NSG 500 EXAM 1 Flashcards by Mr. Bobbits

If a patient isn’t giving you the answers you’re looking for, what’s the best way to get it?

Direct questions/qualifier questions

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What are good ways to ask a patient their story?

Open ended questions

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Cultural sensitivity: purpose, reason it is important, how culture may impact aspects of an exam of emotional health.

Looking at others’ lifestyles. Understanding beliefs. Ask questions.

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The steps of assessment, inspection, palpation, percussion, auscultation;

What they are, how to perform; sequence used; how to palpate (what parts of the hands work best for different purposes; fine discrimination, vibration)

What are normal percussion notes, know where they are found

How to use equipment; how to apply a stethoscope, otoscope

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-It is the process of observation. Your eyes and nose are sensitive tools for gathering data. Observe gait and stance and ease of movement.

-Info about neurological and musculoskeletal integrity.

-Patient’s emotional and mental status: make eye contact? Hygiene? Clothes?

-Color, moisture and odor…possible underlying diseases.

-Inspection -unlike palpation, percussion, and auscultation- can continue through the history taking process and physical examination.

Inspection

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-Involves the use of hands and fingers to gather info through the sense of touch.

-The palmar surface of your fingers and finger pads is more sensitive than the fingertips. Use this surface whenever discriminatory touch is needed for determining position, texture, size, consistency, masses, fluid, and crepitus.

-The ulnar surface of the hand and fingers is the most sensitive for distinguishing vibration.

-The dorsal surface of the hands is best for estimating temperature.

-To palpate organs of the abdominal cavity, stand at the patient’s right side with the patient in supine position. Use warm hands and bend the patient’s knees to help relax the abdomen. Lay the palm of your hand lightly in the abdomen, with the fingers extended and held together. With the palmar surface of your fingers, depress the abdominal wall, using a light and even pressing circular motion. Start with light palpation, then moderate, and finally deep palpation.

Short fingernails are a must to perform palpation!

Palpation

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-Involves striking one object against another to produce vibrations and subsequent sound waves.
-Fingers function as a hammer. Sound waves are heard as percussion tones (called resonance).

-The density of the medium through which the sound waves travel determines the degree of percussion tone. The denser the medium, the quieter the percussion tone. The percussion tone over air is loud, over fluid less loud, and over solid areas soft.

-Tympany, hyperresonance, resonance, dullness, flatness. Tympany is the loudest and flatness is the quietest.

-Because it is easier to hear the change from resonance to dullness proceed with percussion from areas of resonance to areas of dullness.

Percussion

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-Immediate (direct) percussion involves striking the finger or hand directly against the body.

-To perform indirect percussion, the finger of one hand acts as a hammer (plexor) and a finger of the other hand acts as a striking surface.

-To perform it, place your non-dominant hand on the surface of the body with the fingers slightly spread. Place the distant phalanx of the middle finger firmly on the body surface with the other fingers slightly elevated off the surface. Snap the wrist of your other hand downward, and with the tip of the middle finger, sharply tap the interphalangeal joint of the finger that is on the body surface.

-Snapping downward from the elbow or shoulder is a common error.

-Percussion must be performed against bare skin.

-If you are not able to hear the percussion tone, try pressing harder against the patient’s skin with your finger that lies on the body surface.

-Tap sharply and rapidly; once the finger has struck, snap the wrist back, quickly lifting the finger to prevent dampening the sound.

-Use the tip and not the pad of the plexor finger.

-Percuss one location several times.

Percussion Technique

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-Involves listening to sounds. Stethoscope.

-The environment should be quiet and free from distracting noises. Place stethoscope against naked skin. Listen for presence and characteristics of sound.

-Auscultation should be carried out last, except with the abdominal examination, after other techniques have provided information that will assist in interpreting what you hear.

Auscultation

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What is the preferred order for examination of the abdomen?

The correct order for abdominal assessment is inspection, auscultation, percussion, palpation. Palpation is the last step in abdominal assessment. Percussion and palpation can alter the frequency and intensity of bowel sounds.

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Equipment: pneumatic otoscope, reflex hammer, ophthalmoscope, Wood’s lamp, what they are for, how they are used, any differences with pediatrics

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-Provides illumination for examining the external auditory canal and the tympanic membrane.

-Select the largest size speculum that will fit comfortably into the patient’s ear canal.

-You can use the otoscope for the nasal examination if a nasal speculum is not available. Use the shortest, widest otoscope speculum and insert it gently into the patient’s naris.

-The pneumatic attachment for the otoscope is used to evaluate the fluctuating capacity of the tympanic membrane. A short piece of rubber tubing is attached to the head of the otoscope. A hand bulb attached to the other end of the tubing, when squeezed, produces puffs of air that cause the tympanic membrane to move.

Otoscope

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-It is used to test deep tendon reflexes.

-Hold the hammer loosely between the thumb and index finger so that the hammer moves in a swift arc and in a controlled direction.

-As you tap the tendon, use a rapid downward snap of the wrist, tap quickly and firmly, and then snap your wrist back so that the hammer does not linger on the tendon. The tap should be brisk and direct.

-You can use either the pointed or flat end of the hammer. The flat end is more comfortable when striking the patient directly; the pointed end is useful in small areas, such as on your finger placed over the patient’s biceps tendon.

-Your finger can also act as a reflex hammer; this can be particularly useful when you are examining young patients. It is less threatening to a child than a hammer.

Percussion (Reflex) hammer

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-It has a system of lenses and mirrors that enable visualization of the interior structures of the eye. It has a light source that projects through various apertures while you focus on the inner eye. The large aperture, the one used most often, produces a large round beam. The various apertures are selected by rotating the selection dial.

-The lenses in varying powers of magnification are used to bring the structure under examination into focus by converging or diverging light. An illuminating lens indicator displays the lens number positioned in the viewing aperture. The system of lenses compensates for myopia or hyperopia in both the examiner and the patient. There is no compensation for astigmatism.

-The panoptic ophthalmoscope head uses an optical design that allows a larger field of view (25 degrees vs the standard 5 degrees) and increases magnification. The view of the fundus is 5X larger than the view achieved with the standard one.

Ophthalmoscope

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-It contains a light with a wavelength of 360nm. This is the black light that causes certain surfaces to fluoresce.

-It is used primarily to determine the presence of fungi on skin lesions.

-To correctly use it, darken the room, turn on the Wood’s lamp, and shine it on the area or lesion you are evaluating. A yellow-green fluorescence indicates the presence of fungi. Purple color on the skin indicates no fungal infection is present.

-Darkening the room can be intimidating to children. Explain the procedure before performing it and allow them to play with the lamp.

Wood’s lamp

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-Inappropriately laughing

-Flat affect

-Disheveled appearance

-Communication may be altered

-Patient may not be alert and oriented to person, time, place, and situation.

Indications of cognitive impairment (history or PE findings)

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Areas of the brain and their function

In the review session, the ONLY example Dr. Hall provided is… the auditory (hearing) center is in the temporal lobe of the brain.

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Main findings in acromegaly, Turner syndrome, Cushing syndrome, precocious puberty

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Main findings in acromegaly, Turner syndrome, Cushing syndrome, precocious puberty

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Main findings in acromegaly, Turner syndrome, Cushing syndrome, precocious puberty

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Main findings in acromegaly, Turner syndrome, Cushing syndrome, precocious puberty

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Main findings in acromegaly, Turner syndrome, Cushing syndrome, precocious puberty

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Precocious Puberty:

Females <7
Males <9

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Precocious Puberty: - Females <7 - Males <9

8. Exam findings indicative of nutritional deficiency, assessment of nutrition and protein status - Vitamin B Deficiency: Fatigue/tired, headache, pale, palpitations, SOB, sores in mouth or in corners of mouth Vitamin E: nerve and muscle function Protein status: check prealbumin and albumin levels

9. Growth and development milestones in children, walk, talk, use sentences. 1st milestone: smiling 12 months: speech 18 months: walking 3 years old: ask why, short phrases

Difference between an objective and subjective finding, know examples

11. Skin lesions: Description of common macule, papule, vesicle, wheal. Know examples, i.e. what is a freckle?

Macule Flat, circumscribed area that is a change in the color of the skin; less than 1 cm in diameter. Freckle, flat nevi, petechiae. Measles skin lesion.

Papule An elevated, firm, circumscribed area; less than 1 cm in diameter. Wart (verruca), lichen planus.

Vesicle Elevated, circumscribed, superficial, not into dermis; filled with serous fluid; less than 1 cm in diameter. Varicella (chickenpox), herpes zoster (shingles).

Wheal Elevated, irregular-shaped area of cutaneous edema; solid, transient, variable diameter. Insect bite, urticaria, allergic reactions.

What are lesions that require further investigation; what do they look like? - Nevi. Most of them are harmless. Some of them can develop into melanoma. - Actinic keratosis. It can progress into squamous cell carcinoma. - Other common abnormalities; staph and strep infections

When to be concerned about spots on skin? If new or recent change in appearance. If bleeds easily. Fixed. Irregular

Actinic keratosis - Atypical squamous cells confined to the upper layers of the epidermis as a result of sun damage. THESE LESIONS CAN PROGRESS INTO SQUAMOUS CELL CARCINOMA OVER TIME.

Nevi: Although most nevi are harmless, some may be atypical and develop into melanoma.

What do herpes, basal cell, malignant melanoma, and seborrheic keratosis look like? Basal Cell Carcinoma: - Most common type of cancer of the skin. Arises from basal layer of epidermis. - Occurs on exposed parts of the body. It rarely metastasizes.

What do herpes, basal cell, malignant melanoma, and seborrheic keratosis look like? Malignant Melanoma: -Lethal form of cancer that develops from melanocytes. -ABCDE.

What do herpes, basal cell, malignant melanoma, and seborrheic keratosis look like? Herpes: -Varicella-zoster viral (VAV) infection. -Single dermatome that consists of red, swollen plaques or vesicles that become filled with purulent fluid. -Does not cross midline.

12. What are common normal skin lesions on an older adult Lesions that may occur on the skin of healthy older adults (expected findings): -Cherry angiomas are tiny, bright ruby-red to dark blue/black, round papules that may become brown with time.

- Seborrheic keratoses are pigmented, raised, warty lesions, usually on the trunk.

- Sebaceous hyperplasia: yellowish, flattened papule with a central depression that is often difficult to discern from a basal cell carcinoma.

- Cutaneous tags (acrochordon): small, soft, skin colored, pedunculated papules of skin, usually appearing on the neck and upper chest.

- Cutaneous horns: small, hard projections of the epidermis, usually occurring on the forehead and face and can be manifestation of an underlying squamous cell carcinoma or a wart.

- Solar lentigines (singular lentigo): irregular, gray-brown macules that occur in sun-exposed areas. AKA, age spots or liver spots.

13. What to expect when palpating lymph nodes - Differentiating infection from malignancy - Normal changes in the older adult - Where lymph nodes are palpable - How to differentiate a lymph node from a cyst - What does a painful enlarged node indicate v. one that is not painful? - When does an enlarged lymph node require further investigation? - KNOW WHERE LYMPH NODES ARE and which ones will be enlarged by infection area

-If a lymph node is palpable, most times it is enlarged. -Enlarged (swollen) lymph node (lymphadenopathy)swell when the immune system is fighting an infection or illness. -A hard, fixed, painless node suggests a malignant process. -The more tender a node, the more likely it is an inflammatory process. Painful lymph better than nonpainful! -Nodes do not pulsate; arteries do. -A palpable supraclavicular node on the left (Virchow node) is a significant clue of thoracic or abdominal malignancy. -Slow nodal enlargement over weeks and months suggests a benign process; rapid enlargement without signs of inflammation suggests malignancy. -With bacterial infection, nodes become warm or tender to the touch, matted, and much less discrete. -It is possible to infer the site of an infection from the pattern of lymph node enlargement. E.g., infections of the ear usually drain to the preauricular, retropharyngeal, and deep cervical nodes. -In childhood diseases of rubella, rubeola, and varicella often present with obvious cervical nodes, usually posterior rather than anterior. Hepatitis A and B and infectious mononucleosis have the same pattern. -In the elderly, changes in the structure of the lymph node include replacement of lymph tissue by fibrous, scar-like tissue and fatty tissue.

How to differentiate between lymph or cyst? Transillumination. As a rule, nodes do not transilluminate. Fluid-filled cysts do!

14. How to palpate the thyroid; what will you expect to feel -Palpation of thyroid requires gentle touch. It can be palpated from the front or from the back of the patient. -Position the patient to relax the sternocleidomastoid muscles, with the neck flexed slightly forward and laterally toward the side being examined. -Ask the patient to swallow water while you are palpating. -Palpation can be done using the frontal or posterior approach. -The thyroid lobes, if felt, should be small, smooth, and free of nodules. -At its broadest is approx. 4 cm. The right lobe is often 25% larger than the left. -The consistency should be firm, but pliable. - Coarse tissue or a gritty sensation suggests an inflammatory process. -If nodules are present, they should be characterized by number, whether they are soft or hard. An enlarged, tender thyroid may indicate thyroiditis. -If the thyroid is enlarged, auscultate for vascular sounds with the bell of the stethoscope. In a hypermetabolic state, the blood supply is dramatically increased, and a vascular bruit (a soft rushing sound) may be heard. -Older adult: thyroid is more fibrotic, harder, not as smooth. Note: The thyroid gland moves with swallowing. Subcutaneous fat that mimics a goiter does not.

History and physical findings suggestive of hypo and hyperthyroidism

16. History findings suggestive of different types of headaches; migraine, tension, cluster

17. How is pain assessed? What is the gold standard? -A patient’s self-assessment is the gold standard. The patient’s report of pain is the most reliable indicator of pain and should be believed. Some of the most used scales in adults: numeric pain intensity scale, descriptive pain intensity scale, and visual analog scale. How to assess pain in child?, when can a pain scale be used? -Some children as young as 3 yo have adequate communication skills to self-report their pain perception. -Assess the child’s ability to use a self-report pain scale by determining whether the child understands concepts of higher-lower and more-less. -Valid and reliable self-rating pain scales for young children include the Wong-Baker Faces Rating Scale and the Oucher Scale. -Older children and adolescents may use these pain scales or those listed for adults. -For non-verbal children, the FLACC Behavioral Pain Assessment Scale can be used.

18. Overall changes in the older adult to differentiate normal from abnormal

19. Nutrition: What is normal BMI; overweight BMI, obese BMI; physical signs of nutritional deficiency

20. What is physiologic jaundice in the newborn, when is it normal and what does it indicate if abnormal -Jaundice (icterus) is a yellow pigmentation of the skin caused by an increased level of bilirubin in the blood. -Physiologic jaundice (hyperbilirubinemia) of the newborn is a frequently encountered problem in otherwise healthy newborns caused by the lack of maturity of bilirubin uptake and conjugation by the liver. -High bilirubin levels in the newborn period can be associated with hemolytic disease, metabolic and endocrine disorders, anatomic abnormalities of the liver, and infections. -Pathological jaundice in the newborn period is associated with a severe illness. Risk factors for development of pathological jaundice include fetal-maternal blood type incompatibility (hemolytic disease of the newborn), premature birth, exclusive breast-feeding in some infants, maternal age greater than or equal to 25 yo, male sex, delayed meconium passage, excessive birth trauma.

21. How to transilluminate the skull of an infant, what is seen, what is normal -you can transilluminate the skull of an infant who have suspected intracranial lesions or a rapidly increasing head circumference (hydrocephalus). -The procedure must be performed in a completely darkened room. -The transilluminator is placed firmly against the infant’s scalp so that no light escapes. -Begin at the midline frontal region and inch the transilluminator over the entire head. -Observe the ring of illumination through the scalp and skull around the light, noting any asymmetry. -Expected finding: A ring of 2 cm or less beyond the rim of the transilluminator with all regions of the scalp except the occiput, where the ring should be ≤ 1 cm. -Abnormal finding: Illumination beyond these parameters suggest excess fluid or decreased brain tissue in the skull (hydrocephalus).

22. What are normal/abnormal skin changes in pregnancy -Striae gravidum (stretch marks) may appear over the abdomen, thighs, and breasts during the second trimester of pregnancy. -Increase in telangiectasias. They are small, dilated blood vessels consisting of venules or arterioles. Usually resolve after delivery. -Hemangiomas. If present before pregnancy, they may enlarge. New ones may form. -Cutaneous tags. -Increased pigmentation of areolae, nipples, vulvar and perineal regions, axillae, and the linea alba. Pigmentation of the linea alba is called the linea Negra. -Preexisting pigmented nevi and freckles may darken, with some nevi increasing in size. New nevi may form. -Melasma or “mask of pregnancy”. The darkened, blotchy skin is usually symmetric and found on the forehead, cheeks, bridge of the nose, and chin. -Palmar erythema. -Itching over the abdomen and breasts resulting from skin stretching. -Growing phase of the hair is lengthened, and hair loss is decreased. -Acne vulgaris may be aggravated during the first trimester.

-Melasma or “mask of pregnancy”. The darkened, blotchy skin is usually symmetric and found on the forehead, cheeks, bridge of the nose, and chin.

-Increase in telangiectasias. They are small, dilated blood vessels consisting of venules or arterioles. Usually resolve after delivery.

Cellulitis: -Diffuse, acute, infection of the skin and subcutaneous tissue. -Caused by Streptococcus pyogenes or Staphylococcus aureus. -Skin is red, hot, tender, and indurated; borders are not well demarcated. - Regional lymphadenopathy may be present. -Rare to have bilateral cellulitis.

Impetigo: -Common bacterial infection on face. Highly contagious. -Caused by Streptococcus or Staphylococcus infection of the epidermis. -Lesion crusts with a characteristic honey color. -Regional lymphadenopathy may be present.

What are good ways to ask a patient their story:

Open ended questions

If a patient isn’t giving you the answers you’re looking for, what’s the best way to get it:

Direct questions/qualifier questions

Cultural sensitivity:

Looking at others lifestyles. Understanding beliefs. Ask questions.

Inspection takes place through the entire exam.

For abdomen, auscultate before palpation.

Dorsal side of hand to check for temperature.

Finger pads for palpation.

Ulnar surface for vibration.

Stethoscope firmly against skin.

Pneumatic otoscope for kids to tympanic membrane exam.

Percussion tones: Dull = mass/fluid filled Tympanic = lungs If dull in lungs = infection/pneumonia

If you do not have a reflex hammer = use fingers

Cognitive impairment findings: Inappropriately laughing Flat affect Disheveled appearance Communication may be altered

Brain: Parietal = sensation Temporal = auditory Frontal = behavior/speech Cerebral = control of body/writing/drawing

Acromegaly – pituitary tumor Enlarged hands and feet Pronounced facial features

Turners – X,0 No periods. Infertile. Short. Webbed neck.

Cushing - steroid Weight gain. Moon face. Buffalo hump

Precocious Puberty Females <7. Males <9 Breast development, pubic hair growth, enlarged testes and penis

Vitamin B Deficiency Fatigue/tired, headache, pale, palpitations, SOB, sores in mouth or in corners of mouth

Vitamin E = nerve and muscle function

Protein status: check prealbumin and albumin levels

Milestones in kids: REMEMBER IT IS UP TO THIS AGE THAT IS NORMAL. 1st milestone: smiling 12 months: speech 18 months: walking 3 years old: ask why, short phrases

Subjective Data: Patient stated. Chest pain. Review of Systems. HPI SOB

Objective Data: Provider assessment. Vital Signs Physical exam findings

Skin: Macule = freckle. Flat. <1cm Papule = mole. Raised. <1 cm Vesicle = fluid filled. Chicken Pox/Shingles Wheal = hives. Edema. Red. Insect bite

Older adult normal skin findings: Dryness Skin tags Cherry angioma

Malignant Melanoma Irregular border FIXED

Solar Keratosis (Actinic keratosis) – spot on skin. Scaly. NOT normal.

Impetigo: Common bacterial infection on face. Highly contagious.

When to be concerned about spots on skin: If new or recent change in appearance If bleeds easily. Fixed. Irregular

KNOW PICTURES OF HERPES, BASAL CELL SKIN CANCER, MELANOMA

Lymph nodes: If palpable = enlarged. If enlarged = inflammation Cervical chain enlarged think throat infection KNOW WHERE LYMPH NODES ARE and which ones will be enlarged by infection area Elderly: fibrotic or fatty is NORMAL Painful lymph better than nonpainful.

How to differentiate between lymph or cyst:

Transillumination

Transillumination in a newborn/infant looks for:

hydrocephalus

Thyroid exam Feel for movement when swallowing Older adult: fibrotic, harder, not as smooth

Hypothyroid Decreased energy, weight increased

Hyperthyroid Exophthalmos, increased energy, decreased weight

Migraine Unilateral or generalized. Lasts hours to days. Aura. Photosensitivity and sound sensitivity. N/V

Cluster Headache Sudden, intense, one side

KNOW BMI CHART <18.5 = underweight 18.5-24.9 = appropriate 25 – 29.9 – overweight >30 obese

Pain assessment Best way to assess to ask patient. Number scale Interactive assessment on a pediatric patient: age 3

Jaundice in newborn or infant Concerned after first few weeks Check hemolysis

Normal in pregnancy: Striae (stretch marks) Hyperpigmentation on face Linea nigra ***Be able to identify normal vs abnormal in pregnant patient***

1. Interviewing skills: how to approach patients, start the process, obtain information. open ended. Patient should tell you why they are here/clarifying questions

2. Cultural sensitivity: purpose, reason it is important, how culture may impact aspects of an exam of emotional health--- recognize and accept that there are beliefs different than the practitioner Some Asian culture don’t make eye contact

3. The steps of assessment, inspection, palpation, percussion, auscultation (last except in abd FIRST); KNOW ORDER What they are, how to perform; sequence used; how to palpate (what parts of the hands work best for different purposes; fine discrimination, vibration) FINE FINGER TIPS/99 ulnar surface if the hand What are normal percussion notes, know where they are found How to use equipment; how to apply a stethoscope, otoscope( adult pull oricle up and back) kid down and back for tympanic membrane

4. Equipment: pneumatic otoscope ( pressure behind tympanic membrane), reflex hammer, ophthalmoscope (retina HTN/DM abnormal), Wood’s lamp(black light susp fungal infect/ corneal abrasions/foreign bodies eye), what they are for, how they are used, any differences with pediatrics

5. Indications of cognitive impairment (history or PE findings)- inappropriate affect

6. Areas of the brain and their function- frontal speech motor /parietal touch pressure body awareness /temporal hearing facial recognition/occipital vision color cerebellar dysfunction movt coordination

7. Main findings in acromegaly (larger feature feet hand face), Turner syndrome ( no sexual developments), Cushing syndrome (moon face humpback lrg abdominal girth), precocious puberty(early puberty 5-11 yrs)

8. Exam findings indicative of nutritional deficiency, assessment of nutrition and protein status( CMP- albumin) iron- cold headaches dizzy lightheaded B- fissures sores corner mouth B12 burning tongue feet C- slow heal D-fatigue bone pain A- vision

9. Growth and development milestones in children, walk (12 m), talk (2-3 word sentence 24-36 months,

10. Difference between an objective (physical exam, vital signs, labs, tenderness on touch) and subjective finding (what the patient says(nausea, pain, things you cannot see), know examples

11. Skin lesions; Description of common Macule flat color difference less than 1 cm ( freckle) papule, firm less than 1 cm ( mole/wort) Vesicle less than 1 cm clear fluid filled herpes Wheal elevated irregular edema- hives inspect bite Know examples; ie what is a freckle? What are lesions that require further investigation; what do they look like- bleeds easily when touched/asymmetrical/irregular border/color variations/ dia >1/4 inch/ changes over time MELANOMA Other common abnormalities; staph (kids-mouth/chin/contagious impetigo/abscess) and strep infections (strep throat) What do herpes , basal cell, malignant melanoma and seborrheic keratosis look like

12. What are common normal skin lesions on an older adult -skin tags cherry sebhorrheic keratosis

13. What to expect when palpating lymph nodes Differentiating infection from malignancy infection- infect sore throat fever MAL- not tender immobile/large Normal changes in the older adult- fibrotic/fatty/harder Where lymph nodes are palpable- How to differentiate a lymph node from a cyst transilluminator- shine if fluid filled illuminate cyst/solid not illuminated What does a painful enlarged node indicate v. one that is not painful infection v malignancey When does an enlarged lymph node require further investigation Technique used to differentiate an enlarged node from a cyst

14. How to palpate the thyroid; what will you expect to feel

15. History and physical findings suggestive of hypo and hyperthyroidism HYPER weight loss/tachy/heat sensitivity HYPO- weight gain/fatigued/constipated/cold/dry

16. History findings suggestive of different types of headaches; migraine (may start in childhood /aura pain nausea, unrelenting, tension band like squeeze sinus- tender forehead under eyes cluster- eye are one side or another

17. How is pain assessed? What is the gold standard? How to assess pain in child, when can a pain scale be used- 3 yrs faces scale/point to boo boo

18. Overall changes in the older adult to differentiate normal thinning skin low subcue fat depth perception cognition decline shrinking abnormal -?

19. Nutrition: What is normal BMI; overweight BMI, obese BMI; physical signs of nutritional deficiency

20. What is physiologic jaundice in the newborn, when is it normal- decreased bilirubin after 24 hrs-breast feed/lights and what does it indicate if abnormal-at birth/lasts more than a few weeks

21. How to transilluminate the skull of an infant, what is seen, what is normal bright light to look for increased amounts of fluid (veins normal) hydrocephalis

22. What are normal/abnormal skin changes in pregnancy Normal----Linea nigra-Stretch marks-Puritis

How to approach patient: Knock, address formally, meet/acknowledge others, learn names, ensure confidentiality, sit, don't rush, take notes sparingly, avoid typing, maintain eye contact, respect modesty, save discussions for after patient dresses

Abdominal exam: Inspect, auscultate, palpate, percuss

Exams except abdominal: Inspect, palpate, percuss, ausculate

Inspection: Observation, uses eyes and nose, assesses gait, ease of ADLs, eye contact, demeanor, clothing appropriateness, color/moisture of skin, emotional/mental status, unusual odors. Can continue through entire exam.

Auscultation: Listening, usually with stethoscope; perform in quiet area; listen for sound and intensity, pitch, duration, quality; perform last

Percussion: Finger against finger on body part; dense = quiet, air = loud, fluid = less loud, solid = soft

Tympanic: Loud, high pitch, moderate duration, drumlike quality, ex. Gastric bubble

Hyperresonant: Very loud, low pitch, long duration, boomlike quality, ex. Emphysematous lungs

Resonant: Loud, low pitch, long duration, hollow quality, ex. Healthy lung tissue

Dull: Soft to moderate, moderate to high pitch, moderate duration, thudlike quality, ex. Over liver

Flat: Soft, high pitch, short duration, very dull quality, ex. Over muscle

Immediate percussion: Strike finger/hand directly against body

Indirect/mediate percussion: Strike distal phalanx of middle finger against finger placed on body, originate strike from wrist

Percussion with fist: used to elicit tenderness from liver, gallbladder, kidneys; uses ulnar aspect of fist

Palpation: Gathering information through hands and fingers (touch)

Fine discrimination: Palmar surfaces of fingers and finger pads, sensitive, use for discriminatory touch to determine position, texture, size, consistency, masses, fluid, crepitus

Vibration: Ulnar surface of hand and fingers

Dorsal surface of hand: Use for temperature

How to palpate: Be gentle, warm hands

Pneumatic otoscope: Illuminates external auditory canal and tympanic membrane

Reflex hammer: Tests deep tendon reflexes; use brisk, wrist snap

Opthalmoscope: For inner structures of eye

Large aperture of opthalmoscope: Large round beam, used most often

Small aperture of opthalmoscope: To examine small pupils

Red-free filter of opthalmoscope: Green beam to examine optic disc for pallor and minute vessel changes, permits recognition of retinal hemorrhage, blood appears black

Slit aperture of opthalmoscope: For anterior eye; determines elevation of lesions on retina

Grid aperture of opthalmoscope: For size of fundal lesions

Wood's lamp: Black light (wavelength 360 nm); causes substances to fluoresce; used to see fungi on skin lesions

Cognitive impairment indications: LOC, response to question, reasoning or judgment, arithmetic ability, memory, attention span, specific mental test scores

Complex mental processes: learning, perceiving, decision making, and memory

Older adults complex mental processes: Montreal Cognitive Assessment and miniCog

Signs of possible cognitive impairment: significant memory loss, confusion (impaired cognitive function with disorientation, attention and memory deficits, and difficulty answering questions or following multiple-step directions), impaired communication, inappropriate affect, personal care difficulties, hazardous behavior, agitation, and suspiciousness

Cognitive impairment: Ask patient to complete analogy (analogies), tell the meaning of a fable, proverb, etc. (abstract reasoning), do arithmetic calc, ask to write down a phrase (writing ability), ask to button shirt or comb hair (execution of motor skills), memory tests

Immediate recall or new learning: Listen and repeat a sentence or series of numbers (5-8 forward, 4-6 backward)

Recent memory: View 4-5 objects and tell them you will ask about later. In ten minutes, have them list objects.

Remote memory: Ask about verifiable events or info such as mother's name, high school, common knowledge

Memory loss: may result from disease, infection, temporal lobe trauma

Impaired memory neuro or psych disorders, such as anxiety and depression

Immediate and recent memory loss with retention of remote memory dementia

Cerebrum consists of two hemispheres divided into lobes, responsible for mental status

Cerebral cortex gray outer layer of cerebrum, houses higher mental functions, responsible for perception and behavior

Frontal lobe contains motor cortex, responsible for speech formation (Broca area), decision making, problem solving, concentration, short-term memory; associated areas - emotions, affect, drive, awareness of self and autonomic responses r/t emotional state

Parietal lobe receives/processes sensory data; interprets tactile sensations (temp, pressure, pain, size, shape, texture, two-point discrimination), and visual, taste, smell, and hearing; proprioception (recognition of body parts and awareness of body position); association fibers provide communication between sensory and motor areas of brain

Occipital lobe primary vision center and provides interpretation of visual data

Temporal lobe: Perception and interpretation of sounds as well as localizing their source; contains Wernicke speech area (helps understand spoken and written language)

Temporal lobe is responsible for: perception and interpretation of sounds and determination of their source; involved in integration of taste, smell, and balance. The reception and interpretation of speech is located in the Wernicke area.

Medial temporal lobes include: the hippocampi, essential for memory storage

Basal ganglia system: extrapyramidal pathway and processing station between the cerebral motor cortex and the upper brainstem. Refine motor movements through interconnections with the thalamus, motor cortex, reticular formation, and spinal cord

Cerebellum: aids motor cortex of the cerebrum in the integration of voluntary movement. Processes sensory information from the eyes, ears, touch receptors, and musculoskeletal system. With the vestibular system uses the sensory data for reflexive control of muscle tone, balance, and posture to produce steady and precise movements

Cerebellum's hemispheres have: ipsilateral (same side) control of the body

Brainstem: pathway between cerebral cortex and spinal cord; controls many involuntary functions

Brainstem structures: medulla oblongata, pons, midbrain, and diencephalon. The nuclei of the 12 cranial nerves arise from these structures.

Thalamus: major integrating center for perception of various sensations (pain, temperature) and cortical processing for interpretation; also relays sensory aspects of motor information between the basal ganglia and cerebellum.

Pons: transmits information between the brainstem and the cerebellum, where motor information from the cerebral cortex is relayed to the contralateral cerebellar hemisphere.

Medulla oblongata: where descending corticospinal tracts decussate (cross to the contralateral side).

Medulla oblongata: CN IX to XII Respiratory, circulatory, and vasomotor activities; houses respiratory center Reflexes of swallowing, coughing, vomiting, sneezing, and hiccupping; relay center for major ascending and descending spinal tracts that decussate at the pyramid

Pons: CN V to VIII Reflexes of pupillary action and eye movement Regulates respiration; houses a portion of the respiratory center Controls voluntary muscle action with corticospinal tract pathway

Midbrain: CN III and IV Reflex center for eye and head movement Auditory relay pathway Corticospinal tract pathway

Diencephalon: CN I and II Thalamus Relays impulses between cerebrum, cerebellum, pons, and medulla (see Fig. 23.4) Conveys all sensory impulses (except olfaction) to and from cerebrum before their distribution to appropriate associative sensory areas Integrates impulses between motor cortex and cerebrum, influencing voluntary movements and motor response Controls state of consciousness, conscious perceptions of sensations, and abstract feelings

Epithalamus: Houses the pineal body - sexual development and behavior

Hypothalamus: Major processing center of internal stimuli for autonomic nervous system; maintains temperature control, water metabolism, body fluid osmolarity, feeding behavior, and neuroendocrine activity

Pituitary gland: Hormonal control of growth, lactation, vasoconstriction, and metabolism

Olfactory (I) Sensory: smell reception and interpretation

Optic (II) Sensory: visual acuity and visual fields

Oculomotor (III) Motor: raise eyelids, most extraocular movements Parasympathetic: pupillary constriction, change lens shape

Trochlear (IV) Motor: downward, inward eye movement

Trigeminal (V) Motor: jaw opening and clenching, chewing, and mastication Sensory: sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, facial skin

Abducens (VI) Motor: lateral eye movement

Facial (VII) Motor: movement of facial expression muscles except jaw, close eyelids, labial speech sounds (b, m, w, and rounded vowels) Sensory: taste— anterior two-thirds of tongue, sensation to pharynx Parasympathetic: secretion of saliva and tears

Acoustic (VIII) Sensory: hearing and equilibrium

Glossopharyngeal (IX) Motor: voluntary muscles for swallowing and phonation (guttural speech sounds) Sensory: sensation of nasopharynx, gag reflex, taste— posterior one-third of tongue Parasympathetic: secretion of salivary glands, carotid reflex

Vagus (X) Sensory: sensation behind ear and part of external ear canal Parasympathetic: secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of heart, lungs, and digestive tract

Spinal accessory (XI) Motor: turn head, shrug shoulders, some actions for phonation

Hypoglossal (XII) Motor: tongue movement for speech sound articulation (l, t, d, n) and swallowing

Acromegaly findings: Face and skull— frontal skull bossing, cranial ridges, mandibular overgrowth, maxillary widening, teeth separation, malocclusion, overbite, skin thickening on the face (tongue, lips and nose), hands and feet leading to enlargement, joint enlargement, swelling, pain; vertebral enlargement, kyphoscoliosis Cardiac ventricular enlargement bilaterally with decreased exercise tolerance

Acromegaly def: A rare disease of excessive growth and distorted proportions caused by hypersecretion of growth hormone and insulin-like growth factor after closure of the epiphyses, causes slow skeletal growth and soft tissue enlargement; benign pituitary adenoma or other rare tumor most common cause; familial syndromes (e.g., multiple endocrine neoplasia type 1 and McCune-Albright syndrome).

Turner syndrome findings: Short stature, webbed neck, broad chest/widely spaced nipples, wide carrying angle of elbow (cubitus valgus), low posterior hairline, misshapen or rotated ears, narrow palate with crowded teeth, coarctation of aorta, bicuspid aortic valve, sensorineural hearing loss, infertility. Dx by amnio or chorionic villous sampling, karyotype or chromosome analysis to confirm diagnosis

Turner syndrome: female with 1 X chromosome

Cushing syndrome findings: subj - weight gain, appetite changes, depression, irritability, decreased libido, decreased concentration, impaired short-term memory, easy bruising, menstrual irregularities, weight gain w/ slow height velocity in children; obj - obesity, buffalo hump/fad pad, supraclavicular & abdominal fat, facial plethora or moon facies, thin skin, reddish purple striae, poor skin healing, proximal muscle weakness, hirsutism or female balding, peripheral edema; in kids - short stature, abnormal genital virilization, delayed puberty

Cushing syndrome: d/t prolonged, high doses of glucocorticoids or adrenal gland over secretion leading to excessive production of cortisol or a pituitary tumor leading to excessive secretion of adrenocorticotropic hormone (ACTH); diabetes, HTN, depression, menstrual irregularities are s/e

Precocious puberty findings subj - early breast & pubic hair dev in girls, enlarged testes then penis, early pubic hair in boys; obj - early sexual characteristics, acne, erections, noc emissions, period; accelerated height at early age, sex hormone concentrations appropriate for stage of puberty

Precocious puberty: brain tumor or lesion (hypothalamic hamartoma) activates hypothalamicpituitary-gonadal axis with gonadotropins triggering the growth of the gonads, secretion of the sex hormones, and progressive sexual maturation; can be r/t McCune-Albright syndrome.

Nutritional deficiency findings: below height/weight norms for age, reduced muscle mass, loss of subcutaneous fat, wasted buttocks, thin extremities, prominent ribs, alopecia, possible signs of neglect (diaper rash, dirty body/clothes, skin infections), developmental delay

Anorexia findings: dry skin, lanugo hair, brittle nails, bradycardia, hypothermia, orthostatic hypotension, muscle and subcutaneous fat decreased; obj - hypoglycemia, elevated liver enzymes, and thyroid hormone abnormalities, DSM-V dx criteria refusal to maintain body weight at or above min normal for height/age, fear of gaining, disturbed self-image, amenorrhea

Iron deficiency anemia: fatigue, dry hair, ridged/spoon nails (koilonchia)

Riboflavin (B2) or iron deficiency: cracking or inflammation at the corners of the mouth (angular cheilitis)

Iron or B-vitamin deficiency: Pale or swollen tongue

Iron, zinc, or B-vitamin deficiency: Burning mouth syndrome

Chronic diarrhea: sign of malabsorption - infection, surgery, certain drugs, heavy alcohol use, and digestive disorders such as celiac sprue and Crohn's disease

Babies start to sit up on their own: 6 months

Babies start crawling: 6-9 months

Babies begin to pull themselves up on furniture to stand: 9 months

Babies stand up, hold onto furniture to explore: 9-12 months

Babies walk on their own: 11-13 months

3-4 mos. coo, babble

4- 6 mos. babbles speech-like sounds, including p, b, and m

0- 12 mos. imitates different speech sounds, has 1 or 2 words, such as "mama," "dada," "byebye," but sounds may not be clear

12- 24 mos. increases words each month, 2-word questions or phrases (e.g., "Where baby?" and "Want cookie")

24-36 mos. uses two- to three-word sentences to ask for things or talk about things, large vocabulary, speech understood by family members most of time, asks why

36-48 mos. answers simple questions, uses pronouns like I, me, you. Sentences have four or more words

Objective finding: Information from direct observation - what you see, hear, touch, smell

Subjective finding: What the patient tells you

Organs, masses, lesions: Describe what was found during inspection and palpation including texture, consistency, size, shape, mobility, tenderness, induration, heat, color, location, 'action' - oozing bleeding, discharge, scab formation, scarring, excoriation, etc.

Macule: flat, circumscribed area w/color change; less than 1 cm in diameter

Macule: freckles, flat moles (nevi), petechiae, measles

Papule: elevated, firm, circumscribed area; less than 1 cm in diameter

Papule ex: wart (verruca), elevated moles, lichen planus

Patch: flat, nonpalpable, irregularly shaped macule greater than 1 cm in diameter

Patch ex: vitiligo, port-wine stains, café au lait

Plaque elevated, firm, and rough lesion with flat top surface greater than 1 cm in diameter

Plaque ex: psoriasis, seborrheic, and actinic keratosis

Wheal: elevated, irregular-shaped area of cutaneous edema; solid, transient, variable diameter

Wheal examples: insect bites, urticaria, allergic

Noduleelevated, firm, circumscribed lesion: deeper in dermis than a papule; 1-2 cm in diameter

Nodule example: erythema nodosum, lipoma

Mass: elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis; greater than 2 cm in diameter

Mass examples: Neoplasms, benign tumor, lipoma

Vesicle: elevated, circumscribed, superficial, not into dermis; filled with serous fluid; less than 1 cm in diameter

Vesicle example: Varicella (chickenpox), herpes zoster (shingles)

Bulla: vesicle greater than 1 cm in diameter

Bulla examples: blister, pemphigus vulgaris

Skin changes to investigate: ABCDE - asymmetry, irregular borders, color not uniform diameter >6mm or growing, evolution of existing lesions, esp. in non-uniform/asymmetric way; not healing, crusting, bleeding

Staph infection: causes faruncle, tender, hot, red nodule, purulent (pus) core, may rupture

Strep infection: causes cellulitis; red, hot, tender, and indurated; borders are not well demarcated; Lymphangitic streaks and regional lymphadenopathy may be present

Herpes: grouped vesicles, erode, form crust, type 1 and 2, crossover becoming common, HSV

Basal cell: most common skin cancer, from epidermis; shiny sore, crusting, bleeding, poor healing

Malignant melanoma: lethal, forms from melanocyte; ABCDE

Seborrheic keratosis: pigmented, raised, warty lesions, usually appearing on the trunk. These must be distinguished from other growths such as nevi or actinic keratoses, which may have malignant potential.

Eczematous dermatitis: most common skin prob; contact, allergic, atopic (childhood, skin folds, plaques)

Skin lesions of older adult: cherry angioma, seborrheic keratosis, sebaceous hyperplasia, cutaneous tags, cutaneous horns, solar lentigines,

Signs of lymph system disorder: enlarged lymph nodes (lymphadenopathy), red streaks on the overlying skin (lymphangitis), and lymphedema

Easily palpable lymph nodes: generally are not found in healthy adults

Shotty nodes: small, movable, discrete, small, multiple nodes that feel like BBs or buckshot under the skin) less than 1 cm in diameter that move under your fingers. Generally not consequential, usually represent enlargement after viral infection

Enlarged epitrochlear or supraclavicular nodes: require additional evaluation

Lymph node fixed to surrounding tissues: cause for concern

Palpating lymph nodes (expectations): always there, doesn't transilluminate, solid, not clearly defined, symmetrical, should not be easily palpable, fixed or tender

Malignant node: Hard, fixed, painless node, rapid enlargement w/out signs of inflammation

Inflamed nodes: Very tender

Palpable supraclavicular node on the left: Virchow node; significant clue to thoracic or abdominal malignancy.

Benign node: Slow enlargement over weeks and months

Need investigation: nodes that are hard, fixed/matted, inflamed, tender

Sign of malignancy: Supraclavicular node anterior to the sternocleidomastoid muscle

Tuberculosis: nodes felt in the cervical chains, are usually body temperature, soft, matted, and not tender or painful

Cyst: transilluminates, is discrete, is transient, fluid filled

Thyroid palpation: should be small, smooth, and free of nodules, should rise freely with swallowing. Broadest part approx. 4 cm, right lobe is often 25% larger than left. Should be firm yet pliable.

Coarse tissue/gritty thyroid: suggests an inflammatory process.

Thyroid nodule: should be characterized by number, smooth vs. irregular, soft or hard

Thyroiditis findings: enlarged, tender; should auscultate for vascular sounds with the bell of the stethoscope; hypermetabolic = vascular bruit (a soft rushing sound)

Hypothyroid findings from H&P: subj - weight gain, constipation, fatigue, cold introlerance; obj - weight gain, lethargy, dry skin/hair, thick nails, puffy periorbital area, no goiter

Primary hypothyroidism: Thyroid gland produces insufficient amounts of thyroid hormone

Secondary hypothyroidism: Insufficient thyroid hormone secretion due to inadequate secretion of either thyroid-stimulating hormone (TSH) from the pituitary gland or thyrotropin-releasing hormone (TRH) from the hypothalamus

Hyperthyroid findings: Weight loss, tachycardia, diarrhea, heat intolerance, normal size thyroid, goiter or nodule, fine hair

Migraine hx findings: starts in childhood, unilateral or generalized, hours to days, prodromes - vague neurologic changes, personality change, fluid retention, appetite loss to well-defined neurologic event, scotoma, aphasia, hemianopsia, aura, precip events - females, period, bcp, following stress, can cause nausea/vomiting,

Tension headache hx findings: adulthood, uni- or bilateral, hours to days, any time, bandlike/constricting, prodromes - none, precip - anger, bruxism, stress, daily, male or female

Cluster headache hx findings: adulthood, unilateral, .5 to 2 hours, night, intense/boring/searing/knifelike, prodromes - personality changes, ETOH use, several x nightly, several days, then none, males, tearing/nasal discharge

Pain: various scales, physical manifestations - guarding, groaning, sweating, VS changes, writhing, pupil dilation, pallor, dry mouth, restlessness

Pain: patient self-report

Pain in child: Wong-Baker, Oucher.

Pain in child: when to use pain scale

Abnormal changes in older adult: cognitive, personality

Amsler grid: used to evaluate macular degeneration, central vision; distortion shows problem

140/90 hypertension in older adult

Underweight BMI: below 18.5

Normal BMI: 18.5-24.9

Overweight BMI: 25-29.9

Obese BMI: 30+

Signs of nutritional deficiency: Iron: Fatigue, anemia, decreased cognitive function, headache, glossitis, and nail changes Iodine: Goiter, developmental delay, and mental retardation Vitamin D: Poor growth, rickets, and hypocalcemia

Physiologic jaundice in newborn normal: Day 1-8/10

Physiologic jaundice in newborn abnormal: longer than 2 weeks - suggests liver disease, a hemolytic process, or severe, overwhelming infection

Infant skull transillumination findings normal: suspected intracranial lesions or a rapidly increasing head circumference - ring of 2 cm or less beyond the rim of the transilluminator is expected with all regions of the head except the occiput, where the ring should be 1 cm or less.

Infant skull transillumination findings abnormal: Illumination beyond 2 cm (or 1 cm at occiput) suggests excess fluid or decreased brain tissue in the skull.

Skin changes in pregnancy normal: Striae gravidarum (stretch marks), telangiectasias, which may be found on the face, neck, chest, and arms; usually resolve after delivery. Hemangiomas may increase in size, or new ones may develop. Cutaneous tags (molluscum fibrosum gravidarum) from from epithelial hyperplasia and are not inflammatory. Hyperpigmentation (nipples), melasma. Palmar erythema, linea Negra, itching from stretched skin

Skin changes in pregnancy abnormal: itching w/ rash, generalized itching (palms, soles) d/t decreased bile flow, jaundice,

Exam order: Identifiers, Chief Concern, History of Present Illness, Medical History, Personal/Social History

Skull bones: 7 total (2 frontal, 2 parietal, 2 temporal, and 1 occipital) fused together and covered by the scalp, helpful in identifying landmarks on the head

Face: fused frontal, nasal, zygomatic, ethmoid, lacrimal, sphenoid, and maxillary bones and the movable mandible; has cavities for the eyes, nose, and mouth