Physical Diagnosis Exam 1 Flashcards
Cardiac output
HR + SV
Stroke Volume
The volume of blood pumped from a ventricle of the heart in one beat
Systolic BP represents
the pressure in the arteries when the heart is contracted (contraction)
Diastole BP Represents
the pressure in the arteries when the heart is at rest (relaxed)
BP cuff length / width
80% of upper arm circumference, 40% of upper arm circumference
ausculatory gap
a period when Korotkoff sounds disappear during auscultation
orthostatic hypotension
temporary low BP and dizziness when suddenly rising from a sitting or reclining position
orthostatic bp is positive
Systolic BP decreases at least 20 points or diastolic decreases 10 points
Obtunded LOC
you must shake patient for response
Stupurous LOC
Painful Stimuli for response
Neoglisms
made up words, invented or distorted words
Confabulation
the act of filling in memory gaps with fabrications
Perseveration
persistent repetition of the same word or idea in response to different questions
Echolalia
automatic and immediate repetition of what others say, echoing
Clanging
choosing a word on the basis of sound rather than meaning
compulsions
Repetitive behaviors or mental acts that are performed to prevent a future state of affairs
obsessions
repeated, intrusive, and uncontrollable irrational thoughts or mental images that the patient considers unacceptable
phobias
irrational fears of specific objects or situations
delusions
false beliefs, often of persecution or grandeur, not shared by persons of similar culture that may accompany psychotic disorders
miosis
constricted pupils of less than 2mm
mydriasis
dilated pupils of greater than 6mm
Most common type of skin cancer
basal cell carcinoma 80%
3 types of skin cancer
basal cell carcinoma(80%), squamous cell carcinoma(16%), melanoma(4%)
A in abcde
asymmetry
B in abcde
border
C in abcde
color
d in abcde
diameter
e in abcde
evolution, elevation, enlargement
gender at greater risk for melanoma
Male
What are misinterpretations of real stimuli?
Illusions
What is the term for recurrent, uncontrollable thoughts, images or impulses that a patient considers to be unacceptable?
obsessions
What is it when a patient states persistent repetition of words or ideas?
Perseveration
What is it when a patient is only responsive to painful stimuli?
Stuporous
When you ask a patient to pick a face on the “FACES” scale to assess their pain, they pick this number to describe their pain as “hurts a lot”
4 or 8
which lymph node is most responsible for an abdominal malignancy when this node is enlarged?
Virchows node
What is the best visual exam to assess visual fields?
Confrontation
With unilateral conductive hearing loss, what would the results be in the Weber exam?
Weber test lateralizes to the affected ear.
In rinne exam what should the results be in a normal exam
AC>BC (air conduction is greater than bone conduction)
Patient centered interviewing
a technique in which clinicians follow the patients lead in seeking to elicit the patient’s emotions and personal health agenda to better understand the psychosocial context for disease
Clinician Centered Interview
- clinician takes charge of the interview to meet their needs in acquiring the symptoms and details to identify the disease.
goals of interview
Discovery, sharing, negotiation, union, support
Active listening
Closely attending to what the patient is communicating, using verbal and non verbal skills to encourage the patient to expand.
Autonomy
The patient has choices and may make them, which requires patient education
Beneficence
Practitioner must do good
Close ended question are what?
Yes or no, specific short answers
Coat length for student
Short coat or consultation length coat
Deontological imperatives
Duty to act
Discovery
Information that leads to correct A&P
Empathy
Concern, interest, understanding, respect and friendliness
Concern, interest, understanding, respect and friendliness
Encourages the patient to go on with words or silence, “please go on”
Fairness and justice
Recognizes the balance between autonomy and the interests of larger community
Guided questioning
Moving from open ended to focused questioning, Questions that elicit a graded response Offering multiple choice answers Using echo
hugs
Inappropriate
Negotiation
Negotiate to arrive at a course of workup or care that is consistent with patients need beliefs and desires.
non verbal communication
Appearance grooming eye contact comfortable social distance body language speech patterns self assessment
Non maleficence
Do no Harm
objectivity
Non judgmental attitude
Precision
Pay attention to detail so you can diagnose and treat effectively
Question : Even under threat, i will not use my medical knowledge contrary to the laws of humanity is an example of what?
Non maleficence
Question : Patient wants an unneeded test that is not covered by insurance. Reassuring the patient, explaining the diagnosis and follow up with the patient is an example of what?
Utilitarianism
Question : The health of my patient will be my first consideration is an example of what?
Beneficence
Reassurance
Identify and acknowledge the patients feelings
Sign
seen, observed, lab results, imaging
Support
Support in ways you can and refer in ways you cannot.
sympathy
feeling sorry for someone
symptom
what the patient tells you or how they are feeling
Transitions
Taking time between the HPI and PE to switch gears
Union
to establish a joint effort
Utilitarianism
Consider appropriate resources for the community at large
validation
Validating their feelings
partnering
When building rapport with patients, express your commitment to an ongoing relationship. Make patients feel that no matter what happens, you will continue to provide their care.
Precision:
A history should be reproducible by others
Interviewing techniques
Open-ended questions Closed questions Clarification or elaboration Facilitation Confrontation Silence Direction
7 attributes of a symptom
- Location- where is it, does it radiate? 2. Quality- what does it feel like? 3. Quantity or Severity- how bad is it? (for pain, how bad is it on a scale of 1 to 10?) 4. Timing: Onset, duration, & frequency- when did it start, how long does it last, how often does it occur? 5. Setting in which it occurs- include environmental factors, personal activities (walking), emotional reactions, and any other contributing factors 6. Factors that aggravate or relief the symptom- what makes it better? what makes it worse? 7. Associated manifestations
Gravida
number of pregnancies
Parity
Number of deliveries
Miscarriage’s
Number of miscarriage’s
Living Children
number of living children
GPML
Gravida, Parity, miscarriage’s, Living Children
CAGE questionnaire
cut down, annoyed, guilty, eye opener (alcohol)
Purpose of Record
Best Care Real time documentation Communication Quality assessment Reimbursement Risk management Education and research
RVU
Relative Value Unit
OLDCARTS
Onset, Location, Duration, Character, Aggravating factors, Relieving Factors/ Radiating, Temporal, Severity
Peds growth tools
Growth Chart (M/F), %, Tanner Stages
proper signature
scribble Murphy, PAS -1 For Dr. Doe
HIPPA increased protection for patients when?
1996
Reports required by law
Birth, Death, GSW, Communicable Diseases
Standard Precautions
A strict form of infection control that is based on the assumption that all blood and other body fluids are infectious.
exam techniques
Inspection Palpation Percussion Auscultation
Palpation sensitivity technique
Palmar surface of finger pads
Palpation vibration technique
Ulnar surface of hands (little finger side)
Palpation temperature technique
Dorsal portion of hand (Back)
Percussion technique
Middle finger on body, snap other middle finger on top of it between middle two joints (interphalangeal joint)
Bruit
Low pitched sound created from a turbulent flow, occurs form occlusion or carotid stenosis, sound like a murmur
Types of bruits
Temporal Carotid Thyroid Aortic renal iliac femoral
Cardiac auscultation with diaphragm listens for
S1, S2 murmurs Systolic clicks Pericardial rubs Opening Snaps
Cardiac auscultation with bell listens for
Diastolic gallops S3, S4 Diastolic Rumbles Mitral, Tricuspid
Cardiac Auscultation sites
APTM, APETM (all people enjoy time magazine)
Vital signs
BP, RR, HR, Temp, Waist circumference, BMI, HT, WT
Least accurate temp site
axillary
Oral Tmep
98.6 F / 37 C
Axillary Temp
1 Degree less than oral (97.6F)
Rectal Temp
1 Degree over oral (99.6)
Temp changes during the day
Low in morning, high at night
Hyperpyrexia/Hyperthermia
106 F or greater
BP = _____ x _____
CO x SVR (Cardiac Output / Peripheral Vascular Resistance)
CO = __ x __.
CO = HR x SV (Heart Rate x Stroke Volume)
SV =
stroke volume (volume of blood ejected with each cardiac cycle)
BP: Korotkoff sounds
Top number is systole (first sound heard), bottom number is diastole (sound goes away)
BP cuff too small
high reading
BP cuff too large
low reading
Inflate BP cuff to what level
30 points above palp reading
ausculatory gap usually means
Arterial stiffness, possible atherosclerosis
how to deflate bp cuff
2-3 points per second
MAP
mean arterial pressure
MAP =
(SBP + 2DBP)/3
BP in leg
Prone distal 1/3 of femur auscultate over popliteal 5-10 points lower in thigh than arm
orthostatic hypotension method
BP / HR in two positions Supine after resting 3-10 mins then 3 mins once standing (supine to standing normally systolic drops slightly while diastolic can rise) (sitting > +3-10 mins supine > + 3 mins standing)
orthostatic hypotension causes
Reduced blood volume Medications Aging Immobility, extended bed rest Autonomic nervous system dysfunction Diabetic neuropathy
indications for orthostatic hypotension
Dizziness fainting gi bleeds dehydration diabetes anti hypertension meds
Types of Pain (Nociceptive)(somatic)
Related to tissue damage
Types of Pain: neuropathic
-pain involving CNS or PNS
Types of pain: Psychogenic
Psychiatric conditions Personality and coping Culture norms Social support
Idiopathic
No identifiable etiology
FACES pain scale (alternate)
0-10 0 = No hurt 2 = Hurts a little bit 4 = Hurts a little more 6 = Hurts even more 8 = Hurts a whole lot 10 = Hurts worst
FACES pain scale
0-5 0 = No hurt 1 = Hurts a little bit 2 = Hurts a little more 3 = Hurts even more 4 = Hurts a whole lot 5 = Hurts worst
lethargic
must speak in loud forceful manner
coma
unarousable
Perceptions
awareness of objects through any of the five senses
thought process
the way a person thinks, logic, coherence, relevance
insight
awareness that thoughts, symptoms or behaviors are normal or abnormal.
Judgement
process of comparing and evaluating different possible courses of action
affect
Appearance of observable emotions and mood
mood
Sustained emotion of patient Euthymic = normal Dysthymic = depressed Manic = elated/excited
neologisms
made up words, invented or distorted words
flight of ideas
rapidly changing or disjointed thoughts, fast change of topics
derailment
the shifting from one subject to another with no apparent reason
Circumstantiality
Speech that is delayed in reaching the point and contains excessive or irrelevant details
incoherence
unintelligibility; lack of logic or relevance
blocking
sudden interruption in train of thought, unable to complete sentence, occurs in normal people
confabulation
fabrication of facts to hide memory impairment
Question: When assessing the patient’s thought content, it is important to always follow specific questions to keep the patient on task.
FALSE
Illusions
misinterpretations of real stimuli; e.g., the postman leaves mail, therefore there is a plot to poison the patient
Hallucinations
a subjective external stimuli the patient hears or sees that others do not Hear, see, smell, taste or touch Nothing to do with sleep
assess attention
Digital span: give the patient a string of numbers to recite back to you Serial 7s: ask the patient to subtract serial “7s” from 100 Spelling backward: ask the patient to spell W-O-R-L-D backwards
Remote memory
Historical events, birthdays, SSN
recent memory
Recent memory such as what the patient ate for breakfast, weather, national event
Assess new learning ability by…
Giving the patient three or four words to remember; then ask him to repeat the words after several minutes
Major function of skin
Boundaries for body fluid Protection Modulates body temp Synthesizes Vitamin D Heaviest organ (16% of body weight)
appendages of skin
hair, nails, sweat glands, and sebaceous glands
3 layers of skin
epidermis, dermis, subcutaneous layer
vellus hair
peach fuzz, fine short, less pigmentation
terminal hair
coarse, long hair of eyebrows, scalp, axillary, and pubic regions
sebaceous glands
all surfaces except palms/soles
sweat glands
eccrine and apocrine (groin / axilla)
basal cell carcinoma description
shiny and translucent, grow slow, rare to metastasize
squamous cell carcinoma description
Crusted, scaly, ulcerated, can metastasize
Melanoma description
spread quickly
Melanoma risk factors
HARMM History of previous melanoma Age > 50 Regular dermatologist absent Mole changing Male gender
Additional risk factors for melanoma
≥50 common moles atypical or unusual moles (especially if dysplastic) Red or light hair Actinic lentigines, macular brown or tan spots (usually on sun exposed areas) Heavy sun exposure (especially severe childhood sunburns) Light eye or skin color (especially freckles/burns easily) Family history of melanoma
Lesion description
number size shape color texture Primary Location Configuration
skin lesion: flat
Macule is <1cm Patch > 1cm Cannot palpate lesion with eyes closed
Skin lesion: Raised
Papule < 1cm with no fluid Plaque >1cm no fluid Vesicle <1cm with fluid Bulla >1cm with fluid
Macule
flat <1cm
Patch
flat <1cm
Papule
Raised <1cm, no fluid
Plaque
Raised >1cm, no fluid
Vesicle
Raised <1cm with fluid
Bulla
Raised >1cm with fluid
secondary lesions
Scales Crusts Excoriations Erosions Ulcers Fissures Scars Keloids
Lymph node sites
Preauricular Posterior auricular Occipital Tonsillar Submandibular Submental Superficial (anterior) cervical posterior cervical deep cervical supraclavicular Infraclavicular
When palpating the thyroid
Flex the neck slightly forward Place fingers of both hands with index fingers just below the cricoid cartilage If enlarged, listen over lateral lobes to detect a bruit The thyroid isthmus may not be palpable
Lymph node description
less than 1 cm, bean shaped, not hard,
Virchow’s node
Left supraclavicular node enlargement seen in thoracic or abdominal malignancy
Delphian Nodes
midline of the thyroid membrane
Sister mary joesph node
periumbilical node
esotropia
inward turning of the eye
exotropia
outward turning of the eye
Left hypertropia
Left eye turns up
Left hypotrophia
Left eye turns down
opthalmoscope
darken room disc to 0 Right, right right / Left, left, left 15 in away and start at 15 degree angle follow red reflex in
weber test
test for sensorineural hearing loss, lateralization
rinne test
test for conductive hearing loss, air vs bone
Weber test results
NORMAL: hear the sound in both ears In unilateral CONDUCTIVE HEARING LOSS, sound is heard in the impaired ear (it seems louder) In unilateral SENSORINEURAL HEARING LOSS, sound is heard in the good ear Ex: With someone who has potential hearing loss in the right ear, they will tell you they hear better in either the R side or the L side
Rinne test results
air conduction > bone conduction (normal, sensorineural hearing loss) BC > AC (conductive hearing loss)
infants
0-15 months
toddlers
15 months to 2 years
preschool age
3-5 years
School age
6-12
adolescence
13 and up (teens)
Percent of children who had contact with healthcare professional last year
93.6
ED visits by age
under 15 20%, 15-24 14.5 %
Minor
any person under 18 who is not married or emancipated
If parent is not available
step parent, grandparent, uncle, aunt sibling
Child in custody
caseworker, probation officer, or administrator can consent if parent cant be reached
Considered ordinary medical care
Exams Blood or TB test Preventative care Well child and immunizations (not surgery or anything requiring anesthesia or psych meds)
Emergent care of child when parent is unavailable
May provide emergent care, must first make at least one attempt to contact parent
emancipated minor
Person over the age of 16 can be emancipated ( a minor who is married is given the same legal status as an adult who is married) (Giving birth does not count)
Minors may seek care without adult for??
STD Birth control Pregnancy and the child substance abuse Physical or sexual abuse crisis intervention
Pediatric Vital Signs
RR elevated, HR elevated BP lower Temp same
What vital sign does not change with age
Temperature
Pediatric temperature considered a fever
a rectal temp of 100.4 (38.0C) is considered a fever, 100.3 is not a fever
2 growth charts
CDC charts: Birth - 36 months 2 years to 20 years Male and females have separate charts (CDC and WHO have different charts)
Peds BMI
BMI is age and sex specific Weight (lb.) / length (in) / length (in) x 703 = BMI height = 72in Weight = 205 example = (205/72/72) x 703 = 27.7
Peds BMI weight categories
underweight >5th percentile Normal 5-85 percentile Overweight 85-95 percentile Obese <95th percentile
lanugo
fine, soft hair, especially that which covers the body and limbs of a human fetus or newborn.
slate grey patches
Mongolian spots, look like bruises
Peeling
dry flaky peeling appearance in newborns
stork bite
A patch of deep pink skin found at the nape of the neck
salmon patch
(called a “stork bite” at the back of the neck or an “angel’s kiss” between the eyes) are simple nests of blood vessels (probably caused by maternal hormones) that fade on their own after a few weeks or months.
hemangioma
Lesions often start flat, circular area (halo) of pallor with central area of telangiectasia. Later develop raised red appearance.
milia
White papules on the skin that are keratin filled epithethial cysts which occur in up to 40% of newborns. Spontaneous exfoliation and resolution is expected within a few weeks.
Sebaceous hyperplasia
raised yellow bumps, The lesions are more yellow than milia and are the result of maternal androgen exposure in utero. Sebaceous hyperplasia is a benign finding and spontaneously resolves with time
erythema toxicum
pink rash that appears suddenly anywhere on the body of a term newborn during the first 3 weeks.
Transient Neonatal Pustular Melanosis
Hyperpigmented spots that remain after the fragile pustules have resolved. Because the rash starts in utero, lesions may be in any stage at birth. Etiology is unknown, it has been observed that African Americans infants are more frequently affected with this condition, occurring in up to 4%. (subdued lookin rash)
Mottling
changes in skin color (pale and bluish) Transient lacy erythema that occurs commonly in newborns particular visible when the infant is cold and disappears with warming.
Junctional melanocytic nevus
The lesion is completely flat and is medium to dark brown in color. It may become slightly raised as the infant grows and may become a compound nevus if intradermal melanocytes develop. It is considered a benign lesion.
Acrocyanosis
Temporary cyanotic condition, usually in newborns resulting in a bluish color around the lips, hands and fingernails, feet and toenails. May last for a few hours and disappear with warming.
Cafe au lait spots
Lighter in color than melanocytic nevi and caused by an increased amount of melanin in both melanocytes and epidermal cells, and may increase in number with age.
Sucking blister
Sucking blisters are solitary lesions that occur only in areas accessible to the infant’s mouth. The blister may still be intact at the time of delivery but often appears as a flat, scabbed, healing, area. They are benign and resolve spontaneously.
Misc marks post birth
Vacuum mark, forceps mark, nail scratches, scalp electrode site, facial bruising, jaundice
Harlequin color change
Occurs when the baby is in a side-lying position. The lower half of the body turns red and the upper half blanches with a distinct demarcation line down the midline.
paronychia
inflammation / infection around the nail
Growth chart birth -36 months measurments
Head circumference, weight
Sutures of a newborn skull
Coronal, sagittal, lambdoid, metopic
fontanelles of newborn
Anterior, posterior
Anterior fontanelle
soft spot, 2 frontal and 2 parietal bones meet remains until about 12 months to 2 years
posterior fontanelle
2 parietal and one occipital bones closes within 2-3 months
Newborn head molding
Abnormal head shape that results from pressure on the baby’s head during childbirth
Breech molding
Flat top head appearance, improves within a week
caput succedaneum
diffuse edema of the fetal scalp that crosses the suture lines. usually resolves in the first few days
Cephalohematoma
Swelling caused by bleeding between the osteum and periosteum of the skull. This swelling does not cross suture lines.
caput succedaneum vs cephalohematoma
caput succedaneum crosses the suture lines and is over the periosteum.
Plagiocephaly
asymmetry of the skull, helmet therapy is recommended at age 6 to 7 months mild, moderate or severe can result in walking issues
Normal newborn eyes
Normal greyish blue iris and the clear pupil. True color is not determined until the age of 6 months.
infant visual acuity
1 month = 20/300 6 months = 20/20
red reflex
a luminous red appearance seen upon the retina, should be symmetrical, most important eye exam in pediatric patient
Estropia
inward deviation of one or both eyes (ease in) 1.20%
Extropia
outward turning of the eye or eyes (Exit out)
Newborn nose breathing
Obligate nose breathers Use stethoscope
ankyloglossia
tongue-tie; a defect of the tongue characterized by a short, thick frenulum 4%
Epstein pearls
multiple small, white-yellowish, epithelial inclusion cysts found in the midline of the palate in newborn infants 60% Spontaneously resolves in a few weeks
natal teeth
teeth present at birth 1-2000 - 1-3500 These are mobile and can present an aspiration risk
Thrush
Candida (yeast) infection in the oral cavity, characterized by white plaques or patches on the tongue or mucosa Most common oral fungal infection in children
Cleft lip
congenital facial defect of the lip, can go uncorrected
cleft palate
a congenital split in the roof of the mouth Must be corrected
Demographics for cleft lip / palate
Total 1-700 Native Americans = 1-300 Asians 1-500 Caucasians 1-700 African 1-1200
baby teeth
deciduous teeth, 20 total
permanent teeth
the 32 teeth of the adult which are designed to last a lifetime.(includes wisdom teeth) arrive 6-21 years
geographic tongue
flat, irregular, red lesions on the dorsum of the tongue problem resolves itself.
Tonsil Size Grading
1+ Tonsils are visible, 2+ Tonsils are midway between tonsillar pillars and uvula, 3+ Tonsils touch the uvula, 4+ Tonsils touch each other
What can cause false positive strep test
Mono, Epstein Barr
Epstein Barr and penicillin
can cause rash
Tonsilectomy
Removal of tonsils Sleep apnea Chronic strep
Tonsilitis
Can be: Swollen look like strep (white patches) Viral Can all look like each other Must do culture to confirm diagnosis
Symptom diagnosis
OLDCART Onset, Location, Duration, Character, Aggravating/Alleviating Factors, Radiating, Timing or OPQRST Onset, Palliating/Provoking Factors, Quality, Radiation, Site, Timing
