the 4 diagnostic tecniques
inspection, palpation, percussion, auscultation
standard vital signs
height, weight, temperature, pulse, respiration, blood pressure, +/- pulse ox
things I measure: pulse, respiration, BP
classified fever
> = 100.4
normal pulse
60-100
normal respiration
14-20/minute
“pulse pressure”
difference b/w systolic and diastolic.
narrow value= may represent shock, CHF, or trauma
wide value= valve problem of heart
prior to obtaining BP, no smoking, exercise, or caffeine for 30 minutes before
additional: cuff over brachial artery
ARM with brachial artery at the level of the heart
how much to inflate cuff with taking BP?
30 mmHg above expected systolic level
If you need to take BP again, how long do you wait?
15-30 minutes
Abnormal readings for Orthostatic BP
> 20 drop in systolic
10 drop in diastolic
20 increase in HR
How to take Orthostatic BP
lie down for 5 minutes
take each new reading within 3 minutes of position change
Layers of skin
Epidermis- barrier from environ, waterporof
Dermis- blood vessels, hair follicles, glands, nails
Subcutaneous (Hypodermis)- subC fat & connective tissue
Layers of Epidermis (top layer)
Corneum- shedding dead skin Lucidum- palmar/plantar Granulosum- keratinization Spinosum-spiny shaped cells. strength/flexibility Basale- keratinocytes
Can Lenny Grab Something Big?
Cells within the Epidermis (top layer)
Keratinocytes, Melanocytes, Merkel cells, Langerhan cells
Layers of Dermis (middle layer w blood, vessels, nerves, hair follicles, glands)
Papillary dermis- loose network of collagen
Reticular dermis- densely packed layer of collagen
Ground substance
Layers of SubC (hypodermis) deepest layer
Fibroblasts, adipose, macrophages
SubC fat- deepest layer, collagen & fat cells, conserves hear
Contains larger vessels and nerves
Eccrine glands
cover most of body, abundant on palms, soles, and forehead
keep cool
No odor
Duct opens in PORE @ skin surface
Apocrine glands
concentrated in axillary and genital regions
Secretes into the SAC of hair follicles
releases thick odorless fluid, the odor is caused by bacteria that live on skin that break down apocrine secretions
Triggered by nervous system- stress, hormone, exercise, emotions
Vellous hairs
“V”ery tiny
short and fine (forehead)
Terminal hairs
long and thick (scalp/armpit)
Dermoscopy
transilluminating light with magnification- tool used to better see skin lesions
Morbilliform
“Measles like”
red maculopapular lesions that become confluent on face and body
Diascopy
the test for blanching
apply pressure with hands or glass slide
ABCDE of Melanoma
Asymmetry, Borders, Color, Diameter, Evolution
Secondary findings (referring to lesions)
Arise from changes in primary lesions
Usually d/t exogenous factors- scratching, infection, rubbing, crusting, etc
Maccule
“Freckle”
<1cm, flat, circumscribed
Patch
> 1 cm, flat
hypo or hyper pigmented
“Cafe au lait” spot
Papule
<1 cm, palpable, RAISED, firm, circumscribed, firm, red/brown/or flesh colored
“Seborrheick Keratosis, SK, warty waxy stuck on appearance”
Plaque
Elevated, firm, palpable, >1cm
“Psoriasis”
Nodule
> 1.5 cm
Elevated, circumscribed. deeper & firmer than papule. can be compressible, soft, rubbery, or firm to palpation
“Epidermoid inclusion cyst”
Tumor
> 2 cm, a LARGE nodule
“Lipoma”
Wheel
irregular, comes and goes (transient), superficial edema
“Urticaria, mosquito bite”
Vesicle
< 1 cm, Fluid containing
well circums, usually clear fluid
“Chicken pox” “dew drops on rose petal”
Bulla
> 1 cm, fluid containing-serous fluid well circumscribed.
“Bullous Pemphigoid” fluid usually has a more yellow/fleshy color since it is serous fluid
Pustule
elevated, superficial, well circum. filled with Pus
“folliculitis”
Furuncle
infection of single hair
“Furry uncle” not to be confused with Funcle
S. Aureus
Aka a BOIL
Carbuncle
a car of furry uncles
infection of multiple hair
can form ABSCESS
Secondary lesions
crust, scale, fissure, erosion, ulcer, excoriation, atrophy, lichenification
Crust
dried serum, pus, or blood on the surface
Adherent
May include bacteria
“Impetigo- honey colored crusting”
Scale
Hyperkeratosis
buildup of the Stratum Corneum layer!!
“Psoriasis”
“silvery scale”
Fissure
linear, painful cleft in skin. from marked drying, skin thickening, loss of elasticity
Erosion
partial or sometimes complete loss of Epidermis
Moist, oozing, and/or crusted
“Pemphigus Foliaceus”
Ulcer
Loss of at least the entire Epidermis PLUS superficial Dermis. may have loss of ENTIRE Dermis and some of the hypodermis
“Venous stasis ulcer”
Excoriation
exogenous injury to part of epidermis
can be linear or rounded
usually d/t scratching
“Neurotic excoriation”
Atrophy (2 types)
Epidermal: thinning of epidermis–> wrinkling and shiny appearance
Dermal: los of dermal collagen/elastin leading to depression
“striae/stretch marks d/t topical steroids”
Lichenificaiton
thickening. increased visibility of skin markings
“Lichen simplex chronicus”
Petechiae
deep red/purple lesions
< 0.5 cm
non blanchable
Purpura
> 0.5 cm
round/irregular.
non blanchable
variable distribution
Ecchymosis
“bruise”
fade to green, yellow, brown
irregular borders
represents blood outside of vessels d/t trauma or bleeding disorder
Spider angioma
Blanchable
tiny, up to 2 cm
ppl with liver disease, otherwise healthy, pregnant
Telangiectasias
Blanchable
Hemangioma
BIG RED SPOT ON BABY'S CHEEK Benign, vascular neoplasm Most common tumor of infancy Starts macular --> may get to plaque or nodule *spontaneously involute by age 5-10
Papulosquamous lesions
plaques & scales
Lichen Planus & Psoriasis
Nodular
benign & malignant
Benign: moles (nevi), cherry angioma, epidermoise cyst
Malignant: SCC, BCC
Vesiculobullous Lesions
Vesicles & bulla
Impetigo, Herpes, Pemphigus
Maculopapuler
Viral exanthems
generalized, red, mac-pap rash
Drug Eruptions
Clubbing
rounded, bulbous nail base
Spongy
associated w/ Lung disease
“Schamroth’s sign” no window b/w nails- positive clubbing sign
Beau’s Lines
transverse depressions d/t trauma or acute severe illness
Paronychia
inflammation of proximal lateral nail folds
ppl that bite nails/ skin around nails- becomes inflmaed
Onychocryptosis
“Ingrown Toenail”
Nail grows into the dermis
Terry’s Nails
“Ground glass” appearance
mostly white with a distal band of reddish brown
No Lunula
Leukonychia
tiny white spots on nail d/t trauma
Koilonychia “Spoon nail”
concave
severe iron deficiency
Onycholysis
painless separation
Onychomycosis
fungal infection
Nail pitting
small punctate depressions
caused by nail matrix inflammation
Seen w Psoriasis
Cushing Syndrome
increased cortisol
“Moon face” (meaning round face) w/ red cheeks. excessive hair growth may be present in mustache, sideburn, chin
Nephrotic syndrome
Slit- like eyes in morning excess albumin excretion which causes swollen face and often pale Sodium & Water retention -Periorbital edema -Puffy pale face -Lips may be swollen
Myxedema
-Hair dry, coarse, sparse
-Lateral eyebrows thin
-periorbital edema
-puffy dull face w/dry skin
DULL PUFFY
Loss lateral 1/3 eyebrows
Hypothyroidism
Parotid gland enlargement
may be assoc w/ Obesity, DM, Cirrhosis
Gradual unilateral suggestive of neoplasm
Acute enlargement-mumps
Parkinson’s
decreased facial mobility and “Masklike” faces
Decreased blinking and characteristic stare
Pt seems to peer upward towards observer bc neck & upper trunk flex forward
Facial skin oily, drooling may occur
Bell’s Palsy
idiopathic facial nerve paralysis CN 7
Giant Cell Temporitis (Arteritis) associated with
Polymyalgia Rheumatica- inflammatory condition mostly in older adults
This can cause Temporal Arteritis
Concern: blindness & stroke
Anisocoria
pupils are unequal size
Near far accomodation
10 cm away and >6 feet away
Ptosis
CN 3 problem
Incomplete closure of eye
CN 7 problem
Chalazion
Nontender blockage of Meibomian (sebacous gland) points INSIDE lid
Hordeolum (Stye)
tender, red infection. usually S. aureus can be inner or outer lid inner- blocked meibomian gland outer- obstructed eyelash or tear gland
Dacryocystitis
lacrimal sac inflammation
infection/inflammation
Swelling b/w base of nose and eye
Exophthalmos
seen in Grave’s Disease (Hyperthyroidism)
Hypothyroidism
loss of lateral 1/3 eyebrows
Episcleritis
localized ocular inflammation of episcleral vessels central nodule with radiation of vessels *usually self limiting- benign "work of art" bunch of tiny vessels may be assoc. w/autoimmune
Subconjunctival hemorrhage
hx of cough, sneeze, straining
Asymptomatic, self limited
can reassure pts that it will go away on own
Consider blood thinners
Hyphema
big deal
Grossly visible blood in anterior chamber!
visoion threatening- refer~
Eye puncture
puncture wound with hemorrage and asymmetric, non reactive DILATED pupil
Cataract
clouding of lens
Painless progressive vision loss
Best seen with split lamp
Risk factors: age, smoking, DM, steroid, EtOH
Diabetic Retinopathy
HARD exudates
well defined borders
HTN and DM
Glaucoma (increased pressure)
with cupping
increased pressure results in backward depression
Detached retina
shadow over vision
Papilledema
Optic disc swelling caused by increased intracranial pressure No clear border Fuzzy borders Pt sx: severe HA, nausea, vomiting Emergency: could be stroke, tumor, etc.
Bitemporal Hemianopsia
Optic Chiasm injury
tunnel vision
Cover uncover
testing for Strabismus
*must treat early to prevent vision loss- eye exercises and patching
surgery may be needed
Anterior chamber depth
testing for increased intraocular pressure (i.e. glaucoma)
Crescent shadow is abnormal
Corneal Reflex
cotton swab on cornea
Cranial nerve 5 (sensory) and 7 (motor)
Weber
will lateralize to BAD ear
BC >AC
conductive hearing loss
Pneumatic Otoscopy
testing TM mobility
little puff of air- normal is that TM moves inward
abnormal- no TM movement
i.e. effusion
Serous effusion with air bubbles
viral URI or barotrauma
eustachian tube involved
fullness in ear, popping
Bullous myringitis
painful
hemorrhagic vesicles
commonly conductive hearing loss during infection
otitis externa
swimmers ear
infection of external auditory canal
Septal hematoma
seen following trauma more common in ped patients nasal obstruction, pain, tenderness Soft, tender swelling MUST R/O SEPTAL HEMATOMA IN ALL NASAL TRAUMA AND DOCUMENT
Leukoplakia
Potensh Premalignant
Inability to remove white area
Torus palantinus
Lana
benign, midline mass in hard palate
Herberden’s
Osteroarthritis
DIP joins
“HOD”
Bouchard’s
Rheumatoid Arthritis
PIP joins
“BIRP”