Exam 1 Flashcards
Good facial landmarks for symmetry
nasolabial fold and palpebral fissure
anterior triangle
sternocleidomastoid
posterior triangle
trapezius
lymphs behind ear
posterior auricular, occipital, posterior cervical
lymphs before ear
preauricular, tonsilar, submandibular, submental, deep cervical, supraclaviluar
normal lymph nodes
less than 1/2 cm, movable, non-tender
infected lymph node
enlarged, tender
malignant lymph node
hard, non-tender, irregular, fixed
CN1
olfactory
- sensory
- smell
CNII
optic, sensory, sight
CNIII
oculomotor, pupils, EOM
CN IV
trochlear, EOM
CN V
trigeminal, facial sensation and motor muscles of mastication
CN VI
abducen, EOM
CN VII
facial, muscles, sensory, taste, anterior tongue
CN VIII
acoustic, sensory hearing/balance
CN IX
glossopharyngeal, sensory/motor gag, swallow, cough reflex, taste, posterior tongue
CN X
vagus, sensory and motor
CN XI
accessory, motor neck and shoulder strength
CN XII
hypoglossal, motor, tongue, “you can’t teach an old dog new tricks”
test CNI
Occlude each nostril and breathe to make sure they’re patent
Have pt identify a distinct scent (close eye and occlude one nostril at a time)
test CNII
Have pt read, do Snellen eye chart when covering one eye and then both together (no more than 2 mistakes)
test CN 3,4,6
follow finger through 6 vision fields (EOM)
test CN 5
Sensory- forehead, cheek and chin feel with cotton ball
Motor- strength of jaw muscle, bite on tongue blade and try to pull out on both sides of mouth
test CN 7
Have pt make faces: smile, raise eyebrows, frown, puff out cheeks
test CN 8
Cover L ear and whisper, cover R ear and whisper
Inner ear responsible for balance
test CN 9, 10
Control gag reflex, swallow, cough, symmetrical rise of uvula
Get tongue blade and look for symmetrical rise of uvula, stick tongue out and say “ahh”
test CN 11
Raise shoulders against hands
-turn head left and right against hand
test CN 12
Stick tongue out, move all around, push against sides of mouth
Say “you can’t teach an old dog new tricks”
head stuff in children
- large lymph nodes, open fontanels
- measure head circ
normal thyroid enlargement
teens and pregnancy- high metabolic activity
can assess for bruit in thyroid
tell pt to hold breath, normal is no sound
Cushings
moon face, could be caused by steriods
fetal alcohol face
-short palpebral fissure, thin upper lip, flat midface
TMJ
- can have referred pain
- headache, ear problems, jaw, etc
exam neck
neutral, hyperextended and swallowing for masses, symmetry, condition of the skin, ROM
exam thyroid gland
Use anterior or posterior approach; locate isthmus below cricoid cartilage; note size, shape, consistency, tenderness, and nodules; auscultate bruits
examine cervical lymph nodes
Note size, shape, symmetry, consistency, mobility, location, tenderness, and temperature
Head, face and neck focused assessment
- facial symmetry
- sensation (CN 5,7)
- skin/membranes
- edema, wasting
- masses, tenderness
PMH head face neck
ca history, toxins, allergies, ENT surgeries
- sexual practices (HIV risk)
- thyroid in family
ROS head face neck
wt changes, palpitations, bowel changes, temp intolerance, fever, chills, itching
-ETOH and tobacco
head face and neck PE
Palpation of thyroid, lymph nodes
Inspect hair, skin, periorbital edema
Reflexes (deep tendon)
Examination of mouth, throat, ears, eyes- look or evidence of infection; if evidence of mono- abdominal exam to see if spleen enlarged
tests for head face and neck
TSH CBC Monospot if evidence consistent with mono CXR if lymphadenopathy present Chalmydia, Gonorrhea, HIV testing
hyperthyroid s/s
heat intolerance, bulging eyes, flushed, enlarged thyroid, tachy, weight loss
hypothyroid s/s
-cold intolerance, weak heartbeat, depression, big tongue, high LDL
external ear inspection
- low set is down syndrome
- malformed in kids could mean malformed kidneys
- angle of attachment near 10 degrees
external ear inspection
- low set is down syndrome
- malformed in kids could mean malformed kidneys
- angle of attachment near 10 degrees
ears and aging
hearing loss, thick cerumen, less flexible TM, presbycusis, tinntitis, otoslerosis
-vestibular changes, menieres
presbycusis
lose hearing of higher frequency
tinnitius
- many with hearing loss, most elderly
- can be caused by drugs
otoslerosis
caused by abnormal bone growth, often herediatary
vestibular (inner ear) changes
sensory, dysequillibrium, vertigo
-decrease in receptors, bony labrynth changes
meneieres dx
bone labryrinth dysfunction
- vertigo, ear pressure, tinnitis, neurosensory hearing loss
- *typically unilateral
history of ear
Hearing loss Vertigo Ringing in the ears (tinnitus) Ear drainage (otorrhea) Earache (otalgia)
whispered voice test
assesses gross hearing
Cover one ear and whisper into opposite ear, standing a few feet away
weber test
Tuning fork top of head or forehead
Should be equal in both ears
rinne test
compare bone conduction to air conduction
Air is twice as long as bone, put tuning fork on mastoid process behind ear
Problems in external or middle ear
palpate ear
tragus, mastoid, helix for tenderness
to straighten adult ear
up and back
normal TM
pearly gray, 5 o clock right and 7 o clock left cone of light
assess cornea
shoot air over eye causing them to blink
assess anterior chamber of eye
space between cornea and iris, should be clear, shine light from side
acute closed angle glaucoma
medical emergency
- dilated pupil, red sclera
- pt can go blind
adolescent vision
more nearsighted
children born with ___ vision
2200
aging eyes
-thick cornea, astigmatism, arcus senilus, glaucoma, acuity issues, floaters, presyopia
arcus senilus
white fat deposits around rim of cornea
floaters
loose cells in vitreous cast shadows on retina, can be worrisome
presbyopia
lose close vision as you age
history eye assessment
Vision loss Eye pain -Double vision -Blurred vision Eye tearing -Dry eyes Eye drainage -Floaters Eye appearance changes -glaucoma, surgery, cataracts
exam far vision
snellen chart, 20 20 normal
exam near vision
read newspaper 13-15” away
exam color vision
color bars on snellen or color plates
assess peripheral vision
come in from the periphery in all fields and note field cuts (wiggle fingers)
*will only see gross field cuts, not small changes
extraocular tests
- parallel on inspection
- corneal light reflex (sparkle in same spot)
- 6 fields of gaze
- cover/uncover for drifting (accomodation)
what CNs control eye movement
CN 3,4,6
pupil tests
- reaction to direct light and consensual
- accomodation as finger moves toward patient
conjunctivitis
pink eye
pterygium
benign, abnormal growth of tissue
-can affect vision if it extends over pupil
what to see eyes with otoscope
-red reflex, optic disc, retinal vessels, retina, macula and fovea
optic disc assessment
-round, white in center
macula assessment
area of most acute vision, dark area, not well defined
eye questions
Precipitating event? Previous history? Duration? Contacts??
Associated sx: burning itching, pain, exudate, allergies, trauma, tearing, dryness, photosensitve, visual changes
PE eye
Visual acuity EOM External Structures Corneal clarity Exudate Tearing Facial characteristics Regional lymphadenopathy
conjunctival exam
Note palpebral and bulbar portions Redness Cloudiness Lesions Follicles Edema
differentials for eye
Corneal injury/trauma Blepharitis Scleritis Conjunctivitis Anterior uveitis or iritis Acute angle glaucoma Chemical burn Hordeolum
glaucoma
Usually complain about peripheral vision
Open angle
Closed angle- severe pain, red conjunctiva, dilated pupil, medical emergency
macular degeneration
loss of central vision
frontal sinus
above the eye
maxillary sinus
either side of nose
mumps
parotiditis
taste and smell aging changes
- less sensitive taste (nutrition deficiencies)
- less able to identify odors (safety issue?)
- olfactory dysfunction
olfactory dysfunction associated with
alz, parkinsons, huntingtons
PE nose
- salivary gland- large, tender
- nose, septal deviation, patency
- sinuses- edema, tenderness
- parotid and submandibular glands- edema, red, tender
PE oropharynx
test gag reflex
tonsils PE
color, exudates, enlarge
uvula PE
symmetical rise (CN 9 and 10)
to test trigeminal nerve
bite down on stick both sides of mouth
-stick tongue out and move around
chilitis
crack at corner of mouth
angioedema
need to maintain airway, s/e of ACEi
leukoplakia
- white spots on tongue
* *precancerous
anterior nosebleed
trauma
posterior nosebleed
anticoag, OTC meds, drug use, sinus infection
pharyngitis PE
Include assessment of the upper and lower respiratory systems; eyes, ears, nose, mouth, throat, and lungs.
Also palpate cervical LN
More thorough neck exam if symptoms warrant
respiratory viruses
- s/s HA, fever, chills, rhinnitis, conjunctivities, cough, GI
- inflammed pharynx, present anterior adenopathy
herpes pharyngitis
malaise, fever
-inflammed and ulcered
herpangitis (hand foot and mouth)
malaise, lesions on hand feet buttock gentials
-inflamed and ulcered
group a strep
quick onset, malaise, n/v HA sandpaper rash, cough, conjuncitibvies, inflammation with white/gray tonsilar exudate
peritonsillar abscess
Usually associated with tonsillitis
Most common pathogen GABHS
Key S/S- worsening unilateral sore throat over days, fever, malaise, increasing difficulty with swallowing, speaking, foul smelling breath, drooling
Exam may be difficult= trismus, area adjacent to tonsil swollen, tonsil & uvula deviated, voice muffled
mono
exudates on tonsils
ludwigs angina
medical emergency
- can happen after dental work
- lose airway!
additional throat tests
Strep screen or culture CBC Mono spot Other cultures for viruses, GC ESR if thyroiditis suspected
strep vs mono
anterior nodes-strep
posterior nodes-mono
infant skin
- lanugo, vernix caseosa
- stork bite, cradle cap, milia
- more prone to fluid loss (poor temp regulation)
adolescent skin
- increase in subQ fat
- inc sebaceous gland activity
- secondary sex characteristics
pregnant skin
- linea nigra, cholasma on face, striae gravidarum (stretch marks)
- inc body temp, inc fat deposit
aging skin
- dec collagen and elastin, dec subQ fat
- inc risk of tearing
- dec ability to cool due to dec sweat glands
- more skin lesions
HPI skin
Changes in pigmentation, birthmarks, or moles (size, shape, color)
-skin and hair self care
ROS skin
Neuro GI- ex: liver/jaundice, crohns/lesions CV- HF/edema Respiratory Endocrine
woods light
fungal infection
cyanosis
central vs peripheral
jaundice
locations, sclera
pallor
local vs systemic, low hgb?
dependent rubor
vascular dx
distribution of lesions
can help you diagnose (ex: shingles)
petechiae
small pinpoint red lesions, small capillaries are breaking
purpura
larger than petechiae
-small bursted blood vessels
hematoma
walled off collection of blood, can be evacuated
inspection
-moisture, temp, texture
primary lesion
initial change
secondary lesion
change to primary- can add or take away
-ex: scaling, ulcers, fissures, crusts
serpiginous
snakelike
-seen with hookworm or scabies
arrangement of lesions
discrete- one here and there
- reticular- network like structure
- annular- fungal
wheal
palpable
-temporary elevation of skin, ex: PPD
Lesions < 1cm
Macule (flat)- freckle Papule (elevated) Nodule (deep) Vesicle (clear fluid) Pustule (pus)
lesions > 1cm
Patch (flat)- birthmark
Plaque (elevated)
Tumor (Deep)
Bulla (clear fluid)
psoriasis
a plaque
-silvery appearance
hive
palpable
>1 cm
vesicle
fluid filled
bulla
-fluid filled, often seen in burns
hidradenitis suppurativa
example of a cyst
lichenification
secondary lesions
- thickened elephant like skin
- seen in venous insufficiency
healing pressure ulcer
-doesn’t get better stages at it heals
“healing stage 4” etc.
tilangectasis
-spider angiomas on face
vascular lesions
spider angioma vs cherry angioma
turgor
- decreased = dehydration
- not accurate in elderly due to dec skin elasticity
acne
inflammation of pilosebaceous units with comedones, papulopustules and/or nodular cysts; more severe in males than females
roseacea
-disorder of pilosebaceous units coupled with hyperreactivity of capillaries to heat
-flushing and telangiectasia
Onset 30-59 years. Predominant in females
hidradenitis suppurativa
Major characteristics: chronic, suppurative disease of apocrine gland-bearing skin. May be associated with severe nodulocystic acne and pilonidal sinuses. Onset at puberty, affects females> males.
eczema/dermatitis
polymorphic inflammatory reaction patterns involving the epidermis and dermis. Acute-pruritis, erythema, vesiculation. Chronic-pruritis, xerosis, hyperkeratosis, +/- fissuring
psoriasis
- scaly plaques on extensor surfaces, chronic and recurring
- herediatry, physical trauma is key factor, may flare with stress (BB, steroids, antimalarials, interferon)
erythroderma
severe form of psoriasis
-involves entire body
psoriasis arthritis
arthritis-a seronegative spondyloarthropathy, asymmetric peripheral joint disease, usually in UE esp. in small joints.
seborrheic dermatitis
a common chronic dermatosis with red, scaly lesions where sebaceous glands most active- face, scalp, skin folds. Yellow-red or gray-white scaly macules & papules with sticky appearance“Cradle cap” in infants, pityriasis sicca(dandruff)
dermatophytosis
infection of hair skin nails
tinea pedis
Fungal infection of the feet (athlete’s foot) characterized by erythema, scaling, maceration and/or bulla. Often starts on the feet and spreads to other areas of the body.
tinea manum
Chronic dermatophytic infection of the hand(s) often unilateral, on the dominant hand, associated with tinea pedis.
tinea corpus
Refers to dermatophyte infection of the trunk, arms, legs and/or neck, excludes feet, hands and groin.
tinea capitis
Capable of invading the hair follicles and shaft. Appearance may vary, with mild scaling and broken-off hair, to severe painful inflammation with boggy, nodules draining pus, resulting in scarring and alopecia.
cutaneous candidiasis
- skin folds
- treated with nystatin
- at risk: diabetes, systemic alterations in immunity, use of broad spectrum antibiotics.
impetigo
- infection caused by staph or strep.
- Itching is only symptom.
- *honey comb colored lesions
- common in kids
herpes simplex
primary or recurrrent often appears as clustered vesicles on an erythematous base or keratinized skin or MM.
herpes zoster
acute dermatomal infection associated with reactivation of varicella-zoster characterized by unilateral pain and vesicular or bullous lesions limited to a dermatome. (shingles)
***can be eye emergency
herpes simplex details
- keratinocyte infection
- HSV 1 and 2
HSV2
Fever, lymphadenopathy, perineum pain
Grouped vesicles that ulcerate
Peri-anal lesions
Eruption lasts 18-21 days (8 if recurrent)
Recurrent usually less painful and shorter
Need to distinguish from genital zoster
HARMM melanoma risk model
- hx previous melanoma
- age > 50
- reg dermatologist absent
- mole change
- male gender
ABCDE for lesions
A (asymmetrical) B (borders) irregular C (color) is it changing or multicolored D (diameter) > ½ cm *head of an eraser E (elevation)- is it enlarging?
basal cell carcinoma
translucent nodule, firm border with depressed center
Normally on sun exposed areas
Very common
squamous cell carcinoma
firm scale; often face or back of hand
scaly!
actinic keratosis
pre-cancerous squamous cell
-white scale
malignant melanoma
- irregular, can be dark
- blacks can get this in nail
- can be anywhere on body
leukonychia
white lines or dots, harmless
mees lines
white bands across, can be metal poisoning
beaus lines
indentations, can be from DM, PVD, zinc deficiency
pitting nails
common in psoriasis
skin disorders assoc with crohns and UC
erythema nodusum, pyoderma gangrenosum, aphthous ulcers
skin disorders associated with diabetes
-diabetic dermopathy, acantosis nigraicans, necrobiosis lipoidica diabeticorum
comprehensive health history
- patient identifiers
- reliability
- chief complaint
- HPI, PMH, FH, SH, ROS
OLDCART
part of HPI
-onset, location, duration, character, aggravating, relieving, treatment
PQRST
part of HPI
-Precipitating/palliative factors, Quality/quantity, Region/radiation/related symptoms, Severity, Timing
purpose of HPI
symptom analysis
chief complaint
expressed in pts own words, quote them, reason for visit
PMH
- childhood/adult illness
- allergies, meds
- hospitalizations, injuries
- vaccines, screening exams
- psych/mental health issues
FH
Major illnesses and health status of relatives- ask about age, health status, and presence or absence of blood relatives. Ask specifically about cancer (what kind), HTN, stroke, MI, CAD, neurologic disorders such as epilepsy, Huntington’s disease, dementia, DM, TB, asthma and allergic disorders, arthritis, anemia, thyroid disease, mental illness
Genetic defects- CF, Tay-Sachs, beta thalassemia, hemophilia
Deaths-note cause of death and relationship to pt.
Ethnicity
SH
-relationship status, education, occupation, housing, safety, diet, exercise, sleep, drug alc use, stress, military service
ROS
- list of questions you ask about each system
- chart peritinent pos and negs
general ROS questions
wt. changes, fever, chills, night sweats, changes in appetite, energy level, exercise tolerance, ability to carry out usual ADLs
skin ROS
Any changes including- rashes, itching, pigment changes, moisture or dryness, changes in texture, changes in color, shape of moles, changes in nails, hair growth or loss
eye ROS
any injuries, double vision, changes in acuity, sudden loss of vision, tearing or dryness, blind spots, floaters or seeing spots, eye pain, inability to see at night, photophobia, haloes around lights.
ear ROS
pain, discharge, injury ( including barotrauma), changes in hearing acuity, tinnitus, balance problems, frequency & severity of ear infections, care of ears, including wax removal.
nose ROS
nosebleeds, colds, obstruction, discharge (color & quantity), changes in sense of smell, polyps, sneezing, PND.
mouth/throat ROS
dental problems, lesions, gum problems, bleeding, dentures, adequacy of saliva, hoarseness, dysarthria, sore throats (frequency, severity & duration), changes in tongue appearance, sense of taste. Neck stiffness, pain or tenderness, masses in thyroid, lymph nodes, or other areas.
CV ROS
Chest pain, substernal discomfort, palpitations, syncope, DOE, orthopnea, paroxysmal nocturnal dyspnea, edema, cyanosis, HTN, heart murmurs, varicose veins, phlebitis, claudication, hemoptysis, coldness or color changes in extremities.
Respiratory ROS
Pain (associated with location, quality, relation to breathing, SOB, dyspnea, wheezing, stridor, cough-note time, of day, +sputum production (amount, color), hemoptysis, respiratory infections, TB exposure or infection, fever, night sweats, recent CXR if applicable.
GI ROS
Appetite, dysphagia, indigestions, food intolerance, abdominal pain, heartburn, eructation, nausea, vomiting, hematemesis, jaundice, polyps, constipations, diarrhea, abnormal stools ( change in color, odor, clay or tarry colored, bloody), flatulence, hemorrhoids, recent change in bowel habits.
GU ROS
urgency, frequency, dysuria, colicky pain in flanks, suprapubic pain, facial swelling, nocturia, hematuria, polyuria, oliguria, unusual color or odor of urine. History of stones, infection, nephritis, hernia, hesitancy, changes in force of stream, dribbling, acute retention or incontinence, change in libido, potency, genital lesions, discharge, STIs.
breast ROS
Ask about breast masses or lumps, lesions, tenderness, swelling, nipple discharge, dimpling/retraction, BSE. Remember breast cancer can occur in men as well as women.
musculoskeletal ROS
pain, swelling, redness, heat of muscles, or joints; bone deformity, limited movements, muscle weakness, atrophy, or cramps.
neuro ROS
any headaches, lightheadedness, seizures, paralysis, incoordination, sensory changes, changes in mentation, loss of consciousness, difficulty with memory, or speech, motor disturbances, changes with balance, irregular movements or tremors.
mental ROS
mood changes, emotional problems, anxiety, depression, including suicidal ideation, if appropriate, difficulty with concentration, previous psychiatric care, unusual perceptions, hallucinations.
hemo ROS
anemia, abnormal bleeding or bruising, clotting disorders, history of transfusion, reactions?
endo ROS
polyuria polydipsia, polyphagia, unexplained weight changes, changes in texture of hair, skin, changes in hair distribution, changes in energy, appetite, thyroid enlargement or tenderness, changes in hat, glove, or shoe size, changes in secondary sex characteristics, intolerance to heat or cold.
percussion can tell you
Density (air, fluid, solid)
Size and shape
Tenderness
Deep tendon reflexes
percussion sounds
- resonance- normal lungs
- hyper-resonance- COPD
- dull- organs
- flat- muscle or soft itssue
- tympany- abdomen
