Written Midterm Flashcards
What is the term for the ability of a test to rule out a disease that is not present? NIH and SpPin
Specificity
What is the term for the ability of a test to detect the disease when its present? PID and SnNout
Sensitivity
What is the term for the combination of sensitivity and specificity?
Likelihood ratio
Examination of the head includes the assessment of what 5 areas?
- hair
- scalp
- skull
- face
- skin
What 6 things are being assessed with regards to the head?
- quality
- quantity
- distribution
- baldness
- texture
- lice/nits
What 2 things are being assessed with regards to the scalp?
- redness
- scaling
What 4 things are being assessed with regards to the skull?
- deformity
- size
- lumps
- tender spots
What 5 things are being assessed with regards to the face?
- expression
- symmetry
- lumps
- tenderness
- swelling
What 5 things are being assessed with regards to the skin?
- color
- texture
- thickness
- hair distribution
- lesions
When examining the nose, which 3 items should be used?
- large ear speculum
- nasal illuminator
- nasal speculum
Which 3 portions of the nose should be inspected?
- turbinates
- mucosa
- septum
Which area of the nose should contact be avoided due to sensitivity?
nasal septum
What substance can assist in the inspection of swollen mucosa?
0.5% phenylephrine
What should and should not be used to clean instruments after use?
Use: germicidal solution
Do not use: ETOH
How should you hold the scope when inspecting the nose?
Like holding a pencil
Use the nasal speculum to pull which portion of the nose providing traction? What should be avoided?
alar - pull it laterally; avoid the nasal septum
What 3 things are you inspecting for on the inferior turbinate and inferior border of middle turbinate?
- color
- swelling
- polyps
What 3 things are you looking for when inspecting the nasal mucosa?
- color
- swelling
- bleeding
What 2 things are you looking for when inspecting the nasal septum?
- deviation
- perforation
When inspecting the sinuses, transillumination should be done in a darkened room; what should be seen?
Equal glow on each side
If there is diminished glow from sinus transillumination, what 3 things does that indicate?
- fluid
- a mass
- mucosal thickening
While transillumination is useful, what are considerations that need to be made with diagnosis?
It is non-specific and should NOT be considered a substitute for CT studies
Where should the transilluminator be placed to do an inspection of the sinuses?
- inner rim of eyebrow (angled upward)
- over maxillary sinuses (have pt. open mouth to see illumination through palate)
Examination of the mouth includes assessment of which 6 areas?
- lips
- buccal mucosa
- gums
- teeth
- roof of mouth
- tongue
When inspecting the lips, which 6 things should be noted?
-color
-moisture
-lumps
cracking
-ulcers
-lesions
Which 4 things should be looked for on the buccal mucosa? What instruments should be used for the inspection?
-color
-pigmentation
-ulcers
-nodules
Use a tongue blade and light
What are 2 specific conditions looked for in the buccal mucosa? What other 2 areas should be inspected?
- leukoplakia
- candidiasis
- Stensen’s (parotid) duct
- Wharton’s (submandibular) duct
What 7 things are you looking for when you inspect the gums and teeth?
- inflammation
- bleeding
- retraction
- missing teeth
- caries
- fillings
- abnormal shapes or positions
Aside from any inflammation, bleeding, lesions, etc… what are you looking for while inspecting the tongue?
- Symmetry (CN XII)
- Lateral margins and inferior surface (cancer)
What special considerations should be used when inspecting the tongue of someone over 50 who drinks and smokes?
Use gauze and gloves
Which 4 areas should be inspected in addition to the pharynx?
- soft palate
- pillars
- tonsils
- uvula
When inspecting the pharynx, a tongue blade is place in the middle third of the tongue and is tractioned forward and down. What areas should be avoided? Why?
Avoid the back of the tongue as this stimulates gagging
What 4 things are you looking for when inspecting the pharynx?
- color
- symmetry
- swelling
- exudates
What are 4 clinical features that are associated with an increased likelihood of group A beta-haemolytic streptococcus (GABHS) infection?
- fever (history of)
- lack of cough
- tonsillar exudate
- anterior cervical lymphadenopathy
What has the highest sensitivity and specificity in the diagnosis of GABHS in children and adults?
Use of the modified Centor Score coupled with culture
Which 5 things are you looking for when inspecting the neck?
- swelling
- asymmetry
- deviation of the trachea from midline
- palpation of the lymph nodes and submandibular glands
- palpation of the thyroid
When palpating the lymph node chains and submandibular glands, what 5 things should you be noting?
- size
- shape
- mobility
- consistency
- tenderness
What areas are used to locate the thyroid?
- “Adam’s apple”
- cricoid cartilage
What can you have the patient do to better visualize an enlarged thyroid?
Have the patient swallow water, the bolus will assist in visualizing an enlarged thyroid.
When you palpate the front of the thyroid, what are you noting?
- enlargement
- nodules
If the thyroid is enlarged, what should you do? Which instrument should be used? What could this mean?
- listen for bruits
- use the small diaphragm of your stethoscope
- Toxic Goitre
Examination of the ears includes assessment of which 6 areas?
- outer ear
- auricle
- tragus
- mastoid
- ear canal
- tympanic membrane
- auditory acuity
When examining the auricle, tragus, and mastoid, what should you do and what are you looking for?
- Pull on auricle and press tragus for pain
- Inspect auricle and tragus for lesions
- Inspect mastoid for swelling and redness
Using the largest size speculum you can, you should inspect the ear canal for what 4 things?
- swelling
- redness
- pain
- discharge
What are the 6 main landmarks that can be visualized in a normal tympanic membrane?
- umbo
- cone of light
- pars tensa
- pars flaccida
- short process of malleus
- manubrium of malleus
When inspecting the tympanic membrane, which 3 things are you looking for regarding position?
- bulging
- neutral
- retracted
When inspecting the tympanic membrane, which 5 things are you looking for regarding color?
- pearly gray (normal)
- dull
- cloudy
- amber
- red
Insufflation (pneumatic otoscopy) assesses what 2 things?
- presence of fluid effusions
- suppuration in the middle ear
The normal eardrum should move which directions with which types of pressure?
In and out by increasing and decreasing pressure in the ear canal.
Auto-insufflation involves having the patient do what while you watch for movement of the TM? Who is this best used for?
Vasalva maneuver; Adults
Auditory acuity is evaluated by PE using which 2 exams?
- whispered voice test
- tuning fork tests (Weber, Rinne)
When is a patient considered to have passed the whispered voice test?
If they repeat at least 3 out of a possible 6 numbers/letters correctly
Weber and Rinne tests differentiate between which types of hearing loss?
conductive and sensorineural (SN) hearing loss
Which tuning fork test compares bone conduction in both ears?
Weber
Conductive loss lateralizes to which ear, while sensory loss lateralizes to the other?
Conductive = bad ear Sensory = good ear
Which type of tuning fork test compares air conduction (AC) to bone conduction (BC)?
Rinne
What is considered normal on the Rinne test?
AC is greater than BC
What would the Rinne test show if there was conductive loss?
BC is greater than AC
What would the Rinne test show if there is sensorineural loss?
Both AC and BC are reduced, but AC is still greater than BC.
Combined, Weber and Rinne findings compared well to audiology findings with what percentages?
77% sensitivity
86% specificity
With the Weber and Rinne test, which Hz tuning fork should be used?
512 Hz
During the Weber test, where is the tuning fork placed one it has been struck and is vibrating?
on top of the head or mid-forehead
What is the difference between the way the tuning fork is “started” between Weber and Rinne?
Weber - “whack” on rubber
Rinne - pinch
Where is the activated tuning fork placed during the Rinne test? How does the test progress?
Begin on the mastoid until the tuning fork can not be heard, then position the tuning fork just over the ear.
Hearing impairment is a common, chronic condition in which population/age group? What percentage is affected?
Americans aged 65; between 25-40%
Prevalence of hearing impairment increases dramatically with age, what is the percentage of those affected in those over 75 years? What about those older than 85?
40-66%; 80%
What should happen with patients who are unable to perceive the whispered combination?
Referral for formal testing
The American Speech-Language-Hearing Association has recommended a procedure for pure-tone threshold search test known as…
The modified Hughson-Westlake method
In which ear does testing using the modified Hughson-Westlake method begin?
In the ear in which the patient perceives to have better hearing
With the modified Hughson-Westlake method the tester presents a pure tone at a clearly audible level, then decreases the intensity to what dB level? If the patient responds to this tone, what is then employed? Once the patient can no long respond to the tone, the intensity is increased by how many dB until they can once again respond? What is this called?
10dB; “down 10” pattern is employed; 5dB; initial ascending response
Is the initial ascending response of the modified Hughson-Westlake method the only part of the test? If not, what is the next step?
No, intensity should be turned down by 10dB then increased by 5dB until patient responds again.
With the modified Hughson-Westlake method, when the patient responds a minimum 2 out of 3 responses in the ascending order, the tester records the dB level at which the patient responds as what?
The air conduction threshold
What testing method provides useful quantitative information about the presence of fluid in the middle ear, mobility of the middle ear system, and middle pressure?
Tympanometry
The tympanometry is an objective measure of what?
The changes in the acoustic impedance of the middle ear system in response to changes in air pressure.
Which 2 conditions is the tympanometry test helpful in evaluating? What other situation can the test help discover?
Otitis media with effusion and to a lesser extent, acute otitis media. Presence or absence of TM perforation
Examination of the eyes includes test for which 4 areas?
- vision
- macular degeneration
- position of alignment
- assessment of the pupils
To evaluate far vision, which chart is used? How far away should the patient be?
Snellen chart; 20 feet away from chart
To evaluate near vision, which chart is used? How far away should the patient be?
Rosenbaum chart; 14 inches
How is color vision assessed? What other chart can be used?
Colored lines on the Snellen chart; Ishihara charts
When checking peripheral vision, why do you have to be sure to examine one eye at a time with the contralateral eye closed?
You may miss significant pathology that affects one eye only.
When checking peripheral vision, why do we test with the motion of “wiggling fingers”?
Because subtle motion is missing early in optic nerve defects
If there is the suspicion of a field defect, more subtle testing may be done by the neurologist or ophthalmologist using which 2 screens?
- tangent screen
- Goldmann perimeter
What should be used to screen for Age-related macular degeneration (ARMD)?
Amsler grid
Using the Amsler grid, what will normal patients see? Patients with “dry” macular degeneration? Patients with “wet” macular degeneration? What is the sensitivity and specificity?
Normal = uninterrupted grid
“Dry” = distorted wavy lines (metamorphopsia)
“Wet” = blind spots (scotoma)
Sensitivity 75% and Specificity 85.5%
When checking for eye position and alignment, which 2 conditions are being checked for? Which screen is being used?
-Exophthalmos (proptosis)
-Non-alignment (strabismus)
Hirschberg corneal reflex
When checking the eyebrows, what 3 things are you looking for?
- Quantity
- Loss of the lateral 1/3 (in myxedema)
- Scaling (seborrheic dermatitis)
When examining the eyelids, what 5 things are you looking for?
- edema
- redness
- lesions (hordeolum, chalazions, and blepharitis)
- condition of eyelashes (entropion, ectropion)
- drooping eyelids (ptosis)
When assessing the lacrimal apparatus, what 4 things are you looking for? What test would you use?
-redness
-swelling of the gland or duct
-excess lacrimation
-excess dryness
Tear function can be assessed with the Schirmer’s tear test
When testing tear function with the Schirmer’s tear test, place Whatman 41 filter paper over the lateral third of the lower lid and keep in place for 5 minutes. Wetting of less than how many mm indicates dry eyes.
15mm
When examining the conjunctiva and sclera, what 5 things should be looked for?
- excessive injection (peripheral vs. ciliary)
- jaundice
- chemosis
- local redness
- nodularity (episcleritis)
What is the procedure for examining the cornea and lens?
Use of oblique lighting to detect any opacities
When examining the iris, what should be checked? What are abnormalities a risk factor for?
-crescent shadow for signs of a narrow anterior chamber
Risk factor for: increase intraocular pressure and acute glaucoma
When examining the anterior chamber, what 3 things can be used? What 3 are you looking for?
Examine with a penlight, direct ophthalmoscope (using positive diopters), or slit lamp.
Looking for: hyphema, hypopyon, inflammatory cells floating in the aqueous humor
The size of the normal pupil decreases with age. What is the mean diameter of the pupil at 10 years of age? 30 years? 80 years?
10 = 7mm 30 = 6mm 80 = 4mm
What is the common mnemonic for testing pupillary function? What does it stand for?
PERRLA
Pupils Equal, Round, Reactive to Light (direct and consensual), Accomodation (constriction and convergence)
What are 7 key findings during the PERRLA exam?
- constriction (mioisis)
- dilation (mydriasis)
- hippus
- Argyll-Robinson pupil
- Adie’s pupil
- Horner’s syndrome
- Marcus Gunn pupil
What is the most common pupillary defect, occurring more often than all other defects combined?
Marcus-Gunn pupil
What are 3 causes of a Marcus-Gunn pupil?
- large retinal tear
- optic neuritis
- ischemic optic neuropathy
What are the 3 steps to diagnosing an Afferent Pupillary Defect (Marcus-Gunn pupil)?
- ) Illuminate one pupil - both pupils should constrict
- ) Move light to other eye - both pupils should constrict again
- ) “Swing” light back to first pupil - pupils should remain constricted
T/F: Simple anisocoria is an abnormal condition that requires immediate hospital attention
FALSE!!! Simple anisocoria is a normal finding. There is a difference in pupil size between 0.4mm to < 1mm, with no loss of vision or diplopia. This finding is seen in 38% of healthy persons.
Pathologic anisocoria represents problems with which 4 areas?
- pupillary constrictor muscles
- parasympathetic denervation
- iris disorders
- pharmacologic pupil
What items are helpful in dating the onset of anisocoria, especially if the patient is asymptomatic?
Old photographs
Which pupillary condition results from injury to ciliary ganglia and postganglionic fibers?
Adie’s “Tonic” pupil
Unilateral dilation of pupil with absent, poor light reaction, or extremely slow and prolonged reaction to near vision with slow re-dilation, refers to which condition?
“Tonic pupil”
What will cause constriction in Adie’s pupils?
Instillation of a cholinergic agonist (e.g. pilocarpine)
Which condition is characterized by lesions in sympathetic neurons?
Horner’s syndrome
Horner’s syndrome is identified by which 3 findings?
- ipsilateral miosis
- ptosis
- anhidrosis
The sympathetic denervation of Horner’s syndrome can be confirmed by what means?
Instilling cocaine eye drops in both eyes. These sympathomimetic drops will cause dilation of the “good” side, but not the side with Horner’s.
What is the sensitivity and specificity for anisocoria? Horner’s syndrome?
Aniscoria = 39% sensitivity and 96% specificity Horner's = 95% sensitivity and 99% specificity
Which pupillary condition occurs secondary to neurosyphillis (less commonly Lyme disease, diabetes, sarcoidosis)? Findings include small pupils with no light reaction but intact accommodation reflex bilaterally.
Argyle Robertson pupils
What may be appreciated when testing the pupillary direct light reflex?
Hippus
A positive Hippus occurs when the pupil size does what?
oscillates after initial constriction of the pupil
Hippus has been used traditionally to aid in the assessment of what condition?
Functional hypoadrenalism
A study of workers who spend significant time working on computers found that ____% displayed hippus; it is suggested that this finding is caused by what?
30%; cumulative asthenopia and/or general fatigue
An in-patient study concluded that patients with bedside hippus were more likely to what? What other condition has hippus been associate with?
They were more likely to die within 30 days of observation.
Myasthenia gravis
What 5 things does the extaocular movements exam check for?
- CN 3, 4, 6, and extraocular muscles
- abnormalities in the primary gaze
- congruity of gaze in the 6 cardinal positions
- strabismus
- nystagmus
Which area is the only place in the body where we can “take a snapshot” of a patient’s vasculature? This visualization is as close as we can get to a chemistry screen or an angiogram using a PE procedure. What exam is used?
Retina; ophthalmoscopic exam (aka funduscopic exam)
The ophthalmoscopic exam tells us the state of which 2 systems and which 5 diseases of the eye?
Vascular system and nervous system
- glaucoma
- retinal detachment
- floaters
- macular degeneration
- optic atrophy
What are the 3 adjustable parts of your ophthalmoscope?
- light wheel
- power wheel
- rheostat
On the light wheel, what 3 things is the slit aperture helpful for?
- floaters
- abrasions
- lesions with depth
On the light wheel, what is the small circular aperture helpful for?
un-dilated pupils
On the light wheel, what is the large circular aperture helpful for?
dilated pupil (with mydriatic reagents)
On the light wheel, what is the cobalt filter good for?
Fluorescein dye
The power wheel compensates for the patient’s and/or the physician’s refractive error using what? This also enables you to change your view of structures in the eye.
Diopters
(+) green allows for what?
(-) red allows for what?
(+) green = focus closer
(-) red = focus farther away
When dilating the eye for the ophthalmoscopic exam, what agent should be used? What should not be used? Why?
Use = a weak acting mydriatic agent (Tropicamide .5-1%)
Do not use = Atropine, because it can act for 1 to 2 weeks
Which direction should the patient look during an ophthalmoscopic exam for optimum view of the optic disc?
Slightly up and medially at a distance
T/F: You should examine the patient’s right eye with your right hand, using the left thumb to rest on the eyebrow. (And vise versa on the other side)
True
While focusing on the optic disc, what are 3 things you should examine for?
- clarity of outline
- color (yellow orange to creamy pink)
- size of physiologic cup (cup/disc ratio)
What is the normal range for the cup/disc ratio of the optic disc?
0.2-0.5
What are you looking for when you examine 4 arterioles and crossings?
AV changes and nicking
What are size comparisons of arteries and veins?
Arteries are ~2/3 or 3/5 the size of veins. Arteries are brighter red and exhibit a light reflex
Why is the macula examined at the end of the exam?
Because of the patient’s sensitivity
What are you seeing if you find red dots during your ophthalmic exam? White dots?
Red dots = hemorrhage
White dots = cotton wool (soft exudates) and hard exudates
The skin is usually evaluated as each region of the body is examined. You should note which 8 things?
- color changes
- excessive moisture or dryness
- temperature
- texture
- turgor
- mobility
- edema
- any lesions identified
According to the Fitzpatrick Skin Scale, what are the characteristics of a Type I (scores 0–6)?
- pale white skin
- blond, red, light brown, or medium brown hair
- blue, green, or hazel eyes
- freckles
- Norwegian skin type — always burns, never tans
According to the Fitzpatrick Skin Scale, what are the characteristics of a Type II (scores 7–13)
- white/fair skin
- dark blond, brown, or black hair
- blue, green, hazel, or brown eyes
- Scandinavian skin color — usually burns, tans minimally
According to the Fitzpatrick Skin Scale, what are the characteristics of a Type III (scores 14–20)
- cream white skin
- dark brown or black hair
- blue, green, or dark brown eyes quite common
- German skin color — sometimes mild burn, tans uniformly
According to the Fitzpatrick Skin Scale, what are the characteristics of a Type IV (scores 21–27)
- moderate brown skin
- typical italian or french skin tone — rarely burns, always tans well
According to the Fitzpatrick Skin Scale, what are the characteristics of a Type V (scores 28–34)
- dark brown skin
- Middle Eastern skin types — very rarely burns, tans very easily
According to the Fitzpatrick Skin Scale, what are the characteristics of a Type VI (scores 35+)
- deeply pigmented dark brown to black
- African — never burns, tans very easily
If cyanosis (blue) is present what areas would be central (incl. dx) and what areas would be peripheral (incl. dx)?
Central: lips, buccal mucosa, tongue (e.g., COPD, heart disease)
Peripheral: nail beds (e.g., Raynaud’s disease)
If yellow skin is found, what 3 conditions could be present along with their location?
- Carotenemia (high levels of carotene): palms/soles of feet
- Jaundice (bilirubin rises above 3mg/dL): sclera, buccal mucosa, lips
- Uremia (“uremic frost”)
If red skin is examined, what are 3 conditions that may be responsible?
- inflammation
- fever
- alcoholism
In findings for pallor of anemia, which ones are highest in specificity?
- palmar crease pallor (99%)
- conjunctival pallor (99%)
Checking temperature of the skin assess for which 3 things?
- fever
- coolness
- local inflammation
Checking texture of skin assess what? What are 3 associations?
How smooth or rough the skin feels
Hard texture is associated with scleroderma, myxedema and amyloidosis.
Checking turgor of the skin assesses which 2 things? Where is this checked? What is the association with each?
Mobility and edema
Assess on the back of hands and the pretibial area
Decreased mobility is associated with edema and scleroderma Decreased turgor is seen with dehydration
According to the pitting edema scale, what are the 4 scales?
Trace +1
Mild +2
Moderate +3
Severe +4
According to the pitting edema scale, what is the degree and response for trace +1?
Slight and rapid
According to the pitting edema scale, what is the degree and response for mild +2?
0-0.6cm and 10-15 seconds
According to the pitting edema scale, what is the degree and response for moderate +3?
0.6-1.3cm and 1-2 minutes
According to the pitting edema scale, what is the degree and response for severe +4?
1.3-2.5cm and 2-5 minutes
What are 6 characteristics of lesions?
- Anatomic location & distribution
- Grouping or configuration
- Morphology
- Color
- Size & shape
- Borders
What are the ABCDE warning signs of malignant melanoma?
Asymmetry of shape; half the lesion appears different than the other half.
Border irregularity; poorly circumscribed border. Bleeding.
Color variation; may show variation in color of tan, brown and black. May show white, red or blue
Diameter larger than 6 mm; the size of pencil eraser.
Evolution; is the lesion changing or enlarging.
What 5 conditions will examination of the skin with a Wood’s Lamp show?
Vitiligo – bright white, sometimes with a blue tinge
Post-inflammatory hyperpigmentation – purplish brown
Pseudomonas infection – blue or bluish green
Erythrasma – coral pink or red
Tinea versicolor – yellow to golden orange
Wet preps of skin scrapings examined microscopically with KOH help with the visualization of what?
fungal elements
Skin biopsy (punch biopsy, excisional biopsy) helps to identify what?
malignancies as well as diverse inflammatory disorders and genetic disorders
Which nail lesion has transverse grooves in the nail from stunted growth and is a result of significant infection, renal disease, hepatic disease?
Beau’s lines
Which nail lesion has proximal half is white, distal half is pink and is a result of chronic renal disease?
Lindsay’s nails (half and half nails)
Which nail condition has spoon-like depressions and is a result of iron deficiency anemia?
Koilonychia (spoon nails)
Which nail condition has an angle at the nail base is greater than 180°; normal is 160° (check for ballotability) and is related to heart and pulmonary disease?
Clubbing (pulmonary arthropathy)
Which nail condition has multiple pits in the nail beds and is associated with psoriasis?
Pitting
Which nail condition has white nail beds up to the distal border, then pink and is associated with cirrhosis, hypoalbuminemia?
Terry’s nails
Inspect and palpate the hair for what 3 things?
- quantity
- distribution
- texture
Which condition is loss of hair. Occurs in many conditions, e.g., anemia, heavy metal poisoning, malnutrition, being middle-aged and male.
Alopecia
Which type of hirsutism is seen in Cushing’s disease and Stein-Leventhal syndrome? Restricted to where men are usually hirsute.
Androgen-Dependent
Which type of hirsutism can be caused by certain drugs, starvation? Characterized by long fine hairs all over the body, including forehead.
Androgen-Independent
