PD block 1 Flashcards
otoscope
provides illumination for examining the external auditory canal and the tympanic membrane.
ophthalmoscope
has system of lenses and mirrors to visualize the interior structures of the eye.
ophthalmoscope apertures large
large aperture – (most commonly used) produces a large round beam
sphygmomanometer
a device used to manually measure blood pressure with the use of a stethoscope. The inflatable bladder restricts blood flow, measurements of pressure are recorded when blood flow is just starting and when it ceases to be unimpeded.
thermometers
used to measure body temperature which can be a clue to a pt’s illness/current state
oral temp
oral – placed under the tounge (98.6) (abnormal >100)
rectal temp
rectal – commonly used for infants for accurate reading. (99.6) (abnormal >101)
axillary temp
axillary – held between body and arm. (97.6)
tympanic temp
tympanic – used in the ear – tympanic membrane shares blood supply with hypothalamus. (99.6) (abnormal >101)
stethoscope
can be acoustic, magnetic, or electronicb. Bell – Low pitched sounds – light pressure (harder to hear sounds)c. Used to listen to heart and adnominal sounds Diaphragm – high pitched sounds – firm pressure
Snellen visual acuity
a. Used for screening and examination of far vision for literate, English, verbal adults and school aged childrenb. Recorded as a fraction – numerator = # of feet between chart and pt. and denominator = distance from which a normal person can read the lettering
Rosenbaum visual acuity charts
used to test near vision at distance of 14 in.
512 tuning fork
auditory evaluation via estimating hearing loss in the range of normal speech. This is the lowest intensity of sounds at which an auditory stimulus can be heard.
128 tuning fork
vibratory sensation applied to bony prominence the patient should feel the vibration/tingling.
percussion hammer
used to test deep tendon reflexes, tap should be brisk and direct
tape measure
used to determine circumference, length, diameter. Pull tape tightly without causing depression in skin.
transilluminator
strong light source with narrow beam directed into body cavity to differentiate between various media present in that cavity (air, fluid, tissue). Place beam of light directly against area to observe the presence or absence of illumination and any irregularities.
palmar surface palpation
used for distinguishing size and texture. Any examination that requires fine detail/texture should be done with palmar surface. More nerve endings on this portion of the hand.
ulnar surface palpation
used for detection of vibration
dorsal surface palpation
used for detection of temperature. better than palmar surface because your own body heat does not interfere.
Diaphragm sounds
best for high-pitched sounds (heart sounds and abdominal/bowel sounds)with firm pressure skin converts bell to a diaphragm end piece
Bell Sounds
best for low-pitched sounds when light pressure is used
bruits -
turbulent blood flow through artery & heart
murmurs
turbulent blood flow through heart valve)
normal pulse
Normal: 60-100 beats per minute
resting pulse
number of heart beats per minute while at complete rest; generally 60-100 beats per minute; average 70 bpm; this can vary widely based on general health and fitness, age, underlying medical conditions
Tachycardia pulse
pulse rate>100 beats per minutefever, anxiety, drugs, anemia, exercise, HYPERthryroidism
Bradycardia: pulse
rate<60 beats per minuteHYPOthyroidismdrugs, physical shape, hypothermia
tachycardia
If oxygen demand or metabolic activity increases, blood volume decreases, the body is working, or the sympathetic nervous system is activated (stress, certain drugs), this can induce tachycardia
bradycardia
While the body is at rest there is less oxygen demand and metabolic activity, so the pulse rate decreases. Parasympathetic stimulation and certain drugs can decrease the heart rate significantly below a normal resting heart rate.
Korotkoff sounds. (Seidel/Mosby pg 54-55)
Low-pitched sounds produced by turbulence of blood flow in the artery
ausculatory gap
Korotkoff sounds may disappear 10-15 mmHg below first systolic reading = this is normal and called the ausculatory gap
First and Second Korotkoff sounds
First two audible consecutive beats indicate systolic pressure reading and beginning of Korotkoff soundswhen the Korotkoff sounds disappear, this is the second diastolic sound
Guarding
: protective behavior, distorted posture, reluctance to be moved
Facial mask of pain:
physical pain behavior
lackluster eyes, wrinkled forehead, tightly closed or opened eyes, fixed or scattered movement
Vocalizations:
physical pain behavior
grunting, groaning, crying, talkative patient becomes quiet
Body movements
physical pain behavior
:head rocking, pacing or rubbing; an inability to keep the hands still
Changes in vital signs: Pain
blood pressure, pulse, respiratory rate and depth, with acute onset of pain. Fewer changes in vital signs are found in patients with persistent pain or after they adapt to acute pain.
Facies:
expression or appearance of the face and features of the head and neck indicating a clinical condition or syndromecertain conditions impart a “classic” physical appearance to the face indicating an underlying disease or syndrome. In GA, facies can be used to diagnose condition or syndrome (most often an endocrine disorder, but could be congenital or infectious disease). (PKM lecture on GA)
Hyperthyroid disease
exopthalamos (prominent eyes, lid retraction)
Sclera
The outer layer of the posterior eye, which is a dense, avascular structure. It supports the internal structure of the eye. It also encases the Optic nerve
optic nerve
Optic nerve, which passes through the optic foramen along with the ophthalmic artery and vein, sends signals to the CNS.
cornea
The Cornea is the outer layer of the anterior eye. It is continuous with the Sclera. It is optically clear, has rich sensory innervations, and is also avascular.
Uveal Tract
The Uveal tract consists of the Iris, Ciliary body, and Choroids. T
Iris
(the color of the eye) is a circular, contractile muscular disc that controls the amount of light that is able to reach teh retina.
pupil
The central aperture of the iris is the pupil, which light travels to the retina.
ciliary body
The ciliary body produces the aqueous humor (fluid that circulates between the lens and cornea) and contains the muscles that control accommodation.
Choroid
The Choroid is a pigmented, richly vascular layer that supplies oxygen to the outer layer of the retina.
lens
The Lens is a biconvex, transparent structure located behind the iris. It is supported by fibers that come from the ciliary body. It is highly elastic, and contraction or relaxation of the ciliary body changes its thickness, allowing images of various distances to be focused by the retina.
Retina
The Retina is the sensory network of the eye. It transforms light impulses into electrical impulses, which are transmitted through the optic nerve, optic tract and optic radiation to the visual cortex of the brain, the cerebral cortex. Other landmarks of the retina include the optic disc, where the optic nerve originates, together with the central retinal artery and vein. The Macula, or fovea is the site of central vision.
eyelid
The eyelid is composed of skin, striated muscle, the tarsal plate and conjunctivae. Meibomian glands provide oils to the tear film. The tarsus provides a skeleton to the lid. The eyelid distributes tears over the surface of the eye, limits the amount of lights entering it, and protects the eye from foreign bodies.
The Conjunctiva
is a clear, thin mucous membrane. The palpebral conjunctiva is the part of the conjunctiva that coats the inside of the eyelid. The bulbar conjunctiva is the part that covers the outer surface of the eye. The conjunctiva should be observed for erythema and exudate.
Eye Muscles
superior, inferior, medial, and lateral rectus muscles. superior and inferior oblique muscles, which allow you to move your eyes at an angle.
The Lacrimal Gland
is located in the temporal region of the superior eyelid and is responsible for tear production.
Head Bones
made up of 7 bones: frontalx2, parietalx2, occipital, temporalx2;
Face Bones
mandible, maxilla, zygomatic, sphenoid, lacrimal, and nasal bones.
Externally visible head tissue
Eyes (inner&outer canthus), nose (ala, nares, philtrum, nasal bridge), Ears (tragus, pinna)
landmarks on face
palpebral fissures, eyelids, eyebrows, nasolabial fold, mouth
neck location
begins at base of skull, ends at clavicles/sternum.
neck formed by
cervical vertebrae, ligaments, sternocleidomastoid muscle, and trapezius muslce
neck contains
trachea, esophagus, jugular veins, carotids, and thyroid.
cyanosis:
bluish; lack of oxygen or circulation
pallor:
unhealthy/pale skin;
leukonychia:
white spots on the nail plate; cuticle manipulation or mild trauma
paronychia:
infection or disease around the nail; pain, swelling, redness
koilonychia:
“spoon nail”; nail takes on a spoon-like appearance; can be due to anemia, hypothyroidism
nail pitting:
small pock-mark type indentations in the nail; psoriasis
peau d’orange:
on the breast; skin puckers and resembles an orange peel; lymphatic blockage or advanced breast cancer
edema/dependent edema:
swelling/ extracellular fluid accumulation; in dependent edema, the fluid remains in low points (i.e. the lower extremities); can be due to cardiac insufficiency
striae:
skin irregularity that resembles stripes; many causes and presentations (stretch marks, endocrine disorders, etc.)
alopecia:
hair loss
onycholysis:
spontaneous painless separation of the nail from the bed; trauma, medications, infection, many causes
varicosities:
varicose (enlarged, twisted) veins; due to failure of the valves to prevent backflow; often seen in superficial veins in lower extremities
Beau’s lines:
horizontal/transverse grooves on nail plate; infection, trauma, systemic disease, many causes
hirsutism:
(females) the growth of terminal hair in patterns normally associated with male hair distribution (facial hair, increased body hair); associated with endocrine disorder
clubbing:
instead of growing (relatively) flat and straight, the nail angle increases, leading to a club-like appearance; can be due to prolonged cardiac or respiratory disease or can be idiopathic
sensorineural hearing loss
-PERMANENT-Associated with damage to cochlear hair cells or auditory nerve-EX: old age, noise-induced hearing loss, trauma, chemotherapy, radiation, genetics, etc.-Typically addressed with hearing aids
conductive hearing loss
-NOT TYPICALLY PERMANENT-Associated with any obstruction of sound transmission-EX: fluid in middle ear, ear infections, holes in TM, abnormal bone growth, cerumen impaction, etc.-Typically addressed with medical intervention or surgery (most cases are NOT permanent)
Normal respiration range for adults
12 to 20 breaths per minute
Wood’s light
used to dx fungal infections(epidermal hypo and hyper pigmented lesions, distinguish fluorescing lesions)
Diascopy
blanchabilty of a lesion - differentate between vascular (inflammation), nonvascular (nevi), or hemorrhagic (petechia)
Direct microscopy
samples of flaked skin (scales) - used to determine if fungal infection is present
4 types of biopsy
shave, punch, incisional, excisional
Type of test used for allergy testing
patch or prick test
Wood’s light
used to dx fungal infections(epidermal hypo and hyper pigmented lesions, distinguish fluorescing lesions)
Diascopy
blanchabilty of a lesion - differentate between vascular (inflammation), nonvascular (nevi), or hemorrhagic (petechia)
Direct microscopy
samples of flaked skin (scales) - used to determine if fungal infection is present
4 types of biopsy
shave, punch, incisional, excisional
I P P A
InspectionPalpation Percussion Auscultation
5 types of notes produced by percussion:
1) Tympanic2) Hyperresonant3) Resonant4) Dull5) Flat
Tympanic percussion tone:
Loud, drumlike, gastric bubble
Hyperresonant percussion tone:
Abnormal, very loud, boomlike, Emphysematous lungs
Resonant percussion tone:
Loud, Hollow, Healthy lung tissue
Dull percussion tone:
Thudlike, Over liver
Flat percussion tone:
soft, Over muscle
3 phases of hair growth:
I. Anagen: the phase of active growth. Last approximately 3-4 years. Approximately 84% of the scalp follicles are in anagen growth.II. Catagen: the phase that marks follicular regression. Last approximately 2-3 weeks. 1-2% of scalp follicles are in catagen phase.III. Telogen: the phase that represents a resting period. Lasts approximately 3 months. 10-15% of scalp follicles are in telogen phase.
Traditions of PE
–Usually conducted from pt’s R side –Pt usually seated or supine– Reposition yourself and pt as neededlet pt talksit downexercise a chaperone
Pattern of PE
IPPA:InspectionPalpationPercussionAuscultation(specifics are discussed on other cards)
Epidermis
Topmost, thin layer of skin, made of 3 sub-layers:–Stratum corneum (horny layer): sheds dead keratinocytes from below; keratin is waterproof, protects–Cellular stratum: melanocytes (pigment) + keratinocytes (makes protective keratin)–Basal layer/basement membrane: continually makes new keratinocytes that migrate upward every 4 weeks
Dermis
–Middle of 3 layers–Richly vascular and innervated, hair follicles, sweat glands–Supports and separates epidermis from cutaneous adipose–Elastin, collagen, reticulum : strength, stretchiness
Hypodermis (aka subcutis, aka subcutaneous)
Deepest of 3 layers–Collagen + fat: shock absorber, generates heat/insulation
Hair shaft
The section of hair that protrudes above the level of the skin (from follicle up)
Apocrine glands
–Larger and deeper than eccrine glands–Found only in the axillae, nipples, areolae, anogenital area, eyelids, external ears–Secrete odorless white fluid (“apocrine sweat”) w/ protein, carbohydrates, etc (not stinky in and of itself; it’s bacterial metabolism that makes BO)
Eccrine glands
–Sweat glands that open directly onto surface of skin–Regulate body temperature by secreting water
Nail plate
–The hard, visible part of the nail –Made of keratin–What you apply polish to when you paint your nails
Three segments of hair follicle
–Lower = bulb and suprabulb(from the base of follicle to insertion of erector pili muscle)–Middle = isthmus(short section that extends from insertion of erector pili muscle to entrance of sebaceous gland duct)–Upper = infundibulum(from entrance of sebaceous gland duct to follicular orifice)
Paronychium
–Skin at the lateral edges of the nail plate–Like eponychium, but laterally instead of at the base of nail–Infection = paronychia
Sebaceous gland
Secrete sebum (lipid-rich, keeps skin from drying out)
Hair root
–Round area at base of hair shaft–Houses the hair matrixNote: Follicle = root + its covering
Hair follicle
–The root and its covering–Three segments:-Lower = bulb and suprabulb, from the base of follicle to insertion of erector pili muscle-Middle = isthmus, short section that extends from insertion of erector pili muscle to entrance of sebaceous gland duct-Upper = infundibulum, from entrance of sebaceous gland duct to follicular orifice
Three segments of hair follicle
–Lower = bulb and suprabulb, from the base of follicle to insertion of erector pili muscle–Middle = isthmus, short section that extends from insertion of erector pili muscle to entrance of sebaceous gland duct–Upper = infundibulum, from entrance of sebaceous gland duct to follicular orifice
amastia
absence of breast tissue. May be due to rare congenital abnormality, or more often a bilateral mastectomy.
lactation
production and release of milk by mammary glands.
polymastia
The condition of having more than two breasts
galactorrhea
Lactation not associated with childbearing. Often due to a disruption of communication between the hypothalamus and pituitary glands which leads to elevated levels of prolactin, a hormone that stimulates milk production.
mastalgia
pain in the breast. May be due to hormonal fluctuations (e.g. menstrual cycle), trauma, cyst, infection.
inverted nipple(s)
nipple(s) that are retracted/tucked inward. May affect one or both nipples and can be congenital or acquired. If acquired, can be suggestive of inflammatory or malignant tissue.
everted nipple(s)
nipple(s) that point outward; most nipples have this appearance
gynecomastia
enlargement of breast tissue in males. May occur briefly at birth, briefly around puberty, or in adults >50 years old. Causes include hormonal stimulation (e.g. maternal hormones in newborns), pituitary or testicular tumors, excess body fat (causes increased estrogen production), medications.
Montgomery’s tubercles
sebaceous glands in the areola that produce oily secretions to lubricate and protect the nipple
supernumerary nipple
congenital accessory breast tissue, that may or may not contain glandular tissue. Located along the “milk line” an embryonic ridge that stretches from the from the axilla to the groin; most frequently found inferior to the “normal” breast. More common in black women than white women.
Physiologic factors influencing arterial blood pressure.
BP is affected by three factors:
a. stroke volume (amount of blood pumped by left ventricle in one contraction)
b. heart rate (beats per minute)
c. peripheral vascular resistance (resistance to expansion of vessel walls by circulating blood)
Conditions that affect one of the above factors influence blood pressure: exercise, diet (e.g. sodium), alcohol/drugs, caffeine, stress/anxiety, weight, pain, fever, vascular resistance (e.g. atherosclerosis).
diaphragmatic respirations
synonymous with “abdominal respirations”, “belly breathing”; the diaphragm does most of the work while the chest wall muscles are mostly a rest; normal, quiet breathing
abdominal respirations
synonymous with “diaphragmatic respirations”, “belly breathing”; the diaphragm does most of the work while the chest wall muscles are mostly a rest; normal, quiet breathing
thoracic respirations
performed entirely by expansion of the chest by using the chest wall muscles; the abdomen does not move
paradoxic breathing
a portion of the chest wall sinks inward with each inspiration, common with chest trauma; also a condition seen in diaphragm paralysis when the diaphragm ascends during inspiration
hyperpnea
rapid and deep respirations >20 breaths per minute
apnea
literally “no breathing”, the absence of spontaneous respiration
tachypnea
literally “rapid breathing”, faster than normal respirations >20 breaths per minute
bradynea
literally “slow breathing”, slower than normal
hyperventilation
can be due to tachypnea, hyperpnea or both; an increased amount of air enters the lungs, which results in lowered CO2 levels
Cheyne-Stokes repirations
periodic breathing; repetitive pattern of apnea followed by gradual increasing depth and frequency of respirations
Kussmaul breathing
rapid, very deep, labored and gasping respirations associated with metabolic acidosis
7 dimension of a complaint
LocationqualitySeverityTimingContextmodifying factorsassociated symptoms
IPPA Inspection
use all sensesassess for shape, color, size, symmetry, moisture, intactuse appropriate lighting
IPPA Palpation palmar
fine details/textures, mobility
IPPA Palpation Dorsal
temperature
IPPA Palpation Ulnar
vibrations
IPPA Percussion
increased density, decreased sound
IPPA Percussion Plexor and Pleximeter
Plexor dominate hand, Pleximeter - hand that gets struck
IPPA Ausculation
quiet room, bare skin, ID Characteristics of each sound. Always last exp for ABD.
Heart Rate
radial pulse15x4irregular do for 1 mincheck amplitude 0-4, 2 is normal.
heart rate can identify
distress, anxiety, drugs, cardio and neuro state, psychogenic
temp can indicate
illness or infection
respiration can indicate
signs of distress, brady/tachy, use of accessory muscles
respiration normal
12-20 /min
blood pressure can indicate
peripheral measurement of cardiovascular disease
Represents force of blood against arterial wall
heigh/weight
development
BMI normal
18-24
Hypothermia
radiation, conduction, vaporization (sweating), respiratoryLess than 95
Hyperthermia
fever, metabolic process, environment, activity, hot drinksgreater than 100
Pulse rate
of contractions/min
pulse rhythm
regular (predictable pattern) irregular (not) assess for 1 min
Pulse deficit
absence of palpable pulse for 1+ heartbeatsweaker pulse on one sidedifference btwn apical and radial pulse
Apical Pulse
pulse at Apex (bottom) of heart5-6 intercostal space
Pulse amplitude
force which bolus of blood moves through artery 0-4, 2 is normal
pulse pressure
difference btwn systolic and diastolic S-D=force generated with each contractionnormal - 30-50 mmhg
Pulse paradoxus
exaggerated decrease in amplitude of pulsation with inspirationincrease during expiration
Purpose of taking heart rate (pulse)
Number of cardiac cycles/minute may give clues to cardiovascular or neurologic status, psychogenic factors, or drug use
Adult average pulse
60-90 bmp
Standard “normal” temperature range for adults
97.3 - ~99.5 (oral)
Most average (oral) temperature
98.6F/37C (decreases with age)
Average rectal temperature
99.6
Average axillary temperature
97.6
Average tympanic membrane temperature
99.6
Most accurate temperature measurement method
rectal
How to take respiratory rate
Without patient’s knowledge, observe rise and fall of chest for 15 seconds. Multiply x 4. May be performed while still holding wrist after taking pulse.
Normal respiratory rate range for adults
12-20 respirations/minute
4 parameters to assess for respiration
(1) respiratory rate (2) respiratory pattern (3) respiratory depth (4) signs of distress
Signs of distress in respiration
nasal flaring, cyanosis, labored breathing, tensed accessory muscles, wheezing, tachypnea or bradypnea
Adult blood pressure range
<90
Systole
Maximal ventricular contraction (top number)
Diastole
Maximal ventricular relaxation (bottom number)
Cardiac outout
Stroke volume x heart rate
Stroke volume
Blood pumped by left ventricle in 1 contraction
How to measure cuff size for BP
Bladder length must cover 80% circumference of upper arm, width should be ⅓ - ½ circumference
How to take BP
Locate brachial artery and center cuff (arrow toward) arteryWhile palpating radial pulse, inflate cuff until pulse disappears, deflate cuffRe-inflate cuff to 20-30 mm Hg above reading when pulse disappeared (this is the auscultatory gap)Deflate cuff slowly, note mm Hg when Korotkoff sounds start and stopRepeat in other arm (right tends to be higher)
What can affect BP?
Anxiety, hyper/hypotension, vascular resistance, pain, fever, weight, lifestyle, caffeine, alcohol, drugs
BMI formula
weight (kg) / height (m^2)
Describe the auscultatory gap, method for obtaining it, and the clinical usefulness of it
The auscultatory gap is the period of silence between the Korotkoff sounds Phase 1 and Phase 2. It’s obtained by palpating the blood pressure and adding 20-30 mm Hg to the systolic number. This is useful because it prevents providers from being misled into underestimating the systolic or overestimating the diastolic
What is the most appropriate time in the female menstrual cycle to perform a breast exam?
The week after menses. hormonal changes are least noticeable during this time (breast enlargement, tenderness, increased nodularity)
Korotkoff sounds
Low-pitched sounds produced by turbulence of blood flow in the artery
T/F: Korotkoff sounds are best heard with the bell of a stethoscope.
True, they are LOW-pitched (light pressure with “tunable” stethoscope)
Stated Age vs. Apparent Age
Stated age is the patient’s chronological age.Apparent age is based off appearance, may be older, younger or equal to stated age.
Level of toxicity
Most important in assessing an ill patient. Only mention if the patient is ill; not mentioned if patient is not ill. How sick does the patient appears to you; toxic vs nontoxic appearing.
Acutely ill vs. chronically ill
Acute: sudden, temporary onset of symptoms.Chronic: longer, more generalized pain.
Affect appropriate for situation
Assessing a patient’s mood and behavior. Behavior should usually be cooperative and friendly.
Level of alertness
Patient’s ability to interact and respond to you.
Orientation
Patient’s ability to recognize where the pt is, who the pt is and what time it is.
Tanner Stage
Stages of sexual development in males and females beginning with the adolescent stage through adult stage. Breast development is measured from M1-M5. Pubic Hair development in both males and females is measured from P1-P6. Testes/Scrotum development is measured from G1-G5.
What BMI is considered obese?
30-39.9
What does cachectic mean?
Looks like pt is at the end of his/her lifetime; physical wasting
Weber test- purpose?
Helps to assess unilateral hearing loss
Weber test- procedure?
Place a vibrating tuning fork on the middle of the patient’s head, ask the patient if the sound is heard, ask if sound is heard equally in both ears or better in one. Check this by covering one ear and asking again which ear sounds better (the occluded ear should sound better).
Weber test- what is expected with conductive hearing loss?
The sound is heard better in the bad ear.
Weber test- what is expected with sensorineural hearing loss?
The sound is heard better in the good ear.
Rinne test- purpose?
Helps distinguish whether patient hears better by air or bone conduction
Rinne test- procedure?
Place vibrating tuning fork against patient’s mastoid bone, ask patient if sound is heard, have patient tell you when they no longer hear the sound (count seconds), then move 1-2cm in front of ear, ask patient’s if they can hear it, then have the patient tell you when they no longer hear the sound (count seconds)
Rinne test- expected/normal results?
Aka Rinne positive findings.AC>BC in 2:1 ratio
Rinne test- what is expected with conductive hearing loss?
Aka Rinne negative findings.BC>AC on affected side
Rinne test- what is expected with sensorineural hearing loss?
AC>BC but less than a 2:1 ratio
Whisper test- procedure?
Occlude patient’s untested ear, stand out of line of vision about 1-2 ft away from side being tested (open ear), whisper word with 2 syllables, ask patient to repeat the word, move to other side and do the same with different words, ask patient to repeat the word, exhale fully to produce whisper sound.
Audiogram- what is it?
Audiogram is a graphical display of the hearing tests, graphing frequency (in Hz) vs the intensity/loudness of sounds (in dB).
Audiogram- what’s the purpose?
It is used to show the amount of hearing loss that an individual has for each ear.
Diaphragmatic breathing
Movement of the diaphragm responding to intrathoracic pressure.
Abdominal breathing
Involves contraction of the diaphragm responding and the use of abdominal muscles resulting in the expansion and recoil of the abdominal walls.
Thoracic breathing
The result of the use of intercostal muscles.
Define and discuss Korotkoff sounds.
The low-pitched sounds produced by the turbulence of the blood flow in the artery (pg. 439 Mosby’s). Korotkoff divided the heart sounds heard while taking a BP into 5 phases:
• Phase 1: two consecutive beats indicate the systolic pressure.
• Phase 2: a period of silence know as the auscultatory gap. The gap should be about 10-15 mm Hg from the phase 1 sounds to the phase 3 sounds. Variability in the size of the gap can indicate cardiac abnormalities.
• Phase 3: Crisp heart sounds return.
• Phase 4: Heart sounds become muffled. This is first diastolic number.
• Phase 5: Heart sounds disappear. This is the second diastolic number. The second diastolic number is the one most commonly reported.
physiologic factors influencing arterial blood pressure.
Stroke volume (strength of contractions and volume of circulating blood)
• Heart rate
• Peripheral Vascular Resistance (how much the vessel walls resist exspansion by the circulating blood)
determining orthostatic blood
- Measure BP first in supine, then sitting, then standing positions
- Significant change (pulse increase by more than 15-20bpm or drop in systolic BP of more than 20mmHg within 3 minutes) can indicate disease
- Suggests antihypertensive use, depleted fluid volume (hypovolemia), drug use, autonomic nervous system disease (M 441)
- Indicated when pt is on antihypertensives, complains of fainting/postural lightheadedness, prolonged time in recumbent position (M 441)
acute pain
sudden onset, short duration. Generally associated with surgery, injury, or acute illness
chronic pain
persistent (6 months or longer), associated with prolonged disease
Nociceptive Pain:
A type of time limited pain that resolves when tissue damage has healed. Examples include sprains, bone fractures, cuts, and burns. Nociceptors at the site of tissue damage are activated and signal is conducted via peripheral nerves to the CNS 2 types of nociceptive pain: somatic and visceral
visceral pain
originating from internal organs
somatic pain
originating from superficial/muscular structures of the body
Neuropathic Pain:
Neruopathic pain is also known as chronic pain caused by a primary lesion or dysfunction of the nervous system beyond expected healing. When peripheral nerves are damaged, repeated signals are fired, causing hyperexcitability of the dorsal horn, transmitting a pain signal to the brain causing sustained pain.
parts of GA
a. gender
b. general age category
c. presenting appearance
- level of toxicity
- relative comfort vs. discomfort
- acutely ill vs. chronically ill
- affect appropriate for situation
- posture
- speech
d. mental status
- level of alertness
- orientation
e. body development
- development / general features
- Tanner stage
- body habitus - height / weight / proportionality
- nutritional status (i.e., obese, thin, frail, anorexic, cachectic, etc.)
f. ethnic/racial background (when clinically appropriate)
Visual Acuity: Direct Central Vision
- Snellen chart used for examining far vision by the ability to read sized letters from a distance of 20 feet.
- Rosenbaum chart is used for near sighted vision acuity. It is to be held at 14 inches from eye, `
Visual Acuity: b. Peripheral Vision:
You cover one of your eyes, the patient covers one of theirs but the opposite. You should be looking at each other’s uncovered eye.
• Fully extend you arm (on the side of the open eye) midway between the patient and yourself, and then move your arm slowly centrally, having the patient tell you when the fingers are first seen
Test nasal, temporal, superior, and inferior fields
visual acuity: color vision
ishara color test
Red testing make be helpful in determining optic nerve disease, an afferent pupillary defect often coexists with a red defect.
small aperature
for small pupils slit – for anterior eye and elevation of lenses
red free aperature/polarizing
red free filter – produces green beam for examination of the optic disk for pale appearance and vessel changes. Recognition of retinal hemorrhages (blood appears black)
grid aperature
Grid – Estimation of the size of fundal lesions.
diopter settings
There is an inverse relationship, the higher the diopter, the closer the object. more in the green, closer up.
Cobalt Blue Light:
Aperture setting used to aid in diagnosis in corneal abrasions or ulcers after staining the cornea with an fluorescein.
eye exam external
inspect:
eyebrows, periorbital regions, canthus, conjunctiva, lid covering part of iris, lacrimal gland, duct,
assess: Extraocular movements (EOM), acuity, accomodation
eye exam internal
red reflex,
adjust settings to visualize macula, disk, cup, vessels.
a. Visual Impairment/Loss
blurred vision/loss of vision
Legal Blindness:
blurred vision/loss of vision 20/200
Proptosis/Exophthalmos:
Bulging of the eye anteriorly out of the orbit
Ptosis:
A drooping of the upper eyelid - indicates a congenital or acquired weakness of the levator muscle or a paresis of a branch of the third cranial nerve.
Nystagmus:
Involuntary rhythmic movements of the eyes; the oscillations may be horizontal, vertical, rotary or mixed.
Strabismus
A crossed eye - both eyes not looking in the same place at the same time
Diplopia
he perception of two images – may be monocular or binocular.
• Monocular diplopia is an optical problem,
• Binocular diplopia is an alignment problem
h. Emmetropia:
The condition of the normal eye when parallel rays are focused exactly on the retina and vision is perfect.
Hyperopia:
Farsightedness, a refractive error in which light rays entering the eye are focused behind the retina
Myopia
Nearsightedness, a condition resulting from a refractive error in which light rays entering the eye are brought into focus in front of the retina.
Astigmatism
An abnormal condition in which the light rays cannot be focused clearly in a point on the retina because of an irregular curvature of the córnea or lens
Presbyopia:
Hyperopia and impaired near vision from loss of lens elasticity, generally devloping during middle age.
Anisocoria
Unequal pupil size
soft neck tissue anterior triangle
hyoid bone, cricoid cartilage, trachea, thyroid cartilage, thyroid, anterior cervical lymph nodes
soft neck tissue posterior triangle
the trapezius and sternocleidomastoid and clavicle. Structures within this include posterior cervical lymph nodes
rubor: redness;
response to inflammation/irritation
turgor
i. Gently pinch skin on forearm or sternal area between thumb and forefinger and then release the skin.
ii. Should not be tested on back of patients hand
iii. Skin should feel resilient, move easily when pinched, and return to place immediately when released.
physiologic/hormonal control of breast development
Hormonal control of breast development:
• Estrogen secreted by ovaries during puberty stimulates growth and development of duct system.
• Progesterone secreted by corpus luteum and placenta during pregnancy act with estrogen to bring areola to complete development
hormonal production of milk during lactation
- Prolactin, secreted from pituitary gland, together with adrenal steroids induces lactation. The marked decrease in estrogen and progesterone following childbirth signals the start of prolactin secretion.
- Oxytocin, secreted from hypothalamus stimulates contraction of muscular cells in the milk ducts and mammary glands
Physiologic control of the production of milk during lactation:
• Sucking: The baby nursing from the mother stimulates pulsatile increase in prolactin secretion, stimulating milk secretion and discharge of milk.
lactation-
production and release of milk by mammary glands.
a. mass:
A swelling, growth, or lump in the breast tissue. Note temporal sequence (onset, length of time, come and go), tenderness or pain, size, character, location, shape, consistency (firm, soft, hard), mobility, border, relationship to menses. Most are non-cancerous (e.g. fibrocystic changes, fibroadenoma).
Fibrocystic Changes –
• Benign cysts that are cyclic w/ menses
Usually tender to palpation • Fluid filled cysts that USUALLY occur bilaterally • Single or multiple cysts can occur • Masses are round and well delineated • Mobile • Consistency ranges soft -→firm • No signs of retraction (dimpling) on nipple/skin surface • Age range: 20-49
Fibroadenoma
Benign tumors not cyclic to menses
• Usually non-tender to palpation
• Single, sometimes multiple – usually bilateral
• Round/discoid – Firm/rubbery consistency – well delineated - mobile
• No signs of retraction.
• Age range 15-55
Cancer breast
– Malignant tumors
• Mass is not cyclic to menses
• Usually non-tender
• Consistency is hard/stonelike – irregular shaped - fixed
• Single and usually unilateral
• Signs of retraction in skin/nipples – prominent vasculature (veins)
• Age range 30-80
Fat Necrosis
– Benign lump caused by inflammatory response to local injury.
• Firm. Irregular. Discoloration at site – can be mistaken for Malignant tumor. Biopsy required.
• Can occur at site of past injury/trauma to breast
d. retraction:
Aka dimpling, is a pulling back of the skin on breast or areola/nipple indicating inward pulling by inflammatory or malignant tissue. Note temporal sequence, severity, and associated symptoms e.g. pain.
c. nipple discharge:
Any fluid that seeps out of the nipple of the breast. Note character (spontaneous vs provoked, uni-/bilateral, temporal sequence, color, consistency, odor, amount, associated sx e.g. inflammation. In women, discuss pregnancy, lactation.
b. pain: breast
Aka mastalgia, is any tenderness, discomfort, or pain associated with the breast tissue. Note temporal sequence, character (pulling, stinging, burning, aching), location on breast, radiation to armpit, relationship menses (cyclic-timing/severity), and recent trauma to breast.
Features included in documenting breast masses
- Location: clock positions and distance from nipple
- Size: in centimeters: length, width, thickness
- Shape: round, discoid, lobular, stellate, regular or irregular
- Consistency: film, soft, hard
- Tenderness
- Mobility: movable or fixed to overlying skin or subajacent fascia
- Borders: discrete or poorly defined
- Retraction: presence or absence of dimpling: altered contour
Morphology: macule
flat, cutaneous color change, less than 5mm (freckle)
Morphology papule
elevated, circumscribed area different from skin color; <.5cm in diameter (wort)
Morphology plaque
(psoraisis) elevated, firm, and rough with flat top; greater than .5cm diameter
Morphology patch
flat, non palpable, greater than .5 cm, irregular shape
Morphology Nodule
elevated, firm, extends to dermis, deeper than papule, 1-2 cm.
Morphology • vesicle-
(ex. chickenpox) elevated, superficial; filled with serous fluid; less than .5cm in diameter
Morphology Bulla
-(ex. blister) vesicle >.5cm in diameter
morphology • pustule
-(ex. impetigo, acne) similar to vesicle but filled with purulent fluid
skin exam: location
Region of the body lesion is located.
o Sun-exposed areas o Flexural and extensor aspects of extremities o Stocking and glove regions o Truncal o Face, shoulder, back
skin exam size
Determine size of lesion using a small ruler.
Determining size will allow you to differentiate between lesions
skin exam distribution
localized vs. regional
skin localized distribution
Appears in one small area
- Example: Impetigo, tinea corporis
skin regional distribution
Lesions found in a specific region of the body
skin color
flesh colored, tan, light brown, brown, black, or red/pink
grouping annular
• Annular- arranged in a circle/ring (i.e. ringworm)
grouping arcuate
• Arcuate (arciform)- shaped in a semi-circle, with a trail
grouping circinate
Circinate- shaped like a C
grouping grouped
Grouped- distributed in clearly defined groups
grouping iris
• Iris- dark center with surrounding lighter halo
grouping keratotic
Keratotic- linear scales grouped together
grouping linear
Linear- distributed in a line
grouping reticulated
Reticulated- distributed in a mesh-like pattern
grouping serpiginous
Serpiginous- snake-like distribution
grouping telangiectatic
Telangiectatic- look like broken blood vessels, spider-web like
grouping dermatomal
Dermatomal- lesions follow a dermatome
grouping confluent
Confluent- closely grouped together in no particular pattern
grouping discoid
• Discoid- closely clumped together in a filled-in circle
grouping eczematoid
• Eczematoid- raised plaque of confluent papules
Effusion: x
Effusion: Loss of fluid from blood vessels or lymphatics into the tissues or a body cavity
Frontal Bossing:
an unusually prominent forehead, sometimes associated with a heavier than normal brow ridge. This is a rare physical finding often associated with syndromes in which excess growth hormone is present. Most commonly identified in infants and children.
strawberry tongue –
initially tongue appears white with prominent papillae, white gradually decreases leaving tongue bright red, looks like a strawberry, characteristic of scarlet fever
blood supply to breasts
primarily 1) internal mammary artery and 2) lateral thoracic artery.
drainage for breast
- Blood Drainage:
- To the axillary vein
- Lymphatic drainage: 75% to axillary nodes
- Primarily radially & deep around breast towards axillary nodes.
external exam of head
inspect head, palpate scalp and face head
external exam ears
hearing assistance?
inspect/palpate auricle and mastoid area
test gross hearing
otoscopy - finger strut, canal, TM, Bones
external nose
inspect shape, palpate
patency
nasoscopy - septum, turbinates, vestibule, membranes
external mouth
dentures? inspect lips state of dentention ducts, gums, soft/hard palate, pharynx breath
external neck
gross appearance palpate thyroid exam palpate glands cervico-facial lymph nodes
breast exam
assistant in room,
warm hands,
undress waist up
inspect with arms hanging on sides, on head, on hips, leaning over
palpate all 4 quads and up arm
3 levels of depth
and nipples
in stripe format
skin hair nails exam
sunexposed areas, color, uniformity, moistness, turgor, lesions,
texture, distribution, quantity, resilience
discoloration, symmetry, cleanliness, thickness, adherance, cap refill
