Quiz 1 Flashcards
purpose of cultural competence
reason cultural competence is important
Understanding of a particular culture may be useful in the solution of problems that may at first have seemed intractable.
How culture may impact aspects of an exam of emotional health
cultural definitions of health and illness differ
Beliefs and behaviors that will have an impact on patient assessment include the following:
Modes of communication
Health beliefs and practices
Nature of relationships within a family
Diet and nutritional practices
Steps of assessment in order
- inspection & continue throughout exam: use eyes & nose (smell, gait, eye contact, demeanor, clothing, color/moisture of skin
- palpate
- percussion
- Auscultation last WITH EXCEPTION of abdominal exam
what part of hand to use for distinguishing vibration w/ palpation
ulnar surface of the hand & fingers (pinky side)
what part of hand best to palpate temperature
dorsal (back); not exact but general understanding to compare to other areas of body
What are normal percussion notes, know where they are found (5)
- tympany/tympanic= loudest (drumlike; gastric bubble)
- flatness= soft/quietest (very dull; over muscle)
- hyperresonant= very loud (boom like; emphysematous lungs)
- resonant= loud & hollow (healthy lung tissue)
- dull= soft-mod (thudlike; over liver)
best way to distinguish degree of resonance in percussion
listening to sound change as you move from one area to another; easier to hear change from resonance to dullness
immediate/direct percussion
striking the finger/hand directly against body (tip not pad of finger)
indirect/mediate percussion
finger of one hand acts as hammer (plexor) and a finger of the hand acts a striking surface (tip not pad of finger); keep distal phalanx of middle finger on body with other fingers elevated, snap the wrist of other hand downward and with the tip of middle finger sharply tap the interphalangeal joint of the finger that is on the body surface
when to use fist percussion
elicit tenderness arising from liver, gallbladder or kidneys. Use ulnar aspect of fist to give firm blow to flank and back
how deep can percussion notes (resonance) arise from
vibrations from 4-6cm deep in body tissue; density determines degree of tone
what can impact percussion note tone?
density; the more dense= the quieter the tone
what part of hands are more sensitive for palpation
palmar surface fingers and finger pads > fingertips
when to palpate w/ palmar surface of fingers & finger pads
whenever discriminatory touch is needed for determining position, texture, size, consistency, masses, fluid, crepitus
what to listen for with auscultation
sound: intensity, pitch, duration, quality
How to use/apply an otoscope
Types and how to use/apply a stethoscope
acoustic (diaphragm & bell), magnetic (just a diaphragm), electronic/digital
press diaphragm firmly against SKIN and hold end piece between fingers; don’t touch bell or tubing
when to use diaphragm vs bell of stethoscope
The diaphragm is best for higher pitched sounds, like breath sounds and normal heart sounds. The bell is best for detecting lower pitch sounds, like some heart murmurs, and some bowel sounds
pneumatic otoscope what they are for, how they are used, & any differences with pediatrics
pneumatic attachment used to eval the fluctuating capacity of the TM
produces puffs of air that causes the TM to move
For adults and older children, the pinna is gently retracted in a posterior and cephalad vector. For neonates, the examiner pulls the pinna posteriorly and inferiorly.
reflex hammer what they are for, how they are used, & any differences with pediatrics
used to test deep tendon reflexes
hold loosely between thumb and index so it moves in swift arc and controlled direction; tap quick and firm with snap of wrist
pediatric- use finger instead, less threatening; many providers let child hold hammer while they use finger to tap
ophthalmoscope what they are for, how they are used, & any differences with pediatrics
visualize interior structures of eye using system of lenses and mirror, projects various apertures of light into eye, lens number corresponds to magnification power (diopter)
Positive numbers (plus lenses)= black; clockwise rotation of lens selector
negative numbers (minus lenses)= red; counterclockwise
large aperture used most often= large round beam
whats a panoptic/panoramic ophthalmoscope
allows a larger field of view (25 degrees instead of 5) and increases magnification
fundus 5x larger in undilated eye
what can the plus/minus system on ophthalmoscope compensate for
myopia or hyperopia in both the examiner and the patient; no compensation for astigmatism
Wood’s lamp & what they are for, how they are used, any differences with pediatrics
used to detect fungal infection on skin
light source with a wavelength of 360 mm. It’s a black light that causes certain substances to fluoresce
darken room, shine line on lesion, green/yellow= fungus
pediatric= dark room intimidating. shine lamp on something fluorescent (nondigital watch) to give them sense of what you’re looking for
Indications of cognitive impairment (history or PE findings)
significant memory loss
confusion (impaired cognitive function with disorientation, attention and memory deficits and difficulty answering questions or following multi step directions)
impaired communication
inappropriate affect
personal care difficulties
hazardous behavior
agitation
suspiciousness
Areas of the brain and their function
*** Refer to pic in book pg. 89
transverse gyrus= auditory
broca area= motor speech
prefrontal= behavioral ethical moral social
premotor= intellectual
precentral gyrus= motor
central sulcus
postcentral gyrus= sensory
primary tases area of postcentral gyrus
somatic sensory association area
visual association area
visual cortex
wernicke area (sensory speech area)
Main findings & patho in acromegaly
excessive growth and distorted proportions caused by hypersecretion of GH and insulin-like growth factor (benign tumor most common cause); middle-aged adults
Subjective
slow progressive facial feature exaggeration
increased shoe, ring sizes
same height
oily/sweaty skin
snoring
pain in joints
decrease exercise tol.
objective
frontal skull bossing, cranial ridges, mandibular overgrowth, maxillary widening, teeth separation, malocclusion, overbite
skin thickening on face/tongue/lips/nose, hands/feet = enlargement
joint enlargement/swelling/pain
vertebral enlargement, kyphoscoliosis
cardiac ventricular enlargement bilaterally w/ decreased exercise tol.
main findings in Turner syndrome
partial/complete absence of second X chromosome
subjective
poor height growth
lack of breast development, amenorrhea
normal intelligence
objective
short stature
webbed neck
broad chest, widely spaced nipples
wide carrying ankle of elbow
low posterior hairline, misshapen/rotated ears, narrow palate/crowded teeth
coarctation of aorta, bicuspid aortic valve
sensorineural hearing loss
infertility
main findings in Cushing syndrome
prolonged excessive glucocorticoids
subjective
weight gain, change in appetite
depression, irritable, decrease libido
decreased concentration, impaired short term memory
easy bruising
menstrual abnorms
weight gain but slow height velocity in children
objective
obesity “buffalo hump”
facial plethora “moon face”
thin skin, red/purple striae, poor skin healing
proximal muscle weak
hirsutism or female balding
peripheral edema
children= short stature, abnormal genital virilization, delayed puberty
main findings in precocious puberty
onset of secondary sexual characteristics (breast tissue, pubic hair, enlarged testes then penis) before 7 y/o in white girls, 6 y/o black girls, 9 y/o males
Exam findings indicative of nutritional deficiency, assessment of nutrition and protein status
Growth and development milestones in children, walk, talk, use sentences (Expressive language milestones for infants and children)
Difference between an objective and subjective finding, know examples
subjective= what the patient tells us
objective= what we are seeing, hearing, assessing, discovering
Description of common macule, papule, vesicle, wheal and ex
macule= flat, circumscribed area that is a change in color of the skin. < 1cm diameter . Ex freckle, measles
papule= elevated firm circumscribed area < 1 cm diameter. Ex: wart, elevated mole, lichen planus
wheal= elevated, irregular shaped area of cutaneous edema, solid, transient variable diameter. Ex insect bite, urticaria, allergic rxn
vesicle= elevated circumscribed superficial not into dermis filled with serous fluid < 1 cm diameter. Ex varicella, herpes zoster
What are lesions that require further investigation; what do they look like
Other common skin abnormalities; staph and strep infections
Staph:
furuncle (red hot tender pus)
cellulitis (or strep)
impetigo
What do herpes, basal cell, malignant melanoma and seborrheic keratosis look like
herpes zoster= pain/itch/burn before eruption, single dermatome w/ red swollen plaques/vesicles that fill w/ purulent fluid. Does NOT cross midline
herpes simplex= (1 oral, 2 genital) tender/pain/paresthesia/burning, grouped vesicles red at base then crust.
basal cell= not healing lesion, crusting, itch, bleed, won’t heal. pink red black, brown, white. Rolled boarder indent center. White/yellow waxy taut/shiny
malignant melanoma= new/changing mole, irregular pigmented lesion, asymmetry, irregular boarders, diff shade colors, diameter > 6 mm, evolution/change in existing pigmented lesions esp. nonuniform/asymmetric
seborrheic keratosis= chronic/reccurrent red scaling where sebaceous glads are (scalp, back, diaper area). Scaling, adherent, thick, yellow, crusted
What are common normal skin lesions on an older adult
Normal lesions:
1. cherry angiomas (tiny/bright ruby red-dark blue round papules that may get brown over time)
2. seborrheic keratoses (pigmented raised warty on trunk. *must be differentiated from nevi or acitinic keratoses that could be malignant)
3. sebaceous hyperplasia (yellow flat papules w/ central depressions hard to discern from basal cell carcinoma)
4. cutaneous tags/acrochordon (small soft skin colored pedunculated papules of skin neck/chest)
5. cutaneous horns (small hard projections of epidermis on forehead/face and can mean underlying squamous cell carcinoma or wart
6. solar lentigines= irregular gray/brown macules over sun areas. “Age spots”
Normal characteristics:
skin more pale
increased freckling
hypopigmented patches
flaking/scaling d/t dry skin on extremities
thin skin esp over bone, loose hanging skin d/t lost elasticity/gravity/lost adipose = tenting w/ turgor
wrinkles
senile purpura (bruise) dorsal hands and arms
What to expect when palpating lymph nodes
easily palpable nodes not generally found in healthy adult
may detect small movable discrete shotty nodes (may feel like BBs under skin) less than 1 cm in diameter that move under fingers
when enlarged nodes found explore adjacent areas and regions drained by them for s/sx infection or malignancy
lymph nodes: Differentiating infection from malignancy
malignant= hard fixed painless nodes; palpable supraclavicular node on left (Virchow node) is clue to thoracic or abdominal malignancy
infection= tender
*slow nodal enlargement over weeks= benign, rapid enlargement without signs of inflammation= malignancy
lymph nodes: normal changes in adult
diminish and size decrease w/ advanced age. Nodes of older adults more fibrotic and fatty
lymph nodes: where they’re palpable
neck: occipital, postauricular, posterior cervical, preauricular, parotid, retropharyngeal (tonsillar), submandibular, submental, anterior cervical, supraclavicular (felt when disease)
epitrochlear
inguinal and popliteal
lymph nodes: how to differentiate between cyst
check if it transilluminates
nodes do NOT, cysts do
lymph nodes: painful vs non painful meaning
tender= infection
not= malignant if enlarged
lymph nodes: when does enlarged need further investigation
hard fixed painful
rapid enlargement
tender
> 1 cm
How to palpate the thyroid; what will you expect to feel
History and physical findings suggestive of hypo and hyperthyroidism
. History findings suggestive of different types of headaches; migraine, tension, cluster
gold standard for pain assessment
self-report pain scale ? numerical rating scale
let them pick if more than one available
How to assess pain in child, when can a pain scale be used
children as young as 3 can self report; assess ability to understand higher-lower and more-less
practice using scale using old injury
wong-baker faces rating scale
oucher scale
FLACC for non verbal
Overall changes in the older adult to differentiate normal from abnormal
Nutrition: What is normal BMI; overweight BMI, obese BMI; physical signs of nutritional deficiency
undernutrition= < 18.5
appropriate= 18.5-24.9
overweight= 25-29.9
obesity= 30 or >
What is physiologic jaundice in the newborn, when is it normal and what does it indicate if abnormal
1st day of life, disappears by 8-10th day, can persist 3-4 weeks. Intense/persistent jaundice= liver disease, hemolytic process, or severe infection
examine mucosa and sclera in daylight
How to transilluminate the skull of an infant, what is seen, what is normal
In general, when using a standard 2-cell flashlight held tight (press firmly to skull) to the anterior fontanelle, transillumination of more than 2 cm around the edge of the beam or asymmetry of the transillumination suggests underlying pathology
What are normal/abnormal skin changes in pregnancy
normal= striae gravidarum (stretch marks), telangiectasias (dilate blood vessels) ace/neck/chest/arms, hemangiomas (benign vascular tumor), cutaneous tags, increased pigment areolae, vulva, perianal, axillae, linea alba, preexisting nevi darken/grow or new nevi, melasma (dark blotchy skin) forehead/cheeks/nose/chin, palmar erythema, itching on breasts and abdomen, hair lengthened & hair loss decreased
abnormal= itching with rash esp on palms & soles
What is SLUMS for
The Saint Louis University Mental Status (SLUMS) test is an assessment tool for dementia and mild cognitive impairment
What is the PHQ9 for
depression screening
What is the GAD7 for
anxiety screening
Anxiety can affect a person in numerous ways including insomnia and weight change (whether increase or decrease). When assessing for anxiety, be sure to complete a GAD-7 screening and score in order to give your diagnosis credibility through using medically approved criteria. When using the GAD-7 score, you can then determine the level of anxiety your patient is experiencing whether mild, moderate, or severe. This will help guide you in your decision making regarding the plan/medications you will give your patient.
What meds do you typically start with for anxiety and depression
When thinking about giving medications for anxiety/depression…we typically start with an SSRI or SSNI. These medications are effective and do not have the major side effects of benzos or TCAs.
Maslow’s hierarchy of needs
1- physiological
2- safety
3- belonging and love
4- esteem
5- self actualization
Important diagnostics if cognitive decline is found
If you determine they have a cognitive decline, it is important to get a MRI or CT of their brain. The MRI or CT will help determine what type of dementia they possess.
different types of dementia
alzheimer, vascular, frontotemporal, lewy body, korsakoff syndrome
Alzheimer s/s and diagnostic findings
Signs/Symptoms
Memory Impairment – forgets people
Executive function
Problem solving
Behavioral and psychologic symptoms
Apraxia – Difficulty with movement
Olfactory Dysfunction
Sleep Disturbance
PET/MRI Reading
MRI: Generalized/focal atrophy, white matter lesions, reduced hippocampal volume, medial temporal lobe atrophy
PET: Hypometabolism and hypoperfusion, neurofibrillary tangles
Vascular dementia s/s and diagnostic findings
S/sx
Sudden significant cognitive impairment
*Damage to multiple brain regions
*Strategic infarction - damage to single brain location
PET/MRI reading
MRI: Cerebral small vessel disease including microbleeds, Infarcts >15 mm or any size in cerebral cortex, Infarcts <15 mm in subcortical brain regions, white matter hyperintensities or hypodensities of presumed vascular origin, demyelination, axon loss, and oligodendrocyte loss
frontotemporal dementia s/sx and PET/MRI reading
s/sx
Disinhibition – socially inappropriate behavior
Apathy or loss of empathy – losing interest/motivation/relationships
Hyperorality – altered food preferences such as craving carbohydrates or sweets/binge eating, increase alcohol or tobacco, attempting to eat inedible objects
Compulsive behavior – ritualistic behavior such as hoarding, checking, cleaning; pursuing hobby/religious aspects obsessively
MRI: Frontal or temporal atrophy; Atrophy may affect one brain hemisphere more than the other
Lewy body s/sx and PET/MRI findings
s/sx
Progressive cognitive decline
Abnormal social/occupational functions
Deficit in attention, executive function, and visuoperceptual function
Hallucinations/delusions
Insomnia
Does not forget people
PET: low dopaminergic activity in striatum which is also seen in Parkinson’s Disease, multiple system atrophy, progressive supranuclear palsy
Korsakoff Syndrome s/sx and diagnostic findings
s/sx
Marked deficit in anterograde and retrograde memory
Apathy
Intact sensorium
Relative preservation of long-term memory and cognitive skills
MRI: Reduction in cerebral metabolic rate for glucose and decrease in benzodiazepine receptor; Results from Wernicke encephalopathy, enlargement of cerebral ventricles and sulci
Patient has hx of alcohol use disorder
how to initially address insomnia
When helping a patient with insomnia, do NOT automatically go to a medication such as Ambien, Lunesta, or Restoril. These type of medications are highly addictive and can cause more harm. ALWAYS start with melatonin as this is a natural hormone and one that may be lacking in the patient which is the pathophysiology regarding our sleep-wake cycle. Be careful how you treat your patients. Also getting them to do sleep hygiene also helps with insomnia. Turning off computers/phones allows the brain to relax and prepares one for sleep.
tuning fork 500-1000 hz used for what?
hearing range for normal speech since normal speech can range from 300-3000 hz
a 69 y/o truck driver presents w/ sudden inability to understand spoken language. this indicates a lesion in which area of the brain?
temporal lobe- responsible for comprehension of spoken and written language
