General Appearance, Vital Signs, Skin, Hair, Nails, Head, Neck, and Mental Status Flashcards
General review of systems
Weight loss or gain Fatigue Fever or chills Muscle weakness Night sweats
Skin
Skin changes Rashes Lumps Itching Dryness Color Change
Change in nevi (moles)
Color
Shape
New
weight gain caused by
Excess body fat Edema Ascites Endocrine disorders Medication side effects
what do you do when a patient has gained weight?
Diet?
Physical activity?
Weight loss attempts?
Psychological conditions?
Screen for endocrine disorders
Take a medication history
ALWAYS determine the time frame
for weight gain voluntary or involuntary?
Anorexia-
Loss of desire to eat, could be a sick patient w/ a terminal illness
Anorexia nervosa
Disorder marked by extremely low body weight and distorted body image.
Bulimia-
Disorder characterized by recurrent binge eating and compensatory behaviors to prevent weight gain such as excessive exercise or vomiting
weight loss follow up questions?
Has your appetite increased or decreased?
How long have you been losing weight?
How do you feel about the way you look?
What is your typical diet?
fatigue
common symptom of illness is a Lack of energy to complete tasks, exhaustion, tiredness May signify underlying medical (anemia, thyroid disorder, cardiac ischemia) or psychiatric disease (depression
Affected everyday activities? Time course? Modifying factors? Personal and social issues? was there anything else going on at this time or feel similar?
fatigue differential diagnosis
Anxiety/depression Systemic diseases Infections Cancer Medications And others!
Persistent fatigue
Chronic fatigue
Idiopathic fatigue
persists for more than 1 month
for 6 months or more
not attributed to a psychiatric or medical illness
muscle weakness
Categorized according to anatomic location causing the weakness Muscle Spinal nerve root Peripheral nerves Brain or spinal cord Upper/lower motor neurons disease
Primary muscle or neurologic disorders
Other systemic
diseases
Duration of symptoms? Evolution of symptoms? Distribution of symptoms? Associated signs and symptoms? Risk factors?
Functional weakness
- No true muscle weakness, but this interferes with completing activities of daily living.
True motor weakness
- Difficulty or inability to perform certain tasks. Example: patient that has difficulty rising from a chair.
Normal Temperature
Average oral temperature:
37°C or 98.6°F
Diurnal variation: 35.8°C (96.4°F) to 37.3°C (99.1°F)
temperature lower during sleep
Fever-
Fever of unknown origin (FUO)
Chills-
Temperature over 99 °F during the day and over 100 °F in the evening
- Temperature over 100.9 °F for 3 weeks with no clear etiology.
Involuntary muscle contractions with violent shivering and teeth chattering.
Fevers/chills caused by
Infection Malignancy (can cause night sweats) Inflammation Medications Post-op (chills after anesthesia because of changes in body temp. Endocrine disorders (hypothyroidism)
When someone has fevers/chills ask about?
Alarm symptoms- Rash, SOB (meningitis), chest pain, change in mental status.
Sick contact
Time course (how long has this been going on for)
Associated symptoms
Flushing-
Hot flashes
Hyperhydrosis
Night sweats
Acute onset of cutaneous vasodilation. ex. steroid reaction found in torso or head and can be found in periphery
- Sudden feelings of warmth, sweating. feels like flushing or may accompany it ex. menopause
- Increased sweating beyond necessary to maintain thermal homeostatis. ex. usually caused by medication
- Drenching sweating occurring during sleep requiring the patient to change clothes or bedding in absence of fever or environmental factors. Serious until proven otherwise if… New, Accompanied by Systemic Symptoms (weight loss, lymphadenopathy, cough). Clinical context is crucial! Ask about known co-morbid illnesses, travel/ exposure history.
ex. women going into menopause, red flag for undiagosed malignancy around once a week or once a month, hyperthyroidism, can be caused by medication taken at odd times
Night sweats are caused by
should be asked about?
Hormonal changes GERD Sleep disorders Medications Infection Malignancy inflammation
Alarm symptoms- Weight loss, lymphadenopathy, new symptoms in any organ system.
Bedding , night clothes, medications
Social history that might indicate TB, HIV, hepatitis
what are you looking for in general appearance?
Level of consciousness Apparent state of health Signs of distress Height (stature) and build (habitus) [weight] Skin Dress, grooming, and personal hygiene Facial Expression Odors of body and breath Posture, gait and motor activity
Level of Consciousness factors
Alert- Eyes open; responds appropriately.
Lethargic- Appears drowsy; can open eyes; makes eye contact, responds then may fall asleep.
Obtunded- Can open eyes; responds slowly but is confused; decreased interest in environment.
Stupor- Arouses from sleep only after painful stimuli is utilized; slow to no responses; lapses into unresponsiveness when stimuli is removed.
Comatose- Remains unresponsive to external stimuli.
General appearance
Well appearing Acute or chronically ill Frail Robust vigorous
signs of distress include
clutching chest (cardiac or respiratory)
guarding (indicating pain)
frazzled (anxiety/depression)
Height (stature) and build (habitus) [weight]:
Is the patient unusually short or tall? Is the build slender and lanky, muscular, or stocky? Note general body proportions and look for deformities
- short stature (turner syndrome, renal failure, achondroplastic and hypopituitary dwarfism, long limbs in proportion to trunk in hypognoadism and marfan syndrome height loss in osteoporoisis and vertebral issues; truncal fat w/ thin limbs suggests cushing syndrome
marfan syndrome
connective tissue disorder ex. causing fatal aneurysm from lack of tissues and is very lax
Cushing syndrome
C6-C7 vertebrae with fat pad buffalo hump, facial hair, lines on abdomen, osteoporosis ex-or-endogenous cortisol, when take prednisone a lot, something that develops, pituitary or adrenal adenoma. skinny arms and truncal fat
- increased adrenal cortisol production of cushing syndrome produces round moon face w/ red check w/ excessive hair growth in mustache, sideburn areas, and chin.
general appearance
Skin color and obvious lesions: Brief inspection of exposed skin. Full integument exam later. Looking for: pallor cyanosis Jaundice (icterus) rashes bruises
facial expression
Observe at rest, during conversation, during the physical exam, and during interaction with others
Note eye contact
Look for appropriate changes in facial expression (mask facies is parkinson disease symptom)
natural eye contact, sustained or unblinking, averted quickly or absent? stare of hyperthyroidism, immobile of parkinsonian, flat or sad of depression;
Posture, gait, and motor activity functions
gait steady or unsteady, unassisted? how fast are they moving, involuntary movements w/ preferred posture
posture-sit as if in pain or uncofmroatble, gait & motor activity-tremors, involuntary movement, smooth or self confidence walking w/ balance?
Gaits: spastic scissors propulsive steppage waddling
upper neuron issues after stroke for spastic and scissors
propulsive- spinal stenosis parkinson hurts to go straight
steppage- can’t dorsiflex foot usually w/ a lesion of L5
waddling- hip issue or duck gait
Palpating temperature –
better accuracy using dorsum of examiner’s hands if it is cold and clammy how does it compare to other areas
Places to get a temperature
Axillary (least accurate hold thermometer for 5-10 minutes least accurate
Oral-most commonly used
Temporal Artery- common higher than normal
Rectal Membrane- best and most accurate way to measure temperature inserting toward umbilicus
Tympanic- common higher than oral clean out wax
Hyperthermia
Hyperpyrexia-
Hypothermia-
Fever-
Elevation in body temperature due to loss of homeostatsis with inability to increase heat loss.
Extreme elevation in temperature above 106 degrees F. excessively high temperature above 106F severe illness, crush injury, malignancy, drug reactions, and immune disorders (collagen and vascular diseas)
Abnormally low temperature; below 95 degrees F when taken rectally. abnormally low temperature caused by exposure to cold, paralysis, sepsis alcohol starvation, hypothyroidism, and hypoglycemia
Elevated temperature 38 degrees C (100.4 degrees F) Rectally.
Arterial Pulse Measurement
An assessment of heart rate Radial or other locations Palpate for pattern (rhythm) Regular or irregular Palpate for intensity (strength) Weak, brisk (normal strong), or bounding If regular rhythm and normal rate count for 30 seconds and multiply by 2. If abnormal or irregular, count for a full 60 seconds. do early beats appear in a basically regular rhythm? does irregularity vary consistency w/ respiration? is is irregularly irregular Normal adult range: 60-100 beats/minute
Respiratory Rate
Count the respirations by watching the chest rise and fall. can have retractions It is more accurate if the patient does not know you are counting. expiration prolonged COPD Observe Rate: Normal 12 to 20 breaths/minute Rhythm: Regular, Irregular Depth: Shallow, Deep Effort: Gasping, Labored
Blood Pressure Cuff Measurement
Width of bladder: 40% of upper arm circumference
Length of bladder: 80% of upper arm circumference. arrows of arm width must fall in range for proper measurement.
If the cuff is too narrow, the reading will be high
If the cuff is too wide, the reading will be low on a small arm and high on a large arm
Optimal conditions for taking blood pressure
higher in first thing in the morning, do both arms, must do after multiple visits and if high double check before leaving.
Preparation is vital!
Avoid smoking, caffeine, exercise 30 minutes prior to measurement. (increases rate, cause inflammation in vessels)
Quiet examination room with comfortable temperature.
Arm free of clothing.
Ask the patient which arm they prefer. Avoid using side with a fistula, lymphedema, lymph node excision, extensive scarring or other abnormality.
Patient should sit quietly in a chair for at least 5 minutes prior; back supported and feet on the ground.
List the steps for obtaining an accurate blood pressure, and describe the consequences if proper technique is not observed.
Palpate the brachial artery (antecubital crease; medial to the biceps tendon)
Position the arm so that the brachial artery is at heart level
Rest the arm on a table a little above the patient’s waist OR support the patient’s arm with your own at their mid-chest level
Proper cuff location (2.5 cm above antecubital crease)
Secure the cuff – snug, not tight.
Palpate the radial pulse and inflate the cuff until it disappear Remember this number (systolic BP by palpation).
Deflate the cuff; wait 15-30 seconds.
Place your stethoscope lightly over the brachial artery
Hold arm at level of patient’s heart, and reinflate the cuff 30 mm Hg higher than the systolic number obtained by palpation.
Deflate the cuff at a rate of 2-3 mmHg/second
First sound = systolic blood pressure two consecutive sounds
Disappearance of sound = diastolic blood pressure except when there is an auscultatory gap
Orthostatic blood pressure
Measure blood pressure and
heart rate in two positions
1) Check BP with patient supine after resting 3-10 minutes
2) Wait three minutes
2) Check BP immediately when patient stands up patient usually gets dizzy
Normal: systolic ≤ initial ; diastolic rises slightly
Orthostasis: systolic BP drops ≥ 20 mmHg or diastolic BP drops ≥ 10 mmHg, pulse increases ≥ 20 beats/min
*In some settings it is routine to do this in 3 positions (supine, sitting, standing).
drop in systolic blood pressure of at least 10 mmHg w/in 3 minutes of standing caused by drugs, blood loss, bed rest, and ANS diseases
caused by Medications; Polypharmacy
Moderate or severe blood (or other fluid) loss dehydration
Prolonged bed rest
Autonomic and cardiovascular disorders
Types of hypertension
White Coat- Elevated BP in a clinical setting but not elsewhere. blood pressure >14090 in medical settings and mean awake home readings of 135/85 caused by stress of being in a medical environment
Masked- Normal office BP; but BP elevated when ambulating and at home. Increased risk of cardiovascular disease and organ damage. ex. if you have headache, dizziness, and other common signs of HBP have pt check home or have moving pressure. office blood pressure <140/90 elevated daytime blood pressure above 135/85 at home 10-30% of population w/ increased risk of cardiovascular disease and end organ damage
Nocturnal hypertension
Normally a physiologic dipping of BP occurs when shifting from wakefulness to sleep. With this type of HTN, a nocturnal fall of less than 10% of daytime values is associated with significant risk of cardiovascular disease and organ damage. Only identified by 24 hour monitoring. caused by vascular changes in eyes, headache, and dizziness
Blood pressure measurement
Measurement of BP in both arms at least once
Difference of pressure should be no more than 10 mm Hg per side
Diagnosis of Hypertension: Two or more properly measured BP readings taken on two or more office visits and verified in contralateral arm.
auscultatory gap
start to hear systolic pressure, disappears and then it comes back, at risk for cardiovascular instance, buildup of plague or aneurysm check doing BP while arm is raised and lower while you deflate, or have them make a fist
why do we check both arms for blood pressure?
check both sides if there is a difference of more than 10 mmhm can be caused by aneurysm or stenosis
pain is…
subjective with pain feeling different to each person. find out more by OPQRST
when did it start, at what point is it worse or better, associated sensory loss, other neurological symptoms setting in which it occurs (environmental, emotional) remitting or exacerbating factors what makes it better or worse, associated manifestations
Idiopathic
Neuropathic
Nocioceptive (somatic)
Psychogenic
– Without identifiable etiology
– Direct consequence of lesion or disease affecting somatosensory system ex. disc hernia
– Linked to tissue damage but sensory system is intact
– Associated with psychological factors
ex. if patient states 10/10 and is not in distress could be psychogenic
somatic
visceral
neuropathic
Sharp, stabbing, localized
Deep, achy, poorly localized
Burning, hot, distribution of nerve
actue pain
chronic pain
short lived
lasting at least 12 weeks
- Compare and contrast different methods of obtaining a patient’s temperature.
Oral- most commonly used and for adults correlate more closely w/ correct pulmonary artery temperature are generally lower than core body temperature and lower than core body temperature by (0.7-0.9F) higher than axillary by 1 problems caused by breathing
Rectal- most closely and more reliable because closer to core and not affected by breathing
Temporal- for adults correlate more closely w/ pulmonary artery temperature but are about 0.5C lower, using temporal artery
Axillary- take 5-10 inutes to register and are much less accurate than other measurements
Tympanic- more variable than oral or rectal, better used for children reliable but does it close to hypothalamus where temperature regulation occurs
Pain
1. Describe components of the patient history that are useful in the evaluation of pain.
LOPQRST
tolerance
dependence
addiction
reduced physiological reaction to a drug following repeated use
physical condition in which the body has adapted to the presence of the drug. withdrawal symptoms are eminent
chronic, relapsing disease marked by compulsive drug seeking and use despite harmful consequences
high vmi in men and women and assess for
if bmi greater than 35 if circumference is greater than 35in in men 40 in women.
bmi>25 assess for risk factors of hypertension, high LDL,, low HDL, high triglycerides, high BG, heart disease, cigarette an inactivity
major functions of the skin
keep the body in homeostasis Provides boundaries for body fluid Protects underlying tissues from microorganisms, harmful substances, and radiation Modulates body temperature Synthesizes vitamin D
Three Layers of Skin
Epidermis Outer Layer- Stratum Corneum Inner (cellular) Layers- Stratum Basale and Stratum Spinosum Dermis Subcutaneous tissue
Epidermis
Horny Layer (keratinized layer of dead cells aka stratum corneum) and cellular layer (stratum lucidium, stratum granulosum, stratum spinous, and stratum basal)
dermis-
contains connective tissue, sebaceous glands, hair follicle, and sweat glands and provides nourishment to the epidermis
hypodermis
contains nerves, vein, artery and mostly fat adipose cushioning
sweat glands two kinds and variety
eccrine (widely distributed, open directly onto skin surface, help control body temperature through sweat production)
apocrine (axxilary and genital open to genitals during stress providing body odor).
sebaceous glands
(found everywhere except palms soles secretes fatty, oily substance (sebum) secreted onto skin through hair follicles)
structure of nail
nail bed-tissue under nail
nail plate-fingernail
cuticle-seals space between nail fold and plate
nail root where nail grows from
structure of nail
nail bed-tissue under nail causing plate to be pink
nail plate-fingernail
cuticle-seals space between nail fold and plate or lateral nail fold
nail root where nail grows from
lunula- white area
proximal nail fold- covers nail root
clubbing more convex angle greater than 180 degrees caused by hypoxia
Concerning symptoms associated w/ skin
Hair loss (alopecia)
Rash
Moles
Nail changes
hair loss caused by
Systemic/chronic illness
Infection (systemic or local)
Medication exposure or serious illness in past 3-4 months
Psychiatric disorder
Physical stress or life-threatening psychological stress
Tight braids or “pulled-back” hairstyle – traction alopecia
Hormonal
due to systemic/chronic illness, infection (systemic or local), medication exposure or serious illness in past 3-4 months, psychiatric disorder, physical/psychological life-threatening stress, tight braids, hormones. Alopecia = Hair loss. May be diffuse or patchy, Telogen effluvium = Excessive hair shedding, Male-pattern baldness = Androgenic alopecia. Thinning crown, receding hairline. Trichotillomania = Urge to pull out one’s own hair. Can be diffuse, patchy, or total. Focal patches lost suddenly in alopecia areata w/ scarring alopecia need to refer to dermatology, sparse hair in hypothyrodism and fine silky hair inhyperthyroidism. Inspect for erythema, scaling, pustules, tenderness, bogginess, and scarring (need refferal right away). Pull on hair and if they have telogen bulbs most liekly have telogen effluvium, see if they break off
Alopecia
Telogen effluvium
Male-pattern baldness
Trichotillomania
= Hair loss. May be diffuse or patchy
= Excessive hair shedding
= Androgenic alopecia. Thinning crown, receding hairline.
= Urge to pull out one’s own hair
rash?
what is it caused by caused by
inflammatory skin eruption caused by: Drug reactions Infections (bacterial, viral, fungal)/infestations pregnancy Autoimmune (polycyhtemia vera and thyroid disease) Idiopathic Allergic Neoplastic (lymphomas and leukemia)
macule
primary lesion circumscribed, flat discoloration of only the top layer of horny epidermis of skin less than 1cm w/ a patch is more than 1cm. if a flat spot is larger than >1cm can be blue, red, or hypopigmented from a number of causesfreckle is a type of macule. can be brown, blue, red, or hypo pigmented any color can be associated w/ problems. if a flat spot is small <1cm it is a macule, can be brown, blue, red, or hypopigmented by a number of causes see powerpoint
plaque
primary lesion circumscribed palpable solid lesion 1 cm or larger often formed by confluence of papuples caused by many disease appear red, raised, and dry patchy affecting only horny layer of epidermis
raised spot >1cm psoriasis, atopic dermatisis, or rosea
papule
primary lesion a palpable lesion effecting full thickness of epidermis and dermis <1cm in diameter coloration varies from skin color, yellow, white, brown, red, blue or violaceous with variations from benign to associated w/ a disease
- lesion that is palpable above skin being raised if <1cm, color varies felsh, yellow, white, brown, red, bblue can become confluent and form plaques can be benign or cancerous
nodule/cyst
primary lesion a circumscribed often round, solid lesion larger and deeper than a papule w/ a large one referred to as tumor located completely below the epidermis fully floating in the epidermis almost always associated w/ something that needs treatment
mobile or fixed encapsulated collections of fluid or semisolid
- circumscribed, often round, solid lesion larger and deeper than papule w/ a large one being a tumor ex. BCC, wart
wheal
primary lesion. a firm edematous papule or plaque, resulting from infiltration of the dermis with fluid wheals are transient and may last a few hours to a few days. A wheal is a red, swollen mark or white that can be individual bumps or large connected areas, that is often itchy and changes shape. They usually occur in response to a stimulus like a bug bite or food allergies. causing by increased inflammation of cellularly layer in skin and redness in the horny layer.
firm edematous papule or plaque, resulting from infiltration of dermis w/ fluid transient w/ dermal edema lasting few hours to days ex. hives, urticara
vesicle
primary lesion circumscribed collection of free fluid less than 1cm in height that is located between horny and cellular layer of epidermis ranging from benign to indicator of herpes
if lesion is raised, filled w/ fluid and small <1cm it is a vesicle ex. herpes simplex or shingles
pustule
primary circumscribed collection of leukocytes and free fluid that varies in size and is located under horny layer of epidermis dividing cellular epidermis and comes in contact w/ dermis
ex. acne, chicken pox,
burrow
primary Burrows are tunnels formed in the skin that appear as linear marks. They are a result of an infestation of the skin by parasites such as scabietic mites.
small linear or semipiginous pathways in epidermis created by scabies mites
crust
secondary lesion is a collection of dried serum and cellular debris, scab caused from damage
lichenification
secondary skin has become thickened and leathery caused from continual rubbing or scratching skin caused by chronic eczema
scar
secondary an abnormal formation of connective tissue implying dermal damage after injury or surgery are initially thick and pink but become white and atrophic forming a bump in cellular layer that increases the size of the horny layer w/ no issue
keloid
secondary abnormal proliferation of scar tissue that forms at the site of cutaneous injury (eg, on the site of a surgical incision or trauma); it does not regress and grows beyond the original margins of the scar
erosion
secondary a focal loss of epidermis. do not penetrate below the dermoepidermal junction and therefore heal without scarring from inflammatory or infectious disease
excoriation
secondary lesion that is a scratch caused from ones own compulsion to pick at skin causing red raised bumps and scratches to surface.
fissure
secondary a linear loss of epidermis and dermis with sharply defined nearly vertical walls caused by chapping or eczema
ulcer
secondary focal loss of epidermis and dermis ulcers heal with scarring caused by physical trauma and infection
scale
excess dead epidermal cells of horny layer that are produced by abnormal keratinization and shedding with genetic components or some bacterial causes
moles or nevi
Most moles are harmless, but in some cases, moles may become cancerous.
Monitoring moles and other pigmented patches is an important step in detecting malignant melanoma.
Clusters of pigmented cells
Can come in a range of colors and can develop virtually anywhere on your body.
nevi use ABCDEEFG to describe and characterize could become cancer
- Describe the ABCDE method of screening for melanoma, and describe the skin findings associated with malignant melanoma.
Any two of these factors should be sent to a dermatologist for an assessment. screen anyone w/ >50 moles, and >5-10 atypical moles
A- asymmetry of one side of mole compared to other, B- border irregularity especially if ragged, notched, or blurred, C-color variations w/ more than two colors especially, blue=black, white (loss of pigment due to regression), or red (inflammatory reaction to abnormal cells except of homogenous blue color in blue nevus. the blue or black color w/in a larger pigmented lesion is especially concerning for melanoma. D- diameter >6mm normal one should be approximately the size of a pencil eraser. E- evolving or changing rapidly in size, symptoms, or morphology and is the most sensitive of these criteria. E- elevated. F-firm to palpation. G-growing progressively over several weeks
basal cell carcinoma
Comprises 80% of skin cancers
Shiny and translucent, they grow slowly and rarely metastasize. raised pearly reddish
most common cancer in world, rarely spreads to other parts of body, invdde and destroy local tissues immature cells to basal layer
squamous cell carcinoma
Comprises 16% of skin cancers
Crusted, scaly, and ulcerated, they can metastasiz. roughened hyperkeratotic lesions sun exposed areas
begn usually by acitinic keratosis feeling rough or keratotic arises form sun-damaged skin of head, neck, and dorsal arms and ahnds and can metastasize if left untreated consisting of more mature cells found on scalp, lips, and ears
melanoma
Comprises 4% of skin cancers
Tend to spread rapidly
when examining skin quality what do you look for
color (hyper or hypopigmentatioN, redness/erythema), yellow/jaundice), ecchymosis/bruising, cyanosis)
moisture (Dryness, sweating (moist), and oiliness)
temperature (Identify warmth or coolness of skin)
texture (Rough or smooth)
turgor (Lift fold of skin over back of hand
Note ease with which it lifts up (mobility) and speed with which it returns to place (turgor))
lesions
what do you do differently of people of color
Melanin may obscure changes
Therefore inspect conjunctivae, buccal mucosa, nail beds, and palms to assess color changes.
cyanosis and its location
- indicating severe lack of oxygen forcing areas like extremities to shunt oxygen elsewhere and turn blue ex. COPD exacerbation
Blue coloration of the skin and mucous membranes due to the presence of deoxygenated hemoglobin in blood vessels near the skin surface.
Central cyanosis is often due to a circulatory or ventilation problem (cardiopulmonary failure)
low oxygen levels in blood cause lips, fingers, and toes to turn blue central due to circulatory or ventilation problem (cardiopulmonary failure,
Peripheral - Peripheral cyanosis is the blue tint in fingers or extremities, due to inadequate circulation.
what do you look at in scalp
Look at distribution and quantity of hair
Look for any scalp lesions
what do you look for in nail beds
Look for color and deformity
Clubbing (mostly caused by lung issues or cancers)
lesion characteristics
Anatomic location and distribution Patterns and shapes (morphology) Type of lesion (macules, papules, nevi, vesicles) Color Size
describing a rash what do you look for?
Morphology of lesions - What is the color? Primary or secondary lesions? Are the lesions all the same or variable? Is there any exudate? Size, number? Texture?
Pattern – Shape, round, oval, annular (ring-shaped), iris (target-shaped), serpiginous (snake-like)
Anatomic distribution – localized, generalized, symmetrical, acral (hands and feet), light-exposed areas, intertriginous (skin folds), clustered, dermatomal
pityriasis rosea
Scaly, patchy rash sometimes seen in a Christmas tree pattern
Hearld Patch may appear initially then symmetric spreading
Unknown etiology but may be related to viral infection
single oval, flat-topped superficial erythematous to skin colored plaque or multiple round to oval scaling violaceous plaques contagious infection
dermatomyositis
Inflammatory myopathy Muscle weakness and rash Red/purple patches Unknown etiology, most likely autoimmune - uncommon inflammatory disease w/ rash ad muscle weakness slightly raised reddish scaly rash
athlete’s foot (tinea pedis)
Fungal infection
Usually begins between the toes, but can spread
- fungal infection beginning between toes occurs in people who feet are sweaty in tightfitting shoes scaly rash cuasing itching, stinging, and burning contagious and can be spread
tinea versicolor
Common fungal infection
Discolored patches
hypopigmented, hyperpgimented or tan round to oval macules on upper neck and back, upper chest, and arm w/ slight inducible scale on scraping
small pox
Firm
Well circumscribed vesicles or pustles
May be umbilicated
Caused by viral (variola) infection
erythema infectiosum
“Slapped cheek” rash
“Lace like” rash on extremities
Caused by Parvovirus B19
pigments of skin
melanin- brown skin tone determined by sunlight
carotene- golden yellow pigment subcutaneous fat palms and soles
hemoglobin- RBC oxygen of blood oxyhemoglobin vs. deoxyhemoglobin w/ or without oxygen (causing bluish cast cyanosis best assessed where horny layer is thinnest under fingernails, mouth and mucus membrane, and in mouth
velus hair
short fine, incosncipuous unpigmented
terminal
coarser, thicker, conspicuous, more pigments scalp and eyebrows
jaundice
yellow in sclera, liver disease or excessive hemolysis, palpebral conjunctive, lips hard pallet, yympanic membrane skin,. blanch out color by lips of slide.
caused by the increased amount of bilirubin a pigment involved in the breakdown of RBCs
associated w/ liver failure or disease caused by the
INTERTRIGENOUS
area where two skin areas of skin may come and rub together
patterns of skin lesions
linear, clustered, annular (ring), arciform (arc), dermatomal covering skin band sensory nerve root
signs of cardiac or respiratory distress
clutching of chest, pallor, diaphoresis, labored breathing, wheezing, or coughing
signs of pain
wincing, diaphoresis, protectiveness of a painful area, grimacing, unusual posture
signs of psychological distress
anxious facial expressions, fidgety movements, cold moist palms, inexpressive or flat affect, poor eye contact, yshomotor slowing
posture of someone w/ left sided CHF
leaning forward w/ arms braced COPD
how can a clinician handle a difficult patient?
hard trials and tribulations show your worth like an olympian
clinician should identify many variables associated w/ encounters, identify own underlying negative emotions, adapt approach and redirect encounter exploring why
What are common functional syndromes?
IBS, fibromyalgia, chronic fatigue, TMJ, fatigue, sleep distrubance, musculoskeletal pain, headache, and gastrointestinal problems, overlap or comobrid w/ functional impairment psychiatric comorbitis if chronic more than 6 weeks highly likely it is psych
medical symptoms with a mental health component – patients are not “faking.”
clusters of common sysmptoms caused by psychological reasonsing such as IBS, fibromyalgia, chronic fatigue, TMJ, and multiple chemical sensitivity Conversion disorder, psychogenic non-epileptic seizures
Mental health disorders can be masked by other conditions
Depression
Multiple somatic (body-wide) complaints, aches, pains, fatigue
Hypothyroidism
Anxiety
Palpitations, chest pain
Panic attack
Diaphoresis, paresthesias of extremities, shortness of breath, chest pain, tunnel vision
Delirium presents with psychiatric symptoms but is a medical diagnosis with a medical etiolog
Common or concerning symptoms:
Changes in attention
Changes in mood
Changes in speech
Changes in insight
Changes in orientation
Changes in memory
Anxiety (excessive worrying that interferes with ability to function)
Panic
Ritualistic Behavior (counting, checking)
Delirium (confusion, altered level of consciousness)
Dementia (forgetfulness)
Conversion disorder-
neurological symptoms w/out neuro problems history of abuse or trauma to childhood, recent stressor need to treat underling health depression
Cognitive behavioral therapy and physical therapy
Psychogenic non-epileptic seizures- patients w/ epilepsy can have psychogenic
How do you approach a psych patient
Safety
Create an environment that is safe for both yourself and the patient
Examiner’s behavior
Eye contact
Interpersonal space
Posture
Verbal interventions:
Report and reflect to patient periodically
Accept what the patient says
Express concern and desire to protect patient’s safety
Acknowledge patient’s power to make decisions
Comfort measures
So it sounds like you’ve been feeling… is that accurate?
Resisting writing reflex, instead of writing it off ask what they like and what they don’t like about it and ask why it can be bad
agitated depression
tense posture, restlessness, and anxious fidgeting; crying, pacing, and hand wringing of agitated depression; hopeless slumped posture and slowed movements of depression; agitated and expansive movements of manic disorder
opposite parental cortex
one sided neglect of grooming may result form lesion in opposite partial cortex usually nondominat side
facial expressions seen in psych patients
anger, hostility, suspiciousness, or evasiveness of patients w/ paranoia; elation and euphoria fo mania; flat affect and remoteness of schizophrenia; apathy (dulled affect w/ detachment and indifference) of dementia and anxiety or depression. hallucinations occur in schizophrenia, alcohol withdrawal, and systemic toxicity.
aphasia-
from cerebrovascular infraction can be receptive (impaired comprehension w/ fluent speech) or expressive (preserved comprehension and slow confluent speech) hesitancies and gaps in flow and rhythm of words, disturbed inflections like monotone, circumlocution phrases or sentences are substituted for a word a person cannot think of paraphasia in which words are malformed wrong or invented
test for aphasia
word comprehesnion (ask patient to follow one-stage command)
repetition )repeat a phrase of one-syllable words)
naming- ask patient to name something
reading comprehension- have them read something
writing- have them write something
amnestic disorders
impair merry or new learning ability and reduce social or occupational function, lack global features of delirium or dementia
- Discuss the following common or concerning symptoms as part of the initial assessment. change in weight-
rapid changes over a few days suggest body fluid not tissue, edema from extracellular luid retention found inCHF, nephrotic syndrome, liver failure, and venous stasis. weight gain caused by many drugs, weight loss or loss of 5% or more of usual body weight over 6 month period w/ ddysphagia, vomiting, abdominal pain caused by gastrointestinal diseases, endocrine disorders (diabetes, hyperthyroidism, adrenal insufficianty, chronic infections, HIV/ADS, malignancy, CHF, COPD, renal failure, depression, anorexia or bulimia
Discuss the following common or concerning symptoms as part of the initial assessment. List possible causes for these symptoms (i.e. – differential diagnosis): fatigue
- feeling tired all the time common symptom of depression and anxiety, also caused by infections (hepatitis, mono, and tb), endocrine disorders (hypothyroidism, adrenal insufficiency, diabetes mellitus), heart failure, COPD, kidney or liver disease, electrolyte imbalance, anemia, nutritional deficits and mediation
Describe the use of the stethoscope
The large structure is the diaphragm, the smaller opposite side is a pediatric diaphragm and can be used for a bell, but to fully make it a bell you must remove the top in order to listen to high pitched sounds and things like heart sounds etc.
- Discuss the following common or concerning symptoms as part of the initial assessment. List possible causes for these symptoms (i.e. – differential diagnosis): weakness-
denotes demonstrable loss of muscle power, if localized in a neuroanatomical pattern suggests neuropathy or myopathy
- Discuss the following common or concerning symptoms as part of the initial assessment. List possible causes for these symptoms (i.e. – differential diagnosis): fever-
abnormal elevation in body temperature usually caused by acute or chronic illness feeling hot correlates to a falling temperature
- Discuss the following common or concerning symptoms as part of the initial assessment. List possible causes for these symptoms (i.e. – differential diagnosis): chills-
recurrent shaking chills suggest more extreme swings in temperature and systemic bacteremia. usually characterized with shivering throughout body, feeling cold, goosebumps and shivering accompany rising temperature
- Discuss the following common or concerning symptoms as part of the initial assessment. List possible causes for these symptoms (i.e. – differential diagnosis): night sweats-
fever exagerrate the swing of body temperature rising during day and falling during night causing pt to sweat during nighttime caused by tb and malignancy
- Define and describe the components of the general survey.
apparent state of health level of consciousness signs of distress skin, color,r and obvious lesions, dress, grooming & personal hygiene facial expression odors of body and breath gait and motor activity height and weight
dress grooming & personal hygiene,
- are they dressed? (neglected appearance suggest depression or dementia) overdressed? (hypothyroidism cold intolerance) underdressed? dressed appropriately?, worn down shoes or slipper (gout, bunions, edema, painful foot conditions causing foot or back pain;
; odors of body and breath-
presence of alcohol or acetone (diabetes), pulmonary infections, uremia, or liver failure, drugs or alcohol;
Diaphoresis
-excessive sweating caused by menopause, hyperthyroidism, diabetes, withdrawal, medications heart attack, anaphylaxis, cancers, and pain
Facial grimacing-
painful facial expression caused by injury
Flat affect
- severe reduction in emotional expressiveness caused by depression, schizophrenia appearing apathetic
Immobile face
-facial muscles of face paralyzed or unable to move caused by bells palsy, stroke, or parkinsons
Involuntary movements-
caused by tremor, tics, chorea, mycoclonus, athetosis, dystonia, hemiballismus
Labored breathing-
someone who was having apparent respiratory distress caused by COPD includes trippoding retractions belly breathing
Pallor-
pale whitish color indicating sickness or lack of oxygen due to repiratory distress
Psychomotor slowing
- slow movements caused by schizophrenia
Tremors-
caused by withdrawal, drugs, hyperthyroidism and hypoglycemia
Unkempt-
persons appearance not kept up can be lifestyle, depression, dementia
Wheezing-
caused by respiratory distress and infection associated w/ narrowing of airways
Wincing –
facial expression in response to pain
aortic dissection-
inner layer of aorta, tears w/ blood surging through tear, causing inner and middle layers to separate can be deadly commonly caused by age weakening muscle and CAD can cause death
arrhythmias-
heart beats w/ irregular or abnormal rhythm caused by CAD, electrolyte imbalance
auscultatory gap
- silent interval that may be present between systolic and diastolic pressures can lead to underestimation of systolic pressure from arterial stiffness and atherosclerosis
bradycardia-
tachycardia-
low heart rate can be caused by infection
coarctation of the aorta- narrowing of thoracic aorta, distal to origin of left subclavian artery w/ systolic hypertension greater in arms than legs
fast heart rate can be caused by physical activity, distress, or
coarctation of the aorta-
narrowing of thoracic aorta, distal to origin of left subclavian artery w/ systolic hypertension greater in arms than legs
isolated systolic hypertension
- systolic blood pressure is >140 and distaloic is <90.
Korotkoff sounds-
sounds that you listen to while taking BP
Activities of daily living
- what activities do you need to do daily or weekly to survive and are they hindered
Acute pain
- pain lasting less than 3-6 months usually related to soft tissue damage feeling sharp and severe
Addiction-
Physical dependence-
Tolerance-
physical condition in which the body has adapted to the presence of the drug. withdrawal symptoms are eminent
body’s requirement for something
reduced physiological reaction to a drug
Analgesia-
inability to feel pain caused by nerve damage, long term use of pain meds, damage of kidney
Chronic pain
- pain not associated w/ cancer or other medical conditions that persist for more than 3-6 months, pain lasting more than 1 month beyond course of an acute illness or injury, or recurring at intervals of months or years
Faces pain scale-
using facial expressions to describe pain used for children and people with language barriers
Idiopathic-
Neuropathic
pain without an identifiable etiology
- consequence of a lesion or disease affecting somatosensory system can become independent of injury, burning, lancinating, or shock-like and can persist after healing ex. CNS brain or spinal cord injury from stroke or trauma PNS disoarders trapping or prssing on nerves
Nocioceptive-
somatic pain linked to tissue damage to the skin, musculoskeletal system, or viscera ex. arthritis acute or chronic using anti-inflammatory mediators or psychological neurotransmitters
Numeric rating scale
Visual analog scale-
- scale using facial numbers to rate pain
scale from 1-10 on symptoms how they affect you and how you would describe it
Opioid-
doses correlate w/ sleep disordered breathing and sleep apnea prescriptions have increased correlating w/ overdoses particularly in those 65+ depression, substance abuse, and benzodiazepine treatment
Pain management-
analysis and tools used to help a patient have their pain relieved weighing consequences of addiction and personal comfort
Psychogenic-
anxiety or depression, personality and coping style, cultural norms, and social support systems
nail changes-
include paronychia (causing redness ad irritation infection of lateral folds of nail plate from S. aureus and streptococcus can surround nail plate because of trauma from nail biting, manicuring, or frequent hand immersion in water), clubbing, habit tic deformity (depression of central nail w/ xmas tree appearance from small horizontal depressions, resulting from repetitive trauma from rubbing index finger over them), melanoychia increased pigmentation in nail matrix causing a streak can be caused by nevus if small or subungula melanoma in nail or ethnic variation in multiple), onycholysis (painless separation of whitened opaque nail plate from pinker translucent nail bed goes from distal to proximal due to trauma from excess manicuring, psoriasis, fungal infection, allergic reaction, diabetes, anemia, photosensitive drug reactions, hyperthyroidism, peripheral ischeia, bronchiectasis, and syphilis). onyxhomycosis (from bacertia and mold or nail thickening and subungual debris), terry nails (nail plate turns white w/ ground glass appearcance, no lunula, liver disease, cirrhosis, CHF, and diabetes), transverse linear depressions(from temporary disruption of proximal nail growth from systemic illness, can measure size to determine illness), pitting (punctate depressions of nail palte because of defective layering of superifical nail plate by proximal nail matrix w/ psoriasis, reiter syndrome sarcoidosis, alopecia areata, and localized atopic or chemical dermatitis
rash-
inflammatory skin eruption caused by a Drug reactions, Infections (bacterial, viral, fungal)/infestations, Autoimmune, Idiopathic, Allergic, Neoplastic
Adipose tissue
- subcutaneous fat the skin layer below the dermis that is highly vascularized, w/ major nerves, and provides the cushion for the skin and body
Bulla
–raised, filled w/ fluid, and larger than 1cm ex. herpes
Clubbing
bulbous swelling of soft tissue at nail base w/ loss of normal angle between nail and proximal nail fold increasing it 180 degree, nail bed feels spongy or floating due to vasodilation with increased blood flow to distal portion of digits and changes in connective tissue from hypoxia, innervation, genetic or platelet derived growth factor from fragments of platelet clumps in CAD, lung disease and lung cancer, IBS, and malignancies
Cuticle-
extends from nail fold covering nail root and functioning as a seal protecting it from moisture
Dermis-
provides nutrition to epidermis and is a dense layer of interconnecting collagen and elastic fibers containing sebaceous glands, sweat glands, hair follicles, and terminals of cutaneous nerves
Epidermis-
superficial layer of skin, thin avascular keratinized epithelium consisting of outer horny stratum corneum (dead keratinized cells)and inner cellular layer (stratum basale and spinosum where melanin and keratin are formed
Fine textured hair-
short, fine, inconspicuous vellus hair around body
Induration-inflammation causing loss of elasticity and fibers
Nail bed-
Nail plate
vascular plate attaches to it
- firm rectangular and curving gets pink color from vascular nail bed where it attaches
Sebaceous glands-
Sweat glands-
eccrine glands
apocrine glands
produce fatty substance secreted onto skin surface through hair follicles present on all skin surfaces except palms and soles
eccrine and appocrine
(widely distributed open directly onto skin and control body temperature) and
(found in axillary and genital regions opening onto hair follicles causing adult body odor.
Turgor-
measure of elasticity of skin, reflecting a patient’s state of hydration (change w/ age)
Acne-
most common cutaneous disorder in US, pilosebaceous unit involving proliferation of keratinocytes at opening of follicle increased production of sebum, w/ androms and keratinocytes lug follicular opening cosmetics, humidity, heavy sweating and stress dividing comedonal, inflammatory, and nodulocstic in chest, neck, face, upper back and arms
Dermatomyositis
- uncommon inflammatory disease w/ rash ad muscle weakness slightly raised reddish scaly rash
Psoriasis-
condition speeding up life cycle of skin cells building up rapidly on surface w/ extra forming scales and red patches itchy and sometimes painful chornic
Small pox-
face arms and legs filled w/ clear fluid, pus, then crusts and falls off also have flu like symptoms
Vitiligo-
large confluent completely depigmented patches on dorsal hands and distal forearms
Headache-
ask about severeity, sudden or gradual, increase over time, come in waves, chronic or recurring, recent change, any other symptoms. if it has an aura can be a stroke or CAD,. primary headaches include migraine, tension, cluster, and chronic daily headaches. secondary headaches arise from underlying structural, systemic, or infectious causes such as minenigits or subarachnoid hemorrhage and may be life-threateneing
Head injury/trauma-
sensistivity to light? drowsiness, poor concentration, confusion, memory loss, blurred vision, dizziness, irritability, restlessness fatigure could be concussion up to a brain bleed or vertebral or skull fracture
Neck mass (goiter) –
enlargement of the thyroid gland to twice its normal size can be simple, without nodules, or multinodular and usually euthyroid can cause stridor or upper airway blockage
Swollen glands (lymphadenopathy)
- commonly means pharyngitis palpate to find
Temporomandibular (TMJ) pain
can palpate and see if there is swelling in the jaw muscles or pain upon palpation commonly from gridning teeth
tension headache
- episodic and tend to peak over several hours. new and persisting, progressively severe headaches raise concerns of tumor, abscess or mass lesion, arise in temporal areas, cluster headaches may be retro-orbital
migraine headache
- episodic and tend to peak over several hours. new and persisting, progressively severe headaches raise concerns of tumor, abscess or mass lesion. unilateral headache occurs. nausea and vomiting are common have have symptom prodome prior to onsetflash of light, fortifications, scotomas areas of visual loss.
meningitis
- if headache is severe and sudden of onset consider subarachnoid hemorrhage
thunderclap headaches- reaching maximal intensity over several minutes occur in 70% of patients w/ subarachnoid hemorrhage and are often preceded by sentinel leak headache from vascular leak into subarachnoid space
Acromegaly
-pronounced cheekbones, forehead bulges, jaw is enlarged, facial lines are prominent because of pituitary gland gland producing too much growth hormone
increased growth hormone produces enlargement of both bone and soft tissue w/ an elongated head, bone prominence of forehead, nose, and lower jaw soft tissues of nose, lips, and ears are large and features coarsened
Bruit-
vibrations resulting from turbulence in intracranial or extracranial vessels. systolic in timing can extend into diastole or even be continuous originate in cranium or can be transmitted from arteries in neck causing seizures, headaches, stroke syndromes, intracranial mass lesions, or carotid bruits.
Goiter/Multinodular goiter-
goiter enlarged thyroid, multinodular where there are multiple nodules can be toxic making too much thyroid hormone and cause hyperthyroidism
Multinodular goiter- toxic
Diffusely enlarged thyroid gland- goiter
Great vessels-
deep to the sternocleidomastoids in the neck, carotid artery artery and internal jugular vein, external jugular vein passing diagonally over surface of sternocleidomastoid helpful when trying to identify jugular venous processes.
Hirsutism
-condition of unwanted male pattern hair growth in women resulting in excessive amounts of dark course hair on body areas where men typically grow hair face chest and back
Hyper/hypo-thyroidism
Lymphadenopathy
- disease of the lymph nodes, in which they are abnormal in size, number caused by infections, autoimmune diseases,
Mechanism of injury
- what causes an injury or trauma
Moon face-
medical sign in which face develops rounded appearache due to fat deposits on sides of face because of Cushing’s syndrome or steroid treatment
Myxedema-
caused by severe hypothyroidism showing expressionless face, puffines around eyes and pallow
in severe hypothyroidism mucopolysaccharide deposition in dermis leads to dull, puffy faces. edema pronounced around eyes does not pit w/ pressure and hair and eyebrows are dry, coarse and thinned w/ loss of lateral third of eyebrows and dry skin
Normocephalic-
referring to a head of normal shape and size for a person’s age
Parotitis-
Parotid gland
inflammation of parotid gland ex. mumps. chronic bilateral asymptomatic parotid gland enlargement may be associated w/ obesity, diabetes, cirrhosis, and other conditions w/ swelling in earlobes and above jaw. unilateral enlargement suggest neoplasm and acute in mumps
- superficial to behind the meandible (both visible and palpable when enlarged)
Periorbital edema-
swelling and fluid filled around eyes
TMJ syndrome-
temporomandibular joint acts like sliding hinge connecting jawbone to skill w/ one on each side and with a disorder of TMJ pain commonly due to grinding teeth or clenching can be arthritis, injury or genetics while you sleep causes pain in jaw joint and in muscles that control jaw movements
Anterior triangle-
mandible, sternocleidomastoid laterally and midline of neck medially
Carotid artery-
exteneral jugular vein
Internal jugular vein
artery going up on either side of neck next to trachea splits at the thyroid cartilage
empties blood from back of head and neck on the outside of sternocleidomastoid
near the carotid carrying blood from head and neck to superior vena cava on inside of sternocleidomastoid
Cricoid cartilage
- just below the thyroid cartilage protecting the airway
Frontal bone
Hyoid bone-
Occipital bone
Parietal bone-
Temporal bone-
Vertex of the head-
- bone located at the forehead
top bone above thyroid cartilage, horseshoe shaped bone in anterior midline of neck between chin and thyroid cartilage at mandible
- bone in the back of the head covering the occipital part of brain and cerebellum
bone on the top of the skull
bone by your temple
upper surface of head formed by frontal bone, parietal bones and occipital bone
Posterior triangle-
sternocleidomastoid muscle, trapexius, and clavicle portion of omohyoid in lower part of triangle
Thyroid cartilage-
Thyroid isthmus-
Thyroid lobe-
have notch on superior edge covering thyroid
spans the second, third, and fourth tracheal rings below cricoid cartilage
lobes of thyroid curve posteriorly around sides of trachea, esophagus
anterior cervical
occipital-
posterior cervical-
preauricular-
submandibular-
submental-
supraclavicular-
tonsillar-
- contain superficial and deep cervical chain (deep to sternocleidomastoid and often inacccessibble to examination hook thumb and fingers around either side of sternocleidomastoid muscle to find them
at base of skull posteriorly
postauricular- superficial to mastoid process behind ear lobe
along anterior edge of trapezius
in front of ear
midway between angle and tip of mandible, smaller and smoother than lobulated submandibular gland against which they lie
in midline few centimeters behind tip of mandible
deep in angle formed by clavicle and sternocleidomastoid enlargement of this node on left suggest possible metastasis from thoracic or abdominal malignancy
at angle of mandible
• Assess the hair, scalp, skull, face and skin-
note hair’s quantity, distribution, texture, an any pattern of loss (fine hair causes hyperthyroidism coarse hair hypothyroidism, white ovoid granules adhering to nails may be lice eggs); scalp part hair in several places and look for scaliness, lumps, nevi or other lesions (redness and scaling can indicate dermatitis or psoriasis soft lumps pilar cysts pigmented nevi may be elanoma), observe general size and contour of skull w/ any deformtities depresssions lumps or tendernessw/ enlarged skull hydrocephalus or paget disease w/ palpable tenderness and bony step offs from head trauma; no patients facial expression and contours observe for asymmetry, involuntary movments, edema, and masses. skin observing on face, head, noting color pigmentation, texture, thickness, hair distribution and any lesions (w/ acne, hirsutism/excessive facial hair appearing in polycystic ovary syndrome in woman.
Inspect & palpate the TMJ-
• palpate jaw beginning in front of ear asking them to open mouth check for smooth range of motion, swelling or tenderness or redness
• Inspect and palpate the lymph nodes in the neck-
use pads of index and middle finger press gently on skin w/ patient neck relaxed but slightly flexed forward examining both sides at once for asymmetry swelling tenderness
• Assess range of motion of the neck-
hold the patients head and move it around in all directions, have them resist against you
• Inspect and palpate the thyroid gland-
tip the patient’s head slightly back, using tangential lighting directed diwonward from tip of chin, inspect region below cricoid cartilage to identify contours of gland and observe patient swallowing
• Assess the trachea, the cervical spine, and the cervical muscles-
touch down front of throat, swallowing reflex for swelling etc., have patient flex, extend, rotate, and bend neck by having them look and move their head in all directions noting any tenderness, loss of sensation or weakness
- Describe the indications for listening for a thyroid bruit, and demonstrate appropriate technique.
if thyroid is enlarged listen over lateral lobes w/ stethoscope to detect a bruit, sound similar to cardiac mrurmur heard in cases of hyperthyroidism from graves disease or multinodular goiter
Nephrotic syndrome-
glomerular disease causes excess albumin excretion, which reduces intravascular colloid osmotic pressure, causing hypovolemic, then sodium and water retention w/ face becoming edematous and pale. swelling around eyes in morning making them slits eventually.
Paget’s disease-
enlarged skill of bone
Parkinson’s disease-
neurodegenerative disorder linked to loss of neurotransmitter dopamine, decreased facial mobility and masklike facies w/ dereased blinking and characteristic stare. since neck and upper trunk flex forward pat. seems to peer upward toward observer face becomes oily and drooling occur
Hard fixed lymph node
- not a node but in fact the styloid process
Parotid gland enlargement-
chronic bilateral asymptomatic parotid gland enlargement may be associated w/ obesity, diabetes, cirrhosis, and other conditions w/ swellings anterior to ear lobes and above angles of jaw. gradual unilateral enlargement suggests neoplasm and acute is mumps
Thyroid nodules
- lumps that arise mostly benign in woman but can be cancerous
Discuss the approach to history taking and the significance of findings for the following common or concerning symptoms:• Anxiety
- things like palpitations and chest pain mask it. Need to know that OCD is a type of anxiety disorder. Generalized anxiety disorder- worry about everything and anything not a trigger or particular thing. Panic disorder- chest pain, palpitations, numbness and tingling of fingers sense of impending doom having it more than once. Agoraphobia- fear of leaving house or enclosed space wont wanna leave house for fear of panic attack. OCD- obsessive thinking about same thought over and over and have to carry out compulsion or counting to help relieve obsessive thinking
Discuss the approach to history taking and the significance of findings for the following common or concerning symptoms:
• Confusion
- rule out medical causes first UTI ex. I WATCH DEATH infections, withdrawal, acute metabolic, trauma, CNS disease, hypoxia, deficiencies, environmental, acute vascular, toxins, heavy metals
Discuss the approach to history taking and the significance of findings for the following common or concerning symptoms:
• Depression-
can be masked by multiple somatic (body-wide) complaints, stomach aches, pain, fatigue, hypothyroidism, look for particularly vulnerable patients who are young, female, single, divorced or separated, seriously or chronically ill, bereaved or have other psychiatric disorders or substance abuse
Discuss the approach to history taking and the significance of findings for the following common or concerning symptoms:• Memory loss-
rule out medical causes first UTI ex. I WATCH DEATH infections, withdrawal, acute metabolic, trauma, CNS disease, hypoxia, deficiencies, environmental, acute vascular, toxins, heavy metals
Cognitive function-
orientation, attention, memory, attention and vocuabulary calculations, abstract thinking and constructional ability
Difficult patient-
frequent users of health care system unexplained somatic symptoms most of these patients that seem difficult to deal with or give you a hard time have underlying psychiatric conditions. people w/ depression and anxiety increase difficulty 3X w/ somatization 9X
Medically unexplained symptoms
- 30% of somatic symptoms single complaints that persist longer than other like back pain, headache, or musculoskeletal pain and have no medical causes usually psychological. range from impairment to behaviors for mood and somatic symptoms disorders. 2/3 w/ depression have physical unexplained
Overlap symptoms-
many paitnets have both medical and psychiatric symptoms fatigue, sleep disturbance, musculoskeletal pain, headache, and gastrointestinal problems
Somatic-
70% self limited resolving in 6 weeks, 25% recurring physical symptoms or physical symptoms such as pain, fatigue, or palpitations gastrointestinal sexual or reproductive and neurological symptoms like dizziness or loss of balance that are caused because of psychological causes. distressing somatic symptoms plus abnormal, thoughts, feelings, and behaviors in response to symtpoms w/ somatic symptom and related disorder based on how patient determines them
2. Compare and contrast personality disorders, somatoform disorders, anxiety disorders, disorders of mood, and psychotic disorders, and give examples of each. personality disorder somatoform disorders anxiety disorder disorders of mood psychotic
Difficult patient w/ strong response form you have personality disorder.
personality disorders: when fixed, rigid, interferes w/ not able to function enduring pattern of inner experience and behavior that deviates markedly from expectations of individual’s culture is pervasive and inflexible has early onset of child or adult stable over time and leads to distress or impairment w/ dysfunctional coping styles disrupting and destabilizing relationships. ex. odd and eccentric (paranoid-distrust suspiciousness or delusion-specific to one thing aka gov., schizoid-detachment from social w/ restricted emotional, schizotypal- magical thinking quirky eccentric behavior and cognitive distortions), dramatic emotional or erratic (antisocial-disregard for or violation of rights of others no enoathy remorse , borderline-black/white thinking unstable relationships and impulsive surrounding them ex. Self harm cutting impulsive behavior, histrionic-excessive emotionality and attention seeking, narcissitic-need for admiration, lack of empathy), anxious and fearful (avoidant-social inhibition hypersensitive to negative evaluatoin, dependent-clingy, submissive, needs to be taken care of, OCPD-oderiliness perfectionism control )common w/ alcohol and substance abuse or other of them
anxiety disorder
respond to things w/ fear or dread w/ anxiety, panic, increased heartbeat and sweating if response is more drastic and cannot be controlled interfering w/ normal functioning ex. generalized, panic, agoraphobia, OCD.
disorders of mood
affective inolve persisiten feeling of sadness or periods of feeling overly happy fluctuating from extremes ex. major depressive disorder, bipolar disorder feel tired insomnia if manic don’t feel tired.
psychotic disorders.
– distorted awareness and thinking sucha s hallucinations w/ images or sounds that are not real like hearing voices and delusions false fixed beliefs that they accept as true despite evidence. ex. schizophrenia, brief psychotic disorder (resolves within a month, undergone immense amount of stress in refugee population, asylum seekers), delusional
disorder (fixed false belief and paranoid thinking ex. Grandiose president or done all these things)
Identify and discuss patient characteristics that may indicate a need for mental health screening.
medically unexplained physical symptoms (1/2 have depression or anxiety), multiple physical or somatic symptoms or “high symptom count,” high severity of presenting somatic symptom, chronic pain, symptoms for more than 6 weeks, phsyycian rating as “difficult,” recent stress, low self rating of overall health, frequent use of health care services, substance abuse
Compare and contrast components of the mental status examination with components of the general survey.
General survey looks specifically at the appearance, motor activity, and general expressions but the MSE looks much more in depth at all of those not just looking for the symptoms of a medical issue but asks questions regarding neurological and psychological reasoning.
- Identify and describe components of the mental status examination.
Complete assessment of cognitive (knowledge-related) ability, appearance, emotional mood, speech, thought patterns at the time of the evaluation. Includes observations about the patient’s cooperativeness and ability to answer specific questions. Psychiatry’s physical examination: Assessment of a patient’s overall cognitive and societal functioning, Diagnostic tool, May suggest areas for further testing, Done periodically to monitor or document changes in a patient’s condition, The mental status exam starts as soon as you enter the patient’s room
Appearance
- Overall appearance, Level of consciousness, Wakefulness, awareness, “Awake and alert”,
Hygiene, dress (Poor personal hygiene or grooming may reflect a loss of interest in self-care of physical inability to bathe or dress oneself,”
“Appropriately dressed for the weather”
Motor behavior and posture-
Gait, posture, coordination, involuntary movements, abnormal movements; Psychomotor slowing (depression) or agitation (mania), Facial expressions, Eye contact (MAD), Attitude, Cooperative/uncooperative, Guarded (surface level answer question but just don’t want to tell you about it), Irritated , Indifferent
Speech and language:
able to assess expression, receiving, and comprehending words, Quantity (Talkative, silent),
Rate (Fast, slow,
Pressured-fast to the extreme super quick losing breath in the middle of saying it and you cant interrupt or redirect symptom of mania), Volume (Loud, soft), Articulation (Clear, distinct words, Dysarthric (slurred)), Fluency (Rate, flow, melody of speech (cadence), Stuttering, hesitancies)
Evaluation of aphasia (loss of ability to understand or express speech, Components of MMSE – word comprehension, repetition, naming, reading comprehension, writing
Mood =
how the patient is feeling,
Refers to the underlying emotional “atmosphere” or tone of the person’s answers (Ex: euthymic-normal, dysphoric-sad), Internal emotional state, May use patient’s own words (Ex: sad, angry, worried)
Affect -
your observation of the patient’s outward appearance, Outwardly observable emotional reactions (what mood appears to be) (Ex: Flat – no emotional expression (constricted or blunted- not totally flat but some facial expression), Ex: Labile – wide range of emotions, Comment on appropriateness and congruence-euthymic mood but facial expression flat so opposing to stated mood)
Before asking questions of psych patients what do you tell them?
tell them Normalize it that they ask everyone what you are doing stating you will be asking very personal questions etc.
Thought process:
logic, coherence, and relevance of patients though flow of thought; formulation of thoughts – how is the patient thinking? Logical vs. illogical, Organized vs. disorganized, Circumstantial (long list of other thing and they finally can come to the thing obsessions, speech w/ unecesary detail, indirection and delay in reaching point), tangential (can never answer questions just talk about other things shifting topics loosely connected or unrelated in schizophrenia, manic episodes, and psychotic), flight of ideas, perseveration (same thought over and over common w/ autism)
Thought content:
what is the patient thinking?, Obsessions/Compulsions (repritive behaviors feels driven in response to obsession to reduce anxiety or dreaded even phobias and anxieties), Suicidal ideation,
Homicidal ideation
Perception-
sensory awareness of objects in enivornment and internal or external relationship Hallucinations – lack external stimulation auditory/visual/command (worrisome voices telling patient to do something psychosis hurting people or themselves always ask o they tell you to do anything) PTSD, schizophrenia and alcoholism,
Delusions,
Ex: paranoia, illusions in grief ractions delirium acute and PTSD and schizophrenia
Insight-
Patient’s awareness of situation/abnormality, Note: does not always correlate with the severity of disease lack insight
Judgement-
Patient’s decision-making skills, If you found an envelope that was sealed, stamped, and addressed, what would you do with it? poor in delirium, dementia, intellectual disability, and psychotic states, anxiety, mood disorders, intelligence, education, income, and cultural all influence
Orientation-
requires memory and attention. impaired in delirium. Ability to locate self,
Personal identity + place + time (day of week/date – day month year) specifying what questions were asked
Attention-
ability to focus over time on stimulus can have difficulty giving history so use Serial 7’s cont down from 100, Spell “world” backwards ex. delirium, dementia, intellectual disability, and performance anxiety ex. poor performance for dementia, intellectual disability, anxiety, or depression
Memory
– process of registering or recording info. for asking immediate repetition following storage or retention. Remote – birthdays, anniversaries, names of schools attended, SSN ex. difficult for end stage dementia, , Recent – events of the day, current medications, today’s weather, anxiety, depression, and intellectual disability impairs it New learning ability – 5 minute 3-word recall
Information and Vocabulary-
Current events, “name last 4 presidents.” only problematic in severe cases life-long intellectual impairment from mild or moderate dementia get background information
Calculating-
Ask patient to add, multiply poor performance from dementia or aphasia based on knowledge and education
Abstract thought-
Similarities: Apple/orange; fruit = abstract thinking; round = concrete thinking. Proverbs ( how would you describe what this means interpreting it) : Don’t judge a book by it’s cover, Squeaky wheel gets the grease. concrete responses in people w/ intellectual disability, delirium, or dementia or limited education schizophrenia can respond concretely.
Constructional ability
Copy a figure / Clock draw Be aware of patient’s cultural background and level of education as you are testing. MMSE- higher level of education can score higher than correct can compensate w/ lower level of education can score unusually lower ex. dementia, parietal, lob damage, and intellectual diability
Identify components of the Mini-Mental Status Exam (MMSE), and discuss the indications for using this tool.
Assesses cognitive functioning only, Specific dementia screen. include orientation to time, registration (repetition), naming, reading and doing command
Identify components of the CAGE, and discuss indications for using this tool.
Asking the patient if they have ever felt the need to cut down on their drinking? Have you ever felt annoyed by criticism of your drinking?Have you ever felt guilty about your drinking? Have you ever had a morning eye opener? two or greater of these answers suggests alcohol use problem, cannot be used for other substances
