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”)