Quiz 2 Flashcards
what measures visual acuity, what does it measure, and what CN
CN II (optic nerve)
measures central vision
Snellen chart- 20 feet away
***normal changes older adults
wrinkling, decreased turgor, less hair on the head (fine), more coarse hair on eyebrows/in nose, droopy eyebrows, loss angle of jaw definition, larger pores, decreased senses (smell, taste, hearing)
***HAs
tension= frontal, band-like, dull throb
migraine= unilateral, pulsating, throbbing, n/v, photophobia
sinus HA
cluster= unilateral, behind an eye, severe burning, tearing or nasal drainage
what do the fractions mean in visual acuity testing
numerator= distances of the patient from the chart (20 feet away)
denominator= distance average eye can read the line
smaller the fraction, worse the vision
legal blindness= vision can’t be corrected to better than 20/200
ex: 20/200 means the patient can read at 20 feet what the average person can read at 200 feet
***how to test near vision
Each eye separately w/ handheld card like Rosenbaum Pocket Vision Screener
35cm/14 inch from eyes
how to test peripheral vision, what do abnormalities indicate
through confrontation test
sit 1m/3ft away, NP and pt cover opposite eyes and NP holds up # of fingers in each visual field
only significant if abnormal. Can indicate: stroke, retinal detachment, optic neuropathy, pituitary tumor, compression at optic chiasm, central retinal vascular occlusion
how to perform external eye exam
systematic manner, begin with appendages (eyebrows/surrounding tissue) and move inward
only inspect upper tarsal conjunctivae if concerned about foreign body
cobblestoning on conjuctivae
allergic or infectious conjunctivitis
cornea assessment
shine light, should be no blood vessels
sensitivity controlled by CN V tested with cotton tip to cornea & pt should blink (also tests CN VII facial nerve)
decreased corneal sensitivity= DM, HSV, herpes zoster, conquence of trigeminal neuralgia or ocular surgery
corneal arcus= lipids around cornea= lipid disorder < 40 y/o, common in > 60 y/o
miosis vs mydriasis
miosis= pupil constriction < 2mm. ex Opioid use
mydriasis= pupil dilation > 6mm. ex stimulant use
how to test for afferent pupillary defect and what it means
swinging flashlight test; second pupil should only slightly dilate when light crossing over then should constrict like opposite eye
if second pupil continues to dilate, afferent pupillary defect present AKA Marcus-Gunn pupil
testing for accommodation
pupils dilate w/ distant object (10cm) constrict as moves closer and eyes will converge together
*only of dx importance if defect in pupillary response to light
failure to respond to light but retaining constriction w/ accommodation seen in DM or syphilis
extraocular eye movements
controlled by CN III (oculomotor) IV (trochlear) VI (abducens) and 6 muscles
***strabismus
corneal light reflex test (look at light with both eyes then object) if fail do cover-uncover test
strabismus= cross eyed, eyes don’t line up
and referral to ophthalmologist
exotropic= outward away from nose
esotropic= inward toward nose
may have poor or double vision
**opthalmoscopic/fundoscopic exam
**how to stand and where to look: To exam the patient’s RIGHT eye, hold the ophthalmoscope in your RIGHT hand and use your RIGHT eye to look through the instrument.
inspects optic disc, arteries, veins, retina
needs pupil dilation so dim room; hold 12 inches away then move to 6 inches
red reflex first= light illuminates retina. Absence can mean cataract or hemorrhage
should NOT see discrete areas of light/dark pigment
may see venous pulsations
disc margin sharp well defined yellow to creamy pink color varies w/ race
move closer to eye, vessels seen 3-5 cm away
myopic (constriction)= use minus/red lens
hyperopic= use plus lens
normal disc margin w/ ophth. exam
well define and sharp, yellow to creamy pink but darker in darker skinned people
***retinal abnormalities
myelinated retinal nerve fibers= white area continuous w/ optic disc; no physiologic significance
papilledema= loss of definition of optic margin. Caused by increased ICP
glaucomatous optic nerve head cupping= raised disc margins w/ lowered central area; intraocular pressure, peripheral visual fields are constricted
From review:
**cotton wool spots= ill-defined yellow areas caused by infarction of nerve layer of retina; Vascular disease from HTN or DM
- arterial narrowing
- **Retinal arteriovenous nicking (AV nicking; hypertension/hypertensive retinopathy and cardiovascular diseases such as stroke)
-copper wiring
-disc edema
hemorrhages in retina
disc margin= poorly controlled or undx glaucoma
dot hemorrhages= microaneurysms in diabetic retinopathy
HTN retinopathy
mild= retinal arteriolar narrowing, arteriovenous nicking, opacity (copper wiring) of arteriolar wall; mod risk of stroke, coronary heart disease, death
mod= hemorrhage, cotton wool spots, hard exudates, microaneurysms; strong risk stroke cognitive decline, death
malignant/severe= above signs plus optic disc edema/papilledema; strong risk of death, NEEDS rapid BP lowering
**psuedostrabismus
**BABIES, Asian or native american
false appearance of strabismus caused by flattened nasal bridge or epicanthal folds in babies. Disappears by age 1.
Corneal light reflex can distinguish. *Asymmetric light reflex indicates true strabismus
visual acuity for child
use LEA or HOTV at 4 y/o
stand 10 feet away up to 5 y/o and 10 or 20ft 6 y/o and older
test both eyes first
visual acuity should be:
36-47 months old= 20/50 or better
48-59 months= 20/40
60 months (5 y/o) and up= 20/30
photoscreening is alternative for children 3-6 y/o
specialist if falls outside normal range OR if individual eyes have two-line difference
diabetic retinopathy (proliferative and non-proliferative)
PROLIFERATIVE
dot hemorrhages or microaneurysms and presence of hard and soft exudates
asx or blurred vision, distortion, visual acuity loss in more advanced
ophthalmoscope= balloon-like sacs on BV, blots of hemorrhages on retina, tiny yellow patched hard exudates, cotton-wool spots * (soft exudates)
NONPROLIFERATIVE
development new vessels d/t anoxic stimulation. Bleeding major cause blindness
asx or floaters, burred vision, progressive visual acuity loss, hemorrhage
***cataracts
opacity in lens
central with aging
blurry vision, faded colors, lights too bright, halo around lights, poor night vision/double vision, freq. prescription changes
old age, *** biggest= DM, smoking, obesity, sun exposure (UV light)
children’s ear predisposed to what and why
middle ear effusion
adenoids occlude eustachian tube interfered w/ aeration of middle ear
sensorineural hearing loss
occurs first w/ high frequency sounds (speech and localization of sounds)
***otoscope eval adult and over age of 3
head toward opposite shoulder, auricle upward and back
should see: min cerumen, pink color, hairs in outer third, no odor/lesions/discharge/foreign body
normal TM
translucent, pearly gray, visible landmarks, no perforations. Conical contour with concavity at umbo
bulging TM
more conical, loss body landmarks, distorted light reflex
Hearing eval
CN VIII
whispered voice=occlude non tested ear, stand behind to side arms length exhale full and say 3-6 letters and numbers. Should repeat > 50%. Very good to detect in age 50-70 y/o
Weber and Rinne tests
***Weber test
***Conductive and sensorineural hearing test
assesses unilateral hearing loss
place base vibrating tuning fork midline on head- can hear equally or one ear better?
if unequal, repeat occluding each ear. Should hear BEST in occluded ear
shouldn’t have lateralization
conductive hearing loss= sound heard better in affected ear
sensorineural hearing loss= sound lateralizes to better ear
***rinne test
**Strike fork ONCE Put on mastoid bone (hear for lesser amount of time) bring up to ear and hear air conduction should hear for longer
**looks at JUST conductive hearing loss
distinguish if hears better by ear or bone conduction
air conduction SHOULD be heard longer than bone 2:1 aka heard twice as long (rinne positive)
***cocaine use signs in nose
rhinorrhea, hyperemia, edema nasal mucosa, white powder on hairs
long term= scabs, decrease smell/taste, septum perforation, chronic congestion, nosebleeds, chronic sniffling
allergy signs in nose
bluish gray or pale pink turbinates, swollen boggy
***otoscope eval in infant
pull auricle down and back
TM not conical until > 3 months so diffuse light reflex, limited mobility, dullness, opacity of pink/red TM
hearing test in children
whisper behind them, meaningful words (ex spongebob) they should turn toward. No rinne/weber until can follow instructions 3-4 y/o
***cobblestoning
conjunctiva= conjunctivitis
back of throat= PND, erythema with it
***Tonsil grading
0 to 4+
surgically removed to touching each other > 75% of oropharynx
***ruptured TM
sharp pain, bloody or yellow discharge, tinnitus, hearing loss
***what sound made when laryngeal obstruction
stridor
***what age infant turn head to sounds
4-6 months
***diaphragmatic excursion
purpose= looking for symmetry and how far lungs can expand so looking for difference in size
normal 5-6 cm
increased= concerned about pleural effusion
*** normal respiratory to HR ratio
1:4
***percussion of lungs
patient sitting up with arms on something or folded leaning forward to increase surface size of lung fields
dull sounds= pneumonia or pleural effusion (not air filled) or a mass
***sequence of lung exam on infants
NO percussion and listen first because they may cry
***age related change in older adults with lungs
as you age decreased diaphragmatic excursion bc lose elasticity in lungs
***Tactile fremitus - how to do and what’s increased/decreased
You have increased tactile fremitus over consolidation (fluid or mass; more vibration when it has something to vibrate off of), and you would have decreased air movement so decreased/absent breath sounds
decreased tactile fremitus= increased air so ex emphysema, less vibration bc nothing to vibrate against
vibration on chest wall. Posterior approach, put hands on shoulder blades, have them say 99, and move hands down symmetrically
***Non respiratory disorders that change RR
sepsis or shock
opioids or OD
brainstem CVA
fever
myasthenia gravis
metabolic acidosis (up RR)/alkalosis (down RR)
*** how to test for bronchophony
listen while patient repeats 99, should sound muffled
abnormal= not muffled then there’s consolidation (pleural effusion, pneumonia, etc)
**type of pectoriloquy, which is when voice transmission through lung structures is heard with a higher resonance. That’s why it should be muffled
***how to test for egophony
listen while they say “e”
normal= hear “e”
abnormal= if changes to an “a” means consolidation
***crackles vs rhonchi
auscultate before/after cough, rhonchi will clear after cough crackles will not
***Sequence for CV exam
1 inspect
2 palpate for PMI
3 auscultate
NO percussion
***stethescope
bell= low pitch
diaphragm= high pitch
***Why feel for PMI and what does it mean if there’s a displacement
PMI= point of max impulse where feel heart beat most; looking for left ventricle hypertrophy
displacement= significant CHF or HTN, left ventricle enlarges (hypertrophy) which displaces it
***Heave aka lift
Abnormal large beating of heart…Going to be felt at the left stern edge. And it’s gonna indicate RIGHT ventricular hypertrophy. If you feel a heave which is going to be an abnormal or large beating of the heart.
***JVD
So increase jugular Venus distension or increase Jdp above 3 cm causing jugular Venus distension is gonna indicate that there is some sort of cause for RIGHT sided heart failure.
***S1 S2 what do they mean
S1= start systole closure of AV (mitral & tricuspid) It’s gonna be a low pitch sound, and you’re gonna hear it best at the apex.
S2= end of systole, start of diastole, higher pitch and shorter, closing of the aortic and pulmonic valves
***murmurs
more serious= diastolic (S2)
less serious (S1)= systolic because not associated with ventricular, diastolic filling
***aortic stenosis vs aortic insufficiency
stenosis= systolic murmur, left 2nd intercostal, harsh murmur
insufficiency/regurgitation= diastolic murmur still heard in left 2nd intercostal space, soft murmur.
***mitral regurgitation
heard best at apex (5th intercostal midclavicular line) heard all the way across systole
S3- left sided (systolic) heart failure and is associated with severe mitral regurgitation, a low ejection fraction, restrictive diastolic filling
***mitral stenosis
diastolic murmur, low pitched, best at apex (5th intercostal midclavicular line)
***grading of murmurs
1-6
grade 1= barely audible
grade 6= loud (hear without stethoscope), feel thrill, and visible
***best way to hear murmur
- changing positions sitting or squatting to standing
- left lateral to hear mitral murmur
***normal JVP range
3cm above sternal angle
6-8cm above atrium
< 9 cm
anything above 9cm = JVD
***causes of edema (non cardiac)
kidney failure
electrolytes
infection
DVT
***bruit
turbulent blood flow= stenosis
***reynaud’s vs arterial disease
reynaud’s= episodic, gets better. Lack of blood flow, loss of pulse, fingers white/blue d/t cold exposure. Most at risk are middle aged women
arterial= doesn’t improve; risk factors PVD and smoking
***venous vs arterial
venous= dependent swelling, worse as day goes on, can be unilateral
arterial= intermittent claudication (pain with walking) worse at night better in am, worse after exercise better with rest. Skin color changes, non healing wounds, diminished pulses
***normal hemodynamic changes in pregnancy
increased blood volume= increase stroke volume/CO, edema
*** tetrology of fallot
pulmonic valve stenosis, ventricular septal defect, aortic shift, and you’re typically going to have right ventricular hypertrophy
objective= parasternal heave, systolic murmur
*** venous hum in a child
benign
***breast exam
normal to notice a lump during menses and a couple days after
risk for cancer= genetic, early menarche, no children, obesity, early menopause, prev. radiation, high density breast tissue
breast exam= patient should be laying w/ arms over head, both breasts simultaneously
dimpling almost always means cancer
***normal breast changes in pregnancy
increased vascular pattern
***mammograms
start age 45
***SE mastectomy
lymphedema (swelling)
***gynecomastia
abnormal increased breast tissue in boys/men caused by low testosterone
***GI exam sequence
inspect, auscultate, palpation, percussion
***parestalsis
controlled by autonomic nervous system
***small bowel obstruction
high pitched, hyperactive
***peritonitis
no bowel sounds
***decreased bowel sounds
constipation, ileus
***increased bowel sounds
hungry, diarrhea
***colon cancer sx
blood in stool, change in bowel pattern, pain, inability to fully evacuate
***percussion of liver
< 12 cm= normal
scratch test if someone is obese
flex knees to relieve pressure if they’re tense
***Cushings
buffalo hump, moon face, purple straie
***GI pregnancy
change in bowel pattern, reflux
*** cirrhosis of liver sx
jaundice, spider angioma, gynecomastia, palmar erythema
***friction rub
sounds like high pitched grating sound WITH inspiration
peritonitis, inflammation, infection
***concern for aneurysm
prominent lateral to umbilicus pulsation
***appendicitis
Rovsing sign is rebound pain elicited in the right lower quadrant with palpation pressure in the left lower quadrant
Psoas sign is assessed by having the patient lie supine and placing your hand just above the knee. Ask the patient to lift the right leg against resistance of your hand. This motion causes friction of the psoas muscle over the inflamed appendix, causing pain.
To assess for the obturator sign, position the patient supine with their right knee bent and leg bent at the hip. Rotate the leg internally at the hip, causing the internal obturator muscle to stretch providing indirect pressure over the appendix.
McBurney point = point tenderness located in the center of the right lower quadrant, approximately 3-4cm towards the midline from the iliac spine.
***CVA tenderness
pyelonephritis
***congenital anomoly of GI
meckle diverticulum
***acites
inspect- full and shiny
percussion- dull instead of tympanic
***menopause
no menses for 12 months
***correct way to insert vaginal speculum
correct size, lubricate, speculum and introitus (entrance of vagina) down
**what specimen send out first for vaginal specimen collection
pap smear sends off first
**STD testing, what kind of cells for BV
clue cells
**first pelvic exam
21 y/o if NOT sexually active, before if is sexually active
***early sign pregnancy
chadwick sign, bluish or purplish discoloration of the labia, vulva, vaginal tissue, fullness/increased blood flow to cervix, occurs at 4 weeks
***how to assess fetal positioning
leopold maneuver
**risk factor testicular cancer
1 undescended or delayed testicles (cryptorchidism)
family hx
HSV
**best position for inguinal hernia
bear down, cough, or stand
palpate upward along vas defferens
**subjective findings Peronie disease
bending of erection, painful erections
**cause of testicular pain
testicular torsion most concerning
**transillumination of testes
fluid vs solid
no percussion in infants
-
tumor on lung exam
dull where expect resonant
absent/decreased breath sounds
tactile fremitus with emphysema
decreased
percussion with pneumonia or pleural effusion
dull instead of tympanic
