Health Assessment Mid Term
Identify approaches for sensitive history information General Guidlines
" I may need to ask you some very personal and possibly embarrassing questions. I am not doing this to be nosey, but to get information so you health needs can be better met. What you say will be held in confidence between you and me. I will not share it with anyone else unless you tell me I can. I have 2 exceptions to this: if you tell me you want to hurt yourself or someone else, then I need to get some other people involved." fist establish a rapport and be non judgmental
special consideration lesbians and sexual minority
"Non care"-describes negative care, not feeling respected or safe with provider. Rough handling, not looks at pt; Screening needs- no different recommendations for all women. *Lesbian women are less likely to get preventative services for cancer Special concerns- intimate partner violence, maintaining a healthy weight, substance abuse.
HPI Nose
"frequent colds," - children more often sick allergy symptoms (timing, treatment); sinus pain (vs tooth pain?), trauma (deviated nasal septum?), smoking/exposure to 2nd hand smoke/cocaine use, meds/OTC *Differentiate "breathing problems" from issues w/ nose or lungs AFRIN NASAL SPRAY CAN HAVE REBOUND EFFECT- with stopping
pediatric voiding cystourethrogram
A voiding cystourethrogram (VCUG) is one example of a special diagnostic test for children. The VCUG is an x-ray that evaluates a child's bladder under fluoroscopy. Contrast material is used to enhance visualization. Parents should be educated about the risks and benefits to this exam. Additional information about this exam and patient education material about the VCUG is included in this link.
differential dx for inguinal hernias
-Femoral Hernia (direct or indirect)Hernia direct.jpgHernia indirect.jpg -Hydrocele -Varicocele -Lymph node swelling (adenopathy) -Lipoma -Cryptorchidism (Undescended testes) -Abscess
Differences between MRI and CT exam
- CT scan uses ionizing radiation, MRI does not MRI - claustrophobia, takes longer than CT MRI - see differences in normal and abnormal tissues, better than CT MRI - no known/documented risks in pregnancy but still need risk/benefit assessment - CT not recommended in pregnancy d/t radiation
Subjective Components
- Chief Complaint - HPI: OLD CARTS - Interval health - PMH - Allergies - Medications - Family History - Social/ habits - ROS
Review clinical genetics and process for obtaining a pedigree: specifics to prenatal/ pregnancy history
- maternal age - hx of prematurity, multiples, spontaneous abortions - fetal position, movement, ultrasound - screening tests - amniotic fluid - meds/teratogens
Headache
- onset - Location: have the patient show where and any radiation of pain - Duration - Character -Aggrevating/ Relieving ( meds) - visual prodrome or other sensory changes - temporal: pattern - severity: quantify, use a pain scale Associated symptoms: - N/V - photophobia - viasual disturbance - difficulty sleeping - increased lacrimation - nasal discharge - tinnitus - parethesias - mobility impairment Precipitating factors: - fever - fatigue - stress - food - prolonged fasting - alcohol - drugs - caffeine - seasonal allergies - menstrual cycle - intercourse - oral contraceptives Usual treatment: medications Headache diary -Effort to treat: sleep, pain meds, caffeine -Meds: antiseizure, beta blockers, Calcium channel blockers, oral contraceptives, SSRIs, caffeine, narcotics
Objective
- what YOU actually see - PHYSICAL EXAMINATION -findings obtained through OBSERVATION, PHYSICAL EXAMINATION, AND DIAGNOSTICS - CHARTING - Vital signs: T, P, RR, BP, HT, WT, BMI, Pain - OPEN WITH STATEMENT OF GENERAL HEALTH!! - well developed well nourished in no acute distress - head to toe - use bullet points - ex: - tonsils 3+ erythematous without exudates. - Skin- multiple 1-3 mm erythematous scabbed papules - can include POCT!!! - writes actually results : NEVER WNL
Subjective component of SOAP
- what the patient/ caregiver TELLS YOU - information you DO NOT see first hand - CHRONOLOGICAL STORY- analysis of symptoms
differential dx of scrotal mass
-Cancer (this does not transilluminate and is nontender when palpated) -Hydrocele (firm mass that transilluminates well) -Spermatocele (presents above the testicle and transilluminates well) -Varicocele (dilated mass of veins, usually on left side and feel like a "bag of worms") -Hernia
differential diagnoses for penile shaft abnormalities
-Sexually Transmitted Infections (see above) -Peyronie's Disease (curved penis due to trauma) -Thrombosed dorsal penile vein -Cancer -Trauma spacer
differential dx for aden-patchy
-Sexually transmitted infections -Cancer -Balanitis (severe cases) -Prostatitis -Anorectal abscess or tumors
differentiated dx of scrotal pain
-Testicular torsion -Epididymitis -Orchitis -Trauma -Fournier's gangrene
Be aware of the U. S surgeon generals family history initiative
-To help focus attention on the importance of family history, the Surgeon General, in cooperation with other agencies with the U.S. Department of Health and Human Services, has launched a national public health campaign, called the Surgeon General's Family History Initiative, to encourage all American families to learn more about their family health history. -The Web-based tool helps users organize family history information and then print it out for presentation to their family doctor. In addition, the tool helps users save their family history information to their own computer and even share family history information with other family members The revised version of the "My Family Health Portrait" tool is a Web-enabled program that runs on any computer that is connected to the Web and running an up-to-date version of any major Internet browser. The new version of the tool offers numerous advantages over previous versions, which had to be downloaded to the user's computer. The Web-based tool helps users organize family history information and then print it out for presentation to their family doctor. In addition, the tool helps users save their family history information to their own computer and even share family history information with other family members.
outline clinical decision make steps an APN uses to reach a diagnosis
1) Chief Complaint: "What brings you into the office today?" - Form beginning differential diagnosis - Determine appropriate body systems Analysis of symptoms - OLD CARTS - Medications - Allergies - Social/ Habits - LMP - FMH Rethink differential diagnosis Focused physical exam - Redefine differential - Compare obtained findings to differential Rule diagnoses in or out - Gather more data if necessary-Hx, PE, labs Diagnosis made based on all collected data Develop plan of care All sections of SOAP note support each other!!!!!
Demonstrate communication skills for conducting effective comprehensive and episodic interview: Interview approach
1) Patient comfort - non judemental - calm - introduce yourself - " "I am a registered nurse working on my graduate degree in nursing. I am studying to be a family nurse practitioner. Family nurse practitioners can independently manage health care and help you achieve optimal health. They work with patients of all ages and can diagnose, order tests, write prescriptions and provide referrals to specialists as needed." 2) how to address the patient 3) will be taking notes
Domestic Violence questions
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 a partner from a previous relationship making you feel unsafe now? 4) does your partner ever humiliate you 5) does he she keep you from seeing friends/ family or from doing the thing you want to do?
prostate cancer
99% are ADENOCARCINOMAS slow growing incidence increase with age - early carcinoma is asymptomatic - urinary symptoms occur as malignancy advance, hard, irregular nodule may be palpable, asymmetric, sulcus, may be obliterated, biopsy required for diagnosis
perform the correct sequence of inspection, palpation, speculum insertion, specimen collection and bimanual examination for female
1. Inspection and palpation of external genitalia (Labia majora, labia minora,Skene and Bartholin glands) Inspect the clitoris, urethral orifice, vaginal introitus, perineum, and anus. - assess mons pubis and hair distribution - Labia majora/minora: symmetry, moisture, redness & swelling, excoriation, discharge, lesions - Clitoris: size, atrophy, inflammation - Urethra: discharge, polyps, irritation, incontinence - Skene glands (periurethral location): discharge - Bartholin glands: 4 and 8 o'clock position, post-lateral position of labia majora: swelling, masses, discharge - Vaginal introitus: muscle tone, gaping or prolapse, discharge, fistula, fissures, lesions - Perineum: tenderness, lesions, fistula, scarring - Anus: discoloration, swelling, lesions, hemorrhoids 2. Speculum insertion- Lubricate speculum or apply lubricant. Gently insert a finger of your other hand just inside the vaginal introitus and apply pressure downward. Ask woman to breathe slowly to relax her muscles. Wait until you feel the relaxation, use fingers to separate the labia minora and insert the speculum along the path of least resistance, slightly downward. Maintaining gentle downward pressure with speculum open it by pressing thumb piece. Visualize cervix and inspect for color, position, size, surface characteristics, discharge, and size and shape of os. 3. Specimen collection→ Brushes and brooms vs spatula. Spatula- collect specimen first from ectocervix. INsert the longer projection of the spatula into the cervical os, rotate it 360 degrees. Cylindrical brush→ collects endocervical cells only. Insert cervical os until the bristles closest to the handle are exposed. Slowly rotate one-half turn. Remove Broom- collecting both ectocervical and endocervical cells at the same time. Insert into cervical os until the lateral bristles bend fully against the ectocervix. Maintain gentles pressure and rotate the brush by rolling the handle between the thumb and forefinger 3-5x to the left and right. Remove Withdrawal of speculum-->Unlock speculum and remove slowly and carefully to inspect the vaginal walls. Maintain downward pressure of the speculum to avoid trauma to the urethra. 4. Bimanual examine→ Change gloves, lubricate→ with index and middle finger as examine fingers insert downward full length into vagina. Palpate the vaginal wall as you insert, feel for cysts, nodules, masses, or growths. Locate cervix and run fingers around circumference, move side to side. Palpate the uterus and palpate Ovaries.
trichomoniasis
40% asymptomatic malodorous (green yellow) purulent discharge frothy bubling ph 5-7 s/s: vulvovaginal erythema hemorrhagic cervical lesions STRAWBERY CERVIX with petechia
obstetric history
5 digit system: G: Gravidity = total number of pregnancy T: Term= number of perm pregnancy >37 weeks P: preterm= number of preterm pregnancies A: abortions= number of spontaneous or induced L: number of living children complication of pregnancy delivery with neonate
acute otitis media
A DX requires: 1) acute onset of signs and symptoms 2) present of a middle ear effusion ( IMMOBILE TM) PLUS: Sings and symptoms of middle ear INFLAMMATION -marked REDNESS of TM - FULLNESS or bulging of TM - Ear pain, tugging or pulling the ear
Hypertension changes to the eye
AV nicking vein will appear decreased as it passes under the arty
differential diagnoses for CVA tenderness are
Acute pyelonephritis Acute glomerulonephritis Renal or Perirenal abscess Acute hydronephrosis
special considerations older adults
Age 55-65 varies, concern for psychosocial aspects of aging ( role changes, losses, financial/status changes, source of support, emotional stressors (depression, loneliness) Special concerns- nutritional deficits, dehydration, falls, cognitive changes, vision and hearing changes, chronic diseases, loneliness, role changes, depression, gynecological issues (dyspareunia, vaginal dryness/atrophy, increased risk of cancers), polypharmacy Physical exam- nutritional/hydration, fall risk, sleep assessment, pain assessment, cognitive assessment, sexual activity
bacterial vaginosis
Amsel Criteria ( 3 out of 4) - Homogenous discharge - + whiff amine test - ph >4.5 - presence of clue cells this homogenous whitish gray "milky discharge" s/s: - little to no inflammation of epithelium + odor itching painful burning urination
Thyroid problems
Ask: changes in emotional stability? increased energy? irritability? nervousness? lethargy? disinterest? change in temp preference? change in texture of hair skin or nails? increased prominence of eyes? puffiness in periobital area blurred or double vision? tachycardia? palpitations? change in menstrual flow? change in bowel habits? medications
list components of the perinatal history
Basic pt info, HPI, maternal OB hx, menstrual hx, gynecologic hx, past medical hx, family hx, personal/social hx, ROS, risk assessment, hx of labor and delivery, postpartum 1) OB Hx: previous pregnancies: gender, weight, gestation, hrs in labor, type of delivery, anesthesia. *should alert you to previous abortion, abnormalities of infant, neonatal deaths, SIDS. Know GTPAL. Specific problems: gestational DM, isoimmunization, IUGR, PIH, hemorrhage, preterm labor, short birth intervals, PP depression, GBBS status 2) Pay attention to drugs with moderate to high teratogenicity (warfarin, tetracycline, phenytoin, isotretinoin, propylthiouracil) 3) Gynecologic Hx: DES exposure (Diethylstilbestrol is a synthetic form of the female hormone estrogen. It was prescribed to pregnant women between 1940 and 1971 to prevent miscarriage, premature labor, and related complications of pregnancy. It is possible that women >41 yrs could have been exposed in utero. ACOG had not eliminated this part of hx yet) a) Sexual/contraceptive hx, abnormal PAP, reproductive tract abnormalities (unusual uterine shape), hx of infertility
Infants assessment head and neck
Birth History: Head molding Caput Vs. Cephalhematoma- both caused by birth trauma Caput= SCALP edema due to trauma when pushing through the birth canal cephalhematoma= collection of blood that is bound by the suture lines head control; symmetry febrile illness posterior fontanel ossifies by 2 months; anterior fontanel ossifies by 12-15 months Considerations: ask about birth history, order, unusual head shape (as above), strength of head control, acute illness, congenital anomalies, congenital screening for hypothyroidism
CRAFFT detecting recreational substance use disorder in adolescents
C= car - ridden in CAR by someone or yourself who was high R= relax - do you use alcohol or drugs to RELAX A= alone - do you ever do drugs or alcohol while you are ALONE F=forget - do you ever FORGET things you do while on drugs or alcohol F= friends - do your FRIENDS or family ever tell you to cut down on drinking or drugs T= trouble - have you ever got in TROUBLE while drinking or doing drugs
History for skin
CC Diagnostic reasoning: focused history - is the rash/ lesion associated with an immediate life threatening condition? 1) fever = look for PETECHIAE 2) allergic reaction 3) rash with fever and mucosal involvement = STEVENS JOHNSON SYNDROME - is the rash/ lesion acute or chronic? 1) onset 2) recurrent - where is the rash lesion in its evolution? 1) initial presentation 2)change 3) spread - Centripetal: rash spreads to the CENTER - Centrifugal: rash spreads AWAY/OUT from center - Cautal: rash spreads DOWN - what does the presence of pruritus(itching) tell me? - macular and papular reactions= viral/ drug reactions - what does associated pain tell me? 1) pain 2) burning - What do associated symptoms tell me? 1) fever, sore throat, headache 2) general health - Are there possible contacts or sources of contagion? 1) living situation (ex: scabies, lice, impetigo) 2) travel (ticks) 3) other exposures 4) pets - is there anything that exacerbates or triggers the reaction? 1) stress, heat and chemicles 2) medications? -DOXYCYCLINE= photo dermatitis - could this rash be caused by medication? 1) side effects 2) allergic reactions 3) commensal skin eruptions 4) worsening of existing skin eruptions - is this inherited or is there a significant dermatological family history? PMH Social: - occupation exposure - home/ hobby exposure - life stress Habits Medications in general ROS/skin: - previous history of skin disease - change in pigmentation - change in mole - excessive dryness or moisture - pruritus - excessive bruising - rash or lesion - medication for skin specific - hair loss or changes - environmental or occupational hazzards - self care behavior
pharyngitis
CC: sore throat red pharynx etiology: viral or bacterial (GABHS) check fever, nodes, exudate sometimes food can get caught in tonsillar crypts: not exudate
psoriasis
CHRONIC AND RECURRENT disease of KERATIN SYNTHESIS subjective: - may have PRURITUS - CONCERNS about appearance objective: - characterized by well circumscribed DRY SILVERY SCALING PAPULES AND PLAQUES - can be associated with psoriatic arthritis in up to 30% of patients
characteristics of urine
CLEAR is expected cloudy - WBCS, bacteria, fecal contamination, prostatic fluids, vaginal secretions RBCs, precipitated crystals Odor - strong sweet= INDICATE DIABETES - foul sell- UTI
Imaging for Gento unit
CT kidney renal ultrasound
Diagnostics with X ray
Capture single image using small amount of radiation Good for assessing injury or fracture
Dental
Caries: first visible as chalky white area> brown or black malocclusion discuss hygiene, dental visists if dentures: remove to examine gums
White color cutaneous color changes
Cause: - ABSENCE OF MELANIN Distribution 1) Generalized - albinism 2) localized - vitiligo
Erythema (red) cutaneous color
Cause: INCREASED cutaneous BLOOD FLOW Distribution 1) localized: - infalmation 2) Generalized - fever - viral - exanthema (widespread rash) - urticaria Additional notes: can be inflammatory, infectious process, certain cutaneous tumors, vascular lesions, (port wine red lesions)
Yellow cutaneous color
Cause: increase BILE pigmentation = generalized= liver disease or Increased CAROTENE pigmentation = generalized (EXCEPT EYES)= hypothyroidism, increased intake of veggies containing carotene
Explain rational for inclusion/ exclusion of specific items for annual exams
Cervical Ca Screening: ● @ age 21- less than 21 y/o should not be screened regardless of sexual onset ● Adolescent needs: ○ Contraception & STI care/ tx ○ No Pap ○ No speculum exam when asymptomatic ○ STI testing via urine ● 21-29: ○ Cytology alone every 3 years ○ HPV testing should not be used to screen ■ Not as a component of cotesting ■ Not as a primary stand alone screen ○ Most carcinogenic HPV infections resolve without intervention ● 30-64: ○ Cytology + HPV (cotesting) every 5 years is preferred ○ Cytology alone every 3 years is acceptable ■ Cotesting enhances detection of adenocarcinoma ■ Cotesting problems- financial and logistical ● Cytology is effective ● HPV (+) & cytology (-): ○ 1: repeat cotest in 12 months OR 2: Immediate genotype for HPV 16 pr HPV 16/18. **If repeat test is (+) refer to colposcopy ● Stop screening?: ○ Age 65 when screening is (-) ■ Negative= 3 consecutive (-) paps ■ Negative= 2 consecutive (-) HPV test ■ **Even is new sexual partner ○ CIN2+ is rare after 65 y/o ○ After hysterectomy with removal of cervix and no history of CIN 2+ ● When not to stop?: ○ Hx. of CIN2, CIN3, AIS ■ Continue routine screen for 20 years- even if > 65 y/o ● ** Screening does not change d/t HPV vaccination
IDENTIFY WHAT TYPE OF INFORMATION IS IN EACH PART OF THE SOAP COMPONENT CC
Chief complaint - in patients OWN words as you hear it- a few words or a quoted sentence, INCLUDING duration of problem - new problem/ episodic visit - significant symptoms and length - follow u/ chronic visit- disease or symptom - MUST BE ON EVERY PATIENT ENCOUNTER
Demonstrate communication skills for conducting effective comprehensive and episodic interview: Special populations
Children - provide distracters - involve older children Adolecents - explain confidentiality - have time alone with teen Elderly - allow more time - help jog memory -be aware of disabilities
Children and ears
Children: breastfed? (helps prevent ear infections)!!!! 2nd hand smoke exposure frequent infections/antbx (risk for hearing loss!! tympanostomy tubes/surgery allergies/nasal congestion *Eustachian tubes in kids=more HORIZONTAL than adults-->why they have ^^ rates of ear infections
Assessment
Diagnosis Synthesis of "S" and "O" Diagnostic impression - varicella, tobacco abuse, annual physical exam - JUST DX and brief qualification of severity - NO PARAGRAPH OR DETAIL JUSTIFICATION OF DX - separate assessment and plan - only as specific as known
differential diagnoses for abnormal GU
Common findings at the urethral meatus are congenital misplacement where the meatus is found on the ventral aspect of the penis (hypospadias) or the upper aspect of the penis (andepispadias). Improper shaping of the meatus may result in meatal stenosis. In an infant, you should note a strong urine stream; a weak urine stream may be indicative of urethral meatus stenosis. Upon examining the patient, note that in the case of phimosis, you will not be able to retract the foreskin from the head of the penis. In paraphymosis, the foreskin becomes trapped behind the glans and cannot be replaced in to its original position. This condition requires immediate surgical intervention to prevent necrosis and eventual gangrene of the glans penis. Additional Differential Diagnoses for abnormal findings on the penis: -Balanitis (inflammation and swelling at the glans of the penis, more common in diabetics) -Chancroid -Ulcer (Herpes Simplex, Syphilis) -Cancer -Condylomata acuminate (related to HPV infection) -Psoriasis
non traumatic red eye
Conjunctivitis (viral bacterial allergic)- common subconjunctival hemmorage - common iritis- common orbital or periobital cellulitis- common herpes simplex keratitis- common acute glaucoma episcleritis/ scleritis blepharitis
identify concepts and principles of clinical decision make General principles
Consider patient's and your cultural perspectives. In differential - Include dx with serious outcomes - Rare dx at bottom of list - Remain open minded - Consider cost, benefit and harm of tests
corns verse callus
Corns: flat or slightly elevated, circumscribed, painful lesions with smooth hard surface, on pressure points Calluses: less well demarcated than corns and are usually not tender; usually occur on the weight bearing areas of the feet and palmar surfaces of hands
Dizziness or Vertigo
Describe vs light headed unsteadiness, loss of balance, falling time of onset, duration of attacks description of attack associated symptoms mediacations and treament Vertigo: whirling sensation or loss of balance dizziness: spinning around or loss of balance
IDENTIFY WHAT TYPE OF INFORMATION IS IN EACH PART OF THE SOAP COMPONENT Assessment
Diagnosis based on S and O a list, each item on SEPERATE LINE NOT A NARRATIVE - your assessment: be sure to account for all abnormalities documented in the S and O above If you are not sure you have criteria for an actual diagnosis list symptoms account for pertinent issues re: HM and HX ( e.g. Hx ETOH abuse; S/P hernia repair)
Diagnostic/ Lab test Term
Diascopy: - a test for BLANCHABILITY performed by applying PRESSURE with finger or glass slide and observing COLOR CHANGES - used to determine whether a lesion is VASCULAR = INFLAMMATORY OR CONGENITAL - NON VASCULAR= NEVUS - or HEMORRHAGIC ( PETECHIA OR PURPRA) = petechia DOES NOT BLANCH Woods light: - to evaluate epidermal HYPOPIGMENTED OR HYPERPIGMENTED lesions and to distinguish FLUORESCING lesions - marked the room and shine light on the area to be examined - look for yellow/ green florescence that indicates the presence of some types of FUNGAL INFECTIONS Transillumination: - to determine the presence of fluid in cysts and masses - FLUID FILLED LESIONS will transilluminate with a RED glow wheres as solid lesions will NOT Skin scrapinping: - KOH= see SPORES AND HYPHAE with FUNGAL infections Tzanck Smear: - scraping of an ULCER BASE to look for TZANCK CELLS - test for HERPES AND CHICEKNPOX Bacterial Culture Viral Culture Punch Biopsy - REMOVES skin lesions using a circular tool - punch out skin lesion only Excisional biopsy - REMOVES entire lesion with layer of skin - see if the lesion has extended into tissue
older adult consideration
Dimensions of Aging (normal): ● Psychosocial aspects of aging: role changes, losses, financial/status changes, sources of support, emotional stresses (loneliness, depression) ● Physical aspects of aging ○ Sensory changes: varies by degree or severity, may increase risk of injury ○ Increased risk of heart disease, cancers, osteoporosis/fractures ○ Possible cognitive decline: varies in severity, may be r/t illness, nutritional/hydration status, or meds Special Concerns: nutritional deficits, dehydration, falls, cognitive changes, vision and hearing changes, chronic diseases, loneliness, role changes, depression, polypharmacy; GYNE issues= dyspareunia, vaginal dryness/atrophy, increased risk of cancers Attitudes: ageism, assumed asexuality, lack of respect Barriers: providers' attitudes, exam rooms/facilities, transportation, finances Inclusive care: consider environment, attitudes, language (respectful) Assessments for Older Women: nutritional/hydration, fall risk, sleep, pain, cognitive, sexual activity
Identify general principles of medical record documentation
Documentation is extremely important in the coding process as the service level is based on what is documented. The resource document for coding is the medical record. Provider documentation has to be the determinate of a diagnosis. Documentation for each encounter should include: Chief complaint (or reason for the encounter, and if it is a follow-up visit what the reason for the follow up is necessary, ie follow-up for diabetes) the relevant history; the physical exam and this would include pertinent positive and negative findings; if something is abnormal the abnormality must be described; also if something is negative or normal a brief statement indicating this is sufficient if the normal is in an unaffected area or asymptomatic organ system, but an entire organ system should not be documented as negative; Also include in the documentation any prior diagnostic test results that are relevant to the presenting problem and your assessment which is clinical impression or diagnosis, the management or plan for care of the problem including follow-up; and the date of the encounter & legible identity of the provider. The clinical thought process of the healthcare provider must be documented in order to receive reimbursement. It is important to document the diagnosis, the status of the diagnosis, for example uncontrolled hypertension, and any revisions of the diagnosis; treatment response such as the patient's progress and response to & changes in treatment; if there is no established diagnosis it is OK to state the clinical impression in the form of a differential diagnosis or possible, probable or rule out diagnosis. Also include the treatment plan including patient instructions, drugs prescribed or recommended; referrals, consultations, and follow-up always noting instructs given on when to call or return sooner than the scheduled appointment or what symptoms require immediate transport to an emergency room. Documentation of tests ordered or reviewed, results interpreted, discussion of findings and interventions are also required (Rapsilber & Anderson, 2000). If diagnostic tests such as labs or xray results were reviewed, a simple note about that should be included such as chest xray unremarkable; Include too any other health risk factors or health promotion interventions even though they may not be directly related to the presenting problem such as tobacco abuse, or use of seatbelts. The CPT & ICD-10 codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record. Chart all that you have done!!! If you code for something that is not substantiated by your charting, it is considered fraud!!! If you don't document something, the rationale for ordering diagnostic & other ancillary services should be easily inferred.
Primary skin lesions Papules
ELEVATED firm circumscribed area less than 1 cm diameter ex: warts elevated moles lichen planus (inflammatory response)
kissing tonsils
ENLARGED TONSILS Hypertrophic tonsils can be caused by recurrent pharyngitis and local inflammation, especially in children and young adults. Inspection of the oral cavity may reveal hypertrophy of the palatine tonsils, which is sometimes called "kissing tonsils" when tonsils meet in the midline or overlap
adolescent development affects decision making
Early Adolescence 10-14yrs→ beginning attempts at complex thinking regarding home and school; developing awareness home and school; developing awareness of social and parental rules and roles, the view of the world and how they fit into it. Middle Adolescence 14-15yrs→ thinking becomes more complex; able to look into the future, plan long term Late adolescence- 16-19yrs→ capable of more complex thinking; able to, more easily make important personal decisions. Decision making is affected by biological development???--QUIZ Question Time of transition from concrete to abstract thinking→ not always at the same time as peers Learning and struggling with intimacy, peer relationships, vocation choices, and morality
Identify approaches for sensitive history information Emotional/suicide
Emotional health - ask when discussing STRESSORS Suicide: - have you lost interest or pleasure in things that you used to enjoy? -have you been feeling down, depressed, stressed out or hopeless? - hurt yourself or others? - plan? Be sure to always ask about HX of mental illness and if they ever had any counseling if indicated you must ask about suicide attempts and ideation if there is an indication and plan you must call 911 using tools such as the PHQ-9 Depression tool or Hamilton Rating Scale for Depression can help quantify the severity of depressive symptoms
anatomy and physiology of skin
Epidermis - outermost layer portion of skin - 2 layers: *STRATUM CORNEUM (protects the body against harmful environmental substances and restricts water loss) * CELLULAR STRATUM (keratin cells synthesize) the epidermis is AVASCULAR and depends on the underlying dermis for its nutrition Dermis -richly VASCULAR CONNECTIVE tissue layer of the skin that supports and separates the epidermis from the CUTANEOUS adipose tissue - sensory nerve fibers located in the dermis form a complex network to provide SENSATION OF PAIN, TOUCH, TEMPERATURE Hypodermis - ADIPOSE tissue layer that generates HEATH and provides INSULATION Appendages: - the epidermis invaginate into the dermis at various points and forms the following; eccrine sweat glands, apocrine sweat glands, sebaceous glands, hair, and nails
hirtuism
GROWTH OF HAIR in a women in MALE distribution patterns on the FACE, BODY, AND PUBIC AREAS subjective: - excessive hair growth on the face or body - onset, severity, and rate depend on underlying cause (ANDROGEN LEVLES) objective: - presence of thick, dark terminal hairs in ANDROGEN SENSITIVE SITES- face, chest, areola, external genitalia, upper and lower back, butt, inner thighs, line alba
Diagnostic with MRI
Good for imaging organs, soft tissues and internal structures
framework of adolescent history
HEEADSSS Home (live with, support system) Education (kids seldom threatened by this. Ask about school/grades, best subject what they like best, if grades have gotten worse—why? Make sure they are actually in school) Eating (obesity vs. eating disorders. Cultural values on wt and shape. Diet, exercise) Activities (what do they do with friends for fun.. boredom can be red flag for depression, are they driving a car, etc.), Drugs (do any of your friends use it? Do you? Include whole range of drugs [club and street drugs, steroids] and ETOH use) Sex (most sensitive, private part of the interview. This is part of your health, questions asked of all patients. Have you ever been in a romantic relationship? Want to prevent STIs and pregnancy. Is sex with coercion or is the experience enjoyable, ask questions that don't assume pt is heterosexual) Ask 5 P's( partners, practices, past hx of STI, protection from STI, pregnancy prevention) Suicide (sleep disturbances, eating, appetite, boredom, family hx of depression, suicide, mental health problems, serious SI or pain, emotional outbursts, hx of past depression/suicide attempts, change in school performance, recurrent accidents, somatic complaints, diminished affect, avoidance of eye contact, preoccupation with death) Safety (do you wear a seatbelt, helmet. Violence-- physical or emotional abuse)
perform detailed history to obtain information about the male GU system, including STD history and voiding or sexual dysfunction
HPI: ● Discharge or lesion on the penis ○ Character of lumps, sores, rash ○ Discharge: color, consistency, odor, tendency to stain underwear ○ Symptoms: burning, itching, stinging ○ Exposure to STI: multiple partners, infection in partners, failure to use or incorrect condom use, history of prior STI ● Swelling in inguinal area ○ Intermittent or constant, association with straining or lifting, duration, presence of pain. ○ Change in size or character of swelling ○ Pain in the groin: character (tearing, sudden, searing, or cutting pain), associated activity (lifting heavy object, coughing, or straining at stool) ○ Use of truss or other treatment ○ Frequent heavy lifting ○ Medications: analgesics ● Testicular pain or mass ○ Change in testicular size ○ Events surrounding onset: noted casually while breathing, after trauma, during a sporting event; sudden onset ○ Irregular lumps, soreness, or heaviness of testes ○ Medication: analgesics, antibiotics ● Curvature of penis in any direction with erection ○ Associated pain ○ Injury to penis ○ Personal history diabetes, contracture of fourth and fifth fingers of the hand (Dupuytren contracture) ○ Family history of condition ○ Medication: propranolol ● Persistent erection unrelated to sexual stimulation ○ Current history of sickle cell anemia, leukemia, multiple sclerosis, diabetes, spinal cord injury ○ Trauma to genitals or groin ○ Associated with alcohol ingestion or medication ○ Medications: erectile dysfunction agents, antidepressants, antipsychotics, anticoagulants, anxiolytics, recreational drugs ● Difficulty with ejaculation ○ Painful or premature, efforts to treat the problem ○ Ejaculate color, consistency, odor, and amount ○ Medications: alpha blockers, antidepressants, antipsychotics, clonidine, methlydrops ● Difficulty achieving or maintaining erection ○ Pain with erection, prolonged painful erection ○ Constant or intermittent, with one or more sexual partners ○ Associated with alcohol ingestion or medication ○ Medications: diuretics, sedatives, antihypertensive agents, anxiolytics, estrogens, inhibitors of androgen synthesis, antidepressants, carbmazepine, erectile dysfunction agents. ● Infertility: ○ Lifestyle factors that may increase temperature of scrotum: tight clothing, briefs, hot baths, employment in high-temperature environment (e.g. steel mill) or requiring prolonged sitting (e.g. truck driving) ○ Length of time attempting pregnancy, sexual activity pattern, knowledge of fertile period of woman's reproductive cycle ○ History of varicocele, hydrocele, or undescended testes ○ Diagnostic evaluation to date: semen analysis, physical examination, sperm antibody titers ○ Medications: testosterone, glucocorticoids, hypothalamic releasing hormone, marijuana Past Medical History ● Congenital anomaly and/or surgery of genitourinary tract: undescended testes, hypospadias, epispadias, hydrocele, varicocele, hernia, prostate; vastectomy ● STIs: single or multiple, specific organism (gonorrhea, syphilis, herpes, HPV, chlamydia), treatment, effectiveness, residual problems,; vaccination for HPV. ● Chronic illness: testicular or prostatic cancer, neurologic or vascular impairment, DM, arthritis, cardiac, or respiratory disease Family History ● Infetility in siblings ● History of prostate, testicular, or penile cancer ● Hernias ● Peyronie disease (contracture of penis) Personal and Social history ● Occupational risk of trauma to suprapubic region or genitalia, exposure to radiation or toxins. ● Exercise: use of protective device with contact sports or bicycle riding ● Concerns about genitalia: size, shape, surface characteritics, texture ● Testicular/ genital self-examination practices ● Concerns about sexual practices: sexual partners (single or multiple), sexual lifestyle (heterosexual, homosexual, bisexual) ● Reproductive function: number of children, form of contraception used, frequency of ejaculation ● Alcohol, marijuana use: quanity and frequency ● Use of drugs
lymph nodes focused assessment
HPI: Enlarged nodes? lumps/knots/bumps/kernels/swollen glands? OLD CARTS; associated local symptoms (pain/redness/warmth/red streaks); associated systemic symptoms (malaise, fever, weight loss, night sweats, abdominal pain/fullness, itching (some tumors cause pruritus); predisposing factors (surgery, trauma, infection); meds (chemo, antibiotics), swelling of extremity PMH: chest imaging (reason/results), use of blood products/transfusion, surgery (trauma to regional nodes), recurrent infections, TB/other skin testing, allergies, autoimmune disorder Fam Hx: malignancy, anemia, recent disease, TB, hemophilia, immune disorders Personal/Social Hx: travel, sex history (risk for HIV), illicit drugs Infants/Kids: ask about recurrent infections, poor growth/failure to thrive, vaccination history PE: Inspection/Palpation: 3 Presenting physical signs of disorders: 1) lymphadenopathy (enlarged nodes), 2) lymphangitis (red streaks on overlying skin), 3) lymphedema -Note consistency, mobility, tenderness, size, warmth of nodes -Easily palpable nodes= NOT typically found in healthy adults -"Shotty" nodes may be detected (small, movable, multiple, feel like BBs/buckshot under skin, <1cm)- usually no clinical consequence, usually follow node enlargement after viral infection -**Any palpable/enlarged nodes in supraclavicular region requires additional eval-NOT NORMAL!! -characterize any large lymph nodes by location/size/shape/consistency (fluctuant, soft, firm, hard), tenderness, mobility or fixation to surrounding tissues, discreteness -fixation: most common in metastatic cancers -fluctuant: feel like they contain fluid; suggest suppuration from infection -"matted"= enlarge node that feels like large mass instead of discrete nodes -**fixed, large, matted, inflamed or tender nodes indicate problem**
pregnancy and eyes
HTN DM PIH use of eye drops - CAN CROSS PLACENTA
POCT influenza test
Have pt blow nostrils into tissue first. Ask pt which nasal they can breathe through better, then insert swab gently until resistance is felt (do NOT push past resistance) and TWIST in circular motion for at least TEN SECONDS and then remove. Will be very uncomfortable for pt. Follow facilities directions for the rest of the test
STAR OF UNIT 2 Conduct a focused history and physical examination related to the head, neck, eyes ears nose throat and normal variations Head and neck
Head: Observe head position: tilted or temore Inspect skull and scalp Inspect facial features Palpate head and scalp when appropriate auscultate the temporal arteries and palpate inspect palpate salivary glands transilluminate skull of infant of infants with rapidly increase HC
Differential diagnosis for HEENT/ Lymphatic: recap
Headache: classic migraine, common migraine, cluster HA, hypertensive, muscular tension, combination HA "Red Eye"/ "Pink Eye": bacterial/viral infection (most common), trauma, glaucoma, systemic disease, congenital anomalies -Traumatic Red Eye: corneal abrasion, corneal foreign body, foreign body under the lid, hyphema (blood behind the cornea) (all first 4-common); UV keratitis, chemical injury, intraocular foreign body, blow out, corneal laceration. -Non-traumatic red eye: conjunctivitis (viral/bacterial/allergic-not true pain or visual loss; discomfort/itching present, some crusting), subconjunctival hemorrhage (frank area of blood noted on sclera, usually r/t intense coughing/valsalva manuever), iritis, orbital or periorbital cellulitis, herpes simplex keratitis (rash around eye, becomes keratitis if spreads into eye), episcleritis (bilateral, purplish color, mild stinging) Painful Red Eye: -Normal vision: episcleritis, keratitis,, cluster HA, corneal abrasion (if not treated, can turn into corneal ulcer) -Vision impaired: iritis, glaucoma, orbital cellulitis, scleritis, corneal abrasion, keratitis, corneal ulcer Vertigo -Labryinthitis: may occur as complication of URI, affects inner ear. Symptoms: vertigo, nystagmus, may ^ in severity w/ head mvmt. Sensorineural hearing loss occurs on affected side. -Meniere's Disease: recurrent attacks abrupt. Affects vestibular labyrinth. Leads to sensorineural hearing loss. Symptoms: severe vertigo, tinnitus, progressive hearing loss starting w/ low tones. -Benign Paroxysmal Positional Vertigo (BPPV): acute onset of vertigo associated w/ rapid head mvmt or positional changes. Transient, a few seconds (quick and fast); women on menses + older adults-more likely to experience. Pharyngitis: -GABHS vs. viral/mono vs. peritonsillar abscess (this can be dangerous if pt is having difficulty swallowing); will usually see post cervical lymphadenopathy w/ mono; anterior with strep Hoarseness (see above) Xerostomia (Dry mouth) -R/t meds, systemic diseases, smoking, radiation treatment (more common in elderly)
adolescent female considerations
Hx: growth and development, specific issues and concerns, screenings tests available, physical growth, puberty, body image, brain maturation, cognitive development, emotional development, identity development, autonomy, social relationships (family and peers) Special issues to consider: sexual behaviors, STIs, pregnancy, birth, abortion, contraceptive use, menstrual disorders and pelvic pain, substance use and abuse, depression, violence (IPV, sexual violence); **detailed psychosocial history using HEADSSS Screening Tests and Guidelines: -gonorrhea and chlamydia: all women 24/25 years and younger at least ANNUALLY -HIV: screening should be discussed and encouraged for sexually active teens -Cervical cytology: Do not initiate screening until age 21 -Vaccinations: influenza, meningitis, HPV, Tdap Exam ● External exam indications: confirm anatomy, assess pubertal development, observe for trauma or pathology ● STI screening: urine and blood (gonorrhea/chlamydia via urine, HIV and syphilis via blood ● Signs of vaginal infection: obtain specimen from vagina without use of speculum ● Indications for a Pelvic Exam: suspected/reported rape or sexual abuse; dysmennorhea unresponsive to NSAIDS; amenorrhea; abnormal vaginal bleeding; lower abdominal pain; contraceptive counseling for IUD for diaphragm; pregnancy; persistent vaginal discharge; urinary tract sx in a sexually active female; Pap test IF indicated and in accordance with current guidelines
paronychia
INFLAMMATION of the paronychium subjective: - Acute= history of nail trauma or manipulation; acute onset - Chronic= history of repeated exposure to moisture i.e. through hand washing; evolves slowly initially with tenderness and mild swelling objective: - REDNESS SWELLING AND TENDERNESS at lateral and proximal nail folds - PURULENT drainage often accumulates under the cuticles - chronic paronychia can produce rippling of the nails
anatomy and physiology of Hair
INSPECT color, distribution, and quality hair loss can be generalized or location diffuse hair loss usually occurs without any inflammation or scarring asymmetric hair loss may indicate pathologic condition fine villus hair covers the body terminal hair occurs on the scalp, pubic, and axillary areas
Anatomy and physiology of nails
INSPECT nails for color, length configuration, symmetry and cleanliness color is various shades of pink pigmentation deposits or bands may be present in the nail beds of person with dark skin Nail plate should appear smooth and flat or slightly convex - look for RIDGING GROOVES DEPRESSIONS AND PITTING - longitudinal ridging and beading are common expected variants Nail base angle should measure 160 degrees. Clubbing occurs angle is increased 180 degrees or more
Describe impact of genetic conditions on client health screening
Identification of individuals or families at risk for genetic diseases by family history will be most beneficial by allowing: ENHANCED patient care, including better identification of individuals at risk of disease, EARLIER detection and management of disease, EARLIER testing and screening for cancer, or earlier fetal assessment in pregnancies at risk. Recording a family history of medical conditions and inherited diseases makes it possible to identify patients and families who are at increased risk of specific disorders, including those caused by single gene mutations (CF or sickle cell disease) or by multifactorial inheritance (cardiovascular disease or diabetes), or to identify pregnancies that are at higher risk of being affected with an inherited disease or birth defect. Can be sensitive questions and need to have appropriate counseling/resources. Need to assess cancer risks, reproductive risks including miscarriage and stillbirths, ethnicity risks, consanguinity risks, congenital anomalies, mental or developmental delay, genetic disorders, metabolic disorders. complex process depending on mechanism of inheritance, environment and client factors persons at highest risk have more than one affected first degree relative
Differentiate and define international classification of disease ICD codes, current procedural terminology CPT codes and CPT evaluation and management E& M
In an effort to standardized diagnosis and cost of services, codes have been developed that are nationally and internationally used. As health care providers, we must be familiar with and use these codes as they aid in the communication of provided health care and support reimbursement for services. As with all of health care, updates are constantly being made and so it is with coding. The system for assigning a number to specific diagnoses is being modified. This diagnostic coding system, which you will learn more about later in this unit, is the International Classification of Diseases or ICD. It is a coding system intended to describe the clinical picture of the patient. For several years we have been using the 9th revision (ICD-9). The U.S. 10th edition, Clinical Modification (ICD-10-CM) was published in 2015 and now in use. What is coding: - transforming verbal or written descriptions into numbers - specific codes describe diseases, injuries, procedures, and level of service - Coding is used in the United States for the collection of information regarding disease, injury and level of service provided to our patients. - Verbal and written descriptions are translated into numbers. Reimbursement is based on these numerical representations, so it is imperative to your practice viability to understand coding procedures.
Identify approaches for sensitive history information Substance abuse
Incorporate during "personal habits" CAGE C= have you ever felt like you should CUT DOWN? A= have people ever been ANNOYED with your drinking? G= have you ever felt GUILTY about your drinking? E= have you ever had a drink first thing in the morning (EYE OPENER) to calm your nerves?
Infants eye examination
Infants: gaze @ mom/object? No red eye in photos? = glaucoma - Leukocoria: abnormal white reflex from back of eye = can indicate RETINOBLASTOMA- malignant tumor arrisng from retina, common in children Sclera may appear somewhat bluish in newborn. Strabismu (abnormal allignemtn of the eyes makes eyes looks different directions): occur some or all of time? (when child is tired vs awake). Visual acuity: measure @ age 3 (should be better than 20/50, 20/20 by age 7). School performance in kids. -Pseudostrabismus: presence of epicanthal folds in newborns/infants creates appearance of strabismus (but don't really have)
Physical exam Hair
Inspect: - scalp - beard / mustache - ears - eyebrows/ eyelashes - hyograstric area - thoracic area - arms/legs - pubic area Evaluation: - quantity - distribution - texture - color -identify nits - elderly (less hair, color) - Children (coarse, curly pubic hair before 9 years of age indicates PRECOCIOUS PUBERTY) TUFTS of hair at SACRAL SPINE = SPINA BIFIDA Coarse hair= HYPOTHYROIDISM Fine hair= Hyperthyoridism Shiny skin with no hair growth may indicate PERIPHERAL VASCULAR PROBLEMS
Begin Unit 6 Male GU anatomical landmarks of male genitourinary system
Kidneys: Inspection/Palpation: The kidneys are inspected during the abdominal exam and are not normally visible on inspection unless the kidneys are dramatically enlarged. A renal mass may be seen in a child or thin adult. Palpating the kidneys is done with the patient in the supine position with one hand pushing the kidney forward from the back and the other hand palpating the kidney by pressing the abdomen. The kidney is usually not palpable in a normal-sized adult but can be palpated in children and thin adults. Auscultation: The patient can remain in the supine position as you auscultate the epigastrium, flank and costovertebral angle for bruits. This part of the examination can also be performed with the patient sitting up or in the prone position. CVA Tenderness Assessing costovertebral tenderness can be done by gently percussing the angle between the paraspinal muscles and the 12th rib. Tenderness is elicited in the CVA by causing the kidneys to move. Inguinal Lymph Nodes The normal pelvis is usually free of palpable lymph nodes, however, small, non-tender nodes may occasionally be palpable in the normal adult. Palpation and inspection of the renal pelvis can reveal enlarged lymph nodes that may require further investigation. Oftentimes, adenopathy will accompany sexually transmitted infections but not always. Adenopathy may be a sign various types of inflammation or malignancies involving the penis, scrotum, anus or lower extremity. Bulges or scars in the inguinal region many be an indication of current or past hernias. Ureters: Because the ureters are positioned deep within the retroperitoneal space, the ureter is not normally visible or palpable. The urethral meatus is assessed when the penis is inspected. Bladder Inspection and palpation of the bladder may reveal can reveal a bladder mass in the suprapubic area. Gentle pressure to a distended bladder in a patient with a suspected mass may induce the urge to void. Bladder palpation is difficult in obese patients and patients who are tense during the exam. Penis and Urethra Inspection and palpation of the penis begins with the glans or the head of the penis. If a patient is uncircumcised, you should draw back the foreskin to examine the glans completely. In the examiner will not be able to retract the foreskin in an adult patient. In the pediatric patient, the foreskin should not be forceably retracted as this may cause adhesions. Press the glans between your thumb and forefinger to assess the presence of a urethral discharge. At the end of the glans is the external urethral meatus.The meatus is normally a vertical slit found at the tip of the glans. Be sure to replace the foreskin to its normal position at the end of the exam to prevent venous/arterial obstructions that can lead to necrosis of the head of the penis. Finally, inspection and palpation of the shaft of the penis should be performed to evaluate the organ for lesions, nodules and other abnormalities. Scrotum, Testes, Epididymis and Spermatic Cord The scrotum contains the testes, epididymis and spermatic cord. These structures should be inspected and palpated in a systematic manner beginning with the scrotum. Inspection of the scrotum should include evaluation of the size, shape and rugae. The testis is examined next and should be an egg shape structure that is normally firm, smooth and approximately 3 by 5cm. Although testes size may vary from patient to patient, an individual's testes are generally both the same size unless disease is present. In the average male patient, the right testicle generallly hangs lower than the left testicle. The epididymis is found behind the testes and is somewhat tender when firm pressure is applied but should feel soft and uniform throughout. The spermatic cord holds the blood vessels, vas deferens and nerves and sits behind the epididymis and should feel like a cordlike structure when palpated. Transillumination is an important assessment technique that helps to differentiate whether the scotal sac is filled with fluid, gas or solid material.Transillumination should be done in a dark room with a bright light to assess the presence of a hydrocele vs. tumor. This technique is done using a flashlight, penlight or other light source and placing it behind the scrotum. Anorectal Exam Rectal exams are often excluded because of patient discomfort and lack of time, but should always be done during a complete physical exam and when a patient presents with genitourinary complaints. Annual exams should also be conducted annually for men to exam the rectum and the prostate. Examination of the rectum includes inspection of perianal skin, digital palpation of the rectum and assessment of the neuromuscular function of the perineum. For this exam, the patient should stand and lean over the exam table. If this is not comfortable, the patient can lie on the left side with the buttocks near the edge of the examining table with knees flexed. First, examine perianal areas for any dermatologic abnormalities, masses or scarring. Spread the buttocks apart and inspect the anus for skin tags, hemorrhoids, fistulas bleeding, rectal prolapse and evidence of sexually transmitted infections. When asking the patient to bear down, take time to check for any evidence of abscess, fistulas or rectal prolapse. In infants, verification of the first meconium stool (which is passed within the first 24 to 48 hours of life) should be assessed to determine patency of the anus. Lack of this event warrants investigation and may indicate an imperforate anus. When indicated, rectal exams in children should be done with the fifth finger rather than index finger. The figure below shows an imperforate anus before and after surgical repair. The Digital Rectal Exam The last part of the anorectal exam is the digital rectal exam (DRE). Liberal amounts of lubricant should be used to increase patient comfort. It is best to inform the patient of each step before you palpate the anus to decrease anxiety.The patient should bear down again to relax the external sphincter and the internal sphincter can be assessed by sweeping 360 degrees around the canal. Patients should be informed that they may feel the urge to defecate during the exam. The DRE should include examination of the anal ring, the lateral and posterior rectal walls, anterior rectal wall and prostate. Note any evidence of masses, tenderness, hemorrhoids, fissures or ulcers and the color and consistency of the stool. During the last part of the DRE, the prostate is palpated. To examine the prostate, the anterior rectal wall surface is palpated to assess the posterior portion of the prostate. Because of the bladder's proximity to the prostate, the patient should be warned that they may feel the urge to urinate during the exam. Locate the median sulcus and note the size, shape and texture of the prostate. A rubbery or boggy feel can indicate benign hypertrophy or prostatitis. A nodular consistency can mean the presence of prostate cancer, prostatic calculi or chronic fibrosis.
malignant melanoma
LETHAL form of skin cancer that develops from MELANOCYTES subjective: - NEW mole or PREEXISTING more that has changes or is changing - new pigmented lesions that has irregularities 0 history of melanoma; family hx of melanoma (1st degree relative) - history of dysplastic or atypical nevi objective: 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. Pigmented may be streaming from border C= Color- the color is NOT the same all over and may have differeing shades of BROWN OR BLACK sometimes with patches of red white or blue D= Diameter, the diameter is >6mm (size of pencil eraser) or is growing larger E= Evolution- changes in existing pigmented lesions, particularly nonuniform asymmetric manner
Demonstrate communication skills for conducting effective comprehensive and episodic interview: Principles of History Taking
Listening Questioning - avoid medical jargon - review text for interviewing techniques Observation - do throughout encounter -does statement match physical presentation - note language and demeanor Integration - summarize to verify
Basal cell carcinoma
MOST common fork of skin cancer cancer arises in the BASAL layer of the epidermis subjective: - PERSISTENT sore or lesion that has not healed - CRUSTING - may ITCH objective: - shiny nodule that is pearly or translucent, may be pink or red or white or tan or black or brown - OPEN SORE, may have CRUSTING, may bleed - redish patch or irritated area, frequency occurring on the CHEST SHOULDERS ARMS OR LEGS - pink growth with a slightly elevated rolled border and a crusted indentation in the center as growth slowly enlarges, tiny blood vessels may develop on the surface - scar like area that is white yellow or waxy and often has poorly defined borders, the skin appears shiny and taut - occurs most frequently on exposed parts of the body the face- face, body, neck, scalp should 95% curable ABCDS to diagnose
MRI and indication for head use in practice!
MRI: Diagnostic test that uses a magnetic field and radio waves to produce detailed pictures of the body's organs and structures. Radio waves manipulate the magnetic position of the atoms of the body Indications for MRI of head: - Diagnose intracranial lesions, many demyelinating diseases - Aneurysms, disorders of EYE and INNER EAR, multiple sclerosis, spinal cord injuries, stroke, tumors
Tanner stages:
Male Hair Development Tanner 1 - no growth of pubic hair - testes, scrotum and penis are the same size and shape as in the young child Tanner 2 - slightly pigmented, longer straight hair, often still downy, usually at base of penis and sometimes on scrotum - enlargement of scrotum and the testes - skin and scrottum becomes redder, thinner and wrinkled - penis no larger or scarcely so Tanner 3 - Dark and pigmented curly pubic hair around base of penis - enlargement of penis especially in length - further enlargement of testes; descent of scrotum Tanner 4 - pubic hair adult in type but not in extent - extends no further than inguinal fold - continued enlargement of the penis - sculpturing of the glans increased pigmentation of scrotum - "note quite and adult" Tanner 5 - hair spread to medial surface of thighs but not upward - adult stage!! - scrotum ample - penis reaching nearly the bottom of scrotum P6 - Hair spread along linea alba
Be familiar with standardized symbols and charting of a pedigree
Male= square Square+ Dot= male who is a carried square filled in = male who is affected circle= female circle+ dot= female carrier circle filled in= affected female diamond= unknown gender
Diagnostic with CT
combines power of x-rays with computer to produce 360 degree, cross-sectional views of body Good for imaging bone, soft tissue, and blood vessels all at same time, detecting cancers, evaluating bleeds, imaging patients with metal (no magnet)
Traumatic Red Eye
NEEDS IMMEDIATE TREATMENT!!! corneal abrasion - common corneal foreign body in eye- common foreign body under the lid- common hyphen (blood behind cornea) - common UV keratitis (eye sunburn) chemical injury intracoccular foreign body blowout fx corneal laceration - if corneal abrasion not treated, may become corneal ulcer
bening prostatic hypertrophy
NON MALIGNANT ENLARGMENT OF THE PROSTATE common in men over 50 years of age symptoms of URINARY OBSTRUCTION - hestancy - decreased force and caliber of stream - incomplete emptying - frequency - urgency - dysuria prostate feels SMOOTH RUBBERY SYMMETRIC AND ENLARGED sulcus may be obliterated Prostate enlargement scale - amount of protrusion into rectum Grade 1: 1-2 cm Grad 2: 2-3 cm Grad 3: 3-4 cm Grad 4: 4 + cm
seborrheic keratoses
NORMAL FINDING in OLDER adults pigmented raised warty lesion appearing on the face or trunk these must be distinguished from ACTINIC KERATOSES which have malignant potential because the lesions may look similar seek assistance of an experienced practitioners for dx
assimilate the advanced nurse role in obtaining a client genetic history
Need basic skills of family history, understanding terminology and patterns of inheritance, knowledge about referrals, and social/psychological impacts. Be aware of sensitive nature of questions. Remember there may be "family secrets". Be accurate when describing conditions. Cultural attitudes impact perceptions of genetic diseases. Some clients may attribute problem to a family issue or shame. Client may have concerns about social stigma-ensure privacy. Carefully explore paternity, mental health, diseases with social stigma. Use open, systematic approach.
Determine the appropriate CPT billing level E& M codes for patients encounters
New Patient (99201-99205) Established Patient (99211-99215) - Determined by E&M New patients must have all 3 COMPONENTS = Hx, PE, Medical Decision Making Plan For established patients: 2 of 3 COMPONENTS are required HX: all 3 are needed: - HPI - ROS - PFSH (past, family, social) PE: Determined by total number of BULLET POINTS in how MANY AREAS Medical decisions making: DROP the lowest level and USE the next highest level - includes diagnosis, data, and risk Problem Vs. Physical Office visit services: - patient has a specific complaint - level of payment is determined by how much work is done by provider - 1st diagnosis: chief complaints of patient - 2nd diagnosis: noteworthy additional finding Preventative visits: - patient comes in specifically for a physical - level of payment is determined by the age of the patient - 1st diagnosis: physical - 2nd diagnosis: noteworthy additional findings Care levels: Level one= minimal Level two= problem problem Level three= expanded problem level four= detailed level 5= comprehensive
Red eye
No pain or visual loss Conjunctivitis- looks more pale pink - generalized redness/ injection of blood vessels - may have some discomfort, itching, depending on cause subconjunctival hemorrhage- looks very red - frank area of blood noted on sclera - may happen with trauma or spontaneously episcleritis - bilateral, purplish color - mild stinging
differential diagnosis for penile discharge
Normal seminal emission Gonococcal Infection Trichomonal Infection Nonspecific urethritis Foreign body
differential diagnosis for bladder distention
Outlet Obstructions Urethral valves (child) Prostatic hypertrophy or carcinoma Urethral stricture Decreased bladder tone: Neurogenic bladder (spinal cord injury) Myogenic bladder (overstretched bladder)
Green - black discoloration associated with nails
PSEUDOMONAS INFECTION PAINLESS!!!!!! may be confused with similar discoloration caused by injury to nailed (subungal hematoma, PAIN!!)
pertinent history of eyes
Pertinent Hx: Eyelids: hordeolum (sty), ptosis (drooping) -Vision: one or both eyes, corrected by lenses, near/far. Disposable/non disposable contacts? -Pain: in eye itself vs. around the eye? -Secretions: color, consistency, timing. Allergies? -Meds: eye drops/ointments? Rx/non-rx (shared eye drops?) -Fam Hx: glaucoma (African americans=more likely to get glaucoma) -Occupation/recreation: use of glasses/protection -Eye make-up: potential infection source (remind to change make-up periodically) -PMH: LASIX surgery, trauma, cataracts? Health conditions that may affect the eye (e.g., diabetes)
well women history and exam
Physical Exam for well-woman - Basic Info (vitals, pain, general appearance) Systems ○ EENT (as indicated); check oral mucosa (concern for STI?) ○ Neck: glands, thyroid ○ Chest/Lungs ○ Heart ○ Spine: vertebral column, gait ○ Skin ○ Breast: ■ inspection of 4 positions- sitting; hands on waist; hands behind head; leaning forward. ■ Axillary and upper arm lymph node assessment in both sitting and supine position ■ Breast palpation in reclined position: all quadrants, Tail of Spence & nipple ○ Abdomen ○ Kidneys ○ Reflexes ○ Peripheral Circulation: varicosities, pulses, edema ○ Pelvic: external and internal genitalia, perineum/anus, bi-manual exam
special considerations with women with disabilities
Physical/mental impairment that substantially limits one or more of major life activities of such individual. Preferred terminology; attitudes, barriers and inclusivity; Provider attitude.
Physical exam of ear
Pneumatic otoscopy allows for visualization of TEMPANIC MEMBRANE movement (blows puff of air in)
identify concepts and principles of clinical decision make Process of clinical decision making
Process used to gather, sort, & evaluate information, then used to devise a diagnosis and treatment plan Deliberate, organized sequential process to identify significant clinical relationships and variables Cumulative, organized and dynamic body of information that is used to make decisions, solve problems, and describe and explain phenomena Skills: abilities/acts/activities used to operationalize knowledge Values: beliefs, ideals, moral boundaries Meaning: understanding of concepts/language within the culture of the advance practice role Experience: The active integration of knowledge, skills, values and meanings used in clinical decision-making
Newborn exam
RN performs systemic exam, place baby in warm environment. Use soft voice and warm stethoscope. As baby is laying want to see flexion of elbows and knees. Check symmetry. -Heart and lungs when baby quite, Count HR full 1 min( Normal 120-160beats/min). Respiratory: should see chest and abd move together(30-60 respirations/min);count for a full min. Lateral aspects best place for breath sounds. -Bowels- Inspect, Auscultate and Palpate the bowel sounds. Usually will be able to feel liver on right side. Usually large abd d/t size of organs. -Lift baby- palpate fontanels and suture lines. Can overlap at times. Normal: flat, soft with pulsation. Hair: fine and silky. -ENT: Eye: Iris=deep blue and sclera=white. Check red reflex intact as well as cx of pupil. Ear: outer canthus of eye should be parallel to pina. Pina(in full term) should be well curved. Check firmness of ear for cartilage presence. Nose: Occlude one side and see if breathing? (ensure mouth is closed) Mouth: mucous membranes should be pink and moist. Rooting reflex: stroke side of cheek and baby will turn head that way. Finger in mouth to test sucking
Capillary hemangioma
Red irregular macular patches Causes: dilation of dermal capillaries
Evaluation and Management Codes: E&M
Reflects level of service; Standardized number used for reimbursement THREE KEY COMPONENTS - History - Physical Exam - Medical Decision-Making Medical decision making refers to the process of establishing a diagnosis and/or selecting a management plan. - It is determined by considering the number of possible diagnoses and/or the number of management options that need to be taken into account, the amount and/or complexity of information that must be obtained, reviewed and analyzed such as medical records, diagnostic tests and other information; and the risk of significant complications, morbidity, and/or mortality along with any co-morbidities associated with the presenting problem, diagnostic procedures and/or possible management options. Other Components - Counseling - Coordination of Care - Nature of Presenting Problem - Time
trichomoniasis
STI elevated ph thick STRAWBERRY CERVIX!!! petechiae bright red white/yellow/green "frothy discharge" dx: present of TRICHOMONADS (motile flagella)
Problem oriented medical record SOAP charting
SUBJECTIVE OBJECTIVE ASSESSMENT PLAN
alopecia areata
SUDDEN rapid patchy loss of hair usually from the scalp or face UNKOWN ETIOLOGY Subjective: - SUDDEN RAPID PATCHY HAIR LOSS - may also report nail pitting; may have family history objective: - HAIR LOSS is in a sharply defined round areas - the hair shaft is poorly formed and breaks off at the skin surface
Physical exam of nails
Shape/ contour - nail based angle should measure 160 degrees - if angle is 180 degrees or more CLUBBING is present which suggest CARDIOPULMONARY or other disorders consistency color Newborns (peel, thin) to aging nails (increase in longitudinal ridges, brittle, thick)
Physical exam skin
Skin General Considerations - Adequate lighting (daylight best, if not fluorescent lighting; and proper exposure - Assess for edema, temperature changes, turgor - Examine visually and with palpation (dorsal surface of hands/fingers most sensitive to temperature perception). - Always inspect/palpate for symmetry* -Inspect for distribution (location, symmetry) ■ Inspect hair (tinea capitis) ■ Inspect mouth (herpes, syphilis) ■ Palpate skin ■ Palpate the regional lymph nodes ■ Perform abdominal exam Morphologic Criteria: - Identify the location of the lesions - Identify the distribution - localized, regional, or generalized - Identify primary or secondary lesion ■ Lesions may be primary (those that occur as initial spontaneous manifestations of a pathologic process) or secondary (those that result from later evolution of or external trauma to a primary lesion). ○ Identify shape and arrangement ○ Describe the margins (borders) ○ Describe pigmentation and variation ○ Palpate for texture and consistency ○ Measure the size of the lesions
Relate symptoms or clinical findings to common pathological conditions
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 cardiovascular disease. Injury, steroids, vasculitis, and several systemic disorders can cause localized hemorrhage into cutaneous tissues, producing red-purple discolorations. - The discolorations produced by injury are ecchymoses; - when produced by other causes they are called petechiae if smaller than 0.5cm in diameter or purpure is larger than 0.5 cm in diameter.
TACE questionnaire framework for prenatal detection for risk drinking
T= how many drinks does it TAKE you to feel high A= have people been ANNOYED by your drinking C= Have you felt you like you need to CUT DOWN E= have you ever had a drink first thing in the morning to get rid of nerves/ hangover EYE OPENER
other head and neck concerns
TMJ- crepitus or crackling bells palsy: facial nerve paralysis showing weakness and drooping of one side of the face SUPRAVENTRICULAR NODES- bad nodes- if palpable can indicate MALIGNANCY
Current Procedural Termininology or CPT code
The CPT code is a listing of descriptive terms and identifying codes for reporting medical, surgical and diagnostic services!! - * procedure done It was developed to provide a standardization of terminology to allow for improved communication between health care providers, patients and third parties. - CPT code is a 5 digit number that describes the service or procedure and resources used to provide care - Over 7,000 codes are available and are divided into 6 sections: Evaluation and Management; Anesthesiology; Surgery; Radiology; Pathology & Laboratory; and Medicine. CPT codes will be what is ultimately placed on a BILLING sheet to determine reimbursement. Golden rule: every patient visit must have a billing level type CPT code attached to it!!! Only if a procedure is done, will a CPT procedure code be attached to a patient visit. Part 2 will continue this coding primer presentation, giving information on how you determine the final level of service CPT code.
otitis media with effusion OME
The presence of FLUID in the MIDDLE EAR withOUT signs or symptoms of ACUTE EAR INFECTION Causes: - obstructed or dysfunctional eustachian tube - URI - Allergies - enlarged lymphoid tissue in nasopharynx Conductive hearing loss occurs! On physical exam: - abnormal color - opacification not related to scarring - air fluid level or bubbles - decreased or absent mobility - NO FINDINGS OF ACUTE INFLAMMATION
secondary skin lesion crust
dries serum, blood or purulent exudates slightly elevated sizes varies brown red black tan or straw colored (scab on abrasion, eczema)
identify the rationionale for and the components of the pre participation encounter
To identify conditions that may interfere with a person's ability to participate in a sport. -To identify health problems that increase the risk of injury or death during sports participations -To help select an appropriate sport for a person's particular abilities and physical status
Dyplastic mole
atypical moles predominantly on the TRUNK LARGE - greater than 5mm with flat component border is ILL DEFINED round, oval, or irregular color= brown but can be mottled with dark brown, pink, tan some people may have 1-5 moles; others more than 100 people with dysplastic moles are at INCREASED risk for MELANOMA FOLLOW ABCDEs
hoarseness
URI; usually viral asthma or allergies smoking/ alcohol occupation/ recreational
candidiasis
VERY ITCHY YEAST INFECTION may have pain with urination COTTAGE CHEESE DISCHARGE - very clumpy dx: positive of PSEUDOHYHAE AND BUDDING infants and young children can have it too!!
Measles Rubeola
VIRAL subjective - FEVER, CONJUCTIVITIS stuffy nose and cough - followed by RED BLOTCHY RASH FIRST ON FACE AND THEN SPREADING TO TRUNCK - child has not had measles vaccine - international travel or exposure to individuals from endemic areas objective: - KOPLIK SPOTS - discrete while macular lesion on buccal mucosa - muscular rash delves on face and neck - maculopapular lesions on trunk and extremities in IRREGULAR confluent patches - rash lasts 4-7 days - symptoms may be MILD TO SEVERE - complications involved infection of the RESPIRATORY TRACT AND CENTRAL NERVOUS SYSTEM
Molluscum contagiosum
VIRAL INFECTION (proxvirus) of skin and mucous membranes; CONSIDERED A STI IN ADULTS in contract to the common non sexually transmitted infection in YOUNG CHILDREN subjective: - painless lesions in genital area; sexually active objective: - WHITE OR FLESH COLORED dome shaped PAPULES that are round or oval - surface has a characteristic central umbilication from which a THICK CREAM CORE can be expressed - lesions may last from SEVERAL MOMTHS TO SEVERAL YEARS - diagnosis usually based on clinical appearance of lesions - direct microscopic examination of stained material from the core will reveal typical molluscum bodies within epithelial cell
Infant and children normal and common skin changes and disorders
Vernix Caseosa: ALL NEWBORNS have some degree. Whitish, moist, cheese like substance Cutis marmorata: mottled appearance of the body and extremities. Normal part of newborns response to changes in ambient temperature cooling or heating (the red skin color when they get cold or hot) acrocyanosis: cyanosis of the hands and feet. Normal in NEWBORNS for the FIRST several days, however, if persist could be underling CARDIAC OR PULMONARY DEFECT mongolian spots: BLUSHI BLACK to SLATE gray spots are sometimes seen on back, butt, shoulders, legs of well babies of all races. Most common on darker skinned babies hemangioma: COMMON IN INFANCY. Superficial and subcutaneous hemangioma are true neoplasms, which develop in the first 1 to 2 months, grow fro 2 to 6 months and regress over the next 5 to 10 years stork bites: salmon patch represents COMMON capillary vascular formation, found mostly on the mid forehand eyelids upper lip and back cafe au lait patches: coffee colored patches may either be harmless or indicative of underlying disease NEROFIBROMATOSIS millie: small whitesh discrete papule on face. COMMONLY FOUND during the first 2-3 months sebaceous hyperplasia: numerous tiny yellow macule and papule in the newborn probably a result of ANDROGEN STIMULATION FROM THE MOTHER nails may peel or be very thin which is normal
HPV
Women- 21-29yrs every 3 yrs with cytology. 30-65yrs every 3 years with cytology or every 5 yrs with a combination of cytology and HPV testing. Pregnant women- Should be screened at same intervals as nonpregnant women. Persons with HIV- Women should be screens within 1 yr of sexual activity or initial HIV diagnosis using conventional or liquid based cytology; testing should be repeated 6 months later.
Hep C
Women- Born b/w 1945-1965. If risk factor present. Pregnant women→ Born b/w 1945-1965, or risk factors present. Men and MSM-Born b/w 1945-1965 or if risk factors present. Persons with HIV- serologic testing at initial eval, annual HCV testing in MSM with HIV infection.
Herpes simplex virus
Women- Type-specific HSV serologic testing should be considered for women presenting for an STD evaluation. (Multiple sex partners) Pregnant women- type-specific serologic tests useful for identifying pregnant women at risk for HSV infection and guiding counseling regarding the risk for acquiring genital herpes during pregnancy Men-Type-specific HSV serologic testing should be considered for women presenting for an STD evaluation. (Multiple sex partners) MSM-Type-specific serologic test considered if infection status is unknown in MSM with previously undiagnosed genital infection. Persons with HIV-Type-specific HSV serologic testing should be considered for women presenting for an STD evaluation. (Multiple sex partners). Persons with HIV and MSM at increased risk for HIV acquisition.
testing for syphillis
Women= all pregnant women at 1st pregnant visit retest in 3rd trimester and delivery during high risk men- at least annual for sexually active MSM. Every 3-6 months if at increased risk persons with HIV for sexually active individuals screen 1st HIV evaluation and at least annually after. More screening depending on risk factors
scarlatina scarlet fever
a BACTERIAL ILLNESS that develops in some people who have STREP THROAT most common in children 5 TO 15 years of age symptoms: - BRIGHT RED RASH that covers MOST of the body (face neck arms trunk legs) - a SORE THROAT - high fever
IDENTIFY WHAT TYPE OF INFORMATION IS IN EACH PART OF THE SOAP COMPONENT Plan
a list of each action listed on SEPERATE LINE - labs and other diagnostic test ordered - medication prescribed/ samples dispensed; OTC drugs recommended - teaching done - referrals made - Follow up: appointment, date, reason for, symptoms to come back or ER visit RTC: return to clinic THE LAST ITEM IN THE LIST WHEN TO RETURN AND FOR WHAT REASON, including symptoms that warrant an earlier call or appointment or er visit DO SOME HEALTH MAINTNANCE/ PROMOTION at each visit, best to be pertinent to cc
Urticaria (hives)
a pruritic circumscribed area of raised ERYTHEMA with central pillow occurring in the superficial dermis; they are often generalized in distribution URTICARIA LESIONS ARE MOST COMMONLY A/W type ONE HYPERSENITIVITY reaction to DRUGS FOODS SYSTEMIC DISEASE PHYSICAL AGENS OR COMPLEMENT MEDIATED REACTIONS may occur with angioedema (swelling under skin) most lesions resolve in 24 hours
varicocele
abnormal tortuosity and dilation of veins of the pampiniform plexus (network of veins) within the spermatic cord more common in the LEFT then right associated with reduced infertility scrotal heaviness or pain "bag of worms" grades as small/ medium/ large very wavy and wrinkly
vitiligo
absence of melanin produces patches of in pigmented skin or hair
Benign paroxysmal positional vertigo
acute onset of vertigo associated with rapid head movement or positional changes transient> few seconds no hearing loss women on menses or older adults affected
Articulare rationale for obtaining a genetic and family history and family pedigree: comprehensive family history guides provider in use of genetic testing and risk prevention interventions
allows for understanding of patterns of inheritance single gene inheritance multifactoral inheritance mitochondrial inheritance
"Facies"
an expression or appearance of the face and features of the head and neck that when considered together is a characteristic of a CLINICAL CONDITION OR SYNDROME in peds: dysmorphic features ex: down syndrome fetal alcohol syndrome genetic disorders
xerostomia
dry mouth!!! medications systemic disease smoking radiation treatment
Sinusitis
an infection of one or more paranasal sinuses complications of URI, allergies, dental infection or strcutural defect of the nose blockage of the sinus, prevents secretions from draining> INFECTION symptoms: - fever - headache - local tenderness - swelling of skin over sinues - purulent nasal drainanage - tooth pain - pain in sinuses with bending over Transillumination; difficult needs bring lifght - use bright light to visualize sinus Just as with AOM sinusitis in children and adults MAY clear withOUT antibiotics symptomatic Treatment with DECONGESTANTS, OTC NSAIDS nasal saline spray: reduces URI AND SINUSITIS discuss smoking, second hand smoke
Clubbing
angle 180 degrees associated iwth respiratory and CV disease colitis thyroid disease
Identify approaches for sensitive history information Identify approaches for sensitive history information
assessing a patients spirituality can be a delicate subject for some however it is important to attend to as supporting a patients spirituality can have a positive influence on the health and be a source of COPING AND HOPE obtaining spiritual assessment may be naturally flow out of the emotional assessment and as an assessment of patients coping strategies spiritual assessment should at minimum determine the patients DENOMINATION, BELIEFS, AND WHAT SPIRITUAL PRACTICES ARE IMPORTANT TO THE PATIENT this information would assist in determining the impact of spirituality if any on the care/ services being provided and will identify if any further assessment is needed the standard require organizations to define the content and scope of spiritual and other assessments and the qualifications of the individuals perforation the assessment a useful tool in assessing spirituality are HOPE AND SPIRIT QUESTIONNAIRE that are found in the appendix of SEIDELS physical examination handbook
chlamydia and conorrhea co infection
bacteria can travel up vaginal cavity and go through tubes: PID (can lead to infertility d/t scarring in tubes) in PG can results in pre term delivery!! dx: urine sample but really cervical swab is gold standard for diagnosis CAN BY ASYMPTOMATIC DIFFUSE PELVIC PAIN may even have fever POSTITIVE CERVICAL MOTION TENDERNESS chlamydia= cervix is very excoriated!! PRONE TO BLEEDING Gonnohrea= cervix is SWOLLEN with some discharge
Microsocpy: what you can diagnosis
bacterial vaginosis candidasis trichomoniasis physiological discharge normal flora: ph 4-4.5 if more basic could indicate infection, epithelial cells, lactobacilli, WBC, RBC
Cholesteatoma
begins as whitish appearing growth - BENIGN growth of protein/ skin cells that builds up behind ear canal may be asymptomatic needs referral for removal!!
cervical abnormalities nabothian cyst
benign not to worry
Blue nail beds
blue nail beds may be transient response to a cold exam room 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
Venous star
bluish spider linear or irregular shape DOES NOT blanch with pressure Cause: increased pressure in superficial veins
Melanoma
borders are MORE IRREGULAR lesions are LARGER often >6mm color= color variation within the lesion is characteristic, ranging from tan-brown, dark brown, black to pink red gray blue or white any lesions thought to be melanoma MUST BE BIOPSIED
Nasal Polyps
can cause symptoms of sinusitis/allergies
different between capillary spider and spider angioma?
capillary spiders are little masses of venlues -when you blanch them they will refill in an erratic not all organized way spider angiomas are arterial - blanch and they will refill in a very organized way from the center out and evenly in all directions
Brown skin cutaneous color changes
cause: - DARKENING of melanin pirgmentation Distribution: 1) Generalized - pituitary, adrenal, or liver disease 2) localized: - nevi, neurofibromatosis
Blue cutaneous
causes: increased UNSATUREATED HEMOGLOBIN secondary to HYPOXIA lips, mouth, nail beds Cardiovascular and pulmonary disease
CIN1 cervical neoplasia
cervical redness with red spots maybe HPV related
lichen sclerosis
chronic dermatosis resulting in WHITE PLAQUES with epidermal atrophy and scarring
bacterial vaginosis
classic appearance is milky discharge reacts with KOH and produces ODOR 3 criteria for DX: 1) odor 2) elevated PH 3) appearance of discharge, CLUE CELLS NOT an sti but sexually motivated may be associated with menses vigorous hygiene makes it worse unhygenic habits can also make it worse older women often have ATROPIC VAGINOSIS (more clear discharge)
Differential diagnosis of Headaches
classic migraine - migraine with aura ( sensory disturbance) common migraine - migraine without aura cluster headaches - severe headache that reoccurs over several weeks usually on one side of head hypertensive muscular tension combination headache - migraines with tension headaches temporal arteritis - EMERGENCY - can lead to blindness - temporal arteries which supply brain become inflamed
Group A beta hemolytic strep
clinical signs most predictive: tonsillar ELARGMENT and EXUDATES tender and enlarged ANTERIOR CERVICAL nodes pharyngeal erythema rapid streps are great; over night throat culture is gold standard viral illness/mononucleosis can have similar presentation
casts
clumps of materials/ cells associated with some degree or proteinuria 2 types: hyaline casts (PROTIENURIA) and cellular casts (DEGENERATED CELLS)
impetigo
common CONTAGIOUS superficial skin infection STAPH FOR STREP subjective: - lesions, typically on face that ITCHES AND BURNS - also on other parts of body associated with minor injuries or insect bites objective: - initial lesion is a small erythematous macule that changes into VESCILE or BULLA with a thin roof - lesion CRUSTS with a characteristic HONEY COLOR from the exudates as the vesicles or bullae rupture - may have regional LYMPHADENOPATHY
uterine fibroids
common benign uterine tumors symptoms: - HEAVY MENSES - AB CRAMPING WITH MENSTRATION - urinary urgency and frequency - constipation - pelvic or lower ab pain objective: - firm nodules in the contour of the uterus on bimanual examination - uterus may be ENLARGED
koilonychia
concave curvature and spoon appearance of nails IRON DEFICIENCY ANEMA syphillis fungal dermatoses hypothermia
specific gravity
concentration of urine evaluates excretory power of kidneys normal range = 1.015 - 1.025 decreased: renal disease, over hydration, diabetes insidious increased: dehydration, renal blood flow, glycosuria, proteinuria, hematuria
special concerns for adolescents
concern for physical growth, puberty, body image, brain maturation and cognitive development, emotional development, identity development, autonomy, social relationships Special concerns- sexual behaviors, STIs, pregnancy, birth and abortion, contraceptive use, menstrual disorders and pelvic pain, substance use and abuse, depression, violence (intimate partner violence, sexual violence) Screening needs- Gonorrhea and chlamydia <24/25 at least annually. HIV screening should be discussed and encouraged for sexually active teens. Cervical cytology at 21. Vaccination (HPV, flu, meningitis, Tdap), pregnancy test if indicated. Physical exam- external examinations indications→ confirm anatomy, assess pubertal development, observe for trauma or pathology. STI screening- urine and blood (gonorrhea/chlamydia via urine; HIV and syphilis via blood). Signs of vaginal infection- obtain specimen from vagina w/o use of speculum (wet mount or sampling for lab test) Indications for a pelvic examine→ suspected/reported rape or sexual abuse, dysmenorrhea unresponsive to NSAIDs, amenorrhea, abn vaginal bleeding, lower abd pain, contraceptive counseling for IUD or diaphragm, pregnancy, persistent vaginal d/c, UTI symptoms in sexually active female, Pap test if indicated and in accordance with current guideline.
HYPO spadiasis
congenital defect in which the urethral meatus is located on VENTRAL (underneath) SURFACE of the glans penile shaft or the base of the penis
Cleft lip/ cleft palate
congenital malformation of the face, may occur together or alone. Unilateral vs bilateral. Incidence=highest in whites & Japanese!! lowest in AA. usually repaired in infancy! Long term problems=hearing loss, chronic otitis media, speech difficulties ,feeding problems, improper tooth development and alignment.
scabies
contagious disease caused by the ITCH MITE SARCOPTES SCABEI symptoms appear 3- 5 weeks after infestation primary lesions are BURROWS PAPULES AND VESCIULAR LESIONS SEVERE ITCHING that worries at night two or three bites ( BREAKFAST LUNCH DINNER) usually appear in a line on exposed areas of the skin in older children and adults lesions occur in the webs of fingers, axillae, and creases of the arm and wrists along with the belt line and around the nipples genitalia and lower buttocks infacts and young children have a different patter of distribution with involvement of the palms soles head back and face secondary infections and CRUSTING develop from SCRATCHING and eczematous changes dx made by observation of the tunnels and burrows and by SCRAPING THE SKIN with MICROSCOPIC EXAMINTIAONT OF THE MITE OR ITS EGGS OR FECES
Hairy leukoplakia
corrugated raised white lesions on the tongue! not removable can be seen in HIV/ AIDS
Violet skin
cutaneous hemoehages or vasculitis Kaposi's sarcoma or hemangioma
proximal subungal infection of nails
deep yellow white cloudy patches to nails associated with HIV
Shades of blue, silver, and grey in skin
depositions of DRUGS / METALS in skin including MINOCYCLINE ischemic skin will appear purple to gray deep dermal nevi appear blue
family history for women
diabetes reproductive organ cancer DES(diethylstilbestrol) exposure congenital anomalies genetics
Older adults nose/ throat
diminished sense of smell!! (decreased # of olfactory fibers) increased nasal hair
adolescents
during puberty the EXTERNIAL GENITALIA INCREASE IN SIZE and begin to assume adult proportions the LABIA MAJOR AND MONS PUBIS become MORE PROMINENT and begin to DEVELOP SIMULTAENOUSLY WITH BREAST development VAGINA LENGTHENS and the epithelial layers THICKENS the uterus, ovaries and fallopian tubes INCREAS IN SIZE AND WEIGHT the uterine musculature and vascular supply increase the endometrial lining thickens in preparation for onset of the menstruation BARTHOLIN AND SKENE GLANDS are usually NOT PALPABLE; if they are enlargement exists. This indicates INFECTION WHICH OFTEN IS GONOCOCCAL
primary skin lesions vescicle
elevated circumscribed superficial not into dermis filled with serious fluid <1cm ex: varicella herpes zoster
primary skin lesions Nodule
elevated firm circumscribed DEEP IN DERMIS than papule 1-2 cm in diameter ex: erethema nodosum lipoma
primary skin lesion Tumor
elevated and solid lesions may or may not be clearly demarcated deeper in dermis >2 cm in diameter ex: neoplasms benigng tumor lipoma
primary skin lessions cyst
elevated circumscribed encapsulated lesion in dermis or sub q layer filled with liquid or semisolid material ex: sebaceous cyst cystic acne
primary skin lesions plaque
elevated firm and rough lesions with flat top surface >1 cm in diameter ex: psoriasis active keratoses
primary lesions wheal
elevated irregular shaped area of cutaneous edema solid transiet variable diameter ex: inset bites urticaria allergic reaction
primary skin lesion pustule
elevated superficial lesions similar to a vesicle but filled with purulent fluid ex: impetigo acne
thyromegaly
enlarged lobe
Painful red eye with normal vision
episcleritits = purplish color in eye bilaterally with mild stinging keratitis= corneal inflammation, when herpes gets into cornea, needs aggressive treatment cluster headache= headache that occurs over several weeks usually on one side of face corneal abrasion corneal ulcer
IDENTIFY WHAT TYPE OF INFORMATION IS IN EACH PART OF THE SOAP COMPONENT Objective
exam related to CC, severity, and ROS - based on if it is a return, episodic vs initial visit - report in head to toe sequence the systems examined with each body system identified and reported on SEPARATE LINE
Infants:
external GENITALIA may be SWOLLEN at BIRTH due to estrogen from the mother newborn normal to have ENLARGED LABIA, some bloody discharge (d/t estrogen from mother) enlarged clitoris NOT NORMAL- alert healthcare providers to the possibility of congenital adrenal hyperplasia a mucoid whitish vaginal discharge is commonly seen during the newborn period and sometimes as last as 4 weeks after birth. Reseal of passive hormonal transfer from the mother and is an EXPECTED FINDING
common variations in male anatomy peyronie disease
fibrous band in the corpus cavernosum bending or indentation of the erection loss of penile length pain with erection history of Dupuytren contracture (finger joint contractors) reduced elasticity of the flaccid penis one or more palpated hardened areas
describe techniques that facilitate patient comfort ...
find out source of anxiety before beginning examine maintain eye contact with patient as much as possible explain procedure and equipment drape to allow minimal exposure ask women to drop and open knees, never try to separate legs begin with start of neutral touch to lower thigh make sure they EMPTY bladder before
primary skin lesion telangiectasia
fine irregular red lines produced by capillary dilation ex: rosacea
Telangiectasis
fine, irregular red line Cause: Dilation of capillaries - permanently small blood vessels consisting of venules, capillaries or arterioles
Primary skin lesions Macules
flat circumscribed area that is a CHANGE in the color of the skin less than 1 cm in diameter ex: freckles flat moles petechia measles
cafe au lait patches
flat evenly pigmented spots varying in color from light brown to dark brown to black in dark skin LARGER THAN 5MM in diameter present at BIRTH OR SHORT AFTER may be associated with NEUROFIBROMATOSIS OR MISCELLANEOUS other conditions including pulmonary stenosis temporal lob dysrythimia and tuberous sclerosis these coffee colored patches may be either HARMLESS OR INDICITIVE OF UNDERLYING DISEASE be suspicious of neurofibromatosis is there are six or more cafe au last macule more than 5m in greater diameter in prepubertal individuals or more than 15 mm in greatest diameter after puberty
primary lesions patch
flat non palpable irregularly shaped macule > 1 cm in diameter ex: vitiligo port wine stains mongolian spots cafe au lait patch
hydrocele
fluid accumulation in the scrotum fluid accumulates as a result of a defect in the TUNICA VAGINALIS (layer that contains testes and part of epidermis) common in infancy painless enlargement of swelling of scrotum contender smooth firm mass superior and anterior to the testes transilluminates!!! does not enter the inguinal canal
Darkening of the nails
from antimalarial drug therapy candidate infection (yeast ) hyperbillirubemia chronic trauma (tight fitting shoes)
Candyloma Acuminata
genital WARTS from HPV soft painless warlike tissue may be pearly filiform cauliflower or plaque like same color as skin or reddish or hyperpigmented
Tinea (dermatophytosis)
group of noncandidal FUNGAL INFECTION that involved the STRATUM CORNEUM, NAILS, OR HAIR tine corporis= non hairy part of the body tinea cruris= groin and inner thigh tine capitis= soap tine pedis= feet tinha unguium= nails Subjective: - may report PRURITUS objective: - lesions vary in appearance and may be PAPULAR PUSTULAR VESICULAR ERYTHEMATOUS OR SCLING - secondary bacterial infection may be present - micorscopic examination of skin scraping with KOH solution shows presence of HYPHAE - infected nails are yellow and thick and may separate from nail bed
traction alopecia
hair loss that is the result of PROLONGED TIGHTLY PULLED HAIRSTYLES subjective: - history of wearing certain HAIRSTYLES such as BRAIDS or from using HAIR ROLLERS and hot combs objective - patchy hair loss that corresponds directly to the area of STRESS - scalp may or may not be inflamed
secondary skin lesions scale
heaped up, keratinized cells flaky skin irregular thick or thin dry or oily variation in size (flaking of skin with sebhorrheic dermatitis or following a drug reaction; dry skin)
conducive hearing loss
hearing loss caused by OBSTRUCTION in the ear canal or middle ear could be as simple as wax also seen in: otosclorsis and OME DX: weber hearing test!!!! - defective ear will hear tuning fork louder and Rinne test
sensorineural hearing loss
hearing loss caused by a lesion in the INNER EAR or the 8th nerve DX: weber test and rinne test
fecal occult blood testing
hemawipes take home kits take home kits
Diabetic eye changes
hemorrhages neovascularizations exudates *think lots of blood in the eye
Otosclerosis
hereditary more common in women results in fixation of stapes - abnormal bone growth around the tiny vibrating bones of the ear Symptoms: tinnitus slowly progressive hearing loss low to medium pitch (conductive hearing loss) noticed btw late teens to 30 years of age (won't see on PE, will know more from hx) !!!
uterine prolapse
herniation of the uterus into or beyond the vagina results from WEAKENING of the structure of the pelvic floor sensation of PELVIC HEAVINESS, tissue PROTRUDING from the vagina urine LEAKAGE difficulty having BM first degree: cervic remains within vagina second degree: cervix is at the introitus third degree prolapse: cervix and vagina drop outside the introits
genital herpes
herpses simplex virus most commonly HSV2 painful lesion on penis genital area or perineum may have burning or pain with urination superficial vesicles on glans shaft or at base often associated with inguinal lymphadenopathy or systemic symptoms including fever
varicella chickenpox
highly communicable disease common in children and young adults subjective: - fever, headache, sore throat, mild malaise - PRURITIC rash that started on scalp and then moved to extremes - started as maculopapular and in a few hours becomes VESICULAR - child has no had varicella vaccine objective: maculopapular and vesicular lesions on trunk, extremities, face, buccal mucosa, palate, or conjuctivae - lesions usually occur in successive outbreaks, with several stage of maturity present at one point - complications include conjunctival involvement, secondary bacterial infection, viral pneumonia, encephalitis, aseptic meningitis, myelitis, Guillain Barre syndrome, Reye syndrome
Articulare rationale for obtaining a genetic and family history and family pedigree: Family History:
i. Goal: to identify patterns, presence of condition or trait and establish a diagnosis ii. FIRST step in genetic screening!!! iii. important component of screening for risk of disease/condition/potential health problems iv. inexpensive, accessible, reliable. Impacts disease management and prevention efforts. v. Inclusion of birth and death records. Marriages, reproductive history and medical problems. vi. Clear Mendelian patterns may emerge. vii. Providers can identify a pattern of risk that impacts treatment and screening decisions.
Review clinical genetics and process for obtaining a pedigree: Family history specifics
i. congenital anomalies ii. mental/dev. delay iii. genetic disorders iv. miscarriage and stillbirths v. ethnicity/ancestry/consanguinity
Review clinical genetics and process for obtaining a pedigree: Neonatal history specifics
i. hearing loss ii. large for gestational age without rationale iii. persistent hyperbilirubinemia iv. hyper- or hypotonia v. newborn screening results
Articulare rationale for obtaining a genetic and family history and family pedigree: Genetics and disease
important role in many aspects of health and disease cardiovascular disease (stroke, HTN, MI aneurysm) other diseases: diabetes (types I and II), parkinson's disease, alzheimer's disease cancer: hereditary forms of breast, ovarian, colorectal cancer mental illness: schizophrenia, bipolar, depression, suicide, substance abuse
paraphimosis
inability to replace foreskin to its usual position after it has been retracted behind the glans glans in congested or enlarged necrosis and gangrene can result
Herpes simplex
infection by HERPES SIMPLEX VIRUS subjective: - tenderness - PAIN - parenthesis - mild burning at the infected sited before onset of lesions objective: - grouped VESCILES on an erythematous base and then erode FORMING CRUST - lesions last 2-6 weeks
folliculitis
infection of hair follicle
Otitis Externa
infection of the auditory canal trauma (Q TIPS) or moist environment favors bacterial or fungus growth Symptoms: - external ear PAIN - external ear itching - pain with manipulation of the tragus - decrease hearing Signs: - SWELLING AND REDNESS OF CANAL - SECRETIONS in the ear canal - foreign body
prostatitis
inflammation and infection of the prostate gland Acute: bacterial infection, STI, adjacent organ disease, complication of biopsy Subjective - pain, urination problems, sexual dysfunction, fever, chills objective - massage of prostate can cause bacteremia, prostate enlarged, acutely tender and often asymmetric, abscess may develop, semila vesicles are often involved and may be dilated and tender, bacteria in urine may be boggy and enlarged and stimulate neoplasm chronic: bacterial or nonbacterial subjective: - asymptomatic, frequent bladder infections, frequent urination, pain in lower abdomen or back objective: - normal in size and consistency, ,ay be enlarged and boggy
atrophic vaginitis
inflammation of the vagina due to the thinning and shrinking of the tissue as well as decreased lubrication caused by LACK OF ESTROGEN DURING MENOPAUSE vaginal soreness or itching discomfort and bleeding with intercourse mucosa is dry and pale can become reddened and develop petechair and superficial erosions
painful red eye WITH vision impairment
iritis = inflammation of the iris glaucoma orbital cellulitis scleritis corneal abrasions = can and cannot have vision problems Keratitis= herpes in the eye - can and cannot have vision problems corneal ulcer- can and cannot have vision problems
magnolian spots
irregular areas of DEEP BLUISH BLAK TO SLATE GRAY pigmentation usually in the sacral and gluteal regions - back and butt shoulders and legss seen predominately in newborns of AFRICAN NATIVE AMERICAN/ AMERICAN INDIAN ASIAN OR LATIN DESCENT importnat to document so no confused for bruise or abuse
secondary skin lesions keloid
irregular shaped elevated progressively enlarging scar grows beyond the boundaries of the wound caused by excessive collagen formation during healing (following surgery)
HSV OF EYE
keratitis = when herpres spears to the eye NEEDS AGGRESSIVE TREATMENT keratitis= corneal inflammation
start of Unit 5: Female GU Menstural history
last menstrual period menarche frequency duraiton character of flow symptoms: - dysmenorrhea - intermenstrual bleeding - pain - PMS
Black skin
lesions that may be melanocytes including nevi and melanoma black eschars collecting of dead skin can arise from vascular infarction, infection ( anthrax, meningococcemia, localized spider bites) arterial insuficciency or vasculitis
secondary skin lesion fissure
linear crack or break from the epidermis to the dermis may not be moist or dry ex: athletes foot crack at the corner of the mouth
earache
loof for: concurrent URI, frequent swimming, head trauma onset duration pain fever discharge related complaints medications:OTC meds or other topical treatments
secondary skin lesion excoriation
loss of epidermis linear hollowed out crusted area (abrasion or scratch, scabies)
secondary lesions skin ulcer
loss of epidermis and dermis concave varies in size ex: decubitus stasis
secondary skin lesions erosion
loss of part of the epidermis depressed moist glistening following rupture of vesicle or bulla ex: varicella after rupture
Vulvular findings: herpes
low grade fever "bumps" pain!!!! recurrent: during, itching, swelling NO SCARRING open sores, weeping etc matching sores on opposite side outbreak likely to occur during IMMUNOCOMPROMISED STATES - PREGNANCY - OTHER DISEAS - STRESS
Plan
management plan - substantiated by the assessment Contain: - pharm or non pharm treatment - proposed data collection: labs - POCT orders - Education - Referalls - Follow up: Appointment date and why returning, symptoms to call office or go to ER - DX and plan can be given corresponding number
Articulare rationale for obtaining a genetic and family history and family pedigree: Genetic/ Family history
many genetic screens available Information included: 1. family structure 2. major medical concerns/chronic conditions 3. demographic information 4. environmental information
smoking
many health risks encouraged sensation = leads to SIDS and asthma
older adults skin conditions
may appear more transparent and paler pigment deposits increased freckling and hypo pigmented patches may develop flaking and scalling due to drier skin thinning of skin loss of elasicity wrinkling Cherry angiomas= ting, bright red, round papule that become brown over times sebhorreic keratosis: pigmented raised warty lesions usually appearing on the face and trunk. Be sure to distinguish between actinic keratosis sebaceous hyperplasia: occurs as yellowish flattened papule with central depression cutaneous tags (acrochordon) small soft tags of skin usually appearing on the neck and upper chest. They are attached to the body by a narrow stalk and may be or may not be pigmented solar lentigines: irregular round gray brown macules with a rough surface that occur in sun exposed areas " aka age spots" or incorrectly as "liver spots"
thyroid nodules
may be related to IRON DEFICIENCY single node: cyste or tumor diffuse enlargement: goiter, graves disease (hyperthyroidism)
Labryinthitis Disease
may occur as a complication of a URI affects the INNER ear symptoms: - vertigo and nystagmus (rapid eye movements) - may increase severity with head movement SENSIORNEURAL hearing loss occurs on the affected side!
older adults
menopause is defined as 1 year no menses estrogen levels DECREASE causing the LABIA AND CLITORIS to become smaller BOTH ADRENAL ANDROGENS and ovarian tester one LEVELS markedly DECREASES after menopause the ovaries also decrease and follicles gradually disappear
German Measles Rubella
mild FEBRILE highly communicable viral disease subjective: - low grade fever, stuffy nose, sore throat and cough - this is followed by a macular rash on face and trunk that rapidly becomes papular objective: - GENERALIZED light pink to RED maculopapular rash - by the second dar rash spread to the UPPER AND LOWER extremities - it fades within 3 days - redish spot occur on SOFT PALATE during the prodrome or on the first day of rash - infection during first trimester of pregnancy may lead to INFECTION of fetuss and may produce a variety of CONGENITAL ANOMALIES
PSA
more risk if african american discuss PSA at age 50 psa velocity free psd or ratio: ca has smaller proportion of free psa vs complex asa
Red eye or pink eye
most cases caused by BACTERIAL OR VIRAL INFECTIONS trauma glaucoma systemic disease congenital anomalies
screening for down syndrome
most common form of chromosome abnormality among live births and the most frequent form of intellectual disability caused by a demonstrable chromosomal aberration. It is now recommended that all pregnant women be offered screening for down syndrome, regardless of risk factors. A non-directive approach should be used when providing info; be clear that testing is voluntary. First semester combined test is best option for women whose most important goal is to estimate risk early in pregnancy. (best way to screen 1st trimester: nuchal translucency, and biochemical markers. Women who have increased risk for aneuploidy based on screening should be given genetic counseling and offered option of CVS or 2nd trimester amniocentesis.) →1st trimester combined test: sonographic determination of nuchal translucency and gestational age (crown-rump length) combined with the serum markers pregnancy-associated plasma protein-A Screening can be performed at 9-13 wks of gestation with free beta-hCG or at 11-13 wks with beta-hCG. Chorionic villus sampling (CVS) for definitive prenatal diagnosis must be available to women who undertake first trimester screening and are screen positive. →2nd trimester test: alpha-fetoprotein recommended for detection of neural tube defects. **Special considerations for testing: Consequences of screening should be considered (psychological, and procedure-related loss of fetus). Most positive results are associated with a normal pregnancy outcome. Give info for detection, false positive rates, advantages/disadvantages, limitations, risk/benefit
eczematous dermatitis
most common inflammatory skin disorder, several forms including IRRITANT CONTACT DERMATITIS, ALLERGIC CONTACT DERMATITIS, ATOPIC DERMATITIS subjective: - itching may or may not be present - those with atopic dermatitis often report ALLERGY SYMPTOMS (allergic rhinitis, asthma) objective -acute phase characterized by ERYTHEMATOUS PRURITIC WEEPING VESCICLES - subacute exzema characterized by erythema and scaling - chronic stage characterized THICK LICHENFIED PRURITIC PLAQUES - atopic dermatitis; during childhood lesions involved flexures the nape and dorsal aspect of limbs - in adolescents and adulthood lichenfied plaques affect flexures head and neck
Cocain abuse
nasal symptoms d/t snorting/insufflation: sniffling, congestion, recurrent nosebleeds, sinus problems. Very recent use: hyperemia, edema of nasal mucosa, rhinorrhea. Chronic use: scabs on nasal mucosa, decreased perception of taste/smell, perforation of nasal septum
Stiff neck
neck/ head injury, strain - occupational swelling of neck - lymph nodes? - anterior: STREP posterior: MONO Fever Character treatment/ medication
Diabetic women
need to achieve glycemic control pre conceptually increased risk for congenital defects in fetus- cardiac- if mom does not have controlled glucose
Results of urinalysis Nitrites
nitrites are POSITIVE with gram NEGATIVE BACTERIA : E COLI KLEBSIELLA PNEUMOIA PROTEUS MIRABILIS and NOT with bacteria that do not produce nitrate reductase (substance that changes nitrates to nitrites like staphsaprophyticus, enterococcus, pseudomonas) SPECIFIC FOR UTI positive nitrates and negative leuks likely UIT negative nitrates and positive leuks can be UTI
Physical exam of the eye
no red reflex? Possible retinal blastoma or cataract. -Vision screening, corneal light reflex, assess for nystagmus (fine oscillating movement, 1-2 beats is normal w/ extreme gaze), visual fields (assumes YOU have normal fields!) -If pt has myopia (nearsighted), dial ophthalmoscope to the negative/minus/red lens -If hyperopia (farsighted), dial to positive/black lens Follow optic disc-margins should be sharp, maybe little fuzzy nasally; arterioles=more narrow & red *Diabetes changes: hemorrhages, exudates, neovascularization *HTN changes: A/V nicking: vein appears to be depressed as it passes under the artery -Pingueculum (yellowish spot) Non CA cuased by UV, slightly raised yellowish Pterygium (if goes into cornea):- when BUMPS MOVE INTO IRIS more common in rural areas/ w/ ppl who work outside; comes from repeated irritation to eye due to wind/dust/sun (usually doesn't disturb vision/cause pain) - no treatment for either pingueculum or pterygium unless vision impairment -Hordeolum (Sty) vs. Chalazion: chalazion: sty turned bad/untreated; becomes "walled off," can see crusting/draining; requires excision/drainage -Periorbital Cellulitis: infectious process, can extend into eye-needs aggressive treatment and needs to be treated fully - NEEDS AGGRESIVE TREATMENT ■ HTN is most commonly diagnosed disease by eye doctors
Adolecents and ears
noise occupational/recreational exposur q-tips should be used to clean outside ear ONLY!!!
older adult and ears
noise exposure tinnitus subtle signs of hearing loss presbycusis (gradual LOSS of high frequency) ears grow larger!! DECREASED sebaceous glands -->drying of cerumen cilia=coarse
uroglobin
normal 0.2-1.0 produced in intestinal tract, chemical reduction of the billirubin >2.0= ABNORMAL indicates LIVER DAMAGE OR HEMOLYTIC DISEASE < or absent: HEPATOBILLIARY DUCT OBSTRUCTION
Ketone
normal = NONE, buff- pink reagent color (ketones = product of fat metabolism) if POSITIVE need to inquire why your patient is using FAT AS ENERGY SOURCE causes for positive results: - fasting - strenuous exercise - vomtting - PG - starvation - dehydration - diabetic ketoacidosis
epithelial cells
normal = a few epi cells in urine line renal tubules positive results: can indicate 3 different cell types: - renal - transitional in uterus/ bladder - squamous in urethra
ph
normal is 5-9 average is 6 >6.5 = ALKALEMIA - UIT - diet high in citrus fruits/ veggies - old specimen <5.5= ACIDIC - metabolic or respiratory acidosis - starvation - dehydration - diet high in meat or cranberries
WBC
normal is = 0-4 inflammatory process positive results: UTI plynonephritis vafinal secretions
crystals
normal is NONE indicates renal stone formation urea crystals high serum URIC ACID LEVELS gout phosphate and calcium oxalate crystals - parathyroid abnormalities, malabsorption
blood in urine
normal is NONE orange reagent color green spots on reagent: RBCs; green color; free HgB/ myoglobin positive results: - clouding urine UTI - clear urine with gross hematuria = meses - clear urine with microscopic hematuria (MI trauma, transfusion reaction, sickle cell anemia, HTN renal disease)
glucose
normal is NONE positive result: trace, 1+ - 4+ glucose renal threshold 160-180mg/dl can indicate DIABETES
nitrite
normal is NONE white reagent color conversation of nitrate to nitrite by GRAM NEGATIVE BACERIA if positive CULTURE IS NEEDED
protein
normal is NONE yellow reagant color; indicates KIDNEY function or UTI INFLAMATION if more than trace amount; SIGNIFICANT PROTEINURIA benign conditions; stress, pregnancy, URI fever strenuous exercise positive results: HTN DIABETES POST RENAL INFECTION PREECLAMPSIA MULTIPLE MYELOMA
bilirubin
normal= NONE positive result= water soluble conjugated bilirubin latent or unsuspected LIVER DISEASE /OBSTRUCTION foam test: yellow foam means bilirubin (when you shake sample)
Head injury
objective description of event state of consciousness after injury - ASK ABOUT LOC- prior to head injury Associated symptoms: - head and neck pain - laceration - altered LOC - local tenderness - changes in breathing pattering - blurred or double vission - discharge from nose or ears - N/V - dizziness (vertigo) vs lightheadedness Medications, OTC, alcohol, street drugs Additional notes: o State of consciousness after injury: immediately and 5 minutes later; duration of unconsciousness; combative, confused, alert, or dazed o Predisposing factors: seizure disorders, hypolgycermia, poor vision, ligh-headedness, syncope o Associated Symptoms: head or neck pain, lacerations, local tenderness, change in breathing patern, blurred or double vision, discharge from nose or ears, nausea or vomiting, urinary or fecal incontinence, ability to move all extremities
Nose and throat Infants
obligatory nose breathers!!! - need SUCTION when sick, congestion makes feeding harder Epstein pearls (white spots in mouth)=reassure parents these are normal. Toddlers put things in mouth-careful about aspiration. Discuss infant PO care w/ parents; minimize juice and no bedtime/naptime bottles (^ caries). Teeth: 20 by 30months
Review clinical genetics and process for obtaining a pedigree: what to include
obtain 3 GENERATIONS of family history: AGE AND DX - parents aunts uncles - grandparents - siblings - children Include major health or genetic disorders: - hypertension - cancer - cardiac - respiratory - kidney disease - strokes - thyroid disease - asthma - diabtetes - hepatitis - familial disorders - spontaneous abortions and stillbirths incldue: - family relationships - age - age of death - cause of death
Herpes lesions
occurs on gums/lips; r/t stress; painful; multiple small erosions
Nail yellow discoloration
occurs with several disease including PSORIASIS AND FUNGAL INFECTIONS may occur with CHRONIC RESPIRATORY DISEASE
OLD CARTS
onset location duration Character Aggrevating Factors Relieving Factors Temporal Severity
pregnant women nose/ throat
ore likely to have stuffy nose nose bleeds * DUE TO VACULAR CHANGE
color of urine
pale straw to dark amber alternating factors: - hydration - foods ( beets can make pee purple) - disease (hyperbilirubinemia = greenish yellow or brown) - drugs (pygidium= red/ orange color)
anatomy of the eye
palpebral tissue: the open space between the eyelids limbus: border between iris and sclera cranial nerves: SO4 (superior oblique) LR6 (lateral rectus) and all of the rest are III Involved cranial nerves: superior oblique muscle (CN IV, trochlear), lateral rectus (CN VI, abducens), other muscles=oculomotor (III)
glynocological history
pap smear- normal current guidelines, abnormal- when how treated f/u glynocological procedures surgeries STIS vaginal infection cancer or reproductive organs contraception- current method if ay, attitude about current method and knowledge of alternatives. previous methods sexual history: - sexually active currently - how long sexually active - current number of partners - total number of lifetime partners - are apartments men, women or both - satisfaction vs pain - discomfort - difficulties -STI protection - IPV
linea nigra
pigmentation of the linea alba DURING PREGNANCY ite extends from the symphysis pubis to the top of the fungus in the midline
Green fingernails
possible pseudomonas aeruginosa infection "blue green puss bacteria" attack immunocompromised or people in the hospital longer than a week
Identify approaches for sensitive history information Occupational/ environmental
pre employment work related injuries worksite assessment issues involving environment and occupational exposures are often seen in the healthcare setting evaluation of exposures and risks is imperative for all patients regardless of age even second hand exposure for example cigarette smoke and some hobbies can have a great impact on health status occupational injuries require evaluation of patient impairment, disability and workers compensation the environment and occupation histories can be included as part of PATIENT SOCIAL HISTORY
common abnormalities hernia
protrusion of a peritoneal - lined sac through some defect in the abdominal wall direct hernia: budge in the area of the hesselbach triangle (inguinal ligament, recurs shealth, inferior epigastric vessels) burgers anteriorly, easily reducible, pushes on side of finger on exam, sac protrudes directly through inguinal wall indirect hernia: protrude into inguinal canal from the deep ring, touches fingertip on examination
Menieres disease
recurrent attacks, abrupt affects VESTIBULAR labyrinth leads to sensorineural hearing loss symptoms: severe vertigo tinnitus progressive hearing loss starting with LOW TONES
apthous ulcer "canker sore"
recurrent small round or ovoid ulcers with circumscribed margins, erythematous haloes, and yellow or gray floors Topical corticosteroids (TCs) remain the mainstays of treatment fails to respond to local measures, systemic immunomodulators may be required
Spider Angioma
red central body with radiating SPIDER LIKE legs that BLANCH with pressure to the central body Cause: liver disease, vitamin B deficiency, Idiopathic
purpura
red/ purple NONBLANCHABLE discoloration GREATER THAN 0.5 cm in diameter cause: intravascular defections, infection
Petechiae
red/ purple NONBLANCHABLE discoloration LESS THAN 0.5 cm diameter Causes: intravascular defects, infection
Echymoses
red/ purple NONBLANCHABLE discoloration of VARIABLE SIZE bruise causes: vascular wall destruction, trauma, vasculitis
common eye complaints
redness, swelling visions issues pain in or around the eye secretions, discharge floaters: sudden onset or increase in #?= floaters are usually considered a medical emergency because they can be sign of retinal tear or detachment!!! (s/s usually include INCREASED NUMBER + PERIPHERAL VISSION LOSS)
scarring alopecia
replacement of HAIR FOLLICLES WITH SCAR TISSUE subjective: - may have other concurrent SKIN or systemic disorders objective: - patching HAIR LOSS - scalp may be INFLAMMED - hair follicles may be PUSTULAR OR PLUGGED
IDENTIFY WHAT TYPE OF INFORMATION IS IN EACH PART OF THE SOAP COMPONENT Subjective
report in the sequence bellow, with each topic identified and reported in a SEPARATE line HPI: Onset, Location, Duration, Character, Aggravating, Relieving, Temporal/ Timing, Severity (OLD CARTS) - place positive FIRST then DENIES for everything else - episodic visit, DO ROS related to CC, list pertinent systems with negative and positive - CHRONOLOGICAL STORY - elaboration of chief complaint Interval health - How has your health been since the last visit - ask every visit- " SINCE YOUR LAST APPOINTMENT HAVE YOU NEEDED TO SEE ANOTHER PROVIDER OR SPECIALIST, BEEN TO THE ER OR BEEN SICK" - always review prior appointment note : ask about diagnosis from last visit, has it resolved or not Past Medical History: - update every visit - Major illness and chronic disease, including emotional or psychiatric diagnosis - Acute or episodic visit: any past illness directly relate to the chief complaint - Child under 5 years old and under: prenatal, labor, delivery, and neonatal history - Hospitalizations, surgeries and injuries: Date, diagnosis, outcome including complications Medications: - prescriptions - OTC - vitamins - Herbal supplements - current dose and administration - immunization status Allergies: - medications including PCN - plants - animals - foods - latex Family History: - Family pedigree: - 3 generations - grandparents - parents, aunts, uncles - siblings - children * AGE AND HEALTH PROBLEM * If deceased age and cause of deth * illness of familial nature * update every visit Social/ habits Social - Social support: how patient gets along with family members, who lives with them - Occupational history: type of job- " please describe your job" -economic status: is income and health insurance adequate - Educational level: Children- how they like and are doing in school, extracurricular activities Habits - Etoh, recreational drugs - Children: nail bitting, tantrums, bowel/ bladder, thumb sucking - Sleep - Activities, exercise, leisure - Daily profile - Diet- 24 hours recall - Development: children less than 5, age of developmental milestone - Minimum diabetes, heart disease, cancer Sexual history: - either with social/ habits or with GU - Include: number of current and past partners, satisfaction and issues, pregnancy, STI prevention, screen for sexual and physical abuse Safety - seatbelt, smoke/ Co detectors, guns, safe home? - environmental exposures - cultural influences: belief and practice that include behavior - spirituality/religion: sigificance of life, beliefs and practices that influence care, faith tradition - coping - wellness exam: obtain all info - focused: obtain only related info ROS - head to toe - list possible symptoms - wellness exam - all systems - focused- analysis of symptoms - chart positive and negative responses - part of history/ subjective- TOLD BY PATIENT - NOT PART OF OBJECTIVE/ PHYSICAL EXAM
Maternal PKU
requires dietary modification to avoid harm to fetus, follow throughout life
secondary skin lesion lichenification
rough thickened epidermis secondary to persistent rubbing itching or skin irritation often involves flexor surface of extremity (chronic dermatitis)
squamous cell carcinoma
second most common form of skin cancer arise in the EPITHELIUM subjective: - PERSISTENT sore or lesion that has NOT health or that has grown in size - may have CRUSTING AND/OR BLEEDING objective: - elevated growth with a central depression - wart-like growth, may have CRUSTING, may BLEED - OPEN SORE, may have crusting - occur most commonly in SUN EXPOSED AREAS particularly the scalp back of hands lower lip and ear, rim of ear and lower lip especially vulnerable 95% curable ABCDS for diagnosis
pityriasis rosea
self limiting INFLAMMATION of unknown cause subjective: - sudden onset with occurrence of a primary (herald) oval or round plaque - Herald lesion (a skin rash that sometimes begins as a large spot on chest, belly, or back followed by a pattern of smaller lesions) often missed - eruption occurs 1-3 weeks later and lasts several weeks - Pruritus may be present with the generalized eruption Objective: - lesions usually pale, erythematous, and macular with fine scaling but may be papular or vesicular - lesions develop on the EXTREMITIES AND TRUNK; palms and soles are not involved and facial involvement is rare - trunk lesions characteristically distributed in parallel alignment following the direction of the rubs in a christmas tree like pattern
CANT MISS DIAGNOSES
signs of a bleed, tumor abnormal neurological signs - TIA vs CVA vs Bells palsy temporal arteritis - older adults, temporal pain Meningitis - kernigs: is positive when the thigh is flexed at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful (leading to resistance). This may indicate subarachnoid hemorrhage or meningitis. - brudzinski: any of several symptoms of meningeal irritation occurring especially in meningitis; especially :involuntary bending of the knees and hips of a supine patient caused by lifting the head of the patient so that the chin moves towards the chest.
millia
small whitish discrete papule on the face they are commonly found during the first 2-3 months of life the sebaceous glands function in an immature fashion at this age and are easily plugged by sebum
Pregnant normal conditions or changes
striae gravidarum (stretch marks) may appear on abdomen, thighs, and breasts during SECOND trimester telangiectasis (vascular spiders) appear on FIFTH month of pregnancy mostly on face, neck, chest, and arms increased pigmentation hemangioma may increase in size chloasma: (mask of pregnancy) blotchy in appearance and usually symmetrical. Occurs generally on the forehead, checks, bridge of nose and chin ITCHING over the abdomen and breast- normal UNLESS accompanied by a rash
social history of women
substance abuse- tobacco, alcohol, recreational drugs, caffeine, sexual history
Allergic rhinitis
symptoms: - rhinitis with clear watery mucous, sneezing, itchy nose and eyes Seasonal versus perennial: - if symptoms are seasonal occurrence- early spring ( tree pollen) early summer (grass pollen) early fall (weed pollen) - common indoor allergens: animal dander, dust mites, mold Vaso-motor rhinitis= non allergic reaction; response to stimuli Physical exam: - PALE SWOLLEN BOGGY MUCOSA AND TURBINATES - inflamed mucous membranes with hay fever - violet colored mucous membranes - nasal smear with EOSINOPHILS Tx: - may improve school and work performance, minimize days lost
head and neck physical exam
tape measure - for HC (measure above eyebrows) occiput circumference is usually 2-3 cm larger than chest circumference inspect- note symmetry, facial features for shape, symmetry with rest, movement, expression thyroid nodules: single cyst or tumor - diffuse enlargement is goiter or graves disease usually only auscultate thyroid FEEL OR SEE enlargement test TMJ for crepitus and pain
Identify approaches for sensitive history information sexual assessment
the focus of the sexual health history is to determine RISK FACTORS and ISSUES that might interfere with sexual function and satisfaction asking about physical symptoms such as DISCHARGE OR DYSPAREUNIA are important but also evaluate the emotional response of sexual pleasure and any partner issues the sexual health history can be addressed when gathering patient information about the urinary system
candidiasis
thick white clumpy discharge s/s vulvar itching red irritation urethal inflammation vulvar swelling and tissue
secondary skin lesions scar
thin to thick fibrous tissue that replaces normal skin following injury or lacerations to the dermis (healed wound or surgical incision)
seconarday lesion of skin atrophy
thinning of skin surface and loss of skin markings skin translucent and paper like ex: striae aged skin
old adult assessment head and neck
thyroid gland becomes more FIBROTIC t 4 production is DECREASED issues with dizziness/ vertigo, weakness, impair balance
pregnancy assessment head and neck
thyroid will not change in size if has adequate iodine intake inquire about weeks gestation, presence of preexisting disease, PIH (pregnancy induced Hypertension) and alcohol use
Problem Oriented Medical Record (POMR) purpose and components
to standardize communication Biographical/ identifying/ demographic information source of history CHIEF COMPLAINT - brief sentence or short notation - usually in patients own words "quotations" Soap charting!! - NEW SOAP NOTE FOR EACH PATIENT VISIT
syphillis
treponema pallidum contracted with sore, 2 weeks post exposure painless lesion on penis solitary lesion firm round commonly located on glans but can be on foreskin indurated borders with a clear base scraping can show SPIROCHETES - slender, spiral, undulating bacteria - under microscope
Identify approaches for sensitive history information Domestic violence
unfortunately domestic and partner violence is a living reality for many patients inquire about FEELING SAFE and ISSUES OF SAFETY at every wellness exam- child and adult alike all female gene exams and when YOU HAVE AN INDEX OF SUSPICION it is important to ask specifically and discreetly often patients may not bring the issue up themslves appendix in sidel will show beginning questions questions can be part of sexual health or genitourinary review it may be helpful to PREFACE THE QUESTIONS BY LETTING YOUR PATIENT KNOW THAT DOMESTIC OR PARTNER VIOLENCE IS UNFORTUNATLY COMMON AND SO YOU ASK ALL YOUR PATIENTS ABOUT THE ISSUE in complete privacy ask if the patient has ever been in a realtionship in which she/he felt unsafe if the answer is yes- ask if she or he feels safe in his or her current situation - if the response is no as if she he would like you to help him or her find safe environment - unless volunteered by the patient DO NOT seek out to identify the threatening individual
Depression that occurs in nails
usually response to SYSTEMIC DISEASE including SYPHILLIS disorders producing high fevers periperal vascular disease uncontrollled DM *single nail indicates injury not systemic problem
herpes zoster ( shingles)
varicella zoster viral infection subjective: - pain - itching - burning of the DERMATOME area usually precedes eruption by 4 to 5 days objective: - SINGLE dermatome that consists of red, swollen, plaques or vesicles that becomes filled with purulent fluid
Nevi Moles
vary in SIZE and DEGREE of pigmentation nevi are present on most persons regardless of skin color and may occur anywhere on body may be FLAT RAISED DOME SHAPED SMOOTH ROUGH OR HAIRY color ranges from pink, tan, gray and shades or brown to black most nevi are HARMLESS some may be DYPLASTIC PRECACNEROUS OR CACNEROUS occur more often in lighter skinned than darker skinned strong associated between SUN EXPOSURE and NUMBER OF NEVI increased number throughout infancy and childhood with EAK incidence in 4th to 5th decades nevi diminish in # with advanced age junction nevus= flat well circumscribed compound nevus= surface elevated and mother
Primary lesions skin Bulla
vescicle >1 cm ex blister pemphigus vulgaris
older adults and eyes
vision changes: presbyopia (in 50's often need reading glasses) color vision decreased depth perception decrease pupillary constrictions> decreased night vision central vision= macular degeneration peripheral vision loss= glaucoma dry eyes/ tearing, ectropion (eyes turn outward away form eye ball), eyes may appear more sunken ( decrease periobatal fat), cornea is clear, arcus senillis = opaque band at the limbus ( no effect on vision, not painful) cataracts >40% at age 75- 80 need replacement lens
recognize variants and abnormalities condyloma acuminatum
warty lesions due to HPV soft painless flesh colored lesions may occur in cluster or cauliflower like masses
hypothyroidism
weight gain constipation fatigue cold intolerance
hyperthyroidism
weight loss tachycardia diarrhea heat sensitivity
POCT for Strep
with 2 of the appropriate swabs in one hand, use tongue depressor in other hand to depress the tongue. In a quick motion, swab one tonsil (especially into any exudate), slide over uvula to other tonsil, swab other tonsil, and then remove. One tonsil swab can be use for rapid strep test, and the other swab should be save for a culture if necessary If is positive pt is Tx w/out follow-up testing If negative throat culture is obtained
Hep B
women at increased risk pregnant women= test for HBsAG at first prenatal visit of each pregnancy regardless of prior testing; retest at delivery if at high risk Men= at increased risk, All MSM should be tested for HBaAg persons wtith HIV test= HDsAG and anti- HbC and or/ anti -Hbs
Nisseria gonnorrhea- Gonorrhea
women sexually active <25 > 25 at high risk retest 3 months after treatment pregnant women- all < 25 or >25 years at high risk, treats 3 months after treatment MSM- annually at sites of contact (urethra recturm or pharynx) regardless of condom use. Every 3-6 months if ay increased risk Persons with HIV- ist evaluation screen, and annually after that. Frequent screening for risk behaviors.
current screening for HIV
women: all ages 13-64 years who seek evaluation for STDs all pregnant women at first prenatal visit retest at 3rd trimester if high risk!! Men: all agres 13-64 years of age seeking evaluation of STDs annually for sexually active MSM if HIV status is unknown or and the patient himself or his sex partners have had more than 1 sexual partner since most recent HIV test *should be assessed and encouraged according to CDC
chlamydia testing
women= sexually active and under 25 years of age, sexually active 25 years and over at increased risk retest 3 months after treatment!! all pregnant women under 25 years old, >25 if at increased risk. Retest during the 3rd firmest for women <25 or at risk. Pregnant women with chlamydial infection should have test of cure 3-4 weeks after treatment and be retested within 3 months. Men: young men in high prevalence clinical settings or high populations with high burden of infection. MSM- annually at site of contact (urethra, rectum) regardless of condom use. Eery 3-6 months high risk Persons with HIV- screen at 1st evaluation, and annually. Frequent screening depending on risk behaviors
Candidasis
yeast! any age, removable w/ gauze; systemic illness vs. use of steroid inhalers? Thrush can occur in infants, will decrease once immune system develops
screening for sickle cell disease
○ African descent, Mediterranean, Caribbean, India, and Blacks ○ Newborn SCD screening in Illinois since 1989 ○ Screening should be encouraged preconceptually
follicles acid supplementation for preconception
○ CDC Rec: 0.4mg for all women of childbearing age ○ IF history of neural tube defect: 4.0mg at least one month prior to conception and for the first 12 weeks of pregnancy ○ Bread products have folic acid supplementation
Different hearing test for kids per hearing ppt
○ Conventional Audiometry: mass testing in schools, refer out for further testing ○ 0-6mo→ Behavioral Observation ■ least reliable ○ 6mo-2yrs → Visual Reinforcement Audiometry; localize sound to source ○ 2yrs-4yrs → Condition Play Audiometry; condition child to throw block in water when hear sound Tympanometry ■ not a hearing test; tests tympanic membrane mobility; tests for effusion that interferes with hearing ● Behavioral Signs of HL: inconsistent response to name, talking loudly/softly, attention problems, change in school performance, not startle to loud sounds ● Hearing aids→ typically used for bilateral hearing loss ○ also need referral to a SLP ● Cochlear Implants: electrode in cochlea; pt has to have an intact auditory nerve Screening in Adults ○ Hearing impairment underdiagnosed in adults Types ■ Conductive: perforated ™, middle ear effusion, cerumen, etc ■ Sensorineural: 90% of hearing loss results from permanent damage of hair cells!! ■ Presbycusis: sensorineural due to aging→ treated with hearing aids
risk assessment for PCC
○ Family history of both biological parents ○ Includes nine components→ family history, medical/surgical history, infection history, OB/Gyn history, environmental history, nutrition history, male partner's history, physical exam, laboratory tests
Hearing loss powerpoint screening infants and children
○ Hearing loss is MOST common birth abnormality→ early diagnosis and intervention is crucial ■ Mandatory to screen all infants by 3 mos of age!!! ○ Risk Factors for Newborns: family hx, congenital infections, craniofacial abnormalities, congenital syndromes, down syndrome, LBW, mechanical ventilation >5 days, bacterial meningitis, low apgar scores ototoxic meds, severe hyperbilirubinemia (25-30, significant high bili), mom with rubella during pregnancy ○ Newborn Screening Tests ■ OAE Test (otoacustic emissions): used in healthy babies; probe put in ear and sound to cause movement ● can pass this screening and still have mild hearing loss ■ Auditory Brainstem Response ABR: performed by audiologist on high risk infants ● requires sedation!!! ■ *** need to ask about these tests at first pediatrician visit!! ○ Causes for hearing loss: ■ AOM, OME, swimmers ear, cerumen build up, etc. ○ *** DO NOT USE WHISPER TEST FOR KIDS
prior to screening
○ Information regarding: purpose of screening, voluntary nature of screening, information about specific conditions being screened for, estimation of carrier risk in their ethnic or racial group, factors to consider in deciding to have or not have screening ○ Genetic counselors for some screenings
CDC recommendations for preconception
○ Interventions for identified risks: chronic and infectious disease management as part of childbearing related care ○ Interconception care: systematic follow-up and care between pregnancies ○ Prepregnancy checkup: add to recommended regimen of prenatal and postpartum visits: encourage vitamins, etc. ○ Health insurance coverage for women of limited income ○ Few research studies have been conducted regarding effectiveness of PCC screening
ashkanakeniz jews
○ Most from Eastern European (Ashkenazi) Jewish communities in US ○ ACOG offer if one Jewish grandparent has dx ○ Offer screening if pt is unsure of Ashkenazi heritage or is part of a mixed marriage ○ Test Jewish partner first ○ Testing is less reliable for non-Jews and non-Ashkenazi Jews ● What diseases should be screened for→ ○ ACOG standard: screen for Canavan disease, CF, familial dysautonomia, Tay-Sachs, cost is around $200
ACOG and american college of medication genetics recommendation
○ Screening for cystic fibrosis IF: positive family history, partners of individuals with CF, couples planning a pregnancy, couples seeking prenatal care ○ Recommended that CF testing offered to whites (highest incidence) and Ashkenazi Jews (highest detection rate)
Describe methods for tests for STDs
● 24-25 years old gonorrhea and chlamydia testing ● HIV encouraged if sexually active ● PAP smear and cytology for >21 years old ○ OR previous positive results before age 21 screen per guidelines ● HIV/syphilis: test in blood ● Gonorrhea and chlamydia: test in urine ● TRICH: wet mount with NaCl ● Candida: wet mount with KOH ● Gonococcal culture: sterile cotton swab
review the standard pediatric history
● 90% of problems in kids are identified in history rather than the physical exam**** ● Children are seen frequently for well child visits from 0-5 years especially ○ Focus on parental concerns, development, anticipatory guidance to caregivers ● Early years history is from the parent but as child grows older history is from both parent and child ● Knowledge of growth and development milestones is crucial→ must adapt questions and anticipated issues to their age ● TEXT PAGE 18-20 HAS ROS QUESTIONS ADAPTED TO AGE ● Parents have minimal exposure to young children, may have little family/social support in the community, may lack confidence in child rearing skills, need reassurance and guidance ● Begin with parental concerns, ask about concerns related to learning, development, and behavior as well as physical health ● Parents are more likely to address concerns and provide information if provider inquires about them ● Focus on→ ○ Nutrition ○ Sleep ○ Elimination patterns ○ developmental/school progress or issues, day care ○ Habits (crying, temperament, discipline) ○ activity/exercise ○ Amount of TV/video game time per day ● Past history focus→ ○ Perinatal (thoroughness depends on age of child and or problems identified) ○ Immunizations (record dates) ○ Allergies ○ Medications: OTCs, vitamins, anti-pyretics ○ Developmental milestones/school progress, ages child achieved certain milestones ● Be prepared to respond to concerns as you take the history ● Many questions are related to behavior which differs than adult history
dx for bruits
● A-V Fistula ● Renal artery stenosis ● Vascular tumor
role of APN in adolecent care
● Advocate, ally, and resource ● Many adolescents do not take advantage of or have many resources regarding their health and concerns ● Most health problems in this age group originate from social and behavioral factors and often relate to experimentation and risk taking (drinking and driving, STIs) ● ***Parent-family connectedness and perceived school connectedness protective against every health risk behavior EXCEPT PREGNANCY*** ● Parent expectations of school achievement were associated with lower levels of health risk behaviors ● Parent disapproval of early sexual debut was associated with later onset of intercourse ● Adolescent is a time for EXPERIMENTATION ● Do not always learn from previous experiences ● Younger adolescents are concerned about provide characteristics: disease transmission in health care setting Interviewing Adolescents ● Introduce yourself first to child then the parent ● Family and past history may be best obtained from the parent ● Address CC before beginning psychosocial history ● Parents and other family members should not be present during HEEADSSS ● Ensure confidentiality: exceptions being risk of hurting self or others ● Start with lighter, non-threatening, innocuous conversation to decrease anxiety ● Do not need to follow HEEADSSS order rigidly ● Look for strengths and signs of resilience during interview as well as risk
intrapartum / postpartum key historical
● Data that may impact infant in the immediate post-birth period: length of ROM, length of labor, maternal fever, fetal status in labor (tachycardia, FHR patterns, meds given, analgesia/anesthesia, time of birth, route of delivery) ● Data recorded on L&D record
technique for examining a newborn
● Hearing assessment is now done in Illinois on all babies at birth at the hospital ● Ballard screening tool is now used for gestational age ● Feeling liver edge is common ● Spleen is uncommon to feel: seen with CMV and severe ABO incompatibility ● Kidneys also are not usually palpable but may be with polycystic kidney disease ● Take axillary temperature ● Keep in warm environment ● Listen to lungs when baby is quiet or takes a deep breath when crying ● 30-60RR is normal, rate is normally irregular, abnormal respiratory status would be cyanosis, retractions, and tachypnea ● HR 120-160 bpm ● Check body proportions and symmetry as baby moves around ● Mouth should be closed when checking nasal patency ● When baby is crying look at oral cavity, palpate hard and soft palates, midline and symmetrical uvula, epstein pearls (small white dots) are normal ● Listen and palpate abdomen in all four quadrants in clockwise direction ● At 40 weeks testes should be descended ● Baby should void within 24 hours, usually happens during delivery ● Barlow's test: hip dislocation ○ Asymmetry of gluteal folds may indicate hip dislocation
neonatal history
● History is the mother's history in the first few hours/days ● APGARS, resuscitation, BW, lab tests (glucose, bli, CBC, type/Rh) ● S/S of disease are often subtle in infants so careful review of history in addition to physical is very important to identify risk ○ Example: tachypnea may be a symptom of RDS, sepsis, heart disease, hypoglycemia, hypothermia, metabolic disorder etc. History may give more clues than the physical ○ ALWAYS review feeding, elimination, activity/behavior when assessing infant
differetial diagnoses for visible and or palpable kidneys
● Hydronephrosis ● Polycystic disease ● Large simple cyst ● Carcinoma
aspects of the health history of female that are important
● Identifying information, CC, HPI ● Reproductive History* ○ Last menstrual period (LMP) ○ Pregnancy history - GTPAL (G=pregnancies, T= term births, P=preterm births, A=abortions, L= living children) ○ Gynecologic History ● Sexual History* ● Medical Surgical History ● Current Health Care ● Age Appropriate Social History* ○ Tobacco/ETOH/Drugs ○ Depression ○ Intimate Partner Violence ● Family Hx ● ROS
key historical impact of the maternal history on nenalt management
● Infections (STIs, HIV, Hepatitis, Toxoplasmosis, Rubella, CMV, Varicella, Group B strep ● UTIs ● Vaginal bleeding ● Lifestyle habits: smoking, alcohol, drugs, excessive exercise, life stress ● psychosocial : unwanted pregnancy, domestic abuse, lack of social support, psych disorder ● Environmental/Socioeconomic: income issues, work environment, unsafe neighborhood
expected finding in the exam of a full term newborn
● Molding - tell parents it will go away ● Caput succedaneum - crosses suture lines, resolves ● Pustular melanosis - leaves hyper pigmented areas, normal, self-resolving ● Diaphragmatic (abdominal) breathing ● Acrocyanosis - blue hands and feet, common in first 24 hrs ● Peeling skin - normal in postmature newborn ● Mottling ● Lanugo (may have some balding where lanugo has disappeared) ● Vernix caseosa - cheese-like substance that cover baby during gestation, may remain in folds ● Milia ● Telangiectatic nevi (stork bites) - blanchable, usually on face or nape of neck, self-resolving ● Mongolian spots - bluish spots around sacrum, must document, don't mistake for abuse, mostly on Blacks or Asians ● Erythema toxicum - small pustules with erythematous base, resolves spontaneously, red raised papules ● Breast engorgement in males and females from maternal hormones ● Withdrawal vaginal bleeding - normal response to withdrawal of hormones ● Penile/urethral cyst - normal, usually self-resolving, may be lanced ● Edema of the eyelids is common ● Post-mature newborn with peeling skin is normal ● Central cyanosis is abnormal: inadequate oxygenation ● Acrocyanosis: bluish pale color in hands and feet that is exaggerated by cold stress and decreased perfusion, not abnormal in first 24 hours ● Jaundice is abnormal in first 24 hours, blanch skin over bony prominence and assess sclera to check ● Green tinged umbilical cord: meconium in amniotic fluid
outline components of preconception care and give example of teaching
● Portion of every primary care visit for women of childbearing age ● Not covered by insurance ● Important to understand potential harmful exposures in prenatal period that impact fetus ● PCC has been shown to improve pregnancy planning: leads to better outcomes for both women and infants in combination with prenatal care ● Goal is to prepare for potential pregnancy: healthy ● Encourage a reproductive life plan for every women, man, or couple: when they want to or plan to get pregnant ● Consumer awareness: make public aware of impact that untreated illnesses and adverse health behaviors have on pregnancies ● Preventative visits: routine visits offer a time to incorporate PCC health care
men who have sex with men guidelines
● Recommended routine lab screening for common STIs at least annually ● HIV serology ● Syphilis serology ● Hep B virus ● Oral sex in past year: urethral infection and rectal infection with N. gonorrhoeae and C. trachomatis ○ Pharyngeal infection with N. gonorrhoeae ● Consider eval for HSV ● Chlamydia, gonorrhea, and PID colonize the cervix in females versus the urethra in males ○ Cervical swab is the gold standard but can also use urine screening
Identify approaches for sensitive history information Sentative topics in general
● Sensitive topic are really defined by your patient, as something might be sensitive for one and not another!!! As providers, we need to approach common sensitive topics, such as sexuality and substance use questions, with thoughtfulness. It is best to ask sensitive type questions once rapport and trust has been established with the patient, usually later in the interview as oppose to the beginning. If resistance in answering is apparent, move on to a less threatening topic and return to the question at a later time in the visit or even at the next visit. A common characteristic of inexperienced students is jumping right into sensitive topic questions in a blunt manner. This can be off-putting to the patient and hinder your relationship. When approaching sensitive topic questions during the health history interview, transition by making a statement something like, " I need to now ask you some questions about very personal issues. Though it may be hard or embarrassing to answer, the information is important so I can provide you with the best care possible and any issues you might have can be addressed."
