CMS practical Flashcards
anthropometric findings (height and weight) in fatty liver disease
increase BMI; central adiposity
blood pressure findings in fatty liver disases
increased blood pressure
skin exam findings in fatty liver disease
Spider Angiomas
Signs of portal hypertension: Edema, ascites, caput medusae
Palmar erythema
Jaundice (eyes, skin)
liver percussion and palpation findings in fatty liver disease
Hepatomegaly
Liver larger than 12 cm (mid-clavicular) or 8 cm (midsternal)
Palpation: firmness - cirrhosis
spleen percussion and palpation findings in fatty liver disease
Splenomegaly (due to portal hypertension associated w/ liver fibrosis)
ascites findings in fatty liver disease
Ascites (due to portal hypertension + fluid retention)
blood pressure in obesity
hypertension
heart rate in obesity
increased
respiratory rate in obesity
increased
waist circumference in obesity
increased
skin exam in obesity
Acanthosis Nigricans (IR)
Striae (stretch marks)
Acrochordons (skin tags) -associated w/ IR
Edema
Xanthoma
external eye exam in obesity
xanthoma
liver percussion and palpation in obesity
Hepatomegaly (due to NAFLD – comorbidity)
heart auscultation in obesity
Extra sounds (S3 + S4) due to cardiovascular comorbidities
Stenosis + regurgitation due to cardiovascular comorbidities
ascites findings in obesity
Fluid accumulation (due to comorbidities)
peripheral edema findings in obesity
yes Due to comorbidities (CHF, venous insufficiency)
blood pressure in diabetes
high
skin exam in T2DM
T2DM:
-acanthosis nigricans
-eruptive xanthomas
-central adiposity/weight gain
-diabetic dermopathy
- skin tags (?)
feet findings in T2DM (part of skin exam)
-ulcers
- pre-ulcerative callus/ corn
opthalamoscopic exam in diabetes
Diabetic Retinopathy:
-Microaneurysms: small swellings attached to vessels
-Flame hemorrhages
-Hard exudates
-neovascularization
-glaucoma
-AV nicking
-proliferative diabetic retinopathy
peripheral pulses (post tibial and dorsals pedis) in diabetes
Diminished (grade 0 or 1) due to peripheral artery disease (atherosclerosis) or diabetic neuropathy (poor circulation due to n. damage that control vessel constriction/ dilation)
-PAD presence in over 50% of pts
sensory exam (Ipswich touch test, soft touch, vibration, pain) findings in diabetes
128 Hz tuning fork (vibration) test: absence of vibratory perception
Ipswich touch test: absence of light touch on 2 or more sites (out of 6) is + for diabetic neuropathy
shoulder inspection findings
- Inspect the anterior + lateral aspects of the shoulder
- note: scares, bruising, swelling, abnormal bony prominence, deltoid wasting - Inspect scapulae + related muscles
- note: scars, muscle symmetry, scoliosis, winged scapula
-erythema, swelling, gross deformities, bruising/trauma, scars, asymmetry
Normal: well perfused consistent skin colour, all bony landmarks visible, no swelling, shoulder intact bilaterally with no gross deformities, bruising, no indications of lesions, scars or surgeries
palpation of shoulder findings
Sternoclavicular joint, clavicle, acromioclavicular joint, acromion, coracoid process, spine of scapula, greater tubercle (humerus), biceps tendon, subacromial and subdeltoid bursae + SITS m. insertions
-proximal humerus, tendon insertions, local muscles
-assess for tenderness and crepitus
ROM in shoulder findings
Flexion, Extension, Abduction, Adduction, Internal + External Rotation
- for adduction - cross arm in front of body
AROM: state expected degree range
PROM: assess for instability, laxity, apprehension, pain, popping, clicking, crepitus
RROM: indicate muscles being assessed, hold for 5 seconds
* Flexion: deltoid, biceps,
* Extension: triceps, posterior deltoids
* Abduction: supraspinatus (up to 90 degrees), deltoids (past 90 degrees)
* Adduction: infraspinatus, subscapularis
* External rotation: teres minor, infraspinatus
* Internal rotation: subscapularis
external rotation lag in shoulder findings
- Flex pts elbow to 90 and lift 20 in scapular plane
- Passively take pt to mx external rotation + instruct pt to hold
(+): shoulder internally rotates/ cannot maintain position for 2 seconds
- supraspinatus + infraspinatus tear
internal rotation lag findings in shoulder
1.Brings arm into max internal rotation behind pts back
2. Lift forearm away from back into 20 degrees of ext
3. ask pt to maintain position but remain support at elbow
(+): If pt cannot maintain position for 2 seconds - Subscapularis tear
painful arc test in shoulder
- Ask pt to raise their arms w/ thumbs pointing upward
- Assess for smooth, pain-free movement
Pain < 60 = frozen shoulder
(+): pain btwn 60-120 → supraspinatus impingement, rotator cuff tendonitis/ tear
Pain > 180 degrees = AC joint
In pts w/ RC tendonitis, ROM is all normal
in pts w/ cuff tears, ROM is normal RROM strength is reduced
drop arm test in shoulder
- Passively adduct pts arm to 90 while supported the elbow
- Tell pt that when they release their arm, to lower it back slowly to neutral position
(+): sudden drop/ pain → supraspinatus tear
blood pressure in hypothyroid
diastolic hypertension
temperature in hypothyroid
slightly low
heart rate in hypotension
bradycardia
waist to hip ratio in hypothyroid
weight gain (5 lbs)
skin exam in hypothyroid
Lateral 1/3 eyebrow thinning
Puffy face/ eyelids
Skin pallor or yellowing (carotenemia)
Dry Skin
hair and nails in hypothyroid
Thin brittle nails
Thinning hair/ alopecia
thyroid findings in hypothryoid
Goiter, bogginess, nodules, tenderness
If healthy should feel cartilaginous rings
deep tendon reflex in hypothyroid
*ACHILES reflex
Delayed DTRs (grade 1)
*grade 2 is normal
blood pressure in non-organic fatigue
mild hyoptension
temperature in non-organic fatigue
low grade fever
heart rate in non-organic fatigue
tachycardia
respiratory rate in non orngaic fatigue
tachypnea
oropharyngeal exam in non-organic fatigeu
Non-exudative pharyngitis
-erythematous posterior pharynx
- Normal findings (that are also present in CSF):
- Uniformly coloured, soft, moister soft and hard palate
- Thin white coat on tongue
- Tonsils not enlarged (0 or 1+)
- Lateral margins
- Uvula positioned midline
cervical and axillary lymph nodes in non-organic fatigue
Lymphadenopathy
Tender lymph nodes
- <2cm is normal, >3cm is enlarged
- Should be soft
- If rubbery or hard= bad
oropharyngeal exam for insomnia
tonsil size grading 0-4
if its at 3+ or 4+ it would maybe be obstruction
Mallampati score: tonsils, soft palette + uvula
** pt must stick out tongue as much as possible**
no tongue depressor used
Class 1: The patient’s tonsils, uvula, and soft palate are completely visible.
Class 2: Hard and soft palate, upper tonsils, and uvula are visible.
Class 3: Hard and soft palate are visible; uvula is somewhat obscured.
Class 4: Only hard palate is visible.
Class 3 + 4 = higher risk of OSA
Also assess posterior pharynx:
-evidence of post nasal drip (erythema)
-evidence of GERD (ulceration, enamel erosion)
- cobble stoning
nose and sinus exam (external, internal, sinus) findings for insomnia
Asymmetry may be deviated septum – trouble breathing waking them up
internally swollen turbinate’s –rhinitis, allergies – obstruction that causes them to wake up constantly
mucous – can lead to post nasal drip
Polyps, redness of mucous – may indicate sinusitis
Test breathing through nose to
*must comment on the inferior turbinate**
Nasal septum is intact not perforated
If sinus palpation tender – increase suspicion of post nasal drip – increase suspicion of insomnia
septal deviation , nasal poylps (OSA)
neck circumference in insomnia
≤ 40cm increases risk of OSA
landmarks to measure: hyoid – sternum – half way in between measure
lung auscultation in insomnia
Fluid / crackles due to heart failure
** when doing back: make sure to tell patient to cross their arms and want to see at least 2 areas along the sides**
heart auscultation in insomnia
Heart failure – extra heart sounds (s3) – backflow fluid into lungs causes difficulty breathing causes them to wake up hypoxic episodes
if severe regurgitation
possible s4 if they have hypertension
abdominal palpation in insomnia
IBS (waking up for diarrhea) – palpation may be sensitive/ tender to touch
GERD: lying down, acid can flow up to esophagus
Emphasize no epigastric pain (GERD)
when testing for peripheral artery disease what must u do
do bilaterally i.e. bp, pulses
blood pressure in both arms of peripheral artery disease findings
hypertension
skin exam in peripheral artery disease
Cold skin temp
Presence of foot ulcers (between toes too “kissing ulcers)
Discolouration (leads to gangrene)
Skin perfusion (pallor (10 sec) upon elevation in supine OR prone + rubor (10sec) when seated pr prone/ supine - soft for like 5 sec)
Shiny skin
Distal hair loss
- Back of hands to assess for rubor
- Purple blue discolouration
- Temperature bilaterally on legs on multiple points
Elevation pallor then dependent rubor
hair and nails in peripheral artery disease
Dystrophic nail changes (discolouration, hypertrophic nails, splinter hemorrhages)
Hair loss on toes + distal ankles
pulses in peripheral artery disease
Rate (0-3+) – diminished in PAD (radial, carotid, femoral, posterior tibial, dorsalis pedis)
do bilaterally at same time, except for carotid
auscultation of bruits using what side of stethoscope
bell
bruits in peripheral artery disease
Shows: stenosis or atherosclerosis. Use bell (diaphragm for carotid)
Presence of carotid (hold breath), aorta, renal, femoral, iliac, popliteal bruit
most reliable for PVD = femoral
neurological testing in peripheral artery disease (sensory: soft touch, vibration, pain)
Soft touch – 2 spots on hand (palm + back of wrist) + 2 spots on feet (1 sole + 1 on ankle) – bilaterally
Sharp vs dull same 8 locations – use cotton swab – one side is dull one sharp
Vibration: 1st joint of thumb + toe, ask them what they feel – vibration, ask them when it stops + then stop the vibration (4 spots) – 128 hz TF
WEEK 11 headaches DOOOO
