Physical exam 2 (13-19, 21)

tinea pedis (athlete's foot)

"athlete's foot" a fungal infection, first appears as small vesicles between toes, on sides of feet, and on soles; grows scaly and hard; found in chronically warm, moist feet; children after gymnasium activities, athletes, aging adults who cannot dry thier feet well

loss of outer corssed fibers at one chiasm

(e.g. aneurysm or left internal carotid artery exerts pressure on uncrossed fibers); injury yields nasal hemianopia

lesion at optic chiasm

(e.g. pituitary tumor) injury to crossing fibers yields loss of nasal part of each retina and loss of both tempora lvisula fields; bitemporal hemianopasia

whispered voice test

- Stand arm's length (2 feet) behind the person. - Test one ear at a time while masking hearing in the other ear to prevent sound transmission around the head. - This is done by placing one finger on the tragus and pushing it in and out of the auditory meatus. - Move your head to 1 to 2 feet from the person's ear. - *Whisper slowly a set of 3 random numbers and letters, such as "5, B, 6."* - Normally the person repeats each number/letter correctly after you say it. If the response is not correct, repeat the whispered test using a different combination of 3 numbers and letters. - A passing score is correct repetition of at least 3 of a possible 6 numbers/letters. - Assess the other ear using yet another set of whispered items "4, K, 2."

macrocephalic

- an enlarged head or head rapidly increasing in size; e.g. hydrocephalus (increased CSF) ma

microcephalic

-head size less than norms for age mi

head injury (subjective data)

1. any injury/ blow to head 2. onset 3. setting 4. feel just before injury 5. lose consciousness/ fall 6. knocked unconscious 7. history of illness 8. location 9. duration 10. associated symptoms 11. pattern 12. effort to treat

lungs subjective data

1. cough 2. shortness of breath 3. chest pain with breathing 4. history of respiratory infections 5. smoking history 6. environmental exposure 7. patient centered care

ear subjective data

1. earache 2. infections 3. discharge 4. hearing loss 5. environmental noise 6. tinnitus 7. vertigo 8. patient centered care

skin, hair, nails checklist

1. inspect skin: color, general pigmentation, hypo/hyperpigmentation, color changes 2. palpate skin: temperature, moisture, texture, thickness, edema, mobility/ turgor, hypgiene, vascularity/ bruising 3. note lesions: color, shape/configration, size, locaiton/ distribution 4. inspect/palpate hair: texture, distribution, lesions 5. inspect/palpate nails: shape and contour, consistency, color 6. teach self exam

peripheral circulation subjective data

1. leg pain/ cramps 2. skin changes on arms/ legs 3. swelling in arms/ legs 4. lymph node enlargement 5. medications 6. smoking history

infant hearing loss tests

1. otoacoustic emission (OAE) test- for this test a probe is placed just inside the baby's ear canal to measure the response (echo) when clicks or tones are played into the baby's ears 2. auditory brainstem response- clicks or tones are played through soft earphones placed over the baby's ears while electrodes placed on the baby's head measure how the auditory nerve nad brainstem carry sound from the ear to the brain; the electrodes come off like stickers and are painless; the baby can rest or sleep during both tests, each takes 5-10 minutes

three erthematous states of newborn

1. skin has beefy red flsuh for first 24 hours d/t vasomotor instability 2. harlequin color change 3. eryhema toxicum

infant and children eye subjective data

1. vaginal infections in mother at delivery 2. which developmental milestones have been noted 3. are there routine vision tests at school 4. is parent aware of safety measures to protect child's eyes from trauma

aging adult eye subjective data

1. visual difficulty when climbing stairs or driving/ night vision 2. when was the last time tested for glaucoma 3. history of cataracts 4. do your eyes ever feel dry? burning? 5. any decrease in usual activites such as reading, sewing, driving?

keloid (secondary lesion)

A benign excess of scar tissue beyond sites of injury: surgery, acne, ear piercings, tattoos, infections, burns. Looks smooth, rubbery, shiny and "clawlike"; feels smooth and firm. Found in ear lobes, back of neck, scalp, chest and back; may occur months to years after inital trauma; most common ages are 10-30 years; higher incidence in blacks, Hispanics, and asians

aphthous ulcers

A common "canker sore" is a vesicle at first and then a small, round, "punched-out" ulcer with a white base surrounded by a red halo. It is quite painful and lasts for 1 to 2 weeks. The cause is unknown, although it is associated with stress, fatigue, and food allergy.

cheyne-stokes respiration

A cycle in which respirations gradually wax and wane in a regular pattern, increasing in rate and depth and then decreasing; the breahing periods last 30-45 seconds, with periods of apnea (20 seconds) alternating the cycle; the most common cause is severe heart failure; other causes are renal failure, meningitis, drug overdose, and increased intracranial pressure; occurs normally in infants and older adults during sleep

deep vein thrombophlebitis

A deep vein is occluded by a thrombus, causing inflammation, blocked venous return, cyanosis, and edema. virchow triad is the classic 3 factors that promote thrombogenesis: stasis, hypercoagulability, and endothelial dysfunction; cause may be prolonged bed rest, history of varicose veins, trauma, infection, cancer, obesity, immobility, heart failure, or use of estrogen hormones

Branchial Remnant and Ear Deformity

A facial remnant or leftover of the embryologic branchial arch usually appears as a skin tag; in this case, one containing cartilage. occurs most often in the preauricular area, in front of the tragus; when bilateral, there is increased risk for renal anomalies

normal anterior chamber

A light directed across the eye from the temporal side illuminates the entire iris evenly because the normal iris is flat and creates no shadow.

enophthalmos (sunken eyes)

A look of narrowed palpebral fissures shows with enophthalmos, in which the eyeballs are recessed. Bilateral enophthalmos is caused by loss of fat in the orbits and occurs with dehydration and chronic wasting illnesses.

bell palsy

A lower motor neuron lesion (peripheral), producing rapid onset of cranial nerve VII paralysis of facial muscles; almost always unilateral; this may be a reactivation of herpes simplex virus latent since childhood; complete paralysis of one half of hte face; person cannot winkle forehead, raise eyebrow, close eelid, whistle, or show teeth on affected side

pectus excavatum

A markedly sunken sternum and adjacent cartilages (also called funnel breast). Depression begins at second intercostal space, becoming depressed most at junction of xiphoid with body of sternum. More noticeable on inspiration. Congenital, usually not symptomatic. When severe, sternal depression may cause embarrassment and a negative self-concept. Surgery may be indicated.

ecchymosis

A purplish patch resulting from extravasation of blood into the skin, >3 mm in diameter

strawberry mark (immature hemangioma)

A raised bright red area with well-defined borders about 2 to 3 cm in diameter. It does not blanch with pressure. It consists of immature capillaries, is present at birth or develops in the first few months, and usually disappears by age 5 to 7 years. Requires no treatment, although parental and peer pressure may prompt treatment.

Retention "Cyst" (Mucocele)

A round, well-defined, translucent nodule that may be very small or up to 1 to 2 cm. It is a pocket of mucus that forms when a duct of a minor salivary gland ruptures. The benign lesion also may occur on the buccal mucosa, on the floor of the mouth, or under the tip of the tongue.

furuncle

A small boil located in the skin or mucous membrane; appears red and swollen and is quite painful. Avoid any manipulation or trauma that may spread the infection.

candidiasis or monilial infection

A white, cheesy, curdlike patch on the buccal mucosa and tongue. It scrapes off, leaving a raw, red surface that bleeds easily. Termed thrush in the newborn. It is an opportunistic infection that occurs after the use of antibiotics and corticosteroids and in immunosuppressed people.

6 minute walk test

ABNOMR: ask the person to stop hte wlak if you measure an SPO2 below 85% to 88% or if extreme breathlessness occurs

crackles

ABNORM _____________ are discontinuous popping sounds heard over insprtation

facial structures

ABNORM: edema in the face occurs first around the eyes (periorbital) and the cheeks, where the subcutaneous tissue is relatively loose not grinding if jaw, tics, fasacicularations, or excessive blinking nystagmis accompanies a persistent concern of vertigo fs

symmetry (neck)

ABNORM: head tilt occurs with muscle spasm; rigid head and neck occur with arthritis sn

facial structures

ABNORM: hostility or aggression tesne, rigid muscles may influence anxiety or pain; a flat affect may indicate depression marked asymmetry with central-brain lesion or periphral cranial nerve VII damage fs

thyroid gland

ABNORM: look for diffuse enlargment or a nodular lump abnormalities: enlarged lobes that are easily palpated before swallowing or tender to palpation or presence of lumps tg

skull (infant and children)

ABNORM: note an abnormal increase in head size or failure to grow microcephalic-head size less than norms for age macrocephalic- an enlarged head or head rapidly increasing in size s i/c

widespread color change

ABNORM: pallor/ white erythema/ red cyanosis/ blue jaundice/ yellow

distribution

ABNORM: absent or spase genital hair suggests endocrine abnomrlaities hirsutism-excess body hair; in females this forms a male pattenr on the face and chest and indicates endocrine abnormalities

fontanels

ABNORM: delayed closure or larger than normal ______________ size occurs with hydrocephalus, down syndrome, hypothyroidism, or rickets a small ________________ is a sign of microcephaly, as is early closure f

halitosis

ABNORM: diabetic ketoacidosis has a sweet, fruity breath odor; this acetone smell also occurs in children with malnutrition or dehydration; others are an ammonia breath odor with uremia, a musty odor with liver disease; a foul, fetid odor with dental or respiratory infections; an alcohol odor with alcohol ingestion; a mouselike smell of breath with diptheria

anterior chest inspection

ABNORM: nosiy breathing occurs with severe asthma or chronic bronchitis unequal chest expansion occurs when part of hte lung is obstructed or collapsed or when guarding to avoid postoperative or pleursiy pain

Range of motion (neck)

ABNORM: thyroid enlargement may be a unilateral lump, or it may be diffuse and look like a doughnut lying across hte lower neck rom

drunsen

ABNORM: _____________ are easily confused with the abnromal finding hard exudates, which can occur with a more circular or linear pattern; also ___________________ in the macular area occur with macular degenration d

decreased/ absent breath sounds

ABNORM: _______________ occur: 1. when bonrchial tree is obstructed at some point by secretions, mucus plug, or a foreign body 2. in empyhsema as a resutl of loss of elasticity in the lung fibers and decreased force of inspirated air; the lungs also are already hyperinflated, so the inhaled air does not make as much noise 3. when anything obstructs transmission of sound betwen the lung and stethoscope such as pleurisy or pleural thicking or air or fluid in hte pleural space a silent cehst meas that no air is moving in or out, an ominous sign

increased tactile/vocal fremitus

ABNORM: _______________ occurs with compression or consolidation of lung tissue (e.g. lobar pneumonia); this is present only when the bronchus is patent and the consolidation extends to hte lung surface; only gross changes ________________; small areas of pneumonia do not significantly affect it

wheezes

ABNORM: ________________ are continuous musucal sounds heard maily over expiration

mobility

ABNORM: ________________ is decreased with edema

pleural friction fremitus (thorax exam)

ABNORM: ________________ is palpable with inflammation of hte pleura

cyanosis

ABNORM: ________________- indicates hypoxemia and occurs with shock, cardiac arrest, heart failure, chronic bronchitis, and congential heart disease

fungal infections

ABNORM: _________________ are common in older adults, with thickened, crumbling toe-nails and erythematous scalining between the toes

thoracic cage

ABNORM: _________________ cyanosis occurs with tissue hypoxia

ronchal fremitus (thorax exam)

ABNORM: _________________ is palpable with thick bornchial secretions

edema

ABNORM: _________________ shows in depdent body parts (feet, ankles, and sacral areas), where the skin looks puffy and tight unilateral _________________ has a local or peripheral cause; bilateral __________ or generalized ______________, consider a central problem such as heart failure or kidney failure

streptococcal pharyngitis

ABNORM: _________________ shows with erythmatous, enlarged tonsils with exudates; four features suggests __________________: absence of cough; swollen, tender anterior cervical nodes; fever >1004; tonsilar exudate. with these features and in children 3-14 years, rapid antigen testing is warranted

loss of collagen

ABNORM: _________________ with aging increases risk of skin tears from minor trauma or from moving or grabbing the person

nail color

ABNORM: _________________- cynaosis or marked pallor brown linear streaks espeically sudden apperance are abnormal in light-skinned people and may indicate melanoma splinter hemorrhages, transverse ridges, or Beau lines

bilteral pitting edema

ABNORM: __________________ calls for an examination of the neck veins; if the neck veins are abnormally distended, the peripheral edema may be related to heart disease or pulmonary hypertension; if neck veins are normal, something else may cause the edema, (e.g. liver disease, nephrosis, chronic venous insufficiency, antihypertensive or hormonal medications

erythema

ABNORM: __________________ occurs with polycythemia, venous stasis, carbon monoxide poisoning, and extravascular presence of RBCs (petechiae, ecchymosis, hematoma)

scalp hair

ABNORM: ___________________ note dull, coarse, or brittle ________________ gray, scaly, well defined areas with broken hairs accompany tinea capitis, a ringworm infection found mostly in school age children

voice sounds

ABNORM: ___________________ consolidation or compression of lung tissue will enhance the ____________ making the words more distinct

increased breath sounds

ABNORM: ___________________ mean that sounds are louder than they should be (E.g. bronchial sounds are abnormal when they are hear over the peripheral lung fields); they have a high-pitched tubular quality, with a prolonged expiatory phase and a distinct pause between inspiration and expiration; they sound very close to the stethoscope, as if they were right in the tubing close to your ear; they occur when consolidation (e.g. pneumonia) or compression (e.g. fluid in the interplerual space) yields a dense lung are that enhances the transmission of sound from the bronchi; when the inspired air reaches the alveoli, it hits solid lung tissue that conducts sound more efficiently to the surface

viral pharyngitis

ABNORM: ___________________ shows erythematous tonsils with no hypertrophy ox exudates; when accompanied by cough, hoarseness, and rhinorrhea, a rapid antigen test and/or culture may not be needed in low-risk grouops

thickness

ABNORM: ___________________ very thin, shiny skin (atrophic) occurs with aterial insufficiecny

sclearal icterus

ABNORM: ____________________ is an even yellowing of the sclera extending up to hte cornea, indicating jaundice

crepitus

ABNORM: _______________________ is a coarse, crackling sensation palpable over the skin surface; it occurs in subcutaneous emphysema when air escapes from the lung and enters the subcutaneous tissue, as after open thoracic surgery or injury

infant and children lung assessment

ABNORM: a 1-minute apgar with a total score of 3-6 indicates a moderately depressed newborn needing more resuscitation and subsequent close observation; a score of 0-2 indicates severely depressed newborn needing full resuscitation, ventilatory assistance, and subsequent intensive care

forced expiratory time

ABNORM: a ________________of 6 seconds or more occurs with obstructive lung disease; refer this person for more precise pulmonary function studies

femoral arteries

ABNORM: a bruit occurs with turbulent blood flow, indicating partial occlusion

infant/ children color vision

ABNORM: a color-deficient person cannot see the letter against the field iccv

cornea and lens

ABNORM: a corneal abrasion causes irregular ridges in reflected light, producing a shattered look to light rays

nasal cavity

ABNORM: a deviated septum looks like a hump or shelf in one nasal cavity; perforation is seen as a spot of light form a penlight shining in the other naris and occurs with cocaine use epistaxis commonly comes from the anterior septum

neck (infant)

ABNORM: a short neck or webbing may indicate congenital abnormality (e.g. down/ turner syndrome) or it may occur alone head tilt and limited ROM occur with torticollis (wryneck) or from sternomastoid muscle injury during birht or a congenital defect resistance to flexion (nuchal rigidity) and pain may indicate meningitis n i

fontanels

ABNORM: a true tense or bulging ______________ occurs with acute increased intracranial pressure depressed and sunken fontanels occur with dehydration or malnutrition marked puslations occur with increased increased intercranial pressure f

temperature of legs

ABNORM: a unilateral cool foot or leg or a sudden temperature drop as you move down the leg occurs with arterial ischemia

palpate anterior chest

ABNORM: abnromally wide costal angle with little inspiratory variation occurs with emphysema; a lag in expansion occurs with atelectasis, pneumonia, and postoperative guarding a palpable grating sensation with breathing indicates pleural friction fremitus

hearing acuity (infants/children)

ABNORM: absence of alerting behavior may indicate congenital deafness failure to localize sond no inteligible speech by 2 years old

iris and pupils

ABNORM: absence of iris color occurs with albinism brushfield spots usually suggest down syndrome constant nystagmus, prolonged setting-sun sign, marked stabismus, and slow lateral movements suggest vision loss ip

external nose

ABNORM: absence of sniff indicates obstruction (e.g. common cold, nasal polyops, rhinitis)

newborn visual acutiy

ABNORM: absent blinking absent pupillary light reflex, especially after 3 weeks, indicates blindness nv

Ascultation (infant head)

ABNORM: after 5 years of age, bruits indicate increased intracranial pressure, aneurysm, or arteriovenous shunt a i

aging adult skin thickness

ABNORM: aging skin increases risk for pressure ulcer development

ankle-brachial index

ABNORM: an ABI between .91 and 1 is borderline cariovascualr risk an ABI of 0.9 or lower indicates PAD

infants and young children (ear exam)

ABNORM: an abnormal response is no movemnt; drum hypomobility indicate effusion or a high vacuum in the middle ear; for hte newborn's first 6 weeks, drum immobility is the best indicator of middle ear infection

epitrochlear lymph node

ABNORM: an enlarged ________________ occurs with infection on the hand or forearm; ______________ occurs in conditions of generalized lymphadenopathy; lymphoma; chronic leukemia; infectious mononuclerosis; HIV infection

ocular fundus

ABNORM: an interruption in the red reflex indicates opacity in the cornea or lens; an absent red reflex occurs with congential cataracts or retinal disorders of

eyelids and lashes

ABNORM: an upward lateral slope together with epicanthal folds and hypertelorism (large spacing between eyes) occurs with Down syndrome el

infants and children (oral exam)

ABNORM: ankylogossia, a short lingual frenulum, can limit protrusion and impair speech development; trauma may indicate child abuse from forced feeding of bottle or spoon; a high-arched palate is suually normal in a newborn, but a very narrow or high arch also occurs with Turner syndrome, Ehlers-Danlos syndrome, Marfan syndrome, and treacher collins syndrome or develops in the mouth-breather in chronic allergies

tongue

ABNORM: any lesion or ulcer persisting for more htan 2 weeks must be investigated an indurated area may be a mass or lymphadenopathy, and it must be investigated

infant and children lung assessment

ABNORM: asymmetric expansion occurs with diaphragmatic hernia or pneumothroax; crepitus is palpable around a fractured clavicle, which may occur with difficult forceps delivery

tactile/vocal fremitus

ABNORM: asymmetric findings suggest dysfunction that you can assess further with the stethoscope

percuss the chest

ABNORM: asymmetry is important: one side with prominent dullness or marked hyperresonance indicacets underlying disease; hyperresonance is a lower pitched, booming sound found when too much air is present such as in emphysema or pneumothroax a dull note signals abnormal density in the lungs, as with pneumonia, pleural effusiion, atelectasis, or tumor

inspect and palpate legs

ABNORM: asymmetry of 1-3 cm occurs with mild lymphedema; 3-5 cm with moderate lymphedema; and more than 5 cm with severe lymphedema asymmetric calf swelling of >2 cm occurs with DVT, but betware of diagnosing DVT with one finding

corneal light reflex/ hirschberg test

ABNORM: asymmetry of the light reflex indicates deviation in alignment form eye muscle weakness or paralysis; if you see this, perform the cover test

infants and young children (ear exam)

ABNORM: atresia- absence or closure of the ear canal

anterior chest inspection

ABNORM: barrel chest has horizontal ribs and costal angle >90 degrees hypertrophy of abdominal muscles occurs in chronic emphysemea tense, sttrained, tired faces and purse-lipped breathing accompany COPD; by exhaling slowly and against a narrow opening, the pressure in the bronchial tree remains positive, and fewer airways collapse

tongue

ABNORM: beefy red, swollen tongue; smoth glossy areas; enlarged tongue occurs with hypothyroidism, acromegaly; a small tongue accompanies malnutrition dry mouth occurs with dehydration; fever; tongue has deep vertical fissures saliva is decreased when taking antichonlinergics and other medications excess saliva and drooling occur with gingivostomatitsi and Parkinson's disease

pertibial edema

ABNORM: bilateral, dependent pitting edema occurs with heart failrue, diabetic neuropathy, and hepatic cirrhosis

ascultate chest

ABNORM: brehat sounds are changed by obstruction in the passageways or by disease in the lung parenchyma, the pleura, or chest wall

skin discoloration

ABNORM: brown discoloration occurs with chronic venous stasis caused by hemosiderin deposits from red blood cell degradation venous ulcers occur usually at medial malleolus becaus eof bacterial invasion of poorly drained tissues with arterial deficit, ulcers occur on tips of toes, metatarsal heads, and lateral malleoli

gastrocnemius

ABNORM: calf pain is not specific for DVT because it occurs also with superficial phlebitis, Achilles tendinitis, gastrocnemius and plantar muscle injury, and lumbosacral disorders

anterior chest inspection

ABNORM: cerebral hypoxia may be reflected by excessive drowsiness or anxiety, restlessness and irritability clubbing of distal phalanx occurs with COPD because of growht of vascular connective tissue cutaneous angiomas associated with liver disease or portal hypertension may be evident on the chest

neck (infant)

ABNORM: cervical nodes >1cm are considered enlarged thyroglossal duct cyst-cystic lummp high up in midline, tense, nontender, freely movable, and rises when swallowing supraclavicular nodes enlarge with Hodgkin lymphoma n i

lips

ABNORM: cheilitis- cracking at the corners; herpes simplex and other lesions

infants and young children (ear exam)

ABNORM: chronic OM relieved by tympanostom tubes foreign body must be removed

audiometric testing

ABNORM: conductive and sensorneural loss

buccal mucosa

ABNORM: dappled brown patches are present with Addison's disease (chronic adrenal insufficienty) orifice of Stenson duct looks red with mumps Koplik spots- early prodromal (early warning sign of measles) candida infection usually rubs off, leaving a clear or raw dendured surface the chalky white raised patch of leukoplakia is abnromal

leg color changes

ABNORM: dependent rubor (deep blue-red color) occurs with severe arterial insufficiency; chronic hypoxia produces loss of vasomotor tone and pooling of blood in veins delayed venous filling occurs with arterial insufficiency

inspect and palpate legs

ABNORM: diffuse bilateral edema occurs with systemic illnesses acute unilateral painful swellign and asymmetry of calves of 1 cm or more is abnormal; refer the person to determine whether DVT is present

infant and children lung assessment

ABNORM: diminished breath sounds occur with pneumonia, atelectasis, pleural effusion, or pneumothorax persistent fine crackles that are scattered over the chest occur with pneumonia, bronchiolitis, or atelectasis crackles only in upper lung fields occur wit hcystic fibrosis; crackles only in lower lung fiels occur with heart failure

infants and childrne peripheral vascular system

ABNORM: diminished or absent femoral pulses but normal upper-extremity pulses suggest corctation of aorta enlarged, warm, tender nodes indicate current infection; look for source of infection

teeth and gums

ABNORM: discolored teeth appear brown wit hexcessive fluoride use, yellow with tobacco use grinding down of tooth surface; plaque-soft debris; caries-decay malocclusion, protrusion of upper or lower incisiors

infants and young children (ear exam)

ABNORM: ear pain and ear rubbing are associated with acute OM, as are a bulging red eardrum and middle ear effusion; fever is usually present, but not always present

aging adult ocular structures

ABNORM: ectropin (lower lid dropping away) and entropion (lower lid turning in) aao

leg color changes

ABNORM: elevational pallor (marked) indicates arterial insufficiency

infant and children lung assessment

ABNORM: expiratory wheezing occurs with lwoer airwa obstruction (e.g. asthma or bronchilitis); when unilateral, it may be foreign body aspiration persistent peristaltic sounds with diminished breaht sounds on the same side may indicate diaphragmetic hernia stridor is a high-pitched inspiratory corwing sound heard without the stethoscope, occuring with upper airway obstruction (e.g. croup, foreign body aspiration, acute epiglottitis)

eyeballs

ABNORM: expothalamos (protruding eyes) enpothalmos (sunken eyes)

diagnostic positions test

ABNORM: eye movemnt is not parallel; failure to follow in a certain direction indicates weakness of an EOM or dysfunction of the cranial nerve innervating it

profile sign

ABNORM: flattening of angle and clubbing (diffuse enlargement of termian lphalanges) occur with congenital cyanotic heart disease and cor pulmonale

skull (infant and children)

ABNORM: frontal bulges or bossing occur with prematurity or rickets s i/c

radial pulses

ABNORM: full, bounding pulse (3+) occurs with hyperkinetic states (exercise, anxiety, fever) anemia, and hyperhtyroidism weak , thready pulse (1+) occurs with shock and PAD

hypothermia

ABNORM: general _______________ accompanies shock, cardiac arrest localized _________________ occurs in perippheral arterial insufficiency and Rayund disease

conjunctiva and sclera

ABNORM: general reddening cyanosis of lower lids pallor near outer canthus of the lower lid may indicate anemia (the inner canthus normally contains less pigment)

teeth and gums

ABNORM: gingival hyperplasia, crevices between teeth and gums, pockets of debris; gums bleed with slight pressure, indicating gingivitis dark line on gingival margins occurs with lead adn bismuth poisonining

general external ocular structures

ABNORM: groping with hands squinting or craning forward

hair lesions

ABNORM: head or pubic lice; distinguished dandruff from nits of lice, which are oval and adherent to hair shaft and cause intense itching

palpate anterior chest

ABNORM: if any lumps are found in preste tissue, refer the patient to a specialist

cover test

ABNORM: if the eye jumps to fixate on the designated point, it was out of alingment before ct

confrontation test

ABNORM: if the person is unable to see the object as the exaimer does, the test suggests peripheral field loss; in an older adult this screens for glaucoma; promptly refer to a specialist for more precise testing; acutely diminished visual fields occur with diseases of the retina and stroke

head posture/ head control

ABNORM: in childrne head tilt occurs with habit spasm, poor vision, and brain tumor; head lag after 4 months may indicate mental or motor retardation hp

lips

ABNORM: in light-skinned poeple: cirucmoral pallor occurs with shock and anemia; cyanosis with hypoxemia and chilling; cherry red lips with carbon monoxide poisoning, acidosis fro maspirin poisoining, or ketoacidosis

aging adult visual acuity

ABNORM: in older adults with severe vision impairment, 46.7% reported having fallen in the previous year aav

acne

ABNORM: in people with dark skin color, ____________ has resulting effects of hypetpigmentation, keloids, and scarring

infant and children lung assessment

ABNORM: in the immediate newborn period, depressed respirations are caused by maternal drugs, interruption of hte uterine blood upply, or obstruction of the cracheobronchial treewith mucus or fluid

infants and children (nasal exam)

ABNORM: inability to pass catheter through nasal cavity indicates choanal atresia, wich needs immediate intervention

throat

ABNORM: infectious mononucleosis shows erythematous, exudative elarged tonsils that kiss hte uvula

Iris and pupil

ABNORM: irregular shape although they may be nomral, all unequal size pupils call for considerartion of CNS injury dilated pupils dilated and fixed pupils constricted pupils unequal or no resposne to light absence of constrcition or convergence; asymmetric response

nail surface

ABNORM: jagged nails, bitten to the quick, or traumatized nail folds suggest nervous picking habits chronically dirty nails suggest poor self-care or the chronic staining of some occupations and cigarette use

eyelids and lashes

ABNORM: lid lag with hyperthyroidism incomplete closure creates risk for cornea damage ptosis, drooping of upper lid periorbital edema lesions ectropion and entropion

scleroderma

ABNORM: literally, hard skin, is a chronic connective tissue disorder associated with decreased mobility

infants and young children (ear exam)

ABNORM: low-set ears are found with genetic disorders, inclduing trisomy 21 (down syndrome); large prominent ears, misshapen ears, and creases on earlobes are nonspecific preaurical skin tages may occur alone or with other facial abnoramlities

percuss the chest

ABNORM: lungs are hyperinfleted with chronic emphysema, which results in hyperresonace where you would expect cardiac dullness dullness behind the right breast occurs with right middle lobe pneumonia

infant and children lung assessment

ABNORM: marked retractions of sternum and intercostal muscles indicate increased inspiratiory effort, as in atelectasis, pneumonia, asthma, and acute airway obstruction rapid respiratory rates accompany pneumonia, fever, pain, heart disease, and anemia in an infant tachypnea of 50-100 breaths/minute during sleep may be an early sign of heart failure

size and shape (head)

ABNORM: microcephaly, abnormally small head; macrocephaly, abnormally large head (hydrocephaly, acromegaly); note lumps, depressions, or abnormal protrusions s/s

size and shape

ABNORM: microtia- ears smaller than 4 cm vertically; macrotia- ears larger than 10 cm edema with infection or trauma

spriometer

ABNORM: mild obstruction of airflow is an FEV1/FCV ratio of 60-70%; moderate obstruction is a measure of 50-60% severe obstruction is a ratio less than 50%

sensation/ strength lower extremities

ABNORM: motor loss occurs with severe arterial deficit; sensory loss occurs with arterial defect, especially diabetes

bruising/ contusion

ABNORM: multiple _______________ at different stages of healing and excessive ___________ above the knees or elbows raise concern about abuse

infants and children (nasal exam)

ABNORM: nasal flraring in the infant indiactes respiratory distress; a transverse ridge across the nose occurs in a child with chronic allergies from wiping the nose upward with thet palm; nasal narrowing on inhalation is seen with chronic nasal obstructio nadn mouth breathing

inspect and palpate arms

ABNORM: needle trakcs in hands, arms, anterior cubiatl fossae occur with intravenous drug use; linear scars in wrists may signify past suicial behavior

infants and children (oral exam)

ABNORM: no teeth by 1 year; discolored teeth appear yellow or yellow-brown with infants taking tetracycline or who were exposed during hte last trimester; appear green or blakc with excessive iron ingestion; malocclusion: upper or lower dental arches out of alignment

inguinal lymph nodes

ABNORM: nodes that are enlarged, tender, or fixed in the area

infant and children lung assessment

ABNORM: note a barrel shape persisting after age 6 years, which amy develop with chronic asthma or cystic fibrosis

Snellen eye chart

ABNORM: note hesitancy, squinting, leaning forward, misreading letters

Range of motion (neck)

ABNORM: note pain at specified movement notee ratchety or limited movement from cervical arthirits or inflammation of neck muscles; the arthritic neck is rigid, the person turns at the shoulders rather than at the neck rom

decreased tactile/vocal fremitus

ABNORM: occurs with obstructed bronchus, pleural effusion or thickening, pneumothorax, or emphysema; any barrier that comes between the sound and your palpating hand ____________________

conjunctiva and sclera

ABNORM: opthalmia neunatorium is a purulent discharged caused by a chemical irritant or a bacterial or viral agent from the birth canal cs

tongue

ABNORM: oral precancerous and canerous lesions; the lareral and ventral tongue and the floor of the mouth are high-risk sites for oral squamous cell cancer

tenderness

ABNORM: pain with movement occurs with otitis externa and furuncle pain at the mastoid process may indicate mastoiditis or enlarged posterior auricular node

aging adult (face/neck)

ABNORM: painful to palpation with giant cell arteritis, an inflammatory condition affecting older adults, with peak incidences between 70-90 years aa

modified allen test

ABNORM: pallor that persists or a sluggish return to color suggests occlusion of hte collateral arterial flow; an equivocal result is 8 to 14 seconds; equal to or greater than 15 seconds is a negative result; avoid radial artery cannulation until adequate circulation is shown

inspect and palpate legs

ABNORM: pallor with vasoconstriction; erythema with vasodilation; cyanosis malnutrition: thin, shiny, atrophic skin; thick-riged nails; loss of hair; ulcers; gangrene; malnutrition, pallor, and coolness occur with arterial insufficiency

ocular fundus

ABNORM: papilledema is rare in the infant because the fontanels and open sutures absorb any increased intracranial pressure if it occurs of

thoracic cage

ABNORM: people with COPD often sit in a tripod position, leaning forward with arms braced against their knees, chair, or bed; this gives them leverage so the abdominal, intercostal, and neck muscles can all aid in respiration

integrity of membrane (tympanic membrane)

ABNORM: perforation shows as a dark oval area or as a larger opening on the drum; vesicles on the drum

nasal cavity

ABNORM: polyps are smooth, palge gray, avascular, mobile, nontender

turgor

ABNORM: poor _______________- is evident is severe dehydration or extreme weight loss; the pinched skin reces slowly or tents and stands by itself

anterior chest inspection

ABNORM: rectus abdominus and intercostal msucles are used to force expiration in COPD tachypnea and hyperventilation, bradypnea and hypoventilation, periodic breahting

skin condition

ABNORM: reddened, excessively warm skin with inflammation crusts and scaling occurs with otitis exerna, eczema, contact dermatitis, seborrhea enlarged, tender lymph nodes in the region indicate inflammation of the pinna or mastoid process red-blue discoloration with frostbite tophi, sebaceous cyst, chondrodermatitis, keloid, carcinoma

external canal

ABNORM: redness and swelling occur with otitis externa; canal may be completely closed with swelling purulent otorrhea suggests otitis externa or OM if the drum has ruptured frank blood or clear, watery drainage (CSF) after head injury suggests basal skull fracture and warrants immediate referral foreign body, polyp, furuncle, exostosis

capillary refill

ABNORM: refill lasting more than 1-2 seconds signifies vasoconstriction or decreased cardiac output (hypovolemia, heart failure, shock) the hands are cold, clammy, and pale

pregnant woman peripheral vascular system

ABNORM: remain alert for generalized edema plut hypertension, which suggests pre-eclampsia, a dangerous obstetric condition

anterior chest inspection

ABNORM: retraction suggests obstruction of respiratory tract or that increased inspiratory effort is needed, as which atelectasiss; bulging indicates trapped air as in the forced expiration associated with emphysema or asthma accessory muscles are used in acute airway obstruction and massive atelectasis

position (tympanic membrane)

ABNORM: retrated drum due to vacuum in middle ear with obstructed eustachian tube; bulging drum due to increased pressure i nOM

nasal cavity

ABNORM: rhitis, nasal mucosa is swollen and bright red with URI discharge is common with rhitnitis and sinusitis, varying from watery and copious to thick, purulent, and green-yellow with chronic allergy mucosa look swollen, boggy, pale, and gray

newborn hair

ABNORM: scaly, crusted scalp occurs with seborrheic dermatitits, cradle cap

conjunctiva and sclera

ABNORM: scleral icterus tenderness, foreign body, discharge, or lesions

wells score for leg deep vein thrombosis

ABNORM: score of 1-2= moderate brobability 3 or more= high probability of DVT

palpating sinuses

ABNORM: sinus areas ar etender to palpation in people with chronic allergies and acute infection another sign of sinusitis is to check for focal pain when the person bends over (if able)

cafe au lait spot

ABNORM: six or more _______________, each more than 1.5 cm in diameter, are diagnositic of *neurofibromatosis, an inherited neurocutaneous disease*

thoracic cage

ABNORM: skeletal deformities may limit thoracic cage excursion: scoliosis, kyphosis AP- transverse diameter, or barrle chest; ribs are horizontal, chest appears as if held in continuous inspiration; this occurs in COPD from hyperinflation of the lungs neck muscles are hyperthyropied in COPD form aiding in forced respirations across the osbstructed airways

external auditory meatus

ABNORM: sticky, yellow discharge accompanies otitis externa or may indicate OM if the drum has ruptured; impacted cerumen is a common cause of conductive hearing loss

lacrimal apparatus

ABNORM: swelling of hte lacrimal gland may show as a visible bulge in the outer part of the upper lid puncta red, swollen,tender to pressure watch for any regurgitation of fluid out of the puncta, which confirms duct blockage

temporal area (head)

ABNORM: tenderness and a hard band to palpaion with temporal arteritis crepitiation, limited ROM, or tenderness at the temporomandibular joint ta

percussion (infant head)

ABNORM: the cracked pot sound occurs with hydrocephalus from separation of cranial sutures (Macewen sign) p i

presbyoptia

ABNORM: the decrease in power of accommodation with aging; is suggested when the person moves the card farther away

palate

ABNORM: the hard palate appears yellow with jaundice; in blacks iwht jaundice it may look yellow, muddy yellow, or green-brown oral kaposi sarcoma is the most common early lesion in peopel wiht AIDS a bifid uvula looks as if it is split in two; more common in American Indians any deviation to the side or absent movement indicaes nerve damage of hte uvula, which also occurs with piliomyelitis and diptheria

Snellen eye chart

ABNORM: the larger the denominator, the poorer the vision; if vision is poorer than 20/30, refer to an opthalmologist or optometrist; impaired vision results form refractive error, opacity in the media or disorder in the retina or optic pathway

lymph nodes (neck)

ABNORM: the parotid is swollen with MUMPS parotid enlargement has been found with AIDS ln

whispered voice test

ABNORM: the person is unable to hear whispered items; a whisper is a high frequency sound and used to deetct high tone loss

eyelids and lashes

ABNORM: the setting sun sign also occurs with hydrocephalus as the globes protrude blank sunken eyes accompany malnutrition, dehydration, and a severe illness el

test hearing acuity

ABNORM: this single question in people over 50 years has up to 90% agreement with hearing loss documented by audiometric testing

throat

ABNORM: tonsils are enlarged to 2+ 3+ or 4+ with acute infection

symmetric expansion

ABNORM: unequal chest expansion occurs with marked atelectasis, lobar pneumonia, pleural effusion, thoracic trauma such as fractured ribs, or pneumothorax; pain accompanies deep breathing when the pleurae are inflamed

eyebrows

ABNORM: unequal or absent movement with nerve damage scaling with seborrhea

pertibial edema

ABNORM: unilateral edema occurs with occlusion of a deep vein; unilateral or bilateral edema occurs with lymphatic obstructinn; with these factors it is brawny or nonpitting and feels hard to thte touch

facial features

ABNORM: unilateral immobility indicates nerve damage (central or peripheral); e.g. angle of mouth droop on paralyzed side some _________________ are characteristic of congenital abnormalities or chronic allergy ff

varicose veins

ABNORM: varicosities occur in the saphenous veins; exaimation techniques to assess valve incompetency within varicose veisn are not reliable because valve incompetence can be widely distributed throughout the leg; imaging by doppler ultrasound is an objective, noninvaisve measure of valvular incompetency

infants and childrne peripheral vascular system

ABNORM: weak pulses occur with vasoconstriction of diminsihed cardiac output full, bounding pulses occur with patent ductus arteriosus from the large left-to-right shunt

tongue

ABNORM: whit CNXII damage, the dongue deviates toward the parayzed side; a fine tremor of the tongue occurs with hyperthyoridism; a coarse tremor occurs with cerebral palsy and alcoholism

throat

ABNORM: with an acute infection tonsils are bright red and swollen and may haev exudate or large white spots; a white membrane covering the tonsils may accompany infectious mononucleosis, leukemia, and diptheria

tuning fork tests

ABNORM: with documented hearing loss, these tests may help distinguish conductive loss from sensorineural loss; but they cannot screen a conductive loss from a mixed conductive/sensorineural loss

color and characteristics (tympanic membrane)

ABNORM: yellow- amber drum color occurs with OM with effusion red color with acute OM absent or distorteed landmarks air/fluid level or air bubbles behind drum indicate OM with effusion

throat

ABNORM:clinical features help but are not sufficient in determining the cause of pharyngitis

vitiligo

ABNROM. an acquired condition is ________________, the complete absence of melanin pigment in patchy areas of white or light skin on the face, neck, hands, feet, and body folds and around orifices; _____________________ occurs in all people, although dark-skinned people are more severely affected and potentially suffer a greater threat to body image

seasonal allergic rhinitis (hay fever)

AR is an abnormal immune response fro mrepeated exposure to antigens, with rhinorrhea, itching of nose and eyes, lacrimation, nsasal congestion, and sneezing; note serious edema and swelling of turbinates to fill the air space; turbinates are usually pale, and their surface looks smooth and glistening; common allergens are dust mite, animal dander, mold, pollen; AR produces disordered sleep, obstructive sleep apnea, sinusitis, aboidance of outdoor activities, and poor work performance

cultural aspects vision

African americans are 3-6 times more likely to develop glaucoma than Caucaisians; primary open-angle glaucoma is leading cause of blindness in African Americans and Hispanics; family history of glaucoma in a first-degree relative increases the risk of the disease; measurement of intraocular pressure alone is not sufficient to detect glaucoma; visual field testing using special equipment increases detection

scar (secondary lesion)

After a skin lesion is repaired, normal tissue is lost and replaced with connective tissue (collagen). This is a permanent fibrotic change. Examples: healed area of surgery or injury, acne.

allodynia

Allodynia is an unusual symptom that can result from several nerve-related conditions. When you're experiencing it, you feel pain from stimuli that don't normally cause pain

upward palpebral slant

Although normal in many children, when combined with epicanthal folds, hypertelorism (large spacing between the eyes), and Brushfield spots (light-colored areas in outer iris), it indicates Down syndrome.

tattoos subjective data

Although professional tattooing now uses aseptic conditions, non-TB myocabcterial infections still occur and inflammatory/ hypersensitivity reactions skin cancers can occur, but is is unclear whether these are coincidental or due to potential carcinogenic tattoo inks

aneurysms

An _______________ is a sac formed by dilation in the artery wall. Atherosclerosis weakens the middle layer (media) of the vessel wall. This stretches the inner and outer layers (intima and adventitia), and the effect of blood pressure creates the balloon enlargement. The most common site is the aorta, and the most common cause is atherosclerosis. The incidence increases rapidly in men older than 55 years and women older than 70 years; the overall occurrence is four to five times more frequent in men.

otitis media with effusion (OME)

An amber-yellow drum suggests serum in middle ear that transudates to relieve negative pressure from the blocked eustachian tube. you may note an air/fluid level with fine black dividing line or air bubbles visible behind drum. Symptoms are feeling of fullness, transient hearing loss, popping sound with swallowing. Also called serous otitis media (glue ear)

kyphosis

An exaggerated posterior curvature of the thoracic spine that causes significant back pain and limited mobility. severe deformities impair cardiopulmonary function; if hte neck muscles are strong, compensation occurs by hyperextension of head to maintain level of vision

Otitis Externa (Swimmer's Ear)

An infection of the outer ear, with severe painful movement of the pinna and tragus, redness and swelling of pinna and canal, scanty purulent discharge, scaling, itching, fever, and enlarged tender regional lymph nodes; hearing normal or slightly diminished; more common in hot, humid weather; swimming causes canal to become waterlogged and swell; skinfolds set up for infection; prevent by using rubbing alcohol or 2% acetic acid eardrops after every swim

hypoventilation

An irregular shallow pattern caused by an overdose of narcotics or anesthetics. May also occur with prolonged bed rest or conscious splinting of the chest to avoid respiratory pain.

cholesteatoma

An overgrowth of epidermal tissue in the middle ear or temporal bone may result over the years after a marginal TM perforation. It has a pearly white, cheesy appearance. Growth of cholesteatoma can erode bone and produce hearing loss. Early signs include otorrhea, otalgia, unilateral conductive hearing loss, tinnitus.

eyelids and lashes

Asian infants normally have an upward slant of the palpebral fissues; entropion, an inward turning of the eyelid, is found normally in some Asian childrne; if the lashes do not abrade the corneas, it is not significant el

conjunctiva and sclera

Ask person to look up; using thumbs, slide lower lids down along orbital rim, being careful not to push against eyeball Inspect exposed area; eyeball should look moist and glossy Numerous small blood vessels normally show through transparent conjunctiva Otherwise, conjunctivae clear and show normal color of structure below; pink over lower lids and white over sclera Note any color change, swelling, or lesions

five A's of smoking cessation

Ask- about tobacco use status at every visit advise- give clear, nonjudgmental, personalized suggestions assess- person's readiness for interest in quitting assist- each person with a specific cessation plan that includes medications, behavior, exercise, or referrals arrange- follow up visits

corneal light reflex/ hirschberg test

Assess the parallel alignment of the eye axes by shining a light toward the person's eyes. direct the person to stare straight ahead as you hol dthe light about 12 inches away; note the reflection of hte light on the two corneass; it should be ini exactly the same spot on each eye

pleural effusion (fluid) or thickening

Auscultation Breath sounds decreased or absent. Voice sounds decreased or absent. When remainder of lung is compressed near the effusion, may have bronchial breath sounds over the compression along with bronchophony, egophony, whispered pectoriloquy. Adventitious Sounds Crackles, pleural rub. pe

atelectasis (collapse)

Auscultation Breath sounds decreased vesicular or absent over area. Voice sounds variable, usually decreased or absent over affected area. Adventitious Sounds None if bronchus is obstructed. Occasional fine crackles if bronchus is patent.

asthma (reactive airway disease)

Auscultation Diminished air movement. Breath sounds decreased, with prolonged expiration. Voice sounds decreased. Adventitious Sounds Bilateral wheezing on expiration, sometimes inspiratory and expiratory wheezing. as

lobar pneumonia

Auscultation Tachycardia. Loud bronchial breathing with patent bronchus. Voice sounds have increased clarity; bronchophony, egophony, whispered pectoriloquy present. Children—Diminished breath sounds may occur early. Adventitious Sounds Crackles, fine to medium. lp

telangiectasia (vascular lesions)

Caused by vascular dilation; permanently enlarged and dilated blood vessels that are visible on the skin surface.

foreign body

Children particularly are apt to put an object up the nose, producing unilateral mucopurulent drainage and foul odor. Because some risk for aspiration exists, removal should be prompt. Watch out for impaction from a small button battery from an electronic device (watch, video game). Once occluding the nostril, the battery can release voltage or chemicals that cause burns, necrosis, or perforation.

fungal infection (otomycosis)

Colony of black or white dots on drum or canal wall suggests yeast or fungal infection

scale (secondary lesion)

Compact, desiccated flakes of skin, dry or greasy, silvery or white, from shedding of dead excess keratin cells. Examples: after scarlet fever or drug reaction (laminated sheets), psoriasis (silver, mica-like), seborrheic dermatitis (yellow, greasy), eczema, ichthyosis (large, adherent, laminated), dry skin.

acute bronchitis

Condition An acute infection of the trachea and larger bronchi characterized by cough, lasting up to 3 weeks. Most cases are viral and do not require antibiotics. Epithelium of bronchi are inflamed and damaged, releasing proinflammatory mediators. Large airways are narrowed from capillary dilation, increased mucus production, loss of cilia function, and swelling of epithelium. More cases occur with smokers, aging adults, children, and in winter months. ab

acute respiratory distress syndrome (ARDS)

Condition An acute pulmonary insult (trauma, gastric acid aspiration, shock, sepsis) damages alveolar capillary membrane, leading to increased permeability of pulmonary capillaries and alveolar epithelium and to pulmonary edema. Gross examination (autopsy) would show dark red, firm, airless tissue, with some alveoli collapsed and hyaline membranes lining the distended alveoli. Subjective Acute onset of dyspnea, apprehension. ard

asthma (reactive airway disease)

Condition An allergic hypersensitivity to certain inhaled allergens (pollen), irritants (tobacco, ozone), microbes, stress, or exercise that produces a complex response characterized by bronchospasm and inflammation, edema in walls of bronchioles, and secretion of highly viscous mucus into airways. These factors greatly increase airway resistance, especially during expiration, and produce the symptoms of wheezing, dyspnea, and chest tightness. as

pleural effusion (fluid) or thickening

Condition Collection of excess fluid in the intrapleural space, with compression of overlying lung tissue. Effusion may contain watery capillary fluid (transudative), protein (exudative), purulent matter (empyemic), blood (hemothorax), or milky lymphatic fluid (chylothorax). Gravity settles fluid in dependent areas of thorax. Presence of fluid subdues all lung sounds. most common cause is heart failure; also infection and cancer pe

lobar pneumonia

Condition Infection in lung parenchyma leaves alveolar membrane edematous and porous; thus red blood cells (RBCs) and white blood cells (WBCs) pass from blood to alveoli. Alveoli progressively fill up (become consolidated) with bacteria, solid cellular debris, fluid, and blood cells, which replace alveolar air. This decreases surface area of the respiratory membrane, causing hypoxemia. History Fever, cough with pleuritic chest pain, blood-tinged sputum, chills, SOB, fatigue. lp

atelectasis (collapse)

Condition _____________ shrunken section of alveoli or an entire lung as a result of (1) airway obstruction (e.g., the bronchus is completely blocked by thick exudate, aspirated foreign body, or tumor); the alveolar air beyond the obstruction is gradually absorbed by the pulmonary capillaries, and the alveolar walls cave in); (2) compression on the lung; and (3) lack of surfactant (hyaline membrane disease). Inspection Cough. Lag on expansion on affected side. Increased respiratory rate and pulse. Possible cyanosis. a

symmetric expansion

Confirm symmetric chest expansion by placing your warmed hands on the posterolateral chest wall with thumbs at the level of T9 or T10. Slide your hands medially to pinch up a small fold of skin between your thumbs Ask the person to take a deep breath. Your hands serve as mechanical amplifiers; as the person inhales deeply, your thumbs should move apart symmetrically. Note any lag in expansion.

purpura

Confluent and extensive patch of petechiae and ecchymoses; >3 mm, flat, red to purple, macular hemorrhage. Seen in generalized disorders such as thrombocytopenia and scurvy. Also occurs in old age as blood leaks from capillaries in response to minor trauma and diffuses through dermis.

miosis

Constricted and fixed pupils. Occurs with use of pilocarpine drops for glaucoma treatment, the use of narcotics, with iritis, and with brain damage of pons

star-shaped opacity- cortical cataract

Cortical cataract shows as asymmetric, radial, white spokes with black center. Through ophthalmoscope, black spokes are evident against the red reflex (not shown here). This forms in the outer cortex of lens, progressing faster than nuclear cataract.

ulcer (secondary lesion)

Deeper depression extending into dermis, irregular shape; may bleed; leaves scar when heals. Examples: stasis ulcer, pressure sore, chancre.

scarred drum

Dense white patches on the eardrum are sequelae of repeated ear infections. They do not necessarily affect hearing.

habit-tic dystrophy

Depression down middle of nail or multiple horizontal ridges, caused by continuous picking of cuticle by another finger of same hand, which causes injury to nail base and nail matrix.

atelectatic crackles

Description: Sounds like fine crackles but don't last long and are not pathologic. Disappear after first few breathes. Heard in axillae and bases of the lungs ac

baby bottle tooth decay

Destruction of numerous deciduous teeth may occur in infants and toddlers who take a bottle of milk, juice, or sweetened drink to bed and prolong bottle-feeding past the age of 1 year. Liquid pools around the upper front teeth. Mouth bacteria act on carbohydrates in the liquid, especially sucrose, forming metabolic acids. Acids break down tooth enamel and destroy its protein.

neuropathic ulcer

Diabetes hastens changes described with arterial ischemic ulcer, with generalized dysfunction in all arterial areas: peripheral, coronary, cerebral, retinal, and renal. peripheral diabettic ulcer has its pathogenesis in sensory neuropathy with lsos of productive sensation, autonmic neropathy with decreased sweating and dry skin, adn motor neuropathy with foot deformity

mydriasis

Dilated and fixed pupils. Enlarged pupils occur with stimulation of the sympathetic nervous system, reaction to sympathomimetic drugs, use of dilating drops, acute glaucoma, or past or recent trauma. CNS injury, circulatory arrest, or deep anesthesia

vesicle (primary lesion)

Elevated cavity containing free fluid, up to 1 cm; a "blister." Clear serum flows if wall is ruptured. Examples: herpes simplex, early varicella (chickenpox), herpes zoster (shingles), contact dermatitis.

cyst (primary lesion)

Encapsulated fluid-filled cavity in dermis or subcutaneous layer, tensely elevating skin. Examples: sebaceous cyst, wen.

Angular Cheilitis (Stomatitis, Perleche)

Erythema, scaling, and shallow and painful fissures at the corners of the mouth occur with excess salivation and Candida infection. it is often seen in edentous persons and thsoe with poorly fitting dentures, causing folding in ot corners of hte mouth, which creates a warm, moist environmen tfaving growth of yeast

allergic drug reaction

Erythematous and symmetric rash, usually generalized. Some drugs produce urticarial rash or vesicles and bullae. History of drug ingestion.

arrhythmia

Example: atrial fibrillation history: palpitations, syncope a

hirsutism

Excess body hair in females forming a male sexual pattern (upper lip, face, chest, abdomen, arms, legs); caused by endocrine or metabolic dysfunction or occasionally idiopathic.

furuncle

Exquisitely painful, reddened, infected hair follicle. May occur on tragus on the cartilaginous part of ear canal. regional lymphadenopathy often accompies a ____________

tinea versicolor

Fine, scaling, round patches of pink, tan, or white (thus the name) that do not tan in sunlight, caused by a superficial fungal infection. Usual distribution is on neck, trunk, and upper arms—a short-sleeved turtleneck sweater area. Most common in otherwise healthy young adults. Responds to oral antifungal medication.

labial herpes simplex (cold sores)

Herpes simplex virus (HSV) infection has a prodrome of skin tingling and sensitivity. Lesion then erupts with tight vesicles followed by pustules and produces acute gingivostomatitis with many shallow, painful ulcers. Common location is upper lip; also in oral mucosa and tongue.

Pediculosis Capitis (Head Lice)

History includes intense itching of the scalp, especially the occiput. The nits (eggs) of lice are easier to see in the occipital area and around the ears, appearing as 2- to 3-mm oval translucent bodies, adherent to the hair shafts. Common among school-age children. Over-the-counter pediculicide shampoos are available; however, nit removal by daily combing of wet hair with a fine-tooth metal comb is especially important.

buccal mucosa

Hold cheek open with a wooden tongue blade, and check for color, nodules, or lesions. Should look pink, smooth, and moist, although pathchy hyperpigmentation is common and nomral in dark-skinned people

papilledema (choked disc)

Increased intracranial pressure causes venous stasis in the globe, showing redness, congestion, and elevation of the disc; blurred margins; hemorrhages; and absent venous pulsations. this is a serious sign of intracranial pressure, usually caused by a space-occupying mass (e.g. brain tumor or hematoma); visual acuity is not affected

Cellulitis

Inflammation of loose, subcutaneous connective tissue. Shows as thickening and induration of auricle with distorted contours

normal lung

Inspection AP < transverse diameter, relaxed posture, normal musculature; rate 10 to 18 breaths/min, regular; no cyanosis or pallor. Palpation Symmetric chest expansion. Tactile fremitus present and equal bilaterally, diminishing toward periphery. No lumps, masses, or tenderness.

acute bronchitis

Inspection Cough is productive or nonproductive. Also sore throat, low-grade fever, postnasal drip, fatigue, substernal aching. Palpation No pain, no increased fremitus. Percussion Resonance predominates. Auscultation May be clear and equal bilaterally. No egophony. Adventitious sounds No crackles (distinguishes the consolidation of pneumonia, no wheeze). ab

asthma (reactive airway disease)

Inspection During severe attack: increased respiratory rate, SOB with audible wheeze, use of accessory neck muscles, cyanosis, apprehension, retraction of intercostal spaces. Expiration labored, prolonged. When chronic, may have barrel chest. Palpation Tactile fremitus decreased, tachycardia. Percussion Resonant. May be hyperresonant if chronic. as

lobar pneumonia

Inspection Increased respirations >24/min. Guarding and lag on expansion on affected side. Children—Sternal retraction, nasal flaring. Palpation Chest expansion decreased on affected side. Tactile fremitus increased if bronchus patent, decreased if bronchus obstructed. Percussion Dull over lobar pneumonia. lp

pleural effusion (fluid) or thickening

Inspection Increased respirations, dyspnea; may have dry cough, tachycardia, cyanosis, asymmetric expansion, abdominal distention. Palpation Tactile fremitus decreased or absent. Tracheal shift away from affected side. Chest expansion decreased on affected side. Percussion Dull percussion. No diaphragmatic excursion on affected side. pe

acute respiratory distress syndrome (ARDS)

Inspection Restlessness; disorientation; rapid, shallow breathing; productive cough; thin, frothy sputum; retractions of intercostal spaces and sternum. Decreased PaO2, blood gases show respiratory alkalosis, x-ray films show diffuse pulmonary infiltrates; a late sign is cyanosis. Palpation Hypotension. Auscultation Tachycardia. Adventitious Sounds Crackles, rhonchi. ard

Iris and pupil

Iris normally appears flat, with round regular shape and even coloration Note size, shape, and equality of pupils; normally pupils appear round, regular, and of equal size in both eyes; in the adult, resting pupil size is from 3-5 mm; a small number of people normally have pupils of two different sizes, which is called anisocoria

AIDS-related Kaposi Sarcoma: Patch Stage

Kaposi sarcoma (KS) is a vascular tumor and is the most common tumor in HIV-infected persons. Considered an AIDS-defining illness, KS can occur at any stage of HIV infection. Here multiple patch-stage early lesions are faint pink on the temple and beard area. They easily could be mistaken for bruises or nevi and be ignored. the use of highly active antiretroviral therapy has decrease risk of this cancer

bulla (primary lesion)

Larger than 1 cm diameter; usually single chambered (unilocular); superficial in epidermis; it is thin walled, so it ruptures easily. Examples: friction blister, pemphigus, burns, contact dermatitis.

tumor (primary lesion)

Larger than a few cm in diameter, firm or soft, deeper into dermis; may be benign or malignant, although "______" implies "cancer" to most people. Examples: lipoma, hemangioma

diagnostic positions test

Leading eyes through six cardinal positions of gaze will elicit any muscle weakness during movement; ask the person to hold the head steady and follow the movement of your finger with only the eyes; hold the target back about 12 inches so the person can focus on it confortably, move it to each of the six positions then back to center; progress clockwise

periorbital edema

Lids are swollen and puffy. Lid tissues are loosely connected, so excess fluid is easily apparent. This occurs with local infections; crying; and systemic conditions such as congestive heart failure, renal failure, allergy, hypothyroidism (myxedema).

carbon monoxide poisoning (erythema)

Light skin: bright cherry red in face and upper torso dark skin: cherry red color in nail beds, lips, and oral mucosa

fissure (secondary lesion)

Linear crack with abrupt edges, extends into dermis, dry or moist. Examples: cheilosis - at corners of mouth due to excess moisture; athlete's foot.

sebaceous cyst

Location is commonly behind lobule, in the postauricular fold. A nodule with central black punctum indicates blocked sebaceous gland. Filled with waxy sebaceous material and is painful if it becomes infected. often are multiple

erythema migrans of lyme disease

Lyme disease (LD) is not fatal but may have serious arthritic, cardiac, or neurologic sequelae. It is caused by a spirochete bacterium carried by the black or dark brown deer tick. Deer ticks are common in the Northeast, upper Midwest, and California (with cases occurring in people who spend time outdoors) in May through September. The first stage (early localized LD) has the distinctive bull's eye, red macular or papular rash (shown above) in 50% of cases. The rash radiates from the site of the tick bite (5 cm or larger), with some central clearing, and is usually located in axillae, midriff, inguina, or behind knees, with regional lymphadenopathy. Rash fades in 4 weeks; untreated individual then may have disseminated disease with fatigue, anorexia, fever, chills, joint or muscle aches. Antibiotic treatment shortens symptoms and decreases risk for sequelae.

crackles-coarse

Mechanism: Inhaled air collides with secretions in the trachea and large bronchi cc

wheeze- low pitched

Mechanism: airflow obstruction as described by the vibrating reed mechanism in high pitched wheezes; the pitch of the wheeze cannot be correlated to the size of the passageway that generates it wl

atelectatic crackles

Mechanism: sections of alveoli are not fully aerated, the deflate and accumulate secretions. Crackles heard when these sections re-expand with a few deep breaths. ac

moderate nonproliferative diabetic retinopathy

Microaneurysms are round, punctate red dots that are localized dilations of a small vessel. Their edges are smooth and discrete. The vessel itself is too small to view with the ophthalmoscope; only the isolated red dots are seen. Dot hemorrhages are deep intraretinal hemorrhages that look splattered on. They are distinguished from microaneurysms by the blurred irregular edges. Lipid (hard) exudates are small, yellow-white spots with distinct edges and a smooth, solid-looking surface. They often form a circular or linear pattern. (This is in contrast with drusen, which have a scattered haphazard location)

impetigo

Moist, thin-roofed vesicles with thin, erythematous base. Rupture to form thick, honey-colored crusts. Contagious bacterial infection of skin; most common in infants and children. infection can spread to other obdy areas and other children and adults by direct contact

exostosis

More common than osteoma. Small, bony hard, rounded nodules of hypertrophic bone, covered with normal epithelium; arise near the drum but usually do not obstruct the view of the drum; usually multiple and bilateral, occur more frequently in cold-water swimmers; needs no treatment, although may cause accumulation of cerumen, which blocks the canal

proliferative diabetic retinopathy

Neovascularization is new vessel formation that looks like radiating spokes.

external canal

Note any redness and swelling, lesions, foreign bodies, or discharge If any discharge is present, note color and odor Also, clean any discharge from speculum before examining other ear to avoid contamination with possibly infectious material For person with hearing aid, note any irritation on canal wall from poorly fitting ear molds

barrel chest

Note equal AP-to-transverse diameter and that ribs are horizontal instead of the normal downward slope. This is associated with normal aging and also with chronic emphysema and asthma as a result of hyperinflation of lungs.

severe nonproliferative diabetic retinopathy

Note lipid exudates as described and larger flame-shaped hemorrhages that look linear or spindle shaped.

sigh

Occasional sighs punctuate the normal breathing pattern and are purposeful to expand alveoli. Frequent sighs may indicate emotional dysfunction and also may lead to hyperventilation and dizziness.

optic atrophy (disc pallor)

Optic atrophy is a white or gray color of the disc as a result of partial or complete death of the optic nerve. This results in decreased visual acuity, decreased color vision, and decreased contrast sensitivity.

stage 3 pressure ulcer- full thickness skin loss

PI extends into subcutaneous tissue and resembles a crater; see subcutaenous fat, granulation tissue, and rolled edges, but not muscle, bone, or tendon

stage 4 pressure ulcer- full thickness skin/tissue loss

PI involves all skin layers and extends into supporting tissue; exposes muscle, tendon, or bone, and may show slough (stringy matter attached to wound bed) or eschar (black or brown necrotic tissue) rolled edges, and tunneling

Chondrodermatitis Nodularis Helicus

Painful nodules develop on the rim of the helix as a result of repetitive mechanical pressure or environmental trauma; they are small, indurated, dull red, poorly defined, and very painful

radial pulses

Palpate both radial pulses, noting rate, rhythm, elasticity of vessel wall, and equal force Grade force (amplitude) on a three-point scale 3+, increased, full, bounding 2+, normal 1+, weak 0, absent

atelectasis (collapse)

Palpation Chest expansion decreased on affected side. Tactile fremitus decreased or absent over area. With large collapse, tracheal shift toward affected side. Percussion Dull over area (remainder of thorax sometimes may have hyperresonant note).

plaque (primary lesion)

Papules coalesce to form surface elevation wider than 1 cm. A plateau-like, disk-shaped lesion. Examples: psoriasis, lichen planus.

Toxic Alopecia

Patchy, asymmetric balding that accompanies severe illness or use of chemotherapy where growing hairs are lost and resting hairs are spared. Regrowth occurs after illness or discontinuation of toxin.

normal lung

Percussion Resonant. Auscultation Vesicular over peripheral fields. Bronchovesicular parasternally (anterior) and between scapulae (posterior). Infant and young child—bronchovesicular throughout. Adventitious Sounds None.

aging adult visual acuity

Perform same examination as described in adult section Central acuity may decrease, particularly after 70 years of age; peripheral vision may be diminished aav

german measles (rubella)

Pink, papular rash (similar to measles but paler) first appears on face, then spreads. Distinguished from measles by presence of neck lymphadenopathy and absence of Koplik spots.

plagiocephaly

Positional or deformational plagiocephaly has increased dramatically since the "Back to Sleep" campaign started in 1992 to prevent SIDS. It is asymmetry of the cranium when seen from the top caused by a positional preference. It is not associated with premature closing of cranial sutures, and growth of the brain proceeds normally. This can be mitigated by "tummy time," when the parent places the infant prone for awake playing. Physical therapy and helmet therapy are further treatments.

pleural friction fremitus

Produced when inflammation of the parietal or visceral pleura causes a decrease in the normal lubricating fluid; the opposing surfaces make a coarse grating sound when rubbed otgether during breathing; this sound is best detected by ascultation, but it may be palpable and feels liek two pieces of leather grating together; it is synchronus with respiratory excursion; also called palpable friction rub

dental caries

Progressive destruction of tooth. Decay initially looks chalky white. Later it turns brown or black and forms a cavity. early decay shows only on x-ray image; susceptible sites are tooth surfaces where food debris, bacterial plagque, and saliva collect

lichenification (secondary lesion)

Prolonged, intense scratching eventually thickens the skin and produces tightly packed sets of papules; looks like surface of moss (or lichen)

ptosis (drooping upper lid)

Ptosis occurs from neuromuscular weakness (e.g., myasthenia gravis with bilateral fatigue as the day progresses), oculomotor cranial nerve III damage, or sympathetic nerve damage (e.g., Horner syndrome) or is congenital as in this example. It is a positional defect that gives the person a sleepy appearance and impairs vision.

tonic pupil (adie's pupil)

Reaction to light and accommodation is sluggish. Tonic pupil is usually unilateral, a large regular pupil that does react, but sluggishly after long latent time. There is no pathologic significance.

Iris and pupil

Record normal response to all these maneuvers as PERRLA, or Pupils Equal, Round, React to Light, and Accommodation

diaper dermatitis

Red, moist, maculopapular patch with poorly defined borders in diaper area, extending along inguinal and gluteal folds. History of infrequent diaper changes or occlusive coverings. Inflammatory disease caused by skin irritation from ammonia, heat, moisture, occlusive diapers.

blepharitis (inflammation of the eyelids)

Red, scaly, greasy flakes and thickened, crusted lid margins occur with staphylococcal infection or seborrheic dermatitis of the lid edge. Symptoms include burning, itching, tearing, foreign body sensation, and some pain.

Furuncle and Abscess

Red, swollen, hard, tender, pus filled lesion caused by acute, localized bacterial (usually staphylococcal) infection; usually on back of neck, buttocks, occasionally on wrists or ankles. Furuncles are due to infected hair follicles, whereas abscesses are due to traumatic introduction of bacteria into the skin. Abscesses are usually larger and deeper than furuncles.

paronychia

Red, swollen, tender inflammation of the nail folds. Acute paronychia is usually a bacterial infection; chronic paronychia is most often a fungal infection from a break in the cuticle in those who perform "wet" work.

measles (rubeola)

Red-purple maculopapular blotchy rash in dark skin and in light skin appears on third or fourth day of illness. Rash appears first behind ears and spreads over face, then over neck, trunk, arms, and legs; looks "coppery" and does not blanch. Characterized by Koplik spots in mouth - bluish white, red-based elevations of 1 to 3 mm.; vaccine refusal has caused a decline in herd immunity nad numerous outbreaks of infectious diseases

frostbite

Reddish blue discolration and swelling of auricle after exposure to extreme cold. Vesicles or bullae may develop, the person feels pain and tenderness, ear necrosis may occur

aging adult ocular fundus

Retinal structures generally have less shine; blood vessels look paler, narrower, and attenuated; arterioles appear paler and straighter, with a narrower light reflex; more arteriovenous crossing defects occur aaof

occlusions

Risk factors for atherosclerosis include obesity, cigarette smoking, hypertension, diabetes mellitus, elevated serum cholesterol, sedentary lifestyle, and family history of hyperlipidemia.

Tinea Capitis (Scalp Ringworm)

Rounded, patchy hair loss on scalp, leaving broken-off hairs, pustules, and scales on skin. Caused by fungal infection; lesions may fluoresce blue-green under Wood's light. Usually seen in children and farmers; highly contagious; may be transmitted by another person, by domestic animals, or from soil.

Intertrigo (Candidiasis)

Scalding red, moist patches with sharply demarcated borders, some loose scales. Usually in genital area extending along inguinal and gluteal folds. Aggravated by urine, feces, heat, and moisture, the Candida fungus infects the superficial skin layers.

erosion (secondary lesion)

Scooped out but shallow depression. Superficial; epidermis lost; moist but no bleeding; heals without scar because erosion does not extend into dermis.

excoriation (secondary lesion)

Self-inflicted abrasion; superficial; sometimes crusted; scratches from intense itching. Examples: insect bites, scabies, dermatitis, varicella.

otitis externa

Severe swelling of canal, inflammation, tenderness. Canal lumen is narrowed to 1/4 of it's normal size

cornea and lens

Shine light from side across cornea, and check for smoothness and clarity Oblique view highlights any abnormal irregularities in corneal surface There should be no opacities (cloudiness) in cornea, anterior chamber, or lens behind the pupil Do not confuse an arcus senilis with an opacity; arcus senilis is normal finding in aging persons

sensorineural hearing loss

Signifies the pathology of the inner ear, cranial nerve VIII, or the auditory areas of the cerebral cortex; a simple increase in amplitude may not enable the person to understand words; _________________________ may be caused by presbycusis, a gradual nerve degeneratio nthat occurs with aging, and by ototoxic drugs, which affect the hair cells in the cochlea

biot respiration

Similar to Cheyne-Stokes respiration, except that the pattern is irregular. A series of normal respirations (three to four) is followed by a period of apnea. The cycle length is variable, lasting anywhere from 10 seconds to 1 minute. Seen with head trauma, brain abscess, heat stroke, spinal meningitis, and encephalitis.

osteoma

Single, stony hard, rounded nodule that obscures the drum; nontender; overlying skin appears normal; attached to inner third, teh bony part of canal; benign, but refer for removal

bradypnea

Slow breathing. A decreased but regular rate (<10 per minute), as in drug-induced depression of the respiratory center in the medulla, increased intracranial pressure, and diabetic coma.

Bullous Myringitis

Small vesicles containing blood on the drum; accompany mucoplasma pneumonia and virus infections; blood tinged discharge and severe otalgia may be present

chickenpox (varicella)

Small, tight vesicles first appear on trunk and spread to face, arms, and legs (not palms or soles). Shiny vesicles on an erythematous base are commonly described as the "dewdrop on a rose petal." Vesicles erupt in succeeding crops over several days; they become pustules and then crusts. Intensely pruritic.

tophi

Small, whitish yellow, hard, nontender nodules in or near helix or antihelix; contain greasy, chalky material of uric acid crystals and are a sign of gout.

nasal polyps

Smooth, pale gray nodules, which are overgrowths of mucosa, most commonly caused by chronic allergic rhinitis. May be stalked. A common site is protrusion from the middle meatus. Often multiple, they are mobile and nontender in contrast to turbinates. They may obstruct air passageways as they get larger. Symptoms include the absence of a sense of smell and a "valve that moves" in the nose as the person breathes.

nodule (primary lesion)

Solid, elevated, hard or soft, larger than 1 cm. May extend deeper into dermis than papule. Examples: xanthoma, fibroma, intradermal nevi.

weber test normal

Sound is equally loud in both ears; sound does not lateralize

wheal (primary lesion)

Superficial, raised, transient, and erythematous; slightly irregular shape due to edema (fluid held diffusely in the tissues). Examples: mosquito bite, allergic reaction, dermographism.

Iris and pupil

Test for accommodation by asking person to focus on a distant object. This dilates pupils; then have person shift gaze to near object, such as your finger held about 7 to 8 cm (3 inches) from nose. Normal response includes: Pupillary constriction Convergence of axes of eyes

shallow anterior chamber

The iris is pushed anteriorly because of increased intraocular pressure. Because direct light is received from the temporal side, only the temporal part of the iris is illuminated; the nasal side is shadowed, the "shadow sign." This may be a sign of acute angle-closure glaucoma; the iris looks bulging because aqueous humor cannot circulate.

turbinates

The lateral walls of each nasal cavity contain three parallel bony projections (Superior, Middle, and Inferior).; they increase the surface area so more blood vessels and mucous membranes are available to warm, humidify, and filter the inhaled air

atrophic scar (secondary lesion)

The resulting skin level is depressed with loss of tissue; a thinning of the epidermis. Example: striae.

iritis (circumcorneal redness)

There is a deep, dull red halo around the iris and cornea. Note that redness is around the iris, in contrast with conjunctivitis, in which redness is more prominent at the periphery. Pupil shape may be irregular from swelling of iris. Person also has marked photophobia, constricted pupil, blurred vision, and throbbing pain. Warrants immediate referral.

argyll robertson pupil

There is no reaction to light; pupil does constrict with accommodation. Small and irregular bilaterally. Argyll Robertson pupil occurs with central nervous system syphilis, brain tumor, meningitis, and chronic alcoholism.

Seborrheic Dermatitis (Cradle Cap)

Thick, yellow-to-white, greasy, adherent scales with mild erythema on scalp and forehead; very common in early infancy. Resembles eczema lesions, except that cradle cap is distinguished by absence of pruritus, presence of "greasy" yellow-pink lesions, and negative family history of allergy.

narrowed (attenuated ) arteries

This is a generalized decrease in arteriole diameter. The light reflex also narrows. It occurs with severe hypertension (shown above on the right) and with occlusion of the central retinal artery and retinitis pigmentosa.

acute otitis media

This results when the middle ear fluid is infected. An absent light reflex from increasing middle ear pressure is an early sign. Redness and bulging are first noted in superior part of drum (pars flaccida), along with earache and fever. Then fiery red bulging of entire drum occurs along with deep throbbing pain. Accompanied by possible fever and transient hearing loss. Pneumatic otoscopy reveals drum hypomobility.

Iris and pupil

To test pupillary light reflex, darken room and ask person to gaze into distance; this dilates pupils; advance a light in from side and note response Normally you will see constriction of same-sided pupil (a direct light reflex) and simultaneous constriction of other pupil (a consensual light reflex)

beau line

Transverse furrow or groove. A depression across the nail that extends down to the nail bed. Occurs with any trauma that temporarily impairs nail formation, such as acute illness, toxic reaction, or local trauma. Dent appears first at the cuticle and moves forward as nail grows.

cranial nerve III damage

Unilateral dilated pupil has no reaction to light or accommodation and occurs with oculomotor nerve damage. Ptosis with eye deviating down and laterally may be present.

eyelids and lashes

Upper lids normally overlap superior part of iris, and approximate completely with lower lids when closed. The skin is intact without redness, swelling, discharge, or lesions Palpebral fissures horizontal in non-Asians; Asians normally have an upward slant Note that eyelashes are evenly distributed along lid margins and curve outward

foreign body

Usually it is children who place a foreign body in the ear, which is later noted on routine examination. Common objects are beans, corn, breakfast cereals, jewelry beads, small stones, sponge rubber. Cotton is most common in adults and becomes impacted from cotton-tipped applicators. A trapped live insect is rare but makes the person especially frantic.

monocular blindness

When light is directed into blind eye, no response in either eye. When it is directed to normal eye, both pupils constrict (direct and consensual response to light) as long as the oculomotor nerve is intact

excessive cup-disc ratio

With primary open-angle glaucoma, the increased intraocular pressure decreases blood supply to retinal structures. The physiologic cup enlarges to more than half of the disc diameter, vessels appear to plunge over edge of cup, and vessels are displaced nasally. This is asymptomatic, although the person may have decreased vision or visual field defects in the late stages of glaucoma.

treated (nosebleeds)

_________ rationale: person should site with head tilted forward, pinch soft part of nose above nostril for 10-15 minutes

cough up any phlegm/ sputum

__________ rationale: chronic bronchitis has history of productive cough for 3 montsh o fthe year for 2 years in a row

tobacco use (subjective data)

__________ rationale: chronic use of _________________ leads to tooth loss, coronal and root caries, and peridontal disease in older adults chronic use of tobacco, alcohol, and both together highly increases risk for oral and pharyngeal cancers

pain wake you up at night (peripheral vascular subjective data)

__________ rationale: night leg pain is common in aging adults; it may indicate ischemic rest pain of PAD, severe night mucsle cramping, or restless leg syndrome

adenocarcinoma cancer

__________ usually starts in periphery and escapes early detection;

child's teeth erupt on time (infnat/childrne subjective data)

___________ rationale: delayed with Down syndrome, cretinism, rickets

child have a cough? seem congested? noisy breahting? (subjective data)

___________ rationale: screen for osnet nad follow course of childhood chronic asthma, bonrchitis

measures taken to chldproof home (subjective data)

___________ rationale: young children, especially <3 years are at risk for foreign body aspiration, poisnoing, and injury assess knowledge of parent and caregievrs

papillae

____________ are the rough, bumpy elevations on the dorsal surface; the larger vallate __________________ are in an inverted V shape across the posterior basae of the tongue, not to be confused with abnormal growths

small cell (oat cell) cancer

____________ compreses and narrows central bronchi

venous flow

____________ is accomplished by: 1. contracting skeletal muscles that milk the blood proixmally back toward the heart; 2. the pressure gradient caused by breathing, in which inspiration makes the thoracic pressure decrease and the abdominal pressure increase; and 3. the intraluminal valves, which ensure unidirectional flow; each valve is a paried semilunar pocketthat opens toward the heart and closes tightly when filled to prevent backflow of blood

smokers in home or car with child (subjective data)

____________ ratioanle: postnatal second hadn smoke exposure increases risk for acute and chronic ear and respiratory infections in children

family history of allergies, tuberculosis, asthma

____________ rationale: assess possible risk factors

sore throat/ tonsilitis (infant/children subjective data)

____________ rationale: children 5-15 years have a higher incidence of streptococcus (GAS) pharyngitis than adults; must confirm with rapid antigen test and backup throat culture

child's teeth straight (infnat/childrne subjective data)

____________ rationale: look for malocclusion

usual amount of physical activity (aging adult subjective data)

____________ rationale: may have reduced exercise capacity because of pulmonary function deficits; sedentary or bedridden people are at risk for respiratory dysfunction

sore throat (Subjective data)

____________ rationale: most __________________ are viral and resolve in 3-5 days without antibiotics; however group a streptococal (GAS) pharyngitis is more likely with fever over 100.4 F , absence of cough, tonsillar exudates, and cervical adenopathy; confirm with rapid antigen test and backup throat culture; untreated strept (GAS) throat can cause peritonsillar absess, rheumatic fever, and glomerulonephritis

epistaxis/ nosebleeds (subjective data)

____________ rationale: occurs with trauma, vigorous nose blowing, foreign bodies

child using a bottle (infnat/childrne subjective data)

____________ rationale: prolonged bottle use increases risk for tooth decay and middle ear infections

newborn sebum

____________, which holds water in the skin, is present for the first few weeks of life, producing milia and cradle cap in some babies; then sebaceous glands decrease in size and production and do not resume function until puberty

large cell cancer

_____________ also starts in periphery with tumors arranged in clusters;

factors for skin disease/ breakdown

_____________ include: thinning of the skin decrease in vascularity and nutrients loss of protective cushioning of the subcutaneous layer lifetime of envionrmental trauma to the skin social changes of aging increasingly sedentary lifestyle chance of immobility

linear lesion

_____________ is a scratch, streak, line, or stripe

color (optic disc)

_____________ is normally cream yellow-orange to pink ABNORM: pallor, hyperemia

hirsutism

_____________ is shaggy or excessive hair

alpoceia

_____________ is significant hair loss; a full head of hair equates with vitality in many cultures; if treated as a trivial problem, the person may seek alternative, unproven methods of treatment

neuropathic ulcer

_____________ occur with repetitive stress over at risk areas; over half of diabetic ulcers become infected and about 20% of infections lead to some level of amputation

tracheal shift

_____________ occurs when: the treachea is pushed to the unaffected/healthy side with an aortic anneurysm, tumor, unilaterla thyroid lobe enlargement, and pneumothorax ts

diaphoresis (moisture)

_____________ or perfuse perspiration accompanies an increased metabolic rate such as occurs in heavy activity or fever

Deep Vein Thrombosis

_____________ presents with unilateral swelling of the affected leg, tenderness to severe pain, possibly warmth and redness form accompanying inflammation, and possibly superficial venous dilation; evaluate these symproms considering patient's current history and medical conditions; for more accurate resutls use the wells criteria; note that the wells score has been validated in the outpaitent settings, but some evidnece finds it insufficeint to rule out DVT in the inpatient setting; doppler ultrasound imaging should be done

vertigo (subjective data)

_____________ rationale: benign paroxysmal positional vertigo is the most common type of vertigo, with brief spinning sensations; occurs with dysfunction of labrynth; increases risk for falls and doing daily activities distinguish true vertigo from dizziness or light-headedness

how often do you cough? any special time of day?

_____________ rationale: conditions with characteristic timing of cough: (1) continuous throughout day- acute illness; (2) afternoon/ evening- exposure to irritants at work; (3) night-postnasal drip, sinusitis; (4) early morning- chronic bronchial inflammation of smokers

specific symptoms signal breathing problems

_____________ rationale: general symptoms: cough, SOB; some gases produce specific symptoms: carbon monoxide- dizziness, headache, fatigue; sulfur dioxide- cough, congestion

lsote teeth/ chew food (aging adult mouth/ teeth subjective data)

_____________ rationale: note a decrease in eating meat, fresh vegetablse, and cleansing foods such as apples

new change in exercise (peripheral vascular subjective data)

_____________ rationale: pain of musculoskeletal origin rather than vascular

cough description

_____________ rationale: some conditions have characteristic cough: myoplasma pneumonia- hacking; early heart failure- dry; croup- barking; colds, bonrchotiis, pneumonia- congested

history of respiratory infections (subjective data)

_____________ rationel: consider sequelae after these conditions

target lesion

_____________ resembles iris of eye, concentric rings of color in lesions

squamous cell cancer

_____________ usually starts in central bronchi near the hilus;

skin changes on arms/legs (peripheral vascular subjective data)

_____________: any skin changes on arms/ legs; what color any change in temperature do leg veins look bulging and crooked/ how treated do you use support hose any sores/ ulcers; where

patient centered care

_____________: last TB skin test, chest x-ray, pneumonia vaccine, influenza immunization

secondary skin lesions

______________ are due to a change in a primary lesion over passage of time; an evolutionary change; note: combinations of primary and secondary lesion may coexist in the same person; such combined designations may be termed papulosquamous, maculopapular, vesiculopustular, or papulovesicular

striae

______________ are jagged linear stretch marks of silver to pink color that appear during the 2nd trimester on the abdomen, breasts, and sometimes thighs; they occur in half of all pregnancies; they fade after delivery, but do not dissapear

lymph nodes

______________ are small, oval clumps of lymphatic tissue located at intervals along the vessels; most nodes are arranged in groups, both deep and superficial, in the body; ______________ filter teh fluid before it is returned to the bloodstream and filter out microorganisms that could be harmful to the body; the pathogens are exposed to B and T lymphocytes in the lymph nodes, and these moutn an antigen-specific response to elminate pathogens; with local inflammation the _____________ in that area become swollen and tender

gyrate lesions

______________ are twisted, coiled, spiral, snakelike

headache (subjective data)

______________ ask about: onset (gradual over hours to days or suddenly) ever having this kind of headache before location localization (one side/ all over) character (throbbing or aching) mild, moderate, severe course and duration precipitating factors associated factors

headache (subjective data)

______________ ask about: onset (gradual over hours to days or suddenly) ever having this kind of headache before location localization (one side/ all over) character (throbbing or aching) mild, moderate, severe course and duration precipitating factors associated factors any other illnesses any medications what makes it wrose any family history of headaches frequency of headaches are they getting worse or better when are they in relation to your menstrual period effort to treat

smoking history (peripheral vascular subjective data)

______________ do you smoke; packs per day; when started; how many years; tried to quit; what worked when quitting; what didn't help

inspect extenal nose

______________ for symmetry, any deformity, or lesions

extraneous noises confused with lung pathology

______________ include: 1. examiner's breathing on stethoscope tubing 2. stethoscope tubing bumping together 3. patient shivering 4. patient's hairy chest, movement of hairs sounds like crackles- minimize this by pressing harder of wetting hair 5. restling of paper gown or paper drapes ABNORM: crackles are an abnormal lung sound

pressure injury risk factors

______________ include: impaired mobility thin fragile skin of aging decreased sensory perception (not responding to pain accompanying prolonged pressure) impaired level of consciousness moisture from urine or stool incontinence excessive prespriation/ wound drainage shear injury poor nutrition infection

tropia

______________ is a constant malalignment of the eyes

ankle circumference

______________ is a more reliable mesure of edema, using a nonstretchable tape at a point 7 cm proximal to the midpoint of the medial malleolus; because peripheral edema is a common clinical sign in a great number of conditions, it is important to detect true changes in the most accurate way possible; check with institution to conform to a consistently used scale

skin color

______________ is derived from three sources: 1. mainly from the brown pigment melanin 2. from the yellow-orange tones of the pigment carotene 3. form the red-purple tones in the underlying vascular bed

edema

______________ is fluid accumulating in the interstitial spaces; it is not present nomrally; to check for _________________, imprint your thumbs firmly for 3-4 seconds against the ankle or tibia; normally the surface stays smooth; _________________ masks skin color and obscures pathologic conditions such as jaundice or cyanosis because the fluid lies between the surface and pigmented vascular layers, making dark skin look lighter

recruitment-

______________ is hearing loss with low intensity speech, but sound becomes painful when the sspeaker repeats in a loud voice

shape (optic disc)

______________ is normally round or oval ABNORM: irregular shape

molding

______________ is overriding of hte cranial bones; usually the parietael bone overrides the brontal or occipital bone; reassure parents that this laws only a few days or a week; babies delivered by C-section are noted for their evenly round heads m

lung cancer

______________ is the 2nd most commonly diagnosed cnacer in both men and women, but it is leaeding cause of cancer death in the US; tobacco smoking causes almost 90% of lung cancers, and smoking causes a high mutational burden; this means that there are many mutations in the DNA genome of smokers compared with very low mutation rate of nonsmokers; the complexity of this high mutation rate is what makes it so difficult to identify targeted drug treatments with __________________

skin

______________ is the largest organ system in the body; it guards hte body from environmental stresses (e.g. trauma, pathogens, dirt) and adapts it to other environmental influences (e.g. heat, cold)

curtis marmoata

______________ is transient mottling in the trunk and extremities in response to cooler room temperatures; it forms a reticulated red or blue pattern over the skin

lymphoid tsisue

______________ is well developed at birth and grows to adult size when the hild is 6 years old; the ____________________ continues to grwo rapidly until age 10 or 11, actually exceeding adult size during puberty; it then atrophies slowly

sebum

______________ oils and lubricates the skin and hair follicles and forms and emulsion with water that retards water loss from the skin; dry skin results from loss of water, not directly from loss of ____________

dryness of the mouth (aging adult mouth/ teeth subjective data)

______________ raitonale: xerostomia is a side effect of many drugs: antidepressants, anticholinergics, antispasmodis, antihypertensies, antipsychotics, bronchodilators

ear infections (children subjective data)

______________ rationale: first episode within 3 months of life increases risk for recurrent OM; recurrent OM is 3 episodes in past 3 months or 4 within a year passive and parental smoke are risk factors for OM day care attendance and bottle-feeding are risk factors for OM

treatments treid for cough

______________ rationale: assess effectiveness of coping strategies

shortness of breath related to food, pollen, dust, animals, season, etc.

______________ rationale: asthma attacks may occur with a specific alelrgen or extreme cold, anxiety; asthma often described as chest tightness

lymph node enlargement (peripheral vascular subjective data)

______________ rationale: enlarged lymph nodes occur with infection, malignancies, and immunologic diseases

shortness of breaht with daily activities (aging adult subjective data)

______________ rationale: older adults have a less efficient respiratory system (decreased vital capacity, less surface area for gas exchange); thus the have less tolerance for activity

care for own teeth/ dentures (aging adult mouth/ teeth subjective data)

______________ rationale: self-care may be decreased by physical disability, loss or access and/or income, vision loss, confusion, or depression

pain with breathing (aging adult subjective data)

______________ rationale: some adutls feel pleurtiic pain less intensely tha nyounger adults; precisely localized sharp pain (points to it with one finger) consider fractured rip or muscle injury

affects on everyday life (tinnitus)

______________ rationale: tinnitus can cause sleep disturbance, depression, or anxiety and be so debilitating that person cannot lead a normal life

louder at night (tinnitus)

______________ rationale: tinnitus seems louder with no competition from environmental noise

smoking history (peripheral vascular subjective data)

______________ rationale: tobacco constricts arteries, increase coagulability, injures endothelium, and promotes inflammaiton; smoking is the strongest risk factor for PAD; starting at <16 years more than doubles future PAD risk

environmental exposure (subjective data)

______________ rationale: traffic related air pollution increases risk of allergic rhinitis and asthma; farmers may be at risk for grain or pesticide inhalation; people in rural midwest have risk for histoplasmosis exposure; those in southwest and Mexico have risk for coccidioidomycosis; coal miners have risk for pneumococnoiosis; stone cutters, miners, and potters have risk for silicosis; other irritants: asbestos, radon; assess self-care measures

shortness of breath (subjective data)

______________ rationel: in hospitalized patients, ____________ is a common burdensome symptom and a predictor of negative outcomes

localized damage

______________ restuls in blind spot (scotoma) corresponding to particular area

confrontation test

______________ screens for peripheral vision; it compares the person's periphearl vision with your own, assuming your's is normal

aneurysms

______________ types: thoracic aortic arch abdominal aorta femoral popliteal

lymph node enlargement (peripheral vascular subjective data)

______________: any swollen glands? where? how long? any recent change how do they feel to you are swollen glands associated with pain?

prodrome

______________: change in mood, behavior, hunger, cravings, yawning p

peripheral cyanosis

______________: due to exposure to cold or anxiety light/dark skin: nail beds dusky

hypo/hyperpigmentation

_______________ are areas of postinflammation that appear as dark or light spots after acne has resolved

keratoses

_______________ are riased, thickened areas of pigmenetation that lok crusted, scaly, and warty

facial strutures

_______________ are symmetric; the eyebrows, eyes, ears, nose, and mouth appear about the same on both sides

headache (subjective data)

_______________ ask about: any other illnesses any medications what makes it wrose any family history of headaches frequency of headaches are they getting worse or better when are they in relation to your menstrual period effort to treat

hair color

_______________ comes from melanin production and may vary from pale plond to total black; graying begins as early as the 30s because of reduced melanin production in the follciles; genetic factors affect the onset of aging

axillary nodes

_______________ drain the breast and upper arm

cervical nodes

_______________ drain the head and neck

lymphatics

_______________ functions to: 1. conserve fluid and plasma proteins that leak out of the capillaries, 2. form a major part of the immune system that defends the body against disease, 3. absorb lipids from the small intestine

aging adult skin subjective data

_______________ include: 1. which changes have you noticed in your skin in the past few years 2. any delay in wound healing, any itching? 3. any skin pain 4. any change in feet, toenails? Any bunions? can you wear shoes 5. have you had any falls, how many 6. any history of peripheral vascular disease 7. what do you do to care for your skin

skin assessment subjective data

_______________ includes: 1. past history of skin disease 2. change in pigmentation 3. change in mole size/color 4. excessive dryness or moisture 5. puritus 6. excessive bruising 7. rash or lesion 8. medications 9. hair loss 10. change in nails 11. environmental or occupational hazards 12. patient-centered care

skin subjective data adolescent

_______________ includes: have you noticed any skin problems such as pimples, blackheads? how long have you had them? how do you treat them? how do you feel about it?

torus palatinus

_______________ is a benign bony ridge running in the midline of the hard palate and occurs in 20-35% of the US population, more commonly in females

cleft palate

_______________ is a congential defect, the failure of fusion of hte maxillary processes; wide variation occurs in the extent of cleft formation, form upper lip only, palate only, uvula only, to cleft of the nostril and the hard nad soft palates

nystagmus

_______________ is a fine oscillating movement best seen around the iris; mild ________________ at extreme laterla gaze is normal; at any other position it is not

headache

_______________ is a leading cause of acute pain and lost productivity, as well as a leading reason for seeking care in outpatient offices, urgent care centers, and emergency depratments

presyncope (dizziness)

_______________ is a light-headed, swimming sensation or feeling of fainting or falling caused by decreased blood flow to brain or heart irregularity causing decreased cardiac output

accomodation

_______________ is adaptation of hte eye for near vision; it is accomplished by increasing the curvature of the lens through the muscles of the ciliary body; although the lens cannot be observed directly, the components of ___________________ can be observed by convergence (motion toward) of the eyes and pupillary constriction

actinic/senile/solar keratosis

_______________ is less common; these lesions are red-tan scaly plaques that increase over the years to become raised and roughened; they may have a slievry-white scale adheret to hte plaque; they occur on sun-exposed surfaces and are directly related to sun exposure; they are prelmalignant and may develop into squamous cell carcinoma

tortuosity (retinal vessels)

_______________ is mild vessel twisting; when present in both eyes is usually congenital and not significant ABNORM: extreme _________________ or marked assymetry in two eyes

myopa

_______________ is the most common visual disorder during childhood; criteria for referral are: 1. age 3 years- vision 20/50 or less in either eye 2. age 4 and older- 20/40 or less in either eye 3. difference between two eyes is one line or more 4. child shows other signs of vision impairment regardless of acuity

tinnitus (subjective data)

_______________ is thte perception of sound without an external source; it occurs with sensorineural hearing loss, cerumen impaction, middle ear infection, and other ear disorders

vertigo (dizziness)

_______________ is true rotational spinning often from labyrinthine-vestibular disordedr in the inner ear

harlequin color change

_______________ occurs when the baby is in a sie lying position; the lower half turns red and the upper half blances with a distinct demarcation line down the middle; the cause is unknwon, and it is transient

tracheal shift

_______________ occurs when: the trachea is pulled toward the affected/diseased side with large atelectasis, pleural adhesions, or fibrosis ts

rhionrrhea

_______________ occurs with colds, allergies, sinus infection, trauma

patient centered care (subjective data)

_______________ rationale: potential trauma from invasive instruments; cotton-tipped applicators can impact cerumen, causing hearing loss prescribe frequency of hearing assessment according to age or risk factors

child hearing well (children ears subjective data)

_______________ rationale: those exposed to maternal rubella or maternal ototoxic drugs in utero; premature infants; low birth weight infants; trauma or hypoxia at birth; infants with congenital liver or kidney disease in children the incidence of meningitis, measles, mumps, OM, and any illness with persistent high fever may increase risk for hearing deficit

change in sexual function (peripheral vascular subjective data)

_______________ rationale: aortoiliac occlusion is associated with erectile dysfunction (Leriche syndrome)

shortness of breath efforts to relieve hard-breathing attack

_______________ rationale: assess affect of coping strategies and need for teaching

how does SOB affect work/ home activities

_______________ rationale: assess affect on ADLS

history of COPD/ Tuberculosis (aging adult subjective data)

_______________ rationale: assess coping strategies; activities may decrease because of increasing shortness of breath or pain

efforts to relieve pain (earache subjective data)

_______________ rationale: assess effect of coping strategies

unsuually frequent/ severe colds respiratory infections

_______________ rationale: because most people have had some oclds, it is more meaningful to ask about excess number of severity

grinding teeth (infnat/childrne subjective data)

_______________ rationale: bruxism ususally occurs in sleep or from dental problems or nervous tension

chest pain with breathing (Subjective data)

_______________ rationale: chest pain of thoracic origin occurs with muscle soreness from coughing or form inflammation of pleura overlying pneumonia; distinguish this from chest pain of cardiac origin or heartburn of stomach acid

history of shortness of breath

_______________ rationale: determine how much activity precipitates shortness of breath-state specific number of blcoks walked, number of stairs; chronic idyspnea is SOB lasting >1 month and may have neurogenic, respiratory, or cardiac origin; it also occurs with anemia, anxiety, and deconditioning

child's dental habits (infnat/childrne subjective data)

_______________ rationale: evaluate child's self-care; early self-care has best compliance

trauma (subjective data)

_______________ rationale: may cause deviated septum, which may cause nares to be obstructed

frequent colds (subjective data)

_______________ rationale: most people have occasional colds; thus asking this more precise question yields more meaningful data

claudication distance

_______________ rationale: not sudden decrease in claudication distance or pain not relieved by rest

history of vascular problems (peripheral vascular subjective data)

_______________ rationale: risk factors for PVD; diabetes and smoking are stronger risk factors for PVD than they are even for heart disease

smoking history (subjective data)

_______________ rationale: state number of packs per day and number of years smoked to determine risk factors

taking medications (tinnitus)

_______________ rationale: the main ototoxic drugs in clinical use: aminoglycoside antibiotics (loss develops in 20% of patients) and the anticancer drug cisplatin (loss in 60-65% of patients); also possibly ototoxic are furosemide, vancomycin, and chronic use of aspirin

claudication distance

_______________ rationale: the number of blocks walked or stairs climbed to produce pain

child put objects in ears/ older child or adolescent in contact sports (children ears subjective data)

_______________ rationale: these children are at increased risk for trauma

leg veins look bulging (peripheral vascular subjective data)

_______________ rationale: varicose veins

zosteriform lesions

_______________ resembles linear arrangement along a unilateral nerve route

concussion

_______________ results after a direct blow to the skull causes the brain to shift rapidly back and forth inside; evidence consistently shows that helmet use decreases the severity of injuries after a motorcycle crash and increases the chance of survival

macula damage

_______________ results in central blind area, e.g. diabetes

central gray opacity-nuclear cataract

_______________ shows as an opaque gray surrounded by a black background as it forms in the center of lens nucleus; through the opthalmoscope it looks like a black center against the red reflex; it begins after age 40 years and develops slowly, gradually obstructing vision

otorrhea

_______________ suggests infected ear canal or perforated ear drum such as external otitis- purulent, sanuineous, or watery drainage acute OM with perforation- purulent discharge cholesteaoma- dirty yellow-gray discharge, foul odor

sebaceous hyperplasia (skin texture)

_______________-- consists of raised yellow papules with a central depression; they are more common in men, occuring over hte forehead, nose, or cheeks; they have a pebbly look

child had frequent or severr colds (subjective data)

_______________: rationale: limit of 4-6 uncomplicated upper respiratory infections per year is expected in early childhood

needle marks

________________ abnorm: from street drugs may be visible on the antecubital ossae, forearms, or any available vein

age-related sensorineural loss/ presbycusis

________________ affects half of those over 60 and 80% of those over 85; the incidence will increase as currnet baby boomers age; despite its prevalence loss is underscreened and undertreated; this leads to social isolation, diminished quality of life, even cognitive impairment and depression; hearing aids can improve this loss

periodontal disease

________________ affects the structures surrounding the tooth, including the gingiva and alveolar bone; this condition is caused by chornic inflammation, which is a key factor linking type 2 diabetes and peridontitis; this connection is a concern because rates of obesity are increasing in children along with increasing incidence of type 2 diabetes; the chronic elevated blood glucose levels result in gingival inflammation, which leads to gingivits and peridontal disease

vascular spiders/ spider angioma

________________ are common in pregnancy because of increased estrogen and may resolve after childbirth; these lesions hvae tiny red centerse with radiating branches and occur on hte face, neck, upper chest, and arms

preauricular lymph nodes

________________ are in front of the ear

margins (optic disc)

________________ are normally distinc tand sharply demarcated, although the nasla edge may be slightly fuzzy

fissures

________________ are the separations of lung lobes that run obliquely through the chest

aging adult eyes

________________ brings a risk of vision-robbing diseases; in older adults the most common causes of decreased visual functionning are: cataract glaucoma age related macular degeneration diabetic retinopathy

lymphatic system organs

________________ include: spleen tonsils thymus

otosclerosis (adult ears)

________________ is a cause of conductive hearing loss in young adults between the ages of 20-40 years; it is a gradual bone formation that causes the footplate of the stapes to become fixed in the oval window, impeeding the transmission of sound and causing progressive deafness

mole/ nervus

________________ is a clump of melanocytes, tan-to-brown color, flat or raised; acquired _____________ have symmetry, small size (6mm or less), smooth borders, and single uniform pigmentation

erythema toxicum

________________ is a common rash that appears in the first 3-4 days of life; sometimes called flea bite rash or newborn rash, it consits of tiny punctate red macules nad papules on the cheks, trunk, chest, back, and buttocks; the causes is unknwon, no treatment is needed

bruising

________________ is a common soft-tissue injury following nrapid, traumatic, or breech birth; multiple ______________ in various stages of healing or pattern injury suggests abuse

Heads UP

________________ is a concussion training program created by the CDC for nurses, athletes, and coaches of youth sports to identify concussions in youth athletes

expothalmos (protruding eyes)

________________ is a forward displacement of the eyeball and widneed palpebral fissues; not the lid lag in which the upper lid rests well above the limbus and white sclera is visible; acquired bilateral _________________ is associated with thyrotoxocis

tuberculosis (TB)

________________ is an airborne lung disease that has infected one-third of hte world's population; because of increased globalization and air travel, _________ has been termed a social and migratory disease; ______________ is rampant in crowded living conditions with scant physical space between persons; in addition ___________ is spread in countries with armed conflict

red reflex

________________ is caused by thte reflection of the opthalmoscope light off the inner retina; keep sight of hte ____________ and move closer to the eye; if lost, the light has wantered off the pupil ABNORM: cataracts appear as black areas against the ______________

esophoria

________________ is nasal (inward) drift of the eyes

20/20

________________ is normal visual acuity

lymphedema

________________ is the accumulation of protein rich fluid in the interstitial spaces of the arm following breast surgery or treatment; it results from axillary lymph node removal, radiation therapy, fibrosis, or inflammation; once protein-rich lymph builds up in the interstitial spaces, it further raises local colloid osmotic pressure, which promotes more fluid leakage

terminal hair

________________ is the darker, thicker hair that grows on the scalp and eyebrows, and after puberty, on the axillae, the pubic area, and the face and chest in the male

seborrheic kertaosis

________________ look dark, greasy, and stuck on; they develop mostonly on the trunk but also on the face and hands and on both unexposed nad sun exposed areas; they do not becoem cancerous

lymphedema

________________ objective data include unilateral swelling, measurement of arm volume, nonpitting brawny edema, overlying skin indurated; early knowledge is important because there are treatments to prevent it: deep breathing and ball squeezing exercises, simple lympahtic drainage massage, elevation, compression garments, and strength training as long as no infection is present

tracheal shift

________________ occurs when: tracheal tug is a rhythmic downward pull that is synchronous with systole and occurs with aortic arch anneruysm ts

clubbing of nails

________________ occurs with congenital cyanotic heart disease, lung cancer, and pulmonary diseases; in early _______________, the agnle straightens out to 180 degrees and the nail base feels spongy to palpation, then the nail becomes convex as the digit grows

swelling in arms/ legs (peripheral vascular subjective data)

________________ rationale: edema is bilaterla when the cause is generalized (heart failure) or unilateral when it is the result of a local obstruction or inflammation

coping strategies

________________ rationale: hearing loss can cause social isolation, decreased quality of life, functional decline, cognitive decline, depression

cough up any blood

________________ rationale: hemoptysis; some other conditions have characteristic sputum production: (1) white or clear mucid- colds, bronchitis, viral infections; (2) yellow or green- bacterial infections; (3) rust colored- TB, pneumococcal pneumonia; (4) pink, frothy- pulmonary edema, some sympatomimetic medications have side effect of pink-tinged mucus

change in taste/smell (aging adult mouth/ teeth subjective data)

________________ rationale: some poeple add extra salt and sugar to enhance food when taste begins to wane; diminished smell also may detect food spoilage, natural gas leaks, or smoke from a fire

hit on ear/ side of head (earache subjective data)

________________ rationale: trauma may rupture the TM

sinus pain (subjective data)

________________ rationale: up to 90% of patients with viral URI also have viral sinusitis, which resolves without antibiotics

popliteal aneurysm

________________ relatively uncommon; occurs in 5-20% of people with AAA

otitis media/ OM

________________ risk factors include: absence of brestfeeding in the first three months of age preterm birth exposure to secondhand tobacco smoke daycare attendance male sex pacifier use seaonality (fall and winter) bottle-feeding

bifid uvula

________________ shows the uvula split either completely or partially and occurs in about 2% of the general population adn up to 10% in some American Indian groups

palpation

________________ test patency of each nostril

general background

________________ the color normally varies from light red to dark brown-red generally corresponding with the person's skin color; your view should be clear, no lesions should obstruct retinal structures ABNORM: leasions, hemorrhages, exudates, microaneurysms

melasma

________________, or the mask of pregnancy, is a patchy tan-to-dark brown discoloration of the face

dysphagia (subjective data)

________________- rationale: occurs with pharyngitis, gastroesophagel reflux disease, stroke, and other neurologic diseases, esophageal cancer

aging adult skin nails

________________-- growth rate decreases, and local injuries in the nail matrix may produce longitudinal ridges; the surface may be brittle or peeling and sometimes yellowed; toenails are also thickened and may grow misshapen, almost grotesque

aging adult lungs subjective data

________________: 1. noticed any shortness of breath/ fatigue 2. usual amount of physical activity 3. history of COPD/ TB how are tehye getting along each day? 4. chest pain with breahting

palpate the sinus areas

________________: note any tenderness

purpuric lesions (vascular lesions)

________________: caused by blood flowing out of breaks in the vessels; red blood cells and blood pigments are deposited in the tissues; difficult to see in dark-skinned people e.g. petechiae, purpura, ecchymosis, contusion/ bruise

central cyanosis

________________: increased amount of unoxygenated hemoglobin; due to chronic heart and lung disease causing arterial desaturration _________________ causes: light skin: dusky blue dark skin: dark but dull, lifeless; only severe cyanosis is apparaent in skin, check conjunctivae, mucosa, nail beds

hyperthyroidism

________________: skin feels moother and softer, like velvet

hypothyroidism

________________: skin feels rough, dry, and flaky

dehydration (mositure)

_________________ ABNORM: mucous membranes are dry, and lips look parched and racked; with extreme dryness, the skin is fissued reembling cracks in a dry lake bed

peripheral artery disease (PAD)

_________________ affects noncoronary arteries and usually refers to arteries supplying the limbs; it is usually caused by atherosclerosis, and less commonly by embolism, hypercoagulabe states, or arterial dissection

polycyclic lesion

_________________ annular lesions that grow together, e.g. lichen planus, psoriasis

secondary sex characteristics

_________________ appear during adolescence are evident in the skin; in the female, the diameter of the areola enlarges and darkens, and breast tissue develops; coarse pubic hair develops in males and females, then auxillary hair, and then coarse facial hair in males

isolated head tremors

_________________ are benign and include head nodding (as if saying yes or no) and tongue protrusion iht

headache

_________________ are classified by etiology (tension, migrane, sinus); however misdiagnosis is common, with migraine especially being misclassified as sinus or tension

perforators

_________________ are connecting veins that join the superficial to deep veins; they also have one-way valves that route blood from the superficial veins into the deep veins and prevent reflux to the superficial veins

tonsils

_________________ are graded in size as: 1. visible 2. halfway between tonsillar pillars and uvula 3. touching the uvula 4. touching one another

keloids

_________________ are scars that form at the site of a wound and grow beyond hte normal boundaries of a wound

cherry/ senile angiomas

_________________ are small 1-5 mm smooth, slightly raised bright red dots that commonly appear on the trunkn in all adults older than 30; they normalyl increase in size and number with aging and ar enot significant

conductive hearing loss

_________________ blocks sound transmission somewhere in the external auditory canal, tympanic membrane, or middle ear

anemia/ shock (pallor)

_________________ causes light skin: generalized pallor dark skin: brwon skin appears yellow-brown, dull; black skin apperas ashen gray, dull; skin loses glow; check areas with least pigmentation such as conjunctivae, mucous membranes

local arterial insufficiecny (pallor)

_________________ causes light skin: marked localized pallor (e.g. lower extremities, espcially when elevated) dark skin: ashen gray, dull; cool to palpation

pingueculae

_________________ commonly show on the sclera; these yellowish elevated nodules are caused by a thikening of the bulbar conjunctiva from prolonged exposure to the sun, wind, and dust; ________________ appear at 3 and 9 o clock positions first on the nasal side then temporal side pin

newborn sweat glands

_________________ do not secrete in response to heat until the first few months of life and then only minimally throughout childhood

lymphatics

_________________ form a completely separate vessel system that retrieves excess fluid and plasma proteins from the interstitial spaces and returns them to the bloodstream; fluid moves according to a pressure gradient (filtration); at the arterial end the hydrostatic pressure is caused by the pumping action of the heart and pushes somewhat more fluid out of the capillaries than the venules can absorb; this fluid is vacuumed out of the interstitial spaces by the lymph vessels; without lymphatic drainage, fluid would build up in the interstitial spaces and produce edema

occlusions

_________________ in arteries are caused by atherosclerosis, which is the chronic gradual buildup of (in order) fatty streaks, fibroid plaque, calcification of the vessel wall, and thrombus formation. This reduces blood flow with vital oxygen and nutrients.

ABCDEF rule

_________________ indicate abnormal characteristics of mole: A- asymmetry B- border irregularity C- color variation D- diameter >6mm E- elevation/ evolution F- funny looking additional symtpoms

leukoedema

_________________ is a benign milky, bluish-white opaque appearance of the buccal mucosa that occurs commonly in African Americans

acrocyanosis

_________________ is a bluish color around the lips, hands and fingernails, and feet and toenails; this may last for a few hours and dissapear with warming

milia

_________________ is a common variation, tiny white papules on the forehead and eyelids and on cheeks, nose, and chin, caused by sebum that occlues the opening of hte follicles; ____________ resolves spontaneously within a few weeks

male-pattern balding/ alopecia

_________________ is a genetic trait; it is usually a gradual receeding of hte anterior hairline in a symmetric W shape

scleral crescent

_________________ is a gray-white, new moon shape; it occurs when pigment is absent in the choroid layer and you look directly at the sclera

pilar cyst

_________________ is a smooth, firm, fluctant swelling on the scalp that contains sebum and keratin; tense pressure of the conents causes overlying skin to be shiny and taut; it isa benign growth

cholasma

_________________ is an irregular brown patch of hyperpigmentation on the face; it may occur with pregnancy or in women taking oral contraceptive pills; ________________ decreases after delivery or discontinuation of the pills

jaundice

_________________ is first noted in the junction of the hard and soft palate in the mouth and in the sclera; then the eyes appear yellow; the scleral yellow of jaundice extends up to the edge of the iris

anasarca

_________________ is generalized edema over the whole body

erythema

_________________ is intense redness of the skin from excess blood in the dilated superifcial capillaries; this sign is expected with fever, local inflammation, or emotional reactions such as blushing in vascular flush areas

eversion of hte upper lid

_________________ is not part of hte normal exam, but is useful for inspecting the conjunctiva of hte upper lid, as with eye pain or suspicifion of a foreign body; most people are apprehensive of any eye manipulation; enhance cooperation by using a calm and gentle, yet deliberate approach

collagen

_________________ is the tough, fibrous protein that enables skin to resist tearing

anisocoria

_________________ is unequal pupil size; although this nromally exists in 5% of hte population, consider CNS disease

scalp hair

_________________ may be fine or thick and may look stright, curly, or kinky; it should look shiny, although this characteristic may be lost with the use of some beauty products such as dyes, rinses, or permanents

lymphadenopathy

_________________ means enlargement of the lymph nodes >1cm form infection, allergy, or neoplasm l

otitis media/ OM

_________________ occurs because of obstruction of hte eustachian tube or passage of nasopharyngeal secretions into the middle ear; this creates a ripe enviornment for for bacteria to grow; acute ______________ is so common that up to 60% of childrne expeirence an episode in the first year of life, and by age 3 83% have suffered an episode

otalgia

_________________ occurs directly form ear disease or is referred pain from a problem in teeth or oropharynx

nystagmus

_________________ occurs with disease of the semicircular canals in the ears, a paretic eye muscle, multiple sclerosis, or brain lesions

jaundice

_________________ occurs with hepatitis, cirrhosis, sickle cell disease, transfusion reaction, and hemolytic disease of the newborn

facial sensations

_________________ of pain or touch are mediated by the 3 sensory branches of cranial nerve V, the trigeminal nerve

use support hose (peripheral vascular subjective data)

_________________ rationale: avoid compression stockings with PAD sinc etehy further impede blood flow; they are indicated to presecnt leg swelling in standing worksers or thrombus formation

leg sores/ ulcers (peripheral vascular subjective data)

_________________ rationale: leg ulcers occur with chronic arterial and venous disease

ever tried to quit; smoking history

_________________ rationale: most people already know they should quit smoking; instead of admonishing, assess smoking behiavior and ways to modify daily smoking activities, identify triggers nad how to manage withdrawal

describe ype of pain/ come on gradually or suddenly (peripheral vascular subjective data)

_________________ rationale: peripheral vascular disease (PVD) includes PAD and venosu disease

relation between discharge and ear pain

_________________ rationale: typicalyl with perforation- ear pain occurs first, stops with a popping sensation, then drainage occurs

aggrivated by activity/ walking (peripheral vascular subjective data)

_________________ rationale: with PAD, blood flow cannot match muscle demand during exercise; therefore people feel muscle fatigue or pain when walking (claudication); but only 10% of those with PAD have this symptom

medications (peripheral vascular subjective data)

_________________ which medications are you taking (e.g. oral ocntraceptives/ hormone replacment)

infant and children lungs subjective data

_________________: child had frequent or severe colds? any history of allergy in family? does child have a cough? seem congested? noisy breathing? which measures taken to child proof home/ yard? any smokers in home or in car with child?

moisture

_________________: perspiration appears normally on the face, hands, axillae, and skinfolds in response to activity, a warm environment, or anxiety

history of respiratory infections (subjective data)

_________________: any past history of breathing trouble an unusually frequent or usually severe colds? any family history of allergies, tuberculosis, or asthma

mouth

_________________: begin with anterior structures and move psoteriorly; use a tongue blade to retract structures and a bright light for optimal visualization

aura

_________________: visual changes such as blind spots or flashes of light, tingling in an arm or leg, vertigo

tonic neck reflex

__________________ ABNORM: beyond 5 months may indicate brain damage tnr

pseudofolliculitis

__________________ aka razor bumps or ingrown hairs are caused by shaving too closely with an electric or stright razor

grouped lesion

__________________ are clusterse of lesions, e.g. vesicles of contact dermatitis

voice sounds

__________________ are not elicited routinely; rather these are supplemental manuvers performed if you suspect lung pathology on the basis of eralier data; when performed, you are testing for possible presence of bronchophony, egophony, and whispered pectoriloquy

pulsations (retinal vessels)

__________________ are present in veins near the disc as their drainage meets the intermittent pressure of arterial systole ABNORM: absent pulsatiosn

freckles/ ephelides

__________________ are small, flat macules of brown melanin pigment that occur on sun-exposed skin

lymph nodes

__________________ are small, oval clusters of lymphatic tissue that are set at intervals along the lymph vessels like beads on a string; the nodes slowly filter the lymph and engulf pathogens, preventing harmful substances form entering the circulation; ________________ are located throughout the body but are accessible to examination only in the head, neck, arms, axillae, and inguinal region; the greatest supply is in the head and neck

cyanosis

__________________ can be a nonspecific sign; a person who is anemic could have hypoxia without looking blue because not enough hemoglobin is present ot color the skin; on the other hand, a person with polycythemia looks ruddy blue all the time and may not be hypoxic

smoking history (subjective data)

__________________ cigarettes, cigars? at what age? how many packs per day? for how long? ever tried to quit? what helped? live with someone who smokes?

wells score for leg deep vein thrombosis

__________________ combined findings into a simple scoring system; these criteria separate patients into groups of low, moderate, or high risk probability of DVT

skin functions

__________________ include: protection preventing penetration perception temperature regulation identification communication wound repair absorption and excretion production of vitamin D

conductive hearing loss

__________________ involves a mechanical dysfunction of the external or middle ear; it is a amplitude is increased enough to reach normal nerve elements in the inner ear; _____________________ may be caused by impacter cerumen, foreign bodies, a perforated tympanic membrane, pus or serum in the middle ear, and otosclerosis

physiologic jaundice

__________________ is a normal variation in about half of all newborn; a yellowing of the skin, sclera, and mucous membranes develops after the 3rd of 4th day of life because of increased red blood cells that hemolyze after birth

fixation

__________________ is a reflex direction of hte eye toward and object attracting our attention; the image is fixed in the center of hte visual field, the fovea centralis; this consists of very rapid ocular movements to put hte target back on the fovea and somewhat slower movements to track hte target and keep its image on the fovea; these ocular movements are impaired by drugs, alcohol, fatigue, and inattention

jaundice

__________________ is a yellowish skin color that indicates rising amounts of bilirubin in the body; except for physiologic __________________ in the newborn, ________________ does not occur normally

petygium

__________________ is an abnormal opacity of hte bulbar conuncitva, but one that grows over the cornea pet

kyphosis

__________________ is associated iwth aging, especially the dowager's hump of postmenopausal osteoporotic women; however, it is common well before menopause; women with adequate exercise habits are less likely to have ____________

cyanosis

__________________ is difficult to observe in darkly pigmented people; given that most conditions causing ___________ also decrease oxygenation of the brain, other clinical signs such as changes in level of consciousness and signs of respiratory distress are evident

presbycusis

__________________ is gradual onset over years, bilateral, mostly high-frequency lsos, worse in nosiy environments, whereas a trauma hearing loss is often sudden; refer any sudden hearing loss in one or both ears not associated with URI

phoria

__________________ is mild weakness, apparent only with the cover test and less likely to cause amblyopia than a tropia but still possible

extrinsic/allergic asthma/ pediatric onset asthma

__________________ ivolves a compelx interaction between genetic susceptibility (bronchial hyperresponsibeness, atopy, elevated immunoglobulin E) and environmental factors (viral respiratory infections, air pollution); long term exposure to traffic-related air pollution increases risk for allergic disease in children

infant and children lung assessment

__________________ normally yields bronchovesicular breath sounds in the peripherla lung fields of hte infant and young child up to age 5-6 years; their relatively thin chest walls with underdeveloped msuculature do not damp off the sound as do the thicker walls of adults; thus breath sounds are lounder and harsher

chronic inflammation (lymph nodes)

__________________ occurs in tuberculsosis when the nodes are clumped ci

consistency

__________________ of nails: the surface is smooth and regular, not brittle or splitting nail thickness is uniform the nail firmly adheres to the nai lbed, and the nail base is form to palpation

cyanotic nail beds

__________________ or sluggish color return: consider cardiovascular or respiratory dysfunction, septic shock

carotenemia

__________________ produces a yellow-orange cololr in light-skinned people but no yellowing in the sclera or mucous membranes; it coems from ingesting large amounts of foods containing carotene, a vitamin A precursor; the color is best seen on the palms and soles, forehead, tip of hte nose, and nasolabial folds, chin, behind the ears, and over the nuckles; it fades to normal color within 2-6 weeks of withdrawing carotene rich foods

infections (subjective data)

__________________ rationale: a shitory of chronic ear problems alerts you to possible hearing loss

change in temperature (peripheral vascular subjective data)

__________________ rationale: coolness occurs with PAD

sounds seem hollow

__________________ rationale: this happens when cerumen expands and becomes impacted, as after swimming or showering

vertigo (dizziness)

__________________ together with unilateral hearing loss suggests meniere disease

cyanosis

__________________- is a bluish mottled color from decreased perfusion; the tissues have high levels of deoxygenated blood; this is best seen in the lips, nose, cheeks, ears, and oral mucous membranes and in artifial fluorescent light

inspect with nasal speculum

__________________: color an integrity of nasal mucosa septum-note any deviation, perforation, or bleeding turbinates- note color, any exudate, swelling, or polyps

associated factors

__________________: any relation to other symptoms: any nausea and vomiting? Any vision changes, pain with bright lights, neck pain or stiffness, fever, weakness, moodiness, stomach problems? rationale: nausea, vomiting, visual distrubances are associated with migraines; anxiety and stress are associated with tension headaches; nuchal rigidity and fever are associated with meningiits or encephalitis

any other illnesses

__________________: do you have any other illnesses rationale: hypertension, fever, hypothyroidism, and vasculitis produce headaches

take any medications

__________________: do you take any medications rationale: oral contraceptives, bronchodilators, alcohol, nitrates, and carbon monoxide inhalation produce headaches

aging adult skin moisture

__________________: dry skin is common in the aging person because of a decline in the number nad output of the sweat glands and sebaceous glands; the skin itches and looks flaky and loose

persistent lump (lump/swelling)

__________________: for a lump that persists, how long have you had it? has it changed in size? rationale: _________________ arouses suspicion of malignancy; for people older than 40, suspect malignancy until proven otherwise

onset (neck pain)

__________________: how did the pain start: injury, automobile accident, after lifting, from a fall? or with fever? or did it have a gradual onset? rationale: of neck stiffness, headache, fever, occurs with meningitis

duration (head injury)

__________________: how long were you unconscious? any symptoms afterward-headache, vomiting, projectile vomiting? Any change in level of consciousness after injury: dazed or sleepy? rationale: a changing level of consciousness is most important in evaluating neurological deficit

pattern/ family history

__________________: pattern: any family history of migraines? rationale: migraines have a family history

tenderness (lump/swelling)

__________________: rationale: ___________ suggests acute infection in the neck

lose of consciousness

__________________: rationale: _______________ before a fall may have a cardiac cause, e.g. heart block

foceps delivery

__________________: rationale: ________________ increses risk for caput succedaneum, cephalohematoma, and bell palsy

smoking/ chewing tobacco

__________________: rationale: _________________________ increase risk for oral and respiratory cancer

having this kind of headache before

__________________: rationale: a red flag is a severe HA in an adult or child who never had one before (could be cerebral hemorrhage, stroke, etc.)

does stress seem to bring it on (neck pain)

__________________: rationale: creates a viscious cycle; tension increases ___________ and disability, whihc produces more anxiety

irradiation of head, neck, upper chest

__________________: rationale: icnreased risk for salivary or thyroid tumors

smoking/ moderate-heavy alcohol drunking

__________________: rationale: increase risk for cancer

maternal alcohol/ street drugs

__________________: rationale: increases risk for fetal alcohol spectrum disorders with distinctive facial features. Cocaine use causes neurologic, developmental, and emotional problems

mild, moderate, severe headache

__________________: rationale: pain is often severe with migraine or excruciating with cluster headache

history of head/neck surgery

__________________: rationale: surgery for head and neck cancer often is difiguring and increases risk for body image disturbance

headache location

__________________: rationale: tension headaches are occipital, frontal, or bandlike tightness; migraines are supraorbital, retroorbital, or frontotemporal; sinus headaches produce pain around the eye or cheek

headache localization

__________________: rationale: unilateral or bilateral (e.g. with cluster headaches, pain is always unilateral and on the same side of the head)

headache character

__________________: throbbing or aching, vicelike, constant pressure, dull rationale: is vislike with tension headache, throbbing with migraine or temporal arteritis

headache course and duration

__________________: time of day: morning evening, awaken from sleep; how long do they last? Hours? days? rationale: migraines occur >15 days/month if chronic or <15 days/month is episodic, each lasting 1-3 days

headache precipitating factors

__________________: what brings it on: activity or exercise, work environment, emotional upset, anxiety, alcohol? note signs of depression rationale: alcohol, stress, mensturation, and eating chocolate or cheese may precipitate migraines

effort to treat

__________________: what seems to help: going to sleep, medications, positions, rubbing the area rationale: with migraines people lie dow nto feel better, whereas with cluster headaches they need to move-even to pace the floor- to feel better

plapation

__________________: when indicated in adults, bimanual palpation of mouth in neonate, palpate for integrity of palate and assess sucking reflex

precipitating factors (neck pain)

__________________: which movements cause pain? do you need to lift or bend at work or home

diaphoresis (moisture)

___________________ ABNORM: occurs with thyrotoxosis, heart attack, anxiety, or pain

light/clay-colored stools and dark gold urine

___________________ accompany jaundice in both light and dark skinned people

altered taste (subjective data)

___________________ any change in sense of taste

senile lentigines

___________________ are common variations of hyperpigmentation; commonly called liver spots, these are small, flat, brown macules; these circumscribed areas are clusters of melanocytes that appear after excessive sun exposure; they appear on the forearms and dorsa of the hands; they are not malignant and require no treatment

sun exposure/ ciragette smoking

___________________ further accentuate aging changes in the skin; coarse wrinkling, decreased elasticity, atrophy, speckled and uneven coloring, more pigment changes, and a yellowed, leathery texture occur; ______________ is more evidente in light skinned persons

fetal alcohol spectrum disorder

___________________ include a wide range of neurologic and behavioral deficits, even without facial malformations; infants often have smaller head circumference, decreased birth and behavioral deficits, even without facial facial malformations; infants often have smaller head cirnference, decreased birth weight and length, feeding problems, and irritability

lesion in globe or optic nerve

___________________ injury here yields one blind eye, or unilateral blindness

melanocytes

___________________ interspersed along the basal cell layer produce the pigment melanin that gives brown tones to the skin and hair; people of all skin colors have the same number of _____________; however, the amount of melanin they produce varies with genetic, hormonal, and environmental influences

mixed hearing loss

___________________ is a combination of conducive and sensorineural types in the same ear

age related hearing loss (presbycusis)

___________________ is a sensorineural lsoss that affects the middle ear structures or causes damage to nerve cells in the inner ear or to cranial nerve VIII; the person first notices a high-frequency tone loss; also it is harder to hear consonants than vowels, and words sound garbled; the ability to localize sound is impaired; this lloss is accentuated with competing background noise

disequilibrium (dizziness)

___________________ is a shakiness or instability when walking related to musculoskeletal disorder or multisensory deficits

loss of eyebrows/ scalp hair

___________________ is expected with chemotehrapy and hypothyroidism

cerumen

___________________ is genetically determined, with two differnt types; wet honey-brown wax occurs in Caucasians and African Americans, adn a dry, flaky white wax is found in East Asians and American Indians

junctional nervus

___________________ is macular only and occurs in children and adolescents

changing chest size expiration

___________________ is primarily passive; as the diaphragm relaxes, elastic forces within the lung, chest cage, and abdomen cause it to dome up; all this squeezing creates a relatively positive pressure within the alveoli, and the air flows out

accompanying cold symptoms (earache subjective data)

___________________ rationale: virus/bacteria from upper respiratory infection may navigate up the eustachian tube to inflame the middle ear

deep vein thrombophlebitis

___________________ requires emergency referral because of risk for pulmonary embolism; note that upper extremity DVT is increasingly common as a result of frequent use of invasaive lines such as central venous catheters

ascultate chest

___________________ the lung fields over the anterior chest from the apices in the supraclavicular areass down to hte 6th rib; progress form side to side as you move donward and listen to one full respiration in each location; use the same sequence as percussion; do not place your setethoscope directly over female preasts; displace breast and listen directly over the chest wall

acute infection (lymph nodes)

___________________, acute onset, <14 days duration, nodes are bilateral, enlarged, warm, tender, and firm but freely movable ai

head subjective data

___________________: ask about 1. headache 2. head injury 3. dizziness 4. neck pain, limitation of motion 5. lumps or swelling 6. history of head or neck surgery

swelling in arms/ legs (peripheral vascular subjective data)

___________________: in one or both? when star? what time of daw is it worse? does it come and go/ constnat what brings it on what relieves it is it associated wit hpain, heat, redness, ulceration, hard skin

aging adult hair

___________________: males have symmetric W shaped balding in the frontal areas; some testoterone is present in both males and females; as it decreases wit hage, axillary and pubic hair decrease; as the female's estrogen decreases, testosterone is unopposed, and the female may have bristly facial hairs

newborn nails

___________________: may be blue for the first few hours of life then they turn pink

thickness

___________________: the epidermis is uniformly thin over most of the body, although thickened callus areas are normal on the palms and soles; a callus is a circumscribed overgrowth of epidermis and is an adaptation to excessive pressure from the friction of work and weight bearing

general external ocular structures

___________________: you will have noted hte person's ability to move around the room, with vision functioning well enough to respond to your directions; also not facial expression; a relaxed expression accompanies adequate vision

skin subjective data adolescent

____________________ RATIONALE: over 85% of teenagers have acne; the psychological effect is significant, with poor self-estteem, scarring, depression; multifactoral causes include increaesd sebum production, microbes, inflammation

age related hearing loss (presbycusis)

____________________ affects more men than women of hte same age and ther is a lower prevalence among African Americans compared with whites or Hispanics; reasons are unknown, but theories relate to melanin pigment protection in the cochlea or other environmental factors; there is a socioecnomic gradient of lsos too; wiht adults of lower income or education level at greater risk

eyelashes

____________________ are short hairs in double or triple rows that curve outward from the lid margins, fintering out dust and dirt

xanthelesma

____________________ are soft raised yellow lipid-laden plaques occuring on the lids at the inner canthus; they commonly occur around the 50s and mroe frequently in women; they occur with both high and normal levels of cholesterol and have no pathologic significance x

vision difficulty (subjective data)

____________________ assess: any difficulty seeing or blurring, blind spots (constant or does it come and go, objects appear out of focus or clouding over objects, spots move in front of your eyes) any halos/rainbows around objects any blind spotes any night blindness

hyperthyroidism

____________________ has an increased metabolic rate, causing warm, moist skin

age-related macular degeneration (aging adult eyes)

____________________ is a loss of central vision caused by yellow deposits (drusen) and neovascularity in the macula; _________________ prevalence rises sharply with older age

Migraine headache

____________________ is disabling, affecting work productivity, routine household chores, and social relationships; chronic ________________ is more common in women than men, with peaks in midlife for both sexes; chrionic ______________ is more prevalent among whites and Hispanics; current theories of ____________________ are: stimulation of cranial nerve V with neurotransmitter changes in the central nervous system and change in vessel tone

age related hearing loss (presbycusis)

____________________ is documented in 2/3 of adults over 70 years of age and is associated with communication problems, a decrease in health-related quality of communication problems, a decrease in health-related quality of life, and a loss of physical nad cognitive unction as well as depression, dementia, an increase in falls, an increase in hospitalizations, social isolation and lonliness, and even increased mortality

neck (infant)

____________________ looks short; it legnthens during the first 3-4 years; you can see the _______________ by supporting the infant's shoulders and tilting the head back a little; this position also enhances palpation of the trachea, which is buried deep in the neck; feel for the row of cartilaginous rings in the midline or just slightly to the right of midline n i

drainage patterns

____________________ of the lymphnodes go from the face down the neck; when nodes are enlarged, check the area they drain for hte soruce of the problem; explroe hte area proximal to the enlarged node

jaundice

____________________ on the first day of life may indicate hemolytic disease; ______________ after 2 weeks may indicate biliary tract obstruction

acrochordons (skin texture)

____________________ or skin tags are overgrowths of normal skin that form a stalk and are polyp-like; they occur frequently on eyelids, cheeks, and neck, axillae, and trunk

medications (peripheral vascular subjective data)

____________________ rationale: these may cause a hypercoagualbe state; also note low-dose aspirin or clopidogrel is used to prevent blodo clots in selected people

location (neck pain)

____________________: does pain radiate? to shoulders, arms?

pertibial edema

_____________________ has not been proven to be an objective, reliable, or sensitive measurement for edmea; pressure used is arbitrary as is judgmenet of depth and rate of pitting

aging adult skin mobility and turgor

_____________________ is decreased (less elasticity) and the skin recedes slowly or tents and stands by itself

optic disc

_____________________ is the msot prominent landmark in the retina; located on the nasal side of the retina; explore: color shape margins cup-disc ratio

positional molding/ positional plagiocephaly

_____________________ may occur as the infant continually sleeps in teh recommended position of hte back to decrease the incidence of SIDS; this is a flattening of the dependent cranial bone, the occiput in an infant who did not have flatness at birth pp

middle ear functions

_____________________: 1. conducts sound vibrations from the outer ear to the central hearing appartus in the inner ear 2. it protects the inner ear by reducing the amplitude of loud sounds 3. the eustachian tube allows equalization of air pressure on each side of the tympanic membrane so the membrane does not rupture

inspect with penlight

_____________________: lips, teeth and gums, tongue, buccal mucosa- note color; whether structures are intact; any lesions palpate aand uvula- note integrity and motility as person phonates grade tonsils pharyngeal wall- note color, any exudate, or lesions

thoracic exam preparation

_____________________: person sit upright; man disrobe to waist; woman leave gown on begin just after palpating thyroid gland; inspect, palpate, percuss, and ascultate posterior and lateral then move anterior after exam clean endpiece with alcohol wipe equipment: stethscope, alcohol wipe

pressure injuries

______________________ appear on the skin over a bony prominence when circulation is impaired, e.g. when confined to bed or immobilized; immobilization impedes delivery of blood carying oxygen and nutrients to the skin, and it impedes venous drainage carryin metabolic wastes away from the skin; this results in ischemia and cell death; common sites are on the back (heel, ischium, sacrum, elbow, scapula, vertebra) or the side (ankle, knee, hip, rib, shoulder)

cataract (aging adult eyes)

______________________ is a clouding of the crystalline lens partly due to UV radiation; this is curable with lens replacement surgery, which the older person can consider when vision changes interfere with daily activities

hoarseness (subjective data)

______________________ rationale: of hte larynx has many causes: overuse of voice, URI, chronic inflammation, lesions, or a neoplasm

primary angle-closure glaucoma (PACG)

______________________ shows circumcorneal redness around the iris, with a dilated pupil; pupil is oval, dilated; cornea looks steamy; and anterior chamber is shallow; acute glaucoma occurs with sudden increase in intraocular pressure from blocked outfolow from anterior camber

history of head/neck surgery

______________________: ever had surgery, for what condition when did it occur results

associated symptoms (head injury)

______________________: any pain in the head or neck, vision change, discharge from ear or nose- is it bloody or watery? Are you able to move all extremities? Any tremors, staggered walk, numbness and tingling?

exophoria

_______________________ is temporal (outward) drift of the eyes

single nodule

_______________________, thyroid noduels are palpable in 1-5% of ambulatory care patients but can be identifited in 50% of ultrasound studies; over 95% of these are benign; suspect any painless, rapidly growing nodule, especially a single nodule in a young person

general pigmentation

_______________________: observe the skin tone, normally it is even an conssitent with genetic background; it varies from pinkinsh tan to ruddy dark tan or from light to dark brown and may have yellow or olive overtones; dark-skinned people normally have areas of lighter pigmentation on the palms, nail beds, and lips ABNORM: vitiligo

cancerous nodes (lymph nodes)

________________________ are hard (feel like a rock), >3 cm, unilateral, nontender, matted, and fixed to adjacent structures cn

behavioral manifestations of heairng loss

________________________ include: child is inattentive in casual conversation child reacts more to movement and facial expression than sound the child's facial expression is straine/d/ puzzled child frequently asks to have statemnts repeated child confuses words that sound alike the child has an accompanying speech problem (i.e. motonous or garbled) the child appears shy and withdrawn child frequently complains of earaches child hears better when enviornment is more conductive

subjective skin history infants and children

________________________: 1. does the child have any birthmarks 2. was there any change in skin color as a newborn (i.e. jaundice or cyanosis) 3. have you noticed any rash or sores: What brings it on (i.e. new food or formula) 4. does the child have any diaper rash, how treated, how often are diapers changed, how is skin cleaned? 5. does the child have burns or bruises, where and how did it happen 6. has the child had exposure to contagious skin conditions (i.e. scabies, lice, etc.) or communicable diseases (measles, chickenpox, scarlet fever) or toxic plants (i.e. poison ivy) are vaccines up to date 7. does the child have any habids such as nail biding, twisting hair, rubbing head 8. which steps are taken to protect child from sun exposure, how do you treat sunburn

glaucoma (aging adult eyes)

_________________________ an optic nerve neuropathy characterized by loss of peripheral vision, caused by increased intraocular pressure; age is the primary risk for ____________________; because women have a longer life expectancy, more women have it than men

dental caries (tooth decay)

________________is an infectious process that occurs when bacteria (streptococcus mutans) interact with carbs in juice, sweet drinks, or food and then soften and demineralize the tooth enamel; there has been a significant increase in the US; 42% of children 2-11 have dental caries in primary teeth; 23% of children 2-11 have untreated ________________ and 21% 6-11 have _________________ in their permanent teath; in all groups, black and Hispanic children and children in lower income families have more decay

caput succedaneum

a _______________ is edematous swelling and ecchymosis of the presenting part of hte head caused by birth trauma; it feels soft, and it may extend across suture lines; it gradually resolves during the first few days of life and needs no treatment cs

bruit

a __________________ is a soft, pulsatile, wooshing blowing sound heard with the bell of a stethoscope; a ________________ is not present normally b

red sacrococcygeal dimple

a __________________ occurs with a pilondial cyst or sinus

pigment crescent

a ___________________- is black; it is caused by accumulation of pigment in the choroid

cephalhematoma

a ____________________ is a subperiosteal hemorrhage, which is also a result of birth trauma; it is soft, fluctant, and well defined over one cranial bone because the periosteum holds the bleeding in place; no discoloration is present, but it looks bizarre; parents need reassurance taht it will be reabsorbeed during the first few weeks of life without treamtent; rarely, a large _______________ may persist to 3 months ch

phoria

a ____________________ is mild weakness noted only when fusion is blocked p

chalazion

a beady nodule, ___________________ is an obstructio nand inflammation of a meiboman gland; if chronic, it is a nontender, firm, discrete swelling with freely movable skin overlying the nodule; if acutely inflammed, it is tender, warm, and red and points inside nad not on lid margin

epulis

a benign nontender, fibrous nodule of hte gum seen emerging between the teeth; an overgrowth of vascular granulation tissue

infant and children lung assessment

a child may sit upright on the parent's lap; offer the stethoscope and let hte cild handle it; this reduces any fear of the eqipment; promote hte child's participation; school-age childrne usually are desilghted to hear thier own breath sounds when you place the stethocope peroperly; while lsitening ot breath sounds, ask tehe child to take a deep breath and blow out the penlight while holding your stethscope with the other hand

atopic dermatitis (eczema)

a chronic inflammatory skin lesion caused by overstimulated immune system, genetic changes in skin, and environmental triggers; erythematous papules and vesicles, with weeping, oozing, flaking, fissures, crusts, adn severe pruritus; great effect on quality of life: sleep behavior, mood, absence from school or work

hypoxemia

a decrease in oxygen in the blood, ________________, also increases respirations but is less effective than hypercapnia

parkinson syndrome

a deficiency of the neurotransmitter dopamine and degeneration of the substantia nigra of the basal ganglia in the brain; the immobility of features produces a face that is flat and expressionless, masklike, with elevated eyebrows, staring gaze, oily skin, and drooling

myxedema/ hypothyroidism

a deficiency of thyroid hormone means that the thyroid furnace is cold; this reduces the metabolic rate and, when severe, causes a nonpitting edema or myxedema; usual cause is Hashimoto thyroiditis (autoimmune disorder)

aging adult taste/smell

a dminished sense of _______________ decreases the older audlt's interest in food and may contribute to malnutrition; saliva production decreases; saliva acts as a solvent for foot flavors and helps move food around the mouth; decreased saliva flow also occurs with the use of medications that have an anticholinergic effect; more than 250 medications have a side effect of dry mouth

spider or star angioma (vascular lesions)

a fiery red, star-shaped marking with a solid circular center; capillary radiations extend form the central arterial body; with pressure, note a pulsating central body and planching legs; develops on face, neck, or chest; may be associated with pregnancy, chronic liver disease, or estrogen therapy or may be normal

pectus carinatum

a forward protrusion of the sternum, with ribs sloping back at either side and vertical depressions along costochondral junctions (pigeon breast); less common than pectus excavatum, htis minor deformity requries no treatment; if severe, surgery may be indicated

aging adult nose

a gradual loss of subcutaneous fat starts during later adult years, making the nose appear more promient; the nasal hairs grow coarser and stiffer and may not filter the air as well; the hairs ptotrude and may cause itching and sneezing; the sense of smell may diminish after age 60 yeras because of a decrease in the number of olfactory nerve fibers

congenital torticollis

a hematoma in one sternomastoid muscle, probably injured by intrauterine manipulation, results in head tilt to onoe side and limited neck ROM to the opposite side; you feel a firm, discrete, nontender mass in mid-muscle on the involved side; this require treatment, or the muscle can become fibrotic and permanently shortened with permanent limitation of ROM, asymmetry of the head and face, and visual problems from a nonhorizontal position of the eyes

psoriasis

a hereditary chronic inflammatory skin disease with environmental triggers; plaque ____________ is a raised scaly erythematous patch, with silvery scales, often pruritic and painful; occurs on scalp, extensor surfaces of knees and elbows, lower back; accompanied by nail pitting, onychlosis

aging adult ear exam

a high-tone frequency hearing loss is apparant for those affected with presbycusis; not any difficulty hearing in the whispered voice test and hearing consonants during conversational speech; the aging adult thinks people are mumbling and feels isolated in family/ friend groups

perforated septum

a hole in the septum (usually cartilage part) caused by snorting cocaine or methamphetaimeine, chronic infection, trauma of picking crusts or nasal surgery; it is seen directly or as a spot of lgiht when the penlight is directed into the other naris

prematurity/ malnutrition

a lack of subcutaneous fat in a newborn indicates ________________

buccal mucosa

a larger patch may also be present along the _____________; this is leukoedema, a benign, milky, bluish-white, opaque area, more common in blacks and East indians; when mild, the patch disappears as you stretch the cheeks; it is always bilateral; with age it looks grayish-white and thickened; the cause is unknown; do not mistake leukoedema for oral infections such as candidiasis

scoliosis

a lateral s-shaped curvature of the thoracic and lumbar spine, usually with involved vertebrae rotation; note unequal shoulder and scapular height and unequal hip levels, rib interspaces flared on convex side; more prevalent in adolescent age-groups, especially girls; mild deformities are asymptomatic; if severe deviation is present, scoliosis may reduce lung volume, and person is at risk for impaired cardiopulmaonry function; primary impairment is cosmetic deformity, negatively affecting self image

contusion (bruise)

a mechanical injury results in hemorrhage into tissues; skin is intact; color in a liht skinned person is uaually (1) red-blue or purple immediately after or within 24 hours of trauma and generally progresses to (2) blue to purple, (3) blue-green, (4) tellow, and (5) brown to disappearing; a recent bruise in a dark-skinned person is deep, dark purple

external eye structures

a neonate usually holds the eyes tightly shut; do not attempt to pry them open, that just increases contraction of hte orbicularis oculi muscle; hold the newborn supine and gently lower the head; the eyes will open; the eyes will open when you turn an infant at arm's length and slowly turn him or her in one direction ex

conjunctiva and sclera

a newborn may have a transient hemical conjunictivitis fro mthe instillation of silver nitrate; this appears within 1 hour and lasts not more than 24 hours after birth; the ___________ should be white and clear, although it may have a blue tint as a result of thinness at birth; the lacrimal glands are not functional at birth cs

skull (infant and children)

a newborn's head may feel asymetric; and the involved ridges more prominent because of molding of the cranial bones during engagement and passage through teh birth canal s i/c

lanugo

a newborn's skin is covered with fine downy _________ especially in a preterm infant; dark skinned newborns have more __________ than lighter-skinned newborns; scalp hair may be losst in the first few weeks after birth, especially at the temples and occiput; it grows back slowly

drunsen

a normal development on the retinal surface are ___________________, or benign degenerative hyaline deposits, are normal development on retinal surface. they are small, round, yellow dots that are scattered haphazardly on the retina. although they do not occur in a pattern, they are usually symmetrically placed in eyes with no effect on vision d

infants and children (oral exam)

a nromal finding in infants is hte sucking tubrecule, a small pad in the middle and upper lip fro mthe firction of breast or bottle feeding; note the number of teeth and whether it is appropriate for the child's age; also note pattern of eruption, position, condition, and hygiene; for children younger than 2, the childs age in months - 6 should equal the expected number of deciduous teeth; normally all 20 are present by 2 1/2 years; saliva is present after 3 months and shows in excess with teething children

number (retinal vessels)

a paired artery and vein pass to each quadrant; vessels look straighter on the nasal side ABNORM: absence of major vessels

audiometric testing

a pure tone _____________________ gives a precise quantative measure of hearing by assessing the person's ability to hear sounds of varying frequency; with patient sitting, prop their elbow on the armes of the chair with the hand makign a gentle fist; tell patient the will hear faint tones of different pitches raise finger as soon as you hear tone and lower finger as soon as you no longer hear the tone; choose tones of random loudness in decibles on the audioscope; each tone is on for 1.5 seconds and off for 1.5 seconds; test each ear separetely and record the results

subconjunctival hemorrhage

a red patch on the sclera, ____________________, looks alarming but is usually not serious; the red patch has sharp edges like a spot of paint, although here it is extensive; it occurs from increased intraocular pressure from coughing, vomiting, weight lifting, labor durign childbirth, straining at stool, or trauma

cavernous hemangioma (mature)

a reddish blue, irregularly shaped, solid and spongy mass of blood vessels. it may be present at birth and may enlarge during first 10-15 months and does not involute sponatneously

retinal detachment

a shadow or diminished vision in one quadrant or one half of the visual fieldd

ankylglossa

a short lungal frenulum, fixating the tonge tip tho the floor of hte mouth and gums; this limits mobility and affects speech if hte tongue tip cannot be elevated to the alveolar ridge; a congenital deficit

neoplasm in thorax/abdomen (lymph nodes)

a single enlarged, nontender, hard left supraclavicular node may indicate ____________________ neo

tooth avulsion

a traumatic injury may dislodge a primary (deciduous) or permanent tooth form the alveolar socket; trauma is often result of falls or sport collision; the time to reimplantation is crucial for viability; during this time, the tooth must be stored in an appropriate solution (milk is acceptable) because dry storage >15 minutes increases risk of necrosis; do not touch root; ask patient about tetanus vacine and bacterial endocarditis prophylaxis

pterygium

a triangular opaque wing of bulbar conjunctiva overgrwos toward the center of the cornea; it looks membranous, translucent, and yellow to wihte; usually invades from the nasal side; adn may obstruct vision as it covers pupil; it occurs usually from chronic exposure to hot, dry, sandy climate which stimulates the growht of a pinguecula into a pterygium

horner syndrome

a unilateral small, regular pupil does react to light and accommodation. occurs with __________________, a lesion of the sympathetic nerve; also not ptosis and absence of sweat (anhydrosis) on the same side

egophony

abnormal finding: over area of consolidation or compression the spoken eee sound changes to a bleating long aaa sound

bonrhophony

abnormal finding: pathology that increases lung density enhances transmission of voice sounds; you asculate a clear ninenty nine; the words are more distinct than normal and sound close to your ear

whispered pectoriloquy

abnormal: with only small amounts of consolidation, the whispered voice is transmitted very clearly and distinctly, although still somewhat faint; it sounds as if the person is whispering right into the stehoscope one two three

acute otitis media

absent or distorted light reflex (tympanic membrane) indicates: bulging of eardrum suggested condition: ____________________

cachetic apperance

accompanies chronic wasting diseases such as cancer, dehydration, adn starvation; features include sunken eyes, hollow cheeks; and exhausted, defeated expression

lymphedema

acute ___________________ (within the first 18 months) is reversible with treatment if no tissue damage has occurred; chronic ____________ is more difficult, and can lead to pain, disfigurement, mobility dysfunctino, difficulty fitting into clothing, increased weight of arm making it hard to do daily activities, negative body image, and a constant emotional reminder of cancer

sinusitis

acute inflammed sinus areas following URI are over 90% viral in origin and do not need antibiotics; consider bacterial infection when signs las over 10 days without improvement; major signs are mucopurlent drainage, nasal obstruction, facial pain or pressure; may also have fevr, chills, and malaise

ABCDEF rule

additional symptoms: rapidly changing lesion, new pigmented lesion, development of itching, burning, or bleeding in a mole; all of these should raise suspicion of malignant melanoma and warrant referral

permanent teeth

adults have 32 _____________________, 16 in each arch; each tooth has three parts; the crwon, the neck, and the root; the gums collar the teeth; they are thick, fibrous tissues covered with mucous membrane; they are different from the rest of the oral mucosa because of their pale pink color and stippled surface

venous (stasis) ulcer

after acute DVT or chronic incompetent valves in deep veins; venous ulcers account for 80% of leg ulcers

cultural aspects vision

age related macular degeneration is present in 19.7% of adults over 75; and it is more prevalen tin Caucaisans; risk factors include positive family history, cigarette smoking, hyperopia, light iris color, hypertension, hyeprcholesterolemia, female gender

migraine hedache

aggravating symptoms or triggers: hormonal fluctuations (premenstrual) foods (e.g. alcohol, caffeine, MSG, nitrates, chocolate, cheese) Hungre Letdown after stress sensory stimuli (e.g. flashing lights/ perfumes) changes in weather physical activity m

cluster headache

aggravating symptoms/ triggers: exacerbated by alcohol, stress, daytime napping, wind or heat exposure c

tension headache

aggravating symptoms/ triggers: stress, anxiety, depression, poor posture; not worsened by physical activity t

acute venous symptoms

aggrevating factors: pain may increase with palpation

chronic venous symptoms

aggrevating factors: prolonged standing, sitting

chronic arterial symptoms

aggrivating factors: activity; claudication distance is specific number of blocks/stairs it takes to produce pain elevation (rest pain indicates severe involvement)

aging adult (peripheral circulation)

aging produces a progressive enlargement of the intramuscular calf veins; prolonged bed rest, prolonged immobilization, and heart failrue increase the risk for deep vein thrombosis and subsequent pulmonary embolism; these conditions are common in aging and also with malignancy and myocardial infarction; low-dose anticoagulatn medication reduces risk of venosu thromboembolism

otitis media wiht effusion

air/fluid level or air bubbles (tympanic membrane) indicates: serous fluid suggested condition: __________________

fetal alcohol spectrum disorder

alcohol is teratogenic to the developing fetus, resulting in severe cognitive and psychosocial impairment and changes in facial and brain structure; the incidence is increasing in the US, even with public warnings to avoid alcohol during pregnancy

glacuoma patient education

all adults over 40 should be screened it is the leading cause of irreversible blindness among blacks and hispanics the two most common forms are primary open angle (7X more common) and primary angle closure

tuberculosis (TB)

almost 68% of US _______________ caess occur among foreign-born persons, the top five countires of origin being Mexico, the Philippines, India, Vietnam, and China; about 90% of cases are attributable to reactivation of latent _______________; others at risk for _____________ are those with HIV coinfection, homeless, and those living in group settings such as shelters, prisons, and long-term care facilities

inner ear

although the ____________________ is not accessible to direct examination, you can examine its functions

facial structures

although the shape of facial structures may vary somewhat depending on ancestry, features always should be symmetric; expect symmetry of eyebrows, palpebral fissures, nasolabial folds, and sides of hte mouth fs

otitis media/ OM

ambulatory visits for acute ____________ ahve decreased in the past 20 years, a decrease best explained by a concurrent increase in the number of smoke-free households; public awareness of hte dangers of SHS on child health together with the surge in no-smoking rules in households and vehicles may be responsible; also hospital admissions for acute OM have decreased since the addition of pneumococcal and influenza vaccinatiosn to the early childhood immunization schedule

middle age/older adults (oral cancers)

among ____________________the indicende of oral/pharyngeal cancers had declined over the past 30 years, possibily due to a reduction in smoking rates (although tobacco and alcohol use still account for 75% of oral cancers); however, the decline is reversing, with a rise in oropharyngeal cancer now linked to infection with HPV; these cancers occur in younger adults too, more often in men than in women, and are associated with changes in sexual norms; these sexual factors include oral sex (especially >5 oral sexual partners), multiple sexual partners, and having oral sex at a younger age (possibily perceived as less risky than genital sex); the HPV vaccine offers the most effective protection from the onocogenic HPV 16 strain; education is crucial

bronchial (tracheal sounds)

amplitude: loud

bronchovesicular

amplitude: moderate

vesicular

amplitude: soft

acinus

an _______________ is a functiona respiratory unit that consits of the broncioles, alveolar ducts, alveolar sacs, adn the alveoli; gaseous exchange occurs across the respiratory membrane in the aolveolar ducts and in the millions of alveoli; alveoli are clustered like grapes around each alevolar duct; this creates millions of interalveolar septa that increase tremendously the working space available for gas exchange; this bunched arrangement creates a surface area for gas exchange around the size of a tennis court

aging adult ear exam

an aging adult may have pendulous earlobes with linear wrinkling because of loss of elasticity of the pinna; coarse, wry hairs may be present at the opening of hte ear canal; during otoscopy the eardrum normally may be whiter in color and more opaque, duller than in the younger adult; it also may look thickened

AV crossing (retinal vessels)

an artery and vein may cross paths; this is not significant if within 2 DD of disc and if no sign of interruption of blood flow is seen; there should be no indenting or displacing of vessel ABNORM: corssings more than 2 DD away from disc nicking or pinching of underlying vessel; vessel engorged peripheral to crossing

graves disease/ hyperthyroidism

an autoimmune disease with increased production of thyroid hormones causes an increased metabolic rate; this is manifested by goiter, eyelid retraction, and expothalamos

cephalhematoma

an infant with _______________ is at greater risk for jaundicae as the red blood cells within the hematoma are broken down and reabsorbed ch

aging adult eyes

an infiltration of degenerative lipid material shows around the limbus; pupil size decreases; the lens loses elasticity, becoming hard and glasslike; this glasslike quality decreases the ability of hte lens to change shape to accommodate for near vision, a condition termed presbiopia

scabies

an intensely pruritic contagion caused by scabies mite; mites form a linear or curved elevated burrow on the fingers, web spaces of hands, and wrists; highly contagious; severe itching causes sleep disturbance and bacterial skin infections; common communicable disease in resource poor countries

carcinoma

an ulcer with rolled dges; indurated; occurs particularly at sides, base, and under the tongue; it grows insidiously nad may go unnoticed for months; it may have associated lukoplakia; rich lymphatic drainage increases risk for early metastasis; smoking and alcohol use account for msot cases of oral cancer; HPV-related oral pharyngeal cancers also are increased

stroke/brain attack

an upper motor neuron lesion (central); a ________________ is an acute neurologic deficit caused by blood clot of a cerebral vessel, as in atherosclerosis (ischemic stroke), or a rupture in a cerebral vessel (hemorrhagic stroke)

0.9-0.71

ankle-brachial index indicates mild PAD

.7-.41

ankle-brachial index indicates moderate PAD

<.3

ankle-brachial index ischemia, with impending loss of tissue

.4 to .3

ankle-brachial index severe PAD, usually with rest pain except in presence of diabetic neuropathy

eustachain tube

another opening into the middle ear is the _________________, which connects the middle ear with the nasopharynx and allows passage of air; the tube is normally closed, but it opens with swallowing or yawning

thyroid gland

anterior approach: stand facing the person; try to identify the isthmus by placing your thumb 3 cm below the thyroid cartialge prominence as the person swallows; then ask them to tilt the head forward and to the right; use the right tumb to displace the trachea slightly toward the person's right; hook the left thumb and fingers around the sternomastoid muscle; feel for lobe enlargement as the person swallows tg

dorsalis pedis

anterior tibial artery travels down the front of the leg on to the dorsum of the foot, where it becomes the ___________________

bleeding gums (subjective data)

any __________, how long have you had them

allergies (subjective data)

any ____________ or hay fever; to what how determined which type of environment makes it worse use inhalers/ nasal spray/ nose drops? how long

hoarseness (subjective data)

any _____________, voice change? how long? feel like having to clear throat/ lump in throat? use voice a lot at work or recreation? seem associated with cold or sore throat?

lumps or swelling (subjective data)

any _______________ in the neck? recent infection/ tenderness history of prior irradiation difficulty swallowing smoking/ packs per day last alcoholic drink thyroid problems

sinus pain (subjective data)

any _______________ or sinusitis? how is it treated? chronic postnasal drip?

chest pain with breathing (Subjective data)

any _______________? point to exact location? when did it start? constnat, comes and go? describe pain: burning, stabbing? brought on by respiratory infection, cough, or trauma? efforts to treat it?

bruising/ contusion

any __________________ should be consistent with the expected trauma of life; normally there are no venous dilations or varicosities

toothache (subjective data)

any ___________________, do teeht seem sensitive to hot or cold? lost any teeth?

redness or swelling (subjective data)

any ___________________? any infections, now or in the past? When do they occur? in a particualr time of year? anyone else at home with the same condition?

epistaxis/ nosebleeds (subjective data)

any _________________________? how often? how much bleeding color of blood/ clots from one or both nostrils aggrivated by picking/ scratching how treated

dysphagia (subjective data)

any difficulty swallowing? how long have you had it? feel as if food gets stopped at a certain point? pain with it?

discharge (subjective data)

any discharge fro myour ears does it look like pus or is it bloody any odor any relation between discharge and ear pain

infections (subjective data)

any ear infections? adult or choldhood? how frequent were they? how were they treated

earache (subjective data)

any earache/ pain in ears location? hurt when pushing on ear? character? accompanying cold symptoms/ sore throat ever been hit on ear/ side of head efforts to relieve pain

history of ocular problems (subjective data)

any history of injury or surgery to eye? or any history of allergies?

leg pain/ cramps (subjective data)

any leg pain/ cramps; where? describe the type of pain, is it burning, aching, cramping, stabbing aggrivated by activity/ walking how many blocks does it take to produce pain has amount changed recetly is the pain worse with elevation/ cool temperature does hte pain wake you up at night recent change in exercise what relives the pain: dangling, walking, rubbing is it associated with change in sexual function any history of vascular/ heart problems

associated symptoms (neck pain)

any limitations to range of motion, numbness or tingling in shoulders, arms, or hands

discharge (subjective data)

any nasal __________________ or runny nose? continuous? watery, purulent, mucoid, bloody?

frequent colds (subjective data)

any unusually frequent or severe colds (upper respiratory infections) how often do they occur

watering, discharge (subjective data)

any watering or excessive tearing? any discharge, matter in the eyes, is it hard to open eyes in the morning, what color is discharge? how do you remove matter from eyes?

pattern (head injury)

are symptoms worse, better, unchanged since injury

environmental exposure (subjective data)

are there any ____________ that may affect breathing? where doe sperson work? do you do anything to protect lungs such as wear mask or have vent system checked at work? do you know which specific symptoms to note that may signal breathing problems

squamous cell carcinoma

arise from actinic keratoses or denovo; erythematous scaly patch with sharp margins, 1 cm or more; develops central ulcer and surrounding erythema; usually on hands or head, areas exposed to UV radiation; less common than basal cell but grows rapidly

polyp

arises in canal form granulomatous or mucosal tissue; redder than surrounding skin and bleeds easily; bathed in foul, purunelt discharge; indicates chronic ear disease; benign but refer for excision

arrector pilli

around the hair follicle are the muscular __________________, which contract and elevate the hair so it resembles goose flesh when the skin is exposed to cold or in emotional states

caliber (retinal vessels)

arteries and veins show a regular decrease in caliber as they extend into the periphery ABNORM: focal constriction neovascularization (proliferation of new vessels)

color (retinal vessels)

arteries are brighter red than veins; they also have the arterial light reflex, with a thin stripe of light down the middle

jaundice

as levels of serum bilirubin rise, _________________ is evident in the skin over the rest of teh body; this is best assessed in natural daylight; common calluses on the palms and soles look yellow, do not interpret these as ______________________

otoscope examination

as you inspect the external ear, note the size of the auditory meatus; choose hte largest speculum that fits comfortably in the ear canal, and attach it to the otoscope; tilt the person's head slightly away from you toward the opposite shoulder to bring the eardrum into better view pull the pinna up and back on an adult or older child to straighten the S-curve of the canal; pull the pinna down on an infant and child younger than 3; hold pinna gently but firmly; do not release traction until exam is done and otoscope is removed

skull (infant and children)

as you palpate the newborn's head, the suture lines feel like ridges; by 5-6 months they are smooth and not palpable ABNORM: sutures palpable when the child is older than 6 months s i/c

anemia, shock, arterial insufficiency

ashen gray color in dark skin or marked pallor in light skin occurs with _____________________

acutely ill person lung assessment

ask a second examiner to hold the person's arms and support them in the upright position; if no one else is available, you need to roll the person from side to side, examining the uppermost half of the thorax; this obviously prevents you from comparing findings from one side to another; in addition, side flexion of the trunk alters percussion findings because the ribs of the upper side may flex closer together

neck pain (subjective data)

ask about any neck pain? onset location associated symptoms precipitating factors stress bring it on? able to work/ sleep?

lacrimal apparatus

ask the person to look down; with your thumbs, slide the outer part of the upper lid up along the bony orbit to expose under the lid; inspect for any redness or swelling

varicose veins

ask the person to stand up so you can assess the venous system; note any visible, dilated, and tortuous veins; if ______________ are present, ask if they cause pain, swelling, fatigue, cramping

tactile/vocal fremitus

assess ___________________; __________ is a palpable vibration; sounds generated from the larynx are transmitted through patient bronchi and hte lung parenchyma to hte chest wall, where you feel them as vibrartions use either the palmar base of the fingers of the ulnar edge of one hand and touch the person's chest while he or she repeats the words "ninty-nine" or blue moon; these are resonent phrases the generate strong vibrations; start over the lung apices and palpate from one side to the other

change in nails

assess any ________________: shape, color, brittleness? do you tend to bite/ chew nails

neck (infant)

assess muscle development with gentle passive ROM; cradle the infant's head with your hands and turn it side to side and test forward flexion; extension, and rotation; note any resistance to movement, especially flexion; ask a child to actively move through the ROM, as you would an adult n i

auscultation

assess normal breath sounds note any abnormal breath sounds if abnormal breath sounds present, perform bronchophony, whispered petoriloquy, egophony note any adventitious sounds

infant/ children visual fields

assess peripheral vision with the confrontation test in children older than 3 years when the preschooler is able to stay in position; as with the adult, the child should see the moving target at hte same time your eyes do; use a small toy and make the test a game; oftne teh child forgets to stay ow or stop when the toy is seen; rather, note the instant the child's eyes deviate or head shifts position to gaze at the toy icvf

palpate anterior chest

assess tactile fremitus; begin palpating over the lung apices in the supraclavicular areas; compare variations from one side to the other as the person repeates ninety nine; avoid palpating over female prest tissue because it normally damps the sound

anterior chest inspection

assess the quality of respirations; normal relaxed breathing is automatic and effortless, regular ande ven, adn produces no noise; the chest expands symmetrically with each inspiration, not any localized lag on inspiration no retraction or bulging of the interspaces should occur on inspiration

thoracic cage

assess the skin color and condition; color should be consistent with person's genetic background, with allowance for sun-exposed areas on the chest and the back; no cyanosis or pallor should be present; note any lesions; inquire about any change in nverus on the back

strasbismus, diplopia (subjective data)

assess: any history of crossed eyes, now or in the past, does it occur with fatigue ever see double? constant or come and go? does it go away if you cover one eye or the other

cluster headache

associated symptoms: Ipsilateral autonomic signs: nasal congestion or runny nose, water or reddened eye, eyelid drooping, miosis feelings of agitation c

migraine hedache

associated symptoms: Aura prodrome nausea, vomiting, photophobia, phonophobia, abdominal pain person looks sick family history m

tension headache

associated symptoms: fatigue, anxiety stress sensation of a band tightening around head, or being bripped like a vise sometimes photo or phonophobia t

acute arterial symptoms

associated symptoms: 6 p's: pain, pallor, pulselessness, parasthesia, poikiliothermia, paralysis

chronic venous symptoms

associated symptoms: edema, varicosities, weeping ulcers at ankles

chronic arterial symptoms

associated symptoms: low ankle-brachail index; cool, pale skin; diminished pulses, pallor on elevation

acute venous symptoms

associated symptoms: red, warm, swollen leg

surfactant

at 32 weeks, ________________ the complex lipid substence needed for sustained inflation of the air sacs, is present in adequate amounts for life

puberty skin characteristics

at ______________, secretion from apocrine sweat glands increases in respoonse to heat and emotional stimuli, producing body odor; sebaceous glands become more active; the skin looks oily, and acne develops

infants/children eyes

at birth eye function is limited, but it matures fully during the early years; peripheral vision is intact in the newborn infant; the macula, the area of keenest vision is absent at birth, but is developing by 4 months and is mature by 8 months; eye movements may be poorly coordinated at birth; by 3-4 months of age the infant establishes binocularity and can fixate on a single image with both eyes simultaneously

infants and young children (ear exam)

at birth the patency of hte ear canal is determined, but the otoscopic exam is not performed because the canal is filled with amniotic fluid and vernix caseosa; after a few days the TM is examined; during the first few days it often looks thickened and opaque; it may look injected, meaning having a mild redness from increased vascluarity; it also looks injected in infants after crying

occipital lymph nodes

at the base of the skull

skin physical examination

at the beginning of the __________________, assess hte person's hands and fingernails to accustom them to your touch; as you move through the exam, scrutinize the outer skin surface first before you concentrate on the underlying structures; separate integritinous areas such as under large breasts, obese abdomen, and teh groin and inspect them thoroughly; these areas are dark, warm, and moist and provide the perfect conditions for irritation or infection; remove the person's socks and inspect the feet, tonails, and folds between the toes

caruncle

at the inner canthus the __________________ is a small, fleshy mass containing sebaceous glands

popliteal artery

at the lower thigh, the femoral artery courses posteriorly; then it is termed the __________________; below the knee the _____________ divides into the anterior tibial artery and the posterior tibial artery

visual pathway/ fields

at the optic chiasm, nasal fibers cross over; the left optic tract has fibers from the left half of each retina, and the right tract contains fibers from only the right; thus the right side of the brain looks at the left side of the world, and vice versa

bulb matrix

at the root, the _________________ is the expanded area where new cells are produced at a high rate

ear infections (children subjective data)

at what age was the first episode how many in the past 6 months how many total how treated any ear surgery, such as insertion of ear tubes/ removil of tonsils infections increasing in frequency or severity anyone at home smoke child receive care outside of home

nasal cavity

attach the short-wide tipped speculum to the otoscope head and insert hsi combined apparatus into the nasal vestibule, avoiding pressure on the nasal speculum; gently lip the tip of hte nose with the finger before inserting

infants and children (nasal exam)

avoid hte nasal speculum when examining the infant nad young child; instead gently push up the tip of hte nose with the thumb while using the other hand o shine a light into the naris; with a toddler be alert for possible foreign bodies lidged in the nasal cavity

normal skin color

baseline knowledge is importnat to assess color or pigment changes; if this is the first time you are examining the person, ask about his or her usual skin color and any self-monitoring practices

infants and children (oral exam)

be discriminating whe nusing tongue blade; it may be necessary for a full view of oral structures, but it produces a strong gag reflex in hte infant; you may avoid the tongue blade completely with a cooperative preschooler and school0age child; sometimes you will encounter uncooperative young children who clench the teeth and refuse to open the mouth; if all efforts have failed, slide the tongue blade along hte buccal mucosa and turn it between the back teeth; push down to depress the tongue, stimulating the gag reflex; child will open mouth for a few seconds giving the examiner a brief look at the throat

pulsus paradoxus

beats have weaker amplitude with inspiration, stronger with expiration; best determined using blood pressure measurement; reading decreases during inspiration and increases with expiration associated with: common finding in cardiac tamponade (pericardial effusion in which high pressure compresses the heart and blocks cardiac output) and in severe bronchospasm of acute asthma

aging adult skin

because _______________ can be viewed directly, they carry a profound psychological impact; for many people self-esteem is linked to a youthful appearnce; although sagging and wrinkling skin and graying and thinning hair are normal processes of aging, they prompt a loss of self-esteem for many adults

culture/ genetics peripheral circulation

because family history of PAD is independently and strongly associated with PAD prevalence nad severity, it would follow what genetic factors have a role, but data here are limited; there is no ideal biomarker to screen for PAD, and genetic developments that would target therapeutic interventions are larging; for environmental factors, cigarette smoking is a particularly strong risk factor for all persons with PAD, as are diabetes and hypertension; other risk factors are elevated levels of total choelsterol and obesity

infants and children (oral exam)

because hte _______________ is very intrusive for infants or young children, the timing is best toward the end of the complete exam, along with the ear exam; but if crying episodes occur earleir, sieze the opportunity to exame the mouth and oropharnx

infant hearing loss tests

because the 1st 3 years of life represent the most intensive period for speech and language development, identifying hearing loss as early as possible is a high priority; evidence shows that children with hearing loss who receive early intervention and amplification before 6 months of age do better than those receiving services after 6 months; by the 1st grade children identified earlier are 1-2 years ahead of their later-identified peers in language, cognitive, and social skills

infants and children (oral exam)

bednar aphthae are traumatic areas or ulcers on the posterior hard palate on either side of the midline; they result from abrasiosn while sucking; the tonsils are not visible in the newborn; they gradually enlarge during childhood, remaining proprotionately larger until puberty; tonsils appear still larger if hte infant is crying or gagging; normally the newborn can produce a strong, lusty cry

percuss the chest

begin percussing hte apices in the supraclavicular areas; then, percussing the interspaces and comparing one side with the other, move down the atneiror chest interspaces are easier to palpate on the anterior chest than on the back; do not percuss directly over female breast tissue because this would produce a dull note; shift the breast tsisue over slightly, using the edge of hte stationary hand; in females with large breasts, percussion may yield little useful data

tonsils

behind the anteiror tonsilar pillar are the ____________, each a mass of lymphoid tissue; the ______________ are the same color as the surrounding mucous membrane, although they look more granular and thier surface shows deep crypts; _________________ enlarges during childhood until puberty and then involutes

subcutaneous layer

beneath the epidermis and dermis is the ______________ of adipose tissue

cricoid cartilage

beneath the thyroid cartilage _____________________or upper tracheal ring; beneath the _________________ the isthmus of the tyroid gland hugs the 2nd and 3rd tracheal rings

venous flow

besides the presence of intralumanial valves, venous structure differs from arteria lstructure; because venous pressure is lower, walls of the veins are thinner than those of the arteries

fungal infection

black or white dots on drum or canal (tympanic membrane) indicates: colony of growth suggested condition: ____________________

hyphema

blood in the anterior chamber is a serious result of herpes zoster infection. Also occurs with blunt trauma (fist or basefall) or spontaneous hemorrhage. Suspect scleral rupture or major intraocular trauma. Note gravity settles blood in front of the iris

trauma, skull fracture

blue or dark red cololr (tympanic membrane) indiacates: blood behind drum suggested condition: ___________________

venous lake (vascular lesions)

blue-purple dilation of venules and capillaries in a star-shaped, linear, or flaring pattern; pressure causes them to empty or disappear; located on the legs near varicsoe veins and also on the face, lips, ears, and chest

deciduous/ temporary teeth

both sets of teeth begin development in utero; children have 20 _______________; all 20 _______________ should appear by 2 and 1/2 years of age; the _________________- are lost beginning at 6 years through 12 years of age; they are replaced by the permanent teeth starting with the central incisiors; the permanent teeth appear earlier in girls than boys and they erupt earlier in blacks than whites

acute otitis media

bright red color (tympanic membrane) indicates: infection in middle ear suggested condition:__________________

acute tonsillitis and phayngitis

bright red throat; swollen tonsils; white or yellow exudate on tonsils and phyarynx; swollen uvula; and enlarged, tender anterior cervical and tonsilalr nodes; accompanied by severe sore throat, painful swallowing, fever >101 F of sudden onset; bacterial infections may have absence of cough

oral kaposi sarcoma

bruiselike, dark red or violet, confluent macule, usually on the hard palate, may be on soft palate or gingival margin; oral lesions may be among the earliest lesions to develop with AIDS

Ascultation (infant head)

bruits are common in the skull in children younger than 4 or 5 years or in childrne with anemia; they are systolic or continuous and are heard over the temporal area a i

arterial (ischemic) ulcer

buildup of fatty plaques on intima (atherosclerosis) pluts hardening, calcification of atererial wall (arteriosclerosis)

aging adult eyes

by 70 years of age the normally transparent fibers of hte lens begin to thicken and yellow; this is the beginning of cataract

7-8 years of age

by ________________, when the child is familiar with reading letters, begin using the standard Snellen alphabet chart; normally the child achieves 20/20 acuity by 6-7 years of age 7

respiratory system functions

by supplying oxygen to the blood and eliminating excess carbon dioxide, respiraton maintisn the pH or the acid-base balance of blood; the body tissues are bathed by blood that normally has a narrow acceptable range of pH. although a number of compensatory mechanisms regulate the pH, the lungs helps maintain the balance by adjusting the level of carbon dioxide through respiration; hypoventilation causes carbon dioxide to build up in the blood, and hyperventilation causes carbon dioxide to be blown off

single nodule

cancerous nodules usually are hard and fixed to surrounding structures; at increased risk are females; persons with a history of goiter or nodules, or family history of thyroid cancer; size >4cm; persons with a history of radiation exposure especially in childhood

cultural aspects vision

cataracts are a leading cause of blindness worldwide, 80% are estimated to be preventable or curable with surgery; cataract surgery is cost-effective and nhelps reduce poverty by returning peple to work and increasing social mobility; barriers include low socioeconomic status, transporation issues, lack of insurance, and surveillance methods

hemangiomas (vascular lesion)

caused by a benign proliferation of blood vessels in the dermis e.x. port-wine stain, strawberry mark, cavernous hemangioma

cafe au lait spots

caused by increase dmelanin pigment in basal cell layer light skin: tan to brown, irreguraly shaped, oval patch with fell definned borders

leukoplakia

chalky white, thick, raised patch with well-defined borders. the lesion is firmly attached and does not scrape off; it may occur on the lateral edges of tongue; it is caused by chronic irritation of smoking and alcohol use; lesions are precancerous; must refer to specialist

linea nigra

change in hormone levels cause numerous color changes; on the abdomen is the ______________, a brownish-black line down the midline

aging adult eyes

changes in eye structure cause distinct facial changes in aging; loss of skin elasticity causes wrinkling and drooping; fat tissues and muscles atrophy; lacrimal glands involute, causign decreased tear production and a feeling of dryness and burning

aging adult lungs

changes result in an increase ins small airway closure, which yields a decreased vital capacity (the maximum amount of air that a person can expel from the lungs after first filling the lungs to the maximum) and an increased residual volume (the amount of air remaining in the lungs even after the most forceful expiration); with aging, histologic changes (i.e. gradual loss of intralveolar septa and decreased number of alveoli) also occur; therefore less surface area is available for gas exchange; in addition, the lung bases become ventilated as a result of closing off of a number of airways; this increrases the older person's risk for dyspnea with exertion beyond his or her usual workload

sternomastoid, the scaleni, and the trapezi

changing chest size forced inspiration such as that after heavy exercise or occurring pathologically with respiratory distress commands the use of accessory neck mucles to lift up the sternum and rib cage; these neck muscles are the _______________________

chronic venous symptoms

character: aching, tiredness, feeling of fullness

tension headache

character: bandlike tightness, viselike, nonthrobbing, nonpuslatile t

cluster headache

character: continuous, burning, piercing, excruciating c

chronic arterial symptoms

character: intermittent claudication, feels like cramp, numbness and tingling, feeling of cold

acute venous symptoms

character: moderat eto intense, sharp; deep muscle tender to touch

acute arterial symptoms

character: throbbing

migraine hedache

character: throbbing, pulsating m

fetal alcohol spectrum disorder

characteristic facies include narrow palpebral fissure, epicanthal folds, thin upper lip,, and midfacial hypoplasia; these malformations may be recognizable at birth but more so during childhood

facial features

check ______________ for symmetry, apperance, and presence of swelling; note symmetry of wrinkling when the infant creis or smiles (both sides of lips rise/ both sides of forehead wrinkle); normally no swelling is evident; parotid gland enlargement is best seen when teh child sits and looks up at the ceiling, the swelling appears below the angle of the jaw ff

pertibial edema

check for _______________; firmly depress the skin over tie tibia or the medial maleolus for 5 secnds and release; normally, your finger should leave no indentation, although a pit is commonly seen if the person has been standing all day or is pregnant

tongue

check the ___________ for color, surface cahractersitics, and moisture; the color is pink nad even; hte torsal surface is normally roughened from the papillae; a thin whie coating may be present; ask the person to touch the tongue ot the roof of hte mouth; the ventral surface should look smooth and glistening nad shows veins

corneal light reflex

check the ______________ by shining a light toward the child's eyes; the light should be reflected at the same spot in the two corneas; some assymetry under 6 months of age is nomral ABNORM: asymmetry in corneal light reflex after 6 months is abnormal and must be referred

epitrochlear lymph node

check the _________________ in the depression 2-3 cm above and behind the medial condyle of the humerus; do this by shaking hands with the person and reaching your other hand under the person's lebow to the groove between the biceps and triceps muscles, above the medial epicondyle; they are not normally palpable

fetal alcohol spectrum disorder

children may exhibit intrusive talking, inattention, poor abstract reasoning, and problems with independente acivities of daily living; the severity of _____________ increases with the amount of alcohol consumed during pregnancy; this is now the leading preventable cause of intellectual disability, learning disability, and birth defects

atopic/allergic facies

children with chronic allergies often develop characteristic facial features; these include exhausted face, blue shadows below the eyes form sluggus venous return; a double or single crease on hte lower eyelids; a central facial pallor; and open-mouth breathing, which can lead to malocclusion of the teeth and malformed jaw because the child's bonse are still forming

spoon nails

chronic iron deficiency anemia may show ________________ with a concave shape

annular lesion

circular begins in center and spreads to periphery, e.g. tinea corporis or ringworm; tinea versicolor; pityriasis rosea

ascultate chest

clean the flat diaphragm endpiece of the stethoscope and hold it firmly on the chest wall; listen to at least one full respiration in each location; side-to-side comparison is most imporant do not confuse background nosie with lung sounds while standing behind the perosn, listne to the following lung areas: posterior form the apices at C7 to hte bases and laterally from the axilla down to the 7th or 8th rib

stridor

clinical example: croup and acute epiglottitis in children and foreign inhalation; obstructed airway may be life-theratening s

wheeze- high pitched

clinical example: diffuse airway obstruction from acute asthma or chronic emphysemea wh

crackles-fine/ formerly rales

clinical example: late inspiratory crackles: occur with restrictive disease; pneumonia, heart failure, and interstitail fibrosis early inspiratory crackles: occur with obstructive disease; chronic bronchitis, asthma, and emphysema posturally induced crackles: are fine crackles that appear with a change form sitting to the supine position or with a change from supine to supine with legs elevated cf

wheeze- low pitched

clinical exmaple: bronchitis, single bornchus obstruction from airway tumor wl

macula

clumped pigment may occur with aging; within the _____________ you may note the foveal light relfex; this is a tiny white glistening dot reflecting the opthalmoscope light ABNORM: clumped pigment occurs with trauma or retinal deatchment hemorrhage or exudate in the macula occurs with senile macular degeneration

inspect tympanic membrane

color and characteristics note position (flat, bulging, retracted) integrity of membrane

infant/ children color vision

color deficient is an inherited recessive X-linked trait affecting about 8% of white males and 4% of black males; it is rare in females, the condition is relative and not disabling, although it may affect the person's ability to discern traffic lights or school performance in which color is a leraning tool iccv

teeth and gums

compare the number of teeth with hte number expected for the person's age; ask the person to bite as if chewing something and note alignment of upper nad lower jaw; normally occlusion in the back is the upper teeth resting directly on the lower teeth; in the front, the upper incisiors slightly override the lower incisiors

emphysema

condition caused by destruction of pulmonary connective tissue (elastin, collagen); characterized by permanent enlargement of air sacs distal to terminal bronchioles and rupture of interalveolar walls; this increases airway resistance, especially on expiration, producing a hyperinflated lung and an increase in lung volume; cigarette smoking accounts for 80-90% of cases e

pneumothorax

condition free air in pleural space causes partial to complete lung collapse; air in pleural space neutralizes the usual negative pressure present; thus lung collapses; ususally unilateral, can be spotaneous, traumatic, or tension inspection: unequal chest expansion; if large, tachypnea, cyanosis, apprehension, bulging in interspaces p

chronic bronchitis

condition proliferation of mucus glands in the passage-ways, resulting in excessive mucus secretion; inflammation of bronchi with partial obstruction of bronchi by secretions or constrictions; sections of lung distal to obstruction may be deflated; ______________ is usually caused by cigarette smoking cb

heart failure

condition pump failure with increasing pressure of cardiac overload causes pulmonary congestion or an increased amount of blood present in pulmonary capillaries; depedennt air sacs deflated; pulmonary capillaries are engorged; bronchial mucosa may be swollen inspection: increased respiratory rate, SOB on exertion, orthopnea, paraoxysmal nocturnal dyspnea, nocturia, ankle edema, pallor in light-skinned people hf

lung cancer

condition this is the most fatal of malignancies, claiming as many lives per year as breast, colorectal, and porstate cancers combined; the major cause is tobacco smoking, followed by exposure to second hand smoke, and asbestos exposure; four types: squamous cell usually starts in central bronchi near the hilus; adenocarcinoma usually starts in periphery and escapes early detection; large cell also starts in periphery with tumors arranged in clusters; small cell (oat cell) compreses and narrows central bronchi lc

pneumocystitis jiroveci (P. carinii) pneumonia

condition this virulent form of pneumonia is a protozoal infection associated with AIDS; the parasite P. jiroveci is common in the US and harmless to most people, except to the immunocompormised, in whom suffer a diffuse interstitial pneumonia; cysts containing the organism and macrophages form in the laveolar spaces, alveolar walls thicken, and the disease spreads to bilateral interstitail infiltrates of foamy, protein-rich fluid pj

pulmonary embolism

condition undissolved materials (thrombus or ari bubbles, fat globules) originating in legs or pelvis detach and travel throguh venous system, returning blood to right heart, and lodge to occulde pulmonary vessels; over 95% raise from DVT in lower legs as a result of stasis of blood, vessel injury, or hypercoagulability; pulmoanry occlusion results in ischemia of downstream lung tissue, increased pulmonary artery pressure, decreased cardiac output, and hypoxia; rarely, a saddle embolus in bifurication of pulmonary arteries leads to sudden death form hypoxia; More often small-to-medium pulmonary branches occlude, leading to dyspnea; these may resolve by fibrolytic activity pe

tuberculosis

condition: inhalation of tubercule bacilli into the alveolar wall starts: 1. inital complex is acute infalmmatory response- macrophages engulf bacilli but do not kill them; tubercule forms around bacilli 2. scar tissue forms; lesion calcifies and shows on x-ray 3. reactivation of previously healed lesion; dominant bacilli now multiply, producing necrosis, cavitation, and caseous lung tissue 4. extensive destruction as lesion erodes into bronchus, forming air filled cavity; apex usually has the most damage t

capillary refill

conditions can skew findings include: cool room, decreased body temperature, cigarette smoking, peripheral edema, and anemia

palpation

confirm symmetric expansion tactile fremitus detect any lumps, masses, tenderness

test visual fields

confrontation test

choanal atresia

congenital bony seputm between nasal cavity and the pharyns is not common in the newborn; but when bilateral, it is an airway emergency because newborns are obligate nose breathers; not any obstructionstridor, and cyclical cyanosis that improves with crying because baby then breathes through the mouth; when unilateral, the infant may be asymptomatic until first respriatory infection

children history of allergy in family (subjective data)

consider new foods or formula as possible allergens; exclusive bresatfeeding >6 months protects against ear, throat, and sinus infections; this protection lasts well beyond infancy and up to 6 years of age

corneal reflex

contact with a whisp of cotton stimulates a blink in both eyes, called the ________________; the trigeminal nerve carries the afferent sensation into the brain, and the facial nerve carries the efferent message that stimulates the blink

ascultate chest

continue to visualize approximate locations of the lobes of each lung so you correlate your findings to anatomic areas; you you listen, think what am I hearing and what should I expect to hear? you should expect to hear three types of normal breath sounds in the adult and older child: bronchial (sometimes called tracheal/ tubular), bonrchovesicular, and vesicular

inspect anterior eyeball structures

cornea and lens iris and pupils size, shape, and equality pupillary light reflex accommodation

inspect extrocular muscle function

corneal light reflex (Hirschberg test) cover test (if indicated) diagnostic position test

addison's disease

cortisol deficiency stimulates increased melanin production light skin: bronzed appearance; an eternal tan, most apparent around nipples, perenium, genetalia, and pressure points dark skin: easily masked; rely on lab/ clinical findings

postnasal drip/ sinusitis

cough at night would indicate __________________

exposure to irritants at work

cough in afternoon or evening would indicate ______________

chronic bronchial inflammation of smokers

cough in early morning would indicate _______________

acute illness

cough throughout the day would indicate _______________

pulmonary edema, some sympatomimetic medications

cough up pink, frothy- ___________________ have side effect of pink-tinged mucus

TB, pneumococcal pneumonia

cough up rust colored- _____________________

colds, bronchitis, viral infections

cough up white or clear mucid- ___________________

bacterial infections

cough up yellow or green- ___________________

spinous process

count down these knobs on the vertebrae, which stack together to form the spinal column; note that she __________________ align wiht their same numbered ribs only down to T4; after t4, the ________________________ angle downward from their vertebral body and overly the vertebral body and rib below

infant and children lung assessment

count the respiratory rate for 1 full minute; normal rates for hte newborn are 30-40 breaths/min but may spike up to 60 breaths/minute; obtain the most accurate respiratory rate by counting when the infant is asleep because infants reach rapid rates with little excitation when awake; the respiratory pattern may be irregular when extremes in room temperature occur with feeding or sleeping; brief periods of apnea less than 10-15 seconds are common; this period breathing is more common in premature infants

cover test

covered eye- if the weaker eye is covered, once macular image is suppressed, it will drift toward a relaxed condition; as eye is covered, it jumps to restablish fixation if weakness exists

cultural aspects vision

culturally based variability exists in the color of hte iris and retinal pigmentation, with darker iridies having darker retinas behind them; individuals with light retinas generally have better ninght vision but can have pain in an environment that has too much light

drum rupture

dark, round or oval areas (tympanic membrane) indiacates: perforration suggested condition: _________________

increasing intraocular pressure damage

decrease in peripherla vision (e.g. glaucoma); starts with paracentral scotoma in early stage

venous stasis (erythema)

decreased blood blow from area, engored venules light skin: dusky rubror of dependent extremities; a preulde to necerosis with pressure sore dark skin: easily masked; use palpation for warmth or edema

fissueed or scrotal tongue

deep furrows divide the papillae into small irregular rows; the condition occurs in 5% of the general population and in down syndrome; the incidence increases with age; vertical or longitudinal fissures also occur with dehydration because of reduced tongue volume

deep cervical lymph nodes

deep under the sternomastoid muscle

migraine hedache

definition: HA of genitically transmitted vascular and trigeminal nerve origin; HA plus prodrome, aura, other symptoms; 2-3 times more common in women than in men m

cluster headache

definition: rare HA that is intermittent, excruciating, unilateral, with autonomic signs c

tension headache

defintiion: headache of musculoskeletal origin; may be mild to moderate, less disabling form of migraine t

pain (subjective data)

describe: come on suddenly? quality- burning, itching, sharp, stabbing foreign body sensation? deep aching or headache in brow area?

pleural friction rub

description: a very superficial sound that is coarse and low pitched; it has a grating quality as if two pieces of leather are being rubbed together; soulds like crackles, but close to the ear; sounds louder if you push the stethoscope harder onto the chest wall; sound is inspiratory and expiratory pf

crackles-fine/ formerly rales

description: discontinuous, high-pitched, short crackling, popping sounds heard during inspiration that are not cleared by coughing; you can stimulate this sound by rolling a strand of hair between your fingers near your ear or by moistening your thumb and index finger and separating them near your ear cf

stridor

description: high-pitched, monophonic, inspiratory, crowing sound; lounder in neck than over chest wall s

wheeze- high pitched

description: high-pitched, muscial squeaking sounds that sound polyphonic (multiple notes in a musicla cord); predominate in expiration but may occur in inspiration wh

crackles-coarse

description: loud, low-pitched bubbling and gurgling sounds that start in early inspiration and may be present in expiration; may decrease somewhat by suctioning or coughing but reappear shortly- sounds like opening a velcro fastener cc

wheeze- low pitched

description: low pitched; monophonic, single note, muscial snoring, moaning sounds; they are heard throughout the cycle, although they are more prominent on expiration; may clear somwhat by coughing wl

percuss the chest

determine the predominant note over the lung fields; start at the apices and percuss the pand of normally resonant tissue across the tops of both shoulders; then, percussing in the interspaces, *make a side to side comparison* all the way down the lung region; percuss at 5 cm intervals; avoid the dampening affect of the scapulae and ribs

cranial nerve VI

diagnostic position test for ______________________ straight temporal

cranial nerve IV

diagnostic position test for ____________________________ down and nasal

cranial nerve III

diagnostic position test: for _______________________ straight nasal up and nasal up and temporal Down and temporal

incompetent valves

dilated and tortuous veins create __________________, wherein the lumen is so wide that the valve cusps cannot appxoimate; this condition increase venous pressure, which further dilates the vein; some people have a genetic predisposition to _______________, but venous pooling also occurs in obese people and women following multiple pregnancies

chronic otitis media

diminished or absent landmarks (tympanic membrane) indiacates: thickened drum suggested condition: _________________

nose subjective data

discharge frequent colds (upper respiratory infections) sinus pain trauma epistaxis (nosebleeds) allergies altered smell

discrete lesions

disctinct individual lesions that remain separated; e.g. acrocordon or skin tags, acne

cup-disc ratio (optic disc)

distinctness varies; when visible, physiologic cup is a brighter yellow-white than rest of the disc; its width is not more than one half the disc diameter ABNORM: cup extending to the disc border

aging adult head/neck subjective data

dizziness effects on daily life pain affect on daily life rationale: assess self-care, assess potential for injury

jaundice

do not confuse scleral _______________ with the normal yellow subconjunnctival fatty deposits that are common in the outer sclera of dark-skinned persons; the scleral __________________ extends up to the edge of the iris

environemntal noise (subjective data)

do you consider the noise level where you are working to be high what about leisure time regular exposure to sounds you have to shout to make yourself heard by someone else noise protection- steps to protect ears

cough (lungs subjective data)

do you have a____________, when did it start/ gradual/ sudden how long? how often do you cough? do you cough up any phlem/ sputeum? cough up blood? describe cough? anything precipite cough? activity make it better/ worse? treatments tried? cough bring on anything, i.e. chest pain?

hearing loss (subjective data)

do you have trouble hearing onset? character? which situations do you notice hte loss? do people seem to shout at you? dor ordinary sounds seem hollow? recently traveled on plane? family history of loss? effort to treat? coping strategies

tattoos

document presence of ____________________ on the person's chart; inspect skin of _________________ for any infection or inflammation; normally there are no reactions

infant/ children (nose/ mouth) subjective data

does child have any mouth infections/ sores does child have frequent sore throat/ tonsilitis did child's teeth erupt on time how are child's dental habits

Lesions

does the _________________ blanch with pressure or stretch? stretching the area between thumb nad index finger decreases the underlying red doens, thus providing more contrast and brightening macules; red macules will bland momentarily whereas those from extravaseted blood (petechiae) do not; blanching also helps identify a macular rash in dark-skinned people

chest pain

does the cough bring on any _______________? is it tiring? are you concerned about it? rationale: note severity

aging adult mouth/ teeth subjective data

dryness in mouth/ taking medications lost any teeth/ chew foods able to care for own teeth/ dentures change in sense of taste or smell

cluster headache

duration: abrupt onset, peaks in minutes, lasts 45-90 minutes c

tension headache

duration: gradual onset, lasts 30 minutes to days t

bronchial (tracheal sounds)

duration: insipiration < expiration

bronchovesicular

duration: inspiration= expiration

vesicular

duration: inspiration> expiration

migraine hedache

duration: rapid onset, peaks 1-2 hr, lasts 4-72 hr, sometimes longer m

infancy

during __________________, trunk growth predominates, so head size changes in proprotion to height

neck (infant)

during infancy, cervical lymph nodes are not palpable normally; but a child's lymph nodes are more prominent than an adult's until after puberty when lymphoid tissue begins to atrophy; palpable nodes less than 3mm are normal; they may be up to 1 cm in size in the cervical and inguinal areas but are discere, move easily, and are nontender; children have a higher incidence of infection, so expect greater incidence of inflammatory adenopathy; no other masses should occur in the neck n i

fetal period

during the _______________, head growth predominates

halitosis

during the exam, notice any breath odor, _______________; this is common and usually has a local cause such as poor oral hygiene and decaying food debris between the teetth; other common smells are caused by odoriferous foods, alcohol consumption, heavy smoking, or dental ifnection; occasionally may indicate systemic disease

infants and children respiratory considerations

during the first 5 weeks of feta llife the primiteve lung bud emerges; by 16 weeks teh conducing airways reach the same number as in the adult; at 32 weeks surfactant is present i nadequate amounts; and by birth, the lungs have 70 million primitive alveoli ready to start the job of respiration

pregnant woman (face)

during the second trimester cholasma may show on the face; this is a blotchy, hyperpigmented area over the cheeks and forehead that fades after delivery; the thyroid gland may be palbable during pregnancy pw

veins in the arm

each arm has two sets of veins: superifial and deep; the superfiical veins are in the subcutaneous tissue and are responsible for most of the venous return

pulse

each heartbeat creates a pressure wave, which makes the arteries expand and then recoil; it is teh recoil that propels blood through like a wave; all arteries have this pressure wave, or _______________, throughout their length, but you can feel it only at body sites where the artery lies close to the skin and over a bone

conjugate movement

each muscle is coordinated, or yoked with one in the other eye; this ensures that when the two eyes move, their axes always remain parallel, called ______________________; parallel axes are important becasue hte human brain can tolerate seeing only one image; humans have a binocular, single-image visual system; this occurs because our eyes move as a pair

pulsus bisferiens

each pulse has two strong systolic peaks with a dip in between; best assessed at the carotid artery associated with: aortic valve stenosis plus regurgitation

infant and children ear subjective data

ear infections does the child seem to be hearing well does child put objects in ears is older child/adolescent active in contact sports

size and shape

ears are of equal size bilaterally with no swelling or thickening; ears of unequal size and shape may be a normal familial trait with no clinical significance

full, bounding pulse

easily palpable, pounds under your fingertips associated with: hyperkinetic states (exercise, anxiety, fever), anemia, hyperthyroidism

venous return

efficient ___________ depends on contracting skeletal muscles, competent alves in the veins, and a patent lumen; problems with any of these three elements lead to venous stasis; at risk for venous disease are people who undergo prolonged standing, sitting, or bed rest because they do not benefit from the milking action that walking accomplishes

effort to treat (head injury)

emergency department or hospitalized? any medications

fear/ anger

emotion: ______________ causes peripheral vasoconstriction, leading to false pallor

embarrasment

emotion: ____________________ causes flushing in face and neck; leading to false erythema

communication (skin function)

emotions are expressed in the sign language of the face and body posture; vascular mechanisms such as blushing or blanching also signal emotional states

simple diffuse goiter

endermic goiter, a chrnoic enlargement of the thyroid gland, is common in wide regions of the world (especially montainous regions) where the soil is low in iodine; iodine is an essential element in the formation of thyroid hormones

throat

enlarge the view of the posterior pharyngeal all by depresisng the tongue with a tongue blade; push down halfway back on the tongue; if you push on its tip, the tumg humps up in hte back; press slightly off center to avoid eliciting the gag reflex or allow person to depress their own tongue; scan posterior wall for color, exudate, and lesions; discard tongue blade when done

hot room

environment _________________ causes vasodilation; leading to false erythema

chilly/ air conditioned room

environment ___________________ causes vasoconstriction; leading to false pallor, coolness

cigarette smoking

environment _____________________ causes vasoconstriction; leading to false pallor

raynaud phenomenon

episodes of abrupt, progressive tricolor change of the fingers in response to cold, vibration, or stress; 1. white from sympathetic-mediated vasoconstriction and resulting deficit in supply; 2. blue from slight relaxation of spasm that allows a slow trickle of blood throug the capillaries and increased oxygen extraction of hemoglobin; 3. red (rubror) in heel of hand caused by return of blood into dilated capillary bed/ reactive hypemia

ascultate chest

evaluate norma lbreaht sounds, noting any abnormal breath sounds and adventitious sounds; if the situation warrants, assess voice sounds on anterior chest

ascultate chest

evaluate presence and quality of normal breath sounds; the person is sitting, leaning forward slightly, with arms resting comfortable across the lap; instruct hte person to breathe through the mouth, a bit deeper than usual, but stop if they begin to feel dizzy; be careful to monitor breahting throughout hte exam and offer itmes for the person to rest and breahte normally; ensure they do not hyperventilate ot hte point of fainting

vertigo (subjective data)

ever felt _______________? is feeling worse with change in head position, getting in or out of bed, rolling over, bending forward, tilting head back? ever felt dizzy, as if you are not quite steady, like falling or loosing balance, giddy, light-headed

tinnitus (subjective data)

ever felt ringing, roaring, buzzing in ears? when did it occur? how long have you had it seem louder at night? taking any medications? affects on every day life?

trauma (subjective data)

ever had any trauma or a blow to the nose? can you breathe through nose? are both sides obstructed or one?

glaucoma (subjective data)

ever tested for glaucoma? results? any family history of glaucoma?

respiratory muscle weakness

exam: atrophy diagnostic study: maximal inspiratory and expiratory pressures rw

restrictive

exam: decreased beath sounds, chest morphology, pleural rub, basal dullness diagnostic study: chest radiography (effusion, anatomic abnormality), spirometry, PFT r

restrictive/ constricctive pericardial disease

exam: decreased heart sounds diagnostic study: echocardiography rc

heart failure

exam: edema, JVD, S3 displaced cardiac apical impulse, hepatojugular reflex, murmur, crackles, wheezing, tachycardia, S4 diagnostic study: ECG, brain natriuretic peptide, echocardiography, stress testing, coronary angiography hf

aspiration

exam: intermittent crackles, wheezes diagnostic study: chest radiogrpahy, esophagoradiography, esophageal pH a

valvular

exam: murmur JVD diagnostic study: echocardiography va

psychological

exam: sighing diagnostic study: normal p

peripheral vascular exam preparatin

examin arms at beginning during vital signs and person is sitting examine legs after abominal exam have person stand to evaluate leg veins compare findings with opposite extremity equipment: paper tape measure, tourniquet/ BP cuff, stethoscope, doppler ultrasound

infants and young children (ear exam)

examination of the external ear is similar to that described for the adult, with the addition of examination of position adn alignment on head; note the ear position; the top of the pinna should match an imaginary line extending from the corner of the eye to the occiput; the ear should also be positioned within 10 degrees of vertical

alveolar

examination: fever, crackles, increased fremitus, bronchophony diagnostic study: chest radiography, chest CT, brochoscopy/bronchoalveolar lavage, culture or biopsy a

interstitial

examination: hypoxia, clubbing, persistent inspiratory crackles diagnostic study: chest radiography (fibrosis, interstitial markings), chest CT, bronchoscopy/biopsy i

arrhythmia

examination: irregular rhythm, pauses diagnostic study: ECG, event recorder, holter monitor, stress testing a

obstruction of air flow

examination: wheezing, barrel chest, decreased breath sounds, accessory muscle use, clubbing, pradoxical pulse diagnostic study: peak flow, spirometery, chest radiography (hyperinflation, pulmonary function tests o

vascular

examination: wheezing, lower extremity swelling, pleural rub, prominent P2, murmur, right ventricular heave, jugular venous distension diagnostic study: D-dimer, ventilation/perfusion scan, CT angiography, echocardiography, right heart catheterization v

culture/ genetics peripheral circulation

examining risk factors by gender, data showed that depressio nwas the strongest risk factor in women for PAD; because PAD is underrecognized and undertreated in women, mental helath screening may target more women i nneed of care; across age ranges, African Americans have twice the burden of PAD than do Caucasians; traditional risk factors for African Americans are high, but adjusting these does not eliminate the high prevalence

obstruction of air flow

example: COPD history: tobacco use, cough, relief with bronchodilator, increased sputum production, hemoptysis and weight loss with malignancy o

psychological

example: anxiety history: anxiety, depression, history of trauma/ abuse p

valvular

example: aortic stenosis history: posprandial, night cough va

alveolar

example: chronic pneumonia history: fever, productive cough, shortness of breath a

vascular

example: chronic pulmonary emboli history: fatigue, pleuritic chest pain, prior emboli/deep venous thrombosis, syncope v

aspiration

example: gastroesophageal reflux disease history: postprandial, night cough a

interstitial

example: idiopathic fibrosis history: exertional dyspnea, dry cough, malignancy, presciption or illict drug use, chemical exposures i

atelectatic crackles

example: in aging adults, in bedridden persons, or in persons just aroused from sleep ac

heart failure

example: ischemic cardiomyopathy history: dyspnea on exertion, paroxysmal noctural dyspnea, orthopnea, cheste pain or tightness, prior coronary artery disease or atrial fibrillation hf

restrictive/ constricctive pericardial disease

example: metastic tumor history: viral infection, chest radiation, imflammatory diseases rc

respiratory muscle weakness

example: phrenic nerve palsy history: known neuromusclar disorders, weakness rw

pleural friction rub

example: pleuritis, accompanied by pain with breathing (rub disappears after a few days if pleural fluid accumulates and separates pleurae) pf

restrictive

example: pleurla effusion history: pleuritic chest pain, dyspnea not improved with oxygen r

crackles-coarse

examples: pulmonary edema, pneumonia, pulmonary fibrosis, adn the terminally ill who have a depressed cough reflex cc

acromegaly

excessive secretion of growth hormone from the pituitary gland after puberty creates an enlarged skull and thickened cranial bones; elongated head, massive face, overgrowth of nose and lower jaw, heavy eyebrow ridge, coarse facial features

pregnant woman peripheral vascular system

expect diffuse bilateral pitting edema in the lower extremities, especially at the end of the day and into the third trimester; nearly 80% of pregnant women have some peripheral edema because of increased water retention; varicose veins in the legs are also common in the third trimester

buccal mucosa

expect to find Stensen duct, the opening of hte parotid salivary gland; it looks like a small dimple opposite the upper second molar; you may also see a raised occlusion line on the buccal mucosa parallel with hte level the teeth meet; this is caused by the teeth cloasing against the cheek

altered smell (subjective data)

experience any change in sense of smell rationale: sense of smell diminishes with cigarette smoking, chronic allergies, aging

dizziness (subjective data)

experience any dizziness? describe it for me onset abrupt or gradual? after change in position such as sudden standing associated factors. any nausea and vomiting, pallor, immobility, decreased hearing acuity, or tinnitus along with the dizziness? any palitations or shortness of breath

otoscopic exam

external canal cerumen, discharge, foreign bodies, lesions redness or swelling of canal wall

tactile/vocal fremitus

factors affecting ______________ include: ____________ is most promeint between the scapula ad around hte sternum, sites where hte major bronchi are closest to the chest wall; it normally decreases as you progress down because mroe and more tissue impedes sound transmission _____________ feels greater over a thing chest wall than over an obese or heavily muscular one where thick tissue damps the vibration a loud, low-pitch generates more fremitus than a soft, high-pitched one

severe anemias

fatigue, exertional dyspnea, rapid pulse, dizziness, impaired mental function accompany most _________________

diabetic retinopathy

findings are nonproliferative changes that occur within the retina (microaneurysms, dot hemorrhages, blot hemorrhages, lipid exudates), and proliferative changes that occur on the inner surface of the retina or vitreous; proliferative changes are new vessel formations, or neovascularization, that increase risk of retinal detachment or vitreous hemorrhage

infant and children lung assessment

fine crackles are the adventitious sounds commonly heard in the immediate newborn period form opening of hte airways and clearing of fluid; because the newborn's chest wall is so thin, transmission of sounds is enhanced; and sound is heard easily all over the chest, making localization of breath sounds a problem; even bowel sounds are easily heard in the chest; try using the pediatric diaphragm endpiece or palce the bell over the infant's interspaces and not over ribs

vellus hair

fine faint __________________ covers most of the body (except the palms and soles, the dorsa of the distal parts of the fingers, the umbilicus, the glans penis, and inside the labia)

distribution

fine vellus hair coats the body, wheereas coarser terminal hair grow at the eyebrows, eyelashes, and scalp; during puberty, _______________ conforms to normal male and female patterns; at first, coarse curly hairs develop in the pubic area, then axillae, and last the facial area

vertebra prominens

flex the head and feel the most prominent bony spur protruding at the base of the neck; this is the spinous procress of C7, it is called the _____________________; if two bumps seem equally prominent, the upper one is C7 and lower is T1

gastrocnemius

flex the person's knee and then ngently compress the length of ___________ muscle anteriorly against the tibia; no tenderness should be present

ankle-brachial index

for _______________, the patient is lying flat with the head and heels fully supported; confirm no smoking within 2 hours and a 5-10 minute rest period supine before measurement; choose correct cuff width for arm and ankle; position the ankle cuff just above the malleoli with straight wrapping

people with smoking history

for ____________________,, dyspnea, and cough, use the short 5-item Lung Function Questionnaire to identify who should be assessed with spirometry for COPD

vibratility test

for a secure seal, choose the largest speculum that fits in the ear canal without causing pain; a ribber tip on the end of the speculum gives a better seal; give a small pump to the bulb and release the bulb; normally the TM moves in with a slight puff and out with a slight release

near vision

for people older than 40 or at the hospital bedside, test _________________ with a handheld vision screener with variosu sizes of print hold the card in good light about 14 inches form the eye (this distance equals the print size on the 20-foot chart) test each eye separately, with the person wearing glasses

posterior tibial pulse

for the _______________________, curve your fingers around the medial malleolus; press softly; you will feel the tapping right behind it in the groove between the malleolus and the Achilles tendon; if you cannot, try passive torsiflexion of the foot to make the pulse more accessible

buccal mucosa

fordyce granules are small, isolated white or yellow papules on the mucosa of cheek, tongue, and lips; these little sebaceous cysts are painless and not significant

horny cell layer

from the basal layer the new cells migrate up and flatten into the ____________________; this consists of dead keratinized cells that are interwoven and closely packed

cover test

function of the extaocular muscles during movement can be assessed during the early weeks by the child's following a brightly colored toy as a target; an older infant can sit on the parent's lap as you move the toy in all directions; after 2 years of age, direct the child's gaze though the six cardinal positions of gaze; you may stabilize the chin to prevent them from moving the entire head ct

inspect external eye structures

general eyebrows eyelids/ lashes eyeball alignment conjunctiva and sclera lacrimal apparatus

hyperthermia

generalized ________________ occurs with an increased metabolic rate such as in fever or after heavy exercise; a localized are feels ___________________ with trauma, infection, or sunburn

hypothermia

generalized coolness may be induced as in __________________ used for surgery or high fever; localized coolness is expected with an immobilized extremity, as when a limb is in a cast or with an intraveous infusion

fontanels

gently palpate the skull and _______________ while hte infant is calm and somewhat in a sitting position (crying, lying down, or vomiting may cause the anterior fontanel to look full and bulging); the skull should feel smooth and fused except at the _________________-; the _________________ feel firm, slightly concave, and well defined against the edges of the cranial bones; you may see slight pulsations in the anterior ___________________ f

water hammer (corrigan) pulse

greater than normal force, then collapses suddenly associated with: aortic valve regurgitation, patent ductus arteriosus

meconium in utero

green-brown discoloration of the skin, nails, and cord occurs with passing of _________________, indicating fetal distress

vernix cerosa

green-tinged ______________ occurs with meconium staning

pregannt woman (mouth exam)

gum hypertrophy (surface looks smooth and stippling disappears) may occur normally at puberty or during pregnancy

gingivitis

gum margins are red and swollen and beled easily; gingival tissue may be desquamated, exposing roots of teeth; inflammation is usually caused by poor dental hygiene or vitamin C deficiency; the condition may occur in pregnancy and puberty because of changing hormonal balance

submandibular lymph nodes

halfway between the angle and the tip of the manidble

weak, theady pulse

hard to palpate, need to search for it, may fade in and out, easily obliterated by pressure *associated with*: decreased cardiac output, peripheral arterial disease, aortic valve stenosis

pseudostrabismus

has the appearance of strabismus because of epicanthic fold but is normal for a young child.

sore throat (Subjective data)

have any ____________? frequency you get them? associated with cough, fever, fatigue, decreased appetite, headache, postnasal drip, hoarseness worse when arising? usualyl get thorat culture for sore throats? any documented as strept? how treated?

leg color changes

have the person sit up with both legs over the side of the table; compare the color of both feet- the time it takes for color to return to the feet is 10 seconds or less; also note the time it takes for superficial veins around the feet to fill- normal is about 15 seconds; *this test is unreliable if the person has concomitant venous disease with incompetent valves*

child hearing well (children ears subjective data)

have you noticed that the infant startles with loud noise? babble at six months? do they talk? when did the start? ever had child's hearing tested? if loss did it follow any maternal diseases during pregnancy

shortness of breath (subjective data)

having any _______________? any within the last day? ever had any _______________? affected by positions, such as lying down? occur at any specific time of day or night? associated with night sweat? cough, chest pain, or bluish color? episodes related to food, pollen, dust, animals, season? what do you do during attack? how does it affect work or ADL's

symmetry (neck)

head position is centered in the midline, and the accessory neck muscles should be symmetric; the head should be held erect and still sn

6 years old

head size is greater than chest circumference at birth; the head size grows during childhood, reaching 90% of its final size when the child is _______________________

regional examination

help the person remove clothing and assess the skin as one entity; stand back at first to get an onverall impression; this helps reveal distribution patterns; then inspect lesions carefully; with a rash, check all areas of the body because the person cannot see some locations; inspect mucous membranes too, because some disorders have characteristic lesions here

tachypnea

high book: >24 breaths per minute; school: >20

pregnant woman (peripheral circulation)

hormonal changes cause vasodilation adn the resulting drop i nblood pressure; the growing uterus obstructs drainage of the iliac veins and the inferior vena cava; this condition causes low blood flow and increases venous pressure; this in turn causes dependent edema, varicosities in the legs and vulva, and hemorrhoids

patient centered care (subjective data)

how do ou clean your ears? last time hearing checked? if hearing loss was noted, did you obtain a hearing aid? how long have you had it? do you wear it? how does it work? any trouble with upkeep, cleaning, changing batteries

2-3 weeks

how long have you had cough rationale: acute cough lasts less than _________________

2 months

how long have you had cough: rationale: chronic lasts over _____________________

venous disease

hypercoagulable states and vein wall trauma are other factors that increase risk for _________________

rash or lesion

identify new or relevant exposure, any household or social contacts with similar symptoms myriad over the counter remedies are available; people try them and seek frofessional help only when they do not work assess person's perception of cause: fear of cancer, tickborne illness, or sexually transmitted infections assess effectiveness of coping strategies; chronic skin diseases may increase risk for loss of self-esteem, social isolation, and anxiety; stress can exacerbate chronic skin illness

stroke/brain attack

if ___________________ is suspected, ask the person to smile; there is paralysis of the lower facial muscles but the upper half of the face is not affected because of the intact nerve from the unaffected hemisphere, the person is still able too wrinkle the forehead and close the eyes; requires emergency treatment

lymph nodes (neck)

if any nodes are palpable, note thier location, size, shape, delimination (discrete or matted together), mobility, consistency, and tenderness; cervical nodes are palpable in healthy persons although this palpability decreases with age; normal nodes feel moveable, discrete, soft, and nontender ln

lymph nodes (neck)

if nodes are enlarged or tender, check the area they drain for the source of hte problem; i.e. those in the upper cervical or submandibular area often relate to inflammation or a neoplasm in the head and neck; follow up on your findings; an enlarged node, particularly when you cannot find the source of hte problem, deserves prompt attention ln

Snellen eye chart

if person is unable to see even largest letters, shorten distance until chart is seen and record that distance; if visual acuity is even lower assess whether the person can count your fingers when they are spread in front of the eyes or distinguish light perception from the penlight ABNORM: schedule prompt referral to opthalmologist

Lesions

if present, document: color elevation pattern or shape (grouping distances of each lesion) size in centimeters location and distribution on body any exudate. note color and odor

pertibial edema

if present, grade it on the following scale: 1+ mild pitting, slight indentation, no perceptable swelling of leg 2+ moderate pitting, indentation subsides rapidly 3+ deep pitting, indententation remains for a short time, leg looks swollen 4+ very deep pitting, indentation lasts a long time, leg is grossly swollen and distorted

perforation

if the acute otitis media is not treated, the drum may rupture from increased pressure. Perforations also occur from trauma. Usually the perforation appears as a round or oval darkened area on the drum. Central perforations occur in the pars tensa. Marginal perforations occur at the annulus. Marginal perforations are called attic perforations when they occur in the superior part of the drum, then pars flaccida

ear irrigation

if the ear is intact and no current infection is present, a preferred method of cleaning the adult canal is to soften the cerumen with a warmed solution of mineral oil and hydrogen peroxide; the canal is irrigated with warm water with a bulb syringe or a low-pulsatile dental irrigator; direct fluid to the posterior wall; leave space around the irrigator tip to escape; do not irrigate if the history or exam suggests perforation or infection

lung function questionnaire

if the score is 18 or less the patient may be at risk for COPD; COPD includes chronic bronchitis, emphysema, or both

ascultating the thyroid

if the thyroid is enlarged, __________________ for a bruit ABNORM: a bruit occurs with accelerated or turbulent blood flow, indicating hyperplasia of the thyroid as

popliteal pulse

if there is difficulty feeling the ___________, turn the person prone and lift up the lower leg; let the leg relax against your arm and press in deeply with your two thumbs; often a norma lpoplitela pulse is impossible to palpate

malocclusion (aging adults)

if tooth loss occurs, the remaining teeth drift, causing _________________; the stress of chewing with maloclusing teeth causes: (1) further tooth loss; (2) muscle imbalnce from a mandible and maxilla now out of alignment, which produces muscle spasms, tenderness, and chronic headaches; and (3) stress on the temporomandibular joint, leading to osteoarthiritis, pain, and inability to fully open the mouth

leg color changes

if you suspect an arterial deficit, raise the legs about 30 cm off hte table and ask the person to wag the feet for 30 seconds to drai noff venous blood; the skin color now reflects onyl contribtuin of aterial blood; a lgiht-skinned person's feet normally look a little pale, but should still be pink; a dark-skinned person's feet are more difficult to evaluate, but the soles should reveal extreme color change

meth mouth

illicit methamphetime abuse (crystal meth, meth ice) leads to extensive dental caries, ginigvitis, tooth cracking, and edentulism; methampheatime causes vasoconstriction and decreased saliva, and its use increases the urge to consume sugars and starches and give up oral hygiene; absence of buffering saliva leads to increased aciditiy, and plaque enourages bacterial growth; these conditions and carbohydrate presence produce caries, crackign of enamel, and damage

ulnar and radial artery

immediately below the elbow the brachial artery bifurcates into the ____________________; these run distally and form two arches supplying the hand; these are called the superficial and deep palmar arches; the radial pulse lies just medial to the radius at the wrist; the ulnar artery is in the same relation to the luna, but it is deeper and often difficult to feel

aging adult ears

impacted cerumen is common in aging adults nad other at-risk groups (e.g. institutionalized and mentally disabled), who may underreport hte associated hearing loss; cerumen impaction also blocks conduction in those wearing hearing aids; cerumen should be removed when it leads to conductive heraing loss or interferes with full assessment of hte ear; ceruminolytics are wax-softening agents that expedite removal with eletric or manual irrigiatiors

mypoia

in _____________, the globe is longer tha nnormal and light rays focus in front of the retina compensate for myopia in yourself or the other person by using a negative diopter (Red number) this corrects the focal point onto the retina

changing chest size inspiration

in _______________, increasing the size of the thoracic container creates a slightly negative pressure in relation to the atmosphere; therefore air rushes in to fill the partial vacuum; the major muscle responsible for this increase is the diaphragm; during ________________, contraction of the bell-shaped diaphragm causes it to descent and flatten; this lengthens the vertical diameters; intercostal muscles lift the sternum and elevate the ribs, making them more horizontal; this increases the AP diameter

adolescence

in ________________ facial hair develops first above the lip, then on cheeks and below the lip, and last on the chin; a noticeable enlargement of the thyroid cartilage occurs, and the voice deepens

hyperopia

in _________________, the globe is shorter than normal; light rays would focus behind the retina (if they could pass through); compensate for hyperopia by using a positive diopter (black number) this bends the light rays so the focal point is on the retina

changing chest size forced expiration

in ____________________, the abdominal muscles contract powerfully to push the abdomenal viscera forcefully in and up against the diaphragm, making it dome upward and squeeze the lungs

infants and young children (ear exam)

in addition to its place in the complete exam, eardrum assessment is mandatory for any infant or child requiring care for illness or fever; for the infant or young child, the timing of the ________________________ is best toward hte end of hte complete exam; many young children protest vigirously during the procedure no matter how well you prepare and it is difficult to establish cooperation afterward; save the _________________ nutil last

external eye structures

in addition to observing the ocular structures, this also tests the vestibular function reflex; the baby's eyes look in the same direction as the body is being turned; when turning stops, the eyes shift to the opposite direction after a few quick beats of nystagmus; also termed dolls eyes, this reflex disappears by 2 months of age ex

melanocytes

in aging hair matrix, number of functioning ________________ decreases; therefore the hair looks gray or white and feels thin and fine

posterior tibial artery

in back of the leg, the ________________ travels down behind the medial malleolus and forms the plantar arteries in the foot

infants/children eyes

in structure the eyeball reaches adult size by 8 years; at birth the iris shows little pigment, and the pupils are small; the lens is nearly spherical ata birth, growing flatter throughout life; its consistency changes from that of soft plastic at birth to rigid glass in old age

aging adult oral cavity

in the ________________, the soft tissues atrophy, adn the epithelium thins, especially in teh cheeks and tongue; this results in loss of taste buds, with about an 80% reduction in taste functioning; further impairments to taste include a decrease in salivary secretion that is needed to dissolve flavoring agents; atropic tissues ulcerate easily, which increases risk for infections, such as oral candidadiasiss; the risk for malignant lesions also increases

pregnant woman

in the ___________________, the thyroid gland enlarges slightly as a result of hyplasia of the tissue and increased vascularity

Iris and pupil

in the acute-care setting, gaguge the pupil size in milimeters; both before and after the light reflex; recording the pupil size in milimeters is more accurate when many nurses and physicians care for the same person or when small changes may be signifigant signs of increasing intracranial pressure; normally the resting size is 3, 4, or 5 mm and decreases equally in response to light

apex (lung border)

in the anterior chest, the _________________, or highest point of lung tissue is 3-4 cm above the inner third of the clavicles

aging adult eyes

in the early 40s, a person may have blurred vision and difficulty reading; the aging person also needs more light to see because of a decreased adaptation to darkness, and this condition may affect hte function of night driving; all of these changes affect safety, increase the risk of falls and accidental injuries, and challenge the ability to live independently

calf pump/ peripheral heart (venous flow)

in the legs, this mechanism is called the _____________; when walking, the calf muscles alternately contract (systole) and relax (diastole); in the contraction phase the gastrocnemius and soleus muscles squeeze the veins and direct the bllod flow proximally; because of the valves, venous blood flows just one way-toward the heart

thickness

in the neonate, the epidermis is normally thin, but you will note well defined areas of subcutaneous fat; the baby skin dimples over joints but there is no break in the skin; check for any defect or break especially over teh spine

aging adult ears

in the older adult, cilia linidng the ear canal becoem coarse and stiff; this may cause cerumen to accumulate andoxidize, which greatly reduces hearing; the cerumen itself is drier because of atrophy of the apocrine glands; a life history of frequent ear infections may result in scarring on the drum

posterior cervical lymph nodes

in the posterior triangle along the edge of the trapezius muscle

hyperventilation

increase in both rate and depth; normally occurs with extreme exertion, fear, or anxiet; also occurs with diabetic ketoacidosis (kussmaul respirations), hepatic coma, slicylate overdose (producing a respirtory alkalsosis to compensate for metabolic acidosis), lesions of the midbrain, and alteration in blood gas concentration (Either in increase in CO2 or a decrease in oxygen; hyperventilation blows off CO2, casing a decreased level in the blood alkalosis

hyperemia (erethema)

increased blood in engorged arteries, i.e. inflammation, fever, alcohol intake, blushing light skin: red, bright pink dark skin: purplish tingue but difficult to see; palpate for increased warmth with inflammation, taut skin, and hardening of tissues

polycythemia (erethema)

increased red blood cells, capillary stasis light skin: ruddy blue in face, oral mucosa, conjuncitva, hands, adn feet dark skin: well concealed by pigment; check for redness in lips

jaundice

increased serum bilirubin form liver inflammation or hemolytic disease such as after severe burns or infections

carotenemia

increased serum carotene from ingestion of large amounts of carotene rich foods

hearing loss (subjective data)

indicators of ___________________ include: person lip reads/ watches face and lips closely rather tha nyour eyes frowns or strains to hear postures head to catch sounds with better ear misunderstnds your questions or frequently asks you to repeat acts irritable or shows startle reflex when you raise voice person's speech sounds garbled inappropriately loud voice falt, monotnous tone of voice

conjuncivitis

infection of the ocnjunctiva, "pink eye," has red, beefy-looking vessels at periphery but is usually clearer around iris, commonly form viral or bacterial infection, allergy, or chemical irritation; purulent discharge accompanies bacterial infection; preauricular lymph node is often swollen and painful, with a history of upper respiratory infection

late clubbing

inner edge of nail elevates; nail bed angle is greater than 180 degrees. distal phalanx looks rounder, wider, and shiny chronic lung inflammation, lung cancers, heart defects with right-to-left shunts may cause release of growth factors (E.g. platelet-derived growth factor) and promote growth of vessels; clubbing usually develops slowly over years; if hte primary disease is treated; clubbing can reverse

otoscope examination

insert the speculum slowly and carefully along the axis of hte canal; watch the insertion then put eye up to otoscope; avoid touching inner bony section of canal wall which is sensitive to pain; if you annot see anything try to reposition head, apply more traction, and re-angle otoscope to look forward at the person's nose once in place, may need to rotate otoscope to see the entire eardrum; perform the ______________ before testing hearing, ear canals with impacted cerumengive erroneous impresion of pathologic hearing loss

infants and children (oral exam)

insert your gloved finger into the baby's mouth and plapate hte hard and soft palate as the baby sucks; the sucking reflex can be elicited in infants up to 12 months old as teeth begin to erupt in the older infant and child, check age at eruption, sequence, and condition; teeth should emerge straight up or down from the gums, and enamel should be clear white and smooth; lift upper lip to check for dental caries; normally there are none

aging adult eyes

inside the globe the vitreous humor is not renewed continuously; thus floaters appear from debris that accumulates; visual acuity diminishes gradually after 50 years and even more after 70 years; near vision is commonly affected because of decreased power of accommodation in hte lens

meninges

inside the skull the brai nis held by membraneous __________________; these suspend and support hte brain and are shock absorbers in case of trauma; because of the rigid bone, a traumatic blow to the skull jostles the brain back and forth and may result in concussion

skin discoloration

inspect and palpate legs: in the presence of _____________________, skin ulcers, or gangrene, note the size and exact location

temperature of legs

inspect and palpate legs: palpate for tempereature along the lgs down to the feet, comparing symmetric spots; the skin should be warm and equal bilaterally; bilateral cool feet may be caused by environmental factors such as cool room temperature, apprehension, adn cigarette smoking; if any increase in temperature is present higher up the leg, not if it is gradual or abrupt

tongue

inspect carefully the enture U shaped area under the tonge behind the teeth; not any white patches, nodules, or ulcerations; if lesions are present or for any person older than 50 years or with a positive history of smoking or alcohol use, use your gloved hand to palpate the area and the rest of hte oral mucosa; place other hand under the jaw to stabilize tissue and capture any abnormality

integrity of membrane (tympanic membrane)

inspect hte eardrum and the entire circumference of the annulus for perforations; the normal TM is intact; some adults show scarring, which is a dense white patch on the drum; this is sequela of repeated ear infections

facial structures

inspect hte face, noting the facial expression and its appropriateness to behavior or reported mood; anxiety is common in the hospitalized or ill peron fs

lips

inspect the ______________ for color, mositure, crackling, or lesions; retract the lips and note their inner surface as well; all racial groups have ____________ that are deeper or pinker than facial skin; however, some African Americans normally have blusish lips and a dark line on the gingival margin

toenails

inspect the ______________, separate toes nad note smooth skin inbetween ABNORM: athletes foot scaling

ocular fundus

inspect the fundus of the young child and school-age child as an adult; allow the child ot handle the equipment; explain why you are darkining the room and that you will leave a small light on; assure the child the procedure will not hurt; direct the child to look at an appealing picture, perhaps a toy or animal during the exam of

nasal cavity

inspect the turbinates (the bony ridges curving down from the lateral walls); the superior turbinate will not be in view, but middle and inferior turbinates appear same light red color ans the nasal mucosa; not any swelling but do not push the speculum past it; turbinates are vascular and tender if touched

pneumocystitis jiroveci (P. carinii) pneumonia

inspection: anxiety, SOB, dyspnea on exertion, malaise are common; also tachypnea; fever; a dry, nonproductive cough; intercostla retractions in children; cyanosis palpation: decreased chest expansion percussion: dull ovoer areas of diffuse infiltrate auscultation: breath sounds may be diminished adventitious sounds: crackles may be present but often are absent pj

chronic bronchitis

inspection: hacking, rasping cough productive of thick mucoid sputum; chronic- dyspnea, fatigue, cyanosis, possible clubbing of fingers palpation: tactile fremitus nomrmal percussion: resonant auscultation: normala vesicular; voice sounds normal; chronic-prolonged expiration adventitious sounds: crackles over deflated areas; may have wheeze cb

emphysema

inspection: increased AP diameter; barrel chest; accessory muscles used to aid respiration; tripod position; SOB, muscles used to aid respiration expecially on exertion; ;respiratory distress; tachypnea palpation: decreased tactile fremitus and chest expansion e\

stage 1 pressure ulcer nonblanchable erythema

intact skin is red but unbroken; localized redness in lightly pigmented skin does not blanch; dark skin appears darker but does not blanch; may have changes in sensation, temperature, or firmness

esotropia

inward turning of the eye

hordeolum (stye)

is an acute localized staphylococcal infection of ht ehair follocles at the lid margin; it is painful, red, and swollen- a superifial elevated pustule at the lid margin; rubbing the eyes can cause cross-contamination and development of an other stye; managed iwth warm compresses, topical antibiontic ionment, may be combined with steroid ointment

dacryoadentis

is an infection of the lacrimal gland; pain, swelling, redness, occur in the outer third of the upper lid; it occurs with mumps, measles, and infectious mononucleosis or from trauma

dacryocystitis

is infection and blockage of sac and cut; pain, warmth, redness, and swelling occur below the inner canthus toward the nose; tearing is present; pressure yields purulent discharge form puncta

basal cell carcinoma

is most often on the lower lid and presents as a small, painless nodule with central ulceration and sharp, rolled-out peraly edges; it occurs in older adults; associated with UV exposure and light skin; it is locally invasive, but metastasis is rare

strasbismus

is true disparity of hte eye axes; this consttant malilignment is also temred tropia and is likely to cause amblyopia

infants and children (nasal exam)

it is essential to determine the patency of the nares in the immediate newborn period because most newborns are obligate nose breathers; nasares blocked with amniotic fluid are suctioned gently with a bulb syringe; if obstruction is suspected, a small-lumen catheter is passed down each naris to confirm patency

asthma

it is knwon that some childrne with persistent _______________ have reduced growth of lung function; these children are at increased risk of chronic airflow obstruction and possibly COPD by early adulthood; adult asthma is a chronic lung condition of airflow obstruction and airway inflammation; this obstruction usually is reversible and managed by avoidance of known triggers (smoking, pets, chemicals, household allergens) and with drug therapy

contusion (bruise)

it is not psosible to date a bruise by its color; pressure will not cause it to blanch; a ________________ usually occurs due to trauma but can also result from bleeding disorders and liver dysfunction note that a ____________ is different from petechiae, ecchymosis ,and purpura because these are not caused by blunt force trauma

ulnar pulses

it usually is not necessary to palpate the _______________; if indicated, reach the hand under hte person's arm and palpate along the medial side of th eforearm, although the ______________ often are not palpable in a healthy person

supraclavicular lymph nodes

just above and behind the clavicle, at the sternomastoid muscle

vestibule

just inside each naris widens into the ______________

retracted drum

landmarks look more prominent and well defined. Malleus handle looks shorter and more horizontal than normal. Short process is very prominent. Light reflex is absent or distorted. The drum is dull and lusterless and does not move. these signs indicate negative pressure and middle ear vacuum form obstructed eustachian tube and serous otitis media

port-wine stain

large, flat, macular patch covering the scalp or face, frequently along the distribution of cranial nerve V; the color is dark red, bluish, or purplish and intensifies with crying, exertion, or exposure to heat or cold; the marking consists of mature capilalries; it is presnt at birth and usually does not fade; the use of yellow light lasers makes photoabolation of the lesion possible with minimal effects

eye care (subjective data)

last vision test? color vision test? environmental conditions that may affect eyes? medications currently taking? smoking? coping with vision loss? maintain living environment the same? fear complete loss of vision?

lateral chest

laterally lung tissue extends from teh apex of the axilla down to hte 7th or 8th rib; the right upper lobe extends form the apex of the axilla down to the horizontal fissure at the fifth rib; the right middle lobe extends from the horizontal fissure down and forward to the sixth rib at the midclavicular line; the right lower lobe contues from the 5th to the 8th rib in the midaxillary line

hypopyon

layer of white blood cells in anteiror chamber occurs with irits and with inflammation of the anterior chamber; symptoms are pain, red eye, and possibly decreased vision

skin characteristics (objective data)

learn to consicesouly attend to __________________; you grow so accustomed to seeing the skin you are likely to ignore it as you assess the organ systems underneath; yet the skin holds information about body circulation, nutritional status, signs of systemic diseases, and topical data on the integument itself

confluent lesions

lesions run together, e.g. urticaria/ hives

primary

lesions that develop on previously unaltered skin are called __________________

infants and children (oral exam)

let the parent help position the child; place the infant supine on the examining table with the arms restrained; the older infant and toddler may be held on the parent's lap with one of the parent's hands ggently holding the arms down; only if necessary, direct the parent's other hand to hold the child's head against the parent's chest

herpes simplex virus (HSV)

lid vesicles from primary ______________ associated with fever, preauricular lymphadenopathy; herpes zoster opthalmicus is a serious presentation of shingles involving the opthalmic nerve; may have prodrome: numbness nad tingling or burning along nerve route, fever, headache, and malaise

inspect and palpate arms

lift both hte person's hads in your hands; inspect and then turn the persons hads over, noting color of skin and nail beds; temperature, texture, and turgor of skin; and the presence of any lesions, edema, or clubbing

axillary lines

lift up the person's arm 90 degrees and divide the lateral chest by three _____________________: the anterior axillary line, posterior axillary line, and midaxillary line

jaundice

light skin: yellow in sclera, hard palate, mucous membranes, then over skin dark skin: check sclera for yellow near limbus; do not mistake normal yellow fat deposits for _____________; best noted in junction of hard and soft palate, also palms

carotenemia

light skin: yellow-orange in horehead, palms and soles, naoslabial folds, but no yellowing in sclera or mucous membranes dark skin: yellow-orange tinge in palms and soles

modified allen test

limitations of the ________________ are that it is subjective nad requries patient cooperation that may not occur in emergency or ritical care situations- just the times when you need to cannulate the radial artery; doppler flow studies can ensure colateral flow that is quantifiable; a small, flat probe is taped to the palm at the end of the patient's index finger; a baseline value for blood flow is recorded and then compared for change when the two arteries are occluded

primary contact dermatitis

local inflammatory reaction to an irritant in the environment or an allergy. characteristic location of lesions often gives clue; often erythema shows first, followed by more swelling, wheals, or macropapular vesicles, sclaes; frequently accompanied by intense puritus; posion ivy

deep tissue pressure injury

localized, non-blancahble color change to deep red, maroon, purple in intact or nonintact skin; dark skin apepars darker but does not blanch; epidermis may separate, revealing dark wound or blood filled blister; preceded by pain and temperature change; begin in muscle closest to bone, in older adults and those with a lower BMI, commonly on the skin over coccyx, sacrum, buttocks, heels

cluster headache

location: always one-sidded often behind or around hte eye, temple, forehead, cheek c

acute venous symptoms

location: calf

migraine hedache

location: commonly one-sided but may occur on both sides; pain is often behind the eyes, the temples, or forehead m

chronic arterial symptoms

location: deep muscle pain, usually in calf, but may be lower leg or dorsum of foot

bronchovesicular

location: over major bronchi where fewer alveoli are located: posterior between scapulae especially on right; anterior, around upper sternum in 1st and 2nd intercostal spaces

bronchial (tracheal sounds)

location: trachea and larynx

tension headache

location: usually both sides, across frontal, temporal, and/or occipital region of head: forehead, sides, and back of head t

acute arterial symptoms

location: varies, distal to occlusion, may involve entire leg

chronic venous symptoms

locoation: calf, lower leg

pallor

look for ______________ in dark skinned people by the absence of luster in the underlying red tones; the brown-skinned individual shows yellowish-brown color, and the black-skinned person appears ashen or gray; observe generalized __________________ in the mucous membranes, lips, and nail beds; look for _____________ of anemia in the palpebral conjunctiva and nail beds

dehydration (mositure)

look for __________________ in the oral mucous membranes; normally there is none, and the mucous membranes look smooth and moist; be aware that *dark skin may normally look dry and flaky but this does not necessarily indicate systemic dehydration*

eyebrows

look for symmetry between the two eyes; normally the eyebrows are present bilaterally, move symmetrically as the facial expression changes, and have no scaling or lesions

foot care

look for: red spots, sensitive areas, discoloration, cuts, blisters, and ingrown toenails; use a mirror to check bottoms of your feet; if diabetic, check feet daily wash feet regularly, especially between toes; dry feet carefully after a shower or bath keep toenails trimmed straight across, file at edges wear clean socks every day

stage 2 pressure ulcer partial-thickness skin loss

loss of epidermis and exposed dermis; superficial ulcer looks shallow like an abrasion or open blister with a red-pink wound bed; no visible fat or deeper tissue

aging adult (peripheral circulation)

loss of lymphatic tissue leads to fewer numbers of lymph nodes in older people and to a decrease in the size of the remaining noedes

infants and children (peripheral circulation)

lymph nodes are relatively large in children, and the superficial ones often are plpable even when teh child is healthy; with infection, excessive swelling and hyperplasia occur; enlarged tonsils are familiar signs in respiraotry infections; the excessive lymphoid response also may account forthe common childhood symptom of abdominal pain with seemingly unrelated problems such as upper respiratory infection; possibly the inflammation of hte mesenteric lymph nodes produces abdominal pain

patch (primary lesion)

macules that are larger than 1 cm, examples mongolian spot, vitiligo, cafe au lait spot, cholasma, measles rash

aging adult oral cavity

many dental changes occur with aging; the tooth surface is abraded; the gums begin to recede, and the teeth begin to erode at the gum line; a smooth v-shaped cavity forms around the neck of the tooth, exposing the nerve and makign the tooth hypersensitivie; some tooth loss may occur fro mbone resorption, which decreases the inner tooth structure and outer support; natural tooth loss is exacerbated by years of inadequat edental care, decay, poor oral hygiene, and tobacco use

eyelids and lashes

many infants have an epicanthal fold, an excess skinfold extending over the inner corner of the eye, partly or totally overlapping the inner canthus; it occurs frequenly in Asian children and in 20% of whites; in non-Asians, it appears as the child grows usually by 10 years of age el

aging adult (face/neck)

many older adults have low-lying thyroid glands that are impossible to palpate; the gland lies behind the sternomastoid muscles and clavicles aa

positional molding/ positional plagiocephaly

marked _______________________ requries a custom-shaped helmet to afford room for brain growth in the flattened area while moderating growht in other areas; use dbefore sutures fuse; ________________ also occurs with rickets pp

craniosysostosis

marked assymetry, as in ____________________, is a severe deformity caused by premature closure of the sutures; this causes a distincitve head shape that correlates with the speciifc closed suture c

sinusitis

maxillary ______________ has dull, throbbing pain in cheek and teeth and pain with palpation adn when bending over; frontal _________________ has pain above supraorbital ridge

cleft lip

maxillofacial clefts are common contenital deformities and occur with strong family history; maternal use of phenytoin, alcohol, and certain drugs; and maternal diabetes; early treatment preserves the functions of speech and language formation and deglutition

hearing loss

may be sensorineural, conductive, or mixed

raynaud phenomenon

may have cold, numbness, or pain along with pallor cyanosis stage; then burning, throbbing pain, swelling along with rubror; avoidance of cold is the most effective therapy; when episodes do occur, rewarm hands by donning gloves, rubbing in warm water, or using chemical rewarmers; afeer rewarming, a typical attack lasts 15-20 minutes; avoid smoking, sympathomimetic drugs, certai ndrugs for migrain headaches and for ADHD

cover test

meanwhile the macular image has been suppressed on the covered eye; if muscle weakness exists, the covered eye drifts into a relaxed position now uncover the eye and observe it for movement; it should stare straight ahead; if it jumps to re-establish fixation, eye muscle weakness exists; repeat with other eye ct

skull (infant and children)

measure an infant's head size with measuring tape at each visit up to age 2 years, then annually up to age 6 the newborn's head measures about 32-38 cm and is 2 cm larger than chest circumference; at age 2 both measurements are the same; during childhood hte chest circumference grows to exceed head circumference by 5-7 cm s i/c

spriometer

measuring pulmoanry function status in an ambulatory care setting, a handheld ______________ measures lung health in chronic conditions such as asthma; ask the patient to inhale deeply and then to exhale into the _______________ as fast as possible until the most air possible is exhaled; the forced vital capacity is the total volume of air exhaled; the forced expiratory volume in 1 second is the volume exhaled in the first measured second; a normal outcome is a FEV1/FVC ratio of 75% or greater, meaning that no significant obstruction of airflow is present

forced expiratory time

measuring pulmoanry function status the ________________ is the number of seconds it takes for the person to exhale form total lung capacity to residual volume; it is a screening measure of airflow obstruction; although the test usually i not performed in the respiratory assessment; is is useful when you wish to screen for pulmonary function ask the person to inhale as deeply as possible then blow all out hard, as quickly as possible, with the mouth open; listen with stethoscope over the sternum; the normal expiration time is 4 seconds or less

pulse oximeter

measuring pulmoanry function status: the _________________ is a noninvasive method to assess arterial oxgen sturation; a healthy person with no lung disease and no anemia normally has an SPO2 of 97% however; *every SPO2 result must be evaluated in context of the person's hemoglobin level, acid-base balacne, and ventilatory status*

wheeze- high pitched

mechanism: air squeezed or comprssed through passageways narrowed almost to closure by collapsing, swelling, secretions, or tumors; the passageway walls oscilalte in apposition between the closed and barely open positions; the resulting rsound is simiilar to that of a vibrating reed wh

pleural friction rub

mechanism: caused when pleurae becoem inflammed nad lose their normal lubricating fluid; thier opposing roughened pleural surfaces rub together during respiration; heard best in anterolateral wall where greatest lung mobility exists pf

crackles-fine/ formerly rales

mechanism: inspiratory crackles; inhaled air collides with previously defled passageways; airways suddenly pop open, creaing explosive crackling sound expiratory crackles: sudden airway closing cf

stridor

mechanism: originating in larynx or trachea, upper airway obstruction from swollen, inflamed tissues or lodged foreign body s

pregnant skin characteristics

metabolism is increased in pregnancy; as a way to dissipate heat, the peripheral vasculature dilates, and the sweat and sebaceous glands increase secretion; fat deposits are laid down, particulalry in the buttocks and hips, as maternal reserves for the nursing baby

taste buds

microscopic ________________ are in the papillae at the back and along the sides of the tongue and on the soft palate

submental lymph nodes

midline, behind the tip of hte mandible

inhalers/ nasal spray/ nose drops (allergies)

misue of _______________ irriates the mucosa, causing rebound swelling, a common problem

infants and children (oral exam)

mobility should allow the tongue to extent at least as far as the alveolar ridge; note any brusiing or laceration on the bubccal mucosa or gums of the infant or young child on the palate, epstein pearls are a normal finding in newborns and infants; they are small, whitish, glistening, pearly papules along the median raphe of the hard palate and on the gums, where tehy look like teeth; tehy are small retention cysts and disappear in the first few weeks

vascular spiders/ spider angioma

more than 5 __________________ occur with significant liver disease when the liver cannot metabolize estrogen

abdominal aortic aneursym AAA

most common are fusiform in shape extending from below the renal arteries to invovle the entire intrarenal aorta and often involve the common iliac arteries; pressure causes lower abdominal pain and dull lower back pain

petechiae

most of the diseases causing bleeding and microembolsim formation such as thrombocytopenia, subacute bacterial endocarditis, and other septicemias are characterized by _________________- in the mucous membranes and on the skin; inspect in the mouth, particularly the buccal mucosa, and conjunctivae

head/neck infant and children history

mother use of alcohol/street drugs during pregnancy? delivery vaginal/c-section/forceps baby head growth pattern

tenderness

move hte pinna and push on the tragus; they should feel firm, and movement should produce no pain; palpating hte mastoid process should also produce no pain

cranial nerves

movement of the extraocular muscles (EOMs) is stimulated by three __________________; the abducens nerve innervates the lateral rectus muscle; the trochlear nerve innervates the superior oblique muscle; and the oculomotor nerve innervates all the rest- the superior, inferior, and medial rectus and the inferior oblique muscle

opthalmoscope

moving in on a 15 degree lateral line should bring view just to the optic disc; if the optic disc is not in sight, track a blood vessel as it grows alrger and you will find the disc; systematically inspect structures in the ocular fundus: 1. optic disc, 2. retinal vessels, 3. general background, 4. macula

multinodular goiter

multiple nodules usually indicate infmallation or a ____________________ rather than a neoplasm; however, suspet any rapidly enlarging or firm nodule; refer all patients with a nodule for ultrasonography

consistency

nail _______________ ABNORM: pits, transverse grooves, or lines may indicate a nutrient deficiecny or accompany acute illness that disrupts nail growth; nails are thickened and riged with arterial insufficiency; a spongy nail base accompanies clubbing

pregnant woman (mouth/nose)

nasal stuffiness and epistaxis may occur during pregnancy as a result of increased vascularity in the upper respiratory tract; the gums also may be hyperemic and softened and may bleed with normal toothbrushing; pregnancy does not cause tooth decay or loss

HIV infection (lymph nodes)

nodes with ____________ are enlarged, firm, nontender, and mobile; occipital node enlargement is common with ___________________ hiv

adventitious sounds

nore presence of ________________; these are added sounds that are not normally heard in the lungs; if present, they are heard as being superimposed on the beath sounds; they are caused by moving air colliding with secretions in the tracheal broncheal passageways or poppoing open of previously deflated airways; sorces differ as to the classification and nomenclature of these sounds, but crackles/rales and wheeze/ronchi are terms commonly used by examiners; if you hear ________________, describe the mas inspiratory versus expiratory, loudness, pitch, and location on the chest wall

near vision

normal ______________ avlue is 14/14 in each eye, read without hesitancy and without moving the card closer or farther away

bonrhophony

normal finding: normal voice transmission is soft, muffled, and indistinct; you can hear sound through the stethoscope but cannot distingusih exactly what is being said

egophony

normal finding: normally you should hear eeee through the stethoscope

newborn visual acutiy

normal findings as you introduce an object to the infant's line of vision: birth to 2- refusal to open eyes after exposure to bright light; increasing alertness to object; infant may fixate on the object 2-4 weeks- infant can fixate on object by 1 month- infant fixate and follow light or bright toy by 6 weeks- infant makes visual response to your face by 3-4 months- infant can fixate, follow, and reach for toy by 6-10 months- infant can fixate and follow toy in all directions

chronic obstructive breathing

normal inspiration and prolonged expiration to overcome increased airway resistance; in a person with chronic obstructive lung disease, any situation calling for increased hart rate (exercise) may lead to dyspneic episode (air trapping) because person does not have enough time for full expiration

superficial varicose veins

normal leg veins have dilated as a result of chronic increased venous pressure and incompetent valves that permit reflux of blood back toward leg instead of forward toward heart; varicose veins are 3 times more common in women than men; older age increases risk as a result of thinning of elastic lamina of veins and degeneration of vascular smooth muscle; size ranges from 1 mm to 1 cm in diameter; color ranges from red to blue or purple

rinne test sensorineural loss

normal ratio of AB>BC is intact but is reduced overall; that is, person hears porrly both ways; confirm with audiometry

diagnostic positions test

normal resposne to __________________ is parallel tracking of the object with both eyes

confrontation test

normal results for the ___________ are about 50 degrees upward, 90 degrees temporally, 70 degrees inferiorly, and 60 degrees nasally

texture

normal skin ________________ feels smooth and firm, with an even surface

vesicular

normal: over peripherla lung fields where air flows through smaller broncholes and alveoli

whispered pectoriloquy

normal: the normal response is faint, muffledd, and almost inaudible

anterior chest inspection

normally accessory muscles are not used to augment respiratory effort; however, with very heavy exercise the accessory neck muscles are used momentarily to enhance inspiration the respiratory rate is within normal limits for the person's age, and the pattern of breathing is regular; occasional signs normally punctuate breathing

control of respirations

normally our breathing patterns change without our awareness in respones to cellular demands; this involuntary control of respirations is mediated by the respiratory center in the brainstem (pons and medulla); the major feedbakc loop is humoral regulation, or the change in carbon dioxide and oxygen levels in the blood, and less importantly, the ion level

teeth and gums

normally the gums look pink or coral with a stippled surface; the gum margins at the teeth are tight and well defined; check for swelling; retraction of gingival margins; and spongy, bleeding, or discolored gums; some african americnas normally haev a dark metallic line along the gingival margin

external nose

normally the nose is symmetric, in the midline, and in proprotion to other facial features; inspect for nay deformity, asymmetry, inflammation, or skin lesions; if an injury is reported or suspected, palpate genrly for any pain or break in contour

lacrimal apparatus

normally the puncta drain the tears into the lacrimal sac; presnce of excessive tearing may indicate blockage of the nasolacrimal duct; check this by pressing the index finger against the sac, just inside the lwoer orbital rim, not against the side of the nose; pressure slightly everts the lower lid, but there should be no other rsponse to pressure

eyelids and lashes

normally the upper lids overlie the superior part of the iris; in newborns the setting sun sign is common; the eyes appear to deviate down and you see a white rim of sclera over the iris; it may show as you rapidly change the neonate from sitting to supine position el

trachea

normally, the ______________ is midline; palpate for any ________________ shift, place your index finger on the trachea in the sternal notch and slip it off to catch side; the space should be sysmmetric on both sides; not any deviation from midline t

infants and young children (ear exam)

normalyl the tympanic membrane is intact; in a child being treated for chronic OM, you may note the presence of a tympanostomy tube in the central part of the eardrum; this is inserted surgically to equalize pressure and drain secretions; finally, although the condition is not normal, it is not uncommon to note a foreign body in a child's canal such as a small stone or bead

facial structures

note any abnormal facial features (coarse features, expothalmos, changes in skin color or pigment) or any abnormal swelling; also not any involuntary movements in the facial muscles; normally none occur fs

tactile/vocal fremitus

note any areas of abnormal fremitus; sound is conducted better through a uniformly dense structures than through a porous one, which changes in shape and solidity; thus conditions that increase the density of lung tissue make a better conducting medium for sound vibrations and increase ________________

Range of motion (neck)

note any limitation of movement during active motion; ask the person to touch the chin to chest, turn head to right and left, try to touch each ear to the shoulder (without elevating shoulders), and extend the head backward; when neck is supple, motion is smooth/ controlled rom

Range of motion (neck)

note any obvious pulsations; the carotid artery runs medial to the sternomastoid muscle, and it creates a brisk localized pulsation just below the angle of the jaw; normally there are no other pulsations when the person is seated rom

nasal cavity

note any polyps (benign growths that accompany chronic allergy), and distinguish them from the normal turbinates

test hearing acuity

note behavioral response to conversational speech whispered voice test

thoracic cage

note shape and configuration of hte chest wall; the spinous processes should appear in a straight line; the thorax is symmetric, in an elliptical shape, with downward sloping ribs, about 45 degrees relative to the spine; the scapulae are placed symmetrically in each hemithorax

percuss the chest

note the borders of cardiac dullness normally found on the atneior chest, and do not confues these with suspected lung pathology; in the right hemithorax, the upper border of liver dullness is located in the fifth intercostal space in the right midclavicular line; on the left, tympany is evident over the gastric space

size and shape (head)

note the general size and shape; normocephalic is the term taht denotes a round symmetric skull that is appropriately related to body size s/s

inspect and palpate arms

note the presence of any scars on hands and arms; many occur normally with usual childhood abrasions or occupations involving hand tools

external auditory meatus

note the size of hte opening to direct your choice of speculum no swelling, redness, or discharge should be present some cerumen is usually present; the color varies from gray-yellow to light brown and black, and the texture varies from moist and waxy to dry and desiccated; a large maount of cerumen obscures visualization of hte canal and drum

sores or lresions (subjective data)

noticed any _______________ in mouth, tongue, or gums how long have you had them single or multiple seem to be associated with stress, season change, food how treated

arterial (ischemic) ulcer

objective data: coolness in only one foot or leg, pallor, elevational pallor and dependent rubror; diminished pulses; systolic bruits; signs of malnutrition (thin shiny skin, thick-ridged nails, atrophy of muscles); distal gangrene

superficial varicose veins

objective data: dilated, tortuous veins; new varicosities sit on surface of muscle or bone; older ones are deep and feel spongy

deep vein thrombophlebitis

objective data: increased warmth; swelling; redness; dependent cyanosis is mild or may be absent; tender to palpation

venous (stasis) ulcer

objective data: lower leg edema that does not resolve with diuretic therapy; firm, brawny edema; coarse, thickened skin; pulses normal; brown pigment discoloration; petechiae; dermatitis; venous stasis causes increased venous pressure, which then causes red blood cells to leak out of veins into skin; RBCs break down to hemosiderin (iron deposits), which are brown pigment deposits; borders are irregular; venous ulcers are shallow and may contain granulation tissue; a weepy, pruritic stasis dermatitis may be present

visual pathway/ fields

objects reflect light; the light rays are refracted through the transparent media (cornea, aqueous humor, lens, and vitreous body) and strike the retina; the retina transforms the light stimulus into nerve impulses that are conducted through the optic nerve and the optic tract to the visual cortex of the occipital lobe the image formed on the retina is upside down and reversed from it's actual appearnce in the outside world; all retinal fibers collect to form the optic nerve, but they maintain this same spaital arrangement, with nasal fibers running medially and temporal fibers running laterally

skull (infant and children)

observe the infnat's head from all angles, not just hte front; the contour should be symmetric; some racial variations occur in normal head shapes; two common variations cause the shape of the skul to look assymetric, caput succadenum and cephalhematoma s i/c

nasal cavity

observe the nasal septum for deviation; a deviated septum is common and is not significant unless air flow is obstructed; if present in a hospitalizaed patient, document divided septum if person needs suctioning/ NG tube; also not nay perforation or bleeding in the septum

palate

observe the uvula; it normally looks like a fleshy pendant hanging in the midline; ask hte person to say ahhh and note hte soft palate and uvula rise in the midline; this tests one function of cranial nerve X, the vagus nerve

hydrocephalus

obstruction of drainage of cerbrospinal fluid results in excessive accumulation, increasing intracranial pressure, and enlargement of the head; the face looks small compared with the enlarge cranium; the increasing pressure also produces dilated scalp veins, frontal bossing, and downcast or setting sun eyes; the crhanial bones thin, sutures separate, and percussion yields a cracked pot sound

decreased tactile fremitus

occurs when anything obstructs transmission of vibrations (e.g. an obstructed bronchus, pleural effusion or thickening, pneumothorax, and emphysema); any barrier that gets in the way of sound and your palpating hand decrease fremitus

increased tactile fremitus

occurs with conditions that increase the density of lung tissue, thereby making a better conducting medium for vibrations (e.g. compression or consolidation [pneumonia]); there must be a patent bronchus, and consolidation msut extend to lung surface for increased fremitsu to be apparent

malignant melanoma

of the major subtypes of early melanoma, the most common is superficial spreading melanoma; it begins as a brown to black macule with irregular borders and color variation; nodular melanoma is the next most common, with quickly growing blue, black, pink, or red nodules, possibly with ulceration or bleeding

sternal angle

often called hte angle of Louis, this is the articulatio nof hte manubrium and body of the sterium and is continuous with the 2nd rib; the ___________________ is useful place ot start counting ribs, which helps localize a respiratory finding horizontally; identify the ____________________, palpate lightly to the 2nd rib, and slide down to the 2nd intercostal space; each intercostal space is numbered by the rib above it; continue counting down the ribs in the middle of the hemithorax, not close to the sternum where the costal cartilages lie too close together to count; you can palpate easily down to the 10th rib

thyroid gland

often you cannot palpate the _______________________; if a person has a long, thin neck, you sometimes feel the isthmus over the tracheal rings; the laterla lobes usually are not palpable; palpable lobes feel rubbery but smooth; check them for enlargement, consistency, symmetry, and presence of nodules tg

bridge

on its leading edge the superior part of the nsoe is the ___________________

darwin tubecule

on some people you may note a ______________, a small painless nodule at the helix; this is a congenital variation and is not significant

oblique

on the nateiror chest the _____________ fissue crosses the 5th rib in the midaxillary lien and terminates at hte 6th rib in the midclavicular line

pressure injuries

once a ____________ ooccurs they are rassessed by stage, depending on the pressure ulcer depth once stage 3 or 4 ulcers occur, measure wound size daily using disposable rulers with mm and cm markings and measure the greatest overall length and width

nervus simplex/ stork bite/ salmon patch

one common vascular birthmark is a _________________; it is a flat, irregularly shaped red or pink patch found on the forehead, eyelid, or upper lip but most commonly at the back of hte neck; it is present at birth and usually fades within the first year

adventitious sounds

one type of _____________________, atelectatic crackles, is not pathologic; atelectatic crackles are short, popping, crackling sounds that last only a few breaths; when secretions of alveoli are not fully aerated (as in sleepers or in older adults), they deflate slightly and accumulate secretions; crackels are heard when these secretiosn are expanded by a few deep breaths; atelectastic crackles are heard only in the periphery, usually in a dependent portion of hte lungs, and disappear after hte first few breaths or after a cough

aging adult (peripheral circulation)

only about 10% of people with PAD have the classic symptom of intermittent claudication; about 40% do not state the symptom of leg pain, and the remaining 50% present with a mix of leg symptoms different from IC; IC is pain in a speciifc muscle group that is brought on by walking and is relieved by rest; IC impairs both walking distance and the person's quality of life; many older adults are disabled, suffer from arthiris or peripheral neuropathy, and cnanot or will not walk; this delays PAD diagnosis and accounts for so many undiagnosed by history alone

infants and children (nasal exam)

only in children older tahn 8 years of age do you need to palpate the sinus areas; in younger children sinus areas are too small for palpation

paranasal sinuses (children)

only the maxillary and ethmoid ____________ are present at birth; the maxillary sinuses reach full size after all permanet teeth have erupted; the ethmoid sinuses grow rapidly between 6-8 years of age and after puberty; the frontal sinuses are absent at birth, farily well developed between 7-8 years and reach full size after puberty; teh sphenoid sinuses are minute at birth and develop after puberty

chronic venous symptoms

onset and duration: chronic pain, increases at end of day

chronic arterial symptoms

onset and duration: chronic pain, onset gradual after exertion

acute arterial symptoms

onset and duration: sudden onset (within 1 hr) a

acute venous symptoms

onset and duration: sudden onset (within 1 hr) v

inspect ocular fundus

optic disc (color, shape, margins, optic-disc ratio) retinal vessels (number, color, AV ratio, caliber, crossings, tortuosity, pulsations) general background (color, integrity) macula

dental caries (tooth decay)

other groups at risk for _________________ and lack of access to dental care are rural residents, minorities, older adults, pregnant women, the homeless, those with low income, pwople with deelopmental disabilities, and people who are insitutionalized; these trends are significant because poor oral health is associated with diabetes, coronary artery and peripheral vascular disease, and metabolic syndrome, possibily through a mechanism of chronic inflammation

exotropia

outward turning of the eye

keloid

overgrowth of scar tissue, which invades original sitet of trauma. It is more common in darkly pigmented people, although it occurs in whites; in the ear it is most common at lobule at site of a pierced ear

superifical cervical lymph nodes

overlying the sternomastoid muscle

gingival hyperplasia

painless enlargement of hte gums, sometimes overreaching the teeth; this occurs with puberty, pregnancy, and leukemia and wiht long therapeutic use of phenytoin

Hodgkin lymphoma (lymph nodes)

painless, rubery, discrete nodes that gradually appear occur with _______________, commonly in the cervical region hl

infants and childrne peripheral vascular system

palpable lymph nodes occur often in healthy infants and children; they are small, firm (shotty), mobile, and nontender; they may be sequalae of infection such as inguainl nodes from a diaper rash or cervical nodes from a respiratory infection; vaccinations also can produce local lympadenopathy; note characteristics of any palpable nodes and whether they are local or generalized

palpate anterior chest

palpapate symmetric chest expansion; place your hands on the anterolaterla wall with the thumbs along the costal margins and pointing toward the xiphoid process ask the person to take the deep breath; watch your thumbs move apart symmetrically and note smooth chest expansion with your fingers; any limitation in thoracic expansion is easier to detect on the anterior cheset becasue greater range of motion exists with breathing here

Lesions

palpate ______________, wear a glove if anticiating contact with blood, mucosa, or body fluids; roll a nodule to assess depth; gently scrape a scale to see if it comes off, not nature of base and if any bleeding; note surrounding skin temperature

twelfth rib

palpate midway between the spine and the merson's side to identify its free tip

infant and children lung assessment

palpate symmetric chest expansion by encircling the infant's thorax with both hands; further palpation should yield no limps, masses, or crepitus, although you may feel the costochondral junctions in some normal infants

brachial pulses

palpate the ________________ if there is suspected arterial insufficiency, their force should be equal bilaterally

peripheral arteries (legs)

palpate the _________________ in both legs; grade the force on a three point scale

inguinal lymph nodes

palpate the __________________; it is not unusual to find palpable ndes that are small (1 cm or less), moveable, and nontender

palpate anterior chest

palpate the anterior chest wall to note any tenderness (normally none present) and detect any superficial lumps or masses (again, nomrally none are present); note skin mobility and turgor and skin temperautre and moisture

skin temperature

palpate the skin; it should be warm and the ________________ should equal bilaterally; warmth suggests normal circulatory status; hands and feet may be slightly cooler in a cool environment

temporal area (head)

palpate the temporal artery above the zygomatic (cheek) bone between the eye and top of the ear ta

tuberculosis

palpation: skin mosit at night from night sweats percussion: resonant initially; dull over any effusion auscultation: normal or decreased vesicular breath sounds adventitious sounds: crackles over upper lobes common, persist following full expiration and cough t

heart failure

palpation: skin mosit, clammy; tactile fremitus normal percussion: resonant auscultation: normal vesicular; heart sounds include s3 gallop adventitious sounds: crackles at lung bases hf

pneumothorax

palpation: tactile fremitus decreased or absent; tracheal shift to opposite side; chest expansion decreased on affected side; tachycardia, decreased BP percussion: hyperresonant auscultation: breath sounds decreased or absent; voice sounds decreasde or absent adventitious sounds: none p

viiligo (pallor)

patchy depigmentation from destruction of melanocytes _________________ causes light/dark skin: patchy mliky-shite spots, often symmetric bilaterally

flu vaccine

patient centered care rationale: _______________ is modifed annually; the CDC recommends the annual ____________ for everyone age 6 months or odler, especially important for those at high risk of flu complications, including pregnant women, older adults and young children, those with chronic medical connditions, residents of nursing homes and group care, health care workers, and those who are immunocompromised

geographic tongue

pattern of normal coating interspersed with pright red, shing, circular bald areas caused by atrophy of hte filiform papillae, with raised pearly borders; pattern resembles a map and changes wiht time; not significant, and cause is not known

curtis marmoata

peersistent or pronounced __________________ occurs with Down syndrome or prematurity

identification (skin function)

people identify one another by unique combinations of facial characteristics, hair, skin color, and even fingerprints; self-image is enhanced or diminished by the way society's standards of beauty measure up to each person's perceived characteristics

diabetes mellitus/ chronic kidney disease

people with ________________ may have calcified arteries that occasionally ar enoncompressible and give a falsely high (or negative) ankle pressure; thus the presnce or severity of PAD may be underestimated

percussion

percuss over lung fields

emphysema

percussion: hyperresonant auscultation: decreased breath sounds; may have prolonged expiration; muffled heart sounds resultin gfrom overdistension of lungs adventitious sounds: usually none; occasionally wheeze e

ocular fundus

perform a fundoscopic exam on an infant between 2 and 6 months of age; the fundus appears pale, and the vessels are not fully developed; there is no foveal light reflection because the macula area will not mature until 1 year of

cover test

perform the ________________ on all children; this test detects small degrees of deviated alignment by interrupting the fusion reflex that normally keeps the two eyes parallel; ask the child to stare straight ahead at your nose or at a familiar puppet; with an opaque card, cover one eye; as it is covered, note the uncovered eye; a normal response is a steady, fixed gaze ct

aging adult (peripheral circulation)

peripheral blood vessels grow more rigid with age, termed arteriosclerosis; this condition produces the rise in systolic blood pressure; do not confuse the process with atherosclerosis, or the deposition of fatty plaques on the intima of hte arteries; both processes are present with PAD in aging adults; PAD is underdiagnosed and undertreated, yet it is a large cause of morbidity and mortality in the US

cyanosis (newborn)

persitsnt generalized ________________ indicates distress such as cyanotic congenital heart disease

rinne test conductive loss

person hears euqally long bone conduction as by air conduction or even longer (AC<BC); the Rhinne test may be accurate to detect conductive loss, adn loss can be confirmed by audiometry

vaccinations up to date (infnat/childrne subjective data)

pertussis/ whooping cought is on the rise due to lack of adherence to recommended vaccine schedule and waning immunity in adolescentts and adults, who become carriers to unvaccinated infants

prolonged elevation

physical ________________ causes cecreased arterial perfusion leading to pallor and coolness

dependent position

physical _________________ causes venous pooling leading to redness, warmth, distended veins

immobilization, prolonged inactivity

physical ____________________ causes slowed circulation, leading to pallor, coolness, pale nail beds, prolonged capillary filling time

mobility turgor

pinch up a large fold of skin on the anterior chest under the clavicle; _________________ is the ease of the skin to rise, and ____________ is the ability to return to place promptly when released; this reflects elasticity of the skin

bronchial (tracheal sounds)

pitch: high

vesicular

pitch: low

bronchovesicular

pitch: moderate

Insertion of tympanostomy tubes

polyethylene tubes are inserted surgically into the eardrum to relieve middle ear pressure and promote drainage of chronic or recurrent middle ear infections. number of acute infections decrease because of improved aeriation; Tubes extrude spontaneously in 12 to 18 months

examination preparation

position the person sitting up straight; if they wear dentures, offer a paper towel and ask the person to remove them equipment: otoscope with short, wide-tipped nasal speculum attachment; penlight; two tongue blades; cotton gauze pad (4x4 inches); gloves

infants and young children (ear exam)

positioning of hte child is important, you need a clear view of hte canal; avoid harsh restraint, but you must protect the eardrum from injury in case of sudden head movement; enlist the aid of a cooperative parent; prop an infant upright against the parent's chest or shoulder, with the parent's arm around the upepr part of the head; a toddler can be held in the parent's lap with his or her arms gently secured; as you pull on the pinna, gently push on the tragus as a lead-in to inserting the speculum tip; this sometimes helps avoid the startling poke of hte speculum tip

thyroid gland

posterior approach: curve your right fingers between the trachea and sternomastoid muscle, retracting it slightly, and ask the person to take a sip of water; the _______________ moves up under palpating fingers with the trachea nad larynx as the person swallows; reverse the procedure for the left side tg

thyroid gland

posterior approach: to palpate, move behind the person; ask them to sit up straight and then bend the head slightly forward and to the right; this relaxes the neck muscles on the right side; use fingers of the left hand to push the trachea to the right tg

soft palate

posterior to the hard balate is teh _________________, an arch of muscle that is pinker in color and mobile

craniosynostosis

premature closing of one or multiple cranial sutures results in a malformed head and a cosmetic deformity; mechanisms involve genetic mutations coding several proteins or browth factor receptors; severe deformities cannot contain the brain, eyes, and optic nerves inside the cranial vault, and hypoplasia of the face results warranting surgery

vernix caseosa

present at birth is __________________, the thick, cheesy substance made of sebum and shed epithelial cells

eversion of hte upper lid

procedure: keep both eyes open and look down slide upper lid along bony orbit to lift eyelashes grasp lashes between thumb nad forefinger and gently pull down and out with other hand place tip of applicator stick on upepr lid above level of internal tarsal plates gently push down with the stick as you lift the lashes, this flips the lid inside out secure everted position by holding lashes against bony orbital rim inspect for color change, swelling, lesion, foreign body return to normal by pulling lahse outward as person looks up

Snellen eye chart

procedure: place ____________________ in well lit spot at eye level position person exactly 20 feet from chart use an opaque card to shield one eye at a time during the test; do not use person's fingers due to potential inadvertent peaking leave glasses/ contacts on; remove reading glasses ask person to read smallest line of letters possible and the next smallest line

confrontation test

procedure: position yourself eye level about 2 feet away looking straiht at yo, the person covers one eye with an opaque card as you cover the opposite eye hold a wiggling finger as a target midline between you and the person and slowly advance it from the periphery in several directions ask the person to say no when the target is first seen esetimate angle between the anteroposterior axis of the eye and the peripheral axis when the object is seen

opthalmoscope

procedure: tell person to look at mark on wall across room to help keep dilated pupils and retinal structures still begin 10 inches away from the person at an angle of 15 degrees lateral to line of vision note red glow of light off the retina as you advance adust the lens to +6 and note any opacities in the media; these appear as black dots interrupting the red reflex; normally none are present progress toward the persion untin your foreheads almsot touch adjust diopter to bring ocular fundus into focus

excessive cerumen

produced or is impacted because of narrow, tortuous canal or poor cleaning method. may show as round ball partially obscuring drum or totally occluding canal; even when canal is 90% to 95% blocked, hearing stays normal; but when last 5-10% is totally occluded (when cerumen expands after swimming or showering), person has ear fullness and sudden hearing loss

thumb sucking (infnat/childrne subjective data)

prolonged ________________ after age 6-7 may affect occlusion

vacuum in middle ear from obstructed eustachain tube

prominent landmarks (tympanic membrane) indiacates: retraction of drum suggsted condition: ___________________

infants and young children (ear exam)

pull the pinna straight down in an infant or child ounger than 3 years; this method matches the slope of the ear canal

aging adult ocular structures

pupils are small in old age, and the pupillary light reflex may be slowed; the lens loses transparency and looks opaqueaao

bronchial (tracheal sounds)

quality: harsh, hollow, tubular

bronchovesicular

quality: mixed

vesicular

quality: rustling, like sound of wind in trees

cluster headache

quantity and severity: can occur multiple times a day, in clusters, lasting weeks severe stabbing pain c

tension headache

quantity and severity: diffuse, dull aching pain; mild to moderate pain t

migraine hedache

quantity and severity: moderate-to-severe pain m

parotid gland enlargement

rapid painful inflammation of parotid occurs with mumps; mumps is a contagious viral infection of the salivary glands preventable by a vaccine; parotid swelling also occurs with blockage of a duct; stensen duct obstruction can occur in aging adults dehydrated from diuretics or anticholinergis

tachypnea

rapid, shallow breathing. increased rate >24 per minute; this is a normal response ot fever, fear, or exercise; rate also increases with respiratory insufficiecny, pneumonia, alkalosis, pleurisy, and lesions in the pons

normal adult respiratory pattern

rate- 10-20 breaths/ minute depth-500-800 mL pattern- even the ratio of pulse to respirations if farily constnat, about 4:1; both values increase as a normal resposne to exercise, fear, or fever depth- air moving in and out with each respiration

developmental milestones in the child (infant/child eye subjective data)

ratinoale: the parent is most often the one to detect vision problems

eye care (subjective data)

rationale: self-care behaviors for eyes and vision work related eye disease, e.g. auto-mechanic medication side effects, e.g. predisone and cataracts cigarette smoking associated with AMD, diabetic retinopathy, and eye inflammation constant spatial layout eases navigation through the home

blind spotes (vision difficulty)

rationale: Scotome, a blind spot inside an area of normal or decreased vision, occurs with glaucoma nad optic nerve disorders

pruritus

rationale: _____________-- is the most common skin symptom; occurs with dry skin, aging, drug reactions, allergy, obstructive jaundice, uremia, lice presence or absence of ________________ helps diagnosis; scratching causes excoriation of primary lesion

redness or swelling (subjective data)

rationale: ______________ occurs with conjunctivits and other red-eye conditions

glaucoma (subjective data)

rationale: _________________ is characterized by increasing intraocular pressure

history of ocular problems (subjective data)

rationale: __________________ alergens (e.g. makeup, contact solution) cause irritation of conjunctiva or cornea

strabismus

rationale: __________________ is a deviation in the parallel axes of the two eyes

diplopia

rationale: __________________ is the perception of two images of a single object; ________________ in one eye is caused by dry eyes, uncorrected refractive error, or cataract; binocular _______________, seen only when both eyes are open, occurs with misalignment of axes of the eyes

quality (pain)

rationale: _____________________ is valuable in diagnosis; photophobia is inability to tolerate light; some common eye diseases do not cause pain (e.g. cataract, glaucoma)

watering, discharge (subjective data)

rationale: ______________________- lacrimation/ tearing and epiphora/excessive tearing are caused by irritation or obstruction in drainage of tears purulent discharge is thick and yellow; crusts form at night; assess hygiene practices and how to avoid cross-contamination

what do you do to care for your skin

rationale: a bland lotion is important to retain moisutre in aging skin; dermatitis may ensure from certain cosmetics, creams, ointments, and dyes applied to achieve a youthful apperance; aging skin has a delayed inflammatory response to irritants; if not alerted by warning signs, continued exposure may cause dermatitis

burns, bruises, where, how

rationale: a careful history can distinguish expected childhood bumps and bruises from any lesion that indicates abuse or neclect: cigarette burns, excessive bruising, expecially above knees or elbows; linear whip marks; history does not coincide with physical appereance and location of lesion

use of glasses/ contact lenses (subjective data)

rationale: adults with glasses or contacts need an annual check to keep prescription current; adults without correction need a check every 2-3 years; an exam after age 40 should screen for age-related diseases assess-self care behaviors

hair loss/growth

rationale: assess for alpoceia or hirstrusim

which changes have you noticed in your skin

rationale: assess impact of aging on self-concept; normal aging changes may cause distess, many aging changes including skin cancers are result of chronic sun damage

patient centered care

rationale: assess self-care and influence on self-concept, may be importnat with media emphasis in society of high norms of beauty; many OTC remidies are costly and exacerbate skin problems

last test for glaucoma (aging adult subjective data)

rationale: at 60-65 years people need annual exmans to screen for vision changse and age-related eye disorders if they have glaucoma, compliance may be a problem with eye drop therapy if symptoms are absent

medications

rationale: drugs, especially antibiotics, may cause allergic skin eruption; drugs may increase sunlight sensitivity and give burn response (sulfonamides, thiazide diuretics, oral hypogylcemic agents, tetracycline); drugs can cause hyperpigmentation: (antimalarials, anticancer agents, hormones, metals, and tetracycline)

protecting from sun exposure/ sunscreen/ treat sunburn

rationale: excessive sun, including severe or blistering sunburns in childhood, increases risk for melanoma in later life

spots (vision difficulty)

rationale: floaters area common with myopia or after middle age as a result of condensed vitreous fibers; usually not significant but acute onset of floaters ("shade" or "cobwebs") occurs with retinal detachment

rash or sores in children

rationale: generalized rash, consider allergic reaction to new food irritability/ general fussiness may indicate presence of puritius

vaginal infections in mother (infant/child eye subjective data)

rationale: genital herpes and gonorrhea have risk of eye disease for the newborn

halos/ rainbows around objects (vision difficulty)

rationale: halos around lights occur with acute narrow-angle glaucoma

sores or lresions (subjective data)

rationale: history helps determine whether oral lesions have infectious, traumatic, immunologic, or malignant etiology

change in pigmentation

rationale: hypopigmentation (loss of color) hyperpigmentation (increase in color) generalized change suggests systematic illness: pallor, jaundice, cyanosis

any falls this year/ how many

rationale: look for multiple bruises/ trauma from falls

vision difficulty (aging adult subjective data)

rationale: loss of depth perception, contrast sensitivity, peripheral or central vision may occur

which environments do you notice hearing loss (ear subjective data)

rationale: loss shows with competition from background noise, as at a party

environmental/ occupational hazards

rationale: majority of skin cancers result from _________________; people at risk: outdoor sports enthuasists, farmers, sailors, outdoor workers, creosote workers, roofers, coal workers; unprotected sun exposure accelerates aging and produces lesions, at more risk: light skinned people, light eye and hair color, freckles, and those regularly in sun identify contactants that produce lesions or contact dermatitis tell peoplel with chronic recurrent hives to keep diary of meals and environemnt to identify triggers

excessive bruising

rationale: multiple cuts and bruises, bruises in various stages of healing, bruises above knees and elbows, and illogical explanation-consider physical abuse; frequent falls may be caused by dizziness of neurologic or cardiovascular origin; frequent minor trauma may be a side effect of alcoholism or other drug abuse

night blindness (vision difficulty)

rationale: night blindness occurs with optic atrophy, glaucoma, and vitamin A deficiency

diaper rash/ cared for washing/changing diapers/ cleaning

rationale: occlusive diapers/ infrequent chaning may cause rash; infant may be allergic to certain detergent or disposable wipes

environemntal noise (subjective data)

rationale: old trauma to hearing initially goes unnoticed but results in further decibel loss in later years

change in skin color of newborn

rationale: physiologic jaundice

any delay in wound healing/ itching

rationale: pruritus with aging occurs with side effects of medicine or systemic disease (e.g. liver or kidney disease, cancer, lymphoma), but senile pruritus is usually caused by dry skin (xerosis), too-frequent bathing, or use of soap; starching produces excoriations

rash or lesion

rationale: rashes are a common cause of seeking healthcare; a careful history is important; it may predict the type of lesion you will see in the exam and its cause; identify hte primary site; it may give clue to cause; identify and migratory pattern or evolution

history of diabetes/ peripheral vascular diasease

rationale: risk for skin lesions in feet or ankles

excessive dryness or moisture

rationale: seborrhea- oily xerosis- dry

past history of skin disease

rationale: significant familial predisposition: allergies, hay fever, psoriasis, atopic dematitis, acne identify offending allergens

change in mole

rationale: signs suggests neoplasm in pigmented nervus; may be unaware of change in nervus on back or buttocks that he or she cannot see

changes in feet, tonails, bunions, wearing shoes

rationale: some aging people cannot reach down to their feet to give self-care

other skin pain

rationale: some diseases such as herpes zoster/ shingles produce more intesne sensations of pain, itching in aging people; other diseases may reduce pain sensation in extremities; in addition, some aging people tolerate chronic pain as part of growing old and hesitate to complain

sudden onset (pain)

rationale: sudden onset of eye symptoms (pain, floaters, bind spot, loss of peripheral vision) requires emergency referral

Snellen eye chart

record the result using numeric fraction at the end of the last successful line indicate whether the person missed letters or if connective lenses were worn

Splinter hemorrhages

red-brown liner streaks from damage to nail bed capillaries; they occur with systemic diseases (vasculitis), with trauma or sports-related injuries, and with endocarditis

cluster headache

relieving factors/ efforts to treat: need to move, pace floor

migraine hedache

relieving factors/efforts to treat: lie down, darken room, use eyeshade, sleep, take NSIAD early, try to avoid opioid m

tension headache

relieving factors/efforts to treat: rest, massaging muscles in area, NSAID medication t

chronic venous symptoms

relieving factors: elevation, lying, walking

acute venous symptoms

relieving factors: pain medication

chronic arterial symptoms

relieving factors: rest (usually within 2 min) dangling (severe involvement)

uremia

renal failure causes retained urochrome pigments in the blood light skin: orange-green or gray overlying pallor of anemia, may have ecchymoses and purpura dark skin: easily masked, rely on lab and clincal findings

percuss the chest

resonance is hte low-pitched, clear, hollow sound that predominates in healthy lung tissue in the adult; however, resonnance is a relative term and has no constant standard; the resonant note may be duller in the athlete with a heavily muscular chest wall and in the heavily obese adult in whom subcutaneous fat produces scattered dullness

changing chest size

respiration is the physical act of breathing; air rushes into the lungs as the chest size increases and is expelled from the lungs as the chest recoils; the mechanical expansion and contraction of the chest cavity alters the size of the thoracic container in two dimensions: 1. vertical diameter shortens or lengthens, which is accomplished by upward or downward movement of the diaphragm; and 2. anteroposterior diameter increases or decreases, which is accomplsihed by elevation of depressio nof the ribs

pulsus bigeminus

rhythm coupled, every other beat comes early, or normal beat followd by premature beat; force of premature beat decreased because of shortened cardiac filling time asosociated with: conduction disturbance (e.g. premature ventircular contraction, premature atrial contraction)

pulsus alterans

rhythm regular, but vorce varies, with alternating beates of large and small amplitude associated with: when heart rate is normal, pulses alterans occurs with severe left ventricular failure, caused by ischemic herat disease, valvular heart disease, chronic hypertension, or cardiomyopathy

malignant melanoma

risk facotrs: uv radiation from sun exposure and indoor tanning, aging, and family history in men, most are located on teh trunk and back in women, most on legs and feet in older adults more on head nad neck

lymphedema

risk factors include age, obesity, extent of axillary surgery, axillary radiation, infection, surgery occurred on dominant or nondominant side, and failure to exercise or use other activiteis to prevent ______________

glacuoma patient education

risk factors include: older age, black or hispanic heritage, diabetes mellitus, and a family history of glaucoma regular screening at age 40 by an eye professional and earlier for those with risk factors treatment may include eye drop medication, laser trabeculoplasty, and/or surgery to slow or prevent further vision loss; treament does not recover vision already lost from glaucoma; early detection is critical to stop progress of the disease

tinea corporis (ringworm)

scales-hyperpigmented in whites, depigmented in dark-skinned people; on chest, abdomen, back of arms forming multiple circular lesions with clear centers

test hearing acuity

screening for a hearing deficit begins during the history; "Do you have difficulty hearing now?" if the answer is yes, perform audiometric testing or refer for audometric testing; if no screen using teh whispered voice test

hair lesions

separate the hair into sections and lift it; observe the scalp; with a history of tiching, inspect hte hair behind the ears and in the occipital areas as well; all should be clean and free of ________________ or pest inhabitants; many people ahve seborrhea/dandruff, which is indicated y loose white flakes

acne

severe ______________ includ espapules, pustules, and nodules; acne lesions usually appear on the face nad sometimes on the chest, back, and shoulders; _____________ may appear as early as 7-8 years of age, lesions increase in nubmer and severity and peak at 14-16 for girls and 16-19 for boys

anterior chest inspection

shape and configuration of anterior chest wall. the ribs are slopping downward with symmetric interpsaces. the costal angle within 90 degrees. development of abdominal msucles is epxected for the person's age, weight, and athletic condition. note hte person's facial expression; the facial expression should be realexed and beingin, indicating an unconscous effor of breathing ; assess the level of consciousness; the level of consciousness should be alert and cooperative; note skin color and condition; the lips and nail beds are free of cyanosis or unusual pallor; the nails are of normal configuration; explore any lesions

pitting

sharply defined pitting and crumbling of nails with distal detachment often occurs with psoriasis

palate

shine your light up to the rof of the mouth; the more anterior hard palate is white with irregular transverse rugae; the posterior soft palate is pinker, smooth, and upwardly movable; a normal variation is a nodular bony ridge down the middle of the hard palate, a torus palatinus; this benign growth arises after puberty; it is more common in American Indians, Inuits, and Asians; it is more common in females than males

orthopnea

shortness of breath affected by position rationale: ______________ is difficulty breathing when supine; state number of pillows needed to achieve comfort (e.g. 2 pillows)

paroxysmal nocturnal dyspnea

shortness of breath specific time of day/ night rationale: __________________ is awakening form sleep with SOB and needing to upright to achieve comfort

herpes simplex virus (HSV)

signs are acute, painful reddened conjunctivae; unilateral maculopapular rash with vesicles and ulcers; and ocular signs that threaten vision; severity inreases with older age

neuropathic ulcer

signs include decreased refelxes, loss of proprioception, loss of vibration sensation, small muscle wasting, loss of warm and col sensatio nadn pinprick, decreased refelxes, poor blod flow, adn cold feet; without careful vigilance of pressure points on feet, ulcers may go unnoticed

extraocular muscles

six muscles attach the eyeball to its orbit and serve to direct our eyes to points of interest; these ___________________ give the eye both straight and rotary movement; the four straight rectus muscles are the superior, inferior, laterla, and medial rectus muscles; the two slanting or oblique muscles are the superior and inferior muscles

inspect external ear

size and shape of auricle position and alignment on head note skin condition- color, lumps, lesions check movement of auricle and tragus for tenderness evaluate external autidory meatus- note size, swelling, redness, discharge, cerumen, lesions, foreign bodies

wound repair (skin function)

skin allows cell replacement of surface wounds

temperature regulation (skin function)

skin allows heat dissipation through sweat glands and heat storage through subcutaneous insulation

absorption and excretion (skin function)

skin allows limited excretion of some metabolic wastes, by-products of cellular decomposition, such as minerals, sugars, amino acids, cholesterol, uric acid, and urea

prevents penetration (skin function)

skin is a barrier that stops invasion of microorganisms and loss of water and electrolytes from the body

perception (skin function)

skin is a vast sensory surface holding the neurosensory end-organs for touch, pain, temperature, and pressure

protection (skin function)

skin minimizes injury from physical, chemical, thermal, and light-wave sources

pressure injury due to medical device

skin or mucosa has PI that looks like pattern or shape of medical device, e.g., IV hub, endotracheal tube, cervical collar, anti-thromboembolism stocking

koplik spots in measles

small blue-white spots with irregular red halo scattered over mucosa opposite the molars; an early sign, and pathognomic, of measles

herpes zoster

small, grouped vesicels emerge along route of cutaneous sensory nerve, then pustules, then crusts; caused by dormant varciella zoster virus, a reactivation of hte dormatnt virus of chickenpox; acute appearance, unilateral, does not cross moidline; commonly on trunk it can be anywhere; if on opthalmic branch of cranial nerve V, it poses risk to eye; most common in adults older than 50; pain is severe and long-lasting in adults, called postherpic neuralgia

smoking, alcohol consumption (subjective data)

smoking? pipe or cigarettes? smokeless tobacco? how many packs per day for how many years? when was the last alcoholic drink? how much did you drink at that time? How much do you usually drink?

test visual acuity

snellen eye chart near vision (those older than 40 years or having difficulty reading)

macule (primary lesion)

soley a collor change, flat and circumsribed, less than 1 cm; examples: freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever

papule (primary lesion)

someting you can feel, i.e. solid, elevated, circumscribed, less than 1 cm diameter, caused by superifcial thickening in epidermis; examples: elevated nervus (mole), lichen planus, molluscum, wart

mouth and throat subjective data

sores or lesions sore throat bleeding gums toothache hoarseness dysphagia altered taste smoking or alcohol consumption

rinne test normal

sound is heard twice as long by air conduction as by bone conduction; a positive Rinne or AC>BC

weber test sensorineural loss

sound lateralizes to better ear or unaffected ear; poor ear (the one with nerve loss) is unable to percieve the sound; however, many people with unilateral loss (conductive or sensorineural) still localize sound to midline; confirm with audiometry

weber test conductive loss

sound lateralizes to poorer ear fro mbackgorund room noise, which masks hearing in normal ear; poorer ear is not distracted by background noise and thus has better chance to hear bone conducted sound; examples: transient conductive loss with serous or purulent otitis media

superficial varicose veins

subjective data: aching heaviness in calf, easy fatigability, restless legs, burning, throbbing, cramping

venous (stasis) ulcer

subjective data: aching in calf or lower leg, worse at end of day, worse with prolonged standing or sitting; pain lessens with leg elevation; itching with stasis dermatitis

arterial (ischemic) ulcer

subjective data: deep muscle pain in calf or foor, claudication (pain with walking); pain worsens with leg elevation; pain at rest indicates worsening of condition

deep vein thrombophlebitis

subjective data: sudden onset of intesne, sharp, deep msucle pain

pulmonary embolism

subjective: chest pain, worse on deep inspiration, dyspnea inspection: apprehensive, restless, anxiety, mental status changes, cyanosis, tachypnea, cough, hemoptysis, PaO2 <80% on pulse ox; arterial blood gases show respiratory alkalosis palpation: diaphoresis, hypotension auscultation: tachycardia, accentuated pulmonic component of S2 heart sound adventitious sounds: crackles, wheezes pe

lung cancer

subjective: fatigue, nausea, and vomiting, change in taste perception, anorexia; persistent cough may also be productive; dyspnea; dull poorly localized chest pain; 10-25% are asymptomatic inspection: weight loss, cubbing, hoarseness, anemia, hemoptysis, decreased O2 saturation on oximetry auscultation: may have wheezing, atelectasis, pleural effusion, pneumonia distal to obstruction

tuberculosis

subjective: intiially asymptomatic, showing as positive skin test or on x-ray study; progressive TB involves weight loss, anorexia, easy fatigability, low-grade afternoon fevers, night sweats; may have pleural effusion, recurrent lower respiratory infections inspection: cough intially nonproductive, later productive of purulent, yellow-green sputum; may be blood tinged; dyspnea, orthopnea, fatigue, weakness t

lymphatics

substances pass around the microcirculation by a concentration gradient; most plasma proteins are too big to be pushed out of the arterioles; they remain and create teh force for colloid osmotic pressure that pulls interstitial fluid back into the venules; a few smaller plasma proteins do escape teh arterioles; they are captured by the lymph vessels and eventually returned to the bloodstream

light-skinned people

sun-burns, skin cancers, and other skin problems are more likely in __________________

folliculitis barbae

superficial inflammatory infection of hair follicles; multiple pustules, whiteheads, with hair visible at center and erythematous base; usually involves face nad neck and is common in black and latino men if they have tight curly hair; occurs after shaving when growing out hairs curl in on themselves and pierce the skin, making a foreign-body inflammatory reaction

posterior auricular/ mastoid lymph nodes

superifical to the mastoid process

anterior thoracic landmarks

suprasternal notch sternum sternal angle costal angle

aging adult skin

sweat and sebaceous glands decrease in number and function, leaving dry skin; decreased response of hte sweat glands to thermoregulatory demand also puts the aging person at greater risk for heat stroke

tactile/vocal fremitus

symmetry is most importnat; the vibrations should feel the same in the corresponding area on each side; avoid palpating over the scapulae because bone damps out sound transmission

allergic conjunctivitis

symptoms include eye itching (not present in nonallergic condition), redness, watering, discomfort; it does not obscure vision; signs are diffuse redness of conjunctivae, lid swelling, upper tarsal surface that shows velvety thickening, redness, small papillae

myxedema/ hypothyroidism

symptoms include fatigue and cold intolerance; signs include puffy, edematous face, especially around eyes (perioribtal edema); puffy hands and feet; coarse facial features; cool, dry skin; dry, coarse hair and eyebrows; slow reflexes; and sometimes thick speech

graves disease/ hyperthyroidism

symptoms include nervousness, fatigue, weight lsos, muscle cramps, and heat intolerance; signs include forceful tachycardia; shortness of breath; excessive sweating; fine muscle tremor; thin silky hair; warm, moist skin; infrequent blinking; a staring apperance; brisk ankle jerks

neuropathic ulcer

symptoms include nubmness and tingling, pain, weakness, loss of balance, falling, allodynia

conjuncivitis

symptoms include: itching, burning, foreign body sensation, and eyelids stuck together on awakening; persno has normal vision, normal pupil size, and reaction to light

color and characteristics (tympanic membrane)

systematically explore its landmarks; the normal eardrum is shiny and translucent wit ha pearl gray color; the cone-shaped light reflex is prominent in the anteroinferior quadrant; this is the reflection of the otoscope light; sections of the malleus are visible through the translucent drum: the umbo, manubrium, and short process; (infrequently you may also see the incubus behind the drum; it shows as a whitish haze in the upper posterior area) at the periphery, the annulus looks whiter and denser

puncta

tears drain into the ___________________, visible on the upper lid and lower lids as the inner canthus; they drain into the nasolacrimal sac, throuugh the 1/2 long nasolacrimal duct, and empty into the inferior meatus inside the nose; a tiny fold of mucous membrane prevents air from being forced up the nasolactimal duct when the nose is blown

egophony

technique: ascultate the chest while hte person phonates a long ee-ee-ee sound

bonrhophony

technique: ask person to repeat ninenty nine while you listen with the stethoscope over teh chest wall; listen especially if you suspect pathology

whispered pectoriloquy

technique: ask the person to whisper a phrase as one-two-three as you ascultate

anterior fontanel

teh _________________ may be small at birth and enlarge to 2.5 by 2.5 cm; a large diameter of 4-5 cm occasionally may be normal under 6 months; a small fontanel usually is normal; the _________________ closes between 9 months to 2 years; early closure may be insigificant if the head grows normally af

cranial nerve XII

test _________________ by asking the person to stick out their tongue; it should protrude in the midleine; not any tremor, lsos of movement, or deviation to the side

mobility and turgor

test ___________________ over the abdomen in an infnat; ABNORM: poor _______________ indicates dehydraation especially combined with delayed capillary refill and tachypnea; also occurs with malnutrition

infant/ children color vision

test children once between the ages of 4 and 8 years, or adults for preemployment exams; use the Ishihara test, in which each card has a pattern of dots printed against the background of many colored dots; ask the child to identify each pattern; a person with normal color vision can see each pattern iccv

sensation/ strength lower extremities

test lower legs for ____________________ for those with history of diabetes, PAD, or HIV, test for sensation on the sole of the foot using a monofilament

Range of motion (neck)

test muscle strength and the status of cranial nerve XI by trying to resist the person's movements with your hands as the person shrugs the shoulders and turns the head to each side as the person moves the head, note enlargement of teh salivary and lymph glands; normally, no enlargement is present; not a swollen parotid gland when the head is extended; alo note thyroid gland enlargement rom

external nose

test the patency of the nostrils by pushing each nasal wing shut with the finger while asking the person to sniff inward through the other naris; this reveals any obstruction, which later is explored with the nasal speculum; the sense of smell is not tested in a routine exam

strasbismus

testing for ___________________- (squint, corss eye) is an importnat screening measure between 3 and 5 years; ______________________ causes disconjugate vision becasue one eye deviates off the fixation point; to avoid diplopia or unclear images, the brain begins to suppress data from the weak eye, causing visual acuity in this otherwise normal eye to deteriorate from disuse; early recognition and treatmetn are essential to restroe binocular vision; diagnosis after 6 has poor prognosis s

facial bones

the 14 _______ articulate at stuures, except for the mandible

equilibrium

the 3 semicircular canals, or labyrinth, in the inner ear constantly feed information to your brain about the position of your body in space; they work like plumb lines to determine verticality or depth; the plumb lines of the ear register the angle of your head in relation to gravity; if the labyrinth ever becomes inflamed, it feeds the wrong information to the brain, creating a staggering gait and a strong spinning, whirling sensation called vertigo

vertebra prominens

the C7 vertebra has a long spinous process that is palpable when the head is flexed; this is called the ________________

aging adult peripheral vascular system

the DP and PT pulses may become more difficult to find; trophic changes associated with arterial insufficiency als occur normally with aging

skull

the ____________ is a rigid bony box that protects the brain and special sense organs, and it include shte bones of the cranium and the face

eccrine glands

the _____________ are coiled tubules that open directly onto the skin surface and produce a dilute saline solutuion called sweat; the evaporation of sweat reduces body temperature; _________________ are widely distributed through the body and are mature in the 2 month old infant

sphenoid sinuses

the _____________ are deep within the skull in the sphenoid bone

popliteal pulse

the _____________ is a more diffuse pulse and can be difficult to localize; with the leg extended but relaxed, anchor the thumbs on the knee and curl your fingers around into the poplitela fossa; press your fingers forward hard to compress the arter against the bone; often it is just lateral to the medial tendon

eye

the _____________ is about 1 inch in diameter; more than half of the neocortex is involved in processing visual information; because vision is so important, the ________________ is well protected by the bony orbital cavity, surrounded with a cushion of fat

ethmoid sinus

the _____________ is located between the orbits

visceral pleura

the _____________ lines the outside of hte lungs, dipping down into the fissures

paranasal sinuses

the ______________ are air-folled pockets within the cranium; they communicate with the nasal cavity and are linged with ciliated mucous membranes; they lighten the weight of the skull bones, serve as resonators for sound production; and provide mucus, which drains into the nasal cavity; the ______________ openings are narrow and easily occluded, which may cause inflammation or sinusitits

nails

the ______________ are hard plates of keratin on the dorsal edges of the fingers and toes; the _________- plate is clear, with fine longitudinal ridges that become prominent in aging; ____________ take their pink color from the underlying nail bed of highly vascular epithelial cells

temporal arteries

the ______________ can be palpated in front of the ear

right lymphatic duct

the ______________ empties into the right subclavian vein; it drains the right side of the head and neck, right arm, right side of the thorax, right lung and pleura, right side of the heart, and right upper section of hte liver

normal adult thorax

the ______________ has an elliptical shape with an anteroposterior-to-trnasverse diameter documented at 1:2 or 0.70

macula

the ______________ is 1 DD in size and 2 DD temporal to the disc; inspect this area last in the funduscope exam; a bright light on this area of central vision causes watering and discomfort and pupillary constriction; normal color of this area is somewhat darker than the rest of the fundus but is even and homogenous

inner ear

the ______________ is embedded in bone; it contains the bony labrinth, semicircular canals, and cochlea

epitrochlar node

the ______________ is in the antecubital ofssa and trains the hand and lower arm

nail surface

the ______________ is normally slightly curved or flat, and the posterior and lateral nail folds are smooth and rounded; nai ledges are smooth, rounded, and clean, suggesting adequate self-care

nose

the ______________ is the first segment of the respiratory system; it warms, moistens, and filters the inhaled air, and it is the sensory organ for smell

vernix cerosa

the ______________ is the mist, white, cream cheese-like substance that covers part of hte skin in all newborns; perspiration is present after 1 month of age

bronchial tree

the ______________ protects alveoli form small particulare matteri n the inhaled air; it is lined with goblet cells, which secrete mucus that trap the parciles, and cilia, which sweep particles upward where they can be swallowed or expelled

nasolabial folds

the ______________, the creases extending from the nose to each corner of the mouth should look symmetric

cranial bones

the ______________- include: frontal, parietal, occipital, and temporal

frontal sinuses

the _______________ ar elocated in the frontal bone above and medial to the orbits

eyeballs

the _______________ are aligned normally in their sockets with no protrusion or sunken apperance; blacks normally have a slight protrusion of the eyeball beyond the supraorbital ridge

sternal angle

the _______________ aslo marks hte site of tracheal bifurication into the right and left main bronchi; it correspodns with the upper border of the atria of hte heart, and it les above hte 4th thoracic vertebra on the back

midclavicular line

the _______________ bisects the center of each clavicle at a point between the palpated sternoclavicular nad arcomioclavicular joints

coronal suture

the _______________ crowns the head from ear to ear at the union of the frontal and parietal bones

columella

the _______________ divides the two nares and is continuous inside with the nasal septum

bony labryinth

the _______________ holds the sensory organs for equilibrium and hearing; within the _______________, the vestibular and the semiciruclar canals comprise the vesetibular apparatus nad the cohlea contains the central hearing apparatus

suprasternal notch

the _______________ is a hollow u-shaped depression just above the sternum between the clavicles

frenulum

the _______________ is a midline fold of tissue that connects the tongue to the floor of the mouth

lympathic system

the _______________ is a separate vessel system from the cardiovascular system and a major part of the immune system, whose job it is to detect and elminate foreign substances from the body; the vessels gather the clear, watery fluid from the tissue spaces into the circulation

posterior chest

the _______________ is comprised of almost lal lower lobe; the upper lbes comprise only a smaller band of tissue from their apices at T1 down to T3 or 4; at this level the lower lobes begi nand their inferior border reaches down to hte level of T10 on expiration and T12 on inspiration; the right middle lobe does not project onto the posterior chest at all;if the person abducts the arms and places the hands on the back of the head, the division between the upper and lower lobes corresponds to the medial border of the scapulae

nasal cavity

the _______________ is much larger tha nthe external nose; it extends back over the rooth of the mouth; the naterior edge of the ______________ is lined with numerous coarse nasal hairs, or vibrissae; the rest of the cavity is lined with a blanket of ciliated mucous membrane; the nasal hairs filter the coarses matter form inhaled air, whereas the mucous blankets filters out dust and bacteria; nasal mucosa appears redder than oral mucosa because of the rich blood supply present to warm inhaled air

fovea centralis (inner layer)

the _______________ is the area of sharpest and keenest vision

thymus

the _______________ is the flat, pink-gray gland located at the superior mediastinum behind the sternum and in front of hte aorta; it is relatively large in the fetus nad young child and atrophies after puberty; it is important in developing the T lymphocytes of hte immune system in children; the B lymphocytes originate in teh bone marrow and mature in the lymphoid tissue

uvula

the _______________ is the free projection hanging down from the middle of the soft palate

ala

the _______________ is the lateral outside wing of hte nose on either side

mediastinum

the _______________ is the middle section of the thoracic cavity containing the esophagus, trachea, heart, and great vessels;

parietal pleura

the _______________ lines the inside of the chest wall and diaphragm

mandible

the _______________ or lower jaw; moves up, down, and sideways form the temporomandibular joint, which is anterior to each ear

apocrine glands

the _______________ produce a thick, milky secretion and open into the hair follicles; they are located mainly in the axillae, anogenital area, nipples, and navel and are vestigal in humans; they become active during puberty, and secretion occurs with emotional and sexual stimulation; bacterial flora residing on the skin surface react with apocrinre sweat to produce a characteristic musky body odor; the function of _____________ decreases in the aging adult

deep veins (femoral and poplitela veins)

the _______________ run alongside the deep arteries and conduct most of the venous return from the legs; these are _____________________; as long as these veins remain intact, the superficial veins can be excised withotu harming the circuation

maxillary sinuses

the ________________ ar ein the maxilla/ cheekbone along the side walls of hte nasal acvity

tonsils

the ________________ are located at the entrance to the respiratory and gastrointestinal tracts and respond to local inflammation

midsternal line

the ________________ bisects the center of the chest

lymphatic vessels

the ________________ have a unique structure; lymphatic capillaries start as microscopic open-ended tubes, which siphon interstitial fluid; the capillaries converge to form vessels and drain into larger ones; the vessels have valves; therefore flow is one way from the tissue spaces into the bloodstream; the many valves make the vessels look eaded; the flow of lymph is slow compared to blood; lymph flow is propelled by contraction of the skeletal muscles, by pressure changes secondary to breathing, and contraction of the vessel walls themselves

lens (middle layer)

the ________________ is a biconvex disc located just posterior to the pupil; the transparent ______________ serves as a refracting medium, keeping a viewed object in continual focus on the retina; its thickness is controlled by the ciliary body; the ____________ bulges for focusing on near objects and flattens for far objects

cafe au lait spot

the ________________ is a large round or oval patch of light brown pigmentation, which is usualyl present at birth; these patches are usually normal

eye

the ________________ is an asymmetric sphere composed of three concentric coats: 1. the outer fibrous sclera, 2. the middle vascular choroid, and 3. the inner nervous retina; inside the retina is the transparent vitreous body; the only parts accesssible to exam are hte sclera anteriorly and the retina through the opthalmoscope

thyroid gland

the ________________ is an important endocrine gland with a rich blood supply; it straddles the trachea in the middle of hte neck; this highly vascular endocrine gland synthesizes and secretes thyroxine and triiodotyronine, hormones that stimulate the rate of cellular metabolism; the gland has two lobes, both conica lin shape, each curving posteriorly between the trachea and the sternomastoid muscle; the lobes are connected by a thin isthmus

thyroid gland

the ________________ is difficult to palpate; position a standing lamp to shine tangentially across the neck to highlight any possible swelling; tilt the head back to stretch the skin against the thyroid; supply the person with a glass of water and first inspect hte neck as they sip and swallow; _______________ moves up with a swallow and then falls to its resting position tg

oropharynx

the ________________ is separated from the mouth by a fold of tisseu on each side, the anterior tonsilaer pilalr

external nose

the ________________ is shaped like a triangle with one side attached to the face; the upper third of the _____________ is made up of bone; the lower part is cartilage

dermis

the ________________ is the inner supportive layer consisting of mostly connective tissue, or collagen; the ______________ also has resilient elastic tissue that allows the skin to stretch with body movements; the nerves, sensory receptors, blood vessels, and lymphatics lie in the dermis; in addition, appendages from the epidermis such as the hair follicles, sebaceous glands, and sweat glands are embedded in the ________________

hair root

the ________________ is the part of the hair follicle embedded below the skin

hair shaft

the ________________ is the visible projecting part of the hair follicle

temporal artery

the ________________ lies superior to the temporalis muscle; its pulsation is palpable anterior to the ear

palpebral conjunctiva

the ________________ lines the eyelids and is clear, with many small blood vessels; it forms a deep recess and then folds back over the eye

erythema

the ________________ of fever or localized inflammation has an increased skin temperature from the increased rate of blood flow; because you cannot see inflammation in ndark-skinned people, you must palpate the skin for increased warmth or taut or tightly pulled surfaces that may indicate edema and hardening of deep tissues or blood vessels

1-3-6 program

the ________________ of universal newborn hearing screening operates in all states in the US, resulting in screenings for 96% of babies within the 1st month of life 1- all newborns are screened for hearing loss before they leave the hospital or within 1 month of life 3- all infants who do not pass the hearing screening should be scheduled immediately for a follow-up appointment with an audiologist; this must happen by 3 months 6- if the follow-up exam confirms that the baby has hearing loss, the baby must receive appropriate interventions by 6 months of age, including hearing devices and early communication intervention

dorsalis pedis pulse

the ________________ pulse requires a very light touch; normally it is just lateral and parallel with the extensor tendon of the big toe; do not mistake the puse of your own fingertips for that of the person

midaxillary line

the ________________ runs down form the apex of hte axilla lnd lies parallel to the posterior and anterior axillary line

lambdoid suture

the ________________ separates the parietal bones crosswise form the occipital bone

trachea/ bonrchi

the ________________ transport gases between the environment and the lung parenchyma

parotid glands

the _________________ are in the cheeks over the mandible, anterior to and below hte ear; they are the largest of the salivery glands but are not normally palpable

vascular system

the _________________ consists of the vessels for transporting fluid such as the blood or lymph; any disease in the vascular system impairs the delivery of oxygen and nutreints to the affected cells and retards the elimination of carbon dioxide and waste products from cellular metabolism

posterior axillary line

the _________________ contines down form the psterior axillary fold where the latissimus dorsi muscle inserts

infants/ children nose

the _________________ develops its shape during adolescnce, along with secondary sex characteristics; this growth stats at age 12 or 13 years, reahcing full growth at age 16 for females and 18 for males

thoracic duct

the _________________ drains the entirety of the body except the right arm, head, neck, right side of thorax, lung, pleura, heart, and upper section of liver

opthalmoscope

the _________________ enlarges the view of the eye so you can inspect hte media and the ocular fundus; it accomplishes this by directing a beam of light through the pupil to illuminate hte inner structures

scapular line

the _________________ extends through the inferior angle of the scapula when the arms are at the sides of the body

mongolian spot

the _________________ is a common variation of hyperpigmentation in African American, Asian, American Indian, and Latino newborns; it is a blue-black-to purple macular area at the base of the sacrum or buttocks but sometimes on the abomden, thighs, shoulders, or arms; it is caused by deep dermal melanocytes; it gradually fades during the first year

aging adult skin

the _________________ is a mirror that reflects aging changes that proceed in all our organ systems; it just happens to be the one organ that we can view directly; the _______________ carries a slow atrophy of skin structures, the aging skin loses its elasticity; it folds and sags; by the 70s to 80s, it looks parchment thin, lax, dry, and wrinkled

diameter of optic disc (DD)

the _________________ is a standard of measure for other fundus sctructures; to describe a finding, note its clock-face position and its relationship to the disc in size and distance

hard palate

the _________________ is anterior, made up of bone, and is a whitis color

neck

the _________________ is delimited by the base of the skull and inferior border of the mandible above and by the manubrium setrni, near the clavicle, the first rib, and the throacic vertebra below; the neck is a conduit for hte passage of many structures that are lying is close proximity: blood vessels, muscles, nerves, lymphatics, and viscera of the respiratory and digestive systems

ear

the _________________ is hte sensory organ for hearing and maintaing equilibrium; it has three parts: the external, middle, and inner ______________

spleen

the _________________ is located in the left upper quadrant of hte abdomen; if has four functions: 1. destroy old red blood cells; 2. produce antibodies; 3. store red blodo cells; and 4. filter microorganisms from the blood

canthus

the _________________ is the corner of the eye, the angle where the ldis meet

annulus

the _________________ is the outer fibrous rim of the drum

submandibular gland

the _________________ is the size of a walnut; it lies beneath the mandible at the angle of hte jaw; wharton duct runs up and forward to the floor of the mouth and opens at either side of the frenulum

retina (inner layer)

the _________________ is the visual receptive layer of the eye in which light waves are changed into nerve impulses; it surrounds the soft, gelatinous vitreous body; the _____________ structure sviewed through the opthalamoscope are the optic disc, the retinal vessels, the general background, adn the macula

epidermis

the _________________ is thin but tough; its cells are bound tightly together into sheets that form a rugged protective barrier; it is stratified into several zones, the basal layer and the horny cell layer the ________________ is avascular; it is nourished by blood vessels in the dermis below

femoral arteries

the _________________ just below the inguinal ligament halfway between the pubis and anterior superior iliac spines; to help exose the ____________________, particularly in obese people; as the person to bend his kness to the side in a froglike position; press firmly and the nslwoly release, noting the pulse tap under your fingertips; if weak or diminished, ascultate the site for a bruit

trachea

the _________________ lies anterior to the esophagus and is 10-11 cm long in the adult; it begins at the level of the cricoid cartilage in the neck and bifuricates just below the sternal angle into the right and left main bronchi; posteriorly tracheal bifurication is at the level of T4 or 5; the right main bonrchus is shorter, wider, and more vertical than the left main bronchus

sebaceous glands

the _________________ produce a protective lipid substance, sebum, which is secreted through the hair follicles; ________________ are everywhere except on the palms and soles; they are most abundant in the scalp, forehead, face, and chin

opthalmoscope

the _________________ should function as an appendange of your own eye hold the opthalmoscope right up to your own eye, braced firmly against the cheek and brow extend the index finger onto the lens seslector dial so that you can refocus as needed darken the room to help dilate the pupils remove eyeglasses and those of the other person/ contacts may be left in place select large round aperature for routine exam, if pupils are small use the small white light

lymphatics

the _________________ vessels converge and drain into two main trunks which enter into the venous system at the subclivian veins

base (lung border)

the _________________, or lower lung border rests on on the diaphragm at about the 6th rib in the midclavicular line; laterally lung tissue extends from the apex of the axilla down to the 7th or 8th rib; posteriorly the location of C7 marks the apex of lung tissue and T 10 usually corresponds to the base; deep inspiration expands the lungs and their lower border drops to the level of T12

eyelids

the __________________ are two rapid window shades that protect the eye from injury, strong light, and dust; the upper ______________ is the larger and more mobile one

sternomastoid muscle

the __________________ arises from the sternum and the clavicle and extends diagnonally across the neck to the mastoid process behind the ear; it accomplishes rotation and flexion

romberg test

the __________________ assesses the ability of the vestibular apparatus in the inner ear to maintain standing balance; the _________________ also assesses intactness of the cerebellum and proprioception

thoracic cage

the __________________ is a bony structure with a conical shape, naoorwer at the top; defined by he sternum, 12 pairs of ribs, and 12 thoracic vertebrae

posterior traingle

the __________________ is behind the sternomastoid muscle, with the trapezius muscle on the other side and its base along the clavicle below; it contains the posterior belly of the omohyoid muscle; these triangles are helpful guidelines when describing findings in the neck

nasopharnx

the __________________ is continuous with the oropahrynx, although it is above the oropharynx and behind the nasal cavity; the pharyngeal tonsils and eustachian tube openins are located here

newborn skin

the __________________ is thin, smooth, and elastic and is relatively more permeable than that of the adult; thus, the infnat is at greater risk for fluid loss

olfactory receptors

the __________________ lie at the roof of the nasal cavity and in the upper one third of the septum; these receptors for smell merge into the olfactory nerve, cranial nerve I, which transmits to the temporal lobe of the brain

eardrum/tympanic membrane

the __________________ separates the external and middle ear and is tilted obliquely to the ear canal, facing downward and somewhat forward; it is translucent with a pearly gray color and a prominent cone of light in the anterioinferior quadrant which is the reflection of hte otoscope light

inferior border of the scapula

the __________________: the scapulae are located symmetrically in each hemithorax; the lower tip is usually at the 7th or 8th rib

lungs

the ___________________ are paired, but not precisely symmetric structures; the right _____________ is shorter than the left _________ becuase of the underlying liver; the left _________ is narrower than the right ________ because the heart bulges to the left; these lobes are not arranged in horizontal bands; rather they stack in diagnoal sloping segments

anterior axillary line

the ___________________ extends down from the anterior axillary fold where hte pectoralis major muslce inserts

thyroid cartilage

the ___________________ has a small, palpable V in it's upper edge; this is the prominent adam's apple in men

choroid (middle layer)

the ___________________ has dark pigmentation ot prevent light from reflecting internally and is heavily vascularized to deliver blood to the retina; anteriorly, the ________________ is continuous with the ciliary body and the iris

immune system

the ___________________ is a complicated network of organs and cells taht work together to protect the body; it detects and eliminates foreign pathogens, both that come in from the environment and those arising from inside (Abnormal or mutant cells); it accomplishes this by phagocytosis of the substances by neutrophils and monocytes/macrophages and production of specific antibodies or specific immune responses by lymphocytes

macula (inner layer)

the ___________________ is located on the temporal side of the fundus; it is a slightly darker pigmented region surrounding the fovaea centralis; the _________________ receives and transduces light from the center of the visual field

compound nervus

the ___________________ is macular and papular, it appears in young adults

iris and pupils

the ___________________ is normally blue or slate gray in light-skinned newborns and brown in dark-skinned infants; by 6-9 months the permanent color is differentiated; brushfield spots, or white specks around the iris may be normal a searching nystagmus is common just after birth; the pupils are small, but constrict to light ip

carotid artery

the ___________________ is palpated in the groove between the steromastoid muscle and the trachea

anterior chamber (middle layer)

the ___________________ is posterior to the cornea and in front of hte iris and lens; it contains the clear, watery aqueous humor that is produced continually by the ciliary body; the continuous flow of fluid serves to deliver nutrients to the surrounding tissues and drain metabolic wastes; intraocular pressure is determined by a balance between the amount of aqueous fluid produced and resistance to its outflow at the angle of the anterior chamber

pupil (middle layer)

the ___________________ is round and regular; its size is determined by a balance between the parasympathetic and sympathetic chains of hte ANS; stimulation of hte parasympathetic branch through CN III, causes constriction of the pupil; stimulation of hte sympathetic branch dilates the pupil and elevates the eyelid; the ______________ size also reacts to the amount of ambient light and accommodation, or focusing an object on the retina

palpebral fissure

the ___________________ is the ellipitcal open space between the eyelids; when closed, the lid margins approximate completely

cornea (outer layer)

the ___________________ is thin, transparent, and very sensitive to touch; contact with a whisp of cotton stimulates a blink in both eyes, called the corneal reflex; the trigeminal nerve carries the afferent sensation into the brain, and the facial nerve carries the efferent message that stimulates the blink

sublingual glands

the ___________________ lie in the floor of the mouth

posterior chamber (middle layer)

the ___________________ lies behind the iris and to the sides of the lens; it contains the clear, watery aqueous humor that is produced continually by the ciliary body; the continuous flow of fluid serves to deliver nutrients to the surrounding tissues and drain metabolic wastes; intraocular pressure is determined by a balance between the amount of aqueous fluid produced and resistance to its outflow at the angle of the anterior chamber

posterior fontanelle

the ___________________ may not be palpable at birth; if it is, it measures 1 cm and closes by 1-2 months pf

bulbar conjunctiva

the ___________________ overlays the eyeball, with the white sclera showing through; at the limbus, the conjunctiva merges with the cornea, which covers the lens and pupil

sagittal suture

the ___________________ separates the head lengthwise between the two parietal bones

superficial veins (great saphenous)

the ___________________, inside the leg starts at the medial side of the dorsum of the foot; you can see it ascent in front of the medial malleolus; then it crosses the tibia obliquely and ascends along the medial side of the thigh;

palpebral fissures

the ___________________, the openings between the eyelids, are equal bilaterally

submandibular glands

the ____________________ are beneath the mandible at the angle of hte jaw

inguinal nodes

the ____________________ in the groin drain most of the lymph of the lower extremity, the external genitalia, and the anterior abdominal wall

subcutaneous layer

the ____________________ is adispose tissue, which is lobules of fat cells; the _______________ stores fat for energy, provides insulation for temperature control, and aids in protection by its soft cushioning effect; the loose ________________ also gives skin increased mobility under structures underneath

posterior pharyngeal wall

the ____________________ is seen behind the tonsils; some small blood vessels may show on it

optic disc (inner layer)

the ____________________ is the area in which fibers from the retina converge to form the optic nerve; located toward the nasal side of the retina, it has these characteristics: a color that varies form creamy yellow-orange to pink; a round or oval shape; margins that are distinct and sharply demarcated, especially on the temporal size; and a physiologic cup, the smaller circular area inside the disc where blood vessels enter and exit

Snellen eye chart

the ____________________ is the most commonly used and accurate measure of visual acuity; it has lines of letters arranged in decreasing size

middle ear

the _____________________ is a tiny air-filled cavity inside the temporal bone; it contains tiny ear bones, or auditory ossicles: the malleus, incus, and stapes; it has several openings; the opening to the outer ear is covered by the tympanic membrane; the opening to the inner ear is the oval window at the end of the stapes and the round window

sclera (outer layer)

the _____________________ is a tough, protective white covering; it is continuous anteriorly with the smooth, transparent cornea, which covers the iris and pupil; the cornea is part of the refractign media of the eye, bending incoming light rays to focus them on the inner retina

diaphragm

the _____________________ is the floor of hte throacic cage and is a musculotendinous septum that separates the thoracic cavity from the abdomen

anterior triangle

the _____________________ lies in front, between the sternomastoid and the midline of hte body, with its base up along the lower border of the mandible nad its apex down at the suprasternal notch

retinal vessels (inner layer)

the _____________________ normally include a paired artery and vein extending to each quadrant, growing progressively smaller in caliber as they reach the periphery; the arteries appear brighter red and narrower than the veins, and they have a thin sliver of light on them; the general backgorund varies in color, depending on the person's skin color

hypothalamic-pituitary-thyroid axis

the _____________________ regulates the production of thyroid hormones by a negative feedback system; the hypothalamus secretes thyrotropin releasing hormoens which acts on the anterior pituitary to secerete thyroid stimulating hormone, which directs the thyroid gland to produce T3 and T4 hormones; whe nT3 and T4 hormoens are high in the bloodstream, they direct the pituitary and hypothalmus to shut off their signaling hormones

costochondral junctions

the ______________________ are the points at which ribs join the cartilages; they are not palpable

iris (middle layer)

the ______________________ functions as a diaphragm, varying the opening at its center, the pupil; htis controls the amount of light admitted into the retina; the muscle fibers of the ________________ contract the pupil in bright light and accommodate for near vision; they dilate in dim light and accommodate for far vision; the color of the _______________ vaires from person to person

lacrimal gland

the ______________________ in the upper outer corner over the eye, secretes tears; the tears wash across the eye and are drawn up evenly as the lid blinks

6 minute walk test

the ______________________ is a safe, simple, inexpensive clinical measure of functional status in aging adults; the _________________ is used as an outcome measure for people in pulmonary rehab because it mirror s conditions that are used in everyday life; locate a flat-surfaced corridor that has little foot traffic, is wide enough to permit comfotable turns, and has a controlled environment; ensure that hte perosn is wearing ocmofrtable shoes and equip him or her with a pusle oximeter to monitor oxygen saturation; ask the person to set their own pace to cover as much ground as possible in 6 minutes, and assure the person it is all right to slow down or stop to rest at any time; use a stopwatch to time the walk; *a person who works >300 meters in 6 minutes is more likely to engage in ADLS*

modified allen test

the ______________________ is used to evaluate the adequacy of collateral circulation before cannulating the radial artery; A. formlmy occlude both hte ulnar and radial arteries of one hand while the person makes a fist several times; this causes hte hand to blanch; B, ask the person to open the hand without hyperextening it; then release pressure on the ulnar artery while maintaing pressure on the radial artery; adequate circulation is suggested by a palmar blush, a return to normal color in less than 7 seconds; although it is simple nad useful, it is relatively crude and subject to error (i.e. you must occlude both arteries uniformly with 11 pounds of pressure for the test to be accurate)

lacrimal apparatus

the _______________________ provides constant irrigation to keep the ocnjunctiva and cornea moist and lubricated

pupillary light reflex

the ________________________ is hte normal constriction of hte pupils when bright lights shines on the retina; it is a subcortical reflex arc, the sensory afferent link is CN II (optic nerve) and the motor efferent path is CN III (oculomotor nerve)

tongue

the ability of hte ________________ to change shape and position enhances its functions in mastication, swallowing, teeth cleansing, and speech formation; the _______________ also functions in taste sensation

aging adult oral cavity

the absence of some teeth and trouble with mastication encourage the older person to eat soft foots (usually high in carbohydrates) and decrease meat and fresh vegetabale intake; this produces a risk for nutritional deficit for protein, vitamins, and minerals

sutures

the adjacent cranial bones unite at meshed immovable joints called _______________; the bones are not firmly joined at birth; this allows for the mobility and change in shape needed for the birth processes; the ___________________ gradually ossify during early childhood

ocular fundus

the amount of data gathered during the fundoscopic exam depends on the child's ability to hold the eyes still and your ability to glean as much information as possible in a brief period of time a complete __________________ exam is difficult to perform on an intanft, but at least a check of the red reflex when the infant fixates at the bright light for a few seeconds; not any interruption of

hearing

the amplititude of a sound is how loud it is; its frequency is the pitch or number of cycles per second; the sound waves produce vibrations on your tympanic membrane; these vibrations on your tympanic membrane; these vibrations are carried by the middle ear ossicles to your oval window

kiesselbach plexus

the anterior part of hte septum holds a rich vascular network, ___________________, the most common site of nosebleeds

thoracic cage

the anteroposterior diameter should be less than the transverse diameter; the ratio of AP to transverse diameter is about 0.70- 0.75 in adults, and it increases with age the neck and trapezius muscles should be developed normally for age and occulation note the position the person takes ot breathe; this includes a relaxed posture and the ability to support one's own weight with arms comfortably at the sides or in the lap

palate

the arching roof of the mouth is the _________________; it is divided into two parts

fontanels

the bones of the neonatal skull are separated by sutures and __________________, the spaces where the sutures intersect; these membrane covered soft spots alalow for growth of the brain during the first year; they gradually ossify

sternum

the breastbone has three separate parts, the manubrium, the body, and the xiphoid process

candidasis

the candida species as normal oral flora is present in 60% of healthy adults; overgrowth occurs with steroid inhaler use, HIV infection, use of broad-spectrum antibiotics, or corticosteroids, leukemia, malnutrition, or reduced immunity

Traction alopecia

the cause is mechanical, not androgenic, and the hair loss is linear or oval along hairline, a part in hair, or scattered; the fringe sign is alopecia along the temporal hairline; trauma is from tight braiding, tight ponytail, barrettes, cornrows, hair weaves, black hair is intrinsicly fragile and continuous pulling in one direction can break ahir and cause loss; improves with loosening braides especially around hairline; redoing braids in a differnet direction, or using larger diameter braids

aging adult lung assessment

the chest cage commonly shows an increased AP diameter, giving a round barrel shape and kyphosis or an outward curvature of the thoracici spine; the person compensates by holding the head extended and tilted back; you may palpate marked bony prominences because of decreased subcutaneous fat; chest expansion may be somewhat decreased with the older person, although it still should be symmetric; the costla cartilages become calcified with aging, resulting in a less mobile thorax

infant/ children visual acuity

the child's age determies the screening measures used icv

herpes simplex 1 (HSV-1)

the common cold sores are groups of clear vesicles with a surrounding indurated erythematous base; these evolve into pustules, which rupture, weep, and crus and heal in 4 to 10 days; the most likely is the lip-skin unction; infectiou often recurrs in the same sight; _____________ is highly contagious and spread by direct contact; recurrent infections may be precipitaed by sunlight, fever, colds, and allergy

teeth and gums

the condition of the teeth is an index of the person's general health; you exam should not replace the regular dental exam; but note any disease, absent, loose, or abnormally positioned teeth; the teeth noramlly look white, straight, evenly spaced, and clean and free of debris or decay

arcus senilis

the cornea may look cloudy with age; an _____________________ is commonly seen around the cornea; this is a gray-white arc or circle around the limbus; it is caused by deposition of lipid material; as more lipid accumulates, the cornea may look thickened and raised, but the _________________ has no effect on vision as

aging adult lungs

the costal cartilage become calcified; thus the thorax is less mobile; respiratory muscle strength declines after age 50 years and continues to decrease into the 70s; a more significant change is the decrease in elastic properties within the lungs, making them less distensible and lessening their tendency to collapse and recoil; in all, the *aging lung is a more rigid structure that is harder to inflate*

veins

the course of the __________________ is parallel to the arteris, but the direction of flow is opposite; the ____________ absorb CO2 and waste products from the periphery and carry them back to the heart; the body has more veins, and they lie closer to the skin surface; ______________ accessible to examination are jugular, arm, and leg

percuss the chest

the depth of penetration of _______________ has limits; _____________ sets into motion only the outer 5-7 cm of tissue; it does not penetrate ro reveal change in density deeper tha nthat; in addition, an abnormal finding must be 2-3 cm wide to yield an abnormal percussion note; lesions smaller than that are not detectable by percussion

anterior fontanelle

the diamond-shaped ________________ closes between 9 months - 2 years

malleus

the drum is oval and slightly concave, pulled in at its center by one of the middle ear ossicles, the ________________; the parts of hte _________________ show through the translucent drum; these are the umbro, the manubrium, and the short process

eardrum/tympanic membrane

the ear canal is a cul-de-sac 2.5-3 cm long in the adult and termaintes at the ______________________

position (tympanic membrane)

the eardrum is flat and slightly pulled in at the center

pregnant woman lungs

the enlarging uterus elevates the diaphragm 4 cm during _____________________; this decreases the vertical diameter of the thoracic cage, but this increase is compensated for by an increase in the horizontal diameter; the increase in estrogen level relaxes the chest ligaments allowing for an increase in the transverse diameter of the cage by 2 cm, and the costal angle widens; the total circumference of the chest cage increases by 6 cm; the diaphragm moves even more during pregnancy, which results in a 40% increase in tidal volume

infants and children (ear)

the eustachian tube is relatively shorter and wider, and its position is more horizontal than the adult's thus it is easier for pathogens from the nasopharynx to migrate through to the middle ear; the lumen is surrounded by lymphoid tissue, which increases during childhood; thus the lumen is easily occluded; these factors place the infant at greater risk for middle ear infections that the adult; the infant's and the young child's external ear canals are shorter and have a slope opposite to that of hte adult's

conjunctiva

the exposed part of the eye has a transparent protective covering, the _________________; the ________________ is a thin mucous membrane folded like an envelope between the eyelids and eyeball

auricle/ pinna

the external ear is caleld the ___________________ and consists of movable cartilage and skin

external auditory canal

the external ear's characteristic shape serves to funnel sound waves into the opening, the ___________________ the __________________ is lined with glands that secrete cerumen, a yellow, waxy material that lubricates and protects the ear; the wax forms a sticky barrier that helps keep foreign bodies from entering and reaching the sensitive tympanic membrane; carumen migrates out ot hte meatus by movements of chewing and talking

infant/ children visual acuity

the eye exam is often deferred at birth because of transient edema of the lids from birth trauma or instillation of silver nitrate at birth; the eyes should be examined wihtin a few days and at every well-child visit thereafter icv

aging adult ocular structures

the eyebrow may show loss of the outer 1/3 to 1/2 of hair because of a decrease in hair follicles; the remaining brow hair is coarse; as a result of atrophy of elastic tissues, the skin around eyes may show wrinkles or crow's feet; the upper lid may be so elongated as to rest on the lashes, resulting in pseudoptosis aao

aging adult ocular structures

the eyes may appear sunken from atrophy of the orbial fat; in addition, the orbital fat may herniate, causing bulging at the lower lids and inner third of the upper lids aao

aging adult

the facial bones and orbits appear more prominent, and the facial skin sags as a result of decreased elasticity, decreased subcutaneous fat, and decreased moisture in the skin; the lower face may look smaller if teeth have been lost

thoracic cage

the first seven ribs attach directly to the sternum via their costal cartilages; ribs 8, 9, and 10 attach to the costal cartilage above, and ribs 11 and 12 are floating with free palpable tips

acute rhinitis (nonallergic)

the first sign is clear, watery discharge, rhinorrhea, which later becomes purulent, with sneezing, nasal itching, stimulation of cough reflex, and inflammed mucosa, which causes nasal obstruction; turbinates ar edark red and swollen

tongue

the floor of the mouth consists of the horsehoe-shaped mandible bone, the _____________, and underlying muscles; the ______________ is a mass of striated muscle arranged in a crosswise pattern so it can change shape and position; undeneath, the ventral surface of hte tongue is smooth and shiny and has prominent veins

tip

the free corner of hte nose is called the _______________

hearing

the function at the brainstem is binomial interaction, which permits locating the direction of a sound in space and identifying the sound the function of the cortex is to interpret the meaning of hte sound and begin the appropriate response; all this happens in the split second that it takes you to react to the alarm

hearing

the function of _____________________ involves the auditory systems at three levels: peripherla, brainstem, and cerebral cortex; at the peripheral level the ear transmits sound and converts its vibrations into electrical impulses, which can be analyzed by the brain

iscchemia

the function of hte arteries is to supply oxygen adn essentia lnutrients to the cells; __________________ is a deficient supply of oxygenated arterial blood to a tissue caused by obstruction of a blood vessel; a complete blockage leads to death of the distal tissue; a partial blockage creates an insufficient supply and the ischemia may be apparent only at exercise when oxygen needs increase

saliva

the glands secrete _________________, the clear fluid that moistens and lubricates the food bolus, starts digestion, and cleans and protects the mucosa

presbyopia

the glasslike quality of the lens decreases the ability of the lens to change shape to accommodate for near vision, a condition termed ______________; by 40 years of age 50% of people have __________ and need printed images magnified; the prevalence is 83% in later years

pregnant woman lungs

the growing fetus increases the oxygen demand on the mother's body; this is met easily by the increasing tidal volume; little change occurs in the respiratory rate; an increased awareness of the need to breathe develops early in pregnancy; this physiologic dyspnea affects close to 75% of women, does not alter activiteis of daily leiving, and is not associated with cough, wheezing, or exercise

lanugo

the hair follicles develop in the fetus at 3 months' gestation; by midgestation most of the skin is covered with ________________, the fine downy hair of the newborn infant

lymph nodes

the head and neck have a rich supply of 60-70 ___________________

arteries

the heart pumps freshly oxygenated blood through the ________________ to all body tissues; the pumping heart meakes this a high-pressure system; the _____________ walls are strong, tough, and tense to withstand pressure demands; ________________ contain elastic fibers, which allow their walls to stretch with systole and recoil with diastole; they also contain muscle fibers, which control the amount of blood delivered to the tissues; the VSM contracts or dilates, which changes the diameter of the arteries to control the rate of blood flow

aging adult lungs

the histologic changes also increase the ________________________ risk for postoperative pulmonary complications; he or she has a greater risk for postop atelectasis and infection from a decreased ability to cough, and loss of protective airway reflexes, and increased secretions

face

the human __________________ has many appearances and expressions that reflect mood; the expressions are formed by the facial muscles, which are mediated by cranial nerve 7, the facial nerve; facial muscle function is symmetric bilaterally, except for an occasional quirk or wry expression

cleft lip/ palate

the incidence of ___________________ is 1 in every 940 births in the US; isolate cleft palate is less common; rates are higher in Asians and American Indians and lower in African heritage births; males have a 1-2 ratio over females for cleft lip with or without cleft palate

acne

the increase in sebaceous gland activity creates increased oiliness and ___________; ___________ is hte most common skin problem of adolecence; almost all teens have ______________ even in the milder form of open comedones and closed comedones

infant and children lung assessment

the infant breathes through the nose rather than the mouth and is an obligate nose breather until 3 months; slight flaring of the lwoer costal margins may occur with respirations, but normally no flaring of hte nostrils and no sternal retractions or intercostal retractions occur; the diaphragm is the newborn's major respiratory muscle; intercostal muscles are not well developed; thus you can observe the abdomen bulge with each inspiration but see little thoracic expansion

tonic neck reflex

the infant can turn the head side to side by 2 weeks and shows the _________________ when supine and the head is turned to one side (extension of same arm and leg, flexion of opposite arm and leg); _________________ disappears between 3 and 4 months, and then the head is maintained in the midline tnr

head posture/ head control

the infant can turn the head side to side by 2 weeks and shows the tonic neck reflex; ___________________ is achieved by 4 months when the baby can hold the head erect and steady when pulled to a vertical position hp

infant and children lung assessment

the infant has a rounded thorax with a nequal AP-to-transverse chest diameter; by age 6 years the thorax reaches the adult ratio of 1:2; the newborn's chest circumference is 30-36 cm and 2 cm smaller than head circumference until 2 years of age; the chest wall is thin and with little musculature; the ribs and xiphoid are promoinent; you can both see and feel the sharp tip of the xiphoid process; the thoracic cage is soft and flexible

3 months

the infant starts salivation at ______________; the baby drools for a few months before learning to swallow the saliva; this drooling does not hearld the eruption of the first tooth, although many parents think it does

carcinoma

the initial lesion is round and indurated; it becoems crusted and ulcerated with an elevated border; most occur between the outer nad middle thirds of hte lip; any lesion that is still unhealed after 2 weeks should be referred

basal layer

the inner ___________________ forms new skin cells; _______________ is part of the epidermis

infants and children (ear)

the inner ear starts to develop early in the 5th week of gestation; in early development the ear is posteriorly rotated and low set; it later ascends to its normal placement around eye level; if materna lrubella infection occurs during the first trimester, it can damage the organ of Corti and impair hearing

pleurae

the inside of the envelope, the _______________ is potentia lspace fileld only with a few mililiters of lubricating fluid; it normally has a vacuum, or negative pressures, which holds the lungs tightly against the chest wall; the lungs slide smoothly and noiselessly up and down during respiration, lubricated by a few mililiters of fluid

aging adult ocular structures

the lacrimal apparatus may decrease tear production, causing the eyes to look dry and lusterless and hte person to report a burning sensation aao

parotid gland

the largest salivary gland, the _______________, lies within the cheeks in front of the ear, extending from the zygomatic arch down to the angle of the jaw; its duct, Stensen duct, runs forward to open on the buccal mucosa opposite the second molar

diabetic retinopathy (aging adult eyes)

the leading cause of blindness in adults 25-74 years of age; this vision impairment results in difficulty driving, reading, managing diabetes treatment, and other self-care; the prevalence has decreased slightly as a result of intensified prevention measures and newer treatments, such as injection of steroids into the vitreous and anti-growth factor drugs; however, this process could be offset by increasing obesity rates, increasing number of older adults ,and improved detection of diabetes

lateral chest

the left lung contains only two lobes, upper and lower; these are seen laterally as two triangular areas separated by the oblique ifssure; the left upper lobe extends form teh apex of the axilla down to the 5th rib at hte midaxillary line; the left lower lobe continues down to the 8th rib in the midaxillary line

malignant skin lesions

the link between UV radiation and skin cancer is well known; the UV radiation is sunlight and indoor tanning beds promotes all three forms of skin cancer shown; more than and half a person's lifetime sun damage occur before adulthood

oral cavity

the lips are the anterior border of the _________________, the transition zone form outer to the inner mucous membrane lining hte __________________; the cheeks are the side walls of the ___________________

ectropion

the lower lid is loose and rolling out (Eversion), does not approximate to the eyeball; puncta cannot siphon tears effectively; thus excess tearing results; the eyes feel dry and itchy because the tears do not drain correctly; exposed palpebral conjunctiva increases risk for inflammation; it occurs in aging from atophy of elastic and fibrous tissues but may result from trauma, chronic inflammation, or Bell palsy

entropion

the lower lid rolls in (inversion) because of spasm of lids or scar tissue contracting; constant rubbing of lashes may irritate cornea, leading to tearing nad red eye; the person feels a foreign body sensation

infants and children (peripheral circulation)

the lymphatic system has the same function in children as in adults; lymphoid tissue is well developed by birth and grows rapidly until age 10-11 years; by 6 years of age the lymphoid tissue reaches adult size; it surpasses adult size by puberty, and then it slowly atrophies; it is possible that the excessive antigen stimulation in children causes the early rapid growth

neck muscles

the major _____________ are the sternomastoid and the trapezius muscles; they are innervated by cranial nerve XI, the spinal accessory nerve

brachial artery

the major artery supplying the arm is the ______________, which runs in the biceps-triceps furrow of the upper arm and surfaces at the antecubital fossa in the elbow medial to the biceps tendon

femoral artery

the major artery to the leg is the ____________________, which passes under the inguinal ligament; the _________________ travels down the thigh

keratin

the major ingredient of the epidermal cells is the tough, fibrous protein _____________

malignant melanoma

the malignant transformation of melanocytes may arise from a preexisting nervus or de novo; usually brown; can be tan, black, pink-red, purple, or mixed pigmentation; often irregular or notched borders; may have scaling, flaking, oozing texutre

epistaxis

the most common site of a nosebleed is Kiesselbach plexus in the anterior septum; peak incidence is bimodal, <18 years and >50 years; causes include nose picking, foreceful coughing or sneezing, fracture, foreign body, ilicit drug use, topical nasal drugs, warfarin, aspirain, or a coagulation disorder; bleeding from the naterior septum is easily controlled and rarely severe; a posterior hemorrhage is less common but more profuse, harder to manage, and more serious

otitis media/ OM

the most importnat side effect of _________________ is persistence of fluid in the middle ear after treatment; this middle ear effusio ncan impair hearing, placing the child at risk for delayed cognitive development

oral cavity

the mouth is the first semgent of hte digestive system and an airway for the respiratory system; the _________________ is a short passage bordered by the lips, palate, cheeks, and tongue; it contains the teeth and gumes, tongue, and salivary glands

ciliary body (middle layer)

the muscles of the _______________ control the thickness of the lens

septum

the nasal cavity is divided medially by the ________________ into two slitlike air passages; in many people, the _______________ is not absolutely straight and may deviate toward one passage

aging adult (face/neck)

the neck may show an increased anteriror cervical curve when the head and jaw are extended forward to compensate for kyphosis of hte spine; during the exam, direct the older adult to perform ROM slowly; he or she may experience dizziness with side movements; an older adult may have prolapse eof the submandibular glands, which could be mistaken for a tumor; but drooping submandibular glands are soft and present bilaterally aa

infants and children (nasal exam)

the newborn may have milia across hte nose; the nasal bridge may be flat in black and Asian children; there should be no nasal flaring or narrowing with breath

infant and children lung assessment

the newborn's first respiratory assessment is part of hte APGAR scoring system to measure hte successful transition to extrauterine life; the five standard parameters are scored at 1 minute and 5 minutes after birth; a 1 minute score of 7-10 indicates a newborn in good condition, needing only suctioning of nose and mouth and otherwise routine care

pathways of hearing

the normal pathway of hearing is air conduction, described earlier; it is the most efficent; an alternate route of hearing is by bone conduction; here the bones of the skull vibrate; these vibrations are transmitted directly to the inner ear and to cranial nerve VIII

hypercapnia

the normal stimulus to breath for most people is an increase in carbon dioxide in the blood, or _________________

agining adult (mouth exam)

the nose may appear more prominent on the face from loss of subcutaneous fat; in the edentulous person, the mouth and lips fold in, giving the person a purse-string appearanc;e hte teeth may look slightly yellowed, although the color is uniform; yellowing results form dentin visible through worn enaamel; the surface of the incisiors may show vertical cracks from a lifetiem of exposure to extreme temperatures; teeth may look longer as gum margins recieve

aging adult lung assessment

the older person may tire easily during ascultation when deep mouth breathing is required; take care that this person does not hyperventilate and become dizziy; allow brief rest period or quite breathing; if hte person does feel faint, holding the breath for a few seconds restoes equilibrium

aging adult skin

the outer layer of the epidermis thins and flattens; this allows chemicals easier to access into the body; wrinkling occurs because the underlying dermis thins and flattens; a loss of elastin, collagen, and subcutaneous fat and reduction in muscle tone occur; the loss of colalgen increases risk for shearing, tearing injuries

external auditory canal

the outer third of the ________________ is cartilage, the inner two thirds tunnels though the temporal bone and is covered by thin, sensitive skin; the canal has a slight S-curve in the adult; the outer one third curves up and toward the back of hte head, whereas the inner two thirds angles down and forward toward the nose

nares

the oval openings at the base of the nose are called the _______________

shock

the pallor of __________________ presents with rapid pulse rate, oliguria, apprehension, and restlessness

ascultate chest

the passage of air through the tracheobronchial tree cretes a characteristic set of sound that are audible through the chest wall

primary angle-closure glaucoma (PACG)

the person experiences a sudden clouding of vision, sudden eye pain, and halos around lights; this requries emergency treatment to avoid permanet vision loss

normal eye

the person's eye and your eye are normal; the 0 diopter (clear glass) will focus sharply on the retina

costodiaphragmetic recces

the pleurae extend approximately 3 cm below the level of hte lungs, forming the _____________________; this is a porential space; when it fills with air of luid it compromises lung expansion

infants and young children (ear exam)

the position of hte eardrum is mroe horizontal in the noenate, making it more difficult to see completely and harder to differentiate from the canal wall; by 1 month of age, the trum is in the oblique position as in the older child, and examination is a bit easier

vertebral (midspinal) line

the posterior chest wall has the __________________, which divides the posterior surface in half

cerumen

the presence and composition of _____________ are not related to poor hygiene; ______________ is supposed to be present to lubricate, waterproof, and clean the externa lauditory canal; _______________ also is antibacterial, and it traps foreign bodies; take care to avoid mistaking the flaky, dry cerumen for ezcematous lesions

asthma

the prevalence of _________________ is 8.4% in children ages <18 years, making it hte most common chronic disease in childhood; the highest burden of _____________ is among those living at or below the federal poverty level

AV ratio (retinal vessels)

the ratio comparing the artery-to-vein width is 2:3 or 4:5 ABNORM: arteries too constricted veins dilated

infants and children respiratory considerations

the relatively smaller size and immaturity of children's pulmonary systems and presence of caregivers who smoke result in enormous vulnerability and increased risk to child health; if the mother smokes during pregnancy, the baby has increased risk of low birth weight, decreased head growth, and SIDS; after birth, second hand smoking exposure increases the infant's risk of upper and lower respiratory tract infections, otitis media, asthma, tooth decay, hearing loss, and metabolic syndrome, as well as later risk for ADHD, behavioral disorders, learning disabilites, cognitive disabilities, and problems at school; it is crucial for pregnant women and infants and children to avoid SHS

pars tensa

the remainder of the eardrum which si thicker nad more taut is the ___________________

pleural cavities

the right and left _____________________ are on either side of the meadiastinum and contain the lungs

costal angle

the right and left margins form an __________________ where they meet the xiphoid process; usually 90 degrees or less, this angle increases when rib case is chronically overinflated, as in emphysema

horizontal (minor) fissure

the right lung also contains the __________________, which divides the right upper and middle lobes; this fissure extends form the 5th rib in the right midaxillary line to the 3rd intercostal space or 4th rib at the right sternal border

conjunctiva and sclera

the sclera is china white, although blacks occasioanlly have a gray-blue or muddy color to the sclera; also in dark-skinned people you normally may see small brown macules (like freckles) on the sclera, which should not be confused with foreign bodies or petechiae; finally blacks may have yellowish fatty deposits beneath the lids away from the cornea

confrontation test

the sensitivity of ____________________ can be increased by combining the wiggling finger with a moving red target; hold a 5-mm red topped pin beyond the boundary of each quadrant between the horizontal and vertical axes; ask the person to state when the pin first appears red

4 weeks

the skin cells are constantly being shed, or desquamated, and are replaced with new cells from below; the epidermis is completely replaced every ______________________

skin condition

the skin color is consistent with the person's facial skin color; the skin is intact, with no lumps or lesions

epidermis dermis

the skin has two layers: the outer, highly differentiated ___________________ and the inner supportive _______________

production of vitamin D (skin function)

the skin is the surface on which UV lights converts cholesterol into _____________

pars flaccida

the small, slack superior segment of the TM is called the ____________________

sub-lingual gland

the smallest, tthe almond-shaped _______________ lies wihtin the floor of the mouth under hte tongue; it has many small openings along hte sulbingual fold under the tongue

hearing

the sound waves travel through the cochlea, which is coiled like a snail shell, and are dissipated against hte round window; along the way to the basilar membrane vibrates at a point specific to the frequency of hte sound; the numerous fibers along the basilar membrane are the receptor hair cells of hte organ of corti, the sensory orgna of hearing; as the hair cells bend, they mediate the vibratiosn into electric impulses; the electrical impulses are conducted by autditory portion of cranial nerve VIII

voice sounds

the spoken voice can be ascultated over the chest wall just as it can be felt in tactile fremitus; normal vocie transmission is soft, muffled, and indistincg; you can hear sound through the stethoscope but cannot distinguish exactly what is being said; pathology that increases lung density enhances transmission of voice sounds

lymph nodes

the superficial groups of ________________ are accessible to inspection and palpation and give clues to the status of the lymphatic system

smooth, glossy tongue (atrophic Glossitis)

the surface is slick and shiny, mucosa thins and looks red from decreased papillae; accompanied by dryness of tongue and burning; occurs with vitamin B 12 deficiency, folic acid deficiency, and iron deficiency anemia

meibomian glands

the tarsal plates contain the _________________, modified sebaceous glands that secrete an oily lubricating material onto the lids; this stops the tears form overflowing and helps form an airtight seal when the lids are closed

diaphragmatic excursion

the technique of measuring ___________________ using percussion is *no longer recommended* for two reasons: 1. in persons with lung disease, evidence shows that clinicans usually overestimate diaphragmatic movement and that their results differ from chest image by 1-3 cm 2. evidence shows that diaphragmatic excusion of <2 cm is an unreliable and infrequent sign of COPD; you should attend to other physical examination signs of COPD

agining adult (mouth exam)

the teeth surfaces may look worn down or abraded; old dental work deteriorates, especially at the gum margins; the teeth loosen with bone resorptio nand my move with palpation the tongue looks smoother as a result of papillary atrophy; the aging adult's buccal muscsoa is thinned and may look shiner as though it were varnished

aging adult (face/neck)

the temoral arteries may look twisted and prominent; in some ___________________ a mild rhythmic tremor of the head may be normal; if some teeth have been lost, the lower face looks unusually small, with the mouth sunken in aa

temporal area (head)

the temporomandiublar joint is just below the temporal artery and anterior to the tragus; palpate the joint as the person opens the mouth and note normally smooth movement with no limitation or tenderness ta

crust (secondary lesion)

the thickened, dried-out exudate left when vesicles/pustules burst or dry up. Coor can be red-brown, honey, or yellow, depending on the fluid's ingredients (blood, serum, pus). Examples: Impetigo (dry-honey colored), weeping eczematous dermatitis, scab after abrasion.

pleurae

the thin, slippery _____________ are serous membranes that form an envelope between the lungs and the chest wall

pregnant woman lung assessment

the thoracic cage appears wider, and the costal angle widens by about 50%; respirations are deeper, with a 40% increase in tidal volume

pharynx

the throat/ ______________ is the area behind the mouth and nose

neck (infant)

the thyroid gland is difficult to palpate in an infant because of hte short, thick neck; the child's thyroid may be palpable normally n i

enlarged tongue (macroglossia)

the tongue is enlarged and may protrude from the mouth. the condition is not painful but may impair speech development; it occurs with down syndrome, cretinism, myxedema, and acromegaly; a transient swelling also occurs with local infection

dead space

the trachea nad bonrchi constitute the _______________, or space that is filled with air but is not available for gaseous exchange; this is about 150 mL in the adult

nail color

the translucent nail plate is a window to the even, pink nail bed underneath; dark skinned people may have brown-black pigmented areas or linear bands or streaks along the nail edge; all people normally have white hairline markings from trauma or picking at the cutickle called leukonyhiha

allergic salute and crease

the transverse line on the nose is a feature of chronic allergies; it is formed when the child chronically uses the hand to push the nose up and back to relieve itching and free swollen turbinates, which allow air passage

posterior fontanelle

the triangle-sphaped ______________________ is closed by 1-2 months

trapezius muscles

the two ___________________ on the upper back arise from the occipital bone and the vertebrae and extend fannign out to the scapula and clavicle; the _____________________ move the shoulders and extend and turn the head

inspect and palpate arms

the two arms should be symmetric in size ABNORM: edema of upper extremities occur when lymphatic drainage is obstructed after breast surgery or radiation

diopter

the unit of strength of each lens is the __________________, the black numbers indicative a positive ______________; they focus on objects nearer in space to the opthalmoscope; the red numbers show a negative _______________ and are for focusing on objects farther away

lid lag

the upper eyelid should continue to overlap the superior part of the iris, even during downward movement; you should not see a white rim of sclera between teh lid and iris; if noted this is ___________________, which occurs with hyperthyroidism

allergic conjunctivitis

the upper lid, conjunctiva, and cornea are inflamed from senal allorgen (e.g. pollen, spores) or persistent allergen (dust mite, animal dander)

bifid uvula

the uvula looks partly severed and may indicate a submucous cleft palate, which feels like a notch at the junction of hard and soft palates; this may affect speech development because it precents necessary air trapping; the incidence is more common in American Indians

senile purpura

the vascularity of the skin diminishes while the vascular fragility increases; a minor trauma may produce dark red discolored areas, or ________________

inspect and palpate legs

the venous pattern normally is flat nad barely visible; note varicosities, although these are best assessed while standing; both legs should be symmetric in size without any swelling or atrophy; if the lower legs look asymmetric or if DVT is suspected, measure the calf circumference with a nonstretchable tape measure; measure at the widest point, takign care to measure the other leg in exactly the same place; if lymphedema is suspected, measure also the ankle, distal calf, knee, and thigh

superficial veins (small saphenous)

the________________, outside the leg, starts on the lateral side of the dorsum of the foot and ascends behind the lateral malleolus, up the back of the leg, where it joints the popliteal vein; blood flows from the superficial veins into the deep veins

respiratory system functions

there are four major ________________: 1. supplying oxygen to the body for energy production 2. removing carbon dioxide as a waste product of energy reactions 3. maintaing homeostasis (acid-base balance) of arterial blood; 4. maintaing heat exchange (less important in humans)

transillumination

there is no evidence to support the practice of ______________ of the frontal or maxillary sinuses when you suspect sinus inflammation; the diagnosis requires distinct differences in the illumination of one of the sinus pair; thus the technique is not helpful in chronic sinusitis that has diffuse swelling of all sinus mucosa; although there is more fluid collection with acute sinusitis, the asymmetry of light illumination is not valid because many healthy sinuses do not normally _________________

second hand smoke

there is no safe level of ______________ for nonsmokers, pregnant women, babies, or children; nonsmokers exposed to ________________ at home or work increase risk for heart disease by 25-30% and risk for stroke by 20-30%; pregnant women exposed to _____________ increase risk of low-birht weight infants, as well as the risk of SIDS; babies and children exposed to _______________ are at increased risk for upper and lower respiratory tract infections, otisi media, asthma, dental caries, hearing loss, metabolic syndrome, ADHD, behavioral disorders, learning disabilities, and school difficulties

Blue Drum (Hemotympanum)

this indicates blood in the middle ear, as in trauma resulting in skull fracture

onchomycosis

this is a slow, persistent fungal infection of fingernails and, more often, toenails, common in older adults; fungus causes change in color (green where nail plate separated from bed), texture, and thickness, with nail crumbling or breaking and loosening of hte nail plate, usually beginning at hte distal edge and progressing proximally

black hairy tongue

this is not hair but rather the elongation of filiform papillae and painless overgrowth of mycelial threads of fungal infection on the tongue; color varies from black-brown to yellow; it occurs after use of antibiotics, which inhibit normal bacteria and allow proliferation of fungus; and with heavy smoking

down syndrome

this is the most common chromosomal aberration; head and face characteristics includ upslanting eyes with inner epicanthial folds; flat nasal bridge; small, broad, flat nose; protruding, thick tongue; ear dysplasia; short, broad neck with webbing; small hands with single palmar crease; child also has mental disability, often congenital heart deformities

corneal abrasion

this is the most common result of blunt eye injury, but irregular ridges are usually only visible when fluorescin stain reveals yellow-green blanching; top layer of corneal epithelium is removed due to scratches or poorly fitting or overworn contact lenses; because the area is rich in nerve endings, the person feels intense pain; a foreign obdy sensation; and lacrimation, redness, and photophobia

retinal vessels

this is the only place in the body where you can view blood vessels directly; many systemic diseases that affect the vascular system show signs i nthe ____________________; note: number color AV ratio caliber AB crossing tortuosity pulsations

inspection

thoracic cage respirations skin color and condition person's position facial expression level of consciousness

acute arterial symptoms

those at risk: history of vascular surgery; arterial invasive procedure; abdominal aneurysm (emboli); trauma, including injured arteries; chronic atrial fibrillation

chronic venous symptoms

those at risk: job with prolonged standing or sitting; obesity; multiple pregnancies; prolonged bed rest; history of heart failure, varicosities, or thrombophlebitis; veins crushed by trauma or surgery

chronic arterial symptoms

those at risk: older and middle age adults; african americans 2x more likely; smoking is strongest risk, also hypertension, diabetes, hypercholesterolemia, obesity, vascular disease

cluster headache

timing: 1-2/day, each lasting 1/2 to 2 hr for 1-2 months; then remission for months or years c

migraine hedache

timing: around 2 per month, lasts 1-3 days around 1 in 10 patients have weekly headaches m

tension headache

timing: situational, in response to overwork, posture t

petechiae

tiny punctate hemorrhages, 1-3 mm, round and discrete; dark red, purple, or brown in color; caused by bleeding from superifial capillaries; will not blanch; may indicate abnormal clotting factors; in dark-skinned people _______________ are best visualized in the areas of ligher melanization; when the skin is black or dark brown; ____________ cannot be seen in the skin

size and shape (head)

to assess shape, place fingers in the person's heir and palpate the scalp; the skull normally feels symmetric and smooth; cranial bones that have normal protrusions are the forehead, side of each parietal bone, occipital bone, and mastoid process behind each ear, there should be no tenderness to palpation s/s

infants and young children (ear exam)

to help prepare the child, let him hold your funny looking flashlight; you may wish to have the child look in the parent's or a toy puppet's ear as you hold the otoscope

infant and children lung assessment

to prepare, let the parent hold an infant supported against the chest or shoulder; ignore the usual sequence of hte physical exam; size hte opportunity wiht a sleeping infant to insepct and then listen to lung sounds next; this way you can concentrate on the breath sounds before the baby wakes up and possibly cries; however, infant crying does not have to be a problem because it actually enahces palpation of tactile fremitus and ascultation of breath sounds

albinism (pallor)

total absence of pigment melaning throughout integument _________________ causes light skin: whitish, pink dark skin: tan, cream, white

throat

touching the posterior wall with the tongue blade elicits the gag reflex; this tests cranial nerves IX and X, the glossopharyngeal and vagus

infants and childrne peripheral vascular system

transient acrocyanosis and skin mottling at birth; pulse force should be normal and symmetric; it also should be the same as in the upper and lower extremities

battle sign

trauma to the side of the head may lead to a basilar skull fracture involving the temporal bone; this shows as ecchymotic discoloration just posterior to the pinna and over the mastoid process; a look inside the ear canal may show hemotympanum as well

tuning fork tests

tuning fork tests measure hearing by air conduction and bone conduction, in which the sound vibrates through the cranial bones to the inner ear; the AC route throug hthe ear canal and middle ear is usually the more sensitive route; if hearing loss is identified by history or whispered voice test, __________________ traditionally were used to diagnose conductive from sensorineural loss; the Rhinne test is mroe accurate in detecting conductive hearing loss; neither test can distingusih normal hearing from a sensorineural loss in both ears, you should rely of audiometry

pusutule (primary lesion)

turbid fluid (pus) in the cavity; ircumscribed and elevated; examples: impetigo, acne

paranasal sinuses

two pairs of _____________ are accessible to exam, the frontal and maxillary sinuses

salivary glands

two pairs of __________________ are accessible to examination on the face, the parotid and submandipular; a third pair, are the sublingual

carinoma

ulcerated, crusted nodule with indurated base that fails to heal; bleeds intermittently; must refer for biopsy; usually occurs on the superior rim of the pinna, which has the most sun exposure; may occur also in ear canal and show chronic discharge that is either serosanguinous or bloody

arterial (ischemic) ulcer

ulcers at toes, metatarsal heads, heels, and lateral ankle and are characterized by pale ischemic base, well defiend edges, and no bleeding; they look dry and punched out; arterial ulcers are more common in those with smoking, diabetes, hyperlipidemia, and hypertension

venous (stasis) ulcer

ulcers occuur at medial malleolus and tibia; characterized by bleeding, uneven edges

inspect and palpate legs

uncover the legs while keeping the genitalia draped; inspect both legs together, noting skin cololr, hair distribution, venosu pattern, size, and any skin lesions or ulcers normally hair covers the legs; even if leg hair is shaved, you will not hair on the dorsa of the toes

cover test

uncovered eye- if it jumps to fixate on designated point, it was out of alignment before, i.e. cover the stronger eye and weaker eye has to fixate

jugulodigastric/tonsillar lymph nodes

under the angle of the mandible

meatus

underlying each turbinate is a cleft, the ______________, which is named for the turbinate above; the sinuses drain into the middle _____________, and tears from the nasolacrimal duct drain into the inferior __________________

glacuoma patient education

unrecognized and untreated, glaucoma is chronic, progressive, and causes irreversible visual field loss; this progresses to tunnel vision and then to loss of central vision

strasbismus

untreated _________________ can lead to permanetn visual damage; the resulting loss of vision from disuse is amblopia ex anopsia; about 1-6% of children under 6 years of age have amblyopia or risk factors; untreated vision problems may cause accidents, injuries, depression, anxiety, problems at school, and poor self-esteem; also these children are targets of bullying behaviors s

peritonsillar abcess

untreated acute streptococal pharyngitis may cause suppurative complications, peritonsillar abscesses, or suppurative thrombophlebitis; therombophlebitis is Lemierre syndroem, a rare but life-threatening condition caused by the gram-negative F. necrophorum, leading to sepsis; the two major red flags are woresning symptoms or neck swelling, along with fever and decreased range of motion

infants and children (oral exam)

use a game to prepare the young child; encourage preschool child to use a tongue blade to look into a puppet's mouth; or place a mirror so the child can look into his or her mouth just as you look; the school-age child is usually cooperative and loves to show off missing or new teeth

Wood's light

use a magnifier and light for closer inspection of a lesion; use a _________________ to detect fluorsecing lesions; under the ______________, lesions with blue-green fluorescence indicate fungal infection (e.g. tinea capitis/ scalp ringworm)

3-6 years of age

use a picture chart or snelle E chart for preschooler from _________________; the E chart shows the capital letter E in varying sizes pointing in different directions; the child points his or her fingers in the direction of the table legs 3

hearing acuity (infants/children)

use developmental milestones to assess hearing in an infnat; also attent to parent's concern over an infnat's inability to hear; their assessment is usually well founded the room should be silent and hte baby content; make a loud, sudden noise out of hte baby's peripheral range of vision about 12 away; you may need to repeat a few times, but you should note: newborn- startle/ morro reflex, acoustic blink reflex 3-4 month- acoustic blink reflex, infant stops movement and appears to listen, stops sucking, quiets if crying, cries if quiet 6-8 month- ifnant turns head to localize sound, responds to own name preschool/ stool age- child screened with auiometry

lymph nodes (neck)

use gentle pressure because strong pressure could push the nodes into neck muscles; it is usually most efficient to palpate with both hands and compare the side symmetrically; however, the submental gland under the tip of the chin is easier to position the person's head; for the deep cervical chain, tip the person's head toward the side being examined to relax the ipsileraral muscle; then you can press your fingers under the muscle; search for the supraclavicular node by having the person hunch the shoulders and elbows forward, this relaxes the skin; the inferior belly of the omohyoid muscle crosses the posterior triangle here; do not mistake it for a lymph node ln

ankle-brachial index

use hte doppler probe for bot hmeasurements; in all sides locate the pulse with the doppler and inflate teh cuff 20 mmHg above the disapperance of flow signal; then deflate slowly to detect reappearance of flow signal; moving counterclockwise, measure: right arm, right posterirtibial, right dorsalis pedis, left PT, left DP, left arm

keep skin on feet soft and smooth

use mild soap/ skin lotion avoid adding oils or bubble bath to the bath, it makes the feet and tube slippery

ankle-brachial index

use of the doppler stethoscope is a highly specific, noninvasive, and readily available way to determine the extent of peripheral arterial disease

profile sign

use the ________________, viewing the finger from the side, to detect early clubbing; the norma lnail-bed angle is 160 degrees

doppler ultasonic probe

use this device to detect a weka peripheral pulse, to monitor blood pressure in infants or children, or to measure a low blood pressure or blood pressure in a lower extremity; the _________________ magnifies the pulsatile sounds from the heart and blood vessels; position the person supine, with the legs externally rotated so you can reach the medial ankles easily; place a drop of coupling gel on the transducer; palce the transducer over a pulse site at a 90 degree angle; apply light pressure; locate pulse by the swishing, whooshing sound

lymph nodes (neck)

using a gentle circular motion of your finger pads, palpate the __________________; beginning with the preauricular _____________________ in front of the ear, palpate the 10 groups in routine order; many nodes are closely packed, so you msut be systematic and thorough in your exam ln

palpate chest

using the fingers, gently _______________ wall; this enables you to note any areas of tenderness, to note skin temperature and mositure, to detect any superficial lumps or masses, and to explore any skin lesions noted on inspection

palpating sinuses

using your thumbs, press the frontal sinuses by pressing firmly up and under the eyebrows and over the maxillary sinuses below the cheekbones; take care not to press directly on the eyes; the person should feel firm pressure, but no pain

bell palsy

usually presents with smooth forehead, wide palpebral fissure, flat nasolabila fold, drooling, and pain behind hte ear; this is greatly improved if corticosteroids and antivirals are given within 72 hours of onset

basal cell carcinoma

usually starts as a small, pink or red papule (may be deeply pigmented) with a pearly translucnet top and overlying telangiectasia; then develops rounded pearly borderse with central red ulcer or looks like large open pore with central yellowing; *most common form of skin cancer,* slow but inexorable growth________________ occur on sun-exposed areas of face, ears, scalp, shoulders

culture/ genetics peripheral circulation

variables for African americans are smoking, blood pressure, total choleterol, BMI, glucose, healthy diet, and physical activity; researchers found hte prevalence in African Americans increased with the frequency of poor health indicators in these 7 categories; a poor score in 3 or more of the healt hindicators increased the risk for PAD; thus the health care team must provide comprehensive screenigns for Africna Americans, women, and all aging persons and tailor managment of the disease

venous flow

veins drain the deoxygenated blood with its waste products from teh tissues and return it to hte heart; unlike the arteries, veins are a low-pressure system; because tehy do not have a pump to generate their flow, they need a mechanism to keep blood moving

capacitance vessels

veins have a larger diameter and are more distensible; they can expand and hold more blood whel blood volume increases; this is a compensatory mechanism to reduce stress (preload) on the heart; because of this ability to stretch, veins are called _________________

ronchial fremitsu

vibration felt when inhaled air passes through thick secretions in the larger bronchi; this may decrease somewhat by coughing

nasal cavity

view each ________________ with the person's head erect and the nwhen the head tiled back; inspect nasal mucosa, noting nromal red color and smooth, mosit surface; note any swelling, discharge, bleeding, or foreign body

profile sign

view the index finger at its ___________ and note the angle of the nail bas;e it should be about 160 degrees; the nail base is firm to palpation; curved nails are a variation of normal with a convex profile, they may look like clubbed nails, but the angle is normal

Eyes subjective data

vision difficulty (decreased acuity, blurring, blind spots) pain strabismus, diplopia redness, swelling watering, discharge history of ocular problems glaucoma use of glasses or contact lenses patient-centered care

stabismus and amblyopia

vision screening is crucial in preschool children to detect _________________; US. Preventative services task force recommends screening at least once in all children age 3-5 to detect __________________ or risk factors

lesion on optic tract or optic radiation

visual field loss in nasal and temporal fields; loss of same have of visual field in both eyes if homonymous hemianopsia

cultural aspects vision

visual impariment is not being able to see letters on the eye chart at line 20/50 or below; African Americancs were the minority group with the highest prevalence of VI and blindness; VI and blindness have a huge impact on physical and mental health, increasing risk for lost productivity, chronic health conditions, accidents and injuries, social isolation, depression, and mortality; visual impairment is largely due to uncorrected refractive error and could so easily be improved through glasses, contact lenses, and refractive surgery; vision screening is low in cost and yields huge releif from the health problems above

blood flowing to feet

walking sit down and rotate ankles in one then other direction but feet up when sitting, lying down, stretching, wiggling toes if sitting a long time, stand up and move every half hour to hour uncross legs often when sitting

use of glasses/ contact lenses (subjective data)

wear glasses/ contact lenses? how do they work? last time prescription was checked? was it changed? any pain, photophobia, watering, or swelling with contact lenses how often do you care for contacts

shoes

wear shoes that fit and are comfortable, when when outside always measure feet toward end of day when feet may be largest if one foot is larger than the other, buy shoes that fit the larger one chose shoes so that the ball of the foot fits comfortably into the widest part of the shoe and toes are not crowded low-heeled shoes are safer nad less damaging to toes

urticaria (hives)

wheals coalesce to form extensive reaction, intensely pruritic

hypothalamic-pituitary-thyroid axis

when T3 and T4 hormone levels are low, the pituitary sends out increasing TSH to stimulate nw production of T3 and T4 homrones; your body metabolism is most comfortable in a healthy balance of hormone levels

secondary

when a lesion changes over time or changes due to scratching or infection, it is called ________________

pseudostrabismus

when epicanthal folds are present, they give a false appearance of malalingment, temred __________________- p

infants and young children (ear exam)

when examining an infant or young child, a pneumatic bulb attahment enables you to direct a light puff or air toward the drum to assess vibratility

pupillary light reflex

when one eye is exposed to a bright light, a direct reflex and consensual reflex occur; this happens because the optic nerve carries the seensory afferent in and then synapses with both sides of hte brain

limbus

when open the upper lid covers part of the iris; the lower lid margin is just at the _____________, the border between the cornea and the sclera

infants and children respiratory considerations

when the cord is cut, blood is cut off from the placenat and it gushes into the pulmoanry circulation; respiratory development continues throughout childhood, with increases in diameter and length of airways and in size and number of alveoli, reaching the adult range of 300 million by adolescence

infants and children respiratory considerations

when the newborn inhales the first breath, the lusty cry that follows reassures straining parents that their baby is all right; the baby's body systems all develop in utero, but the respiratory system alone does not function until after birth; birth demands its instant performance

pallor

when the red-pink tones from the oxygenated hemoglobin in blood are lost, the skin takes on the color of connective tissue (collagen) which is mostly white; _______________- is common in high-stress states, such as anxiety or fear because of the powerful peripheral vasoconstriction from sympathetic nervous system stimulation

arteriovenous crossing (nicking)

when vein is occluded, it dilates distal to crossing. This person also has disc edema nad hard exudates in a macular star pattern that occurs with acutely elevated hypertension; with hypertension, the arteriole wall thickens and becomes opaque so that no blood is seen inside it

sequeuale of infections

white dense areas (tympanic membrane) indicates: scarring suggested condition: ______________

objective vertigo (dizziness)

with ______________, the person feels like the room is spinning

subjective vertigo (dizziness)

with ________________, the person feels like they are spinning

age-related macular degeneration (aging adult eyes)

with _________________ the person is unable to read books or papers, sew, or do fine work and has difficulty distinguishing faces; when the lifestyle is oriented around these activiteis, loss of central vision causes great distress; peripheral vision is not affected; for a while the person can manage self-care nad not become completely disabled

widespread color change

with _____________________, note any color change over the entire body; normally there is no change; in dark-skinned people the amount of nomral pigment may mask color changes; lips and nail beds vary with skin color and may not be accurate; more reliable sites are under the tongue, the buccal mucosa, palpebral ocnjunctiva, and sclera

tongue

with a glove, hold hte tongue with a cotton gauze pad for traction and swing it out and to each side; inspect for any white patches or lesions, normally none are present; if present, palpate for induration

aging adult skin hair

with aging, the amount of hair decreases in the axillae and pubic areas; after menopause white women may develop bristly hairs on the chin or upper lip resulting from unopposed androgens; in men, coarse terminal hairs develop in the ears, nose, and eyebrows, although the beard is unchanged

aging adult skin thickness

with aging, the skin looks as thin as parchment, and hte subcutaneous fat diminishes; thinner skin is evident over the dorsa of hte hands, forearms, lower legs, dorsa of feet, and bony prominences; the skin may feel thicker over the abdomen and chest

percussion (infant head)

with an infnat, you may directly percuss with your plexor finger against the head surface; this yields a resonant or cracked pot sound, which is normal before closure of the fontanels p i

cushing syndrome

with excessive secretion of adrenocorticotropic hormone and chronic steroid use, the person develops a rounded, moonlike face; prominent jowls; red cheeks; hirsutism on the upper lip, lower cheeks, and chin; and acneiform rash on the chest

acute tonsillitis and phayngitis

with symptoms or sore throat lasting >3-5 days, consider streptoccal infection and confirm with rapid antigen testing or throat culture; treat positive tests with antibiotics; untreated group a streptococcus (GAS) throat pharyngitis may produce peritonsillar abscesses, lymphadenitis, or rheumatic fever

capilalry refill

with the index or middle fingertip at heart level, depress the nail edge att least 5 seconds to blanch and the nrelease, noting the return of color; normally return is instant or at least within a few seconds in a cold environment; this indicates the status of the peripheral circulation; healthy return is 1-2 seconds

throat

with the light observe the oval, rough-surffaced tonsils behind the anterior tonsilar pillar; their color is the same pink as hte oral mucosa, and their surface is peppered with indentations or crypts; in some people the crypts collect small pluts of whitis cellular debris; this does not indicate infection; however, there should be no exudate on the tonsils

newborn visual acutiy

with the newborn, test visual reflexes and attending behaviors; test light perception suing the blink reflex; the neonate blinks in response to light; these reflexes indicate that the lower point of the visual apparatus is intact; but you cannot infer the the infant can see; this requires later observation to show how the brian received images and interpred them nv

capillary refill

with the person's hands near the level ofo his or her heart, check ________________; this is an index of peripheral perfusion and cardiac output; depress and blanch the nail beds; release and note the time of color return; usually the vessels refill within a fractiion of a second; consider it normal if cololr returns in less than 1-2 seconds

tarsal plates

within the upper lid _______________ are strips of connective tissue that give it shape

otitis media with effusion (OME) or chronic otitis media

yellow-amber color (tympanic membrane) indiacates: serum or pus suggested condition: _____________________

throat

you may normally see 1+ or 2_ tonsils in healthy people, especially children because lymphoid tissue is proprortionately enlarged until puberty