Exam 1 Material
Single Alcohol Screening Question (SASQ)
"How many times in the past year have you had five or more drinks in a day (men) or four or more drinks in a day (women)." The SASQ has a sensitivity ranging from 0.73 to 0.88 for detecting unhealthy alcohol use with a specificity ranging from 0.74 to 1.00.45
Question to screen for depression
"Over the past 2 weeks, have you felt down, depressed, or hopeless?" screens for depressed mood.
Question to screen for adhedonia
"Over the past 2 weeks, have you felt little interest or pleasure in doing things?" screens for anhedonia.
The principal symptoms should be well-characterized, with descriptions of
(1) location, (2) quality, (3) quantity or severity, (4) timing, including onset, duration, and frequency, (5) the setting in which they occur, (6) factors that have aggravated or relieved the symptoms, and (7) associated manifestations.
Enlarged or tender nodes, if unexplained, call for
(1) re-examination of the regions they drain and (2) careful assessment of lymph nodes in other regions to identify regional from generalized lymphadenopathy.
anatomy of the nail
- Body - Free edge - Root (beneath skin) - Lunula: half moon area of white due to increase in basal layer - Eponychium: cuticle - Hyponychium: epithelium under nail to secure it to the skin - Matrix: area of growth.
Steps for Examining the Optic Disc and Retina
- locate the optic disc (vessel gets larger as you approach) - bring the disc into sharp focus - inspect the optic disc (sharpness, color, size of the cup, and symmetry) - look at swelling of the optic disc for increased intracranial pressure - inspect fundus for spontaneous venous pulsations - inspect the retina including arteries and veins - follow the vessels peripherally in each direction - identify any lesions - inspect fovea and surrounding macula --> have patient look directly into the light
Autonomic stimulation to the eye:
- parasympathetic: pupillary constriction - sympathetic: pupillary dilation and raising of the upper eyelid
Thrush on the Palate (Candidiasis)
- yeast infection - thick white plaques adhere to underlying mucosa - predisposing factors = prolonged antibiotic treatment, corticosteroid use, AIDS
Guiding Style of Motivational Interviewing
-Ask open ended questions -listen to capture their account -inform by asking permission to provide info and then asking what the implications might be for the patient
Angular Cheilitis
-Fissured areas in the corner of the mouth (commissures) -Can see similar appearance with severe riboflavin (Vitamin B2) deficiency
Steps in clinical reasoning
-Identify abnormal findings. -Localize findings anatomically. -Interpret findings in terms of probable process. -Make hypotheses about the nature of the patient's problem. -Test the hypotheses and establish a working diagnosis. -Develop a plan agreeable to the patient.
Exudative Tonsillitis
-Red throat with white exudate on tonsils -Fever, enlarged cervical nodes = Group A strep or mono
palpating the thyroid
-Stand behind the client -Sit up straight, lean slightly right -Ask client to take a sip of water and hold -Find the landmarks >Cricoid >Thyroid isthmus >Slide fingers laterally to be on top of thyroid -Push thyroid to the right w/ left hand, ask the client to swallow water. Thyroid should rise with swallowing -Palpate the gland for size, texture -Repeat on the other side Displace the trachea to the right with the fingers of the left hand; with the right-hand fingers, palpate laterally for the right lobe of the thyroid in the space between the displaced trachea and the relaxed SCM muscle.
Romberg Test
-assesses ability of vestibular apparatus in inner ear to help maintain standing balance
Great vessels of the neck
-carotid artery -internal jugular vein -external jugular vein
Advanced Interviewing
-challenging patients -sensitive topics
purpose of conversation with patient
-establish a trusting and supportive relationship -gather information -offer information
social determinants of health
-neighborhood and built environment -health and health care -social and community context -education -economic stability
Abnormalities of the Optic Disc
-papilledema -glaucoma -optic atrophy
Red Spots and Streaks in the Fundi
-superficial retinal hemorrhages- small, linear, flame shaped, red -preretinal hemorrhage-blood escapes into potential space bc retina and vitreous, causes sudden increase in intracranial pressure -deep retinal hemorhhage-dot/blot- small rounded slightly irregular red spots -microaneurysms- tiny, round red spots in and around the macula -neovascularizations- formation of new blood vessels- more numerous
pain scale
0-10
Conversion formulas for BMI
1 lb = 0.45 kg; 1 in = 2.54 cm; 100 cm =1 m.
Critical Appraisal of the Clinical Evidence
1. Are the results valid (can you believe them)? 2. What are the results (magnitude and precision)? 3. How can you apply the results to patient care (generalizability)?
The American Geriatrics Society recommends a five-step approach to screening decisions:
1. Assess patient preferences 2. Interpret the available evidence 3. Estimate prognosis 4. Consider treatment feasibility 5. Optimize therapies and care plans
Steps for Using the Ophthalmoscope
1. Darken the room, turn on OTSCP light, check on back of hand for desired brightness 2. Turn len disc to 0 diopter, keep finger on the edge of lens disc to focus during fundoscopy 3. R eye to R eye to R hand 4. Brace OTSCP against your head, handle tilted laterally 20˚. Have patient look over your shoulder at point behind you 5. position yourself 15 in from patient, shine light and check red reflex 6. Place thumb of other hand across patient's eye prow, steading hand. Stay focused on red reflux and move in with OTSCP at 15 ˚ angle toward pupil
10 Tips: Choose MyPlate
1. Find your healthy eating style 2. Make half your plate fruits and vegetables 3. Focus on whole fruits 4. Vary your veggies 5. Make half your grains whole grains 6. Move to low-fat or fat-free milk or yogurt 7. Vary your protein routine 8. Drink and eat beverages and foods with less sodium, saturated fat, and added sugars 9. Drink water instead of sugary drinks 10. Everything you eat and drink matters
Contraindications for mydriatic drops include
1. Head injury and coma, in which continuing observations of pupillary reactions are essential 2. Any suspicion of narrow-angle glaucoma 3. pregnancy
steps in clinical decision making
1. Identify the patient problem 2. Assess: collect history and physical data 3. Formulate competing diagnoses (differential) 4. Order diagnostics 5. Select diagnosis 6. Develop a treatment plan 7. Implement and evaluate: Follow-up
seven attributes of a symptom
1. Location. Where is it? Does it radiate? 2. Quality. What is it like? 3. Quantity or severity. How bad is it? (For pain, ask for a rating on a scale of 1 to 10.) 4. Timing. When did (does) it start? How long did (does) it last? How often did (does) it come? 5. Setting in which it occurs. Include environmental factors, personal activities, emotional reactions, or other circumstances that may have contributed to the illness. 6. Remitting or exacerbating factors. Does anything make it better or worse? 7. Associated manifestations. Have you noticed anything else that accompanies it? (SEE O.L.D.C.A.R.T.S.)
Normal Variations of the Optic Disc
1. Physiologic cupping 2. Temporal cup 3. Rings and crescents 4. Medulated nerve fibers
Steps in Beginning the Physical Examination
1. Reflect on your approach to the patient. 2. Adjust the lighting and the environment. 3. Check your equipment. 4. Make the patient comfortable. 5. Observe standard and universal precautions. 6. Choose the sequence, scope, and positioning of examination.
lymph nodes of the head and neck
1. Submental lymph node group—in the midline a few centimeters behind the tip of the mandible 2. Submandibular lymph node group—midway between the angle and the tip of the mandible 3. Preauricular lymph node group—in front of the ear 4. Posterior auricular lymph node group—superficial to the mastoid process 5. Tonsillar (jugulodigastric) lymph node group—at the angle of the mandible 6. Occipital lymph node group—at the base of the skull posteriorly 7. Anterior superficial cervical lymph node group— superficial to the SCM muscle 8. Posterior cervical lymph node group—along the anterior edge of the trapezius 9. Deep cervical chain lymph node group—deep to the SCM muscle and often inaccessible to examination 10. Supraclavicular lymph node group—deep in the angle formed by the clavicle and the SCM muscle
pupillary abnormalities
1. Tonic pupil (adie pupil) 2. Oculomotor Nerve Paralysis (CN 3) 3. Horner's syndrome 4. Small, irregular pupils (argyll robertson pupils) 5. Equal pupils and one blind eye
Common pain scales used
1. VAS, visual analogue scale 2. NRS, numerical rating scale 3. SDS, simple descriptor scale 4. Wong-Baker FACES scale
At what age should a clinician begin asking the parent to leave the room during examination to ensure confidentiality?
10 or 11
doppler detects fhr after
10 weeks
How far away should a handheld eye chart be when testing for near vision?
14 ft away from patient
Recommended BP for older adults
150/90 or lower with therapy
Recommended serving of fish for pregnant women
2 servings a week without mercury or shellfish
BP readings should be a part of the exam for children greater than
2 years old
How far away should patient be when testing central vision with Snellen chart?
20 ft away from chart
In the United States, a person is usually considered legally blind when vision in the better eye, corrected by glasses, is
20/200 or less. Legal blindness also results from a constricted field of vision, which is 20 degrees or less in the better eye.
when to administer tdap in pregnancy
27 to 36 weeks
adult teeth
32 teeth
Width of the inflatable bladder of the cuff should be about
40% of upper arm circumference (about 12 to 14 cm in the average adult).
realistic weight loss goal to reduce DM
5 to 10 percent weight loss
Length of the inflatable bladder should be about
80% of upper arm circumference
The U.S. Preventive Services Task Force (USPSTF) has issued a grade ____ recommendation strongly encouraging annual BP screening of adults aged 40 years and older and those at increased risk for high BP.
A
The USPSTF has given a grade __ recommendation to screening all adults, particularly pregnant women, for tobacco use and providing behavioral interventions and/or pharmacotherapy for tobacco cessation to all who are using tobacco.
A
The USPSTF issued a grade ___ recommendation for screening high-risk nonpregnant adults and adolescents for syphilis infection.
A
Episcleritis
A benign, usually painless localized ocular inflammation of the episcleral vessels. Vessels appear movable over the scleral surface. May be nodular or show only redness and dilated vessels.
Blepharitis
A chronic inflammation of the eyelids at the base of the hair follicles, often from S. aureus. There is also a scaling seborrheic variant.
contrast sensitivity function
A function describing how the sensitivity to contrast (defined as the reciprocal of the contrast threshold) depends on the spatial frequency (size) of the stimulus.
Kayser-Fleischer Ring
A golden to red brown ring, sometimes shading to green or blue, from copper deposition in the periphery of the cornea found in Wilson disease. Due to a rare autosomal recessive mutation of the ATO7B gene on chromosome 13 causing abnormal copper transport, reduced biliary copper excretion, and abnormal accumulation of copper in the liver and tissues throughout the body. Patients present with liver disease, renal failure, and neurologic symptoms of tremor, dystonia, and a variety of psychiatric disorders.15,16
Pinguecula
A harmless yellowish triangular nodule in the bulbar conjunctiva on either side of the iris. Appears frequently with aging, first on the nasal and then on the temporal side.
Pathways of light reaction
A light beam shining onto one retina causes pupillary constriction in that eye, termed the direct reaction to light, and in the contralateral eye, the consensual reaction to light. The initial sensory pathways are similar to those described for vision: retina, optic nerve (CN II), and optic tract, which diverges in the midbrain. The motor impulses back to the constrictor muscles of the iris of each eye are transmitted through both oculomotor nerves (CN III)
Visual Analogue Scale for fatigue (VAS-F)
A measure of subjective quantification of fatigue levels, requiring the person to respond to descriptors on two subscales.
Setting up a 2x2 table
A negative result from a test with a high sensitivity (i.e., a very low false-negative rate) usually excludes disease. This is represented by the mnemonic SnNOUT—a Sensitive test with a Negative result rules OUT disease. Conversely, a positive result in a test with high specificity (e.g., a very low-false-positive rate) usually indicates disease. This is represented by the mnemonic SpPIN—a Specific test with a Positive result rules IN disease.
Stye (Hordeolum)
A painful, tender, red infection at the inner or outer margin of the eyelid, usually from Staphylococcus aureus (at the inner margin—from an obstructed meibomian gland; at the outer margin—from an obstructed eyelash follicle or tear gland).
Alexithymia
A person's inability to, or difficulty in, describing or being aware of emotions or mood
Apgar scoring system
A scoring system for assessing the status of a newborn that assigns a number value to each of five areas of assessment.
Mobility of the eardrum can be evaluated with a pneumatic otoscope.
A serous effusion, a thickened tympanic membrane, or purulent otitis media may decrease mobility. If there is a perforation, there will be no mobility.
Allergy Crease
A slightly discolored line across the nose from where they rub it so much
Smooth Tongue (Atrophic Glossitis).
A smooth and often sore tongue that has lost its papillae suggests a deficiency in riboflavin, niacin, folic acid, vitamin B12, pyridoxine, or iron, or treatment with chemotherapy.
Chalazion
A subacute nontender, usually painless nodule caused by a blocked meibomian gland. May become acutely inflamed but, unlike a stye, usually points inside the lid rather than on the lid margin.
corneal scar
A superficial grayish-white opacity in the cornea, secondary to an old injury or to inflammation. Size and shape are variable. Do not confuse with the opaque lens of a cataract, visible on a deeper plane and only through the pupil.
Leukoplakia
A thickened white patch (leukoplakia) may occur anywhere in the oral mucosa. The extensive example shown on this buccal mucosa resulted from frequent chewing of tobacco, a local irritant. This benign reactive process of the squamous epithelium may lead to cancer and should be biopsied. Another risk factor is human papillomavirus infection.
Corneal Arcus (arcus senilis)
A thin grayish-white arc or circle not quite at the edge of the cornea. Accompanies normal aging but also seen in younger adults, especially African Americans. In young adults, suggests possible hyperlipoproteinemia. Usually benign.
pterygium
A triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea, usually from the nasal side. Reddening and irritation may occur. May interfere with vision as it encroaches on the pupil.
Lid Retraction and Exophthalmos
A wide-eyed stare suggests retracted eyelids. Note the rim of sclera between the upper lid and the iris. Retracted lids and "lid lag" when eyes move from up to down markedly increase the likelihood of hyperthyroidism, especially when accompanied by a fine tremor, moist skin, and heart rate >90 beats/min. Exophthalmos describes protrusion of the eyeball, a common feature of thyroid eye disease, triggered by autoreactive T lymphocytes. In this disorder, there is a spectrum of eye changes, ranging from lid retraction to extraocular muscle dysfunction, dry eyes, ocular pain, and lacrimation. Changes do not always progress. In unilateral exophthalmos, consider thyroid eye disease (though usually bilateral), trauma, orbital tumor, and granulomatous disorders.
Adapting Interviewing Techniques to Specific Situations
ACC: focus your information gathering not only on the CC (if there is one) but also chronic health issues and any changes to them since their last visit. You should also ask about routine health care maintenance, especially in an ambulatory setting with a primary care focus. ER: R/O life threatening causes, may need to elicit history from family or other source if pt unresponsive; prepare for interruptions ICU: collecting info from pt may be difficult--elicit family member for hx in this case; if pt responsive include how pt would like to direct care (ex: advanced directives) Nursing home: attempt hx from resident first--may need to confirm certain info with staff or family; include ADLs Home: focus on level of function, evaluate environment, assess pt's access to help from family/friends
Screening for Perinatal Depression
ACOG recommends that clinicians screen women at least once during the perinatal period for depression and anxiety symptoms using a standardized, validated tool. Additionally, the United States Preventive Services Task Force (USPSTF) recommends that clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions (B recommendation). Commonly used depression screening tools for the pregnant or peripartum adult include the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire-9 (PHQ-9).
Excercise recommendations for pregnancy
ACOG recommends that pregnant women should engage in ≥30 minutes of moderate exercise on most days of the week unless there are contraindications.
how often to screen for prenatal partner violence
ACOG recommends universal screening of all women for domestic violence without regard to socioeconomic status, including pregnant women at the first prenatal visit and at least once each trimester.
If dementia is suspected, the clinician should assess the patient's ability to perform _____.
ADLs
Acute Otitis Media
Acute Otitis Media is when the TM presents with erythema, thickened or clouding, bulging, limited or absent mobility, air filled level and/or bubbles, usually no light reflex. The entire TM is "hyperemic" or "injected".
CDC Exercise Recommendations for Older Adults
Adults need at least: 2 hours and 30 minutes (150 minutes) of moderate-intensity aerobic activity (i.e., brisk walking) every week and muscle-strengthening activities on two or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms) OR 1 hour and 15 minutes (75 minutes) of vigorous-intensity aerobic activity (i.e., jogging or running) every week and muscle-strengthening activities on two or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms) OR an equivalent mix of moderate- and vigorous-intensity aerobic activity and muscle-strengthening activities on two or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders, and arms)
Physical Activity Guidelines for Americans
Adults should do at least 150 to 300 minutes of moderate-intensity aerobic activity or 75 to 150 minutes of vigorous-intensity aerobic activity each week. Moderate- or greater-intensity muscle-strengthening activity that involves all major muscle groups on 2 or more days a week. Greater health benefits can be achieved by increasing the frequency, duration, and/or intensity of physical activity. Adults should avoid being sedentary; doing any amount of moderate-to-vigorous intensity physical activity has health benefits. Older adults should also engage in balance training activities.
The major dementia syndromes include
Alzheimer disease (AD), vascular dementia, frontotemporal dementia, dementia with Lewy bodies, Parkinson disease with dementia, and dementia of mixed etiology.
Older adult: cup to disc ratio
An increased cup-to-disc ratio suggests primary open angle glaucoma (POAG), caused by irreversible optic neuropathy and leading to loss of peripheral and central vision and blindness (Fig. 27-10). Prevalence of POAG is four to five times higher in adults with African and Latino ancestry. People of Asian descent are more prone to develop angle-closure glaucoma and normal-tension glaucoma.
Angioedema
Angioedema is a localized subcutaneous or submucosal swelling caused by leakage of intravascular fluid into interstitial tissue. Two types are common. When vascular permeability is triggered by mast cells in allergic and NSAID reactions, look for associated urticaria and pruritus. These are uncommon in angioedema from bradykinin and complement-derived mediators, the mechanism in ACE-inhibitor reactions. Angioedema is usually benign and resolves within 24-48 hrs. It can be life threatening when it involves the larynx, tongue, or upper airway or develops into anaphylaxis.
Annular Lesions:
Annular describes lesions that are round with central clearing. Clearing begins in the center and spreads from the center out. An example would be tinea corporis. Discoid is also a round lesion however, there is no central clearing.
Peri-tonsillar Abscess
Another potential finding is a peri-tonsillar abscess. Notice the large inflamed area with well-defined edges. Depending on the size of the abscess uvula deviation, muffled voice, foul breath, and lymphadenopathy can occur.
______________ can contribute to epistaxis.
Anticoagulants, NSAIDs, vascular malformations, and coagulopathies
Drugs associated with weight loss include
Anticonvulsants Antidepressants Levodopa Digoxin Metformin Thyroid medication
Disorders/situations influencing judgement
Anxiety, mood disorders, intelligence, education, income, and cultural values
Apththous Ulcers
Aphthous ulcers, or canker sores, are very painful episodic ulceration that can occur anywhere in the mouth, except the attached gingiva, hard palate, and dorsum of the tongue.
Hard Exudates
Appear creamy or yellowish, often bright w/ well-defined borders. Small and round, may coalesce; often cluster in patterns. 2/2 diabetes, HTN
Newborns and infants tips for assessment
Approach gradually Encourage caregivers to feed the baby during the visit to calm them Keep your voice calm Focus on the caregivers Mouth and ear exam last
Testing the near reaction is helpful in diagnosing
Argyll Robertson, tonic (Adie) pupils, and other neurologic syndromes
testing convergence
Ask the patient to follow your finger or pencil as you move it in toward the bridge of the nose. The converging eyes normally follow the object to within 5 cm to 8 cm of the nose
To search thoroughly for a foreign body in the eye, evert the upper lid following the steps below.
Ask the patient to look down and relax the eyes. Be reassuring and use gentle deliberate movements. Raise the upper eyelid slightly so that the lashes protrude, then grasp the upper eyelashes and pull them gently down and forward (Fig. 12-28) Then place a small stick such as a tongue blade or an applicator at least 1 cm above the lid margin at the upper border of the tarsal plate. Push down on the tongue blade as you raise the edge of the lid, thus everting the eyelid or turning it "inside out." Do not press on the eyeball itself (Fig. 12-29). Secure the upper lashes against the eyebrow with your thumb and inspect the palpebral conjunctiva (Fig. 12-30). After your inspection, grasp the upper eyelashes and pull them gently forward. Ask the patient to look up. The eyelid will return to its normal position.
Static Finger Wiggle Test
Ask the patient to look with both eyes into your eyes. As you return the patient's gaze, place your hands about 2 feet apart, lateral to the patient's ears. Wiggle both your fingers simultaneously, and bring them slowly forward, curving inward along the imaginary surface of the bowl toward the central vision line. At each position, ask the patient to tell you as soon as he or she sees the finger movement. Based these reports, map out the maximum lateral extent of the left and right monocular visual fields when the patient's left eye repeatedly does not see your fingers until they have crossed the line of gaze, a left homonymous hemianopsia is present.
how to test hypoglossal nerve XII
Ask the patient to put out his or her tongue (Fig. 14-12). Inspect it for symmetry
Determining the Patient's Weight
Ask the patient to remove shoes and outdoor garments as appropriate. If weighing a patient with a stoma or catheter bag, ensure it is emptied beforehand. Ensure the scales are balanced, or display zero, before weighing the patient. The patient should remain as still as possible while being weighed. Monitor to ensure that: Clothing is not touching any fixed part of the scales or surroundings. Body weight is not supported on an object (e.g., a walking stick or wall) and the patient's feet are not placed on the floor (when using chair scales). Once the scales register a weight, record the reading on the scales in the appropriate documentation. Once accurate weight is recorded, assist the patient to move away from the weighing scale. Ensure that he or she is dressed appropriately and comfortable at the end of procedure. When monitoring periodical weight change, ensure the patient always wears clothing of similar weight.
Key Components of the Mental Status Examination
Assess appearance and behavior, including level of consciousness (alert, lethargy, obtundation, stupor, coma), posture and motor behavior (relaxed, slumped tense, restless, anxious, fidgeting, agitated, expansive), dress, grooming, personal hygiene, facial expression (e.g., anxiety, depression, apathy, anger, elation, immobility), affect (appropriate, flat, blunted, labile, inappropriate), and manner (e.g., anger, hostility, suspiciousness, evasiveness, apathy, detached, indifferent, anxious, depressed). Assess speech and language, including quantity, rate (fast, slow), volume (loud, soft), articulation (e.g., clear, nasal), and fluency (e.g., hesitancy, inflections, circumlocutions, paraphasia). Assess mood (e.g., sadness, melancholy, contentment, joy, euphoria, elation, anger, rage, anxiety, worry, detached, indifferent). Assess thoughts (logic, relevance, organization, coherence) and perceptions (illusions, hallucinations). Assess insight (aware, absent) and judgment (appropriate, poor). Assess cognition, including orientation, attention (digit span, serial 7s, spelling backward), memory (remote, recent, new learning), and higher cognitive functions (information and vocabulary, calculations, abstract thinking, constructional ability).
Key Components of the Examination of the Pregnant Woman
Assess general health, emotional state, nutritional status, and neuromuscular coordination. Measure height and weight. Calculate BMI. Measure the blood pressure at every visit. Inspect the head and neck (facial skin changes or edema, hair condition and distribution, conjunctival pallor, nasal congestion or epistaxis, teeth and gum health, thyroid masses or nodules). Inspect, percuss, and auscultate the thorax and lungs. Palpate location of the apical impulse. Auscultate the heart (S1 splitting, murmurs, venous hum or mammary souffle). Inspect the abdomen (striae, scars, size, shape, and contour). Palpate the abdomen (masses, fetal movement, uterine contractility and fundal height). Auscultate fetal heart tones (location, rate and rhythm). Inspect the external genitalia (labial varicosities, cystoceles, rectoceles, lesions, sores, Bartholin and Skene gland tenderness and cysts). Inspect the internal genitalia by performing speculum and bimanual examinations. Speculum examination: Inspect the cervix (color, shape, os closure) and vaginal walls (color, relaxation, rugae, and discharge). Perform a Pap smear if indicated. Bimanual examination: Palpate the cervix (length, os), uterus (shape, consistency, and position), adnexa (masses, tenderness), pelvic floor strength. Inspect the anus (masses or hemorrhoids). Examine the extremities (varicosities, edema) and elicit reflexes (hyperreflexia). Perform Leopold maneuvers (if indicated).
Timed Get Up and Go Test
Assesses mobility and risk for falls in the elderly Performed with patient wearing regular footwear, using usual walking aid if needed, and sitting back in a chair with armrest. On the word, "Go," the patient is asked to do the following: Stand up from the armless chair Walk 3 m (in a line) Turn Walk back to chair Sit down Repeat. Time the second effort. Observe patient for postural stability, steppage, stride length, and sway. Scoring: Normal: completes task in <10 sec Abnormal: completes task in >20 sec Low scores correlate with good functional independence; high scores correlate with poor functional independence and higher risk of falls."
Because diabetes is an important modifiable risk factor for CVD, the USPSTF has issued a grade __________ recommendation to screen for abnormal blood glucose in overweight or obese adults aged 40 to 70 years.
B
The U.S. Preventive Services Task Force (USPSTF) has issued a grade ____ recommendation supporting behavioral counseling to minimize UV radiation exposure in fair-skinned persons aged 6 months to 24 years
B
The U.S. Preventive Services Task Force (USPSTF) made a grade ____ recommendation in 2016 for depression screening in clinical settings that can provide "accurate diagnosis, effective treatment, and appropriate follow-up."
B
The USPSTF has given a grade ____ recommendation for chlamydia and gonorrhea screening in sexually active women aged 24 years and younger; the evidence is insufficient to make a recommendation for sexually active men.
B
The USPSTF has issued a grade ____ recommendation to screen for IPV among women of reproductive age and refer those screening positive to support services.
B
The USPSTF issued a grade __ recommendation supporting behavioral counseling for all sexually active adolescents and for adults who are at increased risk for STIs, including HIV/AIDS.
B
The most common skin cancer is
BCC, followed by SCC, and then melanoma.
uterine contractions before 37 weeks
Before 37 weeks, regular uterine contractions with or without pain and bleeding are abnormal, suggesting preterm labor.
Benefits and Harms of Screening
Benefits: Mortality reduction Morbidity reduction Reassurance Harms: False-positive results that can cause anxiety and lead to additional testing Overdiagnosis of low-risk disease that will never cause any clinical problems but may lead to overtreatment False reassurance from false-negative tests Pain or discomfort from diagnostic tests Incidental findings leading to additional tests and treatments Complications from treating disease
Exotosis of the ear canal
Benign bony outgrowth, usually capped by cartilage, that osteomas or exostoses (Fig. 13-10). These are nonmalignant overgrowths, which may obscure the tympanic membrane.
_____ are the attitudes or feelings that we attach to perceived differences.
Biases
Blanchable vs. nonblanchable lesions
Blanchable lesions are erythematous and suggest inflammation. Nonblanching lesions such as petechiae, purpura, and vascular structures (cherry angiomas, vascular malformations) are not erythematous, but rather bright red, purple, or violaceous. They are nonblanching because blood has extravasated out from the capillaries into the surrounding tissues.
Hyperresonant percussion note
Booming sound indicates pneumothorax or emphysema
Patient Instructions for Skin Self-Examination
Box 10-1 Examine your body front and back in the mirror, then look at right and left sides with your arms raised. Bend elbows and look carefully at forearms, underarms, and palms. Look at the backs of your legs and feet, the spaces between your toes, and the soles. Examine the back of your neck and scalp with a hand mirror. Part hair for a closer look. Finally, check your back and buttocks with a hand mirror.
Examining the Ears with the Otoscope
Box 13-1
Screening for Depression: The Patient Health Questionnaire (PHQ-9)
Box 9-6
Cysts of the neck in infant
Branchial cleft cysts appear as small dimples or openings anterior to the midportion of the sternocleidomastoid muscle. They may be associated with a sinus tract. Preauricular cysts and sinuses are common, pinhole-size pits, usually located anterior to the helix of the ear. They are often bilateral and may be associated with hearing deficits and renal disorders. Thyroglossal duct cysts are located at the midline of the neck, just above the thyroid cartilage. These small, firm, mobile masses move upward with tongue protrusion or with swallowing. They are usually detected after 2 years.
How can you identify your own biases?
By having self awareness
Best alcohol screening tool
CAGE questionairre
If the large pupil reacts poorly to light or anisocoria worsens in light, the large pupil has abnormal pupillary constriction, seen in
CN III palsy. Consider intracranial aneurysm if the patient is awake and transtentorial herniation if the patient is comatose.
Asymmetric protrusion of tongue suggests a lesion of
CN XII (tongue points toward the side of the lesion).
Prolonged expiration is common in
COPD
Candida
Candida or yeast presents is as a white exudate, cottage cheese-like plaque on the side of the mouth, throat or tongue. This is common in infants, immunocompromised patients, and after antibiotic therapy.
Apparent State of Discomfort or Distress. Does the patient show evidence of the problems listed below?
Cardiac or respiratory distress Pain Anxiety or depression
Pearls to evaluate potentially abnormal facies
Carefully review the history, especially the family history, pregnancy, and perinatal history. Note abnormalities of growth/development or dysmorphic somatic features. Measure and plot percentiles, especially of head circumference, height, and weight. Consider the three mechanisms of facial dysmorphogenesis: -Deformations from intrauterine constraint -Disruptions from amniotic bands or fetal tissue -Malformations from intrinsic abnormality (either face/head or brain) Examine parents and siblings (similarity may be reassuring but might also point to a familial disorder). Determine whether facial features fit a recognizable syndrome. Compare against references, pictures, tables, and databases.
Causes of hoarseness
Causes range from diseases of the larynx to extralaryngeal lesions that press on the laryngeal nerves.
Common or Concerning Symptoms of the eye
Change in vision: blurred vision, loss of vision, floaters, flashing lights Eye pain, redness, or tearing Double vision (diplopia)
Parotid Gland Enlargement
Chronic bilateral asymptomatic parotid gland enlargement may be associated with obesity, diabetes, cirrhosis, and other conditions. Note the swellings anterior to the ear lobes and above the angles of the jaw. Gradual unilateral enlargement suggests neoplasm. Acute enlargement is seen in mumps.
Chondrodermatitis helicis
Chronic inflammatory lesion that starts out as painful, tender papule on the helix or antihelix, then ulcerates and crusts Must r/o carcinoma
external os
Closed external os if nulliparous; os open to size of fingertip if multiparous
Caring for Patients with Altered Cognition
Collateral information: Obtain collateral information from family members and caretakers. Neuropsychological testing: Consider formal neuropsychological testing. Contributing factors: Investigate contributing factors such as medications; metabolic abnormalities; depression; delirium; substance abuse; and other clinical and psychiatric conditions, including vascular risk from diabetes and hypertension. Caregivers: Counsel families about the challenges for caregivers. The National Institute on Aging website: https://www.nia.nih.gov/health/topics/caregiver-health/ is especially helpful about "Alzheimer caregiving." Review household safety measures. Drivers with dementia: Learn the laws about reporting drivers with dementia in your state. Consult the American Academy of Neurology evidence-based practice parameters for drivers with dementia, updated in 2010, and guidelines from numerous professional organizations, including the American Medical Association. Note, however, that underlying quantitative evidence linking assessment to road safety is limited. A 2013 Cochrane review details the pitfalls of disqualifying impaired drivers, which can lead to depression and social withdrawal if disqualification is premature. The review concludes that for drivers with dementia, there is no good evidence that neuropsychological or on-road assessment will maintain mobility and improve safety. The authors call for more research to develop assessment tools "that can reliably identify unsafe drivers with dementia in an office setting" and determine what changes in function provide a threshold for disqualification, as no single validated test is available. Advance directives: Encourage patient and family discussion of appointing a health care proxy and arranging for power of attorney, health care power of attorney, and advance directives while the patient can still contribute to active decision making.
Marginal Gingivitis
Common among teenagers and young adults. The gingival margins are reddened and swollen, the interdental papillae are blunted, swollen, and red. Brushing the teeth often makes the gums bleed.
Approach to the initial prenatal visit
Confirmation of pregnancy Determining gestational age and expected date of delivery Symptoms of pregnancy Concerns and attitudes toward the pregnancy Current health and past clinical history Past obstetric history Risk factors for maternal and fetal health Family history of patient and father of the newborn Plans for genetic screening and aneuploidy testing Plans for breastfeeding Plans for postpartum contraception
Confluent Lesions:
Confluent describes lesions that appear to run together. They are not distinct in their borders. An example would be urticaria.
Strategies to Assess Cranial Nerves in Newborns and Infants
Congenital facial nerve palsy can result from birth trauma or developmental defects. Dysphagia, or difficulty in swallowing, can occasionally be due to injury to cranial nerve IX, X, and XII.
nasal congestion only on one side
Consider a deviated nasal septum, nasal polyp, foreign body, Wegener granuloma, or carcinoma.
Bright Futures Health Supervision Outline
Context Priorities for the Visit Health Supervision History General questions Past medical history Family history Social history Surveillance of development Review of systems Observation of parent-child/youth interaction Physical examination Assessment of growth <2 years: weight, length, head circumference, and weight-for-length ≥2 years: weight, height, and BMI Listing of particular components of the examination that are important for the child at each age visit Screening Universal screening Selective screening Risk assessment Immunizations Anticipatory Guidance Information for the health care professional Health promotion questions for the priorities for the visit Anticipatory guidance for the parent and child"
Cryptic Tonsils
Cryptic tonsils have small pockets or folds that trap food and lead to tonsillar stones. This can cause foul-smelling breath and feeling the sensation of "something stuck" in the back of the throat.
______ is a system of shared ideas, rules, and meanings that influences how we view the world, experience it emotionally, and behave in relation to other people.
Culture
There is generalized fat distribution in simple obesity and truncal fat with relatively thin limbs in
Cushing syndrome and metabolic syndrome.
Prenatal multivitamins & minerals
Daily prenatal vitamin and mineral supplements should include 600 IU of vitamin D and at least 1,000 mg of calcium. If not present in the prenatal vitamins, recommend 150 to 290 μg of daily iodine in pregnant and breastfeeding women, as iodine deficiency is widespread. Women should be advised that excess amounts of fat-soluble vitamins like vitamins A, D, E, and K can cause toxicity.
Conditions that affect patient's pain coping strategies
Depressive, somatoform, and anxiety disorders
Personal and Social History
Describes educational level, family of origin, current household, personal interests, and lifestyle
Facts about Tobacco Use
Despite declining smoking rates over the past several decades, an estimated 47.4 million (19%) of U.S. adults aged 18 years or older were using tobacco products in 2017, including smoking combustible tobacco products. The use of tobacco products decreased from 2011-2017 among high school students (24.2% to 19.6%) and among middle school students (7.5% to 5.6%). However, e-cigarettes or electronic nicotine delivery systems (ENDS) have become the most frequently used tobacco product among youth, many of whom use two or more tobacco products. Use of these devices is called "vaping." Cigarette smoking causes more than 480,000 deaths in the United States each year, nearly one-fifth of all deaths. Nonsmokers exposed to smoke have increased risk of lung cancer, ear and respiratory infections, and asthma.
The Confusion Assessment Method (CAM) Diagnostic Algorithm
Diagnosing delirium requires features 1 and 2 and either 3 or 4. 1. Acute change in mental status and fluctuating course: Is there evidence of an acute change in cognition from baseline? Does the abnormal behavior fluctuate during the day? 2. Inattention: Does the patient have difficulty focusing attention? 3. Disorganized thinking: Does the patient have rambling or irrelevant conversations, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? 4. Abnormal level of consciousness: Is the patient anything besides alert—hyperalert, lethargic, stuporous, or comatose?
diplopia causes
Diplopia is seen in lesions in the brainstem or cerebellum and with weakness or paralysis of one or more extraocular muscles, as in horizontal diplopia from palsy of CN III or VI or vertical diplopia from palsy of CN III or IV. Diplopia in one eye, with the other closed, suggests a problem in the ocular surface, cornea, lens, or macula.
Discrete Lesions:
Discrete describes a well demarcated individual lesion. An example would be a wart.
______ is the explanation that the clinician brings to the symptoms. It is the way that the clinician organizes what he or she learns from the patient into a coherent picture that leads to a clinical diagnosis and treatment plan.
Disease
What should you do if an angry patient is yelling?
Do not try to get the patient to lower their voice or calm down. Initially, listen carefully and try to understand what they are saying. Once you have established rapport, gently suggest moving to a different location that is not upsetting to other patients or families.
If you suspect depression, assess its severity and any risk of suicide. Ask:
Do you feel discouraged or depressed? How low do you feel? What do you see for yourself in the future? Have you had thoughts of death? Do you ever feel that life isn't worth living? Or that you want to be dead? Have you ever thought of killing yourself? Have you thought about how or when you would try to kill yourself? Do you have a plan? What do you expect is going to happen after you die?
Interim Patient History
Documents events since last meeting Useful for chronic disease and hospitalization follow up
Oculovestibular Reflex with Caloric Stimulation (CNs III, IV, VI, VIII)
Done for comatose patients Make sure the eardrums are intact and the ear canals clear. Elevate the patient's head to 30 degrees to perform the test accurately. Place a towel or basin under the ear to catch any water that spills over. With a large syringe, inject ice water through a small catheter that is lying in (but not plugging) the ear canal. Watch for deviation of the eyes in the horizontal plane. You may need to use up to 120 mL of ice water to elicit a response. In the comatose patient with an intact brainstem, the eyes drift toward the irrigated ear. Repeat on the opposite side, waiting 3 to 5 minutes, if necessary, for the first response to disappear. No response to stimulation indicates brainstem injury.
Infant: Brushfield spots (seen with an ophthalmoscope) are a ring of white specks in the iris. Although sometimes present in normal children, these strongly suggest
Down syndrome.
Upslanting palpebral fissures are noted in Down syndrome.
Down syndrome.
Canal of Schlemm
Drains the aqueous humor of the eye This circulatory system helps to maintain and control the intraocular pressure
Wharton ducts
Ducts of submandibular glands
Mononucleosis
Edematous and exudative tonsillitis is the hallmark of Mononucleosis. The patient has difficulty swallowing due to severe sore throat. Foul-smelling breath, garbled speech, posterior lymphadenopathy and overwhelming fatigue are also common. If mononucleosis is suspected an abdominal assessment for splenomegaly and hepatomegaly must be performed. If a patient presents with pharyngitis and mononucleosis is also suspected penicillin is not recommended for treatment due to the development of a rash.
Where would you find the alcohol, smoking, and drug use history?
Either in the social history or present illness section
Entropion
Entropion, more common in the elderly, is an inward turning of the lid margin. The lower lashes, which are often invisible when turned inward, irritate the conjunctiva and lower cornea. This is different from trichiasis where there is aberrant inward growth of the eyelashes, but the eyelid position remains normal. Ask the patient to squeeze the lids together and then open them; then check for an entropion that is less obvious.
Reasons why there is an advantage to examining on the right side of the patient
Estimates of jugular venous pressure are more reliable, the palpating hand rests more comfortably on the apical impulse, the right kidney is more frequently palpable than the left, and examining tables are frequently positioned to accommodate a right-handed approach.
_____ are a set of principles that have been created through reflection and discussion to guide our behavior.
Ethics
Key Components of the Head and Neck Examination
Examine the hair (quantity, distribution, texture, any pattern of loss). Examine the scalp (scaliness, lumps, nevi, lesions). Examine the skull (size, contour, deformities, depressions, lumps, tenderness). Inspect the skin in the head and face (expression, contours, asymmetry, involuntary movements, edema, masses). Palpate the cervical lymph nodes (size, shape, delimitation, mobility, consistency, tenderness). Examine the trachea (deviation, breath sounds over it). Examine thyroid gland (size, shape, and consistency).
FICA spiritual assessment tool
F: Faith and beliefs I: Importance and influence C: Community A: Address
Patient's Perspective
FIFE Feelings, fears and concerns about the problem Ideas about the nature and cause of the problem Effect of the problem on the patient's life and function Expectations of the disease, or clinician are often based on prior experiences or family experiences
Common or Concerning Symptoms
Fatigue & Weakness Fever, Chills, Night Sweats Weight Changes Pain
Nonmaleficence or primum non nocere
First do no harm
Fissured Tongue.
Fissures appear with increasing age, sometimes termed furrowed tongue. Food debris may accumulate in the crevices and become irritating, but a fissured tongue is benign.
folic acid in pregnancy
Folate deficiency in pregnancy has a well-documented association with neural tube defects (NTDs). ACOG recommends that all women contemplating pregnancy take 400 μg of folic acid supplementation in addition to a folate-rich diet, which is also supported by the USPSTF (grade A recommendation). Supplementation should be initiated 3 months prior to conception and continued through the first trimester
Problem Oriented History
For other patients who seek care for a specific complaint, such as a cough or painful urination
Proptosis
Forward displacement of an organ, especially an eyeball. Note the rim of sclera from proptosis, an abnormal protrusion of the eyeballs in hyperthyroidism, leading to a characteristic "stare" on frontal gaze. If unilateral, consider an orbital tumor or retrobulbar hemorrhage from trauma.
location of fhr
From 10 to 18 weeks' gestation, the fetal heart tones are located along the midline of the lower abdomen. After that time, the fetal heart tones are best heard over the back or chest and depend on fetal position; the Leopold maneuvers can help identify the position. After 24 weeks, auscultation of more than one fetal heart tone in different locations with varying rates suggests multiple gestation. The FHR ranges between 110 and 160 beats per minute (BPM). A heart rate of 60 to 90 BPM is usually maternal, but an adequate FHR should be confirmed. Sustained dips in FHR, or "decelerations," have a wide differential diagnosis but always warrant investigation, at least by formal FHR monitoring.
palpating the sinuses
Frontal: above eyebrows Maxillary: below eyes, mid cheek on either side of nose Use gentle pressure against bony prominence in each area. Assess for discomfort.
Special Areas of Concern When Assessing Older Adults
Functional impairments in activities of daily living and instrumental activities of daily living Medication management Smoking Alcohol Nutrition
Assessing Functional Status
Functional status is the ability to perform tasks and fulfill social roles associated with daily living across a wide range of complexity. The 10-Minute Geriatric Screener (Box 27-6) is brief, has high interrater agreement, and can be used easily by office staff. It covers the three important domains: physical, cognitive, and psychosocial function and addresses key sensory modalities and urinary incontinence, an often-unreported problem.
Swinging Flashlight Test
Functional test for impairment within the optic nerves. As you swing the light onto one eye the other should dilate as well.
Causes of weight loss include
GI diseases; endocrine disorders (diabetes, hyperthyroidism, adrenal insufficiency); chronic infections, HIV/AIDS; malignancy; chronic cardiac, pulmonary, or renal failure; depression; and anorexia nervosa or bulimia;
Basic Structure of the Clinical Reasoning Process
Gather initial patient information (health history and physical exam) Organize and interpret info to synthesize the problem (problem representation) Generate hypotheses (differential diagnoses) for the patient's problem Test hypotheses until you have a working diagnosis Plan the diagnostic and treatment strategy
Head to toe assessment includes
General Skin Head, Eyes, Ears, Nose, Throat (HEENT) Neck Breasts Respiratory Cardiovascular Gastrointestinal GU PV MS Neuro Hematological Endocrine Psych
Approaches to Searching for Probable Causes of the Findings
Generate an exhaustive list. Select the most specific and critical findings to support your hypothesis. Match these findings against all conditions that can produce them. Eliminate diagnostic possibilities that fail to explain the findings. Weigh competing possibilities and select the most likely diagnosis. Give special attention to potentially life-threatening conditions.
Nephrotic Syndrome
Glomerular disease causes excess albumin excretion, which reduces intravascular colloid osmotic pressure, causing hypovolemia, then sodium and water retention. The face becomes edematous and often pale. Swelling usually appears first around the eyes and in the morning. When severe, the eyes appear slit like.
In older adults, common causes of hyperthyroidism are
Graves disease and toxic multinodular goiter.
Grouped Lesions:
Grouped lesions are lesions clustered together. An example of grouped lesions are those of herpes simplex virus. There are multiple lesions present that are all grouped together.
Gingival Hyperplasia
Gums enlarged by hyperplasia are swollen into heaped-up masses that may even cover the teeth. The redness of inflammation may coexist, as in this example. Causes include phenytoin therapy (as in this case), puberty, pregnancy, and leukemia.
Generalized lymphadenopathy is seen in multiple infectious, inflammatory, or malignant conditions such as
HIV or AIDS, infectious mononucleosis, lymphoma, leukemia, and sarcoidosis.
Herpes Simplex (Cold Sore, Fever Blister)
HSV produces recurrent and painful vesicular eruptions of the lips and surrounding skin. A small cluster of vesicles first develops. Healing takes 10-14 days
Common or Concerning Symptoms of ears and nose
Hearing loss Earache and ear discharge Ringing in the ears (tinnitus) Dizziness and vertigo Nasal discharge (rhinorrhea) and nasal congestion Nosebleed (epistaxis)
conductive hearing loss
Hearing loss or impairment resulting from interference with the transmission of sound waves to the cochlea; noisy environment may help
Healed Chorioretinitis
Here inflammation has destroyed the superficial tissues to reveal a well-defined, irregular patch of white sclera marked with dark pigment. Size varies from small to very large. Toxoplasmosis is illustrated. Multiple, small, somewhat similar- looking areas may be due to laser treatments. Here there is also a temporal scar near the macula.
Loss of SVPs occurs with
High intracranial pressures (above 190 mm H2O) that change the pressure gradient between cerebrospinal fluid pressure and intraocular pulse pressure in the optic disc. Other causes include glaucoma and retinal vein occlusion
Examples of subjective data
History of Present Illness, past medical history, family history, social history and review of systems.
HEEADSSS assessment
Home Education and employment Eating Activities Drugs Sexuality Suicide and depression Safety
If anisocoria worsens in darkness, with normal pupillary reaction to light but abnormal pupillary dilation in one eye, this suggests
Horner syndrome affecting sympathetic innervation.
Hutchinson Teeth in Congenital Syphilis
Hutchinson teeth are smaller and more widely spaced than normal and are notched on their biting surfaces. The sides of the teeth taper toward the biting edges.
Midline structures of the neck
Hyoid (Mobile), Thyroid Cartilage, Cricoid Cartilage, Tracheal rings, Thyroid gland, Sternal Notch
Components of Health History
Identifying Data Reliability Chief Complaint(s) Present Illness Past History Family History Personal and Social History Review of Systems (include pertinent positives and negatives)
For adults, the comprehensive health history includes:
Identifying Data and Source of the History, Chief Complaint(s), Present Illness, Past History, Family History, Personal and Social History, and Review of Systems. Most complete health history Includes all subjective and info and risk identification
BP Cuff size errors
If the cuff is too small (narrow), the blood pressure will read high; if the cuff is too large (wide), the blood pressure will read low on a small arm and high on a large arm.
If patients or families report slow progression of forgetfulness, you should probe into other problems that may accompany the memory problems. "Have you noticed other concerning changes?" "Have you noticed unusual movements that you couldn't control?"
If the patient affirms one-sided hand tremor or difficulty starting movements, consider Parkinson disease. In a younger adult patient with unusual limb movements, you should assess the family history for Huntington disease.
Older adult: eye assessment
If the pupil dilates as the light swings over, a relative afferent pupillary defect is present, which is suspicious for optic nerve disease. Refer to an ophthalmologist. Using the ophthalmoscope beam, check at 1 to 2 ft for a red reflex. With the ophthalmoscope lens at +10 diopters, inspect each lens close to the eye for opacities. Do not depend on the flashlight alone because the lens may look clear superficially. Retinal microvascular disease is linked to cerebral microvascular changes and cognitive impairment.
_____ can be defined as how the patient experiences symptoms. Many factors may shape this experience, including prior personal or family health, the effect of symptoms on everyday life, individual outlook and style of coping, and expectations about medical care.
Illness
comprehensive family history should include
In a general healthcare setting, providers should collect family histories by eliciting general health information about the relatives represented on a patient's pedigree. Examples of conditions to ask about are: a.Major medical concerns b.Chronic medical conditions (something for which medication or therapy is required, for example) c.Hospitalizations or major surgeries d.Birth defects e.Mental retardation, learning disabilities, or developmental delay
Rheumatoid Nodules
In chronic rheumatoid arthritis, look for small lumps on the helix or antihelix and additional nodules elsewhere on the hands and along the surface of the ulna distal to the elbow (p. 832), and on the knees and heels. Ulceration may result from repeated injuries. These nodules may antedate the arthritis.
Rinne test in conductive hearing loss
In conductive hearing loss, sound is heard through bone as long as or longer than it is through air (BC = AC or BC > AC). In sensorineural hearing loss, sound is heard longer through air (AC > BC).
Ectropion
In ectropion, the lower lid margin turns outward, exposing the palpebral conjunctiva. When the punctum of the lower lid turns outward, the eye no longer drains well, and tearing occurs. Ectropion is also more common in older adults.
Attrition of Teeth; Recession of Gums
In many older adults, the chewing surfaces of the teeth are worn down by repetitive use so that the yellow-brown dentin becomes exposed—a process called attrition. Recession of the gums, which exposes the roots of the teeth may occur, giving a "long in the tooth" appearance.
oblique light illumination in acute open-angle glaucoma
In open-angle glaucoma, the common form of glaucoma, the normal spatial relation between iris and cornea is preserved and the iris is fully lit.
Myxedema
In severe hypothyroidism (myxedema) mucopolysaccharide deposition in the dermis leads to a dull, puffy facies. The edema, often pronounced around the eyes, does not pit with pressure. The hair and eyebrows are dry, coarse, and thinned, classically with loss of the lateral third of the eyebrows. The skin is dry.
Middle Ear
In the air-filled middle ear, there are three ossicles—the malleus, incus, and stapes—which are tiny bones that function to transform sound vibrations from the external ear into mechanical waves that then travel through the inner ear. Two of the ossicles, the malleus and the incus, are visible through the tympanic membrane and are angled obliquely. The ossicles are attached to the center of the tympanic membrane by the malleus (Fig. 13-3). Find the handle and the short process of the malleus, the two chief landmarks. From the umbo, where the eardrum meets the tip of the malleus, a light reflection called the cone of light fans downward and anteriorly. Above the short process lies a small portion of the eardrum called the pars flaccida. The remainder of the drum is the pars tensa. Anterior and posterior malleolar folds, which extend obliquely upward from the short process of the malleus,separate the pars flaccida from the pars tensa, but are usually invisible unless the eardrum is retracted. A second ossicle, the incus, can sometimes be seen through the drum in the area posterior and superior to the umbo.
Precision
In the context of reproducibility, precision refers to being able to apply the same test to the same unchanged person and obtain the same results. Precision is often used when referring to laboratory tests. A statistical test used to characterize precision is the coefficient of variation, defined as the standard deviation divided by the mean value. Lower values indicate greater precision.
Parkinson Disease
In this neurodegenerative disorder linked to loss of the neurotransmitter dopamine, there is decreased facial mobility and masklike facies, with decreased blinking and a characteristic stare. Since the neck and upper trunk tend to flex forward, the patient seems to peer upward toward the observer. Facial skin becomes oily, and drooling may occur.
_________________ have the highest suicide rates of any racial/ethnic group.
Indian/Alaska Native men ages 15 to 24 years
Older Adult Immunizations
Influenza vaccination: One high-dose vaccine annually Tetanus, diphtheria, and acellular pertussis (Tdap) vaccination: Administer 1 dose to older adults who previously did not receive a dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) as an adult or child Tetanus and diphtheria toxoids (Td): One dose Td booster every 10 years Varicella (Chicken pox) vaccination: Administer 2 doses to older adults without evidence of immunity to varicella 4 to 8 weeks apart Zoster (Shingles) vaccination: Administer 2 doses of recombinant zoster vaccine (RZV) 2 to 6 months apart to adults ≥50 years regardless of past episodes of herpes zoster or receipt of zoster vaccine live (ZVL) Pneumococcal vaccination: Administer to immunocompetent older adults 1 dose of 13-valent pneumococcal conjugate vaccine (PCV13, Prevnar13) at age 65 years or older then followed by 1 dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23, Pneumovax23) at least 1 year after PCV13. Once a dose of PPSV23 is given at age 65 years or older, no additional doses of PPSV23 should be administered.
Immunization guidelines for adults
Influenza vaccine-inactivated (IIV), recombinant (RIV), or live attenuated (LAIV) Pneumococcal polysaccharide vaccine (PPSV23) and pneumococcal conjugate vaccine (PCV13) Varicella vaccine (VAR) Herpes zoster vaccine-recombinant (RZV) or live (ZVL) Tetanus, diphtheria (Td) or tetanus, diphtheria, pertussis (Tdap) vaccine Human papilloma virus (HPV) vaccine Hepatitis A vaccine (HepA) Hepatitis B vaccine (HepB)
Clues to physical and sexual abuse
Injuries that are unexplained, seem inconsistent with the patient's story, are concealed by the patient, or cause embarrassment Delay in getting treatment for trauma History of repeated injuries or "accidents" Presence of alcohol or drug abuse in patient or partner Partner tries to dominate the visit, will not leave the room, or seems unusually anxious or solicitous Pregnancy at a young age; multiple partners Repeated vaginal infections and STIs Difficulty walking or sitting due to genital/anal pain Vaginal lacerations or bruises Fear of the pelvic examination or physical contact Fear of leaving the examination room
Key Components of the Nose and Paranasal Sinus Examination
Inspect the anterior and inferior surfaces of the nose (asymmetry, deformities, tenderness). Test for nasal obstruction on each ala nasi (if indicated). Inspect the nasal mucosa, nasal septum, inferior and middle turbinates, and corresponding meatuses with a light source or otoscope with large speculum (deviation, marked asymmetry, polyps, ulcers). Palpate the frontal sinuses (tenderness, pressure, fullness). Palpate the maxillary sinuses (tenderness, pressure, fullness).
Key Components of the Ear Examination
Inspect the auricle and surrounding tissue (deformities, lumps, pits, or skin lesions). Move the auricle and palpate the auricle, tragus and mastoid (tenderness). Examine ear canals and tympanic membranes with an otoscope. Inspect the ear canal (cerumen, discharge, foreign bodies, redness of the skin, or swelling). Inspect the tympanic membrane and malleus (color, contour, perforations, mobility). Test auditory acuity or gross hearing with the whispered voice test. If hearing loss or difficulty is present, determine sensorineural versus conductive hearing loss with tuning fork tests. Test lateralization if unilateral hearing loss or difficulty (Weber) is present. Compare air conduction versus bone conduction (Rinne).
Key Components of the Mouth and Pharynx Examination
Inspect the lips (color, moisture, lumps, ulcers, cracking, or scaliness). Inspect the oral mucosa (discoloration, ulcers, white patches, nodules). Palpate the oral mucosa (if indicated for any lesions, thickening). Inspect the gingiva (erythema, discoloration, ulceration, swelling). Inspect the gum margins and interdental papillae (swelling, ulceration). Inspect the teeth (missing, discolored, misshapen, or abnormally positioned). Inspect the roof (hard palate) and floor of the mouth (erythema, discoloration, nodules, ulcerations, or deformities). Test the hypoglossal nerve, or CN XII (symmetry of tongue protrusion). Inspect the tongue (color, texture, lesions). Palpate the tongue (if indicated for any lesions, thickening). Inspect the soft palate, anterior and posterior pillars, uvula, tonsils, and pharynx (color, symmetry, exudate, swelling, ulceration, or tonsillar enlargement). Test the vagus nerve, or CN X (symmetry of uvula).
Household Safety Tips for Older Adults
Install bright lighting and lightweight curtains or shades. Install handrails and lights on all staircases. Pathways and walkways should be well-lit. Remove items that cause tripping like papers, books, clothes, and shoes from stairs and walkways. Remove or secure small throw rugs and other rugs with double-sided tape. Wear shoes both inside and outside the house. Avoid bare feet and wearing slippers. Store medications safely. Keep commonly used items in cabinets that are easy to reach without using a step stool. Install grab bars and nonslip mats or safety strips in baths and showers. Repair faulty plugs and electrical cords. Install smoke alarms and have a plan for escaping fire. Secure all firearms. Have a clinical alert device/system for calling a universal emergency number such as 911 or emergency contacts.
Transtheoretical Model for Behavior Change
Involves progression through a series of five stages: •Precontemplation • Contemplation • Preparation • Action • Maintenance
General Appearance: Apparent State of Health.
Is the patient acutely or chronically ill, frail, or fit and robust?
Weakness definition
It denotes a demonstrable loss of muscle power
Key Points in the Care of the Older Adult in the Primary Care Setting
It is crucial to recognize geriatric syndromes, multifactorial conditions occurring primarily in older adults, in the primary care setting. The most important geriatric syndromes in primary care are falls, urinary incontinence, frailty, and cognitive impairment. Elements of ideal geriatric primary care include assessment of functional status, frequent medication review, careful evaluation of the benefits and burdens of any new test or treatment, and frequent assessment of goals of care and prognosis. Innovative delivery systems—either comprehensive care, consulting assessment or hospital-level care for acute conditions at home—can improve geriatric primary care. High-value features of geriatric care systems include ensuring 24/7 access to care, providing a team-based approach in performing medication reconciliation and comprehensive geriatric assessments, and integrating palliative care into treatment planning.
Examples of opening statements in HPI
JM is a 48-year old man with poorly controlled DM presenting with 3 days of fever.
Common or Concerning Symptoms of hair skin and nails
Lesions Rashes and itching (pruritus) Hair loss and nail changes
A patient starting to have visual hallucinations may be suffering from __________
Lewy body dementia.
U.S. Department of Agriculture dietary guidelines
Limiting sodium intake to <2,300 mg/day since excess sodium intake can lead to hypertension, a major risk factor for CVD. Limiting added sugars and saturated fats each to ≤10% of total calories. Alcohol, if consumed, should be consumed in moderation.
terminal hair
Long, coarse, pigmented hair found on the scalp, legs, arms, and bodies of males and females.
Peutz-Jeghers Syndrome
Look for prominent small brown pigmented spots in the dermal layer of the lips, buccal mucosa, and perioral area. These spots may also appear on the hands and feet. In this autosomal dominant syndrome, these characteristic skin changes accompany numerous intestinal polyps. The risk of gastrointestinal and other cancers ranges from 40-90%. Note that these spots rarely appear around the nose and mouth.
Inspecting the TM
Look for the red bulging tympanic membrane of acute purulent otitis media and for the amber color of a serous effusion.
Vaccines NOT safe in Pregnancy
MMR, Polio, zoster(shingles), live flu, Varicella (chicken pox) *if not immunized against Rubella, give vaccine AFTER delivery.
Guideline for oral presentation--new patient
Make a convincing case for the important problems, the differential, and the plan. Make it structured, organized, and targeted, as it should take only 3-5 minutes. Opening Statement Briefly state the chief complaint and why the patient was admitted. Include pointed and relevant historical information. Source If indicated, briefly note if/why the patient cannot give a reliable history. Note any information sources besides the patient. If there is no comment on the source, it will be assumed that all information came from a reliable patient. Present Illness Your differential diagnosis should guide what you include. Consider starting with: " ... usual state of health until ... " Be chronologically organized and clear without analyzing. Remember the attributes of the chief complaint. Include elements of the past history (with supporting studies and therapeutic interventions), medications, family history, social history (including psychosocial factors) that specifically contribute to the Present Illness. Include pertinent positives and negatives to help the listener understand your differential diagnosis. Only include an ER course if it significantly affects/alters triage or immediate treatment decisions prior to coming to your care. Other History Include important Past Medical History (with supporting history/data). Exclude minor diagnoses without impact on current care. Include important meds with doses of relevant ones. Omit unimportant medications. Include allergies. Include focused Family History/Social History/Review of Systems. Do not repeat previously stated information. Physical Examination Always include general appearance and specific vitals. Include pertinent elements of examination and any abnormal findings. Note the remainder as "unremarkable." Labs/Data Include pertinent or otherwise significant labs/studies Start with basic blood tests first. It is appropriate to mention other tests as being "normal." Synthesis Consider beginning with: "And in summary ... " Assess and synthesize, avoid summarizing and regurgitating information. Demonstrate your thinking about the patient-specific differential diagnosis. If multiple issues are present, weave together or discuss lesser issues in problem list. Enumerated Problem List Start with most important problem first. Use most specific label for the problem you can. Avoid labeling a problem solely by its organ system. Include your understanding of the cause of the problem. Include a diagnostic and/or therapeutic specific plan for addressing it.
"Steps to Promote Optimal Weight
Measure BMI and waist circumference. -Adults with a BMI ≥25 kg/m2, men with waist circumferences >40", and women with waist circumferences >35" are at increased risk for heart disease and obesity-related diseases. -Measuring the waist-to-hip ratio (waist circumference divided by hip circumference) may be a better risk predictor for individuals older than 75 years. Ratios >0.95 in men and >0.85 in women are considered elevated. Determine additional risk factors for cardiovascular diseases, including smoking, high blood pressure, high cholesterol, physical inactivity, and family history. Assess dietary intake. Assess the patient's motivation to change. Provide counseling about nutrition and exercise.
You should provide information relative to Adult Illnesses in each of four areas:
Medical Surgical Obstetric/gynecologic Psychiatric *You should also cover selected aspects of Health Maintenance, including Immunizations, and Screening Tests, together with the results and the dates they were last performed. If the patient does not know this information, written permission may be needed to obtain old medical records.
________, which guide our professional behavior, are not static, but several principles have guided clinicians throughout the ages.
Medical ethics
_____ are the single most common modifiable risk factor associated with falls.
Medications
Clues to Alcohol-Use Disorders in Older Adults
Memory loss, cognitive impairment Depression, anxiety Neglect of hygiene, appearance Poor appetite, nutritional deficits Sleep disruption Hypertension refractory to therapy Blood sugar control problems Seizures refractory to therapy Impaired balance and gait including falls Recurrent gastritis and esophagitis Difficulty managing warfarin dosing Use of other substances that may lead to addiction such as sedatives or opioid analgesics, illicit drugs, nicotine
Carcinoma of mouth/oral cancers
Men age >50 years, smokers, and heavy users of chewing tobacco and alcohol are at highest risk for cancers of the tongue and oral cavity, usually squamous cell carcinomas on the side or base of the tongue. Any persistent nodule or ulcer, red or white, is suspect, especially if indurated. These discolored lesions represent erythroplakia and leukoplakia, respectively, and should be biopsied.
Gold standard of BP measurement
Mercury sphygmomanometer
Visual Field Defects
Meyer loop: inferior retina; loops around inferior horn of lateral ventricle. Dorsal optic radiation: superior retina; takes shortest path via internal capsule.
Screening for Dementia: The Mini-Cog
Mini-Cog" Test Quick method for assessing dementia. If abnormal, screen further with MMSE. Use these two methods: the clock drawing test with word recall test (three unrelated words). Instruct patient to draw a clock and mark it with the hands showing a certain time. Example: Instruct patient to "Draw a clock that shows 20 minutes past 4." -Scoring clock test: Hands point to the correct time and numbers on clock are in correct sequence question will ask you to identify the MMSE "activity" that is being performed.
best-known screening test for dementia but is now copyrighted for commercial use, so is less accessible.
Mini-Mental State Examination Recommended screening tests now include the Mini-Cog and the Montreal Cognitive Assessment (MoCA)
When to refer or provide treatment (psych)
Moderate to severe symptoms Threat to self or others Positive screens for suicide and severe depression Positive drug or alcohol screenings
Review of Systems
Mostly pertains to symptoms If illnesses remembered, put them in PMH section Move major health events to HPI also Use a head to toe approach for questions
Hereditary Hemorrhagic Telangiectasia (Osler-Weber-Rendu syndrome)
Multiple small red spots on the lips strongly suggest hereditary hemorrhagic telangiectasia, an autosomal dominant endothelial disorder causing vascular fragility and arteriovenous malformations (AVMs). Telangiectasias are also visible on the oral mucosa, nasal septal mucosa, and fingertips. Nosebleeds, gastrointestinal bleeding, and iron deficiency anemia are common. AVMs in the lungs and brain can cause life-threatening hemorrhage and embolic disease.
Tinnitus is a common symptom, increasing in frequency with age. When associated with fluctuating hearing loss and vertigo, suspect
Ménière disease
Vertigo with hearing loss and nystagmus typifies
Ménière disease.
Facts about Unhealthy Weight and Diabetes Mellitus
Nearly 38% of U.S. adults are obese, including about 8% who are severely obese. The prevalence of obesity is highest among non-Hispanic black females (56.9%) and Hispanic females (45.7%). The lowest prevalence is among Asian males (11.2%) and Asian females (11.9%). Overweight and obesity are associated with a 20% increased risk for all-cause mortality. An estimated 23.4 million U.S. adults have diagnosed diabetes and 7.6 million adults have undiagnosed diabetes. The prevalence varies by sex and race/ethnicity. Diabetes is a major risk factor for cardiovascular disease and was either a cause or contributor to more than 330,000 deaths in 2015.
Common or Concerning Symptoms of the neck
Neck mass or lump Thyroid mass, nodule, or goiter Neck pain (See Chapter 23: Musculoskeletal System, pp. 752-753.) Headache (See Chapter 24: Nervous System, pp. 852-854.)
Psych assmt. includes:
Nervousness, tension, mood, including depression, memory change, suicide attempts, if relevant.
Which patients require a comprehensive health history?
New patients in the office or acute care setting (However, in many situations a more flexible focused, or problem- oriented, interview may be appropriate.)
Infant stridor
New-onset stridor that appears following birth can be due to infections such as croup, a foreign body, or gastroesophageal reflux. Inspiratory stridor beginning at birth suggests a congenital abnormality. See Table 25-8, Abnormal Infant Cries, p. 1070.
Is it acceptable to use patient family members or friends as an interpetor?
No, confidentiality may be violated, meanings may be distorted, and transmitted information may be incomplete. Untrained interpreters may try to speed up the interview by telescoping lengthy replies into a few words, losing much of what may be significant detail.
Demographic with highest prevalence for HTN
Non-Hispanic black adults (42%) have the highest prevalence of hypertension in the United States, followed by whites (28%), Hispanics (26%), and Asians (25%).
Paralanguage
Nonlinguistic means of vocal expression: rate, pitch, tone, and so on.
Primitive Reflexes
Normally disappear within 1st year of life. May reemerge following frontal lobe lesion. Include: Moro reflex, rooting reflex, suckling reflex, Palmar and plantar reflexes, Babinski reflex see pocket guide table 25-3 for specific info on reflexes
palpating cervical lymph nodes
Note size, shape, symmetry, consistency, mobility, location, tenderness, and temperature You can usually examine both sides at once, noting both the presence of lymph nodes as well as asymmetry. For the submental nodes, however, it is helpful to feel with one hand while bracing the top of the head with the other. 1. Submental—palpate in the midline a few centimeters behind the tip of the mandible. 2. Submandibular—midway between the angle and the tip of the mandible. These nodes are usually smaller and smoother than the lobulated submandibular gland against which they lie. 3. Preauricular—palpate in front of the ear (Fig. 11-9). 4. Posterior auricular—palpate behind the ear and superficial to the mastoid process. 5. Tonsillar (jugulodigastric)—palpate at the angle of the mandible. 6. Occipital—palpate at the base of the skull posteriorly. 7. Anterior superficial cervical—palpate for these nodes anterior and superficial to the SCM muscle. 8. Posterior cervical—palpate along the anterior edge of the trapezius by flexing the patient's neck slightly forward toward the side being examined (Fig. 11-10). 9. Deep cervical chain—deep in the SCM muscle and often inaccessible to examination. Hook your thumb and fingers around either side of the SCM muscle to find them. 10. Supraclavicular—palpate deep in the angle formed by the clavicle and the SCM muscle (Fig. 11-11).
Use specific terms to describe skin lesions and rashes, including:
Number—solitary or multiple; estimate of total number Size—measured in millimeters or centimeters Color—including erythematous if blanching; if nonblanching, vascular-like cherry angiomas and vascular malformations, petechiae, or purpura Shape—circular, oval, annular, nummular, or polygonal Texture—smooth, fleshy, verrucous or warty, keratotic; greasy if scaling Primary lesion—flat, a macule or patch; raised, a papule or plaque; or fluid filled, a vesicle or bulla (may also be erosions, ulcers, nodules, ecchymoses, petechiae, and palpable purpura) Distribution/Location—including measured distance from other landmarks Configuration—grouped, annular, linear
Important Topics for Prenatal Health Promotion and Counseling
Nutrition Weight gain Exercise and physical activity Substance use including tobacco, alcohol, and illicit drugs Intimate partner violence screening Screening for perinatal depression Immunizations Prenatal laboratory screening Genetic testing and aneuploidy screening Prenatal supplementation Unintended pregnancy
History of present illness questions to ask?
O.L.D.C.A.R.T.S. Onset-when did symptoms begin? Location-where exactly do you feel the symptoms? Duration- Is this ongoing or intermittent? Characteristic- describe the symptom Aggravating and alleviating factors Related factors Treatments tried Severity
Herpes Zoster Vaccine
Offer RZV vaccine (two doses, 2 to 6 months apart) to adults 50 years and older, including adults who have had shingles or received the previous shingles vaccine. The herpes zoster vaccine effectively reduces the short-term risks for zoster and postherpetic neuralgia in adults ≥50 years.
cataracts
Opacity of the lenses visible through the pupil. Risk factors are older age, smoking, diabetes, corticosteroid use.
Absence of a red reflex suggests
Opicaity of lens (cataract), detached retina, or retinoblastoma in children
Otitis Media with Effusion
Otitis Media with Effusion is when the TM is retracted or bulging, results in impaired mobility, yellowish, air-fluid level and/or bubbles....often more bubbles will be obvious. Note the presence of some hyperemia.
High-Yield Screening Questions for Office Practice: Anxiety
Over the past 2 weeks, have you been feeling nervous, anxious, or on edge? Over the past 2 weeks, have you been unable to stop or control worrying? Over the past 4 weeks, have you had an anxiety attack— suddenly feeling fear or panic?
allergic rhinitis
Pale boggy nasal mucosa is common with allergic rhinitis.
Skin Color and Obvious Lesions. Inspect for any changes in skin color, scars, plaques, or nevi.
Pallor, cyanosis, jaundice, rashes, bruises, or mottling of the extremities should be pursued.
conditions that can mimic depressive symptoms
Parkinson disease, traumatic brain injury (TBI), recent myocardial infarction (MI) or stroke, and hypothyroidism, alcohol/substance use
Sexual History: The 5 P's
Partners Prevention of pregnancy Protection from STDs Practices Past history of STDs Plus
Key Components of the Full-Body Skin Examination
Patient Position—Seated Inspect the hair and scalp (distribution, texture, and quantity). Inspect the head and neck, including forehead, eyebrows, eyelids, eyelashes, conjunctivae, sclerae, nose, ears, cheeks, lips, oral cavity, chin, and beard. Inspect the upper back. Inspect the shoulders, arms, and hands including palpation of fingernails. Inspect the chest and abdomen. Inspect the anterior thighs and legs. Inspect the feet and toes including soles, interdigital areas, and toenails. Patient Position—Standing Inspect the lower back. Inspect the posterior thighs and legs. Inspect the breasts, axillae, and genitalia including axillary and pubic hair. Alternative positioning is having the patient supine then prone. The systematic flow of examination from head to foot anteriorly to posteriorly remains.
Perforation of the Tympanic Membrane
Perforations are holes in the eardrum, usually from purulent infections of the middle ear. They may be central, if not involving the edge of the drum, or marginal, when the edge is involved. When perforations heal the membrane covering the perforation may be notably thin and transparent; this is called a monomer and may be difficult to distinguish from a true perforation. The more common central perforation is illustrated here. A reddened ring of granulation tissue surrounds the perforation, indicating chronic infection. The tympanic membrane itself is scarred, and no landmarks are visible. Discharge from the infected middle ear may drain out through the perforated opening, which often closes in the healing process, as in the next photo. There may be associated earache or even hearing loss, especially if the perforations are large.
Improving Medication Safety among Older Adults
Perform a thorough medication history includes name, dose, frequency, and the patient's view of the reason for taking each drug. Ask the patient to bring in all medication bottles and over-the-counter products to develop an accurate medication list. Complete a medication reconciliation at every visit especially after care transitions. Explore all components of polypharmacy—a major cause of morbidity—including suboptimal prescribing, concurrent use of multiple drugs, underuse, inappropriate use, and nonadherence. Ask specifically about over-the-counter products; vitamin and nutritional supplements; and mood-altering drugs such as opioids, benzodiazepines, and recreational substances. Assess medications for drug interactions.
Risk Factors for Melanoma
Personal or family history of previous melanoma ≥50 common moles Atypical or large moles, especially if dysplastic Red or light hair Solar lentigines (acquired brown macules on sun-exposed areas) Freckles (inherited brown macules) Ultraviolet radiation from heavy sun exposure, sunlamps, or tanning booths Light eye or skin color, especially skin that freckles or burns easily Severe blistering sunburns in childhood Immunosuppression from human immunodeficiency virus (HIV) or from chemotherapy Personal history of nonmelanoma skin cancer
activities of daily living (ADLs)
Physical ADLs: bathing, dressing, toileting, transfers, continence, feeding, managing money Instrumental ADLs: Using the telephone, Shopping, Preparing food, Housekeeping, Laundry, Transportation, Taking medicine
nasal polyps
Polyps are sack-like growths of tissue which may be inflamed. They can obstruct breathing if too large. Polyps are common with chronic allergic rhinitis, chronic sinusitis, asthma and CF
Which incidences increase the likeliness of malnutrition?
Poverty, old age, social isolation, physical disability, emotional or mental impairment, lack of teeth, ill-fitting dentures, alcoholism, and drug abuse increase the likelihood of malnutrition.
telogen effluvium
Premature shedding of hair
The Sequence and Context of the Interview
Preparation: Reviewing the clinical record. Setting goals for the interview. Reviewing your clinical behavior and appearance. Adjusting the environment. ● The Sequence of the Interview: Greeting the patient and establishing rapport. Taking notes. Establishing the agenda for the interview. Inviting the patient's story. Identifying and responding to emotional cues. Expanding and clarifying the patient's story. Generating and testing diagnostic hypotheses. Sharing the treatment plan. Closing the interview and the visit. Taking time for self-reflection. ● The Cultural Context of the Interview: Demonstrating cultural humility—a changing paradigm.
Immunizations
Process of inducing or providing immunity by administering an immunobiologic agent. • Cornerstone of public health • Significantly contributed to the prevention and control of infectious diseases everywhere. • Immunity can be active or passive.
peripheral cataract
Produces spoke-like shadows that point—gray against black, as seen with a flashlight, or black against red with an ophthalmoscope. A dilated pupil, as shown here, facilitates this observation.
Tips for Communicating Effectively with Older Adults
Provide a well-lit, moderately warm setting with minimal background noise, chairs with arms, and access to the examining table. Face the patient and speak in low tones; make sure the patient is using glasses, hearing devices, and dentures, if needed. Adjust the pace and content of the interview to the stamina of the patient; consider two visits for initial evaluations. Allow time for open-ended questions and reminiscing; include family and caregivers when indicated, especially if the patient has cognitive impairment. Make use of screening instruments, the clinical record, and reports from other health disciplines. Provide written instructions and make sure they are in large print and easy to read. Always give the patient an updated medication list that includes the name of the medication, dosage instructions, and why the medication is being prescribed.
Influenza Vaccine
Provide flu shots to everyone aged 6 months or older and especially to those with chronic pulmonary conditions, nursing home residents, household contacts, and healthcare personnel during the flu season including pregnant women during any trimester.
Ptosis
Ptosis is a drooping of the upper lid. Causes include senescence, myasthenia gravis, damage to the oculomotor nerve (CN III), and damage to the sympathetic nerve supply (Horner syndrome). A weakened muscle, relaxed tissues, and the weight of herniated fat may cause senile ptosis. Ptosis may also be congenital.
otoscopic exam in children
Pull the pinna straight down and hold otoscope "upside down"
Tonic Pupil (Adie Pupil)
Pupil is large (dilated), regular, and usually unilateral. Reaction to light is severely reduced and slowed, or even absent. Constriction during the near vision is present, although very slow (tonic). These changes reflect parasympathetic denervation. Slow accommodation causes blurred vision.
Mental Health Screening Tools
ROS - Subjective - History of Mental Health Concerns Objective • Suicide Assessment: Suicide Risk Assessment • Depression Assessment: PHQ_9 • Anxiety Assessment: GAD7 • Cognitive Impairment Assessments: MMSE & MoCA Test
What are three obvious examples of issues that can raise biased attitudes and pose barriers during the interview?
Race, drug use, and homosexual practices
Skin assmt includes
Rashes, lumps, sores, itching, dryness, color change, changes in hair or nails.
Human Papillomavirus Vaccine
Recommend HPV vaccination for females and males starting at age 11 or 12 years (as early as age 9 years); females age 13 through 26 years and for males age 13 through 21 years who have not been vaccinated previously or who have not completed the vaccination series; and MSM ages 22 through 26 or men who are immunocompromised. For men, the vaccine can prevent HPV-related diseases (genital warts, anal cancer, and penile cancer), lower the risk of oropharyngeal cancers, and possibly reduce HPV transmission to female sexual partners.
Varicella Vaccine
Recommend VAR to adults born in the United States in 1980 or later who have not received two doses of chickenpox vaccine or never had chickenpox. A two-dose series of varicella vaccine is recommended for children under age 13 and those aged 13 and older who were previously unvaccinated and who have no evidence of immunity. Live vaccines should not be given to pregnant women or people who have a very weakened immune system, which includes people with HIV infection and a CD4 count less than 200.
Hepatitis B Vaccine
Recommend a two- or three-dose series for those at risk for hepatitis B infection including those with hepatitis C virus infection, chronic liver disease, HIV infection, sexual exposure risk, current or recent injection drug use, or percutaneous or mucosal risk for exposure to blood and persons who are incarcerated or travel in countries with high or intermediate endemic hepatitis B. Persons not at risk but wanting protection from hepatitis B infection should also receive the full two- or three-dose series.
Hepatitis A Vaccine
Recommend a two-dose series for those at risk for hepatitis A infection including those with chronic liver disease or clotting factor disorders; MSM; injection or noninjection drug users; and people who are homeless, travel in countries with high or intermediate endemic hepatitis A, and who have close personal contact with international adoptee with high or intermediate endemic hepatitis A. Persons not at risk but wanting protection from hepatitis A infection should also receive the full two-dose series.
Tetanus, Diphtheria, Pertussis Vaccine
Recommend once, regardless of last Td vaccine. Offer the Td vaccine booster every 10 years. Pregnant women also need Tdap vaccine during every pregnancy.
Pregnancy Tumor (Pregnancy Epulis or Pyogenic Granuloma)
Red purple papules of granulation tissue form in the gingival interdental papillae, in the nasal cavity, and sometimes on the fingers. They are red, soft, painless, and usually bleed easily. They occur in 1-5% of pregnancies and usually regress after delivery. Note the accompanying gingivitis.
Sinus Infection
Red, inflamed nasal mucosa with drainage is commonly seen in sinus infections.
optic disc
Region at the back of the eye where the optic nerve meets the retina. It is the blind spot of the eye because it contains only nerve fibers, no rods or cones, and is thus insensitive to light.
THE TAVISTOCK PRINCIPLES
Rights: People have a right to health and health care. Balance: Care of individual patients is central, but the health of populations is also our concern. Comprehensiveness: In addition to treating illness, we have an obligation to ease suffering, minimize disability, prevent disease, and promote health. Cooperation: Health care succeeds only if we cooperate with those we serve, each other, and those in other sectors. Improvement: Improving health care is a serious and continuing responsibility. Safety: Do no harm. Openness: Being open, honest, and trustworthy is vital in health care
Risk factors for AD
Risk factors include advancing age, family history, and the gene mutation apolipoprotein (APOE) ∊4. Risk of AD more than doubles in first-degree relatives. Risk doubles in the presence of one APOE ∊4 allele and increases fivefold or more in the presence of two alleles, although only 2% of the population carries these genes.44
Risk factors for delirium
Risk for developing delirium depends on both predisposing conditions that increase susceptibility and the immediate precipitating factors. Delirium is common in hospitalized general medical patients; rates are even higher following major elective surgeries. Intensive care unit admissions are associated with a high incidence of delirium regardless of age. Even though delirium is associated with poor patient outcomes, more than 50% of cases are undetected.
Tori Mandibularis.
Rounded bony growths on the inner surfaces of the mandible are typically bilateral, asymptomatic, and harmless.
SOAP progress notes
S: the subjective component that represents the patient's perspective about their problems O: The objective component, describes the clinician's observations. A: the assessment component, provides the clinician's analysis of the information contained in the subjective and objective sections of the note. Finally, P: the plan component, describes the treatment plan, including the planned frequency of visits, etc, any recommendations made, and when appropriate, the patient's prognosis. Always sign and date the notes each time you write them.
common textures in skin disorders
Scaling can be greasy, like seborrheic dermatitis or seborrheic keratoses, dry and fine like tinea pedis, or hard and keratotic like actinic keratoses or SCC.
Scar tissue of ear
Scar tissue can appear within the ear from otitis media, perforated TM, and/or trauma
Important Topics for Health Promotion and Counseling for mental health
Screening for depression Assessing for suicide risk Screening for neurocognitive disorders: dementia and delirium Screening for substance use disorders, including misuse of alcohol and prescription drugs
Edinburgh Postnatal Depression Scale (EPDS)
Screening test used to identify depression during pregnancy or in the postpartum period The EPDS includes anxiety symptoms, which are a prominent feature of perinatal mood disorders, and excludes constitutional symptoms of depression, such as changes in sleeping patterns, that are common in pregnancy and the postpartum period. The EPDS has relatively high sensitivity and specificity.
Screening and Counseling Guidelines for Adults:Unhealthy Alcohol Use
Screening tools: • The Single Alcohol Screening Question (SASQ) • The Alcohol Use Disorders Identification Test- Consumption (AUDIT-C) • CAGE tool • Patients with positive screens ask about blackouts, seizures, accidents or injuries while drinking, job loss, marital conflict, legal problems, and drinking while driving or operating machinery.
_______ is a continual part of professional development in clinical work. It brings a deepening personal awareness to our work with patients and is one of the most rewarding aspects of providing patient care.
Self-reflection
Social History Domains
Sexual orientation and gender identity (SOGI) Personal geographic map Significant relationships Local support systems Work history/occupation Education Lifestyle Activities of daily living Nutrition Exercise Alcohol use Tobacco use Illicit drug use Safety measures Spirituality Sexual history
When assessing the adolescent, how do you establish rappoprt?
Show interest early and then sustain connection through communication
Xanthelasma
Slightly raised, yellowish, well-circumscribed cholesterol-filled plaques that appear along the nasal portions of one or both eyelids. Half of affected patients have hyperlipidemia; it is also common in primary biliary cirrhosis.
Bullous Myringitis
Small vesicles containing blood on the drum; accompany mucoplasma pneumonia and virus infections
Tophi
Small, whitish yellow, hard, nontender nodules in or near helix or antihelix; contain greasy, chalky material of uric acid crystals and are a sign of gout.
Atrophic Glossitis
Smooth, beefy red tongue is consistent with Atrophic Glossitis. This often indicates a possible B complex vitamin deficiency, iron deficiency or chemotherapy.
Light-Colored Spots in the Fundi
Soft Exudates: Cotton-Wool Spots Hard Exudates Drusen Healed Chorioretinitis
Common or Concerning Symptoms of the throat and mouth
Sore throat Gum swelling/bleeding gums Hoarseness Malodorous breath (halitosis)
Carcinoma of the Lip
Squamous cell carcinoma usually affects the lower lip; may appear scaly plaque with or without crust or as a nodular lesion
Determining the Patient's Height
Stadiometers are devices specifically designed for the accurate measurement of height. Ask the patient to stand on the stadiometer, facing forward as tall and straight as possible with arms hanging loosely at the sides. The patient's feet should be flat on the baseplate of the stadiometer and positioned slightly apart, in line with the hips, to aid balance. The patient's knees should be straight, and the buttocks and shoulders should touch the stadiometer. Ensure the patient's head is in the midline position—an imaginary line from the center of the earhole to the lower border of the eye socket. Bring the headplate down onto the head, ensuring it rests on the crown of the head (i.e., the top back half). Read the measurement. Your eyes should be level with the counter/pointer and measurement read to the nearest 1 mm. Record the measurement and assist the patient off the stadiometer. Should you be making repeated measurements on the same individual on different days, it is advisable to measure at the same time of day if possible. Throughout the day, height decreases due to compression of the spine.
Managing Chronic Pain: Steps for Measurement-Based Care
Step 1: Measure pain intensity and pain interference. A validated two-item questionnaire is available for primary care asking patients to rate pain in the past month and interference with daily activities on a scale of 1 to 10. Step 2: Measure mood. Treatable depression, anxiety, and posttraumatic stress disorder (PTSD) frequently accompany chronic pain. The PHQ-4 is a four-item questionnaire for detecting anxiety and depression. The Primary Care-PTSD is a four-question screen for PTSD. Step 3: Measure the effect of pain on sleep. Opioid doses correlate with sleep-disordered breathing and sleep apnea. Step 4: Measure risk of co-occurring substance abuse, estimated at 18% to 30%. Step 5: Measure the opioid dose and calculate the opioid dose equivalency using available web-based calculators.
Serous Effusion
Sterile fluid accumulation in the middle ear
Serious Effusion
Sterile fluid accumulation in the middle ear Here is an example of a serious otitis/middle ear effusion with fluid bubbles. Note how the light reflex (cone of light) is DULL and displaced. When fluid bubbles are present, the eustachian tube is potentially open and not completely blocked.
______ typically produces white or yellow exudates on the tonsils or posterior pharynx, a beefy-red uvula, and palatal petechiae
Streptococcal pharyngitis
Assessing Cranial Nerves in a Comatose Patient
Structural lesions from stroke, abscess, or tumor mass may lead to asymmetrical pupils and loss of the light reaction. In structural hemispheric lesions, the eyes "look at the lesion" in the affected hemisphere. In a unilateral pontine lesion or in seizure affecting one hemisphere, the eyes "look away" from the affected side. In a comatose patient with absent doll's eye movements, the eyes continue to look straight ahead, with no movement relative to head position. This is suspicious for a lesion of the midbrain or pons. Blinking is absent in both eyes in CN V lesions and on the side of weakness in lesions of CN VII. Absent blinking and sensorineural hearing loss occur in acoustic neuroma.
________________ is one of the most challenging tasks for any beginning student.
Structuring how to document the HPI in the clinical record
Newborns: A unilateral dark, purplish lesion, or "port wine stain" over the distribution of the ophthalmic branch of the trigeminal nerve may be a sign of
Sturge-Weber syndrome, which is associated with seizures, hemiparesis, glaucoma, and mental retardation.
Eye Medical Emergencies
Sudden Blindness Flashing light or spots moving in front of eyes Eye pain in and around the eyes
Describing Primary Skin Lesions: Flat, Raised, and Fluid-Filled
Table 10-1
Systemic Diseases and Associated Skin Findings
Table 10-10
Acne Vulgaris—Primary and Secondary Lesions
Table 10-11
Signs of Sun Damage
Table 10-12
Pressure Injuries
Table 10-13
Additional Primary Lesions: Pustules, Furuncles, Nodules, Cysts, Wheals, Burrows
Table 10-2
Dermatology Safari: Benign Lesions
Table 10-3
Rough Lesions: Actinic Keratoses, Squamous Cell Carcinoma, and Their Mimics
Table 10-4
Pink Lesions: Basal Cell Carcinoma and Its Mimics
Table 10-5
Brown Lesions: Melanoma and Its Mimics
Table 10-6
Hair Loss
Table 10-8
Findings in or Near the Nails
Table 10-9
Neurocognitive Disorders: Delirium and Dementia
Table 9-2
Erosion of Teeth
Teeth may be eroded by chemical action. Note here the erosion of the enamel from the lingual surfaces of the upper incisors, exposing the yellow-brown dentin. This results from recurrent regurgitation of stomach contents, as in bulimia.
Semantic qualifiers
Terms used to compare and contrast - Acute vs chronic - dull vs sharp - proximal vs distal etc.
Weber test
Test done by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate in which ear the tone can be heard. Done when bilateral hearing loss is suspected.
Key Components of the Examination of the Nervous System (Cranial Nerves Only)
Test sense of smell (I) Test visual acuity in each eye (II) Inspect optic fundi with an ophthalmoscope (disc bulging, blurred margins, pallor, cup enlargement) (II) Test visual fields by confrontation (visual field defects) (II) Inspect size and shape of pupils (size, asymmetry) (II, III) Test pupillary reactions to light (II, III) Check pupillary constriction, convergence, and lens accommodation (II,III) Test extraocular movements (asymmetry, weakness, palsy, nystagmus) (III,IV, VI) Palpate temporal and masseter muscles (motor weakness) (V) Test sensation in face (sensory loss) (V) Inspect face (asymmetry, lower lid droop, abnormal movements) (VII) Test muscles of facial expression: raise eyebrows, frown, close eyes tightly against resistance, show teeth, smile, puff cheeks (asymmetry) (VII) Assess gross hearing with whispered voice test (VIII) Determine hearing loss with tuning fork tests (Rinne and Weber if indicated) (VIII) Assess swallowing and palate/uvula movement (IX, X) Assess speech (articulation, voice quality) (V, VII, IX, X, XII) Test trapezii or sternocleidomastoid strength against resistance (weakness, asymmetry) (XI) Inspect and test tongue movement (deviation, atrophy, fasciculations) (XII)
Key Components of the Ophthalmologic Examination
Test visual acuity using a Snellen eye chart. Test visual fields by confrontation. Test color vision and contrast sensitivity. Assess position and alignment of the eyes (protrusion, deviation). Inspect eyebrows (fullness, distribution, scaliness). Inspect eyelids and eyelashes (width, edema, color, lesions, eyelid closure). Assess the lacrimal apparatus (lumps, swelling, tearing, dryness). Inspect the conjunctivae and sclerae (vascular pattern, color, nodules, swelling). Inspect the cornea, iris, and lens (opacity, anterior chamber depth). Inspect the pupils (size, shape, symmetry). Test for pupillary reaction to light (direct and consensual light reactions). Inspect the light reflection in the corneas. Test the extraocular muscle movements. Perform ophthalmoscopic (funduscopic) examination including optic disc and cup,retina, and retinal vessels.
Facts about Unhealthy Alcohol Use
The 2017 NSDUH estimated that more than 140 million Americans aged 12 years and older were current alcohol users based on consumption of alcoholic beverages in the past 30 days. 16.7 million were classified as heavy drinkers, and 66.6 million were classified as binge drinkers. An estimated 16 million Americans met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) definition for alcohol use disorder based on meeting criteria for dependence or abuse.
iron supplementation in pregnancy
The CDC recommends 30 mg/day of oral iron supplementation be started at the first prenatal visit
Assessment tool for delirum
The Confusion Assessment Method (CAM) (Box 9-11) is recommended for screening at-risk patients. The CAM instrument can quickly and accurately detect delirium at the bedside.
Screening for Dementia: The Montreal Cognitive Assessment (MoCA)
The Montreal Cognitive Assessment (MoCA) was designed as a rapid screening instrument for mild cognitive dysfunction. It assesses different cognitive domains: attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. Time to administer the MoCA is approximately 10 minutes.
Screening for Substance Use Disorders
The National Institute on Drug Abuse (NIDA) recommends first asking a highly sensitive and specific single question: "How many times in the past year have you used an illegal drug or used a prescription medication for nonclinical reasons? • If the response is positive, ask specifically about nonclinical use of illicit and prescription drugs. Once you identify substance abuse, continue with questions.
Screening Recommendations for HIV
The USPSTF gives a grade A recommendation for HIV screening of adolescents and adults from age 15 to 65 years and for screening all pregnant women. Screening is also recommended for younger adolescents and older adults who are at increased risk for infection. The CDC recommends universal HIV testing for adolescents and adults aged 13 to 64 years in healthcare settings and prenatal testing of all pregnant women. The CDC recommends an opt-out approach to HIV testing—notifying the patient verbally or in writing that testing will be performed unless the patient declines. Separate written consent is not required. Patients and prospective sex partners should be tested before beginning a new sexual relationship. One-time testing for low-risk patients is reasonable, but at least annual testing is recommended for high-risk groups, defined as MSM; individuals with multiple sexual partners; past or present injection drug users; persons who exchange sex for money or drugs; and sex partners of persons who are HIV infected, bisexual, or injection drug users. Patients beginning treatment for tuberculosis and those with any STI or requests for STI testing should be tested for coinfection with HIV.
Recommended tools to screen for IPV
The USPSTF recommends several screening instruments, including the Humiliation, Afraid, Rape, Kick (HARK); Hurt, Insult, Threaten, Scream (HITS); Extended-HITS (E-HITS); Partner Violence Screen (PVS); and Woman Abuse Screening Tool (WAST). The sensitivity of these tests ranged from 64% to 87% while specificity ranged from 80% to 95%.
Pharyngitis
The ability to differentiate between mononucleosis and pharyngitis is an essential for the advanced practice nurse. With pharyngitis the tonsils are red and swollen with crypts filled with purulent exudate. Enlarged anterior cervical lymph nodes, and palatal petechiae are present. A patient can develop pharyngitis after tonsillectomy.
pertinent negatives
The absence of certain signs and symptoms normally expected of specific illnesses or conditions; these findings warrant no medical care or intervention, but demonstrate the thoroughness of the patient exam and history.
acoustic blink reflex
The acoustic blink reflex is a blinking of the infant's eyes in response to a sudden sharp sound.
Horner Syndrome
The affected pupil is small, unilateral, reacts briskly to light and near effort, but dilates slowly, especially in dim light. Anisocoria is >1 mm, with ipsilateral ptosis of the eyelid and often loss of sweating on the forehead. These findings reflect the classic triad of Horner syndrome—miosis, ptosis and anhydrosis, due to a lesion in the sympathetic pathways anywhere from the hypothalamus through the brachial plexus and cervical ganglia into the sympathetic fibers of the eye. Causes include ipsilateral brainstem lesions, neck and chest tumors affecting the ipsilateral sympathetic ganglia, orbital trauma, or migraines. In congenital Horner syndrome, the involved iris is lighter in color than its fellow (heterochromia).
optic fundus
The area at the inside back of the eye that can be seen with an ophthalmoscope.
Abrasion of Teeth with Notching
The biting surface of the teeth may become abraded or notched by recurrent trauma, such as holding nails or opening bobby pins between the teeth. Unlike Hutchinson's teeth, the sides of these teeth show normal contours; size and spacing of the teeth are unaffected.
Causes of hypothermia
The chief cause of hypothermia is exposure to cold. Other causes include reduced movement as in paralysis, interference with vasoconstriction from sepsis or excess alcohol, starvation, hypothyroidism, and hypoglycemia. Older adults are especially susceptible to hypothermia and also less likely to develop fever.
external ear
The external ear comprises the auricle and ear canal. The auricle consists chiefly of cartilage covered by skin and has a firm elastic consistency. Its prominent curved outer ridge is the helix. Parallel and anterior to the helix is another curved prominence, the antihelix. Inferiorly is the fleshy projection of the earlobe, or lobule. The ear canal opens behind the tragus, a nodular protrusion that points backward over the entrance to the canal
Cushing Syndrome
The increased adrenal cortisol production of Cushing syndrome produces a round or "moon" face with red cheeks. Excessive hair growth may be present in the mustache, sideburn areas, and chin (as well as the chest, abdomen, and thighs).
Acromegaly
The increased growth hormone of acromegaly produces enlargement of both bone and soft tissues. The head is elongated, with bony prominence of the forehead, nose, and lower jaw. Soft tissues of the nose, lips, and ears also enlarge. The facial features appear generally coarsened.
Strategies That Promote Weight Loss
The most effective diets combine realistic weight loss goals with exercise and behavioral reinforcements. Encourage patients to walk 30 to 60 minutes 5 or more days a week, or a total of at least 150 minutes a week. The total calorie deficit goal, usually 500 to 1,000 kilocalories a day, is more important than the type of diet. Since many types of diets have been studied and appear to confer similar results, support the patient's preferences as long as they are reasonable. Encourage proven behavioral habits such as portion-controlled meals, meal planning, food diaries, and activity records. Follow professional guidelines for pharmacologic therapies and surgical procedures in patients having high weights and morbidities who do not respond to conventional treatment. Reducing weight by even 5% to 10% can improve blood pressure, lipid levels, and glucose tolerance, and reduce the risk of diabetes or hypertension.
Present illness should include
The narrative should include the onset of the problem, the setting in which it has developed, its manifestations, and any treatments. What effect has it had on the patient's life?
Revised Pressure Injury Staging System
The new revised staging system uses the term injury instead of ulcer and denotes stages using Arabic numerals rather than Roman numerals Stage 1: Intact skin with a localized area of nonblanchable erythema, which may appear differently in darkly pigmented skin. Stage 2: Partial-thickness loss of skin with exposed dermis Stage 3: Full-thickness skin loss, in which adipose (fat) is visible in the ulcer and granulation tissue and rolled wound edges, is often present. Stage 4: Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone in the ulcer. Unstageable: Full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because it is obscured by slough or eschar. Deep tissue pressure injury: Persistent nonblanchable deep red, maroon, or purple discoloration.
Assessing EOMs
The normal conjugate movements of the eyes in each direction. Note any deviation from normal (strabismus), or dysconjugate gaze. Nystagmus, a fine rhythmic oscillation of the eyes. A few beats of nystagmus on extreme lateral gaze are normal. If you see this, bring your finger in to within the field of binocular vision and look again. Lid lag as the eyes move from up to down.
Chief complaint
The one or more symptoms or concerns causing the patient to seek care usually one sentence
obstetric visit exam includes
The physical examination findings at every visit should include vital signs (especially blood pressure and weight), fundal height, verification of fetal heart rate (FHR), and determination of fetal position and activity, as described in Techniques of Examination to follow. At each visit, the urine should be tested for infection, glucose, and protein.
Clinical/Diagnostic Reasoning
The process by which clinicians • collect cues • process the information • come to an understanding of a patient problem or situation • plan and implement interventions • evaluate outcomes • reflect on and learn from the process
Small, Irregular Pupils (Argyll Robertson Pupils)
The pupils are small, irregular and usually bilateral. They constrict with near vision and dilate with far vision (a normal near reaction) but do not react to light, seen in neurosyphilis and rarely in diabetes.
what kind of setting should you examine the eyes during exam?
The room should be darkened for the ophthalmoscopic examination. This promotes papillary dilation and visibility of the fundi.
Standard BP cuff size
The standard cuff is 12 × 23 cm, appropriate for arm circumferences up to 28 cm.
thyroid in various conditions
The thyroid is soft in Graves disease and may be nodular; it is firm in Hashimoto thyroiditis (though not always uniformly) and malignancy. The thyroid is tender in thyroiditis.
Otoscopic Findings
The tympanic membrane is pearly gray. The cone of light or the "Light Reflex" is located and the presence of cerumen is noted. Along with the assessment of the tympanic membrane's color and contour the presence of a myringotomy tube or any damage such as perforations or scarring is also noted.
Recording Behavior and Mental Status
These findings suggest depression.
Testing for Aphasia
These questions help identify the type of aphasia.
At what age should drug and alcohol abuse be assessed?
These topics should be introduced, along with tobacco use, in front of the parent with children at ages 6 or 7.
Hertel Exophthalmometer
This instrument measures the distance between the lateral angle of the orbit and an imaginary line across the most anterior point of the cornea. The upper limits of normal are 20 to 22 mm.
Acute Necrotizing Ulcerative Gingivitis
This uncommon form of gingivitis occurs suddenly in adolescents and young adults and is accompanied by fever, malaise, and enlarged lymph nodes. Ulcers develop in the interdental papillae. Then the destructive (necrotizing) process spreads along the gum margins, where a grayish pseudomembrane develops. The red, painful gums bleed easily; the breath is foul.
Tips for Draping the Patient
Thoughtful draping preserves the patient's modesty and helps you focus on the area being examined. With the patient sitting, for example, untie the gown in back to better listen to the lungs. For the breast examination, with the patient supine, uncover the right breast but keep the left chest draped. Drape the right chest again, then uncover the left chest and proceed to examine the left breast and heart. For the abdominal examination, only the abdomen should be exposed. Adjust the gown to cover the chest and place the sheet or drape at the inguinal level. To help the patient prepare for potentially awkward segments of the examination, briefly describe your plans before starting, for example, "Now I am going to move your gown so I can check the pulse in your groin area," or "Because you mentioned irritation, I am going to inspect your perirectal area."
Memory Aids for Generating Differential Diagnosis
Toxin/Trauma including medications Oncologic Musculoskeletal/Rheumatologic Gastrointestinal Pulmonary Renal Infectious Neurologic Cardiovascular Endocrine Metabolic/Genetic Dermatologic Psychiatric Genitourinary/Gynecologic Hematologic VINDICATE Vascular Infectious Neoplastic Drug related Inflammatory/Idiopathic/Iatrogenic Congenital Autoimmune/Allergic Trauma/Toxic Endocrine/Metabolic"
Causes of septal perforation include
Trauma, surgery, intranasal use of cocaine or amphetamines
For patients who cannot identify the English alphabet, there are other options to test vision.
Tumbling "E's" can be used, in which the patient points to the direction of the open face of the letter "E." Allen cards display standardized pictures that can be recognized by children over the age of 2 years.
Watch for very short stature in
Turner syndrome, childhood renal failure, and achondroplastic and hypopituitary dwarfism;
Two or more yes responses to CAGE questionnaire
Two or more affirmative answers to the CAGE Questionnaire suggest alcoholism. They indicate that you need to ask more questions about blackouts (loss of memory for events during drinking), seizures, accidents or injuries while drinking, job loss, marital conflict, or legal problems. Also ask specifically about drinking while driving or operating machinery.
pregnant patient write up
Typically, the record for a pregnant patient follows a standard order: age, Gs and Ps, weeks of gestation, means of determining gestational age (ultrasound vs. LMP), followed by chief complaint, chief pregnancy complications, then important history
Chancre of Primary Syphilis
Ulcerated papule with an indurated edge; appears 3-6 weeks after initial infection infection from the spirochete Treponema pallidum.
BMI ranges in children
Underweight is <5th percentile, at risk of overweight is ≥85th percentile, and overweight is ≥95th percentile.
Screening and counseling guidelines for adults include:
Unhealthy alcohol use Tobacco misuse Sexually transmitted infections (STIs) (chlamydia, gonorrhea, and syphilis) HIV/AIDS
Equal Pupils and One Blind Eye
Unilateral blindness does not cause anisocoria as long as the sympathetic and parasympathetic innervation to both irises is normal. A light directed into the seeing eye produces a direct reaction in that eye and a consensual reaction in the blind eye. A light directed into the blind eye, however, causes no response in either eye.
Responding to emotional cues of patient
Use feedback, continuers, and reflection
Problem Focused Patient History
Useful for determining diagnosis and treatment Focused on presenting problem
General assessment includes:
Usual weight, recent weight change, any clothes that fit more tightly or loosely than before. Weakness, fatigue, fever
Constitutional symptoms
Usual weight, weight changes, fever, weakness, fatigue Found in HPI
_____ are the standards we use to measure our own and others' beliefs and behaviors. These may appear to be absolutes.
Values
What factors vary the reliability of the health history?
Varies according to the patient's memory, trust, and mood
Facial Expression
Watch for the stare of hyperthyroidism, the immobile facies of parkinsonism, and the flat or sad affect of depression. Decreased eye contact may be culture- specific or suggest anxiety, fear, or sadness.
Subjective Data
What the patient tells you The history, from chief complaint through Review of Systems Example: Mrs. G is a 54-year-old hairdresser who reports pressure over her left chest "like an elephant sitting there," which goes into her left neck and arm.
Objective Data
What you detect on the examination All physical examination findings Example: Mrs. G is an older white female, deconditioned, pleasant, and cooperative. BP 160/80, HR 96 and regular, respiratory rate 24, afebrile.
When Does It Make Sense to Consider Screening for a Disease or Condition?
When a disease or condition causes substantial public health burden. When the natural history is well understood and there is a recognized latent or early symptomatic stage. When screening tests are available, acceptable, and accurate. When treatment for patients with clinically detected disease is available, acceptable, and more effective when delivered at the time of screening diagnosis. When screening programs are cost-effective. When net health benefits of screening outweigh the harms.
When does it make sense to consider screening?
When a disease or condition causes substantial public health burden. When the natural history is well understood and there is a recognized latent or early symptomatic stage. When screening tests are available, acceptable, and accurate. When treatment for patients with clinically detected disease is available, acceptable, and more effective when delivered at the time of screening diagnosis. When screening programs are cost-effective. When net health benefits of screening outweigh the harms.
Examining ophthalmic fundus of patient with surgically removed lens
When the lens has been removed surgically, its magnifying effect is lost. Retinal structures then look much smaller than usual, and you can see a much larger expanse of the fundus.
In left-sided optic nerve damage, the pupils usually react as follows:
When the light beam shines into the normal right eye, there is brisk constriction of both pupils (direct response on the right and consensual response on the left). When the light swings over to the abnormal left eye, partial dilation of both pupils will occur. The afferent stimulus on the left is reduced, so the efferent signals to both pupils are also reduced and a net dilation occurs. This demonstrates an afferent pupillary defect, sometimes termed a Marcus Gunn pupil.
BP categories for adults
When the systolic and diastolic levels fall in different categories, use the higher category. For example, 170/88 mm Hg is stage 2 hypertension; 136/78 mm Hg is stage 1 hypertension.
Important Topics for Health Promotion and Counseling in the Older Adult
When to screen Screening for visual and hearing impairments Exercise and physical activity Household safety and fall prevention Immunizations Cancer screening Detecting the "3 Ds": delirium, dementia, and depression Elder mistreatment and abuse
Fundoscopic Findings
While examining the blood vessels it should be noted that artioles are smaller and reflect more light than venules. Persistent hypertension leads to arteriole narrowing known as "nicking" were the arterioles and venules cross. Persistent hypertension can also lead to brightly colored arterioles, with either a copper or silver wire look. Later, with further progression flame hemorrhage and cotton wool spots can develop placing the retina at increased risk for local hemorrhage or clot.
Oral Hairy Leukoplakia.
White patches Patches of the lateral tongue (#1 stie) Almost assoc w/ HIV (pre AIDS sign) Infreq seen in patients w/ other immunosupp Caused by EBV
Zosterform Lesions:
Zosterform lesions are lesions grouped in a linear format; that is they appear to form a line. Zosterform refers to lesions caused by herpes zoster. With herpes zoster lesions, the lesions are distributed along a dermatome and is unilateral.
If the thyroid gland is enlarged, listen over the lateral lobes with a stethoscope to detect
a bruit, a sound similar to a cardiac murmur but of not of cardiac origin. A localized systolic or continuous bruit may be heard in hyperthyroidism from Graves disease or toxic multinodular goiter.
macule
a circumscribed flat area of change in color of the skin <1 cm in diameter. Examples include freckles, flat moles, and port-wine stains and the rashes of rickettsial infections, rubella, and measles.
wheal
a circumscribed, raised lesion consisting of dermal edema and is also known as hives or urticaria. Wheals typically last <24 hours. Wheals are a common manifestation of hypersensitivity to drugs; stings or bites; autoimmunity; and, less commonly, physical stimuli including temperature,pressure, and sunlight.
motivational interviewing
a collaborative, person-centered form of guiding to elicit and strengthen motivation for change
astigmatism
a condition in which the eye does not focus properly because of uneven curvatures of the cornea
Asymmetry of the corneal reflections indicates
a deviation from normal ocular alignment. A temporal light reflection on one cornea, for example, indicates a nasal deviation of that eye.
presbycusis
a gradual loss of sensorineural hearing that occurs as the body ages
One-sided neglect may result from
a lesion in the opposite parietal cortex, usually the nondominant side.
differential diagnosis
a list of potential diagnoses compiled early in the assessment of the patient
In the DSM-5, dementia is classified as
a major neurocognitive disorder.
Masses in the neck may cause tracheal deviation to one side, raising suspicion of conditions in the thorax such as
a mediastinal mass, atelectasis, or a large pneumothorax
Delirium
a multifactorial syndrome, is an acute confusional state marked by sudden onset; fluctuating course; inattention; and, at times, changing levels of consciousness.
Wong-Baker FACES scale
a pain assessment tool that asks patients (often children) to select one of several faces indicating expressions that convey a range from no pain through the worst pain
vesicle
a small circumscribed elevation of the epidermis containing clear fluid <1 cm in diameter. Vesicles are characteristic of herpes infections, acute allergic contact dermatitis, and some autoimmune blistering disorders such as dermatitis herpetiformis.
papule
a small solid elevation of the skin <1 cm in diameter. Examples include nevi, warts, lichen planus, insect bites, seborrheic keratoses, actinic keratoses, some lesions of acne, and skin cancers.
nodule
a solid elevation of the skin >1 cm in diameter that usually extends into the deeper skin layers. Examples include cysts, lipomas, and fibromas.
Orthostatic hypotension is
a sustained reduction in SBP of at least 20 mm Hg or in DBP of at least 10 mm Hg within 3 minutes of standing. Causes of orthostatic hypotension include drugs, moderate or severe blood loss, prolonged bed rest, and diseases of the autonomic nervous system.
Common causes of developmental delay include
abnormalities in embryonic development, hereditary and genetic disorders, environmental and social problems, other pregnancy or perinatal problems, childhood diseases such as infection (e.g., meningitis), trauma, and severe chronic disease.
Dementia is notable for low concentration levels of
acetylcholine
Diphtheria
acute infection of the throat and upper respiratory tract caused by the diphtheria bacterium
Movement of the auricle and tragus is painful in __________ (inflammation of the ear canal), but not in ____________ (inflammation of the middle ear).
acute otitis externa; otitis media
Peripheral vision loss can be seen in
advanced open-angle glaucoma (p. 381) with unilateral loss with hemianopsia and quadrantic defects
fhr heard with audible fetoscope
after 18 weeks
When to measure fundal height?
after 20 weeks
What is defined as identifying data?
age, gender, occupation, marital status Source of the history—usually the patient, but can be family member, friend, letter of referral, or the medical record ■ If appropriate, establish source of referral, since a written report may be needed.
Risk factors for primary essential HTN
age, genetics, black race, obesity and weight gain, excessive salt intake, physical inactivity, and excessive alcohol use.
Breath odors can reveal the presence of
alcohol or acetone (diabetes), pulmonary infections, uremia, or liver failure. Never assume that alcohol on a patient's breath explains changes in mental status or neurologic findings. These changes can have serious but treatable causes such as hypoglycemia, subdural hematoma, or postictal state (the abnormal condition occurring between the end of an epileptic seizure and return to baseline condition).
Screen all older adults for
alcohol use "Use the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) to assess unhealthy alcohol use among older adults
Because early detection of at-risk behaviors may be challenging, the USPSTF recommends screening for risky or hazardous alcohol use and brief behavioral counseling interventions when indicated for
all adults in primary care settings, including pregnant women (grade B).
Potentially Infectious Fluids
all blood and other body fluids containing visible blood, semen, and vaginal secretions and cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids.
Fagan Nomogram
allows you to determine the post test probability given the pre test probability and the LR+ for a disease
Strabismus can lead to
amblyopia (lazy eye)
Medications known to cause permanent hearing loss
aminoglycosides (e.g., gentamicin) and many chemotherapeutic agents (e.g., cisplatin and carboplatin). Temporary damage to hearing may be caused by aspirin, nonsteroidal anti-inflammatory agents (NSAIDs), quinine, and loop diuretics (e.g., furosemide).
Hydrocephalus, subdural hematoma, or, rarely, brain tumor or inherited syndromes may cause
an abnormally large head size.
micrognathia
an abnormally small chin Micrognathia may also be part of a syndrome, such as the Pierre Robin syndrome.
Discharge of mucopurulent fluid from the puncta suggests
an obstructed nasolacrimal duct or a canaliculitis.
The most superficial layer, the epidermis, is a thin avascular keratinized epithelium consisting of two layers:
an outer horny stratum corneum of dead keratinized cells and an inner cellular layer, the stratum basale and the stratum spinosum, also known as the malpighian layer, where both melanin and keratin are formed. Migration from the inner to the outer layer takes approximately 1 month.
Asymmetric tonsils, particularly when associated with other symptoms, may signify
an underlying pathology such as lymphoma.
Pallor indicates
anemia
central cyanosis or pallor is seen in __
anemia
Universal newborn screening
anemia screening, blood lead levels, sickle cell disease, vision, hearing, developmental screening, and others (e.g., tuberculosis).
Affect of paranoid patient
anger, hostility, suspiciousness, or evasiveness
Older adults: Overclosure of the mouth may lead to maceration of the skin at the corners, or ________.
angular cheilitis.
Medications causing photosensitivity
antibiotics like tetracycline, doxycycline, sulfa and fluroquinolones, NSAIDs, diruetics, retenoids, Statins, epidermal growth factor receptor inhibitors, neuroleptics, and many others
Compulsions, obsessions, phobias, and anxieties often occur in _______ disorders.
anxiety
Low concentrations of serotonin with high levels of norepinephrine have been associated with .
anxiety symptoms
Depression, particularly recurrent/chronic depression, is frequently comorbid with
anxiety, personality disorders, and substance use
mental disorder
any condition or syndrome with clinical manifestations characterized by significant impairment in cognition, emotion regulation, or behavior, measured in terms of deviation from some normative concept and leading to significant distress and/or disability in social, occupational, or other important activities of daily life.
pertinent positives
any symptoms brought up during visit that may be related to the CC
Affect of dementia, anxiety, or depression patient
apathy (dulled affect with detachment and indifference)
Target (bull's-eye or iris) lesions
appear as rings with central duskiness and are classic for erythema multiforme.
The mental status examination consists of six components:
appearance and behavior; speech and language; mood; thoughts and perceptions; insight and judgment; and cognitive function.
general survey of physical examination
appearance, LOC, dress, grooming, apparent state of health, any discomfort or distress, skin color and obvious lesions, personal hygiene, facial expression, odors of body and breath, poture, gait, motor activity
Infant: Colobomas
are missing sections of tissue in the eye (e.g., in the iris alone or iris plus retina). These may be seen with the naked eye and represent defects in the iris and may be associated with vision loss.
Nasal polyps
are pale saclike growths of inflamed tissue that can obstruct the air passage or sinuses, seen in allergic rhinitis, aspirin sensitivity, asthma, chronic sinus infections, and cystic fibrosis.
Perceptions
are sensory awareness of objects in the environment and their interrelationships (external stimuli). They also refer to internal stimuli such as dreams or hallucinations (Box 9-9).
Fasciculations
are small irregular twitching movements affecting small groups of muscle fibers. Seen in CN XI and XII.
An auscultatory gap is associated with
arterial stiffness and atherosclerotic disease If you find an auscultatory gap, record your findings completely (e.g., 200/98 mm Hg with an auscultatory gap from 170 to 150 mm Hg). An unrecognized auscultatory gap may lead to serious underestimation of SBP (150 instead of 200 in the example below) or overestimation of diastolic blood pressure (DBP).
Conditions that are comorbid with pain
arthritis, diabetes, HIV/AIDS, substance abuse, sickle cell disease, or psychiatric disorders.
Confidentiality in the room with visitors
ask permission from patient to discuss history in front of visitors first
The Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) questionnaire
asks about how often the person drinks alcohol, how many standard alcohol drinks are consumed on a typical day, and how often the person consumes six or more drinks on one occasion. The AUDIT-C, which is scored from 0 to 12, has sensitivities ranging from 0.73 to 1.00 using cutoffs of ≥3 (women) or ≥4 (men).
Numerical rating scale
asks patients to rate their perceived level of pain intensity on a numerical scale from 0-10 or 0-100. "0"-no pain, "10"-worst pain ever.
CAGE or TACE quesionairre
assesses for alcohol abuse in adults
Small, deformed, or low-set auricles may indicate
associated congenital defects, especially renal disease.
The ABCDE Rule
asymmetry, border, color, diameter, evolving See Box 10-4 With the exception of a homogenous blue color in a blue nevus, blue or black color within a larger pigmented lesion is especially concerning for melanoma. Early melanomas may be <6 mm, and many benign lesions are >6 mm. Evolution, or change, is the most sensitive of these criteria. A reliable history of change may prompt biopsy of a benign-appearing lesion.
RhoGAM given when
at 28 weeks and within 72 hours of delivery to mother -also given after amniocentesis
Major depressive disorder (MDD) is characterized by
at least 2 weeks of depressed/irritable mood, with at least four of the following: anhedonia, insomnia or hypersomnia, decreased self-esteem, low energy, poor concentration or indecision, changes in appetite, feeling slowed or restless, and thoughts of death or suicide.
How many generations should be included in your genomic pedigree?
at least 3
Palpation of an irregularly irregular rhythm may likely indicate __________. For all irregular patterns, an ECG is needed to identify the arrhythmia.
atrial fibrillation
Detection of an irregularly irregular rhythm suggests
atrial fibrillation.
pedunculated lesion
attached by a narrow stalk or pedicle
explicit bias
attitudes or beliefs that one endorses at a conscious level
implicit bias
attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner
Much of the middle ear and all of the inner ear are inaccessible to direct examination. Assess their condition by testing _________
auditory function.
Sjogren's syndrome
autoimmune destruction of minor salivary glands and lacrimal glands seen in older adults
In older adults, causes of hypothyroidism include
autoimmune thyroiditis, followed by drugs, neck radiotherapy, thyroidectomy, or radioiodine ablation.
Risk factors for hypothyroidism include
autoimmune thyroiditis, older age, Caucasian race, type 1 diabetes, Down syndrome, goiter, external beam radiation to the head and neck area, and family history.
Cholinergic diffuse modulatory systems arise from the _______________The medial septal nuclei and basal nucleus of Meynert project widely upon the cerebral cortex, including the hippocampus. It is the major center for acetylcholine (ACh) production in the CNS. ACh helps regulate sleep, arousal, and attention (Fig. 9-4).
basal forebrain and brainstem.
Move _____ the sitting patient to feel the thyroid gland and to examine the back, posterior thorax, and the lungs.
behind
Torus palatinus
benign bony ridge running in the middle of the hard palate
Drusen
benign deposits on the ocular fundus that show as round yellow dots and occur commonly with aging
drusen
benign deposits on the ocular fundus that show as round yellow dots and occur commonly with aging
Gold standard
best measurement of whether patient has disease
A bulging, tense fontanelle is observed in infants with increased intracranial pressure, which may be caused by
bleeding, central nervous system infections, neoplastic disease, or hydrocephalus.
Red inflamed lid margins occur in
blepharitis, often with crusting.
scotomas
blind or partially blind areas in the visual field fixed defects, or scotomas, suggest lesions in the retina, visual pathway, or brain.
chadwick sign
bluish discoloration of cervix that occurs normally in pregnancy at 6 to 8 weeks' gestation
Rapid changes in weight (over a few days) suggest changes in
body fluids, not tissues.
Bipolar disorders present with
both depressive episodes, such as in major depressive disorder (MDD), as well as manic or hypomanic episodes. Symptoms of manic episodes include euphoric/irritable mood, grandiosity, decreased need for sleep, talkativeness, racing thoughts, distractibility, increased goal-directed behavior or agitation, and an increase in reckless pleasure-seeking (having unprotected sex, spending excess money, foolish investments).
The Spectrum of Cognitive Decline
box 9-10
The Spectrum of Cognitive Decline (cont)
box 9-10
bartholin cyst
buildup of pus within the Bartholin glands (within the labial folds)
aphthous ulcers
canker sores
A newborn's scalp may be swollen over the occipitoparietal region. This is called
caput succedaneum and results from capillary distention and extravasation of blood and fluid resulting from the vacuum effect of rupture of the amniotic sac. This swelling typically crosses suture lines and resolves in 1 to 2 days.
Peaceful tachypnea (without increased work of breathing) may be a sign of
cardiac failure.
Gradual vision loss usually arises from
cataracts, glaucoma, or macular degeneration.
Macular degeneration
causes poor central vision and blindness (Fig. 27-11).76 Types include dry atrophic (more common but less severe) and wet exudative, or neovascular. See Table 12-12, Light-Colored Spots in the Fundi, p. 394.
A common type of localized swelling of the scalp in infants is a
cephalohematoma, caused by subperiosteal hemorrhage from the trauma of birth. This swelling does not cross over suture lines and resolves within 3 weeks.
The largest part of the brain is the
cerebrum
External ear causes include
cerumen impaction, infection (otitis externa), trauma, squamous cell carcinoma, and benign bony growths such as exostosis or osteoma.
An important goal is to minimize the number of times you ask the patient to
change position from supine to sitting, or standing to lying supine
Who should you direct your questions to at first during interview of a child?
child, if they can talk
An enlarged cup suggests
chronic open angle glaucoma
The structures within the CNS are intricately connected to one another through a variety of complex pathways called
circuits or networks.
annular lesion
circular, begins in center and spreads to periphery
Nasal cavity function
cleansing, humidification, and temperature control of inspired air.
When using an interpreter, how should your questions be constructed?
clear, short, simple
A congenital fissure of the median line of the palate is a
cleft palate.
posterior fontanel
closes 2-3 months
anterior fontanel
closes at 18-22 months
Nummular or discoid lesion
coin-shaped, no central clearing
Excess clothing may reflect
cold intolerance of hypothyroidism, hide skin rash or needle marks, mask anorexia, or signal personal lifestyle preferences
Cholesteatoma
collection of skin cells and cholesterol in a sac within the middle ear Cholesteatoma is trapped epithelial tissue behind the TM. It can be congenital or acquired. It can result from untreated or chronic recurrent otitis media. There may be a bulging, spherical white cyst behind an intact TM. If the TM ruptures it may emit foul smelling discharge. Cholesteatoma is conductive to hearing loss. It can also expand into bony tissue and act destructive like a tumor.
Acute Otitis Media with Purulent Effusion
commonly caused by bacterial infection from S pneumoniae and H influenzae. stmpyoms: earache, fever, and hearing loss. ear drum reddens and loses its landmarks. red is most obvious near the umbo. spontaneous rupture (perforation) of the drum may follow with discharge of purulent material into the ear canal. hearing loss is a conductive type
Rinne test
compares air conduction and bone conduction. place stem of the vibrating tuning fork on the person mastoid process and ask him or her to signal when the sound goes away. used to evaluate hearing loss in one ear
Abnormalities of Thought Content
compulsions, obsessions, phobias, anxieties, feelings of unreality, feelings of depersonalization, delusions
In unilateral ___________ hearing loss, sound is heard in (lateralized to) the impaired ear.
conductive Explanations include otosclerosis, otitis media, perforation of the eardrum, and cerumen.
Hearing disorders of the external and middle ear cause ________
conductive hearing loss.
right tympanic membrane
cone of light at 5 o'clock
left tympanic membrane
cone of light reflex at the 7 o'clock position
Sustained nystagmus within the binocular field of gaze is seen in
congenital disorders, labyrinthitis, cerebellar disorders, and drug toxicity.
An enlarged posterior fontanelle may be present in
congenital hypothyroidism
Infant: A prominent, protruding tongue may signal
congenital hypothyroidism, Down syndrome, or Beckwith-Wiedemann syndrome. If associated with hypoglycemia and omphalocele, macroglossia is likely Beckwith-Wiedemann syndrome.
A newborn who truly cannot open an eye (even when awake and alert) may have
congenital ptosis. Causes may include birth trauma and third cranial nerve palsy.
Anemia in pregnancy may cause
conjunctival pallor.
If fundal height is 4 cm larger than expected
consider multiple gestation, a large fetus, extra amniotic fluid, or uterine leiomyoma. If fundal height is 4 cm smaller than expected, consider low-level amniotic fluid, missed abortion, intrauterine growth retardation, or fetal anomaly. These conditions should be investigated by ultrasound.
Inaudible Korotkoff Sounds
consider the possibilities of severe vascular disease or shock
If hoarseness is acute,
consider voice overuse, acute viral laryngitis, and possible neck trauma.
cerebellum and brainstem
consists of the midbrain, pons, and the medulla.
miosis
constricted pupils
Direct pupillary response
constriction of the pupil when the light is shown in the eye
inner ear
contains cochlea, semicircular canals, and vestibular sacs The cochlea is dedicated to hearing, whereas the semicircular canals and otolith organs are dedicated to balance. Together these three structures form the labyrinth.
If vision loss is painful, causes are usually in the
cornea and anterior chamber such as corneal ulcer, uveitis, traumatic hyphema, and acute angle closure glaucoma. Optic neuritis from multiple sclerosis may also be painful.Immediate referral is warranted. If associated with headache, a thorough neurologic examination is warranted.
A red painful eye is seen in
corneal abrasions, foreign bodies, corneal ulcers, acute angle closure glaucoma, herpes keratitis, fungal keratitis, hyphema, and uveitis.
Premature closure of cranial sutures causes
craniosynostosis (p. 1066) and an abnormally shaped skull.
As you provide care for an ever-expanding and diverse group of patients, it is increasingly important to understand how ____ shapes not just the patient's beliefs, but your own.
culture
Hair breaks along the shaft suggest
damage from hair care or tinea capitis.
When collecting the health history, it is strongly advised to collect the ____ and ____, especially in urgent, emergent, or hospital settings.
date and time
Kaposi Sarcoma in AIDS
deep purple color lesions , low -grade vascular tumor associated with human herpesvirus 8 Lesions may be raised or flat About a third of pts with capos have lesions in oral cavity, others in GI tract and lungs
ulcer
deeper loss of the epidermis and at least the upper dermis
Hallucinations may occur in
delirium, dementia (less commonly), posttraumatic stress disorder, schizophrenia, and substance use.
Causes of poor performance include
delirium, dementia, intellectual disability, and performance anxiety.
Judgment may be poor in
delirium, dementia, intellectual disability, and psychotic states.
Remote memory is usually preserved in early stages of ______ but may be impaired in its later stages.
dementia
Recent memory is impaired in
dementia and delirium. Amnestic disorders impair memory or new learning ability and reduce social or occupational functioning but lack the global features of delirium or dementia. Anxiety, depression, and intellectual disability may also impair recent memory.
With intact vision and motor ability, poor constructional ability suggests
dementia or parietal lobe damage. Intellectual disability can also impair performance.
Name two conditions that may result in the "silent patient."
dementia, depression
Kubler-Ross stages of grief
denial, anger, bargaining, depression, acceptance
Most common dental problem in children especially poverty stricken children
dental caries
Bright red edematous mucosa underneath a denture suggests
denture stomatitis (denture sore mouth). There may be ulcers or papillary granulation tissue.
Types of psych screenings
depression suicide anxiety substance/alcohol abuse
Neglected appearance may appear in
depression and dementia but should be compared with the patient's norm.
Grooming and personal hygiene may deteriorate in
depression, schizophrenia, and dementia
Low levels of serotonin, norepinephrine, and dopamine have been associated with
depressive symptoms.
Persistent depressive disorder (PDD) is characterized by
depressive/irritable mood lasting for at least 2 years with at least two of the aforementioned depressive symptoms.
The key to a thorough and accurate physical examination is
developing a systematic sequence of examination.
Early closure of the fontanelles can be due to
developing microcephaly or to craniosynostosis or some metabolic abnormalities.
Hyper- or hypoglobus may refer to
deviation in the globe position, which may result from congenital abnormalities, lacrimal gland enlargement, mucocele, or ocular tumors.
Weight loss with relatively high food intake suggests
diabetes mellitus, hyperthyroidism, or malabsorption. Consider also binge eating (bulimia) with clandestine vomiting.
Tests of attention
digit span reciting months of yr forward/back (back no longer than 2x forward)
Aphasia is a
disorder of language.
Vitiligo may be patchy and isolated or may group around the
distal extremities and face, particularly around the eyes and mouth.
Beneficence
doing good
Cutaneous Cyst on ear
dome shaped lump in the dermis forms a benign closed firm sac attached to the epidermis
Easiest way to obtain BP in young children
doppler
Causes of generalized itching, without apparent rash, include
dry skin; pregnancy; uremia; jaundice; lymphomas and leukemia; drug reactions; and, less commonly, polycythemia vera and thyroid disease.
Two types of sweat glands
eccrine and apocrine The eccrine sweat glands are widely distributed, open directly onto the skin surface, and help to control body temperature by their sweat production. In contrast, the apocrine sweat glands are found chiefly in the axillary and genital regions and usually open into hair follicles. Bacterial decomposition of apocrine sweat is responsible for adult body odor.
Affect of manic patient
elated and euphoric
A small hard tender "tonsillar node" high and deep between the mandible and the SCM is probably an
elongated temporal styloid process.
Black Hairy Tongue.
elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue
Reduced growth in height may indicate
endocrine disease, other causes of short stature, or, if weight is also low, other chronic diseases.
The dermis is a dense layer of interconnecting collagen and elastic fibers containing
epidermal appendages such as pilosebaceous glands (oil glands), sweat glands, hair follicles, and most of the terminals of the cutaneous nerves. Inferiorly, the dermis merges with subcutaneous fatty tissue, or adipose tissue.
chronic pain
episode of pain that lasts for 6 months or longer; may be intermittent or continuous
acute pain
episode of pain that lasts from seconds to less than 6 months associated with trauma, surgery, or illness
Abnormalities in eye movements include
esotropia (inward deviation), exotropia (outward deviation), hypertropia (upward deviation), and hypotropia (downward deviation) of the eyes.
whisper voice test
examiner stands behind pt and has pt occlude one ear while the examiner whispers 2 syllable words to the unoccluded ear This test detects significant hearing loss of greater than 30 dB. A formal hearing test is still the reference standard.
There are two common kinds of aphasia—
expressive, or Broca aphasia, with preserved comprehension with slow, nonfluent speech and receptive, or Wernicke aphasia, with impaired comprehension with fluent speech.
Recurrent shaking chills suggest
extreme swings in temperature and systemic bacteremia
prongs of fork during rinne test
face forward
feeling hot and sweating accompany a
falling temperature.
Common risk factors in patients with anxiety and related disorders include
family history of anxiety, personal history of anxiety or mood disorder, childhood stressful life events or trauma, being female, chronic medical illness, and behavioral inhibition.
hyperopia
farsightedness
presbyopia
farsightedness caused by loss of elasticity of the lens of the eye, occurring typically in middle and old age.
_________ is a nonspecific symptom with many causes. It refers to a sense of weariness or loss of energy that patients describe in various ways.
fatigue
The first step to effective reassurance is identifying and accepting the patient's _____
feelings without offering reassurance at that moment.
Risk factors for hyperthyroidism include
female gender, older age, African ancestry, low iodine intake, family history, and medications (amiodarone).
Inaudible fetal heart tones may indicate
fewer weeks of gestation than expected, fetal demise, false pregnancy, or observer error; inability to locate the FHR should always be investigated with formal ultrasound.
Autonomic Nerve Supply to the Eyes
fibers traveling in the oculomotor nerve CN III and producing pupillary constriction are part of the parasympathetic nervous system. The iris is supplied by sympathetic fibers. When these are stimulated the pupil DILATES and the upper eyelid rises a little. The sympathetic pathway starts in the hypothalamus and passes into the brainstem and cervical cord into the neck. The neurons travel with the brachial plexus at the lung apex before returning back to the superior cervical ganglion near the mandible. From there, it follows the carotid artery or its branches into the orbit. A lesion anywhere along this pathway may impair sympathetic effects that dilate the pupil and will cause miosis.
Affect of schizophrenic patient
flat affect and remoteness
Geographic Tongue.
flat, irregular, red lesions on the dorsum of the tongue
Focus or problem oriented health history
focuses on a specific complaint for a returning patient
Subcortical structures of the brain
fornix, cingulate cortex, basal ganglia, and basal forebrain
paranasal sinuses
frontal, ethmoid, sphenoid, maxillary Only the frontal and maxillary sinuses are readily accessible on clinical examination
cortical structures of brain
frontal, temporal, parietal, and occipital lobes
If family members or caregivers have noticed personality changes in the patient, consider __________
frontotemporal dementia.
Beginners need to spend more time than seasoned clinicians on selected portions of the examination, such as the
funduscopic examination or cardiac auscultation.
How to test CN X
gag reflex, ability to swallow, say "ahhh"
Causes of weight loss include:
gastrointestinal diseases, endocrine disorders (diabetes mellitus, hyperthyroidism, adrenal insufficiency), chronic infections; malignancy; chronic cardiac, pulmonary, or renal failure; depression; and anorexia nervosa or bulimia
Excessive worry persisting over a 4-week period suggests a possible
generalized anxiety disorder
Anxiety disorders include
generalized anxiety disorder, social phobia, panic disorder, posttraumatic stress disorder (PTSD), and acute stress disorder.
If vision loss is associated with headache, jaw pain or claudication, it may be associated with
giant-cell arteritis. If painless, it may be associated with a vascular occlusion, retinal detachment, or hemorrhage.
The interdental papillae are swollen in ________
gingivitis.
Gum abnormalities: Redness of the gingiva suggests ______; a black line might indicate ___________
gingivitis; lead poisoning.
Causes of anterior pathway defects include
glaucoma, optic neuropahty, optic neuritis, and glioma
Holes in shoes or slippers suggest
gout, bunions, edema, or other painful foot conditions. Run-down shoes can contribute to foot and back pain, calluses, falls, and infection.
Fusobacterium necrophorum pharyngitis
gram negative obligate anaerobe abscess, tonsillitis, and Leimerre's syndrome, a rare life threating complication of oropharyngeal infection
Gravidity and parity
gravidity refers to the number of times that a woman has been pregnant, and parity is the number of times that she has given birth to a fetus to a viable age (≥24 gestational weeks), regardless of whether the child was born alive or was stillborn.
Illusions may occur in
grief reactions, delirium, acute and posttraumatic stress disorders, and schizophrenia.
Fatigue is a normal response to
hard work, sustained stress, and grief
questions to assess domestic violence
have you ever been hit, kicked, punched or otherwise hurt by someone with in the past year, do you feel safe in your current relationship, and is there a partner from a previous relationship who is making you feel unsafe now?
serpiginous or gyrate lesion
having linear, branched, and curving elements
Risk factors for thyroid cancer include
head and neck radiation exposure; having a first-degree relative diagnosed with thyroid cancer; and hereditary conditions such as multiple endocrine neoplasia syndrome type 2 or familial medullary thyroid cancer. Women are three times as likely to be diagnosed with thyroid cancer as men.
Physical assmt of children under 2 includes
head circumference, weight, length, weight-for-length
Palpable tenderness or bony step-offs on skull may be present after
head trauma.
In general, it is important to encourage any adult, but especially the elderly or chronically ill, to establish a _______, an individual who can act for the patient in life-threatening situations
health proxy
Sensoneural hearing loss
hearing loss caused by damage to the cochlea's receptor cells or to the auditory nerves; also called nerve deafness; pt may c/o that people mumble
If the BMI is above 25 kg/m2, assess the patient for additional risk factors for
heart disease and other obesity-related diseases: hypertension, high low-density lipoprotein (LDL) cholesterol, low high-density lipoprotein (HDL) cholesterol, high triglycerides, high blood glucose, family history of premature heart disease, physical inactivity, and cigarette smoking.
Jugular venous distention is a hallmark of
heart failure.
Phys assmt over 2 includes
height, weight , BMI
disease/illness distinction model
helps elucidate the different yet complementary perspectives of the clinician and the patient
deoxyhemoglobin (HHb)
hemoglobin with no oxygen bound to it
To empathize with your patient you must first identify ______
his or her feelings.
Where do you move major health events in the ROS?
history of present illness or past medical history
Retrosternal goiters can cause
hoarseness, shortness of breath, stridor, or dysphagia from tracheal compression; neck hyperextension and arm elevation may cause flushing from compression of the thoracic inlet from the gland itself or from clavicular movement (Pemberton sign). More than 85% of goiters are benign.
Perforated TM
hole in eardrum
Description of skin lesions (Merck Manuals link)
https://www.merckmanuals.com/professional/dermatologic-disorders/approach-to-the-dermatologic-patient/description-of-skin-lesions
An enlarged skull may signify
hydrocephalus or Paget's disease of bone
Difficulty with close work suggests __________ and, difficulty with distance vision, suggest __________.
hyperopia (farsightedness) or presbyopia (aging vision); myopia (nearsightedness).
Family history should include the age and cause of death of each family member and list the absence or presence of these diseases:
hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, cancer (specify type), arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, alcohol or drug addiction, and allergies, as well as symptoms reported by the patient.
Fine hair is seen in _________.
hyperthyroidism
In the lid lag of ________, a rim of sclera is visible above the iris with downward gaze
hyperthyroidism
intolerance to heat, weight loss, moist velvety skin, and palpitations point to possible _________
hyperthyroidism.
Watch for long limbs in proportion to the trunk in
hypogonadism and Marfan syndrome
Entertain _____ rather than drawing conclusions
hypotheses
Delayed closure of the fontanelles is usually a normal variant, but can be due to
hypothyroidism, megalocephaly, increased intracranial pressure, or rickets.
Intolerance to cold, weight gain, dry skin, and slowed heart rate point to _________.
hypothyroidism.
coarse hair seen in ________
hypothyroidism.
Abnormalities of Perception
illusions and hallucinations
primary prevention
immunizations, chemoprevention, medical procedures, and behavioral counseling.
Difference between immunization and vaccination
immunobiologic cannot be equated automatically with development of adequate immunity.
In__________ patients with sepsis, fever may be absent, low-grade, or drop below normal (hypothermia).
immunocompromised
As with anxiety, assessing the______ of depressive symptoms on the patient's life is vital to the overall assessment.
impact
The purpose of confidentiality is to
improve health care, not to keep secrets
Cigarettes are often reported how?
in pack year history Ex: a person who smokes 1.5 packs/day for 12 years has an 18 pack year history
Causes of orthostatic hypotension
include medications, autonomic disorders(dysfunction of the nerves), diabetes, prolonged bed rest, volume depletion, amyloidosis(built up of protein), postprandial state(after meal ingestion), and cardiovascular disorders.
Infants: In craniotabes, the cranial bones feel springy. Craniotabes can result from
increased intracranial pressure, as with hydrocephaly, metabolic disturbances such as rickets, and infection such as congenital syphilis.
infant: Dilated scalp veins are indicative of long-standing
increased intracranial pressure.
Excessive eye tearing may be from
increased production, caused by conjunctival inflammation or corneal irritation, or impaired drainage, caused by ectropion (p.385) and/or nasolacrimal duct obstruction. Dryness from impaired secretion is seen in Sjögren syndrome.
mental illness is associated with
increased risks for chronic medical conditions, decreased life expectancy, disability, substance abuse, and suicide.
Generally you do not perform rectam exams on which patient?
infant, unless suspected abdominal mass or questionable patency of anus
Causes of fever include
infection, trauma such as surgery or crush injuries, malignancy, drug rx, immune disorders such as collagen vascular ds
Fatigue is a common symptom of depression and anxiety, but also consider
infections (such as hepatitis, infectious mononucleosis, tuberculosis); endocrine disorders (hypothyroidism, adrenal insufficiency, diabetes mellitus); heart failure; chronic disease of the lungs, kidneys, or liver; electrolyte imbalance; moderate to severe anemia; malignancies; nutritional deficits; and medications.
Pharyngitis
inflammation of the pharynx
Tender nodes suggest _______; hard or fixed nodes suggest ___________.
inflammation; malignancy.
All cancer is genetic, but only a small portion is _____
inherited
How often is a comprehensive health history taken?
initial encounter, annually, and if there is a presenting acute problem
Most other dementias have an ______ onset.
insidious (or slowly progressing)
Concrete responses to abstract quotes are common in people with .
intellectual disability, delirium, or dementia but may also reflect limited education. Patients with schizophrenia may respond concretely or with personal and bizarre interpretations
secondary prevention
interventions (screening tests) designed to find disease or disease processes at an early stage when the patient has not yet manifested any signs or symptoms (asymptomatic) of the condition. The rationale for secondary prevention is that treating an early-stage disease is often more effective than treating disease at a later more advanced stage.
If vision loss is bilateral and painful, consider
intoxication, trauma, chemical or radiation exposures.
Abnormalities in the cranial nerves of an infant or newborn can suggest an
intracranial lesion such as hemorrhage or a congenital malformation (or alternatively peripheral nervous system problems).
Possible internal causes of diffuse nonscarring hair shedding in young women are
iron deficiency anemia and hyper- or hypothyroidism.
Dementia
is "an acquired condition that is characterized by a decline in at least two cognitive domains (e.g., loss of memory, attention, language, or visuospatial or executive functioning) that is severe enough to affect social or occupational functioning."
The Patient Health Questionnaire 9 (PHQ-9)
is a brief nine-item questionnaire focused on the nine diagnostic criteria for Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) depressive disorders. It is one of the most validated tools in mental health and can be a powerful tool to assist clinicians with diagnosing depression and monitoring treatment response).
bulla
is a circumscribed elevation of the epidermis containing clear fluid >1 cm in diameter. Classic autoimmune bullous diseases include pemphigus vulgaris and bullous pemphigoid.
patch
is a circumscribed flat area of change in color of the skin >1 cm in diameter.
plaque
is a large flatter elevation of the skin, sometimes formed by papules coalescing. Lesions of psoriasis and granuloma annulare commonly form plaques.
pustule
is a small circumscribed elevation of the epidermis filled with purulent fluid. Pustules are common in bacterial infections and folliculitis.
Leukocoria
is a white papillary reflex (instead of the normal red papillary reflex). It can be a sign of a rare tumor called retinoblastoma.
Insight
is an awareness that symptoms or disturbed behaviors are normal or abnormal; for example, distinguishing between daydreams and hallucinations that seem real.
Stridor
is an ominous, high-pitched musical sound from severe subglottic or tracheal obstruction that signals a respiratory emergency. Causes include epiglottitis,2 foreign body, goiter, and stenosis from placement of an artificial airway.
Papilledema
is rare in infants because the fontanelles and open sutures accommodate any increased intracranial pressure, sparing the optic discs.
Common cause of strawberry tongue, red uvula, and pharyngeal exudate
is streptococcal pharyngitis.
Orientation
is the awareness of personal identity, place, and time, which requires both memory and attention. You can usually assess orientation during the interview. Disorientation is common when attention is impaired, as in delirium.
Thought process
is the logic, organization, coherence, and relevance of the patient's thought as it leads to selected goals (how people think). Assess the the patient's thought processes throughout the interview.
Judgment
is the process of comparing and evaluating alternatives when deciding on a course of action; it reflects values that may or may not be based on reality and social conventions or norms. Assess judgment by noting the patient's responses to family situations, jobs, use of money, and interpersonal conflicts. "How do you plan to get help after leaving the hospital?"
Configuration
is the shape of single lesions and the arrangement of groups of lesions. Some descriptive terms to learn are linear or striate (straight line); annular (ring-like, with central clearing); nummular or discoid (coin-shaped, no central clearing); target, bull's eye, or iris (rings with central duskiness); and serpiginous or gyrate (having linear, branched, and curving elements). Examples are herpes zoster with unilateral and dermatomal vesicles; herpes simplex, with grouped vesicles or pustules on an erythematous base; tinea pedis with annular lesions; and poison ivy allergic contact dermatitis with linear lesions.
Uncontrolled hypertension is a major risk factor for
ischemic heart disease, cerebrovascular disease, congestive heart failure, and chronic kidney disease.
Copper bracelets and magnetic wrist straps suggest
joint pain
The extraocular muscles that are responsible for eye movements are the
lateral and medial recti, the superior and inferior recti, and the superior and inferior obliques
preferred position for chronic obstructive pulmonary disease (COPD) or acute pericarditis patient
leaning forward with arms braced (tripod position)
a protein cytokine secreted and stored in fat cells that modulates hunger
leptin
Prior to 34 to 36 weeks, the cervix should retain its usual length of about
less than 3 cm cervical effacement before 36 weeks suggests preterm labor
The primary goals of the patient interview are to
listen and to improve the well-being of the patient through a trusting and supportive relationship
Simple Descriptor Scale
lists words that describe different levels of pain intensity such as no pain, mild pain, moderate pain, and severe pain
Actinic lentigines
liver spots/age spots/sun spots Distinguish such lesions from a basal cell carcinoma, a translucent nodule that spreads and leaves a depressed center with a firm elevated border. D/t UV radiation, do NOT cause cancer. A dark raised asymmetric lesion with irregular borders may be a melanoma.
Tenderness of the nasal tip or ala suggests
local infection such as a furuncle, particularly if there is a small erythematous and swollen area.
Norepinephrine diffuse modulatory systems arise from the _______ which is a small cluster of locus coeruleus neurons projects axons that innervate vast areas of the CNS, including the spinal cord, cerebellum, thalamus, and cerebral cortex. It makes norepinephrine, which regulates mood, arousal, attention, and cognition
locus coeruleus
erosions
loss of epidermal or mucosal epithelium
tympanitic percussion note
loud intensity, high pitch, longer duration heard over parts of GI tract that contain air
resonant percussion note
loud intensity, low pitch, long duration heard over lung tissue
Risk factors for periodontal disease include
low income, male sex at birth, smoking, diabetes, and poor oral hygiene.
High-risk patients may have subtle early signs of depression, including
low self-esteem, loss of pleasure in daily activities (anhedonia), sleep disorders, and difficulty concentrating or making decisions.
Mood disorders with depressive symptoms include
major depressive disorder (MDD), persistent depressive disorder (PDD), bipolar disorders, disruptive mood dysregulation disorder (DMDD), and premenstrual dysphoric disorder (PMDD).
The most common causes of diffuse hair thinning are
male and female pattern baldness.
A persistent neck mass in an adult older than 40 years should raise a suspicion of ___________.
malignancy.
Neck nodules that are ≥2 cm, firm, and fixed to adjacent tissues are concerning for _______.
malignancy.
Basal Cell Carcinoma of ear
malignant tumor of the basal cell layer of the epidermis
insufflator
may be used as a pneumatic device attached to the Otoscope. It tests for mobility of the ear drum, which is often absent when there is fluid behind the TM. It is not commonly used in Adult primary care, but may be used more frequently in pediatrics and in ENT specialty practices.
Kappa Score
measures the amount of agreement that occurs beyond chance
dull percussion note
medium intensity, medium pitch, medium duration heard over solid organs (like the liver)
To establish rapport with a child or adolescent , the key is to
meet children on their own level.
Scalp: Look for pigmented nevi that raise concern of
melanoma.
Highest risk for HIV
men who have sex with men (MSM) (82% of new infections among males), African Americans (43% of new infections), and Hispanics/Latinos (26% of new infections); injection drug users represent 6% of new HIV infections.
Enlargement of a supraclavicular node, especially on the left (Virchow's node), suggests possible
metastasis from a thoracic or an abdominal malignancy.
In those with normal hearing, air conduction is _____ sensitive than bone conduction (AC > BC).
more
Rapid respiratory rates tend to increase the discrepancy between oral and rectal temperatures. In these situations, rectal temperatures are
more reliable.
Medications should be noted including:
name, dose, route, and frequency (include non prescription and herbal remedies also)
Sagittal suture synostosis causes a
narrow head from lack of growth of the parietal bones.
myopia
nearsightedness
Anterior and posterior triangles of the neck.
neck is divided into anterior and posterior triangles by the sternocleidomastoid muscle Anterior cervical triangle: the mandible above, the SCM muscle laterally, and the midline of the neck medially. Posterior cervical triangle: the SCM muscle, the trapezius, and the clavicle. Note that a portion of the omohyoid muscle crosses the lower portion of this triangle and can be mistaken for a lymph node or mass.
Newborns: Pigmented light-brown lesions (<1 to 2 cm at birth) are café-au-lait spots. Isolated lesions have no significance, but multiple lesions with sharp borders may suggest ________
neurofibromatosis.
Denial of impairment may accompany some _____ disorders.
neurologic particularly disorders affecting the parietal lobe.
Weakness, especially if localized in a neuroanatomical pattern, suggests possible
neuropathy or myopathy.
Where should you seat the interpreter during an interview with the patient?
next to you so that you both can establish rapport
Tiny white ovoid granules that adhere to hairs may be
nits (lice eggs).
Can you co-administer pneumoccocal vaccines?
no-space them out one year
Examples of continuuers
nodding head, "uh-huh", "I see", "Go on"
When assessing young children, start with the
non-distressing maneuvers and then to potentially distressing maneuvers
The single most important rule of the interview is to be ____.
non-judgmental
petechiae
nonblanchable punctate foci of hemorrhage
ecchymoses
nonblanchable, larger areas or purpura
purpura
nonblanchable, raised and palpable
Fordyce Spots (Fordyce Granules)
normal sebaceous glands that appear as small yellowish spots in the buccal mucosa or on the lips
Slow central vision loss may occur with
nuclear cataract (p. 387) and macular degeneration
Good descriptions of lesions include each of the following elements:
number, size, color, shape, texture, primary lesion, location, and configuration. For example, for seborrheic keratosis, examine this record: "Multiple 5-mm to 2-cm tan to brown, oval, stuck-on, flat-topped verrucous plaques on the back and abdomen, following skin tension lines." Note the description of each element: number, multiple; size, 5 mm to 2 cm; color, tan to brown; shape, oval; texture, flat-topped verrucous; primary lesion, plaques; location, on the back and abdomen; and configuration, following skin tension lines.
Signs of chronic sun damage include
numerous solar lentigines on the shoulders and upper back, many melanocytic nevi, solar elastosis (yellow, thickened skin with bumps, wrinkles, or furrowing), cutis rhomboidalis nuchae (leathery thickened skin on the posterior neck), and actinic purpura.
Excessive fastidiousness may be seen in
obsessive compulsive disorder
How often should obstetric visits be scheduled
obstetric visits traditionally follow a set schedule: monthly until 28 gestational weeks, then biweekly until 36 weeks, then weekly until delivery.
Secondary hypertension causes include
obstructive sleep apnea, chronic kidney disease, renal artery stenosis, medications, thyroid disease, parathyroid disease, Cushing syndrome, hyperaldosteronism, pheochromocytoma, and coarctation of the aorta.
Personal and Social History should include
occupation and the last year of schooling; home situation and significant others; sources of stress, both recent and long-term; important life experiences, such as military service, job history, financial situation, and retirement; leisure activities; religious affiliation and spiritual beliefs; and activities of daily living (ADLs). Baseline level of function is particularly important in older or disabled patients The Personal and Social History also conveys lifestyle habits that promote health or create risk such as exercise and diet, including frequency of exercise, usual daily food intake, dietary supplements or restrictions, and use of coffee, tea, and other caffeine-containing beverages and safety measures, including use of seat belts, bicycle helmets, sunblock, smoke detectors, and other devices related to specific hazards. You may want to include any alternative health care practices
Presbycusis
occurs with aging. This is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve.
Infant: Alternating convergent or divergent strabismus persisting beyond 3 months, or persistent strabismus of any type, may indicate
ocular motor weakness or another abnormality in the visual system.
tympanogram
often done in children to assess for fluid in the middle ear that can lead to hearing loss
Hypothermia is more common in
older patients.
If patients or loved ones do confirm forgetfulness, ask about the _____ and _____.
onset and duration. "When did you first notice the forgetfulness?" "Did it happen over time, or was it sudden?"
The assessment should begin with _____-ended questions
open
Stensen's duct
opening of the parotid salivary gland
Testing for color vision can be particularly helpful in ruling out damage to the
optic nerve, which often exhibits red-green color deficits and red color desaturation.
Lagophthalmos
or failure of the eyelids to close, which can happen after neuromuscular palsy, trauma, and thyroid eye disease, exposes the corneas to serious damage. These patients should be referred to ophthalmology for urgent evaluation and possible treatment.
Nontender nodular swellings covered by normal skin deep in the ear canals suggest
osteomas or exostoses (Fig. 13-10). These are nonmalignant overgrowths, which may obscure the tympanic membrane.
Fever, chills, and pain suggest underlying
osteomyelitis.
Watch for height loss in
osteoporosis and vertebral compression fractures.
Pain on movement of the pinna occurs with
otitis externa
Tenderness behind the ear occurs in
otitis media and mastoiditis.
Middle ear disorders include
otitis media, congenital conditions, cholesteatomas, otosclerosis, tympanosclerosis, tumors, and perforations of the tympanic membrane.
It is important to identify other potential causes of anxiety, panic disorder, OCD, PTSD, social anxiety such as
over-the-counter and prescribed medications, illicit substances, caffeine, alcohol, or other medical and psychiatric comorbidities. Hyperthyroidism, cardiopulmonary disorders, and traumatic brain injury (TBI) are common comorbid conditions that accompany excessive or uncontrollable anxiety. Anxiety is often comorbid with substance use and mood disorders.
Keloid of ear
overgrowth of scar tissue
HEAD-TO-TOE PHYSICAL EXAMINATION
p. 253-257 pdf textbook
ADAPTING THE PHYSICAL EXAMINATION: SPECIFIC PATIENT CONDITIONS
p. 259-262 pdf textbook
swelling of the optic nerve indicates __________ which signals what?
pailledema; serious disorders of the brain, such as meningitis, subarachnoid hemorrhage, trauma, and mass lesions
fifth vital signs
pain, smoking, O2 sat
Bullous myringitis is also a common sequela presenting with
painful hemorrhagic vesicles on the tympanic membrane. Both of these conditions require urgent, often surgical, management by an otolaryngologist.
Mucous Patch of Syphilis.
painless lesion of secondary syphilis is highly infectious, slightly raised, oval, and covered by a grayish membrane
vellus hair
pale, fine body hair of children and adult females
Dysconjugate Gaze
paralysis of gaze or lack of coordination between the movements of the two eyes
Overlap of the cranial bones at the sutures at birth, called molding, results from
passage of the head through the birth canal; it disappears within 2 days.
Newborns: Both erythema toxicum and pustular melanosis may appear similar to the
pathologic vesiculopustular rash of herpes simplex or Staphylococcus aureus skin infection.
Data flows spontaneously from the ____, but task organization is your responsibility.
patient
Skilled interviewing is both
patient centered and clinician centered *Focus on patient and symptoms
A problem representation usually contains
patient's initial information (chief complaint, epidemiology, risk factors)
Enlarged tender lymph nodes commonly accompany ________.
pharyngitis.
Scalp: look for soft lumps that may be
pilar cysts (wens)
Petechiae
pinpoint purple or red spots from minute hemorrhages under the skin
Assessing ocular fundus
place scope to 0 position patient 10 in away A dark light reflex can result from cataracts, retinopathy of prematurity, or other disorders. A white retinal reflex (leukokoria) is abnormal, and cataract, retinal detachment, chorioretinitis, or retinoblastoma should be suspected. Occlusion of the red reflex by the lens may represent a cataract.
Vaccines safe during pregnancy
pneumococcal, meningococcal, and hepatitis B. Hepatitis A, meningococcal polysaccharide and conjugate, and pneumococcal polysaccharide vaccines can be given, if indicated.
Streptococcal pneumonia causes
pneumonia, bacteremia, meningitis
Hirsutism (excessive facial hair) may appear in some women with
polycystic ovary syndrome.
Some newborns with _____ have a "ruddy" or purplish color.
polycythemia
Common oral causes of breath malodor include
poor oral hygiene, tobacco smoking, plaque retention on teeth and mouth appliances such as retainers and dentures, periodontal diseases (gingivitis, ulcers, periodontitis)
Lymphatic drainage patterns are helpful when assessing
possible malignancy or infection. For suspected malignant or inflammatory lesions, look for enlargement of the neighboring regional lymph nodes; when a node is enlarged or tender, look for a source in its nearby drainage area.
Actinic Cheilitis
precancerous lesion on lower lip red, white, ulcerated and or crusted appearance
Actinic keratosis are known as a
precancerous lesion.
Transtheoretical Model for Behavioral Change
precontemplation, contemplation, preparation, action, maintenance, relapse
Facial edema after 20 gestational weeks may reflect
preeclampsia
hyperreflexia in pregnancy may indicate
preeclampsia
If depressive symptoms worsen in sync with a female patient's menstrual cycle, she may have
premenstrual dysphoric disorder (PMDD).
most common cause of hearing loss
presbycusis
Major health events should be moved to the _____ or _____ in your write-up.
present illness or past history
Cervical opening or shortening (cervical effacement) prior to 37 weeks may indicate
preterm labor.
Pneumatic otoscope
procedure for examining the ear using air Diminished movement of tympanic membrane with acute otitis media; no movement with otitis media with effusion.
Pilosebaceous glands (oil glands)
produce a fatty substance secreted onto the skin surface through the hair follicles. These glands are present on all skin surfaces except the palms and soles.
Infant: A positive Chvostek sign
produces facial grimacing caused by repeated contractions of the facial muscles. Chvostek sign is noted in cases of hypocalcemic tetany, tetanus, and tetany due to hyperventilation.
Baker Act
provides individuals who have a mental illness, or who may harm or neglect themselves or others, with an emergency service and temporary detention for psychiatric evaluation and voluntary or involuntary short-term community inpatient treatment. Detained for 72 hours Must be evaluated within 24 hours
Marchman Act
provides substance abusers access to emergency services and temporary detention on either a voluntarily or involuntarily basis.
When you suspect a ____ or ______ disorder, do not spend too much time trying to get a detailed history
psychiatric or neurologic Shift to the mental status examination, focusing on level of consciousness, orientation, and memory
Too much dopamine with low concentrations of serotonin in certain areas of the brain lead to symptoms of
psychosis and mania.
Symptoms associated with weight loss require a good _____ history.
psychosocial
Patients with ______ disorders often lack insight into their illness.
psychotic
Delusions and feelings of unreality or depersonalization are often associated with ______ disorders.
psychotic Delusions may also occur in delirium, severe mood disorders, and dementia.
Otoscopic Exam in adults
pull pinna up and back
gold standard for temperature checks
pulmonary artery
consenual pupillary response
pupil constriction in opposite eye
mydriases
pupil dilation. sympathetic. radial muscles contract
Key information collected verbatim from your patient needs to include what?
quotations
Serotonergic diffuse modulatory systems arise from the _______, which are clustered along the midline of the brainstem and project extensively to all levels of the CNS. The nuclei make serotonin, a neurotransmitter that helps regulate mood, arousal, and cognition
raphe nuclei
What must you establish before exploring the chief complaint?
rapport
In viral rhinitis, the mucosa is __________; in allergic rhinitis, it may be___________.
reddened and swollen; pale, bluish, or red.
If hoarseness lasts over 2 weeks,
refer for laryngoscopy and consider causes such as reflux; vocal cord nodules; hypothyroidism; head and neck cancers including thyroid masses; and neurologic disorders like Parkinson disease, amyotrophic lateral sclerosis, or myasthenia gravis.
Dysarthria
refers to defective articulation.
Though the most commonly recognized color vision abnormalities are sex-linked congenital red-green deficiencies, other color vision and contrast sensitivity anomalies can
reflect acute or chronic optic nerve or retinal disease.
Autonomy
reminds us that patients have the right to determine what is in their own best interest
systemic causes of halotosis
respiratory causes such as sinusitis, tonsillitis, pharyngitis, foreign bodies, neoplasms, abscesses, and bronchiectasis. Other systemic causes are uncommon such as gastric acid reflux, hepatic cirrhosis, poorly controlled diabetes mellitus, impaired fat digestion, and inborn errors of metabolism such as trimethylaminuria
Dysphonia
results from impaired volume, quality, or pitch of the voice.
TM: An unusually prominent short process and a prominent handle that looks more horizontal suggest a
retracted tympanic membrane.
Standard position of clinician during physical exam
right side
Feeling cold, goose bumps, and shivering accompany a
rising temperature
Tattoos and piercings may be associated with
risk-taking behavior in adults such as alcohol or drug abuse
all women should have which titers drawn during pregnancy
rubella
Hallucinations occur in
schizophrenia, alcohol withdrawal, and systemic toxicity.
CRAFFT questionnaire
screening tool for adolescent alcohol and drug abuse
Functional Assessment
screens the safety of independent living, the need for home health services, and quality of life There are two standard categories of assessment: physical activities of daily living (ADLs) and instrumental activities of daily living (IADLs). (Instead of asking about each area separately, have the patient go through a typical day, in detail. Start with an open-ended questions)
Scalp: Look for redness and scaling that may indicate
seborrheic dermatitis or psoriasis,
Scaliness of eyebrows occurs in
seborrheic dermatitis, lateral sparseness in hypothyroidism.
Additional suggested templates for documenting HPI
see pic
Classification for gestational age and birth weight
see pic
Determining gestational age and the expected date of delivery
see pic
Developmental Task of Adolescents
see pic
Documentation of attributes of the CC
see pic
Example of recording the physical examination for the older adult
see pic
HEADSSS Psychosocial Interview Technique—Adolescents
see pic
Key Components of Pediatric Health Promotion
see pic
Signs that an infant can hear
see pic
Suggested structure in documenting the HPI (one chief complaint)
see pic
Visual acuity in children
see pic
Visual milestones of infancy
see pic
tips for using otoscope on children
see pic
Positive and Negative Predictive Values
see pic See chapter 7 for more in depth info on how to calculate
When assessing any type of violence such as elder abuse, vulnerable adult, or IPV, ____ interviewing is essential
sensitive ex: "Because abuse is common in many lives of my patients, I've begun to ask about it routinely." "Are there times in your relationships that you feel unsafe or afraid?" "Have you ever been hit, kicked, punched, or hurt by someone you know?"
___ is the probability that a person with disease has a positive test
sensitivity aka true positive rate represented as a/(a+c) in 2x2 table
In unilateral ___________ hearing loss, sound is heard in the good ear.
sensorineural
Disorders of the inner ear cause
sensorineural hearing loss from congenital and hereditary conditions, presbycusis, viral infections such as rubella and cytomegalovirus, Ménière disease, noise exposure, ototoxic drug exposure, and acoustic neuroma.
Korotkoff sounds
series of sounds that correspond to changes in blood flow through an artery as pressure is released
Infants: Extensive retinal hemorrhages may suggest
severe anoxia, subdural hematoma, subarachnoid hemorrhage, or trauma. Beyond the newborn period, retinal hemorrhages may be a sign of nonaccidental trauma (child abuse).
Nose anatomy
shaped by bone and hyaline cartilage The internal nares are composed of the septum, the center wall of bone and cartilage, and the turbinates, the scroll like bones covered with mucous membranes. These structures are assessed for nasal patency and for the presence of disease. Percussion or palpation may be used externally for pain assessment over the sinus areas.
Measure pulse when child is
silent
Loss of smell occurs in
sinus conditions, head trauma, smoking, aging, use of cocaine, and Parkinson disease.
Vital signs and skin assessment the patient is
sitting on the edge of the bed or examining table, unless this position is contraindicated. You should be standing in front of the patient, moving to either side as needed.
What position should patient be in while assessed neurologically?
sitting or supine
preferred position for LHF patients
sitting upright
heaviest body organ
skin
Hidradenitis suppurativa involves
skin containing a high density of apocrine glands, including the axillae, groin, and under the breasts
secondary lesion
skin lesion that evolves from a primary lesion or that is caused by external forces, such as infection, scratching, trauma, or the healing process
A high BMI is associated with
sleep apnea, nonalcoholic fatty liver disease, osteoarthritis, CVD, and metabolic disorders, including dyslipidemia (imbalance of lipids aka cholesterol) and type 2 diabetes.
Premature closure of the sutures or microcephaly may cause
small head size.
Koplik Spots
small, blue-white spots with red halo over oral mucosa; early sign of measles
Muller's muscle
smooth muscle fibers of the inferior insertion of the levator palpebrae that insert into superior tarsal plate, helps with elevation of the eye, giving wide-eyed deer in headlights look of frightened person
flat percussion note
soft intensity, high pitch, short duration hard to listen to if flat note heard over lungs-indicates pleural effusion if heard over protruded abdomen-indicates acites
Hegar's sign
softening of the lower uterine segment
Designating the _____ helps you to assess the type of information provided and any possible biases.
source of referral
In contrast to most other interviews, interviews with adolescents should start with
specific directed questions to build trust and rapport and start the conversation. You may have to do more talking than usual.
_____ is the probability that a non diseased person has a negative test
specificity aka true negative rate represented as d/(b+d) in 2x2 table
Newborns: Midline hair tufts over the lumbosacral spine region suggest a possible
spinal cord defect.
It is important to avoid ____ when assessing the aging patient.
stereotypes
HPI
story of patient's problem come's first in document
Linear or striate lesion
straight line
Tonsillar exudates with a beefy red uvula are common in
streptococcal pharyngitis but warrant rapid antigen- detection testing or throat culture for diagnosis.
Posterior pathway defects include
stroke and chiasmal tumors
Isolated systolic hypertension (SBP ≥140 mm Hg with DBP <90 mm Hg) after age 50 years and pulse pressure ≥60 increase risk of
stroke, renal failure, and heart disease.
A pressure difference of more than 10 to 15 mm Hg occurs in
subclavian steal syndrome, supravalvular aortic stenosis, and aortic dissection and should be investigated.
A red painless eye is seen in
subconjunctival hemorrhage and episcleritis.
Dopaminergic diffuse modulatory systems arise from the ___________________, which make dopamine, a neurotransmitter that regulates mood, arousal, cognition, and motor control (Fig. 9-3).
substantia nigra and the ventral tegmental area The substantia nigra and ventral tegmental area lie close together in the midbrain. They project to the striatum (caudate nucleus and putamen) and limbic and frontal cortical regions, respectively.
Discoid lupus erythematosus has characteristic lesions on
sun-exposed skin of the face, especially the forehead, nose, and the ear.
In acute otitis externa (Fig. 13-11), the canal is often
swollen, narrowed, moist, erythematous or pale, and tender.
any woman who gives birth to a stillborn fetus should be tested for
syphilis.
Hair shedding at the roots is common in
telogen effluvium and alopecia areata.
PrEP drugs
tenofovir/emtricitabine PrEP is recommended for HIV-negative people who are at risk for HIV through sexual transmission or illicit drug injection. Consistent use has been shown to reduce the risk of HIV infections.
The most important component of the nose and sinus examination of the infant is to
test for patency of these nasal passages. The nasal passages in newborns may be obstructed in choanal atresia. In severe cases, nasal obstruction can be assessed by attempting to pass a no. 8 feeding tube through each nostril into the posterior pharynx. This is usually done in the delivery room to assess for choanal atresia or other sources of unilateral or bilateral obstruction.
Diencephalon
thalamus, hypothalamus, epithalamus
The extraocular muscles are innervated by three cranial nerves:
the abducens, the trochlear, and the oculomotor. The abducens nerve (CN VI) innervates the lateral rectus muscle. The trochlear nerve (CN IV) supplies the superior oblique muscle. The oculomotor nerve (CN III) supplies all the rest of the extraocular muscles. Nerve damage or injury to the muscle, due to head trauma, congenital causes, or central lesions, can cause aberrations in this yoked system and lead to diplopia (double vision).
frailty
the condition of being weak and delicate
Oculomotor Nerve (CN III) Paralysis
the dilated pupil is fixed to light and near effort; ptosis of the upper eyelid and lateral deviation of the eye are almost always present
Care for a child should be focused on ____
the family as a whole (ex: ask about what a certain family member thinks about a situation that may not be present today, ask if there are other areas that concerns the family that they would like addressed today)
Tympanosclerosis
the formation of dense connective tissue in the middle ear, often resulting in hearing loss when the ossicles are involved
hearing gloss is considered
the inability to hear tones at frequencies between 500 and 4,000 Hz
oblique light illumination in acute narrow-angle glaucoma
the iris bows abnormally far forward, forming a very narrow angle with the cornea. The light then casts a crescentic shadow (Fig. 12-18). This narrow angle increases the risk for acute narrow-angle glaucoma, a sudden increase in intraocular pressure when drainage of the aqueous humor is blocked.
Cognition
the mental activities associated with thinking, knowing, remembering, and communicating Cognitive function includes orientation, attention, and memory (remote, recent, new learning) as well as higher cognitive functions such as information and vocabulary, calculations, abstract thinking, and constructional ability.
depression risk factors
the most common include a personal history of a depressive episode, a family history of first-degree family members with depression, personal history of recent stressful life events or significant childhood adversity, chronic and/or disabling medical illness, and female gender.
When listing patient problems which problem is listed first?
the most serious problem
The source of the health history can be
the patient, a family member or friend, an officer, a consultant, or the medical record.
steropsis
the process by which the visual cortex combines the differing neural signals caused by binocular disparity, resulting in the perception of depth (3D vision)
Likelihood ratio of negative test
the ratio of getting a negative test result in a diseased person divided by the probability of getting a negative test result in a nondiseased person.
Likelihood ratio of positive test
the ratio of getting a positive test result in a diseased person divided by the probability of getting a positive test result in a nondiseased person.
Psoriasis frequently affects
the scalp, extensor surfaces of the elbows and knees, umbilicus, and the gluteal cleft.
CN X paralysis
the soft palate fails to rise and the uvula deviates to the opposite side and "points away from the lesion"
Korotkoff sounds in aortic regurgitation
the sounds never disappear. If the difference is 10 mm Hg or greater, record both figures (e.g., 154/80/68).
pseudoisochromatic plates
the standard test for screening color perception Persons with defective color vision may fail to distinguish between figure and background colors in a pseudoisochromatic test and hence fail to read the figures.
In your clinical documentation, the problem representation is called
the summary statement
visual field
the whole area that you can see without moving your head or eyes
In chronic otitis externa, the skin of the canal is often
thickened, red, and itchy.
Ptosis is seen in
third nerve palsy (CN III), Horner syndrome (ptosis, miosis, forehead anhidrosis), or myasthenia gravis.
The general survey continues
throughout the history and examination.
Abnormal eye protrusion or proptosis may be due to
thyroid eye disease, congenital abnormalities, orbital infections, or ocular tumors.
goiter
thyroid function may be increased or decreased
The best body part to assess cyanosis is
tongue or inside of mouth
Plagiocephaly may also reflect pathology such as
torticollis from injury to the sternocleidomastoid muscle at birth or lack of stimulation of the infant.
The diagram format is more helpful than the narrative for
tracing genetic disorders
Many drugs are associated with weight gain, such as
tricyclic antidepressants; insulin and sulfonylurea; contraceptives, glucocorticoids, and progestational steroids; mirtazapine and citalopram, paroxetine; gabapentin and valproate; and metoprolol, atenolol and propranolol.
All pregnant patients should be offered both aneuploidy screening and diagnostic genetic testing to rule out common chromosomal aneuploidies, such as
trisomies 21, 18, and 13 and sex-chromosome abnormalities. Additionally, carrier screening for certain autosomal-recessive disorders such as Tay-Sachs disease, spinal muscular atrophy (SMA), cystic fibrosis (CF), and fragile X syndrome is recommended for targeted screening
Night sweats occur in
tuberculosis and malignancy
Weber and Rinne tests
tuning fork to distinguish between conductive and sensorineural hearing losses To conduct these tests, make sure the room is quiet, and use a tuning fork of 512 Hz. These frequencies fall within the range of conversational speech, namely 500 to 3,000 Hz and between 45 and 60 dB.
For palpable solitary nodules,_________ and ________ are advised.
ultrasound and possible fine-needle aspiration Ultrasound usually reveals multiple additional nonpalpable nodules; only 5% of nodules are malignant.
anisocoria
unequal pupil size Causes include blunt trauma to the eye, open-angle glaucoma (p. 381), and impaired parasympathetic innervation to the iris, as in tonic pupil and oculomotor nerve (CN III) paralysis. When anisocoria is greater in dim light, the smaller pupil cannot dilate properly, as in Horner syndrome, caused by an interruption of the sympathetic innervation.
Most errors in blood pressure readings in children are due to
using an incorrect cuff size.
an irregularly shaped uterus suggests
uterine leiomyomata, or fibroids, or a bicornuate uterus, one with two distinct cavities separated by a septum.
Subconjunctival hemorrhages are common in neonates born via
vaginal delivery.
If vision loss is bilateral and painless, consider
vascular etiologies, stroke, or non-physiologic causes.
A red eye with a gritty sensation is seen in
viral conjunctivitis and dry eye.
Moving specks or strands in the visual field suggest
vitreous floaters flashes of light may accompany this symptom Flashing lights with new vitreous floaters suggest traction on the retina with detachment of the vitreous body from the retina. Prompt consultation is indicated to rule out retinal tears or detachments.
If sudden visual loss is unilateral and painless, consider
vitreous hemorrhage from diabetes or trauma, macular degeneration, retinal detachment, retinal vein occlusion, or central retinal artery occlusion.
How to calculate BMI
weight (kg) / height (m^2)
Soft Exudates: Cotton-Wool Spots
white or grayish, ovoid lesions with irregular "soft" borders. They are moderate in size but usually smaller than the disc. They result from extruded axoplasm from retinal ganglion cells caused by microinfarcts of the retinal nerve fiber layer. Seen in hypertension, diabetes, HIV and other viruses, and numerous other conditions.
Rates of drug overdose deaths continue to increase, driven by illicitly manufactured synthetic opioids such as fentanyl, and are highest among
whites and American Indian/Alaska Natives
Jaundice
within the first 24 hours of birth may be from hemolytic disease of the newborn which is always pathologic. Late-appearing jaundice or jaundice that persists beyond 2 to 3 weeks should raise suspicions of biliary obstruction or liver disease.
Lichen planus frequently arises on the
wrists, forearms, genitals, and lower legs.
Acute otitis externa and acute or chronic otitis media with perforation usually present with
yellow-green discharge.
Look carefully for symptoms of depression in vulnerable patients, especially those who are
young, female, single, divorced or separated, seriously or chronically ill, bereaved, or have other psychiatric disorders including substance abuse. A personal or family history of depression also places patients at risk.
Screening for Unhealthy Weight and Diabetes Mellitus
• BMI- used to screen for overweight and obesity • DM = modifiable risk factor for CVD. • Screen for abnormal blood glucose in overweight or obese adults aged 40 to 70 years. • Diagnosis of type 2 diabetes can be made based on repeated measures of hemoglobin A1c levels ≥6.5%, fasting blood glucose ≥126 mg/dL, or an oral glucose tolerance test result ≥200 mg/dL.
Behavioral Counseling
• Behavior change can be difficult. • How ready or willing is the patient to making the change. Do they feel a change is necessary? • Transtheoretical or Stages of Behavior Change Model
Sexually Transmitted Infections- Counseling
• Behavioral counseling for all sexually active adolescents and for adults who are at increased risk for STIs, including HIV/AIDS. • Clinicians must master the skills of eliciting the sexual history and asking frank but tactful questions about sexual practices. • Counseling should be interactive, nonjudgmental, and combine information about general risk reduction with personalized messages based on the patient's personal risk behaviors.
Motivational Interviewing
• Effective strategy for patients in the pre-contemplative or contemplative stages. • Acknowledges that patients are the experts on themselves • Seeks to understand their perspectives about a given behavior in order to find out their motivation for resistance. • Collaborative conversation style • Ask open ended questions • Listen to ensure understanding patients experience • Inform - Ask permission to provide information and asking what the implications might be more the patient
Harms of Screening
• False-positive results that can cause anxiety and lead to additional testing • Overdiagnosis of low-risk disease that will never cause any clinical problems but may lead to overtreatment • False reassurance from false-negative tests • Pain or discomfort from diagnostic tests
Prevalence
• Important variable when interpreting the predictive value statistics
Benefits of Screening
• Mortality reduction • Morbidity reduction • Reassurance
Tobacco Screening and Counseling
• The USPSTF recommends (grade A) that clinicians ask all adult patients about tobacco use, advise tobacco cessation for tobacco users, and then offer behavioral support and possibly pharmacotherapy. • Questions one may ask at every visit include "Have you ever used tobacco (smoke, chew, e-cigarettes) or vapor products?" • 5 A's- Ask, Advise, Assess, Assist, Arrange • Stages of change model • For nonsmokers, ask about exposure to secondhand smoke and tobacco use by other persons in the household or workplace. • The most commonly used pharmacotherapies are nicotine replacement therapy. For example patches, gum
Screening for Sexually Transmitted Infections
• USPSTF- Chlamydia and gonorrhea screening in sexually active women aged 24 years and younger. Screening high risk non pregnant adults and adolescents for syphilis infection. • The CDC recommends chlamydia and gonorrhea screening annually for all sexually active women aged <25 years and older and women with risk factors. • Chlamydia, gonorrhea, syphilis screening are recommended at least once a year for all sexually active gay, bisexual, and other MSM. • Screening recommendations for HIV- Box 6-23. Identifying early HIV infection and initiating treatment decreases the risk of progressing to AIDS.
Screening Guidelines for Adults (health promotion)
• Unhealthy weight and diabetes mellitus • Substance use disorders • HIV infection • Intimate partner violence, elder abuse, abuse of vulnerable adults
pedigree
•Pedigree: uses standard symbols and terminology to represent a large amount of information in a diagram •Preferred method of organizing and displaying family history •Benefits: 1)organize a great deal of information 2)visualize inheritance patterns and familial clustering
Genetics/genomics risk assessment
•Risk assessment •Collection -Personal history, physical exam findings, lab results, imaging studies -Family history •Interpretation -Who is at increased risk? •Intervention -When and how to refer
Familial cancer syndrome red flags
•Young -Breast <45, Colon <50 •Rare -Examples: Ovarian, Male Breast •Multiple -Two or more different cancers in the same person, or multifocal/bilateral tumors •Family History -Two or more family members with the same or related types of cancer. -Breast/Ovary, Breast/Thyroid/Uterine, Breast/Sarcoma/Brain
Techniques of Skilled Interviewing
■ Active listening ■ Adaptive questioning ■ Nonverbal communication ■ Facilitation ■ Echoing ■ Empathic responses ■ Validation ■ Reassurance ■ Summarization ■ Highlighting transitions
Factors related to present illness
■ Amplifies the Chief Complaint, describes how each symptom developed ■ Includes patient's thoughts and feelings about the illness ■ Pulls in relevant portions of the Review of Systems (see below) ■ May include medications, allergies, habits of smoking and alcohol, since these are frequently pertinent to the present illness
GUIDELINES FOR WORKING WITH AN INTERPRETER
■ Choose a professional interpreter in preference to a hospital worker, volunteer, or family member. Use the interpreter as a resource for cultural information. ■ Orient the interpreter to the components you plan to cover in the interview; include reminders to translate everything the patient says. ■ Arrange the room so that you and the patient have eye contact and can read each other's nonverbal cues. ■ Seat the interpreter next to you and allow the interpreter and the patient to establish rapport. ■ Address the patient directly. Reinforce your questions with nonverbal behaviors. ■ Keep sentences short and simple. Focus on the most important concepts to communicate. ■ Verify mutual understanding by asking the patient to repeat back what he or she has heard. ■ Be patient. The interview will take more time and may provide less information.
ADAPTIVE QUESTIONING: OPTIONS FOR CLARIFYING THE PATIENT'S STORY
■ Directed questioning—from general to specific ■ Questioning to elicit a graded response ■ Asking a series of questions, one at a time ■ Offering multiple choices for answers ■ Clarifying what the patient means
Sequence of the Interview
■ Greeting the patient and establishing rapport ■ Inviting the patient's story ■ Establishing the agenda for the interview ■ Expanding and clarifying the patient's story; generating and testing diagnostic hypotheses ■ Creating a shared understanding of the problem(s) ■ Negotiating a plan (includes further evaluation, treatment, and patient education) ■ Planning for follow-up and closing the interview.
CAGE questionnaire to assess alcoholism
■ Have you ever felt the need to Cut down on drinking? ■ Have you ever felt Annoyed by criticism of drinking? ■ Have you ever felt Guilty about drinking? ■ Have you ever taken a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover? *Can use to assess drug abuse too.
Past history should include
■ Lists childhood illnesses ■ Lists adult illnesses with dates for at least four categories: medical; surgical; obstetric/ gynecologic; and psychiatric ■ Includes health maintenance practices such as: immunizations, screening tests, lifestyle issues, and home safety
Family History includes
■ Outlines or diagrams of age and health, or age and cause of death of siblings, parents, and grandparents ■ Documents presence or absence of specific illnesses in family, such as hypertension, coronary artery disease, etc.
Clinician goals for cultural competence
■ Self-awareness. Learn about your own biases . . . we all have them. ■ Enhanced communication. Work to eliminate assumptions about what is "normal." Learn directly from your patients—they are the experts on their culture and illness. ■ Collaborative partnerships. Build your relationships with patients on respect and mutually acceptable plans.
EXPLORING THE PATIENT'S PERSPECTIVE ILLNESS Learning about the patient's perception of illness means asking patient-centered questions in the six domains listed below. Doing so is crucial to patient satisfaction, effective health care, and patient follow-through
■ The patient's thoughts about the nature and the cause of the problem ■ The patient's feelings, especially fears, about the problem ■ The patient's expectations of the clinician and health care ■ The effect of the problem on the patient's life ■ Prior personal or family experiences that are similar ■ Therapeutic responses the patient has already tried
A child with abnormal shape or length of palpebral fissures:
■ Upslanting (Down syndrome) ■ Downslanting (Noonan syndrome) ■ Short (fetal alcohol effects)