Midterm 509 Flashcards
Closely attending to what the patient is communicating, connecting to the patient’s emotional state, and using verbal and nonverbal skills to encourage the patient to expand on his or her own feelings or concerns
Active Listening
The capacity to identify with the patient and feel the patient’s pain as your own, then respond in a supportive manner.
Empathetic Responses
Guided questions show you sustained interest in the patient’s feelings and deepest disclosures and allows the interviewer to facilitate full communication, in the patient’s own words, without interruption
Guided Questions
Includes eye contact, facial expression, posture, head position and movement such as shaking or nodding, interpersonal distance, and placement if the arms or legs. Crossed, neutral or open
Non Verbal Comminication
Affirm the legitimacy of the patient’s emotional experience
Validation
Help the patient feel that problems have been fully understood and are being addressed
Reassurance
Express your commitment to an ongoing relationship
Partnering
Giving a summary of the patient’s story to communicate that you have been listening carefully
Summarization
Inform your patient when you are changing directions
Transitions
Empowering the patients to ask questions, express their concerns and probe your recommendations
Empowering the patient
True or False: You should always use peoples first language such as they have diabetes they are not a diabetic
True
What does FIFE stand for?
Feelings
Ideas
Functional effect
Expectations
What does feelings in FIFE include?
Fears or concerns about the problem
What does Ideas in FIFE include?
The nature and the cause of the problem
What does Function in FIFE consist of?
The problem on the patients life and how they function
What does expectations include in FIFE?
What are the patients expectations of the disease, of the clinician, or of the healthcare, this is often based on prior experiences.
What is adaptive questioning?
It is the same as guided questioning.
What are some techniques of guided questioning?
Moving from _________ to ___________ ended questioning
Open to closed
Using questions that elicit a graded response is a technique of?
Adaptive or guided questioning
In adaptive questioning you should ask a ________ of questions, one at a time
Series
You should always _______________ what the patient means
Clarify
Should you offer multiple choice questions to patients in adaptive questioning?
Yes
You should always encourage with ______________, and use ___________ to reiterate what the patient has said
Encourage and echoing
Silence in patients can be….
Therapeutic for patients or a time of reflection
What do you do with talkative patients?
Use summarization and redirection
If the patient has a confusing narrative what should the NP do?
Assess mental status, uses guided questioning, clarify and summarize
What if the patient has emotional lability and they begin to cry? What is the best option for the NP to do?
Use empathy
If an angry or aggressive patient is seen at the clinic it is important for the NP to?
Use active listening and remain calm
A patient comes in flirting with the NP she or he should?
Redirect the patient and set clear boundaries
With the Discriminatory patients the NP should assess what?
The patient severity
How should an NP handle a discriminatory patient?
Create a therapeutic alliance with the patient and create a supportive environment from the healthcare team
How should the NP communicate with someone with hearing loss?
Ask the patient what the best way is to communicate with them
Always speak in a normal volume and rate
And use a teach back method
How should a NP handle a patient that is non adherent?
Assess socioeconomic factors
Cognition
Cultural beliefs
When should the NP complete a comprehensive exam?
When they are seeing the patient for the first time
A focused assessment should only be used in which situation?
When the patient is returning to your care
a patient with an “urgent care” need
in the emergency room
Is the ROS subjective or objective?
Subjective
When obtaining the HPI what is the acronym used to assess a “problem”?
OLDCARTS
What does OLDCARTS stand for?
Onset Location Duration Characteristics Aggravating Factors Relieving Factors Treatment Severity
When filling out the ROS if you didn’t ask the question should you fill the box in with “denies”
No. It should be not assessed
What should be listed under the medical illness?
Things such as diabetes, HTN, hepatitis, asthma, and HIV
Also hospitalizations, number and gender of sexual partners, and safety engaging in sex
When obtaining a surgical history what is important to document?
Dates
Indications
And types of operations: i.e. c-sections
What is included in OBGYN history?
Obstetric history
Menstrual history
Methods of contraception
Sexual function
What is listed in psychiatric history ROS?
Illness Timeline Diagnoses Hospitalizations Treatments
Summarizes all related problems that support a differential diagnosis is called a
Problem list
In a problem list what is listed first the most serious and active problems or past problems?
The active and most serious
What is a differential diagnosis?
A list of possible diagnoses for a supported problem list
____________ ______________ is abnormal findings that support your diagnosis.
Pertinent positives
_______________ ______________ are normal findings that rule out a diagnosis
Pertinent Negatives
An elevated A1C to diagnose diabetes is an example of
Pertinent positive
A normal A1C when looking for a diagnosis of diabetes is
Pertinent negative
If there is no place for OBGYN or psychiatric in the ROS where should you list it?
Past medical history
When leaving the arm hanging dependent and taking a blood pressure, this can cause a what type of reading?
False high
A blood pressure cuff that is too __________ will cause a false high blood pressure?
Small
How many visits are needed to diagnose HTN?
2
What stage HTN is a blood pressure that is greater >140/>90?
HTN stage 2
When a patient only has a blood pressure reading that is high in the office it is called?
White coat syndrome
If a patients blood pressure is always normal at the doctors office what is this called?
Masked HTN
How would the provider be able to identify white coat syndrome or masked HTN from an office visit?
Ask the patient to check blood pressure at home and bring with them to follow up visit
Anorexia can be what three things?
- Pathological or intentional
- Symptom of a disease
- Side effect of a medication such as chemo
True or False Bulimia is never intentional
False
It is always a psychological problem
T or F
Hallucinations include external stimuli
False
__________ is when you misinterpret external stimulation
Illusion
Think magic show it is an optical illusion
HALLUCINATIONS or ILLUSIONS are manifested on one of the 5 senses?
Hallucinations
When screening in the office for depression which question are is used?
PHQ2
If a patient answers yes to either question you move on to the PHQ9
Sudden interruption of speech in midsentence or before the idea is completed, attributed to “losing the thought.” Blocking occurs in normal people.
Blocking
The mildest thought disorder, consisting of speech with unnecessary detail, indirection, and delay in reaching the point. Some topics may have a meaningful connection. Many people without mental disorders have circumstantial speech.
Circumstantiality
Speech with choice of words based on sound, rather than meaning, as in rhyming and punning. For example, “Look at my eyes and nose, wise eyes and rosy nose. Two to one, the ayes have it!”
Clanging
Fabrication of facts or events in response to questions, to fill in the gaps from impaired memory
Confabulation
Tangential speech with shifting topics that are loosely connected or unrelated. The patient is unaware of the lack of association.
Derailment (loosening of associations)
Repetition of the words and phrases of others
Echolalia
An almost continuous flow of accelerated speech with abrupt changes from one topic to the next. Changes are based on understandable associations, plays on words, or distracting stimuli, but ideas are not well connected.
Flight of ideas
Speech that is incomprehensible and illogical, with lack of meaningful connections, abrupt changes in topic, or disordered grammar or word use. Flight of ideas, when severe, may produce incoherence.
Incoherence
Invented or distorted words, or words with new and highly idiosyncratic meanings
Neologisms
Persistent repetition of words or ideas
Perservation
___________ may be striking in schizophrenia
Blocking
___________ occurs in people with obsessions
Circumstantiality
_____________ occurs in schizophrenia or manic episodes
Clanging
_____________ is seen in Korsakoff syndrome from alcoholism
Confabulation
_____________ is seen in schizophrenia, manic episodes, and other psychotic disorders
Derailment
________ occurs in manic episodes and schizophrenia
Echolalia
__________ ____ __________ is most frequently noted in manic episodes
Flight of ideas
______________ is seen in severe psychotic disturbances
Incoherence
___________ are observed in schizophrenia, psychotic disorders, and aphasia
Neologisms
______________ occurs in schizophrenia and other psychotic disorders
Perservation
What does the visual acuity 20/100 mean?
It means that at 20 feet the patient can read a print that a person with normal vision could read at 100 ft.
The ________ the second number in visual acuity the worse the patient vision is
Larger
What visual acuity is termed legally blind?
20/200
What is the diagnosis of sudden painless vision loss that is unilateral?
Retinal Detachment
How can you differentiate between retinal detachment and another cause?
Is there pain and is it unilateral or bilateral
What conditions do not have a red reflex?
In patients with cataracts
Patients that have an artificial eye
What are less common for absence of red reflex?
Detached retina or children with a retinoblastoma
What would you do if you suspected a retinoblastoma in a child?
Send them out quick especially since it is fast growing.
If a patient has nystagmus when they turn their head side to side what would the NP think the culprit was?
Inner ear
What is nystagmus?
An involuntary eye movement which may cause the eye to rapidly move from side to side, up or down, or in a circle. It can cause slightly blurry vision
Nystagmus is seen in ___________ disease.
Cerebellar
Nystagmus is seen with what other symptoms?
Gait ataxia
Dysarthria (increases with retinal fixation)
Internuclear Opthalmoplegia
What is important for the NP to note when seeing nystagmus?
The direction of gaze in which it appears, the plan of the nystagmus (horizontal, vertical, rotary, or mixed) and the direction of the quick and slow components
If you see nystagmus what should you ask the patient to do so you can observe it increases in speed or decreases?
Fix their vision
Sudden visual loss that is unilateral and painful is associated with ________ _________ and called ______________
Multiple sclerosis and called Optic Neuritis
If the NP suspects Optic Neuritis what should they do?
Treat it quickly
What are signs of an increase in ICP?
Papillodemia of the optic disc Headache Blurred vision Feeling less alert than usual Nausea Vomiting Behavior Weakness or problems with moving or talking Lack of energy or sleepiness
In what diagnoses does hallucinations occur?
Delirium, Dementia (is less common), PTSD, schizophrenia and substance abuse
Which test would you use for dementia?
Mini-cog
In an eye what is typically transparent but become injected (blood shot) during times of injury, infection or inflammation?
The conjunctiva
This picture is an example of?
Papillodema
What is an important cause of poor central vision in older adults?
Macular degeneration
There are two types of macular degeneration what are they?
Dry Atrophic which is more common and less severe. And wet exudative or neovascular.
What is a drusen in the eye?
They are YELLOW deposits in the eye under the retina. They are made up of lipids and proteins. They can increase the risk of Macular degeneration
Ptosis is what?
Drooping of an eye lid
What can cause ptosis?
Damage to cranial nerve 3 which is the oculomotor nerve
What is cranial nerve 1?
Olfactory which innervated the nose
What is cranial nerve II?
Optic which is sensory of the eye
What is cranial nerve III?
Occulomotor nerver: All eye muscles except those supplied by IV and VI
Cranial nerve IV?
Trochlear motor which deals with the superior oblique muscle of the eye
What is cranial nerve V?
Trigeminal
Sensory: Face, sinuses, teeth, etc
Motor: muscles of mastication
What is cranial nerve VI?
Abducent muscle
Motor: external recuts muscle in the eye
What is cranial nerve VII?
Facial
Motor: muscles of the face
What is cranial nerve VIII?
Vestibular cochlear
Sensory: inner ear
What is cranial nerve IX?
Glossopharyngeal
Motor: pharyngeal musculature
Sensory: Posterior part of the tongue, tonsils, pharynx
What is cranial nerve X?
Vagus Nerve
Motor: Heart, lungs, bronchi, GI tract
Sensory: Heart, lungs,bronchi, trachea, larynx, pharynx, GI tract and outer ear
What is cranial nerve XI?
Accessory Motor nerve
Motor: sternocleidomastoid and trapezius muscle
What is cranial nerve XII?
Hypoglossal nerve
Motor: muscles of the tongue
What does this picture represent? What causes it?
Glaucomatous Cupping
This is caused by increased IOP within the eye and leads to increased cupping and atrophy. The base of the enlarged cup is pale.
Appearance: Death of optic nerve fibers leads to loss of the tiny disc vessels.
What does this picture represent? And what causes it?
Optic Atrophy
Process: The physiologic cup is enlarged, occupying more than half of the disc’s diameter, at times extending to the edge of the disc. Retinal vessels sink in and under the cup, and may be displaced nasally.
Appearance: Color white
Tiny disc vessels are absent
This is seen in: Optic neuritis, multiple sclerosis, temporal arteritis
What is this picture? And what does it mean?
This is medullated nerve fibers. They are benign. They are not common.
What is this and what does it mean?
Superficial retinal hemorrhage this is caused by severe HTN, papillodema , and occlusion of the retinal vein
What does this picture show and what causes this?
Preretinal hemorrhage
This is typically larger that retinal hemorrhages
Causes: sudden increases in intracranial pressure
What does this picture show and what causes this?
Deep retinal hemorrhage
They are small and rounded, slightly irregular
They occur in the deeper layer of the retina than a flame shaped hemorrhage.
Common Cause: diabetes
What does this picture show and what does it mean?
Microaneurysm
Tiny, round, red dots in and around and in the macular area
Hallmark sign of diabetic retinopathy
What does this picture show and what does it mean?
Neovascularization
Refers to the formation of new blood vessels.
They are more tortuous and narrower than the neighboring blood vessels.
This is common feature of diabetic retinopathy
These vessels can grow into the virtuous and cause retinal detachment or hemorrhage may cause a loss of vision.
What does this picture show and what are the causes?
Soft Exudates: Cotton wool spots
Ovoid lesions that are WHITE OR GRAYISH with irregular or soft borders.
Caused by microinfarcts of the retinal nerve fiber layer
Seen in HTN, diabetes HIV and other viruses, and numerous other conditions
What does this picture show and what causes it?
Hard exudates
They are CREAMY AND YELLOWISH, often bright, lesions with WELL DEFINED “hard” borders. They are small and round
Often occur in CLUSTERS or in circular, linear, or star shaped patterns
They are lipid residues or serous leakage from damaged capillaries
Causes: Diabetes and vascular dysplasia’s
What does this picture show and what does it mean?
Drusen
Yellowish round spots that vary from tiny to small
The edges can be soft or hard
They are HAPHAZARDLY distributed but may concentrate at the posterior pole between the optic disc and macula
they are dead retinal pigment epithelial cells
Seen in normal aging and are related degeneration
What does this picture show and what does it mean?
Healed Chorioretinitis
These are inflammation that has destroyed the superficial tissues to reveal a well-defined, irregular patch of white sclera marked with DARK pigment
This is seen in toxoplasmosis, or if similar in nature could be caused by a laser.
What type of retinal hemorrhage is benign and requires no treatment?
Sub conjunctival hemorrhage
How long does it take for a subconjunctival hemorrhage take to heal?
2 weeks
What causes a sub conjunctival hemorrhage?
Leakage of blood outside the vessel producing homogenous red area, no ocular discharge, vision not affected, usually resulting from trauma, or sudden increase in venous pressure
What are signs and symptoms of conjunctivitis?
Diffuse dilation of conjunctival vessels with redness that tens to be maximal peripherally
There is generally mild discomfort rather than pain
Vision is not affected except for mild temporary blurriness due to discharge
Ocular discharge: Watery, mucoid, or mucopurulent
Pupil isn’t affected
Cornea: clear
Significance: bacterial, viral, and other infection, HIGHLY CONTAGIOUS, allergy or irritation
What is a normal finding of cranial nerve I (olfactory nerve)
That smell is decreased in the elderly
What can cause a loss of smell cranial nerve I (olfactory)
Elderly, head trauma, smoking (nicotine damages CN I), cocaine use and Parkinson’s disease
What causes epistaxis?
Trauma (esp. nose picking)
Inflammation
Drying and crusting of the nasal mucosa
Tumors
Foreign bodies
If a patient is coughing up blood what other cause besides lungs should you rule out?
Nose bleeding
What are signs of seasonal allergies?
Itching, watery eyes, sneezing, ear congestion, post nasal drainage
What might you see on otoscope evaluation on a patient with allergies?
Slight bulging when the allergies are bad
What is the difference between otitis media and otitis external?
Otitis media is a middle ear infection
Otitis external is the outer ear
What’s a quick way to determine if a patient has otitis external versus media?
If you move the ear it is super painful in otitis externa
Movement of the auricle and tragic is painful in acute otitis externa (inflammation of the ear canal), but not in otitis media (Inflammation of the middle ear)
If there is tenderness behind the ear would you suspect otitis externa or otitis media?
Otitis media
In otitis externa the ________ is often swollen, narrowed, moist, pale and tender. It may be reddened.
Canal
What cranial nerve is tested when the patient is told to shrug their shoulders?
CN XI the spinal accessory nerve
If a patient has generalized weakness would you suspect the shoulder shrug to also be weak?
No. This should not be weak in a patient that has generalized weakness
If it is weak you should suspect a peripheral nerve disorder
What muscle are you testing with the shoulder shrug test?
Strength of the trapezii
When you see Acanthosis nigricans what should it clue you in on?
Insulin resistance
Diabetes and PCOS are two patients you may see this in.
Where would you see acanthosis nigricans?
In the skin folds around the neck, under the arms
If a patient has acanthosis nigricans does it indicate acute or chronic insulin resistance?
Chronic
What does gradual vision loss come from?
Cataracts, glaucoma, or macular degeneration
What condition would you see peripheral vision loss?
Open angle glaucoma
Pallor color in skin indicates?
Anemia
If there is cyanosis in the skin this can be indicative of what underlying cause?
Decreased oxygen in the blood or decreased blood flow from being cold
What causes jaundice?
Increased bilirubin
A ________ is circumscribed FLAT area of change in color of the skin < 1 cm in diameter
Macula
A __________ is a circumscribed flat area of change in color of the skin > 1 cm in diameter
Patch
A _______ is a small solid elevation of the skin < 1 cm in diameter
Papule
What are some examples of papules?
Nevi, warts, lichens planus, insect bites, seborrheic keratoses, actinic keratoses, some lesions of acne, and skin cancers
A _________ is a large flatter elevation of the skin, sometimes formed by papules coalescing
Plaque
What are some examples of plaques?
Psoriasis and granuloma annulare
A ___________ is a solid elevation of the skin > 1 cm in diameter that usually extends into the deeper skin layers
Nodule
What are some examples of nodules?
Cyst, lipomas and fibromas
A __________ is small circumscribed elevation of the epidermis filled with purulent fluid
Pustules
Examples of pustules
Are common in bacterial infections and folliculitis
A _______ is a small circumscribed elevation of the epidermis containing clear fluid < 1 cm in diameter
Vesicle
What are some common examples of a vesicle?
Herpes, acute allergic contact dermatitis, and some autoimmune blistering disorders such as dermatitis herpetiformis
A _______ is s a circumscribed elevation of the epidermis containing clear fluid > 1cm in diameter.
Bulla
Where are bullas commonly seen?
Autoimmune bullous diseases include pemphigus Calgary’s and billows pemphigoid
A ________ is a circumscribed, raised lesion consisting of dermal edema and is also known as hives or urticaria
Wheals
How long to wheals typically last?
24 hours
What causes wheals to appear?
Common causes include:
Hypersensitivity to drugs
Stings or bites
Autoimmunity
And less commonly physical stimuli including temperature, pressure and sunlight
What area of the body does psoriasis frequently affect?
Scalp, extensor surfaces of the elbows and knees, umbilicus, and the gluteal cleft
Where would you see lichen planus?
Arises on the wrist, forearms, genitals and lower legs
Discoid lupus erythematosus has characteristic lesions on sun exposed skin such as the …
Face, especially the forehead nose and the ear
Hidradenitis suppurativa involves skin containing high levels of ___________ glands which is in what region of the body.
Apocrine
Axillae, groin and under the breast
Oval lesions on trunk, that in older children often are in a Christmas tree pattern is called
Pityrasis rosacea
Cherry angiomas are benign or malignant?
Benign
What can cherry angiomas mimick?
Petechia
What’s the difference between cherry angiomas and petechia?
Cherry angiomas are age related and PAPULAR
Petechia are flat and ruptured capillaries
What are the signs of lymes disease?
Rash that is often in a bulls eye pattern also called erythema migrans
Flu like symptoms, fever and headache, fatigue
What is the coloration of a Mongolian spot and where are they located?
Dark or bluish pigmentation over the buttocks and lower lumbar regions
Who typically has Mongolian spots?
Common in newborns that are African, Asian and Mediterranean descent
What is another name for Mongolian spots?
Slate Blue patches
Do Mongolian spots disappear with age?
Yes
What should the nurse practitioner do if she sees a mongolian spot?
Document this so that later it isn’t confused for bruising
What are common labs that you should check with vitiligo?
Thyroid labs TSH, Free T3, and free t4
CBC
If a patient has vitiligo what are they more likely to have?
Other autoimmune diseases
What skin cancer is the most common?
Basal cell carcinoma
What is the most common characteristic of basal cell?
Pink patch that does not heal
May have focal scaling
What is the rule to diagnose and find melanoma or skin irregularities
The ABCDE rule
What does ABCDE stand for?
A- asymmetry B- Border C- Color D- Diameter E- evolving
What are concerning color variations of a mole?
A blue or black appearance, brown red, loss of pigment or redness
When looking at a patient with a lot of moles what are you looking for?
The ugly duckling the mole that is different from the others
What are the risk factors to melanoma?
Family history
> or = 50 common moles
Atypical or large moles, esp if dysplastic
Red or light hair
Solar letigines (acquired brown macules on sun exposed areas
Freckles which are inherited brown macules
UV radiation from heavy sun exposure, sunlamps, or tanning beds
Light eye or skin color, esp skin that freckles or burns easily
Severe blistering sunburns as a child (due to altering the genetic coating of the basal cells)
Immunosuppressive from HIV or chemo
Personal history
What cranial nerve do you assess when you touch the soft palate and view the uvula?
Vagus nerve
What is this called and what is the cause?
Paronychia
A superficial of the proximal and lateral nail folds adjacent to the nail plate
Usually a staph aureus or strep species
What does this picture show and what does it mean?
Clubbing
Possibly from hypoxia, changes in innervation, genetics, or a platelet derived growth factor from fragments of platelet clumps
What is this picture and what causes it?
Depression of the central nail with a Christmas tree appearance from small horizontal depressions
Caused from rubbing the index finger over the thumb or vice versa
Melanonychia
Caused by increased pigmentation in the nail matrix
This could be normal in patients of ethnic decent
It also could be a nevus
If a wide streak and irregular could be a subungal melanoma
What is this and what causes it?
This is a painless separation of the whitened opaque nail plait from the pinker translucent nail bed.
Causes: excess manicuring
Psoriasis
Fungal infection, and allergic reactions to nail cosmetics
Systemic causes: diabetes, anemia, photosensitive drug reactions, bronchiectasis and syphilis
What does this picture show and what causes this?
This is the most common cause of nail thickening and subungal debris.
Most often from the dermatophyte Trichophyton rubrum
Affect 1 in 5 over the age of 60
Best way to treat this is to treat and prevent tinea pedis
What does this picture show and what causes it?
Terry nails
The nail plate turns white with a ground glass appearance
A distal band of reddish brown and obliteration of the lunula
Common affects all fingers, but may appear in only one finger
Seen in liver disease, usually cirrhosis
Heart failure
Diabetes
With a goiter can the thyroid function be normal? High? Or low?
All three
Intolerance to cold, weight gain, dry skin, and bradycardia point to which underlying disease?
Hypothyroidism
Intolerance to heat, moist velvety skin, and palpitations point to what disease process?
Hyperthyroidism
Fine hair is seen in hypo or hyperthyroidism?
Hyperthyroidism
Course hair is seen in hypo or hyperthyroidism?
Hypothyroidism
An enlarged skull could be due to what two things?
Paget’s disease or hydrocephalus
Enlargement of a supraclavicular node especially on the left side (virchows node) suggest what possible disease?
Thoracic or abdominal metastatic disease
Tender lymph nodes suggest what?
Inflammation
Hard and fixed lymph nodes suggest?
Malignancy
What diseases would you see generalized lymphadenopathy?
HIV or AIDS
Infectious mononucleosis
Lymphoma
Luekemia
And sarcoidosis
Masses in the neck that cause deviation of the trachea are suspicious for what type of issues?
Thoracic or mediastinal mass
Atelactisis
Large pneumothorax
____________ is an ominous high pitched musical sound from severe subglottic or tracheal obstruction that signals a respiratory emergency
Stridor
What are causes of Stridor?
epiglottis, foreign body, goiter, and stenosis from an artificial airway
Retrosternal goiters can cause what symptoms?
Hoarseness, stridor, SOA, stridor or dysphagia
What is the pemberton sign?
Neck hyper extension and arm elevation may cause flushing from compression of the thoracic inlet from the gland itself or from clavicular movement
The thyroid is ________ in Graves’ disease and may be modular
Soft
The thyroid is ________ in Hashemito thyroiditis and thyroid cancer
Firm
A localized systolic or continuous _______ may be heard in __________ from Graves’ disease or toxic multinodular goiter.
Bruit
Hyperthyroidism
What would you do if you felt nodules on the thyroid?
Order and ultrasound and possible fine needle aspiration are advised
What type of vein distends in heart failure?
Jugular
What causes cushing sydrome?
An increase in adrenal cortisol production
What are some signs you may see in a patient that has Cushings disease?
“Moon” face
Red cheeks
Excessive hair growth in the mustache, sideburn, and chin areas
What causes nephrotic syndrome?
Excess albumin excretion which reduces intravascular colloid osmotic pressure causing hypovolemia and NA and H20 retention
What signs would lead you to suspect nephrotic syndrome?
Swelling in the face
Pallor in the face
What disease would you see myxedema as a secondary issue in?
Hypothyroidism
What are signs of myxedema?
Dull edema in the face typically around the eyes. They do not pit when you push on them
Hearing disorders of the external and middle ear are called?
Conductive hearing loss
What are some causes of conductive hearing loss?
Cerulean impaction Ear infection Trauma Squamous cell carcinoma Benign bony growths such as exotosis
What is exotosis?
A type of bony growths that is extra bone that grows from an already existing bone
Disorders of the inner ear cause what kind of hearing loss?
Sensoneural hearing loss
Presbycussis is an example of which hearing loss?
Sensoneural
What can cause Sensoneural hearing loss
Hereditary conditions Presbycussis Viral infections such as rubella or CMV Ménière’s disease Noise exposure Ototoxic meds Acoustic neuromas
In which hearing loss do others have issues hearing others complaining that they mumble?
Sensoneural
In which hearing loss does loud background noise hinder?
Sensoneural
IN what hearing loss is background noise helpful?
Conductive
What is an antibiotic that can cause permanent hearing loss?
Aminoglycosides such as gentamicin
What caustic medication can cause hearing loss?
Chemotherapy agents
Temporary hearing loss may be caused by what over the counter medications
ASA
NSAIDS
Temporary damage can be caused by which antibiotics?
Quinines and loop diuretics
What ear condition causes perforation with usual presence of yellow green discharge?
Acute or chronic otitis media
What other causes can cause ear pain?
Referred pain from the mouth, throat or neck
what is a common symptom increasing frequency with age?
Tinnitus
When a patient has fluctuating hearing loss and vertigo what disease would you suspect?
Meniere disease
___________ is the sensation of true rotational movement of the patient or the surroundings
Vertigo
What causes vertigo?
Issues of the inner ear
Peripheral lesions of CN VIII
Lesions in its central pathways or nuclei in the brain
What should you do if you suspect vertigo in the patient?
Distinguish peripheral from central neurological causes
If a patient has meniers disease, ataxia, and diplopia and dysarthria what cause would you suspect?
Central neurological causes in the cerebellum or brain stem or posterior fossa tumor
What another issue can cause menieres, diplopia, ataxia?
Vestibular migraine
If a patient feels faint, lightheaded, weak in the legs?
Presyncope from an arrhythmia, orthostatic hypotension, or vasovagal stimulation
Drug induced rhinitis occurs with excessive use of what?
Topical decongestants
Cocaine
How many days should a “sinus infection” be present before deeming it bacterial?
More than 7 with purulent drainage and facial pain
What common medications can cause nasal stuffiness?
OCP’s
Alcohol
Cocaine
What if the nasal congestion is only one sided?
Consider a deviated septum Nasal polyp Foreign body Granulomatous disease Carcinoma
If movement of the auricle and tragus are sensitive what is the most likely cause?
Otitis externa
What type of myringitis is also a common painful hemorrhagic vesicle on the tympanic membrane.
Bullous myringitis
What would you need to do if you see bullous myringitis?
Send them to a otolaryngology for surgical management
Nontender modular swellings covered by normal skin deep in the ear canals suggest what?
Osteomas or exostoses
NON MALIGNANT overgrowths that may obscure the tympanic membrane
What does this picture show?
Acute otitis externa
In _______ ________ _______ the canal is often swollen, narrowed, moist, erythematous or pale, and tender
Acute otitis externa
In ____________ otitis e=sterna the skin of the canal is often thickened red and itchy
Chronic
An unusually prominent short process and a prominent handle that looks more horizontal suggest a ?
Retraced tympanic membrane
If you test the ear drum with pneumatic otoscope the mobility of a serous effusion would be?
A thickened tympanic membrane and decreased
A tuning for does or does not distinguish normal hearing from bilateral sensorineural loss
Does not
In unilateral conductive hearing loss the use of the tuning fork would be heard in the ________ ear
The impaired
In unilateral sensorineural hearing loss using a tuning for which ear is the sound heard?
The good ear
In conductive hearing loss sound from the tuning fork is heard for longer through bone or air?
For as long or longer through bone than air
In sensorineural hearing loss using the tuning fork the sound is heard longer through air or bone?
Air
What would tenderness of the nasal tip or ala suggest?
Infection such as a faruncle
In viral rhinitis the mucosa is what color
Red and swollen
In allergic rhinitis the mucosa is what color?
Pale, blue or red
What are causes of septal perforation?
Trauma, surgery, and intranasal use of cocaine
______ ______ are pale sacklike growths of the inflamed tissue that can obstruct the air passage of sinuses
Nasal polyps
When would you see nasal polyps?
In allergic rhinitis ASA sensitivity Asthma Chronic sinusitis Cystic fibrosis
Local tenderness together with symptoms such as facial pain, pressure or fullness purulent nasal discharge, nasal obstruction, and small disorder esp present for more than 7 days, suggest what?
Bacterial rhinosinusitis involving the frontal or maxillary sinuses
What does this show?
A normal tympanic membrane
What does this picture show
Perforation of the tympanic membrane
What does this picture show?
Tympanosclerosis
What is tympanosclerosis?
Scarring process of the middle ear from otitis media
When severe it can cause conductive hearing loss
What does this picture show?
Serous effusion
What are serous effusions caused by?
Viral infections and flying
What does this picture show?
Otitis media with effusion
What does this picture show and what does it mean?
Bullous Myringitis
If ____________ lasts over 2 weeks, refer for laryngoscopy and consider causes such as reflux; vocal cord nodules; hypothyroidism; head and neck cancers including thyroid masses; and neurologic disorders like Parkinson disease, amyotrophic lateral sclerosis, or myasthenia gravis.5
Hoarseness
What does this picture show?
Torrous palatinus
Benign
What is this and what is it indicative of?
Asymmetric protrusion suggests a lesion of CN XII (tongue points toward the side of the lesion
What does this show?
Angular Cheilitis
Angular cheilitis starts with softening of the skin at the angles of the mouth, followed by fissuring. It may be due to nutritional deficiency or, more commonly, overclosure of the mouth, seen in people with no teeth or with ill-fitting dentures. Saliva wets and macerates the infolded skin, often leading to secondary infection with Candida, as seen here.
What does the show?
Angular Cheilitis
Angular cheilitis starts with softening of the skin at the angles of the mouth, followed by fissuring. It may be due to nutritional deficiency or, more commonly, overclosure of the mouth, seen in people with no teeth or with ill-fitting dentures. Saliva wets and macerates the infolded skin, often leading to secondary infection with Candida, as seen here.
What does the show?
Actinic Cheilitis
Actinic cheilitis is a precancerous condition that results from excessive exposure to sunlight and affects primarily the lower lip. Fair-skinned men who work outdoors are most often affected. The lip loses its normal redness and may become scaly, somewhat thickened, and slightly everted. Solar damage predisposes to squamous cell carcinoma of the lip, so examine these skin lesions carefully.
What does the show?
Herpes
What does the show?
Angioedema
What does this show?
Hereditary Hemorrhagic Telangiectasia (Osler–Weber–Rendu syndrome)
Multiple small red spots on the lips strongly suggest hereditary hemorrhagic telangiectasia, an autosomal dominant endothelial disorder causing vascular fragility and arteriovenous malformations (AVMs). Telangiectasias are also visible on the oral mucosa, nasal septal mucosa, and fingertips. Nosebleeds, gastrointestinal bleeding, and iron deficiency anemia are common. AVMs in the lungs and brain can cause life-threatening hemorrhage and embolic disease
What does this show?
Peutz–Jeghers Syndrome
Look for prominent small brown pigmented spots in the dermal layer of the lips, buccal mucosa, and perioral area. These spots may also appear on the hands and feet. In this autosomal dominant syndrome, these characteristic skin changes accompany numerous intestinal polyps. The risk of gastrointestinal and other cancers ranges from 40–90%. Note that these spots rarely appear around the nose and mouth
What does this show?
Chancre of Primary Syphilis
This ulcerated papule with an indurated edge usually appears after 3–6 wks of incubating infection from the spirochete Treponema pallidum. These lesions may resemble a carcinoma or crusted cold sore. Similar primary lesions are common in the pharynx, anus, and vagina but may escape detection since they are painless, nonsuppurative, and usually heal spontaneously in 3–6 wks. Wear gloves during palpation since these chancres are infectious.
What does the show?
Carcinoma of the Lip
Like actinic cheilitis, squamous cell carcinoma usually affects the lower lip. It may appear as a scaly plaque, as an ulcer with or without a crust, or as a nodular lesion, as illustrated here. Fair skin and prolonged exposure to the sun are common risk factors.
What is this show?
Normal large tonsils
What does this show?
Exudative Tonsillitis
This red throat has thick white exudates on the tonsils. This, together with fever and enlarged cervical nodes, increases the probability of group A streptococcal infection or infectious mononucleosis. Anterior cervical lymph nodes are usually enlarged in the former, posterior nodes in the latter.
What does this show?
Pharyngitis
This photo shows a reddened throat without exudate. Redness and vascularity of the pillars and uvula are mild to moderate.
What does this show?
Diphtheria
Diphtheria, an acute infection caused by Corynebacterium diphtheriae, is now rare but still important. Prompt diagnosis may lead to life-saving treatment. The throat is dull red, and a gray exudate (pseudomembrane) is present on the uvula, pharynx, and tongue. The airway may become obstructed. Prompt diagnosis may lead to life-saving treatment.
What does this show?
Thrush on the Palate (Candidiasis)
Thrush is a yeast infection from Candida species. Shown here on the palate, it may appear as cream-colored or bluish white pseudomembranous patches on the tongue, mouth, or pharynx (see p. 968). Thick, white plaques are somewhat adherent to the underlying mucosa. Predisposing factors include prolonged treatment with antibiotics or corticosteroids and immunocompromised status.
What does this show?
Kaposi Sarcoma in AIDS
The deep purple color of these lesions suggests Kaposi sarcoma (KS), a low-grade vascular tumor associated with human herpesvirus 8 (HHV-8). These nontender lesions may be raised or flat. About a third of patients with KS have lesions in the oral cavity; other affected sites are the gastrointestinal tract and the lungs
What does this show?
Fordyce Spots (Fordyce Granules)
Fordyce spots are normal sebaceous glands that appear as small yellowish spots in the buccal mucosa or on the lips. Here they are seen best anterior to the tongue and lower jaw. These spots are usually not numerous.
What does the show?
Koplik Spots
Koplik spots are an early sign of measles (rubeola). Search for small white specks that resemble grains of salt on a red background. They usually appear on the buccal mucosa near the first and second molars. In this photo, look also in the upper third of the mucosa. The rash of measles appears within a day.
What does this show?
Petechiae
Petechiae are small red spots caused by blood that escapes from capillaries into the tissues. Petechiae in the buccal mucosa, as shown, are often caused by accidentally biting the cheek. Oral petechiae may be due to infection or decreased platelets, and trauma.
What does this show?
Leukoplakia
A thickened white patch (leukoplakia) may occur anywhere in the oral mucosa. The extensive example shown on this buccal mucosa resulted from frequent chewing of tobacco, a local irritant. This benign reactive process of the squamous epithelium may lead to cancer and should be biopsied. Another risk factor is human papillomavirus infection.
What does this show?
Black Hairy Tongue.
Note the “hairy” yellowish to brown and black hypertrophied and elongated papillae on the tongue’s dorsum. This benign condition is associated with Candida and bacterial overgrowth, antibiotic therapy, and poor dental hygiene. It also may occur spontaneously.
What does this show?
Mucous Patch of Syphilis.
This painless lesion of secondary syphilis is highly infectious. It is slightly raised, oval, and covered by a grayish membrane. It may be multiple and occur elsewhere in the mouth.
What intercostal space for a needle decompression of a tension pneumothorax
2nd
Between what intercostal space is a chest tube placed?
4th and 5th
When looking at an X-ray when would you see the correct placement of an ET tube?
Level of the 4th rib
Aspiration pneumonia is more common in which lung and which lobes?
Right middle and lower lobes
Why is aspiration pneumonia more common in the right lung?
Because the bronchus is more vertical. This is why when advancing an advanced airway it goes too far into the right lung.
What are some causes of pleural effusions?
Heart failure cirrhosis and nephrotic syndrome
What are causes of pleural exudates?
Pneumonia Pulmonary embolism TB Pancreatitis Malignancy
Irritation of the parietal pluura produces pleuritic pain upon what?
Taking a deep inspiration in viral pleurisy, pneumonia, PE, pericarditis, and collagen vascular disease
What are key components to diagnosis of COPD?
Degree of dyspnea combined spirometer
___________ occurs in partial lower airway obstruction from secretions and tissue inflammation in asthma or from a foreign body.
Wheezing
Cough can signal which side heart failure?
Left
What are causes of cough and hemoptysis?
Bronchitis, malignancy, cystic fibrosis,and less commonly to bronchiactesis
Blood that originates in the stomach is usually __________ than blood from the respiratory tract and may be mixed with food particles
Darker
If a patient presents with a clenched fist over their chest think?
Angina pectoris
If a patient points to the pain on the chest think?
Musculoskeletal pain
When a patient presents with a hand moving from the neck to the epigastric region it suggest?
Heartburn
unilateral decrease or delay in chest expansion occurs in _________ fibrosis of the underlying lung or pleura, pleural effusion, lobar pneumonia, plural pain with associated splinting, unilateral bronchial obstruction and paralysis of the hemidiaphragm.
Chronic
What is tactile fremitus?
refers to the vibration of the chest wall that results from sound vibrations created by speech or other vocal sounds
Tactile fremitus is _________ or _________ when the voice is higher pitched or soft or when the transmission of vibrations from the larynx to the surface of the chest is impeded by a thick chest wall, an obstructed bronchus, COPD, pleural effusion, fibrosis, air (pneumothorax) or an infiltrating tumor.
Decreased or absent
What does asymmetric fremitus suggest?
The likelihood of unilateral pleural effusions, pneumothorax, neoplasm
What would increase unilateral tactile fremitus?
Unilateral pneumonia which increases transmission through consolidated tissue
__________ replaces resonance when fluid or solid tissue replaces air containing lung or occupies the pleural space beneath percussing fingers.
Dullness
If you have a unilateral hyperressonance sound in lungs what would you suspect?
Large pneumothorax or air filled bulla
When would you hear crackles?
Abnormalities of the lung parenchyma (pneumonia, interstitial lung disease, pulmonary fibrosis, atelactasis, heart failure
Or in the airways such as bronchitis or bronchiectasis
When are wheezes heard?
Arise due to narrowed airways in COPD and asthma
Bronchitis
Rhonchi is used to decried sounds from __________ in large airways that may change with coughing
Secretions
Fine latte inspiration crackles that persist from breath to breath suggest?
Abnormal lung tissue
Where are the crackles of heart failure are usually best heard where?
In the posterior inferior lung fields
Clearing of crackles, wheezing or rhonchi after coughing or position change suggest?
Inspissated secretions (thickened) seen in bronchitis and atelectasis
What is a clinical emergency seen in asthma or COPD?
Silent chest
Where would you hear stridor and laryngeal sounds the loudest?
Neck
True wheezes or rhonchi are _________ over the neck
Faint or absent
Where would you hear pleural friction rubs?
Pleurisy
Pneumonia
Pulmonary embolism
Increased or decreased
Transmitted voice sounds suggest that embedded airways are blocked by inflammation or secretions
Increased
If the “ee” sound more like a “A” and has a nasal bleating quality this would be indicative of?
Egophony
If the patient says 99 and it is muffled and in distinct it is normal, if they are louder this is called
Bronchophony
What conditions would you see localized bronchophony and egophony?
In lobar consilidation from pneumonia.
When the patient whispers 99 this is normally heard faintly or not at all. If it is heard loudly this would be called
Whispered pectoriloquy
When checking the right middle lobe using percussion what must you first do to minimize the risk of missing the dullness?
Move the breast
Rarely in ____________ the PMI is located on the right side of the chest
Dextrocardia
A PMI greater than _____ cm is evidence of the left ventricular hypertrophy
2.5 cm
When would you see left ventricular hypertrophy
In HTN or dilated cardiomyopathy
Where would the PMI possibly be found in someone with COPD
Xiphoid or epigastric region
