NURS 550 midterm

Techniques of Examination: Breath Sounds

o Characteristics of normal breath sounds (pg. 303) Vesicular: soft and low pitched, low intensity; usually heard over most of both lungs Bronchial: louder and higher in pitch and intensity; usually heard over the manubrium Bronchovesicular: intermediate intensity and pitch; usually heard over the 1st and 2nd interspaces (major bronchi) Tracheal: very loud and high pitched, heard over trachea and neck o Adventitious (added) sounds: Crackles (formerly called rales) • Abnormal respiratory sound heard more often during inspiration and characterized by discrete discontinuous sounds • Fine: high pitched, and relatively short in duration • Coarse: low pitched, and relatively longer in duration o Adventitious (added) sounds: Rhonchi (sonorous wheezes) • Deeper, more rumbling, more pronounced during expiration, more likely to be prolonged and continuous, and less discrete than crackles • Caused by the passage of air through an airway obstructed by thick secretions, muscular spasm, new growth, or external pressure o Adventitious (added) sounds: Wheezes (sibilant wheeze) • Continuous, high-pitched, musical sound (almost a whistle) heard during inspiration or expiration • Caused by a relatively high-velocity air flow through a narrowed or obstructed airway • May be caused by the bronchospasm of asthma (reactive airway disease) or acute or chronic bronchitis • Examination of the posterior chest - Auscultation o Adventitious (added) sounds: Friction Rub • Occurs outside the respiratory tree • Dry, crackly, grating, low-pitched sound and is heard in both expiration and inspiration • Caused by inflamed, roughened surfaces rubbing together o Adventitious (added) sounds: Mediastinal Crunch (Hammam Sign)) • Dry, crackly, grating, low-pitched sound and is heard in both expiration and inspiration • Caused by inflamed, roughened surfaces rubbing together • Occurs outside the respiratory tree

Family History & Personal and Social History

Family History • Hypertension (HTN) • Dyslipidemia • Diabetes • Heart disease • Thrombosis • Peripheral vascular disease (PVD) • Abdominal aortic aneurysm • Ages at time of illness and death Personal and Social History • Employment • Tobacco use • Nutritional status - Usual diet - Weight - Exercise

Clinical Manifestations: Signs/Symptoms

Fever Malaise Headache Nausea/vomiting Rash Inflammation of pharynx, uvula, tonsils with white-gray tonsillar exudate Swollen/tender anterior cervical lymphadenopathy Absence of cough and nasal congestion/discharge

Clinical Manifestations: Signs/Symptoms

Fever Shaking chills Cough w/phlegm that doesn't improve or worsens SOB with daily activities Chest pain w/breathing and/or coughing Suddenly feels worse after recent cold or flu Symptoms can vary in certain populations Newborns/infants may not show signs of infection Older adults and immunocompromised patients may have fewer & milder symptoms (i.e. lower than normal temperature) Older adults sometimes present with sudden changes in mental status

Physical Examination

First, observe the patient, then begin assessing the vital signs - Blood pressure o Select the proper size cuff o Position the patient properly o Make sure there is a brachial pulse o Apply the cuff correctly o Assess blood pressure for hypertension - Heart rate: radial vs. apical

Primary Skin Lesions

Flat Non -palpable +Macule - small spot +Patch - larger than macule Elevated Solid Palpable Papule -up to 0.5 cm Plaque -larger than 0.5 cm, usually coalescence of papules Nodule - larger than 0.5 cm, deeper and firmer than papule Tumor - a large nodule Wheal - irregular, localized skin edema Elevated fluid filled Vesicle - up to 0.5 cm filled with serous fluid Bulla - > than 0.5 cm, filed with serous fluid Pustule -filled with pus

3 differential diagnoses and how they differ from main assessment topic

Foreign body - swelling and erythema is localized around the foreign object Cerumen impaction - hard plug obstructing ear canal, lead to hearing loss and otitis externa Malignant Otits Externa - rare but extremely lethal infection, caused by P.aeruginosa. Found in older adults with diabetes. The infection invades surrounding tissue and can cause osteomyelitis at the base of the skull and purulent meningitis

Notes: Assessment for Peripheral Arterial Disease

Four P's of occlusion -Pain -Pallor -Pulselessness -Poikilthermia (cold)

3 Differential Diagnoses -- Differ From Main Assessment Topic

Full Septsis workup; cbc with differential 2. Adenoids - rule/out inflammation adenoids - tonsillectomy Adenoids are two small pads of tissues high in the back of the nose believed to play a role in immune system activity. This function may make them particularly vulnerable to infection, inflammation and swelling. Because adenoids are near the opening of the Eustachian tubes, inflammation or enlargement of the adenoids may block the tubes, thereby contributing to middle ear infection. Inflammation of adenoids is more likely to play a role in ear infections in children because children have relatively larger adenoids. 3. Congenital abnormalities or systemic abnormalities - labs to r/o The differential diagnosis herein are all more serious issues to need to be resolved in order to uncover and resolve possibly serious health issues.

Review of Systems

General - fever (subjective) with chills and sweats, denies fatigue, weakness, weight loss, or malaise - Skin - denies rashes, lesions, discolorations - HEENT - positive for generalized headache, sore throat, pain with swallowing and rhinorrhea. Denies difficulty swallowing saliva, earache, sinus congestion, sinus pain, visual or auditory aura - Neck - denies lump, pain, stiffness, or decreased range of motion - Cardiac - denies chest pain, pressure, tightness, palpitations - Pulmonary - denies cough, wheeze, hemoptysis - GI - denies nausea, vomiting, abdominal pain - GU - denies missed menses, urinary frequency, urgency or hematuria - MS - denies cramping, pain, - Neuro - denies unilateral weakness, numbness, tingling

Hearing Acuity Tests

Gross hearing: screening for hearing deficits; not measure of the degree of loss • (Whispered) Voice Test - Test: Examiner whispers 2 syllable words slowly as client masks other sounds by pushing tragus in and out - Normal: Client repeats each word correctly

Comprehensive Health History: You've Opened the Door!

Identifying Information - Name - Age - Address - Occupation • Source of Referral • PCP • Nearest relative, contact information • Date and Time • Source of history, reliability • Note: this information is very important but is often ignored

The Complete Health History

Identifying information • Chief complaint or concern (CC) • History of present illness (HPI) • Past medical history (PMH) • Family history (FH) • Social history (SH) • Review of systems (ROS)

Techniques of Examination

Important areas of examination - Arms o Size, symmetry, skin color o Radial pulse, brachial pulse o Epitrochlear lymph nodes - Legs o Size, symmetry, skin color o Femoral pulse and inguinal lymph nodes o Popliteal, dorsalis pedis, and posterior tibial pulses o Peripheral edema

Objective

In this section you document what you observe during the examination and visit.

ASTHMA

A chronic condition that involves inflammation of the airways, with varying degrees of airway obstruction and hyper-responsiveness Pathological process: reversible bronchial hyper-responsiveness involving a release of inflammatory mediators, increased airway secretions and bronchoconstriction The disease process and severity vary greatly. A "stepwise" or "staging" approach has been created to help diagnose, classify, treat and monitor therapy for asthma

Nail Assessment

Assess: • Nail bed color (translucent with pink nail bed) • Texture (smooth, ridging, pitting) • Consistency (firm, spongy) • Nail angle (< 160 degrees-normal) • Surrounding tissues • Note changes with aging:thicker, dull, splitting, longitudinal bands

Procedure used to diagnose clinical problem

Assessment is though questioning the patient on their symptoms, when they start, what makes them worse or better Physical Exam Inspect inside of of the nares with otoscope may be pale, bluish, or red Nasal polyps Diagnostic Studies Radioallergosorbent test preformed on blood will indicate the increased eosinophilia associated with allergies Skin test will identify specific allergens

Assessment Skill/Techniques /Labwork /Procedure used to diagnose clinical problem

Assessment- onset, duration, *any knowledge of previous level of function, new medications or any medications likely to cause toxicity. Mental Status changes notable to a specific time of day Environmental factors- do they reside in an institution- recent outbreaks of respiratory infections, influenza, pneumonia Physical exam- possible causes of sepsis, skin infections, UTI Screenings Mini COG Assessment Instrument for Dementia- Specificity 89-96% MMSE- Specificity 92-99% Memory Impairment screen-Specificity 96-97% Montreal Cognitive Assessment Geriatric Depression Scale- Labwork- Basic metabolic profile, Serum B12 and folic acid, CBC with differential, urinalysis with culture and sensitivity, FTA-ABS, Lyme serology, ESR, pulse oximetry, chest xray Procedures- 24 hour urine, EEG, Lumbar puncture for CSF Seek to rule out: Depression Drug side effects Metabolic Disorders Infection disease Head Trauma

CN VI Abducens

EOM have pt move eyes side to side

Types of Pain

- Nociceptive or somatic - related to tissue damage Neuropathic - resulting from direct trauma to the peripheral or central nervous system Psychogenic - relates to factors that influence the patient's report of pain Psychiatric conditions Personality/ coping style Cultural norms Social support systems Idiopathic - no identifiable etiology

History of Present Illness/Injury

- Onset - When did the symptoms and/or signs begin, what was the mechanism of injury - Chronology - episodic, variable, constant, etc - Quality - sharp, dull, ache, sudden, insidious - Severity - pain rating, 0-10 pain scale, interferes with daily activities - Modifying factors - aggravating and alleviating factors - Additional symptoms - unrelated or significant symptoms - Treatment - medications, herbs, "home remedies", rest, activity, splint, etc - Use "OLDCART" to assist you (Onset, Location, Duration, Character , Aggravating factors, Relieving factors, Treatments"

Physical Examination

- Vital signs - Physical examination findings - the use of "normal", "within normal limits", "unremarkable" and other phrases are NOT acceptable. - Diagnostic results - Measurements including height, weight, screening tools, etc. - Mental Status -Weight 50 Kg previously documented height 5'3" -Vital signs - BP 118/76, HR 104, RR 16, T 38.2C, pulse Ox 99% RA -Diagnostic results •Rapid strep test positive

Recording the General Survey and Vital Signs

" Mr. Green is a young, healthy appearing man, well- groomed and pleasant. Height is 66", weight 142 lbs, BMI 23, BP 118/76 right and left arms, HR 68 reg, RR 18, T 98.2 F"

Recording Behavior and Mental Status

"Mental Status: alert, relaxed, and cooperative. Though process coherent, insight good. Oriented to person, place, and time. Detailed cognitive testing deferred."

Personality Disorders

"an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual's culture" Borderline Personality- Can appear demanding, disruptive, or manipulative

Grading Amplitude of Arterial Pulses

*3+ Bounding • 2+ Brisk, expected (normal) • 1+ Diminished, weaker than expected • 0 Absent, unable to palpate

Medically Unexplained Symptoms

30% of symptoms are medically unexplained • When patients exhibit physical symptoms that are not fully explained by a medical condition consider the diagnosis of somatoform disorder. • Somatic complaints include single complaints such as back pain, headache, or musculoskeletal complaints • 2/3 of patients with depression present with physical complaints and half report multiple unexplained or somatic symptoms

Hair Assessment

• Distribution • Thickness • Texture • Infections • Scalp Lesions • Normal age related changes Alopecia & traction alopecia

Differential Diagnoses and how they differ from main assessment topic

A delirium may be superimposed on depression Depression: in past two weeks have you felt down, depressed, hopeless? In past two weeks, have you felt little interest or pleasure in doing things? Anhedonia? Mental status exam Dementia & Cognitive Impairment- screen for dementia with The Mini-Cog page 1002 Bates' Delirium has acute onset/ dementia has insidious onset Delirium: total duration from hours to weeks/dementia has total duration from months to years. see Table 20-2 Delirium and Dementia page 1001 Bates' 3. Altered Consciousness

Focused History

A focused history is performed in emergency situations and/or when the patient is already under the ongoing care of the clinician and presents with a specific problem oriented complaint. Identifying data Chief Complaint Data from the patient's medical history, family history and social history that are pertinent to the chief complaint Problem oriented ROS

Signs to alert you for Malignant Melanoma !!!

ABCDE DANGER SIGNS: ABCDE • Asymmetry • Border irregularity • Color variation • Diameter • Elevation and Enlargement

3 differential diagnoses and how they differ from main assessment topic

Acute Bronchitis: inflammation of the mucous membrane that lines the bronchi. Chills and chest discomfort are mild in comparison to PNA. Lung sounds: wheezes and/or rhonchi, no egophony. Fremitus is equal. CHF: Congestive Heart Failure. Dry hacking cough with other symptoms: paroxysmal nocturnal dyspnea (PND), orthopnea, SOB can occur at rest, no associated fever. Pleural effusion: Abnormal build up of fluid in the pleural space. Usually secondary to another condition. As effusion increases lung sounds decrease, fremitus decreases, as do egophony and whispered pectoriloquy.

Otits Externa

Acute inflammation and pain of the external auditory canal Condition found in swimmers, commonly known as swimmer's ear Caused by pseudomonas and fungal organisms Also caused by trauma; by inserting objects or cotton swabs to clean ear canal

Otitis Media

Acute otitis media: the diagnosis of fluids/rapid onset of infection in the middle ear, multiple symptoms. Otitis media with effusion: the diagnosis is otitis media with effusion, there is evidence of fluid in the middle ear, but when there are presently no signs or symptoms of infection. Chronic suppurative otitis media: persistent ear infection can result in tearing or perforation of the eardrum.

Objective Data—The Physical Exam

Additional techniques - Color changes - Doppler ultrasonic stethoscope - Ankle-brachial index (ABI) Capillary refill

Diagnosis

Additional tests There are other diagnostic tests if there is any doubt about a diagnosis. Alternatives are pursued if the condition hasn't responded to previous treatments, or if there are other persistent or serious problems. Tympanometry. This test measures the movement of the eardrum. The device, which seals off the ear canal, adjusts air pressure in the canal, thereby causing the eardrum to move. measures of pressure within the middle ear. Tympanocentesis. Rarely, a doctor may use a tiny tube that pierces the eardrum to drain fluid from the middle ear - Tests to determine the infectious agent in the fluid may be beneficial if an infection hasn't responded well to previous treatments. Other tests For persistent ear infections or persistent fluid buildup in the middle ear, a patient can be referred to an audiologist, speech therapist for tests of hearing, speech delays, and language comprehension. Endoscopy view nasal passages and adenoids CT scan for detailed images of the sinus cavity and adenoids MRI for imaging of the anatomy as well In order to confirm diagnosis of otitis media Physical inspection of the ear canal Labs (labwork helps to reveal if the patient's health status in declining and this is the first sign of the problem, ex rule out septsis...) Tympanocentesis

Clinical Manifestations: Signs/Symptoms

Age- typically affects persons over 60 Develop over months or years No physical motor or sensory alterations until condition is advanced Memory impairment is the predominant symptom. Cognitive impairment can include aphasia, apraxia, agnosia, and impairment in executive functioning.

History

Allergies - list of allergies to food, medication, and products with type of reaction - Medical - past and present medical conditions (i.e. asthma, hypertension, malaria, etc.) - Surgical - past surgeries (i.e. appendectomy, CABG, craniotomy, etc.) - Family - mother, father, siblings, etc. - Social - occupation, alcohol, drug, tobacco use, risky behavior - Immunizations - current and past received with dates - Screenings/Health Promotion - mammography, testicular exams, dental, vision - Review of Systems - systemic symptoms related to the current problem(s) including pertinent positives and negatives

Red Flags Neck

Any enlarged or tender nodules if unexplained should call for reexamination of the regions they drain and careful assessment of lymph nodes elsewhere to determine whether process is regional or systemic -Palpation of enlarged supraclavicular nodes should warrant further investigation Tender nodes= infection/inflammation Hard or Fixed nodes=suggest malignancy

Past Medical History- Skin Subjective

Any previous dermatologic illnesses. Ask about infectious diseases with associated skin changes like chicken pox, measles, impetigo, pityriasis rosea, and others. Identify chronic skin problems such as acne vulgaris or rosacea, psoriasis, and eczema. Ask about prior diagnosis of skin cancer. • Previous history of skin disease • Any change in pigmentation • Any dryness or oiliness • Tattoos • Hair Texture • Hair loss • Changes in nail shape or color; biting nails • Do you work with chemicals or specific substances? • How do you care for your skin, hair, and nails

General Survey Objective Assessment

Apparent State of Health • Level of Consciousness • Signs of Distress • Skin Color and note lesions • Dress, Grooming, and Personal Hygiene • Facial Expression Odors of Breath and Body • Posture, Gait, and Mobility • Height and Weight • BMI • Waist Circumference

Behavior and Mental Health Status

As you talk to a patient, you will quickly begin to discern the patient's level of alertness, mood, orientation, attention, and memory • Conversation with the patient will also allow you to assess about the patients judgment, insight, and any thought disorder or disorder of perception

General Survey

Ask patient to walk into room & sit in chair. As they do so, narrate and comment upon at least 5 of the following 8 items: skin color posture obvious physical deformities mobility gait personal hygiene mood affect, hearing, speech (ask 2 or 3 simple questions to assess hearing and speech

Assessment Skill/Techniques Procedure used to diagnose BCC

Ask patients if they have noticed any changes in their skin If patient reports a change/new growth, further explore if patient has personal OR family history of skin cancer (type, treatment) During skin exam, carefully inspect/palpate any skin lesions (may require magnifying glass) Note and describe: type of lesion, color, texture, size, shape, location, number Diagnosis is confirmed with biopsy Treatment based on location, size, depth of tumor (curettage and electrodessication; Mohs procedure; excision; pharmacologic, etc.)

Air and Bone Conduction

BC is tested • Test: Vibrating tuning fork is placed on the midline of skull • Normal: Should hear tone equally in both ears • Abnormal: - Unilateral conductive • Sound lateralized to impaired ear - Unilateral sensorineural • Sound lateralized to good ear AC is compared to BC • Test: - Stem of the vibrating tuning fork is placed on the mastoid process - Patient indicates when vibrating sound ends - Quickly move fork next to ear canal, sound should continue - Patient indicates when vibration discontinues • Normal: AC > BC; AC should be twice as long as BC • Abnormal: - Conductive • BC = AC or BC > AC - Sensorineural • AC > BC

HTN Screening

BP should be taken at documented at EVERY visit!!! How do we define HTN? This is HTN: • Over 60 and no CKD or DM - >150/90 - GOAL is <150/90 • Under 60 • Any age with CKD or DM - Begin when BP >140/90 - GOAL: <140/90

CN II Optic CN III Oculomotor

CN II Optic CN III Oculomotor Size ,shape, symmetry of pupils .Assess the Light Reaction pupillary reaction to light use penlight. Dim room lights > ask patient to look into distance and shine a penlight obliquely toward each pupil>Assess for direct reaction is pupillary constriction in the same eye and consensual reaction pupillary reaction in opposite eye

CN IV Trochlear

CN IV Trochlear downward inward rotation of eyes

CN IX Glossopharyngeal

CN IX Glossopharyngeal (motor pharynx) and sensory: posterior portion of ear and eardrum, pharynx and posterior tongue ask pt. to say "ah" and note mobility of uvula. Does the uvula rise and fall? Does the rise and fall of uvula look symmetrical?

CN V Trigeminal

CN V Trigeminal Motor aspect - assess Masseter/Temporal muscle strength- ask patient to clench and unclench jaw and lateral jaw movement CN V - Trigeminal 3 divisions (Ophthalmic, maxillary and mandibular )- Sensory aspect - assess light touch and pain- use cotton ball & pin prick on patient's face. Patient eyes closed with this assessment- demonstrate the feeling of light touch and pain on patient's hand before assessing face.

CN Vll Facial

CN Vll Facial -Motor aspect- Inspect facial expression for symmetrical smile, frown, grimace, closing eye and mouth/ Sensory aspect -taste CN VII Facial- Motor aspect-Palpate TMJ ( temporomandibular joint ) tips of fingers in front of tragus of each ear > pt opens mouth > fingertips drop into joint space when pt opens mouth ->check for smooth range of motion ROM , assess for swelling, tenderness of joint.

CN Vlll Acoustic

CN Vlll Acoustic: hearing cochlear division and balance vestibular division Whisper Voice Test test for auditory acuity- excellent screening test for hearing loss Stand 2 feet behind patient and ask patient to occlude one ear at a time, whisper. Weber test : Use tuning fork. In a normal Weber test, assess lateralization of sound to both sides of head.. In a normal test, sound is heard equally and lateralizes to both sides of head. Rinne Test: Use tuning fork. In a normal Rinne test, air conduction is greater than bone conduction. Air conduction in seconds (area assessed in front of ear) is greater than bone conduction in seconds (area assessed over mastoid bone.

CN X Vagus

CN X Vagus (motor aspect of palate, pharynx, and larynx) and sensory pharynx and larynx gag reflex use tongue blade

CN XI- Spinal Accessory

CN XI- Spinal Accessory - motor sternocleidomastoid and upper trapezius muscles- place hand on cheek and test strength of cervical spine as patient turns head toward provider's hand and provider resists head turn

CN XII Hypoglossal

CN XII Hypoglossal (motor movement of tongue) ask patient to stick out tongue and check for tongue deviation to the right or left. Do not ask patient to wiggle tongue.

CN lll Oculomotor, lV Trochlear, Vl Abducens

CN lll Oculomotor, lV Trochlear, Vl Abducens Assess eye movements through six cardinal positions of gaze -assessment of extraocular movements >instruct patient to follow your finger with eyes as you draw an H in air while keeping their head straight.

CN1 Olfactory

CN1 Olfactory use 2 different common scents (example: ground coffee or vanilla extract )to test sense of smell. Patient occludes one nostril at a time and closes eyes. Ask to inhale gently. With normal assessment, patient identifies each scent correctly.

CNIII Oculomotor

CNIII Oculomotor most extraocular movements, opening eye lid elevation and pupillary constriction/ loss of extraocular movement-diplopia

CNll Optic

CNll Optic test Visual Acuity - download Snellen eye chart from internet >display well-lit Snellen chart on wall >patient should stand 2 feet from chart for purpose of this submission, but with true exam, post snellen chart 20 feet in front of patient> instruct patient to cover one eye with card and read to smallest line of print of which they can accurately read at least 50% > pt. to wear glasses or contacts if they normally wear them> record smallest line patient is able to read For example, 20/30. CNll Optic test Visual Fields by confrontation or fishbowl test of peripheral vision

Differential Diagnoses and how they differ from main assessment topic

COPD - over distention of airspaces distal to terminal bronchioles with destruction of alveolar septa, alveolar enlargement and limitation and expiratory air flow Breath sounds decreased to absent with delayed expiration Adventitious sounds: none or the crackles wheezes, rhonchi associated with chronic bronchitis Cough with scant mucous sputum Chronic Bronchitis - excessive mucous production in bronchi followed by chronic obstruction of airways Breath sounds: vesicular Adventitious sounds: none, possible course crackles in early inspiration and expiration and possible wheezes and rhonchi Cough: chronic, sputum mucoid - purulent, may be blood streaked *Chronic bronchitis and COPD often present together similar history; slow and progressive, smoking, and dyspnea hallmark signs Both have slowly progressive symptoms whereas asthma has acute episodes with intermittent symptom free time

External Ear Exam

External ear: - Angle of attachment and position - Inspect the auricles and mastoid area for size, shape, symmetry, landmarks, color, position, and deformities or lesions, or inflammation - Drainage: clear, blood, or purulent •External ear canal: - Color, drainage, lesions, lumps, and foreign objects - Inflammation - Swelling External ear: - Consistency and tenderness •External ear canal: - Patency - Palpate tragus, mastoid, and helix for tenderness, swelling, nodules

Skin Cancer

Change in mole or lesion -Warning signs • New pigmentations • Pain • Itching • Tenderness • Change in size or bleeding of a mole

3 differential diagnoses and how they differ from main assessment topic

Common Cold: viral or bacterial; sinus pain/tenderness; chest congestion Sinusitis: viral, bacterial, or fungal infection; inflammation of sinuses; causes facial pain, pressure, and thick greenish mucus discharged from the nose; severe complication can affect the brain; diagnostic testing include X-ray/CT to confirm the severity of the condition; TX depends on cause Upper Respiratory Infection: infectious disease/contagious; many different subtypes; causes congestion;, sore throat, headache, cough, malaise, and decreased appetite; treated through the use of antibiotic

3 differential diagnoses and how they differ from main assessment topic

Common cold Upper respiratory infection Community acquired pneumonia Is difficult to distinguish in the catarrhal stage unless there is a known exposure or patient is unvaccinated. Pertussis is often suspected when the cough, which is initially intermittent, becomes paroxysmal. Often paroxysms terminate with inspiratory whoop and can be followed by post-tussive vomiting. * May occur in vaccinated persons with less severity.

Health History: HPI lymphatics

Common or concerning symptoms - Pain in arms/legs - Intermittent claudication - Cold, numbness, pallor in legs, hair loss - Swelling in calves, legs, or feet - Color change in fingertips or toes in cold weather - Swelling with redness or tenderness Peripheral arterial disease (PAD) - Intermittent claudication • Arterial spasm: fingers and toes • Venous peripheral vascular disease - Swelling of feet and legs • Past Medical History: - Cardiac surgery or hospitalization - Acute rheumatic fever, unexplained fever, swollen joints, vasculitis - Chronic illness

Techniques of Examination - Legs

Compare one foot and leg with the other • Check for pitting edema • Severity of edema graded on four-point scale (slight to very marked) • If edema is present, look for causes - Recent deep venous thrombosis - Chronic venous insufficiency - Lymphedema • Note color of skin - Local area of redness - Brownish areas near ankles - Ulcers and where - Thickness of skin (Venous ulcers are wet in appearance, Arterial ulcers are dry) • Femoral pulse - Press deeply below inguinal ligament, midway between anterior superior iliac spine and symphysis pubis • Popliteal pulse - Flex knee some, leg relaxed - Place fingertips of both hands to meet midline behind knee and press deeply into popliteal fossa • Dorsalis pedis pulse - Feel dorsum of foot, lateral to extensor tendon of great toe • Posterior tibial pulse - Curve fingers behind and slightly below medial malleolus of ankle

Comprehensive or Focused

Comprehensive • New patients • Identifies and rules out physical causes related to patient concerns • Baseline • Health promotion Focused • Established patients • Focused concerns • Symptoms of specific system(s)

Red Eye

Conjunctivitis • Subconjunctival hemorrhage • Corneal abrasion or infection • Acute iritis • Glaucoma

Mental Status Examination

Consists of the following components: • Appearance and behavior • Speech and language • Mood • Thoughts and perceptions • Cognitive function: memory, attention, information and vocabulary, calculations, abstract thinking, and constructional ability

3 differential diagnoses and how they differ from main assessment topic

Corneal abrasion Cornea can become scratched or abraded by a variety of situations, including trauma and foreign bodies. A common foreign body that causes corneal abrasions is a contact lens. Photophobia and significant tearing are common with abrasions. Fluorescein staining identifies an obvious break in the corneal surface with uptake of the stain. Diagnostic study is not indicated unless signs of infection are evident. Chemical burns Occurs from topical contact from many agents. Chemical burns make up the majority of ocular burns. Acidic burns do not penetrate the eye structure, alkali burns do cause penetrating injuries. The chemical should be identified as quickly as possible so that appropriate decontamination measures can be instituted immediately. Patient should be referred to an opthalmologist to determine the severity of injury. Herpes Zoster Herpes zoster is caused by the varicella-zoster virus and can affect the opthalmic branch of the cranial nerve V. Opthalmic involvement is often heralded by lesions on the tip of the nose. Lesions are usually preceded by a period of several days during which the patient experiences malaise and neuralgia along the affected nerve root. The pain is severe accompanied by systemic symptoms, including fever and fatigue. Photophobia may be present. Vision may be altered. Inspection of the cornea following fluorescein stain may reveal punctate or dentitic ulcerations. Patient should be referred to an opthalmologist. Specialist examination, including slit lamp to assess the degree of involvement. Virual cultures may be obtained.

Conjunctivitis

Definition: The most common cause of eye redness is conjunctivitis, which involves an inflammation of one or more areas of the conjunctiva. It is important to discriminate between allergic, viral, bacterial and other causes of conjunctivitis in order to provide definitive treatment.

Basal Cell Carcinoma

Definition: Basal cell carcinoma is a slow-growing malignancy involving areas of the skin exposed to the sun Key points: Most common malignancy in humans, more than 4 million cases diagnosed annually in the US Results from abnormal growth of cells in the basal layer of the epidermis Rarely spreads from initial site to other parts of the body Can become invasive and destroy surrounding tissues if not diagnosed and treated, there are some aggressive forms that can be fatal (rare)

Pneumonia

Definition: Pneumonia is a bacterial, viral, or fungal infection of one or both sides of the lungs that causes the air sacs, or alveoli, of the lungs to fill up with fluid or pus. (NHLBI, 2016) Bacterial PNA: Sputum is mucoid or purulent; may be blood-streaked, diffusely pinkish, or rusty. Common pathogens are S. pneumoniae, Haemophilus influenza, and Moraxella catarrhalis. Myocoplasma and viral PNA: Dry hacking cough that may become productive of mucoid sputum. Acute febrile illness, often with malaise, headache, and possibly dyspnea. Community Acquired PNA (CAP): Most common form, occurs outside of hospital or other health care facilities. Infection by breathing in germs (especially while sleeping). Hospital Acquired PNA (HAP): Hospitalized patients develop. Usually more serious due to already being sick and germs more resistant to typical antibiotics that treat bacterial PNAs. Ventilator-assisted PNA (VAP): Patients on ventilators are at increased risk. Atypical Pneumonia: Usually community acquired, infections with less common bacteria: Legionella pneumphila, Mycobacterium pneumoiae, Chlamydia pneumoniae Aspiration PNA: Inhalation of food, drink, vomit or saliva into lungs. Disruptions to gag reflex (brain injury, stroke) or excessive alcohol/drug intake can cause.

Bacterial Pharyngitis

Definition: Rapid onset of sore throat and pharyngeal inflammation, usually caused by Group A Streptococcus

Pertussis

Definition: a respiratory illness commonly known as whooping cough, is a very contagious disease spread through the air caused by Bordetella pertussis. The bacteria attach to the cilia that line part of the upper respiratory system. The bacteria release toxins, which damage the cilia and cause airways to swell.

External Eye Exam

Extraocular Eye Muscles: • Test eye movements using six cardinal fields of gaze. - Check for nystagmus - Note lid lag - Note exposure of sclera above iris • Use corneal light reflex to test extraocular muscle balance - If imbalanced, perform cover-uncover test

True or False: Objective data is more important than subjective, because subjective data is lacking in quantification? Advanced

FALSE! • Research suggests: -~80% of diagnoses are made based on history alone. -Physical exam adds another 10%

Dementia

Definition: clinical syndrome of widespread progressive deterioration of cognitive abilities and normal daily functioning. An acquired condition that is characterized by a decline in at least two cognitive domains (e.g loss of memory, attention, language, or visuospatial or executive functioning) that is severe enough to affect social or occupational functioning. Four primary dementia classifications have been defined according to clinical and research criteria: 1) Alzheimer's disease (11% of Americans over 65 years, 2/3 women); 2) vascular dementias; 3) frontotemporal dementias; and 4) dementia with Lewy bodies/Parkinson's disease dementia.

3 differential diagnoses and how they differ from main assessment topic

Delirium- generally have more acute or rapidly progressive onset associated with hallucinations, illusions, incoherent speech. Depression- patients will complain of memory problems. Patient will have negative thoughts about themselves, expressing guilty feelings, worthlessness, hopelessness, thoughts of death. Urinary Tract Infection- acute mental status change with elevated WBC count or a left shift, pyuria on urinalysis.

History of Present Illness HPI

Description of the patient's chief complaint starting from the last time the patient felt well Attempt to understand the full story of the development and expression of the chief complaint in the context of the patient's life Determine the actual reason for coming in at this particular time. Why Today???

Special Considerations: History

Infants and Children - Hemophilia - Renal disease - Coarctation of the aorta - Leg pains during exercise Pregnant Women - Blood pressure • Pre-pregnancy levels • Elevation during pregnancy • Associated symptoms and signs • Legs • Edema • Varicosities • Pain or discomfort Older Adults • Leg edema • Interference with activities of daily living • Ability of the patient and family to cope with the condition • Claudication - Area involved, unilateral or bilateral, distance one can walk before its onset, sensation, length of time required for relief

Neck: Trachea and Thyroid

Inspect and palpate the trachea for any deviation : masses or mediastinal shift could make trachea asymmetrical. Inspect Thyroid : region below cricoid cartilage note contour and symmetry. Steps for Palpating Thyroid Gland (Posterior Approach) Bates' text page 263.Thyroid isthmus is overlying the second, third, and fourth tracheal rings /patient sips water as provider palpates thyroid from posterior approach. Why does the patient sip water during this assessment? Note size, shape, consistency, nodules or tenderness

Techniques of Examination - Arms

Inspect both arms from fingertips to shoulders - Note the following: o Size, symmetry, and any swelling o Venous pattern o Color of skin and nail beds; texture of skin • Palpate radial pulse - Use finger pads on flexor surface of wrist - Partially flex patient's wrist - Compare pulse in both arms • Palpate brachial pulse - Flex elbow slightly - Palpate artery medial to biceps tendon in antecubital crease • Epitrochlear nodes - Flex elbow 90° - Support forearm - Feel in groove between biceps and triceps muscle, 3 cm above medial epicondyle

Assessment Skill/Techniques /Labwork /Procedure used to diagnose clinical problem

Inspect the external aspects of the ear, such as the auricle, lobule, tragus, and entrance to the ear canal Assess for lumps, deformities, lesions, erythema, and discharge Perform the tug test; move the auricle up and down, press the tragus, and press behind the ear firmly. If pain is felt during movement of the auricle and tragus, it is suggestive of otitis externa. If the pain is felt during firmly pressing behind the ear it is suggestive of otitis media Use an otoscope to inspect the ear canal. To straighten the ear canal pull the auricle upward, then backward, and the away from the head. Note any odor, discharge, erythema, foreign objects, swelling, and assess cerumen color and consistency. No further diagnostic testing needed. If discharge is seen, may send for culture and sensitivity. If patient fails to respond to treatment, refer to ENT specialist.

Objective Assessment neck

Inspect the neck-note scars or assymmetryand any visible enlargements of glands or lymph nodes • Palpate the lymph nodes- average node about 1cm, typically insignificant <2cm; soft in consistency

Objective Assessment of Trachea and Thyroid

Inspect the trachea for any deviations • Palpate for any deviations of the trachea • Inspect the neck for the thyroid gland • Observe the patient swallowing • Palpate the thyroid gland- noting size, shape, and consistency

Techniques of Examination

Inspection Note rate, rhythm, depth, and effort of respirations Chest symmetry and AP diameter (help with differential diagnosis as COPD has increased AP diameter) Asthma findings: Accessory muscle use common with asthma exacerbation Palpation Areas of tenderness and visible deformities Assess tactile fremitus Asthma findings: tactile fremitus decreased Percussion Identify margin or organs including the lungs Assessed posteriorly to inferiorly (superior to inferior) Hyper resonance is suggest air trapping (COPD or tension pneumothorax) Dullness indicates consolidation (Pneumonia, severe atelectasis, pleural effusion) Asthma findings: resonant to diffusely hyperresonant **Auscultation Listen for a full cycle of inspiration and expiration first note qualities of breath sounds then listen for adventitious breath sounds Asthma findings: Wheezing is on of the hallmarks signs of asthma (also COPD and bronchitis) Severe asthma wheezes and breath sounds may be absent due to low resp. flow

Physical Examination

Inspection of arteries and veins • Palpation of arterial pulses - Brachial - Radial - Femoral - Popliteal - Dorsalis pedis - Posterior tibial Palpate for artery characteristics: - Rate and rhythm - Pulse contour (waveform) - Amplitude (force) - Symmetry - Obstructions - Variations

Internal Eye Exam

Inspection of interior eye with ophthalmoscope permits visualization of: - Optic disc - Arteries - Veins - Retina • Adequate pupil dilation is often necessary Ophthalmoscopic Examination: • Visualize red reflex - Opacities appear as black densities • Examine - Fundus - Vascular supply - Disc margins - Macula Look for unexpected findings such as: - Myelinated nerve fibers - Papilledema - Glaucomatous cupping - Drusen bodies - Cotton wool bodies - Hemorrhages

Cardinal techniques of examination

Inspection: Visual observance of details Palpation: Tactile Pressure from finger pads Percussion: if right handed, use of the plexor finger of the right hand (usually the third finger) to deliver a rapid tap or blow against the pleximeter finger (middle finger of left hand) laid against the surface of the chest or abdomen. Produces audible sound and palpable vibrations Provider uses their sense of touch and hearing Auscultation: use of diaphragm or bell of the stethoscope to detect characteristics of heart, lung, bowel sounds and bruits in arteries

Assessment Skill/Techniques /Labwork /Procedure used to diagnose clinical problem

Inspection: observe respirations, use of accessory muscles, symmetry of chest movement. Palpation: any area of discomfort or pain; tactile fremitus (palpable vibrations felt when patient is speaking, uneven with unilateral PNA) Percussion: dullness is found with PNA. Auscultation: general lung fields, pay close attention to areas where abnormalities were already detected. Bronchial breath sounds over the infected area often w/crackles. Bronchophony "ninety-nine", egophony "ee", & whispered pectoriloquy "one-two-three" are positive in area of consolidation. Fever & cough with the presence of bronchial breath sounds and egophony more than triples the likelihood of PNA. Have patient take a deep breath and cough to clear the airway if adventitious sounds are heard (can eliminate or change the quality of sounds) *Always compare bilateral lungs in each area of assessment Vital signs: include SPO2 Chest x-ray CBC: WBC often elevated CURB-65 to determine if hospitalization needed Confusion, BUN > 20mg/dl, RR >30 bpm, SBP <90 or DBP < 60, age 65 or older (1 pt awarded for each factor present) *can perform sputum if able to produce but usually reserved for hospitalized patients.

Clinical Manifestations/Signs Symptoms

May have abnormality of perception-an illusion- misinterpretation of real external stimuli Recent memory impairment Concrete responses evident - concrete thinking compared to abstract thinking

Techniques of Examination

Mental Status- Mini Mental Status Exam page 733 Bates' CN1 through Xll Motor System: Muscle bulk, tone, strength ,coordination, gait, stance Sensory System: pain and temperature, position, and vibration, light touch, discrimination sensation Deep tendon, abdominal, and plantar reflexes

Delirium

Multifactorial syndrome Acute confusional state : Sudden onset Fluctuating course Inattention At times, changing level of consciousness Common in elderly especially during hospitalizations, after elective surgery, and ICU admissions

Nails

Nails: Clubbing: bulbous swelling of nail base loss of normal angle between nail and nail fold ? Hypoxia, change in innervation, genetics, or fragments of platelets Spooning: nutritional deficiency Paronychia: superficial infection of nail plate, nail folds red, swollen, and tender Staph aureus or Streptococcus/ often related to trauma of nail biting, manicuring, frequent water immersion

Internal Nose and Sinuses

Nasal cavity - Inspect nasal mucosa • Color • Discharge • Masses or lesions • Use otoscope to view middle and inferior turbinates; color and bogginess - Inspect nasal septum • Position, straightness, and thickness • Perforations, deviation, or inflammation, - The sense of smell (cranial nerve I) is often tested with recognition of different odors

Ear Exam

Normal Exam: - External auditory canals patent and clear of debris or drainage. - Tympanic membrane clear translucent with pearly gray and intact; cone of light visualized in right ear at 5 o'clock and 7 o'clock in left ear

Respiratory Rate and Rhythm

Observe rate, rhythm, depth and effort of breathing • Count the number of respirations in one minute • Adult respirations about 20 per minute • Prolonged expiration can be see in patients with an obstructive respiratory disease

Assessment Skill/Techniques /Labwork /Procedure used to diagnose clinical problem

Obtain a history of the redness and it's progression. Ask about other symptoms, such as eye itching, pain, swelling, discharge, or photophobia. Ask about exposures to chemical agents. Ask about systemic symptoms such as general malaise, skin rashes, and cold or allergy symptoms. Ask about family history of eye conditions. If the patient had eye trauma or abrasion, find out patient's tentanus status. Determine patient's corrected visual acuity, then observe general characteristics of the redness, and finishing with a rapid assessment to rule out signs of trauma. Note if there is any photophobia and adjust the light to patient's comfort if possible. Assess the outer and appendage structures, looking for swelling, redness, discharge, or lesions. Next, focus on the eye itself, observing the cornea and conjunctiva for redness and noting the degree of pattern, and location of the redness. Identify any shadowing by passing oblique lighting over the anterior chamber. Assess the palpebral and tarsal conjunctiva beneath the lids; observe for foreign bodies or lesions. Assess the size, shape, and responsiveness of the pupils. If tolerated, perform a funduscopic examination. Depending on the history and examination of the eyes, it may be necessary to extend the assessment to the skin, ears, nose, throat and joints to assess for infections, allergy, or rheumatic disorders. Diagnostic tests are helpful in assessing conjunctivitis. Studies can include viral and bacterial cultures of the conjunctiva or tests for atopy.

The Vital Signs

Offers critical information that will influence the direction of your visit • Blood pressure and pulse are taken first; respirations should be counted without patient being aware • Temperature is assess in various sites

Ear

Otoscopic Exam visualize auditory canal and tympanic membrane Know proper hand position on otoscope to ensure patient safety during procedure. Use otoscope: Grasp auricle firmly and and pull it upward, backward and slightly away from head > hold otoscope between thumb and fingers and brace your hand against the patient's face. Your hand and instrument can then detect unexpected movements by the patient. Light points toward floor. Narrate the characteristics of the tympanic membrane. For example, pearly gray tympanic membrane or reddened, edematous tympanic membrane with otitis media. Note color and exudate.

Differential diagnoses and how they differ from main assessment topic

Respiratory Virus - HA, fever, chills, malaise, accompanied by rhinitis, cough, conjunctivitis Herpes Pharyngitis - Malaise and fever with inflamed ulcerative lesions Hand-foot-and-mouth disease - malaise, ulcerative lesions in mouth, hands, feet, buttocks, or genitalia Diptheria - HA, rhinitis, fever, chills, dysphagia, difficulty breathing; pharynx inflamed with thick, gray membrane

Internal Ear Exam

Otoscopic Exam visualize auditory canal and tympanic membrane Know proper hand position on otoscope to ensure patient safety during procedure. Use otoscope: Grasp auricle firmly and and pull it upward, backward and slightly away from head > hold otoscope between thumb and fingers and brace your hand against the patient's face. Your hand and instrument can then detect unexpected movements by the patient. Light points toward floor. Narrate the characteristics of the tympanic membrane. For example, pearly gray tympanic membrane or reddened, edematous tympanic membrane with otitis media. Note color and exudate.

Clinical Manifestations: Signs/Symptoms

Pain Edema of the ear canal Erythema Discharge

Neck - Lymph Nodes

Palpate 10 Lymph nodes : note size, shape, discrete or matted together, mobility, consistency, tenderness. Normal characteristics of normal lymph node: small, round, mobile, discrete, non-tender. Practice technique for locating and palpating all nodes. Know location for Preauricular, Posterior Auricular, Occipital, Tonsillar, Submental, Submandibular, Superficial Cervical, Posterior Cervical, Deep Cervical Chain, Supraclavicular Bates' textbook page 259. Abnormal node characteristics: enlarged, tender, fixed to underlying tissue. Tender could indicate inflammation or infection Fixed nodes could indicate malignancy

Clinical Manifestations: Signs/Symptoms

Patient may present with one of the 5 warning signs of BCC Persistent, non-healing sore that bleeds/oozes, especially on sun-exposed area (face, chest, arms, legs, shoulders) A red patch or "irritated" area that is painful or itchy (may also be without pain) A shiny nodule or bump (can be pink, red, white, tan, black, brown) A pink growth with elevated/rolled border and central, crusted indentation; may note telangiectasias A white or yellow area that is shiny/taut and has the appearance of a scar (this may indicate invasive BCC)

Differential Diagnoses

Peripheral arterial disease - Stenosis of the blood supply to the extremities by atherosclerotic plaques • Raynaud phenomenon - Exaggerated spasm of the digital arterioles (occasionally in the nose and ears) usually in response to cold exposure • Arterial embolic disease - Atrial fibrillation can lead to clot formation within the atrium, which may be dispersed throughout the arterial system. *Venous thrombosis - Sudden or gradual with varying severity of symptoms - Can be the result of trauma or prolonged immobilization • Venous ulcers - Results from chronic venous insufficiency in which lack of venous flow leads to lower extremity venous hypertension

Assessment Skill/ Techniques/Labwork/Procedure used to Diagnose Clinical Problem

Pulmonary function tests of spirometry Forced expiratory volume in 1 second (FEV1)/Forced Vital Capacity (FVC) ratio with diminished FEV1 indicate obstructed airflow Some degree of reversibility occurs with bronchodilators Physical assessment; wheezing and cough ( Chest XR - typically clear, helpful with differential diagnosis rule-out Peak flow meters should not be used as diagnostic tests, ok to use for monitoring ongoing symptoms and evaluate treatment Symptoms are a large part clinical diagnosis (night time symptoms, triggers, onset, patterns of wheezing and shortness of breath)

Assessment Skill/Techniques /Labwork /Procedure used to diagnose clinical problem

Rapid antigen testing or throat culture To examine, look into the patient's mouth using a good light and a tongue depressor to inspect the throat and tonsils for color, ulcers, white patches, and nodules Centor Score Age (3-14= +1, 14-44= 0, >45= -1) Tonsillar exudate/swelling Tender/swollen anterior cervical lymph node Fever Cough (present=0, absent= +1)

Signs, Symptoms And Clinical Manifestations

Rapid onset of Acute Otitis Media have the following findings upon physical assessment: Subjective Patient usually complains of painful ache within ear. Objective Otalgia (pain in the ear) Otorrhea (drainage exiting the ear) Headache Fever Irritability Loss of appetite Vomiting Diarrhea

Allergic Rhinitis

Rhinorrhea: refers to drainage from the nose and is often associated with nasal congestion, or a sense of stuffiness or obstruction Can be caused by viral infections, allergic rhinitis ("hay fever") and vasomotor rhinitis Definition: occurs when your immune system overreacts to particles, or allergens, in the air that you breathe causing symptoms such as sneezing and a runny nose Common causes: pollen from trees, grasses, and weeds; dust; animal dander; cockroaches; mold

Clinical Manifestations/Signs Symptoms

SYMPTOMS: Intermittent sensation of chest tightness, cough (typically non-productive), shortness of breath, and/or wheezing Symptoms may become relatively persistent and effect quality of life Symptoms worsen with activity, viral infection, or exposure to allergens Symptoms are a large part of asthma staging; night time symptoms, use of SABA, and interference with activities SIGNS: Wheezing, deep respiratory effort triggers paroxysmal cough, use of accessory muscles, tachypnea Patients with asthma often have other signs of atopy (AR, atopic dermatitis)

Assessment Skill/ Techniques/Labwork/Procedure used to Diagnose Clinical Problem

Screen at risk patients with CAM The Confusion Assessment Method Diagnostic Algorithm: Acute change in mental status and fluctuating course Inattention Disorganized thinking Abnormal level of consciousness Diagnosing delirium requires features 1 and 2 and either 3 or 4.

Sinuses

Sinuses - Inspect the frontal and maxillary sinus areas for swelling - Palpate frontal and maxillary sinuses for tenderness - Transillumination of the frontal and maxillary sinuses may be performed if sinus tenderness is present or infection is suspected

Personal and Social History

Skin care habits • Cleansing routine, soaps, oils, lotions • Cosmetics, home remedies, sun screens • Recent changes in skin care habits • Exposure to sunlight or tanning beds • Skin self-examination • Nail care habits • Exposure to environmental or occupational hazards • Recent psychological or physical stress • Use of alcohol, tobacco, or recreational drugs Previous history of skin diseases or problems Allergies to food, plants, animals, drugs Familial predisposition Allergies, hay fever, psoriasis, eczema, acne Rash or lesions OTC, anxiety, self-esteem, sexually transmitted, tickborne Change in color Warning signs -ABCDE, itching, burning, bleeding Excessive bruising, Falls, medication, abuse

Clinical Manifestations: Signs/Symptoms

Sneezing; especially in the morning Runny nose and postnasal drip Drainage is clear and thin Itchy and watery eyes Cobblestone look to posterior pharynx Throat discomfort Itchy ear, nose, and throat Fatigue, no fever Nasal mucosa will be boggy and pale Ear congestion may be present

Visual Acuity

Snellen eye chart - 20 feet from chart - Cover one eye - 20/20 normal - client can read what the normal person can read at 20 feet • Myopia - Impaired far vision - 20/40 - larger the bottom number the poorer the vision • Presbyopia - Impaired near vision > 45 y.o., ↓ accommodation Near Vision Acuity: -Use Rosenbaum pocket screener -Each eye tested individually

extra

Splitting of heart sounds: Explanation of mechanism What is splitting? What does it reflect? Instead of a single sound, you may hear two. During inspiration: ↑ capacitance pulm vascular bed → ejection of blood from vent delayed. P2 closes followed by A2 A2: louder. Heard throughout the precordium (pressure higher across aorta) P2: soft, heart best 2nd and 3rd LSB Not supposed to hear on expiration Auscultating Murmurs • Heart murmurs - Timing and duration: decide systolic or diastolic murmur - Pitch: high, medium or low - Intensity: 6 point scale grade I to VI - Pattern: crescendo-decreshendo - Quality: blowing, harsh, rumbling, musical - Location and radiation - Respiratory phase variations Systolic and diastolic murmurs • S1 Systole S2 diastole S1 • TV / MV AV/PV • Systolic Murmurs: AS, MR, MVP • Diastolic murmurs: AI, MS Systolic murmurs AS: Ejection click Mis systolic murmur Creschendo decreschendo Peak aortic area Radiation to carotids MR: Pansystolic murmur. Location: apex. Radiation to axilla MVP: mid systolic click with late systolic murmur. Diastolic murmurs AI: listen at the LSB. Early diastolic murmur. MS: opening snap (OS) OS followed by mid diastolic rumble. Extra heart sounds • Systolic click: EJ click of AS. Non ejection click of MVP • Opening snap • S3 and S4: heard best with the bell at the apex. L lateral decubitus position. S3 or ventricular gallop • Volume overload condition • Hear it in early diastole: rapid filling phase rushing to the LV • Tensing of chordae tendonae from pressure from LA --S3 • Normal children and young adults (heart can handle higher volume) S4 (atrial gallop) • Pressure overload problem • LV contracting againsts an increased pressure eg. HTN • With time ↑ stiffness • S4: heard when atrium contracts againsts a still LV • End of diastole right before the next cycle begins

How to Interview a Patient

Stay calm!! • Prepare before you go into the room - Read the chart, familiarize yourself with the patient • Set an agenda - Time, needs, issues • Look and be professional - If you look the part you have already conquered the first hurdle

Special Considerations pregnant women

Striaegravidarum(stretch marks) • Telangiectasias/hemangiom as • Cutaneous tags • Increased pigmentation • Palmar erythema • Itching • Altered hair growth

General Survey

Subjective Assessment • Fatigue and Weakness • Fever • Weight Changes • Pain Health History Common or Concerning Symptoms +Fatigue and Weakness Fatigue-a nonspecific symptom that refers to a sense of weariness or loss of energy Weakness- denotes a demonstrable loss of muscle power Important to elicit life circumstances when symptoms occur- fatigue unrelated to such warrant further investigation +Fever -an abnormal elevation in body temperature (above 100.4F) Normal temperatures can vary throughout day Inquire about any recent illnesses? Has the patient checked their temperature? Night sweats? Chills? +Weight Changes How is your weight compared to a year ago? How do your clothes fit? If there is a change in weight- inquire about change in diet or activity. Is it intentional? Any mechanical factors contributing to weight gain or loss? What medications is patient taking? Any drugs, alcohol, or smoking?

3 differential diagnoses and how they differ from basal cell carcinoma

Superficial BCC (pink patch, may have scaling) Nodular BCC (pink papule which may have pigmentation, overlying telangiectasias Ulcerated BCC (ulcer that does not heal, rolled border) Lesions that Mimic BCC Types Actinic keratosis or squamous cell carcinoma in situ (keratotic scaling Sebaceous hyperplasia (yellowish papule with central depression, surrounding telangiectasias Squamous cell carcinoma (also ulcer, firmer edges/border)

History Taking-Skin

Symptom Analysis including onset, progression, trigger, aggravating or alleviating factors; How has it changed since first appearance; and all associated symptoms-itching, malaise, and so on. Ask about dryness, pruritis, sores, rashes, lumps, unusual odor or perspiration, changes in moles or warts, lesions that do not heal, or areas of chronic irritation. Any changes in skin coloration or texture

Events in cardiac cycle

Systole: LV contracts --Vent pressure > Atrial Pressure --- closure of MV--- S1 heard • Vent ejects most blood- pressures fall--- vent pressure < aortic pressure--- AV closes - S2 heard. Another diastole begins. • Diastole: LV pressure < LA pressure. MV opens. • Usually silent event. If you hear a snap after S2 think of MS (OS opening snap

Assessment Skill/Techniques /Lab work /Procedure used to diagnose clinical problem

The diagnosis of pertussis is usually made based on its characteristic history and physical examination. A laboratory test may be done, which involves taking a specimen from the back of the patient's throat (through the nose). Culture of the bacterium Bordetella pertussis from nasal secretions can confirm the diagnosis, especially early in the course of the disease. A negative culture does not exclude the diagnosis. Culture is considered the gold standard because it is the only 100% specific method for identification. PCR - PCR is a rapid test and has excellent sensitivity. Tests vary in specificity, so obtaining culture confirmation of pertussis for at least one suspicious case is recommended any time there is suspicion of a pertussis outbreak. Results should be interpreted along with the clinical symptoms and epidemiological information. PCR should be tested from NP specimens taken at 0 to 3 weeks following cough onset, but may provide accurate results for up to 4 weeks. After the fourth week of cough, the amount of bacterial DNA in the nasopharynx rapidly diminishes, which increases the risk of obtaining falsely-negative results. Serology - Useful for diagnosis in later phases of the disease. For the CDC single point serology test, the optimal timing for specimen collection is 2 to 8 weeks following cough onset, when the antibody titers are at their highest; however, serology may be performed on specimens collected up to 12 weeks following cough onset.

Documenting the Chief Complaint Do Not Confuse the CC and HPI

The primary reason the patient is seeking medical attention, recorded using the patients own words, in quotes X duration - "abdominal pain" x 3 months - Chest pain • One sentence, never more than two • Do not editorialize or embellish - The chief complaint is not your interpretation of why a patient is seeking help, but the patient's

Clinical Manifestations: Signs/Symptoms

The primary symptom of conjunctivitis, eye redness, is fairly consistent among the various causes. The degree of accompanying eye symptoms, such as discomfort, itching, and discharge, as well as extraorbital symptoms helps to define the problem.

Subjective

The subjective section is what the patient tells you about their current condition and past conditions.

Plan

This is where the treatment plan goes. - Medications - Diagnostic tests (i.e. laboratory, radiologic, hearing, etc.) - Education - Counseling - Referrals - Procedures performed and the outcomes/result(s) - Return to office date(s)/Follow up Sample - Amoxicillin 875mg BID for 10 days - Rapid Strep test done in office - Verbal instructions given on warm salt water gargles and spit 3-4 times a day; rest; increased fluids; rest; no work 2 days note given to patient - Patient instructed to return to the office in 2 days if no improvement. To report to the emergency department with difficulty swallowing, breathing, rash develops, or symptoms worse verbalized understanding.

Assessment

This section is where the diagnosis and differential diagnosis are listed for the date the note is written. Sample Diagnosis: - Strep Pharyngitis • Differential Diagnosis: - Viral pharyngitis - Rheumatic fever - Scarlet fever

Clinical Manifestations: Signs/Symptoms

Three stages: Catarrhal stage: can last 1-2 weeks and includes a runny nose, sneezing, low-grade fever, and a mild cough (all similar symptoms to the common cold). Paroxysmal stage: usually lasts 1-6 weeks, but can persist for up to 10 weeks. The characteristic symptom is a burst, or paroxysm, of numerous, rapid coughs. At the end of the cough paroxysm, the patient can suffer from a long inhaling effort that is characterized by a high-pitched whoop (hence the name, "whooping cough"). Infants and young children often appear very ill and distressed, and may turn blue and vomit. "Whooping" does not necessarily have to accompany the cough. Convalescent stage: usually lasts 2-6 weeks, but may last for months. Although the cough usually disappears after 2-3 weeks, paroxysms may recur when- ever the patient suffers any subsequent respiratory infection. The disease is usually milder in adolescents and adults, consisting of a persistent cough similar to that found in other upper respiratory infections. However, these individuals are still able to transmit the disease to others, including unimmunized or in completely immunized infants.

LOCATES

To help you remember - L ocation O ther associated symptoms C haracter (or quality) A lleviating/aggravating T iming E nvironment/setting S everity

PQRSSTA

To help you remember - P rovocative/Palliative Q uality R egion S everity S etting T iming A ssociated symptoms

Mouth and Throat

Wear gloves and apply antiseptic gel Inspect lips, oral mucosa, gums, teeth, floor and roof of mouth, tongue, soft and hard palate, pharynx, uvula and tonsils for symmetry, color, lesions, exudate .

Subjective Assessment

• Inquire about any common or concerning symptoms: • Any noted changes in your skin, hair or nails? • Any rashes, sores, lumps, or itching? • Any growths that you are concerned about? Any new growths or moles? Do you have any moles that have changed in size, shape, or color?

Blood Pressure

• "True Blood Pressure"- is the average of blood pressures over days and weeks • Home and ambulatory blood pressure measurements are more accurate in predicting cardiovascular disease and end organ damage than traditional office reading Width of cuff should be about 40% of arm circumference; length should be about 80% of upper arm • Arm should be free of clothing and at hear level • Ideally patient should be sitting quietly for at least 5 minutes in a chair with feet on floor

The head Subjective Assessment

• Any loss of consciousness? Or change in consciousness? • Any history of seizures? • Any recent changes in vision such as double vision? • Any chronic nausea or vomiting especially projectile? • Any frequent or severe headaches? Where is pain or discomfort? • Any recent head trauma? • Any chronic analgesic use

Thorax and Lungs Differential Diagnoses

• Asthma (reactive airway disease) - Reversible small airway obstruction due to inflammation and hyperreactive airways • Atelectasis - Incomplete expansion of the lung at birth or the collapse of the lung parenchyma at any age • Bronchitis - Inflammation of the large airways • Pleurisy - Inflammatory process involving the visceral and parietal pleura, which becomes edematous and fibrinous • Pleural effusion - Excessive nonpurulent fluid in the pleural space • Empyema - Purulent exudative fluid collected in the pleural space • Lung abscess - Well-defined, circumscribed mass defined by inflammation, suppuration, and subsequent central necrosis • Pneumonia - Inflammatory response of the bronchioles and alveoli to an infective agent (bacterial, fungal, or viral) • Influenza - Viral infection of the lung - Normally an upper respiratory infection, but due to alterations in the epithelial barrier, the infected host is more susceptible to secondary bacterial infections. • Tuberculosis - Chronic infectious disease that most often begins in the lung but may then have widespread manifestations • Pneumothorax - Presence of air or gas in the pleural cavity • Hemothorax - Presence of blood in the pleural cavity • Lung cancer - Generally refers to bronchogenic carcinoma, a malignant tumor that evolves from bronchial epithelial structures • Cor pulmonale - Acute or chronic condition involving right-sided heart failure • Pulmonary embolism - Embolic occlusion of pulmonary arteries - Relatively common condition - Difficult to diagnose • Older Adults • Chronic obstructive pulmonary disease - COPD is a nonspecific designation that includes a group of respiratory problems in which cough, chronic and often excessive sputum production, and dyspnea are prominent features. - Not limited to older adults, smokers at greatest risk - Emphysema, bronchiectasis, and chronic bronchitis are the main conditions that are included in this group • Emphysema - Condition in which the lungs lose elasticity and alveoli enlarge in a way that disrupts function • Bronchiectasis - Chronic dilation of the bronchi or bronchioles is caused by repeated pulmonary infections and bronchial obstruction. • Chronic bronchitis - Large airway inflammation, usually a result of chronic irritant exposure; more commonly, a problem for patients older than 40

Why is the Patient Here? •

• Begin with open-ended questions - Requires patients to actually describe their complaints - Obtain accurate, patient-specific information • Avoid closed-ended questions - Similar to a long health history survey - Actually takes longer than open-ended questions • Be attentive while the patient is speaking - Of yourself • Silence, non-verbal encouragement , body language -The Patient • Look for non-verbal signs and cues • Ask question(s) and then ask again, using the patients own words • What is the patient's personal story • Ask emotion-seeking questions

Techniques of Examination: Vocal Resonance

• Bronchophony - Greater clarity and increased loudness of spoken sounds • Pectoriloquy - Extreme bronchophony where even a whisper can be heard clearly through the stethoscope • Egophony - Intensity of the spoken voice is increased and there is a nasal quality. - e's become stuffy broad a's

Differential Diagnoses

• Cardiac Disorders • Bacterial endocarditis - Bacterial infection of the endothelial layer of the heart and valves • Congestive heart failure - Heart fails to propel blood forward with its usual force, resulting in congestion in the pulmonary or systemic circulation • Myocardial infarction - Ischemic myocardial necrosis caused by abrupt decrease in coronary blood flow to a segment of the myocardium • Conduction disturbances - Atrial flutter - Sinus bradycardia - Atrial fibrillation - Heart block - Atrial tachycardia - Ventricular tachycardia - Ventricular fibrillation • Infants and Children Tetralogy of Fallot - Ventricular septal defect - Pulmonic stenosis - Dextroposition of the aorta - Right ventricular hypertrophy • Ventricular septal defect - Opening between the left and right ventricles • Patent ductus arteriosus - Failure of the ductus arteriosus to close after birth • Atrial septal defect - Congenital defect in the septum dividing the left and right atria • Acute rheumatic fever - Systemic connective tissue disease occurring after streptococcal pharyngitis or skin infection • Older Adults • Atherosclerotic heart disease - Caused by deposition of cholesterol, other lipids, and by a complex inflammatory process • Mitral insufficiency/Regurgitation - Abnormal leaking of blood through the mitral valve, from left ventricle into left atrium • Angina - Pain caused by myocardial ischemia • Aortic sclerosis - Thickening and calcification of aortic valves

Past Medical History

• Cardiac surgery and hospitalization • Rhythm disorder • Acute rheumatic fever, unexplained fever, swollen joints, inflammatory rheumatism • Chronic illness

Thorax and Lungs HPI

• Chest pain - Initial questions should be as broad as possible, such as, "Do you have any discomfort or unpleasant feelings in your chest?" - Ask the patient to point to the location of the pain - Use OLDCART • Onset and duration • Associated symptoms • Efforts to treat • Other medications • Recreational drugs (e.g., cocaine) Chest pain - Aside from lung conditions, chest pain may arise from cardiac, vascular, gastrointestinal, musculoskeletal, or skin pathology; it is also commonly associated with anxiety - Lung tissue itself has no pain fibers; pain in lung conditions usually arises from inflammation of the adjacent parietal pleura - Other surrounding structures may also irritate the parietal pleura, causing pain • Shortness of breath (Dyspnea) - Non-painful but uncomfortable awareness of breathing that is inappropriate to the level of exertion - Begin assessment with a broad question, such as, "Have you had any difficulty breathing?" - Determine the severity of dyspnea based on the patient's daily activities • Shortness of breath (Dyspnea) - Onset - Pattern - Position most comfortable, number of pillows used - Related to extent of exercise, certain activities, time of day, eating - Harder to inhale or exhale - Severity - Associated symptoms - Efforts to treat • Wheezing - Wheezes are musical respiratory sounds that may be audible to the patient and to others - Airway obstruction form secretions, inflammation or foreign body • Cough - Reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi - May be cardiovascular in origin; left sided failure • Cough Ask the patient to describe the volume of any sputum and its color, odor, and consistency - Onset - Nature of cough; dry or produces sputum, or phlegm - Sputum production: frequency and amount in 24 hours - Sputum characteristics; mucoid, foul smelling - Pattern - Severity - Associated symptoms - Efforts to treat • Hemoptysis • Hemoptysis is the coughing up of blood from the lungs; it may vary from blood-streaked phlegm to frank blood - Ask the patient to describe the volume of blood produced as well as other sputum attributes - Try to confirm the source of the bleeding by history and examination before using the term "hemoptysis"; blood may also originate from the mouth, pharynx, or gastrointestinal tract

The Cardiovascular System HPI

• Chest pain - Onset and duration - Character - Location - Severity - Associated symptoms - Treatment - Medications: prophylactic penicillin • Fatigue - Unusual or persistent - Inability to keep up with peers - Associated symptoms - Medications: beta-blockers • Cough - Onset and duration - Character - Medications: ACE inhibitors • Difficulty breathing (dyspnea, orthopnea) - Aggravated by exertion - On level ground, climbing stairs - Worsening or remaining stable - Lying down or eased by resting on pillows • (How many? Or sleep in a recliner?) - Paroxysmal nocturnal dyspnea • Syncope associated with: - Palpitation - Dysrhythmia - Unusual exertion - Sudden turning of neck (carotid sinus effect) - Looking upward (vertebral artery occlusion) - Change in posture

Skin Assessment Objective Data

• Color & pigmentation • Normal: pink or appropriate for race & even pigmentation • Change in pigmentation • Vitiligo • Widespread skin color changes • Pallor • Cyanosis • Erythema • Jaundice

Inflammatory versus Bacterial Infections

• Eczematous Dermatitis • Most common inflammatory skin disorder: • Irritant contact dermatitis • Allergic contact dermatitis • Atopic dermatitis • Psoriasis • Chronic and recurrent disease of keratin synthesis • Rosacea • Chronic inflammatory skin disorder • Folliculitis • Inflammation and infection of the hair follicle and surrounding dermis • Furuncle (boil) • Deep-seated infection of the pilosebaceous unit • Cellulitis • Diffuse, acute, infection of the skin and subcutaneous tissue

Objective Assessment

• Equipment Needed: • Gloves • Good lighting • Ruler • Inspect and Palpate the skin • Note the color of the skin throughout the examination • Palpate for temperature, moisture, texture, edema, and turgor • Closely inspect any lesions

Thorax and Lungs Physical Examination

• Examination of the anterior and posterior chest in sitting and supine positon - Proceed in an orderly fashion: inspect, palpate, percuss, and auscultate - Anteriorally with percussion, the heart normally produces an area of dullness to the left of the sternum from the 3rd to 5th rib interspaces - Supraclavicular retraction is often present • Inspect the chest; front and back, noting thoracic landmarks, for the following: - Size and shape (anteroposterior diameter compared with the lateral diameter) - Symmetry - Color - Superficial venous patterns - Prominence of ribs • Evaluate respirations for the following: - Rate - Rhythm or pattern • Inspect chest movement with breathing for the following: - Symmetry - Use of accessory muscles • Note any audible sounds with respiration • Palpate the chest for the following: - Symmetry - Thoracic expansion - Sensations such as crepitus, grating vibrations - Tactile fremitus • Percuss on the chest, comparing sides, for the following: - Diaphragmatic excursion - Percussion tone intensity, pitch, duration, and quality • Auscultate the chest with the stethoscope diaphragm, from apex to base; comparing sides for the following: - Intensity, pitch, duration, and quality of breath sounds - Adventitious breath sounds (crackles, rhonchi, wheezes, friction rubs) - Vocal resonance

External Nose and Sinuses

• External nose - Inspect nose and nares • Nose for shape, size, and color • Nares for flaring, narrowing, or discharge - Palpate nose • Displacement of bone or cartilage • Tenderness • Masses - Evaluate patency of nares

-Physical examination findings

• General -Well nourished and hydrated 28 yo female. Awake, alert and orient; appropriately dressed for season. Pleasant and cooperative. *Skin - hot, dry and pink. No rashes or lesions including petechiae noted • HEENT - normocephalic, symmetric face features. No tenderness in scalp, face, ethmoid/maxillary/frontal sinuses. Negative transillumination. External ears without deviations, ear canal clear bilaterally, tympanic membranes pearly grey with cone of light, bony landmarks visualized bilaterally. Nasal mucosa pink and moist turbinates with no edema or erythema. Oral mucosa pink and moist, dentition without obvious caries; no lesions oral cavity. Pharynx with moderate erythema tonsillar pillars ¼ bilaterally. No exudate. Uvula midline gag reflex present. • Neck - supple. Anterior cervical lymphadenopathy with mobile, tender nodes bilaterally all less than 1 cm diameter. No JVD - Cardiac - S1 S2 with no murmurs, gallops, or clicks. PMI 5th ICS mid-clavicular line - Pulmonary - lungs clear to auscultation bilaterally in all fields. Negative tactile fremitus, egophony, bronchophony, and whispered pectoriloquy - GI - no masses or pulsations. Bowel sounds normoactive all 4 quadrants. No organomegaly no bruits. -GU- denies missed menses, urinary frequency, urgency or hematuria - MS - Strength 4/5 bilateral upper and lower extremities. Gait steady - Neuro - awake, alert, and oriented to name, place, date, and surroundings. No nuchal rigidity, Kernigs or Brudzinski signs

Techniques of Examination

• General techniques - Examine the posterior thorax and lungs while the patient is sitting - Examine the anterior thorax and lungs with the patient supine - Compare one side of the thorax and lungs with the other, so the patient serves as his or her own control - Proceed in an orderly fashion: inspect, palpate, percuss, and auscultate • Initial survey (Inspection) of respiration and the thorax - Observe the rate, rhythm, depth, and effort of breathing - Inspect for any signs of respiratory difficulty o Assess the patient's color o Listen to the patient's breathing o Inspect the patient's neck - Observe the shape of the chest • Observe for peripheral clues may suggest pulmonary or cardiac difficulties: - Breath: odor - Skin, nails, and lips: cyanosis or pallor - Fingers: clubbing - Lips: pursing - Nostrils: flaring • Examination of the posterior chest - Inspection o From a midline position behind the patient, note the shape of the chest and the way in which it moves • Palpation of the thoracic muscles/skeleton - Pulsations - Tenderness - Bulges/depressions - Masses - Unusual movement/positions - Elasticity of rib cage - Immovability of sternum - Rigidity of thoracic spine • Position of the trachea (head & neck exam) • Percuss chest -Anterior -Lateral -Posterior • Compare tones bilaterally Examination of the posterior chest - Percussion o Perform from side to side to assess for asymmetry o Strike using the tip of your tapping finger o Use the lightest percussion that produces a clear note o Percussion helps establish whether the underlying tissues (5-7 cm deep) are air-filled, fluid-filled, or solid o Percussion notes Flatness, dullness, resonance, hyperresonance, tympany • Percussion tone indicators for lungs -Resonance is normal. -Hyperresonance indicates hyperinflation. -Dullness indicates diminished air exchange - Palpation o Assess any observed abnormalities and identify any tender areas Feel for tactile fremitus, or palpable vibrations as the patient is speaking o Chest expansion o Place thumbs at the level of the 10th rib with fingers loosely grasping and parallel to the lateral rib cage; watch the distance between the thumbs as they move apart during inspiration • Auscultation with a stethoscope provides important clues to the condition of the lungs and pleura • All sounds can be characterized in the same manner as the percussion notes: - Intensity - Pitch - Quality - Duration • Posterior chest - Auscultation o Auscultation of the lungs is the most important examination technique for assessing air flow through the tracheobronchial tree o Together with percussion, it also helps to assess the condition of the surrounding lungs and pleural space o Listen to the breath sounds with the diaphragm of a stethoscope after instructing the patient to breathe deeply through an open mouth o Use the pattern suggested for percussion, moving from one side to the other and comparing symmetric areas of the lungs o Listen to at least one full breath in each location

Subjective Assessment neck

• Has the patient noticed any "swollen glands" or lumps in neck? • Any pain in neck or tenderness? • Any enlargements in neck area or goiter? • Any intolerances to extremes in weather? • Do you perspire more than others that you know? • Any palpitations? • Any changes in bowels- constipation vs diarrhea? • Any change in weight?

Family History & Personal and Social History

• Heart disease • Hypertension • Dyslipidemia • Diabetes • Congenital heart defects • Long QT syndrome • Family members with cardiac risk factors • Employment - Physical demands - Environmental hazards • Tobacco use • Nutritional status • Personality assessment • Relaxation activities • Use of alcohol and/or drugs

Health History

• History of Present Illness (HPI) "OLDCART" - - - Onset - Location/Radiation - Duration - Characteristic - Associated Symptoms - Relieving /aggravating factors - Treatments

Differential Diagnosis

• In deciding which disease to include in the differential, consider: - What's the most life-threatening disease the patient could have? - Could this be a common disease presenting with unusual features? - What diseases present with misleading symptoms? - What rare diseases could be causing these signs and symptoms?

Sequence of Cardiac examination

• Inspection • Apical impulse - Should be visible at about the midclavicular line in the fifth left intercostal space • In some patients, it may be visible in the fourth left intercostal space • It should not be seen in more than one space if the heart is healthy • Obscured by obesity, large breasts, or muscularity Palpating the Chest Wall • Using the finger pads, palpate for heaves or lifts from abnormal ventricular movements: forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs. • Using the ball of the hand, palpate for thrills, or turbulence/ vibrations transmitted to the chest wall surface by a damaged heart valve • Examples: 1. Sustained lift at the Tricuspid area: RV 2. Systolic thrill at tricuspid area: VSD 3. Thrill at the Mitral area: MR or MS • Palpation • Apical impulse - If it is more vigorous than expected, characterize it as a heave or lift. - Point of maximal impulse (PMI) • Point at which the apical impulse is most readily seen or felt - Thrill: a fine, palpable, rushing vibration, a palpable murmur • Carotid artery palpation Assessing the Point of Maximal Impulse (PMI) • Inspect the left anterior chest for a visible PMI • Using your finger pads, palpate at the apex for the PMI • The PMI may be: - Tapping — normal - Sustained — suggests LV hypertrophy from hypertension or aortic stenosis - Diffuse — suggests a dilated ventricle from congestive heart failure or cardiomyopathy • Locate the PMI by interspace and distance in centimeters from the midsternal line • Assess location, amplitude, duration, and diameter Assessing the Carotid Pulse • Keep the patient's head elevated to 30° • Place your index and middle fingers on the right then the left carotid arteries, and palpate the carotid upstroke • Never palpate right and left carotid arteries simultaneously • The upstroke may be: - Brisk - normal - Delayed - suggests aortic stenosis - Bounding - suggests aortic insufficiency • Listen with the stethoscope for any bruits - Bruits - turbulent blood flow outside the heart due to flow through narrowed or dilated vessel Percussion * Of limited value in defining borders of heart or determining its size Chest radiograph is far more useful in defining the heart borders Listening to the Heart — Auscultation • Listen in all 6 listening areas for S1 and S2 using the diaphragm of the stethoscope • Then listen at the apex with the bell • The diaphragm and the bell - The diaphragm is best for detecting high-pitched sounds like S1, S2, and also S4 and most murmurs - The bell is best for detecting low-pitched sounds like S3 and the rumble of mitral stenosis • Auscultation • Assess overall rate and rhythm • Frequency • Intensity • Duration • Pathology • Auscultation • Basic heart sounds - S1 or S2 most distinct - Splitting - S3 and S4 difficult to hear • Extra heart sounds - Gallops - Mitral snaps - Ejection clicks - Friction rubs

Mouth and Oropharynx - Inspection & Palpation

• Lips - Note color, moisture, lumps, ulcers, cracking, or scaliness • Oral Buccal Mucosa - Note color, moisture, ulcers, and nodules - Stenson ducts, Fordyce spots • Gums and teeth - Note color, presence, and position of teeth, occlusion, alignment Roof of mouth - Note color • Tongue and floor of mouth - Note color and texture, ulcers, nodules, coating, lesions - Ask patient to extend; deviation, tremor, limitation of movement - Frenulum • Oropharynx: - Soft palate - Anterior and posterior pillars - Uvula - Tonsils - Pharynx • Note color, symmetry, presence of exudate, swelling, ulceration, or tonsillar enlargement • Elicit gag reflex (cranial nerves IX and X)

Assessing Skin Lesions

• Location and Distribution • Type of Skin Lesion • Color • Patterns and shapes Characteristics • Exudates • Color • Odor • Amount • Consistency • Configuration (arrangement) • Annular (rings) • Grouped/Clustere d • Linear • Arciform (bowshaped) • Dermatomal

Pain Assessment

• Location • Severity -use of rating scales • Associated Features • Attempted Treatments, Medications, and Impact on Daily Activities

Develop a Complete, Framed Differential Diagnosis (Hypothesis)

• Not all diagnoses in a given differential are: - equally likely - equally important • You must select: - a leading (working) hypothesis - a must not miss hypothesis - An active alternative hypothesis

Special Considerations: History

• Pregnant Women • History of cardiac disease or surgery • Dizziness or faintness on standing • Indications of heart disease during pregnancy: - Progressive or severe dyspnea - Progressive orthopnea - Paroxysmal nocturnal dyspnea - Hemoptysis - Syncope with exertion - Chest pain related to effort or emotion • Older Adults • Common symptoms of cardiovascular disorder - Confusion and syncope - Palpitations - Coughs and wheezes - Hemoptysis - Shortness of breath - Chest pain and tightness - Incontinence, impotence, and heat intolerance - Fatigue - Leg edema • If diagnosed with heart disease - Drug reactions - Capability of performing activities of daily living - Coping - Orthostatic hypotension

Special Considerations: History

• Pregnant Women • Weeks of gestation • Presence of multiple fetuses, polyhydramnios, other conditions in which uterus displaces diaphragm • Exercise type and energy expenditure • Exposure to and frequency of respiratory infections, annual influenza immunization • Older Adults • Exposure to and frequency of respiratory infections - History of pneumococcal and flu vaccine • Effects of weather on respiratory efforts and infection occurrence • Immobilization and sedentary habits • Difficulty swallowing • Altered activities from respiratory symptoms • Older Adults - Smoking history - Cough - Dyspnea on exertion or breathlessness - Fatigue - Weight changes - Fever and night sweats

Heart Rate and Rhythm

• Radial Pulse is commonly used to assess the heart rate • With the pads of index and middle finger compress the radial artery until a maximal pulse is detected- count pulse for 30 seconds and multiply by 2; normal is 50-90 per minute • Assess rhythm (pattern) by feeling the radial pulse; compare to rhythm by listening at the cardiac apex

Pediatric Considerations

• Seborrheic dermatitis • Little known about etiology • Condition most commonly occurs in infants within the first 3 months of life. • Miliaria (prickly heat) • Caused by sweat retention from occlusion of sweat ducts during periods of heat and high humidity • Impetigo • Common, contagious superficial skin infection Acne vulgaris Impaction and obstruction of the outflow of sebum Chickenpox (varicella) Acute, highly communicable disease common in children and young adults Measles (rubeola) Measles virus infects by invasion of the respiratory epithelium. German measles (rubella) Mild, febrile, highly communicable viral disease

Review of Systems

• Should elaborate on the chief complaint and HPI • Don't ask questions that the patient may not know Review of Systems Do you have a problem with your prostate? Do have anemia, heart failure, cancer? Do you frequently urinate during the night? Have you noticed a change in the stream of your urine? Do you avoid drinking fluids during work? Do you feel tired often? Are you short of breath? Have you had any weight loss recently?

Elder Considerations

• Stasis dermatitis • Occurs on the lower legs in some patients with venous insufficiency • Solar keratosis (actinic keratosis) • Squamous cell carcinoma confined to the epidermis • Physical abuse in older adults • Look for bruising, burns, abrasions, or areas of tenderness • Particularly on hidden areas such as the axillae, inner thighs, soles of the feet, palms, and abdomen

SOAP stands for:

• Subjective • Objective • Assessment • Plan

Skin Assessment

• Temperature - use back of hands to assess • Moisture • Turgor • Lesions • describe Example: Color : cyanosis = decreased oxygenation Jaundice of eye sclera and skin = Liver disease

The head Objective Assessment

• The Hair- quantity, distribution, texture, and pattern of loss • Scalp- check for scales, lumps, or lesions • Skull- size and contour; observe suture line • Face- facial expressions; look for symmetry, masses, or involuntary movements • Skin- color, pigment, texture, hair distribution

Comprehensive History

• The comprehensive history is to be performed on all non-emergent, new patients who will be receiving ongoing primary care from a particular provider or group. • It is also expected within the hospital setting. Patient Identifiers Reliability Chief Complaint HPI Past Medical History Family History Social History Review of Systems (ROS)

Physical Examination

• The examination of the heart includes the following: - Inspecting - Palpating - Percussing the chest - Auscultating the heart • In assessing cardiac function, it is a common error to listen to the heart first - It is important to follow the proper sequence

Past Medical History

• Thoracic trauma or surgery • Dates of hospitalization for pulmonary disorders • Use of oxygen and ventilation-assisting devices - CPAP or BiPAP • Chronic pulmonary diseases or other respiratory disorders • Previous testing such as peak flow, PFT's, bronchoscopy, CXR • Immunization against Streptococcus pneumoniae, Influenza

Other Skin Disorders

• Tinea(dermatophytosis) • Group of noncandidal fungal infections that involve the stratum corneum, nails, or hair • Acanthosis nigrans • Nonspecific reaction pattern associated with obesity, certain endocrine syndromes or malignancies, or as an inherited disorder

Family History & Personal and Social History

• Tuberculosis (TB) • Cystic fibrosis • Emphysema • Allergy, Asthma, Atopic dermatitis (triad) • Malignancy • Bronchiectasis • Bronchitis • Clotting disorders (risk of pulmonary embolism) • Any of forementioned disorders in family history • Employment/Occupation • Home environment • Tobacco use • Exposure to respiratory infections, influenza, tuberculosis • Nutritional status • Medications including use of herbal or other remedies • Travel exposures • Hobbies • Use of alcohol/drugs • Exercise tolerance

Set the Stage

• Welcome the patient using their name • Introduce yourself and your role • Remove communication barriers - Family or professional translator • Ensure patient privacy and comfort • Set the agenda for the visit - What are you going to do

Chief Complaint

• What brought the patient to the office • Example: Sore throat for 2 days

Temperature

•Average oral temperature is 37 degrees C (98.6 F) -rectal temps are higher by an average of 0.5 degrees C -axillary temps are lower by an average of 1 degree C but considered less accurate can take 5-10 minutes -tympanic temps are typically 0.8 degrees C (1.4 degrees F) higher than oral temps; Cerumen impaction distorts reading; Otitis media can distort reading - use of temporal thermometers is growing especially in pediatrics

Eye Physical Assessment

•External Examination: - Inspect eyebrows for size, extension, and hair texture - Inspect orbital area for edema, puffiness, and sagging tissue below orbit • Eyelid inspection - Inspect closed lid for fasciculations and tremors - Check ability to close completely/open widely - Observe margin for flakiness, redness, and swelling - Look for eyelashes - Note eye opening • Ptosis - Note any eversion or inversion of lids Eyelid palpation - Palpate for nodules - Palpate the eye itself through closed lids • Conjunctivae inspection - Usually unapparent, clear, and free of erythema - Inspect lower portion by pulling down lower lid - Upper lid is inspected only if foreign body is in the eye. - Look for redness/exudate - Look for pterygium • Abnormal growth of conjunctiva that extends over the cornea from the limbus *Cornea -Examine clarity of the cornea by shining light on it. • Cornea is normally avascular; blood vessels should not be present. -Test sensitivity (cranial nerve V) by touching the cornea with a cotton wisp to elicit blink (cranial nerve VII). -Inspect for corneal arcus (arcus senilis). • Composed of lipids deposited in the periphery of the cornea *Iris and pupil -Inspect iris for pattern, color, and shape -Test for direct/consensual light response -Test pupils for accommodation •The pupils should constrict when the eyes focus on the near object -Estimate pupil size and compare for equality • Lens -Inspect for transparency/clarity • Sclera -Examine to ensure that it is white -Inspect for senile hyaline plaque • Lacrimal apparatus - Inspect lacrimal gland - Palpate lower orbital rim near inner canthus