Exam 2 Flashcards
HEENT, CV, PV, Thorax and Lungs
Erb’s point
3rd ICS on the left sternal border
best heard in the left lateral recumbent position
Mitral area
Also apex of the heart, best auscultated on the 5th ICS, at MCL
S3 - other name, best heard
common in? pathologic in?
causes?
Best heard with bell of stethoscope in the mitral/apical area, in early diastole, with person in left lateral decubitus position
- When rapid filling ends and slow filling starts
A PHYSIOLOGIC S3 is common in young people (to age 35-40), last trimester of pregnancy, and athletes In older people, may be associated with volume overload
A PATHOLOGIC S3, or ventricular gallop, is abnormal in people over age 40 (high ventricular filling pressures and abrupt deceleration of inflow across the mitral valve at the end of rapid filling phase of diastole)
Causes include decreased myocardial contractility, HF and ventricular volume overload from aortic or mitral regurgitation, and left-to-right shunts.
KENTUCKY
S4 - other name, best heard
Atrial gallop
Occurs in late diastole, due to atrial contraction, right before S1, due to pressure overload
Heard in mitral/apical area, in left lateral recumbent position, with bell
May sometimes occur in people over 40 after exercise
However, almost always pathological including hypertension, aortic stenosis, and ischemic and hypertrophic cardiomyopathy.
TENNESSEE
“be lub dub” (s1 s4 s2)
S1 is louder than S2
At the apex (5th ICS at MCL)
S2 is louder than S1
At the base
Abnormal JVP # in cm’s
causes?
> 3 cm above the sternal angle or more than 8 cm in total distance above the right atrium
Elevated JPV 95% specific for: increased L ventiruclar end diastolic pressure and low L ventricular EF
May correlate with:
acute and chronic HF, tricuspid stenosis, chronic pulmonary HTN, SVC obstruction, cardiac tamponade and constrictive pericarditis.
Where JVP is best assessed
From pulsations in the RIJV, which is directly in line with the SVC and RA.
When to begin screening for cardiovascular risk factors
Age 20 for individual risk factors or “global” risk of CVD and for any family history of premature heart disease (age < 55 in first-degree male relatives and age < 65 in first-degree female relatives)
Atypical acute coronary syndrome symptoms in women
Particularly in age > 65, upper back, neck or jaw pain, SOB, PND, n/v, and fatigue
Carotid upstroke always occurs in…
systole immediately after S1 so sounds or murmurs coinciding with the upstroke are systolic, those after are diastolic
Grade 1 murmur
Very faint, heard only when listener is tuned in, may not be heard in all positions
Grade 2 murmur
Quiet, but heard immediately after placing the stethoscope on the chest
Grade 3 murmur
Moderately loud
Grade 4 murmur
Loud, with palpable thrill
Grade 5 murmur
Very loud, with thrill. May be heard when the stethoscope is partly off the chest
Grade 6 murmur
Very loud, with thrill. May be heard with stethoscope entirely off the chest
PMI best palpated…
when patient is in the left lateral decubitus position if not found in supine position, may help if s/he stops breathing while you check location, diameter, amplitude and duration
Lateral displacement toward the axillary line from ventricular dilatation is seen in HF, CMY and ischemic heart disease.
PMI diameter
< 3 cm or size of a quarter, occupies one interspace May feel larger in left decubitus position A diffuse PMI of > 3 cm may singal LV enlargement, > 4 cm LV overload 5 x more likely
PMI amplitude
- Brisk, tapping, diffuse or sustained?
- Normal: small in diameter and brisk and tapping
- Abnormal: one example - hyperkinetic high-amplitude impulse occurs in hyperthyroid, severe anemia, pressure overload of LV from HTN or AS, or volume overload of the LV from AR
PMI duration
- Normal: Lasts through 2/3 of systole or less
- Abnormal: example, sustained high-amplitude impulse may indicate LVH
Stethoscope DIAPHRAGM
better for picking up high-pitched sounds of S1 and S2, murmurs of aortic and mitral regurgitations and pericardial friction rubs
Stethoscope BELL
more sensitive to low-pitched sounds of S3 and S4 and the murmur of mitral stenosis
Auscultating for MITRAL STENOSIS
Pt in left lateral decubitus position, place bell of stethoscope lightly on the apical impulse (may also hear S3 and S4 and mitral murmurs)
Auscultating for AORTIC REGURGITATION
Pt sits up, leans forward, exhales completely and stop breathing after exhalation. Place diaphragm on the left sternal border and at the apex, pausing so that patient can breathe
Split S1
Delayed closure of the tricuspid valve, best heard in the lower left sternal border
Is not affected by respiratory cycle
Diastolic murmurs
usually represent valvular heart disease
Systolic murmurs
may correlate with valvular heart disease but can be physiologic flow murmurs arising from normal heart valves
Murmur of aortic stenosis radiates to
carotids, down left sternal border, even to apex (if severe = radiates to 2nd and 3rd interspaces)
carotid upstroke is delayed
intensity, soft but can be loud (4/6 or more)
Murmur in mitral regurgitation radiates to
left axilla
Murmur descriptors
- S - Site: location of maximal intensity
- C - Characteristic: Crescendo, descrecendo, crescendo-decresendo, plataeu
- R - radiates?
- I - intensity (grades) 1-6, 4-6 requires thrill
- P - pitch: high, medium, low
- T - Timing - systolic or diastolic
Fully described murmur
best heard in the 4th left interspace
blowing decrescendo
with radiation to the apex (aortic regurgitation)
grade 2/6
medium-pitched
diastolic murmur
Peripheral artery disease defined
as atherosclerotic disease distal to the aortic bifurcation, some guidelines also include the abdominal aorta
Key components of Peripheral Arterial Exam
- measure BP in both arms
- palpate carotid upstroke, auscultate for bruits
- auscultate for aortic, renal and femoral bruits, palpate the aorta and assess its maximal diameter
- Palpate the pulses of brachial, radial, ulnar, femoral, popliteal, DP, and PT arteries
- Inspect ankles and feet for color, temp, skin integrity
Signs of heart failure in infants
tachypnea, tachycardia and hepatomegaly
Noncardiac Signs of cardiac disease in infants
- Poor feeding
- FTT
- Irritability
- Tachypnea
- Hepatomegaly
- Clubbing
- Poor overall appearance
- Weakness
- Fatigue
Split S2 in neonates
Detected in silence or when baby asleep
Its detection eliminates many, but not all, of the more serious congenital cardiac defects
S3 - Third heart sounds in children
Represent rapid ventricular filling
Normal in children
Should be differentiated from third heart sound gallop (pathologic)
Fourth heart sounds in children
NOT common
Suggest HF
Murmurs in infants
Benign if not other non-cardiac signs present, disappear by age 1 year
Pathological with other physical findings
Coarctation of the aorta
Blood pressure is lower in legs than arms (when normally, BP in legs should be higher in arm)
Still’s murmur
- Grade 1-2/6
- Benign murmur present in pre-school or school age children -
- musical, vibratory, early and midsystolic murmur with multiple overtones located over mid or lower LSB; carotic artery compression will usually cause the precordial murmur to disappear.
- Extremely variable; accentuated with exercise
- May be heard with a carotid bruit which may be eradicated with carotid artery compression
Examples of pathological murmurs that appear in infancy and childhood
Aortic stenosis (systolic, crescendo-decrescendo, aortic area),
and Mitral Valve Disease e.g. MR, MVP, MS
MR - systolic, pansystolic, mitral area
MV prolapse - systolic, midsystolic click with late systolic murmur, mitral area
MS - diastolic, opening snap plus mid-diastolic rumble, mitral area
Benign murmur in adolescents
pulmonary flow murmur (chronic anemia or following exercise)
Pneumatic otoscope
tool that allows to assess mobility of the tympanic membrane
Rinne test
Compares bone conduction and air conduction and determines whether hearing loss is conductive vs. sensorineural
Normal: Air conduction > bone conduction
Conductive loss: Bone conduction >= to air conduction in bad ear
Sensorineural loss: AC > BC in both good and bad ears
hypertensive retinopathy
vascularity cross over into cup and disc
Recommendations of flu vaccine
Should be prioritized for pregnant and postpartum women, residents of nursing homes and LTC facilities, American Indians and Alaska natives, healthcare personnel, and household contacts less than/equal to 5 and greater than/equal to 50
left homonymous hemianopsia
can’t see on left side on both eyes
Recommendations of pneumonia vaccine
65 and older,
19-64 smoker or asthma,
2+ who are immunocompromised
residents of nursing homes or LTC facilities
adults 2-64 years with SCD, CV and pulmonary disease, DM, ETOH, cirrhosis, cochlear implants and leaks of CSF
paroxysmal nocturnal dyspnea
cardiac in nature, sob at night which is relieved by sitting up
pupillary responses
convergence, accomodation, the near reaction and the light reaction
LDCT annual for lung CA
USPSTF vs American Cancer society
Per USPSTF: 50-80 year old with 20 pack year smoking hx or currently smoking or have quit w/in 15 years
Per American Cancer Society: 55-74 year old with 30 pack year or have quit w/in 15 years
STOP screening once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability to or willingness to undergo invasive diagnostic procedures or to have curative treatment
pneumonia
pain with deep inspiration, purulent sputum, fever
weber test
Test assesses for lateralization in unilateral hearing loss
Conductive Loss: Lateralizes to bad ear
Sensorineural Loss: Lateralizes to good ear
aortic stenosis
midsystolic murmur, diminished S2, thrill transmitted to the carotid artery from the 2nd intercostal space
papilledema
bulging disc, related to high ICP
rib fracture
Upon examination, with one hand on the sternum and the other on the thoracic spine, the FNP squeezes the chest. This results in the patient’s local pain (distant from your hands)
heart failure: JVP measurement, carotid upstrokes and sound over carotid
JVP is 5 cm, carotid upstrokes are brisk, bruit is heard over carotid artery
Screening recommended for athletes
screening for risk factors and family history, history and physical
no imaging needed unless significant risk factors noted on exam
Heart failure with LVH
sustained PMI, elevated JVP, isolated systolic hypertension, widened pulse pressure
carotid upstroke/downstroke (or contour of the pulse wave)
Pressing inside the medial border of a relaxed SCM muscle, at the level of the cricoid cartilage while slowly increasing pressure until you feel a maximal pulsation; then slowly decrease pressure until you best sense the arterial pressure and contour will allow to assess this
croup
2 day history mild rhinorrhea, low grade fever, cough worse early in AM, inspiratory stridor, positive Hoover’s sign (indrawing of the chest wall)
Also known as laryngotracheal bronchitis usually due to viral cause
epiglottitis
child sitting stiffly in tripod position, difficulty swallowing saliva, sore throat, rarely seen thanks to the Hib vaccine
mitral valve prolapse
often preceded by midsystolic click with late systolic murmur, persistent til 2nd heart sound
best heard in mitral area
The setting sun sign
occurs with hydrocephalus when anterior fontanelles is bulging and eyes are deviated downward revealing upper scleras
substernal retractions
types of retractions
early systolic ejection sounds
Occur shortly after S1 Relatively high in pitch - best heard with diaphragm
Aortic ejection sound - heard at base and apex (louder), does not vary with respiration - indicative of dilated aortic, aortic valve disease or a bicuspid aortic valve
Pulmonic ejection sound - heard best in LEFT 2nd and 3rd ICS - intensity decreases with inspiration - indicative of dilatation of PA, pulm HTN, and pulmonic stenosis.
Systolic clicks
usually caused by MVP
Clicks are usually mid- to late-systolic
Heard medial to apex or at the left sternal border - heard best with diaphragm - may be followed by late systolic murmur from mitral regurg that crescendos up to S2
Squatting delays the click and murmur due to increased venous return.
Standing moves them closer to S1
Opening snap
MITRAL STENOSIS
Heard very early diastolic sound caused by abrupt deceleration during opening of a stenotic MV
Best heard medial to apex and along lower LSB
High pitch and snapping quality
Heard best with diaphragm
AHA CV Risk Categories for Women HIGH
>=1 of CHD, CVD, PAD, AAA, DM or ESRD or 10-year predicted risk of > 10%
AHA CV Risk Categories for Women AT RISK
- >=1 major risk factor incl smoking, bp >=120/>=80 or treated HTN, total cholesterol >= 200, HDL < 50 or treated dyslipidemia obesity, poor diet, physical inactivity or family hx of premature CVD
- evidence of advance subclinical atherosclerosis, metabolic syndrome or poor exercise capacity on a treadmill test
- systemic autoimmune collagen vascular disease e.g. lupus or rheumatoid arthritis
- history of preeclampsia, GD, pregnancy-induced HTN
AHA CV Risk Categories for Women IDEAL
- Total (untreated) cholesterol < 200
- (untreated) BP < 120/80
- (untreated) FBG < 100
- BMI < 25
- Non-smoking
- Physical activity: 150 minutes per week moderate intensity or 75 minutes/week vigorous intensity or combo
- Healthy diet
Cyanotic heart diseases
DANGEROUS Pulmonary artery stenosis Pulmonary atresia Tetralogy of Fallot Tricuspid atresia Trunkus arteriosus Hypoplastic left heart syndrome Transposition of great arteries
Acyanotic heart diseases
OK PDA Atrial septal defect Ventricular septal defect Coarctation of aorta Aortic stenosis Pulmonary artery stenosis (mild) PFO - may remain open after birth
Identify this Eye Picture
Papilledema
Swelling of the optic disc and anterior bulging of the physiologic cup
a/s with IICP
Name this Eye Picture
Glaucomatous cupping
Death of optic nerve fiblers leads to loss of the tiny disc vessels
Increased intraocular pressure within eye leads to increased cupping (backward depression of the disc) and atrophy.
The base of the enlarged cup is pale.
Name this Eye Photo
Normal
Color yellowish orange to creamy pink
Disc vessels tiny
Disc margins sharp (except perhaps nasally)
Physiologic cup is located centrally or somewhat temporally. It may be conspicuous or absent. Its diambeter from side to side is usually less than half that of the disc.
Name this Eye Photo
Hypertensive retinopathy
Marked arterial-venous crossing changes are seen, especially along the inferior vessels. Copper wiring of the arterioles is present.
Other possible characteristics are Concealment or AV nicking, banking, and tapering
Name this Eye Photo
Diabetic retinopathy
deep retinal hemorrhages; microaneurysms and neovascularization (new blood vessels)
soft exudates: cotton wool spots (diabetes)
hard exudates
Name this Eye Photo
Drusen
Yellowish round spots that vary from tiny to small.
Edges may be soft or hard.
They are haphazardly distributed.
Seen in normal aging and age-related macular degeneration.
Name this Eye Photo
Esotropia (intermittent alternating convergent strabismus)
Developmental disorder
Usually appears in early childhood
[Note: exotropia is intermittent alternating DIVERGENT strabismus]
Name this visual field defect
Left homonymous hemianopsia
A complete interruption of fibers in the optic radiation, produces a visual defect similar to that produced by a lesion of the optic tract
Coarctation of aorta
Blood pressure of upper extremities is higher than blood pressure in lower extremities
Conductive hearing is caused by
“conducting bad behavior”
Hearing disorders of external and middle ear such as:
Cerumen impaction, infection (otitis externa), trauma, SCC and benign bony growths such as exostoses or osteomas.
Middle ear disorders include otitis media, congenital conditions, cholesteatomas and otosclerosis, tumors and perforation of the TM.
Weber: Lateralizes to bad ear
Rinne: bone conduction is equal or longer than air conduction
Sensorineural hearing loss is caused by
disorders of the inner ear from congenital and hereditary conditions such as
presbycusis, viral infections such as rubella and cytomegalovirus, Meniere disease, noise exposure, ototoxic drug exposure and acoustic neuroma.
Weber test: sound lateralizes to good ear
Rinne test: sound is heard longer through air (AC > BC)
Anxiety with hyperventilation: symptoms and relieving factors
Sighing, lightheadedness, numbness or tingling of the hands and feet, palpitations, chest pain
Other possible manifestations: chest pain, diaphoresis, palpitations
Relieving factors: breathing in and out of a paper or plastic bag may help
Intermittent claudication
Pain or cramping in legs during exertion that is relieved by rest within 10 minutes
Caused by narrowing or blockage in the main artery taking blood to your leg due to hardening of the arteries (atherosclerosis).
Usually in age 50+, with higher incidence in smokers, those who have diabetes, heart diease or elevated cholesterol.
Tx: Modification of risk factors, exercise, e.g. structured walking program, medications, angioplasty, bypass surgery
Neurogenic claudication
Pain with walking or prolonged standing
Radiating from the spinal area into the buttocks, thighs, lower legs or feet
Is a type of intermittent claudication
Carotid upstroke is delayed in…
aortic stenosis
Carotid pulse is bounding in…
aortic regurgitation
Carotid pulse is small, thready or weak in…
cardiogenic shock
Carotid bruit indicates…
aortic stenosis, mitral regurgitation, PDA or coarctation of the aorta
Rhinosinusitis s/s
purulent nasal drainage, facial pain increases with valsalva maneuvers and leaning forward
Pupillary light reactions
direct light reaction, consensual reaction to light
CN II, CN III
Absence of red reflex indicates
opacity of the lens (cataract), vitreous, and less commonly, detached retina
or, in children, retinoblastoma
Opthalmoscope settings
0: to view fundus
+10 or +12: to view anterior structures such as vitreous and lens
Leukoplakia
A thickened white patch occurring anywhere in oral mucosa. This benigh reactive process of the squamous epithelium may lead to cancer and should be biopsied.
Diffuse enlargement of the thyroid can be caused by…
Graves disease, Hashimoto thyroiditis, and endemic goiter
Where is stridor the loudest?
over the neck
S1 sound indicates…
indicates closure of the mitral valve
S2 sound indicates…
closure of the aortic valve
Sudden dyspnea occurs in…
PE, spontaneous PTX and anxiety
Xiphoid process is most prominent in…
newborns and young infants
Newborn or child with possible abnormal facies, carefully review…
- family history
- pregnancy
- perinatal history
Pneumonia in infants s/s
abnormal work of breathing (nasal flaring, grunting, retractions), fever, tachypnea, dyspnea, plus abnormal findings on auscultation such as crackles rule in PNA
Best symptom in ruling OUT pneumonia: absence of tachypnea
[Note: rhonchi indicate upper respiratory infections and wheezing occur normally in asthma or bronchiolitis]
PDA or patent ductus arteriorosus s/s
continuous murmur begin in systole into diastole (s2), with silent interval late in diastole
due to hole
associated with hyperdynamic precordium and bounding distal pulses
In infants/children,
a true gallop rhythm s/s
tachycardia plus a loud S3, S4 or both
Pathologic and indicate HF (poor ventricular function)
Children: Adenoidal hypertrophy
Nasal voice plus snoring
Children: hypernasal speech
submucosal cleft palate
Children: hoarse voice plus cough
viral infection (croup)
Childhood asthma s/s
Increased work of breathing, expiratory wheezing and a prolonged expiratory phase.
Wheezes are often accompanied by inspiratory rhonchi.
Asthma flares often occur with viral infections.
In pediatric population
4th heart sounds represent decreased ventricular compliance, suggesting heart failure
chest pain: angina pectoris
location?
quality?
problem r/t to?
timing?
aggravate?
factors that relieve?
symptoms?
- retrosternal, anterior chest, radiates to shoulders, armss, neck, lower jaw, upper abdomen
- quality: pressing, squeezing, heavy, burning
- problem: cardiovascular
- severity: mild - moderate ; discomfort rather than pain
- timing: 1-3 mins but up to 10 mins; can be up to 20 mins
- aggravate: exertion, colds, meals, emotional stress, at rest
- relieve: rest, nitroglycerin
- sx’s: dyspnea, nausea, sweating
fist over sternum
chest pain: mycardial infarction
problem r/t to?
location?
quality?
timing?
aggravate?
factors that relieve?
symptoms?
- cardiovascular
- retrosternal or chest radiating shoulders, arms, neck, lower jaw, upper abdomen
- pressing, squeexing, tight, heavy, burning
- severity: not always a severe pains
- 20 mins to few hrs
- not always triggered by exertion
- not relieved by rest
- sx’s: dyspnea, nausea, vomiting, sweating, weakness
chest pain: pericarditis
problem r/t to?
location?
quality?
timing?
aggravate?
factors that relieve?
symptoms?
- cardiovascular
- retrosternal or left precordial, radiate to tip of left shoulder
- sharp, knife like
- severe
- persistent
- aggravate: breathing, changing positions, coughing, lying down , swallowing
- seen in autoimmune, post MI, viral infection, chest irradiation
chest pain: aortic dissection
problem r/t to?
location?
quality?
timing?
aggravate?
factors that relieve?
symptoms?
- cardiovascular
- anterior or posterior chest, radiating to neck, back or abdm
- ripping, tearing
- very severe
- abrupt onset, early peak, hrs +
- aggravate: HTN
- no relief
- sx’s: if thoracic, Hoarseness dysphagia, also syncope, hemiplegia, paraplegia
chest pain: pleuritic pain (inflamm of parietal pleura)
problem r/t to?
location?
quality?
timing?
aggravate?
factors that relieve?
symptoms?
- pulmonary
- chest wall
- sharp, knife like
- severe
- timing: persistent
- aggravate: deep inspiration, coughing, movements of trunk
- no relief
- sx’s: underlying illness
What etiology? Dyspnea:
- dyspnea progresses slowly
- aggravate: lying down, exertion
- relief: rest, sitting up, dypnea may be persistent
- sx’s: cough, orthopnea, paroxysmal nocturnal dyspnea; wheezing
- setting: hx of heart disease or predisposing factors
Left sided heart failure (L ventricular failure or mitral stenosis)
- elevated pressure in pulmonary capillary bed w/ transduction of fluid into interstitial spaces and alveoli, decreased compliance (increased stiffness) of lungs, increased work of breathing
What etiology? Dyspnea:
- chronic productive cough then slow progressive dyspnea
- aggrevate: exertion, inhaled irritants, respiratory infections
- relief: expectoration; rest, though dyspnea persistent
- sx’s: chronic productive cough, recurrent respiratory infection, wheezing
- setting: hx of smoking, air pollutants, COPD
chronic bronchitis
- excessive mucus production in bronchi, after chronic obstruction of airways
What etiology? Dyspnea:
- slowly, progressive dyspnea, mild cough later
- aggravate: exertion
- relief: rest, dyspnea peristent
- sx’s: cough with scant mucoid sputum
- setting: hx smoking, air pollutants
COPD
- overdistention of air spaces distal to terminal bronchioles, with destruction of alveolar septa, alveolar and limitation of expiratory air flow
What etiology? Dyspnea:
- acute episodes, then sx’ free periods; nocturnal episodes
- aggravate: allergens, irritants, respiratory infxns, exercise, cold, emotions
- relieve: remove irritants
- sx’s: wheezing, cough, chest tightness
- setting: environmental
asthma
- reverisble bronchial hyperresponsiveness; release of inflammatory medaitors, increased airway secretions, bronchoconstriction
What etiology? Dyspnea:
- progessive dyspnea; varies on the cause
- aggravate: exertion
- relief: rest; dyspnea persistent
- sx’s: weakness, fatigue, (less common: cough)
- setting: varied
diffuse interstitial lung diseaes
(sarcoidosis, widespread neoplasms, idiopathic pulmonary fibrosis, asbestosis)
- abnormal & widespread infiltration of cells, fluid, collegen into interstitial spaces b/t alveoli; many causes
What etiology? Dyspnea:
- acute illness, timing depends on cause
- aggravate: exertion, smoking
- relief: rest, persistent dyspnea
- sx’s: pleuritic pain, cough, sputum, fever (may not be present)
pneumonia
- infection of lung parenchyma from respiratory bronchioles to the alveoli
What etiology? Dyspnea:
- sudden onset of tachypnea, dyspnea
- aggravate: exertion
- relief: rest, persistent dyspnea
- sx’s: none, retrosternal oppressive pain if massive occlusion, pleuritic pain, cough, syncope, hemoptysis, and/or unilateral leg swelling and pain from instgating DVT, anxiety
- setting: PP or post op; prolonged bed rest, HF, chronic lung disease, fractures of hip or leg, DVT, hypercoagulability, heredity or acquired (hormone therapy)
acute pulmonary embolism
- sudden occlusion of part of pulmonary arterial tree by blood clot that usually originates in deep veins of legs or pelvis
What etiology? Dyspnea:
- episodic
- aggravate: rest
- relief: breathing in & out of paper bag
- sx’s: sighing, lightheadedness, numbness or tingling of hands and feet, palpitations, chest pain
- other manfestations of anxiety: chest pain, diaphoresis, palpitations
anxiety with hyperventilation
- overbreahing, with resultant respiratory alkalosis and fall in aterial partial pressure of carbon dioxide (pCO2)
exotosis: non malignant overgrowth blocking tympanic membrane
tophi: deposit of uric acid crystals form chronic tophaceous gout
- hard nodules in helix or antihelix
chalky white
can be on joints, hands
cutaneous cyst aka sebaceous cyst
dome shape lump in dermis forms a benign closed firm sac to epidermis
basal cell carcinoma (teletangectious (tiny blood vessels)
in fair skin, overexposed to sunlight
rheumatoid nodule
- chronic RA, look for small lumps on helix or antihelix and nodules on hands and ulnar to elbow, knees, heels
ulceration from repeated injuries
preauricular skin tags/cysts
common
a/s with hearing deficits and/or renal problems
preauricular sinus/pit
a/s hearing loss, renal deveelopment issues (SCREEN & repeat screening!)
assess kidney
normal TM
pinkish gray; malleus behind upper drum
perforation of tympanic membrane
- from infxn of middle ear
TM becomes scarred ; discharge may drain out; pain relief once perforates
tympanosclerosis
scarring process of middle ear form otitis media from hyaline, Ca, phosphate crystal deposits in TM and middle ear
serous effusion
- viral upper respiratory infection (otitis media w/ serous effusion) or sudden changes in atmospheric pressure from flying or diving (otitic barotrauma) = eustachian tube can’t equalize air pressure in middle to outer ear
- amber fluid; air bubbles
acute otitis media with purulent effusion
- S. pneumoniae or H influenzae
sx: earach, fever, hearing loss
TM reddens, loses landmarks, bulges laterally towards eye
bullous myringitis
- painful hemorrhagic vesicles appear on TM, ear canal or both
sx’s: earach, blood tinged discharge from ear and conductive hearing loss
bulla on TM
- caused by mycoplasma, viral and bacterial otitis media
acute otitis externa
- red bulging TM; amber serous effusion
swimmers ear, common in diabetics, tug test +
esotropia
inward deviation
exotropia
outward deviation
exophthalmus
bulging out, permanent
hyperthyroidism
Examining the optic disc and retina
- locate optic disc (yellow/orange)
- sharp focus: adjust lens, if no refractive error for both, should be 0 diopters (if nearsighted = minus diopers, if far sighted = plus diopters)
- inspect optic disc for sharpness, color, size of central cup, comparative symmetry
how to use opthalmoscope
- dark room
- turn focusing wheel to 0 diopter (which neither converge or diverge lights)
- hold scope in RIGHT hand with MY RIGHT eye to see pt’s RIGHT eye (vise versa to L eye)
- hold scope against medial aspect of my bony orbit with handle 20 degrees slant form vertical
- tell pt look up and over my shoulder and point on the wall
- i’m 15 inches away and 15 degrees lateral to pt’s line of vision
geographic tongue
- benign condition
- scattered smooth red areas denuded of papillae, with normal rough and coated areas
map like pattern that changes over time
fissured tongue
- appear with increasing age
“furrowed tongue”
food gets stuck and irritates
benign
candidiasis
- thick white coat from candida infection
- raw red surface was scraped off
infxn can occur w/o white coating
seen in immunosuppression from chemotherapy or prednisone therapy
black harry tongue
- associated with candida and bacterial overgrowth, antibiotic therapy, poor dental hygiene
can occur spontaneously
smooth tongue (atrophic glossitis)
- lost its papillae, sometimes in patches
- deficiency in riboflavin, niacin, folic acid, vitamin B12, pyridoxine, iron, or treatment to chemotherapy
oral hairy leukoplakia
- whitish raised asymptomatic plaques with feathery or corrugated pattern, on sides of tongue
CAN’T be scraped off
caused by Epstein barr virus, HIV, AIDS
varicose veins
- small purplish or blue/black round swellings under tongue with age
dilatations of lingual veins
no clinical significance
mucous patch of syphyilis
- painless lesion secondary to syphilis
highly infectious
slightly raised, oval, covered by grayish membrane
multiple or elsewhere in mouth
tori mandibularis
- rounded bony growths on inner surfaces of mandible
bilateral, asx, harmless
aphthous ulcer (canker sore)
- painful, shallow whiteish gray oval ulceration with halo of reddened mucosa
single or multiple
heals in 7-10 days but can recur in behcet disease
leukoplakia
- peristent painless white patches in oral mucosa, undersurface of tongue white
patches any size raise sus of SCC! NEED BX
carcinoma, floor of mouth
- ulcerated lesion common in carcinoma
red area medially (erythoplakia) = malignancy (biopsy!!)
nasal abnormalities
ulcers or nasal polyps (pale, sac like growths of inflamed tissue that obstruc tthe air passage or sinuses; seen in allergic rhinitis, aspirin sensitivity, asthma, chronic sinus infections, CF)
pale boggy nasal mucous membranes are found in children with
allergic rhinitis
purulent rhinitis is common in what type of infections?
viral infections
in young preschool children, foul smelling, purulent, unilateral discharge from nose may be due to
foreign body
more likely to stick objects into body orifices
signs of sinusitis in children
- purulent rhinorrhea > 10 days
- worsening course
- severe sx’s, high fever, purulent rhinorrhea > 3 days
headache, sore throat, tenderness over sinuses on percussion or palpation
Describing retractions
supraclavicular, intercostal, substernal, subcostal
chondrodermatitis: chronic inflammatory lesion
need bx to rule out carcinoma
common in bed bound pt’s
starts out as painful tender papule on helix or antihelix
in newborns and young infants, nasal flaring can mean
upper respiratory infection
pneumonia
serious respiratory infection
nasal flaring + grunting + tachypnea =
LOWER respiratory infection (anything lower than vocal cords)
pneumonia, bronchiolitis
in infants, best findings to ruling IN pnemonia? ruling out?
ruling in pneumonia: increase breathing + crackles
ruling out: NO tachypnea
acute cough (< 3 weeks) causes
most common: viral upper respiratory infections (sputum translucsent, white, gray)
acute bronchitis, pneumonia, L sided HF , asthma, foreign body, smoking, ace inhibitor
subacute (3-8 weeks) cough causes
post infectious (lingering), pertussis, acid reflux, bacterial sinusitis, asthma
chronic (> 8 weeks) cough causes
smoking, post nasal drip, asthma, GERD, chronic bronchitis, bronchiectasis
attributes of a symptom
location, quality, quantity/severity, timing, onset (when did it start), duration, frequency, modifying factors, associated manifestations
influenza shots can be given ____ or older and should especially be given to those with:
nasal spray is only approved for what ages
_>_6 months
chronic pulmonary conditions, nursing home residents, > 50 years old, american indians and alaska natives, household contacts, health care, pregnant people
nasal spray: healthy 2-49 years old and not recc every year
chronic venous insufficiency
medial or lateral malleolus
ulcers that are small, brown painful granulation tissue and fibrin, necrosis
irregular borders, flat, slightly steep
arterial insufficiency
toes, feet, areas of trauma (ie: shins)
severe pain unless masked by neuropathy
decreased pulses, trophic changes, pallor on elevation
neuropathic ulcer
develops in pressure points with diminished sensation
diabetic neuropathy, neurologic disorders, hansen disease
no pain; unnoticed
decreased sensation and absent ankle jerks
