H&P Test 1

What test do you use to test eye movements?

6 cardinal fields of gaze. Form an H with your movements and pause at each point. Make sure to test convergence, so at the end bring point towards bridge of the nose. -look for nystagmus and lid lag

What is considered a normal heart rate?

60-100 BMP

The length of the bladder of the bp cuff should be what percentage of the circumference of the patient's arm?

80%

What is considered normal body temperature?

98.6 F (37C)

What is considered bradypnea?

<10-12 Respirations/Minute

What is considered a normal blood pressure?

<120/<80 mmHg

what is considered bradycardic?

<60 BPM

What is considered tachycardic?

>100 BPM

What is considered tachypnea?

>20 Respirations/minute

What type of exam is the only exam where the order of inspection, auscultation, percussion and palpation matter? and what should the order be?

Abdominal Exam; you want to auscultate before you do any percussion or palpation and do any sort of physical manipulation

What cranial nerve(s) are you testing with the uvula and palate?

CN IX and X

What cranial nerve is tested for corneal sensitivity?

CN V (Trigeminal Nerve)

What cranial nerve is tested when testing the corneal reflex motor response is to blink?

CN VII (Facial)

What CN are you testing during auditory acuity in the ear?

CN VIII

What cranial nerve are you testing with the tongue?

CN XII

What types of diseases do you mainly see nail clubbing with?

Cardiovascular or pulmonary diseases

How do you test for strabismus? What is indicative of a positive strabismus test?

Cover test; Strabismus is present if the eye that is not occluded shifts to refixate on the target when the fellow (previously fixating eye) is covered

What is dried exudate celled?

Crust

What does CAGE stand for?

Cutting down (ex: Have you ever felt you needed to cut down on your drinking?) Annoyance (ex: Have people Annoyed you by criticizing your drinking?) Guilty Feelings (ex: Have you ever felt Guilty about drinking?) Eye Opener (ex: Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?)

What type of percussion sound will you hear with organs/tissue?

Dull, soft, thud like

What are the 5 external eye components?

Eyelids, conjunctiva, lacrimal gland, eye muscles, bony skull or orbit *think: MELCOB muscles, eyelids, lacrimal gland, conjunctiva, orbit or bony skull

A blood pressure cuff that is too small will give you what type of reading?

Falsely high

A blood pressure cuff that is too big will give you what type of reading?

Falsely low

What 2 tests can you perform to test for auditory acuity?

Finger Rub and Whisper Test

During an ophthalmoscopic examination, what is the first thing you should locate?

First, locate the optic disc.

What type of assessment has a limited history and ROS?

Focused Assessment

What is the most common viral infection of the nails?

Human papillomavirus is the most common viral infection of the nail; this presents as warts

what type of percussion sound will you hear with excessive air?

Hyper-resonant, very loud, booming

You see arterial nicking, tapering and banking on your fundoscopic exam, what is this indicative of?

Hypertension

What 2 diseases are retinopathy most commonly associated with?

Hypertension and Diabetes Mellitus FE: neovascularization, hemorrhage, pigment changes, and exudates (hard/soft/cotton wool spots)

When testing for patency? Do you ask the patient to inhale or exhale?

INHALE!!!!!

What is onychomycosis? What usually causes it?

Nail thickening and debris dermatophyte infection (Trichophyton rubrum)

Should pupils constrict or expand when looking at near objects?

Pupils should constrict with near vision

what are the size guidelines for purpura and petechiae?

Purpura: >5mm Petechiae: <5mm

If the patient has longitudinal erythronychia and they are monodactylous, what should you do? What may this be associated with?

REFER FOR BIOPSY! this may be associated with benign or malignant nail tumors

What is it called when superficial epidermal cells are dead and cast off from the skin?

Scale

What type of data is what the patient tells you, what the patients family members tell you, what you read in past medical charts? This is also the patient's symptoms.

Subjective data

You go back into a patient's chart and look at previous labs and diagnostic testing. What type of data is this?

Subjective data. Only the lab tests YOU conduct is objective.

What is *Paronychia* and what causes it?

Superficial infection of nail folds adjacent to the plate Causes: Staph aureus, Strep species, and pseudomonas aeruginosa

What eye muscle rotates the eye inward and downward?

Superior Oblique

What eye muscle move the eye upward or elevates the eye?

Superior rectus

True or False: any defect in visual field should prompt a more through evaluation (i.e., ophthalmology)

TRUE

True or false: sometimes what a patient tells you and how they say it can be used as objective data?

TRUE. Sometimes what a patient tells you and how they say it can be used for objective data (ex: if they have slurred speech, pressured speech, flight of ideas)

On your fundoscopic exam, the vein appears to taper down on either side of the artery. What is this called?

Tapering

What part of the growth cycle in the hair is the resting phase?

Telogen phase; the hair phase is completely at rest and the club hair is completely formed.

what BMI is considered normal?

18.5-24.9

If blood pressure is elevated, how many readings should you take with at least how many minutes in-between?

2 readings; at least 2 minutes in between

How many mmHg should you deflate/second when taking a blood pressure?

2-3mmHg

How far should the lower border of the blood pressure cuff be from the antecubital crease?

2.5 cm

What does 20/20 vision mean? What about 20/10?

20 is the distance of patient from chart/distance the average patient can read the same line Example: with 20/10, the patient is seeing at 20 feet, what the average patient can see at 10 feet.

What BMI is considered overweight?

25-29.9

How many drinks/day and drinks/week can women and men above 65 have before it increases your risk for misuse?

3/day 7/week

How long should the patient refrain from smoking, caffeine or exercise before taking their blood pressure?

30 minutes

When you stop feeling a pulse on a palpated pressure, how many mmHg should you add when pumping up the cuff?

30 mmHg

What BMI is considered obese?

30 or greater

How many drinks/day and drink/week can men under 65 have before it increases your risk for misuse?

4/day 14/week

The width of the bladder of the bp cuff should be what percentage of the circumference of the patient's arm?

40%

How long should the patient sit with both their back and feet supported before taking their blood pressure?

5 minutes

How many Hz is a tuning fork?

512 Hz; normal speech is 300-3,000 Hz

What are Terry Nails? What disease most commonly associated with Terrys Nails?

nails appear white with dark red tip; the lunula is not visible; cirrhosis

what is a hordeolum?

obstructed meibomian gland or eyelash follicle

What is a horizontal defect?

occlusion of a branch of the CRA

What is exotropia?

outward turning of the eye

When do you want to test visual acuity?

prior to manipulating or shining light on/in eyes

What is exopthalmos?

protrusion of the eyeball

When looking through an ophthalmoscope, if you are looking at the patient right eye, what eye should you be using to look through the device?

right eye use the same eye as the patient to avoid nose-to-nose contact

What are blanching skin conditions suggestive of?

Vascular inflammation

What is strabismus?

anomaly of ocular alignment (aka lazy eye)

What is Onychogryphosis also known as, and what is it caused by?

"rams horn nail" usually in older, neglected individuals. causes include self-neglect, poor fitting shoes/trauma, and peripheral vascular disease

What 5 things make up the fundus?

*think FROMB Fovea Retina Optic Disc Macula Blood Vessels

How much lower is an oral temperature than core/rectal temperature?

0.4-0.5 degrees C

How much does your temperature fluctuate throughout the day?

1 degree C

How much higher is an oral temperature than an axillary temperature?

1 degree C

Your patient has hypertension: what will you see on a fundoscopic exam?

1. Narrowing of blood vessels 2. Fullness: when the BV become narrowed, they get full and this can change the light reflex. This is known as "copper wiring" 3. Narrowed Wall: this prevents us from seeing blood on the outside of the light reflex and is known as "silver wiring"

Name the 10 lymph nodes to palpate on the head and neck.

1. Occipital 2. Pre auricular 3. Post auricular 4. Tonsillar 5. Submandibular 6. Submental 7. Posterior cervical 8. Superficial/Anterior cervical 9. Supraclavicular 10. Cervical nodes deep to the SCM

What type of questions can you use to determine alcohol/illicit drug misuse?

CAGE questions

What are the two types of hair follicles? What are their differences?

1. Terminal: these are longer and thicker and extend into the subcutaneous fat 2. Vellus: these are shorter, finner, and thicker and only extend into the dermis

How much lower is an axillary temperature than rectal/core temperature?

1.4-1.5 degrees C

What is considered a normal respiratory rate?

10-12 to 20

What is considered febrile?

100.4 F (38C)

What is considered an elevated blood pressure?

120-129/<80 mmHg

What is considered hypertension stage 1?

130-139/80-89

What cranial Nerve is tested for visual acuity?

CN II (optic)

How is a nodule different that a papule?

A nodule is larger and deeper than a papule.

BC vs AC in SNHL

AC>BC in SNHL

When performing an otoscopic exam, should you look into the speculum before or after inserting it into the ear?

AFTER; you want to insert the speculum before looking through the scope

Is the hair cycle in humans synchronous or asynchronous?

ASYNCHRONOUS. The hair follicle undergoes growth and regression cycles.

How many incorrect numbers/letters during the whisper test are considered abnormal? What should you do in the event of abnormal results?

Abnormal: 4 out of the 6 letter/number combinations are incorrect; Abnormal results: conduct further testing by audiometry.

An established patient will have what type of encounter?

An established patient can have either a focused or comprehensive encounter.

What phase of the growth cycle in hair is the growing phase?

Anagen Phase

I inspect my patients iris and pupils for shape and size. I notice that one pupil is 7mm and the other pupil is 4mm. What is this condition called?

Anisocoria

What shape is described as ring-like with central clearing?

Annular

Where is the carotid artery best found? What can you ask the patient to do if you cannot hear it?

Anterior margin of the SCM; you can ask the patient to hold their breath and turn their head slightly away from you

What is the term used to describe no obvious trauma or acute deformities to the head?

Atraumatic (AT)

What is decreased skin thickness due to thinning?

Atrophy

BC vs AC in CHL

BC>AC or BC=AC

On your fundoscopic exam, the vein appears to be twisted on the distal side of the artery. What is this called?

Banking

What color skin lesions is especially concening?

Blue-black, white, and red

What is the Rinne test testing for?

Bone conductive vs. air conduction

What artery do you center the bladder of the blood pressure cuff over when taking a blood pressure?

Brachial Artery

What is considered rough and dull surfaces of nail palate?

Brittle Nails; this is a common nail disorder predominately affecting women over the age of 50 years old

If the thyroid gland is enlarged, what should you auscultate and look for?

Bruits

How do you check an orthostatic blood pressure?

Check the patient's blood pressure lying supine (have them lay for 3-10 minutes) Check the patient's blood pressure standing (check within 3 minutes of standing)

What is a subungual hematoma?

Collection of blood under the nail plate

What type of encounter do new patients typically have? These have a complete ROS.

Comprehensive

What type of assessment includes more than just the main reason for the visit? This type of assessment is typically used for new patients that are getting established.

Comprehensive Assessment

How do you test visual fields? How is this test performed?

Confrontation -position yourself directly in front of the patient, a couple feet away -have the patient cover one eye and you cover the corresponding side eye (pt.s left eye= examminer right eye) -position your finger halfway between you and the patient and move from outside visual field to in and note ay deficits -do this for each eye and all 4 quadrants

I shine light in the left eye and the right pupil constricts. What is this called?

Consensual response to light

What is miosis of the pupil?

Constriction of the pupil <2mm.

What is drusen?

Dead retinal pigment epithelial cells seen in normal aging and age related macular degeneration these are yellowish round spots that vary from tiny to small

What layer of the skin does a fissure extend into?

Dermis

What type of lighting is preferred for ophthalmoscopic examination?

Dim room lights; this is important because we require adequate pupillary dilation

What part of the ophthalmoscope allows for change in focal length and adjust for refractory differences in patient and observer?

Diopter dial (lens disc)

I shine light into the left eye and the left pupil constricts. What is this called?

Direct response to light

When testing the iris and pupil, you should test for response to light. What is direct response and what is consensual response?

Direct: pupil constricts when you shine light in it Consensual: opposite pupil constricts

Which two sinuses do you palpate to check for tenderness?

Frontal and Maxillary

What is the inside, back surface of the eye that is made up of the retina, optic disc, macula, fovea and blood vessels?

Fundus

What should you do with the auricle when expecting the ear?

Grasp the auricle, pull it upward, backward, and slightly away from head

What is defined as repetitive picking at the proximal nail fold?

Habit tic deformity

What do bruits sound like?

Harsh, blowing sounds associated with abnormal blood flow

What type of encounter does screening tests and lifestyles issues?

Health Maintenance

What is herpetic whitlow? Who is this commonly seen in?

Herpetic whitlow is herpes simplex virus involving the skin or periungual area; this is typically seen in children who suck their finger during primary herpetic gingivostomatitis

What eye muscle rotates the eye outward and upward?

Inferior Oblique

What eye muscle moves the eye downward (depression)

Inferior Rectus

What turbinates will you see when inspecting the nose?

Inferior and Middle you do not see the superior turbinate

If you palpate the thyroid gland and it has a gritty sensation, what is that suggestive of?

Inflammatory proces

What part of the aperture dial on an ophthalmoscope should we use?

Large: usually use this one

What eye muscle moves the eye outward away from the nose?

Lateral Rectus

What are you palpating for in the mouth?

Lesions and tenderness

What is skin mobility? In what types of conditions will you see decreased skin mobility?

Lift a fold of skin and note ease with which it lifts Decreased in edema and scleroderma

What eye muscle moves the eye inward toward the nose?

Medial Rectus

What is the ABCDE rules and what does it raise suspicion for?

Melanoma; Asymmetry Border Irregularity Color (esp. blue-black, white and red) Diameter (>6mm) Evolving

What is nail pitting? and what is it associated with?

Nail pitting is focal areas of abnormal keratinization of the nail matrix that produce foci of parakeratotic cells in the dorsal nail plate as it grows beyond the cuticle. It is associated with psoriasis, alopecia areata, and eczema.

On your fundoscopic exam, the vein appears to stop abruptly on either side of the artery. What is this called?

Nicking

Will petechiae or purpura blanch under pressure?

No because it is hemorrhagic.

What are non-blanching skin conditions suggestive of?

Non-vascular or hemorrhagic

What is the typically time for a capillary refill?

Normal is under <2 seconds

Term used for a normally developed head, face and skull

Normocephalic (NC)

What shape is described as coin-like with no central clearing? Can often be hard to distinguish between this shape and circular.

Nummular

What type of data is labs/diagnostic tests that you perform at the time of the visit?

Objective data

What type of data is your findings/signs?

Objective data

What is a horizontal defect of the eye?

Occlusion of a branch of the central retina or optic nerve that causes a horizontal defect

If you cannot find the thyroid gland, what can you offer the patient to help you?

Offer them water to swallow during exam; the thyroid should rise freely with swallowing

What 2 patient populations should you never forget to counsel regarding sexual health?

Pediatrics and geriatrics pediatrics: counsel early and start asking questions geriatrics: never stop counseling (highest rate of STDs in nursing homes)

Besides palpating sinuses, what else can you do to check for sinus tenderness?

Percussion

What does PERRL or PERRLA stand for?

Pupils Equal Round Reactive to Light Accommodation (near reaction)

What type of encounter typically involves determining the patient's quality of life, response to treatment, compliance to treatment, and self management

Ongoing chronic problem follow up

What do you use to inspect the inside of the nares?

Otoscope with the largest ear speculum

What is the most common type of longitudinal melanonychia due to?

PHYSIOLOGIC. Mainly seen in darkly pigmented skin as multiple bands affecting multiple nail beds

What test can you do to determine how high to inflate the blood pressure cuff?

Palpated Pressure **palpate the radial artery, pump it up until you can no longer feel a pulse, add 30 mm Hg to it **wait 15-30 seconds and then take their blood pressure

What is the hole through which light enters?

Pupil

What is longitudinal erythronychia?

Pink to red streak in the nail plate that corresponds to band of thinned, more transparent nail plate

If you press into an area that has edema and the depression persists after release, what is this called?

Pitting 0= no pitting 4+: more severe; this stays pitted for more than 2 minutes

What type of encounter is useful for specific complaints (ex: sore throat) and has a limited components to history?

Problem oriented

What causes green nail syndrome?

Pseudomonas aeruginosa; this infection deposits pyocyanin in the nail plate causing a blue-green pigment

Which route of taking temperature is closest to core temperature?

Rectal Temperature

What is a splinter hemorrhage?

Red to black, small thin longitudinal line under the nail plate; if they are distal then they are more likely a result of trauma; if they are proximal then they are more likely a result of systemic disease

What part of the ophthalmoscope controls brightness?

Rheostat

With nail clubbing, what do you see a loss of?

Schamroth Window; you should have a diamond shaped space between nail beds so loss of this window is indicative of clubbing Nail clubbing: increased distal mass at the tips of the fingers and increased longitudinal and transverse nail plate curvature

What are lesions that represent evolved changes from the primary disorder?

Secondary Lesions

You perform transillumination testing and no light is transmitted, what does this suggest?

Sinusitus

How should the thyroid gland feel when palpated?

Small, smooth and free of nodules

Visual acuity testing done in the office is often done using what? How do you preform this test?

Snellen (wall) chart, which tests distance vision (20 feet) test each eye individually, opposite eye covered, and at appropriate distance

What is skin turgor? In what types of conditions will you get decreased skin turgor?

Speed with which skin returns to normal; typically 1-2 seconds Decreased skin turgor in dehydrated patients

What is koilonychia? What disease is this commonly seen in?

Spoon shaped nails often seen as an occupational change or rarely in iron-deficiency

What is another name for the parotid duct?

Stensons duct

What is transillumination testing?

The examiner is in a dark and uses a bright light against the frontal/maxillary sinus. Normal: light is transmitted No light transmission suggests sinusitus

In unilateral conductive hearing loss, which ear will be louder?

The impaired ear with conductive hearing loss will be louder

What control the size of the pupil?

The iris controls the size of pupil, controlling the amount of light entering the eye

What are beau lines in the nails?

These are transverse grooves. These are a temporary arrest of the proximal nail matrix proliferation that appear as transverse grooves.

What are longitudinal grooves in the nails?

These lines go longitudinally rather than horizontally as seen with transverse grooves. Longitudinal grooves are a compression of the nail matrix.

What is bitemporal hemianopsia?

This is loss of vision in the outside half of each eye. Both temporal regions (outside region) of each eye loose vision.

What is considered a normal percussion sound?

Tympanic or resonant loud and drum-like

Do Weber and Rinne test for unilateral or bilateral hearing loss?

Unilateral; Any hearing deficit should be considered for referral for audiometry testing! Tuning fork tests do not distinguish normal hearing from bilateral sensorineural loss or from mixed conductive-sensorineural loss

What 2 tests can be conducted to determine unilateral hearing loss?

Weber and Rinne

What is another name for the submandibular duct?

Whartons duct

Will telangiectasia blanch with pressure?

Yes, because it is vascular

What is testing for patency?

You close one of the patient's nostrils and have them inhale

Should you have empathy or sympathy?

You should have EMPATHY, NOT sympathy/pity.

What i subungual hyperkeratosis?

abnormal keratinization of distal nail bed with accumulation of scales under distal nail plate

What part of the stethoscope do you use to hear low frequency?

bell low frequency; light pressure

When auscultating the thyroid gland, you should use the _________ to listen for _________ frequency sounds.

bell; low

What test is used to test for iris and pupil accommodation?

change in near reaction **have the patient look at a distant object and then at near object held about 10cm from bridge of nose. The pupils should constrict with near vision.

What is xanthelasma?

cholesterol filled plaques commonly associated with hyperlipidemia and biliary cirrhosis

What is blepharitis?

chronic inflammation at the base of hair follicle

What part of the stethoscope do you use to hear high frequency?

diaphragm high frequency; high pressure

How many mmHg should you continue to listen for after you no longer hear the "tic" from the diastolic pressure?

continue listening for 10-20mmHg

What is onycholysis? What nail condition is most commonly associated?

distal or distolateral separation of the nail plate; the onycholytic portion will appear white; this is mainly associated with squamous cell carcinoma

What is ptosis?

drooping eyelid

What is mydriasis of the pupil?

failure to constrict with pupils remaining >6mm

What is dystrophy?

general term referring to altered/disturbed nail growth (i.e.; affecting nail matrix)

What is considered hypertension stage 2?

greater than or equal to 140/90

What is xanthelasma commonly associated with?

hyperlipidemia and biliary cirrhosis

What is an abnormal sclera called? What does this look like?

icteric; this is jaundiced/ yellow

How do you document oxygen saturation and what do you need to include?

in percentage (ex: 98%) and oxygen source (ex: room air, nasal cannula)

What is retronychia?

incomplete nail shedding that leads to embedding proximal nail plate into proximal nail fold mainly d/t repetitive trauma

What is anisocoria of the pupil?

inequality of pupillary size

What is a furuncle? What are multiple furuncles together called?

inflamed hair follicle; carbuncle

What is chelitis?

inflammation of the lips

What is episcleritis?

inflammation of the superficial layers of the sclera

What is esotropia?

inward turning of the eye

What is left homonymous hemianopsia?

left homonymous hemianopsia= right optic nerve; right homonymous hemianopsia=left optic nerve the person only sees one have of the visual world of each eye

What part of the eye is affected when the patient has cataract?

lens; a cataract is clouding of the lens d/t UV radiation or secondary to underlying disease/medication

What BMI is considered underweight?

less than 18.5

what is entropion?

lid margin turns inward

What is ectropion?

lower lid turns outward

At what time of day is your temperature the lowest? Highest?

lowest in the morning; highest in the evening

What are the 5 internal eye components?

scleara, cornea, iris, lens, and retina

What is a chalazion?

subacute obstruction of meibomian gland

in unilateral sensory neuronal hearing loss, which ear will be louder?

the normal ear will be louder; the ear with SNHL will be quieter

What is pterygium?

thickening of bulbar conjunctiva

When assessing the gingiva and buccal mucosa what should you always use?

tongue blade, light source, and gloves

How many affirmative CAGE questions suggest alcohol/illicit drug misuse?

two or more

What does longitudinal melanonychia raise suspicion of?

ungual melanoma

What is Leukonychia/ transverse leukonychia?

white spots in the nail; defective keratinization of distal matrix with persistence of parakeratotic cells in ventral nail plate

What is icterus?

yellowing of sclera associated with jaundice