Module 2 Flashcards
Physical exam for integumentary
Inspect & palpate. Lift a fold of skin to check mobility (how easy it lifts) & turgor (how quickly it returns into place).
Skin: Note color: increased pigment, redness, pallor cyanosis,jaundice. Note moisture, temp, texture, mobility & turgor.
Hair: quantity, distribution, and texture
Nails: color, shape, lesions, clubbing
Integumentary health history
Have you noticed changes in skin, hair, nails?
Any rashes, sores, lumps, itching?
Any moles or growths that have changed in size, color or shape?
Causes of change in skin temperature
Fever, hyperthyroidism- warmth, hypothyroidism- cool, localized warmth with inflammation or cellulitis
Causes of change in skin texture
Hypothyroidism- roughness
Hyperthyroidism- velvety texture
Causes of change in skin mobility and turgor
Decreased mobility in edema & scleroderma
Decreased turgor in dehydration
Expect changes in older adults.
Edema grading scale
1+: slight indentation (2mm); normal contours; interstitial fluid volume 30% above normal
2+: deeper pit (4mm); pitting lasts longer; fairly normal contour
3+: deep pit (6mm); remains several seconds; obvious by general inspection
4+: deep pit (8mm); prolonged pitting; frank swelling
Brawny: no pitting; excessive accumulation; skin shiny; fluid cannot be displaced
Melanoma ABCD’s
Assymetry of shape - halves appear different
Border irregularity- such as scalloped contour
Color variation- tan,brown,black,red,white,blue
Diameter (larger than 6mm) pencil eraser size
Primary skin lesions
Initial presentation
Macule
Primary lesion
Small flat spot up to 1.0 cm
Ex. Hemangioma, vitiligo
Patch
Primary lesion
Flat spot 1.0cm or larger
Ex. Cafe au lait spot
Plaque
Primary lesion
Elevated lesion 1.0cm or larger, often formed by coalescence of papules
Ex. Psoriasis
Papule
Primary lesion
Elevated lesion up to 1.0cm
Ex. Psoriasis
Nodule
Primary lesion
Knot-like, larger than 0.5cm; deeper & firmer than papule
Ex. Dermatofibroma
Cyst
Primary lesion
Nodule filled with expressible material (liquid or semisolid)
Ex. Epidermal inclusion cyst
Wheal
Primary lesion
Somewhat irregular, transient, superficial area of localized skin edema
Ex. Urticaria
Vesicles
Primary lesion
Up to 1.0cm; filled with serous fluid
Ex. Herpes simplex, herpes zoster
Bulla
Primary lesion
1.0 cm or larger; filled with serous fluid
Ex. Insect bite
Pustule
Primary lesion
Filled with pus
Ex. Acne, smallpox
Burrow
Primary lesion
Minute slightly raised tunnel; commonly found in finger webs & sides of fingers
Ex. Scabies
Scale
Secondary lesion
Thin flake of dead exfoliated epidermis
Ex. Icthyosis vulgarisms, dry skin
Crust
Secondary lesion
Dried residue of skin exudates (sperm,pus,blood)
Ex. Impetigo
Lichenification
Secondary lesion
Visible & palpable thickening of epidermis and roughening of the skin; increased visibility of normal furrows
Ex. Neurodermatitis
Scars
Secondary lesion
Increased connective tissue
Ex. Hypertrophic scar
Keloid
Secondary lesion
Hypertrophic scarring that extends beyond the borders of the initiating injury
Erosion
Secondary lesion
Nonscarring loss of superficial epidermis; moist surface but no bleeding
Ex. Aphthous stomatitis
Excoriation
Secondary lesion
Linear or punctuate erosions
Ex. Cat scratches
Fissure
Secondary lesion
A linear crack in the skin often caused by excessive dryness
Ex. Athletes foot
Ulcer
Secondary lesion
A deeper loss of epidermis and dermis; May bleed and scar
Ex. Stasis ulcer of venous insufficiency, syphilitic chancre
Stage one pressure ulcer
Presence of reddened area that fails to Blanche with pressure and changes in temp
Stage two pressure ulcer
Skin forms of blister or sore
partial thickness skin loss
Involves epidermis, dermis or both
Stage III pressure ulcer
A crater appears in skin with full thickness skin loss
Damage to or necrosis of subcutaneous tissue that may extend to, but not through underlying muscle
Stage four pressure ulcer
Deepening ulcer
full thickness skin loss
destruction, tissue necrosis or damage to underlying muscle, bone and sometimes tendons and joints
Alopecia
Clearly demarcated round or oval patches of hair loss
affecting young adults and children
no visible scaling or inflammation
Trichotillomania
Hair loss from pulling, plucking or twisting hair
hair shafts are broken and of varying lengths
more common in children; Often stress-induced
Tines capitis
Round scaling patches of alopecia
Hair broken off close to surface of scalp
Usually caused by a fungal infection
Mimics seborrheic dermatitis
Clubbing Of the nails
Bulbous swelling of soft tissue at nail base
Angle increases to 180° or more & Nailbed feels spongy or floating
Seen in congenital heart disease, interstitial lung disease and lung cancer, inflammatory bowel disease and malignancies
Head and neck health history
Any headaches, changing vision, hearing loss, vertigo, nosebleed, sore throat, hoarseness, swollen glands, goiter
Ex. How is your vision? how is your hearing?
Exam of head
Hair: Note quantity, distribution, texture and any pattern of loss
Scalp: Part hair in several places look for scaliness, lumps, nevi or other lesions
Skull: Notes size and contour; note any deformities, depressions, lumps or tenderness
Face: Facial expression and contours; observe for asymmetry, involuntary movements, edema and masses
Eye exam
Visual acuity Visual fields Conjunctiva and sclera Cornea, lens, pupils Extra ocular movements Fundi, including optic disc and cup, retina, retinal vessels
Ear exam
Pull ear up and back in adult to insert otoscope
Pull pinna down and back in child under three
Whispered voice test to check auditory acuity
Tuning fork test for conductive versus neurosensory hearing loss
Meningial headache
Generalized
Steady or throbbing, very severe
rapid onset; usually less than 24 hours
Associated with fever, stiff neck and change in mental status
Migraine
Unilateral -70%; bifrontal or global-30%
Throbbing or aching, variable severity
Fairly rapid onset, lasts 4-72hrs
Associated with nausea, vomiting, photophobia, phonophobia,aura
Tension headache
Usually bilateral
Steady, pressing or tightening; non throbbing
Mild-moderate with gradual onset lasting 30min - 7 days
Nausea absent
Cluster headache
Unilateral; usually behind or around eye/temple
Deep, continuous, severe
Abrupt onset, peaks within minutes. Lasts up to 3hours
Clustered - several each day for 4-8 weeks
Visual acuity & 20/20 vision
To test visual acuity you place the patient 20 feet from the snellen chart.
Visual acuity is expressed as two numbers, the first indicates the distance of the patient from the chart and the second the distance at which a normal eye can read the line of letters.
Conjunctivitis
1) Pattern of redness is maximal peripherally.
2) Mild discomfort.
3) Vision not affected other than mild blurring due to discharge.
4) Watery, mucoid or mucopurulent discharge.
5) Pupil unaffected and cornea clear.
6) Bacterial, viral infections; highly contagious; allergy or irritation
Subconjunctival hemorrhage
1) Sharply demarcated red area that resolves over two weeks.
2) No pain
3) Vision unaffected.
4) No discharge.
5) Pupil not affected; cornea clear.
6) Often no significance; may result from trauma, bleeding disorders or sudden increasing venous pressure (cough)
Acute iritis
1) Ciliary injection pattern of redness with dilation of deeper vessels that are visible as radiating vessels or reddish violet flush around the limbus.
2) Moderate aching deep pain.
3) Decreased vision with photophobia
4) No discharge.
5) Pupil is small & irregular; Cornea is clear or slightly clouded.
6) Associated with systemic infections such as herpes zoster, tuberculosis; refer promptly
Acute glaucoma
1) Dilation of deeper vessels creating a reddish violet flush around the limbus.
2) Severe aching deep pain
3) No discharge
4) Pupil dilated and fixed;
5) Cornea steamy,cloudy
6) Acute increase in intraocular pressure constitutes an emergency
Weber test
Test for lateralization done by placing the tuning fork firmly on top of the patients head or on the mid forehead.
Rinne test
Compares air conduction and bone conduction.
Place the base of the lightly vibrating tuning fork on the mastoid bone behind the ear and level with the canal.
When the patient can no longer hear the sound quickly place the fork close to the ear canal and ascertain whether the sound can be heard again. (U of fork forward)
Normally sound is heard longer through air than through bone (ac>bc)
Conductive hearing loss
External or middle ear disorder impairs sound conduction to inner ear (foreign body, otitis media, perforated eardrum, otosclerosis)
Onset up age 40
Little effect on sound, hearing improves in noisy environment, voice remain soft because inner ear and cochlear nerves are intact.
Weber test: sound lateralizes to impaired ear
Rinne test: bc>ac
Whispered voice test
Test for auditory acuity
Stand 2 feet behind the seated patient so the patient cannot read your lips, occlude the non-test ear with a finger and gently rub the tragus in a circular motion to prevent transfer of sound to the non-test ear.
Whisper a combination of three numbers and letters using different combinations for each ear.
Is abnormal if four of the six possible numbers (2 attempts) and letters are incorrect; conduct further testing by audiometry.
Sensorineural hearing loss
Inner ear disorder involves cochlear nerve and neuronal impulse transmission to the brain
Onset in middle or later years
Problem not visible
Higher registers are lost, sound may be distorted, hearing worsens a noisy environment, voice maybe loud because hearing is difficult
Weber test: Sound lateralizes to good to ear
Rinne test: ac>bc
Acute Otitis media with purulent effusion
Symptoms: earache fever and hearing loss
Cause: bacterial, usually S pneumoniae or H. influenzae
On exam eardrum is reddened, loses its landmarks and bulges laterally
More common in children than adults
Serous effusion
Usually caused by viral upper respiratory infections (otitis media with serious effusion) or by sudden changes in atmospheric pressure
Symptoms include fullness and popping sensations in the ear, mild conduction hearing loss and sometimes pain.
Amber fluid behind the eardrum is characteristic
Perforated eardrum
Usually caused by purulent infections of the middle ear
maybe classified as central perforations or marginal perforations, which involve the margin
Tympanosclerosis
Large chalky white patch, irregular margins
deposition of hyaline material within the layers of the tympanic membrane, may sometimes follow a severe episode of otitis media
does not impare hearing
Health history for mouth, pharynx, nose, neck and regional lymphatics
Ask about:
Sore throat pharyngitis
bleeding of the gums
local lesions;any tendency to bleed/ bruise environmental allergies
acid reflux
smoking; inhalation of fumes or other irritants swollen glands or lumps in the neck
any evidence of enlarged thyroid gland
ask about temperature intolerance & sweating nasal congestion, stuffiness, nasal discharge
Tooth pain
Exam of the nose
Inspect the anterior and interior surfaces of the nose
press on the tip of the nose with the thumb to widen the nostril and use the penlight or otoscope like to get a partial view of the nasal vesicle
note any asymmetry or deformity; test for nasal obstruction
Exam of the mouth
Observe lip color and moisture, note any lumps, ulcers, cracking, scaliness
Inspect Mucosa for color, ulcers, white patches and nodules
Inspect hard and soft palate, tongue, trachea and teeth
Examination of the neck
Palpate lymph nodes
palpate thyroid gland
Inspect trachea
Thyroid
Located above the suprasternal notch
influences metabolism, growth and development, and body temperature
Hypothyroidism
Symptoms: Fatigue, lethargy, modest weight gain with anorexia, dry coarse skin and cold intolerance, swelling of face hands and legs, constipation, weakness, muscle cramps, arthralgias, parathesias, impaired memory and hearing
On exam: Dry coarse cool skin, sometimes yellowish from carotene, with non-pitting edema and lost a hair
Periorbital puffiness
decreased systolic and increased diastolic blood pressures
bradycardia, and in late stages hypothermia
sometimes decreased intensity of heart sounds
Impaired memory, mixed hearing loss, somnolence, peripheral neuropathy, carpal tunnel syndrome
Hyperthyroidism
Symptoms: Nervousness weight-loss despite increased appetite Excessive sweating & heat intolerance Palpitations Frequent bowel movements Tremor and proximal muscle weakness
On exam:
Warm smooth moist skin
With Graves’ disease, Eye signs such as stare, lid lag and exopthalmos
Increased systolic and decreased diastolic blood pressures
Tachycardia or atrial fibrillation
Hyperdynamic cardiac pulsations with an accentuated s1
Tremor and proximal muscle weakness
Transillumination of the sinuses
Perform in a darkened room; use a narrow light source.
1) Placed the light snugly under each brow close to the nose
2) Shine light downward from just below the inner aspect of each eye
3) look through the open mouth at the hard palate; a reddish glow indicates a normal air filled maxillary sinus
