MT 1 Flashcards
Vital Signs
Temperature, pulse, respiratory rate, Blood pressure
Normal core temperature
97-99.5 (would have to swallow a pill to measure)
Oral and tympanic temperature
1 degree lower than core. Quicker to respond to changes
Rectal
About equal to core. Slower to répond to changes
Highest temperature in the day
4 pm
Lowest temperature in the ay
4 am
When is temperature elevated
infections, cancer (leukemia lymphoma), immunological diz (SLE, Sarcoid), hyperthyroidism.
When is temperature decreased
Exposure, hypothyroidism, addison disease, DM, liver and kidney failure
How long should a patient not have eaten or consumed a beverage before oral temperature
30 minutes
How to get temperature with TA when perspiration
while still holding button touch the soft depression behind the ear.
Normal pulse
60-100
When is pulse increased
infections, anxiety, fever, heart or respiratory failure
What is the most commonly assessed artery
radial.
How long must you could pulse for
30 sec
Will the rate always be the same on both sides?
YES
Will the intensity always be the same on both sides?
NO! Intensity may be different with blockage
Rating amplitude of pulse
4+ Bounding 3+ increased (anxiety, athersclorosis, hyperthyroid) 2+ normal 1+ diminished, barely palpable 0: Absent
Respiratory rate in adults
12-18 cpm
Respiratory rate in children
May be up to 20 cpm
Respiratory rate in newborn
May be up to 44 cpm
Bradypnea
Less than 10 cpm
Tachypnea
Greater than 20 cpm
When is respiratory rate increased
infections, anxiety, fever, heart or respiratory failure
What does deep, rapid breathing cause?
hypercapnea
What happens if a BP cuff is too tight?
False high reading
Where should you place the BP cuff?
So the arrow is at the bradial a.
What does the disappearance of the pulse indicate?
systolic BP. Raise cuff 20-30 more
What should not be consumed before BP measurement?
caffeine
What is the rate the BP cuff should be decreased
2-3 mmhg per sec
Disapearance of first beat
systolic
disappearance of second beat
diastolic
How long to wait between readings?
1 minute
Why do you have to wait?
venous congestion can cause low systolic and high diastolic
How to record bp?
Systolic/diastolic in mmhg. Arm position and time
Systolic less than 120
normal. Recheck in 2 years
Diastolic less than 80
Normal. Recheck in 2 years
Systolic 120-139.
Prehypertension. Recheck in 1 year. Talk about lifestyle modifications.
diastolic 80-89
Prehypertension. Recheck in 1 year. Talk about lifestyle modifications.
Systolic 140-159
Hypertension stage 1 (based on average of two or more seated readings taken at two or more visits after an initial screening). Confirm within 2 months
Diastolic 90-99
Hypertension stage 1 (based on average of two or more seated readings taken at two or more visits after an initial screening). Confirm within 2 months
Systolic greater than 160 classifications
Hypertension stage 2 (based on an average of two or more seated readings taken at two or more visits after an initial screening).
Diastolic greater than 100 classifications
Hypertension stage 2 (based on average two or more seated readings taken at two or more visits after an initial screening).
Systolic 160-179 follow up
Refer to PCP within 1 month
diastolic 100-109
Refer to PCP within 1 month
systolic 180-219
Refer to PCP within 1 week
Diastolic 110-119
refer to PCP within 1 week
Systolic greater than 220
Refer within 24-48 hours if target organ damage absent. Refer within a few hours if target organ damage present
Diastolic greater than 120
Refer within 24-48 hours if target organ damage absent. If present refer within a few hours.
Where is there no lymphatics
CNS, internal ear, bone and cartilage
Function of lymphatics
Drainage of tissue fluid (allows entry of plasma proteins and cellular debris), absorption and transport of fat from GI, Defense mechanism
Where does the lymphatic system drain
Venous system
Lymph nodes
Located along course of lymphatics. B and T cells reside in the nodes. Foreign proteins are phagocytized. Screen off infections from the rest of the body.
Lymphadenopathy
enlarged by hyperplasia, leukocytic infiltration, and edema. Can be tender to palpation
Suggested lymph order
OPPSDATSS.
Occipital
Drains posterior scalp
Posterior aurical
Drains scalp, auricular, external auditory meatus
Posterior Cervical
Drains scalp, nasopharynx, skin of neck, occipital and posterior auricle nodes
Superficial Cervical
Drains cervicle, cheek, neck
Deep cervical
Drains most of head and neck lymph draining.
Anterior Auricular
Drains upper and medial 2/3 of lower lids, auricle, external auditory meatus
Tonsilar
Drains tonsils and tongue
Submandibular
Drains upper lid and cheeks, lateral 1/3 of lower lids, tongue, floor of mouth, soft palate, anterior nasal cavity, sinuses
Submental
Tip go tongue, floor of mouth, lower lip, skin of chin
What size lymph nodes are considered abnormal
Greater than 1 cm
______ nodes are typically soft
inflammed
What do tender nodes suggest
inflammation
Nodes from lymphoma are
firm and rubbery
Mestatic nodes feel ______
hard
______ and _____ nodes that increase in size over time are consistent with malignancy
Fixed, matted
Thyroid gland
Largest endocrine gland in the body. Butterfly shaped and envelops the upper trachea.
What does thyroid hormone do
promotes growth and maturation, carbohydrate metabolism, increases HR and cardiac outputs, involved with thermoregulations
You must make sure you are _____ to the SCM to feel the thyroid
medial
How to evaluate the thyroid gland
Have patient turn head to relax SCM, displace the larynx with thumb, palpate the thyroid with fingers of the fellow hand.
Normal thyroid feel
May not be felt
Goiter
spongy or soft. May hear a bruit
Cancer or scarring with thryoid
Hard
infections or hemorrhage with thryoid
tender
Additional tests if thyroid abnormal
Pulse rate, temperature, fine peripheral tumor, abnormal deep tendon reflex, weight change, exophthalmometry.
Indications for examination of throat or nose
epiphora, dry eye, ansomia (lack of smell), HA, diplopia, proptosis, pain behind or around eyes, occipital area, bitemporal area, conjunctivitis, immunological conditions (pemphigus, SLE, sjorgrens), infectious disorders (HIV, HSV, syphilis)
Turbinates
Filters air, increase area that humidifies air
Where is the opening of the lacrimal duct
below the inferior turbinate
Where does sinus drain
below the middle turbinate
Inspections of external structures of nose
Check for swelling, trauma, congenital abnormalities. Check for symmetry of nares. Check for patency of nares
What to evaluate on nose
Look at nasal septum (alignment, perforation, bleeding), nasal mucosa (color, swelling, discharge, masses, or trauma), inferior and middle turbinate (size, color, and presence of masses)
Examination of mouth
Look for normal color, symmetry, abnormal growths, or lesions
Inspecting the pharynx
Depress middle third of tongue while patient breaths and says ah, evaluate color, symmetry, growths. Evaluate for tonsil enlargement, inflammation, debris, or membranes.
Auricle (pinna)
The external ear
External auditory canal
Canal to TM. S shaped. About 2.5 cm long. Pull on helix to straighten. Outer 1/3 is cartilage and inner becomes bone and has sebaceous and ceruminous cells and hair.
Middle ear
Air filled cavity in temporal bone lined with living cells. TM is the external border. Contains the ossicles (males, incus, stapes). Closed system except connection to nasopharynx by eustachian tube.
How to pull ears in an adult
Back up out
How to pull ears in child
back down out
Inner ear
Cavity with vestibule, semicircle canals, and cochlear. Cochlea transmits sounds to CN VIII. Semiscircular canals involved with vestibular function
Conduction hearing loss
Airwaves cannot be transmitted in. Commonly caused by cerium impaction. Also occurs with perforation of TM, infection, or scaring
Sensorineural hearing loss
Often a result of trauma from noise insult or temporal bone injury. Also possible with tumor, metabolic disorders (thyroid and DM), medications (aspirin)
Otalgia
Ear pain. Most often from acute otis media. May also develop from referred pain from teeth, TMJ, pharynx, cervical pain, inflammation, etc.
Otorrhea
Discharge from the ear. Often from infections but blood marks trauma
Tinnitus
Ringing in the ears. Can occur due to inner ear disease such as Menier’es disease (also nystagmus), noise trauma, drugs (ASA, systemic amino glycosides)
Menier’s disease
Tinnitus and nystagmus
External examination of the ears
Look for deformation, nodules, lesions, signs of inflammation. Palpate for tenderness.
Otoscopy of TM
Pearly gray appearance, light reflex in antero-inferior of TM (base at the chin), flat to concave with no bulging of the membrane.
Menubrium
Long arm of malleus
Pars plicata
Loose
Pars tensa
tight
Umbo
end of manubrium
Fibrous annulus
where canal connects to TM
Otis Externa
Swimmers ear. Itching in ear canal. Pain with tugging on pinna. Watery to pus discharge. Hearing loss possible with swelling.
Acute Otis Media
Typically associated with infections. May have concurrent conjunctivitis. Often presents with fever. Deep seated earache. Conductive hearing loss. Buldging TM.
Otis Media with Effusion
More common in adults with viral URI. Often asymptomatic but hearing loss common. Cracking sound when swallowing. Conductive hearing loss. Decongestants may be useful. Viral so no AB.
Wax appearance
Golden–>darker
Caloric Reflex Test (COWS testing)
Not typically done. Put cold in one ear and warm in another and if working will get nystagmus. Vomiting is common.
Romberg test
Visual system, proprioceptive, and vestibular system of inner ear contribute to our ability to remain still and upright. Have patient stand for 30s. Negative romberg indicates the patient can stand for 30s.
What result is normal for a romberg?
Negative
Frontal lobe Evaluation
Appearance, Attention, Attitude, Behavior, Thought process
Judgement
Ask patient what they would do with a postcard
Orientation
Ask their name, where they are, and what time it is.
Memory
Short term. Ask pt. to remember 3 things. have them repeat them back. 5 minutes later ask them again
Affect
Judge person’s emotional state based on interview
Concentration
Ask patient to count backward from 100 by 7 or 3 or spell the word world backwards
Evaluation of motor function
Look at symmetry
Muscle Strength
have the pt. push against you
Muscle Tone
Slight residual tone in relaxed muscle. Ask patient to relx and you move the limb.
Muscle spasticity
Increased tone resulting in resistance to stretching
Muscle flaccidity
decreased tone (limpness)
Sensory Function of pain, crude, temperature
Look at pain, crude, temperature. Look at ulnar, radial, median, lateral and medial plantar, and calcaneal
Sensory Function transmit of pain, curde, temperature.
Fibers enter the spinal cord, synapse with secondary sensory neurons which then cross to the opposite side and travel up the lateral spinothalamic tract to the thalamus.
If patient had a lesion on the right lateral spinothalamic tract at T-10 which foot would have loss of sensation?
Left foot
Vibration Sense
One of the first things lost in diabetic neuropathy
Where to test proprioception
Big and little toe and index and little finger
Vibration sense, proprioception, fine touch sensory function transmission
Fibers enter the spinal cord, synapse with secondary sensory neurons, stay on the same side, travel up the posterior columns and cross at the medulla to the thalamus
If patient had a posterior column lesion on the right side at T-10 which foot would you expect to have loss of vibration sense
Right foot
What would you expect if a patient had peripheral neuropathy from DM
Bilateral loss.
Deep Tendon Reflex
Check sensory motor pathway in spinal cord. Muscles must be relaxed.
Biceps deep tendon reflex
C5, C6
Triceps deep tendon reflex
C6, C7
Patellar reflex
L2, L3, L4
Achilles reflex
S1.
Jendrassike Maneuvar
Can use to help with reflexes.
Grading reflexes
0-non 1:sluggish 2: active or expected response 3: more brisk than expected, slightly hyperactive 4: Brisk, hyperactive, with intermittent or transient clonus.
What causes Decreased reflexes
Lower motor lesions (in the two neuron reflex arc).
Causes for decreased reflexes
Peripheral neuropathy (DM, alcoholism), nerve trauma, hypothyroidism, adies syndrome
What causes increased reflexes
upper motor lesions (above spinal reflex arc)
Causes for increased reflexes
brain and spinal cord injury, stroke, hyperthyroidism, MS
Glabellar Reflex
Ask patient to attempt not to blink while gently tap centrally between eyebrows. May be loss in dementia
Myerson Sign
When a patient with parkinson cannot stop blinking with glabellar
Normal recording for glabellar reflex
negative
Cerebellum
Aids motor cortex in integration of voluntary movement. Processes sensory information from eyes, ears, touch, musculoskeleton. Integrates information from vestibular system to help control posture, balance, gain, and muscle tone.
Coordination of Cerebellum Accuracy
Have patient perform quickly. Finger to nose with eyes closed each side or have patient hit your finger
Coordination of Cerebellum Rapid
Palm flips
Cerebellum walking functions
Walk heel to toe. Exaggerate findings
cerebellar gait
like drunk
sensory ataxia
Loss in DM or MS. Wide based, patient watches ground, slaps feet down
parkinson gait
Short, shuffling, hesitation on start and difficulty of stopping
why to do a neurological exam
increased ability to dx correct dx, increased ability to refer, cost containment
Indications for screening CN
HA, change in or loss of consciousness, dizziness, ataxia, VF loss, unexplained VA loss, dysphasia, TIA, change in personality, decreased cognition, weakness or numbness, pain, tremor, gait disorders, unexplained diplopia, nerve or muscle palsies, uveitis, DM
Cranial Nerves
n. that branch from brain or brainstem
CN I
Olfactory. Have patient close eyes. Occlude one nose and have ID smell.
Causes for poor CN I function
rhinitis due to allergy, common cold, trauma to nose, trauma to frontal lobe, frontal lobe lesions, may be early signs of alzehimers
CN V (motor portion)
Have patient clench jaw. Try to pull down. palpate muscle for even tone.
CN V sensory
Opthlamic, Maxillary, Mandibular
Opthalmic of CN V
upper lids, forhead, cornea, top of nose.
Maxillary of CN V
lateral surface of nose, cheek area, lower lids
Mandibular of CN V
Lower jaw, side of face
Sensory evaluation of CN V
Touch, pain, crude.
Cause of poor sensory function of CN V
HS, HZ, cavernous sinus lesion. Will have decreased sensation and strength on the side.
VII Motor
Facial N. Have patient do what you do. Wrinkle, smile, frown, raise brows, purse lips. Test orbicularis by trying to hold shut.
Do we test sensory function of facial n.
NO
Poor CN VII
Paralysis and decreased muscle strength on the affected side. Common cause bell’s palsy and acoustic neuroma
VIII
Controls hearing and equilibrium. Equilibrium tested by caloric test. Can use finger or running fork to compare hearing ability on each side.
Weber Test
Tests by hearing by bond conduction. Place the base of the fork on top of the skull. Ask patient to vocalize the sound. Conduction loss: heard better on side with conduction loss Neurological loss: heard better on good side
Rinne Test
Bone conduction should be equal. Air conduction should be better than bone conduction. Should be equal in the air. If bone conduction is not equal, nerve damage on shorter side.
If air conduction > bone
Something blocking the sound waves. Cerumen, perforation in TM, fluid behind TM
IX: glossopharyngeal and X: Vagus Sensory
Sensory and motor for both. Check gag reflex by touching posterior 3 of tongue, soft palate or posterior pharyngeal wall with a cotton swab.
What to ask about with IX and X
Difficulty swallowing and change in voice.
IX and X Motor
Use tongue blade and say ah. Look at elevation of soft palate. Expect symmetry. Uvula deviates toward normal side!
What could cause lack of symmetry with uvula?
Deviates to normal side. Space occupying lesions, vertebral artery aneurysms
XI
Accessory. Motor to SCM and trapezius. have patient turn upright head each direction against your hand. Have patient raise shoulders
XII
hypoglosal. Motor to tongue. Ask pt to stick tongue out. Deviates to affected side. Also have pt. push tongue against your hand. Decreased strength on affected side.
Diastole
No pulse. Ventricles relax and begin to fill. Atria contract complete filling
Systole
Ventricles contract.
S1
occurs during systole. M and T valves close. Ejects blood into aorta and pulmonary artery. Associated with pulse
S2
Low ventricular pressure allows A and P valves to close. Dub.
Signs for cardiac exam
chest pain from ischemia, irregular rhythm or rate, SOB, orthopnea, fatigue, edema, nocturia.
Heart Auscultation
Listen over valvular areas of heart. Listen to aortic and mitral (left side of heart). Have pt. lean forward to hear better
Aortic Asuclation
Outflow sound. 2nd intercostal side adjacent to sternum on the right side. 4 finger down from color bone and close to breast bone.
Mitral Asuclation
5th intercostal space. 4 finger up from breast bone and five fingers over from breast bone. Not on rib.
S3
Early diastole. Lub-dupa
S4
Lat diastolic. ta-lup-dup. Always pathological
S2 splitting
May be heart on deep inspiration of young patients
Stenoses
Passage through leaflets is narrowed. Murmurs heard as blood rushes through the open valve. Aortic/pulmonic: systolic murmur. Mitral/Tricupsid: diastolic murmur.
Regurgitation
Incomplete valve closure causes blood to fall backward. Mitral/Tricuspid: systolic murmur. Aortic/pulmonic: diastolic
Most common cause of vascular disease
Atherosclerosis
Symptoms of vascular disease
TIA (cerebrovascular dz), Angina pectoris (chest pain), Calf pain and weakness with walking, paresthesias, pallor (peripheral valve disease)
5 P sign of vascular disease
Pain, Pallor, paresthsia), paralysis , pulseslessness.
Auscultation of carotids
Listen for bruits in three spots on carotid. High on the neck. Hold breath
When do you hear bruit on carotid due to stenosis
Heard from 50-90
What may you hear with auscultation of carotid with young and thin
nothing or heart beat
Palpation of carotid
One at a time after asuclation. Low.
Dorsalis Pedis
Slightly lateral to highest cuneiform born. Dorsiflexion increases ease.
Posterior tibial pulses
Posterior and slightly superior to medial malleous. Plantar flexion increases ease.
Beta Blockers
Can cause bronchospasm. 8-13% decrease in lung function with topical timolol. Can be fatal in first 24 hours.
ASA and Asprin
Can cause asthma attack
Antihistamine
Can cause change in pulmonary secretions
Narcotics
Decrease respiratory rate
Asking about pulmonary dz
Coughing, SOB, Chest pain (more normally heart dz), use of oxygen, any lung problems (TB, Asthma, Allergies), Smoker, environment, exercise tolerance
Observation of patient
See if breathing labored. Look if sit upright or tripod (emphysema). pursing lips, appearance of upper body.
If just nail beads blue
heart problem
If nail and lips blue
both lungs and heart
Breathing with auscultation of lungs
have patient breath deep through mouth
lower lung spot on posterior
pt finds bottom of breast and traces back
middle lung spot on posterior
feel L of scapula and put in there. Have pt hung
Top lung spot on posterior
Draw line from shoulders and lower
Lower anterior lung spot
Breast and over
Side anterior lung spot
Slide over from breast and below arm
Middle anterior lung spot
Hand width up from breast and half over
Top anterior lung spot
4 down color bone and midline
Normal breath sounds on back
Bronchovesicular over main bronchi, vesicular. Heard with inspiration
Rhonchi
Dry, low snore like. Due to partial obstruction. Often be secretions. Heard more on expiration. Can be cleared by cough
Wheeze
Musical squeak or whistling. Due to air being forced. Heard on inspiration but louder on expiration
Rub
Rubbing sound which can sound mechanical. Inflammation causes rubbing go pleural sac against chest wall. Inspiration and/or expiration
Crackles (rales)
Bubbly, cracking noise, often discrete rather than continuous. Fine (high pitched) or course not cleared by cough. From filled spaces as can occur with pulmonary edema, CHF, pneumonia. Inspiration more common.
Forced Expiratory Flow rate
NOT lung volume but force. Must stand. Record highest from 3.
High FER
> expected
Normal
80-expected
Low
When is FER reduced
Smoking, bronchitis, COPD, emphysema, asthma
When to caution BB
When less than 80
when no BB
when less than 50
Standard precautions
Assume all patients have BB pathogens. Protect from all fluids except sweat. No mucous membranes and non-intact skins.
Personal hygeine
no dry or cracking skin
Sharps
needles, scaples, lancets, glass lids, tubes. Dispose whtn 3/4 full
Biohazard
gloves, depressors, bandages, plastic thermometer covers, dispose of when 3/4 full
When to do in office glaucometry
DM patient that don’t know HBA1c or last measurement. Any patient with any symptoms suggesting Dm.
Systemic Symptoms of DM
increased thirst, increased urine, recent weight change
Visual symptoms of DM
change in RE, retinal vascular changes, transient blurring
Should you ever use the sampler
NO
When to test with control solution
New strips, once a week, weird readings, drop glaucometer.
Squeezing finger
Not to hard so you don’t get interstitial fluid
What can lower blood sugar values
Dehydration
What to do when get values suggesting DM
Send for plasma glucose
When to refer
greater than 140
plasma fasting glucose
126
