Quiz 1

Question 1

purpose of cultural competence

Question 2

reason cultural competence is important

Answer 2

Understanding of a particular culture may be useful in the solution of problems that may at first have seemed intractable.

Question 3

How culture may impact aspects of an exam of emotional health

Answer 3

cultural definitions of health and illness differ

Beliefs and behaviors that will have an impact on patient assessment include the following:
Modes of communication
Health beliefs and practices
Nature of relationships within a family
Diet and nutritional practices

Question 4

Steps of assessment in order

Answer 4

1. inspection & continue throughout exam: use eyes & nose (smell, gait, eye contact, demeanor, clothing, color/moisture of skin
2. palpate
3. percussion
4. Auscultation last WITH EXCEPTION of abdominal exam

Question 5

what part of hand to use for distinguishing vibration w/ palpation

Answer 5

ulnar surface of the hand & fingers (pinky side)

Question 6

what part of hand best to palpate temperature

Answer 6

dorsal (back); not exact but general understanding to compare to other areas of body

Question 7

What are normal percussion notes, know where they are found (5)

Answer 7

1. tympany/tympanic= loudest (drumlike; gastric bubble)
2. flatness= soft/quietest (very dull; over muscle)
3. hyperresonant= very loud (boom like; emphysematous lungs)
4. resonant= loud & hollow (healthy lung tissue)
5. dull= soft-mod (thudlike; over liver)

Question 8

best way to distinguish degree of resonance in percussion

Answer 8

listening to sound change as you move from one area to another; easier to hear change from resonance to dullness

Question 9

immediate/direct percussion

Answer 9

striking the finger/hand directly against body (tip not pad of finger)

Question 10

indirect/mediate percussion

Answer 10

finger of one hand acts as hammer (plexor) and a finger of the hand acts a striking surface (tip not pad of finger); keep distal phalanx of middle finger on body with other fingers elevated, snap the wrist of other hand downward and with the tip of middle finger sharply tap the interphalangeal joint of the finger that is on the body surface

Question 11

when to use fist percussion

Answer 11

elicit tenderness arising from liver, gallbladder or kidneys. Use ulnar aspect of fist to give firm blow to flank and back

Question 12

how deep can percussion notes (resonance) arise from

Answer 12

vibrations from 4-6cm deep in body tissue; density determines degree of tone

Question 13

what can impact percussion note tone?

Answer 13

density; the more dense= the quieter the tone

Question 14

what part of hands are more sensitive for palpation

Answer 14

palmar surface fingers and finger pads > fingertips

Question 15

when to palpate w/ palmar surface of fingers & finger pads

Answer 15

whenever discriminatory touch is needed for determining position, texture, size, consistency, masses, fluid, crepitus

Question 16

what to listen for with auscultation

Answer 16

sound: intensity, pitch, duration, quality

Question 17

How to use/apply an otoscope

Question 18

Types and how to use/apply a stethoscope

Answer 18

acoustic (diaphragm & bell), magnetic (just a diaphragm), electronic/digital

press diaphragm firmly against SKIN and hold end piece between fingers; don’t touch bell or tubing

Question 19

when to use diaphragm vs bell of stethoscope

Answer 19

The diaphragm is best for higher pitched sounds, like breath sounds and normal heart sounds. The bell is best for detecting lower pitch sounds, like some heart murmurs, and some bowel sounds

Question 20

pneumatic otoscope what they are for, how they are used, & any differences with pediatrics

Answer 20

pneumatic attachment used to eval the fluctuating capacity of the TM
produces puffs of air that causes the TM to move

For adults and older children, the pinna is gently retracted in a posterior and cephalad vector. For neonates, the examiner pulls the pinna posteriorly and inferiorly.

Question 21

reflex hammer what they are for, how they are used, & any differences with pediatrics

Answer 21

used to test deep tendon reflexes
hold loosely between thumb and index so it moves in swift arc and controlled direction; tap quick and firm with snap of wrist

pediatric- use finger instead, less threatening; many providers let child hold hammer while they use finger to tap

Question 22

ophthalmoscope what they are for, how they are used, & any differences with pediatrics

Answer 22

visualize interior structures of eye using system of lenses and mirror, projects various apertures of light into eye, lens number corresponds to magnification power (diopter)
Positive numbers (plus lenses)= black; clockwise rotation of lens selector
negative numbers (minus lenses)= red; counterclockwise
large aperture used most often= large round beam

Question 23

whats a panoptic/panoramic ophthalmoscope

Answer 23

allows a larger field of view (25 degrees instead of 5) and increases magnification

fundus 5x larger in undilated eye

Question 24

what can the plus/minus system on ophthalmoscope compensate for

Answer 24

myopia or hyperopia in both the examiner and the patient; no compensation for astigmatism

Question 25

Wood’s lamp & what they are for, how they are used, any differences with pediatrics

Answer 25

used to detect fungal infection on skin light source with a wavelength of 360 mm. It's a black light that causes certain substances to fluoresce darken room, shine line on lesion, green/yellow= fungus pediatric= dark room intimidating. shine lamp on something fluorescent (nondigital watch) to give them sense of what you're looking for

Question 26

Indications of cognitive impairment (history or PE findings)

Answer 26

significant memory loss confusion (impaired cognitive function with disorientation, attention and memory deficits and difficulty answering questions or following multi step directions) impaired communication inappropriate affect personal care difficulties hazardous behavior agitation suspiciousness

Question 27

Areas of the brain and their function

Answer 27

*** Refer to pic in book pg. 89 transverse gyrus= auditory broca area= motor speech prefrontal= behavioral ethical moral social premotor= intellectual precentral gyrus= motor central sulcus postcentral gyrus= sensory primary tases area of postcentral gyrus somatic sensory association area visual association area visual cortex wernicke area (sensory speech area)

Question 28

Main findings & patho in acromegaly

Answer 28

excessive growth and distorted proportions caused by hypersecretion of GH and insulin-like growth factor (benign tumor most common cause); middle-aged adults Subjective slow progressive facial feature exaggeration increased shoe, ring sizes same height oily/sweaty skin snoring pain in joints decrease exercise tol. objective frontal skull bossing, cranial ridges, mandibular overgrowth, maxillary widening, teeth separation, malocclusion, overbite skin thickening on face/tongue/lips/nose, hands/feet = enlargement joint enlargement/swelling/pain vertebral enlargement, kyphoscoliosis cardiac ventricular enlargement bilaterally w/ decreased exercise tol.

Question 29

main findings in Turner syndrome

Answer 29

partial/complete absence of second X chromosome subjective poor height growth lack of breast development, amenorrhea normal intelligence objective short stature webbed neck broad chest, widely spaced nipples wide carrying ankle of elbow low posterior hairline, misshapen/rotated ears, narrow palate/crowded teeth coarctation of aorta, bicuspid aortic valve sensorineural hearing loss infertility

Question 30

main findings in Cushing syndrome

Answer 30

prolonged excessive glucocorticoids subjective weight gain, change in appetite depression, irritable, decrease libido decreased concentration, impaired short term memory easy bruising menstrual abnorms weight gain but slow height velocity in children objective obesity "buffalo hump" facial plethora "moon face" thin skin, red/purple striae, poor skin healing proximal muscle weak hirsutism or female balding peripheral edema children= short stature, abnormal genital virilization, delayed puberty

Question 31

main findings in precocious puberty

Answer 31

onset of secondary sexual characteristics (breast tissue, pubic hair, enlarged testes then penis) before 7 y/o in white girls, 6 y/o black girls, 9 y/o males

Question 32

Exam findings indicative of nutritional deficiency, assessment of nutrition and protein status

Question 33

Growth and development milestones in children, walk, talk, use sentences (Expressive language milestones for infants and children)

Question 34

Difference between an objective and subjective finding, know examples

Answer 34

subjective= what the patient tells us objective= what we are seeing, hearing, assessing, discovering

Question 35

Description of common macule, papule, vesicle, wheal and ex

Answer 35

macule= flat, circumscribed area that is a change in color of the skin. < 1cm diameter . Ex freckle, measles papule= elevated firm circumscribed area < 1 cm diameter. Ex: wart, elevated mole, lichen planus wheal= elevated, irregular shaped area of cutaneous edema, solid, transient variable diameter. Ex insect bite, urticaria, allergic rxn vesicle= elevated circumscribed superficial not into dermis filled with serous fluid < 1 cm diameter. Ex varicella, herpes zoster

Question 36

What are lesions that require further investigation; what do they look like

Question 37

Other common skin abnormalities; staph and strep infections

Answer 37

Staph: furuncle (red hot tender pus) cellulitis (or strep) impetigo

Question 38

What do herpes, basal cell, malignant melanoma and seborrheic keratosis look like

Answer 38

herpes zoster= pain/itch/burn before eruption, single dermatome w/ red swollen plaques/vesicles that fill w/ purulent fluid. Does NOT cross midline herpes simplex= (1 oral, 2 genital) tender/pain/paresthesia/burning, grouped vesicles red at base then crust. basal cell= not healing lesion, crusting, itch, bleed, won't heal. pink red black, brown, white. Rolled boarder indent center. White/yellow waxy taut/shiny malignant melanoma= new/changing mole, irregular pigmented lesion, asymmetry, irregular boarders, diff shade colors, diameter > 6 mm, evolution/change in existing pigmented lesions esp. nonuniform/asymmetric seborrheic keratosis= chronic/reccurrent red scaling where sebaceous glads are (scalp, back, diaper area). Scaling, adherent, thick, yellow, crusted

Question 39

What are common normal skin lesions on an older adult

Answer 39

Normal lesions: 1. cherry angiomas (tiny/bright ruby red-dark blue round papules that may get brown over time) 2. seborrheic keratoses (pigmented raised warty on trunk. *must be differentiated from nevi or acitinic keratoses that could be malignant) 3. sebaceous hyperplasia (yellow flat papules w/ central depressions hard to discern from basal cell carcinoma) 4. cutaneous tags/acrochordon (small soft skin colored pedunculated papules of skin neck/chest) 5. cutaneous horns (small hard projections of epidermis on forehead/face and can mean underlying squamous cell carcinoma or wart 6. solar lentigines= irregular gray/brown macules over sun areas. "Age spots" Normal characteristics: skin more pale increased freckling hypopigmented patches flaking/scaling d/t dry skin on extremities thin skin esp over bone, loose hanging skin d/t lost elasticity/gravity/lost adipose = tenting w/ turgor wrinkles senile purpura (bruise) dorsal hands and arms

Question 40

What to expect when palpating lymph nodes

Answer 40

easily palpable nodes not generally found in healthy adult may detect small movable discrete shotty nodes (may feel like BBs under skin) less than 1 cm in diameter that move under fingers when enlarged nodes found explore adjacent areas and regions drained by them for s/sx infection or malignancy

Question 41

lymph nodes: Differentiating infection from malignancy

Answer 41

malignant= hard fixed painless nodes; palpable supraclavicular node on left (Virchow node) is clue to thoracic or abdominal malignancy infection= tender *slow nodal enlargement over weeks= benign, rapid enlargement without signs of inflammation= malignancy

Question 42

lymph nodes: normal changes in adult

Answer 42

diminish and size decrease w/ advanced age. Nodes of older adults more fibrotic and fatty

Question 43

lymph nodes: where they're palpable

Answer 43

neck: occipital, postauricular, posterior cervical, preauricular, parotid, retropharyngeal (tonsillar), submandibular, submental, anterior cervical, supraclavicular (felt when disease) epitrochlear inguinal and popliteal

Question 44

lymph nodes: how to differentiate between cyst

Answer 44

check if it transilluminates nodes do NOT, cysts do

Question 45

lymph nodes: painful vs non painful meaning

Answer 45

tender= infection not= malignant if enlarged

Question 46

lymph nodes: when does enlarged need further investigation

Answer 46

hard fixed painful rapid enlargement tender > 1 cm

Question 47

How to palpate the thyroid; what will you expect to feel

Question 48

History and physical findings suggestive of hypo and hyperthyroidism

Question 49

. History findings suggestive of different types of headaches; migraine, tension, cluster

Question 50

gold standard for pain assessment

Answer 50

self-report pain scale ? numerical rating scale let them pick if more than one available

Question 51

How to assess pain in child, when can a pain scale be used

Answer 51

children as young as 3 can self report; assess ability to understand higher-lower and more-less practice using scale using old injury wong-baker faces rating scale oucher scale FLACC for non verbal

Question 52

Overall changes in the older adult to differentiate normal from abnormal

Question 53

Nutrition: What is normal BMI; overweight BMI, obese BMI; physical signs of nutritional deficiency

Answer 53

undernutrition= < 18.5 appropriate= 18.5-24.9 overweight= 25-29.9 obesity= 30 or >

Question 54

What is physiologic jaundice in the newborn, when is it normal and what does it indicate if abnormal

Answer 54

1st day of life, disappears by 8-10th day, can persist 3-4 weeks. Intense/persistent jaundice= liver disease, hemolytic process, or severe infection examine mucosa and sclera in daylight

Question 55

How to transilluminate the skull of an infant, what is seen, what is normal

Answer 55

In general, when using a standard 2-cell flashlight held tight (press firmly to skull) to the anterior fontanelle, transillumination of more than 2 cm around the edge of the beam or asymmetry of the transillumination suggests underlying pathology

Question 56

What are normal/abnormal skin changes in pregnancy

Answer 56

normal= striae gravidarum (stretch marks), telangiectasias (dilate blood vessels) ace/neck/chest/arms, hemangiomas (benign vascular tumor), cutaneous tags, increased pigment areolae, vulva, perianal, axillae, linea alba, preexisting nevi darken/grow or new nevi, melasma (dark blotchy skin) forehead/cheeks/nose/chin, palmar erythema, itching on breasts and abdomen, hair lengthened & hair loss decreased abnormal= itching with rash esp on palms & soles

Question 57

What is SLUMS for

Answer 57

The Saint Louis University Mental Status (SLUMS) test is an assessment tool for dementia and mild cognitive impairment

Question 58

What is the PHQ9 for

Answer 58

depression screening

Question 59

What is the GAD7 for

Answer 59

anxiety screening Anxiety can affect a person in numerous ways including insomnia and weight change (whether increase or decrease). When assessing for anxiety, be sure to complete a GAD-7 screening and score in order to give your diagnosis credibility through using medically approved criteria. When using the GAD-7 score, you can then determine the level of anxiety your patient is experiencing whether mild, moderate, or severe. This will help guide you in your decision making regarding the plan/medications you will give your patient.

Question 60

What meds do you typically start with for anxiety and depression

Answer 60

When thinking about giving medications for anxiety/depression...we typically start with an SSRI or SSNI. These medications are effective and do not have the major side effects of benzos or TCAs.

Question 61

Maslow's hierarchy of needs

Answer 61

#1- physiological 2- safety 3- belonging and love 4- esteem 5- self actualization

Question 62

Important diagnostics if cognitive decline is found

Answer 62

If you determine they have a cognitive decline, it is important to get a MRI or CT of their brain. The MRI or CT will help determine what type of dementia they possess.

Question 63

different types of dementia

Answer 63

alzheimer, vascular, frontotemporal, lewy body, korsakoff syndrome

Question 64

Alzheimer s/s and diagnostic findings

Answer 64

Signs/Symptoms Memory Impairment – forgets people Executive function Problem solving Behavioral and psychologic symptoms Apraxia – Difficulty with movement Olfactory Dysfunction Sleep Disturbance PET/MRI Reading MRI: Generalized/focal atrophy, white matter lesions, reduced hippocampal volume, medial temporal lobe atrophy PET: Hypometabolism and hypoperfusion, neurofibrillary tangles

Question 65

Vascular dementia s/s and diagnostic findings

Answer 65

S/sx Sudden significant cognitive impairment *Damage to multiple brain regions *Strategic infarction -  damage to single brain location PET/MRI reading MRI: Cerebral small vessel disease including microbleeds, Infarcts >15 mm or any size in cerebral cortex, Infarcts <15 mm in subcortical brain regions, white matter hyperintensities or hypodensities of presumed vascular origin, demyelination, axon loss, and oligodendrocyte loss

Question 66

frontotemporal dementia s/sx and PET/MRI reading

Answer 66

s/sx Disinhibition – socially inappropriate behavior Apathy or loss of empathy – losing interest/motivation/relationships Hyperorality – altered food preferences such as craving carbohydrates or sweets/binge eating, increase alcohol or tobacco, attempting to eat inedible objects Compulsive behavior – ritualistic behavior such as hoarding, checking, cleaning; pursuing hobby/religious aspects obsessively MRI: Frontal or temporal atrophy; Atrophy may affect one brain hemisphere more than the other

Question 67

Lewy body s/sx and PET/MRI findings

Answer 67

s/sx Progressive cognitive decline Abnormal social/occupational functions Deficit in attention, executive function, and visuoperceptual function Hallucinations/delusions Insomnia Does not forget people PET: low dopaminergic activity in striatum which is also seen in Parkinson’s Disease, multiple system atrophy, progressive supranuclear palsy

Question 68

Korsakoff Syndrome s/sx and diagnostic findings

Answer 68

s/sx Marked deficit in anterograde and retrograde memory Apathy Intact sensorium Relative preservation of long-term memory and cognitive skills MRI: Reduction in cerebral metabolic rate for glucose and decrease in benzodiazepine receptor; Results from Wernicke encephalopathy, enlargement of cerebral ventricles and sulci Patient has hx of alcohol use disorder

Question 69

how to initially address insomnia

Answer 69

When helping a patient with insomnia, do NOT automatically go to a medication such as Ambien, Lunesta, or Restoril. These type of medications are highly addictive and can cause more harm. ALWAYS start with melatonin as this is a natural hormone and one that may be lacking in the patient which is the pathophysiology regarding our sleep-wake cycle. Be careful how you treat your patients. Also getting them to do sleep hygiene also helps with insomnia. Turning off computers/phones allows the brain to relax and prepares one for sleep.

Question 70

tuning fork 500-1000 hz used for what?

Answer 70

hearing range for normal speech since normal speech can range from 300-3000 hz

Question 71

a 69 y/o truck driver presents w/ sudden inability to understand spoken language. this indicates a lesion in which area of the brain?

Answer 71

temporal lobe- responsible for comprehension of spoken and written language