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Partner Violence Screen (PVS)

1. Have you been hit, kicked, punched or otherwise hurt by someone within the past year? 2. Do you feel safe in your current relationship? 3. Is there a partner from a previous relationship that is making you feel unsafe now? First question covers dimension of physical violence, and the latter evaluate the woman's perception of safety and estimate her short term risk of further violence.

Palpable lymph nodes of head and neck

1. The occipital nodes at the base of the skull 2. The postauricular nodes located superficially over the mastoid process 3. The preauricular nodes just in front of the ear ( 4. The parotid and retropharyngeal (tonsillar) nodes at the angle of the mandible 5. The submandibular nodes halfway between the angle and the tip of the mandible 6. The submental nodes in the midline behind the tip of the mandible Then move down to the neck, palpating in the following four-step sequence: 1. The superficial cervical nodes at the sternocleidomastoid muscle 2. The posterior cervical nodes along the anterior border of the trapezius muscle 3. The cervical nodes deep to the sternocleidomastoid (the deep cervical nodes may be difficult to feel if you press too vigorously; probe gently with your thumb and fingers around the muscle) 4. The supraclavicular areas, probing deeply in the angle formed by the clavicle and the sternocleidomastoid muscle, the area of Virchow nodes

Optic Disc

1.5 cm in diameter unit of measure in diameters, ie 2 disc diameters from the optic nerve at 2 o'clock position

How much cardiac output does each kidney recieve?

1/8 of cardiac output through the renal arter

When do pancreatic islet cells develop and what do they do?

12 weeks gestation, and produce insulin

When is bone growth completed by?

20 yrs - the last epiphysis closes and becomes firmly fused to the shaft Once bone growth stops, bone density and strength continue to increase. Peak bone mass is not achieved till 35

Visual Acuity in kids

20/50 by age 3 20/40 by age 4 20/30 by age 5 flip the numbers in denominator and age

How long is the alimentary tract

27 feet long runs from mouth to anus

Spinal Nerves

31 pairs arise from spinal cord and exit at the intervertebral foramen

What is the newborn expected respiratory rate?

40-60 but up to 80 breaths per minute

How often should you hear bowel sounds and what do they sound like

5-35 per minute clicks and gurgles

Expected Heart Measurements

5-7cm at 5th ICS 4-6cm at 4th ICS 3-4cm at 3rd ICS 1-3cm at 2nd ICS

Pulsus Paradoxus

> 10 mmHg decrease in systolic blood pressure with inspiration Caused by PVC, Trachobronchial obstruction, bronchial asthma, emphysema, pericardial effusion, contrictive pericarditis

Investigate these types of nodes

> 2cm Mildly painful Fixed to contiguous tissues and relatively immovable.

Preeclampsia Risk Factors

> 40 yrs First Pregnancy Preexisting chronic HTN Renald disease DM Multifetal Gestation Family Hx Obesity

Patch

A flat, nonpalpable, irregularly shaped macule greater than 1 cm in diameter Ex: Vitiligo, port wine stains, hyperpigmented macule, cafe au lait patch

Transmission of Pain Impulses

A two-way control of pain transmission occurs in the spinal nerve pathways. After the pain impulses reach the spinal cord's dorsal horn, the pain signal may be modified when other stimuli are present form either the brain or the periphery. Substances such as endorphins (endogenous opioids) and gamma-aminobutyric acid (GABA) can change or inhibit the pain perceived. Pain impulse transmission can be reduced when non-pain impulses compete to transmit sensations along the same spinal pathways to the brain. Emotions, cultural background, sleep deprivation, previous pain experiences and age are factors that have an impact on a person's perception and interpretation of pain.

Rate and depth of breathing will increase with:

Acidosis CNS Lesions in Pons and Medulla Anxiety Aspriing Poisoning Hypoxemia Pain

What are the milk producing cells and where do they empty?

Acinar Cells - empty into Lactiferous Ducts

Cough Onset

Acute = infection esp with fever. No fever = foreign body or inhaled irritants

Encephalitis

Acute inflammation of the brain and spinal cord involving the meninges, often due to a virus Patho • A virus may be transmitted by the bite of an arthropod or mosquito, such as with West Nile virus, eastern equine encephalitis, and Japanese encephalitis. Herpes simplex virus may be another cause. • Nerve cell degeneration occurs leading to edema, increased intracranial pressure, and areas of necrosis Subjective Data • Mild viral illness with fever • Recovery and quiet stage followed by onset of lethargy, restlessness, and mental confusion Objective Data • Altered mental status, confusion, stupor, coma • Photophobia • Stiff neck • Muscle weakness, paralysis, ataxia

Physical Exam: Skin inspection

Adequate exposure of the skin is necessary. It is essential to remove clothing and to fully remove drapes or coverings as each section of the body is examined. Make sure that the room temperature is comfortable. Look carefully at all areas, remembering to inspect areas that are usually not exposed, such as the axillae, buttocks, perineum, backs of thighs, and inner upper thighs. Remove shoes and socks to look at the feet. Pay careful attention to intertriginous surfaces (areas where two skin surfaces may touch, e.g., axillae and groin), especially in infants, older adults and bedridden patients. As you complete the examination for each area, re-drape or cover the patient. When inspecting the skin, it is important to have a systematic routine in place to ensure that no areas are forgotten. Skin thickness varies over the body, with the thinnest skin on the eyelids and the thickest at areas of pressure or rubbing, most notably the soles, palms, and elbows. Note calluses on the hands or feet. Look for corns on pressure points. Corns are flat or slightly elevated, circumscribed, painful lesions with a smooth, hard surface. A superficial area of hyperkeratosis is called a callus. Calluses usually occur on the weight-bearing areas of the feet and on the palmar surface of the hands. Calluses are less well demarcated than corns and are usually not tender

Adie Pupil (Tonic Pupil)

Affected pupil dilated and reacts slowly or fails to react to light. Responds to convergence Impairment of postganglionic parasympathetic innervation to sphincter pupillae accompanied by diminished tendon reflex

Pneumothorax

Air or gas in pleural cavity Tension pneumo - air leaks into pleural cavity Mediastinal shift with tracheal deviation away from involved side in tension pneumo Unexplained persistent tachycardia

Adolescents

Apocrine glands enlarge and become active, causing increased axillary sweating and sometimes body odor. Sebaceous glands increase sebum production causing oily appearance which leads to acne.

Retinal Structures

Arterioles smaller than venules, ratio of 3:5 or 2:3 Arterioles are brighter

The hip and joint consist of

Articulations between the acetabulum and the femur

Tempomandibular Joint consists of?

Articulations between the mandible adn the temporal bone in the cranium. Each is located in the depression just anterior to the tragus of the ear. Gliding action permits lateral movement, protrusion, and retraction of the mandible.

Physical examination: Skin Palpation

As you inspect, palpate the skin for moisture, temperature, texture, turgor, and elasticity. Palpation may yield additional data for describing lesions, particularly in relation to elevation or depression. Minimal perspiration or oiliness should be present. Increased perspiration may be associated with activity, warm environment, obesity, anxiety, or excitement; it may be especially noticeable on the palms, scalp, forehead, and in the axillae. The intertriginous areas or skin in body folds may also be damp leading to development of intertrigo The skin should range from cool to warm to the touch. Use the dorsal surface of your hands or fingers because these areas are most sensitive to temperature perception. At best, this assessment is a rough estimate of skin temperature; what you are really looking for is bilateral symmetry. Environmental conditions, including the temperature of the examining room, as well as body location may affect surface temperature. The texture should feel smooth, soft, and even. Roughness on exposed areas or areas of pressure (particularly the elbows, soles, and palms) may be caused by dry skin or irritation. Extensive or widespread roughness may be the result of a keratinization disorder or damaged skin. Hyperkeratoses, especially of the palms and soles, may be the sign of a systemic disorder such as exposure to arsenic, other toxins, or a sign of internal malignancy. Assessment of skin elasticity can be helpful to detect certain conditions. Gently pinch a small section of skin on the forearm or sternal area between the thumb and forefinger and then release the skin. The skin should move easily when pinched and return to place immediately when released. Poor skin turgor can indicate severe dehydration. The skin is very slow to return to normal and "tents" up. This may occur with excessive vomiting, diarrhea, or dehydration for another cause. Skin that is firm or cannot be pinched may suggest an underlying connective tissue disease such as scleroderma.

Exophthalmus Mean Protrusion

Asian - 18.6mm White - 21.7 mm Black - 24.7 mm

Allen Test

Assesses patency of the ulnar artery 1. With the patient's palm facing upward, compress the radial and ulnar artery with your fingers. 2. Have the patient close and open the fist five times and then leave the blanched palm open. 3. Release pressure on the ulnar artery alone and watch for palmar reperfusion within 4 to 5 seconds. 4. If palmar reperfusion does not occur, suspect ulnar artery insufficiency and do not puncture the radial artery.

Neurovascular assessment after sports injury

Assessment of circulation and nerve sensation is important when an extremity is injured. Perform the following steps to complete a neurovascular assessment distal to the injury. Use the contralateral extremity for comparison. ASSESSMENT Color Temperature Capillary refill time Swelling Pain Sensation Movement UNEXPECTED FINDINGS Pallor or cyanosis Cool or cold Greater than 4 seconds Significantly swollen Presence of moderate to severe pain Numbness, tingling, pins-and- needles sensation Decreased or no movement

Cervical Chest Pain Characterisics

Associated w/ injury provoked by activity, persists after activity; painful on palpation and or movement

Psychoneurotic Chest Pain

Associated with/after anxiety; poorly described; located in intramammary region

Limb Measurement Tests

Asymmetry in limb size extremities. Leg length is measured from the anterior superior iliac spine to the medial malleolus of the ankle, crossing the knee on the medial side. Arm length is measured from the acromion process through the olecranon process to the distal ulnar prominence. The circumference of the extremities is measured in centimeters at the same distance on each limb from a major landmark. Athletes who use the dominant arm almost exclusively in their activities (e.g., pitchers and tennis players) may have some discrepancy in circumference. For most people, no more than a 1-cm discrepancy in length and circumference between matching extremities should be found.

S4 heart sound

Atria contracting against a Stiff or Hypertrophic ventricle (ventricular compliance is lost) (aortic stenosis, restrictive cardiomyopathy) Caused by papillae, valves, and ventricular walls vibrating during the second (late) phase of diastole / presystole. Can easily be confused with split S1 due to timing Common in older patients le-lub-dub or KEN-tuck-y

Actinic Keratosis

Atypical squamous cells confined to the upper layers of the epidermis. Occurs secondary to chronic sun damage. Some lesions can progress to squamous cell carcinoma over time Subjective Data • History of chronic sun exposure • Increasing number of lesions with age Objective Data • Raised, gritty, erythematous lesion that is usually with an irregular, rough surface • Lesion is most common on the dorsal surface of the hands, arms, neck, and face (

External Ear

Auricle should be same color as facial skin Darwin tubercle, a thickening along upper ridge of helix is expected variation.

Cystic Fibrosis

Autosomal recessive disorder of exocrine glands involving lungs, pancreas, and sweat glands. Thick mucous causes progressive clogging of the bronchi and bronchioles. Cough with sputum is hallmark in kids under 5 yrs. Barrel chest Nasal Polyps Low body mass due to malabsorption Pulmonary dysfunction leads to clubbing COPD signs/symptoms

Bald Spots in children and infants

Bald spots in children? History is important. The differential diagnosis includes tinea capitis, alopecia areata, or trichotillomania (compulsive hair-pulling). Infants who sleep on their backs may develop areas of alopecia from pressure on the occiput. Supine sleeping is proven to reduce the risk for sudden infant death (SIDS). Providing tummy time while the infant is awake can promote motor development and decrease the likelihood of developing a bald spot.

Cat Scratch Disease

Bartonella henselae and Bartonella clarridgeiae Subjective Data • Bite, scratch, or wound from cat or kitten • Inoculation lesion: a papule or pustule lasts 3-5 days and then becomes vesicular and crusts in 2-3 days • Painful enlarged lymph nodes Objective Data • Inoculation lesion; may be healing • Lymphadenopathy develops in 1-2 weeks in the region that drains the primary lesion. • Single lymph node most often, but multiple nodes are involved occasionally • Tender nodes commonly in head, neck, and axillae; the accessible nodal areas in the arms and legs are less often involved. • Nodes can be very large—up to several centimeters; often red and tender and occasionally suppurate • Diagnosis can be made in the presence of a nodal enlargement lasting longer than 3 weeks, accompanied by an inoculation lesion of the skin and after an interaction with a cat, a cat scratch, or cat lick on a break in the skin. • Lymphadenopathy can last for 2-4 months or even longer.

Scoliosis

Be suspicious if you see a lateral curvature of rib hump lateral curvature of the spine Measure with scoliometer

Test for Applying Mydriatics

Before instillation of a mydriatic, inspect the patient's anterior chamber by shining a focused light tangentially at the limbus (the union of the conjunctiva and the sclera). Note the illumination of the iris nasally. This portion of the iris is not lighted when the patient has a shallow anterior chamber, indicating a risk of acute-angle glaucoma. Mydriatics should be avoided in these patients.

Concentric Circle Technique

Begin at the outermost edge of the breast tissue and spiral your way inward toward the nipple

Permanent teeth

Begin forming in the jaw by 6 months of age. Pressure from these teeth causes resorption of the deciduous teeth roots until the crown is shed. Eruption of permanent teeth begins about 6 years of age and is completed around 14-15 yrs

Midsystolic (Ejection) Murmur

Begins after S1, ends before S2. Crescendo-decrescendo quality

When do sutures ossify?

Begins at 6yrs old when brain growth finishes.

Middiastolic murmur

Begins at clear interval after S2

Late Diastolic (Presystolic) Murmur

Begins immediatley after S1

Late Systolic Murmur

Begins mid to late systole crescendos endas at S2. Often introduced by mid to late systolic clicks

Early Systolic Murmur

Begins with S1, decrscendos, ends well before S2

Fat Necrosis in Breasts

Benign breast lump occurs as inflammatory response to local injury Necrotic fat and cellular debris become fibrotic and may contract into a scar Caused by Trauma to breast including surgery Area of discoloration around a firm irregular mass

Duct Ectasia

Benign condition of the subareolar ducts that produces nipple discharge Subareolar ducts become dilated and blocked Most common in menopausal women Discharge often green or brown in color, may be sticky

Polymorphic Eruption of Pregnancy

Benign dermatoses in THIRD trimester of a FIRST pregnancy etiology is unclear, resolves after delivery, does not occur in subsequent pregnancies. Intensely pruritic rash that began on the abdomen then spreads to thighs, buttocks, and arms after a few days. Periumbilical area is spared Intensely pruritic rash, erythematous urticaria like papules and plaques on abdomen, thighs, buttocks, arms No lesions of face, palms, soles Often halos of blanching surround the papules

Fibrocystic Changes

Benign fluid filled cysts formation caused by ductal enlargement Usually bilateral and multiple Common in 30-55 yrs old Associated with a long follicular or luteal phase of the menstrual cycle Subjective data Tender and painful breasts and or palpable lumps that fluctuate with menses Usually worse premenstrually Objective Data Round soft to firm tense, mobile masses with well-delineated borders Usually tender Usually Bilateral.

Fibroadenoma

Benign tumor composed of stomal and epithelial elements that represent a hyperplastic or proliferative process in a single terminal ductal unit. Can occur at any age After Menopause tumors often regress Subjective Data Painless lumps that don't fluctuate with the menstrual cycle Usually bilateral, nontender Biopsy to r/o carcinoma

Intraductal Papillomas and Papillomatosis

Benign tumors of the subareolar ducts that produce nipple discharge Wartlike tumor in the lactiferous duct 2-3 cm in diameter Spontaneous nipple discharge that is serous or bloody.

Essential tremor

Bilateral Symmetric, primarily seen in hands or outstretched arms, intention tremor. It can be seen in head, trunk, voice, tongue. May worse with stress or fatigue may improve with alcohol. Progressive. No cerebral patho. Autosomal Dominant inheritance pattern

Infarction produces this type of sputum

Blood clotted, large amounts of blood

Hemothorax

Blood in pleural cavity Tachycardia, hypotension, lightheadedness

Pregnant patients

Blood pressure decreases around 8 weeks gestation, gradually falling until a low point is reached at mid pregnancy. The diastolic BP rises to prepregnant levels by term. During pregnancy some patients may experience pain due to several physiologic processes: Back Pain - due to lax ligaments, weight gain, hyperlordosis, and anterior tilt of pelivs Cramping or pressure - may be signs of premature labor or Braxton Hicks contractions (start around 6 weeks of pregnancy). Epigastric Pain - from gravid uterus Round ligament pain - due to stretching of ligaments and enlarging of uterus Pressure on bladder may occur from the weight of the enlarging uterus

Viral infection has this type of sputum:

Blood streaked but not commonly.

Opthalmascope

Blood vessel seen at 3-5 cm from pt. Myopic (near sighted) - use minus (red) lens Hpyeropic / lacks lens (aphakic) use plus lens

Auricle Color

Blueness - degree of cyanosis Pallor or Excessive redness - Vasomotor instability Extreme pallor - frost bite Cauliflower Ear - Blunt trauma and necrosis of underlying cartilage. Tophi - Small whitish uric acid crystals along the peripheral margins of auricles = Gout Sebaceous cyst, elevations in the skin with a punctum - blocked sebaceous gland

Venous Star

Bluish spider, linear or irregularly shaped; does not blanch with pressure Cause: Increased pressure in superficial veins

Blurred vs Double Vision

Blurred vision is problem with visual acuity. Diplopia is perception of two images, can be monocular or binocular. This is an Alignment problem.

Temperature

Body temperature is regulated and maintained by the hypothalamus. When pathogens invade the body, exogenous pyrogens, endotoxins produced by the pathogen, are released and travel to the hypothalamus. The hypothalamus responds by raising the body's temperature set point leading to a fever. Epinephrine is then released which increases the metabolic rate and muscle tone. The body generates heat by shivering, a rapid contraction of skeletal muscles. The body conserves heat by vasoconstriction, which reduces heat loss through the skin. Body cooling occurs by vasodilation which increases heat loss through the skin, increased sweating, and evaporation of perspiration.

Where are lmyphocytes primarily produced?

Bone Marrow, these are called B Lymphocytes which produce antibodies and are characterized by immunoglobulins on surface. B lymphocytes live about 3-4 days Involved in the Humoral Response.

Classic Pain Patterns

Bone and Soft Tissue pain - may be tender, deep, aching Tumor - Heavy throbbing, and aching pain may be associated with a tumor pressing on a cavity Nerve Tissue Damage - Burning, Shock-like pain Myocardial infarct - clenched fist over chest with diaphoresis and grimacing Visceral or Colic Pain - Cramping Spasms

Osteoarthritis Sign in Fingers

Bony overgrowth in the distal interphalangeal joints which are felt as hard non-tender nodules usually 2-3mm in diameter but sometimes encompass the entire joint

Turbinates (conchae)

Bony structures that form the lateral walls of the nose and protrude into nasal cavity. Purpose: Increase the nasal surface area to warm, humidify, and filter inspired air. Inferior meatus drains the nasolacrimal duct. Middle meatus drains the paranasal sinuses. Superior meatus drains posterior ethmoid sinus.

Melanoma

Border is irregular, lesions tend to be larger, often greater than 6mm. Color variation within the lesion is characteristic ranging from tan brown, dark brown, or black, pink, red, gray, blue, white Any lesion suggestive of melanoma must be biopsied.

Strabismus

Both Eyes do not focus on an object simultaneously but can focus with either eye Patho: Paralytic, ICP, CN 3 damage from brain swelling. S/s: Poor vision, sudden onset double vision, eye deviation Extraocular muscle impairment. Ex: if right sixth nerve is damaged, right eye does not move temporally. Detected by: Cover-Uncover test, children - use strabismoscope or photoscreening.

Special Concerns for a patient with a spinal cord injury or lesion

Bowel and Bladder- some do not have voluntary bladder or bowel movements. Do not remove indwelling catheter unless it isn't working. Tactile stimulation can cause incontinence.

Premature Thelarche

Breast enlargement in girls younger than 8yrs of age • Cause is unknown. However, increased sensitivity of breast tissue to estradiol (E2), transient E2 secretion from ovarian cysts, dietary estrogen intake, and transient activation of the hypothalamo-pituitary-gonadal (HPG) axis have been proposed as possible mechanisms • Most cases have an onset in girls under age 2 years. • In most cases, breasts continue to enlarge slowly throughout childhood until full development is reached during adolescence.

Secondary Apnea

Breathing stops and will not begin spontaneously unless resuscitative measures are immediately instituted. Any event that severely limits the absorption of oxygen into the bloodstream will lead to secondary apnea.

Lung Cancer

Bronchogenic carcinoma is a malignant tumor that evolves from bronchial epithelial structures cough, wheezing, hemoptysis Postobstructive pneumonia with consolidation - airway obstruction

Exopthalmos

Bulging of Eye out of orbit Graves disease. When unilateral consider retro-orbital tumor Exopthalmometer to measure.

Bossing

Bulging of the skull of the frontal areas - associated with prematurity, thalassemia, paget disease, rickets.

What CN Innervate the facial Muscles?

CN 5 CN 7

New Born Eyelids

Can be edematous at birth

Accuracy of blood pressure readings

Can be undermined by some conditions: Cardiac Dysrhythmias - if HR irregularity is sustained, take the average of several blood pressure readings and document the problem Aortic Regurgitation - if the sounds of an aortic regurgitation do not disappear the diastolic pressure will be obscured Venous Congestion - If sluggish venous flow occurs due to a pathologic event or repeated slow inflation of the cuff, the systolic pressure will be heard lower than it actually is and the diastolic even higher Valve Replacement - if the sounds are heard all the way down to a zero gauge reading, listen carefully for the first muffling of the sound (Kortokoff phase 4) to determine the diastolic pressure. More modern valves do not cause this discrepancy.

Carotenemia

Carotenemia, or xanthoderma, common in infants who have started eating baby foods, is yellow pigmentation of the skin and increased bet-carotene levels in the blood. Carotenemia does not cause orange discoloration of the sclerae, and thus is usually easy to distinguish from jaundice. IN most cases, this benign condition follows increased consumption of carotene rich foods such as carrots, squash, and sweet potatoes. If discontinued, skin color will normalize in a few weeks

Best places to palpate pulse?

Carotid brachial Radial Femoral Popliteal Dorsalis Pedis posterior tibial arteries

Bruit auscultations sites

Carotid - ask pt to stop breathing for a few heart beats to hear over respiration Subclavian Abdominal Aorita Renal Illiac Femoral arteries

Palpation of Carotid Artery

Carotid pulse located just medial to and below the angle of the jaw

Toxoplasmosis

Cat litter box disease, or raw undercooked meat Subjective Data • No significant symptoms • History of eating raw or rare meat or uncooked eggs • History of direct contact with cat feces, cleaning the litter box, gardening in feces-contaminated soil Objective Data • Single node, chronically enlarged and nontender • Node is usually in the posterior cervical chain

Pulsus Alternans

Caused by LV Failure, more significant if pulse is slow

History of Present Illness: Hair

Changes in hair: loss or growth, distribution, texture, color • Occurrence: sudden or gradual onset, symmetric or asymmetric pattern, recurrence • Associated symptoms: pain, itching, lesions, presence of systemic disease or high fever, recent stress, hair-pulling, infection • Exposure to drugs, environmental or occupational toxins or chemicals, commercial hair care chemicals • Nutrition: dietary changes, dieting • What the patient has been doing for the problem, response to treatment, what makes the problem worse or better • How the patient is adjusting to the problem • Medications: drugs or preparations for hair loss (minoxidil, finasteride, dihydrotestosterone [DHT] inhibitors)

Roasacea

Chronic Inflammatory Skin Disorder Patho Cause unknown, occurs most often in persons with a fair complexion Lasts for years Subjective Data • Itching is absent. • Many patients report a stinging pain associated with flushing episodes. • Common triggers are exposure to the sun, cold weather, sudden emotion, (e.g., laughter or embarrassment), hot beverages, spicy foods, and alcohol consumption. Objective Data • Eruptions appear on the forehead, cheeks, nose, and occasionally about the eyes. • Characterized by telangiectasia, erythema, papules, and pustules that occur particularly in the central area of the face • Although rosacea resembles acne, comedones are not present. • Tissue hypertrophy of the nose (rhinophyma) may occur, characterized by sebaceous hyperplasia, redness, prominent vascularity, and swelling of the skin of the nose

Bronchiectasis

Chronic dilation of the bronchi or bronchioles caused by repeated pulmonary infections and bronchial obstruction Cough with large amounts of sputum is major clue.

Tuberculosis

Chronic infectious disease that most often begins in the lung but may have widespread manifestations Tubercle Bacillus is inhaled Subjective Data • Latent period: asymptomatic, some regional lymph nodes may be involved • Active infection: fever, cough, weight loss, night sweats • History of travel to region with endemic tuberculosis or close contact with infected person Objective Data • Latent disease: no pulmonary findings • Active disease: consolidation and/or pleural effusion may develop with corresponding findings and cough with blood-streaked sputum • Positive tuberculin skin test, sputum testing for acid fast bacilli, and Interferon Gamma Release Assay (IGRA)

Ulcerative Colitis

Chronic inflammatory disorder of the oclon and recutm that produces mucosal friability and areas of ulceration Bloody, frequent, watery diarrhea. 20-30 stools per day.

Rheumatoid Arthritis

Chronic systemic inflammatory disorder of the synovial tissue surrounding the joints Polymorphonuclear lueukocytes aggregate within inflammed synovial tissue and fluid Inflammatory cytokines and enzymes that are released can result in damage to bone, cartilage and other tissues Join pain or stiffness esp in morning after periods of inactivity Fatigue, myalgias, weight loss, low grade fever common Synovitis present on exam

Coining and Cupping

Coining - used by asian subcultures, can be confused for disease or abuse. Coin dipped in mentholated oil is rubbed across skin. believed to release excess force from the body and hence restore balance. Cupping - small heated glasses are placed on the skin forming a suction that leaves a red or purpuric circular mark, drawing out the bad force

Features of Normal vs Dysplastic Moles

Color Normal - Uniformly tan or brown; all moles on one person tend to look alike. All moles on one person tend to look alike. Dysplastic - Mixture of tan, brown, black, and red/pink; Moles on one person often do not look alike Shape Normal - Round or oval with a clearly defined border that separates the mole from surrounding skin Dysplastic - Irregular borders may include notches; may fad into surrounding skin and include a flat portion level with skin Surface Normal - Begins as flat; smooth spot on skin; becomes raised; forms a smooth bump Dysplastic - May be smooth, slightly scaly, or have a rough irregular, "pebbly" appearance Size Normal -Usually less than 6 mm ( size of a pencil eraser) Dysplastic - Often larger than 6 mm and sometimes larger than 10mm Number Normal - 10-40 in typical adult scattered over body Dysplastic - Many people do not have increased number; however persons severely affected may have more than 100 moles Location Normal - Usually above the waist on sun-exposed surfaces of the body; scalp, breast, and buttocks rarely have normal moles Dysplastic - May occur anywhere on the body, but most commonly on back; may also appear below waist and on scalp, breast, and buttocks

Physical Examination: Nail color

Color. The shape and opacity of nails vary considerably among individuals. Nail bed color should be variations of pink. Pigment deposits or bands may be present in the nail beds of persons with dark skin. Yellow discoloration occurs with several nail diseases, including psoriasis and fungal infections, and may also occur with chronic respiratory disease. Proximal subungual fungal infection is associated with HIV infection. Diffuse darkening of the nails may arise from antimalarial drug therapy, candidal infection, hyperbilirubinemia, and chronic trauma, such as occurs from tight-fitting shoes. Green-black discoloration, which is associated with Pseudomonas infection, may be confused with similar discoloration caused by injury to the nail bed (subungual hematoma). Pain accompanies a subungual hematoma, whereas Pseudomonas infection is painless. Nail beds that are blue may be a transient response to a cold examining room. A single blue or black nail may indicate melanoma or bruising/bleeding from trauma. Generalized blue nails may be caused by conditions that produce cyanosis such as asthma, cardiac disorders, or severe anemia. Other causes of blue nails include silver poisoning, medication side effects, and Wilson disease, an inherited disorder of copper metabolism. Splinter hemorrhages, longitudinal red or brown streaks, may occur in endocarditis, vasculitis, with severe psoriasis of the nail matrix or as the result of minor injury to the proximal nail fold (habit-tic deformity). White spots in the nail plate (leukonychia punctate), a common finding, result from cuticle manipulation or other forms of mild trauma that injure the nail matrix. These spots need to be differentiated from longitudinal white streaks or transverse white bands that are indicative of a systemic disorder. Separation of the nail plate from the bed produces a white, yellow, or green tinge on the nonadherent portion of the nail.

Infants and Children: Impetigo

Common contagious superficial skin infection Staph or Streptococcal infection of dermis Subjective Data • Lesion, typically on the face, that itches and burns • Also on other parts of body associated with minor injuries or insect bites Objective Data • Initial lesion is a small erythematous macule that changes into a vesicle or bulla with a thin roof. • Lesion crusts with a characteristic honey color from the exudate as the vesicles or bullae rupture • May have regional lymphadenopathy.

S1 Intensity increased in

Complete Heart Block rhythm disruption - Fibrillation Just Remember Dysrhtmias or Intensity, DysrhytmIa has an I in it.

Types of Histories

Complete History - Most often recorded first time you see the patient. Inventory History - touches on major points without going into detail. Useful when getting a feel for the situation and entire history taking will be completed in more than one session Problem (or focused) history - taken when problem is acute, possibly life threatening Interim History - designed to chronicle events that have occured since your last meting with the patient. Should be complemented by the patients previous record.

Dislocation

Complete separation of the contract between two bones in a joint Often caused by pressure of force pushing the bone out of the joint, acute trauma Can occur more easily in patients with hyperextensibility conditions (Marfan, Ehlers-Danlos) Inability to use joint accompanied with deformits

What is bile composed of and what does it do?

Composed of cholesterol, bile salts, pigements Maintains alkaline pH of the small intestine and emulsifies fats

Carpal Tunnel Syndrome

Compression of the median nerve Caused by microtrauma, local edema, or inflammation, repetitive motion or vibration of the hands Numbness, buring, tingling in the hand often occurs at night. Pain may radiate to arms Weakness of the thumb and flattening of the thenar eminence of the palm Reproduction of symptoms with provocation of Tinel and Phalen Maneuvers

Tetralogy of Fallot

Congenital heart defect composed of four cardiac defects: ventricular septal defect, pulmonic stenosis, dextroposition of the aorta, and right ventricular hypertrophy Subjective Data • Dyspnea with feeding, poor growth, exercise intolerance • Paroxysmal dyspnea with loss of consciousness and central cyanosis (hypercyanotic episode or tetralogy spell) Objective Data • Parasternal heave and precordial prominence, systolic ejection murmur over the third intercostal space, sometimes radiating to the left side of the neck; a single S 2 is heard Older children develop clubbing of fingers and toes May develop HF if not surgically corrected

Lymphangioma characteristics

Congenital malformation of dilated lymphatics transilluminates; hemangiomas do not. Painless cystic masses Usually manifest during the first year of life and enlarge from an upper respiratory infection May simulate lymph node enlargement.

Cochlea

Contains Organs of Corti, transmits sound to CN VIII

Frontal Lobe

Contains the motor cortex associated with voluntary skeletal movement and fine repetitive motor movements as well as control of eye movements.

Descending Spinal Tracts

Corticospinal, reticulospinal, vestibulospinal Convey impulses from brain to various msucle groups by inhibiting or exciting spinal activity Muscle tone, posture, precise motor movements.

Respiratory Rate

Count respirations just after pulse, do not tell patient. RR 12-20 expected Ratio to heart is 1:4

Peripheral Nervous System is comprised of:

Cranial and Spinal Nerves Ascending and descending pathways

Latex Allergy Type IV Dermatitis

Delayed Hypersensitivity reaction, T cell mediated Subjective Data • Exposure to latex products • Rash at area of contact Objective Data • Skin reaction usually begins 48-72 hours after contact • Vesicular lesions, erythema localized to area of contact • Reaction may progress to oozing skin blisters

Annulus

Dense fibrous ring that surrounds the tympanic membrane. Concave pulled in at Umbo (center) by malleus

Down Syndrome Facies

Depressed Nasal Bridge Epicanthal folds Mongoloid slant of eyes low set ears

What are the functions of the spleen?

Destroy RBC's Produce Antibodies Store RBC's Filter Microorganisms. Store Produce Down Far

Strabismoscope

Detects strabismus (eye misalignment) in routine eye testing in children

Osteoarthritis

Deterioration of the articular cartilage covering the ends of bone in synovial joints From cartilage abrasion, pitting, and thinning the bone surfaces are eventually exposed with bone rubbing on bone Bone spurs can occur from remodeling Pain Onset after 40 yrs old Joints may enlarge due to bone growths May have crepitus and limited painful ROM

Frontal Sinus

Develop during childhood Located in the frontal bone superior to the nasal cavities.

Diabetic Retinopathy (Proliferative)

Development of new vessels as a result of anoxic stimulation. Vessels grow out of retina toward vitreous humor. New vessels lack supporting structure and are likely to hemorrhage. Bleeding is the leading cause of blindness. Can be controlled by lasertherapy. S/s: floaters, blurred vision, visual acuity loss in later stages. Generally asymptomatic.

Indications of Rheumatoid Arthritis

Deviation of the fingers to the ulnar side Swan Neck Deformities Boutonnier Deformities

Monofilament

Device used to test for loss of protective sensation particularly on the plantar surface of the foot (for diabetic or peripheral neuropathy) press hard enough to make monofilament bend. test several areas on foot. hold pressure aprox 1.5 seconds.

Use Right Lateral Recument for

Dextrocardia

Displacement of the apical impulse to the right without a loss or gain in thrust suggests

Dextrocardia, Diaphgramatic Hernia, Distened Stomach or a pulmonary abnormality

Glaucoma

Disease of optic nerve due to high ICP Acute Angle - Dramatically elevated ICP. Iris blocks the exit of aqueous humor from anterior chamber. Intense ocular pain, blurred vision, halos around lights, red eye, dilated pupil. Open Angle - caused by decreaseing aqueous humor absorption leads to increased resistance and painless buildup of pressure. No Symptoms, more common. Gradual loss of peripheral vision over years. Inspection: Optic nerve damage clearly seen during dilated exam. Cupping of the optic nerve.

Corneal Ulcer

Disruption of the corneal epithelium and stroma Pain, photophobia, hx of wearing contacts, blurry vision, feeling something in eye Purulent exudates, inflammation, Border sharply demarcated. Base appearing ragged and gray. Patho: RA, Sjogren syndrome, lupus, Wegener Granulomatosis, polyarteritis nodosa

Molding of the head in infants

Distressing for parents, reassure them with drawings. Usually resolves within 1 week of birth.

Patent Ductus Arteriosus In Utero

Diverts blood away from the lungs

Internal Nose

Divided by septum into two anterior cavities: the vestibules. Air passes to the Choanae - posterior opening leading to nasopharynx.

Patient positioning for examination

Dorsal Recumbent - For genital or rectal examination. Pt supine with knees bent and feet flat. Place drape in a diamond position from chest to toes. Lateral Recumbent - Side lying position with legs extended or flexed. Can be used in listening to heart sounds or palpating the spleen. Sims - Can be used for examination of the rectum or obtaining a rectal temperature. Pt starts in a lateral recumbent position. Torso is rolled toward a prone position; the top leg is flexed sharply. Drape patient from shoulders to toes Lithotomy - used for pelvic examination. Pt begins in dorsal recumbent, feet at corners of table. Stabilize feet in stirrups and slide the buttocks down to the edge of the table. Drape in diamond position.

Babinski Reflex

Dorsiflexion of the great toe with our without fanning of the other toes. Indicates Pyramidal tract (Corticospinal and Corticobublar tracts) disorder. Expected finding in children < 2yrs (16 - 24 months) If pt ticklish, use firm touch.

Diabetic Retinopathy (Background / Non Proliferative)

Dot hemorrhages or microaneurysms and the presence of hard or soft exudates. Hard exudates from lipid transudation through incompetent capillaries Soft exudates (Cotton Wool Spots) caused by infarction of the nerve layer. S/s: Blurred vision, distortion, visual acuity loss in advanced stages.

What constitutes the greater and lesser omentum

Double folds of the peritoneum around the stomach

Bulge Sign

Effusion of fluid in the knee With the patient's knee extended, milk the medial aspect of the knee upward two or three times, and then milk the lateral side of the patella. Observe for a bulge of returning fluid to the hollow area medial to the patella

Vesicle

Elevated, circumscribed, superficial, not into dermis, filled with serous fluid, less than 1 cm in diameter Ex: Varicella (chickenpox), Herpes zoster (shingles)

Plaque

Elevated, firm, and rough lesion with flat top surface greater than 1 cm in diameter Ex: Psoriasis, seborrheic, and acitinc keratosis

Nodule

Elevated, firm, circumscribed lesion; deeper in dermis than a papule, 1-2 cm in diameter

Wheal

Elevated, irregular-shaped area of cutaneous edema; solid, transient, variable diameter Ex: Insect Bites, Urticaria, allergic reaction

Arterial Embolic Disase

Emboli in arterial system Pain is common Paresthesia Occlusion of small arteries and necrosis (blue to syndrome) Endocarditis = splinter hemorrhages in nail beds.

Pulmonary Embolism

Embolic occlusion of pulmonary arteries Pleuritic Chest Pain with or without dyspnea is a major clue to embolism

During fetal development what does the skeletal system arise from?

Embryologic connective tissues that form cartilage that calicifies to become bone

Retinoblastoma Child / Infant

Embryonic malignant tumor arising from the retina. Autosomal Dominant trait or (RB1 gene on Chromosome 13) White Reflex (Cat's eye) on Photographs

Anterior Cerebral Artery Stroke

Emotional lability Confusion, amnesia, personality changes Urinary incontinence Contralateral hemiplegia or hemiparesis, greater in lower than upper extremities

Hydrocephalus Facies

Enalrged Head Thinning of Scalp with dilated scalp veins Bossing of the skull Sclera visible above the iris Can have paresis of upward gaze (Sunsetting sign)

Patient safety - Multiple Meds / Iatrogenic disorders

Encourage patient to bring in medication bottles, if using multiple docs, use a single pharmacy so computer can flag drug interactions.

What are three physical signs that a disorder of the lymph system may be present?

Enlarged Lymph nodes (Lymphadenopathy) Red Streaks on the overlying skin (Lymphangitis) Lymphedema

Hurler Syndrome Facies

Enlarged skull with low forehead, corneal clouding, short neck.

Hypertension

Essential or Primary hypertension - no discernable cause. If pt complains of recurrent epistaxis (nose bleeds) or headaches that disappear as the day progresses should have their blood pressure carefully monitored. If diastolic BP > 90mm Hg, or if you suspect coarction of the aorta, measure BP in legs. Place the patient in prone position. If patient is in supine position flex the leg as little as possible.

Otoscope

Examines the auditory canal and tympanic membrane. Can also be used for nasal examination.

Pleural effusion

Excessive nonpurulent fluid in the pleural space Cough with progressive dyspnea is a typical presenting concern. Dullness to percussion and decreased tactile fremitus are the most useful findings. Percussion is hyperressonant in the area above the perfusion.

Elbow Pronation and Supination ROM

Expect 90 degrees on both

Elbow ROM

Expect Flexion of 160 degrees and extension returning to 0 degrees or 180 degrees of full extension

Prominent Epicanthal Folds

Expected in asian infants Can suggest Down Syndrome in other races

Temperature

Expected range: 97.2 - 99.9F or 36.2 - 37.7C Average: 98.6 or 37C

Hearing loss Risk Factors - Adults

Exposure to industrial or recreation noise Genetic disease : Meniere disease Neurodegenerative and autoimmune disorders Syphillis Ototoxic medications

Inguinal Ligament (Poupart Ligament)

Extends form the anterior superior spine of the ilium on each side of the pubis

External, middle, and inner Ear Anatomy

Externa ear - cartilage covered

Midbrain CN 3-4

Eye and Head Movement Auditory relay pathway Corticospinal tract pathway

Miosis

Eye constriction < 2 mm Caused by Iridocyclitis, Miotic Eye Drops (Pilocarpine), and opioid abuse

CN 7 (Facial)

Facial expression except jaw, close eyelids, labial speech sounds (b, m, w, and rounded vowels) Anterior 2/3 of tongue, sensation to pharynx Secretion of saliva and tears

When entire one side of face is affected by asymmetry suspect..

Facial nerve paralysis

Spirtuality - FICA

Faith, Belief, Meaning - What is your spiritual or religious heritage - Do the beliefs help you cope with stress Importance and Influence - How have these beliefs influenced how you handle stress? Community - Do you belong to a formal spiritual or religious community Address/Action in Care - How do your religious beliefs affect your healthcare decisions (eg birth control)? pg. 10

Pseudostrabismus

False appearance of crossed eyes caused by flattened nasal bridge or epicanthal folds. Goes away by 1 yr old Use corneal light reflex to differentiate from actual strabismus

HOTV

Far Vision Wall chart composed only of H's, O's, T's, and V's. Child test, ask child to point to letter and match it on board.

Snellen eye chart / Sloan Letters

Far Vision eye chart used by eye care professionals and others to measure visual acuity. Used for Far vision Numerator = patient distance from chart / Denominator = distance from which a normal person can read Indicate ability to read next smaller line with a + and how many letters they got. example: 20/25 + 2 this indicates the patient read all fo the 20/25 line correctly and 2 of the letters in the 20/20 chart correctly.

S1 Intensity Decreased in

Fat or Fluid Emphysema, obesity, pericardial fluid, pulmonary HTN, diseased/calcified mitral valve Just remember the Two F's

FRAIL Scale

Fatigue Resistance (Ability to climb one flight of stairs) Ambulation (ability to walk one block) Illness > 5 Loss of weight > 5%

Hemangioma

Feels spongy, appears reddish blue. Valsalva maneuver may enlarge the mass May simulate lymph node enlargement.

Cerebellar gait (cerebellar ataxia)

Feet wide based. Staggering and lurching, swaying of trunk.

The knee consists of which bones?

Femur Tibia Fibula Patella

Fetoscope and Leff Scope

Fetal monitoring equipment Fetoscope - has a band that fits against the head of the listener and makes handling of the instrument unnecessary. The metal band also aids in bone conduction of sound, so that the heart tones are heard more easily Leff Scope - has a weighted end that, when placed on the abdomen does not need stabilization by the healthcare provider. These instruments can detect heart fetal heart rate at 17-19 weeks of gestation. The doppler method is more sensitive and can detect fetal heart at 10-12 weeks of gestation

Bacterial Endocarditis

Fever, Fatigue Sudden onset of CHF - SOB, ankle edema Murmur Signs of neuro dysfunction Janeway Lesion Osler nodes

Classic Meningitis Signs

Fever, Stiff Neck, Altered Mental Status. Most pt do not have all three. Other potential Signs include: Headache, Rash, N/V, Chills, Myalgia.

Wood's Lamp

Filtered black light that is used to illuminate skin disorders like fungi or skin lesions. Yellow - green fluorescence indicates fungi. Shine light on something fluorescent like non digital watch to give child sense of what you are looking for. wavelength of 360nm

Hyperthyroid Facies

Fine Mosie Skin with Fine Hair Prominent eyes and lid retraction Startled Expression

Telangiectasia

Fine irregular red line Refill eratticly when blanched Cause: Dilation of the capillaries

Telangiectasia

Fine, irregular, red lines produced by capillary dilation Ex: Telangiectasia in rosacea

Accuracy of movements

Finger to nose test, index finger 18 inches away Heel to Shin Test

What positions should you have the patient in for breast examination?

First seated Arms extended over the head or flexed behind the neck Seated and leaning forward In Recumbent position

Uremia (trimethylamines) smells

Fishy, stale

Lower Motor Neuron Lesion

Flaccid Paralysis - Muscles Fasciculations Muscle Atrophy Diminished / Absent Deep Tendon Reflexes No Plantar Response Damage affects muscle on same side of body

Pes Planus

Flat footed even when not weight bearing

Junction Nevus

Flat or slightly elevated; dark brown -nevus cells lining dermo epidermal junction -Should be removed if exposed to repeated trauma

Signs suggestive of breast cancer

Flattening of nipple Skin Dimpling

Thenar Eminence

Fleshy mound on the palm at the base of the thumb

Thomas Test

Flexion contracture of hip Have pt lie supine fully extend one leg flat on the examining table and flex the other leg with the knee to chest. Observe pt ability to keep extended leg flat on the table. Lifting the extended leg off the table indicates a hip flexion contracture in the extended leg.

Sternocleidomastoid and trapezius muscles evalution

Flexion with palpation, extension against resistance, rotation against resistance. With Rotation, XN 11 is tested simultaneously.

Tracheomalacia

Floppy airway or trachea Noisy breathing or wheezing in infancy is often inspiratory stridor Tends to be benign

Paget Disease of the Bone (Osteitis Deformans)

Focal metabolic disorder of the bone Excessive bone resorption and bone formation produce a mosaic pattern of lamellar bone Vertigo and headache from skull involvement Progressive deafness from involvement of the ossicles Bowed tibias, misshapen pelvis, or prominent skull forehead may be evident Frequent fractures

Onychomycosis (Fungal Crumble)

Fungal infection of nail, causes it to crumble. Can cause loss of dexterity, or ability to walk Distal nail plate turns yellow or white as hyperkeratotic debris accumulates, causing the nail to separate from the nail bed (onycholysis) Pitting does NOT occur, separates it from psoriasis

A firm mass over the dorsum of the wrist may be a

Ganglion Cyst

Muscular Dystrophy

Group of genetic disorders involving gradual degeneration of muscle fibers progressive symmetric weakness Early signs include clumsiness, difficulty climbing stairs and frequent falls Waddling gait Positive Gower Sign Progressive loss of function

Tinea (Dermatophytosis)

Group of noncandidal fungal infections that involve the stratum corneum, nails, or hair Patho • Infection by dermatophytes, typically acquired by direct contact with infected humans or animals; invade the skin and survive on dead keratin. • Lesions are usually classified according to anatomic location and can occur on nonhairy parts of the body (tinea corporis), on the groin and inner thigh (tinea cruris), on the scalp (tinea capitis), on the feet (tinea pedis), and on the nails (tinea unguium). Subjective Data • May report pruritus. • May report hair breaking. • Nail changes accompany onychomycosis. Objective Data • Lesions vary in appearance and may be papular, pustular, vesicular, erythematous, or scaling ( • Secondary bacterial infection may be present. • Microscopic examination of skin scraping with potassium hydroxide (KOH) solution shows presence of hyphae. • Infected nails are yellow and thick and may separate from the nail bed.

Newborns and Infants

HR - variable anywhere from 200bpm to 120bpm a few hours after birth. Tachycardia can indicate infection or paroxysmal atrial contractions. Respiratory Rate - 40-60 breaths per minute, can be up to 80. C-section infants have a more rapid respiratory rate than infants. Blood Pressure - 60-90 systolic and 30-62 diastolic Hypertension may be result of thrombosis, coarction of the aorta, renal artery stenosis, cystic disease, hydronephrosis, congenital adrenal hyperplasia, CNS disease ** check cap refill even if BP is normal should be under 2 seconds. 6-7 seconds = very poor perfusion.

Older Adults

HR 40-100bpm Hypertension > 140/90 Normotensive at 55 years of age will have a 90% lifetime risk of developing htn

Stroke Risk Factors

HTN Obesity Sedentary Smoking Stress Cholesterol, Triglycerides Oral Contraceptives Sickle Cell Disease Fam Hx DM, CVD, HTN, Cholesterol Congenital Cerebrovascular anomalies.

Scarring Alopecia

Hair folicles get replaced with scar tissue, permanent hair loss. May have Lupus Erythematous Hair Follicles may have pustule or plugged

Hirsutism

Hair grows on face, body, pubic areas in a male distribution. Can be caused by high androgen levels from ovaries or adrenal glands or by hair follicles that are more sensitive to normal androgen levels; free testosterone is the androgen that causes hair growth. Androgen Sensitive sites: face, chest, areola, external genitalia, upper and lower back, buttocks, inner thigh, and linea alba.

Traction Alopecia

Hair loss from repetitive and excessive pulling or stretching of the hair (Braids, hair rollers, hot combs) Follicle is not damaged and the loss is reversible.

Types of Nevi

Halo Nevus Intradermal Nevus Junction Nevus Compound Nevus Hairy Nevus

Rapid rhythmic alternating movements

Have seated person alternately pronate and supinate hands, patting knees, and gradually increasing speed OR Have person touch thumb to each finger on the same hand sequentially from index to little finger and back, gradually increasing speed

Palmar Grasp (Birth)

Head midline, touch palm of infant hand from the ulnar side (opposite thumb). Should have strong grasp. Disappears by 3 months

Aortic Valve Ejection Click

Hear best at Apex at the base in 2nd Right IC Pt sitting ro supine Heard during early systole, intense, high pitched, radiates, not affected by respirations.

Subaortic Stenosis Murmur

Heard at apex and along left sternal border Murmur fills systole. Thrill palpable at apex during systole. Arterial pulse brisk. Double wave in carotid common. Jugular venous pulse prominent Fibrous ring usually 1-4mm below the aortic valve

Mitral Valve Prolapse

Heard at apex and left lower sternal border Easily missed in supine position. listen with pt upright. Late systolic murmur Valve is competent early in systole but prolapses into atrium later in systole; may become progressively severe, resulting in a holosystolic murmur; often concurrent with pectus excavatum

Mitral Valve Opening Snap

Heard best with Diaphragm medial to apex, may radiate to base 2nd left IC Heard during early diastole briefly before S3 High pitch, sharp snap or click. Not affected by respiration. Easily confused with S2

Increased S4

Heard best with bell at apex Pt supine or in left lateral recumbent position Heard during late diastole or early systole, low pitch

Gallops

Heard best with bell at apex. Pt supine or in left lateral recumbent position Heard during presystole, intense and easily heard

Pulmonic Stenosis Murmur

Heard in pulmonic area, radiates to left and into neck. Thrill in 2nd and 3rd IC Systolic ejection murmur common in Right ventricular hypertrophy. Can be condused with VSD Cause almost always congenital.

Aortic Stenosis Murmur

Heard over the aortic area; ejection sound at second right intercostal border Midsystolic ejection murmur, radiates has palpable thrill in carotid Caused by a congenital bicuspid valve, rheumatic heart disease, atherosclerosis Can cause sudden death particularly in kids

Mitral Stenosis Murmur

Heard with bell at apex, patient in left lateral decubitus position Visible lift in right parasternal area if right ventricle hypertrophied Caused by Rheumatic Fever or Cardiac Infection

Tricuspid Stenosis

Heard with bell over tricuspid area Diastolic Rumble Arterial pulse amplitude decreased, jugular venous pulse prominent. Usually seen with mitral stenosis, rarely occurs along. Caused by Rheumatic heart disease, congenital defect.

Holding head to one side may indicate

Hearing or vision loss, or torticollis (shortening or excessive contraction of the sternocleidomastoid muscle.)

Dextrocardia

Heart points to the right side instead of the left (mirror imaged)

Gait Test

Heel to Toe Walking

Auricle (Pinna) Anatomy

Helix - prominent outer rim Antihelix - parallel and anterior to helix Concha - Deep cavityy containing auditory canal meatus Tragus - protuberance lying anterior to auditory canal meatus Lobule - soft lobe on bottom of Auricle

Posterior Cerebral Artery Stroke

Hemianesthesia Contralateral hemiplegia, greater in face and upper extremities than in lower extremities, cerebellar ataxia, tremor Visual loss—homonymous hemianopia, cortical blindness Receptive aphasia Memory deficits

Hemorrhages in Retina

Hemorrhage in disc margin = poorly controlled glaucoma Dot Hemorrhages = Diabetic Retinopathy

Pregnant Patients

History of present illness Obtain description of the current pregnancy, and identify previous medical care. Identify specific problems e.g bleeding, spotting, nausea, vomiting, fatigue, edema. Include info about illness, injuries, surgeries, or accidents or other injuries since conception. Obstetric History Include Gravidity and Parity, dates of delivery and length of pregnancy, weight gender of infant, and type of delivery. Any previous children removed from home due to abuse or neglect? Menstrual History Age of menarche, characteristics of cycle, unusual bleeding, dates of ovulation Gynecologic History Date of most recent pap smear / HPV test, or surgeries. Include sexual history, and any history of STI's Past Medical History Risk factors for HIV, hepatitis, herpes, tuberculosis, and exposure to environmental and occupational hazards Family History Family history of genetic conditions, multiple births, gestational diabetes, preeclampsia/eclampsia or pregnancy induced hypertension or congenital anomalies Personal and Social History Other children / pets - CATS can carry toxoplasmosis which is teratogenetic to the fetus. Feelings toward pregnancy - planned, unplanned? Review of Systems Give special attention to the reproductive system (including breasts) and cardiovascular system (documentation of prepregnancy blood pressure if possible) Assess endocrine for signs of diabetes and thyroid dysfunction. Assess urinary tract for infection, and review kidney function. Assess respiratory function bc it can become compromised later in pregnancy or with tocolytic therapy for preterm labor. Evaluate Dental care needs bc treatment of periodontitis can prevent preterm birth and or low birth weight. Risk Assessment Identify conditions from H&P that threaten well being of patient / fetus. I.e Gestational diabetes, preterm labor, preeclampsia/ eclampsia, pregnant patient malnutrition and vitamin deficiency, and use of potentially teratogenetic agents such as lithium valproic acid or ACE inhibitors. Postpartum Postpartum depression - feeling down, depressed, or hopeless, sleep disturbance, loss of energy, eating disturbance, trouble concentrating, restlessness, sad mood, anxiety, fatigue, feelings of worthlessness, inappropriate guild, and suicidal ideation.

Placing Reflex (4 days of age)

Hold the infant upright under the arms next to a table or chair; touch the dorsal side of the foot to the table or chair edge; observe flexion of the hips and knees and lifting of the foot as if stepping up on the table; age of disappearance varies

Pregnant Patients

Hypothalmic-pituitary neurohoromonal changes occur with pregnancy 1st trimester - Increased sleep needs, but may not feel rested. Late in pregnancy - sleep disturbances

Proper sequence for heart exam

IPPA Inspect, Palpate, Percuss, Auscultate Auscultating first is a common error.

Ear Anatomy

Identifies, localizes, and interprets sound. Maintains Balance Divided into external, middle, and inner ear.

Orthostatic BP

If patient is taking antihypertensives, has a depleted blood volume, or complains of fainting or postural lightheadedness, measure the blood pressure in a the arm within 3 minutes after the patient stand. If orthostatic hypotension is present, expect to see a significant drop in systolic pressure (greater than 20 mmHg) and a 10mm Hg drop in diastolic pressure. Increase in HR occurs as well. Mild blood loss, drugs, autonomic nervous system disease or prolonged time in a recumbent position can contribute to orthostatic hypotension.

Spasticity

If spasm occurs during exam gently support area to avoid injury to patient. Allow spasm to resolve before continuing exam.

Impaired hearing or speech

If using interpreter talk to patient at a normal speed, not to interpreter. If patient wants to lipread be careful not to move your face out of sight of the patient.

Ottawa Ankle Rules

In cases of acute ankle injury, the Ottawa Ankle Rules help identify the characteristics of patients needing an ankle radiograph series. There must be pain in the malleolar zone and one of the following: • Bone tenderness along the distal 6 cm of the posterior edge of the fibula or tip of the lateral malleolus • Bone tenderness along the distal 6 cm of the posterior edge of the tibia or tip of the medial malleolus • Inability to bear weight for four steps both immediately after the injury and in the emergency department Absolute exclusion criteria for an ankle radiograph series include the following: age younger than 18 years, intoxication, multiple painful (distracting) injuries, pregnancy, head injury, and neurologic deficit. The Ottawa Ankle Rules have 98.5% sensitivity for detecting an ankle fracture that is present on radiography.

Physical Examination Infants and Children:

In the first few hours of life, the infant's skin may look very red. The gentle pink coloring that predominates in infancy usually surfaces in the first day after birth. Skin color is partly determined by the amount of subcutaneous fat: the less subcutaneous fat, the redder and more transparent the skin. Dark-skinned newborns do not always manifest the intensity of melanosis that will be readily evident in 2 to 3 months. The exceptions in this regard are the nail beds and skin of the scrotum.

Vertebral or Basilar Artery Stroke

Incomplete occlusion Unilateral and bilateral weakness of extremities; upper motor neuron weakness involving face, tongue, and throat; loss of vibratory sense, two-point discrimination, and position sense Diplopia, homonymous hemianopia Nausea, vertigo, tinnitus, and syncope Dysphagia Dysarthria Sometimes confusion and drowsiness Anterior portion of pons "Locked-in" syndrome—no movement except eyelids; sensation and consciousness preserved Complete occlusion or hemorrhage Coma Miotic pupils Decerebrate rigidity Respiratory and circulatory abnormalities Death

Breast Cancer Risk Factors

Increased with Age Transgender men who have no had bilateral mastectomies remain at risk In BRCA1 or BRCA2 Mutation (45-80% chance) Cancer in one breast increase risk in the other One Parent, sibling, child - double risk Two parents, siblings, child - triple risk Atypical Hyperplasia Lobular Cancer In Situ (LCIS) Fibrocystic changes without proliferative breast disease do not affect breast cancer risk White / Caucasian Radiation therapy for another type of cancer in the chest area Menarche before age 12 or menopause after age 55 Older women with dense tissue Diethylstilbestrol (DES) Therapy in the 40s-60s Nuliparity or first child after age 30 Hormone therapy - estrogen and progesterone Alcohol Obesity Lack of physical activity

Push up on infant liver

Increases Right Atrial pressure Murmur of a left to right shunt through septal opening or PDA will disappear. Murmur of right to left shunt will intensify.

Air Trapping

Increasing difficulty in getting breath out

Funnell chest (Pectus Excavatum)

Indentation of the lower sternum above the Xiphoid process

Skin Color

Individuals with dark skin may show pigmentary demarcation lines. These are normal in Black and Japanese populations

Moist Productive Cough caused by:

Infection and can be accompanied by sputum production

Acute Suppurative Lymphadenitis

Infection and inflammation of a lymph node; may affect a single or localized group of nodes Node is usually firm and tender Mainly caused by Group A Strep and Staph

Erythema / Cobblestone Appearance on Conjuctiva

Infectious Conjunctivits, or allergic rxn

Lingula

Inferior Tonguelike Projection on left upper lobe

Mastitis

Inflammation and infection of the breast tissue most often caused by staph Usually in lactating patients after milk is established 2nd-3rd week after delivery Sudden onset of swelling, tenderness, redness and heat in the breast. Underlying pus filled abscess may impart a bluish tinge to the skin

Pain

Inflammation helps sustain pain response. Chronic Pain - last several months or longer and is sustained by a pathophysiological process (joint disease, chronic inflammation, headache, or cancer) Neuropathic Pain - long term pain associated with damage or dysfunction of the central or peripheral nervous system (amputation, complex regional pain syndrome) Nociceptors are free nerve endings in the peripheral nervous system that are activated to transmit pain impulses from the sit of injury. Biochemical mediators such as bradykinin, prostaglandins, serotonin, glutamate, and substance P help transmit the pain impulses from the nerve endings along nerve pathways. Pain impulses transmit from the site of injury to the Dorsal Horn of the spinal cord through the ascending spinal tracts to the thalamus and cerebral cortex. Sharp well localized pain is transmitted through large myelinated A-delta fibers. Dull burning, diffuse, and chronic pain is slowly transmitted through small unmyelinated C-polymodal fibers.

Myocarditis

Inflammation of Myocardium / Heart muscle Subjective Data • Initial symptoms vague • Fatigue • Dyspnea • Fever • Palpitations • History of recent (within 1-2 weeks) flu-like syndrome of fevers, arthralgias, and malaise or pharyngitis, tonsillitis, or upper respiratory tract infection Objective Data • Cardiac enlargement • Murmurs • Gallop rhythms • Tachycardia • Dysrhythmias • Pulsus alternans (alternation of strong and weak arterial pulse due to alternate strong and weak ventricular contractions)

Bronchitis

Inflammation of large airways leads to increased mucus secretions. Acute Bronchitis can be accompanied by fever an CP. Usually due to infection or smoking. Chronic bronchitis = productive cough May have hacking nonproductive cough, can lead to wheezing

Episcleritis

Inflammation of sclera, superficial. Anterior to the insertion of rectus muscles. Simple - moderate to severe episodes at 1-3 month intervals. Lasts 7-10 Days, Resolved 2-3 weeks. Nodular - Prolonged attacks of inflammation. More painful. Underlying Condition

Bursitis

Inflammation of the bursa due to repetitive movement and excessive pressure on the bursa.. can also be due to infection or gout Commonly found in shoulder, elbow, hip, knee with pain and stiffness limited ROM from swelling point tenderness and erythematous warm site Soreness may radiate to tendons at the site

Meningitis

Inflammation of the meninges of the brain or spinal cord Patho • The bacterial, viral, or fungal organism often colonizes in the upper respiratory tract, invades the bloodstream, and then crosses the blood-brain barrier to infect the cerebrospinal fluid and meninges. Subjective Data • Fever, chills • Headache, stiff neck • Lethargy, malaise • Vomiting • Irritability • Seizures Objective Data • Altered mental status, confusion • Nuchal rigidity • Fever • Brudzinski and Kernig signs may be positive. • Petechiae and purpura with meningococcal meningitis • Lumbar puncture and cerebrospinal fluid culture confirm the diagnosis.

Necrotizing Enterocolitis

Inflammatory disease of the gastrointestinal mucosa associated with prematurity and immaturity of the gastrointestinal tract

Pleurisy

Inflammatory process involving visceral and parietal pleura Respirations rapid and shallow with diminished breath sounds. Pleural friction rub can be ausculated Fever may be present

Pneumonia

Inflammatory response of the bronchioles and alveoli to an infective agent Acute infection to the pulmonary parenchyma. Febrile, tachypneic, tachycardic.

Where does the vulva and lower third of the vagina drain to?

Inguinal nodes

What are the functions of saliva?

Inhibit Dental Caries Start Digestion of Carbs Moisten Mouth

Median Nerve

Innervates the palm of the hand and the palmar surface of the thumb, index, and middle fingers, and half of the ring finger

Chest examination steps in order:

Inspect Palpate Percuss Auscultate

CN 3, 4, 6 Examination

Inspect eyelids for drooping Inspect pupil size for equality and their direct and consensual response to light and accommodation Test Extra-ocular eye movements

CN 5 Trigeminal Examination

Inspect face for muscle atrophy and tremors Palpate jaw muscles for tone and strength when patient clenches teeth Test superficial pain and touch sensation in each branch (test temp if unexpected finding to pain or touch) Test corneal reflex

CN 7 Examination

Inspect symmetry of facial features with various expressions Test ability to identify sweet and salty tastes on each side of the tongue

Knee Effusion

Inspect the extended knee for its natural concavities on the anterior aspect, on each side, and above the patella. Loss of these concavities may suggest a knee effusion. An effusion of the knee fills the suprapatellar pouch and the concavity below the patella medially. When this occurs, the usual indentation above and on the medial side of the patella is filled out to be convex rather than concave.

Physical examination: Nail inspection and palpation

Inspect the nails for color, length, configuration, symmetry, and cleanliness. The condition of the fingernails can provide important insight to the patient's sense of self as the condition of the hair and nails gives a clue about the patient's level of self-care and some sense of emotional order and social integration. The nails also can demonstrate physical examination signs that may indicate an underlying systemic disease. Nail edges should be smooth and rounded. Jagged, broken, or bitten edges or cuticles are indicators of poor care habits and may predispose the patient to localized infection. Ragged cuticles are also a classic sign of dermatomyositis. Peeling nails (from the plate splitting into layers) are usually found in individuals whose hands are subject to repeated water immersion or who have underlying psoriasis. Examine the proximal and lateral nail folds for redness, swelling, pus, warts, cysts, and tumors. Pain usually accompanies ingrown nails and infections.

Upper airway is obstructed when there is:

Inspiratory Stridor Hoarse cough or cry Flaring of the alae nasi Retraction at the Suprasternal notch

Musculoskeletal Chest Pain

Intensified or provoked by movement, particularly twisting or costochondral bending; long lasting; often associated with focal tenderness

What compose the breasts vascular supply?

Internal Mammary Artery Lateral Thoracic Artery

Horner Syndrome - possible test ?

Interruption of sympathetic nerve innervation to eye. Autosomal dominant, or acquired. Ipsilateral miosis, mild ptosis, loss of hemifacial sweating. Anisocoria - difference in pupil size is greater in darkenss Dilation lag, dry skin on affected side.

Visual Field Defects

Interruption of vascular supply to optic nerve Bitemporal Hemanopia - Lesion, pituitary tumor Homonymous Hemianopia - lesion of optic nerve

What can abdominal scarring indicate?

Intraabdominal adhesions

Lordosis

Inward curvature of the lower spine that occurs in an effort to shift the center of gravity back over the lower extremities. Leads to back pain.

Failure to constrict with light stimulus

Iridiocyclitis, CN II or III Destruction, Brain herniation (Fixed Dilated Pupils)

Biot Respiration

Irregularly interspersed periods of apnea in a disorganized sequence of breaths Caused by increased ICP, Drug OD, Medulla Damage. Very poor prognosis

Keloid

Irregularly shaped, elevated, progressively enlarging scar; grows beyond the boundaries of the wound; caused by excessive collagen formation during healing Ex: Keloids form after surgery

Types of Latex Reactions

Irritant Contact Dermatitis - Chemical irritation the does not involve the immune system. Symptoms are usually dry, itching, irritated areas on the skin, typically the hands Type IV dermatitis (Delayed hypersensitivity) - Allergic contact dermatitis that involves the immune system and is caused by the chemicals used in latex products. The skin reaction usually begins 24-48 hours after contact and resembles that caused by poison ivy. May progress to oozing skin blisters. Type I Systemic Reaction - True allergic reaction caused by protein antibodies (IgE) that form as a result of interaction between a foreign protein and the body's immune system. The antigen-antibody reaction causes the release of histamine, leukotrienes, prostaglandins, and kinins. Symptoms include local urticaria (skin wheals, generalized urticaria and angioedema, asthma, eye nose itching, GI symptoms, anaphylaxis, chronic asthma, and permanent lung damage.

Thumb Abduction test

Isolates the strength of the abductor pollicis brevis muscle, innervated only by the median nerve Have pt place hand palm up and raise the thumb perpendicular to it. Apply downward pressure on the thumb to test muscle strength. Weakness is associated with carpal tunnel syndrome

What does the spleen do?

It filters bacteria out of the blood, produces phagocytes to fight off foreign invaders.

Cultural Competency

It involves recognizing one's own culture, value's, biases and using effective patient centered communication skills. A culturally competent healthcare provider adapts to the unique needs of patients of backgrounds and cultures that differ form his or her own. This adaptability coupled with a genuine curiosity about a patient's beliefs and values lay the foundation for a trusting patient provider relationship. Culture in its broadest sense reflect the whole of human behavior including ideas and attitudes, ways of relating to one another, manners of speaking, and the material products of physical effort, ingenuity, and imagination.

Cultural Response Examples

Japan - family considered legitimate decision making authority for competent and incompetent patients. Middle Easter / Navajo - believe that a patient should not be told of a diagnosis of metastatic cancer or a terminal prognosis for any reason. Navajo believe that thought and language have the power to shape reality. Talking about a possible outcome is thought to ensure the outcome. Avoid speaking in a negative way US - speak loudly, the English however speak more modulated. Want to be logical and avoid subjective. get to the point Japanese - opposite of US, use indirection, talk around points, emphasize attitudes and feelings Native Americans - Allow silence, gives them time to think Spanish - Use firm eye contact, so do the french. Firm eye contact however can be considered rude by asian and middle eastern cultures. Italians - use touch, pat on arm in a reassuring way Americans avoid this.

Dystonia

Jerky Dancing movements appear nondirectional

Coloboma of Iris

Keyhole pupil, photophobia Cause: failure of closure of the retinal fissure

Genu Valgum

Knock Knees Present if a space of 2.5cm exists between the medial malleoli

Femoral Stretch Test Detects

L1, L2, L3, l4 nerve root irritation The femoral stretch test or hip extension test is used to detect inflammation of the nerve root at the L1, L2, L3, and sometimes L4 level. Have the patient lie prone and extend the hip. No pain is expected. The presence of pain on extension is a positive sign of nerve root irritation

Patellar Reflex - Spinal Nerve Levels Evaluated

L2, L3, L5 (Deep Tendon Reflex)

Straight Leg Raising Detects

L4, L5, S1 nerve root irritation Radicular pain below the knee may be associated with disk herniation. Flexion of the knee often eliminates the pain with leg raising. Repeat the procedure on the unaffected leg. Crossover pain in the affected leg with this maneuver is more indicative of sciatic nerve impingements.

Plantar Reflex - Spinal Nerve Levels Evaluated

L5, S1, S2 Superficial Reflex

Spleen Laceration

LUQ pain with radiation to left should (positive kehr sign) Hypovolemia

Galactorrhea

Lactation not associated with childbearing Elevated prolactin levels bc of disruption in communication between pituitary and hypothalamus Spontaneous and serous or milky.

Chronic Bronchitis

Large Airway inflammation from irritant exposure Severe cases may result in right ventricular failure. Cough and sputum production are impressive. Wheezing and crackles.

Infants with right sided CHF have this feature on exam

Large Firm Liver with inferior edge as much as 5-6cm below the Right Costal Margin This usually preceedes pulmonary crackles unlike in adults.

Childhood and preadolescence represent what phase of breast development?

Latent

Ascending Tracts (Lower Motor Neuron)

Lateral Spinothalamic Anterior Spinothalamic Posterior column Anterior and Dorsal Spinocerebellar Highlighted in blue on image.

What are the three articulating compartments in the knee?

Lateral Tibiofemoral Medial Tibiofemoral Patellofemoral

Descending Tracts (Upper Motor Neuron)

Lateral and Anterior Corticospinal Medial And Lateral Reticulospinal Highlighted in red on image.

CN 6 (Abducens)

Lateral eye movement

The _________________ forms the Left border of the heart

Left Ventricle

What causes the apical impulse

Left Ventricle contraction and thrust Felt at midclavicular, fifth intercostal

Tabetic Gait

Legs far apart, feet slap ground. Steppage Gait

Malignant Melanoma

Lethal form of skin cancer that develops from melanocytes Patho • Melanocytes migrate into the skin, eye, central nervous system, and mucous membrane during fetal development. • Less than half of the melanomas develop from nevi; the majority arise de novo from melanocytes. • The exact cause of malignancy is not known; heredity, hormonal factors, ultraviolet light exposure, or an autoimmunologic effect may contribute to causation. Subjective Data • New mole or preexisting mole that has changed or is changing • New pigmented lesion that has irregularities• History of melanoma • History of dysplastic or atypical nevi • Family history of melanoma (first-degree relative) • Significant tanning bed use Objective Data • ABCDE changes in moles • A Asymmetry of lesion: one-half of a mole or birthmark does not match the other • B Borders: edges are irregular, ragged, notched, or blurred. Pigment may be streaming from the border. • C Color: the color is not the same all over and may have differing shades of brown or black, sometimes with patches of red, white, or blue. • D Diameter: the diameter is >6 mm (about the size of a pencil eraser) or is growing larger. • E Evolution: changes seen in existing pigmented lesions, particularly in a nonuniform, asymmetric manner.

What does delayed umbilical cord separation indicate

Leukocyte Adhesion Deficiency which is an autosomal recessive disorder that causes recurrent infections. UC usually drops off by 1-2 weeks

Entropion

Lid Turned in toward eye. Foreign Body Sensation. Increased risk for infection

Maxillary Sinus

Lies along the lateral wall of the nasal cavity in the maxillary bone

Exercise Intensity

Light: walking 10 to 15 steps, preparing a simple meal for one, retrieving a newspaper from just outside the door, pulling down a bedspread, brushing teeth Moderate: making the bed, dusting and sweeping, walking a level short block, office filing Moderately heavy: climbing one or two flights of stairs, lifting full cartons, long walks, sexual intercourse Heavy: jogging, vigorous athletics of any kind, cleaning the entire house in less than a day, raking a large number of leaves, mowing a large lawn with a hand mower, shoveling deep snow

Fissure

Linear crack or break form the epidermis to the dermis, may be dry or moist Ex: Athletes foot, cracks at the corner of the mouth

Paranasal sinus

Lined with mucous and ciliary bodies that move secretions along excretory pathways Frontal, ethmoid, sphenoid, maxillary sinuses make up the paranasal sinuses. Only Maxillary and Frontal sinus can be examined

Xanthelasma

Lipid deposits on eyelids Lipid Metabolism Problem

Arcus Senilis (Corneal Arcus)

Lipids in periphery of cornea. Complete circle is Cirucs Senilis

Prosthetic Mitral Valve

Listen for distinct click early in diastole, loudest at the apex and transmitted precordially.

Upper Motor Neuron Lesion

Little or No Muscle Atrophy Weakness Babinski Positive Diminished or absent Superficial Reflex Hyperactive Deep Tendon Reflex Paralysis of voluntary movements Damage above level of brainstem affects opposite side of body. Damage below brainstem affects same side of body.

Dullness on percussion

Lobar pneumonia or pleural effusion

Arterial aneurysm

Localized dilation generally defined as 1.5 timrs the diameter of a normal artery caused by weakness in the wall Results form atherosclerosis, family hx, htn, smoking play a big role Most commonly in aorta, renal femoral, popliteal arteries Asymptomatic until adjacent structure is dissected or compressed. With dissection patient describes a severe ripping pain Pulsatile swelling along the course of an artery Thrill or bruit may be evident

Renal abscess

Localized infection in the medulla or cortex of the kidney Similar symptoms to pyelonephritis

Lacrimal Gland

Located in Temporal Region of Superior Eyelid Produces Tears which drain into lacrimal sac via Canaliculi

Smell Receptors

Located in olfactory epithelium

Ulcer

Loss of epidermis and dermis; concave varies in size Ex: Decubiti, stasis ulcers

Single Peripheral Nerve Injury

Lost sensation is greatest in central portion of the nerve's anatomic distribution with a surrounding zone of partial loss because adjacent nerve distributions overlap. All or selected forms of sensory discrimination may be lost.

Emphysema

Lungs lose elasticity and alveoli enlarge in a way that disrupts function Dyspnea common at rest. Chest may be barrel shaped Scattered crackles or wheezes Overinflated hyperresonant lungs Inspiration is limited with a prolonged expiratory effor longer than 4-5 seconds Extensive smoking hx Alveolar gas is trapped in expiration, gas exchange seriously compromised.

What are the hormones in pregnancy

Luteal and Placental These cause the lactiferous ducts to proliferate, and alveoli to increase extensively in size and number -> causes breasts to enlarge 2x or 3x

What does the lymphatic system consist of?

Lymph Fluid Collecting Lymphatic Ducts Lymph Nodes Thymus Tonsils Adenoids Peyer Patches in the small intestine Bits of lymph tissue found in other parts of the body including stomach mucose, appendix, bone marrow, and lungs.

What happens if the lymph system is obstructed?

Lymph may diffuse into the vascular system, or collateral connecting channels may develop.

Muscle Strength Assessment Grades

MUSCLE FUNCTION LEVEL / GRADE No evidence of movement 0 Trace of movement 1 Full range of motion, but not against gravity with passive movement* 2 Full range of motion against gravity but not against resistance 3 Full range of motion against gravity and some resistance, but 4 weak Full range of motion against gravity, full resistance 5

Pericardial Friction Rub

Machine Like sound During sytole and diastole Heard distinctly toward the apex, but resonates everywhere.

Patent ductus Arteriosus has this type of murmur?

Machine-like continuous murmur, which can lead to LV overload and HF.

Hypothalmus

Maintains temperature control, water metabolism, body fluid osmolarity, feeding behavior, and neuroendocrine activity Autonomic nervous system

Gynecomastia

Male breasts • Result of increased body fat; hormone imbalance from puberty or aging; by testicular, pituitary, or hormone-secreting tumors; by liver failure; or by a variety of medications including anabolic steroids, marijuana, some antihypertensives, some antipsychotics, or those containing estrogens or antiandrogens • When testosterone levels are low relative to estrogen, breasts grow larger and are more noticeable. • Increased body fat, which in turn produces more estrogen, can also cause breast enlargement. Subjective Data • Breast enlargement • Relevant medication history (estrogens, antiandrogens, anabolic steroids, tricyclic antidepressants, spironolactone, 5-α reductase inhibitors, ketoconazole, cimetidine, recreational drugs—especially marijuana) Objective Data • Smooth, firm, mobile, tender disk of breast tissue located behind the areola • Usually non-tender • May be unilateral or bilateral • Amount of breast tissue varies; can be small overgrowth of breast tissue around the areola and nipple, to larger, more "female"-looking breasts

Stomach Cancer

Malignancy that arises from epithelial cells of the mucous membrane Most common in lower half of stomach. Symptoms are vague Loss of appetite, feeling of fullness, weight loss, dysphagia, persistent epigastric pain may have midepigastric tenderness, hepatomegaly, enlarged supraclavicular nodes and ascites.

Non-Hodgkin Lymphoma

Malignant neoplasm of the lymphatic system and the reticuloendothelial tissues • Non-Hodgkin lymphomas occur most often in lymph nodes in the chest, neck, abdomen, tonsils, and skin; they may also develop in sites other than lymph nodes such as the digestive tract, central nervous system, and around the tonsils. • Most arise in B cells; the rest occur in T cells Subjective Data • Painless enlarged lymph node(s) • Fever, weight loss, night sweats, abdominal pain, or fullness • Family history of non-Hodgkin lymphomas Objective Data • Nodes may be localized in the posterior cervical triangle or may become matted, crossing into the anterior triangle. • Nodes usually well defined and solid • Cannot distinguish the findings of these conditions from those in Hodgkin lymphoma through physical examination alone

Colon Cancer

May involve the recutm, sigmoid, proximal and descending colon. Subjective • Symptoms depend on cancer location, size, and presence of metastases • May describe abdominal pain, blood in the stool, or a recent change in the frequency or character of stools • Earliest sign may be occult blood in the stool, which can be detected by guaiac-based fecal occult blood testing (gFOBT) Objective • Few early examination findings • If disease has progressed, may have palpable abdominal mass in right or left lower quadrants or show signs of anemia from occult blood loss (e.g., pallor and tachycardia) • Rectal cancer may be palpable by digital rectal examination

Layrngocele

May simulate lymph node enlargement.

Thyroid Goiter

May simulate lymph node enlargement.

Graves Disease

May simulate lymph node enlargement. Causes enlarged thyroid goiter

Brachial Cleft Cyst

May simulate lymph node enlargement. sometimes accompanied by a tiny orifice in the neck along the lower third of the anteromedial border of the sternocleidomastoid muscle between the muscle and the overlying skin; may fluctuate in size when inflamed)

Tinel Sign

Median nerve integrity

Brainstem structures

Medulla Oblongata Pons Midbrain Diecephalon Nuclei of 12 cranial nerves arises from these structures

Rotator Cuff Tear

Microtrauma and tearing of hte rotator cuff muscles, most often the supraspinatus From repeated overhead lifting Pain in shoulder and deltoid area common - can wake pt up at night Inability to maintain a lateral raised arm against resitance Grating sound on movement crepitus and weakness in external shoulder rotation

Hot and Cold Balance

Middle Eastern, Asian, Southeast Asian, Hispanic, and Chinese (Yin/yang) Cold Conditions / Hot Treatments Cancer - Beef Cold - Cereal Earaches - Chili Peppers Headaches - Chocolate Joint Pain - Eggs Malaria - Goats Milk Menses - liquor Pneumonia - Onions Stomach Cramps, Teething, Tuburculosis - Peas Hot Medicines / Herbs Anise Aspirin Castor Oil Cinnamon Cod Liver Oil Garlic Ginger Root Iron Tobacco Penicillin Vitamins Hot Conditions / Cold Treatments Constipation - Barley Water Diarrhea - Chicken Fever - Dairy Products Infection - Fresh Vegetables Kidney Problems - Fruits and Honey Rash - Goat Meat Sore Throat - Raisins Cold Medicines / Herbs Bicarbonate of sode Milk of Magnesia Orange Flower Water Sage

Hypertensive Retinopathy

Mild - Narrowing, Nicking, Copper Wiring Moderate - Hemmorage (blot, dot, flame shaped), cotton wool spots, hard exudates Malignant / Severe - All of above + Papilledema - Medical emergency. Death Imminent Rapidly Decrease BP

Mid to Late nonejection systolic click caused by

Mitral Prolapse

Thrill during systole at the apex =

Mitral Regurgitation

Thrill during Diastole at the Apex =

Mitral Stenosis

Functional Asseessment for all Patients

Mobility - difficulty walking standard distances 1/2 miles, 2-3 blocks, 1/3 block, across room Upper Extremity function - able to grasp / reach overhead Household Chores ADL's - eating, toileting, clothing self, grooming, bathings, continence Instrumental activities of daily living - Shopping, medication management, money management, transportation, preparing meals, using telephone, housework

Chronic infectious disease has this type of sputum:

More abundant in morning, slight intermittent blood streaking and occasionally large amounts of blood.

Heart position in infants and young children

More horizontal than adults. As a result the apex of the heart rides higher sometimes well into the fourth left intercostal space. Adult heart position reached by age 7.

Metatarsus Adductus (Metatarsus Varus)

Most common congenital foot deformity can be fixed or flexible Caused by intrauterine positioning Medial adduction of the toes and forefoot results from angulation at the tarsometatarsal joint Heel and ankle are uninvolved The lateral border of the foot is convex The crease is sometimes apparent on the medial border of the foot

Mucus vs Cerumen

Mucus contains immunoglobulins and enzymes that serve as defense against infection. Vs Cerumen in external auditory canal is acidic.

Fetor hepaticus, hepatic failure, portal vein thrombosis, portacaval shunts smell like:

Musty fish, clover

Nail Plate

Nail Plate. The nail plate should appear smooth and flat or slightly convex. Complete absence of the nail (anonychia) may occur as a congenital condition. Look for nail ridging, grooves, depressions, and pitting. Longitudinal ridging and beading are common expected variants. Longitudinal ridges and grooves may also occur with lichen planus of the nail. Transverse grooves result from repeated injury to the nail, usually the thumb, as with chronic manipulation to the proximal nail fold. The most common cause is picking at the thumb with the index finger (habit-tic deformity). Chronic inflammation, such as occurs with chronic paronychia or chronic eczema, produces transverse rippling of the nail plate. Transverse depressions that appear at the base of the lunula occur after stress that temporarily interrupts nail formation.

Lumbar Stenosis

Narrowing of the spinal canal Caused by bone and ligament hypertrophy Pain with walking or standing upright that seems to originate in the buttocks and may then radiate down the legs. Pain relieved by bending forward Pain worsened by prolonged standing, walking, or hyperextending the back Stopped forward gait may be present.

Nasal Floor and Roof

Nasal Floor Formed by Hard and Soft Palate. Roof is formed by the frontal and sphenoid bone.

Amsler grid

Near vision test to assess central vision and to assist in the diagnosis of age-related macular degeneration. Monitors about 10 degrees of central vision and is used when retinal drusen bodeis are seen during an opthalmogic exam or when strong history of mac degeneration present.

Encephalocele

Neural tube defect with protrusions of brain and membranes that cover it through openings in the skull

Infants

Neurological impulses primarily handled by brainstem and spinal cord at birth. Reflexes: sucking, rooting, yawn, sneeze, hiccup, blink at bright light, withdrawal from painful stimuli. Primitive Reflexes: Moro, stepping, palmar, plantar grasp

Carotid Palpation

Never palpate both sides Carotid Sinus Massage can cause slowing of pulse and drop BP = Syncope If trouble finding pulse, rotate patient head to side being examined to relax sternocleidomastoid

Acanthosis Nigricans (AN)

Non specific reaction pattern associated with obesity, certain endocrine syndromes, or malignancies or as an inherited disorder Patho • Insulin resistance and hyperinsulinism may lead to an activation of insulin-like growth factor receptors, promoting epidermal growth. • Inherited form: rare, autosomal dominant trait with no obesity or associated endocrinopathies • Malignant form: results from secretion of tumor products with insulin-like activity or transforming growth factor alpha, which stimulates keratinocytes to proliferate Subjective Data • May have history of obesity, endocrine disorders • With a rise in childhood obesity, this is seen more often in children and adolescents. • Appearance in older adult associated with malignancy Objective Data • Symmetric, brown thickening of the skin with plaques or patches of thickened skin with a velvety or slightly verrucous texture • Lesions range in severity from slight discoloration of a small area to extensive involvement of wide areas. • Most common site of involvement is the axillae, but the changes may be observed in other flexural areas of the neck, groin, and arms. • Involvement of the dorsal and palmar hands or mucosal surfaces may indicate malignant association.

Osteoarthritis risk factors

Obesity Female Hx of Osteoarthritis Hypermobility syndromes > 40 yrs old High level of sports activities Peripheral Neuropathy Occupation req over use of joints

tympanometer

Objective way of assessing the ossicular chain, eustachian tube, and tympanic membrane. transmits sound energy in to the ear. Measures compliance of the system, compliance measured in mm of cc of volume indicates the amount of mobility in the middle ear. Probe introduces pressure of 200daPa decapascals if air pressure. meausres ear canal volume.

Tuberculous cavity produces this type of sputum

Occasional large amounts of blood, but make sure blood is not swallowed from a nosebleed or GI bleed

Nevi (Moles)

Occur in forms that vary in size and degree of pigmentation. Occur more often in lighter skinned individuals. Nevi can develop into a melanoma. Alterations in dark skinned people are best seen in the sclera, conjunctiva, buccal mucosa, tongue, lips, nail beds, and palms.

Inner Ear Development - Infants

Occurs during first trimester of pregnancy. Insult during this time can impair hearing.

What does a low liver border 2-3cm below costal margin indicate?

Organ enlargement or downward displacement of the diaphragm because of emphysema or pulm disease

Infant Hemodynamic Expectations at birth

PVR decreases SVR increases Ductus Arteriosus closes within 12-14 hours

Partial Spinal Sensory Syndrome (Brown-Sequard Syndrome)

Pain and temperature sensation are lost one to two dermatomes below the lesion on the opposite side of the body from the lesion. Proprioceptive loss and motor paralysis occur on the lesion side of the body.

Hawkins test

Pain indicates rotator cuff tear or impingement. Flex elbow to 90 degrees and abduct the arm to ninety and internally rotate humerus.

Mumps is characterized by

Painful swelling of parotid glands unilaterally or bilaterally, and salivary glands along mandible. This swelling may obscure the angle of the jaw. vs Cervical adenitis which does NOT obscure the angle of the jaw.

Spindle Shaped Fingers

Painful swelling of the proximal interphalangeal joints which causes spindle-shaped fingers. Associated with acute stage of Rheumatoid Arthritis

Which Glands produce saliva?

Paired Parotid Submandibular Sublingual

Chest Wall Sweep

Palm at patient's right clavicle at the sternum. Sweep Downward form the clavicle to the nipple feeling for superficial lumps.

Thyroglossal Duct Cyst

Palpable cystic mass in the neck PATHOPHYSIOLOGY • Remnant of fetal development • Rises from the foramen cecum at junction of anterior two-thirds and posterior third of tongue • Any part can persist, causing a sinus, fistula, or cyst. Subjective Data • Tenderness, redness, swelling in midline of neck • Difficulty swallowing or breathing Objective Data • Freely movable cystic mass in neck midline • Moves upward with tongue protrusion and swallowing • May have small opening in skin, with drainage of mucus

Pleural friction rub

Palpable, coarse, grating vibration usually on inspiration

Pulsus Bisferiens

Palpate carotid artery for this pulse Percussion and Tidal wave Caused by Aortic Stenosis combined with aortic insufficiency

Wedge method

Palpate from the center of the breast in a radial fashin returning to the areola to begin each spoke.

Physical Examination: Hair inspection and Palpation

Palpate the hair for texture while inspecting it for color, distribution, and quantity. The scalp hair may be coarse or fine, curly or straight, and should be shiny, smooth, and resilient. Palpate the scalp hair for dryness and brittleness that could indicate a systemic or genetic disorder. Color will vary from very light blond to black to gray and may show alterations with rinses, dyes, or permanents. The quantity and distribution of hair vary according to individual genetic makeup. Hair is commonly present on the scalp, lower face, neck, nares, ears, chest, axillae, back and shoulders, arms, legs, toes, pubic area, and around the nipples. Note hair loss, which can be either generalized or localized. Inspect the lower legs and feet for hair loss that may indicate poor circulation or nutritional deficit. Look for any inflammation or scarring that accompanies hair loss, particularly when it is localized. Diffuse hair loss usually occurs without inflammation and scarring. Note whether the hair shafts are completely absent or simply broken off. Genetically predisposed men often display a gradual symmetric hair loss on the frontal or vertex of the scalp during adulthood. Asymmetric hair loss may indicate a pathologic condition. Women in their 20s and 30s may also develop adrenal androgenic female-pattern alopecia (hair loss), with a gradual loss of hair from the central scalp. Fine vellus hair covers the body, whereas coarse terminal hair occurs on the scalp, pubic, and axillary areas, on the arms and legs (to some extent), and in the beard of men. The male pubic hair configuration is an upright triangle with the hair extending midline to the umbilicus. The female pubic configuration is an inverted triangle; the hair may extend midline to the umbilicus. Look for hirsutism in women—growth of terminal hair in a male distribution pattern on the face, body, and pubic area. Hirsutism, by itself or associated with other signs of virilization, may be a sign of an endocrine disorder. Hair patterns vary across races and ethnicities. African hair is typically coarser, drier, and curlier than Asian or White hair. People of African descent may have multiple hairs protruding from the same shaft (pili-multigemini). This can be a normal finding but may also indicate an underlying scarring process. Asians have very straight, shiny hair and often have sparser body hair. Note that cosmetic procedures may alter the color, texture, and distribution of hair on patients.

What are the major landmarks of the face?

Palpebral fissures Nasolabial Fold

PanOptic Opthalmoscope

Panoramic opthalmosocope head uses an optical design that allows a larger field of view 25 degree vs 5 degrees and increases magnification. As a result the fundus is five times larger than the view achieved with a standard scope in an undilated eye. Comes with a smart phone adapter.

What membranes surround the lungs?

Parietal and Visceral Pleurae

The Five P's of Sexual History

Partners Practices Protection from STIs Past history of STIs Prevention of pregnancy These areas should be openly discussed with patients.

Nose and Nasopharynx

Passage for inspired air, humidify, filter, and provide resonance for laryngeal sound

Diastole phases

Passive - blood moves on own then Atrial ejection

Infant Tendon Reflex Ages

Patellar Tendon - at birth Achilles and Brachioradial - 6 months Ankle clonus can be common, but should not be sustained.

Thrill during systole at the L Upper Sternal Border w/ extensive radiation =

Patent Ductus Arteriosus

Neuropathic Pain

Patho Potential causes include postherpetic neuralgia, diabetic peripheral neuropathy, trigeminal neuralgi, or radiculopathy damaged peripheral nerves fire repeatedly. dorsal horn neurons are hyper-excited and transmit enhanced pain to the brain. Causes sustained pain Subjective Data Burning, intense tightness, shooting, stabbing, electric shock-like sensations Pain sensations may be worse at night exaggerated pain response sleep disturbance allodynia - pain response to stimuli that are not typically painful interference with ADLs Objective data Confirmed self report of pain for all painful body regions distribution of pain sensations - glove or stocking leg pain response to non-painful stimulus - stroking skin sensory loss - light, touch, pin prick, vibration sense, proprioception numbness may be present in painful areas

Drug Eruptions

Patho • Immunologically mediated cutaneous reactions to medications include immunoglobulin E (IgE)-dependent, cytotoxic, immune complex, and cell-mediated hypersensitivity reactions. • Nonimmunologically mediated reactions include direct release of mast cell mediators and idiosyncratic reactions. Subjective Data • Rash appears from 1 to several weeks after taking a drug. • Pruritus may be present. • Offending drug often difficult to find. Do not forget about supplements or over-the-counter treatments. Objective Data • Most common: discrete to confluent erythematous macules and papules on the trunk, face, extremities, palms, or soles of the feet • Rash fades in 1-3 weeks and may desquamate.

Older Adults: Stasis Dermatitis

Patho • Occurs on the lower legs in some patients with venous insufficiency • Incompetent venous valves, inadequate tissue support, and postural hydrostatic pressure contribute to the development of venous stasis. • Dermatologic changes secondary to the effects of extravasated blood, which induces a mild inflammatory response in the dermis and subcutaneous fat • Most patients with venous insufficiency do not develop dermatitis, which suggests that genetic or environmental factors may play a role. • May occur as an allergic response to an epidermal protein antigen created through increased hydrostatic pressure, or because the skin has been compromised and is more susceptible to irritation and trauma Subjective Data • Sense of fullness or dull aching in the lower legs and ankles • Gradual increase in pigmentation and redness • Area may be itchy and/or painful Objective Data • Erythematous, scaling, weeping patches on lower extremity; ulceration may be present • Dermatitis may be acute, subacute, or chronic and recurrent.

Folliculitis

Patho • Presence of inflammatory cells within the wall and ostia of the hair follicle creates a follicular-based pustule. • Inflammation can be either superficial or deep; deep folliculitis can result from chronic lesions of superficial folliculitis or from lesions that are manipulated. • Persistent or recurrent lesions may result in scarring and permanent hair loss. Subjective Data • Acute onset of papules and pustules associated with pruritus or mild discomfort; may have pain with deep folliculitis • Risk factors: frequent shaving, immunosuppression, hot tubs without adequate chlorine, preexisting dermatoses, long-term antibiotic use, occlusive clothing and/or occlusive dressings, exposure to hot humid temperatures, diabetes mellitus, obesity, and use of EGFR (epithelial growth factor receptor) inhibitor medications Objective Data • Primary lesion is a small pustule 1-2 cm in diameter that is located over a pilosebaceous orifice and may be perforated by a hair. • Pustule may be surrounded by inflammation or nodular lesions; after the pustule ruptures, a crust forms. • May have suppurative drainage with deep folliculitis. • Any hair-bearing site can be affected; the sites most often involved are the face, scalp, thighs, axilla, and inguinal area.

Herpes Simplex

Patho • Two virus types cause the infection: type 1, usually associated with oral infection, and type 2, with genital infection. • Crossover infections are becoming common. Subjective Data • Exposure to ticks • Constitutional symptoms of fatigue, anorexia, and headache may develop. • Expanding rash Objective Data • Early localized infection typically manifested by a single erythema migrans skin lesion, a flat to slightly raised, erythematous skin lesion (usually ≥5 cm in diameter) that is round or oval in shape, with central clearing (classic target or bull's-eye appearance). • Early disseminated infection is usually manifested by multiple erythema migrans skin lesions, by neurologic symptoms such as facial palsy, meningitis, or encephalitis, or by symptoms of carditis such as lightheadedness, palpitations, dyspnea, chest pain, or syncope. • Late disease usually manifested by arthritis atrophicans or atrophic dermatitis.

Eczematous Dermatitis

Patho: Intercellular edema, and epidural breakdown Three stages: acute, subacute, chronic Itching makes rash worse, can get infected and start crusting. Most common inflammatory skin disorder. Irritant contact dermatits Allergic contact dermatitis Atopic Dermatitis Subjective Data • Itching is typically present. • Those with atopic dermatitis often report allergy history (allergic rhinitis, asthma). • For irritant or allergic contact, exposure history is important. Objective Data • Acute phase characterized by erythematous, pruritic, weeping vesicles • Subacute eczema characterized by erythema and scaling • Chronic stage characterized by thick, lichenified, pruritic plaques • Atopic dermatitis: during childhood, lesions involve flexures, the nape, and the dorsal aspects of the limbs; in adolescence and adulthood, lichenified plaques affect the flexures, head, and neck

AV Fistula

Pathologic communication between an artery and vein Congenital or acquired Pt may present with lower extremity edema, varicose veins, or claudication

Hypertension

Pathophysiology - defined as a BP > 140/90 Essential htn - pathologic origin is poorly understood Secondary HTN - potential causes include renal disease, renal artery stenosis, aldosteronism, thyroid disorders, coarction of the aorta, pheochromocytoma Patient Subjective Data Essential HTN is asymptomatic In malignant / severe HTN - headache, blurred vision, dyspnea or encephalopathy may be present Patient Objective Data -Multiple confirmed bp readings at or above 140/90 or in children greater than 95% for age, gender, height -End organ damage eg papilledema and evidence of heart failure

PAINAD scale

Patients whose dementia is so advanced that they cannot verbally communicate

Mastectomy

Pay attention to scar line, this is where malignancy may reoccur

What muscles form the floor of the breasts?

Pectoralis Major Pectoralis Minor Serratus Anterior Subscapularis Latissimus Dorsi External Oblique Rectus Abdominis Please Play Sublime Songs Like Ebin Rucca

Skin Types

People burn or tan depending on their skin type, the time of year, and how long they are exposed to UV rays. The six types of skin, based on how likely it is to tan or burn, are as follows: I: Always burns, never tans, sensitive to UV exposure II: Burns easily, tans minimally III: Burns moderately, tans gradually to light brown IV: Burns minimally, always tans well to moderately brown V: Rarely burns, tans profusely to dark VI: Never burns, deeply pigmented, least sensitive Although everyone's skin can be damaged by UV exposure, people with skin types I and II are at the highest risk.

Enlarged spleen vs enlarged Left kidney?

Percussion can differentiate Enlarged spleen = dull Enlarged Kidney = resonant

What structures line the abdominal cavity?

Peritoneum Serous Membrane These form a protective cover for many of the abdominal organs.

A regular paroxysmal cough is heard in?

Pertussis

Korotkoff Sounds

Phase 1 - sharp thud Phase 2 - blowing or swishing sound Phase 3 - Softer thud than phase 1, still crisp Phase 4 - Softer Blowing sound that disappears Phase 5 - silence. Muffled sound is first diastolic sound. Auscultory gap widens with systolic hypertension in older persons due to loss of arterial pliability. It also widens with a drop in diastolic pressure when chronic severe aortic regurgitation is present. Auscultory gap narrows in cases of pulsus paradoxus due to cardiac tamponade or other constrictive cardiac events.

Patterns of Injury in Physical Abus

Physical findings in children who are physically abused include bruises, burns, lacerations, scars, bony deformities, alopecia, retinal hemorrhages, dental trauma, and head and abdominal injuries. Skin and hair abnormalities may be the most visible clues in detecting this problem. It is important to examine the skin that is usually covered by clothing. • Bruises: These may be patterned consistent with the implement used, such as belt marks, marks from a looped electric cord, and oval or fingertip grab marks. Bruising associated with abuse occurs over soft tissue; toddlers and older children who bruise themselves accidentally do so over bony prominences. Any bruise in an infant who is not yet developmentally able to be mobile should be cause for concern. • Lacerations: Lacerations of the frenulum and lips are associated with forced feeding. Human bites can cause breaks in the skin and leave a characteristic bite mark. • Burns: Patterns that are common include scald burns in stocking and glove distribution (when hands or feet are placed on hot surface or immersed); buttock burns consistent with immersion; and cigarette burns, a characteristic small, round burn, often on areas hidden by clothing. The absence of splash marks or a pattern consistent with spills of hot liquids may be helpful in differentiating accidental from deliberate burns. • Hair loss: Patchy hair loss or bald spots, in the absence of a scalp disorder such as ringworm, may indicate repeated hair-pulling. • Presence of anogenital warts in a child under 2 years should also raise suspicion of physical and/or sexual abuse, although these can be auto-inoculated.

Bimanual Digital Palpation

Place one hand palmar surface facing up under the patient's right breast. Position hand so that it acts as a flat surface against which to compress the breast tissue. With the fingers of the other hand walk across the breast tissue feeling for lumps as you compress the tissue between your fingers and your flat hand.

Assess superficial and deep tendon reflexes with these tests:

Plantar Reflex Abdominal reflexes Cremastic Reflex in Male Patients Biceps, Brachioradialis, triceps, patellar, and Achilles deep tendon reflexes Ankle clonus (Descending tracts- Lateral and Anterior Corticospinal tracts) Upper motor neuron disorders

fullness in the popliteal space may indicate a

Popliteal (Baker) cyst

When do Fontanels ossify?

Posterior - 2 months Anterior - 12 - 15 months

Cervical spine palpation areas

Posterior neck Cervical Spine Paravertebral Trapezius Sternocleidomastoid

Observe patient gait for:

Posture Rhythm and sequence of stride and arm movements

Medial and Lateral Reticulospinal

Posture and Romber Gait Instinctual motor Reactions (Descending Tract/Upper Motor Neuron Disorders)

Parkinsonian

Posture stooped, body is held rigid. Short shuffling steps. Difficulty starting or stopping.

Autonomic hyperreflexia (dysreflexia)

Potentially life threatening condition associated with high level (T6 or higher) spinal cord injury. Symptoms: High blood pressure, sweating, blotchy skin, nausea, goose bumps due to stimulation of bowel or bladder, or skin below spinal lesion. Causes: reaction to cold, hard examination table, cold stirrups, insertion and manipulation of a vaginal speculum, pressure during the bi manual or rectal examination Treatment: Remove cause of stimulation for High BP. If removal of stimulation does not bring BP down, and or patient has throbbing headache or nasal obstruction treat this as a medical emergency. Never leave patient unaccompanied. pg 39

Pleural Chest Pain Characteristics

Precipitated by breathing or coughing, usually described as sharp. Present during respiration, absent when breath held.

Neonate / infant pain scale

Premature infant pain profile (PIPP) used to assess procedural pain in preterm and full term neonates between 28-40 weeks. Measures Vital signs and pain behaviors - Brow bulge, eye squeeze, and nasolabial furrow Neonatal infant pain scale is used to assess procedure pain in preterm and full term infants up to 6 weeks of age . Facial expression, cry, breathing pattern, arm and leg movements, and state of arousal are observed and scored CRIES Scale - crying requires oxygen to keep sat above 95. Increase vital signs, expression, and sleeplessness is design to evaluate postoperative pain in newborns and infants.

Hearing loss Risk factors - Infants and Children

Prenatal Factors: Perinatal infeciton, irradiation, drug abuse Assisted ventilation > 14 days Hyperbilirubinemia requiring exchange transfusion Extracorporeal membranous oxygenation Infection: bacterial meiningits, recurrent episodes of acute otitis media or otitis media with effusion Cleft Palate Head trauma Hypoxic episode

Increased fremitus caused by:

Presence of fluids or a solid mass within the lungs lung consolidation heavy but non-obstructive bronchial secretions compressed lung (Courser or rougher in feel)

Cardarelli sign

Press on thyroid cartilage and displace it to patients left. This increases contact between bronchus and the aorta allowing systolic pulsation from the aorta to be felt at the surface if an aneurysm is present.

How does the kidney serve as an endocrine gland?

Produces renin, which controls aldosterone secretion Primary source of erythropoiten production in adults, influences bodys red cell mass. Produces active form of vitamin D

Multiple Sclerosis (MS)

Progressive Autoimmune disorder, destruction of myelin sheaths of brain's white matter. Leads to decreased transmission of nerve impulses. Gradual unpredictable progression. Symptom onset 20-40 yrs. Women affected twice as much as men. Subjective Data • Fatigue • Urinary frequency, urgency, or hesitancy • Sexual dysfunction • Vertigo, weakness, numbness • Blurred vision, diplopia, loss of vision • Emotional changes • Relapse symptoms develop rapidly over hours or days, and symptoms take weeks to recede. Objective Data • Muscle weakness, ataxia • Hyperactive deep tendon reflexes • Paresthesia, sensory loss, such as loss of vibration sense • Intention tremor • Optic neuritis • Cognitive changes • Magnetic resonance imaging (MRI) reveals brain lesions that are typically periventricular, ovoid, and perpendicular to the ventricles; spinal cord lesions may also be found.

Venous thrombosis

Prolonged immobilization Tenderness, DVT, PE may occur without warning Compare one extremity to other Minimal ankle edema, low grade fever, tachycardia

Anterior and Dorsal Spinocerebellar Tract

Proprioception (Ascending Tract/Lower Motor Neuron Disorders)

Oculomotor CN III damage

Pupil Dilated and Fixed, eye deviated laterally and downward accompanied with ptosis.

Mydriasis

Pupil Dilation > 6mm Caused by Iridocyclits, mydriatic eye drops (atropine), midbrain reflex (arc reflex), lesions, hypoxia, Oculomotor CNIII damage, acute angle glaucoma, cocaine and amphetamine abuse.

Empyema

Purulent exudative fluid collected in the pleural space Non free flowing purulent fluid collection develops most commonly from adjacent infected tissues. Pt presents febrile and tachypneic with cough, CP, progressive dyspnea develops. Cough can have blood or sputum. Percussion dull Fremitus absent

Pinch Skin for Turgor Test

RETURN TO NORMAL AFTER THE PINCH DEGREE OF DEHYDRATION <2 seconds <5% loss of body weight 2-3 seconds 5%-8% loss of body weight 3-4 seconds 9%-10% loss of body weight >4 seconds >10% loss of body weight Because the normal range of skin moisture is broad, look at other factors that may suggest a problem. Excessive sweating or dryness alone rarely has pathologic significance in infants or children. Children with atopic dermatitis or chronic skin changes involving the face will commonly rub their eyes, sufficiently sometimes to cause an extra crease or pleat of skin below the eye. This is known as the Dennie-Morgan fold and often referred to as the allergic salute; it is secondary to chronic rubbing and inflammation.

Hip ROM

Raise leg with knee extended flexion of 90, knee to chest flexion of 120, internal rotation 40, external 45, abduction 40 to 45, adduction 20 to 30, standing swing leg back hyperextension 15

Lateral and Anterior Corticospinal Tract

Rapid Rhythmic Alternating Movements Voluntary Movement Deep Tendon Reflexes Plantar Reflex (Descending Tract/Upper Motor Neuron Disorders)

RESPECT Model of Cross-Cultural Communication

Rapport Empathy Support Partnership Explanations Cultural Competence Trust pg. 31

Pain Reassessment

Reassess patient at peak action of analgesic

Equilibrium

Receptors in semicircular canals and vestibule sends signals to the cerebellum to maintain equiliibrium

Spider Angioma

Red Central Body with radiating spider like legs that blanch with pressure to the central body Refill uniformly bc they are arterial Cause: Liver disease, vitamin B deficiency, idiopathic

Capillary Hemangioma (Nevus Flammeus)

Red irregular macular patch Cause: dilation fo the dermal capillaries

Ecchymosis

Red-purple non blanchable discoloration of variable size Cause: Vascular wall destruction, trauma, vasculitis

Petechiae

Red-purple nonblachable discoloration less than 0.5cm diameter Cause: Intravascular defects, infection

Purpura

Red-purple nonblanchable discoloration greater than 0.5 cm in diameter Cause: Intravascular defects, infection

Pursing of the lips

Reduces sensation of dyspnea

Basal Ganaglia

Refines motor movements EPS pathway and processing station between cerebral motor cortex and upper brain stem.

Pons CN 5-8

Reflexes of pupillary action and eye movement Regulates respiration, houses a portion of the respiratory center Control voluntary muscle action with corticospinal tract pathway. (Eyes - pupils, Breathing, voluntary muscle action)

Thalamus

Relays sensory aspects of motor info between the basal ganglia and cerebellum Major integrating center for the perception of various sensations such as pain and temperature

Thelarche Phase

Represents the first sign of puberty in girls (breast development)

Dermis

Richly vascular connective tissue layer, separates the epidermis from adipose tissue. Sensory nerve fibers located in dermis and provide sensation of pain, touch, temperature. Also contains autonomic motor nerves that innervate blood vessels, glands, and the arrector pili muscles

Most of the anterior surface of the heart is formed by the

Right Ventricle

Jugular veins reflect

Right side of heart Level at which the jugular venous pulse is visible gives an indication of right atrial pressure

What side should you approach patient from during abdominal exam?

Right side, allows for tangential view and enhances shadows and contouring

Basal and Squamous Cell Cancer

Risk factors - Older than 50 yrs - Exposure to UVA / UVB - Indoor tanning device - Blistering sunburns -Chromic and cumulative exposure - squamous cell carcinoma -Intermittent exposure - basal cell carcinoma -Geographic location near equator or high altitudes -Inability to tan skin type i and ii -Exposure to arsenic creosote, coal, tar, and or --petroleum products -Overexposure to radium, radioisotopes, X-rays -Repeated trauma or irritation to skin -Precancerous dermatoses -Large scars

Equilibrium Test

Romberg Test Feet together, arms at side. Eyes open then Closed Push shoulders, patient should recover. Stand on one foot (eyes closed). Pt should maintain for 5 seconds. Hop in place on one foot then other (eyes open). Pt should maintain for 5 seconds. Loss of balance = positive Romberg = Cerebellar ataxia, vestibular dysfunction, sensory loss

Lichenification

Rought, thickened epidermis secondary to persistent rubbing, itching or skin irritaiton; often involves flexor surface of extremity Ex: Chronic Dermatitis

Achilles Reflex - Spinal Nerve Levels Evaluated

S1 and S2 (Deep Tendon Reflex)

Electrical impulse in the heart

SA -> AV -> Bundle of His -> Purkinje Fibers

What muscles comprise the rotator cuff?

SITS Subscapularis Infraspinatus Teres minor Supraspinatus

Orthopnea

SOB that begins or increases when the patient lies down. Ask if pt needs to sleep on more than one pillow and if it helps.

Pulmonary Valve Ejection Click

Second left intercostal space at sternal border; patient sitting or supine Early systole, less intense than aortic click; intensifies on expiration, decreased on inspiration

Scale (Secondary skin lesions)

Secondary skin lesion, heaped up keratinized cells; flaky skin, irregular; thick or thin; dry or oily; variation in size. Ex: Flaking of skin with seborrheic dermatitis or after a drug reaction; dry skin

Newborn Depressed Respiration can be from:

Sedatives Compromised blood supply Asp meconium Mucus obstruction SCAM

Enhanced physiologic tremor

Seen when arms Extended, dissappears at rest Drugs or Etoh Hyperthyroid, Hypoglycemia Lithium, TCA's, valproate, methylxanthines toxicity

Ejection Click

Semilunar Valves are stenotic - Tricuspid and Aortic

Infant Eustachian Tube

Shorter, wider, more horizontal than an adults. Has an upward curve. Adenoid (tonsils) development may occlude Eustachian tube and interfere with aeration of middle ear. Predisposes children to middle ear effusion.

Neer Test

Shoulder rotator cuff impingement or tear forward flex the patient arm up to 150 degrees while depressing the scapula. increased shoulder pain = rotator cuff inflammation or tear

ROM of Shoulders Exam

Shrug Shoulders Raise both arms forward and straight up over the head - expect flexion of 180 degrees Extend and stretch both arms behind the back - expect hyperextension of 50 degrees Lift both arms laterally and straight up over the head - expect should abduction of 180 degrees Swing arms across the front of the body, expect adduction of 50 degrees Place both arms behind the hips elbows out, expect an internal rotation of 90 degrees Place both arms behind the head elbows out, expect an external rotation of 90 degrees

CN 11 Examination

Shrug Shoulders (Trapezius strength) Turn head to each side against resistance (Sternocleidomastoid)

Ataxic Respirations

Significant disorganization with irregular and varying depths of respiration Caused by increased ICP, Drug OD, Medulla Damage. Very poor prognosis

Myxedema

Skin and tissue disorder due to severe prolonged hypothyroidism • Decrease in metabolic rate, resulting in accumulation of hyaluronic acid and chondroitin sulfate in the dermis • Deposition of glycosaminoglycan in all organ systems leads to mucinous edema of facial features. Subjective Data • Cognitive impairment slowed mentation, poor concentration, decreased short-term memory, social withdrawal, psychomotor retardation, depressed mood, and apathy • Constipation • Muscle pains • Hearing problems, deafness Objective Data • Coarse thick skin, thickening nose, swollen lips, puffiness around eyes • Slow speech • mental dullness, lethargy, mental problems • Weight gain • Thin brittle hair, with bald patches

Anatomic Structures of the Skin

Skin structure and physiologic processes perform the following integral functions: • Protect against microbial and foreign substance invasion and minor physical trauma • Restrict body fluid loss by providing a restrictive barrier • Regulate body temperature • Provide sensory perception via free nerve endings and specialized receptors • Produce vitamin D from precursors in the skin • Contribute to blood pressure regulation through constriction of skin blood vessels • Repair surface wounds by exaggerating the normal process of cell replacement • Excrete sweat, urea, and lactic acid • Express emotions

Compound Nevus

Slightly elevated brownish papule: indistinct border -Nevus cells in dermis and lining dermoepidermal junction -Should be removed if exposed to repeated trauma

Bronchiolitis

Small airway inflammation leads to hyperinflation of lung infants < 6months Wheezing, grunting, diminished breath sounds, AMS, increased AP diameter

Asthma presentation:

Small airway obstruction due to inflammation • Tachypnea and paroxysmal coughing with wheezing on expiration and inspiration • Expiration becomes more prolonged with labored breathing, fatigue, and anxious expression as airway resistance increases. • Hypoxemia by pulse oximetry may develop. • Decreased peak expiratory flow rate

Ophthalmoscope

Small aperture - used for small pupils Red-free filter - produces a green beam for examination of the optic disc for pallor and minute vessel changes; also permits recognition of retinal hemorrhages, with blood appearing black Slit - examination of the anterior eye and determination of the elevation of lesions on the retina. Grid - Estimation of the size of fundal lesions + and - can compensate for myopia or hyperopia in both the examiner and patient. There is not compensation for astigmatism

Janeway Lesions

Small erythematous or hemorrhagic macules appearing on the palms and soles

Peyer Patches

Small raised lymph tissue on the mucosa of the small intestine and consist of many clustered lymphoid nodules.

Far Vision Tests

Snellen Chart E chart for children

Solar Lentigines

Solar lentigines (singular lentigo) are irregular, gray-brown macules that occur in sun-exposed areas that can range in size from a few millimeters to over a centimeter. These are often referred to as "age spots" or incorrectly as "liver spots". Note that "liver spots" have no relationship to the liver. They are epidermal proliferations and are signs of photoaging of the skin.

CN Mnemonic (classification)

Some Say Marry Money But My Brother Says Bad Business Marry Money S = Sensory M = Motor B = Both

Auscultation

Sound characteristics: Intensity Pitch Duration Quality

Percussion

Sound waves heard from vibrations 4-6cm deep in body tissue. Tympanic - gastic bubble. drumlike Hyper-resonant- emphysematous lungs, boomlike Resonant - healthy lung tissue, hollow Dull - over liver, thudlike Flat - over muscle, very dull.

CN 9, 10 Examination

Sour and bitter tastes on each side of tongue Gag reflex Inspect palate and uvula Swallowing difficulty? Guttural speech sounds (nasal or hoarse quality voice)

Raynaud Phenomenon/Disease

Spasm of digital arterioles usually in response to cold exposure. Occasionally in nose and ears common in young women Involved areas feel cold and achy, improve on rewarming triphasic demarcated skin pallor (white) cyanosis (blue) reperfusion (red) vasospasm can last from minutes to less than an hour Secondary reynaud ulcers may appear on tips of digits

Unexpected Gait Patterns

Spastic Hemiparesis Spastic Diplegia (Scissoring) Steppage Dystrophic (Waddling) Tabetic Cerebellar Gait (Cerebellar ataxia) Sensory Ataxia Parkinsonian Gait Dystonia Ataxia Antalgic Limp

Pregnant patients

Spider and cherry angiomas may increase in size due to increased blood flow to the skin. Most pregnant patients have some degree of increased pigmentation. Nevi may grow and change color

Ascending Spinal Tracts

Spinothalmic, spinocerebellar - mediate various sensations Manage sensory signals necessary to perform complex discrimination tasks

Vertebra Prominens

Spinous Process of C7 Better seen and felt with head bent forward.

QRS Complex is the

Spread of stimulus through the ventricles Ventricular Depolarization < 0.12 seconds

Lymphedema Grading

Stage 0 - Latent or subclinical - Swelling is not evident despite impaired lymph transport. Stage I - Pitting may occur. There is early accumulation of fluid relatively high in protein content (e.g., in comparison with "venous" edema), and it subsides with limb elevation. Stage II Tissue fibrosis is present. Limb elevation alone rarely reduces tissue swelling. Pitting may be present. Late in stage II, the limb may or may not pit as tissue fibrosis supervenes. Stage III Pitting is absent. Trophic skin changes are present (acanthosis nigricans, fat deposits, and warty overgrowths).

Infection Precautions

Standard - PPE - Hand Hygiene - Cough Etiquette / Respiratory hygiene - Safe Injection Practices - Safe Handling of potentially contaminated equipment Transmission Based - Airborne / Droplet Precautions -Contact Precautions

Peripheral artery disease

Stenosis of the blood supply to the extremities by atherosclerotic plaques Pain in muscle after exercise disappears with rest. Limb appears healthy but pusles weak or absent Progressive stenosis results in severe ischemia which leads to limb in pain at rest Edema seldom accompanies this disorder, ulceration is common.

External Jugular vein is close to what structure

Sternocleidomastoid IJ is close to carotid artery

Accessory muscles

Sternocleidomastoid Scalenes Pectoralis minor Abdominal Obliques Rectus Abdominis SPARS or RAPSS

What muscles form the neck?

Sternocleidomastoid Trapezius

CN 12 Hypoglossal Examination

Stick tongue out Move tongue toward nose and chin Press tongue against cheek Lingual Speech Sounds (L, T, D, N)

Meningeal or Intracranial Hemorrhage Signs include:

Stiff Neck or Nuchal Rigidity Test with Kernig and Brudzinksi Sign

Still Murmur

Still murmur is recognized as the most common innocent murmur of early childhood. It is described as musical, vibratory, short, and high-pitched. Result of vigorous myocardial contraction Blowing accompanied with split S2 2nd Left IC near left sternal border

Renal Calculi

Stones formed in the pelvis of the kidney from a physiochemical process associated with obstruction and infections in the urinary tract

Pregnant Patients

Striae gravidarum (stretch marks) may appear over the abdomen, thighs, and breasts during the second trimester of pregnancy. They fade after delivery but never disappear. There is an increase in telangiectasias, which may be found on the face, neck, chest, and arms; these appear during the second to fifth months of pregnancy and usually resolve after delivery. Hemangiomas that were present before pregnancy may increase in size, or new ones may develop. Cutaneous tags (molluscum fibrosum gravidarum) are either pedunculated or sessile skin tags that are most often found on the neck and upper chest. They result from epithelial hyperplasia and are not inflammatory. Most resolve spontaneously or can be removed easily. An increase in pigmentation is common and is found to some extent in all pregnant patients. The areas usually affected include the areolae and nipples, vulvar and perianal regions, axillae, and the linea alba. Pigmentation of the linea alba is called the linea nigra. It extends from the symphysis pubis to the top of the fundus in the midline Preexisting pigmented moles (nevi) and freckles may darken, with some nevi increasing in size. New nevi may form. Melasma or "mask of pregnancy," occurs frequently in pregnant patients. The darkened, blotchy skin is usually symmetric and found on the forehead, cheeks, bridge of the nose, and chin Palmar erythema is a common finding in pregnancy. A diffuse redness covers the entire palmar surface or the thenar and hypothenar eminences. The cause is unknown but is likely related to estrogens, and it usually disappears after delivery. Itching over the abdomen and breasts resulting from skin stretching is common and not a cause for concern; however, itching accompanied by a rash may signal a pregnancy-specific dermatosis, which requires further investigation. Itching during pregnancy can also be caused by impaired flow of bile from the liver, which may also produce jaundice. The itching is generalized but may be more severe on the palms and soles. Be alert to these serious manifestations of underlying pathology. Hair growth is altered in pregnancy by the circulating hormones. The growing phase of the hair is lengthened and hair loss is decreased. Two to 6 months after delivery, increased hair shedding occurs (telogen effluvium). Regrowth will occur in 6 to 12 months. Acne vulgaris may be aggravated during the first trimester of pregnancy but often improves in the third trimester.

These indicate a severely obstructed airway:

Stridor is inspiratory and expiratory Cough has a barking character Retractions also involve the subcostal and intercostal spaces Cyanosis is obvious even with supplemental O2.

These indicate an obstruction below the glottis:

Stridor tend to be louder, more rasping The voice is hoarse Swallowing not affected Cough is harsh, barking Positioning of head is not a factor

These indicate an obstruction above the Glottis:

Stridor tends to be quieter The voice is muffled Swallowing is difficult Cough is not a factor Awkward head / neck positioning ( extended with retropharyngeal abscess or head to affected side with peritonsillar abscess)

Cardiac Tamponade

Subjective Data • Anxiety, restlessness • Chest pain • Difficulty breathing • Discomfort, sometimes relieved by sitting upright or leaning forward • Syncope, lightheadedness • Pale, gray, or blue skin • Palpitations • Rapid breathing • Swelling of the abdomen or arms or neck veins Objective Data • Beck triad (jugular venous distention, hypotension, and muffled heart sounds) • Chronically and severely involved pericardium may also scar and constrict, limiting cardiac filling; heart sounds are muffled, blood pressure drops, the pulse becomes weakened and rapid, and paradoxical pulse becomes exaggerated.

Serum Sickness (Type III Hypersensitivity Reaction)

Subjective Data • Enlarged lymph nodes • Pain, pruritus, and erythematous swelling at the injection site • Urticaria, other rashes, lymphadenopathy, joint pain, fever, and at times facial edema • Medications: beta-lactam antibiotics (especially cefaclor), sulfonamide antibiotics, minocycline • Organ transplant Objective Data • Findings become apparent about 7-10 days after administration of the provoking substance. • Urticaria, maculopapular or purpuric lesions • Lymphadenopathy most prominent in the area draining the injection site; can be generalized • Facial and neck edema • Symptoms subside slowly, recurring at times over several weeks.

Roseola Infantum (HHV6)

Subjective Data • Fever—usually high grade and persistent over 3-4 days • Sometimes associated with a mild respiratory illness and lymphadenopathy Objective Data • Adenopathy, discrete and not tender, involves the occipital and postauricular chains and may last for some time • When the fever diminishes, a morbilliform fine maculopapular rash occurs, spreading from the trunk to the extremities; the child begins feeling much better. Common in infancy

CHF Right Sided

Subjective Data • Peripheral edema, particularly at the end of the day or after prolonged sitting • Weight gain Objective Data • Pitting edema in lower extremities • Jugular venous distention • Ascites • Hepatomegaly Jugular Vein Distention is most helpful finding for R CHF.

Ventricular Septal Defect

Subjective Data • Recurrent respiratory infections • If large VSD, rapid breathing, poor growth, symptoms of congestive heart failure Objective Data • Arterial pulse is small, and jugular venous pulse is unaffected. • Holosystolic murmur, often loud, coarse, high-pitched, and best heard along the left sternal border in the third to fifth intercostal spaces • Left peristernal lift • A smaller defect causes a louder murmur and a more easily felt thrill than a large one

Nonpathologic nodes

Submandibular or cervical nodes <1cm in diameter or Inguinal node < 2cm

Cephalhematoma

Subperiosteal collection of blood bound by the suture lines Commonly found in the parietal region Firm, edges are well defined. Does NOT cross suture lines. May liquefy and become fluctuant on palpation.

Stroke / CVA

Sudden interruption of blood supply to part of brain

Alopecia Areata

Sudden rapid coin shaped loss of hair usually from scalp or face Patho • Cause unknown; autoimmune phenomenon from a genetic-environmental interaction may trigger the disease. • Any hair-bearing surface may be affected. • Regrowth begins in 1-3 months; the prognosis for total regrowth is excellent in cases with limited involvement. Subjective Data • Sudden, rapid, round patches of hair loss • May also report nail pitting • May have family history Objective Data • Hair loss is in sharply defined, round areas • Nonscarring • The hair shaft is poorly formed and breaks off at the skin surface. • Small villous hairs indicate hair regrowth.

Hippocratic Facies

Sunker appearance of eyes, cheeks, and temporal areas Sharp nose, dry rough skin. This is terminal stage throat cancer.

Anterior Spinothalamic Tract

Superficial Touch and Deep Pressure (Ascending Tract/Lower Motor Neuron Disorders)

Breast lymphatic network is composed of?

Superficial lymphatics - drain the skin Deep Lymphatics - drain the mammary lobules

Tympanic Membrane

Superior portion (pars flaccida) is more flacid, rest is tense (pars tensa)

Posterior Spinal Artery Stroke

Supplies Posterior Spinal Cord S/S Sensory loss, particularly proprioception, vibration, touch, and pressure (movement preserved)

Anterior Spinal Artery Stroke

Supplies Spinal Cord S/S Flaccid paralysis, below level of lesion Loss of pain, touch, temperature sensation (proprioception preserved)

Posterior Inferior Cerebellar Artery Stroke

Supplies the lateral and posterior portion of the medulla Wallenberg syndrome (swallowing difficulty, hoarseness, dizziness, nausea and vomiting, nystagmus, and problems with balance and gait coordination) Ipsilateral anesthesia of face and cornea for pain and temperature (touch preserved) Ipsilateral Horner syndrome Contralateral loss of pain and temperature sensation in trunk and extremities Ipsilateral decompensation of movement

Anterior Inferior and Superior Cerebellar Arteries Stroke

Supply the Cerebellum S/S Difficulty in articulation, swallowing, gross movements of limbs; nystagmus

Paget Disease

Surface Manifestation of underlying ductal Carcinoma Crustiness on the nipple, areola, and surrounding skin Pruritis of nipple common Red, scaling, crusty patch Does not respond to steroids

Cardiac Chest Pain Characteristics

Susbternal provoked by effort, emotion relieved by rest / nitro can have diaphoresis and nausea

Preeclamspia-Eclampsia

Syndrome specific to pregnancy with HTN that occurs after the 20th week of pregnancy and the presence of proteinuria. Eclampsia is preeclampsia with seizures. Sustained elevation of BP systolic > 160 diastolic > 110

SAFER Approach

Syndromic features Age Family Hx Evaluation of feeding and growth Rheumatic Fever

S2 Intensity increases in

Systemic HTN, Syphilis of Aortic Valve, excercise, excitment Pulmonary HTN, Mitral Stenosis, CHF Think HTN, Aortic Valve and Mitral Valve.

Acute Rheumatic Fever

Systemic connective tissue disease occurring after streptococcal pharyngitis or skin infection • Fever • Inflamed swollen joints • Flat or slightly raised, painless rash with pink margins with pale centers and a ragged edge (erythema marginatum) • Aimless jerky movements (Sydenham chorea or St. Vitus dance) • Small, painless nodules beneath the skin • Chest pain • Palpitations • Fatigue • Shortness of breath Objective Data Jones Criteria for Diagnosis of Rheumatic Fever • Murmurs of mitral regurgitation and aortic insufficiency • Cardiomegaly • Friction rub of pericarditis • Signs of congestive heart failure

Systemic Disorders and the skin

Systemic disorders can produce generalized or localized color changes Localized redness often results from an inflammatory process. Pale, shiny skin of the lower extremities may reflect peripheral changes that occur with systemic diseases such as diabetes mellitus and peripheral vascular disease. Injury, steroids, vasculitis, stasis, and several systemic disorders can cause localized hemorrhage into the skin, producing red-purple discolorations. Bleeding into the skin results in ecchymoses (i.e., bruising); pinpoint bleeding from capillaries occurs is called petechiae (smaller than 0.5 cm in diameter) or purpura (larger than 0.5 cm in diameter)

S1 marks the beginning of

Systole Coincides with rise / upswing of carotid pulse. Best heard at apex

TACE Model

T - How many drinks does it TAKE to make you feel high? A - Have people ANNOYED you by criticizing your drinking? C - Have you felt you out to CUT down on your drinking? E - Have you had an EYE-OPENER Drink first thing in the morning to steady your nerves? Answer to T alone (more than two drinks) or a positive response to two of A,C,E may signal a problem with a high degree of probability

Cremasteric Reflex - Spinal Nerve Levels Evaluated

T12, L1, L2 Superficial Reflex

Lower Borders of Lung descend to where on deep inspiration?

T12, then rise to about T9 on forced expiration

What level does the trachea divide?

T4 or T5 and just below the manubriosternal joint (angle of louis)

Old age and the Thyroid Gland

T4 production and degradation decreases. Thyroid becomes more fibrotic

Upper Abdominal Reflex - Spinal Nerve Level Evaluated

T8, T9, T10 Superficial Reflex

Blood pressure examination

Taken while patient seated, if supine readings will be lower. Standard based on seated position in right arm. Center cuff over brachial artery, lower edge 2-3cm above antecubital If cuff too wide BP will be underestimated. If too Narrow, BP will be high. Adults: Choose a width that is 1/3 to 1/2 the circumference of the limb Length should be twice the width or about 80% of the limb circumference. Bladder should not completely encircle limb. Loose cuff will give inaccurate diastolic reading. Make sure patients arm is at level of heart. Korotkoff sounds - produced by turbulence of blood flow in artery - low pitches, use bell of stethoscope.

What is the major accessible artery of the face?

Temporal artery

CN 2 Examination

Test distant and near vision Perform ophthalmoscopic exam of fundi Test visual fields by confrontation and extinction of vision

CN 8 Examination

Test sense of hearing with whisper screening tests or by audiometry Compare bone and air conduction of sound Test for lateralization of sound

Tinel Sign

Tested by striking the patient's wrist with your index or middle finger where the median nerve passes under the flexor retinaculum and volar carpal ligament Tingling sensation radiating from the wrist to the hand in the distribution of the median nerve is a positive Tinel sign

Rosenbaum Pocket Vision Screener

Tests near vision. Hold card 35cm or 14 inches away

Corneal Sensitivity (Cotton Wisp)

Tests: CN V (Trigeminal) CN VII (Facial) by blinking

Older Adults Nail Changes

The nails thicken, become more brittle, and may be deformed, misshapen, striated, distorted, or peeling. They can take on a yellowish color and may lose their transparency. These changes occur most often in the toenails.

Distinguishing Physical Characteristics

The use of physical characteristics to distinguish a cultural group or subgroup is inappropriate. Do not confuse the physical with the cultural or allow the physical to symbolize the cultural.

Montgomery tubercles or follicles

Tiny sebaceous glands that may be apparent on the areola surface

Lumbosacral Hyperextension in pregnancy

To assess for lumbosacral hyperextension, ask the patient to bend forward at the waist toward the toes. Palpate the distance between the L4 and S1 spinal processes. As the patient rises to standing, from full flexion to full extension, note when the distance between L4 and S1 becomes fixed. If it becomes fixed before the spine is fully extended, the patient will be hyperextended when walking, possibly resulting in lower back pain. Most back pain resolves within 6 months after delivery.

Oral Cavity and Oropharyngeal Cancer Risk Factors

Tobacco use Alcohol use HPV 16 oral infection > 55 yrs old Male UV light exposure - cancer of lip HIV infection, Graft vs Host disease Fanconi Anemia Dyskeratosis Congenita

CN 12 Hypoglossal

Tongue Movement for speech, sound articulation (l, t, d, n) and swallowing.

McMurray Test Detects

Torn Meniscus in knee Have the patient lie supine and flex one knee. Position your thumb and fingers on either side of the joint space. Hold the heel with your other hand, fully flexing the knee, and rotate the foot and knee outward (valgus stress) to a lateral position. Extend and then flex the patient's knee. Any palpable or audible click, pain, or limited extension of the knee is a positive sign of a torn medial meniscus.

Rooting Reflex (Birth)

Touch Corner of infants mouth. infant will move head toward side of stimulation when hungry. Disappears by 3-4 months of age.

Plantar Grasp

Touch plantar surface, toes should curl downward. Reflex strong till 8 months

Pericardium

Tough double walled fibrous sac encasing and protecting the heart. Several mm of fluid are present between the inner and outer layers of the pericardium, provides low friction environment.

Tics, spasmodic muscular contractions of face, head, or neck may indicate

Tourette syndrome, or degenerative changes of the facial nerves

Wide Splitting

Unexpected Heart Sound Occurs in RBBB and in Pulmonic Stenosis, Pulm HTN, Mitral Regurgitation Caused by delayed activation of contraction of the right ventricle

Papilledema

Unexpected Retinal Fining Loss of definition of optic disc margin, initially occurs superiorly and inferiorly. Then nasally and temporally central vessels pushed forward. Veins markedly dilated Venous pulsation not visible and cannot be induced by pressure to globe Caused by increased ICP

Glaucomatous Optic Nerve Head Cupping

Unexpected Retinal Fining Physiologic dis margins are raised with a lowered central area. Impairment of blood supply may lead to optic atrophy causing dis to appear white result of ICP, visual fields are constricted

Myelinated Retinal Nerve Fibers

Unexpected Retinal Fining White area with soft ill defined peripheral margins usually continuous with optic disc, feather margins, absence of pigment has full visual field unlike in chorioretinitis. benign condition

Cotton Wool Spot

Unexpected Retinal Fining ill defined yellow areas caused by infart of nerve layers of the retina. Caused by HTN or DM

Spinal Nerve Superficial Reflexes

Upper Abdominal Lower Abdominal Cremasteric Plantar

For exam what are the four quadrants of the breast?

Upper Inner / Outer Lower Inner / Outer and a Tail of Spence

Where does the greatest amount of glandular tissue lie?

Upper outer quadrant of the breast

If you suspect vascular anomaly of the brain

Use bell of stethoscope and listen of temporal region, over eyres, and below the occiput.. Looking for a bruit - highly suggestive of vascular anomaly.

Jugular Venous Pressure

Use two pocket rulers 15cm long. Expect value of < 9cm H2O These conditions make JVP difficult to examine: severe right heart failure, tricuspid insufficiency, constrictive pericarditis, and cardiac tamponade, volume depletion, extreme obesity

Nasal speculum

Use with penlight to visualize the lower and middle turbinates of the nose.

Amsler Grid

Used for macular degeneration when drusen boders are seen Pt notes line distortion

Rosenbaum or Jaeger Chart

Used for near vision, or can use newsprint Rosenbaum - series of x's and o's and e's

CRAFFT Questionarre

Used primarily for screening alcohol and substance abuse in Adolescents Car Relax Alone Forget Friends Trouble Questions: - Have you ridden in a CAR driven by someone who was high or had been using drugs and alcohol? - Do you ever use alcohol or drugs to RELAX, feel better about yourself or fit in? Do you ever use drugs or alcohol when you are ALONE? - Do you FORGET things you did while using drugs or alcohol - Do your family and FRIENDS ever tell you that you should cut down your drinking or drug use? - Have you ever gotten into TROUBLE while using drugs or alcohol?

CAGE questionnaire

Used to screen for alcoholism Cutting down Annoyance by criticism Guilty feeling Eye Openers

Arthritis/Bursitis Chest Pain Characteristics

Usually lasts for hours; local tenderness and/or pain with movement

Costal Angle

Usually no more than 90 degrees

Biliary Chest Pain Characterisitcs

Usually under right scapula, prolonged in duration Often occurs after eating, will trigge angina more often than mimic it

Cheyne-Stokes

Varying Periods of increasing depth interspersed with apnea Crescendo / Decrescendo sequence - cerebral brain damage, can occur with drug use or severe CHF. May also occur normally in young children and older adults.

Arterial pulses are the result of

Ventricular Systole - Produces a pressure wave

S3 is caused by

Ventricular filling - ventricular walls distend and cause vibration Ventricular Gallop on expiration. Best heard in left lateral decubitus/ recumbent position. Listen at the Apex on Expiration Lub de Dub or TEN-nes-see

Infants and children

Vernix caseosa - a mixture of sebum and cornified epidermis covers the infants body at birth. Subcutaneous fat layer poorly developed in newborns which predisposes them to hypothermia. Lanugo - covers shoulders and back, fine silky hair. commonly seen in preterm infants, and is shed in 10-14 days. Most hair is shed by about 2-3 months of age and replaced by permanent hair. Eccrine sweat glands start to function after first month of life. Apocrine does not start until puberty. Thus children do not have smelly perspiration.

Grade 6 Murmur

Very loud, audible with stethoscope not in contact with chest, thrill palpable and visible

Grade 5 Murmur

Very loud, thrill easiily paplpable

Test Cortical sensory response to:

Vibration with a tuning for over joints or bony prominence on upper and lower extremities Position sense with movement of the great toes or a finger on each hand Identification of familiar object by touch and manipulation Two Point discrimination Identification of number drawn on palm of hand Identification of body area when touched (Posterior, Anterior, and dorsal spinocerebellar spinal tracts) Ascending Tracts for lower motor neuron disorder

Legally Blind

Vision Not correctible to 20/200 or less

CN 2 Optic

Visual acuity and fields

Red Reflex

Visualized first with, hold opthalmascope 12 inches / 30cm away. Light illuminates Retina, opacities stand out as black densities.. Absence of red reflex is improperly positioned opthalmascope, but can indicate total opacity of pupil bc of cataract or hemorrhage.

CN 9 Glossopharyngeal

Voluntary muscles for swallowing and phonation (guttural speech sounds) Sensation of nasopharynx, gag reflex, taste. Posterior 1/3 of tongue Secreation of salivary glands, carotid reflex.

Split S2

When the aortic valve closes significantly earlier than the pulmonic valve, you can hear the two components separately This is an expected event

Pericardial Friction Rub characteristics

Widely heard, sound clearest toward apex May occupy all of systole and diastole; intense, grating, machine-like; may have three components and obliterate heart sounds; if only one or two components, may sound like murmur

Moro / Startle (Birth)

With the infant supported in semisitting position, allow the head and trunk to drop back to a 30-degree angle; observe symmetric abduction and extension of the arms; fingers fan out and thumb and index finger form a C; the arms then adduct in an embracing motion followed by relaxed flexion; the legs may follow a similar pattern of response; the reflex diminishes in strength by 3-4 months and disappears by 6 months.

Cirrhosis

a chronic degenerative disease of the liver characterized by scarring Subjective • May be asymptomatic; others report jaundice, anorexia, abdominal pain, clay-colored stools, tea-colored urine, and fatigue • May describe prominent abdominal vasculature, cutaneous spider angiomas, hematemesis, and abdominal fullness Objective • On examination, the liver is initially enlarged with a firm, nontender border on palpation; as scarring progresses, liver size is reduced and generally cannot be palpated • Neurologic examination abnormalities may be seen (e.g., hepatic encephalopathy) • With progressive disease, portal hypertension and ascites may occur • Muscle wasting and nutritional deficiencies may be evident in late-stage disease • May have abnormal laboratory values (e.g., liver function tests and coagulopathy)

When a joint has an increase or limitation in its range of motion use this tool

a goniometer, measure greatest flexion and extension

Virchow Node

a palpable supraclavicular node on the left, this is a significant clue to thoracic or abdominal malignancy.

Chloasma (mask of pregnancy)

a pigmentation disorder characterized by brownish spots on the face, this can occur during pregnancy after 16 weeks

A dry cough may sound loud and harsh from

a tumor that is compressing respiratory tree, or hoarse in Croup.

Scoliosis abnormality

abnormal lateral curvature of the spine Scoliometer reading of greater than or equal to 7 degrees is a positive screening test

Cubitus Valgus

abnormal outward bending or twisting of the elbow A lateral angle exceeding 15 degrees

Systolic murmurs are best described

according to time of onset and termination

A prolonged expiration and bulging on expiration are probably cause by:

airway outflow obstruction or the valvelike action of compression by a tumor, aneurysm, or enlarged heart. When this happens the costal angle widens beyond 90 degrees.

Angle of Louis

aka Manubriosternal junction. Visible and palpable angulation of the sternum and point at which the second rib articulates with the sternum. Angle of Louis = 2nd rib

Infrequent cough caused by

allergens or environmental insults

Foramen Ovale

allows blood flow from right atrium to left atrium in utero

Chorioretinitis

an inflammatory process involving both the choroid and the retina...floaters, reduced visual acuity, photophobia, hx of cleaning cat box, laser surgery

Pertussis produces..

an inspiratory whoop at the end of a paroxysm of coughing in older children and adults.

Retractions on inspiration are caused by:

an obstruction at any point in the respiratory tract.

Corticobulbar Tract

arising from brain stem innervates the motor functions of the cranial nerves

Decorticate Posturing

arms flexed inward and bent in toward the body and the legs are extended "Core" Injury to corticospinal tract above brain stem.

Sick Sinus Syndrome

arrhythmia in which bradycardia alternates with tachycardia PATHOPHYSIOLOGY • Occurs secondary to hypertension, arteriosclerotic heart disease, or rheumatic heart, or without known cause (idiopathic) SUBJECTIVE DATA • Fainting, transient dizzy spells, light-headedness, seizures, palpitations, and angina OBJECTIVE DATA • Dysrhythmias • Signs of congestive heart failure

Personalized Medicine

as defined by the National Cancer Institute is a form of healthcare that considers information about a person's genes, proteins and environment to prevent, diagnose and treat disease

Temporalis and Masseter muscle strength can be evaluated by

asking the pt to clench the teeth while you palpate the contracted muscles and apply opposing force This also tests CN 5 (Trigeminal)

Two Person Transfer

assistants must work together to lift the patient. The stronger taller person should lift the upper half of the body

Mitral or apical area

at the apex of heart fifth left IC space mid clavicular

Where is the bronchial vein formed

at the hilium of the lung

Atria are also called

auricles because of their earlike shape

Legg-Calve-Perthes Disease

avascular necrosis of the femoral head due to decreased blood supply. Most common in boys between 3-11yrs old Pain os often referred to the medial thigh, knee, or groin Bilat involvement in 10% The child may have a limp that is painless or antalgic (Painful limp with shortened time on an extremity) Loss of internal rotation; abduction and decreased ROM on the affected side

Proprioception

awareness of body position and parts. Dependent on parietal lobe.

Jugular venous pressure disorder

backflow of blood into right atrium during systole. Mild degree of tricuspid regurgitation can be seen in 75% of population Due to htn or pulmonary thrombosis.. these lead to dilation of RV typically no symptoms when mild Severe you will see Right sided HF symptoms like ascites or peripheral edema V wave is much more prominently and occurs earlier often merging with the c wave for expected normal venous pulsations Holosystolic murmur in tricuspid region, pulsatile liver, peripheral edema

gastroesophageal reflux disease (GERD)

backflow of contents of the stomach into the esophagus, often resulting from abnormal function of the lower esophageal sphincter, causing burning pain in the esophagus

Handshake

be careful with patients who have osteoarthritis, or rheumatoidarthritis.

Cardiac Palpation Sequence

begin at apex move to interior left sternal border move up the sternum to the base then down to right sternal border and into epigastrum or axillae

Vertical Strip Technique

begin at teh top of the breast and palpate first downward then upward working your way down over the entire breast. More thorough than concentric circle technique

Where are deeper lymph nodes usually?

beneath the fascia of muscles and within various body cavities.

Deep Tendon Reflexes

biceps, triceps, brachioradialis, patellar, achilles, clonus

What are lymphocytes

body's central response to antigenic substances not uniform in size or function

Kaposi Sarcoma

cancerous condition starting as purple or brown papules on the lower extremities that spreads through the skin to the lymph nodes and internal organs; frequently seen with AIDS Subjective Data • Soft bluish purple and painless skin plaques • May report peripheral lymphedema • May be presenting symptom of HIV/acquired immune deficiency syndrome (AIDS) Objective Data • Cutaneous lesions are characteristically soft, vascular, bluish purple, and painless. • Lesions may be either macular or papular and may appear as plaques, keloids, or ecchymotic areas • KS lesions may be limited to the skin or involve the mucosa, viscera, and lymph nodes or any organ.

Spinothalamic tract

carries fibers for the sensations of light and crude touch, pressure, temperature, and pain

Ascending and descending pathways

carry information to and from the CNS

Older adult Nose and Ears

cartilage formation continues in ears and nose. Making auricle and nose larger.

Vestibulospinal tract

causes the extensor muscles of the body to suddenly contract when an individual starts to fall

Psoriasis

chronic and recurrent disease of keratin proliferation Patho Multifactorial origin with genetic component and immune regulation • Characterized by increased epidermal cell turnover, increased numbers of epidermal stem cells, and abnormal differentiation of keratin expression leading to thickened skin with copious scale • Related to tumor necrosis factor (TNF)-alpha Subjective Data • May have pruritus • Concerns about appearance • Does not typically get superinfected Objective Data • Characterized by well-circumscribed, dry, silvery, scaling papules and plaques • Lesions commonly occur on the back, buttocks, extensor surfaces of the extremities, and the scalp. • Can be associated with psoriatic arthritis in up to 30% of patients. • May have pitting nail involvement.

Crohn Disease

chronic inflammatory disorder that can affect any part of the GI tract the produces ulceration, fibrosis, and malabsorption. Terminal ileum and colon are most common sites Chronic diarrhea with compromised nutritional status Unpredictable flares and remission Abdominal mass may be palpated due to thickened or inflamed bowel Perianal skin tags (good clue for diagnosis), fistulae, and abscesses may be seen

Ankylosing Spondylitis

chronic, progressive arthritis with stiffening of joints, primarily of the spine. Associated wtih HLA-B27 Human Leukocyte Antigen. Leads to eventual fusion and deformity of the spinal column. Begins between 20-40 yrs of age. Begins insidiously with inflammatory low back and buttock pain also involving hip and shoulders.

Cervical spine should be

concave with the head erect

Biliary Atresia

congenital obstruction or absence of some or all of the bile duct system resulting in bile flow obstruction most have complete absence of the entire extrahepatic biliary tree

Cubitus Varus

decreased carrying angle aka medial carrying angle

Band Keratopathy

deposition of calcium in the superficial cornea. Passes over Cornea unlike arcus senilis. Horizontal Grayish Band Hypercalcemia Hyperparathyroid Trauma Renal Failure Sarcoidosis Syphilis

Suprasternal Notch

depression, easily palpable. Visible at the base of the ventral aspect of the neck. Superior to the angle of louis

S2 marks the beginning of

diastole and closure of aortic and pulmonic valves listen at the base on expiration

Hair-Pulling disorder (Trichotillomania)

disorder characterized by recurrent pulling out of the hair resulting in noticeable hair loss; these individuals report tension immediately before or while attempting to resist the impulse, and pleasure or relief when they are pulling out their hair

Meconium ileus

distal intestinal obstruction caused by thick inspissated impacted meconium in the lower intestine

Acrocyanosis without central cyanosis in infants

does not signify pathology. Disappears within a few days Purple color to hands and feet

Pleural friction rub

dry, rubbing, or grating sound usually caused by inflammation. Heard on expiration. loudest over lower lateral anterior surface.

Oliver Sign

elicited by gently grapsing the cricoid cartilage and applying upward pressure whitle the patient stand with thier chin extended upward A downward tug of the trachea may be felt if aneurysm is present.

Have patient do this before abdominal exam begins

empty bladder

Absence of Apical impulse and Faint Heart sounds In left lateral recumbent =

extracardiac problem such as pleural or pericardial fluid

Suspect ______________ when lower face is affected by asymmetry

facial nerve weakness

Patent Ductus Arteriosus

failure of the ductus arteriosus to close after birth, resulting in an abnormal opening between the pulmonary artery and the aorta Subjective Data • Small shunt can be asymptomatic; a larger one causes dyspnea on exertion Objective Data • Dilated and pulsatile neck vessels • Wide pulse pressure • Harsh, loud, continuous murmur heard at the first to third intercostal spaces and the lower sternal border, with a machine-like quality • Murmur usually unaltered by postural change

Hyperventilation (Hyperpnea)

faster than 20 breaths per minute, deep breathing often a symptom of protective splinting from the pain of a broken rib or pleurisy. Massive liver enlargement or abdominal ascites may prevent descent of the diaphragm and produce a similar pattern.

Muscle tone can be assessed by

feeling the resistance to passive stretch

A murmur at the grade IV level or more can be

felt, this palpable sensation is called a thrill.

Gingivae

fibrous tissue covered by mucous membrane that attaches directly to the teeth and maxilla and mandible.

Bursae

flattened fibrous sacs lined with synovial membrane and containing a thin film of synovial fluid

Plagiocephaly

flattened spot on the back side of the head. Can result from premature fusion of one of the sutures.

Mallet Toe

flexion deformity at the distal interphalangeal joint of the foot

Breast Anatomy

from 2nd/3rd-6th/7th rib in females

Venous Ulcers

from chronic venous insufficiencey in which lack of venous flow leads to lower extremetiy venous htn From incompetent valves, loss of pumping effect of leg muscles Leg heaviness Ulcers found on the medial or lateral aspects of lower limbs

Parasympathetic Division

functions in a complementary and counterbalancing manner to conserve body resources and maintain day to day body functions such as digestion and elimination.

cholelithiasis

gallstones in the gallbladder Symptoms may include indigestion, colic, and mild transient jauncie

In a tall slender person the heart tends to

hang vertically and be positioned centrally

Uvula

hangs from the posterior margin of the soft palate

Herbden Nodes

hard non-tender nodules 2-3 mm that are found along the distal interphalangeal joints Sign of Osteoarthritis

Bouchard Nodes

hard non-tender nodules 2-3 mm that are found along the proximal interphalangeal joints Sign of Osteoarthritis

Apical pulse in older adults

harder to find due to increased AP diameter of chest.

Neurologic Hammer

has a soft brush and a tapered tip. allow for examination of sensory perception

For ticklish patietn

have patient do self palpation. and place your hands over the patients fingers.

Thyroid examination

have patient swallow water, easier to visualize from the lateral aspect. Lateral inspection is the most sensitive test for determining the presence of a goiter. A thyroid that is not visible on lateral inspection rules out a goiter.

Babies delivered via C section have a __________ rate than babies delivered vaginally

higher

Bronchial sounds

highest in pitch and intensity and should occur only over the trachea

Diaphragmatic excursion

how much the diaphragm moves with inhalation and exhalation Ask pt to take deep breath and hold it Percuss along the scapular line until you locate the lower border (resonant to dull percussion) Mark point with a marking pen at scapular line. let pt breath Percuss up from the marked point and make a mark at the change from dullness to resonance Excursion distance usually 3-5cm Diaphragm higher on right bc of liver

Hammertoe

hyperextension of the metatarsophalangeal joint and flexion of the proximal interphalangeal joint

Claw Toe

hyperextension of the metatarsophalangeal joint with flexion of the toe's proximal and distal joints

Fine silky hair may be associated with

hyperthyroidism

Pyloric Stenosis

hypertrophy of the circular muscle of the pylorus leads to obstruction of the pyloric sphincter

Unilateral inversion of a nipple

if previously everted, this suggest malignancy Carcinoma can also change the axis of the nipple causing it to point in a different direction

Gray Matter of Spinal Cord

in butterfly shape with anterior and posterior horns, contains nerve cell bodies associated with sensory pathways and Autonomic nervous system

Sound is transmitted

in the direction of blood flow

Bulging fontanel with marked pulsations

indicates ICP from space occupying mass or meningitis

Butterfly rash

indicates Systemic Lupus Erythematous Butterfly Shaped rash over malar surfaces and bridge of nose. Either a blush with swelling or scaly, red, maculopapular lesions may be present.

Air Trapping caused by:

inefficient expiratory effort, increased resistance from chronic bronchitis, decreased elastic recoil of the lung (emphysema), or a drop in critical closing pressure of airway like in asthma.

Osteomyelitis

infection in bone usually from open wound or systemic infection Purulent matter spreads through coretx of the bone and into the soft tissue Decreased blood flow to the affected bone may lead to necrosis Dull pain develops insidiously at the involved site and progresses over days to weeks Limp or decreased movement in infants and children Signs of infection include edema, erythema, warmth at site Tenderness to palpation, fevers

What do you palpate last?

inflamed joints

Lymphangitis

inflammation of lymph vessels tender erythematous streaks extend proximally from the infected area

Cholecystits

inflammation of the gallbladder, usually associated with gallstones blocking the flow of bile RUQ pain, guarding, rebound tenderness Fat intolerance

Hepatitis

inflammation of the liver Subjective • Some are asymptomatic; others report jaundice, anorexia, abdominal pain, clay-colored stools, tea-colored urine, and fatigue Objective • Liver function tests are abnormal • Examination findings may include jaundice and hepatomegaly • With severe or progressive disease, may develop cirrhosis with its associated examination findings

Lymphadenitis

inflammation of the lymph nodes

Acute Pancreatitis

inflammation of the pancreas mild to severe sudden onset of persistent epigastric pain that may radiate to the back. Constant and dull Amylase and Lipase elevated

Pericarditis

inflammation of the pericardium Subjective Data • Sharp and stabbing chest pain (caused by the heart rubbing against the pericardium) • Pain worse with coughing, swallowing, deep breathing or lying flat, or movement • Pain may be most severe when supine, relieved by sitting up and leaning forward • Pain in the back, neck or left shoulder • Difficulty breathing when lying down • Dry cough • Anxiety or fatigue Objective Data • Scratchy, grating, triphasic friction rub on auscultation, comprises ventricular systole, early diastolic ventricular filling, and late diastolic atrial systole • Friction rub easily heard just left of the sternum in third and fourth intercostal spaces Can be caused by meds like procainamide, hydralazine, phenytoin, isoniazid

Pyelonephritis

inflammation of the renal pelvis and the kidney gram negative bacilli Fever and costovertebral tenderness distinguish pyelonephritis from UTI's

Tenosynovitis

inflammation of the tendon and synovial membrane Can cause crepitus

Osgood-Schlatter Disease

inflammation or irritation of the tibia at its point of attachment with the patellar tendon Boys between 9-15 yrs Child walks with limp C/o knee pain Knee swelling aggravated by strenous activity Pain in quads pain with palpation over the tibial tuberosity

Ask patient to ___________________ to listen for S2

inhale deeply best head in pulmonic auscultatory area (2nd left IC at left sternal border)

Simple Arc Reflex

initiated by a spinal afferent (sensory) neuron when stimulus received. Response is transmitted outward toward efferent (motor) neuron in anterior horn of spinal cord via the spinal nerve and peripheral nerve of skeletal muscle

Commissural fibers (Corpus Callosum)

interconnect the counterpart areas in each hemisphere, permitting the coordination of activities between the hemispheres.

What does a high pitched tinkling sound indicate in the abdomen?

intestinal fluid and air under pressure, which is early in obstruction

Where do the jugular veins empty?

into the superior vena cava

Cultural Humility

involves the ability to recognize one's limitations in knowledge and cultural perspective and be open to new perspectives.

Tibial Torsion

inward twisting of tibia

Cerebellum hemispheres

ipsilateral control of body (same side)

Gower Sign

is a medical sign that indicates the weakness of the proximal muscles, namely those of the lower limb.

Traube space

is a semilunar region defined by the sixth rib superiorly, the midaxillary line laterally, and the left costal margine inferiorly. Area is typically tympanitic bc it overlies fundus of the stomach. Spleen enlargement = dullness over taube space

Percussion of heart

is of limited value in defining borders bc of shape of chest and relatively rigid.

Vesicular breath sounds

low-pitched, low-intensity heard over healthy lung tissue

Medium Crackles

lower, more moist sound heard during the midstage of inspiration; not cleared by a cough

Hairy Nevus

may be present at birth, may cover large area, hair growth may occur after several years , should be removed if changes occur

Saliva production older adults

may decrease from anticholinergics and diuretics

Frequent Hiccuping in newborns

may indicate seizures, drug withdrawal, or encephalopathy

Split spinal process on palpation

may indicate spina bifida

Transgender men considerations

may use binder to create more masculine appearance, may be hesitant to remove binder

Scoliometer

measures degree of rotation of the spine to screen for scoliosis positive if read is 7 degrees or more at any level of the spine

Placenta

mediates fetal gas exchange

S4 in older adults

more common; indicates decreased left ventricular compliance.

Kawaski disease accounts for

most murmurs in children

Wheeze (sibilant wheeze)

musical noise sounding like a squeak; most often heard continuously during inspiration or expiration; usually louder during expiration

Acute Glomerulonephritis

nephritis, increased blood pressure, occasionally heart failure; can become chronic leading to kidney failure tea colored urine or gross hematuria edema, htn, oliguria

Muscle wasting occurs after injury as a result of

pain, disease of the muscle, or damage to the motor neuron

Temporomandibular joint Syndrome

painful jaw movement; can have muscle spasm, clicking, popping, crepitus

Osler Nodes

painful red raised lesions that appear on the tips of fingers or toes and are caused by septic Emboli

Stensen Duct

parotid gland outlets that open on the buccal mucosa opposite the second molar on each side of the upper jaw.

Hiatal hernia with esophagitis

part of the stomach passes through the esophageal hiatus in the diaphragm into the chest cavity sudden onset of vomiting, pain, and complete dysphagia

If Radiographic facilities are unavailable to determine heart size

percuss to estimate size

Macewen sign

percussion of the skull near the junction will be resonant; the sign associated with increased intracranial pressure after fontanels are closed.

Pin Hole Test

perform if visual acuity is recorded at less than 20/20 to see if observed acuity is caused by refractive error. Pt holds pinhole over eye, if refractive error is responsible the pt will be able to read one line better.

Infant motor maturation

proceeds in cephalocaudal direction (head down) Head and neck develop first -> trunk -> extremeties

Tuning Fork

produces frequency of sound expressed in cycles per second or Hz. 512hz = 512 cycles per second For auditory evaluation use a fork of 500 - 1000 hz. Estimates hearing loss in range of normal speach Lower frequency can be used for bone conduction.

Cough Postural influences:

reclined or assumed and erect position.. nasal drip and pooling of secretions in upper airway.

Large Bounding Pulse / Hyperkinetic

recorded as +3 Caused by exercise, anxiety, fever, hyper thyroid, aortic rigidity or atherosclerosis

Trigeminal neuralgia (tic douloureux)

recurring episodes of intense stabbing pain in trigeminal nerve area (near mouth or nose) pain triggered by touch, drinking, washing face treatment may require cutting nerve

PItyriasis Rosea

self-limiting inflammation of unknown cause Patho Possible infectious etiolgy like herpes virus Not contagious Subjective Data • Sudden onset with occurrence of a primary (herald) oval or round plaque. • Herald lesion is often missed. • Eruption occurs 1-3 weeks later and lasts for several weeks. • Pruritus may be present with the generalized eruption. • Often occurs in young adults during the spring time. Objective Data • Lesions are usually pale, erythematous, flat-topped papules and plaques with fine scaling • Lesions develop on the extremities and trunk; palms and soles are not involved, and facial involvement is rare. • Trunk lesions are characteristically distributed in parallel alignment following the skin tension lines in a Christmas tree-like pattern.

CN 10 Vagus

sensation behind ear and part of external ear canal Secretion of digestive enzymes, peristalsis, carotid reflex, involuntary action of the heart, lungs, digestive tract

Coronary sulcus

separates atria from ventricles on anterior external surface Groove extending around circumference of heart

Pneumothorax in infant

shifts apical pulse away form the areas of the pneumothorax

Diaphragmatic Hernia in infant

shifts the heart to right. Hernia is usually found on the left.

Torticollis (Wry Neck)

shortening or excessive contraction of the sternocleidomastoid muscle.

Pivot Transfer

stand in front of pt. take the patient's knees between your own knees, grasp the patient around the back and under the arms, raise the pt to a vertical position and then pivot from the wheelchair to the table. Table must be low

Coarction of the aorta

stenosis seen in the descending aortic arch near the origin of subclavian artery and ligamentum arteriosum Congential, but can be acquired from inflammatory aortic disease or severe atherosclerosis May accompany turner syndrome in girls in severe cases HTN, or vascular insufficiency if symptomatic may have symptoms of HF Differences in systolic blood pressure readings between the arm and leg readings Femoral pulses are weaker than radial pulses or femoral is absent.

Hypodermis

subcutaneous layer made up of loos connective tissue filled with adipose. Adipose layer generates heat and provides insulation, shock absorption, and a reserve of calories.

The elbow consists of

the articulation of the humerus , radius, and ulna. These three contiguous surfaces are enclosed in a single synovial cavity with collateral ligaments of the radius and ulna securing the joint.

Where does the large intestine begin

the cecum, which is a blind pouch about 2-3 inches long

Hypothenar Eminence

the fleshy mass at the base of the little finger

Bone Resorption

the removal of minerals and collagen fibers from bone by osteoclasts Dominated in old age vs deposition. Menopausal women, decreased estrogen increases bone resorption and decreases calcium deposition resulting in bone loss and decreased bone density. Weight bearing long bones particularly vulnerable to fracture in old age

Qt Interval

the time elapsed from the onset of ventricular depolarization until the completion of ventricular repolarization.

Scar

thin to thick fibrous tissue that replaces normal skin following injury or laceration to the dermis Ex: healed wond or surgical incision

Pregnancy thryoid

thyroid may hypertrophy. caused by hyperplasia of grandular tissue and increased vascularity. Thyroid bruit may be heard bc of increased vascularity. Presece of a goiter is unexpected.

PR interval is the

time from initial stimulation of the atria to initial stimulation of the ventricles 0.12 - 0.20 seconds

Diastolic murmurs are best classified according to

time of onset only

Hemolytic Uremic Syndrome (HUS)

triad of microangiopathic hemolytic anemia, thrombocytopenia, and uremia

What are the AV valves

tricuspid (three leaflets) and mitral

When HR is about 120 bpm the

two phases of cardiac cycle tend to approximate each other in length.

A foreign body in the bronchus causes:

unilateral retraction suprasternal notch is not involved

Infant Percussion

unreliable, typically not performed.

Stridor indicates a:

upper airway obstruction (trachea or laryngeal area)

Pregnant pt Apiclal impulse is located where

upward and more lateral by 1 - 1.5 cm

Cremasteric Reflex

upward pull of testicles and scrotum due to touch

Hypersensitivity

use lubricant jelly to decrease friction or pressure or avoid area

Trachea pulled toward affected lung in:

volume loss from fibrosis atelectasis Simple collapsed lung

Dystrophic Gait

waddling; increased hip rotation. due to weak hip abductor muscles. Lordosis is common.

Frailty syndrome

weakness, slowing, decreased energy, lower activity, and when sever unintended weight loss.

When in gestation does the liver start to form blood cells?

week 6, synthesizes glycogen by week 9, and produces bile at week 12

Tactile fremitus is absent

when effusion exists

When do you percuss the head?

when evaluating for hypocalcemia Percuss the masseter muscles for chvostek sign

Lymphadenopathy

when its widespread involving several lymph node regions this indicates a systemic disease or disorder.

Shoulder Dislocation

when shoulder contour is asymmetric and one shoulder has hollows in the rounding contour

Phalen Test

wrists are bent down with backs of each hand touching/carpal tunnel sufferers feel tingling or pain within 60 seconds Numbness and paresthesia in the distribution of the median nerve are suggestive of carapl tunnel

Expected Color Changes in the Newborn

• Acrocyanosis: Cyanosis of hands and feet • Cutis marmorata: Transient mottling when infant is exposed to decreased temperature • Erythema toxicum: Pink papular rash with vesicles superimposed on thorax, back, buttocks, and abdomen; may appear in 24 to 48 hours and resolves after several days • Congenital dermal melanocytosis: Irregular areas of deep blue pigmentation, usually in the sacral and gluteal regions; seen predominantly in newborns of African, Native American/American Indian, Asian, or Latin descent • Salmon patches ("stork bites"): Flat, deep pink localized areas usually seen on the midforehead, eyelids, upper lip, and back of neck

LDL Levels and MI

• Adults 21 years or older with LDL 190 mg/dL or greater should be treated with high-intensity statin therapy unless contraindicated. • Individuals with LDL 190 mg/dL or greater or triglycerides 500 mg/dL or greater should be evaluated for secondary causes of hyperlipidemia. • Adults 40 to 75 years with an LDL 70 to 189 mg/dL with diabetes or a 10-year atherosclerotic cardiovascular disease risk greater than 7.5% should be treated with moderate-to high-intensity statin therapy

Colon Cancer Risk Factors

• Age older than 50 years • Family history of colorectal cancer or adenomatous polyps in one or more first-degree relatives and family history of syndromic colon cancer, including familial adenomatous polyposis (FAP), hereditary nonpolyposis colorectal cancer (HNPCC), Turcot syndrome (also associated with brain tumors), Peutz-Jeghers syndrome, and MUYTH-associated polyposis (MAP; mutation in the gene MUYTH ) • Personal history of colon cancer, adenomatous polyps, inflammatory bowel disease (Crohn disease, ulcerative colitis), FAP, HNPCC • Race: African American • Ethnic background: Ashkenazi Jewish • Diet: low-fiber, high in red meat, processed meats, and foods fired, broiled, grilled increases risk; diet high in fruits and vegetable decreases risk • Obesity • Smoking cigarettes • Physical inactivity • Heavy alcohol use • Type 2 diabetes

Characteristics of patients who should have a radiograph of the knee

• Age older than 55 years • Tenderness at head of fibula • Isolated tenderness of the patella • Inability to flex the knee to 90 degrees

Skin Self Examination

• Always use a good light, positioned to minimize distracting glare. Look for a new growth or any skin change. • Be aware of the locations and appearance of moles and birthmarks. • Examine your back and other hard-to-see areas of the body using full-length and handheld mirrors. Ask a friend or relative to help inspect those areas that are difficult to see, such as the scalp and back. • Begin with your face and scalp using one or more mirrors. Proceed downward, focusing on neck, chest, and torso. Patients, check under breasts. With back to the mirror, use hand mirror to inspect back of neck, shoulders, upper arms, back, buttocks, legs. Concentrate especially on areas where dysplastic nevi (those with unexpected changes) are most common—the shoulders and back; and areas where ordinary moles are rarely found—the scalp, breast, and buttocks. Check hands, including nails. In a full-length mirror, examine elbows, arms, underarms. Sitting down, check legs and feet, including soles, heels, nails, and between the toes. Use a hand mirror to examine genitals. See rather than feel any early signs of a mole change. Use a cell phone to take photos of moles and compare the photographs of the same moles over a period of several months. Monitor change in size by measuring. It can be done simply with a small ruler or even by comparing the moles to the size of your thumb or fingernail. • Consult your healthcare provider promptly if any pigmented skin spots look like melanoma, if new moles have appeared, or if any existing moles have changed. See also the ABCDE changes in moles (Melanoma, in Abnormalities).

Infants and Children: Acne Vulgaris

• Androgens stimulate the pilosebaceous units at the time of puberty to enlarge and produce large amounts of sebum. • Simultaneously, the keratinization process in the pilosebaceous canal is disrupted with impaction and obstruction of the outflow of sebum resulting in comedo formation—open blackheads and closed whiteheads. • Wall of the closed comedo may rupture, spilling the follicular contents into the dermis, leading to the development of inflammatory papules. • The presence of Propionibacterium acnes brings in neutrophils, which cause the inflammatory response. • Noninflammatory acne: open (whiteheads) and closed (blackheads) comedones • Inflammatory acne: papules, nodules, or cystic lesions • Characteristic "ice pick" scarring may be present from previous lesions

Knee ROM

• Bend each knee. Expect 130 degrees of flexion. • Straighten the leg and stretch it. Expect full extension and up to 15 degrees of hyperextension.

Cervical Spine ROM

• Bend the head forward, chin to the chest. Expect flexion of 45 degrees. • Bend the head backward, chin toward the ceiling. Expect extension of 45 degrees. • Bend the head to each side, ear to each shoulder. Expect lateral bending of 40 degrees. • Turn the head to each side, chin to shoulder. Expect rotation of 70 degrees.

Lymphedema vs Edema

• Both can be either pitting or nonpitting. • Except in early stages, lymphedema does not resolve with elevation of the affected area. Edema secondary to increased capillary filtration (e.g., chronic venous insufficiency) usually improves. • Diuretics do not help lymphedema. They may help edema. • Be aware that some patients may have both edema and lymphedema.

Infants and Children: Chickenpox

• Caused by the varicella zoster virus (VZV) • VZV is communicable by direct contact, droplet transmission, and airborne transmission • Incubation period 2-3 weeks; the period of communicability lasts from 1 or 2 days before onset of the rash until lesions have crusted over. • Routine childhood immunization has resulted in a significant decline in incidence • After primary infection, VZV remains dormant in sensory nerve roots for life. • Can reactivate to cause shingles Subjective Data • Fever, headache, sore throat, mild malaise • Pruritic rash that started on scalp and then moved to extremities • Started as papular and in a few hours became vesicular • Child has not had varicella vaccine. Objective Data • Papular and vesicular lesions on trunk, extremities, face, buccal mucosa, palate, or conjunctivae • Lesions usually occur in successive clusters eventually spreading to entire body, with several stages of maturity present at one time. • Complications include conjunctival involvement, secondary bacterial infection, viral pneumonia, encephalitis, aseptic meningitis, myelitis, Guillain-Barré syndrome, and Reye syndrome.

History of Present Illness: Nails

• Changes in nails: splitting, breaking, discoloration, ridging, thickening, markings, separation from nail bed • Recent history: systemic illness, high fever, trauma, stress, biting • Associated symptoms: pain, swelling, exudate • Temporal sequence: sudden or gradual onset, relationship to injury of nail or finger • Recent exposure to drugs, environmental or occupational toxins or chemicals; frequent immersion in water • What the patient has been doing for the problem, response to treatment, what makes the problem worse or better • Medications: chemotherapy (taxanes, anthracyclines), psoralens, retinoids, tetracyclines, antimalarials

History of Present Illness: Skin

• Changes in skin: dryness, pruritus, sores, rashes, lumps, color, texture, odor, amount of perspiration; changes in wart or mole; lesion that does not heal or is chronically irritated (see Risk Factors boxes ) • Temporal sequence: date of initial onset; time sequence of occurrence and development; sudden or gradual onset; date of recurrence, if any • Symptoms: itching, pain, exudate, bleeding, color changes, seasonal or climate variations • Location: skinfolds, extensor or flexor surfaces, localized or generalized, sun exposed or protected, mucosal involvement • Associated symptoms: presence of systemic disease or fever, relationship to stress or leisure activities • Recent exposure to environmental or occupational toxins or chemicals, new skin or personal care products, new household cleaning products (aerosols) • Recent exposure to persons with similar skin condition • Apparent cause of problem, patient's perception of cause • Travel history: where, when, length of stay, exposure to diseases, contact with travelers • What the patient has been doing for the problem, response to treatment, what makes the condition worse or better • How the patient is adjusting to the problem • Medications: antibiotics, any new medications, topical preparations to treat—steroids, antifungals

Past Family History

• Current or past dermatologic diseases or disorders in family members; melanoma; dermatoses (e.g., psoriasis); infestations; bacterial, fungal, or viral infections • Allergic hereditary diseases such as asthma or allergic rhinitis

Adolescents Past Medical History

• Eating habits and types of food • Food allergies. Note that food allergies do not classically cause eczema. • Exposure to infectious diseases at day care, school: impetigo; viruses that produce skin rashes (Coxsackie); measles, mumps, rubella, varicella in unvaccinated children • Allergic disorders: eczema, urticaria, pruritus, hay fever, asthma, other chronic respiratory disorders • Pets or animal exposure • Outdoor exposures such as play areas, hiking, camping, picnics, gardening • Skin injury history: frequency of falls, cuts, abrasions; repeated history of unexplained injuries • Chronic hair-pulling or manipulation • Nail-biting

Newborn Skin Lesions / defects associated with systemic conditions

• Faun tail nevus: Tuft of hair overlying the spinal column at birth, usually in the lumbosacral area; may be associated with spina bifida occulta • Epidermal verrucous nevi: Warty lesions in a linear or whorled pattern that may be pigmented or skin colored; present at birth or in early childhood; associated most commonly with skeletal, central nervous system, and ocular abnormalities • Café au lait macules: Flat, evenly pigmented spots varying in color from light brown to dark brown or black in dark skin; larger than 5 mm in diameter; present at birth or shortly thereafter; may be associated with neurofibromatosis or miscellaneous other conditions including pulmonary stenosis, temporal lobe dysrhythmia, and tuberous sclerosis • Freckling in the axillary or inguinal area: Multiple flat pigmented macules associated with neurofibromatosis; may occur in conjunction with café au lait macules • Ash leaf macule: White macules present at birth associated with tuberous sclerosis. Occur most commonly on the trunk, but may also appear on the face and limbs • Facial port-wine stain: When it involves the ophthalmic division of trigeminal nerve, may be associated with ocular defects, most notably glaucoma; or may be accompanied by angiomatous malformation of the meninges (Sturge-Kalischer-Weber syndrome), resulting in atrophy and calcification of the adjacent cerebral cortex • Port-wine stain of limb and/or trunk: When accompanied by varicosities and hypertrophy of underlying soft tissues and bones, may be associated with orthopedic problems (Klippel-Trenaunay-Weber syndrome) • Congenital lymphedema with or without transient hemangiomas: May be associated with gonadal dysgenesis caused by absence of an X chromosome, producing an XO karyotype (Turner syndrome) • Supernumerary nipples: Congenital accessory nipples with or without glandular tissue, located along the mammary ridge; may be associated with renal abnormalities, especially in the presence of other minor anomalies, particularly in whites • "Hair collar" sign: A ring of long, dark, coarse hair surrounding a midline scalp nodule in infants is usually an isolated cutaneous anomaly that may indicate neural tube closure defects of the scalp.

Infants Past Medical History

• Feeding history: breast or formula, type of formula, what foods introduced and when ("Carotenemia" ) • Diaper history: type of diapers used, skin cleansing routines, and methods of cleaning • Types of clothing and washing practices: soaps and detergents used, new blanket or clothing • Bathing practices: frequency, types of soap, oils, shampoos or emollients used • Dress habits: amount and type of clothing in relation to environmental temperature • Temperature and humidity of the home environment: air conditioning, heating system (drying or humidified)

Risk factors for respiratory disability

• Gender: greater in men, but the difference between the sexes diminishes with advancing age • Age: increases with advancing age • Family history of asthma, cystic fibrosis, tuberculosis, and other contagious disease; neurofibromatosis • Smoking • Sedentary lifestyle or forced immobilization • Occupational exposure to asbestos, dust, or other pulmonary irritants and toxic inhalants • Extreme obesity • Difficulty swallowing for any reason • Weakened diaphragm and chest muscles (e.g., amyotrophic lateral sclerosis, polymyositis) • History of frequent respiratory infections

Carotid Artery Bruits

• Heard at just above the medial end of clavicle and anterior margin of sternocleidomastoid muscle • Mild obstruction produces a short, not particularly intense, localized bruit; greater stenosis lengthens the duration and increases the pitch • Complete stenosis may eliminate the bruit • Transmitted murmurs of valvular aortic stenosis, ruptured chordae tendineae of mitral valve, or severe aortic regurgitation can radiate to the carotid • Can be heard with vigorous left ventricular ejection (more commonly in children than in adults) • Occurs with arterial narrowing in cervical arteries (e.g., atherosclerotic carotid arteries, fibromuscular dysplasia, and arteritis)

Venous Hum

• Heard at medial end of clavicle and anterior border of sternocleidomastoid muscle • Usually of no clinical significance • Confused with carotid bruit, patent ductus arteriosus, and aortic regurgitation • In adults, may occur with anemia, pregnancy, thyrotoxicosis, or

Structural heart disease is more likely when the murmur is:

• Holosystolic • Diastolic • Grade 3 or higher • Associated with a systolic click • Increased in intensity with standing • Of a harsh quality

Past medical history: Older adults

• Increased or decreased sensation to touch or to the environment • Generalized chronic itching; exposure to skin irritants, detergents, lotions (any moisturizer that comes in a pump has a high alcohol content), woolen clothing, humidity of environment • Susceptibility to skin infections • Healing response: delayed or interrupted • Frequent falls resulting in multiple cuts or bruises • Risk for pressure ulcers secondary to immobilization or nonambulatory status • History of chronic medical conditions (e.g., diabetes mellitus, vascular disease) • Medications and polypharmacy

Epstein-Barr Virus Mononucleosis

• Initially infects oral epithelial cells; after intracellular viral replication and cell lysis with release of new virions, virus spreads to contiguous structures such as the salivary glands, with eventual viremia and infection of the entire lymphoreticular system, including the liver and spleen • Incubation period of infectious mononucleosis in adolescents is 30-50 days Epitrochlear lymphadenopathy is particularly suggestive of infectious mononucleosis. Splenomegaly Mod-Sever Pharyngitis Petechiae at the junction of hard and soft palate

Documenting Breast Mass

• Location: clock positions and distance from nipple • Size (in centimeters): length, width, thickness • Shape: round, discoid, lobular, stellate, regular or irregular • Consistency: firm, soft, hard • Tenderness • Mobility: movable (in what directions) or fixed to overlying skin or subadjacent fascia • Borders: discrete or poorly defined • Retraction: presence or absence of dimpling; altered contour

Infants and Children: Measles

• Measles virus infects by invasion of the respiratory epithelium. • Local multiplication at the respiratory mucosa leads to a primary viremia, during which the virus spreads in leukocytes to the reticuloendothelial system. • Both endothelial and epithelial cells are infected; infected tissues include thymus, spleen, lymph nodes, liver, skin, conjunctiva, and lung. • Incubation period is commonly 18 days; the period of communicability lasts from a few days before the fever to 4 days after appearance of the rash. • Disease is preventable by immunization. Subjective Data • Fever, conjunctivitis, stuffy nose, and cough, followed by a red, blotchy rash first on the face and then spreading to trunk and extremities • Child has not had measles vaccine. • International travel or exposure to individuals from endemic areas Objective Data • Koplik spots (discrete white macular lesions) on the buccal mucosa • Macular rash on the face and neck • Maculopapular lesions on trunk and extremities in irregular confluent patches • Rash lasts 4-7 days • Symptoms may be mild or severe • Complications involve infection of the respiratory tract and central nervous system.

Hashimoto Disease

• Often causes hypothyroidism • More common in children and women between 30 and 50 years • Progresses slowly over a number of years Subjective Data • Weight gain • Nausea • Fatigue • Enlarged nontender smooth thyroid

When does lymphadenopath requires further investigation?

• Older patients with localized and persistent lymphadenopathy, without evidence of infection or inflammation, might have cancer unless a biopsy proves otherwise • Young adults and children with localized supraclavicular lymphadenopathy • Posterior cervical lymphadenopathy adds a risk for malignancy, more than lymphadenopathy that occurs in the anterior cervical chain • Any lump that grows rapidly and insistently, at any age

Foot ROM

• Point the foot toward the floor. Expect plantar flexion of 45 degrees. • Bending the foot at the ankle, turn the sole of the foot toward and then away from the other foot. Expect inversion of 30 degrees and eversion of 20 degrees • Rotating the ankle, turn the foot away from and then toward the other foot while the examiner stabilizes the leg. Expect abduction of 10 degrees and adduction of 20 degrees • Bend and straighten the toes. Expect flexion and extension, especially of the great toes.

Past Medical History: Nails

• Previous nail problems: injury; bacterial, fungal, or viral infection • Systemic problems: associated skin disorder; congenital anomalies; respiratory, cardiac, endocrine, hematologic, or other systemic disease

Past Medical History: Skin

• Previous skin problems: sensitivities, allergic skin reactions, skin disorders (e.g., atopic dermatitis), congenital or acquired lesions, treatment • Tolerance to sunlight • Diminished or heightened sensitivity to touch • Cardiac, respiratory, liver, endocrine, or other systemic diseases • Hair • Previous hair problems: loss, thinning, unusual growth or distribution, brittleness, breakage, treatment • Systemic problems: thyroid disorder, rheumatologic disease, any severe illness, malnutrition, associated skin disorder

Nervous system allows the body to perform the following:

• Receive sensory stimuli from the environment • Identify and integrate the adaptive processes needed to maintain body functions • Orchestrate body function changes required for adaptation and survival • Integrate the rapid responsiveness of the central nervous system with the more gradual responsiveness of the endocrine system • Control cognitive and voluntary behavioral processes • Control subconscious and involuntary body functions

Past Personal History or Social History

• Skin care habits: cleansing routine; soaps, oils, emollients, or local applications used; cosmetics; home remedies or preparations used; sun exposure patterns and history; sunburn history; use of sunscreen agents; recent changes in skin care habits • Skin self-examination

German Measles (Rubella)

• Spread in droplets that are shed from respiratory secretions of infected persons • Patients are most contagious while the rash is erupting, but they may shed virus from the throat from 10 days before until 15 days after the onset of the rash. • Incubation period is 14-23 days. • Disease is preventable by immunization. Subjective Data • Low-grade fever, stuffy nose, sore throat, and cough • This is followed by a macular rash on the face and trunk that rapidly becomes papular. Objective Data • Generalized light pink to red morbilliform rash • By the second day, rash spreads to the upper and lower extremities; it fades within 3 days. • Reddish spots occur on the soft palate during the prodrome or on the first day of the rash (Forchheimer spots) • Infection during the first trimester of pregnancy may lead to infection of the fetus and may produce a variety of congenital anomalies (congenital rubella syndrome).

Herpes Zoster (Shingles)

• VZV morphologically and antigenically identical to the virus causing varicella (chickenpox) • Dormant viral particles (since the original episode of varicella) in the posterior spinal ganglia or cranial sensory ganglia become activated and spread along the nerve Subjective Data • Pain, itching, or burning of the dermatome area usually precedes eruption by 4-5 days. • After eruption resolves, there may be persistent pain called postherpetic neuralgia. Objective Data • Single dermatome that consists of red, swollen plaques or vesicles that become filled with purulent fluid • Does not cross midline • Disseminated lesions in immunosuppressed or older adults

Timed up and Go Test (TUG test)

• stand up from a chair without using the chair arms, • walk 10 feet (3 meters) to mark on floor, • turn around, • walk 10 feet (3 meters) back to the chair, and • sit down without using chair arms. Should be able to perform within 10 seconds of being asked. > 10 seconds = increased fall risk.

Pointers for Taking the Blood Pressure

- Keep the mercury sphygmomanometer vertical and make all the readings at eye level, no more than 3 feet away - Position the dial of the aneroid sphygmomanometer so it faces you directly no more than 3 ft away. Aneroid manometer needs periodic calibration - Slow or repeated inflations of the cuff can cause venous congestion and result in inaccurate readings. wait at-least 15 seconds between readings. -Electronic sphygmomanometers with a doppler or oscillometric device work by sensing vibrations, converting them to electrical impulses, and transmitting the information to a digital redout. Those devices are more sensitive.

Halo Nevus

- Sharp, oval, or circular; depigmented halo around mole; may undergo many morphologic changes; usually disappears and halo repigments. - Usually found on back in young adults - Usually benign, but biopsy is indicated bc same process can occur around melanoma.

Barlow Ortolani Maneuver

- To detect hip dislocation in newborn

Spine ROM

-Bend forward & touch their toes (Flexion 75-90 degrees) -Bend back at waist (Hyperextension of 30 degrees) -Bend to each side as far as possible, expect lateral bending of 35 degrees bilaterally. -Swing the upper trunk from the waist in a circular motion front to side to back to side while you stabilize the pelvis. Expect rotation of the upper trunk 30 degrees forward and backward

Intradermal Nevus

-Dome shaped; raised; flesh to black color; may be pedunculated or hair bearing -Cells limited to dermis -No indication for removal other than cosmetic

Latex Allergy

-Occurs when the body's immune system reacts with proteins found in latex -Occurs by direct skin or mucous membrane contact or through airborne exposure -Direct Contact is not Necessary, inhalation from powder of gloves can cause allergic rxn

What are the roles of the lymphatic system?

1) Movement of lymph fluid in a closed circuit w/ the cardiovascular system, a major factor in the maintenance of fluid balance 2) Production of lymphocytes w/in the lymph nodes, tonsils, adenoids, spleen, and bone marrow 3) Production of antibodies 4) Phagocytosis of other cells, bacteria, and bits of necrosed tissue or foreign particles; this is a specific function of cells that line the sinuses of lymph nodes 5) Absorption of fat and fat-soluble substances from the intestinal tract 6) Plays an undesirable role in providing at least one pathway for the spread of malignancy

Three Functions of the immune system

1) Protects the body from the antigenic substances of invading organisms 2) Removes damaged cells from the circulation 3) Provides a partial, but often inefficient, barrier to the maturation of malignant cells w/in the body

Edema

1+ Slight pitting, no visible distortion, disappears rapidly 2+ A somewhat deeper pit than in 1+, but again no readily detectable distortion; disappears in 10-15 seconds 3+ Noticeably deep pit that may last more than a minute; dependent extremity looks fuller and swollen 4+ Very deep pit that lasts as long as 2-5 minutes; dependent extremity is grossly distorted

How much time does it take for the arterial pulse to impact the dorsalis pedis artery?

0.2 seconds

How big can lymph nodes get?

0.5 to 1cm

What is in utero GFR?

0.5ml/min before 34 weeks

Thoracic Ratio

0.7 - 0.75. Increases with age. 1.0 = chronic condition present. Chronic asthma, emphysema, cystic fibrosis.

External Auditory Canal

1 inch / 2.5cm long in adults, S shaped

Allis Sign

1 knee significant lower that other knee Suggest Hip Dislocation

Three Functions of the lymphatic system

1. Conserving Fluid and Plasma that leak from capillaries 2. Defending the body against disease as part of the immune system 3. Absorbing Lipids from intestinal tract

How long is the esophagus

10 inches long Connects pharynx to stomach

How long and wide is the trachea?

10-11cm long, 2 cm in diameter

Ribs

12 Pairs Upper 7 connected via costal cartilage to sternum 8,9,10 Joined by costal cartilage only. 11, 12 (Floating Ribs) Only attached posteriorly to thoracic vertebrae

Size of the adult heart

12 cm long 8 cm wide at widest point 6 cm in AP diameter

How long is the illeum

12 ft

When is the kidney able to produce urine during gestation?

12 weeks due to nephrogenesis

What is the female average risk of breast cancer

12%

Adult respiration to heartbeat ratio

1:4

What is the average interval from the appearance of the breast bud (stage 2) to menarche?

2 years

CN Testing

2-12 tested, taste not tested unless aberration found

When does GI tract reach adult function

2-3 years of age

Deciduous teeth

20 deciduous teeth usually erupt between 6 months and 2 yrs.

When does the Immune system and lymphoid system begin developing

20 week gestation

How long is the small intestine

21 ft long

Closure of Ducuts arteriosus takes how long?

24-48 hours

Aortic Ejection Clicks are heard where

2nd Right IC

When does the fetal thyroid gland become functional?

2nd trimester Before this mom is the source of thyroid hormone and requires increased iodine intake. Thyroid in mom enlarges in areas of iodine deficiency

How many alveoli in adults

300 million

When does meconium production occur?

36-38 weeks gestation

Second Pulmonic valve area

3rd Left IC space at left sternal border

When do the pancreatic buds, liver, and gallbladder form in an infant

4 weeks gestation

Spinal Cord

40-50cm long begins at foramen magnum as continuation of medulla oblongata, terminates at L1 or L2

What is the bladder capacity in an adult

400-600 ml

Tricuspid Area

4th Left IC Space along the lower left sternal border

Varicose Vein Risk Factors

4x more in women esp in pregnancy genetic predisposition - children and women Tobacco use Sedentary Lifestyle BMI increased > age = more risk Lower extremity trauma Venous thrombosis

Passive ROM exceeds Active ROM by

5 degrees

Right lung is divided into upper portion at what rib

5th rib in the axilla and 4th rib anteriority by lesser horizontal fissure

What is the vertical span of the liver

6-12 cm / 2.5-4.5 inches

Pulse rate

60-100 bpm, 70 avg athlethes - 50-60bpm If irregular rhyhtm detected count for full 60 seconds Carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial arteries

Older Adults

70 yrs or older, hearing loss that affects ADLs Sensorineural hearing loss occurs with high frequency sounds and then progresses to lower tones. Loss of high frequency interferes with understanding of speech and localization of sound Conductive hearing loss can occur from cerumen impaction and tympanosclerosis or otosclerosis caused be calcification of tissues

how long is the jejunum

8 ft

What is the normal GFR?

90 ml/ min

Bradypnea

< 12 breaths may indicate neurologic or electrolyte disturbance, infection, or a conscious response to protect against the pain of pleurisy or other irritative phenomena. It may also indicate an excellent level of cardiorespiratory fitness.

What lies between the olecranon and the skin

A bursa

Epilepsy

A chronic disorder characterized by recurrent, unprovoked seizures secondary to an underlying brain abnormality Patho Episodic abnormal electrical discharges (excessive concurrent firing) of cerebral neurons may be caused by a central nervous system (CNS) disorder, a CNS structural defect, or a disorder that affects functioning of the CNS; examples include brain injury, infection, toxins, stroke, brain tumor, biochemical disorder, congenital malformations, and hypoxic syndromes. Subjective Data • History of prior seizure • Premonition or aura (headache, mood change, anxiety, irritability, lethargy, changes in appetite, dizziness, and lightheadedness) • Body is stiff and rigid, followed by rhythmic jerking movements. • Eyes roll upward. • Drooling • Loss of bladder or bowel control Objective Data • Tonic phase: brief flexion and characteristic cry with contraction of abdominal muscles, followed by generalized extension for 10-15 minutes; loss of consciousness for 1-2 minutes, eyes deviated upward, and dilated pupils • Clonic phase: contractions alternate with muscle relaxation • Postictal state: coma followed by confusion and lethargy • Common electroencephalographic findings of spikes and waves

Barrell chest past 2nd year of life can indicate

A chronic obstructive pulmonary problem like cystic fibrosis persistence at 5-6yrs is ominous.

Myelomeningocele (Spina Bifida)

A congenital vertebral defect (commonly at the lumbar or sacral level) that allows spinal cord contents to protrude Subjective Data • May have loss of bowel control or constipation • May have loss of bladder control (incontinence or urinary retention) • Mobility problems Objective Data • Exposed meningeal sac filled with fluid and nerves is apparent at birth • Sensory deficit and paralysis or weakness are dependent on level of defect (the higher the defect, the greater is the neurologic dysfunction); may not be symmetric • Rapidly increasing head circumference (hydrocephalus) • May have hip or foot abnormalities • Learning disabilities and perceptual motor skills

Kiesselbach Plexus

A convergence of small fragile arteries and veins. Located on the anterior-superior portion of the septum. Adenoids lie on the posterior wall of the nasopharynx

Furuncle (Boil)

A deep seated infection of the pilosebaceous unit Patho Caused by Staphylococcus Aureus Subjective Data • Acute onset of tender red nodule with center filled with pus. Objective Data • Skin is red, hot, and tender. • Center of the lesion is purulent and forms a core that may rupture spontaneously or require surgical incision • Sites commonly involved are the face and neck, arms, axillae, breasts, thighs, and buttocks.

Stereotype

A fixed image of any group that denies the potential of originality or individuality within the group, must be rejected. Stereotyping occurs in two cognitive phases In the first phase a stereotype becomes activated when an individual is categorized into a social group In the second phase people use these activated beliefs and feelings when they interact with the individual, even when the explicitly deny these stereotypes.

Macule (Primary Skin Lesions)

A flat circumscribed area that is a change in the color of the skin; less than 1cm diameter Ex: Freckles, flat moles (nevi), petechiae, measles

Gout

A form of arthritis resuling from chronically elevated serum uric acid Monosodium urate crystal depositon in joints and surrounding tissues results in acute inflammatory attacks. Sudden onset of hot, swollen join, limited ROM Primarily affects men > 40 and postmenopausal women Usually affects proximal phalanx of the great toe Skin over joint may be shiny and red or purple Uric acid crystals may form as tophi under the skin with chronic gout.

Cerebral Palsy - Children

A group of permanent disorders of movement and posture development associated with nonprogressive (static) disturbances that occurred in the developing fetal or infant brain Subjective Data • Delays in gross motor development that become more obvious as the infant ages • Activity limitation, stiff joints and positioning • May have hearing, speech, and language disorders • Feeding difficulties, poor sucking and swallowing coordination • Seizures Objective Data • Cognitive impairment or learning disabilities may be present • Spastic CP: hypertonicity, tremors, scissor gait, toe walking • Persistent primitive reflexes, exaggerated deep tendon reflexes • Dyskinetic CP: involuntary slow writhing movements of the extremities; tremors may be present. • Exaggerated posturing, inconsistent muscle tone that varies during the day • Ataxic: abnormalities of movement involving balance and position of trunk and extremities • Intention tremors, past pointing • Increased or decreased muscle tone, may have hypotonia as infant • Instability, wide-based gait

Pes Cavus

A high instep / arch - may be associated with claw toes

Periodic apnea of the newborn

A normal condition characterized by an irregular pattern of rapid breathing interspersed with brief periods of apnea that one usually associates with rapid eye movement sleep.

Tactile Fremitus

A palpable vibration of the chest wall produced by the spoken word; AKA vocal fremitus Best felt at the level of bifurcation of the bronchi

Expected sign in nipples

A peppering of nontender, nonsuppurative Montgomery Tubercles is a common and expected finding

Hydrocephalus

A problem in the formation, flow, or absorption of cerebrospinal fluid (CSF) that leads to an increase in volume of the CSF

Primary Apnea

A self-limited condition, and not uncommon after a blow to the head. It is especially noted immediately after the birth of a newborn, who will breathe spontaneously when sufficient carbon dioxide accumulates in the circulation.

Parkinsons

A slowly progressive, degenerative neurologic disorder in which motor function is primarily affected along with behavioral and cognitive problems Characteristic Features: Excessive sweating, Drooling, Gait with rapid short shuffling steps and reduced arm swinging. Patho • Destruction of neurons that transmit dopamine results in poor communication between parts of the brain that coordinate and control movement and balance • Onset after 40 years of age, with 60 years as the mean age of onset Subjective Data • Tremors (sometimes unilateral) occur initially at rest and with fatigue, disappearing with intended movement and sleep; progresses to pill-rolling movement of fingers bilaterally and tremor of the head • Slowing of voluntary and automatic movements, "feel wooden," freezing or unable to continue movements • Numbness, aching, tingling, and muscle soreness occur in many patients • Difficulty swallowing, drooling Objective Data • Tremors • Muscular rigidity, cogwheel rigidity with jerks • Stooped posture, balance and postural instability • Short steps, shuffling, freezing gait, gait may accelerate to maintain upright posture • Slow, slurred monotonous speech, voice softening • Impaired cognition, dementia

Complex Regional Pain Syndrom

A syndrome in which regional pain extends beyond a specific peripheral nerve injury in a extremity with motor, sensory, and autonomic changes Patho No relationship between the original trauma severity and the severity and cause of the symptoms Cause is unknown, but the sympathetic nervous system helps maintain symptoms Subjective Data Burning, shooting, or pain with aching character exaggerated sensitivity to cold or sweating changes pain increases or persist after light pressure Allodynia Objective Data Edema Changes in skin blood flow: abnormal skin color; red and hot, cyanotic, temperature difference of up to 1 degree celcius between the affected and unaffected extremity Increased sweating may be seen.

Normal pressure hydrocephalus

A syndrome simulating degenerative diseases that is caused by noncommunicating hydrocephalus (dilated ventricles with intracranial pressure within expected ranges) Subjective Data • Gait impairment is the first symptom. • Unsteadiness and difficulty turning • Forgetfulness, cognitive impairment • Urinary frequency that progresses to urgency and incontinence over time Objective Data • Gait impairment, wide-based stance, short, small steps, and reduced floor clearance • No tremor • No sensory impairment • Cognitive impairment, attention, and executive function impaired • Impaired memory recall for recent events • CT scan and MRI of the brain reveal enlarged ventricles not attributable to brain atrophy or a congenital problem.

Pierre-Robin Sequence Facies

A triad of micrognathia, glossoptosis, and palatal clefting. Shows a lateral view with severe micrognathia and cleft palate. Not the small retruded mandible.

Aortic Stenosis decreases

A2 intensity

Lachman Test

ACL integrity With the patient supine, flex the knee 10 to 15 degrees with the heel on the table. Place one hand above the knee to stabilize the femur and place the other hand around the proximal tibia. While stabilizing the femur, pull the tibia anteriorly. Attempt to have the patient relax the hamstring muscles for an optimal test. Increased laxity, greater than 5 mm compared with the uninjured side, indicates injury to the ligament.

Where does the testes lymph drain to?

Abdomen

Ptergyium

Abnormal growth of the conjunctiva that extends over the cornea from the limbus. Usually on the Nasal side. Caused by UV light Exposure

Retinal Hemmorhage in Infancy

Acceleration deceleration impact trauma. CHILD ABUSE! (Shaken baby syndrome)

Colostrum

Accumulates in acinar cells toward end of pregnancy contains more protein and minerals than mature milk It contains antibodies and host resistance factors.. Milk starts being produced within 2-4 days after delivery in response to surging prolactin levels, declining estrogen levels, and the stimulation of sucking.

Epiglottitis

Acute life threatening infection involving the epiglottis and surrounding tissues. Begins suddenly and progresses rapidly without cough patient sits straight up with neck extended and head held forward. Appears very anxious, unable to swallow Painful sore throat Muffled Voice Difficulty swallowing High Fever Beefy Red Epiglottis

Kawasaki Disease

Acute small vessel vasculitic illness that may result in the development of coronary artery aneurysms common in boys Symptoms last over 5 days or more. The effects of systemic vasculitis include: Weight loss, fatigue, myalgias, arthritis Fever, conjunctival infection, strawberry tongue, edema of hands and feet. Lymphadenopathy and polymorphous non vesicular rashes.

HEEADSSS

Adolescent Screening Tool Home Environment Eduction, employment Eating Activities (Peer Related), affect, ambitions, anger Drugs Sexuality Suicide Depression Safety from injury and violence

PACES

Adolescent Screening Tool Parent, Peers Accidents, alcohol drugs Cigarettes Emotional Issues School, Sexuality

Rate and Depth of Breathing will decrease with:

Alkalosis CNS lesion in Cerebrum Myasthenia Gravis Narcotic OD Extreme Obesity

Deep Tendon Reflex Testing

All deep tendon reflexes tested, except plantar reflex and test for clonus

Complete Transverse Lesion of the Spinal Cord

All forms of sensation are lost below the level of the lesion. Pain, Temperature, and Touch sensations are lost one to two dermatomes below the lesion.

Expected findings in infants

All infants are flat-footed, and many newborns have a slight varus curvature of the tibias (tibial torsion) or forefoot adduction (metatarsus adductus) from fetal positioning.

Chest Pain from Peptic Ulcer Characteristics

Almost always infradiaphragmatic and epigastric Nocturnal occurrence and daytime attacks relieved by food. Unrelated to activity

Middle Cerebral Artery Stroke

Alterations in communication, cognition, mobility, and sensation Contralateral homonymous hemianopia Contralateral hemiplegia or hemiparesis, motor and sensory loss, greater in face and arm than the leg

Ototoxic medications

Aminoglycosides - Gentamicin, Streptomycin, Chemotherapy - Cisplatin Antimalarial - Quinine Salicylates Furosemide Salt retaining meds like corticosteroids.

Intracranial Tumor

An abnormal growth within the cranial cavity that may be a primary or metastatic cancer Patho • The lesion causes displacement of tissue and pressure, affecting cerebrospinal fluid circulation; function is threatened through compression and destruction of tissues. • The incidence of primary brain tumors increases until about 70 years old and then decreases. Subjective Data • Persistent headache, may awaken patient from sleep • Nausea, early morning vomiting • Unsteady gait, impaired coordination • Memory loss and confusion • Reduced vision acuity, visual loss, diplopia • Behavior or personality change • Seizure • Other symptoms in children may include irritability, lethargy, motor system abnormalities, cranial nerve palsies, weight loss, growth failure, and precocious puberty Objective Data • Signs may vary by location of tumor. • Altered consciousness, confusion • Papilledema • Cranial nerve impairment • Aphasia, language disorder • Vision loss—hemianopia, nystagmus • Gait disturbances, ataxia • Brain imaging by computed tomography (CT) scan or MRI confirms the diagnosis.

Papule

An elevated, firm, circumscribed area; less than 1cm in diameter Ex: Wart (verruca), elevated moles, lichen planus

Facies

An expression or appearance of the face and features of the head and neck that, when considered together, is characteristic of a clinical condition or syndrome. Ask pt to provide an older photo of self bc facies can develop slowly.

Temporal Arteritis (Giant Cell Arteritis)

An inflammatory disease of the branches of the aortic arch, including the temporal arteries Can lead to ischemia of the masseter muscle, tongue, or optic nerve. Flu like symptoms, headache, ocular symptoms, tongue pain, jaw claudication Area over temporal artery may be red swollen

Goniometer (Protractor)

An instrument for measuring angles (as of a joint or the skull)

Winged Scapula

An outward prominence of the scapula indicating injury to the nerve of the anterior serratus muscle

Anatomic Landmarks

Angle of Louis Suprasternal Notch Costal Angle Vertebra Prominens Clavicles

AP drawer test

Anterior and Posterior Cruciate ligament integrity Have the patient lie supine and flex the knee 45 to 90 degrees, placing the foot flat on the table. Place both hands on the lower leg with the thumbs on the ridge of the anterior tibia just distal to the tibial tuberosity. Draw the tibia forward, forcing the tibia to slide forward of the femur. Anterior or posterior movement of the knee greater than 5 mm in either direction is an unexpected finding.

Neck anatomical landmarks

Anterior and Posterior Triangle Clavicle

The Great Vessels

Aorta Superior and Inferior Venae Cavae Pulmonary Arteries Pulmonary Veins Pulmonary Artery - only artery that carries deoxygenated blood

Thrill during Diastole at the Right Sternal Border =

Aortic Regurgitation

Thrill during systole at suprasternal notch / 2nd and 3rd RIC =

Aortic Stenosis

Nodding of the head indicates

Aortic insufficiency esp if synchronized with pulse

Dermatome

Area of skin supplied by a single spinal nerve

Spastic Hemparesis

Arm Flexed, Foot Dragged Scraping Toe, Circled outward and forward (Circumducution), Plantar Flexion

Blood pressure

Arterial blood pressure is the force of blood against the wall of an artery as the ventricles of the heart contract and relax. Systolic Blood pressure is the force exerted when the ventricles contract. Largely the result of cardiac output, blood volume, and compliance of the arteries. Diastolic Blood Pressure is the force exerted by peripheral vascular resistance when the heart is in the filling or relaxed state. Pulse Pressure - Difference between systolic and diastolic BP.

Pulse Rate

Arterial pulse results from ventricular contraction. Pushes a pressure wave of blood throughout the arterial system.

Tuning Fork

Auditory evaluation = 500-1000 Hz fork Vibratory Sensation = 100-400Hz fork apply to bony prominence

Paronychia (Nail Infection)

Bacteria or yeast between nail fold and nail plate. Can be chronic Acute: history of nail trauma Chronic: History of repeated exposure to moisture through hand-washing. Evolves slowly with tenderness and mild swelling. Redness swelling and tenderness at the lateral and proximal nail folds. Purulent drainage often accumulates under the cuticle Chronic Paronychia can produce rippling of the nails.

Grade 1 Murmur

Barely audible in quiet room

Early Diastolic Murmur

Begins with S2

Cardiac Disease Risk Factors

Being Male, though females risk increased in postmenopausal years and with oral contraceptive use. Hyperlipidemia Elevated Homocysteine level (contributes to arterial damage and blood clots) Smoking Family Hx CVD, DM, HTN, Hyperlipidemia Obesity Excessive Fatigue Beta Blockers Dyspnea Paroxysmal nocturnal dyspnea Carotid Sinus Effect - suddent turning of neck Looking up - Vertebral Artery Occlusion

Examine ROM of hand with these movements

Bend fingers forward a the metacarpophalangeal joint then stretch the fingers up and back at the knuckle.. Expect metacarpophalangeal flexion of 90 degrees and hyperextension up to 30 degrees. Touch the thumb to each fingertip and to the base of the little finger, make a fist. Spread the fingers apart and then touch them together Bend the hand at the wrist up and down. Expect flexion of 90 degrees and hyperextension of 70 degrees. With the palm side down, turn each hand to the right and left. Expect radial motion of 20 degrees and ulnar motion of 55 degrees

Argyll Robertson Pupil

Bilateral, miotic, irregularly shaped pupils that fail to constrict with light but retain constriction with convergence; Neurosyphilis or lesions of the midbrain

Subungal Hematoma

Bleeding under nail plate. Can cause nail to seperate. Red to purple color. Hematoma remains until nail grows out, or is decompressed (stick needle through nail plate)

Genu Varum

Bow legged Genu varum is present if a space of 2.5 cm (1 inch) exists between the knees. Common in toddlers until 18 months.

Esophageal Chest Pain Characteristics

Burning, substernal, occasional radiation to shoulder Nocturnal occurrence, usually when lying flat, relief w/ food, antacids sometimes nitro.

Bicep Reflex - Spinal Nerve Levels Evaluated

C5 and C6 (Deep Tendon Reflex)

Brachioradial Reflex - Spinal Nerve Levels Evaluated

C5 and C6 (Deep Tendon Reflex)

Tricep Reflex - Spinal Nerve Levels Evaluated

C6, C7, C8 (Deep Tendon Reflex)

Muscle Strain

Can be due to excess stretching or forceful contraction beyond muscles function capacity Usually due to improper exercise warm up, fatigue, or previous injury. Muscle pain, severity ranges from mild intra fibrous tear to a total rupture of a single muscle Temp muscle weakness

Hand Veins

Can indicate right heart pressure

Ectropion

Can result in excessive tearing, lid turned away from eye

Portable Ultrasound

Can show structure and movement of the body's internal organs as well as blood flowing through blood vessels. Abnormalities that can be detected by ultrasound include cysts, tumors, fluid collection, infections, structural abnormalities of organs, and blockages of major blood vessels.

Dry Nonproductive Cough caused by:

Cardiac problems, allergies, GI reflux with Pharyngeal irritation.

Which artery has the most definitive pulse for evaluation of cardiac function

Carotid

Nail Warts

Caused by HPV, growth at the nail fold

Hordeolum (Stye)

Caused by Staph infection, inflammation of eyelash follicle

Infants and Children: Milaria Rubra (Prickly Heat)

Caused by blocked sweat ducts and trapped sweat beneath skin Results from immaturity of skin structures, overdressed babies during summer. Irregular macular rash on Covered areas of skin

Bigeminal Pulse

Caused by disorder of rhythm Normal pulse followed by PVC Amplitude of pulsation of the PVC is less than that of a normal pulse

Ingrown Nails

Caused by poor fitting shoes, or improper trimming of lateral nail plate, or trauma. Usually on large toe. Redness and swelling at site

Onycholysis

Caused by trauma to long fingernails, or psoriasis, candida or pseudomonas infection, meds, allergic or contact dermatitis, and HYPERthyroidism. Painless nail seperation

Opening Snap

Caused my mitral stenosis, creates an opening snap

Paradoxical aka Reversed Splitting

Caused when closure of aortic valve is delayed. Left bundle branch block or advanced aortic stenosis.

Prosthetic Aortic Valve

Causes a sound in early systole. Intensity depends on type of material used. Animal tissue is the quietest and may even be silent.

Newborn Diaphragmatic Hernia

Causes asymmetric chest expansion If GI Gurgling sounds are persistently heard On the left side 90% of the time, heart displaced to right. Tachypnea Retraction Grunting

The __________________ is the main network of coordination and control for the body

Central Nervous System (Brain and Spinal Cord)

Nucleus Pulposus

Central fibrogelatinous material in each disk - Cushions the vertebral bodies.

In what direction does motility of the GI tract develop?

Cephalocaudal.. allows amniotic fluid to be swallowed by 17 weeks of gestation

Stroke of Internal Carotid Artery

Cerebral Hemisphere, Diencephalon by ophthalmic and ipsilateral hemisphere arteries S/S Unilateral Blindness Severe Contralateral hemiplegia and hemianesthesia Profound Aphasia

Three major units of the brain are the:

Cerebrum Cerebellum Brainstem

Which spinal bones are most mobile?

Cervical Vertebrae Flexion and extension occur between the skull and C1 Rotation occurs between C1 and C2

What are the structures of the neck?

Cervical Vertebrae Ligaments Sternocleidomastoid muslce Trapezius muscle

What is the spine composed of?

Cervical, Thoracic, Lumbar, and Sacral Vertebrae Breakfast at 7, Lunch at 12, Dinner at 5 All but sacral vertebrae are separated by fibrocartilaginous disks

Apneustic Breathing

Characterized by a long inspiration and what amounts to expiration apnea. The neural center for control is in the pons and medulla. When it is affected, breathing can become gasping because inspirations are prolonged and expiration constrained.

Sleep Apnea

Characterized by periods of an absence of breathing and oxygenation during sleep. Due to blockage of the airway when the soft tissue in the back of the throat collapses during sleep, airflow is not maintained through the nose and mouth.

Shaken Baby Syndrome

Child abuse, shaking of child < 1yrs old • Shaking causes the brain to move around in the skull, stretching and tearing nerve tissue and blood vessels and causing brain damage and a subdural hematoma; the spinal cord may also be damaged as the head is whipped back and forth. Subjective Data • Fever • Irritability or lethargy • Decreased food intake • Breathing difficulty or apnea • Seizure • Loss of consciousness Objective Data • Reported history of present illness does not match the nature and severity of findings • Altered level of consciousness • Seizures • Bilateral retinal hemorrhages with retinal detachments or folds • Absence of visible trauma to the head; fingerprint bruises may be seen on infant's upper arms and body • Bruising, bite marks, or burns may be seen in some infants. • CT scan reveals subdural or subarachnoid hemorrhage. • Signs of old and new fractures of long bones and ribs may be seen on radiographs.

Psoriasis of Nail

Chronic and recurrent disease of keratinocyte proliferation Usually occurs simultaneously with the skin disease but can happen on its own. Psoriatic skin lesion, joint pain from psoriatic arthritis in 30% of patients. Yellow scaly debris accumulates. can result in splinter hemorrhages and malformed nails.

Infants and Children: Seborrheic Dermatitis

Chronic, recurrent, erythematous scaling eruption localized in areas where sebaceous glands are concentrated (e.g., scalp, back, and intertriginous and diaper areas) Cause is unknown, occurs within first 3 months of life. Thick Greasy Scalp Scales or body rash. Scalp lesions are scaling, adherent, thick, yellow, and crusted (cradle cap) and can spread over the ears and down the nape of the neck. Lesions elsewhere are erythematous, scaling, and fissured, typically on central body or in diaper area.

Eustachian Tube

Ciliary Action clears middle ear mucosa into the nasopharynx. Drains into the posterior aspect of the inferior turbinate of the nose. Muscles briefly open this passage during yawning, swallowing, sneezing. Equalizes pressure.

Pulmonary tuberculosis smells like

Cinnamon

What is the nipple composed of?

Circular and Longitudinal Smooth Muscle Fibers. Stimulation of smooth muscle causes lactiferous ducts to empty

Microcephaly

Circumference of head is smaller than normal because the brain has not developed properly or has stopped growing head circumference 2-3 standard deviations below the mean

What color is lymph fluid?

Clear, sometimes milky colored or yellow tinged. Contains WBCs (mainly lymphocytes) and RBCs

Older Adults - Competency to Make Decisions

Clinical decision making capacity includes three elements: Patient has a set of goals or values Patient is able to understand and communicate info Patient is able to reason and deliberate about the choice being made by the patient.

Smell of the skin

Clostridium gas gangrene - Rotten Apples Proteus infection - Mousy Pseudomonas infeciton (especially burns) - grapelike Tuburculous Lymphadenitis (scrofula) - Stale Beer Anaerobic infeciton; scurvy - Putrid Intestinal Obstruciton, peritonitis - Feculent Phenylketonuria - Mousy, Musty

A2

Closure of aortic valve

Early Acromegaly Facies

Coarsening feature with broadening of nasal alae and prominence of the zygomatic arches

Cafe Au Lait Macules

Coffee-colored patches (café au lait macules) may be either harmless or indicative of underlying disease. Be suspicious of neurofibromatosis (NF-1) if six or more café au lait macules more than 5 mm in greatest diameter are found in prepubertal individuals or more than 15 mm in greatest diameter after puberty

Kyphosis

Common in aging adults

Anisocoria (Unequal size of pupils)

Congenital - 20 % of people Unliateral sympathetic or parasympathetic pathway destruction

Brachial Cleft Cyst

Congenital Lesion formed by incomplete involution of branchial cleft Subjective Data • Painless mass in lateral neck • May have intermittent swelling and tenderness • Discharge if associated with a sinus tract Objective Data • Oval, moderately movable smooth, nontender, fluctuant mass along anteromedial border of sternocleidomastoid muscle • Usually asymptomatic • If infected, tenderness and erythema

Atrial Septal Defect

Congenital defect in the septum dividing the left and right atria Patho • Large ASD (>9 mm), allows left-to-right shunting of blood • Extra blood from the left atrium may cause a volume overload of the right atrium and the ventricle. • Untreated ASD can result in enlargement of the right side of the heart and shunt reversal (right-to-left shunt) and heart failure. Subjective Data • Often asymptomatic • Heart failure rarely occurs in children but can often occur in adults. Objective Data • Diamond-shaped systolic ejection murmur often loud, high-pitched, and harsh, heard over the pulmonic area • May be accompanied by a brief, rumbling, early diastolic murmur • Does not usually radiate beyond the precordium • Systolic thrill may be felt over the area of the murmur, along with a palpable parasternal thrust. • S 2 may be widely split. • Sometimes the murmur may not sound particularly impressive, especially in overweight children; if there is a palpable thrust and radiation to the back, it is more apt to be significant.

Infant Central Cyanosis indicates

Congenital heart disease

Cystic Hygroma

Congenital malformation of dilated lymphatics Thin Walled contains clear lymph fluid Painless cystic mass May simulate lymph node enlargement.

What are lymph nodes made out of?

Connective tissue few Elastic Fibrils

Dupuytren Contracture

Contractures involving the flexor hand tendons Cause unknown Flexion contractures develop insidiously Incidence increases after age 40 occurs more frequently in men Flexor tendons of the fourth and fifth digits contract causing fingers to curl with impaired extension Tendons easily palpable

Brainstem

Controls involuntary functions

Diencephalon CN 1-2 Thalmus

Conveys all sensory impulses except smell to and from cerebrum before distribution to associative sensory areas. Influences voluntary movements and motor response Controls state of consciousness and abstract feelings

What ligaments provide support for the breast?

Cooper ligaments

Autonomic Nervous System

Coordinates and regulated the internal organs of the body such as cardiac muscle, and smooth muscle. Has two divisions, each balancing the impulses of the other - Sympathetic division, and parasympathetic division

COPD

Cough, Chronic and often excessive sputum production, dyspnea leads to irreversible expiratory airflow obstruction Chronic Bronchitis, Bronchiectasis, Emphysema

Lipemia Retinalis

Creamy white appearance of retinal vessels that occurs with excessively high serum triglyceride levels Grade 1 (Early) - White and creamy aspect of peripheral retinal vessels Grade 2 (Moderate) - creamy color extends toward optic disc Grade 3 (Marked) - Retina appears salmon color, all vessels milky Resolves as triglycerides return to normal.

What is the upper most ring of the tracheal cartilages?

Cricoid

Blepharitis

Crusting of eyelash Bacterial infection, seborrhea, psoriasis, rosacea, or allergic response

BP Cuff for Child

Cuff width should cover aprox 70% of the distance between the acromion and the olecranon (tip of elbow) Bladder length should e 80-100% of the upper arm circumference and bladder width should be at least 40% of the arm circumference at the midpoint of the acromion-olecranon distance Use Kortokoff phase 5 as the diastolic reading unless the sounds are heard down to zero or very low. In that case use Phase 4 (muffling) as diastolic

Dimensions of Cultural Competence

Cultural Encounters - The continuous process of interacting with patients from culturally diverse backgrounds to validate, refine, or modify exiting values, beliefs, and practices about a cultural group and to develop cultural desire, cultural awareness, cultural skill, and knowledge Cultural Desire - motivation to want to engage in the process of becoming culturally competent Cultural Awareness - the deliberate self examination of ones own cultural beliefs and biases towards groups who are different Cultural Knowledge - The process of seeking and obtaining a sound educational base about culturally and ethnically diverse groups Cultural Skill - the ability to collect culturally relevant data regarding the patient's presenting problem as well as accurately performing a culturally based physical assessment

Cutaneous Horns

Cutaneous horns are small, hard projections of the epidermis, usually occurring on the forehead and face and can be the manifestation an underlying squamous cell carcinoma or a wart

Digital Mucous Cysts

Cyst on proximal nail fold, puts pressure on nail matrix and causes a longitudinal groove. Cysts located on the dorsal-lateral finger at the distal interphalangeal join are probably caused by herniation of tendon sheaths or join linings and are related to ganglion and synovial cysts. Contains clear jelly like substance.

A lift along the left sternal border is most likely the result of: A. aortic stenosis. B. atrial septal defect. C. pulmonary hypertension. D. right ventricular hypertrophy.

D. Right Ventricular Hypertrophy

Internal Intercostal Muscles

Decrease the lateral diameter during forceful expiration.

What causes the Foramen Ovale to close?

Decreased Pulmonary Pressure from Pulmonary Arteries relaxing

Older Adult Ventilation

Decreased vital capacity, and increased residual volume. Retained mucus encourages bacterial growth = predisposition to resp infection

Kussmal Respirations

Deep labored breathing pattern; increased rate, large volumes often seen in Diabetic Ketoacidosis

What are the primary muscles of respiration?

Diaphragm and Intercostal Msucles

Pregnancy abnormalities

Diastolic murmur Neck vein distention Clubbing Cyanosis

Cellulitis

Diffuse, acute, infection of the skin and subcutaneous tissue Patho • Majority of cases caused by Streptococcus pyogenes or Staphylococcus aureus . Subjective Data • Break in the skin, such as a fissure, cut, laceration, insect bite, or puncture wound • Pain and swelling at the site • May have fever Objective Data • Skin is red, hot, tender, and indurated; borders are not well demarcated • Lymphangitic streaks and regional lymphadenopathy may be present. • Rare to have bilateral cellulitis.

Hydronephrosis

Dilation of the renal pelvis and calyces due to an obstruction of urine flow anywhere from the urethral meatus to the kidneys

CN 4 Trochlear

Downward and inward eye movement

Crust

Dried serum, blood, or purulent exudates; slightly elevated; siz varies; brown, red, black, tan or straw colored Ex: Scab on abrasion

Malignant Breast Tumors

Ductal carcinoma arises from the epithelial lining of ducts; lobular carcinoma originates in the glandular tissue of the lobules. occurrence usually 45-70 yrs old, but mainly after 50yrs old Painless lumps, change in size, shape or contour of breast Axilla may be tender if lymph nodes involved

Myxedema Facies

Dull, Puffy, Yellowed Skin Coarse Sparse Hair Temporal loss of eyebrows Periorbital edema, prominent tongue.

Pleural effusion exam findings

Dullness to chest percussion = higher probability of pleural effusion If normal tactile fremitus is present it is less likely there is a pleural effusion

Best time to Hear a Split S1

During Deep Inspiration.. Tricuspid valve closure is very faint

Intention Tremor

During intentional movements like writing, pouring water in cup. Does not occur at rest. Cerebellar disorder - MS or Etoh

When is the thymus largest and most active?

During neonatal and preadolescent periods. Atrophies after puberty.

Platypnea

Dyspnea increases in upright posture.

Major landmarks of the back

Each spinal processo of the vertebrae (C7 and T1 most prominent) Scapulae Iliac Crests Paravertebral muscles

Palpation of eyelid

Easiest way to detect ICP, involved eye will be much harder than uninvolved eye Very Firm = Glaucoma, or retrobullar tumor Pain = Scleritis, Orbital Cellulitis, Cavernous Sinus Thrombosis

Mass

Elevated and solid lesion; may or may not be clearly demarcated. Deeper in dermis; greater than 2 cm in diameter Ex: Neoplasms, benign tumor, lipoma

Pregnant Patients

Elevated levels of estrogen = Increased vascularity of upper respiratory tract. Capillaries of nose pharynx and eustacian tube become engorged = Nasal stuffiness, decreased sense of smell, epistaxis, sense of fullness in ears, impaired hearing. Hoarseness and persistent cough

Cyst

Elevated, circumscribed, encapsulated lesion; in dermis or subcutaneous layer; filled with liquid or semisolid material Ex: sebaceous cyst, cystic acne

Cor Pulmonale

Enlargement of Right Ventricle due to lung disease Subjective Data • Fatigue • Tachypnea • Exertional dyspnea • Cough • Hemoptysis • Lightheadedness • Syncope Objective Data • Evidence of pulmonary disease • Wheezes and crackles on auscultation • Increase in chest diameter • Labored respiratory efforts with chest wall retractions • Evidence of right heart failure and hypertrophy • Distended neck veins with prominent A or V waves • Cyanosis • Left parasternal systolic heave • Loud S 2 exaggerated in the pulmonic region

Shotty Lymph Nodes

Enlargement of lymph node after viral infection feels like a BB < 1cm No clinical consequence unless in epitrochlear or supraclavicular regions

What are the growth plates in the long bones called?

Epiphyses

What is the only peripheral lymph center?

Epitrochlear

Newborn Chest Circumference

Equal to head until about 2 yrs old

Heart Sound Locations

Everything hear best at apex except: Split S1 - Tricuspid Intense S2- Base Physiologic Splitting S2 during expiration - Base

Hepatojugular Refulex

Exaggerated when R sided HF present. To assess the hepatojugular reflux maneuver, use your hand to apply firm pressure for 10 seconds to the abdomen in the midepigastric region and instruct the patient to breathe regularly. Observe the neck for an elevation of at least 3 to 4 cm in JVP that lasts beyond a few seconds. The JVP equilibrates to its true level after removal of the abdominal hand pressure.

LH Symbols (LEA Symbols)

Far Vision Consists of four optotypes (circle, square, apple, house) that blur equally. The child has to find a matching block or point to the shape that matches the target presented. Acuity is measured by the smallest symbol the child is able to identify at 10 ft.

Arterial Blood Pressure

Force exerted against the wall of an artery as a bolus of blood exits the hearts LV

Cerebrum

Formed by two cerebral hemispheres, divided into lobes. Hemispheres control the contralateral opposite side of body.

Nasal sinus infection, cancer, or resp infection like empyema, lung abscess, bronchiectasis smells like

Fould, putrid

Sighing

Frequently interspersed deeper breath

Koilonychia (Spoon Nails)

From iron deficiency anemia, syphilis, fungal dermatoses, HYPOthyroidism

What bones are the face made up of?

Frontal Nasal Zygomatic Ethmoid Lacrimal Sphenoid Maxillary Movable Mandible

DKA smells

Fruity or sweet

Full muscle strength requires?

Full ROM

Why might the Right Lung Ride Higher than the Left lung?

Fullness of the dome of the liver

Irritable bowel syndrome

Functional disorder characterized by abdominal pain and altered bowel habits

Sensory Ataxia

Gait is wide based. feet thrown forward and outward. Heels down first. Patient watches ground to guide feet. Positive romberg.

What is the female breast composed of?

Glandular (15-20 lobes per breast around the nipple) and fibrous tissue Subq and retromammary fat Each Lobe is composed of 20-40 lobules Each lobule consists of milk-producing acinar cells

Older adult breast changes

Glandular Tissue Atrophies gradually replaced by fat Inframammary ridge thickens Hang more loosely due to relaxation of the suspensory ligaments Nipples become smaller and flatter lose some erectile ability Loss of axillary may occur Skin may dry and thin

Vaginal speculum

Graves Speculum - 76mm - 170mm lenght and 22mm - 36mm wide. Bottom blade slightly longer Pederson Speculum - same lenght as graves, but narrower. 16-25mm Pediatric or virginal speculum - short narrow flat blade.

Matted Node

Group of nodes that feel connected and seem to move a s a unit

Tonsilits, gingivits, GI reflux, Vincent angina smells like

Halitosis

Increased S3

Heard best will bell at apex Pt in Left lateral Recumbent Position During early diastole, low pitched

CN 8 (Acoustic)

Hearing and equilibrium

LUmbosacral Radiculopathy (Herniated Lumbar Disk)

Herniation of a lumbar disk that irritates the corresponding spinal nerve root Most common at L4,L5 and S1 Between 31-50 yrs old Low back pain with radiation to the buttocks and posterior thigh or down the leg Potential difficulty with heel Walking (L4 and L5) or Toe Walking (S1)

Steppage Gait

Hip and Knee elevated excessively. Foot brought down with slap, patient can not walk on heels. Walks like a horse

Stepping Reflex (Birth - 8 weeks)

Hold the infant upright under the arms and allow the soles of the feet to touch the surface of the table; observe for alternate flexion and extension of the legs, simulating walking; it disappears before voluntary walking.

Mitral Regurgitation

Holosystolic. Heard best at apex, radiates to left axilla Caused by rheumatic fever, MI, myxoma, rupture of chordae

Complementary and alternative treatments

Home based remedies for the common cold are widely used. In children the following may be effective: Buckwheat honey, vapor rub, geranium, and zinc sulfate In adults: Echinacea purpurea, geranium extract, and zinc gluconate may be effective

Pituitary Gland

Hormonal control of growth, lactation, vasoconstriction, and metabolism

Epithalmus

Houses pineal body Sexual development and behavior

Cribiform plate

Houses sensory ending of the olfactory nerve. Lies on the roof of nose.

HITS Screening Tool

Hurt you physically? Insult or talk down to you? Threaten you with physical harm? Scream or curse at you? pg. 10

Older Patient Fall Risk Factors

Hx Stroke Parkinsons Dementia Peripheral Neuropathy Gait, balance, vertigo disorder Lower Extremity weakness or sensory loss Impaired vision

Chest Percussion Tones

Hyperresonance is abnormal, result of air trapping

Pt abdomen is significantly distended, bowel sounds hypoactive or absent. No pain, No masses. DTR diminished. Pt on diuretics for htn. What is suspected cause?

Hypokalemia - paralytic ileus or Narcotics/hypothyroid

CN 1 Examination

Identify aromatic odors, one naris at a time with eyes closed.

L3, L4 can be found where

Illiac crest for epidural during labor

These vaccines may cause axillary node enlargement:

Immunizations, particularly BCG (bacillus Calmette-Guérin), MMR (measles/mumps/rubella), and smallpox vaccination, administered in the upper arm may cause temporary axillary node enlargement. Rarely, human papilloma virus (HPV) vaccination may cause node enlargement in the head and neck region

pes varus

In toeing

Sense of Smell

Inborn errors of metabolism - caused by Phenylketonuria or Tyrosinemia. Smells like Mousy or fishy. Infectious disease - caused by TB or Diphtheria, smells like Stale Beer or sweetish Ingestion of poison or intoxication - caused form cyanide or chloroform salicylates, smells fruity Physiologic non-disease states - sweaty feet, smells cheesy Foreign bodies eg in nose or vagina - organic material like bead in child's nose will have foul smelling discharge.

Atelectasis Presentation

Incomplete expansion of the lung at birth or the collapse of the lung at any age Subjective Data • Frequently seen in the postoperative setting • Symptoms of postobstructive pneumonia may develop in the setting of airway obstruction from a foreign body or tumor. Objective Data • Auscultation dampened or muted in the involved area because the affected area of the lung is airless. • Radiograph may show consolidation associated with a postobstructive pneumonia.

External Intercostal Muscles

Increase the AP chest diameter during Inspiration Think.. external expands

What causes the ductus arteriosus to close?

Increased O2 tension in arterial blood stimulates contraction and closure

Loud S1

Increased velocity of blood flow due to exercise, fever, anemia, hyperthyroid, during exercise, Stenotic Mitral Valve Think S1 stands for Stenotic

Retention Cysts

Inflammation of sebaceous glands in areola. Tender and suppurative.

Decerebrate Posturing

Injury to brain stem

Pseudotumor Cerebri

Intracranial HTN that mimics brain tumors. Possibly due to excess CSF or malabsorption. Obstructed venous drainage, and obesity. Mainly in obese women of childbearing age. Subjective Data • Severe daily headache, throbbing, may awaken patient • Pain behind the eye • Vomiting • Short episodes of blurred vision, double vision • Whooshing sound in ears Objective Data • Papilledema, retinal hemorrhages on fundoscopic examination • Inferior nasal vision field defect • Decreased visual acuity • Alert, unimpaired consciousness • Absence of focal neurologic signs • CT scan or MRI reveals no cause of increased intracranial pressure.

What does the pancreas do?

It produces amylase, protease and lipase then releases them into the small intestine

CN 5 Trigeminal

Jaw opening, chewing, clenching, mastication Sensation to cornea, iris, lacrimal glands, cunjuctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, facial skin

The ______________ forms the more posterior aspect of the heart

Left Atrium

Bell Palsy Facies

Left Facial Palsy (CN7) Facies include asymmetry of one side of the face eyelid not closing completely drooping lower eyelid and corner of mouth and loss of nasolabial fold.

Why are childhood injuries more likely to result in fractures than sprains?

Ligaments are stronger than bone until adolescence

Resting Tremor

Limb at rest Pill rolling movements Parkinsons disease

Antalgic Limp

Limited weight bearing time on affected leg to limit pain.

Erosion

Loss or part of the epidermis; depressed, moist, glistening; follows rupture of a vesicle or bulla Ex: Varicella, variola after rupture

Grade 4 Murmur

Loud associated with thrill

Treacher-Collins Syndrome

Maxillary Hypoplasia Micrognathia Auricular deformity

Esophageal Diverticulum

May simulate lymph node enlargement.

Granular Cell Tumor

May simulate lymph node enlargement.

Pusle Oximeter

Measures percentage of hgb saturated with oxygen (oxyhemoglobin) Deoxygenated Hgb absorbs more red light and allows more infrared light to pass through. The ratio of the absorption is used to calculate the oxy/deoxyhemoglobin ratio

Varu-Valgus Stress Test

Medial or lateral collateral ligament instability in knee Have the patient lie supine and extend the knee. Stabilize the femur with one hand and hold the ankle with your other hand. Apply varus force against the ankle (toward the midline) and internal rotation. Excessive laxity is felt as joint opening. Laxity in this position indicates injury to the lateral collateral ligament. Then apply valgus force against the ankle (away from the midline) and external rotation. Laxity in this position indicates injury to the medial collateral ligament. Repeat the movements with the patient's knee flexed to 30 degrees. No excessive medial or lateral movement of the knee is expected.

Katz hand diagram

Median nerve integrity

Phalen Test

Median nerve integrity

Thumb Abduction Test

Median nerve integrity

What does the liver do?

Metabolism of carbohydrates, fats, and proteins Converts glucose to glycogen Converts amino acids to glucose (gluconeogenesis) Uses cholesterol to form bile salts Breaks down proteins through hydrolysis Stores vitamins and iron Detoxifys Produces antibodies conjugation and excretion of steroid hormones Produces prothrombin, fibrinogen Produces circulating plasma Synthesizes bile

Apical Impulse visible where?

Midclavicular 5th IC Should only be seen in one IC space, can also be seen in 4th IC

Thoracic Landmarks

Midsternal line: vertically down the midline of the sternum Right and left midclavicular lines: parallel to the midsternal line, beginning at midclavicle; the inferior borders of the lungs generally cross the sixth rib at the midclavicular line Right and left anterior axillary lines: parallel to the midsternal line, beginning at the anterior axillary folds Right and left midaxillary lines: parallel to the midsternal line, beginning at the midaxilla Right and left posterior axillary lines: parallel to the midsternal line, beginning at the posterior axillary folds Vertebral line: vertically down the spinal processes Right and left scapular lines: parallel to the vertebral line, through the inferior angle of the scapula when the patient is erect

Pregnancy Ventilation

Minute Ventilation increases from Increased TV. RR remains the same.

Heart position in pregnancy

More horizontal with axis rotation bc enlarged uterus pushes the diaphragm up and shifts heart.

Infants

More susceptible to hypothermia bc of large body surface area to weight ratio, thinner skin, and limited ability to cope with cold stress. Most pain impulses are transmitted along the nonmyelinated slower C fibers bc the myelination to the A-delta fibers continues to develop after birth. Think C for Child Infants are less able to modify pain impulses due to immaturity of dorsal horn synaptic connection and inhibition circuits in the descending spinal cord pathways. This results in greater sensitivity to repeated painful stimuli.

polydactyl and syndactyl

More than 5 digits or Two digits fused together

Fetal Alcohol Syndrome Facies

Most common cause of acquired intellectual disability Poorly formed philthrum Widespread Eyes Inner Epicanthal Folds Ptosis Hirsute Forhead Short Nose Thin Upper Lip

Basal Cell Carcinoma

Most common type of skin cancer, occurs most often on exposed parts of body. Persistent sore or lesion that has not healed

Hypertension Expected Findings

Narrowing of vessels Increased Vascular Tortuosity Copper Wiring (Diffuse Red Brown Reflex) Arteriovenous Nicking Retinal Hemmorage

Medications that may cause essential tremors:

Neuroleptics Valproate Phenytoin Albuterol Psuedophedrine Antiarrhytmics Corticosteroids Caffeine

Older adults

Neurons decrease, brain size decreases, reflexes slow

T4 is found at what level

Nipple line

How does the lymph system move fluid?

No built in pump, relies on the Cardiovascular System. Lymph movement is sluggish.

Older Adults

No diminished perception of pain, may have decreased pain threshold due to neuropathies.

Are bruits heard in lymph nodes?

No only blood vessels

Transillumination of a Lymph Node

Nodes will not transilluminate, only fluid filled cysts do.

Blood Pressure Ranges

Normal - Less than 120 sys and diastolic less than 80 Prehypertension - 120-139 sys or 80-89 Hypertension Stage 1 - 140-159 or 90-99 Stage 2 - 160 or higher or 100 or higher

Abdominal Reflex

Normal response is the ipsilateral contraction of the abdominal muscles with an observed deviation of the umbilicus towards the stroke.

Patterns of respiration

Normal: 12-20 Bradypnea <12 Tachy >20 Hyperventilation Sighing Air trapping Cheyne Stokes Biot Ataxic

Supraclavicular nodes in children

Not usually palpable and associated with high incidence of malignancy in kids.

CN Mnemonic

On Old Olympus Towering Tops A Finn And German Viewed Some Hops

Multiple Spinal Nerve Root Injury

One Root = Incomplete loss of sensation in any area of the skin Two or More Nerves = Zone of sensory loss is surrounded by partial loss. Tendon Reflexes may be lost.

Proprioception and Cerebellar Function Testing

One test is administered for each of the following: Rapid Rhythmic Alternating Movements Accuracy of movements Balance (Romberg) Gait and heel-toe walking

Pain Assessment

Onset Quality Intensity Location Associated symptoms: nausea, fatigue, behavior change, irritability, disturbed sleep, distress caused by pain What the patient thinks is causing the pain or what was the inciting event Effect of pain on daily activities Effect of pain on psyche Pain control measures Medications

Cataracts

Opacity in lens. Denaturing of lens protein from aging, generally central in aging. Steroid use can cause cataracts. Rubella or fetal insults during pregnancy. S/s: Cloudy or blurry vision, faded colors, headlights or lamps appear too bright. Halo around lights. Poor night vision, or double vision. Cloudiness obvious without special viewing equipment.

Temporomandibular Joint ROM

Open and close the mouth expect a space of 3-6 cm between the upper and lower teeth when jaw is open Laterally move the jaw to each side the mandible should move 1-2 cm in each direction Protrude and retract the chin

Infant CN Testing

Optic Blink - CN 2, 3, 4, 6 Rooting and Sucking Reflex - CN 5 Acoustic Blink Reflex / Dolls Eyes - CN 8 Swallowing and Gag Reflex - CN 9, 10 Coordinated sucking and Swallowing - CN 12 / Cerebellum

Peau d' orange sign

Orange Skin - edema due to blocked lymph drainage - Inflammatory Breast Cancer Often seen first in the areola

If newborn has a murmur what do you do?

Order Echo and refer to Pediatric Cardiologist. even if asymptomatic

Diet and Nutrition Practices

Orthodox Jewish - May not take prescribed medications during passover bc the prep of a drug does not meet the religious rules for food at that time Muslim - Must respect Halal (prescribed diet) even through out pregnancy Chinese with hypertension and salt restricted diet may need to consider limited use of MSG and soy sauce Herbal medications like Cassia Senna may cause liver damage

Epidermis

Outermost layer of skin Composed of: Stratum Corneum - composed of closely packed dead keratin filled squamous cells. Chief mechanical barrier protecting body. Takes 28 days for keratinocytes to pass through layers. Not found in mucosal skin. Stratum Lucidum - Only thick skin parts of body have this such as soles of feet and palms. Stratum Granulosum Stratum Germinativum Stratum basale contains melanocytes which synthesize melanin

Meckel Diverticulum

Outpouching of the ileum that varies in size from a small appendiceal process to a segment of bowel several inches long, often in the proximity of the ileocecal valve In children bright or dark red bleeding with little if any abdominal pain is a common presenting concern

Pulmonic Stenosis decreases

P2 intensity

Salivary Glands

Parotid Submandibular Sublingual

What minerals does the musculoskeletal system store?

Phosphorus, Calcium, Carobnate Also produced RBC's via Hemaopoiesis

Physical Abuse in Older Adults

Physical neglect most common type Bruising on extensor surfaces is common and usually accidental Bruising in various stages of healing on inner soft surfaces more indicative of abuse. Determine Mental Status.

What are two parts of the body not supplied by the lymphatic system?

Placenta Brain

Angina Pectoris is described as

Pressure or choking sensation substernal or into the neck. May radiate to jaw and down to the left, and sometimes right arm.

Hirschsprung Disease

Primary absence of parasympathetic ganglion cells in a segment of the colon, which interrupts intestinal motility Symptoms typically begin at birth with failure to pass meconium in the first 24-48 hours after birth Stool palpated in LLQ

Respiratory Rate

Primary muscles of respiration are the diaphragm and the intercostal muscles. Diaphragm is dominant muscle. Contracts and moves down during inspiration. External intercostal muscles increase the anteroposterior chest diameter during inspiration. Internal intercostal muscles decrease the lateral diameter during expiration.

Sympathetic Division

Prods the body into action during times of psychologic Stress

If patient has DM or Peripheral Neuropathy perform this test

Protective sensation using 5.07 monofilament.

Impaired Vision

Pt can have red tipped white cane, or guide animal. Do not pet guide animal. Ask pt if they would like to examine any of the equipment first. May keep tactile contact through examination to make pt feel more comfortbale

Thrill during systole at the Suprasternal notch / 2nd and 3rd LIC =

Pulmonic Stenosis

P2

Pulmonic Valve Closure occurs later during inspiration

Cyanosis that appears after the neonatal period suggests

Pulmonic stenosis Eisenmenger Complex (Heart defect that can lead to right to left shunt Tetralogy of Fallot Or Large Septal Defects

Grade 2 Murmur

Quiet but clearly audible

CN 3 Oculomotor

Raise eyelids and extra-ocular movements Pupillary constriction, change lens shape

What test to evaluate coordination and fine motor skills?

Rapid Rhythmic Alternating Movements Accuracy of upper and lower extremities.

Medulla Oblongata CN 9-12

Respiratory, circulatory, and vasomotor activies. Houses Respiratory Center. Reflexes of swallowing, coughing, vomitting, sneezing, and hiccuping (Mouth and Lungs)

Olecranon Bursitis

Results in swelling and tenderness of the bursa

Macular Degeneration

Retina Deteriorates Dry (Atrophic) - Gradual blurring of central vision Wet (Exudative or neovascular) - new blood vessels grow under center of retina. vessels leak, blead and scar retina destroying central vision. Can happen Rapidly. S/s Blurred decreased Central Vision Straight lines look bent (metamorphopsia) Objects appear different color or shape in each eye Objects appear smaller in one eye (Micropsia) Inspection: Dry form Drusen - multiple spots in macula Wet Form Exudates, blood, scarring, blood vessels below retina.

Retinopathy of Prematurity

Retinal vascular development disrupted in preterm infant. Abnormal proliferation of blood vessels. (Neovascularization) Birthweight < 1500g (highest risk for ROP) or < 30 weeks gestational age Straight, temproally diverted blood vessels on fundoscopic exam

Carcinoma signs

Retractiond and Dimpling can show as a contraction of fibrotic tissue in the breast

Repolarizaiton

Return of stimulated heart muscle to resting state

Subcutaneous nodules along pressure points of the ulnar surface may indicate

Rheumatoid nodules, or gout tophi

The lymphatic ducts that drain the right upper body empties into which vein?The rest of the body?

Right subclavian vein The thoracic duct (emptying rest of body) drains into the Left subclavian vein

Transillumination of infant skull

Ring should be under 2cm. Anything greater suggests excess fluid or decreased brain. tissue in the skull.

Melanoma

Risk Factors: Exposure to sunlight or UVA / UVB ultra violet radiation Severe blistering sunburns, even as a child Indoor Tanning device usage Geographic exposure - people who live in areas that get large amounts of UV radiation like high altitudes. History of melanoma Family history - first degree relative Moles Large congenital nevus > 15cm Immune suppression Skin type, relative inability to tan. (type I and II have highest risk)

Evaluate balance using the ____________________ test

Romberg

Near Vision Tests

Rosenbaum Newsprint Jaeger

Cushing Sydnrome Facies

Round or moon shaped face with thin erythematous skin. Upper thoracic fat pad or "buffalo hump"

What variables contribute to the pulse?

SV Distensibility of aorta and large arteries Obstruction of blood flow - ex PAD / Stenosis / Coarction / Vasculitis Peripheral artery resistance Viscosity of blood

Older adult hemodynamics

SV and CO decrease Tachycardia poorly tolerated bc response to stress and increased oxygen demand is less efficient Return to normal HR takes longer

Pregnancy Hemodynamics

SVR decreases Peripheral Vasodilation = Palmar eryhtema and spider telangiectasis Systolic BP decreases slightly Decrease in diastolic pressure

Infant sutures

Sagittal Coronal Lamboid

Spastic Diplegia

Scissor Gait)- short steps, drag ball of foot, knocked kneed, Thighs Cross

Older adults

Sebaceous and sweat gland activity decreases in older adults, skin become drier with less perspiration. Epidermis thins and becomes more fragile. Dermis shrinks due to aging and sun exposure which causes elasticity and collagen loss. = wrinkles Nails grow slowly due to decreased circulation Vellus to terminal hair occurs in the tragus of men's ears and in the nares.

Sebaceous Hyperplasia

Sebaceous hyperplasia occurs as yellowish, flattened papules with central depressions that are often difficult to discern from a basal cell carcinoma

Seborrheic Keratoses

Seborrheic keratoses are pigmented, raised, warty lesions, usually appearing on the trunk. These must be distinguished from other growths such as nevi or actinic keratoses, which may have malignant potential. Because the lesions may look similar, seek the assistance of an experienced practitioner for differential diagnosis

Pulmonic Valve Area

Second left IC space at Left sternal border

CN 1 (Oflactory)

Sense of smell

Older adults sense of smell

Sense of smell deterioration begins at about 60 yrs of age. Sense of taste deterioration begins at about 50 yrs.

Multiple Peripheral Nerve Injury (Polyneuropathy)

Sensory loss is most severe over the legs and feet or over hands. (Glove and Stocking Distribution). Change is gradual. All forms of sensory discrimination lost.

Infant Vascular Lesions

Several vascular lesions are common in infancy. Infantile hemangiomas are true neoplasms, which develop in the first 1 to 2 months of life, grow for 2 to 6 months, and regress over the next 5 to 10 years. A salmon patch ("stork bite") represents a common capillary vascular formation, found most frequently on the midforehead, eyelids, upper lip, and back of neck. A port wine stain is also a capillary malformation that may be associated with underlying arteriovenous malformations in Sturge-Weber syndrome.

Apert Syndrome

Severe maxillary and midfacial hypoplasia

Crouzon Syndrome

Severe maxillary and midfacial hypoplasia with low set ears. Apert syndrome does not have low set ears.

Infant Ashen White in Color indicates

Shock

S2 Intensity Decreases in

Shocklike state with arterial hypotension = loss of valvular vigor Valves are immobile, thickened, or calcified

Breast Venous Patterns

Should by symmetric Unilateral pattern may indicate increased blood flow to a malignancy

Skin Creases in newborns

Single transverse crease in palm is seen in down syndrome (trisomy 21) children

Macula

Site of Central Vision, 2 disc diameters temporal to the optic disc. Eye should be dilated prior to exam.

Medulla Oblongata

Site where the descending corticospinal tracts decussate (cross to the contralateral side)

Brain and spinal cord are protected by:

Skull and vertebrae, meninges, CSF

Cancer produces this type of sputum

Slight, persistent, intermittent blood streaking

Cerumen

Slightly acidic pH, inhibits gown of microorganisms. Coats canal lining and protects external auditory canal. Cerumen Secreted by the Apocrine glands in the distal third of the canal.

Depolarization

Spread of stimulus through heart muscle

P Wave is the

Spread of stimulus through the atria Atrial Depolarization

Transilluminator

Strong light source used to distinguish whether a body cavity contains fluid, air, or tissue

Patient History

Structure: - First the identifiers: name, date, time age, gender identity, race, source of information, and referral source - Chief Concern - History of Present Illness: - Past Medical History - Family History - Personal and Social history - Review of Systems

What are the Six groups of lymph nodes in the axillary fossa?

Subclavian Central Axillary Subscapular Mammary (Rotter Nodes) External Mammary (Anterior pectoral)

Primary Hepatocellular Carcinoma

Subjective • Symptoms may include jaundice, anorexia, fatigue, abdominal fullness, clay-colored stools, and tea-colored urine Objective • On examination, hepatomegaly with a hard, irregular liver border may be palpated • Liver nodules may be present and palpable, and the liver may be tender or nontender • Examination findings related to cirrhosis may be seen

CHF Left Sided

Subjective Data • Fatigue • Breathing difficulty, shortness of breath • Orthopnea • Exercise intolerance Objective Data • Sudden with acute pulmonary edema or gradual symptom onset • Crackles on pulmonary examination • Systolic CHF has a narrow pulse pressure. • Diastolic CHF has a wide pulse pressure. Cardiomegaly is most helpful exam finding for L CHF. Displaced PMI or abnormal apical impulse.

Lateral Spinothalamic Tract

Superficial Pain and Temperature. (Ascending Tract/Lower Motor Neuron Disorders)

Sensory Fucntion Testing

Superficial Pain and Touch at a distal point in each extremity Vibration and position sense are assessed by testing the great toe. Testing for peripheral neuropathy. Systemic sensory loss = polyneuropathy.

Test Primary sensory responses to:

Superficial Touch Superficial Pain (Lateral and Anterior Spinothalamic Tract) Ascending tracts for lower motor neuron disorders

Lower Abdominal Reflex - Spinal Nerve Level Evaluated

T10, T11, T12 Superficial Reflex

Which joints in the anke permit it to pivot or rotate?

Talocalcaneal Joint (Subtalar) Transverse Tarsal Joint

Fungiform papillae

Taste receptors, scattered throughout the filiform papillae of the tongue. Specific area are sensitive to the five basic taste sensations of sweet, salty, sour, bitter, and umami (savory)

Thrill during systole at the left lower sternal border =

Tetralogy of Fallot

Which nodes are most accessible to palpation?

The "Necklace" of Nodes *Parotid and retropharyngeal (tonsillar) *Submandibular *Submental *Sublingual (facial) *Superficial anterior cervical *Superficial posterior cervical *Preauricular and postauricular *Sternocleidomastoid *Occipital *Supraclavicular Arms *Axillary *Epitrochlear (cubital): elbow Legs *Superficial superior inquinal *Superficial inferior inguinal *Occasionally, popliteal

What covers and anchors the small intestine

The Mesentery - a fan shaped fold of the peritoneum

Pneumonic for valve order

The Poor Man Ate or Try Pulling My Arm Tricuspid -> Pulmonic -> Mitral -> Aortic

W or Reverse Tailor Position

The W or reverse tailor position places stress on the joints of the hips, knees, and ankles. It is commonly seen in children with in toeing associated with femoral anteversion

What are the systems of the Spleen?

The White Pulp - made up of lymphatic nodules and diffues lymphatic tissue The Red Pulp - Made up of venous sinusoids

What forms the arch of the shoulder

The acromion and coracoid process and the ligaments between them

Carrying angle of the elbow

The angle formed by the long axis of the humerus and ulna, resulting in an abducted position of the forearm relative to the humerus. 5-15 degrees

Cervical Nodes

The childhood diseases of rubella, rubeola, and varicella often present with obvious cervical nodes, usually posterior rather than anterior. Hepatitis A or B and infectious mononucleosis have the same pattern of cervical node involvement.

What helps stabilize and protect the head of the femur?

The depth of the acetabulum in the pelvic bone and the joint which is supported by three strong ligaments Bursae reduce friction in the hip

Adolescents

The examination of the adolescent's skin is the same as that for the adult. The adolescent's skin may have increased oiliness and perspiration, and hair oiliness may also be increased. Increased sebum production predisposes the adolescent to develop acne. As a reflection of maturing apocrine gland function, increased axillary perspiration occurs, and the characteristic adult body odor develops during adolescence. Hair on the extremities darkens and becomes coarser. Pubic and axillary hair in both males and females develops and assumes adult characteristics. Males develop facial and chest hair that varies in quantity and coarseness.

Older Adults Hair Changes

The hair turns gray or white as melanocytes cease functioning. Head, body, pubic, and axillary hair thins and becomes sparse and drier. Men may show an increase in coarse aural, nasal, and eyebrow hair; women tend to develop coarse facial hair. Symmetric balding, usually frontal or occipital, often occurs in men.

Pregnant patients - Initial interview

The initial interview includes past history, assessment of health practices, identification of potential risk facts, and assessment of the patient's knowledge expectations, and perceptions as they affect pregnancy. Basic Info Patients age, ethnicity Marital Status, partner, or relationship LMP Previous usual/ normal menstrual period (PUMP or PNMP) Expected date of confinement / Deliver (EDC) Occupation Parents of the baby and his/her occupation if applicable

Carpal Tunnel Evidence Based Practice

The likelihood that a patient will have a positive electrodiagnostic study for carpal tunnel syndrome is increased by the following: weakened thumb abduction; a classic or probable distribution of symptoms on the Katz hand diagram; and hypalgesia (decreased pain sensation along the thumb and median nerve distribution compared with the little finger on the same hand). The Tinel and Phelan tests are less accurate.

What is the heaviest organ in the adult body?

The liver - weighs about 3 lbs

Anatomic Structures of the Nail

The nails are appendages of the skin, which are composed of epidermal cells converted to hard plates of keratin. They protect the fingertips and are important in dexterity. The nail plate sits on the highly vascular nail bed which lies on periosteum. The white crescent-shaped area extending beyond the proximal nail fold marks the end of the nail matrix, the site of nail growth. The layer of skin covering the nail root is the cuticle, or eponychium, which pushes up and over the lower part of the nail body. The paronychium is the soft tissue surrounding the nail border.

Major Fissure of the lungs

The oblique

Physical Exam: Older Adults

The skin of the older adult may appear more transparent and paler in light-skinned individuals. Pigment deposits, increased freckling, and hypopigmented patches may develop, causing the skin to take on a less uniform appearance. Flaking or scaling, associated with the drier skin that comes with aging, occurs most commonly over the extremities. The skin also thins (especially over bony prominences, the dorsal surface of hands and feet, forearms, and lower legs) and takes on a parchment-like appearance and texture

Umbillical Cord Thickenss

Thick = Well Nourished fetus, thin indicates otherwise

Myocardium

Thick muscular middle layer, responsible for pumping action of the heart.

Skin thickness

Thinest on eye lids thickest on soles, palms, elbows

Atrophy

Thinning of skin surface and loss of skin markings, skin translucent and paper-like Ex: Striae; aged skin

Rib Cage Anatomical View

Thoracic vertebrae starts at 7th cervical vertebra which is readily palpated. Can count down thoracic vertebrae after.

Meninges

Three layers surround the brain and spinal cord. They assist in production and drainage of CSF

Acute Diarrhea

Three or more lose stools per day

Which finger to palpate brachial and femoral pulse?

Thumb

What is the largest endocrine gland in the body?

Thyroid Produces T3 and T4

Trachea deviates away from affected side in:

Thyroid enlargement pleural effusion Tension pneumo

Lyme Disease

Tick borne disease that can lead to a multisystemic infection Patho • Spirochetal infection caused by Borrelia burgdorferi • Most common tick-borne disease in the United States • The spirochete deposited by the tick into the skin rather than directly into the bloodstream. • Three phases of the disease are recognized: early localized, early disseminated, and late disease. • The objective clinical manifestations are thought to be due to an inflammatory response to live spirochetes or to their antigens. Subjective Data • Exposure to ticks • Constitutional symptoms of fatigue, anorexia, and headache may develop. • Expanding rash Objective Data • Early localized infection typically manifested by a single erythema migrans skin lesion, a flat to slightly raised, erythematous skin lesion (usually ≥5 cm in diameter) that is round or oval in shape, with central clearing(classic target or bull's-eye appearance). • Early disseminated infection is usually manifested by multiple erythema migrans skin lesions, by neurologic symptoms such as facial palsy, meningitis, or encephalitis, or by symptoms of carditis such as lightheadedness, palpitations, dyspnea, chest pain, or syncope. • Late disease usually manifested by arthritis atrophicans or atrophic dermatitis.

Common cause of alopecia (hair loss) in children

Tinea Capitis (Fungal infection of the scalp)

Severe Cyanosis evident at birth or shortly after suggest:

Transposition of the Great Vessels Tetralogy of Fallot Tricuspid Atresia Severe septal defect Severe pulmonic stenosis

Beau Lines

Transverse depression in nail bed Coronary Occlusion, Hypercalcemia, and Skin disease Grooves disappear when nail grows out

These valves have three cusps

Tricuspid, Pulmonic & Aortic (Semilunar valves)

Latex Allergy Type 1 Reaction

True allergic reaction caused by protein antibodies (IgE antibodies) that form as a result of interaction between a foreign protein and the body's immune system Subjective Data • Exposure to latex • Allergy to cross-sensitizing foods (e.g., banana, avocado, potato, tomato, kiwi) Objective Data • Local: urticaria (skin wheals), • Systemic: generalized urticaria with angioedema (tissue swelling), asthma, eye/nose itching and gastrointestinal symptoms, anaphylaxis (cardiovascular collapse)

CN 11 Spinal Accesory

Turn head, shrug shoulders, some actions of phonation

Webbing, excessive posterior cervical skin, or an unusally short neck is associated with

Turner syndrome - chromosomal anomaly.

What are the seven bones of the skull?

Two Frontal Two Parietal Two Temporal One Occipital

Brain receives blood supply from these:

Two Internal Carotid Arteries (Supply 80%) and two vertebral basilar arteries (Supply 20%). Accounts for 20% of cardiac output.

Cortical Sensory Function Testing

Two Point Discrimination Extinction Phenomenon Graphesthesia Point Location

Point of maximal impulse (PMI)

Typically noted at the left 5th IC Mid Clavicular in adults 4th IC medial to nipple in children. Diameter is < 1cm

T10 is found at what level

Umbillicus

Healthcare Inequalities

Unconscious Bias, Stereotyping, racism, Gender Bias, Limited English Proficiency all underly healthcare inequalities

Ataxia

Uncontrolled falling. Loss of body control.

Upper and Lower Motor Neuron Disease - Face

Upper Motor Neuron = Voluntary movements paralyzed, but emotional spared. (Laughing or crying) Lower Motor Neuron = All facial movements of affected side are paralyzed (Bells Palsy)

Pulmonic Regurgitation Murmur

Valve incompetence allows backflow from the pulmonary artery to the ventricle. Secondary to pulmonary HTN or bacterial endocarditis.

Tricuspid Regurgitation Murmur

Valve incompetence allows backflow from ventricle to atrium Caused by congenital defects, bacterial endocarditis (especially in intravenous drug abusers), pulmonary hypertension, cardiac trauma Holosystolic murmur heard at left lower sternum.

Artery / Vein Structure

Veins have valves to prevent backflow

Thrill during systole and 4th LIC =

Ventricular Septal Defect

Inner Ear

Vestibule Semicircular canals Cochlea

Posterior Column Tract

Vibration Deep Pressure Position Sense Stereognosis Point Location Two-Point Discrimination (Ascending Tract/Lower Motor Neuron Disorders)

Heave or a lift

Vigorous apical impulse LV Hypertrophy, Increase CO

Influenza

Viral infection of lung Cough Fever Malaise Headache Coryza - inflammation of mucous membrane in nose Mild Sore Throat Crackles Wheezes Rhonchi Tachypnea

Flucuant Node

Wavelike motion that is felt when the node is palpated Feels like it contains fluid Suggest suppuration from infection.

Trendelenburg sign

Weak hip abductor muscles The Trendelenburg test is a maneuver to detect weak hip abductor muscles. Ask the patient to stand and balance first on one foot and then the other. Observing from behind, note any asymmetry or change in the level of the iliac crests. When the iliac crest drops on the side of the lifted leg, this indicates the hip abductor muscles on the weight-bearing side are weak

Hyperthyroid

Weight Loss, Tachycardia, Bruit over thyroid. Confirm with labs - T4 and TSH

Lung Abscess

Well-defined, circumscribed mass defined by inflammation, suppuration, and subsequent central necrosis Malaise, fever, SOB Percussion dull Pleural friction rub Foul-smelling sputum

Children Developmental Milestones

What Age Attained: Smiling Head control in prone position grasping Transferring objectes between hands Rolling over Sitting Crawling Independent Walking Toilet trained Saying words like mama and dada

Drusen Bodies / Amsler Grid

When Drusen bodies are increasing in number use amsler grid to evaluate patients central vision. Distortion = macular degeneration

Reflex Apnea

When irritating and nausea-provoking vapors or gases are inhaled, there can be an involuntary, temporary halt to respiration.

Fixed Splitting

When unaffected by respiration. Large atrial septal defect or VSD with left to right shunting, or RV Failure

Cradle Transfer

While bending or squatting bedside the patient, put on arm under both of the patient's knees and the other arm around the back and under the armpits. Stand and carry the patient to the table.

Osteoporosis Risk Factors

White, Asian, Ntative American, NW European descendant Light Body frame, thin Increasing age Hx osteoprosis / previous fractures Nulliparous - woman who has never given birth Amenorrhea or menopause bfore 45 yrs age, postmenopausal Sedentary lifestyle, lack of excercise Constant dieting, inadequate calcium and vitmain D intake, excessive Carbonated soft drinks Scoliosis, RA, Cancer, MS, DM, Hypercortisolism, malabsorption, hypogonadism, hyperthyroidism Drugs that decrease bone density: Thyroxine, Corticosteroids, heparin, Lithium, anticonvulsants, antacids with aluminum. Cigarette smoking or heavy alcohol use

White Banding (Terry Nails)

Whitening of the proximal half to three-quarters of the nail bed. Cirrhosis, CHF, Adult onset DM, and age Transverse white bands cover the nail except for a narrow zone at the distal tip

Asymmetric Tonic Neck or "Fencing" Reflex (2-3 months old)

With the infant lying supine and relaxed or sleeping, turn his or her head to one side so the jaw is over the shoulder; observe for extension of the arm and leg on the side to which the head is turned and for flexion of the opposite arm and leg; turn the infant's head to the other side, observing the reversal of the extremities' posture; this reflex diminishes at 3-4 months of age and disappears by 6 months; be concerned if the infant never exhibits the reflex or seems locked in the fencing position; this reflex must disappear before the infant can roll over or bring the hands to the face.

Child pain scales

Wong Baker Faces Oucher Scale FLACC - for nonverbal children Do not compare child's expression to that on the pain scale. Go by what child points to.

T6 is found at what level

Xiphoid Process

Bacterial infection has this type of sputum:

Yellow, green, rust (blood mixed with yellow sputum), clear, or transparent purulent; blood streaked, sticky

Lymphangioma

a benign tumor formed by an abnormal collection of lymphatic vessels due to a congenital malformation of the lymphatic system

Epicondylitis or tenonities when

a boggy, soft or fluctuant swelling point tenderness at the lateral epicondyle or along the grooves of the olecranon process and epicondyles and increased pain with pronation and supination of the elbow are found

Children

a child may have an increased HR of 10-14 bpm for each celcius degree of temperature elevation. Mean decreases as child ages. Mean Heart Rates < 1 yr = 128-130 2-3 yrs = 116-119 4-5 yrs = 106-108 6-11 yrs = 77-88 12-19 yrs = 72-80 Respiratory Rate New born = 24-50 1 yr = 20-40 3 yr = 20-30 6 yr = 16-22 10 yr = 16-20 17 yr = 12-20

Osteoporosis

a decrease in bone mass that occurs when bone resorption is more rapid than bone deposition Loss of height or acute painful fracture decreased abdominothoracic space Most common fracture is hip, vertebrae, wrist. Most common in postmenopausal women Glucocorticoid excess and hypogonadism are also risk

What is the only clue in children that a critical cardiac malformation is present

a decrease in the percutaneous oxygen saturation Every infant should have pulse ox performed before discharge from newborn nursery

Gentle handshake during exam because..

a firm handshake may cause them significant discomfort if they have an injury or underlying arthritis

Clubfoot (Talipes Equinovarus)

a fixed congenital defect of the ankle and foot Intrauterine Compression / Genetic factors Obvious at birth Toes lower than heel

Ballottement

a palpation technique used in detecting or examining a floating object in the body

nonalcoholic fatty liver disease (NAFLD)

a range of conditions characterized by an accumulation of fat within the liver that affect people who drink little or no alcohol. those with this condition most commonly are middle-aged individuals who are obese and may also have diabetes and elevated cholesterol elevated AST and ALT x 2-3

Gibbus

a sharp, angular deformity associated with a collapsed vertebra due to osteoporosis

Venous and Carotid Pulsations

a wave - The upward a wave, the first and most prominent component, is the result of a brief backflow of blood to the vena cava during right atrial contraction. This peaks slightly before the first heart sound (S1). c wave - The upward c wave is a transmitted impulse from the vigorous backward push produced by closure of the tricuspid valve during right ventricular systole. v wave The upward v wave is caused by the increasing volume and concomitant increasing pressure in the right atrium. It occurs after the c wave, late in ventricular systole. x slope - The downward x slope is caused by passive atrial filling. This ends with the initiation of the v wave. y slope - The y slope following the v wave reflects the open tricuspid valve and the rapid filling of the right ventricle.

Seated with Arms over Head or flexed behind the neck position

adds tension to suspensory ligaments, accentuates dimpling, and may reveal variations in contour and symmetry

Cerebellum

aids motor cortex of cerebrum in voluntary movement. Processes sensory info from eyes, ears, touch receptors, musculoskeletal system. Reflexive control of muscle tone, balance, and posture to produce steady and precise movements.

Flaring of the alae nasi during inspiration is a sign of

air hunger

Crepitus

air in subcutaneous tissue from rupture in respiratory system or by infection with a gas producing organism.. Can be palpated and heard. This always results from a pathologic process.

Water Hammer Pulse / Corrigan Pulse

aka Collapsing pulse Caused by Patent Ductus Arteriosus or Aortic Regurg

Uremia (ammonia) smells like

ammonia

Senile Cardiac Amyloidosis

amyloid, fibrillary protein produced by chronic inflammation or neoplastic disease, deposition in the heart Causes HF Contractility may be reduced Subjective Data • Palpitations, lower extremity edema, fatigue, reduced activity tolerance Objective Data • Pleural effusion • Arrhythmia • Lower extremity edema • Dilated neck veins • Hepatomegaly or ascites • Electrocardiography or echocardiography shows small, thickened left ventricle; right ventricle may also be thickened.

SBIRT (screening, brief intervention, and referral to treatment)

an approach to identify and care for patients affected by alcohol and drug use

Tanner Staging

an evaluation for premature or delayed puberty in children.

Lung Apex Posteriorly

apice rises to the level of T1

Size of left and right ventricles at 1yr old

approximate adult ratio of 2:1

Infant Right and Left Ventricles

are equal in weight and muscle mass, bc the both pump blood into systemic circulation unlike in the adult heart

Melasma

areas of hyperpigmentation on the face and neck that are associated with pregnancy or hormonal variation. Found primarily in adult women, but can happen in men.

What separates the ulna and carpal bones

articular disc

The glenohumeral joint (shoulder) consists of

articulation between the humerus and the glenoid fossa of the scapula.

Radiocarpal joint consists of

articulation of the radius and the carpal bones

What does the tibiotalar joint (ankle) consist of

articulation of the tibia, fibula, and talus

Retractions of the lower chest occur with:

asthma and bronchiolitis

Retinitis Pigmentosa

autosomal recessive disorder in which the genetic defects cause cell death predominantly in the rod photoreceptors Patho: Deafness (Usher Syndrome), Paralysis of extraocular muscles Cardiac conduction defects, ataxia, dysphagia, intellectual delay. absence of VLDL Vey low density lipoprotein S/s: Earliest Symptom: Night Blindness Tunnel Vision, bumping into furniture Loss of vision is painless takes years to decades. Inspection: Optic Atrophy with waxy pallor, narrowing of arterioles, Peripheral Bone Spicule Pigmentation is the hallmark of advanced disease.

The metacarpohalangeal joints are palpated with

both thumbs

Cerebral Aneurysm

bruit over eye may be heard

How much do the kidneys enlarge during pregnancy?

by 1 cm in length

Senile Hyaline Plaque

by medial rectus muscle. Does not imply disease

Crepitus at delivery

can be common around fractured clavicle from difficult forcep delivery

Young Adult Chest Pain

can be from cocaine.. Cocaine causes tachycardia, HTN, Coronary arterial spasm with infarction, and pneumothorax.

Rheumatoid arthritis in pregnant patients

can be suppressed due to immune changes

Posterior Dorsal Tract

carries fibers for sensation of fine touch, two point discrimination, and proprioception

Infant Cardiac Examination

challenging bc of immediate change form fetal to systemic and pulmonary circulation Examine heart within first 24hrs then at 2-3 days of age.

Cyanosis in infants is a

characteristic of congenital heart defect arterial and venous blood mix

what causes the gallbladder to release bile?

cholecystokinin, produced in the duodenum Bile released into cystic duct

Duodenal Ulcer

chronic circumscribed break in the duodenal mucosa that scars with healing localized epigastric pain that occurs when the stomach is empty and relieved by food and antacids

S1 (Lub) is caused by

closure of AV valves (tricuspid and mitral)

S2 (Dub) is caused by

closure of the SL valves (pulmonary and aortic) Listen at the Base on Expiration

Lordosis

common in patients who are obese or pregnant

Cranial Bruits in children

common up to 5 yrs of age. if present after can indicate vascular anomalies or ICP

S3 and S4 in infant

commonly heard. Murmurs usually disappear at 48 hours of age.

Salivary Gland Tumor

commonly involves the parotid. Slow growing painless lumps Difficulty opening the mouth Tumors that are benign are usually smooth. Malignant are often irregular.

Curve of lumbar spine should be

concave

Audible expiratory grunt

consider lower airway obstruction or focal atelectasis

What is a common GI symptom in pregnancy?

constipation due to prolonged transit time GERD from relaxation of lower esophageal sphincter

White Matter of Spinal Cord

contains ascending and descending spinal tracts

Middle Ear

contains ossicles (Malleus, incus, and stapes), these transmit sound

Peristalsis

controlled by autonomic nervous system

Curve of the thoracic spine should be

convex

Lymph nodes in old age

decrease diminish in size and get fibrotic and fatty

Hodgkin Lymphoma

disease marked by chronic enlargement of lymph nodes spreading to other nodes in an orderly way Subjective Data • Painless enlarged lymph nodes • May have abdominal pain, sometimes fever • May have history of infectious mononucleosis Objective Data • Clinical presentation variable • Most commonly, painless enlargement of the cervical lymph nodes, often in the posterior triangle, that is generally asymmetric and progressive Hodgkin disease. Note the impressive extent of the enlargement. • Nodes sometimes matted and firm, almost rubbery • Usually asymmetric; may occasionally be enlarged in similar patterns on both sides of the body • Nodal size may fluctuate

Radial head subluxation (nursemaid's elbow)

dislocation injury caused by jerking the arm upward while the elbow is extended. Jerking pulls apart the elbow joint and tears the margin of annular ligament around the radial head into the joint common in children 1-4 yrs old

Aortic regurgitation murmur

early diastolic murmur-high pitched "blowing" Best heard with Pt sitting and leaning forward using diaphragm 2nd IC Austin-flint murmur is heard with bell Valve incompetence allows backflow from aorta to ventricle Caused by rheumatic heart disease, endocarditis, aortic diseases (Marfan syndrome, medial necrosis), syphilis, ankylosing spondylitis, dissection, cardiac trauma

Ballottement test detects

effusion in the knee With the knee extended, apply downward pressure on the suprapatellar pouch with the web or the thumb and forefinger of one hand, and then push the patella quickly downward against the femur with a finger of your other hand. If an effusion is present, a tapping or clicking will be sensed when the patella is pushed against the femur. Release the pressure against the patella, but keep your finger lightly touching it. If an effusion is present, the patella will float out as if a fluid wave were pushing it

Pustule

elevated, superficial lesion; similar to a vesicle but filled with purulent fluid. Ex: Impetigo, acne

Lymphadenopathy (adenopathy)

enlarged lymph nodes

Sobbing baby allows

evaluation of vocal resonance

Decreased or absent fremitus caused by:

excess air in the lung emphysema pleural thickening or effusion bronchial obstruction

Genu Recurvatum

excessive knee hyperextension - could indicate weakness of quadriceps

Angle between femur and tibia

expected to be < 15 degrees

Lung apex anteriorly

extends 4 cm above the first rib into the base of the neck

Positional plagiocephaly

external deformation. Common among infants with torticolls or those who prefer one head position for sleep

FLACC Scale

face, legs, activity, cry, consolability

Confrontation Test

for peripheral vision

Intestinal obstruction smells

foul or feculent

An inflamed metatarsophalangeal joint of the great toe should make you suspect

gouty arthritis

Alopecia

hair loss

Bronchovesicular sounds

heard over major bronchi. Moderate pitch and intensity

Systolic ejection murmur location in pregnant pt

heard over the pulmonic area in 90% of patients

Situs inversus

heart and stomach are placed to the right and the liver to the left

An incomplete or soft in the center umbilical ring can indicate

herniation

Fine Crackles

high-pitched, discrete, discontinuous crackling sounds heard during the end of inspiration; not cleared by a cough

Coarse, dry, brittle air may indicate

hypothyroidism

When do you perform nipple compression

if patient reports spontaneous nipple discharge Unilateral discharge from a single duct is a concern.

Best position to hear low pitched filling sounds in diastole

in Left lateral recumbent, use bell of stethoscope

Pregnancy Cardiac Output

increased 30-40%, reaches highest level between 25-32 weeks gestation which is maintained until term. CO return to normal 2 weeks after delivery

Pregnancy

increased hormone levels contribute to elasticity of ligaments and softening of the cartilage in the pelvis at about 12-20 weeks Results in increased mobility of the sacroiliac, sacrococcygeal and symphysis pubis joints.

Costal angle in pregnancy

increases from 68.5 to 103.5 degrees. Diaphragm at rises 4cm higher than usual.

Alveoli Development - Infants

increases rapidly during first 2 years. Then slows down by 8 yrs.

Pregnancy plasma volume

increases the blood volume by 40-50% in pregnant pt Reaches max by 30th week Can increase up to 70% in twin pregnancy. Increases HR and SV.. which leads to increased LV wall thickness and mass

Endocardium

innermost layer, lines the chambers of the heart and covers the heart valves and the small muscles associated with opening and closing of these valves.

Eye Muscles

innervated by: CNs III (oculomotor) CN IV (trochlear) CN VI (abducens) The superior oblique is the only muscle innervated by the trochlear nerve CN IV and the lateral rectus muscle is the only muscle innervated by the abducens nerve CN VI.

Abdomen Exam Sequence

inspection, auscultation, percussion, palpation Pay attention to pt comfort level or degree of distress

Caput Succedaneum

is subcutaneous edema over the presenting part of the head at delivery of infant. Most common form of both trauma usually occurs over the occiput

Cerebral Cortex

is the gray outer layer, and houses higher mental functions responsible for general movement, visceral functions, perception, behavior, and their integration,

Hallux Valgus

lateral or outward deviation of the great toe Bursa often forms at the pressure point and if inflamed can become a painful bunion

In a shorter person the heart tends to

lie more to the left and more horizontally

Joints are held together by

ligaments

Heart Anatomy

located from third to sixth costal cartilages behind the sternum Broader upper portion called the Base Narrow lower tip is called the Apex

Left Ventricular size is better judged by the

location of the apical impulse

Excoriation

loss of the epidermis; linear hollowed-out, crusted area Ex: Abrasion or scratch, scabies

Coarse Crackles

loud, bubbly noise heard during inspiration; not cleared by a cough

Rhonchi (sonorous wheeze)

loud, low, coarse sounds like a snore most often heard continuously during inspiration or expiration; coughing may clear sound (usually means mucus accumulation in trachea or large bronchi)

A hard fixed painless node suggests

malignant process

Lymphatic Filariasis (Elephantiasis)

massive accumulation of lymphedema throughout the body; most common cause of secondary lymphedema worldwide Results from widespread inflammation and obstruction of the lymphatics by the filarial worms Wuchereria bancrofti or Brugia malayi; transmitted by mosquitoes Travel to infected areas: Asia, Africa, the Western Pacific, India, Philippines

Diphenylhydantoin

medication that can cause node enlargement.

Thyroglossal Duct Cyst

midline in neck may retract when tongue is protruded May simulate lymph node enlargement.

Linea Alba

midline tendinous seam joining the abdominal muscles

What environmental factor can prolong cap refill?

moderately cool room temp

Grade 3 Murmur

moderatley loud

Splitting in pregnancy

more audible to due increased blood volume and extra effort. Expected finding. 4th heart sound abnormal in pregnant pt.

Patent Ductus Arteriosus (PDA)

more common in premature infants before 30 weeks

Anterior fontanel measurements in infants

no more than 4-5cm in infants under 6 months Closes completely by 12-15 months

Do nodes pulsate?

no, arteries do

Slight deviation of trachea to right is

normal

Babies are this type of breather

obligate nose. Periodic breathing is common with pauses as long as 10-15 seconds

Stridor in newborn

obstruction in upper airway. When accompanied by a cough, hoarseness and retraction this is a serious problem. Floppy epiglottis, congenital defect, croup, edema from infection

Slipped Capital Femoral Epiphysis

occurs when the head of the femur becomes displaced due to a separation at the growth plate ' 8-16 yrs old, girls affected younger Usually unilateral, left side more than right Knee pain and limp Confirm with Xray Reduced internal hip rotation

Tuberculosis Lymph Nodes

often felt in the cervical chains, are usually body temp, soft, matted, and not tender or painful

Pulmonary ejection click is best heard when and where?

on expiration at the 2nd Left IC. Seldom heard on inspiration

Wharton Duct

open on each side of the frenulum under the tongue. Drain saliva from the submandibular and sublingual glands to the sublingual caruncle at the base of the tongue.

Pes Valgus

out-toeing

Appendages

outgrowths of the skin that include: Eccrine sweat glands - open directly onto the surface and help regulate body temperature through sweat excretion. Distributed through out body except at lip margins, eardrums, nail beds, inner surface of the prepuce, and glans penis. Apocrine sweat glands - specialized structures found only in the axillae, nipples, areolae, anogenital area, eyelids, and external ears. They secrete an oily fluid containing protein, carbs, and other substances. Secretions from these glands are odorless; body odor is produced by bacterial decomposition of apocrine sweat. Sebaceous glands - Secrete sebum, a lipid rich substance that acts as a lubricant and moisturizer for skin and hair. Secretion stimulated by sex hormones (testosterone) and varies according to hormonal levels throughout life. Hair - consists of root and shaft which sit in follicle. Melanocytes in the follicle synthesize pigment. Two types of hair: Vellus hair - short and fine, soft, and nonpigmented Terminal hair - Coarser, longer, thicker, and usually pigmented Each hair goes through cyclic changes: anagen (growth) catagen (atrophy) telogen (rest) exogen (shed) Nails - appendages of the skin which are composed of epidermal cells converted to hard plates of keratin. Nail bed lies on the periosteum. White crescent shape is end of nail matrix which is the site of nail growth. Cuticle (eponychium) Paronychium ( soft tissue surrounding nail border)

Graves Disease

overactive thyroid more common in women Palpitations Heat intolerance Weight loss Fatigue Increased appetite, tachycardia Diffuse thyroid enlargement exophthalmos

Loss of thrust may be related to

overlying fluid or air or to displacement beneat the sternm

Muted S2

overlying tissue, fat or fluid.

Surgically augmented breast

palpate as usual Capsular contraction may cause the breast to feel hard Palpate with finger pads bc they are more sensitive than your finger tips.

Bell Palsy

paresis, or paralysis, of one side of the face - Herpes Simplex or Herpes Zoster viral Subjective Data • Rapidly progressive muscle weakness on one side of face (over 2-3 days) • Feeling of facial numbness Objective Data • Facial creases and nasolabial fold disappear on affected side • Eyelid will not close on affected side and lower lid sags; leads to eye irritation; eye may tear excessively • Food and saliva may pool in affected side of mouth • Facial sensation is intact.

Ascites

pathologic increase in fluid in peritoneal cavity

Corticospinal (Pyramidal) Tract

permits skilled, delicate, and purposeful movements

To evaluate thoracic expansion:

place thumbs along spinal process at 10th rib with palms touching posterolateral surface Note any asymmetry. Might not be seen in barrel chest or COPD. Chest already expanded

Locate temporomandibular joint by

placing fingertips just anterior to the tragus of each ear

Infant Purplish Plethora is associated with

polycythemia (increased red cell mass)

Craniosynostosis

premature fusion of one of the sutures.

Sputum in more than small amounts usually indicates

presence of disease

Supernumerary nipples

presence of more than one nipple on a breast Located along the mammary ridge / milk line Can be associated with a congenital renal or cardiac anomaly particularly in whites.

Child Ethmoid and Sphenoid Sinus

present at birth but very small. Sphenoid present by age 5 Frontal by age 7-8

Brachycephaly

preterm infants often have long narrow heads bc their soft cranial bones become flattened with positioning and the weight of the head.

postpolio syndrome (PPS)

progressive muscle weakness in a person previously affected by polio after 10 or more years

intussusception

prolapse or telescoping of one segment of intestine into another, causing intestinal obstruction child inconsolable with legs and knees flexed (doubled up) with pain Sausage shaped mass palpated in RUQ or LUQ whereas RLQ feels empty (Dance Sign)

Pigeon Chest (Pectus Carinatum)

prominent sternal protrusion

Best position to hear relatively high pitched murmurs

pt sitting up leaning slightly forward and preferably during expiration.

Two Circulatory Systems

pulmonary and systemic

Wilms tumor (nephroblastoma)

rapidly developing malignant neoplasm of the kidney that usually occurs in children. usually appears at 2-3 years of age. Painless enlargement

Newborn Coughing

rare, and considered a problem Sneezing is ok - clears the nose

Parietal Lobe

responsible for processing sensory data as it is received. Assists with interpretation of sensations - pain, pressure, temperature, size, shape, texture, two point discrimination, visual, taste, smell, hearing sensations.

ST Segment and T Wave is the

return of stimulated ventricular muscle to a resting state (Ventricular repolarization)

Which kidney is lower?

right kidney, due to large heavy liver above it

Squamous Cell Carcinoma

second most common type of skin cancer. more aggressive This malignant tumor arises in the epithelium and has squamous differentiation. • Lesions occur most commonly in sun-exposed areas, particularly the scalp, back of hands, lower lip, and ear; the rim of the ear and the lower lip are especially vulnerable. Subjective Data • Persistent sore or lesion that has not healed or that has grown in size • May have crusting and/or bleeding Objective Data • Elevated growth with volcano-type pattern • Wartlike growth; may have crusting, may bleed • Scaly red patch with irregular borders may have crusting, may bleed • Open sore; may have crusting

Aortic Valve Area

second right intercostal space at right sternal border

Apnea can be caused by

seizures, CNS trauma, or hypoperfusion, obstructive sleep disorder, drug ingestions.

Chronic cough indicates

significant anatomic change. ie. Tumor, cavitation, or bronchiectasis.

Valve opening is a

silent event

During passive range of motion the muscles should have

slight tension

Diverticular Disease

small bulges or saclike outpouchings through colonic muscle in the intestine • With diverticulitis (when diverticula become inflamed), may experience left lower quadrant pain, anorexia, nausea, vomiting, and altered bowel habits (usually constipation)

U Wave is a

small deflection rarely seen just after the T wave, thought to be related to repolarization of the Purkinje Fibers. They are commonly seen with Bradycardia. Can also be seen with electrolyte abnormalities, hypothermia, and hypothyroidism

Irregular cough is caused by:

smoking, early CHF, foreign body or irritant, tumor compressing bronchial tree

Craniotabes (ping-pong ball skull)

softening of outer table of skull.. like pressing on a ping pong ball. snapping senation Prematurity RIckets Hydrocephalus Marasums Syphillis Thalassemia

Neuroblastoma

solid malignancy of embryonic origin in the peripheral sympathetic nervous system Presents as an asymptomatic abdominal mass ina young child Firm fixed non tender irregular and nodular abdominal mass that crosses the midline

Amphoric Breathing

sound of blowing across mouth of a bottle Heard with a large stiff walled pulmonary cavity tension pneumo bronchopleural fistual

In the tanner system when does the onset of menses usually occur

stage 3 - unusual for it to occur before this stage

Paroxysmal nocturnal dyspnea

sudden onset SOB after period of sleep. Sitting upright helps

Precordial Catch

sudden, sharp, relatively brief pain that does not radiate, occurs most often at rest, is unrelated to exertion, and may not have a discoverable cause

Lymphedema

swelling due to an abnormal accumulation of lymph fluid within the tissues Painless swelling of a limb

Tracheal Tug Sign

synchronous with pulse, suggest present of aortic aneurysm

Most joints are

synovial, enclosed by a fibrous capsule. Contains ligaments and cartilage cover the ends of opposing bones

Guillain-Barre Syndrome (GBS)

temporary paralysis caused by an autoimmune attack on peripheral myelin, causing weakness and usually ascending paralysis of the limbs, face and diaphragm • Distal weakness, usually bilateral and symmetric, and diminished reflexes in ascending pattern • Ataxia, progressing to flaccid paralysis • Facial nerve weakness (Bell palsy), diplopia • Dysphagia, difficulty handling secretions • Respiratory distress • Lumbar puncture reveals increased protein in cerebrospinal fluid.

A persistently thickend Achilles tendon may indicate

tendonitis that can develop with spondyloarthritis or from xanthelasma of hyperlipidemia

Muscles are attached by_____________ and cushioned by ___________________

tendons, cartilage

Percussion Hammer (reflex hammer)

test deep tendon reflexes

What ligament protects the knee from hyperextension?

the ACL Anterior Cruciate Ligament

Muscle Fasciculations occur because

the muscles motor neuron is damaged

Craniosynostosis

the premature fusing of the skull bones abnormal skull, usually not accompanied by intellectual disability watch for ICP

Chronic Pancreatitis

the recurring destruction of the pancreatic tissue that results in atrophy, fibrosis, scarring, and the development of calcification within the gland Constant unremitting abdominal pain, weight loss, and steatorrhea

At what level does the aorta branch into the iliac arteries?

the umbilicus

What are T Lymphocytes?

they are marrow derived, they mature in the Thymus Can discriminate between health and abnormal cells. They also control immune response brought about by B lymphocytes. T cells life span is about 100-200 days

Epicardium

thin outermost muscle layer, covers the surface of the heart and extends on the great vessels.

Children use this for respiration until 6-7 yrs

thoracic intercostal musculature

HIV Risk

transfusion with infected blood or blood concentrates like factor 8 and factor 9 between 1978 and 1985

Pons

transmits info between brainstem and cerebellum. Motor info from cerebral cortex is relayed to the contralateral cerebellar hemisphere

Horizontal jerking of the head indicates

tremor

Tape measure

use one that is 7-12 mm wide

Photoscreening

used to detect amblyopia (lazy eye) and strabismus in children.

Blood drains from the brain through:

venous plexuses and dural sinuses that empty into the internal jugular veins

When heart is beating 68-72 bpm the

ventricular systole is shorter than diastole

Bulla

vesicle greater than 1 cm in diameter Ex: blister, pemphigus vulgaris

Croup

viral infection, barking cough.

Lea or HOTV

visual acuity test beginning at 4 years old Children up to 5 stand 10ft away Children over 6 can stand at 10 or 20ft away

Brushfield Spots

white spots / salt and pepper speckling on the iris associated with Down Syndrome

When does a venous hum occur?

with increased collateral circulation between the portal and systemic venous systems

Tactile fremitus is increased

with lobar pneumonia

Chest pain doesn't generally originate in the heart when:

• There is a constant achiness that lasts all day. • It does not radiate. • It is made worse by pressing on the chest wall. • It is a fleeting, needle-like jab that lasts only a few seconds. • It is situated in the shoulders or between the shoulder blades in the back. Other causes: pulmonary embolism, pleurisy, aortic dissection, tumor

Risk factors for severe hyperbilirubinemia in infants of 35 or more weeks gestation

• Total serum bilirubin (TSB) or transcutaneous bilirubin (TcB) greater than 75th percentile • Jaundice observed in the first 24 hours • Blood group incompatibility with positive direct antiglobulin test, other known hemolytic disease (e.g., G6PD [glucose-6-phosphate dehydrogenase] deficiency), elevated ETCO c (End-Tidal Carbon Monoxide concentration) • Gestational age 35 to 36 weeks • Previous sibling received phototherapy • Cephalohematoma or significant bruising (e.g., from vacuum-assisted delivery) • Exclusive breast-feeding, particularly if nursing is not going well and weight loss is excessive • East Asian race

Past medical history: Pregnant patients

• Weeks of gestation or postpartum • Hygiene practices • Presence of skin problems before pregnancy (e.g., acne may worsen) • Effects of pregnancy on preexisting conditions (e.g., autoimmune disorders may remit; condylomata acuminata commonly become larger and more numerous)