For Midterm Flashcards
normal adult heart rate
60-80 (60-100)
Nodularity (breasts)
think fine curd cottage cheese - fine mass of small little bumps, no discrete mass among the background
in the upper outer quadrant of many young women’s breasts you might find fine or medium nodularity
Systolic ejection murmur possible diagnoses:
Normal, pulmonic, or aortic stenosis
hypertrophic obstructive cardiomyopathy
ASD
tetralogy of Fallot
Otorrhea
drainage from the ear
Whispered pectorliloquy
Whispered words easily heard
suggests lung consolidation
How do you distinguish between dimer and perforation?
use pneumatic otoscope
Squamocolumnar junction
area where the columnar junction of the endocervical canal meets the squamous cells of the external cervix
causes an irregular, deeper red area - usually symmetrical
NORMAL
on younger adolescence, it’s on the outside
later, it regresses
it’s where most HPV lesions occur (cancer)
What would you think of to cause unilateral nasal congestion? Bilateral?
unilateral: nasal mass
bilateral: allergic rhinitis, nasal polyps
Normal PMI is how wide and usually located where?
1-2 cm
medial to the mid-clavicular line at 5th ICS
When doing physical assessment of popliteal artery, remember what 2 things?
- bend knee slightly
- push fingers into popliteal fossa
Should imperforate hymen in prepubertal exam be referred?
yes
Physiological splitting of S2 (normal) heard where/when?
at pulmonic area
during PEAK inspiration
Epistaxis - where do most people commonly bleed?
Kisselbach’s plexus (juncture of all the arteries)
Positive Romberg test (swaying, can’t stand straight with arms out and eyes closed) means
problem with proprioception or ear balance function
“Natural” pacemaker is
SA node
vaginal fornix
space around cervix tucked in the back of vaginal canal
important because things can get lost up there
Odynophonia
pain when speaking
Expected diaphragmatic excursion
5-6cm
What would the patient complain of if they were hyperventilating during your auscultation?
feeling dizzy
Are fallopian tubes normally felt?
No
An 85-year-old female presents with chest pain and dyspnea that is worsen x 3 months. She had a presyncopal episode last week. What type of murmur is this?
- Timing? Systolic
- Location? Left sternal border (LSB) that radiates to apex and carotids
- Shape? Crescendo-decrescendo
- Pitch? Harsh
aortic stenosis
Murmur (5 key etiologies)
- caused by turbulent flow
- flow across partial obstruction of abnormal valve
- backwards through leaky valves
- across shunts like septal defects
- increased flow across normal valve
What should ovaries be like?
2-3 cm, smooth, firm, ovoid, mobile, sensitive to touch
Diastolic murmur grade I out of IV
barely audible
Older adults: be mindful that they may have ___ pulse pressure and ___ hypotension
widened
orthostatic
Rinne test
Always done after Weber
Strike tuning fork and place it on the mastoid bone. (Here, the sound is bypassing external anatomy and being conducted through skull base directly into cochlea. They’ll be able to hear that.) Then, hold the tuning fork in front of their ear, right in the opening of the ear canal. You ask which one is greater.
Mallampati grading 1-4
(tongue extended, mouth open): has to do with the obstruction of the airway in the oropharynx, closely correlated with obstructive sleep apnea
Grade 1: you can see all of the tonsillar pillars, full uvula, all of soft palate (all visible)
Grade 2: can’t see end of uvula or tonsils
Grade 3: root of uvula and end of soft palate
Grade 4: tongue base obstructing all of the posterior oropharynx
Pediatric murmurs are often ___ in children age 3-8
innocent systolic flow murmurs and Grade III or less
Systolic murmur grade II (out of VI) - volume/thrill?
audible but soft no thrill
most cervixes are in what position
midline or downwards
Is tachycardia common during pregnancy? When might you have it?
yes
- 10-20bpm above baseline esp near term
systolic or diastolic? pulmonic stenosis
systolic
PDA continuous murmur sounds like what? Is it a diastolic, systolic, or continuous murmur?
harsh “machinery” murmur
continuous
CN VII
facial nerve
responsible for movement on one side of the face
What do Wheezes represent? Quality?
– obstruction of small airways
– High-pitched musical type sound during inspiration and/or expiration
– A “continuous sound”
Secondary sex characteristics (puberty) appear between ages ___ with breast buds
8-13
Common Cervical Findings: Polyps
Usually friable (crumble/bleed easily), should be removed
Systolic murmur grade IV (out of VI) - volume/thrill?
easily audible with thrill
retrouterine pouch
opens into abdominal cavity
Non-cyclic breast pain
No relationship to menses, post-menopausal
Calcification and ductal dilatation
more common in women 35+
Expected RR for Adult
12-20
uterine fundus
top of the uterus
Systolic murmur grade V (out of VI) - volume/thrill?
easily audible with thrill, heard with stethoscope partially off chest
severe aortic stenosis can radiate where
along the whole precordium/chest
problem-oriented or focused health history
◆ Used when comprehensive history has already been done
◆ Addresses acute or focused problems
◆ Only the need of the moment given full attention
◆ Will include PMH, PSH, FH, as relevant to the presenting complaint or problem.
◆ Most commonly used in reality of clinical practice
pectus carinatum
pigeon chest
How many lobes in right and left lungs?
right: 3
left: 2
Dix-Hallpike test
Test for benign proxismal positional vertigo (stones in the balance canal that spin)
Lay patient down, turn head to one side –
if present you get obvious rotational nystagmus (eye twitching towards the downwards side)
uterus has ___ openings
2
external and internal
Should you be able to palpate ovary in post-menopausal women?
No
Location of PVD symptoms: Buttock, hip - what is the associated artery?
Aortoiliac
Basic principle of vocal resonance: Voice transmission enhanced (improved) if underlying lung field is ____
consolidated (such as in pneumonia)
Expected RR for Newborn
30-60
Diastolic murmur grade III out of IV
easily audible
Location of PVD symptoms: Erectile dysfunction - what is the associated artery?
Iliac-pudendal
What 2 valves are Semilunar?
Aortic, Pulmonic
Late diastolic murmur possible diagnoses:
Tricuspid or mitral stenosis
Breast self exam should be done which day of menstrual cycle?
Day 4-7 of menstrual cycle
Systolic murmur grade III (out of VI) - volume/thrill?
easily audible no thrill
Edema is most commonly a sign of what?
decreased cardiac function leading to decreased capillary flow
increased fluid perfusion, especially in the gravity dependent areas
In primary care, Problem 1 should usually be
“Health Care Maintenance”
Is audible splitting of heart sounds normal during pregnancy?
yes
Tinnitus is often an early sign of
hearing loss
Pectoral/anterior nodes: where are they located? What do they drain/where do they drain into?
- Lower border of pectorals major inside anterior axillary fold
- Drains anterior chest wall and most of breast
- Drains into central axillary nodes
S4 may be physiologic in ___ and ____ and _____
infants, small kids, adults over 50
Extra Heart Sounds in Systole
- Clicks – usually MVP
- Ejection sound (click)
Diastolic murmur grade IV out of IV
loud
Rounding in child’s chest should be gone by age
1
S3 correlates with time of what?
rapid ventricular filling (diastole)
Breast lifespan changes: Pregnancy (4)
- increase in size
- pigmented areas darken
- fat replaced by functional ducts
- Montgomery glands lubricate
Neonates vs adult signs of respiratory distress
Neonates: nasal flaring, retractions, paradoxical mvmts., stridor or grunting
Adults: pursed lip breathing (COPD - this is actually helpful for these patients because it allows more time for expiration)
Aortic area murmurs (2nd ICS, right sternal border) - what could they potentially be?
aortic stenosis
aortic regurgitation
S3
Low-pitched vibration occurring in early diastole after S2
What does Friction rub represent? quality?
– Indicates inflammation of pleural surfaces
– Low-pitched, grating sound
– Occurs on inspiration and expiration
A ____ murmur may reflect the increased flow across AV valves in pregnancy, but is much less common and organic disease should be ruled out
innocent diastolic flow murmur
4 components of the “Plan” portion of the health history
- Diagnostic Tests/Consultation
- Therapeutic Interventions
- Client Education
- Follow up
Supernumerary breasts
Non-functional embryonic milk line from groin to axilla
Glandular tissue and /or pigmented lesion
Turbulence in the great veins can cause an ___ in very small children
innocent venous hum
Systolic click with late systolic murmur possible diagnosis:
Mitral valve prolapse
What are contributing factors to tinnitus? (6)
- TMJ
- Cervical spine
- Iatrogenic - meds (Aspirin, NSAIDS, chemo agents)
- Insomnia
- Psychiatric (depression, anxiety will worsen tinnitus)
- Caffeine and sodium intake
Diastolic murmur grade II out of IV
audible but soft
Bronchophony
When there is increased voice clarity and volume
suggests lung consolidation
What do Rhonchi represent? Quality?
– represent secretions in large airways
– snoring type of sound
– low pitched
– during insp. and/or exp;
– a “continuous breath sound”***
– may change or clear with coughing
For women 30-65 years, what are the pap recommendations?
Pap every 3 years
or
Pap and co-testing with HPV every 5 years if both initial tests negative.
Otalgia
pain in ear
ACS mammography recommendations:
age 45-54 yearly >55 every two years, as long as in good health or 10+ years life expectancy
S1 should be consistent with ____ and ____
carotid pulse and PMI
S4 is common in ___ patients
HTN
If the sound from the Weber test is louder in one side, it means either of 2 things?
they could have a conductive hearing loss in the side that’s hearing the sound LOUDER
Or it could be that’s the better sensory hearing side, so it could be a sensory hearing loss on the softer side
chronic poor oxygen delivery to the peripheral tissues of the hands and feet
cyanosis
S1
systole Closure of the mitral (tricuspid) valve (M before T)
systolic or diastolic? mitral valve prolapse
systolic
What do these tuning fork tests results indicate?
AC>BC bilaterally; Weber lateralized to the Right
sensory hearing loss in the left ear
Systolic murmur grade I (out of VI) - volume/thrill?
barely audible no thrill
Adults: Anterior-posterior (A- P) diam. should be what in relation to transverse diem?
less than
Expected RR for 10 years
16-20
4 important questions to take for history of hearing loss
- Laterality (most important)
- Onset
- Fluctuations
- communication function
Is increase in intensity of S1 normal during pregnancy?
yes
One of the most common forms of vertigo is
benign paroxysmal positional vertigo
Lays down rolls over in bed and spins
What position should patients be in for cardiac auscultation
Supine at 30-45 degrees
Venous vs. arterial phase of epistaxis
Lesser quantity: venous phase
More quantity: arterial phase
2 speculum names and sizes - what’s the difference between the two?
Pedersen: small, medium (S-XL)
Graves: medium, large (S-XL)
difference: width of the beaks
Bronchial/tracheal (tubular) breath sounds: where are they heard? Quality?
– heard over manubrium/ trachea/ large airways (abnormal in other locations)
– relatively loud
– expiratory phase somewhat longer than inspiratory phase or about equal
Location of PVD symptoms: Thigh - what is the associated artery?
Common femoral or aortoiliac
Any time you hear a click, it only refers to
mitral valve prolapse
After initial pap smear at 21 years, they should be done every ___ years until what age?
every 3 years under age 29
Where do you palpate Bartholin’s glands? Is pain normal
5 and 7 o’clock downwards
no pain
Central axillary nodes: where are they located? where do they drain into?
- Palpable high in axilla, close to ribs
- Drains into infra and supraclavicular nodes
Location of PVD symptoms: Upper calf - what is the associated artery?
Superficial femoral
How can slapping someone against the head lead to hearing loss?
Slapping someone alongside the head can form a column of air through ear canal and perforate the eardum, leading to hearing loss
If you note Xanthelasmas (yellowish plaques that occur most commonly near the inner canthus of the eyelid, more often on the upper lid than the lower lid) during eye assessment, what might this indicate?
hyperlipidemia
Pregnant women have a ____ costal angle
widened
Left lateral decubitus position when auscultating accentuates what 3 things?
- left-sided S3
- S4
- mitral murmurs (stenosis)
Otalgia (ear pain) could be referred pain from what 3 areas?
- jaw (bruxism aka teeth grinding)
- cervical spine (sleeping position)
- throat (lesions)
to palpate cervix during bimanual exam, where should abdominal hand be?
midway between umbilicus and pubic bone, applying downward pressure
S1 best heard where?
at the apex with bell
7 components of Pediatric History: SUBJECTIVE DATA
◆ Identification and client profile
◆ Chief Complaint (CC)
◆ Present Concerns/Illness (HPI)
◆ Past Medical History (PMH): including birth, feeding, growth and development, ADLs (diet, sleep, elimination, childcare arrangements, safety practices)
◆ Current development level, including school history
◆ Social and family history, including discipline practices
◆ Review of Systems
systolic or diastolic? mitral stenosis
diastolic
What breath sounds represent opening of small airways or air bubbling through secretions?
Crackles/rales
What position accentuates left sided S3, S4, mitral murmurs like stenosis for auscultation?
Left lateral decubitus
What do these tuning fork tests results indicate?
AC>BC bilaterally; Weber is midline
normal
With head bending forward, ___ usually most prominent vertebrae
C7
Sinuses (4 sets)
- frontal (sometimes - not everyone has them)
- ethmoid
- sphenoid
- maxillary
Some types of xanthoma are indicative of lipid metabolism disorders which indicate increased risk of what?
coronary artery heart disease
Lateral nodes: where are they located? What do they drain/where do they drain into?
- On upper humorous
- Drains most of arm
- Drains into central axillary nodes
During pregnancy, there is an increase in what 3 things?
- plasma volume (50% above baseline by 2nd trimester)
- maternal cardiac output (during early pregnancy)
- uterine blood flow (10x normal)
Problem in inner ear like age-related hearing loss, hair cell deterioration would qualify as ___ hearing loss
sensory
When auscultating older adults, especially those who have a cognitive impairment or something like Parkinson’s, where is it best to begin auscultating?
at the bottom - work up
you may only get 1 or 2 breaths out of them
may hear basilar crackles
Majority of cervical cancers and HPV lesions appear in what area?
Squamocolumnar junction aka transformation zone, ectropian, squamous metaplasia
Vestibulo-ocular reflex
signal sent from your ear about where you’re moving in space and allowing eyes to keep focused as you’re moving - when you’re driving in car you can read a sign
Why do you massage parotid and submandibular glands from front to back?
to get saliva production and therefore assess patency of ducts
Weber screening test
Done first
Strike the tuning fork on the end, then put it in the center of the patient’s forehead.
Can they hear it? Is it louder in one ear or the other?
Most common GYN concerns (6)
- Vaginal discharge
- Abnormal bleeding
- Pelvic pain
- Urinary problems
- Sexual dysfunction
- Infertility
tonsillar grading 0-4
0 - tonsils removed, not present
1 - most people in here, tonsils tucked into pillars
2 - extend beyond pillars
3 - at least halfway to the uvula
4 - airway issue, the tonsils are touching
Vocal Resonance: normal
Normally voice/spoken words heard through stethoscope should be muffled and difficult to understand
Exam: External Neck - when assessing the salivary gland, why do you need to pay attention to parotid tail
tucks behind the ear, where a lot of tumors come from
How does Pneumatic otoscope work? What will you see if eardrum is intact? What will you see if fluid behind TM?
Pushes air up into the ear canal and against the tympanic membrane
If eardrum is intact, you’ll see mobility - if there’s a hole in the eardrum, you the air will go right through and you won’t see the effect at all
If fluid is present behind the TM, you won’t get any movement either
Tricuspid area murmurs (4th and 5th ICS, left sternal border) - what could they potentially be?
tricuspid stenosis, insufficiency, or regurgitation
Is displaced apical impulse common during pregnancy?
yes - rotated axis to left
Should speculum be closed or open when removing?
closed
thrills
vibrations of loud cardiac murmurs
Which is louder, S1 or S2?
S2
What do these tuning fork tests results indicate?
Left BC>AC; Right AC>BC; Weber lateralized to the Left
left conductive hearing loss
Is fertility/ability to get pregnant affected by uterine position?
no
S3 may be physiologic in ___ and ____
children and pregnancy
Pelvic examinations should begin at age
21 years
What do each of the following indicate? 4 parts of the plan: DX:
RX:
Pt. Ed.
F/U:
DX: diagnostic test
RX: therapeutic interventions
Patient education
Follow up
5 key things to note on bimanual exam of cervix
- position related to axis of uterus
- consistency (firm, soft, patency)
- wag cervix for CMT (cervical motion tenderness)
- surface characteristics
- fornices
Sequence from Tanner stage 2-5 takes on average __ years
4 (1.5 to 6 years)
most common cause of hemoptysis is ____
bronchitis
CDC advises ____ screening of sexually active adolescents and women ≤25 years for gonorrheal and chlamydial infection and HIV
annual
PVD: arterial disorders (3)
- Atherosclerosis
- Acute Arterial Occlusion
- Raynaud’s Disease
Opening snap with diastolic rumble murmur possible diagnosis:
Mitral stenosis
hernia of intestines into vaginal wall
enterocele bulging in posterior fornix
Pulmonic area murmurs (2nd and 3rd ICS, left sternal border) - what could they potentially be?
pulmonic stenosis or pulmonic insufficiency
4 major types of pelvic organ prolapse
- anterior comportment prolapse
- posterior compartment prolapse
- enterocoele
- uterine prolapse (apical compartment prolapse)
Most common site for men to get basal cell carcinoma is on where? Where for women?
on the helix of the ear
for women it’s the bridge of the nose
What type of health history is most commonly used in reality of clinical practice?
problem-oriented or focused health history
Breast exam: positions for inspection (4)
- arms at sides
- arms raised
- hands pressed on hips or against temples (Elicits dimpling if mass has infiltrated suspensory ligament)
- leaning forward (with large pendulous breasts reveals asymmetry of breast)
Systole - 4 main points
- Ventricular contraction with increasing pressure
- Mitral/tricuspid valves close (S1) “lubb”
- Ventricular pressure opens aortic and pulmonary valves (silent)
- Ejection
Sexual maturity rating with pubic development - keep in mind that hair development usually follows ___ of breast development
within a few months
Systolic murmur grade VI (out of VI) - volume/thrill?
easily audible with thrill, heard with stethoscope fully off chest
Patient should be in what position when measuring JVP? What side of the neck are you checking?
at 30-45 degrees right side because it corresponds to right atrium
measure at the highest point of pulsations
What is often an early presenting sign of hearing loss?
Tinnitus
Widened pulse pressure in pregnancy is due to
uterine contraction and endogenous hormones resulting in decline in peripheral vascular resistance
Fakuda step test
Patient marching in place, have them close eyes, and they’ll rotate towards the side where there’s ear damage
Just because sputum is discolored, it doesn’t necessarily indicate bacterial infection - what does the discoloration represent?
inflammatory cells which could be either bacterial or viral
Axillary adenopathy
Due to arm or breast infection
Main local causes of edema
• Deep Vein Thrombosis
… Or Infection, trauma, lymphatic obstruction
4 Objective Components of the Pediatric Health History
◆ Physical exam
◆ Laboratory findings
◆ Developmental assessment
◆ Direct observations including parent-child interaction
there are __ pneumonia vaccines recommended in adults
2
prevnar 13 (age 50 and up)
pneumovax (65 and up)
chronic poor oxygen perfusion to the distal tissues of the hand and feet (congenital heart disease)
clubbing
When palpating for tactile fremitus, remember that vibraton is greatest where?
over the large airways
diminishes peripherally
Auricular hematoma
cauliflower ear - wrestling
systolic or diastolic? aortic stenosis
systolic
Normal weber screening test
hearing it equally in both ears
When doing physical assessment of femoral artery, remember what 2 things?
- identify femoral pulse
- listen with diaphragm for bruits
Problem with bones of hearing/TM/external anatomy would quality as ___ hearing loss
conductive
Pertinent history for Rhinology (5)
- nasal congestion
- epistaxis
- rhinorrhea
- sinus pressure
- sense of smell
In the presence of blood, which pap technique is more sensitive?
liquid-based
Innocent murmurs:
- what grade are the normally?
- systolic or diastolic?
- is there radiation?
- where heard best?
- in what position?
- Grade I or II, rare III
- Mid-systolic
- Little or no radiation
- Heard at 2nd-4th LICS
- When patient recumbent – decreases or goes away when sitting
When you’re doing auscultation posteriorly, how should patient hold their arms?
crossed
S2 best heard where?
Heard at base (R and L 2nd ICS) with diaphragm
Squatting / handgrip position accentuates what?
mitral valve prolapse (increased afterload and increased ventricular volume)
A 60-year-old male presents with increasing shortness of breath x 6 months. What type of murmur is this?
- Timing? Systolic
- Location? Apex
- Shape? Holosystolic
- Pitch? Harsh
mitral regurgitation
Extra Heart Sounds in Diastole (3)
- S3
- S4
- OS – Opening Snap
interim health history
◆ A Follow-up approach
◆ Often used for management of chronic disease i.e – every 6 mo for DM client
◆ Detail events since the last meeting with the client
◆ Presumes an intact complete history
Venous PVD:
- pain
- mechanism
- pulses
- color
- temperature
- edema
- skin changes
- ulceration
- gangrene
Venous PVD:
- pain: often painful
- mechanism: venous hypertension
- pulses: normal
- color: normal or cyanotic on dependency; petechiae
- temperature: normal
- edema: present
- skin changes: brown pigmentation around ankle, stasis dermatitis and thickening of leg as scarring develops
- ulceration: if present, think medial sides of ankles
- gangrene: none
systolic or diastolic? tricuspid stenosis
diastolic
If split S2 is heard on expiration, this is what?
paradoxical (pathologic)
Aortic area is where
2nd ICS, right sternal border
lifts/heaves
forceful cardiac contractions
S3 possible diagnosis
Normal in children; occurs in heart failure
Malignant neoplasm
May be solitary, unilateral, firm, fixed, non-tender, + dimpling, edema, scaling, retraction
Which murmur grades do NOT have a thrill?
I, II, III
A ___ murmur occurs in greater than 90% of pregnant women.
Grade II systolic murmur at pulmonary area
Location of PVD symptoms: Foot - what is the associated artery?
Tibial or peroneal
What breath sounds have long inspiratory phase, short expiratory phase?
Vesicular (Soft and whispery quality, low pitched)
Tricuspid area is where?
4th and 5th ICS, left sternal border
are cervical bruits innocent in adults?
NO
systolic or diastolic? tricuspid regurgitation
systolic
pectus excavatum
Funnel chest
Peripheral edema, palmar erythema, and spider telangectasias are all normal or not during pregnancy
normal
Expected RR for 1 year
20-40
11 lymph nodes of external neck
- Pre-auricular
- Post-auricular
- Occipital
- Parotid
- Tonsillar
- Submandibular
- Submental
- Superficial cervical
- Deep cervical
- Posterior cervical
- Supraclavicular
Vestibular symptoms is an umbrella term for
vertigo, vestibular rocking
hernia of posterior vaginal segment often associated with descent of rectum
posterior compartment prolapse
systolic or diastolic? VSD
systolic
Most common benign solid tumor in <25 years
fibroadenoma
> 40 years old, S3 is ___, S4 is ____
S3 abnormal
S4 common
3 Objective Components of the Adult Health History
- physical exam
- lab findings
- direct observations
If vibration symmetry is decreased or absent upon palpation for tactile fremitus:
trapped air in lungs;
thick pleura;
effusion;
obstruction;
massive pulmonary edema
physical assessment of dorsalis pedis artery: where is it located? technique tips?
- lateral to extensor tendon of great toe
- use pads of 2-3 fingers, push gently, grade 0 to 2+
S4
Soft, low-pitched sound in late diastole before S1, therefore an “atrial” sound
Diastole - 4 main points
- Pressure falls aortic & pulmonary valves close – (S2, A2/P2) “dubb”
- Mitral/tricuspid valves open with filling (S3)
- Atrial contraction (S4)
- Ventricles are relaxed
All certifying bodies recommend first pap is at age
21
Key 5 cardiac risk factors
- HTN
- Hyperlipidemia
- Smoking
- Family history
- Obesity
Ptotic (sagging) submandibular gland is part of
normal aging
What’s more concerning, unilateral or bilateral hearing loss?
unilateral hearing loss (One-sided, you might think tumor)
According to ACOG, pelvic exams should be performed only when indicated by the medical history for patients under __ years
21
Breast lifespan changes: Menopause (3)
- glandular tissue replaced by fat
- inframammary ridge thickens
- relaxation of suspensory ligament
Arterial PVD:
- pain
- mechanism
- pulses
- color
- temperature
- edema
- skin changes
- ulceration
- gangrene
Arterial PVD:
- pain: intermittent claudication
- mechanism: tissue ischemia
- pulses: decreased/absent
- color: pale on elevation, dusky/red on dependency
- temperature: cool
- edema: absent/mild
- skin changes: thin, atrophic skin, loss of hair, thick nails
- ulceration: if present, toes or point of trauma on feet
- gangrene: may develop
2 portions of inner ear anatomy
- Cochlea (hearing) Arranged in frequencies from high to low - we hear from 200-20,000 hz
- semicircular canals (balance input) - 3 planes - sense rotational movement
Which female population is HPV more transient in? 21-29 or 30-65?
more transient in 21-29
Subscapular/posterior nodes: where are they located? What do they drain/where do they drain into?
- Lateral border of scapula in posterior axillary fold
- Drains posterior chest wall and portion of arm
- Drains into central axillary nodes
Bronchovesicular breath sounds: where are they heard? Quality?
– Heard over bronchus and upper right posterior lung field; med. pitch
– Inspiratory and expiratory phases are equal
– Abnormal if heard over peripheral lung fields
– Normal child: Bronchovesicular BS throughout is normal
Main systemic causes of edema
- Heart failure
- Venous stasis
.. Or pulmonary, kidney, or liver disease
If wheezes are fixed/localized, think about
possible airway obstruction (foreign body, tumor)
most cervical cancers happen where
squamocolumnar junction in the canal area between the external and internal cervical os - esp in young women (cervical canal)
Are labial adhesions common in prepubertal exam
YES - usually resolves with estrogen exposure in puberty
Normal child percussion:
Hyperresonant (very loud intensity, lower pitched, longer duration, “boom like quality”)
Fibroadenoma - peak incidence? where located? other key characteristics
- Common benign solid tumor in <25 years
- Commonly UOQ, non-tender
- Mobile, smooth, rubbery-firm
Summary statement includes: (4)
◆ Patient Profile
◆ Chief Complaint
◆ Concurrent Illnesses
◆ Positive and pertinent negative findings from history and PE
HPI - OLDCARTS
- Onset
- Location
- Duration
- Character/quality
- Aggravating factors/associated symptoms
- Relieving factors
- Temporal factors
- Severity (scale 1-10)
CN I how do you test?
Olfactory
- University of Pennsylvania Smell Identification Test – UPSIT
- In clinic exam and takes 30-40 minutes to complete
- Objective data for sense of smell
Mitral area murmurs (5th ICS, mid-clavicular line) - what could they potentially be?
mitral stenosis, insufficiency, regurgitation
hernia of anterior vaginal wall often associated with descent of bladder
anterior compartment prolapse
When assessing CN VII, if patient can’t close their eye, that’s automatically what grade on the House-Brackmann Scale?
4
S1 immediately precedes what?
carotid upstroke
systolic or diastolic? mitral regurgitation
systolic
If vibration symmetry is decreased or absent upon palpation for tactile fremitus:
Lung consolidation/ compression/mass;
excess fluids or non-obstructive secretions
Menarche usually occurs at Tanner stage ___, about __ years after bud development
3-4
2
Early diastolic murmur possible diagnoses:
Aortic or pulmonary regurgitation
Delay of pulmonic valve closure will ____ splitting
increase
systolic or diastolic? ASD
systolic
Pericardial friction rub continuous murmur sounds like what? Is it a diastolic, systolic, or continuous murmur?
scratchy
continuous
Is S3 normal during pregnancy?
yes
when you hear opening snap, think of what?
mitral stenosis
Venous hum continuous murmur sounds like what? Is it a diastolic, systolic, or continuous murmur?
low hum
continuous
Xanthomas
yellowish plaques / skin lesions caused by the accumulation of fat in macrophage immune cells
How do you assess the nasal valve?
inhale and look to see if it’s hypermobile
- stent valve with stick then do Cottle maneuver
- stretch their cheek to the side and see if breathing improves
S3 best heard where?
Ventricular sound, at apex, use bell in LLD position kentucky
Expected RR for 3 years
20-30
Fluid cysts - peak incidence? where located? other key characteristics
- Peak incidence age 35-50 years
- Commonly UOQ, tenderness with menses
- Rapid development, firm or fluctuant
How can retroverted, retroflexed uterus be palpated?
rectally or via retrouterine pouch
Normal adult percussion:
Resonant (loud intensity, low pitch, long duration, “hollow quality”)
comprehensive health history
The client’s entire story
If you note Ophthalmitis and petechial / subconjunctival hemorrhages on eyelids, what might this indicate?
bacterial endocarditis
Egophony:
When the spoken “e” sounds like “a”
suggests lung consolidation
Mitral area is where?
5th ICS, mid-clavicular line
Do electrical impulses happen before or after the mechanical actions of the heart?
before
Gynecomastia - more common in what age?
- Enlarged breast in male
- Palpation of glandular tissue instead of fat
- Common in adolescents due to decreased ratio of androgens to estrogens
Pap specimen collection - does order of samples affect the results?
no
Normal JVP
6-8 cm H2O
JVP is distance up from angle to top of pulse wave
systolic or diastolic? pulmonic regurgitation
diastolic
If PMI is shifted to L of mid-clavicular line, what does that indicate?
Increased LV dimension
timing and quality of crackles/rales
Timing: early, mid or late inspiration
Quality: fine, medium or coarse
Holosystolic (pansystolic) murmur possible diagnoses:
Tricuspid or mitral regurgitation
What 2 valves are Atrioventricular?
Tricuspid, Mitral
Symptoms of Chronic Venous Insufficiency (CVI) - 3
- Persistent swelling of the lower legs
- Edema improves with raising legs; worsens later in the day
- Leg pain, dull aching, heaviness or cramping
3 types of health histories
- comprehensive
- problem-oriented or focused
- interim
S3 is considered pathological in what age?
>40 y.o.
Largest area of glandular tissue in the breast; Majority of breast tumors occur here
Tail of spence
molluscum
viral infection that causes little pock-like lesions, often on inner thighs/buttocks
A 15-year-old male presents with shortness of breath over the past 2 weeks. You elicit a recent history of severe sore throat that was not treated with antibiotics. What type of murmur is this? What is the etiology?
- Timing? Systolic and diastolic
- Location? Loudest at 2nd RICS
- Shape? Crescendo-decrescendo
- Pitch? Harsh
Trick question: it’s rheumatoid fever
systolic or diastolic? aortic regurgitation
diastolic
Vestibulo-spinal reflex
efferent motor nerve response that happens automatically when your ear turns to the right and head follows, it gives tone to your neck to support your balance
ACOG recommends first reproductive health visit between ___ yrs. Scope of exam depends on patient need. Often education.
13-15
Internal jugular pulsations/auscultation - what is normal? is the level of pulsations changed by position or affected by respirations?
- normal: rarely palpable, soft, 2 elevations per heartbeat
- Level of pulsations DOES change with position
- DROPs with inspiration
Examining the posterior oropharyngeal wall: what is cobblestoning?
lymphoid tissue in little pockets that line the throat - white, gray, yellowish bumps which can be related to anything that would activate the immune system
physical assessment of posterior tib artery: where is it located? technique tips?
- posterior to medial malleolus
- use pads of 2-3 fingers, push gently, grade 0 to 2+
Cyanosis in the skin, nails, lips is a ___ sign
late
Why do you need to be aware of hx of skull base surgery with rhinorrhea?
spinal fluid can leak through the surgery site even years afterwards
physiologic murmurs associated with what 4 conditions? and remember that they have ___ to innocent murmurs
- pregnancy
- fever
- anemia
- hyperthyroidism
similar characteristics
Location of PVD symptoms: Lower calf - what is the associated artery?
Popliteal
Superior mediastinum; largest at puberty, then involutes
Thymus
GRBAS voice grading
Grade
Raspy-ness
Breathiness
Asthenia - weakness, can’t project or get volume
Strain
Total is 0-15; 15 is severe vocal disability
S3 can be heard in patients who are in ___ failure and are overloaded
heart
Carotid neck pulsations/auscultation - what is normal? is the level of pulsations changed by position or affected by respirations?
- normally vigorous upstroke
- level of pulsations NOT changed by position or affected by respirations
Ejection sound possible diagnosis:
Aortic valve disease
CN VIII how to test?
Cochlear nerve aka Vestibulocochlear
rubbing
Weber, Rinne
one of the leading causes of COPD worldwide is ____
exposure to products of combustion during cooking (cooking over an open flame)
2 major precipitating factors for otorrhea (drainage) which is the hallmark of otitis media
- respiratory infection (URI)
- water exposure
descent of apex of vagina into lower vagina, to the hymen, or beyond vaginal introitus
uterine prolapse (apical compartment prolapse)
Pulmonic area is where?
2nd and 3rd ICS
3 components of vestibular exam
- Oculomotor testing (eye movement)
- Cerebellar testing (neurology lecture)
- Basic balance function
PVD: venous disorders (3)
- Chronic Venous Insufficiency (CVI)
- Deep Vein Thrombosis
- Superficial Thrombophlebitis
What’s the best way to hold the pediatric handheld otoscope?
Brace with fifth finger against child’s temple/face
9 components of Adult History: Subjective Data
◆ Informant
◆ Patient Profile (PP)
◆ Chief Complaint (CC)
◆ History of Present Illness (HPI)
◆ Past Medical History (PMH)
◆ Family History (FH)
◆ Occupational History (OH)
◆ Personal and Social History (PSH)
◆ Review Of Systems (ROS)
In children, AP diameter and transverse diameter should be
equal
If you note Corneal arcus in <40 y.o. during eye assessment, what might this indicate?
hyperlipidemia
adnexa of uterus
ovaries and fallopian tubes
during pregnancy, there is an initial ___ in BP up to 16 weeks, then what happens?
increase
then back to pre-pregnancy level
Physical Findings of CVI (3)
- Edema (dependent on position)
- Bluish discoloration of the skin at the ankles
- With prolonged swelling, venous ulcers can develop at the ankles and these often become infected
Always ask about what 6 things when taking an otology history?
- Hearing loss
- Otorrhea
- Otalgia
- Tinnitus
- Aural fullness
- Vestibular symptoms
When is the Thymus largest?
puberty
An innocent murmur in pregnancy is only ___. IT may change with ____
systolic
posture
Proprioception
your body’s sense of self in space
Common Cervical Findings: Nabothian cysts
Common, 1 cm, smooth, round, yellow lesion
Obstruction of cervical gland with squamous metaplasia
How do you test CN VII? The House-Brackmann Scale for CN VII - what does I indicate? What does VI indicate?
I - normal
VI - complete paralysis
Space between lungs; houses heart, large airways, large blood vessels, lymphatics
Mediastinum
Pertinent history for Laryngology and Head/Neck (6)
- throat pain
- dysphonia
- dysphagia
- neck masses
- oral lesions
- facial pain/numbness
___ could occur with pneumothorax. This is called subcutaneous emphysema
Crepitus like bubble wrap
Lingula
(not a lobe) - area that’s adjacent to left heart border
Components of health history for GU (6)
- Menstrual history
- Sexual/contraceptive history
- Obstetrical history
- Cervical cytology history
- Screening for intimate partner violence
- Gynecological history
- Current symptoms or history of pelvic, vaginal, or vulvar infections
- Symptoms of pelvic organ prolapse or urinary or anal incontinence
- History of gynecologic procedures
Synkinesis
automatically level II on House-Brackmann scale
mis-wiring of facial nerve post-trauma, like after Bells Palsy
Expected RR for 6 years
16-22
S4 is best heard where?
at apex in LLD position with bell Tennessee
What is happening when the mitral and tricuspid valves close? Is the heart in systole or diastole?
systole
85% of uteruses are in what position?
Anteverted, anteflexed
AP diameter ____ with age
increases
CN V
Trigeminal Nerve
- has 3 branches supplies sensation to face
- examine via light touch, using Filament or other fine instrument
– Compare touch from side to side in each of the three branches
– Rate by percentage i.e. 80% R V2 intact
1/3 of older adults have ___ murmur
systolic aortic
If adult is Hyperresonant, think about?
pneumothorax or emphysema
Sit up, lean forward, exhale completely and hold breath – this accentuates what?
aortic murmurs (regurg)
What is normal S2 splitting caused by
increased blood flow
Is the heart right or left dominant?
Right (70%)
paroxysmal nocturnal dyspnea (PND) could be sign that someone’s having problems with ____
heart failure
Is bounding pulse common during pregnancy?
yes
Is pain normal when milking skene’s glands?
no
S2
Closure aortic (pulmonic) valve (A before P)
Cranial nerves:
- I
- II
- III
- IV
- V
- VI
- VII
- VIII
- IX
- X
- XI
- XII
- I Olfactory (Smell)
- II Optic (Sight)
- III Oculomotor (Moves eyelid and eyeball and adjusts the pupil and lens of the eye)
- IV Trochlear (Moves eyeballs)
- V Trigeminal (Facial muscles incl. chewing; Facial sensations)
- VI Abducens (Moves eyeballs)
- VII Facial (Taste, tears, saliva, facial expressions)
- VIII Vestibulocochlear (Auditory)
- IX Glossopharyngeal (Swallowing, saliva, taste)
- X Vagus (Control of PNS e.g. smooth muscles of GI tract)
- XI Accessory (Moving head & shoulders, swallowing)
- XII Hypoglossal (Tongue muscles - speech & swallowing)
Purpose of the bimanual exam?
assess vaginal tone and cervical motion tenderness (CMT) in case of pelvic inflammatory disease
also to palpate the uterus and ovaries through the abdomen
3 components of the past medical history
- childhood illnesses
- adult illnessess
- health maintenance behaviors including immunizations and screening test
An elderly patient with history of smoking 2 packs of cigarettes/day for 50 years complains of progressive shortness of breath. On cardiac exam, the most prominent PMI is in the xiphoid area. This is most likely result of what condition?
pulmonary HTN
A 77-year-old man is experiencing shortness of breath and dizziness. After cardiac catheterization, systolic BP in left ventricle is measured at 180 but systolic BP in aorta is 140. This is most likely caused by what valvuar condition?
aortic stenosis
Patients with aortic stenosis often experience what 3 symptons? What kind of BP discrepancy does it cause?
- dyspnea with exertion
- chest pain
- dizziness
BP in left ventricle will be higher than aorta
Where is the best place to auscultate the splitting of a second heart sound?
Left second and third interspace
20 year old college student experiencing dyspnea on exertion and palpitations. On auscultation, the second heart sound is split and fixed on both inspiration and expiration. What is the most likely cardiac condition associated with this finding?
ASD (atrial septal defect)
Fixed splitting of the second heart sound that does not vary with respiration occurs in ___ defects and also in ____
ASD (atrial septal defects) and right sided heart failure
A 70 year old retired businessman presents to ED with progressive SOB and 2-pillow orthopnea. BP 140/90, JVD present, lower extremity pitting edema to knee, blowing holosystolic murmur heard best at LLSB. What intervention will best help him?
*Removal of intravascular volume with diuresis*
these symptoms are consistent with heart failure
murmur is indicative of tricuspid regurgitation
Normal QRS duration? What would it be after MI with left bundle branch block?
Normal = 100 miliseconds
With block = extended (longer)
Atrial enlargement would cause changes in what portion of the electrocardiogram?
P wave
Cardiac output = HR x stroke volume. So if HR decreases by 20%, how much would cardiac output change if stroke volume is consistent?
20%
39 y/o with 2-day hx of fever, chills, cough with green sputum, dyspnea. Temp is 101.2. Late inspiratory crackles on auscultation of left lower lung posteriorly. “EE” sounds like “AA.” What is this condition? What sound most likely heard on percussion of lungs
pneumonia
dullness
What breath sounds are most consistent with asthma?
wheezes on expiration
Depression of lower part of sterum would be what?
Pectus excavatum
Tingling around the lips can be a symptom of
anxiety
Patient with SOB - dullness to percussion over right lung base. Breath sounds absent at right lung base. No crackles, wheezes, or ronchi. These findings are characteristic of ___ or ____.
Atelectasis or pleural effusion
If needing to put a chest tube in 4th ICS, how does the provider determine where this is?
Find the sternal angle then move finger laterally to second rib. Then walks down from there. 4th ICS is below the 4th rib.
Sensitivity of screening for breast cancer increases with breast MRI at the expense of ____
specificity
35 y/o G0P0 presents to clinic with biateral nipple discharge. Started several weeks ago, occurs irregularly. no symptoms other than slightly irregular period. On exam, the discharge is found to be breast milk, no pus or blood. Normal other labs. What would this be?
Prolactinoma - tumors that secrete prolactin, which causes production of breast milk and suppressing of menstruation
Symptoms: elderly, “tearing” chest pain, asymmetric BP in arms. ECG, cardiac enzymes and chest x-ray normal. This is most likely
dissecting aortic aneurysm
Where is the most important area to obtain cells for a Pap smear?
Transformation zone
Which muscle group is responsible for support of the pelvic floor?
levatori ani
On manual BP testing, what indicates true diastolic pressure?
disappearance of Korotkoff sounds following initial muffling
If heart sound/murmur is heard at the right 2nd interspace to the apex, what would be the typical origin valve?
aortic
If heart sound/murmur is heard at the left 2nd and 3rd interspace close to the sternum, but also at higher or lower leves, what would be the typical origin valve?
Pulmonic
If heart sound/murmur is heard at or near the lower left sternal border, what would be the valve of origin?
Tricuspid
If heart sound/murmur is heard at and around the cardiac apex, what is typically the origin valve?
mitral
