Health Assessment Flashcards
Cultural humanity
A process of learning to have an approach that is other-oriented. Life long commitment to learning and critical self-reflection
Apply the elements of a clinical presentation to a health history
6 items
Chief concern
History of present illness
Past medical history
Family history
Social History
Review of Symptoms ROS
Can Henry Party For Socialism Really
HPI begins with
Chief concern - patients main reason for the episodic visit
What is the best practice in interviewing techniques
Therapeutic approach: active listening, eye contact, avoid looking only at the computer, talk to pt when using interpreter, be professional, know your own biases and avoid bias. Repeat what the patient has said in your own words to ensure accuracy. AVOID medical jargon
Open-ended questions do what
OEQ ultimately saves the clinician time by having the patient elaborate on their symptoms. You start with OEQ
What are Clinician-centered questions
Clinician-centered questions are answers based on the clinicians perspective usually a yes or no
Begin conducting a patient history with
Patient-centered interviewing skills to obtain the patient’s perspective with OEQ
How do you implement an evidence-based assessment
Prioritizing the establishment of a partnership with the patient: this starts with therapeutic communication, listening, responding, and interacting with the focus on the patient’s health and well being
What are the common biases in clinical reasoning
Availability Bias - common dx bc you have seen it alot
Base Rate Neglect - persuing zebras
Representativeness - so focused on being right you ignore atypical features of favored dx
Confirmation Bias - seeking to confirm rather than refuting initial dx
Premature Closure - not fully investigating
Anchoring Bias - giving excess weight to early dx. accepting handed off dx
Availability Bias
Considering easily remembered diagnoses Focusing on a dx because you have been seeing it a lot or just did a paper for class on it
Base Rate Neglect
Pursuing “zebras”. Seen a lot with new NP
Representativeness
Ignoring atypical features that are inconsistent with the favored diagnosis. So focused on proving you’re right you are ignoring some details
Confirmation Bias
Seeking data to confirm rather than refuting the initial hypothesis. Ignoring contradictory evidence
Premature Closure
Stopping the diagnostic process too soon. Don’t collect enough data
Anchoring Bias
Giving excess weight to early/initial information. Just accepting the diagnosis handed off
Identify terms associated with data analysis and problem identification
Clinical reasoning and data analysis have to do with reasoning, skills, and knowledge. It is important to understand what the patient is telling you. Different statements made by the patient could have different meanings, so it is very important to ask the patient and repeat the information back to the patient for accuracy.
What does the HPI provide
The HPI allows the provider to gather pertinent information regarding the chief complaint and start to ID the problem
What are the two main types of clinical reasoning
Analytic/reductionist approach (novice level to complex cases)
Holistic/constructionist (expert level)
Analytic/reductionist approach
Novice level to complex cases. This breaks down the problem into the elements necessary to solve it
Holistic/constructionist approach
This is expert level problem solving based on
Holistic/constructionist approach
This is expert-level problem solving based on previous experience, pattern recognition that is stored in the provider’s personal memory through experience.
Name some diagnostic errors
Knowledge deficit of provider
Faulty data gathering
Faulty information processing
Differential diagnosis
The process of differentiating between two or more conditions that share similar signs and symptoms
An organic process of refining your diagnosis towards a working diagnosis
What is an algorithm also known as
The transformation of a patient’s story into a meaningful clinical problem - a problem representation.
When should new providers use DD
Until they learn to synthesize information into their practice
What is clinical reasoning also known as?
Clinical judgment
When do you start your DD
When you pick up the chart and start gathering information on the patient.
Step one in clinical reasoning - generating differential diagnosis
Identify the problem. Most will be identified by the patient but as the NP we must look at other issues that could lead to the complaint.
(Dysuria at night - maybe its a mobility issue and not a bladder issue).
Step two in clinical reasoning - generating a differential diagnosis
Generating using framework approaches. DD are more than just a list of illnesses that explain s/s or diagnostic results exist but rather DD distinguish a disease or condition from others that present in a similar pattern. done by novice or in situations that are unfamiliar
Step three in clinical
reasoning - generating a differential diagnosis
In order to organize the DD it is very important to look at labs, clinical presentation, and physical examination as a whole in order to prioritize the differential diagnosis based on data
Step four in clinical reasoning - generating a differential diagnosis
Narrow the list. Consider age, gender and ethnicity into your DD to narrow your list of problems
Step five in clinical reasoning - generating a differential diagnosis
Assess for clinical clues during your physical examination and focused on positive assessment findings to confirm your working diagnosis
Eliminate prostetitis in a female patient
Step six in clinical reasoning - generating a differential diagnosis
Always rank your #1 potential diagnosis at the top of your list based on the information from step five
Step seven in clinical reasoning - generating a differential diagnosis
Obtain additional data to test, supplement and validate your hypotheses
Step eight in clinical reasoning - generating a differential diagnosis
Be flexible and organize your DD based on new information. If a working diagnosis cannot be reached and things just don’t make sense, go back to your interview process and see what missing information you can find in order to guide in the right direction. Always reassess and reprioritize new information to support your statements
Define the various sections of a health history
Mary Should Of Had Happiness After Fighting Socialist Reform
Medical history (acute and chronic)
Surgical history
Ob/Gyn
Hereditary conditions
Health maintenance such as vaccines and screenings
Allergies
Family history
Social history
ROS
MSOHHAFSR
Mary Should Of Had Happiness After Fighting Socialist Reform
What’s included in a focused exam
CC, HPI, PMH, PSH, FAMILY HX, current medications (otc or herbal). Allergies to meds, latex or food, Social history (smoking, etoh, drugs, mental health). Review of pertinent systems such as HEENT or review of all symptoms for a comprehensive visit. Physical exam.
What’s included in a focused exam
CC, HPI, PMH, PSH, FAMILY HX, current medications (otc or herbal). Allergies to meds, latex or food, Social history (smoking, EtOH, drugs, mental health). Review of pertinent systems such as HEENT or review of all symptoms for a comprehensive visit. Physical exam.
Define each section of a SOAP note
S - subjective - what the patient reports
O - objective - what the clinician observes and assesses
A - assessment - the diagnosis of diagnostic assessment with rationale
P - plan - the plan of care for the pt including pharmacological and nonpharmacological and patient education
Subjective
Patients point of view. Hx. from the patient, describes patients concerns, symptoms or unexpected findings
Objective
The finding from direct observations, what you smell, see, hear or touch. Objective data is observable and measurable and can be obtained through vital signs, physical examination, labs and diagnostic test.
Assessment
Pulls together the findings and collected in the subjective and objective section to form a diagnosis
*For a sick visit only list pertinent information r/the CC. Do not cover all the systems. Come up w/DD and a working diagnosis.
*For a follow up no DD needed
*For a comprehensive visit - address every system in detail
Plan
Develop a plan for each working diagnosis
Explain Chief Complaint
The main reason for a visit, describes the sx, problem, condition, or diagnosis for the visit - it is in “” and in the patient’s own words
Explain HPI
HPI contains 8 core elements - location, quality, severity, duration, timing, context, modifying factors, associated signs and symptoms. USE OLDCARTSA
Describe reasons for maintaining clear and accurate records
the patients record is a legal document. Court, legal proceedings, as well as incurances can have access to it. It is important to chart in the EMR as soon as possible to maintain information accurately. The patient record provides an opportunity for the clinician to document the care provided at the visit and track how bothe patient
What is the difference between a focused and a comprehensive assessment
the focused and comprehensive assessment have similar components such as demographics, age, gender, ethnicity, CC, HPI, PMH, Social history, etc. However, in the focused visit, only pertinent information will be addressed to the CC and potential body system affected. Comprehensive visits are more in depth and require more detail information to assess or prevent potential medical problems.
Delineate methods for documenting the location and description of findings
Use OLDCARTSA
What are the four classical techniques of physical assessment and proper techniques
Inspection
Palpation
Percussion
Auscultation
Inspection
Process of observation beginning with the initial meeting of the patient and continuing through the history and physical examination. Use adequate lighting, take time to carefully inspect the areas you want to see and validate findings with patient
Palpation
The use of hands and fingers to gather information through the sense of touch. Keep fingernails short, warm hands, be gentle, use correct palpation approach and use appropriate hand surface. Use palmar surface of the hands and finger pads
Palmer and pads - position and texture, size, crepitus, mass or structure
Ulnar - vibration
Dorsal (back of hand) - temperature
Percussion
The use or striking of one object or one finger against another produces vibrations and sound waves. Tapping fingers produces vibrations by impact on underlying tissues
Auscultation
Listening to sounds produced by the body. always do this last in the examination sequence, except with abdominal examination, place the stethoscope on naked skin, listen to one sound at a time, take time to identify characteristics of sound, and do not anticipate the next sound.
What are the different techniques using percussion and when would you use them
- Immediate (direct) - finger strikes directly against body
- Mediate (indirect) Middle finger of dominant hand is hammer; middle finger of non-dominant hand is placed on body and struck.
- Fist-nondominant hand is placed on body and struck with fist of dominant hand. Most commonly used to elicit tenderness from liver, gallbladder or kidneys
Tympany
loud, high drum like Ex. gastric bubble
Hyperresonance
very loud, low, booming Ex emphysematous lung
Resonance
loud, low, hollow. Ex healthy lung tissue
Dullness
soft, moderate, thudlike Ex over liver
Flatness
soft, high, dull Ex over muscle
Gonimeter
Determines degree of joint flexion. Two straight arms that intersect and can be angled and rotated around a protractor
Stethoscope Bell and Diaphragm
Bell - light pressure to hear low frequency sounds
Diaphragm - use pressure to hear high frequencies
Rosenbaugh Eye Chart
Tests for near sightedness
Amsler Grid
used to detect damage to the macula (central part of the retina or optic nerve / macular degeneration. Grid with dot will have blurred area
Ishihara Color Blindness
Color blind chart
Components of a general survey
Systematic assessment of the individual’s health status. The initial general survey includes assessing for problems, instability, or alterations in the airway, breathing, circulation, and neurologic status. Assessment of mental and physical status includes the general survey, measurements of vital signs, habitus, and evaluation of pain.
Normal vital signs for an adult
Temp 96.4 - 99.1
Pulse 60 - 100 bpm
RR 12 - 20 bpm
BP SBP <120 and DBP <80
Child BP
Start at age 3
Components of a general survey
Systematic assessment of the individual’s health status. Initial general survey includes assessing for problems, instability, or alterations in airway, breathing, circulation, and neurologic status. Assessment of mental and physical status include the general survey, measurements of vital signs, habitus, and evaluation of pain.
Pain Scale used with children
Wong/Baker Faces Rating Scale, the Oucher Scale FLACC (nonverbal kids or adults) are examples of faces rating scales reliable for children.
Words a older adult will use for pain
ouchy sore achy
S/S of pain in infant/child
increased pulse and respiratory rate
lower b/p
behavioral cues
less able to modify pain impulses
easily distracted but still have pain
different pain scales
S/S of pain in older population
No diminished perception of pain
Decreased pain threshold
Pain from chronic conditions
What is a general survey?
A general survey is the systematic assessment of the individual’s health status. Initial general survey includes assessing for problems, instability, or alterations in airway, breathing, circulation, and neurologic status. Assessment of mental and physical status include the general survey, measurements of vital signs, habitus, and evaluation of pain.
Underweight BMI
<18.5
Normal BMI
18.5-24.9
Overweight BMI
25.0-29.9
Obesity BMI
I 30-34.9
II 35-39.9
Extreme obesity BMI
III >40
Normal SP02
>95%
Normal HR
60-100
Normal Inspiration
Diaphragm moves down using external intercostal muscles
Normal Expiration
Internal intercostal muscles
Intercostal muscles
External intercostals increase the anteroposterior chest diameter during inspiration.
Internal intercostals decrease the lateral diameter during expiration.
Respiratory Rate (Normal)
12-20
What is pulse pressure
The difference between systolic and diastolic pressures ex: 120/80 Pulse pressure would be 40mm Hg
BP cuff size and position
Width: 40% of upper arm circumference
Length: 80% of upper arm circumference
Apocrine sweat glands
Apocrine sweat glands: think stinky adolescent
Secretion begins at puberty
Secrete thick viscous cloudy fluid in sac of air follicle and eventually to the surface of the skin
Good source for bacteria -> odor
Ears (cerumen), eye lids, Armpits, areola of the breast, anogenital regions.
Eccrine Sweat Glands
Eccrine sweat glands: think everywhere.
Secrete clear thin fluid (sweat) directly onto the skin
Present all over the body.
Temperature control, cooling off and excretion of unwanted substances, protection of the skin
Conduct a history as it relates to the SKIN HAIR & NAILS
Crucial to obtain a history before proceeding to the examination in order to understand the backgrounds of the problem. Use OLDCARTSA to obtain info about the problem.
Assess PMH, PSH, Fam History, Social History
Potassium hydroxide prep
KOH - diagnosis of fungal infections. KOH dissolves everything but hyphae walls. Look at branching structures
Tzanck smear
Test for herpes zoster and multinucleated giant cells such as viruses
Wood’s lamp
Emits UV light.
Coral Pink - bacterial
Greenish-blue - tinea (fungal)
Transillumination
used to determine the presence of fluid in cysts and masses. Will glow red with fluid.
Discuss inspection, palpation techniques for exam of skin, hair, and nails
Examination consists of both inspection and palpation. PE can be conducted as head to toe assessment, region as other systems are being examined or localized to the specific disease area
Describe age specific and/or condition-specific variations in examination of the skin and nails
Premature infants-poor epidermal barrier with a few cornified layers and a deficiency of structural proteins in the dermal layer
Androgenic alopecia
Balding - Nonscarring natural progressive miniaturization of the hair follicle
Telogen Effluvium TE
TE refers to an acute hair loss subsequent to a variety of stresses - crash diet, hypothyroidism, etc
Self limiting
Alopecia Areata
non scarring hair disorder with acute onset. Oval rounded bald patches
Autoimmune with possible herideratary.
May grow back
Patchy Alopecia Areata
Can affect part of the scalp or body structures (beard)
Alopecia Areata Totalis
Loss of all scalp hair follicles
Alopecia Areata Universalis
Loss of ALL body hair follicles
Normal nail angle vs clubbing
Normal 160
Clubbing 180
Test with Schamroth technique
Onycholysis
Detachment of the nail from the nail bed
inflammatory: psoriasis, dermatitis, fungus trauma
Koilonychia
Spoon nail - celiac disease, malignancy, malnutrition
Whitlow (felon)
Infection (bacterial or viral) affecting the distal phalanx
Most common form is herpetic.
Affect ppl who who in water: housewives, dentist, nurses (gloves) bartenders, waiters
Beau lines
Nail formation results in a transverse groove that rund parallel to the lunula
When nail growth in interrupted from trauma, chemo, or sickness
Terry nails
Transverse white bands
Liver failure
DM
CHF
Hyperthyroidism
Malnutrition
Onchomycosis
Fungal infection
Paronychia is superficial absess
Onychocryptosis - ingrown nail
Lesion
primary vs secondary
any pathologic skin change or occurrence
Primary―those that occur as initial spontaneous manifestations of a pathologic process
Secondary―those that result from later evolution of or external trauma to a primary lesion. Examples of secondary lesions: scales, crusts, excoriations, erosions, ulcers, fissures, scars, keloids
Four point dermatologic description
Anatomical location
Distribution of multiple lesions
Morphology: Primary lesion, color and exudate
Morphology: Secondary change if present
Primary skin lesions
MACULE
Macule - Flat less than 1cm in size
Petechiae <4mm nonblanching purpuric macules - broken capillaries.
Etiology: PCN, Phenytoin, fungal, bacterial, viral inf. vaculitis, thrombocytopenia, leukemia, Vit C and Vit K deficiency
Primary skin lesions
PATCH
A patch is flat but it is larger that 1cm
Tinea Versicolor - hypopigmentation from fungal infections
Cafe au lait - larger patches of color from sun or genetics
Primary skin lesions
PAPULE
Elevated or depressed lesion less than 0.5cm, may be solid or cystic. Sessile (no stalk) or Pedunculated (stalk)
Scabies-small red papules with some vesicles and crusting. lesions are LINEAR
Molluscum Contageosum - caused by the DNA poxvirus. Burning and purtius. Smooth surface with central indentation
Example of primary papules
Wart: cause by HPV, hyperkeratotic lesions
Acrochordons (skin tags)
Primary lesions
PLAQUE
Raised defined any color >1cm
Psoriasis: chronic immune mediated condition. Well demarcated silvery plaques can r/t arthritis
Seborrheic Keratosis: benign and asymptomatic in older persons. Commonly found in sun exposed areas.
Xanthelasma
Plaque - on eyes indicates hyperlipidemia
Actinic Keratosis aka Solar keratoses
Can be papules or plaques, pre malignant lesions in sun exposed areas
Wheal
Elevated irregular shaped area of cutaneous edema
Caused by insect bites.
Urticaria - aka hives, edematous papules or plaques that appear suddenly post allergic reaction
Nodule
Elevated and solid, firm confined lesion deeper than a papule in the dermis
Less than 2cm
Basal Cell Carcinoma
Basal Cell Carcinoma
Nodule, most common type of skin ca, sun exposed area, slow growing.
non-healing sore, waxy pearly appearance with some central indentions, well circumscribed
Tumor
Elevated and solid >2cm firm or not may or may not be well demarcated. Lesion deeper than plaque in the dermis
LIPOMA - benign fat tumor soft to touch movable and painless
Pustule
Similar to vesicle but filled with puss
Pustular Acne Vulgaris - obstruction and inflammation of pilosebaceous units (hair follicles and accompanying sebaceous gland)
Acne Rosacea
Folliculitis - inf of hair follicle. Start as red papules then crust
staph or strep, shaving, hot tub
Abcess
Deep seated inflammatory nodule
Furuncle, Carbuncle
Cyst
Elevated encapsulated lesion deep in the dermis, filled with liquid or semisolid material 1cm or larger.
Sebaceous cyst
Vesicles
Elevated fluid filled round circumscribed with thin, translucent wall < 0.5cm
Herpes simplex: viral infection HSV1
Vesicles
Elevated fluid filled round circumscribed with thin, translucent wall < 0.5cm
Herpes simplex: viral infection HSV1
Herpetic Whitlow
Varicella Zoster (chicken pox)
Herpes Zoster (Shingles)
Bulla
Elevated fluid filled round or oval shaped with thin translucent walls more than 0.5cm
Bullous Impetigo
Lichenification
Lichenification:
A rough, thickened, hardened area of the epidermis resulting from chronic irritation such as scratching or rubbing (often involves flexor surfaces
Secondary lesion
Tinea Corporis
Ring worm
Types of Dermatitis
- CONTACT DERMATITIS (80% of cases)
- ALLERGIC CONTACT DERMATITIS
- ATOPIC DERMATITIS
Contact Dermatitis
Contact Dermatitis (80% of cases) nonimmunologic response to a chemical or physical agent. Well demarcated with glazed appearance. Erythema, swelling, blistering and scaling.
Allergic contact dermatitis
A cell-mediated, delayed, type IV hypersensitivity reaction, resulting from contact with a specific allergen to which a patient has developed a specific sensitivity.
Acute Type: Presents as papules and vesicles on an erythematous base
Atopic dermatitis
ECZEMA
Genetic susceptibility and environmental triggers.
75% will report a family history of atopy (allergic rhinitis, asthma, and dermatitis RAD)
Closely r/t asthma and rhinitis
Presents as: Excoriations, erythematous, scaly papules and plaques, vesicles, serous drainage, and crusts are common findings.
Pityriasis rosea
An idiopathic,(may be viral) self-limited
skin eruption characterized by widespread
papulosquamous lesions
Lesions average 1 to 2 cm in diameter
Christmas tree pattern and presence of Herald Patch
Fifth Disease
Fifth’s Disease Also called erythema infectiosum
Caused by parvovirus B19
Transmitted through respiratory secretions and blood
Often have fever, rhinorrhea, myalgias, and a headache
Facial rash that has a “slapped cheek” appearance
Can get a second itchy rash a few days after the facial rash that appears on the chest, back, buttocks, or arms and legs
Hand, Foot, and Mouth disease
Caused by a virus called coxsackievirus A16
Transmitted through respiratory secretions, fecal–oral route, or vesicle fluid
Usually affects infants and children 5 years old or younger
Typically occurs in summer and early fall
Starts with fever, malaise, sore throat, and anorexia
Painful macular or vesicular lesions can develop in the mouth several days after the fever starts
Rash on the palms of the hands and soles of the feet may also develop over 1 or 2 days as a macular and/or vesicular red rash; it may also appear on the knees, elbows, buttocks, or genital area
Scarlet Fever
Caused by group A hemolytic streptococcus
Rash caused by an erythrogenic exotoxin emitted by the streptococci
Most common in children 5–15 years
Most commonly seen in conjunction with strep pharyngitis
Typically starts with a high fever and sore throat
Rash appears after 1–2 days
Maculopapular exanthematous rash that looks like a sunburn and feels like sandpaper
Rash initially appears on the neck and chest, then spreads over the body
Pastia’s sign (linear bright red coloration of the creases in the axillary and inguinal folds)
Tongue may appear white, with red, swollen papillae (white strawberry tongue), but by the fourth or fifth day, it becomes bright red (red strawberry tongue)
Other symptoms include headache, chills, flushed face, nausea, and vomiting
Rash usually fades in 4–5 days and is followed by diffuse desquamation
Basal Cell Carcinoma
PUTON - Put on Sunscreen
P - pearly papule
U - ulcerating
T - telangiectasia
O - on face, scalp, pinnae
N - nodules
S - slow growing
Squamous Cell Carcinoma
NOSUN
N - Nodular
O - Opaque
S - Sun exposed areas
U- Ulcerating
N - Non distinct borders
More aggressive than basal cell, highly treatable
Malignant Melanoma
ABCDE
A - Asymmetric
B - Borders Irregular
C - Color not uniform
D - Diameter unusual >6mm
E - Evolving lesions
Starts in the melanocytes deep. Spreads quickly but is treatable if caught early
Actinic Keratosis
Rough scaly patches. Years of sun exposure. Can develop into skin cancer
Techniques for physical examination of the lymph system
The lymphatic system is examined region by region during the examination of the other body parts and by palpating the spleen, an integral part of the system. Assess the areas of the lymphatic system where the nodes are palpable and accessible.
Review location of the lymph nodes and review location associated with the disease processes
occipital nodes, post auricular, pre auricular, tonsillar, submandibular, submental, posterior cervical, anterior cervical, supraclavicular, axillary, mammary, epitrochlear, superior and inferior inguinal lymph nodes
Occipital Lymph Nodes
Scalp, neck, head (throat, ears)
Scalp, with STDs (syphilis, HIV) and Throat and ear infections other lymph node affected
Is there an infestations, or infections of the scalp, throat,ear periorbital cellulitis?
Posterior auricular
Scalp, ears
Scalp and ears localized infections
As above and do you have fever, chills, ear pain or dranage
Preauricular
Eyelids, temporal region flu/covid
Eye and ear, temporal infections
As above plus Eye pain, drainage?
Submandibular
Tongue, lips, mouth, conjunctiva, pharynx
Infections of head, neck, sinuses, ears, eyes, conjunctiva, scalp, pharynx, mouth and lips
Sore mouth? Dental conditions? Lip or tongue infections?
Submental
Lower lips, floor of mouth, tongue and skin of cheek
Infection or cancer of Floor of the mouth, lip, tongue,
Mono, toxoplasmosis
Sore mouth? Dental conditions? Lip or mouth infections?
Exposure to cats.
Posterior Cervical
Scalp, neck, ears
Localized skin infection, scalp, mononucleosis, toxoplasmosis
Recent contact with other who are ill? Do you have a cat?
Anterior cervical
Larynx, tongue, neck, oropharynx
head
Head, neck, throat infections (strept throat) or malignancies
Do you have fever, chills, sweats, sore throat?
***Right supraclavicular
Sentinel nodes: Lungs, upper GI
Thyroid and larynx
Consider sentinel nodes for Cancer: Lung,esophagus, upper GI
Have you ever smoke?
Do you have a cough?
***Left supraclavicular AKA Virchow node
Sentinel nodes for
Abdomen, GU cancers
Thyroid and larynx
Consider sentinel nodes for abdomen, gastric Lower GI, GU cancers
Do you have heartburn?
Have you been screen for colon cancer?
What is the color of your fecal material?
Axillary lymph nodes
Breast, upper arms, thorax
Breast, upper arms, thorax infection or malignancies
When was your last mammogram? And breast discomfort or change in breast tissue? Any injuries to upper arms? Cough?
Epitrochlear
Ulnar, forearm and hand
Usually not palpable but present with patho of lower arms, hands, fingers
If both axillary and epitrochlear noted decreased likelihood of breast CA
Any injuries, swelling to your arms hands or fingers?
Inguinal node
Lower abdomen, buttock, anus, perineum, genitalia and lower extremities
Superior lateral: drain: Buttock and abdomen,
Superior medial: Drain perineum and genitalia
Inferior nodes: Drain upper legs
Depending on the cluster involved:
-Abdominal or buttock, -rectal infection, cancer?
-STD: any drainage or sore on the genitalia
- Any recent injury or rash to legs or feet?
When deciding DD for patients with lymph disorders use what pneumonic
MIAMI
Malignancies
Infections
Autoimmune disorders
Miscellaneous/unusual disorders
Iatrogenic causes
Disorders of the lymph system present with three physical signs:
Enlarged lymph nodes (lymphadenopathy)
Red streaks in the skin (lymphangitis)
Lymphedema
Node characteristics
The harder the node, the more likely the malignancy
The more tender the node, the more likely inflammation
Nodes do not pulsate; arteries do
A palpable supraclavicular node on the left or right: Further evaluation to r/o Ca. look at them as sentinel nodes for cancer
Left supraclavicular node AKA Virchow node
Lymph nodes in children younger than 2
Common to find firm, discrete, not warm nor tender small node in postauricular/occipital not unusual in children younger than age 2
Past 2 years of age, benign lymph enlargement is uncommon
Palpate the superficial lymph nodes and compare side to side for the following:
Sally Can’t Make Demands To Wayne
Size
Consistency
Mobility
Discrete borders or matting
Tenderness
Warmth
Cat Scratch Fever
a bacterial infection caused from the organism Bartonella henselae.
Cats (mostly kitten) are the reservoirs and vectors
acquire the bacteria from fleas or flea dirt The infected cat licks a person’s open wound or bites or scratches hard enough to break the surface of the skin.
Acute lymphangitis
an inflammation of the lymphatic channels that occurs as a result of infection at a site distal to the channel.
Gram positive strept pyogenes or staph aureus
Lymphatic filariasis (elephantiasis)
Massive accumulation of lymphedema throughout the body
Most common cause of secondary lymphedema worldwide
Lymphoma
Type of cancer that affects the lymphocytes, a type of white blood cell that plays an important role in the immune system.
Hodgkin lymphoma
Malignant lymphoma with presence of reed-Sternberg cells
Usually arise upper body, neck chest or axillae
Usually able to diagnosed earlier so higher survival rate
Non-Hodgkin lymphoma
Malignant lymphoma with absence of reed Sternberg cells.
Most common form of lymphoma.
May arise in any lymph nodes of the body
Identify normal age and condition variations for head and neck
Newborn Skull is considered pliable
Two major fontanels:
Occipital (posterior) Fontanel close within 2 months
Frontal fontanel close by 15
months some by 24 months
At birth Head = ¼ body
Adult = 1/7 of the body
NO FRONTAL SINUSES IN TODDLERS
RED flags associated with neck pain
neck pain assoc with chest pain
recent trauma
fever
Techniques for head and face assessment
Inspection
Palpation
Percussion
Auscultation
Hippocratic facies
Note sunken appearance of the eyes, cheeks, and temporal areas; sharp nose; and dry, rough skin seen in this patient in the terminal stages of throat cancer.
Down syndrome/Trisomy 21
Flattened face, Slanted eyes with inner epicanthal folds, short flat nose, protruding tongue , short neck, single line across the palm of the hands
Parkinson Disease
Decreased facial mobility blunt expression. A mask like face with decreased blinking and a characteristic stare. Peeping upward, oily skin, drooling
Allergic Facies
Transverse nasal crease, allergic salute, allergic shiners (red puffy eyes)
Trigeminal neuralgia AKA tic douloureux
Painful disorder of CNV
produces episodic, paroxysmal, severe, lancinating facial pain lasting seconds to minutes in the distribution of ≥1 divisions of the nerve
No facial drop present, Nasolabial fold present
Bell palsy
CN VII, asymmetry of one side of face, eyelid not closing completely, drooping of lower eyelid corner of mouth and loss of NL fold
Myxedema facies
Severe hypothyroidism: Note dull, puffy, yellowed skin; coarse, sparse hair; temporal loss of eyebrows; periorbital edema; and prominent tongue
Chvostek sign
percussion on the masseter muscle may produce a hyperactive masseteric reflex
Evaluation for hypocalcemia
other than that no percussion on face
Bruit
intracranial bruits are considered common in childhood, and uncommon in neonates
a bruit is highly suggestive of a vascular anomaly
Individuals who have developed diplopia may rarely have a bruit or blowing sound over the orbit indicating an expanding cerebral aneurysm
can be associated with temporal arteritis
Tracheal tugging
Suggests the presence of aortic aneurysm
How to assess the thyroid
Inspection
Symmetry
Swallowing symmetry
Palpation
Size and shape
Configuration and consistency
Tenderness
Nodules
During palpation ask the patient to slightly bend her head toward the thyroid lobe you are palpating
Auscultation
If thyroid gland is enlarged, auscultate for
vascular sounds
In a hypermetabolic state, the blood supply is dramatically increased and a vascular bruit, a soft rushing sound, may be heard
Pneumonic
SNOOP to identify life threatening headaches
Systemic symptoms or conditions
Neurologic signs or symptoms
Onset
Older age
Pattern change - 4P’s
4 P’s of pattern changes of headaches
The 4P’s of pattern change
- progressing to daily
- precipitated by Valsalva
- postural aggravation, and
- papilledema (optic disk swelling from ICP)
can indicate malignancy, vascular, or inflammatory disorders
Types of HA’s
Sinus: pain is behind the forehead and/or cheek
Cluster: pain is around one eye. 30 min to 3 hours. Deep and continuous pain. Ipsilateral lacrimation, red eye, stuffy nose, horner syndrome (miosis. - a constricted pupil, ptosis, anhydrosis - decreased sweating)
Tension: pain is like a band squeezing the head
Migraine: pain, nausea, and visual changes are typical of classic form
Torticollis (wry neck)
Birth trauma, tumors, trauma, cranial nerve palsy, muscle spasms, infection, drug ingestion
Hypothyroidism
Underactive thyroid
Hashimoto disease
Autoimmune antibodies against thyroid gland, often causing hypothyroidism
Myxedema
Skin and tissue disorder usually due to severe prolonged hypothyroidism
TSH >4 Low T4
Hyperthyroidism
Overactive thyroid
Graves disease
Autoimmune antibodies to thyroid-stimulating hormone receptor, leading to overactive thyroid
Low TSH high T4
Explain assessment of the thyroid
If enlarged: Auscultate with bell to see if you hear bruit which is a sign of hyperthyroidism. Thyroid difficult to palpate.
Pregnant women palpate for hyperthyroidism.
Older adult thyroid can feel hard
Infant considerations in head assessment
Measure head and compare to last exam and normal growth. Posterior fontanel close by 2 months. Palpate gently the suture lines. Transillumination used for skull of infant to measure or see any intracranial lesions - due with any rapid change in head circumference.
Macewen sign- abscess or hydrocephalus - cannot be done after 24 months of age
Normal findings of the eye in infants
Vision depends on the maturation of the nervous system. Babies are generally born slightly hyperopic (FARSIGHTED). This farsightedness decreases with age. This results in a vision condition in which distant objects can be seen clearly, but close ones look blurry)
Although peripheral vision is fully developed at birth, central vision develops later. By 2 to 3 weeks of age, lacrimal ducts produce tears, and the infant has control of the eye muscles. By 3 to 4 months of age, binocular vision (SYNC RIGHT AND LEFT SIDE VISION) development is complete. By age 6 months, the infant can differentiate colors. Young children become less hyperopic with growth. The globe of the eye grows as the child’s head and brain grow, and adult visual acuity is achieved at about 4 years of age.
Pediatric Eye Exams
- Essential to have regular eye exams and visual assessments for children; screenings begin at ages 4–5 and then every other year beginning at 6
- Newborn to 3 years: Visual assessment, inspection of eyes, assessment of corneal light reflex and EOMs, pupillary function, and red reflex
Eye Changes and Findings in Pregnant Women
- Hypersensitivity and changes in the refractory power of the eye
- Tears contain an increased level of lysozyme, resulting in a greasy sensation and perhaps blurred vision for contact lens wearers
- Corneal thickening and change of curvature occurs
- decreased or transient loss of accommodation
- Diabetic retinopathy may worsen
- Intraocular pressure falls
- Subconjunctival hemorrhages may occur/resolve spontaneously
Pregnant women: Mild corneal edema occurs, especially in the third trimester, along with corneal thickening. Tears contain increased levels of lysozyme, making contact lenses greasy, which is important to know if a pregnant woman comes to your office with such a problem. A complaint of blurry vision and I can’t keep my contact in without any cardiovascular or neurological abnormalities is actually a normal physiological change, which will resolve by itself after delivery.
Eye changes and exam in the Older Adult
- Presbyopia age related farsightness. Gradual loss of the eye’s ability to focus on nearby objects.
- Farsightedness (Presbyopia) usually becomes noticeable in the early to mid-40s and worsens until around age 65.
- Symptoms include a need to hold reading material at arm’s length to make letters clearer, blurred vision at normal reading distance, and eyestrain after reading.
- Decrease contrast sensitivity
- Complaints of glare
- reduction in the ability to adapt to sudden changes in illumination.
- Dry eye
- Lacrimal glands begin to involute and tear production decreases
- Loss of lens clarity and cataract formation
- Most common causes of decreased visual function include glaucoma, cataracts, and macular degeneration
there are still a number of changes in the aging eye leading to diminished vision. Changes in refractive error in older adults may cause reduced vision (near vision). In all adults, the crystalline lens gradually becomes less flexible and less able to change its curvature (accommodate) with age. This results in the condition known as presbyopia, in which patients lose the ability to focus their eyes on near objects. Starts mid 40’s
Contrast sensitivity is the ability to distinguish objects from the background when they are similar in brightness, and this ability decreases slightly with age.
In addition, largely due to neural changes in the retina, there is an age-related reduction in the ability to adapt to sudden changes in illumination. Finally, dry eye, especially in older women, is also common.
cataract formation or a decrease in clarity of the lens.
Presbyopia – farsightedness, cannot see reading material near and dry eye are a complaint of most older adults
Cataracts, glaucoma, and macular degeneration are common in older adults but not normal findings
Conducting a history r/t the eye
Begin with open-ended questions such as what bring you here, and usually with eye people all believe there have pink eye, lot of them do, but surely not all of them… you always need to ask “How is your vision?” and “Have you had any trouble with your eyes?” If the patient reports a change in vision, pursue the related details.
Honestly in primary care regarding complaint with the eye, first you get your red eye, allergies related symptoms, itchiness…etc… corneal abrasion mostly due to scractch from eye contact, and your stye…. Or pathologies of the eyelids.
Key History Questions r/t the Eye
•History of present illness: Presenting symptoms
Eye pain, swelling, itching, redness, or drainage; changes in vision; photophobia
OLDCAARTS
- Past medical history: Recent injury, trauma, or infection; medications and drugs; allergies; history of eye problems; corrective measures for vision; contact lens practices; systemic disease/disorder with ocular signs and symptoms
- Family history: Ocular and vision history, history of diseases impacting vision
Retinoblastoma (retinal cancer)
Often an autosomal dominant disorder
Glaucoma, macular degeneration, diabetes, hypertension, or other conditions that may impact vision or eye health
Cataracts
Color blindness, cataract formation, retinal detachment, retinitis pigmentosa, or allergies affecting the eye
Nearsightedness, farsightedness, strabismus, or amblyopia
- Social history: Smoking history, ETOH, sleep history, risk factors for HIV exposure, stress and coping, vision requirements, Employment/activities exposure
- Use of protective devices during work or activities that might endanger the eye
- Preventive care considerations: Vitamin A, antioxidants, sunglasses use, cleanliness of contact with eyes, routine eye exams, protective eyewear as needed, limitations on screen time and avoiding eye strain
- Review of systems: General, skin, head/neck, HEENT, CV and pulmonary, GI/GU, M/s, neurologic, endocrine,, and psychiatric
Relevant data include employment, for instance working outside may lead to running eye, and rubbing of the eye, which may introduce bacteria and a pink eye…. activities, allergies, medications, eye lenses, will keep your business going, from pink eye, to corneal abrasion and protective device use. Exposure to irritants and activity risks should be delineated. Routine care of eyes and eye devices should be explored.
Positive history of drug such as cocaine, barbiturates or ETOH ingestion may be responsible to visual changes
- Social history: Smoking history, ETOH, sleep history, risk factors for HIV exposure, stress and coping, vision requirements
- Preventive care considerations: Vitamin A, antioxidants, sunglasses use, cleanliness of contact with eyes, routine eye exams, protective eyewear as needed, limitations on screen time and avoiding eye strain
- Review of systems: General, skin, head/neck, HEENT, CV and pulmonary, GI/GU, M/s, neurologic, endocrine,, and psychiatric
ROS for eyes
- Review of systems
- General: Weight changes, fatigue, fever, pain
- Head/Neck: Acute/recurrent headache, neck pain, lymphadenopathy
- ENT: Ear pain; nasal congestion; rhinorrhea; sinus pain; sore throat; itchy ears, nose, throat
- Eyes: Additional symptoms of redness, discharge, eye pain, vision changes
- Cardio/Resp: Shortness of breath, cough, chest pain, orthopnea
- GI/GU: Nausea, vomiting, likelihood of pregnancy, LMP
- Musculoskeletal: Inflamed joints, arthritis, weakness, gait/posture defects, need for assistive devices
- Neurologic: Numbness, dizziness, light sensitivity, asymmetric facial movements
- Endocrine: Polyuria, polydipsia, polyphagia
- Integumentary: Itching, rashes, lesion changes, nonhealing sores/wounds
- Psychiatric: Depression, worry, insomnia, changes in memory/concentration
RED Flags with EYEs
- Always be alert with a unilateral presentation
- Severe and deep eye pain
- Acute visual changes
- Foreign body or penetrating wound
- Recent history of Chemical injury
- Change in pupil size
- pupil irregularity (not baseline)
- sluggish pupillary reaction to light
- corneal opacification or edema,
- Hyphema (blood between the cornea and the iris, do not confused with subconjunctival hemorrhage
Patient with CC of bilateral eye redness. Which feels like sand in my eyes.
So you have a patient that present to your clinic with CC bilateral eye redness. Which feel like sand in my eyes?
Potential etiologies:
Red eye can be caused by viral illness, most common is the adenovirus, but as well less common is the herpes simplex virus
What do we know about the patho for viral conjunctivitis
Has a gradual onset with unilateral symptoms early and can affect both eyes later on,
Visual acuity is intact
Watery discharge is apparent.
Bacterial infection can also cause red eyes by staph aureus, strept pneumo, N gonnorhea are the most common causes
Bacterial conjunctivitis has a gradual onset, unilateral early, bilateral late, scratchy feeling,
Thick crusty discharge may cause blurry vision
Allergic conjunctivitis.
Chronic seasonal conditions can both eyes to be red and itchy, painless and cause watery discharge.
Injuries
Trauma to the eye can also cause redness, usually improper contact lens care can damage the sclera and cause redness.
Equipment for eye exams
Snellen eye chart: distant central vision. Assess at 20 ft distance
Rosenbaum: Central near vision. Assess at 14”
Penlight: pupillary reaction
Cotton wisp: CNV sensory
Ophthalmoscope
Eye cover, gauze, or opaque card
What is the examination schedule for children
Essential to have regular eye exams and visual assessments for children; screenings begin at ages 4–5 and then every year beginning
- Young children: Vision screening at least once between 3–5 years of age (USPSTF)
- School-aged children: Comprehensive eye/vision examination before entering school and annually thereafter (AOA)
- Adults: Comprehensive eye/vision examination at least every 2 years for asymptomatic, low-risk persons aged 40–64 years of age (AOA)
How do you test peripheral vision
Peripheral vision which is a further assessment of CN2….. So peripheral can be assess through confrontation visual field testing.
Position yourself about 3 feet from your patient at your eyes should be at the same level as your patient… in confromtation testing you are comparing your visual field with your patient visual field.
Have patient cover his left eye while you close your right eye, so you are comparing your field of vision. Ask you patient to look at your eye, some patient get shy so tell them to focus on your eye brow…. Place your hand equidistant between you are your patient and test each quadrant by holding one two or three fingers. Repeat procedure for the other eyes
Entropion
When eyelids turn inward can cause corneal abrasion from eyelashes or infection
Ectropion
Arcus Senilis
Gray or white arc visible above and below the outer part of the cornea. High risk for hyperlipidemia
Anisorcia
Unequal pupil size. Not an issue if born with it. 20% of the population minor to the noticeable pupil size difference
When would you see lid lag in a patient
Hyperthyroidism
CN review
How to assess for CN 3
CN VII
CN VI
Note how to document eye inspection
•External examination without ptosis, strabismus, or exophthalmos. EOM intact. Conjunctiva pink without exudate. Sclera without injection or icterus (jaundice). Cornea clear. Iris without lesions or shallow anterior chamber. PERRLA. Corneal reflex intact.
So here is a retina, first your will see blood vessels…. Arteries are brighter and narrower than the veins , by a ratio of 3/5 or 2/3 remember you only see a portion of the retina at one time so slightly move the angle of the ophathamolscope. Optic nerve is like a beautiful donut.
Always examine pts right eye with your right eye and pts left eye with your left eye
A/V Nicking
poorly controlled hypertension causes the following:
Permanent arterial narrowing
Arteriovenous crossing abnormalities (arteriovenous nicking)
Arteriosclerosis with moderate vascular wall changes (copper wiring) to more severe vascular wall hyperplasia and thickening (silver wiring)
Photoscreening
Photoscreening is a form of vision screening for children. It uses a camera to take images of a child’s undilated eyes, by 5 you can test with a modified vision test instead of letter you might have pictures
•Photoscreening is recommended as an alternative to visual acuity screening for ages
3 to 5
Horner syndrome
Horner syndrome (Horner’s syndrome) results from an interruption of the sympathetic nerve supply to the eye and is characterized by the classic triad of miosis (ie, constricted pupil), partial ptosis, and loss of hemifacial sweating (ie, anhidrosis) more prominent with people with heterochromia, meaning eye colors are different
It is caused by the interruption of sympathetic nervous system innervation to the head, neck, and eye.
Diabetic retinopathy with presence of microaneurysms and the presence of hard and soft exudate and eventually the Development of new vessels as result of anoxic environment. New vessels are fragile and easily break creating some area of hemorrhages
Glaucoma
- Disease of the optic nerve resulting from increased intraocular pressure
- Nerve cells die, producing a characteristic appearance of the optic nerve (increased cupping)
- Opened angle
- Progressive painless visual loss mostly peripheral in nature
- Closed angle
- Acute painful peripheral vision loss often accompanied by conjunctival injectionGlaucoma
Disease of the optic nerve wherein the nerve cells die usually because of excessively high intraocular pressure
Pterygium
•Abnormal growth of conjunctiva that extends over the cornea from the limbus. Ofen seen in patients in the sun alot
aka Surfer’s eye
Amsler Grid
A tool used to detect macular degeneration. Macular degeneration is a age-related disease of the macula (central portion of the retina) that results in loss of central vision. A common disorder in people over 50.
The bell of a stethoscope is used for
High frequency sounds
The diaphragm of a stethoscope is used for
Low-frequency sounds
General Survey and its components
A general survey is a systematic assessment of the individual’s health status. Starts with physiologic stability using the pneumonic ABCDE (airway, breathing, circulation, disability, exposure). Once it is determined the individual isn’t in any acute distress next it is ABC (appearance, behavior, cognition)
The initial general survey includes assessing for problems, instability, or alterations in the airway, breathing, circulation, and neurologic status, which involves exposing an individual as needed in order to safely and effectively complete the exam.
Assessments of mental and physical status include the general survey, measurements of vital signs and body habitus, and evaluation of pain.
