Final Exam Study Guide Flashcards
Barrel Chest
- Costal angle >90 degrees
- Equal AP to transverse diameter and ribs are horizontal instead of normal downward slope
- Normal aging and chronic emphysema and asthma
- Hyperinflation of lungs
Whispered Pectoriloquy
- Ask patient to whisper a phrase.
- Normal response - faint and muffled
- Abnormal - Heard loud and clear over areas of consolidation
Fine Crackles
- NOT CLEARED WHEN COUGHING
- High pitched, short, crackling sounds heard during inspiration
- Air collides against previously deflated airways
- When heard during late respiration - restrictive disease, pneumonia, heart failure
- Early during respiration - Obstructive disease, bronchitis, asthma, emphysema
Coarse Crackles
- Loud low pitched bubbling or gurgling
- Decrease with coughing and suction but will re-appear
- Pulmonary Edema, Pneumonia, depressed cough reflex
Atelectasis Crackles
- Sound like fine crackles but do not last
- Disappear with deep breathing and coughing
- Common with post-operative patients who are bedridden
High pitched wheeze
- Musical squeaking (polyphonic)
- Usually heard during expiration but also inspiration
- Air squeezed through narrow passageways
- Asthma and chronic emphysema
Low Pitched Wheeze
- Monophonic
- Somewhat cleared when coughing
- Airway obstruction
- Bronchitis, bronchus obstruction, airway tumor
Stidor
- High pitched monophonic crowing sound
- Louder in neck than over chest wall
- Heard without a stethoscope
- Caused by upper airway obstruction
- Croup
- Lodged foreign body
- Children (Acute epiglottis)
- No air being let in or out LIFE THREATENING
Pleural Friction Rub
- Superficial coarse and low-pitched
- Grating
- Inflamed pleura (loss of normal lubrication)
- When pain present - pleuritis
Bronchophony
- 99 test
- Normal - Muffled/indistinct sounds
- Abnormal
- Clear ninety nine means increased lung density
- (Sounds close to your hear)
Egophony
- EEEE Test
- You should hear EEE through the stethoscope
- If you hear aaaa sounds it means consolidation or compression.
Pneumothorax
- Free air in pleural space (partial or complete lung collapse
- Unequal chest expansion, tachypnea, cyanosis, apprehension
- Tactile fremitus decreased, tracheal shift to opposite side, chest expansion decreased on opposite side, tachycardia, decreased bp
- Hyperresonant
- Breath sounds decreased or absent, voice sounds decreased or absent
- No adventitious sounds
Normal Lung Sounds
Bronchial - Only heard on anterior. High pitch, loud, more prominent during expiration, harsh and hollow
Bronchovesicular - Sounds have moderate pitch and amplitude. Heard equally during inspiration and expiration. Mixed sounds
Vesicular - Low pitched soft sound during inspiration. Sounds like rustling in the wind
Heart Valve Sound Locations
Aortic Valve - Right side of heart second intercostal space (S2)
Pulmonic Valve - Left side of heart second intercostal space (S2)
Erb’s Point - 3rd-4th intercostal space (S1 and S2)
Tricuspid Valve - Left side of Sternum 4th - 5th intercostal space (S1)
Mitral Valve - Left Midclavicular line 5th - 6th intercostal Space (S1)
S4 Gallop
- Extra sound that occurs after before S1
- Always abnormal and indicates heart failure
- Left sided heard at apex in left lateral position
- Right sided heard at left lower sternal border.
- Occurs in older adults 40-50 with no evidence of cardiovascular disease
- Could indicate coronary artery disease, cardiomyopathy. Decreased compliance of ventricle
- Right sided could indicate pulmonary stenosis or pulmonary hypertension
Thrill
- Place palm gently over chest wall
- Slight vibration on the palm
- Indicates high pressure in the vessels
S2
- Loudest by the base of the heart
- Diastole
- Loudest in pulmonic and aortic valves
- Accentuated S2 means systemic hypertension
- Diminished S2 Shock or aortic/pulmonic stenosis
Murmurs
- Turbulent blood flow and collision currents
- Gentle swooshing sound that can be heard on the chest wall.
- Velocity of blood increases
- Viscosity of blood decreases
- S3 and S4 murmur of mitral stenosis only heard on left side
- Abnormal, described by timing, loudness, pitch, pattern, quality, location, radiation, posture.
S3 Sound and Heart failure
- Heard best in left lateral position
- Normal in Younger athletes and pregnant women
- Occurs with heart failure and volume overload
- Abnormal in older adults
Bruit
- Blowing or swishing sound indicated by blood flow turbulence.
- Auscultated in carotid artery and aorta of abdomen
Assessing for JVD
- Lie back in fowlers position with head turned to side
- Take a ruler and measure the height of the jugular vein from the surface of the neck
- JVD indicates hypervolemia due to congestive heart failure
GSC (Glasgow Coma Scale)
- Used to asses patients mental status or level of consciousness
- Assess functional state of brain as a whole by looking at eye movements, motor function, and speech
- 15 is best score, 7 or less is coma state (unable to maintain airway, should be intubated)
- If patient is awake, ask 4 questions to gauge if they are oriented
- If they answer correctly they are “alert and oriented x4”
Glasgow Coma Scale
Stool Color
- Black - Blood from iron intake or GI Bleeding
- Red - Blood in lower area of GI Tract
- Clay Color - Hepatitis, Liver, or Gallbladder Disease
Stool Examination
- Occult blood test via Guaiac Test or FIT
- FIT - liquid based test stores stool in hemoglobin-stabilizing buffer
- FIT is more sensitive than guaiac testing
Cover Test
- Tests for eye deviation
- Cover one eye at a time using a card for occlusion
- Uncovered eye jumps to fixate when stronger eye is covered
- When weaker eye is covered it drifts back into position
Abnormal Findings Cover Test
Esotropia - Inward turning of the eye
Exotropia - Outward turning of the eye
Phoria - Mild weakness
Tropia - Severe weakness
PERRLA
P - Pupils
E - Equal
R - Round
R - Reactive to
L - Light
A - Accommodation
PERRLA (cont)
- Penlight to assess pupillary light reflex
- Normal response should be constriction of pupils when light is shined. Also tests CN 3
- Check that responses of eyes are equal
- Check accommodation - pupils dilate when looking at distant objects, pupils constrict when looking at objects near their nose. Older adults have difficulty with accommodation
Corneal Light Reflex
- Tests parallel alignment of the eye axes.
- Shine light into patients eyes and light should reflect in the same spot in each eye.
- Abnormal findings include esotropia and exotropia (strabismus/tropia)
Snellen Chart
- Assesses Visual Acuity
- Normal is 20/20
- 20/40 means you can see at 20 feet what normal people can see at 40 feet
Confrontation Test
- Best test for visual fields and peripheral vision
- Peripheral vision is compared against your own
Basic Bedside Daily Assessment
- General appearance - facial expression, body position, skin color, nutritional status, speech, hearing, personal hygiene
- Vital signs - Temp, pulse, respirations, BP, pulse oximetry, pain
- Neurological - Eyes open to name, motor response, verbal response, pupil size, muscle strength, facial droop, sensation, communication, ability to swallow
Basic Bedside Daily Assessment
- Respiratory - Check oxygen mask is comfortable, Note FIO2, auscultate breath sounds, cough and deep breath, incentive spirometer
- Cardio - Auscultate rhythm at apex, check apical pulse against radial pulse, assess heart sounds, check capillary refill
- Skin - Color, temperature, turgor, skin integrity, iv sites, skin breakdown,
Basic Bedside Daily Assessment
Abdomen - Contour (flat, round, protuberant), bowel sounds, drains for color and amount, inquire about passing flatus or stool, knowing diet orders, ice chips
Genitourinary - Voiding regularly, check urine for color/clarity, foley catheter in place, urine output below the expected amount, bladder scan.
Basic Bedside Daily Assessment
- Elevate bed if patient is at high risk of skin breakdown
- Check TED Hose to see if it is in place
- Assist patient in ambulatory needs
- Check risk of falling
- Document assessments
- Note examination findings that require immediate attention
Nose Assessment
- Inspect/palpate
- Check symmetry, deformities, palpate for pain or break in contour, test patency. Absence of patency may mean obstruction. CN 1
- Check Nasal Cavity
- Color/texture of mucosa (pink/red smooth moist), note swelling or bleeding, observe septum for deviation, bleeding, note color of discharge.
- Green/yellow is purulent with rhinitis or sinusitis
- Chronic Allergies may be gray/swollen/pale
Nose Assessment (cont)
- Assess Sinus
- Palpate frontal sinuses by pressing up and under the eyebrows and over the maxillary sinuses below the cheek bone.
- Check for tenderness or pressure (allergies, sinusitis)
Abnormalities in the Throat
- Choanal Atresia - Membrane between nasal cavity and pharynx in newborns if bilateral can be emergent when bony septum obstructs airway
- Perforated septum
- Furuncle - Painful small boil from infection
- Nasal polyps - Skin sacs inside cavity that are painless
General Survey
- Physical Appearance - Age, sex, level of consciousness, skin color, facial features
- Body Structure - Stature, nutritional status, symmetry, posture, body build
- Mobility - Gait, foot placement, range of motion
- Behavior - Facial expression, mood and affect, speech, dress, hygiene
Lawton Instrumental Activities of Daily Living
- Determines most suitable living situation for an older adult.
- Includes use of telephone, shopping, meal preparation, housekeeping, laundry, transportation, self-medication, management of finances
- OARS-IADL (Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire)
- Prerequisite for independent living
- Useful for discharge planning in acute hospital and ongoing function in outpatient settings. Not useful for those residing in an institution because tasks are already being managed.
First Step of Assessment
- Health History
- Review of Systems
- Physical Assessment
- (Integumentary is assessed first)
Health History and Older Adults
- Biographical Data - Age, gender, DOB, Address
- Reason for seeking care
- History of present illness (why they came in)
- Medical history
- Family history
- Lifestyles/Social history
- Functional Assessment (ADL’s)
Health History Older Adults
- Consider normal aging changes, effects of chronic disease, heredity, lifestyle.
- ADL’s include - Eating, bathing, grooming, toileting, walking, transferring to bed or chair
- Instruments of Activities of Daily Living
- Functional assessment - Attention, Memory, Orientation, Language, Visuospatial skills, Higher cognitive function, Dementia, Delirium, Depression
Health History Social and Support
- Social - Relationships with family, social groups, community. Forms of formal and informal assistance
- Support - Informal is family and close friends. Formal is social welfare, social services, healthcare delivery agencies
Caregiver Assessment
- Burnout (signs of somatic complaints, increased stress/anxiety, social isolation, depression, weight loss)
- Sleep disturbances
- Depression
- Morbidity
- Increased mortality
Adduction
- Moving limb towards the midline of body
Costovertebral Angle Test
- Percussion of Kidneys
- Place hand over 12th rib at costovertebral angle on back
- Thump hand with fist
- Abnormal - Sharp pain which occurs with kidney inflammation
Abdominal Regions
RUQ - Liver, Gallbladder, Ascending Colon, Transverse Colon, Head of Pancreas
LUQ - Stomach, Transverse colon, Descending colon, Body of Pancreas
RLQ - Right Ureter, Cecum, Appendix, Right Fallopian Tube, Right Ovary appendix
LLQ - Descending Colon, Left Ureter, Sigmoid Colon, Left Fallopian Tube, Left Ovary
Abdominal Regions
Right Hypochondriac Epigastric Region
Right Lumbar Umbilical Region
Right Iliac Hypogastric Region
Assess Bowel Movements
- How often does the patient have bowel movements
- History of constipation (less than 3 stools a week)
- Most at risk include low calorie low fiber diet and older adults
- Changes in consistency of stool
- Color of stool
- History of steatorrhea (excess fat in stool)
- History of encopresis, stool incontinence
- Difficulty urinating
Palpating of the liver
- Begin palpating liver in the RUQ
- Place left hand under patients back parallel to 11th and 12th rib and lift up.
- Place hand parallel to midline and push deeply down under the right costal margin
- Ask patient to breathe slowly and with every exhale, move palpating hand up 1-2cm.
- Normal to feel liver bump fingers as diaphragm pushes it down during inhalation
- Liver should feel firm, regular ridge.
- Liver is often not palpable
Palpating of the liver
- Chronic Emphysema displaces the liver downward by hyperinflated lungs. If lower edge is well below the right costal margin the size is still normal. Liver more than 1-2 cm below the right costal margin is enlarged.
Palpating the liver
Hook Technique - Stand person up at shoulder and swivel body to the right so you face the persons feet. hook fingers over the costal margin from above. Ask person to take deep breath and try to feel liver edge bump your fingertips.
Ascites Assessment
- Percussion tests Fluid Wave
- Place patients ulnar hand on midline, place left hand on right flank and strike left flank with right hand. You will see a fluid wave and feel the tap on your left hand
- Percussion Shifting fullness test
- Percuss down the side of abdomen. If fluid is present the note will change from tympany to dull as you reach its level
Ascites Assessment
- Single curve, everted umbilicus, bulging flanks when supine. Increase in abdominal girth
- Tympani at top where intestines float, dull over fluid. Produces fluid wave and shifting fullness.
- Palpation - Taut skin and increased intra-abdominal pressure limit palpation.
Rebound Tenderness
- Testes for peritoneal inflammation (appendicitis)
- Blumberg Sign is a positive sign
- Assessed when patient reports abdominal pain or elicit tenderness during palpation
- Hold hand at 90 degrees to abdomen, push down slow and deeply then lift up quick.
- ABNORMAL - pain when lifting
ROM Shoulder
- Forward flexion of 180 degrees
- Hyperextension up to 50 degrees
- Internal rotation of 90 degrees
- Abduction of 180 degrees
- Adduction of 50 degrees
- External rotation of 90 degrees
ROM Knee
Bend Knee - Flexion of 130-150 degrees
Extend each knee - Straight line to 15 degree hyperextension
Check ROM During Ambulation
If able to squat try duck walk, shows intact ligaments and no effusion or arthritis
Musculoskeletal Assessment (Inspection)
- Inspect each joint
- Note size and contour
- Dislocation - Loss of contact between 2 bones
- Subluxation - Misalignment
- Contracture - Shortening of muscle
- Ankylosis - Stiffness or fixation of joint
- Presence of swelling signals joint irritation means effusion, inflammation, or bony enlargement
Palpation Musculoskeletal Assessment
- Temperature. Warmth and tenderness can mean inflammation
- Joints are not normally tender to palpate
- If tenderness occurs localize it
- Arthritis can limit active/passive ROM
- Synovial membrane usually not palpable but feels doughy and boggy when thickened
Grading Muscle Strength
Grade 5 - Normal
Grade 4 - Active against gravity with resistance
Grade 3 - Active against gravity with no resistance
Grade 2 - Active movement with gravity limited
Grade 1 - Only trace or flicker of movement
Grade 0 - No Movement
Shoulder
Shrug Shoulders, flex forward and up, abduct against resistance. (Cranial nerve 11)
Knee
McMurray’s test with report of trauma
- Patient should flex knee
- External rotate hip while pushing inward on knee
- Clicking means torn meniscus
DTR Findings and Responses
4+ - Very brisk hyperactive (disease)
3+ - Brisker than average (may indicate disease/normal)
2+ - Average, Normal
1+ - Diminished, low normal or only occurs with reinforcement
0 - No Response
DTR Findings and Responses
Bicep - Strike blow on your thumb, contraction and flexion of forearm
Triceps - Extension of forearm
Brachioradialis - Flexion and supination of forearm
Quadriceps - Extension of lower leg
Achilles - Foot plantar flexes against hand
Cerebellum
- Coordination and voluntary movements. Coordinates smooth movements.
Coordination Tests
Rapid Altering Movement (RAM) - Pat knees with palm of had as fast as possible.
Finger to finger/nose test - Touch your finger and then patients nose (constant deviation is past pointing)
Heel to shin - Lie supine and slide one heel down over the other legs shin.
Fasciculation
Rapid, continuous twitching of eye
Decorticate Rigidity
Upper Extremities (Flexion of arm/wrists/fingers, adduction of arms tight against thorax)
Lower Extremities (Extension/internal rotation/plantar flexion, indicates hemispheric lesion or cerebral cortex)
Decerebrate Rigidity
Upper Extremities - Stiffly extended/adducted/internally rotated palms pronated
Lower Extremities - Stiffly extended legs/plantar flexion, teeth clenched and neck and back hyperextended
Lesion in brain stem at midbrain or upper pons
Opisthotonos
- Prolonged arching of back with head and heels bent backwards
- Indicates meningeal irritation
Babinski’s Reflex
- Abnormal Response
- Stroke bottom of foot with upside down J motion
- Children under 2 should fan toes
- Adults should curl toes and foot curves forward
- Fanning after age 2 can be upper motor neuron disease of corticospinal cord
PMI
Point of maximum impulse (apical pulse)
Delirium
- Presents as acute change in cognition affecting the domain of attention.
- Attributed to acute illness such as infection or medication side effect.
- Cognitive assessments to detect acute changes in delirium.
- Confusional change or loss of consciousness and perceptual disturbance.
- Disorientation, disordered thinking/perceptions, hallucinations, defective memory, agitation, inattention
MMSE (Mini-mental status examination)
- Quantifies cognitive function and cognitive loss
- Tests orientation, attention, calculation, recall, language, and motor skills.
- Do not Time
Intimate Partner Violence Screening
- Ask every woman at every encounter
- “Have you been abused by your husband/boyfriend/or other intimate partner
- Abuse is not the woman’s fault
- Document nonbiased notes, injury maps, photographic documentation in health record, other aspects of abuse history, can be partial direct quotations.
- Documents need to be in patients words and document poignant (regretful) statements that identify the perpetrator and severe threats.
Child Abuse Screening
- Watch interaction between caregiver and child
- Nonverbal children, caregiver will give subjective data.
- Assess injuries and see if it matches with what you observe clinically
- Children who are developmentally delayed are at higher risk for abuse
Elder Abuse and Neglect
- No specific screening
- Recommend routine screening
- Elder abuse suspicion index can be used for cognitively intact patients. (EASI)
- Consider financial or material abuse along with physical, emotional, and sexual abuse.
- High at risk for financial abuse such as theft, forcible transfer of property and coercion to steal assets.
Child Abuse Indicators
- Immersion injuries in Hot Water
- Pattern burn injury (hair straightening iron burn on butt, burn from steam iron, burn by fork tines, burn caused by lighter
- Cigarette burns
- Fingers - on left cheek
- Belt loops
- Bruising of the pinna and postauricular area or belt and belt buckle
ABCDE
- Used for assessing lesions
- A - Asymmetry
- B - Borders
- C - Color
- D - Diameter
- E - Elevation
Genogram
- Health History
- Graphic family tree that uses symbols to depict gender, relationship and age of immediate blood relatives.
- The health of close family members such as spouse or partner and children is equally important.
- Shows communicable disease or environmental hazards such as tobacco smoke or family member illness.
- Ask specifically about coronary heart disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast/ovarian cancer, colon cancer, sickle cell anemia, arthritis, allergies, alcohol, drug addiction, mental illness, suicide, seizure disorder, kidney disease and TB
Phalen’s Test
- Patient places back of hands together and presses
- Pain/tingling indicates carpal tunnel syndrome
Chorea
- Sudden rapid jerky purposeless movement involving limbs trunk or face. Occurs at irregular intervals and not rhythmic. Accentuated by voluntary acts.
- Disappears with sleep
- Common in Sydenham chorea and Huntington disease
Lesions
- Macule - less than 1 cm and flat (color change)
- Papule - Can feel, less than 1 cm. Superficial thickening
- Nodule - Solid elevated larger than 1 cm. Deep into dermis
- Wheal - Superficial, raised, transient, erythematous. Irregular shape
- Vesicle - Up to 1cm containing free fluid
- Bulla - Larger than 1 cm containing free fluid (ruptures easily)
- Cyst - Fluid filled caivty in dermis or subcutaneous layer
- Pustule - Filled with pus
Lymph Node Assessment
- Palpate range of motion
- Should feel movable, soft, and non-tender
- Should not be joined
- Circular motion with fingerpads
- Begin with preauricular
Otoscope Exam
- Inspect tympanic membrane
- Pull pinna up and back for over 3 y/o
- Translucent and pearly grey with cerumen
- Cone of light 5 oclock right ear 7 oclock left ear
*
Pulse Grading
3+ full and bounding
2+ normal pulse
1+ weak and thready
Doppler
- Used to detect weak peripheral pulse or monitor blood pressure in infants or children
- Can measure low blood pressure or blood pressure in lower extremities
- Position patient supine with legs externally rotated to reach medial ankles.
- Place transducer over pulse site at 90 degree angle.
- Apply light pressure, locate pulse site by swishing and whooshing sounds.
Venous Insufficiency/stasis
- at risk include prolonged standing, sitting or bed rest.
- Blood cannot return from the legs back to the heart due to incompetent valves. This increases venous pressure which dilates the veins.
Order of Joint Assessment
- TMJ
- Cervical Spine
- Shoulder
- Elbow
- Wrists
- Hip
- Knee
- Ankle
- Feet
- Spine
Breast Exam
- Palpation of breasts in supine position to flatten breasts. Palpate light, medium and deep in each location. Use 3 finger pads and rotate. Verticals strip pattern is best way to detect breast mass.
- Women with large breasts use bimanual technique where you support with one hand and palpate with other
Breast Exam
- Note location using a clock face
- Judge size in 3 dimensions
- Shape - oval, round, lobulated, indistinct
- Consistency - soft, firm or hard
- Moveable
- Distinctness - solitary or multiple
- Nipple - displaced or retracted
- Skin over lump - erythemeous dimpled or retracted
- Tenderness
- Lymphademopathy
Pulse Locations
- Radial - Radial Artery
- Ulnar - Ulnar Artery
- Brachial
- Femoral pulse - Femoral artery below the inguinal ligament halfway between pubis and iliac spines
- Popliteal - Behind knee popliteal fossa
- Posterior Tibial - Medial malleolus between malleolus and Achilles tendon
- Dorsalis Pedis - Extensor tendons
