Arif's amazing cards
Partner Violence Screen (PVS)
1. Have you been hit, kicked, punched or otherwise hurt by someone within the past year? 2. Do you feel safe in your current relationship? 3. Is there a partner from a previous relationship that is making you feel unsafe now? First question covers dimension of physical violence, and the latter evaluate the woman's perception of safety and estimate her short term risk of further violence.
Palpable lymph nodes of head and neck
1. The occipital nodes at the base of the skull 2. The postauricular nodes located superficially over the mastoid process 3. The preauricular nodes just in front of the ear ( 4. The parotid and retropharyngeal (tonsillar) nodes at the angle of the mandible 5. The submandibular nodes halfway between the angle and the tip of the mandible 6. The submental nodes in the midline behind the tip of the mandible Then move down to the neck, palpating in the following four-step sequence: 1. The superficial cervical nodes at the sternocleidomastoid muscle 2. The posterior cervical nodes along the anterior border of the trapezius muscle 3. The cervical nodes deep to the sternocleidomastoid (the deep cervical nodes may be difficult to feel if you press too vigorously; probe gently with your thumb and fingers around the muscle) 4. The supraclavicular areas, probing deeply in the angle formed by the clavicle and the sternocleidomastoid muscle, the area of Virchow nodes
Optic Disc
1.5 cm in diameter unit of measure in diameters, ie 2 disc diameters from the optic nerve at 2 o'clock position
How much cardiac output does each kidney recieve?
1/8 of cardiac output through the renal arter
When do pancreatic islet cells develop and what do they do?
12 weeks gestation, and produce insulin
When is bone growth completed by?
20 yrs - the last epiphysis closes and becomes firmly fused to the shaft Once bone growth stops, bone density and strength continue to increase. Peak bone mass is not achieved till 35
Visual Acuity in kids
20/50 by age 3 20/40 by age 4 20/30 by age 5 flip the numbers in denominator and age
How long is the alimentary tract
27 feet long runs from mouth to anus
Spinal Nerves
31 pairs arise from spinal cord and exit at the intervertebral foramen
What is the newborn expected respiratory rate?
40-60 but up to 80 breaths per minute
How often should you hear bowel sounds and what do they sound like
5-35 per minute clicks and gurgles
Expected Heart Measurements
5-7cm at 5th ICS 4-6cm at 4th ICS 3-4cm at 3rd ICS 1-3cm at 2nd ICS
Pulsus Paradoxus
> 10 mmHg decrease in systolic blood pressure with inspiration Caused by PVC, Trachobronchial obstruction, bronchial asthma, emphysema, pericardial effusion, contrictive pericarditis
Investigate these types of nodes
> 2cm Mildly painful Fixed to contiguous tissues and relatively immovable.
Preeclampsia Risk Factors
> 40 yrs First Pregnancy Preexisting chronic HTN Renald disease DM Multifetal Gestation Family Hx Obesity
Patch
A flat, nonpalpable, irregularly shaped macule greater than 1 cm in diameter Ex: Vitiligo, port wine stains, hyperpigmented macule, cafe au lait patch
Transmission of Pain Impulses
A two-way control of pain transmission occurs in the spinal nerve pathways. After the pain impulses reach the spinal cord's dorsal horn, the pain signal may be modified when other stimuli are present form either the brain or the periphery. Substances such as endorphins (endogenous opioids) and gamma-aminobutyric acid (GABA) can change or inhibit the pain perceived. Pain impulse transmission can be reduced when non-pain impulses compete to transmit sensations along the same spinal pathways to the brain. Emotions, cultural background, sleep deprivation, previous pain experiences and age are factors that have an impact on a person's perception and interpretation of pain.
Rate and depth of breathing will increase with:
Acidosis CNS Lesions in Pons and Medulla Anxiety Aspriing Poisoning Hypoxemia Pain
What are the milk producing cells and where do they empty?
Acinar Cells - empty into Lactiferous Ducts
Cough Onset
Acute = infection esp with fever. No fever = foreign body or inhaled irritants
Encephalitis
Acute inflammation of the brain and spinal cord involving the meninges, often due to a virus Patho • A virus may be transmitted by the bite of an arthropod or mosquito, such as with West Nile virus, eastern equine encephalitis, and Japanese encephalitis. Herpes simplex virus may be another cause. • Nerve cell degeneration occurs leading to edema, increased intracranial pressure, and areas of necrosis Subjective Data • Mild viral illness with fever • Recovery and quiet stage followed by onset of lethargy, restlessness, and mental confusion Objective Data • Altered mental status, confusion, stupor, coma • Photophobia • Stiff neck • Muscle weakness, paralysis, ataxia
Physical Exam: Skin inspection
Adequate exposure of the skin is necessary. It is essential to remove clothing and to fully remove drapes or coverings as each section of the body is examined. Make sure that the room temperature is comfortable. Look carefully at all areas, remembering to inspect areas that are usually not exposed, such as the axillae, buttocks, perineum, backs of thighs, and inner upper thighs. Remove shoes and socks to look at the feet. Pay careful attention to intertriginous surfaces (areas where two skin surfaces may touch, e.g., axillae and groin), especially in infants, older adults and bedridden patients. As you complete the examination for each area, re-drape or cover the patient. When inspecting the skin, it is important to have a systematic routine in place to ensure that no areas are forgotten. Skin thickness varies over the body, with the thinnest skin on the eyelids and the thickest at areas of pressure or rubbing, most notably the soles, palms, and elbows. Note calluses on the hands or feet. Look for corns on pressure points. Corns are flat or slightly elevated, circumscribed, painful lesions with a smooth, hard surface. A superficial area of hyperkeratosis is called a callus. Calluses usually occur on the weight-bearing areas of the feet and on the palmar surface of the hands. Calluses are less well demarcated than corns and are usually not tender
Adie Pupil (Tonic Pupil)
Affected pupil dilated and reacts slowly or fails to react to light. Responds to convergence Impairment of postganglionic parasympathetic innervation to sphincter pupillae accompanied by diminished tendon reflex
Pneumothorax
Air or gas in pleural cavity Tension pneumo - air leaks into pleural cavity Mediastinal shift with tracheal deviation away from involved side in tension pneumo Unexplained persistent tachycardia
Adolescents
Apocrine glands enlarge and become active, causing increased axillary sweating and sometimes body odor. Sebaceous glands increase sebum production causing oily appearance which leads to acne.
Retinal Structures
Arterioles smaller than venules, ratio of 3:5 or 2:3 Arterioles are brighter
The hip and joint consist of
Articulations between the acetabulum and the femur
Tempomandibular Joint consists of?
Articulations between the mandible adn the temporal bone in the cranium. Each is located in the depression just anterior to the tragus of the ear. Gliding action permits lateral movement, protrusion, and retraction of the mandible.
Physical examination: Skin Palpation
As you inspect, palpate the skin for moisture, temperature, texture, turgor, and elasticity. Palpation may yield additional data for describing lesions, particularly in relation to elevation or depression. Minimal perspiration or oiliness should be present. Increased perspiration may be associated with activity, warm environment, obesity, anxiety, or excitement; it may be especially noticeable on the palms, scalp, forehead, and in the axillae. The intertriginous areas or skin in body folds may also be damp leading to development of intertrigo The skin should range from cool to warm to the touch. Use the dorsal surface of your hands or fingers because these areas are most sensitive to temperature perception. At best, this assessment is a rough estimate of skin temperature; what you are really looking for is bilateral symmetry. Environmental conditions, including the temperature of the examining room, as well as body location may affect surface temperature. The texture should feel smooth, soft, and even. Roughness on exposed areas or areas of pressure (particularly the elbows, soles, and palms) may be caused by dry skin or irritation. Extensive or widespread roughness may be the result of a keratinization disorder or damaged skin. Hyperkeratoses, especially of the palms and soles, may be the sign of a systemic disorder such as exposure to arsenic, other toxins, or a sign of internal malignancy. Assessment of skin elasticity can be helpful to detect certain conditions. Gently pinch a small section of skin on the forearm or sternal area between the thumb and forefinger and then release the skin. The skin should move easily when pinched and return to place immediately when released. Poor skin turgor can indicate severe dehydration. The skin is very slow to return to normal and "tents" up. This may occur with excessive vomiting, diarrhea, or dehydration for another cause. Skin that is firm or cannot be pinched may suggest an underlying connective tissue disease such as scleroderma.
Exophthalmus Mean Protrusion
Asian - 18.6mm White - 21.7 mm Black - 24.7 mm
Allen Test
Assesses patency of the ulnar artery 1. With the patient's palm facing upward, compress the radial and ulnar artery with your fingers. 2. Have the patient close and open the fist five times and then leave the blanched palm open. 3. Release pressure on the ulnar artery alone and watch for palmar reperfusion within 4 to 5 seconds. 4. If palmar reperfusion does not occur, suspect ulnar artery insufficiency and do not puncture the radial artery.
Neurovascular assessment after sports injury
Assessment of circulation and nerve sensation is important when an extremity is injured. Perform the following steps to complete a neurovascular assessment distal to the injury. Use the contralateral extremity for comparison. ASSESSMENT Color Temperature Capillary refill time Swelling Pain Sensation Movement UNEXPECTED FINDINGS Pallor or cyanosis Cool or cold Greater than 4 seconds Significantly swollen Presence of moderate to severe pain Numbness, tingling, pins-and- needles sensation Decreased or no movement
Cervical Chest Pain Characterisics
Associated w/ injury provoked by activity, persists after activity; painful on palpation and or movement
Psychoneurotic Chest Pain
Associated with/after anxiety; poorly described; located in intramammary region
Limb Measurement Tests
Asymmetry in limb size extremities. Leg length is measured from the anterior superior iliac spine to the medial malleolus of the ankle, crossing the knee on the medial side. Arm length is measured from the acromion process through the olecranon process to the distal ulnar prominence. The circumference of the extremities is measured in centimeters at the same distance on each limb from a major landmark. Athletes who use the dominant arm almost exclusively in their activities (e.g., pitchers and tennis players) may have some discrepancy in circumference. For most people, no more than a 1-cm discrepancy in length and circumference between matching extremities should be found.
S4 heart sound
Atria contracting against a Stiff or Hypertrophic ventricle (ventricular compliance is lost) (aortic stenosis, restrictive cardiomyopathy) Caused by papillae, valves, and ventricular walls vibrating during the second (late) phase of diastole / presystole. Can easily be confused with split S1 due to timing Common in older patients le-lub-dub or KEN-tuck-y
Actinic Keratosis
Atypical squamous cells confined to the upper layers of the epidermis. Occurs secondary to chronic sun damage. Some lesions can progress to squamous cell carcinoma over time Subjective Data • History of chronic sun exposure • Increasing number of lesions with age Objective Data • Raised, gritty, erythematous lesion that is usually with an irregular, rough surface • Lesion is most common on the dorsal surface of the hands, arms, neck, and face (
External Ear
Auricle should be same color as facial skin Darwin tubercle, a thickening along upper ridge of helix is expected variation.
Cystic Fibrosis
Autosomal recessive disorder of exocrine glands involving lungs, pancreas, and sweat glands. Thick mucous causes progressive clogging of the bronchi and bronchioles. Cough with sputum is hallmark in kids under 5 yrs. Barrel chest Nasal Polyps Low body mass due to malabsorption Pulmonary dysfunction leads to clubbing COPD signs/symptoms
Bald Spots in children and infants
Bald spots in children? History is important. The differential diagnosis includes tinea capitis, alopecia areata, or trichotillomania (compulsive hair-pulling). Infants who sleep on their backs may develop areas of alopecia from pressure on the occiput. Supine sleeping is proven to reduce the risk for sudden infant death (SIDS). Providing tummy time while the infant is awake can promote motor development and decrease the likelihood of developing a bald spot.
Cat Scratch Disease
Bartonella henselae and Bartonella clarridgeiae Subjective Data • Bite, scratch, or wound from cat or kitten • Inoculation lesion: a papule or pustule lasts 3-5 days and then becomes vesicular and crusts in 2-3 days • Painful enlarged lymph nodes Objective Data • Inoculation lesion; may be healing • Lymphadenopathy develops in 1-2 weeks in the region that drains the primary lesion. • Single lymph node most often, but multiple nodes are involved occasionally • Tender nodes commonly in head, neck, and axillae; the accessible nodal areas in the arms and legs are less often involved. • Nodes can be very large—up to several centimeters; often red and tender and occasionally suppurate • Diagnosis can be made in the presence of a nodal enlargement lasting longer than 3 weeks, accompanied by an inoculation lesion of the skin and after an interaction with a cat, a cat scratch, or cat lick on a break in the skin. • Lymphadenopathy can last for 2-4 months or even longer.
Scoliosis
Be suspicious if you see a lateral curvature of rib hump lateral curvature of the spine Measure with scoliometer
Test for Applying Mydriatics
Before instillation of a mydriatic, inspect the patient's anterior chamber by shining a focused light tangentially at the limbus (the union of the conjunctiva and the sclera). Note the illumination of the iris nasally. This portion of the iris is not lighted when the patient has a shallow anterior chamber, indicating a risk of acute-angle glaucoma. Mydriatics should be avoided in these patients.
Concentric Circle Technique
Begin at the outermost edge of the breast tissue and spiral your way inward toward the nipple
Permanent teeth
Begin forming in the jaw by 6 months of age. Pressure from these teeth causes resorption of the deciduous teeth roots until the crown is shed. Eruption of permanent teeth begins about 6 years of age and is completed around 14-15 yrs
Midsystolic (Ejection) Murmur
Begins after S1, ends before S2. Crescendo-decrescendo quality
When do sutures ossify?
Begins at 6yrs old when brain growth finishes.
Middiastolic murmur
Begins at clear interval after S2
Late Diastolic (Presystolic) Murmur
Begins immediatley after S1
Late Systolic Murmur
Begins mid to late systole crescendos endas at S2. Often introduced by mid to late systolic clicks
Early Systolic Murmur
Begins with S1, decrscendos, ends well before S2
Fat Necrosis in Breasts
Benign breast lump occurs as inflammatory response to local injury Necrotic fat and cellular debris become fibrotic and may contract into a scar Caused by Trauma to breast including surgery Area of discoloration around a firm irregular mass
Duct Ectasia
Benign condition of the subareolar ducts that produces nipple discharge Subareolar ducts become dilated and blocked Most common in menopausal women Discharge often green or brown in color, may be sticky
Polymorphic Eruption of Pregnancy
Benign dermatoses in THIRD trimester of a FIRST pregnancy etiology is unclear, resolves after delivery, does not occur in subsequent pregnancies. Intensely pruritic rash that began on the abdomen then spreads to thighs, buttocks, and arms after a few days. Periumbilical area is spared Intensely pruritic rash, erythematous urticaria like papules and plaques on abdomen, thighs, buttocks, arms No lesions of face, palms, soles Often halos of blanching surround the papules
Fibrocystic Changes
Benign fluid filled cysts formation caused by ductal enlargement Usually bilateral and multiple Common in 30-55 yrs old Associated with a long follicular or luteal phase of the menstrual cycle Subjective data Tender and painful breasts and or palpable lumps that fluctuate with menses Usually worse premenstrually Objective Data Round soft to firm tense, mobile masses with well-delineated borders Usually tender Usually Bilateral.
Fibroadenoma
Benign tumor composed of stomal and epithelial elements that represent a hyperplastic or proliferative process in a single terminal ductal unit. Can occur at any age After Menopause tumors often regress Subjective Data Painless lumps that don't fluctuate with the menstrual cycle Usually bilateral, nontender Biopsy to r/o carcinoma
Intraductal Papillomas and Papillomatosis
Benign tumors of the subareolar ducts that produce nipple discharge Wartlike tumor in the lactiferous duct 2-3 cm in diameter Spontaneous nipple discharge that is serous or bloody.
Essential tremor
Bilateral Symmetric, primarily seen in hands or outstretched arms, intention tremor. It can be seen in head, trunk, voice, tongue. May worse with stress or fatigue may improve with alcohol. Progressive. No cerebral patho. Autosomal Dominant inheritance pattern
Infarction produces this type of sputum
Blood clotted, large amounts of blood
Hemothorax
Blood in pleural cavity Tachycardia, hypotension, lightheadedness
Pregnant patients
Blood pressure decreases around 8 weeks gestation, gradually falling until a low point is reached at mid pregnancy. The diastolic BP rises to prepregnant levels by term. During pregnancy some patients may experience pain due to several physiologic processes: Back Pain - due to lax ligaments, weight gain, hyperlordosis, and anterior tilt of pelivs Cramping or pressure - may be signs of premature labor or Braxton Hicks contractions (start around 6 weeks of pregnancy). Epigastric Pain - from gravid uterus Round ligament pain - due to stretching of ligaments and enlarging of uterus Pressure on bladder may occur from the weight of the enlarging uterus
Viral infection has this type of sputum:
Blood streaked but not commonly.
Opthalmascope
Blood vessel seen at 3-5 cm from pt. Myopic (near sighted) - use minus (red) lens Hpyeropic / lacks lens (aphakic) use plus lens
Auricle Color
Blueness - degree of cyanosis Pallor or Excessive redness - Vasomotor instability Extreme pallor - frost bite Cauliflower Ear - Blunt trauma and necrosis of underlying cartilage. Tophi - Small whitish uric acid crystals along the peripheral margins of auricles = Gout Sebaceous cyst, elevations in the skin with a punctum - blocked sebaceous gland
Venous Star
Bluish spider, linear or irregularly shaped; does not blanch with pressure Cause: Increased pressure in superficial veins
Blurred vs Double Vision
Blurred vision is problem with visual acuity. Diplopia is perception of two images, can be monocular or binocular. This is an Alignment problem.
Temperature
Body temperature is regulated and maintained by the hypothalamus. When pathogens invade the body, exogenous pyrogens, endotoxins produced by the pathogen, are released and travel to the hypothalamus. The hypothalamus responds by raising the body's temperature set point leading to a fever. Epinephrine is then released which increases the metabolic rate and muscle tone. The body generates heat by shivering, a rapid contraction of skeletal muscles. The body conserves heat by vasoconstriction, which reduces heat loss through the skin. Body cooling occurs by vasodilation which increases heat loss through the skin, increased sweating, and evaporation of perspiration.
Where are lmyphocytes primarily produced?
Bone Marrow, these are called B Lymphocytes which produce antibodies and are characterized by immunoglobulins on surface. B lymphocytes live about 3-4 days Involved in the Humoral Response.
Classic Pain Patterns
Bone and Soft Tissue pain - may be tender, deep, aching Tumor - Heavy throbbing, and aching pain may be associated with a tumor pressing on a cavity Nerve Tissue Damage - Burning, Shock-like pain Myocardial infarct - clenched fist over chest with diaphoresis and grimacing Visceral or Colic Pain - Cramping Spasms
Osteoarthritis Sign in Fingers
Bony overgrowth in the distal interphalangeal joints which are felt as hard non-tender nodules usually 2-3mm in diameter but sometimes encompass the entire joint
Turbinates (conchae)
Bony structures that form the lateral walls of the nose and protrude into nasal cavity. Purpose: Increase the nasal surface area to warm, humidify, and filter inspired air. Inferior meatus drains the nasolacrimal duct. Middle meatus drains the paranasal sinuses. Superior meatus drains posterior ethmoid sinus.
Melanoma
Border is irregular, lesions tend to be larger, often greater than 6mm. Color variation within the lesion is characteristic ranging from tan brown, dark brown, or black, pink, red, gray, blue, white Any lesion suggestive of melanoma must be biopsied.
Strabismus
Both Eyes do not focus on an object simultaneously but can focus with either eye Patho: Paralytic, ICP, CN 3 damage from brain swelling. S/s: Poor vision, sudden onset double vision, eye deviation Extraocular muscle impairment. Ex: if right sixth nerve is damaged, right eye does not move temporally. Detected by: Cover-Uncover test, children - use strabismoscope or photoscreening.
Special Concerns for a patient with a spinal cord injury or lesion
Bowel and Bladder- some do not have voluntary bladder or bowel movements. Do not remove indwelling catheter unless it isn't working. Tactile stimulation can cause incontinence.
Premature Thelarche
Breast enlargement in girls younger than 8yrs of age • Cause is unknown. However, increased sensitivity of breast tissue to estradiol (E2), transient E2 secretion from ovarian cysts, dietary estrogen intake, and transient activation of the hypothalamo-pituitary-gonadal (HPG) axis have been proposed as possible mechanisms • Most cases have an onset in girls under age 2 years. • In most cases, breasts continue to enlarge slowly throughout childhood until full development is reached during adolescence.
Secondary Apnea
Breathing stops and will not begin spontaneously unless resuscitative measures are immediately instituted. Any event that severely limits the absorption of oxygen into the bloodstream will lead to secondary apnea.
Lung Cancer
Bronchogenic carcinoma is a malignant tumor that evolves from bronchial epithelial structures cough, wheezing, hemoptysis Postobstructive pneumonia with consolidation - airway obstruction
Exopthalmos
Bulging of Eye out of orbit Graves disease. When unilateral consider retro-orbital tumor Exopthalmometer to measure.
Bossing
Bulging of the skull of the frontal areas - associated with prematurity, thalassemia, paget disease, rickets.
What CN Innervate the facial Muscles?
CN 5 CN 7
New Born Eyelids
Can be edematous at birth
Accuracy of blood pressure readings
Can be undermined by some conditions: Cardiac Dysrhythmias - if HR irregularity is sustained, take the average of several blood pressure readings and document the problem Aortic Regurgitation - if the sounds of an aortic regurgitation do not disappear the diastolic pressure will be obscured Venous Congestion - If sluggish venous flow occurs due to a pathologic event or repeated slow inflation of the cuff, the systolic pressure will be heard lower than it actually is and the diastolic even higher Valve Replacement - if the sounds are heard all the way down to a zero gauge reading, listen carefully for the first muffling of the sound (Kortokoff phase 4) to determine the diastolic pressure. More modern valves do not cause this discrepancy.
Carotenemia
Carotenemia, or xanthoderma, common in infants who have started eating baby foods, is yellow pigmentation of the skin and increased bet-carotene levels in the blood. Carotenemia does not cause orange discoloration of the sclerae, and thus is usually easy to distinguish from jaundice. IN most cases, this benign condition follows increased consumption of carotene rich foods such as carrots, squash, and sweet potatoes. If discontinued, skin color will normalize in a few weeks
Best places to palpate pulse?
Carotid brachial Radial Femoral Popliteal Dorsalis Pedis posterior tibial arteries
Bruit auscultations sites
Carotid - ask pt to stop breathing for a few heart beats to hear over respiration Subclavian Abdominal Aorita Renal Illiac Femoral arteries
Palpation of Carotid Artery
Carotid pulse located just medial to and below the angle of the jaw
Toxoplasmosis
Cat litter box disease, or raw undercooked meat Subjective Data • No significant symptoms • History of eating raw or rare meat or uncooked eggs • History of direct contact with cat feces, cleaning the litter box, gardening in feces-contaminated soil Objective Data • Single node, chronically enlarged and nontender • Node is usually in the posterior cervical chain
Pulsus Alternans
Caused by LV Failure, more significant if pulse is slow
History of Present Illness: Hair
Changes in hair: loss or growth, distribution, texture, color • Occurrence: sudden or gradual onset, symmetric or asymmetric pattern, recurrence • Associated symptoms: pain, itching, lesions, presence of systemic disease or high fever, recent stress, hair-pulling, infection • Exposure to drugs, environmental or occupational toxins or chemicals, commercial hair care chemicals • Nutrition: dietary changes, dieting • What the patient has been doing for the problem, response to treatment, what makes the problem worse or better • How the patient is adjusting to the problem • Medications: drugs or preparations for hair loss (minoxidil, finasteride, dihydrotestosterone [DHT] inhibitors)
Roasacea
Chronic Inflammatory Skin Disorder Patho Cause unknown, occurs most often in persons with a fair complexion Lasts for years Subjective Data • Itching is absent. • Many patients report a stinging pain associated with flushing episodes. • Common triggers are exposure to the sun, cold weather, sudden emotion, (e.g., laughter or embarrassment), hot beverages, spicy foods, and alcohol consumption. Objective Data • Eruptions appear on the forehead, cheeks, nose, and occasionally about the eyes. • Characterized by telangiectasia, erythema, papules, and pustules that occur particularly in the central area of the face • Although rosacea resembles acne, comedones are not present. • Tissue hypertrophy of the nose (rhinophyma) may occur, characterized by sebaceous hyperplasia, redness, prominent vascularity, and swelling of the skin of the nose
Bronchiectasis
Chronic dilation of the bronchi or bronchioles caused by repeated pulmonary infections and bronchial obstruction Cough with large amounts of sputum is major clue.
Tuberculosis
Chronic infectious disease that most often begins in the lung but may have widespread manifestations Tubercle Bacillus is inhaled Subjective Data • Latent period: asymptomatic, some regional lymph nodes may be involved • Active infection: fever, cough, weight loss, night sweats • History of travel to region with endemic tuberculosis or close contact with infected person Objective Data • Latent disease: no pulmonary findings • Active disease: consolidation and/or pleural effusion may develop with corresponding findings and cough with blood-streaked sputum • Positive tuberculin skin test, sputum testing for acid fast bacilli, and Interferon Gamma Release Assay (IGRA)
Ulcerative Colitis
Chronic inflammatory disorder of the oclon and recutm that produces mucosal friability and areas of ulceration Bloody, frequent, watery diarrhea. 20-30 stools per day.
Rheumatoid Arthritis
Chronic systemic inflammatory disorder of the synovial tissue surrounding the joints Polymorphonuclear lueukocytes aggregate within inflammed synovial tissue and fluid Inflammatory cytokines and enzymes that are released can result in damage to bone, cartilage and other tissues Join pain or stiffness esp in morning after periods of inactivity Fatigue, myalgias, weight loss, low grade fever common Synovitis present on exam
Coining and Cupping
Coining - used by asian subcultures, can be confused for disease or abuse. Coin dipped in mentholated oil is rubbed across skin. believed to release excess force from the body and hence restore balance. Cupping - small heated glasses are placed on the skin forming a suction that leaves a red or purpuric circular mark, drawing out the bad force
Features of Normal vs Dysplastic Moles
Color Normal - Uniformly tan or brown; all moles on one person tend to look alike. All moles on one person tend to look alike. Dysplastic - Mixture of tan, brown, black, and red/pink; Moles on one person often do not look alike Shape Normal - Round or oval with a clearly defined border that separates the mole from surrounding skin Dysplastic - Irregular borders may include notches; may fad into surrounding skin and include a flat portion level with skin Surface Normal - Begins as flat; smooth spot on skin; becomes raised; forms a smooth bump Dysplastic - May be smooth, slightly scaly, or have a rough irregular, "pebbly" appearance Size Normal -Usually less than 6 mm ( size of a pencil eraser) Dysplastic - Often larger than 6 mm and sometimes larger than 10mm Number Normal - 10-40 in typical adult scattered over body Dysplastic - Many people do not have increased number; however persons severely affected may have more than 100 moles Location Normal - Usually above the waist on sun-exposed surfaces of the body; scalp, breast, and buttocks rarely have normal moles Dysplastic - May occur anywhere on the body, but most commonly on back; may also appear below waist and on scalp, breast, and buttocks
Physical Examination: Nail color
Color. The shape and opacity of nails vary considerably among individuals. Nail bed color should be variations of pink. Pigment deposits or bands may be present in the nail beds of persons with dark skin. Yellow discoloration occurs with several nail diseases, including psoriasis and fungal infections, and may also occur with chronic respiratory disease. Proximal subungual fungal infection is associated with HIV infection. Diffuse darkening of the nails may arise from antimalarial drug therapy, candidal infection, hyperbilirubinemia, and chronic trauma, such as occurs from tight-fitting shoes. Green-black discoloration, which is associated with Pseudomonas infection, may be confused with similar discoloration caused by injury to the nail bed (subungual hematoma). Pain accompanies a subungual hematoma, whereas Pseudomonas infection is painless. Nail beds that are blue may be a transient response to a cold examining room. A single blue or black nail may indicate melanoma or bruising/bleeding from trauma. Generalized blue nails may be caused by conditions that produce cyanosis such as asthma, cardiac disorders, or severe anemia. Other causes of blue nails include silver poisoning, medication side effects, and Wilson disease, an inherited disorder of copper metabolism. Splinter hemorrhages, longitudinal red or brown streaks, may occur in endocarditis, vasculitis, with severe psoriasis of the nail matrix or as the result of minor injury to the proximal nail fold (habit-tic deformity). White spots in the nail plate (leukonychia punctate), a common finding, result from cuticle manipulation or other forms of mild trauma that injure the nail matrix. These spots need to be differentiated from longitudinal white streaks or transverse white bands that are indicative of a systemic disorder. Separation of the nail plate from the bed produces a white, yellow, or green tinge on the nonadherent portion of the nail.
Infants and Children: Impetigo
Common contagious superficial skin infection Staph or Streptococcal infection of dermis Subjective Data • Lesion, typically on the face, that itches and burns • Also on other parts of body associated with minor injuries or insect bites Objective Data • Initial lesion is a small erythematous macule that changes into a vesicle or bulla with a thin roof. • Lesion crusts with a characteristic honey color from the exudate as the vesicles or bullae rupture • May have regional lymphadenopathy.
S1 Intensity increased in
Complete Heart Block rhythm disruption - Fibrillation Just Remember Dysrhtmias or Intensity, DysrhytmIa has an I in it.
Types of Histories
Complete History - Most often recorded first time you see the patient. Inventory History - touches on major points without going into detail. Useful when getting a feel for the situation and entire history taking will be completed in more than one session Problem (or focused) history - taken when problem is acute, possibly life threatening Interim History - designed to chronicle events that have occured since your last meting with the patient. Should be complemented by the patients previous record.
Dislocation
Complete separation of the contract between two bones in a joint Often caused by pressure of force pushing the bone out of the joint, acute trauma Can occur more easily in patients with hyperextensibility conditions (Marfan, Ehlers-Danlos) Inability to use joint accompanied with deformits
What is bile composed of and what does it do?
Composed of cholesterol, bile salts, pigements Maintains alkaline pH of the small intestine and emulsifies fats
Carpal Tunnel Syndrome
Compression of the median nerve Caused by microtrauma, local edema, or inflammation, repetitive motion or vibration of the hands Numbness, buring, tingling in the hand often occurs at night. Pain may radiate to arms Weakness of the thumb and flattening of the thenar eminence of the palm Reproduction of symptoms with provocation of Tinel and Phalen Maneuvers
Tetralogy of Fallot
Congenital heart defect composed of four cardiac defects: ventricular septal defect, pulmonic stenosis, dextroposition of the aorta, and right ventricular hypertrophy Subjective Data • Dyspnea with feeding, poor growth, exercise intolerance • Paroxysmal dyspnea with loss of consciousness and central cyanosis (hypercyanotic episode or tetralogy spell) Objective Data • Parasternal heave and precordial prominence, systolic ejection murmur over the third intercostal space, sometimes radiating to the left side of the neck; a single S 2 is heard Older children develop clubbing of fingers and toes May develop HF if not surgically corrected
Lymphangioma characteristics
Congenital malformation of dilated lymphatics transilluminates; hemangiomas do not. Painless cystic masses Usually manifest during the first year of life and enlarge from an upper respiratory infection May simulate lymph node enlargement.
Cochlea
Contains Organs of Corti, transmits sound to CN VIII
Frontal Lobe
Contains the motor cortex associated with voluntary skeletal movement and fine repetitive motor movements as well as control of eye movements.
Descending Spinal Tracts
Corticospinal, reticulospinal, vestibulospinal Convey impulses from brain to various msucle groups by inhibiting or exciting spinal activity Muscle tone, posture, precise motor movements.
Respiratory Rate
Count respirations just after pulse, do not tell patient. RR 12-20 expected Ratio to heart is 1:4
Peripheral Nervous System is comprised of:
Cranial and Spinal Nerves Ascending and descending pathways
Latex Allergy Type IV Dermatitis
Delayed Hypersensitivity reaction, T cell mediated Subjective Data • Exposure to latex products • Rash at area of contact Objective Data • Skin reaction usually begins 48-72 hours after contact • Vesicular lesions, erythema localized to area of contact • Reaction may progress to oozing skin blisters
Annulus
Dense fibrous ring that surrounds the tympanic membrane. Concave pulled in at Umbo (center) by malleus
Down Syndrome Facies
Depressed Nasal Bridge Epicanthal folds Mongoloid slant of eyes low set ears
What are the functions of the spleen?
Destroy RBC's Produce Antibodies Store RBC's Filter Microorganisms. Store Produce Down Far
Strabismoscope
Detects strabismus (eye misalignment) in routine eye testing in children
Osteoarthritis
Deterioration of the articular cartilage covering the ends of bone in synovial joints From cartilage abrasion, pitting, and thinning the bone surfaces are eventually exposed with bone rubbing on bone Bone spurs can occur from remodeling Pain Onset after 40 yrs old Joints may enlarge due to bone growths May have crepitus and limited painful ROM
Frontal Sinus
Develop during childhood Located in the frontal bone superior to the nasal cavities.
Diabetic Retinopathy (Proliferative)
Development of new vessels as a result of anoxic stimulation. Vessels grow out of retina toward vitreous humor. New vessels lack supporting structure and are likely to hemorrhage. Bleeding is the leading cause of blindness. Can be controlled by lasertherapy. S/s: floaters, blurred vision, visual acuity loss in later stages. Generally asymptomatic.
Indications of Rheumatoid Arthritis
Deviation of the fingers to the ulnar side Swan Neck Deformities Boutonnier Deformities
Monofilament
Device used to test for loss of protective sensation particularly on the plantar surface of the foot (for diabetic or peripheral neuropathy) press hard enough to make monofilament bend. test several areas on foot. hold pressure aprox 1.5 seconds.
Use Right Lateral Recument for
Dextrocardia
Displacement of the apical impulse to the right without a loss or gain in thrust suggests
Dextrocardia, Diaphgramatic Hernia, Distened Stomach or a pulmonary abnormality
Glaucoma
Disease of optic nerve due to high ICP Acute Angle - Dramatically elevated ICP. Iris blocks the exit of aqueous humor from anterior chamber. Intense ocular pain, blurred vision, halos around lights, red eye, dilated pupil. Open Angle - caused by decreaseing aqueous humor absorption leads to increased resistance and painless buildup of pressure. No Symptoms, more common. Gradual loss of peripheral vision over years. Inspection: Optic nerve damage clearly seen during dilated exam. Cupping of the optic nerve.
Corneal Ulcer
Disruption of the corneal epithelium and stroma Pain, photophobia, hx of wearing contacts, blurry vision, feeling something in eye Purulent exudates, inflammation, Border sharply demarcated. Base appearing ragged and gray. Patho: RA, Sjogren syndrome, lupus, Wegener Granulomatosis, polyarteritis nodosa
Molding of the head in infants
Distressing for parents, reassure them with drawings. Usually resolves within 1 week of birth.
Patent Ductus Arteriosus In Utero
Diverts blood away from the lungs
Internal Nose
Divided by septum into two anterior cavities: the vestibules. Air passes to the Choanae - posterior opening leading to nasopharynx.
Patient positioning for examination
Dorsal Recumbent - For genital or rectal examination. Pt supine with knees bent and feet flat. Place drape in a diamond position from chest to toes. Lateral Recumbent - Side lying position with legs extended or flexed. Can be used in listening to heart sounds or palpating the spleen. Sims - Can be used for examination of the rectum or obtaining a rectal temperature. Pt starts in a lateral recumbent position. Torso is rolled toward a prone position; the top leg is flexed sharply. Drape patient from shoulders to toes Lithotomy - used for pelvic examination. Pt begins in dorsal recumbent, feet at corners of table. Stabilize feet in stirrups and slide the buttocks down to the edge of the table. Drape in diamond position.
Babinski Reflex
Dorsiflexion of the great toe with our without fanning of the other toes. Indicates Pyramidal tract (Corticospinal and Corticobublar tracts) disorder. Expected finding in children < 2yrs (16 - 24 months) If pt ticklish, use firm touch.
Diabetic Retinopathy (Background / Non Proliferative)
Dot hemorrhages or microaneurysms and the presence of hard or soft exudates. Hard exudates from lipid transudation through incompetent capillaries Soft exudates (Cotton Wool Spots) caused by infarction of the nerve layer. S/s: Blurred vision, distortion, visual acuity loss in advanced stages.
What constitutes the greater and lesser omentum
Double folds of the peritoneum around the stomach
Bulge Sign
Effusion of fluid in the knee With the patient's knee extended, milk the medial aspect of the knee upward two or three times, and then milk the lateral side of the patella. Observe for a bulge of returning fluid to the hollow area medial to the patella
Vesicle
Elevated, circumscribed, superficial, not into dermis, filled with serous fluid, less than 1 cm in diameter Ex: Varicella (chickenpox), Herpes zoster (shingles)
Plaque
Elevated, firm, and rough lesion with flat top surface greater than 1 cm in diameter Ex: Psoriasis, seborrheic, and acitinc keratosis
Nodule
Elevated, firm, circumscribed lesion; deeper in dermis than a papule, 1-2 cm in diameter
Wheal
Elevated, irregular-shaped area of cutaneous edema; solid, transient, variable diameter Ex: Insect Bites, Urticaria, allergic reaction
Arterial Embolic Disase
Emboli in arterial system Pain is common Paresthesia Occlusion of small arteries and necrosis (blue to syndrome) Endocarditis = splinter hemorrhages in nail beds.
Pulmonary Embolism
Embolic occlusion of pulmonary arteries Pleuritic Chest Pain with or without dyspnea is a major clue to embolism
During fetal development what does the skeletal system arise from?
Embryologic connective tissues that form cartilage that calicifies to become bone
Retinoblastoma Child / Infant
Embryonic malignant tumor arising from the retina. Autosomal Dominant trait or (RB1 gene on Chromosome 13) White Reflex (Cat's eye) on Photographs
Anterior Cerebral Artery Stroke
Emotional lability Confusion, amnesia, personality changes Urinary incontinence Contralateral hemiplegia or hemiparesis, greater in lower than upper extremities
Hydrocephalus Facies
Enalrged Head Thinning of Scalp with dilated scalp veins Bossing of the skull Sclera visible above the iris Can have paresis of upward gaze (Sunsetting sign)
Patient safety - Multiple Meds / Iatrogenic disorders
Encourage patient to bring in medication bottles, if using multiple docs, use a single pharmacy so computer can flag drug interactions.
What are three physical signs that a disorder of the lymph system may be present?
Enlarged Lymph nodes (Lymphadenopathy) Red Streaks on the overlying skin (Lymphangitis) Lymphedema
Hurler Syndrome Facies
Enlarged skull with low forehead, corneal clouding, short neck.
Hypertension
Essential or Primary hypertension - no discernable cause. If pt complains of recurrent epistaxis (nose bleeds) or headaches that disappear as the day progresses should have their blood pressure carefully monitored. If diastolic BP > 90mm Hg, or if you suspect coarction of the aorta, measure BP in legs. Place the patient in prone position. If patient is in supine position flex the leg as little as possible.
Otoscope
Examines the auditory canal and tympanic membrane. Can also be used for nasal examination.
Pleural effusion
Excessive nonpurulent fluid in the pleural space Cough with progressive dyspnea is a typical presenting concern. Dullness to percussion and decreased tactile fremitus are the most useful findings. Percussion is hyperressonant in the area above the perfusion.
Elbow Pronation and Supination ROM
Expect 90 degrees on both
Elbow ROM
Expect Flexion of 160 degrees and extension returning to 0 degrees or 180 degrees of full extension
Prominent Epicanthal Folds
Expected in asian infants Can suggest Down Syndrome in other races
Temperature
Expected range: 97.2 - 99.9F or 36.2 - 37.7C Average: 98.6 or 37C
Hearing loss Risk Factors - Adults
Exposure to industrial or recreation noise Genetic disease : Meniere disease Neurodegenerative and autoimmune disorders Syphillis Ototoxic medications
Inguinal Ligament (Poupart Ligament)
Extends form the anterior superior spine of the ilium on each side of the pubis
External, middle, and inner Ear Anatomy
Externa ear - cartilage covered
Midbrain CN 3-4
Eye and Head Movement Auditory relay pathway Corticospinal tract pathway
Miosis
Eye constriction < 2 mm Caused by Iridocyclitis, Miotic Eye Drops (Pilocarpine), and opioid abuse
CN 7 (Facial)
Facial expression except jaw, close eyelids, labial speech sounds (b, m, w, and rounded vowels) Anterior 2/3 of tongue, sensation to pharynx Secretion of saliva and tears
When entire one side of face is affected by asymmetry suspect..
Facial nerve paralysis
Spirtuality - FICA
Faith, Belief, Meaning - What is your spiritual or religious heritage - Do the beliefs help you cope with stress Importance and Influence - How have these beliefs influenced how you handle stress? Community - Do you belong to a formal spiritual or religious community Address/Action in Care - How do your religious beliefs affect your healthcare decisions (eg birth control)? pg. 10
Pseudostrabismus
False appearance of crossed eyes caused by flattened nasal bridge or epicanthal folds. Goes away by 1 yr old Use corneal light reflex to differentiate from actual strabismus
HOTV
Far Vision Wall chart composed only of H's, O's, T's, and V's. Child test, ask child to point to letter and match it on board.
Snellen eye chart / Sloan Letters
Far Vision eye chart used by eye care professionals and others to measure visual acuity. Used for Far vision Numerator = patient distance from chart / Denominator = distance from which a normal person can read Indicate ability to read next smaller line with a + and how many letters they got. example: 20/25 + 2 this indicates the patient read all fo the 20/25 line correctly and 2 of the letters in the 20/20 chart correctly.
S1 Intensity Decreased in
Fat or Fluid Emphysema, obesity, pericardial fluid, pulmonary HTN, diseased/calcified mitral valve Just remember the Two F's
FRAIL Scale
Fatigue Resistance (Ability to climb one flight of stairs) Ambulation (ability to walk one block) Illness > 5 Loss of weight > 5%
Hemangioma
Feels spongy, appears reddish blue. Valsalva maneuver may enlarge the mass May simulate lymph node enlargement.
Cerebellar gait (cerebellar ataxia)
Feet wide based. Staggering and lurching, swaying of trunk.
The knee consists of which bones?
Femur Tibia Fibula Patella
Fetoscope and Leff Scope
Fetal monitoring equipment Fetoscope - has a band that fits against the head of the listener and makes handling of the instrument unnecessary. The metal band also aids in bone conduction of sound, so that the heart tones are heard more easily Leff Scope - has a weighted end that, when placed on the abdomen does not need stabilization by the healthcare provider. These instruments can detect heart fetal heart rate at 17-19 weeks of gestation. The doppler method is more sensitive and can detect fetal heart at 10-12 weeks of gestation
Bacterial Endocarditis
Fever, Fatigue Sudden onset of CHF - SOB, ankle edema Murmur Signs of neuro dysfunction Janeway Lesion Osler nodes
Classic Meningitis Signs
Fever, Stiff Neck, Altered Mental Status. Most pt do not have all three. Other potential Signs include: Headache, Rash, N/V, Chills, Myalgia.
Wood's Lamp
Filtered black light that is used to illuminate skin disorders like fungi or skin lesions. Yellow - green fluorescence indicates fungi. Shine light on something fluorescent like non digital watch to give child sense of what you are looking for. wavelength of 360nm
Hyperthyroid Facies
Fine Mosie Skin with Fine Hair Prominent eyes and lid retraction Startled Expression
Telangiectasia
Fine irregular red line Refill eratticly when blanched Cause: Dilation of the capillaries
Telangiectasia
Fine, irregular, red lines produced by capillary dilation Ex: Telangiectasia in rosacea
Accuracy of movements
Finger to nose test, index finger 18 inches away Heel to Shin Test
What positions should you have the patient in for breast examination?
First seated Arms extended over the head or flexed behind the neck Seated and leaning forward In Recumbent position
Uremia (trimethylamines) smells
Fishy, stale
Lower Motor Neuron Lesion
Flaccid Paralysis - Muscles Fasciculations Muscle Atrophy Diminished / Absent Deep Tendon Reflexes No Plantar Response Damage affects muscle on same side of body
Pes Planus
Flat footed even when not weight bearing
Junction Nevus
Flat or slightly elevated; dark brown -nevus cells lining dermo epidermal junction -Should be removed if exposed to repeated trauma
Signs suggestive of breast cancer
Flattening of nipple Skin Dimpling
Thenar Eminence
Fleshy mound on the palm at the base of the thumb
Thomas Test
Flexion contracture of hip Have pt lie supine fully extend one leg flat on the examining table and flex the other leg with the knee to chest. Observe pt ability to keep extended leg flat on the table. Lifting the extended leg off the table indicates a hip flexion contracture in the extended leg.
Sternocleidomastoid and trapezius muscles evalution
Flexion with palpation, extension against resistance, rotation against resistance. With Rotation, XN 11 is tested simultaneously.
Tracheomalacia
Floppy airway or trachea Noisy breathing or wheezing in infancy is often inspiratory stridor Tends to be benign
Paget Disease of the Bone (Osteitis Deformans)
Focal metabolic disorder of the bone Excessive bone resorption and bone formation produce a mosaic pattern of lamellar bone Vertigo and headache from skull involvement Progressive deafness from involvement of the ossicles Bowed tibias, misshapen pelvis, or prominent skull forehead may be evident Frequent fractures
Onychomycosis (Fungal Crumble)
Fungal infection of nail, causes it to crumble. Can cause loss of dexterity, or ability to walk Distal nail plate turns yellow or white as hyperkeratotic debris accumulates, causing the nail to separate from the nail bed (onycholysis) Pitting does NOT occur, separates it from psoriasis
A firm mass over the dorsum of the wrist may be a
Ganglion Cyst
Muscular Dystrophy
Group of genetic disorders involving gradual degeneration of muscle fibers progressive symmetric weakness Early signs include clumsiness, difficulty climbing stairs and frequent falls Waddling gait Positive Gower Sign Progressive loss of function
Tinea (Dermatophytosis)
Group of noncandidal fungal infections that involve the stratum corneum, nails, or hair Patho • Infection by dermatophytes, typically acquired by direct contact with infected humans or animals; invade the skin and survive on dead keratin. • Lesions are usually classified according to anatomic location and can occur on nonhairy parts of the body (tinea corporis), on the groin and inner thigh (tinea cruris), on the scalp (tinea capitis), on the feet (tinea pedis), and on the nails (tinea unguium). Subjective Data • May report pruritus. • May report hair breaking. • Nail changes accompany onychomycosis. Objective Data • Lesions vary in appearance and may be papular, pustular, vesicular, erythematous, or scaling ( • Secondary bacterial infection may be present. • Microscopic examination of skin scraping with potassium hydroxide (KOH) solution shows presence of hyphae. • Infected nails are yellow and thick and may separate from the nail bed.
Newborns and Infants
HR - variable anywhere from 200bpm to 120bpm a few hours after birth. Tachycardia can indicate infection or paroxysmal atrial contractions. Respiratory Rate - 40-60 breaths per minute, can be up to 80. C-section infants have a more rapid respiratory rate than infants. Blood Pressure - 60-90 systolic and 30-62 diastolic Hypertension may be result of thrombosis, coarction of the aorta, renal artery stenosis, cystic disease, hydronephrosis, congenital adrenal hyperplasia, CNS disease ** check cap refill even if BP is normal should be under 2 seconds. 6-7 seconds = very poor perfusion.
Older Adults
HR 40-100bpm Hypertension > 140/90 Normotensive at 55 years of age will have a 90% lifetime risk of developing htn
Stroke Risk Factors
HTN Obesity Sedentary Smoking Stress Cholesterol, Triglycerides Oral Contraceptives Sickle Cell Disease Fam Hx DM, CVD, HTN, Cholesterol Congenital Cerebrovascular anomalies.
Scarring Alopecia
Hair folicles get replaced with scar tissue, permanent hair loss. May have Lupus Erythematous Hair Follicles may have pustule or plugged
Hirsutism
Hair grows on face, body, pubic areas in a male distribution. Can be caused by high androgen levels from ovaries or adrenal glands or by hair follicles that are more sensitive to normal androgen levels; free testosterone is the androgen that causes hair growth. Androgen Sensitive sites: face, chest, areola, external genitalia, upper and lower back, buttocks, inner thigh, and linea alba.
Traction Alopecia
Hair loss from repetitive and excessive pulling or stretching of the hair (Braids, hair rollers, hot combs) Follicle is not damaged and the loss is reversible.
Types of Nevi
Halo Nevus Intradermal Nevus Junction Nevus Compound Nevus Hairy Nevus
Rapid rhythmic alternating movements
Have seated person alternately pronate and supinate hands, patting knees, and gradually increasing speed OR Have person touch thumb to each finger on the same hand sequentially from index to little finger and back, gradually increasing speed
Palmar Grasp (Birth)
Head midline, touch palm of infant hand from the ulnar side (opposite thumb). Should have strong grasp. Disappears by 3 months
Aortic Valve Ejection Click
Hear best at Apex at the base in 2nd Right IC Pt sitting ro supine Heard during early systole, intense, high pitched, radiates, not affected by respirations.
Subaortic Stenosis Murmur
Heard at apex and along left sternal border Murmur fills systole. Thrill palpable at apex during systole. Arterial pulse brisk. Double wave in carotid common. Jugular venous pulse prominent Fibrous ring usually 1-4mm below the aortic valve
Mitral Valve Prolapse
Heard at apex and left lower sternal border Easily missed in supine position. listen with pt upright. Late systolic murmur Valve is competent early in systole but prolapses into atrium later in systole; may become progressively severe, resulting in a holosystolic murmur; often concurrent with pectus excavatum
Mitral Valve Opening Snap
Heard best with Diaphragm medial to apex, may radiate to base 2nd left IC Heard during early diastole briefly before S3 High pitch, sharp snap or click. Not affected by respiration. Easily confused with S2
Increased S4
Heard best with bell at apex Pt supine or in left lateral recumbent position Heard during late diastole or early systole, low pitch
Gallops
Heard best with bell at apex. Pt supine or in left lateral recumbent position Heard during presystole, intense and easily heard
Pulmonic Stenosis Murmur
Heard in pulmonic area, radiates to left and into neck. Thrill in 2nd and 3rd IC Systolic ejection murmur common in Right ventricular hypertrophy. Can be condused with VSD Cause almost always congenital.
Aortic Stenosis Murmur
Heard over the aortic area; ejection sound at second right intercostal border Midsystolic ejection murmur, radiates has palpable thrill in carotid Caused by a congenital bicuspid valve, rheumatic heart disease, atherosclerosis Can cause sudden death particularly in kids
Mitral Stenosis Murmur
Heard with bell at apex, patient in left lateral decubitus position Visible lift in right parasternal area if right ventricle hypertrophied Caused by Rheumatic Fever or Cardiac Infection
Tricuspid Stenosis
Heard with bell over tricuspid area Diastolic Rumble Arterial pulse amplitude decreased, jugular venous pulse prominent. Usually seen with mitral stenosis, rarely occurs along. Caused by Rheumatic heart disease, congenital defect.
Holding head to one side may indicate
Hearing or vision loss, or torticollis (shortening or excessive contraction of the sternocleidomastoid muscle.)
Dextrocardia
Heart points to the right side instead of the left (mirror imaged)
Gait Test
Heel to Toe Walking
Auricle (Pinna) Anatomy
Helix - prominent outer rim Antihelix - parallel and anterior to helix Concha - Deep cavityy containing auditory canal meatus Tragus - protuberance lying anterior to auditory canal meatus Lobule - soft lobe on bottom of Auricle
Posterior Cerebral Artery Stroke
Hemianesthesia Contralateral hemiplegia, greater in face and upper extremities than in lower extremities, cerebellar ataxia, tremor Visual loss—homonymous hemianopia, cortical blindness Receptive aphasia Memory deficits
Hemorrhages in Retina
Hemorrhage in disc margin = poorly controlled glaucoma Dot Hemorrhages = Diabetic Retinopathy
Pregnant Patients
History of present illness Obtain description of the current pregnancy, and identify previous medical care. Identify specific problems e.g bleeding, spotting, nausea, vomiting, fatigue, edema. Include info about illness, injuries, surgeries, or accidents or other injuries since conception. Obstetric History Include Gravidity and Parity, dates of delivery and length of pregnancy, weight gender of infant, and type of delivery. Any previous children removed from home due to abuse or neglect? Menstrual History Age of menarche, characteristics of cycle, unusual bleeding, dates of ovulation Gynecologic History Date of most recent pap smear / HPV test, or surgeries. Include sexual history, and any history of STI's Past Medical History Risk factors for HIV, hepatitis, herpes, tuberculosis, and exposure to environmental and occupational hazards Family History Family history of genetic conditions, multiple births, gestational diabetes, preeclampsia/eclampsia or pregnancy induced hypertension or congenital anomalies Personal and Social History Other children / pets - CATS can carry toxoplasmosis which is teratogenetic to the fetus. Feelings toward pregnancy - planned, unplanned? Review of Systems Give special attention to the reproductive system (including breasts) and cardiovascular system (documentation of prepregnancy blood pressure if possible) Assess endocrine for signs of diabetes and thyroid dysfunction. Assess urinary tract for infection, and review kidney function. Assess respiratory function bc it can become compromised later in pregnancy or with tocolytic therapy for preterm labor. Evaluate Dental care needs bc treatment of periodontitis can prevent preterm birth and or low birth weight. Risk Assessment Identify conditions from H&P that threaten well being of patient / fetus. I.e Gestational diabetes, preterm labor, preeclampsia/ eclampsia, pregnant patient malnutrition and vitamin deficiency, and use of potentially teratogenetic agents such as lithium valproic acid or ACE inhibitors. Postpartum Postpartum depression - feeling down, depressed, or hopeless, sleep disturbance, loss of energy, eating disturbance, trouble concentrating, restlessness, sad mood, anxiety, fatigue, feelings of worthlessness, inappropriate guild, and suicidal ideation.
Placing Reflex (4 days of age)
Hold the infant upright under the arms next to a table or chair; touch the dorsal side of the foot to the table or chair edge; observe flexion of the hips and knees and lifting of the foot as if stepping up on the table; age of disappearance varies
Pregnant Patients
Hypothalmic-pituitary neurohoromonal changes occur with pregnancy 1st trimester - Increased sleep needs, but may not feel rested. Late in pregnancy - sleep disturbances
Proper sequence for heart exam
IPPA Inspect, Palpate, Percuss, Auscultate Auscultating first is a common error.
Ear Anatomy
Identifies, localizes, and interprets sound. Maintains Balance Divided into external, middle, and inner ear.
Orthostatic BP
If patient is taking antihypertensives, has a depleted blood volume, or complains of fainting or postural lightheadedness, measure the blood pressure in a the arm within 3 minutes after the patient stand. If orthostatic hypotension is present, expect to see a significant drop in systolic pressure (greater than 20 mmHg) and a 10mm Hg drop in diastolic pressure. Increase in HR occurs as well. Mild blood loss, drugs, autonomic nervous system disease or prolonged time in a recumbent position can contribute to orthostatic hypotension.
Spasticity
If spasm occurs during exam gently support area to avoid injury to patient. Allow spasm to resolve before continuing exam.
Impaired hearing or speech
If using interpreter talk to patient at a normal speed, not to interpreter. If patient wants to lipread be careful not to move your face out of sight of the patient.
Ottawa Ankle Rules
In cases of acute ankle injury, the Ottawa Ankle Rules help identify the characteristics of patients needing an ankle radiograph series. There must be pain in the malleolar zone and one of the following: • Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus • Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus • Inability to bear weight for four steps both immediately after the injury and in the emergency department Absolute exclusion criteria for an ankle radiograph series include the following: age younger than 18 years, intoxication, multiple painful (distracting) injuries, pregnancy, head injury, and neurologic deficit. The Ottawa Ankle Rules have 98.5% sensitivity for detecting an ankle fracture that is present on radiography.
Physical Examination Infants and Children:
In the first few hours of life, the infant's skin may look very red. The gentle pink coloring that predominates in infancy usually surfaces in the first day after birth. Skin color is partly determined by the amount of subcutaneous fat: the less subcutaneous fat, the redder and more transparent the skin. Dark-skinned newborns do not always manifest the intensity of melanosis that will be readily evident in 2 to 3 months. The exceptions in this regard are the nail beds and skin of the scrotum.
Vertebral or Basilar Artery Stroke
Incomplete occlusion Unilateral and bilateral weakness of extremities; upper motor neuron weakness involving face, tongue, and throat; loss of vibratory sense, two-point discrimination, and position sense Diplopia, homonymous hemianopia Nausea, vertigo, tinnitus, and syncope Dysphagia Dysarthria Sometimes confusion and drowsiness Anterior portion of pons "Locked-in" syndrome—no movement except eyelids; sensation and consciousness preserved Complete occlusion or hemorrhage Coma Miotic pupils Decerebrate rigidity Respiratory and circulatory abnormalities Death
Breast Cancer Risk Factors
Increased with Age Transgender men who have no had bilateral mastectomies remain at risk In BRCA1 or BRCA2 Mutation (45-80% chance) Cancer in one breast increase risk in the other One Parent, sibling, child - double risk Two parents, siblings, child - triple risk Atypical Hyperplasia Lobular Cancer In Situ (LCIS) Fibrocystic changes without proliferative breast disease do not affect breast cancer risk White / Caucasian Radiation therapy for another type of cancer in the chest area Menarche before age 12 or menopause after age 55 Older women with dense tissue Diethylstilbestrol (DES) Therapy in the 40s-60s Nuliparity or first child after age 30 Hormone therapy - estrogen and progesterone Alcohol Obesity Lack of physical activity
Push up on infant liver
Increases Right Atrial pressure Murmur of a left to right shunt through septal opening or PDA will disappear. Murmur of right to left shunt will intensify.
Air Trapping
Increasing difficulty in getting breath out
Funnell chest (Pectus Excavatum)
Indentation of the lower sternum above the Xiphoid process
Skin Color
Individuals with dark skin may show pigmentary demarcation lines. These are normal in Black and Japanese populations
Moist Productive Cough caused by:
Infection and can be accompanied by sputum production
Acute Suppurative Lymphadenitis
Infection and inflammation of a lymph node; may affect a single or localized group of nodes Node is usually firm and tender Mainly caused by Group A Strep and Staph
Erythema / Cobblestone Appearance on Conjuctiva
Infectious Conjunctivits, or allergic rxn
Lingula
Inferior Tonguelike Projection on left upper lobe
Mastitis
Inflammation and infection of the breast tissue most often caused by staph Usually in lactating patients after milk is established 2nd-3rd week after delivery Sudden onset of swelling, tenderness, redness and heat in the breast. Underlying pus filled abscess may impart a bluish tinge to the skin
Pain
Inflammation helps sustain pain response. Chronic Pain - last several months or longer and is sustained by a pathophysiological process (joint disease, chronic inflammation, headache, or cancer) Neuropathic Pain - long term pain associated with damage or dysfunction of the central or peripheral nervous system (amputation, complex regional pain syndrome) Nociceptors are free nerve endings in the peripheral nervous system that are activated to transmit pain impulses from the sit of injury. Biochemical mediators such as bradykinin, prostaglandins, serotonin, glutamate, and substance P help transmit the pain impulses from the nerve endings along nerve pathways. Pain impulses transmit from the site of injury to the Dorsal Horn of the spinal cord through the ascending spinal tracts to the thalamus and cerebral cortex. Sharp well localized pain is transmitted through large myelinated A-delta fibers. Dull burning, diffuse, and chronic pain is slowly transmitted through small unmyelinated C-polymodal fibers.
Myocarditis
Inflammation of Myocardium / Heart muscle Subjective Data • Initial symptoms vague • Fatigue • Dyspnea • Fever • Palpitations • History of recent (within 1-2 weeks) flu-like syndrome of fevers, arthralgias, and malaise or pharyngitis, tonsillitis, or upper respiratory tract infection Objective Data • Cardiac enlargement • Murmurs • Gallop rhythms • Tachycardia • Dysrhythmias • Pulsus alternans (alternation of strong and weak arterial pulse due to alternate strong and weak ventricular contractions)
Bronchitis
Inflammation of large airways leads to increased mucus secretions. Acute Bronchitis can be accompanied by fever an CP. Usually due to infection or smoking. Chronic bronchitis = productive cough May have hacking nonproductive cough, can lead to wheezing
Episcleritis
Inflammation of sclera, superficial. Anterior to the insertion of rectus muscles. Simple - moderate to severe episodes at 1-3 month intervals. Lasts 7-10 Days, Resolved 2-3 weeks. Nodular - Prolonged attacks of inflammation. More painful. Underlying Condition
Bursitis
Inflammation of the bursa due to repetitive movement and excessive pressure on the bursa.. can also be due to infection or gout Commonly found in shoulder, elbow, hip, knee with pain and stiffness limited ROM from swelling point tenderness and erythematous warm site Soreness may radiate to tendons at the site
Meningitis
Inflammation of the meninges of the brain or spinal cord Patho • The bacterial, viral, or fungal organism often colonizes in the upper respiratory tract, invades the bloodstream, and then crosses the blood-brain barrier to infect the cerebrospinal fluid and meninges. Subjective Data • Fever, chills • Headache, stiff neck • Lethargy, malaise • Vomiting • Irritability • Seizures Objective Data • Altered mental status, confusion • Nuchal rigidity • Fever • Brudzinski and Kernig signs may be positive. • Petechiae and purpura with meningococcal meningitis • Lumbar puncture and cerebrospinal fluid culture confirm the diagnosis.
Necrotizing Enterocolitis
Inflammatory disease of the gastrointestinal mucosa associated with prematurity and immaturity of the gastrointestinal tract
Pleurisy
Inflammatory process involving visceral and parietal pleura Respirations rapid and shallow with diminished breath sounds. Pleural friction rub can be ausculated Fever may be present
Pneumonia
Inflammatory response of the bronchioles and alveoli to an infective agent Acute infection to the pulmonary parenchyma. Febrile, tachypneic, tachycardic.
Where does the vulva and lower third of the vagina drain to?
Inguinal nodes
What are the functions of saliva?
Inhibit Dental Caries Start Digestion of Carbs Moisten Mouth
Median Nerve
Innervates the palm of the hand and the palmar surface of the thumb, index, and middle fingers, and half of the ring finger
Chest examination steps in order:
Inspect Palpate Percuss Auscultate
CN 3, 4, 6 Examination
Inspect eyelids for drooping Inspect pupil size for equality and their direct and consensual response to light and accommodation Test Extra-ocular eye movements
CN 5 Trigeminal Examination
Inspect face for muscle atrophy and tremors Palpate jaw muscles for tone and strength when patient clenches teeth Test superficial pain and touch sensation in each branch (test temp if unexpected finding to pain or touch) Test corneal reflex
CN 7 Examination
Inspect symmetry of facial features with various expressions Test ability to identify sweet and salty tastes on each side of the tongue
Knee Effusion
Inspect the extended knee for its natural concavities on the anterior aspect, on each side, and above the patella. Loss of these concavities may suggest a knee effusion. An effusion of the knee fills the suprapatellar pouch and the concavity below the patella medially. When this occurs, the usual indentation above and on the medial side of the patella is filled out to be convex rather than concave.
Physical examination: Nail inspection and palpation
Inspect the nails for color, length, configuration, symmetry, and cleanliness. The condition of the fingernails can provide important insight to the patient's sense of self as the condition of the hair and nails gives a clue about the patient's level of self-care and some sense of emotional order and social integration. The nails also can demonstrate physical examination signs that may indicate an underlying systemic disease. Nail edges should be smooth and rounded. Jagged, broken, or bitten edges or cuticles are indicators of poor care habits and may predispose the patient to localized infection. Ragged cuticles are also a classic sign of dermatomyositis. Peeling nails (from the plate splitting into layers) are usually found in individuals whose hands are subject to repeated water immersion or who have underlying psoriasis. Examine the proximal and lateral nail folds for redness, swelling, pus, warts, cysts, and tumors. Pain usually accompanies ingrown nails and infections.
Upper airway is obstructed when there is:
Inspiratory Stridor Hoarse cough or cry Flaring of the alae nasi Retraction at the Suprasternal notch
Musculoskeletal Chest Pain
Intensified or provoked by movement, particularly twisting or costochondral bending; long lasting; often associated with focal tenderness
What compose the breasts vascular supply?
Internal Mammary Artery Lateral Thoracic Artery
Horner Syndrome - possible test ?
Interruption of sympathetic nerve innervation to eye. Autosomal dominant, or acquired. Ipsilateral miosis, mild ptosis, loss of hemifacial sweating. Anisocoria - difference in pupil size is greater in darkenss Dilation lag, dry skin on affected side.
Visual Field Defects
Interruption of vascular supply to optic nerve Bitemporal Hemanopia - Lesion, pituitary tumor Homonymous Hemianopia - lesion of optic nerve
What can abdominal scarring indicate?
Intraabdominal adhesions
Lordosis
Inward curvature of the lower spine that occurs in an effort to shift the center of gravity back over the lower extremities. Leads to back pain.
Failure to constrict with light stimulus
Iridiocyclitis, CN II or III Destruction, Brain herniation (Fixed Dilated Pupils)
Biot Respiration
Irregularly interspersed periods of apnea in a disorganized sequence of breaths Caused by increased ICP, Drug OD, Medulla Damage. Very poor prognosis
Keloid
Irregularly shaped, elevated, progressively enlarging scar; grows beyond the boundaries of the wound; caused by excessive collagen formation during healing Ex: Keloids form after surgery
Types of Latex Reactions
Irritant Contact Dermatitis - Chemical irritation the does not involve the immune system. Symptoms are usually dry, itching, irritated areas on the skin, typically the hands Type IV dermatitis (Delayed hypersensitivity) - Allergic contact dermatitis that involves the immune system and is caused by the chemicals used in latex products. The skin reaction usually begins 24-48 hours after contact and resembles that caused by poison ivy. May progress to oozing skin blisters. Type I Systemic Reaction - True allergic reaction caused by protein antibodies (IgE) that form as a result of interaction between a foreign protein and the body's immune system. The antigen-antibody reaction causes the release of histamine, leukotrienes, prostaglandins, and kinins. Symptoms include local urticaria (skin wheals, generalized urticaria and angioedema, asthma, eye nose itching, GI symptoms, anaphylaxis, chronic asthma, and permanent lung damage.
Thumb Abduction test
Isolates the strength of the abductor pollicis brevis muscle, innervated only by the median nerve Have pt place hand palm up and raise the thumb perpendicular to it. Apply downward pressure on the thumb to test muscle strength. Weakness is associated with carpal tunnel syndrome
What does the spleen do?
It filters bacteria out of the blood, produces phagocytes to fight off foreign invaders.
Cultural Competency
It involves recognizing one's own culture, value's, biases and using effective patient centered communication skills. A culturally competent healthcare provider adapts to the unique needs of patients of backgrounds and cultures that differ form his or her own. This adaptability coupled with a genuine curiosity about a patient's beliefs and values lay the foundation for a trusting patient provider relationship. Culture in its broadest sense reflect the whole of human behavior including ideas and attitudes, ways of relating to one another, manners of speaking, and the material products of physical effort, ingenuity, and imagination.
Cultural Response Examples
Japan - family considered legitimate decision making authority for competent and incompetent patients. Middle Easter / Navajo - believe that a patient should not be told of a diagnosis of metastatic cancer or a terminal prognosis for any reason. Navajo believe that thought and language have the power to shape reality. Talking about a possible outcome is thought to ensure the outcome. Avoid speaking in a negative way US - speak loudly, the English however speak more modulated. Want to be logical and avoid subjective. get to the point Japanese - opposite of US, use indirection, talk around points, emphasize attitudes and feelings Native Americans - Allow silence, gives them time to think Spanish - Use firm eye contact, so do the french. Firm eye contact however can be considered rude by asian and middle eastern cultures. Italians - use touch, pat on arm in a reassuring way Americans avoid this.
Dystonia
Jerky Dancing movements appear nondirectional
Coloboma of Iris
Keyhole pupil, photophobia Cause: failure of closure of the retinal fissure
Genu Valgum
Knock Knees Present if a space of 2.5cm exists between the medial malleoli
Femoral Stretch Test Detects
L1, L2, L3, l4 nerve root irritation The femoral stretch test or hip extension test is used to detect inflammation of the nerve root at the L1, L2, L3, and sometimes L4 level. Have the patient lie prone and extend the hip. No pain is expected. The presence of pain on extension is a positive sign of nerve root irritation
Patellar Reflex - Spinal Nerve Levels Evaluated
L2, L3, L5 (Deep Tendon Reflex)
Straight Leg Raising Detects
L4, L5, S1 nerve root irritation Radicular pain below the knee may be associated with disk herniation. Flexion of the knee often eliminates the pain with leg raising. Repeat the procedure on the unaffected leg. Crossover pain in the affected leg with this maneuver is more indicative of sciatic nerve impingements.
Plantar Reflex - Spinal Nerve Levels Evaluated
L5, S1, S2 Superficial Reflex
Spleen Laceration
LUQ pain with radiation to left should (positive kehr sign) Hypovolemia
Galactorrhea
Lactation not associated with childbearing Elevated prolactin levels bc of disruption in communication between pituitary and hypothalamus Spontaneous and serous or milky.
Chronic Bronchitis
Large Airway inflammation from irritant exposure Severe cases may result in right ventricular failure. Cough and sputum production are impressive. Wheezing and crackles.
Infants with right sided CHF have this feature on exam
Large Firm Liver with inferior edge as much as 5-6cm below the Right Costal Margin This usually preceedes pulmonary crackles unlike in adults.
Childhood and preadolescence represent what phase of breast development?
Latent
Ascending Tracts (Lower Motor Neuron)
Lateral Spinothalamic Anterior Spinothalamic Posterior column Anterior and Dorsal Spinocerebellar Highlighted in blue on image.
What are the three articulating compartments in the knee?
Lateral Tibiofemoral Medial Tibiofemoral Patellofemoral
Descending Tracts (Upper Motor Neuron)
Lateral and Anterior Corticospinal Medial And Lateral Reticulospinal Highlighted in red on image.
CN 6 (Abducens)
Lateral eye movement
The _________________ forms the Left border of the heart
Left Ventricle
What causes the apical impulse
Left Ventricle contraction and thrust Felt at midclavicular, fifth intercostal
Tabetic Gait
Legs far apart, feet slap ground. Steppage Gait
Malignant Melanoma
Lethal form of skin cancer that develops from melanocytes Patho • Melanocytes migrate into the skin, eye, central nervous system, and mucous membrane during fetal development. • Less than half of the melanomas develop from nevi; the majority arise de novo from melanocytes. • The exact cause of malignancy is not known; heredity, hormonal factors, ultraviolet light exposure, or an autoimmunologic effect may contribute to causation. Subjective Data • New mole or preexisting mole that has changed or is changing • New pigmented lesion that has irregularities• History of melanoma • History of dysplastic or atypical nevi • Family history of melanoma (first-degree relative) • Significant tanning bed use Objective Data • ABCDE changes in moles • A Asymmetry of lesion: one-half of a mole or birthmark does not match the other • B Borders: edges are irregular, ragged, notched, or blurred. Pigment may be streaming from the border. • C Color: the color is not the same all over and may have differing shades of brown or black, sometimes with patches of red, white, or blue. • D Diameter: the diameter is >6 mm (about the size of a pencil eraser) or is growing larger. • E Evolution: changes seen in existing pigmented lesions, particularly in a nonuniform, asymmetric manner.
What does delayed umbilical cord separation indicate
Leukocyte Adhesion Deficiency which is an autosomal recessive disorder that causes recurrent infections. UC usually drops off by 1-2 weeks
Entropion
Lid Turned in toward eye. Foreign Body Sensation. Increased risk for infection
Maxillary Sinus
Lies along the lateral wall of the nasal cavity in the maxillary bone
Exercise Intensity
Light: walking 10 to 15 steps, preparing a simple meal for one, retrieving a newspaper from just outside the door, pulling down a bedspread, brushing teeth Moderate: making the bed, dusting and sweeping, walking a level short block, office filing Moderately heavy: climbing one or two flights of stairs, lifting full cartons, long walks, sexual intercourse Heavy: jogging, vigorous athletics of any kind, cleaning the entire house in less than a day, raking a large number of leaves, mowing a large lawn with a hand mower, shoveling deep snow
Fissure
Linear crack or break form the epidermis to the dermis, may be dry or moist Ex: Athletes foot, cracks at the corner of the mouth
Paranasal sinus
Lined with mucous and ciliary bodies that move secretions along excretory pathways Frontal, ethmoid, sphenoid, maxillary sinuses make up the paranasal sinuses. Only Maxillary and Frontal sinus can be examined
Xanthelasma
Lipid deposits on eyelids Lipid Metabolism Problem
Arcus Senilis (Corneal Arcus)
Lipids in periphery of cornea. Complete circle is Cirucs Senilis
Prosthetic Mitral Valve
Listen for distinct click early in diastole, loudest at the apex and transmitted precordially.
Upper Motor Neuron Lesion
Little or No Muscle Atrophy Weakness Babinski Positive Diminished or absent Superficial Reflex Hyperactive Deep Tendon Reflex Paralysis of voluntary movements Damage above level of brainstem affects opposite side of body. Damage below brainstem affects same side of body.
Dullness on percussion
Lobar pneumonia or pleural effusion
Arterial aneurysm
Localized dilation generally defined as 1.5 timrs the diameter of a normal artery caused by weakness in the wall Results form atherosclerosis, family hx, htn, smoking play a big role Most commonly in aorta, renal femoral, popliteal arteries Asymptomatic until adjacent structure is dissected or compressed. With dissection patient describes a severe ripping pain Pulsatile swelling along the course of an artery Thrill or bruit may be evident
Renal abscess
Localized infection in the medulla or cortex of the kidney Similar symptoms to pyelonephritis
Lacrimal Gland
Located in Temporal Region of Superior Eyelid Produces Tears which drain into lacrimal sac via Canaliculi
Smell Receptors
Located in olfactory epithelium
Ulcer
Loss of epidermis and dermis; concave varies in size Ex: Decubiti, stasis ulcers
Single Peripheral Nerve Injury
Lost sensation is greatest in central portion of the nerve's anatomic distribution with a surrounding zone of partial loss because adjacent nerve distributions overlap. All or selected forms of sensory discrimination may be lost.
Emphysema
Lungs lose elasticity and alveoli enlarge in a way that disrupts function Dyspnea common at rest. Chest may be barrel shaped Scattered crackles or wheezes Overinflated hyperresonant lungs Inspiration is limited with a prolonged expiratory effor longer than 4-5 seconds Extensive smoking hx Alveolar gas is trapped in expiration, gas exchange seriously compromised.
What are the hormones in pregnancy
Luteal and Placental These cause the lactiferous ducts to proliferate, and alveoli to increase extensively in size and number -> causes breasts to enlarge 2x or 3x
What does the lymphatic system consist of?
Lymph Fluid Collecting Lymphatic Ducts Lymph Nodes Thymus Tonsils Adenoids Peyer Patches in the small intestine Bits of lymph tissue found in other parts of the body including stomach mucose, appendix, bone marrow, and lungs.
What happens if the lymph system is obstructed?
Lymph may diffuse into the vascular system, or collateral connecting channels may develop.
Muscle Strength Assessment Grades
MUSCLE FUNCTION LEVEL / GRADE No evidence of movement 0 Trace of movement 1 Full range of motion, but not against gravity with passive movement* 2 Full range of motion against gravity but not against resistance 3 Full range of motion against gravity and some resistance, but 4 weak Full range of motion against gravity, full resistance 5
Pericardial Friction Rub
Machine Like sound During sytole and diastole Heard distinctly toward the apex, but resonates everywhere.
Patent ductus Arteriosus has this type of murmur?
Machine-like continuous murmur, which can lead to LV overload and HF.
Hypothalmus
Maintains temperature control, water metabolism, body fluid osmolarity, feeding behavior, and neuroendocrine activity Autonomic nervous system
Gynecomastia
Male breasts • Result of increased body fat; hormone imbalance from puberty or aging; by testicular, pituitary, or hormone-secreting tumors; by liver failure; or by a variety of medications including anabolic steroids, marijuana, some antihypertensives, some antipsychotics, or those containing estrogens or antiandrogens • When testosterone levels are low relative to estrogen, breasts grow larger and are more noticeable. • Increased body fat, which in turn produces more estrogen, can also cause breast enlargement. Subjective Data • Breast enlargement • Relevant medication history (estrogens, antiandrogens, anabolic steroids, tricyclic antidepressants, spironolactone, 5-α reductase inhibitors, ketoconazole, cimetidine, recreational drugs—especially marijuana) Objective Data • Smooth, firm, mobile, tender disk of breast tissue located behind the areola • Usually non-tender • May be unilateral or bilateral • Amount of breast tissue varies; can be small overgrowth of breast tissue around the areola and nipple, to larger, more "female"-looking breasts
Stomach Cancer
Malignancy that arises from epithelial cells of the mucous membrane Most common in lower half of stomach. Symptoms are vague Loss of appetite, feeling of fullness, weight loss, dysphagia, persistent epigastric pain may have midepigastric tenderness, hepatomegaly, enlarged supraclavicular nodes and ascites.
Non-Hodgkin Lymphoma
Malignant neoplasm of the lymphatic system and the reticuloendothelial tissues • Non-Hodgkin lymphomas occur most often in lymph nodes in the chest, neck, abdomen, tonsils, and skin; they may also develop in sites other than lymph nodes such as the digestive tract, central nervous system, and around the tonsils. • Most arise in B cells; the rest occur in T cells Subjective Data • Painless enlarged lymph node(s) • Fever, weight loss, night sweats, abdominal pain, or fullness • Family history of non-Hodgkin lymphomas Objective Data • Nodes may be localized in the posterior cervical triangle or may become matted, crossing into the anterior triangle. • Nodes usually well defined and solid • Cannot distinguish the findings of these conditions from those in Hodgkin lymphoma through physical examination alone
Colon Cancer
May involve the recutm, sigmoid, proximal and descending colon. Subjective • Symptoms depend on cancer location, size, and presence of metastases • May describe abdominal pain, blood in the stool, or a recent change in the frequency or character of stools • Earliest sign may be occult blood in the stool, which can be detected by guaiac-based fecal occult blood testing (gFOBT) Objective • Few early examination findings • If disease has progressed, may have palpable abdominal mass in right or left lower quadrants or show signs of anemia from occult blood loss (e.g., pallor and tachycardia) • Rectal cancer may be palpable by digital rectal examination
Layrngocele
May simulate lymph node enlargement.
Thyroid Goiter
May simulate lymph node enlargement.
Graves Disease
May simulate lymph node enlargement. Causes enlarged thyroid goiter
Brachial Cleft Cyst
May simulate lymph node enlargement. sometimes accompanied by a tiny orifice in the neck along the lower third of the anteromedial border of the sternocleidomastoid muscle between the muscle and the overlying skin; may fluctuate in size when inflamed)
Tinel Sign
Median nerve integrity
Brainstem structures
Medulla Oblongata Pons Midbrain Diecephalon Nuclei of 12 cranial nerves arises from these structures
Rotator Cuff Tear
Microtrauma and tearing of hte rotator cuff muscles, most often the supraspinatus From repeated overhead lifting Pain in shoulder and deltoid area common - can wake pt up at night Inability to maintain a lateral raised arm against resitance Grating sound on movement crepitus and weakness in external shoulder rotation
Hot and Cold Balance
Middle Eastern, Asian, Southeast Asian, Hispanic, and Chinese (Yin/yang) Cold Conditions / Hot Treatments Cancer - Beef Cold - Cereal Earaches - Chili Peppers Headaches - Chocolate Joint Pain - Eggs Malaria - Goats Milk Menses - liquor Pneumonia - Onions Stomach Cramps, Teething, Tuburculosis - Peas Hot Medicines / Herbs Anise Aspirin Castor Oil Cinnamon Cod Liver Oil Garlic Ginger Root Iron Tobacco Penicillin Vitamins Hot Conditions / Cold Treatments Constipation - Barley Water Diarrhea - Chicken Fever - Dairy Products Infection - Fresh Vegetables Kidney Problems - Fruits and Honey Rash - Goat Meat Sore Throat - Raisins Cold Medicines / Herbs Bicarbonate of sode Milk of Magnesia Orange Flower Water Sage
Hypertensive Retinopathy
Mild - Narrowing, Nicking, Copper Wiring Moderate - Hemmorage (blot, dot, flame shaped), cotton wool spots, hard exudates Malignant / Severe - All of above + Papilledema - Medical emergency. Death Imminent Rapidly Decrease BP
Mid to Late nonejection systolic click caused by
Mitral Prolapse
Thrill during systole at the apex =
Mitral Regurgitation
Thrill during Diastole at the Apex =
Mitral Stenosis
Functional Asseessment for all Patients
Mobility - difficulty walking standard distances 1/2 miles, 2-3 blocks, 1/3 block, across room Upper Extremity function - able to grasp / reach overhead Household Chores ADL's - eating, toileting, clothing self, grooming, bathings, continence Instrumental activities of daily living - Shopping, medication management, money management, transportation, preparing meals, using telephone, housework
Chronic infectious disease has this type of sputum:
More abundant in morning, slight intermittent blood streaking and occasionally large amounts of blood.
Heart position in infants and young children
More horizontal than adults. As a result the apex of the heart rides higher sometimes well into the fourth left intercostal space. Adult heart position reached by age 7.
Metatarsus Adductus (Metatarsus Varus)
Most common congenital foot deformity can be fixed or flexible Caused by intrauterine positioning Medial adduction of the toes and forefoot results from angulation at the tarsometatarsal joint Heel and ankle are uninvolved The lateral border of the foot is convex The crease is sometimes apparent on the medial border of the foot
Mucus vs Cerumen
Mucus contains immunoglobulins and enzymes that serve as defense against infection. Vs Cerumen in external auditory canal is acidic.
Fetor hepaticus, hepatic failure, portal vein thrombosis, portacaval shunts smell like:
Musty fish, clover
Nail Plate
Nail Plate. The nail plate should appear smooth and flat or slightly convex. Complete absence of the nail (anonychia) may occur as a congenital condition. Look for nail ridging, grooves, depressions, and pitting. Longitudinal ridging and beading are common expected variants. Longitudinal ridges and grooves may also occur with lichen planus of the nail. Transverse grooves result from repeated injury to the nail, usually the thumb, as with chronic manipulation to the proximal nail fold. The most common cause is picking at the thumb with the index finger (habit-tic deformity). Chronic inflammation, such as occurs with chronic paronychia or chronic eczema, produces transverse rippling of the nail plate. Transverse depressions that appear at the base of the lunula occur after stress that temporarily interrupts nail formation.
Lumbar Stenosis
Narrowing of the spinal canal Caused by bone and ligament hypertrophy Pain with walking or standing upright that seems to originate in the buttocks and may then radiate down the legs. Pain relieved by bending forward Pain worsened by prolonged standing, walking, or hyperextending the back Stopped forward gait may be present.
Nasal Floor and Roof
Nasal Floor Formed by Hard and Soft Palate. Roof is formed by the frontal and sphenoid bone.
Amsler grid
Near vision test to assess central vision and to assist in the diagnosis of age-related macular degeneration. Monitors about 10 degrees of central vision and is used when retinal drusen bodeis are seen during an opthalmogic exam or when strong history of mac degeneration present.
Encephalocele
Neural tube defect with protrusions of brain and membranes that cover it through openings in the skull
Infants
Neurological impulses primarily handled by brainstem and spinal cord at birth. Reflexes: sucking, rooting, yawn, sneeze, hiccup, blink at bright light, withdrawal from painful stimuli. Primitive Reflexes: Moro, stepping, palmar, plantar grasp
Carotid Palpation
Never palpate both sides Carotid Sinus Massage can cause slowing of pulse and drop BP = Syncope If trouble finding pulse, rotate patient head to side being examined to relax sternocleidomastoid
Acanthosis Nigricans (AN)
Non specific reaction pattern associated with obesity, certain endocrine syndromes, or malignancies or as an inherited disorder Patho • Insulin resistance and hyperinsulinism may lead to an activation of insulin-like growth factor receptors, promoting epidermal growth. • Inherited form: rare, autosomal dominant trait with no obesity or associated endocrinopathies • Malignant form: results from secretion of tumor products with insulin-like activity or transforming growth factor alpha, which stimulates keratinocytes to proliferate Subjective Data • May have history of obesity, endocrine disorders • With a rise in childhood obesity, this is seen more often in children and adolescents. • Appearance in older adult associated with malignancy Objective Data • Symmetric, brown thickening of the skin with plaques or patches of thickened skin with a velvety or slightly verrucous texture • Lesions range in severity from slight discoloration of a small area to extensive involvement of wide areas. • Most common site of involvement is the axillae, but the changes may be observed in other flexural areas of the neck, groin, and arms. • Involvement of the dorsal and palmar hands or mucosal surfaces may indicate malignant association.
Osteoarthritis risk factors
Obesity Female Hx of Osteoarthritis Hypermobility syndromes > 40 yrs old High level of sports activities Peripheral Neuropathy Occupation req over use of joints
tympanometer
Objective way of assessing the ossicular chain, eustachian tube, and tympanic membrane. transmits sound energy in to the ear. Measures compliance of the system, compliance measured in mm of cc of volume indicates the amount of mobility in the middle ear. Probe introduces pressure of 200daPa decapascals if air pressure. meausres ear canal volume.
Tuberculous cavity produces this type of sputum
Occasional large amounts of blood, but make sure blood is not swallowed from a nosebleed or GI bleed
Nevi (Moles)
Occur in forms that vary in size and degree of pigmentation. Occur more often in lighter skinned individuals. Nevi can develop into a melanoma. Alterations in dark skinned people are best seen in the sclera, conjunctiva, buccal mucosa, tongue, lips, nail beds, and palms.
Inner Ear Development - Infants
Occurs during first trimester of pregnancy. Insult during this time can impair hearing.
What does a low liver border 2-3cm below costal margin indicate?
Organ enlargement or downward displacement of the diaphragm because of emphysema or pulm disease
Infant Hemodynamic Expectations at birth
PVR decreases SVR increases Ductus Arteriosus closes within 12-14 hours
Partial Spinal Sensory Syndrome (Brown-Sequard Syndrome)
Pain and temperature sensation are lost one to two dermatomes below the lesion on the opposite side of the body from the lesion. Proprioceptive loss and motor paralysis occur on the lesion side of the body.
Hawkins test
Pain indicates rotator cuff tear or impingement. Flex elbow to 90 degrees and abduct the arm to ninety and internally rotate humerus.
Mumps is characterized by
Painful swelling of parotid glands unilaterally or bilaterally, and salivary glands along mandible. This swelling may obscure the angle of the jaw. vs Cervical adenitis which does NOT obscure the angle of the jaw.
Spindle Shaped Fingers
Painful swelling of the proximal interphalangeal joints which causes spindle-shaped fingers. Associated with acute stage of Rheumatoid Arthritis
Which Glands produce saliva?
Paired Parotid Submandibular Sublingual
Chest Wall Sweep
Palm at patient's right clavicle at the sternum. Sweep Downward form the clavicle to the nipple feeling for superficial lumps.
Thyroglossal Duct Cyst
Palpable cystic mass in the neck PATHOPHYSIOLOGY • Remnant of fetal development • Rises from the foramen cecum at junction of anterior two-thirds and posterior third of tongue • Any part can persist, causing a sinus, fistula, or cyst. Subjective Data • Tenderness, redness, swelling in midline of neck • Difficulty swallowing or breathing Objective Data • Freely movable cystic mass in neck midline • Moves upward with tongue protrusion and swallowing • May have small opening in skin, with drainage of mucus
Pleural friction rub
Palpable, coarse, grating vibration usually on inspiration
Pulsus Bisferiens
Palpate carotid artery for this pulse Percussion and Tidal wave Caused by Aortic Stenosis combined with aortic insufficiency
Wedge method
Palpate from the center of the breast in a radial fashin returning to the areola to begin each spoke.
Physical Examination: Hair inspection and Palpation
Palpate the hair for texture while inspecting it for color, distribution, and quantity. The scalp hair may be coarse or fine, curly or straight, and should be shiny, smooth, and resilient. Palpate the scalp hair for dryness and brittleness that could indicate a systemic or genetic disorder. Color will vary from very light blond to black to gray and may show alterations with rinses, dyes, or permanents. The quantity and distribution of hair vary according to individual genetic makeup. Hair is commonly present on the scalp, lower face, neck, nares, ears, chest, axillae, back and shoulders, arms, legs, toes, pubic area, and around the nipples. Note hair loss, which can be either generalized or localized. Inspect the lower legs and feet for hair loss that may indicate poor circulation or nutritional deficit. Look for any inflammation or scarring that accompanies hair loss, particularly when it is localized. Diffuse hair loss usually occurs without inflammation and scarring. Note whether the hair shafts are completely absent or simply broken off. Genetically predisposed men often display a gradual symmetric hair loss on the frontal or vertex of the scalp during adulthood. Asymmetric hair loss may indicate a pathologic condition. Women in their 20s and 30s may also develop adrenal androgenic female-pattern alopecia (hair loss), with a gradual loss of hair from the central scalp. Fine vellus hair covers the body, whereas coarse terminal hair occurs on the scalp, pubic, and axillary areas, on the arms and legs (to some extent), and in the beard of men. The male pubic hair configuration is an upright triangle with the hair extending midline to the umbilicus. The female pubic configuration is an inverted triangle; the hair may extend midline to the umbilicus. Look for hirsutism in women—growth of terminal hair in a male distribution pattern on the face, body, and pubic area. Hirsutism, by itself or associated with other signs of virilization, may be a sign of an endocrine disorder. Hair patterns vary across races and ethnicities. African hair is typically coarser, drier, and curlier than Asian or White hair. People of African descent may have multiple hairs protruding from the same shaft (pili-multigemini). This can be a normal finding but may also indicate an underlying scarring process. Asians have very straight, shiny hair and often have sparser body hair. Note that cosmetic procedures may alter the color, texture, and distribution of hair on patients.
What are the major landmarks of the face?
Palpebral fissures Nasolabial Fold
PanOptic Opthalmoscope
Panoramic opthalmosocope head uses an optical design that allows a larger field of view 25 degree vs 5 degrees and increases magnification. As a result the fundus is five times larger than the view achieved with a standard scope in an undilated eye. Comes with a smart phone adapter.
What membranes surround the lungs?
Parietal and Visceral Pleurae
The Five P's of Sexual History
Partners Practices Protection from STIs Past history of STIs Prevention of pregnancy These areas should be openly discussed with patients.
Nose and Nasopharynx
Passage for inspired air, humidify, filter, and provide resonance for laryngeal sound
Diastole phases
Passive - blood moves on own then Atrial ejection
Infant Tendon Reflex Ages
Patellar Tendon - at birth Achilles and Brachioradial - 6 months Ankle clonus can be common, but should not be sustained.
Thrill during systole at the L Upper Sternal Border w/ extensive radiation =
Patent Ductus Arteriosus
Neuropathic Pain
Patho Potential causes include postherpetic neuralgia, diabetic peripheral neuropathy, trigeminal neuralgi, or radiculopathy damaged peripheral nerves fire repeatedly. dorsal horn neurons are hyper-excited and transmit enhanced pain to the brain. Causes sustained pain Subjective Data Burning, intense tightness, shooting, stabbing, electric shock-like sensations Pain sensations may be worse at night exaggerated pain response sleep disturbance allodynia - pain response to stimuli that are not typically painful interference with ADLs Objective data Confirmed self report of pain for all painful body regions distribution of pain sensations - glove or stocking leg pain response to non-painful stimulus - stroking skin sensory loss - light, touch, pin prick, vibration sense, proprioception numbness may be present in painful areas
Drug Eruptions
Patho • Immunologically mediated cutaneous reactions to medications include immunoglobulin E (IgE)-dependent, cytotoxic, immune complex, and cell-mediated hypersensitivity reactions. • Nonimmunologically mediated reactions include direct release of mast cell mediators and idiosyncratic reactions. Subjective Data • Rash appears from 1 to several weeks after taking a drug. • Pruritus may be present. • Offending drug often difficult to find. Do not forget about supplements or over-the-counter treatments. Objective Data • Most common: discrete to confluent erythematous macules and papules on the trunk, face, extremities, palms, or soles of the feet • Rash fades in 1-3 weeks and may desquamate.
Older Adults: Stasis Dermatitis
Patho • Occurs on the lower legs in some patients with venous insufficiency • Incompetent venous valves, inadequate tissue support, and postural hydrostatic pressure contribute to the development of venous stasis. • Dermatologic changes secondary to the effects of extravasated blood, which induces a mild inflammatory response in the dermis and subcutaneous fat • Most patients with venous insufficiency do not develop dermatitis, which suggests that genetic or environmental factors may play a role. • May occur as an allergic response to an epidermal protein antigen created through increased hydrostatic pressure, or because the skin has been compromised and is more susceptible to irritation and trauma Subjective Data • Sense of fullness or dull aching in the lower legs and ankles • Gradual increase in pigmentation and redness • Area may be itchy and/or painful Objective Data • Erythematous, scaling, weeping patches on lower extremity; ulceration may be present • Dermatitis may be acute, subacute, or chronic and recurrent.
Folliculitis
Patho • Presence of inflammatory cells within the wall and ostia of the hair follicle creates a follicular-based pustule. • Inflammation can be either superficial or deep; deep folliculitis can result from chronic lesions of superficial folliculitis or from lesions that are manipulated. • Persistent or recurrent lesions may result in scarring and permanent hair loss. Subjective Data • Acute onset of papules and pustules associated with pruritus or mild discomfort; may have pain with deep folliculitis • Risk factors: frequent shaving, immunosuppression, hot tubs without adequate chlorine, preexisting dermatoses, long-term antibiotic use, occlusive clothing and/or occlusive dressings, exposure to hot humid temperatures, diabetes mellitus, obesity, and use of EGFR (epithelial growth factor receptor) inhibitor medications Objective Data • Primary lesion is a small pustule 1-2 cm in diameter that is located over a pilosebaceous orifice and may be perforated by a hair. • Pustule may be surrounded by inflammation or nodular lesions; after the pustule ruptures, a crust forms. • May have suppurative drainage with deep folliculitis. • Any hair-bearing site can be affected; the sites most often involved are the face, scalp, thighs, axilla, and inguinal area.
Herpes Simplex
Patho • Two virus types cause the infection: type 1, usually associated with oral infection, and type 2, with genital infection. • Crossover infections are becoming common. Subjective Data • Exposure to ticks • Constitutional symptoms of fatigue, anorexia, and headache may develop. • Expanding rash Objective Data • Early localized infection typically manifested by a single erythema migrans skin lesion, a flat to slightly raised, erythematous skin lesion (usually ≥5 cm in diameter) that is round or oval in shape, with central clearing (classic target or bull's-eye appearance). • Early disseminated infection is usually manifested by multiple erythema migrans skin lesions, by neurologic symptoms such as facial palsy, meningitis, or encephalitis, or by symptoms of carditis such as lightheadedness, palpitations, dyspnea, chest pain, or syncope. • Late disease usually manifested by arthritis atrophicans or atrophic dermatitis.
Eczematous Dermatitis
Patho: Intercellular edema, and epidural breakdown Three stages: acute, subacute, chronic Itching makes rash worse, can get infected and start crusting. Most common inflammatory skin disorder. Irritant contact dermatits Allergic contact dermatitis Atopic Dermatitis Subjective Data • Itching is typically present. • Those with atopic dermatitis often report allergy history (allergic rhinitis, asthma). • For irritant or allergic contact, exposure history is important. Objective Data • Acute phase characterized by erythematous, pruritic, weeping vesicles • Subacute eczema characterized by erythema and scaling • Chronic stage characterized by thick, lichenified, pruritic plaques • Atopic dermatitis: during childhood, lesions involve flexures, the nape, and the dorsal aspects of the limbs; in adolescence and adulthood, lichenified plaques affect the flexures, head, and neck
AV Fistula
Pathologic communication between an artery and vein Congenital or acquired Pt may present with lower extremity edema, varicose veins, or claudication
Hypertension
Pathophysiology - defined as a BP > 140/90 Essential htn - pathologic origin is poorly understood Secondary HTN - potential causes include renal disease, renal artery stenosis, aldosteronism, thyroid disorders, coarction of the aorta, pheochromocytoma Patient Subjective Data Essential HTN is asymptomatic In malignant / severe HTN - headache, blurred vision, dyspnea or encephalopathy may be present Patient Objective Data -Multiple confirmed bp readings at or above 140/90 or in children greater than 95% for age, gender, height -End organ damage eg papilledema and evidence of heart failure
PAINAD scale
Patients whose dementia is so advanced that they cannot verbally communicate
Mastectomy
Pay attention to scar line, this is where malignancy may reoccur
What muscles form the floor of the breasts?
Pectoralis Major Pectoralis Minor Serratus Anterior Subscapularis Latissimus Dorsi External Oblique Rectus Abdominis Please Play Sublime Songs Like Ebin Rucca
Skin Types
People burn or tan depending on their skin type, the time of year, and how long they are exposed to UV rays. The six types of skin, based on how likely it is to tan or burn, are as follows: I: Always burns, never tans, sensitive to UV exposure II: Burns easily, tans minimally III: Burns moderately, tans gradually to light brown IV: Burns minimally, always tans well to moderately brown V: Rarely burns, tans profusely to dark VI: Never burns, deeply pigmented, least sensitive Although everyone's skin can be damaged by UV exposure, people with skin types I and II are at the highest risk.
Enlarged spleen vs enlarged Left kidney?
Percussion can differentiate Enlarged spleen = dull Enlarged Kidney = resonant
What structures line the abdominal cavity?
Peritoneum Serous Membrane These form a protective cover for many of the abdominal organs.
A regular paroxysmal cough is heard in?
Pertussis
Korotkoff Sounds
Phase 1 - sharp thud Phase 2 - blowing or swishing sound Phase 3 - Softer thud than phase 1, still crisp Phase 4 - Softer Blowing sound that disappears Phase 5 - silence. Muffled sound is first diastolic sound. Auscultory gap widens with systolic hypertension in older persons due to loss of arterial pliability. It also widens with a drop in diastolic pressure when chronic severe aortic regurgitation is present. Auscultory gap narrows in cases of pulsus paradoxus due to cardiac tamponade or other constrictive cardiac events.
Patterns of Injury in Physical Abus
Physical findings in children who are physically abused include bruises, burns, lacerations, scars, bony deformities, alopecia, retinal hemorrhages, dental trauma, and head and abdominal injuries. Skin and hair abnormalities may be the most visible clues in detecting this problem. It is important to examine the skin that is usually covered by clothing. • Bruises: These may be patterned consistent with the implement used, such as belt marks, marks from a looped electric cord, and oval or fingertip grab marks. Bruising associated with abuse occurs over soft tissue; toddlers and older children who bruise themselves accidentally do so over bony prominences. Any bruise in an infant who is not yet developmentally able to be mobile should be cause for concern. • Lacerations: Lacerations of the frenulum and lips are associated with forced feeding. Human bites can cause breaks in the skin and leave a characteristic bite mark. • Burns: Patterns that are common include scald burns in stocking and glove distribution (when hands or feet are placed on hot surface or immersed); buttock burns consistent with immersion; and cigarette burns, a characteristic small, round burn, often on areas hidden by clothing. The absence of splash marks or a pattern consistent with spills of hot liquids may be helpful in differentiating accidental from deliberate burns. • Hair loss: Patchy hair loss or bald spots, in the absence of a scalp disorder such as ringworm, may indicate repeated hair-pulling. • Presence of anogenital warts in a child under 2 years should also raise suspicion of physical and/or sexual abuse, although these can be auto-inoculated.
Bimanual Digital Palpation
Place one hand palmar surface facing up under the patient's right breast. Position hand so that it acts as a flat surface against which to compress the breast tissue. With the fingers of the other hand walk across the breast tissue feeling for lumps as you compress the tissue between your fingers and your flat hand.
Assess superficial and deep tendon reflexes with these tests:
Plantar Reflex Abdominal reflexes Cremastic Reflex in Male Patients Biceps, Brachioradialis, triceps, patellar, and Achilles deep tendon reflexes Ankle clonus (Descending tracts- Lateral and Anterior Corticospinal tracts) Upper motor neuron disorders
fullness in the popliteal space may indicate a
Popliteal (Baker) cyst
When do Fontanels ossify?
Posterior - 2 months Anterior - 12 - 15 months
Cervical spine palpation areas
Posterior neck Cervical Spine Paravertebral Trapezius Sternocleidomastoid
Observe patient gait for:
Posture Rhythm and sequence of stride and arm movements
Medial and Lateral Reticulospinal
Posture and Romber Gait Instinctual motor Reactions (Descending Tract/Upper Motor Neuron Disorders)
Parkinsonian
Posture stooped, body is held rigid. Short shuffling steps. Difficulty starting or stopping.
Autonomic hyperreflexia (dysreflexia)
Potentially life threatening condition associated with high level (T6 or higher) spinal cord injury. Symptoms: High blood pressure, sweating, blotchy skin, nausea, goose bumps due to stimulation of bowel or bladder, or skin below spinal lesion. Causes: reaction to cold, hard examination table, cold stirrups, insertion and manipulation of a vaginal speculum, pressure during the bi manual or rectal examination Treatment: Remove cause of stimulation for High BP. If removal of stimulation does not bring BP down, and or patient has throbbing headache or nasal obstruction treat this as a medical emergency. Never leave patient unaccompanied. pg 39
Pleural Chest Pain Characteristics
Precipitated by breathing or coughing, usually described as sharp. Present during respiration, absent when breath held.
Neonate / infant pain scale
Premature infant pain profile (PIPP) used to assess procedural pain in preterm and full term neonates between 28-40 weeks. Measures Vital signs and pain behaviors - Brow bulge, eye squeeze, and nasolabial furrow Neonatal infant pain scale is used to assess procedure pain in preterm and full term infants up to 6 weeks of age . Facial expression, cry, breathing pattern, arm and leg movements, and state of arousal are observed and scored CRIES Scale - crying requires oxygen to keep sat above 95. Increase vital signs, expression, and sleeplessness is design to evaluate postoperative pain in newborns and infants.
Hearing loss Risk factors - Infants and Children
Prenatal Factors: Perinatal infeciton, irradiation, drug abuse Assisted ventilation > 14 days Hyperbilirubinemia requiring exchange transfusion Extracorporeal membranous oxygenation Infection: bacterial meiningits, recurrent episodes of acute otitis media or otitis media with effusion Cleft Palate Head trauma Hypoxic episode
Increased fremitus caused by:
Presence of fluids or a solid mass within the lungs lung consolidation heavy but non-obstructive bronchial secretions compressed lung (Courser or rougher in feel)
Cardarelli sign
Press on thyroid cartilage and displace it to patients left. This increases contact between bronchus and the aorta allowing systolic pulsation from the aorta to be felt at the surface if an aneurysm is present.
How does the kidney serve as an endocrine gland?
Produces renin, which controls aldosterone secretion Primary source of erythropoiten production in adults, influences bodys red cell mass. Produces active form of vitamin D
Multiple Sclerosis (MS)
Progressive Autoimmune disorder, destruction of myelin sheaths of brain's white matter. Leads to decreased transmission of nerve impulses. Gradual unpredictable progression. Symptom onset 20-40 yrs. Women affected twice as much as men. Subjective Data • Fatigue • Urinary frequency, urgency, or hesitancy • Sexual dysfunction • Vertigo, weakness, numbness • Blurred vision, diplopia, loss of vision • Emotional changes • Relapse symptoms develop rapidly over hours or days, and symptoms take weeks to recede. Objective Data • Muscle weakness, ataxia • Hyperactive deep tendon reflexes • Paresthesia, sensory loss, such as loss of vibration sense • Intention tremor • Optic neuritis • Cognitive changes • Magnetic resonance imaging (MRI) reveals brain lesions that are typically periventricular, ovoid, and perpendicular to the ventricles; spinal cord lesions may also be found.
Venous thrombosis
Prolonged immobilization Tenderness, DVT, PE may occur without warning Compare one extremity to other Minimal ankle edema, low grade fever, tachycardia
Anterior and Dorsal Spinocerebellar Tract
Proprioception (Ascending Tract/Lower Motor Neuron Disorders)
Oculomotor CN III damage
Pupil Dilated and Fixed, eye deviated laterally and downward accompanied with ptosis.
Mydriasis
Pupil Dilation > 6mm Caused by Iridocyclits, mydriatic eye drops (atropine), midbrain reflex (arc reflex), lesions, hypoxia, Oculomotor CNIII damage, acute angle glaucoma, cocaine and amphetamine abuse.
Empyema
Purulent exudative fluid collected in the pleural space Non free flowing purulent fluid collection develops most commonly from adjacent infected tissues. Pt presents febrile and tachypneic with cough, CP, progressive dyspnea develops. Cough can have blood or sputum. Percussion dull Fremitus absent
Pinch Skin for Turgor Test
RETURN TO NORMAL AFTER THE PINCH DEGREE OF DEHYDRATION <2 seconds <5% loss of body weight 2-3 seconds 5%-8% loss of body weight 3-4 seconds 9%-10% loss of body weight >4 seconds >10% loss of body weight Because the normal range of skin moisture is broad, look at other factors that may suggest a problem. Excessive sweating or dryness alone rarely has pathologic significance in infants or children. Children with atopic dermatitis or chronic skin changes involving the face will commonly rub their eyes, sufficiently sometimes to cause an extra crease or pleat of skin below the eye. This is known as the Dennie-Morgan fold and often referred to as the allergic salute; it is secondary to chronic rubbing and inflammation.
Hip ROM
Raise leg with knee extended flexion of 90, knee to chest flexion of 120, internal rotation 40, external 45, abduction 40 to 45, adduction 20 to 30, standing swing leg back hyperextension 15
Lateral and Anterior Corticospinal Tract
Rapid Rhythmic Alternating Movements Voluntary Movement Deep Tendon Reflexes Plantar Reflex (Descending Tract/Upper Motor Neuron Disorders)
RESPECT Model of Cross-Cultural Communication
Rapport Empathy Support Partnership Explanations Cultural Competence Trust pg. 31
Pain Reassessment
Reassess patient at peak action of analgesic
Equilibrium
Receptors in semicircular canals and vestibule sends signals to the cerebellum to maintain equiliibrium
Spider Angioma
Red Central Body with radiating spider like legs that blanch with pressure to the central body Refill uniformly bc they are arterial Cause: Liver disease, vitamin B deficiency, idiopathic
Capillary Hemangioma (Nevus Flammeus)
Red irregular macular patch Cause: dilation fo the dermal capillaries
Ecchymosis
Red-purple non blanchable discoloration of variable size Cause: Vascular wall destruction, trauma, vasculitis
Petechiae
Red-purple nonblachable discoloration less than 0.5cm diameter Cause: Intravascular defects, infection
Purpura
Red-purple nonblanchable discoloration greater than 0.5 cm in diameter Cause: Intravascular defects, infection
Pursing of the lips
Reduces sensation of dyspnea
Basal Ganaglia
Refines motor movements EPS pathway and processing station between cerebral motor cortex and upper brain stem.
Pons CN 5-8
Reflexes of pupillary action and eye movement Regulates respiration, houses a portion of the respiratory center Control voluntary muscle action with corticospinal tract pathway. (Eyes - pupils, Breathing, voluntary muscle action)
Thalamus
Relays sensory aspects of motor info between the basal ganglia and cerebellum Major integrating center for the perception of various sensations such as pain and temperature
Thelarche Phase
Represents the first sign of puberty in girls (breast development)
Dermis
Richly vascular connective tissue layer, separates the epidermis from adipose tissue. Sensory nerve fibers located in dermis and provide sensation of pain, touch, temperature. Also contains autonomic motor nerves that innervate blood vessels, glands, and the arrector pili muscles
Most of the anterior surface of the heart is formed by the
Right Ventricle
Jugular veins reflect
Right side of heart Level at which the jugular venous pulse is visible gives an indication of right atrial pressure
What side should you approach patient from during abdominal exam?
Right side, allows for tangential view and enhances shadows and contouring
Basal and Squamous Cell Cancer
Risk factors - Older than 50 yrs - Exposure to UVA / UVB - Indoor tanning device - Blistering sunburns -Chromic and cumulative exposure - squamous cell carcinoma -Intermittent exposure - basal cell carcinoma -Geographic location near equator or high altitudes -Inability to tan skin type i and ii -Exposure to arsenic creosote, coal, tar, and or --petroleum products -Overexposure to radium, radioisotopes, X-rays -Repeated trauma or irritation to skin -Precancerous dermatoses -Large scars
Equilibrium Test
Romberg Test Feet together, arms at side. Eyes open then Closed Push shoulders, patient should recover. Stand on one foot (eyes closed). Pt should maintain for 5 seconds. Hop in place on one foot then other (eyes open). Pt should maintain for 5 seconds. Loss of balance = positive Romberg = Cerebellar ataxia, vestibular dysfunction, sensory loss
Lichenification
Rought, thickened epidermis secondary to persistent rubbing, itching or skin irritaiton; often involves flexor surface of extremity Ex: Chronic Dermatitis
Achilles Reflex - Spinal Nerve Levels Evaluated
S1 and S2 (Deep Tendon Reflex)
Electrical impulse in the heart
SA -> AV -> Bundle of His -> Purkinje Fibers
What muscles comprise the rotator cuff?
SITS Subscapularis Infraspinatus Teres minor Supraspinatus
Orthopnea
SOB that begins or increases when the patient lies down. Ask if pt needs to sleep on more than one pillow and if it helps.
Pulmonary Valve Ejection Click
Second left intercostal space at sternal border; patient sitting or supine Early systole, less intense than aortic click; intensifies on expiration, decreased on inspiration
Scale (Secondary skin lesions)
Secondary skin lesion, heaped up keratinized cells; flaky skin, irregular; thick or thin; dry or oily; variation in size. Ex: Flaking of skin with seborrheic dermatitis or after a drug reaction; dry skin
Newborn Depressed Respiration can be from:
Sedatives Compromised blood supply Asp meconium Mucus obstruction SCAM
Enhanced physiologic tremor
Seen when arms Extended, dissappears at rest Drugs or Etoh Hyperthyroid, Hypoglycemia Lithium, TCA's, valproate, methylxanthines toxicity
Ejection Click
Semilunar Valves are stenotic - Tricuspid and Aortic
Infant Eustachian Tube
Shorter, wider, more horizontal than an adults. Has an upward curve. Adenoid (tonsils) development may occlude Eustachian tube and interfere with aeration of middle ear. Predisposes children to middle ear effusion.
Neer Test
Shoulder rotator cuff impingement or tear forward flex the patient arm up to 150 degrees while depressing the scapula. increased shoulder pain = rotator cuff inflammation or tear
ROM of Shoulders Exam
Shrug Shoulders Raise both arms forward and straight up over the head - expect flexion of 180 degrees Extend and stretch both arms behind the back - expect hyperextension of 50 degrees Lift both arms laterally and straight up over the head - expect should abduction of 180 degrees Swing arms across the front of the body, expect adduction of 50 degrees Place both arms behind the hips elbows out, expect an internal rotation of 90 degrees Place both arms behind the head elbows out, expect an external rotation of 90 degrees
CN 11 Examination
Shrug Shoulders (Trapezius strength) Turn head to each side against resistance (Sternocleidomastoid)
Ataxic Respirations
Significant disorganization with irregular and varying depths of respiration Caused by increased ICP, Drug OD, Medulla Damage. Very poor prognosis
Myxedema
Skin and tissue disorder due to severe prolonged hypothyroidism • Decrease in metabolic rate, resulting in accumulation of hyaluronic acid and chondroitin sulfate in the dermis • Deposition of glycosaminoglycan in all organ systems leads to mucinous edema of facial features. Subjective Data • Cognitive impairment slowed mentation, poor concentration, decreased short-term memory, social withdrawal, psychomotor retardation, depressed mood, and apathy • Constipation • Muscle pains • Hearing problems, deafness Objective Data • Coarse thick skin, thickening nose, swollen lips, puffiness around eyes • Slow speech • mental dullness, lethargy, mental problems • Weight gain • Thin brittle hair, with bald patches
Anatomic Structures of the Skin
Skin structure and physiologic processes perform the following integral functions: • Protect against microbial and foreign substance invasion and minor physical trauma • Restrict body fluid loss by providing a restrictive barrier • Regulate body temperature • Provide sensory perception via free nerve endings and specialized receptors • Produce vitamin D from precursors in the skin • Contribute to blood pressure regulation through constriction of skin blood vessels • Repair surface wounds by exaggerating the normal process of cell replacement • Excrete sweat, urea, and lactic acid • Express emotions
Compound Nevus
Slightly elevated brownish papule: indistinct border -Nevus cells in dermis and lining dermoepidermal junction -Should be removed if exposed to repeated trauma
Bronchiolitis
Small airway inflammation leads to hyperinflation of lung infants < 6months Wheezing, grunting, diminished breath sounds, AMS, increased AP diameter
Asthma presentation:
Small airway obstruction due to inflammation • Tachypnea and paroxysmal coughing with wheezing on expiration and inspiration • Expiration becomes more prolonged with labored breathing, fatigue, and anxious expression as airway resistance increases. • Hypoxemia by pulse oximetry may develop. • Decreased peak expiratory flow rate
Ophthalmoscope
Small aperture - used for small pupils Red-free filter - produces a green beam for examination of the optic disc for pallor and minute vessel changes; also permits recognition of retinal hemorrhages, with blood appearing black Slit - examination of the anterior eye and determination of the elevation of lesions on the retina. Grid - Estimation of the size of fundal lesions + and - can compensate for myopia or hyperopia in both the examiner and patient. There is not compensation for astigmatism
Janeway Lesions
Small erythematous or hemorrhagic macules appearing on the palms and soles
Peyer Patches
Small raised lymph tissue on the mucosa of the small intestine and consist of many clustered lymphoid nodules.
Far Vision Tests
Snellen Chart E chart for children
Solar Lentigines
Solar lentigines (singular lentigo) are irregular, gray-brown macules that occur in sun-exposed areas that can range in size from a few millimeters to over a centimeter. These are often referred to as "age spots" or incorrectly as "liver spots". Note that "liver spots" have no relationship to the liver. They are epidermal proliferations and are signs of photoaging of the skin.
CN Mnemonic (classification)
Some Say Marry Money But My Brother Says Bad Business Marry Money S = Sensory M = Motor B = Both
Auscultation
Sound characteristics: Intensity Pitch Duration Quality
Percussion
Sound waves heard from vibrations 4-6cm deep in body tissue. Tympanic - gastic bubble. drumlike Hyper-resonant- emphysematous lungs, boomlike Resonant - healthy lung tissue, hollow Dull - over liver, thudlike Flat - over muscle, very dull.
CN 9, 10 Examination
Sour and bitter tastes on each side of tongue Gag reflex Inspect palate and uvula Swallowing difficulty? Guttural speech sounds (nasal or hoarse quality voice)
Raynaud Phenomenon/Disease
Spasm of digital arterioles usually in response to cold exposure. Occasionally in nose and ears common in young women Involved areas feel cold and achy, improve on rewarming triphasic demarcated skin pallor (white) cyanosis (blue) reperfusion (red) vasospasm can last from minutes to less than an hour Secondary reynaud ulcers may appear on tips of digits
Unexpected Gait Patterns
Spastic Hemiparesis Spastic Diplegia (Scissoring) Steppage Dystrophic (Waddling) Tabetic Cerebellar Gait (Cerebellar ataxia) Sensory Ataxia Parkinsonian Gait Dystonia Ataxia Antalgic Limp
Pregnant patients
Spider and cherry angiomas may increase in size due to increased blood flow to the skin. Most pregnant patients have some degree of increased pigmentation. Nevi may grow and change color
Ascending Spinal Tracts
Spinothalmic, spinocerebellar - mediate various sensations Manage sensory signals necessary to perform complex discrimination tasks
Vertebra Prominens
Spinous Process of C7 Better seen and felt with head bent forward.
QRS Complex is the
Spread of stimulus through the ventricles Ventricular Depolarization < 0.12 seconds
Lymphedema Grading
Stage 0 - Latent or subclinical - Swelling is not evident despite impaired lymph transport. Stage I - Pitting may occur. There is early accumulation of fluid relatively high in protein content (e.g., in comparison with "venous" edema), and it subsides with limb elevation. Stage II Tissue fibrosis is present. Limb elevation alone rarely reduces tissue swelling. Pitting may be present. Late in stage II, the limb may or may not pit as tissue fibrosis supervenes. Stage III Pitting is absent. Trophic skin changes are present (acanthosis nigricans, fat deposits, and warty overgrowths).
Infection Precautions
Standard - PPE - Hand Hygiene - Cough Etiquette / Respiratory hygiene - Safe Injection Practices - Safe Handling of potentially contaminated equipment Transmission Based - Airborne / Droplet Precautions -Contact Precautions
Peripheral artery disease
Stenosis of the blood supply to the extremities by atherosclerotic plaques Pain in muscle after exercise disappears with rest. Limb appears healthy but pusles weak or absent Progressive stenosis results in severe ischemia which leads to limb in pain at rest Edema seldom accompanies this disorder, ulceration is common.
External Jugular vein is close to what structure
Sternocleidomastoid IJ is close to carotid artery
Accessory muscles
Sternocleidomastoid Scalenes Pectoralis minor Abdominal Obliques Rectus Abdominis SPARS or RAPSS
What muscles form the neck?
Sternocleidomastoid Trapezius
CN 12 Hypoglossal Examination
Stick tongue out Move tongue toward nose and chin Press tongue against cheek Lingual Speech Sounds (L, T, D, N)
Meningeal or Intracranial Hemorrhage Signs include:
Stiff Neck or Nuchal Rigidity Test with Kernig and Brudzinksi Sign
Still Murmur
Still murmur is recognized as the most common innocent murmur of early childhood. It is described as musical, vibratory, short, and high-pitched. Result of vigorous myocardial contraction Blowing accompanied with split S2 2nd Left IC near left sternal border
Renal Calculi
Stones formed in the pelvis of the kidney from a physiochemical process associated with obstruction and infections in the urinary tract
Pregnant Patients
Striae gravidarum (stretch marks) may appear over the abdomen, thighs, and breasts during the second trimester of pregnancy. They fade after delivery but never disappear. There is an increase in telangiectasias, which may be found on the face, neck, chest, and arms; these appear during the second to fifth months of pregnancy and usually resolve after delivery. Hemangiomas that were present before pregnancy may increase in size, or new ones may develop. Cutaneous tags (molluscum fibrosum gravidarum) are either pedunculated or sessile skin tags that are most often found on the neck and upper chest. They result from epithelial hyperplasia and are not inflammatory. Most resolve spontaneously or can be removed easily. An increase in pigmentation is common and is found to some extent in all pregnant patients. The areas usually affected include the areolae and nipples, vulvar and perianal regions, axillae, and the linea alba. Pigmentation of the linea alba is called the linea nigra. It extends from the symphysis pubis to the top of the fundus in the midline Preexisting pigmented moles (nevi) and freckles may darken, with some nevi increasing in size. New nevi may form. Melasma or "mask of pregnancy," occurs frequently in pregnant patients. The darkened, blotchy skin is usually symmetric and found on the forehead, cheeks, bridge of the nose, and chin Palmar erythema is a common finding in pregnancy. A diffuse redness covers the entire palmar surface or the thenar and hypothenar eminences. The cause is unknown but is likely related to estrogens, and it usually disappears after delivery. Itching over the abdomen and breasts resulting from skin stretching is common and not a cause for concern; however, itching accompanied by a rash may signal a pregnancy-specific dermatosis, which requires further investigation. Itching during pregnancy can also be caused by impaired flow of bile from the liver, which may also produce jaundice. The itching is generalized but may be more severe on the palms and soles. Be alert to these serious manifestations of underlying pathology. Hair growth is altered in pregnancy by the circulating hormones. The growing phase of the hair is lengthened and hair loss is decreased. Two to 6 months after delivery, increased hair shedding occurs (telogen effluvium). Regrowth will occur in 6 to 12 months. Acne vulgaris may be aggravated during the first trimester of pregnancy but often improves in the third trimester.
These indicate a severely obstructed airway:
Stridor is inspiratory and expiratory Cough has a barking character Retractions also involve the subcostal and intercostal spaces Cyanosis is obvious even with supplemental O2.
These indicate an obstruction below the glottis:
Stridor tend to be louder, more rasping The voice is hoarse Swallowing not affected Cough is harsh, barking Positioning of head is not a factor
These indicate an obstruction above the Glottis:
Stridor tends to be quieter The voice is muffled Swallowing is difficult Cough is not a factor Awkward head / neck positioning ( extended with retropharyngeal abscess or head to affected side with peritonsillar abscess)
Cardiac Tamponade
Subjective Data • Anxiety, restlessness • Chest pain • Difficulty breathing • Discomfort, sometimes relieved by sitting upright or leaning forward • Syncope, lightheadedness • Pale, gray, or blue skin • Palpitations • Rapid breathing • Swelling of the abdomen or arms or neck veins Objective Data • Beck triad (jugular venous distention, hypotension, and muffled heart sounds) • Chronically and severely involved pericardium may also scar and constrict, limiting cardiac filling; heart sounds are muffled, blood pressure drops, the pulse becomes weakened and rapid, and paradoxical pulse becomes exaggerated.
Serum Sickness (Type III Hypersensitivity Reaction)
Subjective Data • Enlarged lymph nodes • Pain, pruritus, and erythematous swelling at the injection site • Urticaria, other rashes, lymphadenopathy, joint pain, fever, and at times facial edema • Medications: beta-lactam antibiotics (especially cefaclor), sulfonamide antibiotics, minocycline • Organ transplant Objective Data • Findings become apparent about 7-10 days after administration of the provoking substance. • Urticaria, maculopapular or purpuric lesions • Lymphadenopathy most prominent in the area draining the injection site; can be generalized • Facial and neck edema • Symptoms subside slowly, recurring at times over several weeks.
Roseola Infantum (HHV6)
Subjective Data • Fever—usually high grade and persistent over 3-4 days • Sometimes associated with a mild respiratory illness and lymphadenopathy Objective Data • Adenopathy, discrete and not tender, involves the occipital and postauricular chains and may last for some time • When the fever diminishes, a morbilliform fine maculopapular rash occurs, spreading from the trunk to the extremities; the child begins feeling much better. Common in infancy
CHF Right Sided
Subjective Data • Peripheral edema, particularly at the end of the day or after prolonged sitting • Weight gain Objective Data • Pitting edema in lower extremities • Jugular venous distention • Ascites • Hepatomegaly Jugular Vein Distention is most helpful finding for R CHF.
Ventricular Septal Defect
Subjective Data • Recurrent respiratory infections • If large VSD, rapid breathing, poor growth, symptoms of congestive heart failure Objective Data • Arterial pulse is small, and jugular venous pulse is unaffected. • Holosystolic murmur, often loud, coarse, high-pitched, and best heard along the left sternal border in the third to fifth intercostal spaces • Left peristernal lift • A smaller defect causes a louder murmur and a more easily felt thrill than a large one
Nonpathologic nodes
Submandibular or cervical nodes <1cm in diameter or Inguinal node < 2cm
Cephalhematoma
Subperiosteal collection of blood bound by the suture lines Commonly found in the parietal region Firm, edges are well defined. Does NOT cross suture lines. May liquefy and become fluctuant on palpation.
Stroke / CVA
Sudden interruption of blood supply to part of brain
Alopecia Areata
Sudden rapid coin shaped loss of hair usually from scalp or face Patho • Cause unknown; autoimmune phenomenon from a genetic-environmental interaction may trigger the disease. • Any hair-bearing surface may be affected. • Regrowth begins in 1-3 months; the prognosis for total regrowth is excellent in cases with limited involvement. Subjective Data • Sudden, rapid, round patches of hair loss • May also report nail pitting • May have family history Objective Data • Hair loss is in sharply defined, round areas • Nonscarring • The hair shaft is poorly formed and breaks off at the skin surface. • Small villous hairs indicate hair regrowth.
Hippocratic Facies
Sunker appearance of eyes, cheeks, and temporal areas Sharp nose, dry rough skin. This is terminal stage throat cancer.
Anterior Spinothalamic Tract
Superficial Touch and Deep Pressure (Ascending Tract/Lower Motor Neuron Disorders)
Breast lymphatic network is composed of?
Superficial lymphatics - drain the skin Deep Lymphatics - drain the mammary lobules
Tympanic Membrane
Superior portion (pars flaccida) is more flacid, rest is tense (pars tensa)
Posterior Spinal Artery Stroke
Supplies Posterior Spinal Cord S/S Sensory loss, particularly proprioception, vibration, touch, and pressure (movement preserved)
Anterior Spinal Artery Stroke
Supplies Spinal Cord S/S Flaccid paralysis, below level of lesion Loss of pain, touch, temperature sensation (proprioception preserved)
Posterior Inferior Cerebellar Artery Stroke
Supplies the lateral and posterior portion of the medulla Wallenberg syndrome (swallowing difficulty, hoarseness, dizziness, nausea and vomiting, nystagmus, and problems with balance and gait coordination) Ipsilateral anesthesia of face and cornea for pain and temperature (touch preserved) Ipsilateral Horner syndrome Contralateral loss of pain and temperature sensation in trunk and extremities Ipsilateral decompensation of movement
Anterior Inferior and Superior Cerebellar Arteries Stroke
Supply the Cerebellum S/S Difficulty in articulation, swallowing, gross movements of limbs; nystagmus
Paget Disease
Surface Manifestation of underlying ductal Carcinoma Crustiness on the nipple, areola, and surrounding skin Pruritis of nipple common Red, scaling, crusty patch Does not respond to steroids
Cardiac Chest Pain Characteristics
Susbternal provoked by effort, emotion relieved by rest / nitro can have diaphoresis and nausea
Preeclamspia-Eclampsia
Syndrome specific to pregnancy with HTN that occurs after the 20th week of pregnancy and the presence of proteinuria. Eclampsia is preeclampsia with seizures. Sustained elevation of BP systolic > 160 diastolic > 110
SAFER Approach
Syndromic features Age Family Hx Evaluation of feeding and growth Rheumatic Fever
S2 Intensity increases in
Systemic HTN, Syphilis of Aortic Valve, excercise, excitment Pulmonary HTN, Mitral Stenosis, CHF Think HTN, Aortic Valve and Mitral Valve.
Acute Rheumatic Fever
Systemic connective tissue disease occurring after streptococcal pharyngitis or skin infection • Fever • Inflamed swollen joints • Flat or slightly raised, painless rash with pink margins with pale centers and a ragged edge (erythema marginatum) • Aimless jerky movements (Sydenham chorea or St. Vitus dance) • Small, painless nodules beneath the skin • Chest pain • Palpitations • Fatigue • Shortness of breath Objective Data Jones Criteria for Diagnosis of Rheumatic Fever • Murmurs of mitral regurgitation and aortic insufficiency • Cardiomegaly • Friction rub of pericarditis • Signs of congestive heart failure
Systemic Disorders and the skin
Systemic disorders can produce generalized or localized color changes Localized redness often results from an inflammatory process. Pale, shiny skin of the lower extremities may reflect peripheral changes that occur with systemic diseases such as diabetes mellitus and peripheral vascular disease. Injury, steroids, vasculitis, stasis, and several systemic disorders can cause localized hemorrhage into the skin, producing red-purple discolorations. Bleeding into the skin results in ecchymoses (i.e., bruising); pinpoint bleeding from capillaries occurs is called petechiae (smaller than 0.5 cm in diameter) or purpura (larger than 0.5 cm in diameter)
S1 marks the beginning of
Systole Coincides with rise / upswing of carotid pulse. Best heard at apex
TACE Model
T - How many drinks does it TAKE to make you feel high? A - Have people ANNOYED you by criticizing your drinking? C - Have you felt you out to CUT down on your drinking? E - Have you had an EYE-OPENER Drink first thing in the morning to steady your nerves? Answer to T alone (more than two drinks) or a positive response to two of A,C,E may signal a problem with a high degree of probability
Cremasteric Reflex - Spinal Nerve Levels Evaluated
T12, L1, L2 Superficial Reflex
Lower Borders of Lung descend to where on deep inspiration?
T12, then rise to about T9 on forced expiration
What level does the trachea divide?
T4 or T5 and just below the manubriosternal joint (angle of louis)
Old age and the Thyroid Gland
T4 production and degradation decreases. Thyroid becomes more fibrotic
Upper Abdominal Reflex - Spinal Nerve Level Evaluated
T8, T9, T10 Superficial Reflex
Blood pressure examination
Taken while patient seated, if supine readings will be lower. Standard based on seated position in right arm. Center cuff over brachial artery, lower edge 2-3cm above antecubital If cuff too wide BP will be underestimated. If too Narrow, BP will be high. Adults: Choose a width that is 1/3 to 1/2 the circumference of the limb Length should be twice the width or about 80% of the limb circumference. Bladder should not completely encircle limb. Loose cuff will give inaccurate diastolic reading. Make sure patients arm is at level of heart. Korotkoff sounds - produced by turbulence of blood flow in artery - low pitches, use bell of stethoscope.
What is the major accessible artery of the face?
Temporal artery
CN 2 Examination
Test distant and near vision Perform ophthalmoscopic exam of fundi Test visual fields by confrontation and extinction of vision
CN 8 Examination
Test sense of hearing with whisper screening tests or by audiometry Compare bone and air conduction of sound Test for lateralization of sound
Tinel Sign
Tested by striking the patient's wrist with your index or middle finger where the median nerve passes under the flexor retinaculum and volar carpal ligament Tingling sensation radiating from the wrist to the hand in the distribution of the median nerve is a positive Tinel sign
Rosenbaum Pocket Vision Screener
Tests near vision. Hold card 35cm or 14 inches away
Corneal Sensitivity (Cotton Wisp)
Tests: CN V (Trigeminal) CN VII (Facial) by blinking
Older Adults Nail Changes
The nails thicken, become more brittle, and may be deformed, misshapen, striated, distorted, or peeling. They can take on a yellowish color and may lose their transparency. These changes occur most often in the toenails.
Distinguishing Physical Characteristics
The use of physical characteristics to distinguish a cultural group or subgroup is inappropriate. Do not confuse the physical with the cultural or allow the physical to symbolize the cultural.
Montgomery tubercles or follicles
Tiny sebaceous glands that may be apparent on the areola surface
Lumbosacral Hyperextension in pregnancy
To assess for lumbosacral hyperextension, ask the patient to bend forward at the waist toward the toes. Palpate the distance between the L4 and S1 spinal processes. As the patient rises to standing, from full flexion to full extension, note when the distance between L4 and S1 becomes fixed. If it becomes fixed before the spine is fully extended, the patient will be hyperextended when walking, possibly resulting in lower back pain. Most back pain resolves within 6 months after delivery.
Oral Cavity and Oropharyngeal Cancer Risk Factors
Tobacco use Alcohol use HPV 16 oral infection > 55 yrs old Male UV light exposure - cancer of lip HIV infection, Graft vs Host disease Fanconi Anemia Dyskeratosis Congenita
CN 12 Hypoglossal
Tongue Movement for speech, sound articulation (l, t, d, n) and swallowing.
McMurray Test Detects
Torn Meniscus in knee Have the patient lie supine and flex one knee. Position your thumb and fingers on either side of the joint space. Hold the heel with your other hand, fully flexing the knee, and rotate the foot and knee outward (valgus stress) to a lateral position. Extend and then flex the patient's knee. Any palpable or audible click, pain, or limited extension of the knee is a positive sign of a torn medial meniscus.
Rooting Reflex (Birth)
Touch Corner of infants mouth. infant will move head toward side of stimulation when hungry. Disappears by 3-4 months of age.
Plantar Grasp
Touch plantar surface, toes should curl downward. Reflex strong till 8 months
Pericardium
Tough double walled fibrous sac encasing and protecting the heart. Several mm of fluid are present between the inner and outer layers of the pericardium, provides low friction environment.
Tics, spasmodic muscular contractions of face, head, or neck may indicate
Tourette syndrome, or degenerative changes of the facial nerves
Wide Splitting
Unexpected Heart Sound Occurs in RBBB and in Pulmonic Stenosis, Pulm HTN, Mitral Regurgitation Caused by delayed activation of contraction of the right ventricle
Papilledema
Unexpected Retinal Fining Loss of definition of optic disc margin, initially occurs superiorly and inferiorly. Then nasally and temporally central vessels pushed forward. Veins markedly dilated Venous pulsation not visible and cannot be induced by pressure to globe Caused by increased ICP
Glaucomatous Optic Nerve Head Cupping
Unexpected Retinal Fining Physiologic dis margins are raised with a lowered central area. Impairment of blood supply may lead to optic atrophy causing dis to appear white result of ICP, visual fields are constricted
Myelinated Retinal Nerve Fibers
Unexpected Retinal Fining White area with soft ill defined peripheral margins usually continuous with optic disc, feather margins, absence of pigment has full visual field unlike in chorioretinitis. benign condition
Cotton Wool Spot
Unexpected Retinal Fining ill defined yellow areas caused by infart of nerve layers of the retina. Caused by HTN or DM
Spinal Nerve Superficial Reflexes
Upper Abdominal Lower Abdominal Cremasteric Plantar
For exam what are the four quadrants of the breast?
Upper Inner / Outer Lower Inner / Outer and a Tail of Spence
Where does the greatest amount of glandular tissue lie?
Upper outer quadrant of the breast
If you suspect vascular anomaly of the brain
Use bell of stethoscope and listen of temporal region, over eyres, and below the occiput.. Looking for a bruit - highly suggestive of vascular anomaly.
Jugular Venous Pressure
Use two pocket rulers 15cm long. Expect value of < 9cm H2O These conditions make JVP difficult to examine: severe right heart failure, tricuspid insufficiency, constrictive pericarditis, and cardiac tamponade, volume depletion, extreme obesity
Nasal speculum
Use with penlight to visualize the lower and middle turbinates of the nose.
Amsler Grid
Used for macular degeneration when drusen boders are seen Pt notes line distortion
Rosenbaum or Jaeger Chart
Used for near vision, or can use newsprint Rosenbaum - series of x's and o's and e's
CRAFFT Questionarre
Used primarily for screening alcohol and substance abuse in Adolescents Car Relax Alone Forget Friends Trouble Questions: - Have you ridden in a CAR driven by someone who was high or had been using drugs and alcohol? - Do you ever use alcohol or drugs to RELAX, feel better about yourself or fit in? Do you ever use drugs or alcohol when you are ALONE? - Do you FORGET things you did while using drugs or alcohol - Do your family and FRIENDS ever tell you that you should cut down your drinking or drug use? - Have you ever gotten into TROUBLE while using drugs or alcohol?
CAGE questionnaire
Used to screen for alcoholism Cutting down Annoyance by criticism Guilty feeling Eye Openers
Arthritis/Bursitis Chest Pain Characteristics
Usually lasts for hours; local tenderness and/or pain with movement
Costal Angle
Usually no more than 90 degrees
Biliary Chest Pain Characterisitcs
Usually under right scapula, prolonged in duration Often occurs after eating, will trigge angina more often than mimic it
Cheyne-Stokes
Varying Periods of increasing depth interspersed with apnea Crescendo / Decrescendo sequence - cerebral brain damage, can occur with drug use or severe CHF. May also occur normally in young children and older adults.
Arterial pulses are the result of
Ventricular Systole - Produces a pressure wave
S3 is caused by
Ventricular filling - ventricular walls distend and cause vibration Ventricular Gallop on expiration. Best heard in left lateral decubitus/ recumbent position. Listen at the Apex on Expiration Lub de Dub or TEN-nes-see
Infants and children
Vernix caseosa - a mixture of sebum and cornified epidermis covers the infants body at birth. Subcutaneous fat layer poorly developed in newborns which predisposes them to hypothermia. Lanugo - covers shoulders and back, fine silky hair. commonly seen in preterm infants, and is shed in 10-14 days. Most hair is shed by about 2-3 months of age and replaced by permanent hair. Eccrine sweat glands start to function after first month of life. Apocrine does not start until puberty. Thus children do not have smelly perspiration.
Grade 6 Murmur
Very loud, audible with stethoscope not in contact with chest, thrill palpable and visible
Grade 5 Murmur
Very loud, thrill easiily paplpable
Test Cortical sensory response to:
Vibration with a tuning for over joints or bony prominence on upper and lower extremities Position sense with movement of the great toes or a finger on each hand Identification of familiar object by touch and manipulation Two Point discrimination Identification of number drawn on palm of hand Identification of body area when touched (Posterior, Anterior, and dorsal spinocerebellar spinal tracts) Ascending Tracts for lower motor neuron disorder
Legally Blind
Vision Not correctible to 20/200 or less
CN 2 Optic
Visual acuity and fields
Red Reflex
Visualized first with, hold opthalmascope 12 inches / 30cm away. Light illuminates Retina, opacities stand out as black densities.. Absence of red reflex is improperly positioned opthalmascope, but can indicate total opacity of pupil bc of cataract or hemorrhage.
CN 9 Glossopharyngeal
Voluntary muscles for swallowing and phonation (guttural speech sounds) Sensation of nasopharynx, gag reflex, taste. Posterior 1/3 of tongue Secreation of salivary glands, carotid reflex.
Split S2
When the aortic valve closes significantly earlier than the pulmonic valve, you can hear the two components separately This is an expected event
Pericardial Friction Rub characteristics
Widely heard, sound clearest toward apex May occupy all of systole and diastole; intense, grating, machine-like; may have three components and obliterate heart sounds; if only one or two components, may sound like murmur
Moro / Startle (Birth)
With the infant supported in semisitting position, allow the head and trunk to drop back to a 30-degree angle; observe symmetric abduction and extension of the arms; fingers fan out and thumb and index finger form a C; the arms then adduct in an embracing motion followed by relaxed flexion; the legs may follow a similar pattern of response; the reflex diminishes in strength by 3-4 months and disappears by 6 months.
Cirrhosis
a chronic degenerative disease of the liver characterized by scarring Subjective • May be asymptomatic; others report jaundice, anorexia, abdominal pain, clay-colored stools, tea-colored urine, and fatigue • May describe prominent abdominal vasculature, cutaneous spider angiomas, hematemesis, and abdominal fullness Objective • On examination, the liver is initially enlarged with a firm, nontender border on palpation; as scarring progresses, liver size is reduced and generally cannot be palpated • Neurologic examination abnormalities may be seen (e.g., hepatic encephalopathy) • With progressive disease, portal hypertension and ascites may occur • Muscle wasting and nutritional deficiencies may be evident in late-stage disease • May have abnormal laboratory values (e.g., liver function tests and coagulopathy)
When a joint has an increase or limitation in its range of motion use this tool
a goniometer, measure greatest flexion and extension
Virchow Node
a palpable supraclavicular node on the left, this is a significant clue to thoracic or abdominal malignancy.
Chloasma (mask of pregnancy)
a pigmentation disorder characterized by brownish spots on the face, this can occur during pregnancy after 16 weeks
A dry cough may sound loud and harsh from
a tumor that is compressing respiratory tree, or hoarse in Croup.
Scoliosis abnormality
abnormal lateral curvature of the spine Scoliometer reading of greater than or equal to 7 degrees is a positive screening test
Cubitus Valgus
abnormal outward bending or twisting of the elbow A lateral angle exceeding 15 degrees
Systolic murmurs are best described
according to time of onset and termination
A prolonged expiration and bulging on expiration are probably cause by:
airway outflow obstruction or the valvelike action of compression by a tumor, aneurysm, or enlarged heart. When this happens the costal angle widens beyond 90 degrees.
Angle of Louis
aka Manubriosternal junction. Visible and palpable angulation of the sternum and point at which the second rib articulates with the sternum. Angle of Louis = 2nd rib
Infrequent cough caused by
allergens or environmental insults
Foramen Ovale
allows blood flow from right atrium to left atrium in utero
Chorioretinitis
an inflammatory process involving both the choroid and the retina...floaters, reduced visual acuity, photophobia, hx of cleaning cat box, laser surgery
Pertussis produces..
an inspiratory whoop at the end of a paroxysm of coughing in older children and adults.
Retractions on inspiration are caused by:
an obstruction at any point in the respiratory tract.
Corticobulbar Tract
arising from brain stem innervates the motor functions of the cranial nerves
Decorticate Posturing
arms flexed inward and bent in toward the body and the legs are extended "Core" Injury to corticospinal tract above brain stem.
Sick Sinus Syndrome
arrhythmia in which bradycardia alternates with tachycardia PATHOPHYSIOLOGY • Occurs secondary to hypertension, arteriosclerotic heart disease, or rheumatic heart, or without known cause (idiopathic) SUBJECTIVE DATA • Fainting, transient dizzy spells, light-headedness, seizures, palpitations, and angina OBJECTIVE DATA • Dysrhythmias • Signs of congestive heart failure
Personalized Medicine
as defined by the National Cancer Institute is a form of healthcare that considers information about a person's genes, proteins and environment to prevent, diagnose and treat disease
Temporalis and Masseter muscle strength can be evaluated by
asking the pt to clench the teeth while you palpate the contracted muscles and apply opposing force This also tests CN 5 (Trigeminal)
Two Person Transfer
assistants must work together to lift the patient. The stronger taller person should lift the upper half of the body
Mitral or apical area
at the apex of heart fifth left IC space mid clavicular
Where is the bronchial vein formed
at the hilium of the lung
Atria are also called
auricles because of their earlike shape
Legg-Calve-Perthes Disease
avascular necrosis of the femoral head due to decreased blood supply. Most common in boys between 3-11yrs old Pain os often referred to the medial thigh, knee, or groin Bilat involvement in 10% The child may have a limp that is painless or antalgic (Painful limp with shortened time on an extremity) Loss of internal rotation; abduction and decreased ROM on the affected side
Proprioception
awareness of body position and parts. Dependent on parietal lobe.
Jugular venous pressure disorder
backflow of blood into right atrium during systole. Mild degree of tricuspid regurgitation can be seen in 75% of population Due to htn or pulmonary thrombosis.. these lead to dilation of RV typically no symptoms when mild Severe you will see Right sided HF symptoms like ascites or peripheral edema V wave is much more prominently and occurs earlier often merging with the c wave for expected normal venous pulsations Holosystolic murmur in tricuspid region, pulsatile liver, peripheral edema
gastroesophageal reflux disease (GERD)
backflow of contents of the stomach into the esophagus, often resulting from abnormal function of the lower esophageal sphincter, causing burning pain in the esophagus
Handshake
be careful with patients who have osteoarthritis, or rheumatoidarthritis.
Cardiac Palpation Sequence
begin at apex move to interior left sternal border move up the sternum to the base then down to right sternal border and into epigastrum or axillae
Vertical Strip Technique
begin at teh top of the breast and palpate first downward then upward working your way down over the entire breast. More thorough than concentric circle technique
Where are deeper lymph nodes usually?
beneath the fascia of muscles and within various body cavities.
Deep Tendon Reflexes
biceps, triceps, brachioradialis, patellar, achilles, clonus
What are lymphocytes
body's central response to antigenic substances not uniform in size or function
Kaposi Sarcoma
cancerous condition starting as purple or brown papules on the lower extremities that spreads through the skin to the lymph nodes and internal organs; frequently seen with AIDS Subjective Data • Soft bluish purple and painless skin plaques • May report peripheral lymphedema • May be presenting symptom of HIV/acquired immune deficiency syndrome (AIDS) Objective Data • Cutaneous lesions are characteristically soft, vascular, bluish purple, and painless. • Lesions may be either macular or papular and may appear as plaques, keloids, or ecchymotic areas • KS lesions may be limited to the skin or involve the mucosa, viscera, and lymph nodes or any organ.
Spinothalamic tract
carries fibers for the sensations of light and crude touch, pressure, temperature, and pain
Ascending and descending pathways
carry information to and from the CNS
Older adult Nose and Ears
cartilage formation continues in ears and nose. Making auricle and nose larger.
Vestibulospinal tract
causes the extensor muscles of the body to suddenly contract when an individual starts to fall
Psoriasis
chronic and recurrent disease of keratin proliferation Patho Multifactorial origin with genetic component and immune regulation • Characterized by increased epidermal cell turnover, increased numbers of epidermal stem cells, and abnormal differentiation of keratin expression leading to thickened skin with copious scale • Related to tumor necrosis factor (TNF)-alpha Subjective Data • May have pruritus • Concerns about appearance • Does not typically get superinfected Objective Data • Characterized by well-circumscribed, dry, silvery, scaling papules and plaques • Lesions commonly occur on the back, buttocks, extensor surfaces of the extremities, and the scalp. • Can be associated with psoriatic arthritis in up to 30% of patients. • May have pitting nail involvement.
Crohn Disease
chronic inflammatory disorder that can affect any part of the GI tract the produces ulceration, fibrosis, and malabsorption. Terminal ileum and colon are most common sites Chronic diarrhea with compromised nutritional status Unpredictable flares and remission Abdominal mass may be palpated due to thickened or inflamed bowel Perianal skin tags (good clue for diagnosis), fistulae, and abscesses may be seen
Ankylosing Spondylitis
chronic, progressive arthritis with stiffening of joints, primarily of the spine. Associated wtih HLA-B27 Human Leukocyte Antigen. Leads to eventual fusion and deformity of the spinal column. Begins between 20-40 yrs of age. Begins insidiously with inflammatory low back and buttock pain also involving hip and shoulders.
Cervical spine should be
concave with the head erect
Biliary Atresia
congenital obstruction or absence of some or all of the bile duct system resulting in bile flow obstruction most have complete absence of the entire extrahepatic biliary tree
Cubitus Varus
decreased carrying angle aka medial carrying angle
Band Keratopathy
deposition of calcium in the superficial cornea. Passes over Cornea unlike arcus senilis. Horizontal Grayish Band Hypercalcemia Hyperparathyroid Trauma Renal Failure Sarcoidosis Syphilis
Suprasternal Notch
depression, easily palpable. Visible at the base of the ventral aspect of the neck. Superior to the angle of louis
S2 marks the beginning of
diastole and closure of aortic and pulmonic valves listen at the base on expiration
Hair-Pulling disorder (Trichotillomania)
disorder characterized by recurrent pulling out of the hair resulting in noticeable hair loss; these individuals report tension immediately before or while attempting to resist the impulse, and pleasure or relief when they are pulling out their hair
Meconium ileus
distal intestinal obstruction caused by thick inspissated impacted meconium in the lower intestine
Acrocyanosis without central cyanosis in infants
does not signify pathology. Disappears within a few days Purple color to hands and feet
Pleural friction rub
dry, rubbing, or grating sound usually caused by inflammation. Heard on expiration. loudest over lower lateral anterior surface.
Oliver Sign
elicited by gently grapsing the cricoid cartilage and applying upward pressure whitle the patient stand with thier chin extended upward A downward tug of the trachea may be felt if aneurysm is present.
Have patient do this before abdominal exam begins
empty bladder
Absence of Apical impulse and Faint Heart sounds In left lateral recumbent =
extracardiac problem such as pleural or pericardial fluid
Suspect ______________ when lower face is affected by asymmetry
facial nerve weakness
Patent Ductus Arteriosus
failure of the ductus arteriosus to close after birth, resulting in an abnormal opening between the pulmonary artery and the aorta Subjective Data • Small shunt can be asymptomatic; a larger one causes dyspnea on exertion Objective Data • Dilated and pulsatile neck vessels • Wide pulse pressure • Harsh, loud, continuous murmur heard at the first to third intercostal spaces and the lower sternal border, with a machine-like quality • Murmur usually unaltered by postural change
Hyperventilation (Hyperpnea)
faster than 20 breaths per minute, deep breathing often a symptom of protective splinting from the pain of a broken rib or pleurisy. Massive liver enlargement or abdominal ascites may prevent descent of the diaphragm and produce a similar pattern.
Muscle tone can be assessed by
feeling the resistance to passive stretch
A murmur at the grade IV level or more can be
felt, this palpable sensation is called a thrill.
Gingivae
fibrous tissue covered by mucous membrane that attaches directly to the teeth and maxilla and mandible.
Bursae
flattened fibrous sacs lined with synovial membrane and containing a thin film of synovial fluid
Plagiocephaly
flattened spot on the back side of the head. Can result from premature fusion of one of the sutures.
Mallet Toe
flexion deformity at the distal interphalangeal joint of the foot
Breast Anatomy
from 2nd/3rd-6th/7th rib in females
Venous Ulcers
from chronic venous insufficiencey in which lack of venous flow leads to lower extremetiy venous htn From incompetent valves, loss of pumping effect of leg muscles Leg heaviness Ulcers found on the medial or lateral aspects of lower limbs
Parasympathetic Division
functions in a complementary and counterbalancing manner to conserve body resources and maintain day to day body functions such as digestion and elimination.
cholelithiasis
gallstones in the gallbladder Symptoms may include indigestion, colic, and mild transient jauncie
In a tall slender person the heart tends to
hang vertically and be positioned centrally
Uvula
hangs from the posterior margin of the soft palate
Herbden Nodes
hard non-tender nodules 2-3 mm that are found along the distal interphalangeal joints Sign of Osteoarthritis
Bouchard Nodes
hard non-tender nodules 2-3 mm that are found along the proximal interphalangeal joints Sign of Osteoarthritis
Apical pulse in older adults
harder to find due to increased AP diameter of chest.
Neurologic Hammer
has a soft brush and a tapered tip. allow for examination of sensory perception
For ticklish patietn
have patient do self palpation. and place your hands over the patients fingers.
Thyroid examination
have patient swallow water, easier to visualize from the lateral aspect. Lateral inspection is the most sensitive test for determining the presence of a goiter. A thyroid that is not visible on lateral inspection rules out a goiter.
Babies delivered via C section have a __________ rate than babies delivered vaginally
higher
Bronchial sounds
highest in pitch and intensity and should occur only over the trachea
Diaphragmatic excursion
how much the diaphragm moves with inhalation and exhalation Ask pt to take deep breath and hold it Percuss along the scapular line until you locate the lower border (resonant to dull percussion) Mark point with a marking pen at scapular line. let pt breath Percuss up from the marked point and make a mark at the change from dullness to resonance Excursion distance usually 3-5cm Diaphragm higher on right bc of liver
Hammertoe
hyperextension of the metatarsophalangeal joint and flexion of the proximal interphalangeal joint
Claw Toe
hyperextension of the metatarsophalangeal joint with flexion of the toe's proximal and distal joints
Fine silky hair may be associated with
hyperthyroidism
Pyloric Stenosis
hypertrophy of the circular muscle of the pylorus leads to obstruction of the pyloric sphincter
Unilateral inversion of a nipple
if previously everted, this suggest malignancy Carcinoma can also change the axis of the nipple causing it to point in a different direction
Gray Matter of Spinal Cord
in butterfly shape with anterior and posterior horns, contains nerve cell bodies associated with sensory pathways and Autonomic nervous system
Sound is transmitted
in the direction of blood flow
Bulging fontanel with marked pulsations
indicates ICP from space occupying mass or meningitis
Butterfly rash
indicates Systemic Lupus Erythematous Butterfly Shaped rash over malar surfaces and bridge of nose. Either a blush with swelling or scaly, red, maculopapular lesions may be present.
Air Trapping caused by:
inefficient expiratory effort, increased resistance from chronic bronchitis, decreased elastic recoil of the lung (emphysema), or a drop in critical closing pressure of airway like in asthma.
Osteomyelitis
infection in bone usually from open wound or systemic infection Purulent matter spreads through coretx of the bone and into the soft tissue Decreased blood flow to the affected bone may lead to necrosis Dull pain develops insidiously at the involved site and progresses over days to weeks Limp or decreased movement in infants and children Signs of infection include edema, erythema, warmth at site Tenderness to palpation, fevers
What do you palpate last?
inflamed joints
Lymphangitis
inflammation of lymph vessels tender erythematous streaks extend proximally from the infected area
Cholecystits
inflammation of the gallbladder, usually associated with gallstones blocking the flow of bile RUQ pain, guarding, rebound tenderness Fat intolerance
Hepatitis
inflammation of the liver Subjective • Some are asymptomatic; others report jaundice, anorexia, abdominal pain, clay-colored stools, tea-colored urine, and fatigue Objective • Liver function tests are abnormal • Examination findings may include jaundice and hepatomegaly • With severe or progressive disease, may develop cirrhosis with its associated examination findings
Lymphadenitis
inflammation of the lymph nodes
Acute Pancreatitis
inflammation of the pancreas mild to severe sudden onset of persistent epigastric pain that may radiate to the back. Constant and dull Amylase and Lipase elevated
Pericarditis
inflammation of the pericardium Subjective Data • Sharp and stabbing chest pain (caused by the heart rubbing against the pericardium) • Pain worse with coughing, swallowing, deep breathing or lying flat, or movement • Pain may be most severe when supine, relieved by sitting up and leaning forward • Pain in the back, neck or left shoulder • Difficulty breathing when lying down • Dry cough • Anxiety or fatigue Objective Data • Scratchy, grating, triphasic friction rub on auscultation, comprises ventricular systole, early diastolic ventricular filling, and late diastolic atrial systole • Friction rub easily heard just left of the sternum in third and fourth intercostal spaces Can be caused by meds like procainamide, hydralazine, phenytoin, isoniazid
Pyelonephritis
inflammation of the renal pelvis and the kidney gram negative bacilli Fever and costovertebral tenderness distinguish pyelonephritis from UTI's
Tenosynovitis
inflammation of the tendon and synovial membrane Can cause crepitus
Osgood-Schlatter Disease
inflammation or irritation of the tibia at its point of attachment with the patellar tendon Boys between 9-15 yrs Child walks with limp C/o knee pain Knee swelling aggravated by strenous activity Pain in quads pain with palpation over the tibial tuberosity
Ask patient to ___________________ to listen for S2
inhale deeply best head in pulmonic auscultatory area (2nd left IC at left sternal border)
Simple Arc Reflex
initiated by a spinal afferent (sensory) neuron when stimulus received. Response is transmitted outward toward efferent (motor) neuron in anterior horn of spinal cord via the spinal nerve and peripheral nerve of skeletal muscle
Commissural fibers (Corpus Callosum)
interconnect the counterpart areas in each hemisphere, permitting the coordination of activities between the hemispheres.
What does a high pitched tinkling sound indicate in the abdomen?
intestinal fluid and air under pressure, which is early in obstruction
Where do the jugular veins empty?
into the superior vena cava
Cultural Humility
involves the ability to recognize one's limitations in knowledge and cultural perspective and be open to new perspectives.
Tibial Torsion
inward twisting of tibia
Cerebellum hemispheres
ipsilateral control of body (same side)
Gower Sign
is a medical sign that indicates the weakness of the proximal muscles, namely those of the lower limb.
Traube space
is a semilunar region defined by the sixth rib superiorly, the midaxillary line laterally, and the left costal margine inferiorly. Area is typically tympanitic bc it overlies fundus of the stomach. Spleen enlargement = dullness over taube space
Percussion of heart
is of limited value in defining borders bc of shape of chest and relatively rigid.
Vesicular breath sounds
low-pitched, low-intensity heard over healthy lung tissue
Medium Crackles
lower, more moist sound heard during the midstage of inspiration; not cleared by a cough
Hairy Nevus
may be present at birth, may cover large area, hair growth may occur after several years , should be removed if changes occur
Saliva production older adults
may decrease from anticholinergics and diuretics
Frequent Hiccuping in newborns
may indicate seizures, drug withdrawal, or encephalopathy
Split spinal process on palpation
may indicate spina bifida
Transgender men considerations
may use binder to create more masculine appearance, may be hesitant to remove binder
Scoliometer
measures degree of rotation of the spine to screen for scoliosis positive if read is 7 degrees or more at any level of the spine
Placenta
mediates fetal gas exchange
S4 in older adults
more common; indicates decreased left ventricular compliance.
Kawaski disease accounts for
most murmurs in children
Wheeze (sibilant wheeze)
musical noise sounding like a squeak; most often heard continuously during inspiration or expiration; usually louder during expiration
Acute Glomerulonephritis
nephritis, increased blood pressure, occasionally heart failure; can become chronic leading to kidney failure tea colored urine or gross hematuria edema, htn, oliguria
Muscle wasting occurs after injury as a result of
pain, disease of the muscle, or damage to the motor neuron
Temporomandibular joint Syndrome
painful jaw movement; can have muscle spasm, clicking, popping, crepitus
Osler Nodes
painful red raised lesions that appear on the tips of fingers or toes and are caused by septic Emboli
Stensen Duct
parotid gland outlets that open on the buccal mucosa opposite the second molar on each side of the upper jaw.
Hiatal hernia with esophagitis
part of the stomach passes through the esophageal hiatus in the diaphragm into the chest cavity sudden onset of vomiting, pain, and complete dysphagia
If Radiographic facilities are unavailable to determine heart size
percuss to estimate size
Macewen sign
percussion of the skull near the junction will be resonant; the sign associated with increased intracranial pressure after fontanels are closed.
Pin Hole Test
perform if visual acuity is recorded at less than 20/20 to see if observed acuity is caused by refractive error. Pt holds pinhole over eye, if refractive error is responsible the pt will be able to read one line better.
Infant motor maturation
proceeds in cephalocaudal direction (head down) Head and neck develop first -> trunk -> extremeties
Tuning Fork
produces frequency of sound expressed in cycles per second or Hz. 512hz = 512 cycles per second For auditory evaluation use a fork of 500 - 1000 hz. Estimates hearing loss in range of normal speach Lower frequency can be used for bone conduction.
Cough Postural influences:
reclined or assumed and erect position.. nasal drip and pooling of secretions in upper airway.
Large Bounding Pulse / Hyperkinetic
recorded as +3 Caused by exercise, anxiety, fever, hyper thyroid, aortic rigidity or atherosclerosis
Trigeminal neuralgia (tic douloureux)
recurring episodes of intense stabbing pain in trigeminal nerve area (near mouth or nose) pain triggered by touch, drinking, washing face treatment may require cutting nerve
PItyriasis Rosea
self-limiting inflammation of unknown cause Patho Possible infectious etiolgy like herpes virus Not contagious Subjective Data • Sudden onset with occurrence of a primary (herald) oval or round plaque. • Herald lesion is often missed. • Eruption occurs 1-3 weeks later and lasts for several weeks. • Pruritus may be present with the generalized eruption. • Often occurs in young adults during the spring time. Objective Data • Lesions are usually pale, erythematous, flat-topped papules and plaques with fine scaling • Lesions develop on the extremities and trunk; palms and soles are not involved, and facial involvement is rare. • Trunk lesions are characteristically distributed in parallel alignment following the skin tension lines in a Christmas tree-like pattern.
CN 10 Vagus
sensation behind ear and part of external ear canal Secretion of digestive enzymes, peristalsis, carotid reflex, involuntary action of the heart, lungs, digestive tract
Coronary sulcus
separates atria from ventricles on anterior external surface Groove extending around circumference of heart
Pneumothorax in infant
shifts apical pulse away form the areas of the pneumothorax
Diaphragmatic Hernia in infant
shifts the heart to right. Hernia is usually found on the left.
Torticollis (Wry Neck)
shortening or excessive contraction of the sternocleidomastoid muscle.
Pivot Transfer
stand in front of pt. take the patient's knees between your own knees, grasp the patient around the back and under the arms, raise the pt to a vertical position and then pivot from the wheelchair to the table. Table must be low
Coarction of the aorta
stenosis seen in the descending aortic arch near the origin of subclavian artery and ligamentum arteriosum Congential, but can be acquired from inflammatory aortic disease or severe atherosclerosis May accompany turner syndrome in girls in severe cases HTN, or vascular insufficiency if symptomatic may have symptoms of HF Differences in systolic blood pressure readings between the arm and leg readings Femoral pulses are weaker than radial pulses or femoral is absent.
Hypodermis
subcutaneous layer made up of loos connective tissue filled with adipose. Adipose layer generates heat and provides insulation, shock absorption, and a reserve of calories.
The elbow consists of
the articulation of the humerus , radius, and ulna. These three contiguous surfaces are enclosed in a single synovial cavity with collateral ligaments of the radius and ulna securing the joint.
Where does the large intestine begin
the cecum, which is a blind pouch about 2-3 inches long
Hypothenar Eminence
the fleshy mass at the base of the little finger
Bone Resorption
the removal of minerals and collagen fibers from bone by osteoclasts Dominated in old age vs deposition. Menopausal women, decreased estrogen increases bone resorption and decreases calcium deposition resulting in bone loss and decreased bone density. Weight bearing long bones particularly vulnerable to fracture in old age
Qt Interval
the time elapsed from the onset of ventricular depolarization until the completion of ventricular repolarization.
Scar
thin to thick fibrous tissue that replaces normal skin following injury or laceration to the dermis Ex: healed wond or surgical incision
Pregnancy thryoid
thyroid may hypertrophy. caused by hyperplasia of grandular tissue and increased vascularity. Thyroid bruit may be heard bc of increased vascularity. Presece of a goiter is unexpected.
PR interval is the
time from initial stimulation of the atria to initial stimulation of the ventricles 0.12 - 0.20 seconds
Diastolic murmurs are best classified according to
time of onset only
Hemolytic Uremic Syndrome (HUS)
triad of microangiopathic hemolytic anemia, thrombocytopenia, and uremia
What are the AV valves
tricuspid (three leaflets) and mitral
When HR is about 120 bpm the
two phases of cardiac cycle tend to approximate each other in length.
A foreign body in the bronchus causes:
unilateral retraction suprasternal notch is not involved
Infant Percussion
unreliable, typically not performed.
Stridor indicates a:
upper airway obstruction (trachea or laryngeal area)
Pregnant pt Apiclal impulse is located where
upward and more lateral by 1 - 1.5 cm
Cremasteric Reflex
upward pull of testicles and scrotum due to touch
Hypersensitivity
use lubricant jelly to decrease friction or pressure or avoid area
Trachea pulled toward affected lung in:
volume loss from fibrosis atelectasis Simple collapsed lung
Dystrophic Gait
waddling; increased hip rotation. due to weak hip abductor muscles. Lordosis is common.
Frailty syndrome
weakness, slowing, decreased energy, lower activity, and when sever unintended weight loss.
When in gestation does the liver start to form blood cells?
week 6, synthesizes glycogen by week 9, and produces bile at week 12
Tactile fremitus is absent
when effusion exists
When do you percuss the head?
when evaluating for hypocalcemia Percuss the masseter muscles for chvostek sign
Lymphadenopathy
when its widespread involving several lymph node regions this indicates a systemic disease or disorder.
Shoulder Dislocation
when shoulder contour is asymmetric and one shoulder has hollows in the rounding contour
Phalen Test
wrists are bent down with backs of each hand touching/carpal tunnel sufferers feel tingling or pain within 60 seconds Numbness and paresthesia in the distribution of the median nerve are suggestive of carapl tunnel
Expected Color Changes in the Newborn
• Acrocyanosis: Cyanosis of hands and feet • Cutis marmorata: Transient mottling when infant is exposed to decreased temperature • Erythema toxicum: Pink papular rash with vesicles superimposed on thorax, back, buttocks, and abdomen; may appear in 24 to 48 hours and resolves after several days • Congenital dermal melanocytosis: Irregular areas of deep blue pigmentation, usually in the sacral and gluteal regions; seen predominantly in newborns of African, Native American/American Indian, Asian, or Latin descent • Salmon patches ("stork bites"): Flat, deep pink localized areas usually seen on the midforehead, eyelids, upper lip, and back of neck
LDL Levels and MI
• Adults 21 years or older with LDL 190 mg/dL or greater should be treated with high-intensity statin therapy unless contraindicated. • Individuals with LDL 190 mg/dL or greater or triglycerides 500 mg/dL or greater should be evaluated for secondary causes of hyperlipidemia. • Adults 40 to 75 years with an LDL 70 to 189 mg/dL with diabetes or a 10-year atherosclerotic cardiovascular disease risk greater than 7.5% should be treated with moderate-to high-intensity statin therapy
Colon Cancer Risk Factors
• Age older than 50 years • Family history of colorectal cancer or adenomatous polyps in one or more first-degree relatives and family history of syndromic colon cancer, including familial adenomatous polyposis (FAP), hereditary nonpolyposis colorectal cancer (HNPCC), Turcot syndrome (also associated with brain tumors), Peutz-Jeghers syndrome, and MUYTH-associated polyposis (MAP; mutation in the gene MUYTH ) • Personal history of colon cancer, adenomatous polyps, inflammatory bowel disease (Crohn disease, ulcerative colitis), FAP, HNPCC • Race: African American • Ethnic background: Ashkenazi Jewish • Diet: low-fiber, high in red meat, processed meats, and foods fired, broiled, grilled increases risk; diet high in fruits and vegetable decreases risk • Obesity • Smoking cigarettes • Physical inactivity • Heavy alcohol use • Type 2 diabetes
Characteristics of patients who should have a radiograph of the knee
• Age older than 55 years • Tenderness at head of fibula • Isolated tenderness of the patella • Inability to flex the knee to 90 degrees
Skin Self Examination
• Always use a good light, positioned to minimize distracting glare. Look for a new growth or any skin change. • Be aware of the locations and appearance of moles and birthmarks. • Examine your back and other hard-to-see areas of the body using full-length and handheld mirrors. Ask a friend or relative to help inspect those areas that are difficult to see, such as the scalp and back. • Begin with your face and scalp using one or more mirrors. Proceed downward, focusing on neck, chest, and torso. Patients, check under breasts. With back to the mirror, use hand mirror to inspect back of neck, shoulders, upper arms, back, buttocks, legs. Concentrate especially on areas where dysplastic nevi (those with unexpected changes) are most common—the shoulders and back; and areas where ordinary moles are rarely found—the scalp, breast, and buttocks. Check hands, including nails. In a full-length mirror, examine elbows, arms, underarms. Sitting down, check legs and feet, including soles, heels, nails, and between the toes. Use a hand mirror to examine genitals. See rather than feel any early signs of a mole change. Use a cell phone to take photos of moles and compare the photographs of the same moles over a period of several months. Monitor change in size by measuring. It can be done simply with a small ruler or even by comparing the moles to the size of your thumb or fingernail. • Consult your healthcare provider promptly if any pigmented skin spots look like melanoma, if new moles have appeared, or if any existing moles have changed. See also the ABCDE changes in moles (Melanoma, in Abnormalities).
Infants and Children: Acne Vulgaris
• Androgens stimulate the pilosebaceous units at the time of puberty to enlarge and produce large amounts of sebum. • Simultaneously, the keratinization process in the pilosebaceous canal is disrupted with impaction and obstruction of the outflow of sebum resulting in comedo formation—open blackheads and closed whiteheads. • Wall of the closed comedo may rupture, spilling the follicular contents into the dermis, leading to the development of inflammatory papules. • The presence of Propionibacterium acnes brings in neutrophils, which cause the inflammatory response. • Noninflammatory acne: open (whiteheads) and closed (blackheads) comedones • Inflammatory acne: papules, nodules, or cystic lesions • Characteristic "ice pick" scarring may be present from previous lesions
Knee ROM
• Bend each knee. Expect 130 degrees of flexion. • Straighten the leg and stretch it. Expect full extension and up to 15 degrees of hyperextension.
Cervical Spine ROM
• Bend the head forward, chin to the chest. Expect flexion of 45 degrees. • Bend the head backward, chin toward the ceiling. Expect extension of 45 degrees. • Bend the head to each side, ear to each shoulder. Expect lateral bending of 40 degrees. • Turn the head to each side, chin to shoulder. Expect rotation of 70 degrees.
Lymphedema vs Edema
• Both can be either pitting or nonpitting. • Except in early stages, lymphedema does not resolve with elevation of the affected area. Edema secondary to increased capillary filtration (e.g., chronic venous insufficiency) usually improves. • Diuretics do not help lymphedema. They may help edema. • Be aware that some patients may have both edema and lymphedema.
Infants and Children: Chickenpox
• Caused by the varicella zoster virus (VZV) • VZV is communicable by direct contact, droplet transmission, and airborne transmission • Incubation period 2-3 weeks; the period of communicability lasts from 1 or 2 days before onset of the rash until lesions have crusted over. • Routine childhood immunization has resulted in a significant decline in incidence • After primary infection, VZV remains dormant in sensory nerve roots for life. • Can reactivate to cause shingles Subjective Data • Fever, headache, sore throat, mild malaise • Pruritic rash that started on scalp and then moved to extremities • Started as papular and in a few hours became vesicular • Child has not had varicella vaccine. Objective Data • Papular and vesicular lesions on trunk, extremities, face, buccal mucosa, palate, or conjunctivae • Lesions usually occur in successive clusters eventually spreading to entire body, with several stages of maturity present at one time. • Complications include conjunctival involvement, secondary bacterial infection, viral pneumonia, encephalitis, aseptic meningitis, myelitis, Guillain-Barré syndrome, and Reye syndrome.
History of Present Illness: Nails
• Changes in nails: splitting, breaking, discoloration, ridging, thickening, markings, separation from nail bed • Recent history: systemic illness, high fever, trauma, stress, biting • Associated symptoms: pain, swelling, exudate • Temporal sequence: sudden or gradual onset, relationship to injury of nail or finger • Recent exposure to drugs, environmental or occupational toxins or chemicals; frequent immersion in water • What the patient has been doing for the problem, response to treatment, what makes the problem worse or better • Medications: chemotherapy (taxanes, anthracyclines), psoralens, retinoids, tetracyclines, antimalarials
History of Present Illness: Skin
• Changes in skin: dryness, pruritus, sores, rashes, lumps, color, texture, odor, amount of perspiration; changes in wart or mole; lesion that does not heal or is chronically irritated (see Risk Factors boxes ) • Temporal sequence: date of initial onset; time sequence of occurrence and development; sudden or gradual onset; date of recurrence, if any • Symptoms: itching, pain, exudate, bleeding, color changes, seasonal or climate variations • Location: skinfolds, extensor or flexor surfaces, localized or generalized, sun exposed or protected, mucosal involvement • Associated symptoms: presence of systemic disease or fever, relationship to stress or leisure activities • Recent exposure to environmental or occupational toxins or chemicals, new skin or personal care products, new household cleaning products (aerosols) • Recent exposure to persons with similar skin condition • Apparent cause of problem, patient's perception of cause • Travel history: where, when, length of stay, exposure to diseases, contact with travelers • What the patient has been doing for the problem, response to treatment, what makes the condition worse or better • How the patient is adjusting to the problem • Medications: antibiotics, any new medications, topical preparations to treat—steroids, antifungals
Past Family History
• Current or past dermatologic diseases or disorders in family members; melanoma; dermatoses (e.g., psoriasis); infestations; bacterial, fungal, or viral infections • Allergic hereditary diseases such as asthma or allergic rhinitis
Adolescents Past Medical History
• Eating habits and types of food • Food allergies. Note that food allergies do not classically cause eczema. • Exposure to infectious diseases at day care, school: impetigo; viruses that produce skin rashes (Coxsackie); measles, mumps, rubella, varicella in unvaccinated children • Allergic disorders: eczema, urticaria, pruritus, hay fever, asthma, other chronic respiratory disorders • Pets or animal exposure • Outdoor exposures such as play areas, hiking, camping, picnics, gardening • Skin injury history: frequency of falls, cuts, abrasions; repeated history of unexplained injuries • Chronic hair-pulling or manipulation • Nail-biting
Newborn Skin Lesions / defects associated with systemic conditions
• Faun tail nevus: Tuft of hair overlying the spinal column at birth, usually in the lumbosacral area; may be associated with spina bifida occulta • Epidermal verrucous nevi: Warty lesions in a linear or whorled pattern that may be pigmented or skin colored; present at birth or in early childhood; associated most commonly with skeletal, central nervous system, and ocular abnormalities • Café au lait macules: Flat, evenly pigmented spots varying in color from light brown to dark brown or black in dark skin; larger than 5 mm in diameter; present at birth or shortly thereafter; may be associated with neurofibromatosis or miscellaneous other conditions including pulmonary stenosis, temporal lobe dysrhythmia, and tuberous sclerosis • Freckling in the axillary or inguinal area: Multiple flat pigmented macules associated with neurofibromatosis; may occur in conjunction with café au lait macules • Ash leaf macule: White macules present at birth associated with tuberous sclerosis. Occur most commonly on the trunk, but may also appear on the face and limbs • Facial port-wine stain: When it involves the ophthalmic division of trigeminal nerve, may be associated with ocular defects, most notably glaucoma; or may be accompanied by angiomatous malformation of the meninges (Sturge-Kalischer-Weber syndrome), resulting in atrophy and calcification of the adjacent cerebral cortex • Port-wine stain of limb and/or trunk: When accompanied by varicosities and hypertrophy of underlying soft tissues and bones, may be associated with orthopedic problems (Klippel-Trenaunay-Weber syndrome) • Congenital lymphedema with or without transient hemangiomas: May be associated with gonadal dysgenesis caused by absence of an X chromosome, producing an XO karyotype (Turner syndrome) • Supernumerary nipples: Congenital accessory nipples with or without glandular tissue, located along the mammary ridge; may be associated with renal abnormalities, especially in the presence of other minor anomalies, particularly in whites • "Hair collar" sign: A ring of long, dark, coarse hair surrounding a midline scalp nodule in infants is usually an isolated cutaneous anomaly that may indicate neural tube closure defects of the scalp.
Infants Past Medical History
• Feeding history: breast or formula, type of formula, what foods introduced and when ("Carotenemia" ) • Diaper history: type of diapers used, skin cleansing routines, and methods of cleaning • Types of clothing and washing practices: soaps and detergents used, new blanket or clothing • Bathing practices: frequency, types of soap, oils, shampoos or emollients used • Dress habits: amount and type of clothing in relation to environmental temperature • Temperature and humidity of the home environment: air conditioning, heating system (drying or humidified)
Risk factors for respiratory disability
• Gender: greater in men, but the difference between the sexes diminishes with advancing age • Age: increases with advancing age • Family history of asthma, cystic fibrosis, tuberculosis, and other contagious disease; neurofibromatosis • Smoking • Sedentary lifestyle or forced immobilization • Occupational exposure to asbestos, dust, or other pulmonary irritants and toxic inhalants • Extreme obesity • Difficulty swallowing for any reason • Weakened diaphragm and chest muscles (e.g., amyotrophic lateral sclerosis, polymyositis) • History of frequent respiratory infections
Carotid Artery Bruits
• Heard at just above the medial end of clavicle and anterior margin of sternocleidomastoid muscle • Mild obstruction produces a short, not particularly intense, localized bruit; greater stenosis lengthens the duration and increases the pitch • Complete stenosis may eliminate the bruit • Transmitted murmurs of valvular aortic stenosis, ruptured chordae tendineae of mitral valve, or severe aortic regurgitation can radiate to the carotid • Can be heard with vigorous left ventricular ejection (more commonly in children than in adults) • Occurs with arterial narrowing in cervical arteries (e.g., atherosclerotic carotid arteries, fibromuscular dysplasia, and arteritis)
Venous Hum
• Heard at medial end of clavicle and anterior border of sternocleidomastoid muscle • Usually of no clinical significance • Confused with carotid bruit, patent ductus arteriosus, and aortic regurgitation • In adults, may occur with anemia, pregnancy, thyrotoxicosis, or
Structural heart disease is more likely when the murmur is:
• Holosystolic • Diastolic • Grade 3 or higher • Associated with a systolic click • Increased in intensity with standing • Of a harsh quality
Past medical history: Older adults
• Increased or decreased sensation to touch or to the environment • Generalized chronic itching; exposure to skin irritants, detergents, lotions (any moisturizer that comes in a pump has a high alcohol content), woolen clothing, humidity of environment • Susceptibility to skin infections • Healing response: delayed or interrupted • Frequent falls resulting in multiple cuts or bruises • Risk for pressure ulcers secondary to immobilization or nonambulatory status • History of chronic medical conditions (e.g., diabetes mellitus, vascular disease) • Medications and polypharmacy
Epstein-Barr Virus Mononucleosis
• Initially infects oral epithelial cells; after intracellular viral replication and cell lysis with release of new virions, virus spreads to contiguous structures such as the salivary glands, with eventual viremia and infection of the entire lymphoreticular system, including the liver and spleen • Incubation period of infectious mononucleosis in adolescents is 30-50 days Epitrochlear lymphadenopathy is particularly suggestive of infectious mononucleosis. Splenomegaly Mod-Sever Pharyngitis Petechiae at the junction of hard and soft palate
Documenting Breast Mass
• Location: clock positions and distance from nipple • Size (in centimeters): length, width, thickness • Shape: round, discoid, lobular, stellate, regular or irregular • Consistency: firm, soft, hard • Tenderness • Mobility: movable (in what directions) or fixed to overlying skin or subadjacent fascia • Borders: discrete or poorly defined • Retraction: presence or absence of dimpling; altered contour
Infants and Children: Measles
• Measles virus infects by invasion of the respiratory epithelium. • Local multiplication at the respiratory mucosa leads to a primary viremia, during which the virus spreads in leukocytes to the reticuloendothelial system. • Both endothelial and epithelial cells are infected; infected tissues include thymus, spleen, lymph nodes, liver, skin, conjunctiva, and lung. • Incubation period is commonly 18 days; the period of communicability lasts from a few days before the fever to 4 days after appearance of the rash. • Disease is preventable by immunization. Subjective Data • Fever, conjunctivitis, stuffy nose, and cough, followed by a red, blotchy rash first on the face and then spreading to trunk and extremities • Child has not had measles vaccine. • International travel or exposure to individuals from endemic areas Objective Data • Koplik spots (discrete white macular lesions) on the buccal mucosa • Macular rash on the face and neck • Maculopapular lesions on trunk and extremities in irregular confluent patches • Rash lasts 4-7 days • Symptoms may be mild or severe • Complications involve infection of the respiratory tract and central nervous system.
Hashimoto Disease
• Often causes hypothyroidism • More common in children and women between 30 and 50 years • Progresses slowly over a number of years Subjective Data • Weight gain • Nausea • Fatigue • Enlarged nontender smooth thyroid
When does lymphadenopath requires further investigation?
• Older patients with localized and persistent lymphadenopathy, without evidence of infection or inflammation, might have cancer unless a biopsy proves otherwise • Young adults and children with localized supraclavicular lymphadenopathy • Posterior cervical lymphadenopathy adds a risk for malignancy, more than lymphadenopathy that occurs in the anterior cervical chain • Any lump that grows rapidly and insistently, at any age
Foot ROM
• Point the foot toward the floor. Expect plantar flexion of 45 degrees. • Bending the foot at the ankle, turn the sole of the foot toward and then away from the other foot. Expect inversion of 30 degrees and eversion of 20 degrees • Rotating the ankle, turn the foot away from and then toward the other foot while the examiner stabilizes the leg. Expect abduction of 10 degrees and adduction of 20 degrees • Bend and straighten the toes. Expect flexion and extension, especially of the great toes.
Past Medical History: Nails
• Previous nail problems: injury; bacterial, fungal, or viral infection • Systemic problems: associated skin disorder; congenital anomalies; respiratory, cardiac, endocrine, hematologic, or other systemic disease
Past Medical History: Skin
• Previous skin problems: sensitivities, allergic skin reactions, skin disorders (e.g., atopic dermatitis), congenital or acquired lesions, treatment • Tolerance to sunlight • Diminished or heightened sensitivity to touch • Cardiac, respiratory, liver, endocrine, or other systemic diseases • Hair • Previous hair problems: loss, thinning, unusual growth or distribution, brittleness, breakage, treatment • Systemic problems: thyroid disorder, rheumatologic disease, any severe illness, malnutrition, associated skin disorder
Nervous system allows the body to perform the following:
• Receive sensory stimuli from the environment • Identify and integrate the adaptive processes needed to maintain body functions • Orchestrate body function changes required for adaptation and survival • Integrate the rapid responsiveness of the central nervous system with the more gradual responsiveness of the endocrine system • Control cognitive and voluntary behavioral processes • Control subconscious and involuntary body functions
Past Personal History or Social History
• Skin care habits: cleansing routine; soaps, oils, emollients, or local applications used; cosmetics; home remedies or preparations used; sun exposure patterns and history; sunburn history; use of sunscreen agents; recent changes in skin care habits • Skin self-examination
German Measles (Rubella)
• Spread in droplets that are shed from respiratory secretions of infected persons • Patients are most contagious while the rash is erupting, but they may shed virus from the throat from 10 days before until 15 days after the onset of the rash. • Incubation period is 14-23 days. • Disease is preventable by immunization. Subjective Data • Low-grade fever, stuffy nose, sore throat, and cough • This is followed by a macular rash on the face and trunk that rapidly becomes papular. Objective Data • Generalized light pink to red morbilliform rash • By the second day, rash spreads to the upper and lower extremities; it fades within 3 days. • Reddish spots occur on the soft palate during the prodrome or on the first day of the rash (Forchheimer spots) • Infection during the first trimester of pregnancy may lead to infection of the fetus and may produce a variety of congenital anomalies (congenital rubella syndrome).
Herpes Zoster (Shingles)
• VZV morphologically and antigenically identical to the virus causing varicella (chickenpox) • Dormant viral particles (since the original episode of varicella) in the posterior spinal ganglia or cranial sensory ganglia become activated and spread along the nerve Subjective Data • Pain, itching, or burning of the dermatome area usually precedes eruption by 4-5 days. • After eruption resolves, there may be persistent pain called postherpetic neuralgia. Objective Data • Single dermatome that consists of red, swollen plaques or vesicles that become filled with purulent fluid • Does not cross midline • Disseminated lesions in immunosuppressed or older adults
Timed up and Go Test (TUG test)
• stand up from a chair without using the chair arms, • walk 10 feet (3 meters) to mark on floor, • turn around, • walk 10 feet (3 meters) back to the chair, and • sit down without using chair arms. Should be able to perform within 10 seconds of being asked. > 10 seconds = increased fall risk.
Pointers for Taking the Blood Pressure
- Keep the mercury sphygmomanometer vertical and make all the readings at eye level, no more than 3 feet away - Position the dial of the aneroid sphygmomanometer so it faces you directly no more than 3 ft away. Aneroid manometer needs periodic calibration - Slow or repeated inflations of the cuff can cause venous congestion and result in inaccurate readings. wait at-least 15 seconds between readings. -Electronic sphygmomanometers with a doppler or oscillometric device work by sensing vibrations, converting them to electrical impulses, and transmitting the information to a digital redout. Those devices are more sensitive.
Halo Nevus
- Sharp, oval, or circular; depigmented halo around mole; may undergo many morphologic changes; usually disappears and halo repigments. - Usually found on back in young adults - Usually benign, but biopsy is indicated bc same process can occur around melanoma.
Barlow Ortolani Maneuver
- To detect hip dislocation in newborn
Spine ROM
-Bend forward & touch their toes (Flexion 75-90 degrees) -Bend back at waist (Hyperextension of 30 degrees) -Bend to each side as far as possible, expect lateral bending of 35 degrees bilaterally. -Swing the upper trunk from the waist in a circular motion front to side to back to side while you stabilize the pelvis. Expect rotation of the upper trunk 30 degrees forward and backward
Intradermal Nevus
-Dome shaped; raised; flesh to black color; may be pedunculated or hair bearing -Cells limited to dermis -No indication for removal other than cosmetic
Latex Allergy
-Occurs when the body's immune system reacts with proteins found in latex -Occurs by direct skin or mucous membrane contact or through airborne exposure -Direct Contact is not Necessary, inhalation from powder of gloves can cause allergic rxn
What are the roles of the lymphatic system?
1) Movement of lymph fluid in a closed circuit w/ the cardiovascular system, a major factor in the maintenance of fluid balance 2) Production of lymphocytes w/in the lymph nodes, tonsils, adenoids, spleen, and bone marrow 3) Production of antibodies 4) Phagocytosis of other cells, bacteria, and bits of necrosed tissue or foreign particles; this is a specific function of cells that line the sinuses of lymph nodes 5) Absorption of fat and fat-soluble substances from the intestinal tract 6) Plays an undesirable role in providing at least one pathway for the spread of malignancy
Three Functions of the immune system
1) Protects the body from the antigenic substances of invading organisms 2) Removes damaged cells from the circulation 3) Provides a partial, but often inefficient, barrier to the maturation of malignant cells w/in the body
Edema
1+ Slight pitting, no visible distortion, disappears rapidly 2+ A somewhat deeper pit than in 1+, but again no readily detectable distortion; disappears in 10-15 seconds 3+ Noticeably deep pit that may last more than a minute; dependent extremity looks fuller and swollen 4+ Very deep pit that lasts as long as 2-5 minutes; dependent extremity is grossly distorted
How much time does it take for the arterial pulse to impact the dorsalis pedis artery?
0.2 seconds
How big can lymph nodes get?
0.5 to 1cm
What is in utero GFR?
0.5ml/min before 34 weeks
Thoracic Ratio
0.7 - 0.75. Increases with age. 1.0 = chronic condition present. Chronic asthma, emphysema, cystic fibrosis.
External Auditory Canal
1 inch / 2.5cm long in adults, S shaped
Allis Sign
1 knee significant lower that other knee Suggest Hip Dislocation
Three Functions of the lymphatic system
1. Conserving Fluid and Plasma that leak from capillaries 2. Defending the body against disease as part of the immune system 3. Absorbing Lipids from intestinal tract
How long is the esophagus
10 inches long Connects pharynx to stomach
How long and wide is the trachea?
10-11cm long, 2 cm in diameter
Ribs
12 Pairs Upper 7 connected via costal cartilage to sternum 8,9,10 Joined by costal cartilage only. 11, 12 (Floating Ribs) Only attached posteriorly to thoracic vertebrae
Size of the adult heart
12 cm long 8 cm wide at widest point 6 cm in AP diameter
How long is the illeum
12 ft
When is the kidney able to produce urine during gestation?
12 weeks due to nephrogenesis
What is the female average risk of breast cancer
12%
Adult respiration to heartbeat ratio
1:4
What is the average interval from the appearance of the breast bud (stage 2) to menarche?
2 years
CN Testing
2-12 tested, taste not tested unless aberration found
When does GI tract reach adult function
2-3 years of age
Deciduous teeth
20 deciduous teeth usually erupt between 6 months and 2 yrs.
When does the Immune system and lymphoid system begin developing
20 week gestation
How long is the small intestine
21 ft long
Closure of Ducuts arteriosus takes how long?
24-48 hours
Aortic Ejection Clicks are heard where
2nd Right IC
When does the fetal thyroid gland become functional?
2nd trimester Before this mom is the source of thyroid hormone and requires increased iodine intake. Thyroid in mom enlarges in areas of iodine deficiency
How many alveoli in adults
300 million
When does meconium production occur?
36-38 weeks gestation
Second Pulmonic valve area
3rd Left IC space at left sternal border
When do the pancreatic buds, liver, and gallbladder form in an infant
4 weeks gestation
Spinal Cord
40-50cm long begins at foramen magnum as continuation of medulla oblongata, terminates at L1 or L2
What is the bladder capacity in an adult
400-600 ml
Tricuspid Area
4th Left IC Space along the lower left sternal border
Varicose Vein Risk Factors
4x more in women esp in pregnancy genetic predisposition - children and women Tobacco use Sedentary Lifestyle BMI increased > age = more risk Lower extremity trauma Venous thrombosis
Passive ROM exceeds Active ROM by
5 degrees
Right lung is divided into upper portion at what rib
5th rib in the axilla and 4th rib anteriority by lesser horizontal fissure
What is the vertical span of the liver
6-12 cm / 2.5-4.5 inches
Pulse rate
60-100 bpm, 70 avg athlethes - 50-60bpm If irregular rhyhtm detected count for full 60 seconds Carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial arteries
Older Adults
70 yrs or older, hearing loss that affects ADLs Sensorineural hearing loss occurs with high frequency sounds and then progresses to lower tones. Loss of high frequency interferes with understanding of speech and localization of sound Conductive hearing loss can occur from cerumen impaction and tympanosclerosis or otosclerosis caused be calcification of tissues
how long is the jejunum
8 ft
What is the normal GFR?
90 ml/ min
Bradypnea
< 12 breaths may indicate neurologic or electrolyte disturbance, infection, or a conscious response to protect against the pain of pleurisy or other irritative phenomena. It may also indicate an excellent level of cardiorespiratory fitness.
What lies between the olecranon and the skin
A bursa
Epilepsy
A chronic disorder characterized by recurrent, unprovoked seizures secondary to an underlying brain abnormality Patho Episodic abnormal electrical discharges (excessive concurrent firing) of cerebral neurons may be caused by a central nervous system (CNS) disorder, a CNS structural defect, or a disorder that affects functioning of the CNS; examples include brain injury, infection, toxins, stroke, brain tumor, biochemical disorder, congenital malformations, and hypoxic syndromes. Subjective Data • History of prior seizure • Premonition or aura (headache, mood change, anxiety, irritability, lethargy, changes in appetite, dizziness, and lightheadedness) • Body is stiff and rigid, followed by rhythmic jerking movements. • Eyes roll upward. • Drooling • Loss of bladder or bowel control Objective Data • Tonic phase: brief flexion and characteristic cry with contraction of abdominal muscles, followed by generalized extension for 10-15 minutes; loss of consciousness for 1-2 minutes, eyes deviated upward, and dilated pupils • Clonic phase: contractions alternate with muscle relaxation • Postictal state: coma followed by confusion and lethargy • Common electroencephalographic findings of spikes and waves
Barrell chest past 2nd year of life can indicate
A chronic obstructive pulmonary problem like cystic fibrosis persistence at 5-6yrs is ominous.
Myelomeningocele (Spina Bifida)
A congenital vertebral defect (commonly at the lumbar or sacral level) that allows spinal cord contents to protrude Subjective Data • May have loss of bowel control or constipation • May have loss of bladder control (incontinence or urinary retention) • Mobility problems Objective Data • Exposed meningeal sac filled with fluid and nerves is apparent at birth • Sensory deficit and paralysis or weakness are dependent on level of defect (the higher the defect, the greater is the neurologic dysfunction); may not be symmetric • Rapidly increasing head circumference (hydrocephalus) • May have hip or foot abnormalities • Learning disabilities and perceptual motor skills
Kiesselbach Plexus
A convergence of small fragile arteries and veins. Located on the anterior-superior portion of the septum. Adenoids lie on the posterior wall of the nasopharynx
Furuncle (Boil)
A deep seated infection of the pilosebaceous unit Patho Caused by Staphylococcus Aureus Subjective Data • Acute onset of tender red nodule with center filled with pus. Objective Data • Skin is red, hot, and tender. • Center of the lesion is purulent and forms a core that may rupture spontaneously or require surgical incision • Sites commonly involved are the face and neck, arms, axillae, breasts, thighs, and buttocks.
Stereotype
A fixed image of any group that denies the potential of originality or individuality within the group, must be rejected. Stereotyping occurs in two cognitive phases In the first phase a stereotype becomes activated when an individual is categorized into a social group In the second phase people use these activated beliefs and feelings when they interact with the individual, even when the explicitly deny these stereotypes.
Macule (Primary Skin Lesions)
A flat circumscribed area that is a change in the color of the skin; less than 1cm diameter Ex: Freckles, flat moles (nevi), petechiae, measles
Gout
A form of arthritis resuling from chronically elevated serum uric acid Monosodium urate crystal depositon in joints and surrounding tissues results in acute inflammatory attacks. Sudden onset of hot, swollen join, limited ROM Primarily affects men > 40 and postmenopausal women Usually affects proximal phalanx of the great toe Skin over joint may be shiny and red or purple Uric acid crystals may form as tophi under the skin with chronic gout.
Cerebral Palsy - Children
A group of permanent disorders of movement and posture development associated with nonprogressive (static) disturbances that occurred in the developing fetal or infant brain Subjective Data • Delays in gross motor development that become more obvious as the infant ages • Activity limitation, stiff joints and positioning • May have hearing, speech, and language disorders • Feeding difficulties, poor sucking and swallowing coordination • Seizures Objective Data • Cognitive impairment or learning disabilities may be present • Spastic CP: hypertonicity, tremors, scissor gait, toe walking • Persistent primitive reflexes, exaggerated deep tendon reflexes • Dyskinetic CP: involuntary slow writhing movements of the extremities; tremors may be present. • Exaggerated posturing, inconsistent muscle tone that varies during the day • Ataxic: abnormalities of movement involving balance and position of trunk and extremities • Intention tremors, past pointing • Increased or decreased muscle tone, may have hypotonia as infant • Instability, wide-based gait
Pes Cavus
A high instep / arch - may be associated with claw toes
Periodic apnea of the newborn
A normal condition characterized by an irregular pattern of rapid breathing interspersed with brief periods of apnea that one usually associates with rapid eye movement sleep.
Tactile Fremitus
A palpable vibration of the chest wall produced by the spoken word; AKA vocal fremitus Best felt at the level of bifurcation of the bronchi
Expected sign in nipples
A peppering of nontender, nonsuppurative Montgomery Tubercles is a common and expected finding
Hydrocephalus
A problem in the formation, flow, or absorption of cerebrospinal fluid (CSF) that leads to an increase in volume of the CSF
Primary Apnea
A self-limited condition, and not uncommon after a blow to the head. It is especially noted immediately after the birth of a newborn, who will breathe spontaneously when sufficient carbon dioxide accumulates in the circulation.
Parkinsons
A slowly progressive, degenerative neurologic disorder in which motor function is primarily affected along with behavioral and cognitive problems Characteristic Features: Excessive sweating, Drooling, Gait with rapid short shuffling steps and reduced arm swinging. Patho • Destruction of neurons that transmit dopamine results in poor communication between parts of the brain that coordinate and control movement and balance • Onset after 40 years of age, with 60 years as the mean age of onset Subjective Data • Tremors (sometimes unilateral) occur initially at rest and with fatigue, disappearing with intended movement and sleep; progresses to pill-rolling movement of fingers bilaterally and tremor of the head • Slowing of voluntary and automatic movements, "feel wooden," freezing or unable to continue movements • Numbness, aching, tingling, and muscle soreness occur in many patients • Difficulty swallowing, drooling Objective Data • Tremors • Muscular rigidity, cogwheel rigidity with jerks • Stooped posture, balance and postural instability • Short steps, shuffling, freezing gait, gait may accelerate to maintain upright posture • Slow, slurred monotonous speech, voice softening • Impaired cognition, dementia
Complex Regional Pain Syndrom
A syndrome in which regional pain extends beyond a specific peripheral nerve injury in a extremity with motor, sensory, and autonomic changes Patho No relationship between the original trauma severity and the severity and cause of the symptoms Cause is unknown, but the sympathetic nervous system helps maintain symptoms Subjective Data Burning, shooting, or pain with aching character exaggerated sensitivity to cold or sweating changes pain increases or persist after light pressure Allodynia Objective Data Edema Changes in skin blood flow: abnormal skin color; red and hot, cyanotic, temperature difference of up to 1 degree celcius between the affected and unaffected extremity Increased sweating may be seen.
Normal pressure hydrocephalus
A syndrome simulating degenerative diseases that is caused by noncommunicating hydrocephalus (dilated ventricles with intracranial pressure within expected ranges) Subjective Data • Gait impairment is the first symptom. • Unsteadiness and difficulty turning • Forgetfulness, cognitive impairment • Urinary frequency that progresses to urgency and incontinence over time Objective Data • Gait impairment, wide-based stance, short, small steps, and reduced floor clearance • No tremor • No sensory impairment • Cognitive impairment, attention, and executive function impaired • Impaired memory recall for recent events • CT scan and MRI of the brain reveal enlarged ventricles not attributable to brain atrophy or a congenital problem.
Pierre-Robin Sequence Facies
A triad of micrognathia, glossoptosis, and palatal clefting. Shows a lateral view with severe micrognathia and cleft palate. Not the small retruded mandible.
Aortic Stenosis decreases
A2 intensity
Lachman Test
ACL integrity With the patient supine, flex the knee 10 to 15 degrees with the heel on the table. Place one hand above the knee to stabilize the femur and place the other hand around the proximal tibia. While stabilizing the femur, pull the tibia anteriorly. Attempt to have the patient relax the hamstring muscles for an optimal test. Increased laxity, greater than 5 mm compared with the uninjured side, indicates injury to the ligament.
Where does the testes lymph drain to?
Abdomen
Ptergyium
Abnormal growth of the conjunctiva that extends over the cornea from the limbus. Usually on the Nasal side. Caused by UV light Exposure
Retinal Hemmorhage in Infancy
Acceleration deceleration impact trauma. CHILD ABUSE! (Shaken baby syndrome)
Colostrum
Accumulates in acinar cells toward end of pregnancy contains more protein and minerals than mature milk It contains antibodies and host resistance factors.. Milk starts being produced within 2-4 days after delivery in response to surging prolactin levels, declining estrogen levels, and the stimulation of sucking.
Epiglottitis
Acute life threatening infection involving the epiglottis and surrounding tissues. Begins suddenly and progresses rapidly without cough patient sits straight up with neck extended and head held forward. Appears very anxious, unable to swallow Painful sore throat Muffled Voice Difficulty swallowing High Fever Beefy Red Epiglottis
Kawasaki Disease
Acute small vessel vasculitic illness that may result in the development of coronary artery aneurysms common in boys Symptoms last over 5 days or more. The effects of systemic vasculitis include: Weight loss, fatigue, myalgias, arthritis Fever, conjunctival infection, strawberry tongue, edema of hands and feet. Lymphadenopathy and polymorphous non vesicular rashes.
HEEADSSS
Adolescent Screening Tool Home Environment Eduction, employment Eating Activities (Peer Related), affect, ambitions, anger Drugs Sexuality Suicide Depression Safety from injury and violence
PACES
Adolescent Screening Tool Parent, Peers Accidents, alcohol drugs Cigarettes Emotional Issues School, Sexuality
Rate and Depth of Breathing will decrease with:
Alkalosis CNS lesion in Cerebrum Myasthenia Gravis Narcotic OD Extreme Obesity
Deep Tendon Reflex Testing
All deep tendon reflexes tested, except plantar reflex and test for clonus
Complete Transverse Lesion of the Spinal Cord
All forms of sensation are lost below the level of the lesion. Pain, Temperature, and Touch sensations are lost one to two dermatomes below the lesion.
Expected findings in infants
All infants are flat-footed, and many newborns have a slight varus curvature of the tibias (tibial torsion) or forefoot adduction (metatarsus adductus) from fetal positioning.
Chest Pain from Peptic Ulcer Characteristics
Almost always infradiaphragmatic and epigastric Nocturnal occurrence and daytime attacks relieved by food. Unrelated to activity
Middle Cerebral Artery Stroke
Alterations in communication, cognition, mobility, and sensation Contralateral homonymous hemianopia Contralateral hemiplegia or hemiparesis, motor and sensory loss, greater in face and arm than the leg
Ototoxic medications
Aminoglycosides - Gentamicin, Streptomycin, Chemotherapy - Cisplatin Antimalarial - Quinine Salicylates Furosemide Salt retaining meds like corticosteroids.
Intracranial Tumor
An abnormal growth within the cranial cavity that may be a primary or metastatic cancer Patho • The lesion causes displacement of tissue and pressure, affecting cerebrospinal fluid circulation; function is threatened through compression and destruction of tissues. • The incidence of primary brain tumors increases until about 70 years old and then decreases. Subjective Data • Persistent headache, may awaken patient from sleep • Nausea, early morning vomiting • Unsteady gait, impaired coordination • Memory loss and confusion • Reduced vision acuity, visual loss, diplopia • Behavior or personality change • Seizure • Other symptoms in children may include irritability, lethargy, motor system abnormalities, cranial nerve palsies, weight loss, growth failure, and precocious puberty Objective Data • Signs may vary by location of tumor. • Altered consciousness, confusion • Papilledema • Cranial nerve impairment • Aphasia, language disorder • Vision loss—hemianopia, nystagmus • Gait disturbances, ataxia • Brain imaging by computed tomography (CT) scan or MRI confirms the diagnosis.
Papule
An elevated, firm, circumscribed area; less than 1cm in diameter Ex: Wart (verruca), elevated moles, lichen planus
Facies
An expression or appearance of the face and features of the head and neck that, when considered together, is characteristic of a clinical condition or syndrome. Ask pt to provide an older photo of self bc facies can develop slowly.
Temporal Arteritis (Giant Cell Arteritis)
An inflammatory disease of the branches of the aortic arch, including the temporal arteries Can lead to ischemia of the masseter muscle, tongue, or optic nerve. Flu like symptoms, headache, ocular symptoms, tongue pain, jaw claudication Area over temporal artery may be red swollen
Goniometer (Protractor)
An instrument for measuring angles (as of a joint or the skull)
Winged Scapula
An outward prominence of the scapula indicating injury to the nerve of the anterior serratus muscle
Anatomic Landmarks
Angle of Louis Suprasternal Notch Costal Angle Vertebra Prominens Clavicles
AP drawer test
Anterior and Posterior Cruciate ligament integrity Have the patient lie supine and flex the knee 45 to 90 degrees, placing the foot flat on the table. Place both hands on the lower leg with the thumbs on the ridge of the anterior tibia just distal to the tibial tuberosity. Draw the tibia forward, forcing the tibia to slide forward of the femur. Anterior or posterior movement of the knee greater than 5 mm in either direction is an unexpected finding.
Neck anatomical landmarks
Anterior and Posterior Triangle Clavicle
The Great Vessels
Aorta Superior and Inferior Venae Cavae Pulmonary Arteries Pulmonary Veins Pulmonary Artery - only artery that carries deoxygenated blood
Thrill during Diastole at the Right Sternal Border =
Aortic Regurgitation
Thrill during systole at suprasternal notch / 2nd and 3rd RIC =
Aortic Stenosis
Nodding of the head indicates
Aortic insufficiency esp if synchronized with pulse
Dermatome
Area of skin supplied by a single spinal nerve
Spastic Hemparesis
Arm Flexed, Foot Dragged Scraping Toe, Circled outward and forward (Circumducution), Plantar Flexion
Blood pressure
Arterial blood pressure is the force of blood against the wall of an artery as the ventricles of the heart contract and relax. Systolic Blood pressure is the force exerted when the ventricles contract. Largely the result of cardiac output, blood volume, and compliance of the arteries. Diastolic Blood Pressure is the force exerted by peripheral vascular resistance when the heart is in the filling or relaxed state. Pulse Pressure - Difference between systolic and diastolic BP.
Pulse Rate
Arterial pulse results from ventricular contraction. Pushes a pressure wave of blood throughout the arterial system.
Tuning Fork
Auditory evaluation = 500-1000 Hz fork Vibratory Sensation = 100-400Hz fork apply to bony prominence
Paronychia (Nail Infection)
Bacteria or yeast between nail fold and nail plate. Can be chronic Acute: history of nail trauma Chronic: History of repeated exposure to moisture through hand-washing. Evolves slowly with tenderness and mild swelling. Redness swelling and tenderness at the lateral and proximal nail folds. Purulent drainage often accumulates under the cuticle Chronic Paronychia can produce rippling of the nails.
Grade 1 Murmur
Barely audible in quiet room
Early Diastolic Murmur
Begins with S2
Cardiac Disease Risk Factors
Being Male, though females risk increased in postmenopausal years and with oral contraceptive use. Hyperlipidemia Elevated Homocysteine level (contributes to arterial damage and blood clots) Smoking Family Hx CVD, DM, HTN, Hyperlipidemia Obesity Excessive Fatigue Beta Blockers Dyspnea Paroxysmal nocturnal dyspnea Carotid Sinus Effect - suddent turning of neck Looking up - Vertebral Artery Occlusion
Examine ROM of hand with these movements
Bend fingers forward a the metacarpophalangeal joint then stretch the fingers up and back at the knuckle.. Expect metacarpophalangeal flexion of 90 degrees and hyperextension up to 30 degrees. Touch the thumb to each fingertip and to the base of the little finger, make a fist. Spread the fingers apart and then touch them together Bend the hand at the wrist up and down. Expect flexion of 90 degrees and hyperextension of 70 degrees. With the palm side down, turn each hand to the right and left. Expect radial motion of 20 degrees and ulnar motion of 55 degrees
Argyll Robertson Pupil
Bilateral, miotic, irregularly shaped pupils that fail to constrict with light but retain constriction with convergence; Neurosyphilis or lesions of the midbrain
Subungal Hematoma
Bleeding under nail plate. Can cause nail to seperate. Red to purple color. Hematoma remains until nail grows out, or is decompressed (stick needle through nail plate)
Genu Varum
Bow legged Genu varum is present if a space of 2.5 cm (1 inch) exists between the knees. Common in toddlers until 18 months.
Esophageal Chest Pain Characteristics
Burning, substernal, occasional radiation to shoulder Nocturnal occurrence, usually when lying flat, relief w/ food, antacids sometimes nitro.
Bicep Reflex - Spinal Nerve Levels Evaluated
C5 and C6 (Deep Tendon Reflex)
Brachioradial Reflex - Spinal Nerve Levels Evaluated
C5 and C6 (Deep Tendon Reflex)
Tricep Reflex - Spinal Nerve Levels Evaluated
C6, C7, C8 (Deep Tendon Reflex)
Muscle Strain
Can be due to excess stretching or forceful contraction beyond muscles function capacity Usually due to improper exercise warm up, fatigue, or previous injury. Muscle pain, severity ranges from mild intra fibrous tear to a total rupture of a single muscle Temp muscle weakness
Hand Veins
Can indicate right heart pressure
Ectropion
Can result in excessive tearing, lid turned away from eye
Portable Ultrasound
Can show structure and movement of the body's internal organs as well as blood flowing through blood vessels. Abnormalities that can be detected by ultrasound include cysts, tumors, fluid collection, infections, structural abnormalities of organs, and blockages of major blood vessels.
Dry Nonproductive Cough caused by:
Cardiac problems, allergies, GI reflux with Pharyngeal irritation.
Which artery has the most definitive pulse for evaluation of cardiac function
Carotid
Nail Warts
Caused by HPV, growth at the nail fold
Hordeolum (Stye)
Caused by Staph infection, inflammation of eyelash follicle
Infants and Children: Milaria Rubra (Prickly Heat)
Caused by blocked sweat ducts and trapped sweat beneath skin Results from immaturity of skin structures, overdressed babies during summer. Irregular macular rash on Covered areas of skin
Bigeminal Pulse
Caused by disorder of rhythm Normal pulse followed by PVC Amplitude of pulsation of the PVC is less than that of a normal pulse
Ingrown Nails
Caused by poor fitting shoes, or improper trimming of lateral nail plate, or trauma. Usually on large toe. Redness and swelling at site
Onycholysis
Caused by trauma to long fingernails, or psoriasis, candida or pseudomonas infection, meds, allergic or contact dermatitis, and HYPERthyroidism. Painless nail seperation
Opening Snap
Caused my mitral stenosis, creates an opening snap
Paradoxical aka Reversed Splitting
Caused when closure of aortic valve is delayed. Left bundle branch block or advanced aortic stenosis.
Prosthetic Aortic Valve
Causes a sound in early systole. Intensity depends on type of material used. Animal tissue is the quietest and may even be silent.
Newborn Diaphragmatic Hernia
Causes asymmetric chest expansion If GI Gurgling sounds are persistently heard On the left side 90% of the time, heart displaced to right. Tachypnea Retraction Grunting
The __________________ is the main network of coordination and control for the body
Central Nervous System (Brain and Spinal Cord)
Nucleus Pulposus
Central fibrogelatinous material in each disk - Cushions the vertebral bodies.
In what direction does motility of the GI tract develop?
Cephalocaudal.. allows amniotic fluid to be swallowed by 17 weeks of gestation
Stroke of Internal Carotid Artery
Cerebral Hemisphere, Diencephalon by ophthalmic and ipsilateral hemisphere arteries S/S Unilateral Blindness Severe Contralateral hemiplegia and hemianesthesia Profound Aphasia
Three major units of the brain are the:
Cerebrum Cerebellum Brainstem
Which spinal bones are most mobile?
Cervical Vertebrae Flexion and extension occur between the skull and C1 Rotation occurs between C1 and C2
What are the structures of the neck?
Cervical Vertebrae Ligaments Sternocleidomastoid muslce Trapezius muscle
What is the spine composed of?
Cervical, Thoracic, Lumbar, and Sacral Vertebrae Breakfast at 7, Lunch at 12, Dinner at 5 All but sacral vertebrae are separated by fibrocartilaginous disks
Apneustic Breathing
Characterized by a long inspiration and what amounts to expiration apnea. The neural center for control is in the pons and medulla. When it is affected, breathing can become gasping because inspirations are prolonged and expiration constrained.
Sleep Apnea
Characterized by periods of an absence of breathing and oxygenation during sleep. Due to blockage of the airway when the soft tissue in the back of the throat collapses during sleep, airflow is not maintained through the nose and mouth.
Shaken Baby Syndrome
Child abuse, shaking of child < 1yrs old • Shaking causes the brain to move around in the skull, stretching and tearing nerve tissue and blood vessels and causing brain damage and a subdural hematoma; the spinal cord may also be damaged as the head is whipped back and forth. Subjective Data • Fever • Irritability or lethargy • Decreased food intake • Breathing difficulty or apnea • Seizure • Loss of consciousness Objective Data • Reported history of present illness does not match the nature and severity of findings • Altered level of consciousness • Seizures • Bilateral retinal hemorrhages with retinal detachments or folds • Absence of visible trauma to the head; fingerprint bruises may be seen on infant's upper arms and body • Bruising, bite marks, or burns may be seen in some infants. • CT scan reveals subdural or subarachnoid hemorrhage. • Signs of old and new fractures of long bones and ribs may be seen on radiographs.
Psoriasis of Nail
Chronic and recurrent disease of keratinocyte proliferation Usually occurs simultaneously with the skin disease but can happen on its own. Psoriatic skin lesion, joint pain from psoriatic arthritis in 30% of patients. Yellow scaly debris accumulates. can result in splinter hemorrhages and malformed nails.
Infants and Children: Seborrheic Dermatitis
Chronic, recurrent, erythematous scaling eruption localized in areas where sebaceous glands are concentrated (e.g., scalp, back, and intertriginous and diaper areas) Cause is unknown, occurs within first 3 months of life. Thick Greasy Scalp Scales or body rash. Scalp lesions are scaling, adherent, thick, yellow, and crusted (cradle cap) and can spread over the ears and down the nape of the neck. Lesions elsewhere are erythematous, scaling, and fissured, typically on central body or in diaper area.
Eustachian Tube
Ciliary Action clears middle ear mucosa into the nasopharynx. Drains into the posterior aspect of the inferior turbinate of the nose. Muscles briefly open this passage during yawning, swallowing, sneezing. Equalizes pressure.
Pulmonary tuberculosis smells like
Cinnamon
What is the nipple composed of?
Circular and Longitudinal Smooth Muscle Fibers. Stimulation of smooth muscle causes lactiferous ducts to empty
Microcephaly
Circumference of head is smaller than normal because the brain has not developed properly or has stopped growing head circumference 2-3 standard deviations below the mean
What color is lymph fluid?
Clear, sometimes milky colored or yellow tinged. Contains WBCs (mainly lymphocytes) and RBCs
Older Adults - Competency to Make Decisions
Clinical decision making capacity includes three elements: Patient has a set of goals or values Patient is able to understand and communicate info Patient is able to reason and deliberate about the choice being made by the patient.
Smell of the skin
Clostridium gas gangrene - Rotten Apples Proteus infection - Mousy Pseudomonas infeciton (especially burns) - grapelike Tuburculous Lymphadenitis (scrofula) - Stale Beer Anaerobic infeciton; scurvy - Putrid Intestinal Obstruciton, peritonitis - Feculent Phenylketonuria - Mousy, Musty
A2
Closure of aortic valve
Early Acromegaly Facies
Coarsening feature with broadening of nasal alae and prominence of the zygomatic arches
Cafe Au Lait Macules
Coffee-colored patches (café au lait macules) may be either harmless or indicative of underlying disease. Be suspicious of neurofibromatosis (NF-1) if six or more café au lait macules more than 5 mm in greatest diameter are found in prepubertal individuals or more than 15 mm in greatest diameter after puberty
Kyphosis
Common in aging adults
Anisocoria (Unequal size of pupils)
Congenital - 20 % of people Unliateral sympathetic or parasympathetic pathway destruction
Brachial Cleft Cyst
Congenital Lesion formed by incomplete involution of branchial cleft Subjective Data • Painless mass in lateral neck • May have intermittent swelling and tenderness • Discharge if associated with a sinus tract Objective Data • Oval, moderately movable smooth, nontender, fluctuant mass along anteromedial border of sternocleidomastoid muscle • Usually asymptomatic • If infected, tenderness and erythema
Atrial Septal Defect
Congenital defect in the septum dividing the left and right atria Patho • Large ASD (>9 mm), allows left-to-right shunting of blood • Extra blood from the left atrium may cause a volume overload of the right atrium and the ventricle. • Untreated ASD can result in enlargement of the right side of the heart and shunt reversal (right-to-left shunt) and heart failure. Subjective Data • Often asymptomatic • Heart failure rarely occurs in children but can often occur in adults. Objective Data • Diamond-shaped systolic ejection murmur often loud, high-pitched, and harsh, heard over the pulmonic area • May be accompanied by a brief, rumbling, early diastolic murmur • Does not usually radiate beyond the precordium • Systolic thrill may be felt over the area of the murmur, along with a palpable parasternal thrust. • S 2 may be widely split. • Sometimes the murmur may not sound particularly impressive, especially in overweight children; if there is a palpable thrust and radiation to the back, it is more apt to be significant.
Infant Central Cyanosis indicates
Congenital heart disease
Cystic Hygroma
Congenital malformation of dilated lymphatics Thin Walled contains clear lymph fluid Painless cystic mass May simulate lymph node enlargement.
What are lymph nodes made out of?
Connective tissue few Elastic Fibrils
Dupuytren Contracture
Contractures involving the flexor hand tendons Cause unknown Flexion contractures develop insidiously Incidence increases after age 40 occurs more frequently in men Flexor tendons of the fourth and fifth digits contract causing fingers to curl with impaired extension Tendons easily palpable
Brainstem
Controls involuntary functions
Diencephalon CN 1-2 Thalmus
Conveys all sensory impulses except smell to and from cerebrum before distribution to associative sensory areas. Influences voluntary movements and motor response Controls state of consciousness and abstract feelings
What ligaments provide support for the breast?
Cooper ligaments
Autonomic Nervous System
Coordinates and regulated the internal organs of the body such as cardiac muscle, and smooth muscle. Has two divisions, each balancing the impulses of the other - Sympathetic division, and parasympathetic division
COPD
Cough, Chronic and often excessive sputum production, dyspnea leads to irreversible expiratory airflow obstruction Chronic Bronchitis, Bronchiectasis, Emphysema
Lipemia Retinalis
Creamy white appearance of retinal vessels that occurs with excessively high serum triglyceride levels Grade 1 (Early) - White and creamy aspect of peripheral retinal vessels Grade 2 (Moderate) - creamy color extends toward optic disc Grade 3 (Marked) - Retina appears salmon color, all vessels milky Resolves as triglycerides return to normal.
What is the upper most ring of the tracheal cartilages?
Cricoid
Blepharitis
Crusting of eyelash Bacterial infection, seborrhea, psoriasis, rosacea, or allergic response
BP Cuff for Child
Cuff width should cover aprox 70% of the distance between the acromion and the olecranon (tip of elbow) Bladder length should e 80-100% of the upper arm circumference and bladder width should be at least 40% of the arm circumference at the midpoint of the acromion-olecranon distance Use Kortokoff phase 5 as the diastolic reading unless the sounds are heard down to zero or very low. In that case use Phase 4 (muffling) as diastolic
Dimensions of Cultural Competence
Cultural Encounters - The continuous process of interacting with patients from culturally diverse backgrounds to validate, refine, or modify exiting values, beliefs, and practices about a cultural group and to develop cultural desire, cultural awareness, cultural skill, and knowledge Cultural Desire - motivation to want to engage in the process of becoming culturally competent Cultural Awareness - the deliberate self examination of ones own cultural beliefs and biases towards groups who are different Cultural Knowledge - The process of seeking and obtaining a sound educational base about culturally and ethnically diverse groups Cultural Skill - the ability to collect culturally relevant data regarding the patient's presenting problem as well as accurately performing a culturally based physical assessment
Cutaneous Horns
Cutaneous horns are small, hard projections of the epidermis, usually occurring on the forehead and face and can be the manifestation an underlying squamous cell carcinoma or a wart
Digital Mucous Cysts
Cyst on proximal nail fold, puts pressure on nail matrix and causes a longitudinal groove. Cysts located on the dorsal-lateral finger at the distal interphalangeal join are probably caused by herniation of tendon sheaths or join linings and are related to ganglion and synovial cysts. Contains clear jelly like substance.
A lift along the left sternal border is most likely the result of: A. aortic stenosis. B. atrial septal defect. C. pulmonary hypertension. D. right ventricular hypertrophy.
D. Right Ventricular Hypertrophy
Internal Intercostal Muscles
Decrease the lateral diameter during forceful expiration.
What causes the Foramen Ovale to close?
Decreased Pulmonary Pressure from Pulmonary Arteries relaxing
Older Adult Ventilation
Decreased vital capacity, and increased residual volume. Retained mucus encourages bacterial growth = predisposition to resp infection
Kussmal Respirations
Deep labored breathing pattern; increased rate, large volumes often seen in Diabetic Ketoacidosis
What are the primary muscles of respiration?
Diaphragm and Intercostal Msucles
Pregnancy abnormalities
Diastolic murmur Neck vein distention Clubbing Cyanosis
Cellulitis
Diffuse, acute, infection of the skin and subcutaneous tissue Patho • Majority of cases caused by Streptococcus pyogenes or Staphylococcus aureus . Subjective Data • Break in the skin, such as a fissure, cut, laceration, insect bite, or puncture wound • Pain and swelling at the site • May have fever Objective Data • Skin is red, hot, tender, and indurated; borders are not well demarcated • Lymphangitic streaks and regional lymphadenopathy may be present. • Rare to have bilateral cellulitis.
Hydronephrosis
Dilation of the renal pelvis and calyces due to an obstruction of urine flow anywhere from the urethral meatus to the kidneys
CN 4 Trochlear
Downward and inward eye movement
Crust
Dried serum, blood, or purulent exudates; slightly elevated; siz varies; brown, red, black, tan or straw colored Ex: Scab on abrasion
Malignant Breast Tumors
Ductal carcinoma arises from the epithelial lining of ducts; lobular carcinoma originates in the glandular tissue of the lobules. occurrence usually 45-70 yrs old, but mainly after 50yrs old Painless lumps, change in size, shape or contour of breast Axilla may be tender if lymph nodes involved
Myxedema Facies
Dull, Puffy, Yellowed Skin Coarse Sparse Hair Temporal loss of eyebrows Periorbital edema, prominent tongue.
Pleural effusion exam findings
Dullness to chest percussion = higher probability of pleural effusion If normal tactile fremitus is present it is less likely there is a pleural effusion
Best time to Hear a Split S1
During Deep Inspiration.. Tricuspid valve closure is very faint
Intention Tremor
During intentional movements like writing, pouring water in cup. Does not occur at rest. Cerebellar disorder - MS or Etoh
When is the thymus largest and most active?
During neonatal and preadolescent periods. Atrophies after puberty.
Platypnea
Dyspnea increases in upright posture.
Major landmarks of the back
Each spinal processo of the vertebrae (C7 and T1 most prominent) Scapulae Iliac Crests Paravertebral muscles
Palpation of eyelid
Easiest way to detect ICP, involved eye will be much harder than uninvolved eye Very Firm = Glaucoma, or retrobullar tumor Pain = Scleritis, Orbital Cellulitis, Cavernous Sinus Thrombosis
Mass
Elevated and solid lesion; may or may not be clearly demarcated. Deeper in dermis; greater than 2 cm in diameter Ex: Neoplasms, benign tumor, lipoma
Pregnant Patients
Elevated levels of estrogen = Increased vascularity of upper respiratory tract. Capillaries of nose pharynx and eustacian tube become engorged = Nasal stuffiness, decreased sense of smell, epistaxis, sense of fullness in ears, impaired hearing. Hoarseness and persistent cough
Cyst
Elevated, circumscribed, encapsulated lesion; in dermis or subcutaneous layer; filled with liquid or semisolid material Ex: sebaceous cyst, cystic acne
Cor Pulmonale
Enlargement of Right Ventricle due to lung disease Subjective Data • Fatigue • Tachypnea • Exertional dyspnea • Cough • Hemoptysis • Lightheadedness • Syncope Objective Data • Evidence of pulmonary disease • Wheezes and crackles on auscultation • Increase in chest diameter • Labored respiratory efforts with chest wall retractions • Evidence of right heart failure and hypertrophy • Distended neck veins with prominent A or V waves • Cyanosis • Left parasternal systolic heave • Loud S 2 exaggerated in the pulmonic region
Shotty Lymph Nodes
Enlargement of lymph node after viral infection feels like a BB < 1cm No clinical consequence unless in epitrochlear or supraclavicular regions
What are the growth plates in the long bones called?
Epiphyses
What is the only peripheral lymph center?
Epitrochlear
Newborn Chest Circumference
Equal to head until about 2 yrs old
Heart Sound Locations
Everything hear best at apex except: Split S1 - Tricuspid Intense S2- Base Physiologic Splitting S2 during expiration - Base
Hepatojugular Refulex
Exaggerated when R sided HF present. To assess the hepatojugular reflux maneuver, use your hand to apply firm pressure for 10 seconds to the abdomen in the midepigastric region and instruct the patient to breathe regularly. Observe the neck for an elevation of at least 3 to 4 cm in JVP that lasts beyond a few seconds. The JVP equilibrates to its true level after removal of the abdominal hand pressure.
LH Symbols (LEA Symbols)
Far Vision Consists of four optotypes (circle, square, apple, house) that blur equally. The child has to find a matching block or point to the shape that matches the target presented. Acuity is measured by the smallest symbol the child is able to identify at 10 ft.
Arterial Blood Pressure
Force exerted against the wall of an artery as a bolus of blood exits the hearts LV
Cerebrum
Formed by two cerebral hemispheres, divided into lobes. Hemispheres control the contralateral opposite side of body.
Nasal sinus infection, cancer, or resp infection like empyema, lung abscess, bronchiectasis smells like
Fould, putrid
Sighing
Frequently interspersed deeper breath
Koilonychia (Spoon Nails)
From iron deficiency anemia, syphilis, fungal dermatoses, HYPOthyroidism
What bones are the face made up of?
Frontal Nasal Zygomatic Ethmoid Lacrimal Sphenoid Maxillary Movable Mandible
DKA smells
Fruity or sweet
Full muscle strength requires?
Full ROM
Why might the Right Lung Ride Higher than the Left lung?
Fullness of the dome of the liver
Irritable bowel syndrome
Functional disorder characterized by abdominal pain and altered bowel habits
Sensory Ataxia
Gait is wide based. feet thrown forward and outward. Heels down first. Patient watches ground to guide feet. Positive romberg.
What is the female breast composed of?
Glandular (15-20 lobes per breast around the nipple) and fibrous tissue Subq and retromammary fat Each Lobe is composed of 20-40 lobules Each lobule consists of milk-producing acinar cells
Older adult breast changes
Glandular Tissue Atrophies gradually replaced by fat Inframammary ridge thickens Hang more loosely due to relaxation of the suspensory ligaments Nipples become smaller and flatter lose some erectile ability Loss of axillary may occur Skin may dry and thin
Vaginal speculum
Graves Speculum - 76mm - 170mm lenght and 22mm - 36mm wide. Bottom blade slightly longer Pederson Speculum - same lenght as graves, but narrower. 16-25mm Pediatric or virginal speculum - short narrow flat blade.
Matted Node
Group of nodes that feel connected and seem to move a s a unit
Tonsilits, gingivits, GI reflux, Vincent angina smells like
Halitosis
Increased S3
Heard best will bell at apex Pt in Left lateral Recumbent Position During early diastole, low pitched
CN 8 (Acoustic)
Hearing and equilibrium
LUmbosacral Radiculopathy (Herniated Lumbar Disk)
Herniation of a lumbar disk that irritates the corresponding spinal nerve root Most common at L4,L5 and S1 Between 31-50 yrs old Low back pain with radiation to the buttocks and posterior thigh or down the leg Potential difficulty with heel Walking (L4 and L5) or Toe Walking (S1)
Steppage Gait
Hip and Knee elevated excessively. Foot brought down with slap, patient can not walk on heels. Walks like a horse
Stepping Reflex (Birth - 8 weeks)
Hold the infant upright under the arms and allow the soles of the feet to touch the surface of the table; observe for alternate flexion and extension of the legs, simulating walking; it disappears before voluntary walking.
Mitral Regurgitation
Holosystolic. Heard best at apex, radiates to left axilla Caused by rheumatic fever, MI, myxoma, rupture of chordae
Complementary and alternative treatments
Home based remedies for the common cold are widely used. In children the following may be effective: Buckwheat honey, vapor rub, geranium, and zinc sulfate In adults: Echinacea purpurea, geranium extract, and zinc gluconate may be effective
Pituitary Gland
Hormonal control of growth, lactation, vasoconstriction, and metabolism
Epithalmus
Houses pineal body Sexual development and behavior
Cribiform plate
Houses sensory ending of the olfactory nerve. Lies on the roof of nose.
HITS Screening Tool
Hurt you physically? Insult or talk down to you? Threaten you with physical harm? Scream or curse at you? pg. 10
Older Patient Fall Risk Factors
Hx Stroke Parkinsons Dementia Peripheral Neuropathy Gait, balance, vertigo disorder Lower Extremity weakness or sensory loss Impaired vision
Chest Percussion Tones
Hyperresonance is abnormal, result of air trapping
Pt abdomen is significantly distended, bowel sounds hypoactive or absent. No pain, No masses. DTR diminished. Pt on diuretics for htn. What is suspected cause?
Hypokalemia - paralytic ileus or Narcotics/hypothyroid
CN 1 Examination
Identify aromatic odors, one naris at a time with eyes closed.
L3, L4 can be found where
Illiac crest for epidural during labor
These vaccines may cause axillary node enlargement:
Immunizations, particularly BCG (bacillus Calmette-Guérin), MMR (measles/mumps/rubella), and smallpox vaccination, administered in the upper arm may cause temporary axillary node enlargement. Rarely, human papilloma virus (HPV) vaccination may cause node enlargement in the head and neck region
pes varus
In toeing
Sense of Smell
Inborn errors of metabolism - caused by Phenylketonuria or Tyrosinemia. Smells like Mousy or fishy. Infectious disease - caused by TB or Diphtheria, smells like Stale Beer or sweetish Ingestion of poison or intoxication - caused form cyanide or chloroform salicylates, smells fruity Physiologic non-disease states - sweaty feet, smells cheesy Foreign bodies eg in nose or vagina - organic material like bead in child's nose will have foul smelling discharge.
Atelectasis Presentation
Incomplete expansion of the lung at birth or the collapse of the lung at any age Subjective Data • Frequently seen in the postoperative setting • Symptoms of postobstructive pneumonia may develop in the setting of airway obstruction from a foreign body or tumor. Objective Data • Auscultation dampened or muted in the involved area because the affected area of the lung is airless. • Radiograph may show consolidation associated with a postobstructive pneumonia.
External Intercostal Muscles
Increase the AP chest diameter during Inspiration Think.. external expands
What causes the ductus arteriosus to close?
Increased O2 tension in arterial blood stimulates contraction and closure
Loud S1
Increased velocity of blood flow due to exercise, fever, anemia, hyperthyroid, during exercise, Stenotic Mitral Valve Think S1 stands for Stenotic
Retention Cysts
Inflammation of sebaceous glands in areola. Tender and suppurative.
Decerebrate Posturing
Injury to brain stem
Pseudotumor Cerebri
Intracranial HTN that mimics brain tumors. Possibly due to excess CSF or malabsorption. Obstructed venous drainage, and obesity. Mainly in obese women of childbearing age. Subjective Data • Severe daily headache, throbbing, may awaken patient • Pain behind the eye • Vomiting • Short episodes of blurred vision, double vision • Whooshing sound in ears Objective Data • Papilledema, retinal hemorrhages on fundoscopic examination • Inferior nasal vision field defect • Decreased visual acuity • Alert, unimpaired consciousness • Absence of focal neurologic signs • CT scan or MRI reveals no cause of increased intracranial pressure.
What does the pancreas do?
It produces amylase, protease and lipase then releases them into the small intestine
CN 5 Trigeminal
Jaw opening, chewing, clenching, mastication Sensation to cornea, iris, lacrimal glands, cunjuctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, facial skin
The ______________ forms the more posterior aspect of the heart
Left Atrium
Bell Palsy Facies
Left Facial Palsy (CN7) Facies include asymmetry of one side of the face eyelid not closing completely drooping lower eyelid and corner of mouth and loss of nasolabial fold.
Why are childhood injuries more likely to result in fractures than sprains?
Ligaments are stronger than bone until adolescence
Resting Tremor
Limb at rest Pill rolling movements Parkinsons disease
Antalgic Limp
Limited weight bearing time on affected leg to limit pain.
Erosion
Loss or part of the epidermis; depressed, moist, glistening; follows rupture of a vesicle or bulla Ex: Varicella, variola after rupture
Grade 4 Murmur
Loud associated with thrill
Treacher-Collins Syndrome
Maxillary Hypoplasia Micrognathia Auricular deformity
Esophageal Diverticulum
May simulate lymph node enlargement.
Granular Cell Tumor
May simulate lymph node enlargement.
Pusle Oximeter
Measures percentage of hgb saturated with oxygen (oxyhemoglobin) Deoxygenated Hgb absorbs more red light and allows more infrared light to pass through. The ratio of the absorption is used to calculate the oxy/deoxyhemoglobin ratio
Varu-Valgus Stress Test
Medial or lateral collateral ligament instability in knee Have the patient lie supine and extend the knee. Stabilize the femur with one hand and hold the ankle with your other hand. Apply varus force against the ankle (toward the midline) and internal rotation. Excessive laxity is felt as joint opening. Laxity in this position indicates injury to the lateral collateral ligament. Then apply valgus force against the ankle (away from the midline) and external rotation. Laxity in this position indicates injury to the medial collateral ligament. Repeat the movements with the patient's knee flexed to 30 degrees. No excessive medial or lateral movement of the knee is expected.
Katz hand diagram
Median nerve integrity
Phalen Test
Median nerve integrity
Thumb Abduction Test
Median nerve integrity
What does the liver do?
Metabolism of carbohydrates, fats, and proteins Converts glucose to glycogen Converts amino acids to glucose (gluconeogenesis) Uses cholesterol to form bile salts Breaks down proteins through hydrolysis Stores vitamins and iron Detoxifys Produces antibodies conjugation and excretion of steroid hormones Produces prothrombin, fibrinogen Produces circulating plasma Synthesizes bile
Apical Impulse visible where?
Midclavicular 5th IC Should only be seen in one IC space, can also be seen in 4th IC
Thoracic Landmarks
Midsternal line: vertically down the midline of the sternum Right and left midclavicular lines: parallel to the midsternal line, beginning at midclavicle; the inferior borders of the lungs generally cross the sixth rib at the midclavicular line Right and left anterior axillary lines: parallel to the midsternal line, beginning at the anterior axillary folds Right and left midaxillary lines: parallel to the midsternal line, beginning at the midaxilla Right and left posterior axillary lines: parallel to the midsternal line, beginning at the posterior axillary folds Vertebral line: vertically down the spinal processes Right and left scapular lines: parallel to the vertebral line, through the inferior angle of the scapula when the patient is erect
Pregnancy Ventilation
Minute Ventilation increases from Increased TV. RR remains the same.
Heart position in pregnancy
More horizontal with axis rotation bc enlarged uterus pushes the diaphragm up and shifts heart.
Infants
More susceptible to hypothermia bc of large body surface area to weight ratio, thinner skin, and limited ability to cope with cold stress. Most pain impulses are transmitted along the nonmyelinated slower C fibers bc the myelination to the A-delta fibers continues to develop after birth. Think C for Child Infants are less able to modify pain impulses due to immaturity of dorsal horn synaptic connection and inhibition circuits in the descending spinal cord pathways. This results in greater sensitivity to repeated painful stimuli.
polydactyl and syndactyl
More than 5 digits or Two digits fused together
Fetal Alcohol Syndrome Facies
Most common cause of acquired intellectual disability Poorly formed philthrum Widespread Eyes Inner Epicanthal Folds Ptosis Hirsute Forhead Short Nose Thin Upper Lip
Basal Cell Carcinoma
Most common type of skin cancer, occurs most often on exposed parts of body. Persistent sore or lesion that has not healed
Hypertension Expected Findings
Narrowing of vessels Increased Vascular Tortuosity Copper Wiring (Diffuse Red Brown Reflex) Arteriovenous Nicking Retinal Hemmorage
Medications that may cause essential tremors:
Neuroleptics Valproate Phenytoin Albuterol Psuedophedrine Antiarrhytmics Corticosteroids Caffeine
Older adults
Neurons decrease, brain size decreases, reflexes slow
T4 is found at what level
Nipple line
How does the lymph system move fluid?
No built in pump, relies on the Cardiovascular System. Lymph movement is sluggish.
Older Adults
No diminished perception of pain, may have decreased pain threshold due to neuropathies.
Are bruits heard in lymph nodes?
No only blood vessels
Transillumination of a Lymph Node
Nodes will not transilluminate, only fluid filled cysts do.
Blood Pressure Ranges
Normal - Less than 120 sys and diastolic less than 80 Prehypertension - 120-139 sys or 80-89 Hypertension Stage 1 - 140-159 or 90-99 Stage 2 - 160 or higher or 100 or higher
Abdominal Reflex
Normal response is the ipsilateral contraction of the abdominal muscles with an observed deviation of the umbilicus towards the stroke.
Patterns of respiration
Normal: 12-20 Bradypnea <12 Tachy >20 Hyperventilation Sighing Air trapping Cheyne Stokes Biot Ataxic
Supraclavicular nodes in children
Not usually palpable and associated with high incidence of malignancy in kids.
CN Mnemonic
On Old Olympus Towering Tops A Finn And German Viewed Some Hops
Multiple Spinal Nerve Root Injury
One Root = Incomplete loss of sensation in any area of the skin Two or More Nerves = Zone of sensory loss is surrounded by partial loss. Tendon Reflexes may be lost.
Proprioception and Cerebellar Function Testing
One test is administered for each of the following: Rapid Rhythmic Alternating Movements Accuracy of movements Balance (Romberg) Gait and heel-toe walking
Pain Assessment
Onset Quality Intensity Location Associated symptoms: nausea, fatigue, behavior change, irritability, disturbed sleep, distress caused by pain What the patient thinks is causing the pain or what was the inciting event Effect of pain on daily activities Effect of pain on psyche Pain control measures Medications
Cataracts
Opacity in lens. Denaturing of lens protein from aging, generally central in aging. Steroid use can cause cataracts. Rubella or fetal insults during pregnancy. S/s: Cloudy or blurry vision, faded colors, headlights or lamps appear too bright. Halo around lights. Poor night vision, or double vision. Cloudiness obvious without special viewing equipment.
Temporomandibular Joint ROM
Open and close the mouth expect a space of 3-6 cm between the upper and lower teeth when jaw is open Laterally move the jaw to each side the mandible should move 1-2 cm in each direction Protrude and retract the chin
Infant CN Testing
Optic Blink - CN 2, 3, 4, 6 Rooting and Sucking Reflex - CN 5 Acoustic Blink Reflex / Dolls Eyes - CN 8 Swallowing and Gag Reflex - CN 9, 10 Coordinated sucking and Swallowing - CN 12 / Cerebellum
Peau d' orange sign
Orange Skin - edema due to blocked lymph drainage - Inflammatory Breast Cancer Often seen first in the areola
If newborn has a murmur what do you do?
Order Echo and refer to Pediatric Cardiologist. even if asymptomatic
Diet and Nutrition Practices
Orthodox Jewish - May not take prescribed medications during passover bc the prep of a drug does not meet the religious rules for food at that time Muslim - Must respect Halal (prescribed diet) even through out pregnancy Chinese with hypertension and salt restricted diet may need to consider limited use of MSG and soy sauce Herbal medications like Cassia Senna may cause liver damage
Epidermis
Outermost layer of skin Composed of: Stratum Corneum - composed of closely packed dead keratin filled squamous cells. Chief mechanical barrier protecting body. Takes 28 days for keratinocytes to pass through layers. Not found in mucosal skin. Stratum Lucidum - Only thick skin parts of body have this such as soles of feet and palms. Stratum Granulosum Stratum Germinativum Stratum basale contains melanocytes which synthesize melanin
Meckel Diverticulum
Outpouching of the ileum that varies in size from a small appendiceal process to a segment of bowel several inches long, often in the proximity of the ileocecal valve In children bright or dark red bleeding with little if any abdominal pain is a common presenting concern
Pulmonic Stenosis decreases
P2 intensity
Salivary Glands
Parotid Submandibular Sublingual
What minerals does the musculoskeletal system store?
Phosphorus, Calcium, Carobnate Also produced RBC's via Hemaopoiesis
Physical Abuse in Older Adults
Physical neglect most common type Bruising on extensor surfaces is common and usually accidental Bruising in various stages of healing on inner soft surfaces more indicative of abuse. Determine Mental Status.
What are two parts of the body not supplied by the lymphatic system?
Placenta Brain
Angina Pectoris is described as
Pressure or choking sensation substernal or into the neck. May radiate to jaw and down to the left, and sometimes right arm.
Hirschsprung Disease
Primary absence of parasympathetic ganglion cells in a segment of the colon, which interrupts intestinal motility Symptoms typically begin at birth with failure to pass meconium in the first 24-48 hours after birth Stool palpated in LLQ
Respiratory Rate
Primary muscles of respiration are the diaphragm and the intercostal muscles. Diaphragm is dominant muscle. Contracts and moves down during inspiration. External intercostal muscles increase the anteroposterior chest diameter during inspiration. Internal intercostal muscles decrease the lateral diameter during expiration.
Sympathetic Division
Prods the body into action during times of psychologic Stress
If patient has DM or Peripheral Neuropathy perform this test
Protective sensation using 5.07 monofilament.
Impaired Vision
Pt can have red tipped white cane, or guide animal. Do not pet guide animal. Ask pt if they would like to examine any of the equipment first. May keep tactile contact through examination to make pt feel more comfortbale
Thrill during systole at the Suprasternal notch / 2nd and 3rd LIC =
Pulmonic Stenosis
P2
Pulmonic Valve Closure occurs later during inspiration
Cyanosis that appears after the neonatal period suggests
Pulmonic stenosis Eisenmenger Complex (Heart defect that can lead to right to left shunt Tetralogy of Fallot Or Large Septal Defects
Grade 2 Murmur
Quiet but clearly audible
CN 3 Oculomotor
Raise eyelids and extra-ocular movements Pupillary constriction, change lens shape
What test to evaluate coordination and fine motor skills?
Rapid Rhythmic Alternating Movements Accuracy of upper and lower extremities.
Medulla Oblongata CN 9-12
Respiratory, circulatory, and vasomotor activies. Houses Respiratory Center. Reflexes of swallowing, coughing, vomitting, sneezing, and hiccuping (Mouth and Lungs)
Olecranon Bursitis
Results in swelling and tenderness of the bursa
Macular Degeneration
Retina Deteriorates Dry (Atrophic) - Gradual blurring of central vision Wet (Exudative or neovascular) - new blood vessels grow under center of retina. vessels leak, blead and scar retina destroying central vision. Can happen Rapidly. S/s Blurred decreased Central Vision Straight lines look bent (metamorphopsia) Objects appear different color or shape in each eye Objects appear smaller in one eye (Micropsia) Inspection: Dry form Drusen - multiple spots in macula Wet Form Exudates, blood, scarring, blood vessels below retina.
Retinopathy of Prematurity
Retinal vascular development disrupted in preterm infant. Abnormal proliferation of blood vessels. (Neovascularization) Birthweight < 1500g (highest risk for ROP) or < 30 weeks gestational age Straight, temproally diverted blood vessels on fundoscopic exam
Carcinoma signs
Retractiond and Dimpling can show as a contraction of fibrotic tissue in the breast
Repolarizaiton
Return of stimulated heart muscle to resting state
Subcutaneous nodules along pressure points of the ulnar surface may indicate
Rheumatoid nodules, or gout tophi
The lymphatic ducts that drain the right upper body empties into which vein?The rest of the body?
Right subclavian vein The thoracic duct (emptying rest of body) drains into the Left subclavian vein
Transillumination of infant skull
Ring should be under 2cm. Anything greater suggests excess fluid or decreased brain. tissue in the skull.
Melanoma
Risk Factors: Exposure to sunlight or UVA / UVB ultra violet radiation Severe blistering sunburns, even as a child Indoor Tanning device usage Geographic exposure - people who live in areas that get large amounts of UV radiation like high altitudes. History of melanoma Family history - first degree relative Moles Large congenital nevus > 15cm Immune suppression Skin type, relative inability to tan. (type I and II have highest risk)
Evaluate balance using the ____________________ test
Romberg
Near Vision Tests
Rosenbaum Newsprint Jaeger
Cushing Sydnrome Facies
Round or moon shaped face with thin erythematous skin. Upper thoracic fat pad or "buffalo hump"
What variables contribute to the pulse?
SV Distensibility of aorta and large arteries Obstruction of blood flow - ex PAD / Stenosis / Coarction / Vasculitis Peripheral artery resistance Viscosity of blood
Older adult hemodynamics
SV and CO decrease Tachycardia poorly tolerated bc response to stress and increased oxygen demand is less efficient Return to normal HR takes longer
Pregnancy Hemodynamics
SVR decreases Peripheral Vasodilation = Palmar eryhtema and spider telangiectasis Systolic BP decreases slightly Decrease in diastolic pressure
Infant sutures
Sagittal Coronal Lamboid
Spastic Diplegia
Scissor Gait)- short steps, drag ball of foot, knocked kneed, Thighs Cross
Older adults
Sebaceous and sweat gland activity decreases in older adults, skin become drier with less perspiration. Epidermis thins and becomes more fragile. Dermis shrinks due to aging and sun exposure which causes elasticity and collagen loss. = wrinkles Nails grow slowly due to decreased circulation Vellus to terminal hair occurs in the tragus of men's ears and in the nares.
Sebaceous Hyperplasia
Sebaceous hyperplasia occurs as yellowish, flattened papules with central depressions that are often difficult to discern from a basal cell carcinoma
Seborrheic Keratoses
Seborrheic keratoses are pigmented, raised, warty lesions, usually appearing on the trunk. These must be distinguished from other growths such as nevi or actinic keratoses, which may have malignant potential. Because the lesions may look similar, seek the assistance of an experienced practitioner for differential diagnosis
Pulmonic Valve Area
Second left IC space at Left sternal border
CN 1 (Oflactory)
Sense of smell
Older adults sense of smell
Sense of smell deterioration begins at about 60 yrs of age. Sense of taste deterioration begins at about 50 yrs.
Multiple Peripheral Nerve Injury (Polyneuropathy)
Sensory loss is most severe over the legs and feet or over hands. (Glove and Stocking Distribution). Change is gradual. All forms of sensory discrimination lost.
Infant Vascular Lesions
Several vascular lesions are common in infancy. Infantile hemangiomas are true neoplasms, which develop in the first 1 to 2 months of life, grow for 2 to 6 months, and regress over the next 5 to 10 years. A salmon patch ("stork bite") represents a common capillary vascular formation, found most frequently on the midforehead, eyelids, upper lip, and back of neck. A port wine stain is also a capillary malformation that may be associated with underlying arteriovenous malformations in Sturge-Weber syndrome.
Apert Syndrome
Severe maxillary and midfacial hypoplasia
Crouzon Syndrome
Severe maxillary and midfacial hypoplasia with low set ears. Apert syndrome does not have low set ears.
Infant Ashen White in Color indicates
Shock
S2 Intensity Decreases in
Shocklike state with arterial hypotension = loss of valvular vigor Valves are immobile, thickened, or calcified
Breast Venous Patterns
Should by symmetric Unilateral pattern may indicate increased blood flow to a malignancy
Skin Creases in newborns
Single transverse crease in palm is seen in down syndrome (trisomy 21) children
Macula
Site of Central Vision, 2 disc diameters temporal to the optic disc. Eye should be dilated prior to exam.
Medulla Oblongata
Site where the descending corticospinal tracts decussate (cross to the contralateral side)
Brain and spinal cord are protected by:
Skull and vertebrae, meninges, CSF
Cancer produces this type of sputum
Slight, persistent, intermittent blood streaking
Cerumen
Slightly acidic pH, inhibits gown of microorganisms. Coats canal lining and protects external auditory canal. Cerumen Secreted by the Apocrine glands in the distal third of the canal.
Depolarization
Spread of stimulus through heart muscle
P Wave is the
Spread of stimulus through the atria Atrial Depolarization
Transilluminator
Strong light source used to distinguish whether a body cavity contains fluid, air, or tissue
Patient History
Structure: - First the identifiers: name, date, time age, gender identity, race, source of information, and referral source - Chief Concern - History of Present Illness: - Past Medical History - Family History - Personal and Social history - Review of Systems
What are the Six groups of lymph nodes in the axillary fossa?
Subclavian Central Axillary Subscapular Mammary (Rotter Nodes) External Mammary (Anterior pectoral)
Primary Hepatocellular Carcinoma
Subjective • Symptoms may include jaundice, anorexia, fatigue, abdominal fullness, clay-colored stools, and tea-colored urine Objective • On examination, hepatomegaly with a hard, irregular liver border may be palpated • Liver nodules may be present and palpable, and the liver may be tender or nontender • Examination findings related to cirrhosis may be seen
CHF Left Sided
Subjective Data • Fatigue • Breathing difficulty, shortness of breath • Orthopnea • Exercise intolerance Objective Data • Sudden with acute pulmonary edema or gradual symptom onset • Crackles on pulmonary examination • Systolic CHF has a narrow pulse pressure. • Diastolic CHF has a wide pulse pressure. Cardiomegaly is most helpful exam finding for L CHF. Displaced PMI or abnormal apical impulse.
Lateral Spinothalamic Tract
Superficial Pain and Temperature. (Ascending Tract/Lower Motor Neuron Disorders)
Sensory Fucntion Testing
Superficial Pain and Touch at a distal point in each extremity Vibration and position sense are assessed by testing the great toe. Testing for peripheral neuropathy. Systemic sensory loss = polyneuropathy.
Test Primary sensory responses to:
Superficial Touch Superficial Pain (Lateral and Anterior Spinothalamic Tract) Ascending tracts for lower motor neuron disorders
Lower Abdominal Reflex - Spinal Nerve Level Evaluated
T10, T11, T12 Superficial Reflex
Which joints in the anke permit it to pivot or rotate?
Talocalcaneal Joint (Subtalar) Transverse Tarsal Joint
Fungiform papillae
Taste receptors, scattered throughout the filiform papillae of the tongue. Specific area are sensitive to the five basic taste sensations of sweet, salty, sour, bitter, and umami (savory)
Thrill during systole at the left lower sternal border =
Tetralogy of Fallot
Which nodes are most accessible to palpation?
The "Necklace" of Nodes *Parotid and retropharyngeal (tonsillar) *Submandibular *Submental *Sublingual (facial) *Superficial anterior cervical *Superficial posterior cervical *Preauricular and postauricular *Sternocleidomastoid *Occipital *Supraclavicular Arms *Axillary *Epitrochlear (cubital): elbow Legs *Superficial superior inquinal *Superficial inferior inguinal *Occasionally, popliteal
What covers and anchors the small intestine
The Mesentery - a fan shaped fold of the peritoneum
Pneumonic for valve order
The Poor Man Ate or Try Pulling My Arm Tricuspid -> Pulmonic -> Mitral -> Aortic
W or Reverse Tailor Position
The W or reverse tailor position places stress on the joints of the hips, knees, and ankles. It is commonly seen in children with in toeing associated with femoral anteversion
What are the systems of the Spleen?
The White Pulp - made up of lymphatic nodules and diffues lymphatic tissue The Red Pulp - Made up of venous sinusoids
What forms the arch of the shoulder
The acromion and coracoid process and the ligaments between them
Carrying angle of the elbow
The angle formed by the long axis of the humerus and ulna, resulting in an abducted position of the forearm relative to the humerus. 5-15 degrees
Cervical Nodes
The childhood diseases of rubella, rubeola, and varicella often present with obvious cervical nodes, usually posterior rather than anterior. Hepatitis A or B and infectious mononucleosis have the same pattern of cervical node involvement.
What helps stabilize and protect the head of the femur?
The depth of the acetabulum in the pelvic bone and the joint which is supported by three strong ligaments Bursae reduce friction in the hip
Adolescents
The examination of the adolescent's skin is the same as that for the adult. The adolescent's skin may have increased oiliness and perspiration, and hair oiliness may also be increased. Increased sebum production predisposes the adolescent to develop acne. As a reflection of maturing apocrine gland function, increased axillary perspiration occurs, and the characteristic adult body odor develops during adolescence. Hair on the extremities darkens and becomes coarser. Pubic and axillary hair in both males and females develops and assumes adult characteristics. Males develop facial and chest hair that varies in quantity and coarseness.
Older Adults Hair Changes
The hair turns gray or white as melanocytes cease functioning. Head, body, pubic, and axillary hair thins and becomes sparse and drier. Men may show an increase in coarse aural, nasal, and eyebrow hair; women tend to develop coarse facial hair. Symmetric balding, usually frontal or occipital, often occurs in men.
Pregnant patients - Initial interview
The initial interview includes past history, assessment of health practices, identification of potential risk facts, and assessment of the patient's knowledge expectations, and perceptions as they affect pregnancy. Basic Info Patients age, ethnicity Marital Status, partner, or relationship LMP Previous usual/ normal menstrual period (PUMP or PNMP) Expected date of confinement / Deliver (EDC) Occupation Parents of the baby and his/her occupation if applicable
Carpal Tunnel Evidence Based Practice
The likelihood that a patient will have a positive electrodiagnostic study for carpal tunnel syndrome is increased by the following: weakened thumb abduction; a classic or probable distribution of symptoms on the Katz hand diagram; and hypalgesia (decreased pain sensation along the thumb and median nerve distribution compared with the little finger on the same hand). The Tinel and Phelan tests are less accurate.
What is the heaviest organ in the adult body?
The liver - weighs about 3 lbs
Anatomic Structures of the Nail
The nails are appendages of the skin, which are composed of epidermal cells converted to hard plates of keratin. They protect the fingertips and are important in dexterity. The nail plate sits on the highly vascular nail bed which lies on periosteum. The white crescent-shaped area extending beyond the proximal nail fold marks the end of the nail matrix, the site of nail growth. The layer of skin covering the nail root is the cuticle, or eponychium, which pushes up and over the lower part of the nail body. The paronychium is the soft tissue surrounding the nail border.
Major Fissure of the lungs
The oblique
Physical Exam: Older Adults
The skin of the older adult may appear more transparent and paler in light-skinned individuals. Pigment deposits, increased freckling, and hypopigmented patches may develop, causing the skin to take on a less uniform appearance. Flaking or scaling, associated with the drier skin that comes with aging, occurs most commonly over the extremities. The skin also thins (especially over bony prominences, the dorsal surface of hands and feet, forearms, and lower legs) and takes on a parchment-like appearance and texture
Umbillical Cord Thickenss
Thick = Well Nourished fetus, thin indicates otherwise
Myocardium
Thick muscular middle layer, responsible for pumping action of the heart.
Skin thickness
Thinest on eye lids thickest on soles, palms, elbows
Atrophy
Thinning of skin surface and loss of skin markings, skin translucent and paper-like Ex: Striae; aged skin
Rib Cage Anatomical View
Thoracic vertebrae starts at 7th cervical vertebra which is readily palpated. Can count down thoracic vertebrae after.
Meninges
Three layers surround the brain and spinal cord. They assist in production and drainage of CSF
Acute Diarrhea
Three or more lose stools per day
Which finger to palpate brachial and femoral pulse?
Thumb
What is the largest endocrine gland in the body?
Thyroid Produces T3 and T4
Trachea deviates away from affected side in:
Thyroid enlargement pleural effusion Tension pneumo
Lyme Disease
Tick borne disease that can lead to a multisystemic infection Patho • Spirochetal infection caused by Borrelia burgdorferi • Most common tick-borne disease in the United States • The spirochete deposited by the tick into the skin rather than directly into the bloodstream. • Three phases of the disease are recognized: early localized, early disseminated, and late disease. • The objective clinical manifestations are thought to be due to an inflammatory response to live spirochetes or to their antigens. Subjective Data • Exposure to ticks • Constitutional symptoms of fatigue, anorexia, and headache may develop. • Expanding rash Objective Data • Early localized infection typically manifested by a single erythema migrans skin lesion, a flat to slightly raised, erythematous skin lesion (usually ≥5 cm in diameter) that is round or oval in shape, with central clearing(classic target or bull's-eye appearance). • Early disseminated infection is usually manifested by multiple erythema migrans skin lesions, by neurologic symptoms such as facial palsy, meningitis, or encephalitis, or by symptoms of carditis such as lightheadedness, palpitations, dyspnea, chest pain, or syncope. • Late disease usually manifested by arthritis atrophicans or atrophic dermatitis.
Common cause of alopecia (hair loss) in children
Tinea Capitis (Fungal infection of the scalp)
Severe Cyanosis evident at birth or shortly after suggest:
Transposition of the Great Vessels Tetralogy of Fallot Tricuspid Atresia Severe septal defect Severe pulmonic stenosis
Beau Lines
Transverse depression in nail bed Coronary Occlusion, Hypercalcemia, and Skin disease Grooves disappear when nail grows out
These valves have three cusps
Tricuspid, Pulmonic & Aortic (Semilunar valves)
Latex Allergy Type 1 Reaction
True allergic reaction caused by protein antibodies (IgE antibodies) that form as a result of interaction between a foreign protein and the body's immune system Subjective Data • Exposure to latex • Allergy to cross-sensitizing foods (e.g., banana, avocado, potato, tomato, kiwi) Objective Data • Local: urticaria (skin wheals), • Systemic: generalized urticaria with angioedema (tissue swelling), asthma, eye/nose itching and gastrointestinal symptoms, anaphylaxis (cardiovascular collapse)
CN 11 Spinal Accesory
Turn head, shrug shoulders, some actions of phonation
Webbing, excessive posterior cervical skin, or an unusally short neck is associated with
Turner syndrome - chromosomal anomaly.
What are the seven bones of the skull?
Two Frontal Two Parietal Two Temporal One Occipital
Brain receives blood supply from these:
Two Internal Carotid Arteries (Supply 80%) and two vertebral basilar arteries (Supply 20%). Accounts for 20% of cardiac output.
Cortical Sensory Function Testing
Two Point Discrimination Extinction Phenomenon Graphesthesia Point Location
Point of maximal impulse (PMI)
Typically noted at the left 5th IC Mid Clavicular in adults 4th IC medial to nipple in children. Diameter is < 1cm
T10 is found at what level
Umbillicus
Healthcare Inequalities
Unconscious Bias, Stereotyping, racism, Gender Bias, Limited English Proficiency all underly healthcare inequalities
Ataxia
Uncontrolled falling. Loss of body control.
Upper and Lower Motor Neuron Disease - Face
Upper Motor Neuron = Voluntary movements paralyzed, but emotional spared. (Laughing or crying) Lower Motor Neuron = All facial movements of affected side are paralyzed (Bells Palsy)
Pulmonic Regurgitation Murmur
Valve incompetence allows backflow from the pulmonary artery to the ventricle. Secondary to pulmonary HTN or bacterial endocarditis.
Tricuspid Regurgitation Murmur
Valve incompetence allows backflow from ventricle to atrium Caused by congenital defects, bacterial endocarditis (especially in intravenous drug abusers), pulmonary hypertension, cardiac trauma Holosystolic murmur heard at left lower sternum.
Artery / Vein Structure
Veins have valves to prevent backflow
Thrill during systole and 4th LIC =
Ventricular Septal Defect
Inner Ear
Vestibule Semicircular canals Cochlea
Posterior Column Tract
Vibration Deep Pressure Position Sense Stereognosis Point Location Two-Point Discrimination (Ascending Tract/Lower Motor Neuron Disorders)
Heave or a lift
Vigorous apical impulse LV Hypertrophy, Increase CO
Influenza
Viral infection of lung Cough Fever Malaise Headache Coryza - inflammation of mucous membrane in nose Mild Sore Throat Crackles Wheezes Rhonchi Tachypnea
Flucuant Node
Wavelike motion that is felt when the node is palpated Feels like it contains fluid Suggest suppuration from infection.
Trendelenburg sign
Weak hip abductor muscles The Trendelenburg test is a maneuver to detect weak hip abductor muscles. Ask the patient to stand and balance first on one foot and then the other. Observing from behind, note any asymmetry or change in the level of the iliac crests. When the iliac crest drops on the side of the lifted leg, this indicates the hip abductor muscles on the weight-bearing side are weak
Hyperthyroid
Weight Loss, Tachycardia, Bruit over thyroid. Confirm with labs - T4 and TSH
Lung Abscess
Well-defined, circumscribed mass defined by inflammation, suppuration, and subsequent central necrosis Malaise, fever, SOB Percussion dull Pleural friction rub Foul-smelling sputum
Children Developmental Milestones
What Age Attained: Smiling Head control in prone position grasping Transferring objectes between hands Rolling over Sitting Crawling Independent Walking Toilet trained Saying words like mama and dada
Drusen Bodies / Amsler Grid
When Drusen bodies are increasing in number use amsler grid to evaluate patients central vision. Distortion = macular degeneration
Reflex Apnea
When irritating and nausea-provoking vapors or gases are inhaled, there can be an involuntary, temporary halt to respiration.
Fixed Splitting
When unaffected by respiration. Large atrial septal defect or VSD with left to right shunting, or RV Failure
Cradle Transfer
While bending or squatting bedside the patient, put on arm under both of the patient's knees and the other arm around the back and under the armpits. Stand and carry the patient to the table.
Osteoporosis Risk Factors
White, Asian, Ntative American, NW European descendant Light Body frame, thin Increasing age Hx osteoprosis / previous fractures Nulliparous - woman who has never given birth Amenorrhea or menopause bfore 45 yrs age, postmenopausal Sedentary lifestyle, lack of excercise Constant dieting, inadequate calcium and vitmain D intake, excessive Carbonated soft drinks Scoliosis, RA, Cancer, MS, DM, Hypercortisolism, malabsorption, hypogonadism, hyperthyroidism Drugs that decrease bone density: Thyroxine, Corticosteroids, heparin, Lithium, anticonvulsants, antacids with aluminum. Cigarette smoking or heavy alcohol use
White Banding (Terry Nails)
Whitening of the proximal half to three-quarters of the nail bed. Cirrhosis, CHF, Adult onset DM, and age Transverse white bands cover the nail except for a narrow zone at the distal tip
Asymmetric Tonic Neck or "Fencing" Reflex (2-3 months old)
With the infant lying supine and relaxed or sleeping, turn his or her head to one side so the jaw is over the shoulder; observe for extension of the arm and leg on the side to which the head is turned and for flexion of the opposite arm and leg; turn the infant's head to the other side, observing the reversal of the extremities' posture; this reflex diminishes at 3-4 months of age and disappears by 6 months; be concerned if the infant never exhibits the reflex or seems locked in the fencing position; this reflex must disappear before the infant can roll over or bring the hands to the face.
Child pain scales
Wong Baker Faces Oucher Scale FLACC - for nonverbal children Do not compare child's expression to that on the pain scale. Go by what child points to.
T6 is found at what level
Xiphoid Process
Bacterial infection has this type of sputum:
Yellow, green, rust (blood mixed with yellow sputum), clear, or transparent purulent; blood streaked, sticky
Lymphangioma
a benign tumor formed by an abnormal collection of lymphatic vessels due to a congenital malformation of the lymphatic system
Epicondylitis or tenonities when
a boggy, soft or fluctuant swelling point tenderness at the lateral epicondyle or along the grooves of the olecranon process and epicondyles and increased pain with pronation and supination of the elbow are found
Children
a child may have an increased HR of 10-14 bpm for each celcius degree of temperature elevation. Mean decreases as child ages. Mean Heart Rates < 1 yr = 128-130 2-3 yrs = 116-119 4-5 yrs = 106-108 6-11 yrs = 77-88 12-19 yrs = 72-80 Respiratory Rate New born = 24-50 1 yr = 20-40 3 yr = 20-30 6 yr = 16-22 10 yr = 16-20 17 yr = 12-20
Osteoporosis
a decrease in bone mass that occurs when bone resorption is more rapid than bone deposition Loss of height or acute painful fracture decreased abdominothoracic space Most common fracture is hip, vertebrae, wrist. Most common in postmenopausal women Glucocorticoid excess and hypogonadism are also risk
What is the only clue in children that a critical cardiac malformation is present
a decrease in the percutaneous oxygen saturation Every infant should have pulse ox performed before discharge from newborn nursery
Gentle handshake during exam because..
a firm handshake may cause them significant discomfort if they have an injury or underlying arthritis
Clubfoot (Talipes Equinovarus)
a fixed congenital defect of the ankle and foot Intrauterine Compression / Genetic factors Obvious at birth Toes lower than heel
Ballottement
a palpation technique used in detecting or examining a floating object in the body
nonalcoholic fatty liver disease (NAFLD)
a range of conditions characterized by an accumulation of fat within the liver that affect people who drink little or no alcohol. those with this condition most commonly are middle-aged individuals who are obese and may also have diabetes and elevated cholesterol elevated AST and ALT x 2-3
Gibbus
a sharp, angular deformity associated with a collapsed vertebra due to osteoporosis
Venous and Carotid Pulsations
a wave - The upward a wave, the first and most prominent component, is the result of a brief backflow of blood to the vena cava during right atrial contraction. This peaks slightly before the first heart sound (S1). c wave - The upward c wave is a transmitted impulse from the vigorous backward push produced by closure of the tricuspid valve during right ventricular systole. v wave The upward v wave is caused by the increasing volume and concomitant increasing pressure in the right atrium. It occurs after the c wave, late in ventricular systole. x slope - The downward x slope is caused by passive atrial filling. This ends with the initiation of the v wave. y slope - The y slope following the v wave reflects the open tricuspid valve and the rapid filling of the right ventricle.
Seated with Arms over Head or flexed behind the neck position
adds tension to suspensory ligaments, accentuates dimpling, and may reveal variations in contour and symmetry
Cerebellum
aids motor cortex of cerebrum in voluntary movement. Processes sensory info from eyes, ears, touch receptors, musculoskeletal system. Reflexive control of muscle tone, balance, and posture to produce steady and precise movements.
Flaring of the alae nasi during inspiration is a sign of
air hunger
Crepitus
air in subcutaneous tissue from rupture in respiratory system or by infection with a gas producing organism.. Can be palpated and heard. This always results from a pathologic process.
Water Hammer Pulse / Corrigan Pulse
aka Collapsing pulse Caused by Patent Ductus Arteriosus or Aortic Regurg
Uremia (ammonia) smells like
ammonia
Senile Cardiac Amyloidosis
amyloid, fibrillary protein produced by chronic inflammation or neoplastic disease, deposition in the heart Causes HF Contractility may be reduced Subjective Data • Palpitations, lower extremity edema, fatigue, reduced activity tolerance Objective Data • Pleural effusion • Arrhythmia • Lower extremity edema • Dilated neck veins • Hepatomegaly or ascites • Electrocardiography or echocardiography shows small, thickened left ventricle; right ventricle may also be thickened.
SBIRT (screening, brief intervention, and referral to treatment)
an approach to identify and care for patients affected by alcohol and drug use
Tanner Staging
an evaluation for premature or delayed puberty in children.
Lung Apex Posteriorly
apice rises to the level of T1
Size of left and right ventricles at 1yr old
approximate adult ratio of 2:1
Infant Right and Left Ventricles
are equal in weight and muscle mass, bc the both pump blood into systemic circulation unlike in the adult heart
Melasma
areas of hyperpigmentation on the face and neck that are associated with pregnancy or hormonal variation. Found primarily in adult women, but can happen in men.
What separates the ulna and carpal bones
articular disc
The glenohumeral joint (shoulder) consists of
articulation between the humerus and the glenoid fossa of the scapula.
Radiocarpal joint consists of
articulation of the radius and the carpal bones
What does the tibiotalar joint (ankle) consist of
articulation of the tibia, fibula, and talus
Retractions of the lower chest occur with:
asthma and bronchiolitis
Retinitis Pigmentosa
autosomal recessive disorder in which the genetic defects cause cell death predominantly in the rod photoreceptors Patho: Deafness (Usher Syndrome), Paralysis of extraocular muscles Cardiac conduction defects, ataxia, dysphagia, intellectual delay. absence of VLDL Vey low density lipoprotein S/s: Earliest Symptom: Night Blindness Tunnel Vision, bumping into furniture Loss of vision is painless takes years to decades. Inspection: Optic Atrophy with waxy pallor, narrowing of arterioles, Peripheral Bone Spicule Pigmentation is the hallmark of advanced disease.
The metacarpohalangeal joints are palpated with
both thumbs
Cerebral Aneurysm
bruit over eye may be heard
How much do the kidneys enlarge during pregnancy?
by 1 cm in length
Senile Hyaline Plaque
by medial rectus muscle. Does not imply disease
Crepitus at delivery
can be common around fractured clavicle from difficult forcep delivery
Young Adult Chest Pain
can be from cocaine.. Cocaine causes tachycardia, HTN, Coronary arterial spasm with infarction, and pneumothorax.
Rheumatoid arthritis in pregnant patients
can be suppressed due to immune changes
Posterior Dorsal Tract
carries fibers for sensation of fine touch, two point discrimination, and proprioception
Infant Cardiac Examination
challenging bc of immediate change form fetal to systemic and pulmonary circulation Examine heart within first 24hrs then at 2-3 days of age.
Cyanosis in infants is a
characteristic of congenital heart defect arterial and venous blood mix
what causes the gallbladder to release bile?
cholecystokinin, produced in the duodenum Bile released into cystic duct
Duodenal Ulcer
chronic circumscribed break in the duodenal mucosa that scars with healing localized epigastric pain that occurs when the stomach is empty and relieved by food and antacids
S1 (Lub) is caused by
closure of AV valves (tricuspid and mitral)
S2 (Dub) is caused by
closure of the SL valves (pulmonary and aortic) Listen at the Base on Expiration
Lordosis
common in patients who are obese or pregnant
Cranial Bruits in children
common up to 5 yrs of age. if present after can indicate vascular anomalies or ICP
S3 and S4 in infant
commonly heard. Murmurs usually disappear at 48 hours of age.
Salivary Gland Tumor
commonly involves the parotid. Slow growing painless lumps Difficulty opening the mouth Tumors that are benign are usually smooth. Malignant are often irregular.
Curve of lumbar spine should be
concave
Audible expiratory grunt
consider lower airway obstruction or focal atelectasis
What is a common GI symptom in pregnancy?
constipation due to prolonged transit time GERD from relaxation of lower esophageal sphincter
White Matter of Spinal Cord
contains ascending and descending spinal tracts
Middle Ear
contains ossicles (Malleus, incus, and stapes), these transmit sound
Peristalsis
controlled by autonomic nervous system
Curve of the thoracic spine should be
convex
Lymph nodes in old age
decrease diminish in size and get fibrotic and fatty
Hodgkin Lymphoma
disease marked by chronic enlargement of lymph nodes spreading to other nodes in an orderly way Subjective Data • Painless enlarged lymph nodes • May have abdominal pain, sometimes fever • May have history of infectious mononucleosis Objective Data • Clinical presentation variable • Most commonly, painless enlargement of the cervical lymph nodes, often in the posterior triangle, that is generally asymmetric and progressive Hodgkin disease. Note the impressive extent of the enlargement. • Nodes sometimes matted and firm, almost rubbery • Usually asymmetric; may occasionally be enlarged in similar patterns on both sides of the body • Nodal size may fluctuate
Radial head subluxation (nursemaid's elbow)
dislocation injury caused by jerking the arm upward while the elbow is extended. Jerking pulls apart the elbow joint and tears the margin of annular ligament around the radial head into the joint common in children 1-4 yrs old
Aortic regurgitation murmur
early diastolic murmur-high pitched "blowing" Best heard with Pt sitting and leaning forward using diaphragm 2nd IC Austin-flint murmur is heard with bell Valve incompetence allows backflow from aorta to ventricle Caused by rheumatic heart disease, endocarditis, aortic diseases (Marfan syndrome, medial necrosis), syphilis, ankylosing spondylitis, dissection, cardiac trauma
Ballottement test detects
effusion in the knee With the knee extended, apply downward pressure on the suprapatellar pouch with the web or the thumb and forefinger of one hand, and then push the patella quickly downward against the femur with a finger of your other hand. If an effusion is present, a tapping or clicking will be sensed when the patella is pushed against the femur. Release the pressure against the patella, but keep your finger lightly touching it. If an effusion is present, the patella will float out as if a fluid wave were pushing it
Pustule
elevated, superficial lesion; similar to a vesicle but filled with purulent fluid. Ex: Impetigo, acne
Lymphadenopathy (adenopathy)
enlarged lymph nodes
Sobbing baby allows
evaluation of vocal resonance
Decreased or absent fremitus caused by:
excess air in the lung emphysema pleural thickening or effusion bronchial obstruction
Genu Recurvatum
excessive knee hyperextension - could indicate weakness of quadriceps
Angle between femur and tibia
expected to be < 15 degrees
Lung apex anteriorly
extends 4 cm above the first rib into the base of the neck
Positional plagiocephaly
external deformation. Common among infants with torticolls or those who prefer one head position for sleep
FLACC Scale
face, legs, activity, cry, consolability
Confrontation Test
for peripheral vision
Intestinal obstruction smells
foul or feculent
An inflamed metatarsophalangeal joint of the great toe should make you suspect
gouty arthritis
Alopecia
hair loss
Bronchovesicular sounds
heard over major bronchi. Moderate pitch and intensity
Systolic ejection murmur location in pregnant pt
heard over the pulmonic area in 90% of patients
Situs inversus
heart and stomach are placed to the right and the liver to the left
An incomplete or soft in the center umbilical ring can indicate
herniation
Fine Crackles
high-pitched, discrete, discontinuous crackling sounds heard during the end of inspiration; not cleared by a cough
Coarse, dry, brittle air may indicate
hypothyroidism
When do you perform nipple compression
if patient reports spontaneous nipple discharge Unilateral discharge from a single duct is a concern.
Best position to hear low pitched filling sounds in diastole
in Left lateral recumbent, use bell of stethoscope
Pregnancy Cardiac Output
increased 30-40%, reaches highest level between 25-32 weeks gestation which is maintained until term. CO return to normal 2 weeks after delivery
Pregnancy
increased hormone levels contribute to elasticity of ligaments and softening of the cartilage in the pelvis at about 12-20 weeks Results in increased mobility of the sacroiliac, sacrococcygeal and symphysis pubis joints.
Costal angle in pregnancy
increases from 68.5 to 103.5 degrees. Diaphragm at rises 4cm higher than usual.
Alveoli Development - Infants
increases rapidly during first 2 years. Then slows down by 8 yrs.
Pregnancy plasma volume
increases the blood volume by 40-50% in pregnant pt Reaches max by 30th week Can increase up to 70% in twin pregnancy. Increases HR and SV.. which leads to increased LV wall thickness and mass
Endocardium
innermost layer, lines the chambers of the heart and covers the heart valves and the small muscles associated with opening and closing of these valves.
Eye Muscles
innervated by: CNs III (oculomotor) CN IV (trochlear) CN VI (abducens) The superior oblique is the only muscle innervated by the trochlear nerve CN IV and the lateral rectus muscle is the only muscle innervated by the abducens nerve CN VI.
Abdomen Exam Sequence
inspection, auscultation, percussion, palpation Pay attention to pt comfort level or degree of distress
Caput Succedaneum
is subcutaneous edema over the presenting part of the head at delivery of infant. Most common form of both trauma usually occurs over the occiput
Cerebral Cortex
is the gray outer layer, and houses higher mental functions responsible for general movement, visceral functions, perception, behavior, and their integration,
Hallux Valgus
lateral or outward deviation of the great toe Bursa often forms at the pressure point and if inflamed can become a painful bunion
In a shorter person the heart tends to
lie more to the left and more horizontally
Joints are held together by
ligaments
Heart Anatomy
located from third to sixth costal cartilages behind the sternum Broader upper portion called the Base Narrow lower tip is called the Apex
Left Ventricular size is better judged by the
location of the apical impulse
Excoriation
loss of the epidermis; linear hollowed-out, crusted area Ex: Abrasion or scratch, scabies
Coarse Crackles
loud, bubbly noise heard during inspiration; not cleared by a cough
Rhonchi (sonorous wheeze)
loud, low, coarse sounds like a snore most often heard continuously during inspiration or expiration; coughing may clear sound (usually means mucus accumulation in trachea or large bronchi)
A hard fixed painless node suggests
malignant process
Lymphatic Filariasis (Elephantiasis)
massive accumulation of lymphedema throughout the body; most common cause of secondary lymphedema worldwide Results from widespread inflammation and obstruction of the lymphatics by the filarial worms Wuchereria bancrofti or Brugia malayi; transmitted by mosquitoes Travel to infected areas: Asia, Africa, the Western Pacific, India, Philippines
Diphenylhydantoin
medication that can cause node enlargement.
Thyroglossal Duct Cyst
midline in neck may retract when tongue is protruded May simulate lymph node enlargement.
Linea Alba
midline tendinous seam joining the abdominal muscles
What environmental factor can prolong cap refill?
moderately cool room temp
Grade 3 Murmur
moderatley loud
Splitting in pregnancy
more audible to due increased blood volume and extra effort. Expected finding. 4th heart sound abnormal in pregnant pt.
Patent Ductus Arteriosus (PDA)
more common in premature infants before 30 weeks
Anterior fontanel measurements in infants
no more than 4-5cm in infants under 6 months Closes completely by 12-15 months
Do nodes pulsate?
no, arteries do
Slight deviation of trachea to right is
normal
Babies are this type of breather
obligate nose. Periodic breathing is common with pauses as long as 10-15 seconds
Stridor in newborn
obstruction in upper airway. When accompanied by a cough, hoarseness and retraction this is a serious problem. Floppy epiglottis, congenital defect, croup, edema from infection
Slipped Capital Femoral Epiphysis
occurs when the head of the femur becomes displaced due to a separation at the growth plate ' 8-16 yrs old, girls affected younger Usually unilateral, left side more than right Knee pain and limp Confirm with Xray Reduced internal hip rotation
Tuberculosis Lymph Nodes
often felt in the cervical chains, are usually body temp, soft, matted, and not tender or painful
Pulmonary ejection click is best heard when and where?
on expiration at the 2nd Left IC. Seldom heard on inspiration
Wharton Duct
open on each side of the frenulum under the tongue. Drain saliva from the submandibular and sublingual glands to the sublingual caruncle at the base of the tongue.
Pes Valgus
out-toeing
Appendages
outgrowths of the skin that include: Eccrine sweat glands - open directly onto the surface and help regulate body temperature through sweat excretion. Distributed through out body except at lip margins, eardrums, nail beds, inner surface of the prepuce, and glans penis. Apocrine sweat glands - specialized structures found only in the axillae, nipples, areolae, anogenital area, eyelids, and external ears. They secrete an oily fluid containing protein, carbs, and other substances. Secretions from these glands are odorless; body odor is produced by bacterial decomposition of apocrine sweat. Sebaceous glands - Secrete sebum, a lipid rich substance that acts as a lubricant and moisturizer for skin and hair. Secretion stimulated by sex hormones (testosterone) and varies according to hormonal levels throughout life. Hair - consists of root and shaft which sit in follicle. Melanocytes in the follicle synthesize pigment. Two types of hair: Vellus hair - short and fine, soft, and nonpigmented Terminal hair - Coarser, longer, thicker, and usually pigmented Each hair goes through cyclic changes: anagen (growth) catagen (atrophy) telogen (rest) exogen (shed) Nails - appendages of the skin which are composed of epidermal cells converted to hard plates of keratin. Nail bed lies on the periosteum. White crescent shape is end of nail matrix which is the site of nail growth. Cuticle (eponychium) Paronychium ( soft tissue surrounding nail border)
Graves Disease
overactive thyroid more common in women Palpitations Heat intolerance Weight loss Fatigue Increased appetite, tachycardia Diffuse thyroid enlargement exophthalmos
Loss of thrust may be related to
overlying fluid or air or to displacement beneat the sternm
Muted S2
overlying tissue, fat or fluid.
Surgically augmented breast
palpate as usual Capsular contraction may cause the breast to feel hard Palpate with finger pads bc they are more sensitive than your finger tips.
Bell Palsy
paresis, or paralysis, of one side of the face - Herpes Simplex or Herpes Zoster viral Subjective Data • Rapidly progressive muscle weakness on one side of face (over 2-3 days) • Feeling of facial numbness Objective Data • Facial creases and nasolabial fold disappear on affected side • Eyelid will not close on affected side and lower lid sags; leads to eye irritation; eye may tear excessively • Food and saliva may pool in affected side of mouth • Facial sensation is intact.
Ascites
pathologic increase in fluid in peritoneal cavity
Corticospinal (Pyramidal) Tract
permits skilled, delicate, and purposeful movements
To evaluate thoracic expansion:
place thumbs along spinal process at 10th rib with palms touching posterolateral surface Note any asymmetry. Might not be seen in barrel chest or COPD. Chest already expanded
Locate temporomandibular joint by
placing fingertips just anterior to the tragus of each ear
Infant Purplish Plethora is associated with
polycythemia (increased red cell mass)
Craniosynostosis
premature fusion of one of the sutures.
Sputum in more than small amounts usually indicates
presence of disease
Supernumerary nipples
presence of more than one nipple on a breast Located along the mammary ridge / milk line Can be associated with a congenital renal or cardiac anomaly particularly in whites.
Child Ethmoid and Sphenoid Sinus
present at birth but very small. Sphenoid present by age 5 Frontal by age 7-8
Brachycephaly
preterm infants often have long narrow heads bc their soft cranial bones become flattened with positioning and the weight of the head.
postpolio syndrome (PPS)
progressive muscle weakness in a person previously affected by polio after 10 or more years
intussusception
prolapse or telescoping of one segment of intestine into another, causing intestinal obstruction child inconsolable with legs and knees flexed (doubled up) with pain Sausage shaped mass palpated in RUQ or LUQ whereas RLQ feels empty (Dance Sign)
Pigeon Chest (Pectus Carinatum)
prominent sternal protrusion
Best position to hear relatively high pitched murmurs
pt sitting up leaning slightly forward and preferably during expiration.
Two Circulatory Systems
pulmonary and systemic
Wilms tumor (nephroblastoma)
rapidly developing malignant neoplasm of the kidney that usually occurs in children. usually appears at 2-3 years of age. Painless enlargement
Newborn Coughing
rare, and considered a problem Sneezing is ok - clears the nose
Parietal Lobe
responsible for processing sensory data as it is received. Assists with interpretation of sensations - pain, pressure, temperature, size, shape, texture, two point discrimination, visual, taste, smell, hearing sensations.
ST Segment and T Wave is the
return of stimulated ventricular muscle to a resting state (Ventricular repolarization)
Which kidney is lower?
right kidney, due to large heavy liver above it
Squamous Cell Carcinoma
second most common type of skin cancer. more aggressive This malignant tumor arises in the epithelium and has squamous differentiation. • Lesions occur most commonly in sun-exposed areas, particularly the scalp, back of hands, lower lip, and ear; the rim of the ear and the lower lip are especially vulnerable. Subjective Data • Persistent sore or lesion that has not healed or that has grown in size • May have crusting and/or bleeding Objective Data • Elevated growth with volcano-type pattern • Wartlike growth; may have crusting, may bleed • Scaly red patch with irregular borders may have crusting, may bleed • Open sore; may have crusting
Aortic Valve Area
second right intercostal space at right sternal border
Apnea can be caused by
seizures, CNS trauma, or hypoperfusion, obstructive sleep disorder, drug ingestions.
Chronic cough indicates
significant anatomic change. ie. Tumor, cavitation, or bronchiectasis.
Valve opening is a
silent event
During passive range of motion the muscles should have
slight tension
Diverticular Disease
small bulges or saclike outpouchings through colonic muscle in the intestine • With diverticulitis (when diverticula become inflamed), may experience left lower quadrant pain, anorexia, nausea, vomiting, and altered bowel habits (usually constipation)
U Wave is a
small deflection rarely seen just after the T wave, thought to be related to repolarization of the Purkinje Fibers. They are commonly seen with Bradycardia. Can also be seen with electrolyte abnormalities, hypothermia, and hypothyroidism
Irregular cough is caused by:
smoking, early CHF, foreign body or irritant, tumor compressing bronchial tree
Craniotabes (ping-pong ball skull)
softening of outer table of skull.. like pressing on a ping pong ball. snapping senation Prematurity RIckets Hydrocephalus Marasums Syphillis Thalassemia
Neuroblastoma
solid malignancy of embryonic origin in the peripheral sympathetic nervous system Presents as an asymptomatic abdominal mass ina young child Firm fixed non tender irregular and nodular abdominal mass that crosses the midline
Amphoric Breathing
sound of blowing across mouth of a bottle Heard with a large stiff walled pulmonary cavity tension pneumo bronchopleural fistual
In the tanner system when does the onset of menses usually occur
stage 3 - unusual for it to occur before this stage
Paroxysmal nocturnal dyspnea
sudden onset SOB after period of sleep. Sitting upright helps
Precordial Catch
sudden, sharp, relatively brief pain that does not radiate, occurs most often at rest, is unrelated to exertion, and may not have a discoverable cause
Lymphedema
swelling due to an abnormal accumulation of lymph fluid within the tissues Painless swelling of a limb
Tracheal Tug Sign
synchronous with pulse, suggest present of aortic aneurysm
Most joints are
synovial, enclosed by a fibrous capsule. Contains ligaments and cartilage cover the ends of opposing bones
Guillain-Barre Syndrome (GBS)
temporary paralysis caused by an autoimmune attack on peripheral myelin, causing weakness and usually ascending paralysis of the limbs, face and diaphragm • Distal weakness, usually bilateral and symmetric, and diminished reflexes in ascending pattern • Ataxia, progressing to flaccid paralysis • Facial nerve weakness (Bell palsy), diplopia • Dysphagia, difficulty handling secretions • Respiratory distress • Lumbar puncture reveals increased protein in cerebrospinal fluid.
A persistently thickend Achilles tendon may indicate
tendonitis that can develop with spondyloarthritis or from xanthelasma of hyperlipidemia
Muscles are attached by_____________ and cushioned by ___________________
tendons, cartilage
Percussion Hammer (reflex hammer)
test deep tendon reflexes
What ligament protects the knee from hyperextension?
the ACL Anterior Cruciate Ligament
Muscle Fasciculations occur because
the muscles motor neuron is damaged
Craniosynostosis
the premature fusing of the skull bones abnormal skull, usually not accompanied by intellectual disability watch for ICP
Chronic Pancreatitis
the recurring destruction of the pancreatic tissue that results in atrophy, fibrosis, scarring, and the development of calcification within the gland Constant unremitting abdominal pain, weight loss, and steatorrhea
At what level does the aorta branch into the iliac arteries?
the umbilicus
What are T Lymphocytes?
they are marrow derived, they mature in the Thymus Can discriminate between health and abnormal cells. They also control immune response brought about by B lymphocytes. T cells life span is about 100-200 days
Epicardium
thin outermost muscle layer, covers the surface of the heart and extends on the great vessels.
Children use this for respiration until 6-7 yrs
thoracic intercostal musculature
HIV Risk
transfusion with infected blood or blood concentrates like factor 8 and factor 9 between 1978 and 1985
Pons
transmits info between brainstem and cerebellum. Motor info from cerebral cortex is relayed to the contralateral cerebellar hemisphere
Horizontal jerking of the head indicates
tremor
Tape measure
use one that is 7-12 mm wide
Photoscreening
used to detect amblyopia (lazy eye) and strabismus in children.
Blood drains from the brain through:
venous plexuses and dural sinuses that empty into the internal jugular veins
When heart is beating 68-72 bpm the
ventricular systole is shorter than diastole
Bulla
vesicle greater than 1 cm in diameter Ex: blister, pemphigus vulgaris
Croup
viral infection, barking cough.
Lea or HOTV
visual acuity test beginning at 4 years old Children up to 5 stand 10ft away Children over 6 can stand at 10 or 20ft away
Brushfield Spots
white spots / salt and pepper speckling on the iris associated with Down Syndrome
When does a venous hum occur?
with increased collateral circulation between the portal and systemic venous systems
Tactile fremitus is increased
with lobar pneumonia
Chest pain doesn't generally originate in the heart when:
• There is a constant achiness that lasts all day. • It does not radiate. • It is made worse by pressing on the chest wall. • It is a fleeting, needle-like jab that lasts only a few seconds. • It is situated in the shoulders or between the shoulder blades in the back. Other causes: pulmonary embolism, pleurisy, aortic dissection, tumor
Risk factors for severe hyperbilirubinemia in infants of 35 or more weeks gestation
• Total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) greater than 75th percentile • Jaundice observed in the first 24 hours • Blood group incompatibility with positive direct antiglobulin test, other known hemolytic disease (e.g., G6PD [glucose-6-phosphate dehydrogenase] deficiency), elevated ETCO c (End-Tidal Carbon Monoxide concentration) • Gestational age 35 to 36 weeks • Previous sibling received phototherapy • Cephalohematoma or significant bruising (e.g., from vacuum-assisted delivery) • Exclusive breast-feeding, particularly if nursing is not going well and weight loss is excessive • East Asian race
Past medical history: Pregnant patients
• Weeks of gestation or postpartum • Hygiene practices • Presence of skin problems before pregnancy (e.g., acne may worsen) • Effects of pregnancy on preexisting conditions (e.g., autoimmune disorders may remit; condylomata acuminata commonly become larger and more numerous)