if sound is heard equally in both ears or better in one. Check this by covering one ear and asking again which ear sounds better (the occluded ear should sound better).
195
Weber test- what is expected with conductive hearing loss?
The sound is heard better in the bad ear.
196
Weber test- what is expected with sensorineural hearing loss?
The sound is heard better in the good ear.
197
Rinne test- purpose?
Helps distinguish whether patient hears better by air or bone conduction
198
Rinne test- procedure?
Place vibrating tuning fork against patient’s mastoid bone, ask patient if sound is heard, have patient tell you when they no longer hear the sound (count seconds), then move 1-2cm in front of ear, ask patient’s if they can hear it, then have the patient tell you when they no longer hear the sound (count seconds)
199
Rinne test- expected/normal results?
Aka Rinne positive findings.AC>BC in 2:1 ratio
200
Rinne test- what is expected with conductive hearing loss?
Aka Rinne negative findings.BC>AC on affected side
201
Rinne test- what is expected with sensorineural hearing loss?
AC>BC but less than a 2:1 ratio
202
Whisper test- procedure?
Occlude patient’s untested ear, stand out of line of vision about 1-2 ft away from side being tested (open ear), whisper word with 2 syllables, ask patient to repeat the word, move to other side and do the same with different words, ask patient to repeat the word, exhale fully to produce whisper sound.
203
Audiogram- what is it?
Audiogram is a graphical display of the hearing tests, graphing frequency (in Hz) vs the intensity/loudness of sounds (in dB).
204
Audiogram- what's the purpose?
It is used to show the amount of hearing loss that an individual has for each ear.
205
Diaphragmatic breathing
Movement of the diaphragm responding to intrathoracic pressure.
206
Abdominal breathing
Involves contraction of the diaphragm responding and the use of abdominal muscles resulting in the expansion and recoil of the abdominal walls.
207
Thoracic breathing
The result of the use of intercostal muscles.
208
Define and discuss Korotkoff sounds.
The low-pitched sounds produced by the turbulence of the blood flow in the artery (pg. 439 Mosby’s). Korotkoff divided the heart sounds heard while taking a BP into 5 phases:
• Phase 1: two consecutive beats indicate the systolic pressure.
• Phase 2: a period of silence know as the auscultatory gap. The gap should be about 10-15 mm Hg from the phase 1 sounds to the phase 3 sounds. Variability in the size of the gap can indicate cardiac abnormalities.
• Phase 3: Crisp heart sounds return.
• Phase 4: Heart sounds become muffled. This is first diastolic number.
• Phase 5: Heart sounds disappear. This is the second diastolic number. The second diastolic number is the one most commonly reported.
209
physiologic factors influencing arterial blood pressure.
Stroke volume (strength of contractions and volume of circulating blood)
• Heart rate
• Peripheral Vascular Resistance (how much the vessel walls resist exspansion by the circulating blood)
210
determining orthostatic blood
* Measure BP first in supine, then sitting, then standing positions
* Significant change (pulse increase by more than 15-20bpm or drop in systolic BP of more than 20mmHg within 3 minutes) can indicate disease
* Suggests antihypertensive use, depleted fluid volume (hypovolemia), drug use, autonomic nervous system disease (M 441)
* Indicated when pt is on antihypertensives, complains of fainting/postural lightheadedness, prolonged time in recumbent position (M 441)
211
acute pain
sudden onset, short duration. Generally associated with surgery, injury, or acute illness
212
chronic pain
persistent (6 months or longer), associated with prolonged disease
213
Nociceptive Pain:
A type of time limited pain that resolves when tissue damage has healed. Examples include sprains, bone fractures, cuts, and burns. Nociceptors at the site of tissue damage are activated and signal is conducted via peripheral nerves to the CNS 2 types of nociceptive pain: somatic and visceral
214
visceral pain
originating from internal organs
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somatic pain
originating from superficial/muscular structures of the body
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Neuropathic Pain:
Neruopathic pain is also known as chronic pain caused by a primary lesion or dysfunction of the nervous system beyond expected healing. When peripheral nerves are damaged, repeated signals are fired, causing hyperexcitability of the dorsal horn, transmitting a pain signal to the brain causing sustained pain.
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parts of GA
a. gender
b. general age category
c. presenting appearance
- level of toxicity
- relative comfort vs. discomfort
- acutely ill vs. chronically ill
- affect appropriate for situation
- posture
- speech
d. mental status
- level of alertness
- orientation
e. body development
- development / general features
- Tanner stage
- body habitus - height / weight / proportionality
- nutritional status (i.e., obese, thin, frail, anorexic, cachectic, etc.)
f. ethnic/racial background (when clinically appropriate)
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Visual Acuity: Direct Central Vision
* Snellen chart used for examining far vision by the ability to read sized letters from a distance of 20 feet.
* Rosenbaum chart is used for near sighted vision acuity. It is to be held at 14 inches from eye, `
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Visual Acuity: b. Peripheral Vision:
You cover one of your eyes, the patient covers one of theirs but the opposite. You should be looking at each other’s uncovered eye.
• Fully extend you arm (on the side of the open eye) midway between the patient and yourself, and then move your arm slowly centrally, having the patient tell you when the fingers are first seen
Test nasal, temporal, superior, and inferior fields
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visual acuity: color vision
ishara color test
Red testing make be helpful in determining optic nerve disease, an afferent pupillary defect often coexists with a red defect.
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small aperature
for small pupils slit – for anterior eye and elevation of lenses
222
red free aperature/polarizing
red free filter – produces green beam for examination of the optic disk for pale appearance and vessel changes. Recognition of retinal hemorrhages (blood appears black)
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grid aperature
Grid – Estimation of the size of fundal lesions.
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diopter settings
There is an inverse relationship, the higher the diopter, the closer the object. more in the green, closer up.
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Cobalt Blue Light:
Aperture setting used to aid in diagnosis in corneal abrasions or ulcers after staining the cornea with an fluorescein.
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eye exam external
inspect:
eyebrows, periorbital regions, canthus, conjunctiva, lid covering part of iris, lacrimal gland, duct,
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assess:
Extraocular movements (EOM), acuity, accomodation
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eye exam internal
red reflex,
| adjust settings to visualize macula, disk, cup, vessels.
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a. Visual Impairment/Loss
blurred vision/loss of vision
229
Legal Blindness:
blurred vision/loss of vision 20/200
230
Proptosis/Exophthalmos:
Bulging of the eye anteriorly out of the orbit
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Ptosis:
A drooping of the upper eyelid - indicates a congenital or acquired weakness of the levator muscle or a paresis of a branch of the third cranial nerve.
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Nystagmus:
Involuntary rhythmic movements of the eyes; the oscillations may be horizontal, vertical, rotary or mixed.
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Strabismus
A crossed eye - both eyes not looking in the same place at the same time
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Diplopia
he perception of two images – may be monocular or binocular.
• Monocular diplopia is an optical problem,
• Binocular diplopia is an alignment problem
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h. Emmetropia:
The condition of the normal eye when parallel rays are focused exactly on the retina and vision is perfect.
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Hyperopia:
Farsightedness, a refractive error in which light rays entering the eye are focused behind the retina
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Myopia
Nearsightedness, a condition resulting from a refractive error in which light rays entering the eye are brought into focus in front of the retina.
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Astigmatism
An abnormal condition in which the light rays cannot be focused clearly in a point on the retina because of an irregular curvature of the córnea or lens
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Presbyopia:
Hyperopia and impaired near vision from loss of lens elasticity, generally devloping during middle age.
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Anisocoria
Unequal pupil size
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soft neck tissue anterior triangle
hyoid bone, cricoid cartilage, trachea, thyroid cartilage, thyroid, anterior cervical lymph nodes
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soft neck tissue posterior triangle
the trapezius and sternocleidomastoid and clavicle. Structures within this include posterior cervical lymph nodes
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rubor: redness;
response to inflammation/irritation
244
turgor
i. Gently pinch skin on forearm or sternal area between thumb and forefinger and then release the skin.
ii. Should not be tested on back of patients hand
iii. Skin should feel resilient, move easily when pinched, and return to place immediately when released.
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physiologic/hormonal control of breast development
Hormonal control of breast development:
• Estrogen secreted by ovaries during puberty stimulates growth and development of duct system.
• Progesterone secreted by corpus luteum and placenta during pregnancy act with estrogen to bring areola to complete development
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hormonal production of milk during lactation
* Prolactin, secreted from pituitary gland, together with adrenal steroids induces lactation. The marked decrease in estrogen and progesterone following childbirth signals the start of prolactin secretion.
* Oxytocin, secreted from hypothalamus stimulates contraction of muscular cells in the milk ducts and mammary glands
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Physiologic control of the production of milk during lactation:
• Sucking: The baby nursing from the mother stimulates pulsatile increase in prolactin secretion, stimulating milk secretion and discharge of milk.
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lactation-
production and release of milk by mammary glands.
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a. mass:
A swelling, growth, or lump in the breast tissue. Note temporal sequence (onset, length of time, come and go), tenderness or pain, size, character, location, shape, consistency (firm, soft, hard), mobility, border, relationship to menses. Most are non-cancerous (e.g. fibrocystic changes, fibroadenoma).
250
Fibrocystic Changes –
• Benign cysts that are cyclic w/ menses
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Usually tender to palpation
• Fluid filled cysts that USUALLY occur bilaterally
• Single or multiple cysts can occur
• Masses are round and well delineated
• Mobile
• Consistency ranges soft -→firm
• No signs of retraction (dimpling) on nipple/skin surface
• Age range: 20-49
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251
Fibroadenoma
Benign tumors not cyclic to menses
• Usually non-tender to palpation
• Single, sometimes multiple – usually bilateral
• Round/discoid – Firm/rubbery consistency – well delineated - mobile
• No signs of retraction.
• Age range 15-55
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Cancer breast
– Malignant tumors
• Mass is not cyclic to menses
• Usually non-tender
• Consistency is hard/stonelike – irregular shaped - fixed
• Single and usually unilateral
• Signs of retraction in skin/nipples – prominent vasculature (veins)
• Age range 30-80
253
Fat Necrosis
– Benign lump caused by inflammatory response to local injury.
• Firm. Irregular. Discoloration at site – can be mistaken for Malignant tumor. Biopsy required.
• Can occur at site of past injury/trauma to breast
254
d. retraction:
Aka dimpling, is a pulling back of the skin on breast or areola/nipple indicating inward pulling by inflammatory or malignant tissue. Note temporal sequence, severity, and associated symptoms e.g. pain.
255
c. nipple discharge:
Any fluid that seeps out of the nipple of the breast. Note character (spontaneous vs provoked, uni-/bilateral, temporal sequence, color, consistency, odor, amount, associated sx e.g. inflammation. In women, discuss pregnancy, lactation.
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b. pain: breast
Aka mastalgia, is any tenderness, discomfort, or pain associated with the breast tissue. Note temporal sequence, character (pulling, stinging, burning, aching), location on breast, radiation to armpit, relationship menses (cyclic-timing/severity), and recent trauma to breast.
257
Features included in documenting breast masses
* Location: clock positions and distance from nipple
* Size: in centimeters: length, width, thickness
* Shape: round, discoid, lobular, stellate, regular or irregular
* Consistency: film, soft, hard
* Tenderness
* Mobility: movable or fixed to overlying skin or subajacent fascia
* Borders: discrete or poorly defined
* Retraction: presence or absence of dimpling: altered contour
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Morphology: macule
flat, cutaneous color change, less than 5mm (freckle)
259
Morphology papule
elevated, circumscribed area different from skin color; <.5cm in diameter (wort)
260
Morphology plaque
(psoraisis) elevated, firm, and rough with flat top; greater than .5cm diameter
261
Morphology patch
flat, non palpable, greater than .5 cm, irregular shape
262
Morphology Nodule
elevated, firm, extends to dermis, deeper than papule, 1-2 cm.
263
Morphology • vesicle-
(ex. chickenpox) elevated, superficial; filled with serous fluid; less than .5cm in diameter
264
Morphology Bulla
-(ex. blister) vesicle >.5cm in diameter
265
morphology • pustule
-(ex. impetigo, acne) similar to vesicle but filled with purulent fluid
266
skin exam: location
Region of the body lesion is located.
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o Sun-exposed areas
o Flexural and extensor aspects of extremities
o Stocking and glove regions
o Truncal
o Face, shoulder, back
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skin exam size
Determine size of lesion using a small ruler.
| Determining size will allow you to differentiate between lesions
268
skin exam distribution
localized vs. regional
269
skin localized distribution
Appears in one small area
| - Example: Impetigo, tinea corporis
270
skin regional distribution
Lesions found in a specific region of the body
271
skin color
flesh colored, tan, light brown, brown, black, or red/pink
272
grouping annular
• Annular- arranged in a circle/ring (i.e. ringworm)
273
grouping arcuate
• Arcuate (arciform)- shaped in a semi-circle, with a trail
274
grouping circinate
Circinate- shaped like a C
275
grouping grouped
Grouped- distributed in clearly defined groups
276
grouping iris
• Iris- dark center with surrounding lighter halo
277
grouping keratotic
Keratotic- linear scales grouped together
278
grouping linear
Linear- distributed in a line
279
grouping reticulated
Reticulated- distributed in a mesh-like pattern
280
grouping serpiginous
Serpiginous- snake-like distribution
281
grouping telangiectatic
Telangiectatic- look like broken blood vessels, spider-web like
282
grouping dermatomal
Dermatomal- lesions follow a dermatome
283
grouping confluent
Confluent- closely grouped together in no particular pattern
284
grouping discoid
• Discoid- closely clumped together in a filled-in circle
285
grouping eczematoid
• Eczematoid- raised plaque of confluent papules
286
Effusion: x
Effusion: Loss of fluid from blood vessels or lymphatics into the tissues or a body cavity
287
Frontal Bossing:
an unusually prominent forehead, sometimes associated with a heavier than normal brow ridge. This is a rare physical finding often associated with syndromes in which excess growth hormone is present. Most commonly identified in infants and children.
288
strawberry tongue –
initially tongue appears white with prominent papillae, white gradually decreases leaving tongue bright red, looks like a strawberry, characteristic of scarlet fever
289
blood supply to breasts
primarily 1) internal mammary artery and 2) lateral thoracic artery.
290
drainage for breast
* Blood Drainage:
* To the axillary vein
* Lymphatic drainage: 75% to axillary nodes
* Primarily radially & deep around breast towards axillary nodes.
291
external exam of head
inspect head, palpate scalp and face head
292
external exam ears
hearing assistance?
inspect/palpate auricle and mastoid area
test gross hearing
otoscopy - finger strut, canal, TM, Bones
293
external nose
inspect shape, palpate
patency
nasoscopy - septum, turbinates, vestibule, membranes
294
external mouth
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dentures?
inspect lips
state of dentention
ducts, gums, soft/hard palate, pharynx
breath
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295
external neck
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gross appearance
palpate
thyroid exam
palpate glands
cervico-facial lymph nodes
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296
breast exam
assistant in room,
warm hands,
undress waist up
inspect with arms hanging on sides, on head, on hips, leaning over
palpate all 4 quads and up arm
3 levels of depth
and nipples
in stripe format
297
skin hair nails exam
sunexposed areas, color, uniformity, moistness, turgor, lesions,
texture, distribution, quantity, resilience
discoloration, symmetry, cleanliness, thickness, adherance, cap refill
