Lecture One (Gen appearance, mental, hair, nails, skin)- Exam 1 Flashcards
What is the general approach to the patient? (5)
How do be systematic and ensure patient comfort?
When should you communicate with the patient?
Converse with the patient while patient is dressed or draped, particularly when discussing bad news or abnormal findings, plan of care or prognosis
What is the exam sequence? what is the exceptation?
- Inspect, palpation, percussion, auscultation
- Except for abdomen, you want to go inspect, auscultation, palpation and percussion
Inspection:
* What often happens?
* Should be applied when?
* Ensure what?
* Observe what?
* In checklists, what do we do>
- Often neglected by examiner
- Should be applied throughout the entire examination and interview process
- Ensure adequate lighting & exposure
- Observe nonverbal communication
- In checklists, verbalize that you are inspecting-> “Taking a look at the skin”, etc
What should you be doing for inspection?
Touching them
What do you do for palpation? What should you maintain?
- Involves use of your hands & fingers to gather information through touch (pt or you might be uncomfortable but you need to work through it)
- Maintain short fingernails, warm hands if possible
Palpation:
* What do you use for sensitivity, vibration and temperature?
- Use palmar surface & finger pads for sensitivity
- Use ulnar surface of hands to discern vibration
- Use dorsal surface of hands to discern temperature
- What does percussion use?
- Is it an easy skill to learn?
- How do you do it?
- Percussion uses sound waves to detect body tissue density
- Hardest skill for students to master
- Firmly place middle distal phalanx on body surface
- Snap wrist of your hand, & with tip of middle finger tap interphalangeal joint of finger that is on body surface
Listen to sound: dense vs. hollow
Auscultation:
* When should you perform?
* Listen for what?
* How do you narrow your perceptual field?
* Perform auscultation when (in order)
- Perform in a quiet setting if possible.
- Listen for intensity, pitch, duration & quality of sound
- Narrow perceptual field by closing your eyes
- Perform auscultation last (except abdomen) so other findings will contribute to interpretation
What are the parts of a stethoscope?
- Bell – transmits low frequency sounds (when held lightly against the area of auscultation)
- Diaphragm – transmits high frequency sounds
What is the technique for two sided stethoscope?
- Less pressure for bell
- More pressure for diaphragm
How does a dual frequency diaphragm work?
Combines both bell (low-frequency) and diaphragm (high frequency) into a single side of the chest piece. You control bell and diaphragm modes by pressure on the chest piece rather than by turning it over.
With general appearance/mental status, they usually what? What should be do in check offs?
- There is overlap between the two
- Covering both together is often appropriate
- Always verbalized in check offs!
- Anything “Observed” you must verbalize (We can’t read your mind!)
What is the general survey in general appearance? (7)
What is the general survey in mental status?
- Observed
- As you talk to a patient, you will quickly begin to discern the patient’s level of
alertness, mood, orientation, attention, and memory - As you continue talking with a patient in depth, you will begin to learn about his insight, judgment, and any thought disorder or disorder of perception
For mental status examinations, what does it consist of?
- Appearance and behavior
- Speech and language
- Mood and Affect
- Thoughts and perceptions
- Cognitive function: memory, attention, information and vocabulary, calculations, abstract thinking, and constructional ability
What are the components of cognitive function?
Cognitive function: memory, attention, information and vocabulary, calculations, abstract thinking, and constructional ability
What is the apparent state of health?
Signs of distress:
* Cardiac or pul/respiratory:
* Pain:
* Anxiety or depression:
- Cardiac or pulmonary/respiratory (Clutching of the chest, pallor, diaphoresis, labored breathing, wheezing/coughing).
- Pain (wincing, diaphoresis, protectiveness of painful area, grimacing, or an unusual posture favoring one limb or region of the body).
- Anxiety or depression (anxious facial expressions, fidgety movements, cold moist palms, flat affect, poor eye contact or psychomotor slowing).
What can we use for pain reference?
What are questions to ask for state of awareness/levels of consciousness?
- Is the patient awake, alert, and responsive to you and others in the environment?
- Does the patient understand your questions?
- Does the patient respond appropriately and reasonably quickly or lose track of the topic and fall silent or even asleep?
What do we do if the patient is non-responsive?
- Speak to the patient by name and in a loud voice
- Shake the patient gently, like wakening a sleeper
What is lethargic, obtunded, stupor, coma?
⭐️
- Lethargic: drowsy, open eyes and look at you, respond to questions, and then fall asleep
- Obtunded: open their eyes and look at you, but respond slowly and are somewhat confused
- Stupor: Completely unarousable except by painful stimuli (sternal rub)
- Coma: Completely un-anarousable
What is attention?
the ability to focus or concentrate
What are the five components of attentions?
- Alert: the patient is awake and aware
- Lethargic: you must speak to the patient in a loud forceful manner to get a response
- Obtunded: you must shake a patient to get a response
- Stuporous: the patient is unarousable except by painful stimuli (sternal rub)
- Coma: the patient is completely unarousable
What are topics for orientation?
- aware of person (who they are)
- place (where they are)
- time (when is it
When can orientation be done?
Can be done by assessing information throughout interview
* Clarification of dates-> you have the medical history so you can dates about that
* What route do you take to the office?
What are some direct questions for orientation you can ask?
- Easily done upon entering room:
- Can you tell me your name please? (confirming chart)
- What is the date? (Or time of appointment?)
- Can you tell me where we are right now?
What are three ways you can document state of awareness/levels of consciousness?
What are some things that we look at for posture and motor behaviors?
What are some things we look for hygiene and grooming?
What are some classic examples of odors of body and breath?
- Fruity breath-Diabetic Ketoacidosis * Alcohol use
When should you observe facial expression? What should you note?
- Observe facial expression at rest, during convo, and social interactions and during PE
- Note expressions of anxiety, depression, apathy, anger, elation, or facial immobility
- Watch for changes throughout
What should we watch closely for in facial expression?
watch closely for eye contact: decreased, increased, blinking, unblinking, flatness
When can a flat affect be seen?
A flat affect (lack of facial movement), can be seen due to a physical reason such as Parkinson’s disease or a psychological reason such as profound depression
What is perceptions, insight, thought processes, judgment?
What is affect in mental status/behavior term?
observable mood of a person expressed through facial expression, body mvts and voice
What are the different moods a patient can be in?
Ststained emotion of the patient:
* euthymic-normal
* dysthymic-depressed
* manic-elated
What is language?
the complex symbolic system for expressing written and verbal thoughts, emotion, attention and memory
What is higher cognitive functions?
Level of intelligence assessed by vocab, knowledge base, calculations and abstract thinking
What are two parts of affect? What are some questions we can ask/see (4)
What is this?
Flat affect
What are seven different moods?
CREASE J
How do you approach assessing mood?
What do you need to ask if patient is in depressed mood?
What are the different parts we need to look in speech and language?
What is fluency?
- Fluency: involves the rate, flow, and melody of speech
- Hesitancies and gaps
- Disturbed inflections
* Monotone inflections (schizophrenia or severe depression)
Fluency:
- What is circumlocutions?
- What is paraphasias?
- Circumlocutions: words or phrases are substituted for the word a person cannot remember; e.g., “the thing you write with” for a pen
- Paraphasias: words are malformed (“I write with a den”), wrong (“I write with a bar”), or invented (“I write with a dar”)
If the patient’s speech lacks meaning or fluency, proceed with what?
With further testing?
T/F: person who can write a correct sentence does not have aphasia
True
Abnormal thought processes
Incoherence:
speech that is incomprehensible and illogical (severe psychotic abnormal thought processes continued disturbances; usually schizophrenia)
Abnormal thought processes
Blocking:
sudden interruption of speech, before the completion of an idea, occurs in normal people
Abnormal thought processes
What is confabulation?
fabrication of facts to hide memory impairment (Kosakoff syndrome from alcoholism)
Abnormal thought processes
Perseveration:
persistent repetition of words or ideas
Abnormal thought processes
Echolalia:
repetition of the words or phrases of others
Abnormal thought
Clanging:
choosing a word on the basis of sound rather than meaning
To assess, follow the patient’s leads and cues rather than what?
asking direct questions
* You mentioned that a neighbor caused your entire illness. Can you tell me more about that?
* What do you think about at times like these?
Abnormalities of Thought Content
- Compulsions:
- Obsessions:
- Phobias:
- Anxieties:
- Compulsions: repetitive behaviors that a person feels driven to perform in response to an obsession, aimed at preventing or reducing anxiety or a dreaded event or situation
- Obsessions: recurrent persistent thoughts,images, or urges experienced as intrusive and unwanted that the person tries to ignore, suppress, or neutralize with other thoughts or actions
- Phobias: persistent irrational fears, accompanied by a compelling desire to avoid the provoking stimulus
- Anxieties: Apprehensive anticipation of future danger or misfortune accompanied by feelings of worry, distress, and/or somatic symptoms of tension
Abnormalities of thought content
- What is feelings of unreatlity?
- What is feelings of depersonaliziation?
- Feelings of Unreality: A sense that the environment is strange, unreal, or remote
-
Feelings of Depersonalization: A sense that one’s self or identity is different, changed, unreal; lost; or detached from one’s
mind or body
What is delusions and what are the different types?
Abnormalities of Perception:
What are illusions and hallucinations?
How do you pursue false perceptions (3)
- “When you heard the voice speaking to you, what did it say? how did it make you feel?
- “After you’ve been drinking a lot, do you ever see things that aren’t really there?”
- “Sometimes after major surgery like yours, people hear peculiar or frightening things. Has anything like this happened to you?”
What is insight? What are some questions?
- Based on reality? Reasonable?
- “What brings you to the hospital?”
- “What seems to be the trouble?”
- “What do you think is wrong?”
For insight, what should you note?
Note whether the patient is aware that a particular mood, thought, or perception is abnormal or part of an illness.
How do we assess judgment?
Assess judgment by noting the patient’s responses to family situations, jobs, use of money, and interpersonal conflicts
What are questions to ask for jugdement? (4)
- “How do you plan to get help after leaving the hospital?”
- “How are you going to manage if you lose your job?”
- “If your husband starts to abuse you again, what will you do?”
- “Who will take care of your financial affairs while you are in the nursing home?”
Cognitive functions
What are ways we test attention? (3)
- Digital span: give the patient a series of digits to recite back to you. Start with two at a time, 1 per second. Can increase
- Serial 7s: ask the patient to subtract serial “7s” from 100
- Spelling backward: ask the patient to spell W-O-R-L-D backwards
Cogn fxns
what is memory?
- Memory: the process of recording and retrieving information
What is long and short term memory?
How can memory be assessed?
- This can be assessed throughout interview without specific “Memory Questions”
For cognitive function, what is the new learning ability?
Higher Cognitive Functions: Information and vocab
* When do you start?
* Ask about what?
* start with what?
* note what?
- Begin assessing during the interview
- Ask about work, hobbies, reading, favorite tv programs, current events
- Start with simple questions, then move to more difficult questions
- Note pt’s grasp of info, complexity of ideas, and choice of vocabulary
Higher Cognitive Functions: Calculating ability
Higher Cognitive Functions: Calculating ability
* How do you test this?
- Simple addition and multiplication; 4 + 3, 5 x 6 then progress to longer or more difficult; 15 + 12, 25 x 6
OR practical application:
- If something costs 78 cents and you give the cashier 1 dollar, how much change would you get back?
Higher Cognitive Functions: abstract thinking
* What are examples of proverbs?
* What are similarities?
how do we test constructional ability?
- Give the pt a piece of blank unlined paper
- Show them one figure at a time and have them copy the object
- Increase in difficulty
- OR
- Ask them to draw a clock face with numbers and hands
What is this an example of?
Constructional ability
What is mini-mental state exam (MMSE)
The MMSE is a brief, quantitative measure of cognitive status in adults. It can be used to screen for cognitive impairment, to estimate the severity of cognitive impairment at a given point in time, to follow the course of cognitive changes in an individual over time, and to document an individual’s response to treatment.
What is an example of mini-mental state exam (MMSE)-> orientation to time, registration, naming and reading
How do you record behavior and mental status?
Skin:
* What type of organ?
* How much of body weight?
* How many layers+ name them?
* What are appendages of the skin?
- Heaviest single organ of the body
- 16% of body weight
- Three layers: Epidermis, Dermism, Subcutaneous tissue
- Hair, nails, and sebaceous and sweat glands are appendages of skin
Hair:
What is vellus and terminal hair?
- Vellus hair – short, fine, less pigmentation
- Terminal hair – coarser, pigmented (scalp/eyebrows)
- What is the purpose of nails?
- What are sebaceous glands?
- Nails - protect distal ends of fingers/toes
- Sebaceous glands – present all surfaces except palms/soles; produce a fatty substance secreted onto skin surface through hair follicles
What are the two types of sweat glands? Explain them?
- Eccrine glands – widely distributed, open directly onto skin surface, help control body temperature
- Apocrine glands – found in axilla and groin, stimulated by emotional stress
What are common or concerning symptoms of skin, hair and nails?
Common or concerning symptoms
* Hair loss
* Rash
* Moles
What should you ask the patient for health history? (5)
- “Have you noticed any changes in your skin? … your hair? … your nails?”
- “Have you had any rashes?…sores?…lumps?…itching?”
- “Have you noticed any new moles?”
- “Has anyone in your family had a skin cancer removed?” What kind?
- “Have you noticed any moles that have changed size, shape, color, or sensation?”
What is the ABCDE?
Screening Moles for Possible Melanoma
What are additional risk factors for melanoma?
- Examination of the skin, hair, and nails begins with what?
- What should you make sure?
- How should you inspect the skin surface?
How should you do the physical exam for skin?
- Inspect and palpate skin together for better exam flow
- Work from Head to Toe
What are the characterisitics to note of the physical exam of the skin?
- Color
- Moisture
- Temperature
- Texture
- Mobility and turgor
- Lesions
What should inspect when assessing color? (what are looking for?_
What do you look for in color inspection?
- Look for erythema (redness), pallor, cyanosis, and jaundice (yellowing)
- Look for areas of hypo- or hyperpigmentation
How do you assess pallor?
How do you assess central cyanosis?
How do you assess jaundice?
- Pallor best assessed at fingertips, lips, and mucous membranes
- For central cyanosis, look in lips, oral mucosa, and tongue as well as nails, hands, and feet
- Jaundice – sclera, conjunctiva, lips, hard palate, tongue, and skin (used penlight if needed)
For lesions, what are some characterisitcs you need to note?
- Anatomic location and distribution
- Patterns, shapes, and size (in mm or cm)
- Type of lesion (macules, papules, nevi, vesicles)
- Color
How do you insect the hair/scalp? What do you note?
- Inspect and palpate in at least two places of head and assess the full body as well
- Note quantity, distribution, texture, and scalp lesions
How do you inspect the nails/nail beds? What do you note?
- Inspect and palpate all fingernails/toenails
- Note color and shape
- Note lesions
- Longitudinal bands of pigment may be a normal finding in people with darker skin
What are you looking/feeling when palpation?
- Skin Temperature
- Skin Moisture and Texture
- Skin Turgor
- Hair texture
- Fingernails and Toenails
For palpation, what are you checking for?
How do you record your finding for skin lesions and raches?
LY for test
- Number-Solitary or multiple, estimate total number
- Size-Measure in mm or cm
- Color-Including erythematous if blanching; if nonblanching, vascular-like cherry angiomas and vascular malformations, petachiae, or purpura. (Blanching-pressing it firmly with your finger to see if redness lightens then refills)
- Shape-Circular, oval, annular (ring-like with central clearing), nummular (coin-like with no central clearing, or polygonal
- Texture-Smooth, fleshy, verrucous or warty, keratotic; greasy if scaling
- Primary Lesion-flat: macule vs. patch; raised: papule vs. plaque; fluid- filled-vesicle vs. bulla (will define later)
- Location-including measured distance from other landmarks
- Configuration-grouped, annular, or linear
What are the primary skin lesion-flat or raised?
Low yield
What are macules?
Multiple 3–8-mm erythematous confluent round macules on chest, back, and arms; morbilliform drug eruption
What are patches?
Large confluent completely depigmented patches on dorsal hands and distal forearms; vitiligo
What are papules?
- Multiple 3–5-mm pink firm smooth domed papules with central umbillications, in mons pubis, and on penile shaft; molluscum contagiosum
What are plaques?
Scattered erythematous to bright pink well-circumscribed flat- topped plaques on extensor knees and elbows, with overlying silvery scale; plaque psoriasis
What are vesicles? (multiple)
Multiple 2–4-mm vesicles and pustules on erythematous base, grouped together on left neck; herpes simplex virus
What are vesicles? (grouped)
- Grouped 2–5-mm vesicles on erythematous base on left upper abdomen and trunk in a dermatomal distribution that does not cross the midline; herpes zoster or “shingles”
Secondary lesions:
* Scales:
* Crusts:
- Scales, which are shed dead keratinized cells, occur with psoriasis and eczema. They’re irregular, flaky, and variable in size. Usually silver, white, or tan, they can be thick, thin, dry, or oily.
- Crusts, in contrast, are dried exudates. Slightly elevated, they vary in size and color depending on the amount and type of exudate. Abrasion scabs and impetigo are examples of crusts.
Secondary lesions:
* Excoriations:
* Erosions:
- Excoriations such as abrasions represent a loss of epidermis and an exposed dermis. They may be linear or have hollowed-out crusted areas.
- Erosions resemble excoriations, except that the depressed area is moist and glistening. They follow a vesicular rupture. An example of this type of lesion occurs with varicella.
Secondary lesions:
* Ulcers:
* Fissures:
- Ulcers are also concave, exudative, and variable in size. Some types, such as pressure ulcers and those caused by diabetic neuropathy, are graded according to depth and severity.
- Fissures are linear breaks in the skin extending from the epidermis to the dermis. Fissures are usually small, deep, and red. Tinea pedis (a fungal infection better known as athlete’s foot) commonly produces fissures.
Secondary lesions:
* Scars:
- Scars are collagenous tissues that permanently replace injured dermis. Scars appear over healed wounds and surgical incisions. Typically irregular, they may be thick or thin and hypertrophic or atrophic. Red, blue, white, and silver are common colors for scars.
Secondary lesions:
* Keloids:
Keloids are progressively enlarging scars that grow beyond the boundaries of the initial wound or incision. Excessive collagen production during healing is generally responsible for keloid formation
- Who is particularly susceptible to skin damage and ulceration?
- What do you need to do?
People confined to bed are particularly susceptible to skin damage and ulceration
* Pressure sores result when sustained compression obliterates arteriolar and capillary blood flow to the skin
* Assess these patients by carefully inspecting the skin that overlies the sacrum, buttocks, greater trochanters, knees, and heels
* Roll patient onto one side to see sacrum and buttocks
What is ulcer’s etiology?
Most common etiology – poor vascularization and pressure
What are checking for in hair distribution?
Female patterned hair loss/Male patterned hair loss
What are we looking at with nails?
What is this?
Clubbing-> can be bengin or cardiac disease
What is ridging?
- Vertical – normal aging, thyroid disease, eczema
What is beau’s lines?
- Deep horizontal ridges, called Beau’s lines, are often symptoms of a serious condition. They may stop nail growth until the underlying condition is treated. Acute kidney disease may also be present if Beau’s lines appear. In addition, when Beau’s lines develop on all 20 nails, it could be a symptom of: Mumps, Diabetes, Thyroid disease, Syphilis
What is central nail canal?
- Severe arterial disease
- Severe malnutrition
- repetitive trauma (not all nails)
What is paronychia?
Trauma, Irritation, Infection
What is capillary refill? Why do we do it?
- Time taken for color to return to an external capillary bed after pressure is applied; <=2 seconds
- Slowed – could be dehydrations, shock, hypothermia
