CM exam 2 Flashcards
what are the seven attributes of a symptom?
location (where is it? where does it radiate?), quality (what is it like?), quantity or severity (how bad is it? 1-10), timing (when did this start, how long does it last, how often does it come?), setting in which it occurs, remitting or exacerbating factors (is there anything that makes it better or worse?), associated manifestations (anything that accompanies it?)
common or concerning symptoms?
headache, change in vision, double vision, hearing loss, earache, tinnitus, vertigo, epistaxis, sore throat, swollen glands, trauma
where must a patient go if they fall from a height equal to their height or higher?
a level 1 trauma center due to hidden injuries
what are some things to assess with head trauma?
is the patient awake/oriented? how did they get hurt? time of injury? loss of consciousness immediately post-injury? subsequent levels of alertness? amnesia (retrograde, anterograde)?, headache (mild, moderate, severe), double or blurred vision? bleeding from ears, nose, mouth, eyes?
concussion
a disturbance in brain function caused by a direct or indirect force to the head; do not have to be knocked out to have a concussion
what clues you into a possible concussion?
headache, physical unsteadiness, impaired brain function, confusion (person, place, time; inadequate answers are suspicious), abnormal behavior
what is the sports concussion tool used in iowa?
sport concussion assessment tool-2
how do you disqualify an athlete based on a concussion?
the screen after a head injury does not match the baseline following injury
when can a high school athlete return to sports?
they may not go back the same day as the injury; may only return after medical practice; RTP (return to practice)
classic migraine
70% unilateral; pulsating or throbbing; hours to days; females have it more often; nausea/vomiting are common; caused by missing meals, menses, BCP, stress, certain foods
cluster
rare, but has classical characteristics; occurs in adulthood, unilateral, 1/2-2 hours, intense burning, searing, knife-like, several nights for several days and then gone, males are more likely to get them, increased tearing/nasal discharge that is almost always unilateral
tension
occurs in adulthood, unilateral or bilateral (if unilateral, do not automatically think classic migraine), hours to days, anytime it can start, band-like and constricting, no prodrome (a “tip off” to the patient they will get one), stress, anger, and teeth grinding can cause them
medication rebound
diffuse, hours at a time, hours or days of last dose, dull or throbbing pain, daily analgesics are a clue, abrupt analgesic stops will cause them
hyperparathyroidism
“speed up”; the following symptoms do not begin at the same time; nervousness, weight loss, excessive sweating, heat intolerance, warm/smooth/moist skin, Grave’s disease, tachycardia
hypothyroidism
“slow down”; fatigue, lethargy, modest weight gain, dry coarse skin, cold intolerance, swelling of face, hands, and legs, bradycardia, impaired memory
what do you exam on the head?
symmetry, presence of hair, scalp (lesions, bugs, bumps, lumps, cysts), face (CN VII), palpation, bony irregularities, oral mucosa (number of teeth, look at tongue), facial sensation, carotid and temporal arteries
what do you check on the TMJ?
alignment and palpate for clicking or crepitus
what do you inspect on the neck?
the general appearance in bright and tangential light, symmetry, lesions, masses, tracheal position, jugular venous distention, range of motion (assess strength), auscultation carotids and thyroid, palpation, nuchal rigidity (stiffness to the neck; check infants and children where this is classic in meningitis), cervical spinous processes, paravertebral musculature, cricoid and thyroid cartilage, position of trachea, thyroid, carotids, lymphatics
what do you always check from birth to 24 months?
head circumference!
why do you transilluminate the skull?
to look for excess fluid accumulation
how do the heads of an adult and an infant compare?
head at birth is 1/4 of body length (adult is 1/8) and the head at birth is 1/3 of the weight (adult is 1/10)
why do infants need to be placed backwards in carseat for first 2 years of life?
because the head is heavy and fairly unstable - not held up by much! in the event of a motor vehicle accident, the head will go into the seat which is safer than forwards
sutures
separate the bones; membranous tissues
fontanelles
areas where sutures intersect
when does the anterior fontanelle close?
18 months (9-24); measures 4-6 cm at birth
when does the posterior fontanelle close?
2 months
why would a fontanelle bulge?
as a result of increased intercranial pressure
why would a patient present with a sunken fontanelle?
dehydration
microencephaly
the head is small due to the brain not growing
hydrocephalus
increased intracranial pressure from deficient CSF circulation (or excess production) that causes the calvaria to become enlarged before the sutures are closed
why would you have overlapping of sutures?
due to molding, or the movement of bones at sutures that occurs during vaginal delivery
caput succedaneum
swelling of scalp during delivery; transluminates; usually occurs over the occipitoparietal area
cephalohematoma
collection of blood underneath the periosteum of the skull; does not cross over suture lines, does not transilluminate
what do the heads of C/S infants look like?
more rounded
plagiocephaly
occurs when an infant lies on one side constantly; due to subsequent flattening, mishapen head; self resolves with age
cranioynostosis
premature closure of sutures that can lead to assymetry; brachycephaly is known as premature closer of coronal cells
bracycephaly
premature closure of coronal suture; typically need a procedure to fix this
lymph nodes (infants)
“shotty”: small, movable, round lymph nodes; not worrisome, not tender, not warm
how do you palpate the neck of an infant?
use 1-2 fingers; the neck is short and thin
congenital muscular torticollis
injury and possible bleed into the SCM at birth that shortens the muscle at birth; treatment is stretching exercises; patient presents with misshapen head, normal fontanelles, flat head on posterior right occipitoparietal area with neck rotated left, sidebent right
what questions should you ask about the ear?
how is your hearing? do you have difficulties understanding people when they talk? what happens in a noisy environment? earache? vertigo? medications (some can mess with hearing over time), resent URI? discharge? tinnitus
tinnitus
ringing in ears
rhinorrhea
runny nose/ discharge
why should you be concerned about unilateral congestion in children?
could have stuck something up their nose
epistaxis
nosebleed; could be caused by trauma, anticoagulants, NSAIDS
what do you check for on the external ear?
deformities, lesions, placement on head, characteristics
what do you palpate for pain before inserting otoscope?
the pinna and tragus; this helps differentiate between otitis externa and otitis media; if either pinna or tragus hurt, could be otitis externa
how do you adjust the ear for an adult while doing an otoscope exam?
pull the pinna lateral, superior, and posterior
how do you adjust the ear for a child while doing an otoscope exam?
pull pinna lateral, inferior, and posterior
what finger is held out during an otoscope exam?
5th digit
what hand do you use to do otoscope exam?
if on the patients left side, use your left hand; if on the patient’s right side, use you right hand
erythema
redness and inflammation of mucous membrane
cerumen
ear wax
why do you use an insufflation bulb?
to test for mobility of TM when air is put into the ear; if there is fluid behind the ear or an infection, the TM will be stuck
what is the biggest mistake with a otoscope?
holding it with your entire fist around it; you should hold it with the first couple fingers and thumb so that your 4th and 5th digits can act as shock absorbers
what do you look for externally on the nose
deformities, lesions; check nares for symmetry
true or false: both nares are the same side
false; it is common for one nare to be larger than the other; this is important for when placing a NG tube on the side that will be most comfortable
what do you check for on the inside of the nose?
polyps, evidence of recent epitaxis, debris, color, and consistency of discharge
how do you check for nasal patency?
occlude one nare and have the patient breathe in; if they can’t breathe out of one nostril, they may have a deviated septum
how do you check CN I?
have them smell with each nostril; this is done when athletes hit their heads really hard
how does weight loss related to smell?
when you lose smell, you can lose taste as well. a patient can lose weight as a result of losing taste.
how do you test the sinuses?
palpation (may feel warm), percussion (for tenderness, not sound; do not do it if the patient says they have pain), transillumination (inspecting for fluid under the flashlight; if fluid present you wont see light)
true or false: hitting the septum will cause epitaxis?
true
polyps
fleshy swellings; can occur in the nose
whisper test
stand behind and to the side 1-2 ft away from patient, have the patient put their finger in the ear not being tested and move it around, exhale fully and whisper 3 letters or numbers, ask the patient to repeat what they heard; do for both ears
weber test
assesses hearing and helps differentiate between neurosensory and conductive hearing loss; vibrate the tuning fork and place in the middle of the patient’s vertex; ask them where they hear the sound (one side, both sides, not at all?)
what frequency tuning fork do you use for the weber test?
512 Hz
if you hear the tuning fork during a weber test on the side of hearing loss, what kind of hearing loss do you have?
conductive because you received input of vibrations via fork
rinne test
helps determine whether each ear detects sounds better through air or bone; use vibrating fork and place on mastoid process, asking the patient to tell them you when they can no longer hear the ringing; next move the tuning fork to 2.5 cm away from patient’s ear and ask the patient when they stop hearing the ringing
what is a normal test result for rinne test?
normally you hear sounds through the air longer; should be a 2:1 ratio; if the hearing is prolonged, you could have neurological issues
conductive hearing loss
external or middle ear disorder caused by foreign body in the ear, otitis media, perforated eardrum, or otosclerosis; sound lateralizes to impaired ear (weber test); bone conduction longer than or equal to air conduction
sensorineural loss
inner ear disorder involving the cochlear nerve; caused by loud noise exposure, inner ear infections, trauma, acoustic neuroma, aging, familial disorders; sound lateralizes to good ear (weber test); air conduction longer than bone conduction
where are the ears positioned on an infant?
upper portion of auricle joins the scalp at or above the level of line drawn from the inner and outer canthus of the eye
true or false: there is a relationship between ear tags and the renal system
true
why is it difficult to see the TM in the first few days of life?
presence of vernix caseosa
where should the child sit during a toddler exam>
on the parent’s lap, facing you; to look at the ears, have parent turn head of child to one side and hug with one arm around the arms and one on the forehead
pneumatic otoscopy
uses insufflator bulb; puffs burst of air into TM to check for movement; if there is no movement, there is fluid behind the ear drum. if there is no fluid (no movement) then you can rule out otitis media
how do newborns breathe?
obligate nose breathers; this makes nasal congestion or obstruction a problem
what indicates allergies in infants?
crease on the nose as a result of wiping the nose upwards
allergic shiners
darkness under eyes caused by venous pooling as a result from chronic congestion
when does the maxillary sinus develop?
1 year
when does the ethmoid and sphenoid sinus develop?
6 years
when does the frontal sinus develop?
10 years
when does sinus development cease?
21 years
can you always see cleft palate on the infant’s lip?
no; you need to look at the palate as well as the lip
antenatal teeth
teeth formed before birth; often taken out because they are usually loose
Epstein’s pearls
pin head sized white or yellow rounded elevations that are located along the midline of the hard palate near its posterior border or gums caused by retained secretions and disappear within a few weeks or months
how do you do a mouth exam on an infant?
have one parent hug the body with one arm and holding the child’s arms underneath; one arm on the forehead; place tongue depressor along the side of the buccal mucosa and slide inside the molars; use gag reflex when necessary and use crying as your friend
when does peak growth of tonsils occur?
2-6 years of age
how are tonsils rated?
1+= barely visible, 2+=visible, 3+= moving in towards the uvula, nearly touching, 4+= “kissing tonsils” that are touching and causing obstruction, 0= not present
when does tooth grow occur?
6-7 months with upper and lower central incisors
what is the rate at which teeth show up after the first teeth appear?
4 teeth every four months
when is tooth growth completed?
2-3 years
when does a child start shedding primary teeth?
5 years
when do secondary teeth usually begin?
6-7 year
halitosis
bad breath
what can cause bad breath in children?
nasal foreign bodies; common in children 9 months to 5 years; present with chronic, unliateral rhinitis or congestion, and halitosis
pharyngitis
sore throat
what causes a sore tongue
vitamin b12 deficiency
what causes gums to bleed
gingivitis, infection
what is the link between gingivitis and heart disease?
theorized that cardiovascular disease may begin in the gums and migrate down
what causes hoarseness?
sore throat, virus, laryngeal disease (cancer)
what can temperature intolerance be a clue of?
thyroidism
what are common HPI and PROS of the mouth in adults?
sore throat, sore tongue, bleeding of gums, hoarseness, swollen glands, temperature intolerance, sweating, skin changes, tobacco use
what is the first sign of a patient vomiting?
mouth flooded by saliva
where is stenson’s duct located?
upper mouth off the 2nd molar in the cheek
how are the teeth numbered?
start in the upper right, go around, come down to the bottom and go back around
leukoplakia
white patches found in the mouth, often on the tongue; thought to be caused by tobacco use
erythroplakia
red irritation
wharton’s duct
on the floor of the mouth, under the tongue
what does an asymmetric protrusion of the tongue suggest/
damage to CN XII; deviation is to the same side of the lesion
uvula
raises as patient says “ahh” and shoudl raise to the midline; if it does not raise to the midline, deviation suggests lesion to CN X
what should you have children do to look at their throats?
pant like a puppy
what should you auscultate?
carotids and thyroid; only find 1 carotid at a time, especially in old people
what should you palpate?
cricoid and thyroid cartilage, position of trachea, thyroid, carotids, lymphatics
where does the thyroid move if the lung loses volume?
towards the affected lung
where does the thyroid move if it is enlarged or during pleural effusion?
away from affected side
where does the thyroid move in tension pneumothorax
away from affected side
where does the thyroid move with a collapsed lung?
towards affected side
what do nodules on thyroid suggest?
thyroiditis, malignant tumors, Hasimoto’s thyroiditis
bruit
abnormal sound in artery due to disturbance of blood flow
hyperthyroidism
speeding up; faster pulse, diaphoretic
hypothyroidism
slowing down; skin is thicker, drier, coarser
what are some common problems with eyes/
focusing problems, cataracts, diabetes, macular degeneration, glaucoma
how do you assess focus issues with eyes?
snellen chart (alphabet) and Rosenbaum (for near vision)
what is the leading cause of blindness if not corrected?
cataracts
what is the leading cause of blindness <65 in the USA?
diabetes; observed as large proliferation of blood vessels that are fragile and can break
what does macular degeneration cause?
loss of central vision; patient will look at you through the corner of their eye; detected with visual acuity and GRID tests
glaucoma
elevated pressure that causes loss in vision; peripheral vision is lost first
what causes transient loss of vision?
in young patient it can be due to migraine, in older patient it can be an emboli problem
what symptom suggests retinal detachment
flashes of light
why do you experience diplopia
can be a one eye optical problem or a 2 eye alignment problem
exophthalmos
bulging eyes; most common causes is thyroid disease
what action does the superior rectus do?
pulls eye superiorly
what action does the lateral rectus do
pulls eye laterally
what action does the medial rectus do
pulls eye medially
what action does the inferior rectus do
pulls eye inferiorly
what action does the inferior oblique do
pulls eye superiorly and laterally
what action does the superior oblique do
pulls eye inferiorly and laterally
what cranial nerves are involved in eye muscle innervation
all are CN III EXCEPT for superior oblique (CN IV) and lateral rectus (CN VI)
where is the lacrimal gland located?
superior and laterally to the eye ball
is it normal for the perioribital skin to show swelling, redness, lesions, ad rash?
depends on the patient; it is common for swelling to occur under the eye with aging
what does thinning of the eyebrow from the middle to lateral aspect of eyebrow suggest
early thyroid problems
what does a pale conjunctiva mean
early sign of anemia
what do swelling and bumps on the conjunctiva indicated?
allergic reaction
what does a red conjunctiva with green/yellow exudate indicate?
conjunctivitis (pink eye)
conjunctiva
lines eye lid and surface of eye
checking for foreign body
use wooden part of cotton-tipped applicator on the outer half of the upper lid at the crease; break suction by pulling on lashes
how do you test for visual acuity?
using the snellen eye chart; in a well lit area, position the patient 20 feet from the chart; if they use glasses for other than reading, they should use them. cover one eye and read the smallest line possible; results recorded as a fraction (numerator is the distance from chart, denominator is the average distance eye can read the chart)
how do you test near vision
use a hand held rosenbaum chart; helps identify need for reading glasses or bifocals; held 14 inches from patient’s face and one eye is tested at a time
assessing visual fields by confrontation
tests for defect in any quadrant of the field of vision; stand 3 feet from the patient at eye level; using one eye at a time; physician brings fingers into the visual field halfway between you and the patient at a 45 degree angle of each quadrant; have the patient report how many fingers they see
Assess extraocular muscles
stand 3 feet from patient and ask them to hold their head still and follow your fingers with their eyes only; draw a large “X” and then a “+”; ; look for nystagmus
convergence test
bring finger towards the patient’s nose; patients eyes should converge down
nystagmus
jerking or drifting of eyes
accommodation testing or near reaction testing
checking to see if eyes will converge and pupils will constrict; when looking farther away, pupil should dilate, eyes will move up and out; when looking closer pupils should constrict, eyes will move down and in; stand in front of patient and to the side; hold a finger and ask them to look at your finger. then ask them to look at the wall behind you
PERLA
pupils equal, reactive to light, accommodating
pupillary responses
constriction is a response to light; this should happen when you shine a light directly into an eye as well as when you shine the light into the other eye (consensual response)
swinging light test
tests impairment of optic nerves (looking to see how quickly the pupil reacts); shine light in one eye and rapidly swing light to the other eye; you should have slight dilation in the second eye while light is crossing the bridge of the nose, but it should still constrict equally to the first eye as the light enters the pupil; if it continues to dilate rather than constrict you have afferent defect
Marcus Gunn pupil
when the pupil does not dilate when you do the swing test; can indicate tertiary syphillis
lateral penlight test
helps estimate the depth of the anterior chamber of the eye; failure to do this test can cause a medical emergency; if patient has a shallow anterior chamber and you dilate it, it will increase the pressure in the eye and cause the patient to lose the eye; if they have normal depth, the light will pass through and hit the nose, if they have shallow depth the light will not go through and you will see a shadow on the nose
corneal light reflex
testing for ocular alignment by reflecting light off patient’s pupils; shine light into patient’s eye and see where the reflection is; make sure light reflects in the same place on each eye; if it does not, this is a good indicator that there is a muscle imbalance or they have a misaligned eye
esotropic
eye turned medially so reflected light is lateral to pupil
exotropic
eye is turned laterally so the reflected light is medial to the pupil
hypertropic
eye is turned superiorly so reflected light is below the pupil
hypotropic
eye is turned inferiorly so the reflected light is above the pupil
uncover testing
used to detect presence of phoria (eye moves because of disturbances in binocular vision); you observe the covered eye as it is uncovered; there should be no movement
esophoria
eye starts lateral and moves medially
exophoria
eye starts medially and moves laterally
corneal sensitivity test
testing CN V; if in tact, CN V senses touch as it would a foreign body in the eye
what does the retina tell us during ophtalmoscopic exam?
early signs of hypertension, papilledema (increased pressure in the brain), diabetes, macular degeneration
what can you see better with green light?
drusen bodies, nerve fiber defects, and blood
what can you see with GRID patter?
size of lesions
what is the slit used to view?
the anterior chamber and corneal injuries
what is blue used for
corneal abrasions
myoptic
near sighted
hyperoptic
far sighted
strabismus
both eyes do not focus on the same object simultaneously, however either eye can focus independently
amblyopia
lazy eye
what do you check in a newborn (eyes)
differently sized eyes, epicanthal folds, distance between eyes, lids
epicanthal folds
vertical fold of skin nasally that covers the lacrimal caruncle; can be a sign of down syndrome, normal variants occur in Asian infants
red reflex
an orange to red light reflection from the fundus; should be equal in both eyes and fill the pupil completely; worrisome of the red reflex is asymmetric
leukocoria
white reflex; caused by congenital cataract or retinoblastoma
true or false: it is abnormal for a baby to open one eye at a time
false; this is normal
when is visual fixation present
birth
when is fixation well developed?
6-9 weeks
when is visual following present?
3 months
when is accommodation present? (pupils dilating and constricting based on distance)
4 months
when is stereopsis present (depth perception)
4 months
what should you test in 3-5 year olds?
red reflex, inspection, visual acuity, cover-uncover test
what is the visual acuity of a newborn
20/400 - 20/800
what is the visual acuity of a >= 3 year old
20/40 or better
strabismus
misalignment of eyes; not necessarily referring to vision; can cause amblyopia
pseudostrabismus
looks like something is abnormal - wide nasal bridge and epicanthal folds; light reflection is on the same place in same eyes; no actual strabismus
what is the single most effective screening test for the presence of amblyopia?
determination of visual acuity via noninvasive screening
what are the requirements for normal visual development/
clear retinal image, equal image clarity, and proper eye alignment
