EXAM 1 2022(Answered)

EXAM 1 2022(Answered) How to approach patient - Knock, address formally, meet/acknowledge others, learn names, ensure confidentiality, sit, don't rush, take notes sparingly, avoid typing, maintain eye contact, respect modesty, save discussions for after patient dresses Abdominal exam - Inspect, auscultate, palpate, percuss Exams except abdominal - Inspect, palpate, percuss, ausculate Inspection - Observation, uses eyes and nose, assesses gait, ease of ADLs, eye contact, demeanor, clothing appropriateness, color/moisture of skin, emotional/mental status, unusual odors. Can continue through entire exam. Auscultation - Listening, usually with stethoscope; perform in quiet area; listen for sound and intensity, pitch, duration, quality; perform last Percussion - Finger against finger on body part; dense = quiet, air = loud, fluid = less loud, solid = soft Tympanic - Loud, high pitch, moderate duration, drumlike quality, ex. Gastric bubble Hyperresonant - Very loud, low pitch, long duration, boomlike quality, ex. Emphysematous lungs Resonant - Loud, low pitch, long duration, hollow quality, ex. Healthy lung tissue Dull - Soft to moderate, moderate to high pitch, moderate duration, thudlike quality, ex. Over liver Flat - Soft, high pitch, short duration, very dull quality, ex. Over muscle Immediate percussion - Strike finger/hand directly against body Indirect/mediate percussion - Strike distal phalanx of middle finger against finger placed on body, originate strike from wrist Percussion with fist - used to elicit tenderness from liver, gallbladder, kidneys; uses ulnar aspect of fist Palpation - Gathering information through hands and fingers (touch) Fine discrimination - Palmar surfaces of fingers and finger pads, sensitive, use for discriminatory touch to determine position, texture, size, consistency, masses, fluid, crepitus. Vibration - Ulnar surface of hand and fingers Dorsal surface of hand - Use for temperature How to palpate - Be gentle, warm hands Pneumatic otoscope - Illuminates external auditory canal and tympanic membrane Reflex hammer - Tests deep tendon reflexes; use brisk, wrist snap Opthalmoscope - For inner structures of eye Large aperture - Large round beam, used most often Small aperture - To examine small pupils Red-free filter - Green beam to examine optic disc for pallor and minute vessel changes, permits recognition of retinal hemorrhage, blood appears black Slit aperture - For anterior eye; determines elevation of lesions on retina Grid aperture - For size of fundal lesions Wood's lamp - Black light (wavelength 360 nm); causes substances to fluoresce; used to see fungi on skin lesions Cognitive impairment indications - LOC, response to question, reasoning or judgment, arithmetic ability, memory, attention span, specific mental test scores Complex mental processes - learning, perceiving, decision making, and memory Older adults complex mental processes - Montreal Cognitive Assessment and miniCog Signs of possible cognitive impairment - significant memory loss, confusion (impaired cognitive function with disorientation, attention and memory deficits, and difficulty answering questions or following multiple-step directions), impaired communication, inappropriate affect, personal care difficulties, hazardous behavior, agitation, and suspiciousness Cognitive impairment - Ask patient to complete analogy (analogies), tell the meaning of a fable, proverb, etc. (abstract reasoning), do arithmetic calc, ask to write down a phrase (writing ability), ask to button shirt or comb hair (execution of motor skills), memory tests Immediate recall or new learning - Listen and repeat a sentence or series of numbers (5-8 forward, 4-6 backward) Recent memory - View 4-5 objects and tell them you will ask about later. In ten minutes, have them list objects. Remote memory - Ask about verifiable events or info such as mother's name, high school, common knowledge Memory loss - may result from disease, infection, temporal lobe trauma Impaired memory - neuro or psych disorders, such as anxiety and depression Immediate and recent memory loss with retention of remote memory - dementia Cerebrum - consists of two hemispheres divided into lobes, responsible for mental status Cerebral cortex - gray outer layer of cerebrum, houses higher mental functions, responsible for perception and behavior Frontal lobe - contains motor cortex, responsible for speech formation (Broca area), decision making, problem solving, concentration, short-term memory; associated areas - emotions, affect, drive, awareness of self and autonomic responses r/t emotional state Parietal lobe - receives/processes sensory data; interprets tactile sensations (temp, pressure, pain, size, shape, texture, two-point discrimination), and visual, taste, smell, and hearing; proprioception (recognition of body parts and awareness of body position); association fibers provide communication between sensory and motor areas of brain Occipital lobe c - primary vision center and provides interpretation of visual data Temporal lobe - Perception and interpretation of sounds as well as localizing their source; contains Wernicke speech area (helps understand spoken and written language) Temporal lobe is responsible for - perception and interpretation of sounds and determination of their source; involved in integration of taste, smell, and balance. The reception and interpretation of speech is located in the Wernicke area. Medial temporal lobes include - the hippocampi, essential for memory storage Basal ganglia system - extrapyramidal pathway and processing station between the cerebral motor cortex and the upper brainstem. Refine motor movements through interconnections with the thalamus, motor cortex, reticular formation, and spinal cord Cerebellum - aids motor cortex of the cerebrum in the integration of voluntary movement. Processes sensory information from the eyes, ears, touch receptors, and musculoskeletal system. With the vestibular system uses the sensory data for reflexive control of muscle tone, balance, and posture to produce steady and precise movements. Cerebellum's hemispheres have - ipsilateral (same side) control of the body Brainstem - pathway between cerebral cortex and spinal cord; controls many involuntary functions Brainstem structures - medulla oblongata, pons, midbrain, and diencephalon. The nuclei of the 12 cranial nerves arise from these structures. Thalamus - major integrating center for perception of various sensations (pain, temperature) and cortical processing for interpretation; also relays sensory aspects of motor information between the basal ganglia and cerebellum. Pons - transmits information between the brainstem and the cerebellum, where motor information from the cerebral cortex is relayed to the contralateral cerebellar hemisphere. Medulla oblongata - where descending corticospinal tracts decussate (cross to the contralateral side). Medulla oblongata - CN IX to XII Respiratory, circulatory, and vasomotor activities; houses respiratory center Reflexes of swallowing, coughing, vomiting, sneezing, and hiccupping; relay center for major ascending and descending spinal tracts that decussate at the pyramid Pons - CN V to VIII Reflexes of pupillary action and eye movement Regulates respiration; houses a portion of the respiratory center Controls voluntary muscle action with corticospinal tract pathway Midbrain - CN III and IV Reflex center for eye and head movement Auditory relay pathway Corticospinal tract pathway Diencephalon - CN I and II Thalamus Relays impulses between cerebrum, cerebellum, pons, and medulla (see Fig. 23.4) Conveys all sensory impulses (except olfaction) to and from cerebrum before their distribution to appropriate associative sensory areas Integrates impulses between motor cortex and cerebrum, influencing voluntary movements and motor response Controls state of consciousness, conscious perceptions of sensations, and abstract feelings Epithalamus - Houses the pineal body - sexual development and behavior Hypothalamus - Major processing center of internal stimuli for autonomic nervous system; maintains temperature control, water metabolism, body fluid osmolarity, feeding behavior, and neuroendocrine activity Pituitary gland - Hormonal control of growth, lactation, vasoconstriction, and metabolism Olfactory - (I) Sensory: smell reception and interpretation Optic - (II) Sensory: visual acuity and visual fields Oculomotor - (III) Motor: raise eyelids, most extraocular movements Parasympathetic: pupillary constriction, change lens shape Trochlear - (IV) Motor: downward, inward eye movement Trigeminal - (V) Motor: jaw opening and clenching, chewing, and mastication Sensory: sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal and mouth mucosa, teeth, tongue, ear, facial skin Abducens - (VI) Motor: lateral eye movement Facial - (VII) Motor: movement of facial expression muscles except jaw, close eyelids, labial speech sounds (b, m, w, and rounded vowels) Sensory: taste— anterior two-thirds of tongue, sensation to pharynx Parasympathetic: secretion of saliva and tears Acoustic - (VIII) Sensory: hearing and equilibrium Glossopharyngeal - (IX) Motor: voluntary muscles for swallowing and phonation (guttural speech sounds) Sensory: sensation of nasopharynx, gag reflex, taste— posterior one-third of tongue Parasympathetic: secretion of salivary glands, carotid reflex Vagus (X) - Sensory: sensation behind ear and part of external ear canal Parasympathetic: secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of heart, lungs, and digestive tract Spinal accessory - (XI) Motor: turn head, shrug shoulders, some actions for phonation Hypoglossal - (XII) Motor: tongue movement for speech sound articulation (l, t, d, n) and swallowing Acromegaly findings - Face and skull— frontal skull bossing, cranial ridges, mandibular overgrowth, maxillary widening, teeth separation, malocclusion, overbite, skin thickening on the face (tongue, lips and nose), hands and feet leading to enlargement, joint enlargement, swelling, pain; vertebral enlargement, kyphoscoliosis Cardiac ventricular enlargement bilaterally with decreased exercise tolerance Acromegaly def - A rare disease of excessive growth and distorted proportions caused by hypersecretion of growth hormone and insulin-like growth factor after closure of the epiphyses, causes slow skeletal growth and soft tissue enlargement; benign pituitary adenoma or other rare tumor most common cause; familial syndromes (e.g., multiple endocrine neoplasia type 1 and McCune-Albright syndrome). Turner syndrome findings - Short stature, webbed neck, broad chest/widely spaced nipples, wide carrying angle of elbow (cubitus valgus), low posterior hairline, misshapen or rotated ears, narrow palate with crowded teeth, coarctation of aorta, bicuspid aortic valve, sensorineural hearing loss, infertility. Dx by amnio or chorionic villous sampling, karyotype or chromosome analysis to confirm diagnosis Turner syndrome - female with 1 X chromosome Cushing syndrome findings - subj - weight gain, appetite changes, depression, irritability, decreased libido, decreased concentration, impaired short-term memory, easy bruising, menstrual irregularities, weight gain w/ slow height velocity in children; obj - obesity, buffalo hump/fad pad, supraclavicular & abdominal fat, facial plethora or moon facies, thin skin, reddish purple striae, poor skin healing, proximal muscle weakness, hirsutism or female balding, peripheral edema; in kids - short stature, abnormal genital virilization, delayed puberty Cushing syndrome - d/t prolonged, high doses of glucocorticoids or adrenal gland over secretion leading to excessive production of cortisol or a pituitary tumor leading to excessive secretion of adrenocorticotropic hormone (ACTH); diabetes, HTN, depression, menstrual irregularities are s/e Precocious puberty findings - subj - early breast & pubic hair dev in girls, enlarged testes then penis, early pubic hair in boys; obj - early sexual characteristics, acne, erections, noc emissions, period; accelerated height at early age, sex hormone concentrations appropriate for stage of puberty Precocious puberty - brain tumor or lesion (hypothalamic hamartoma) activates hypothalamic-pituitary-gonadal axis with gonadotropins triggering the growth of the gonads, secretion of the sex hormones, and progressive sexual maturation; can be r/t McCune-Albright syndrome. Nutritional deficiency finding - below height/weight norms for age, reduced muscle mass, loss of subcutaneous fat, wasted buttocks, thin extremities, prominent ribs, alopecia, possible signs of neglect (diaper rash, dirty body/clothes, skin infections), developmental delay Anorexia findings - dry skin, lanugo hair, brittle nails, bradycardia, hypothermia, orthostatic hypotension, muscle and subcutaneous fat decreased; obj - hypoglycemia, elevated liver enzymes, and thyroid hormone abnormalities, DSM-V dx criteria refusal to maintain body weight at or above min normal for height/age, fear of gaining, disturbed self-image, amenorrhea Iron deficiency anemia - fatigue, dry hair, ridged/spoon nails (koilonchia) Riboflavin (B2) or iron deficiency - cracking or inflammation at the corners of the mouth (angular cheilitis) Iron or B-vitamin deficiency - Pale or swollen tongue Iron, zinc, or B-vitamin deficiency - Burning mouth syndrome Chronic diarrhea - sign of malabsorption - infection, surgery, certain drugs, heavy alcohol use, and digestive disorders such as celiac sprue and Crohn's disease Babies start to sit up on their own - 6 months Babies start crawling - 6-9 months Babies begin to pull themselves up on furniture to stand - 9 months Babies stand up, hold onto furniture to explore - 9-12 months Babies walk on their own - 11-13 months 3-4 mos. - coo, babble 4- 6 mos. - babbles speech-like sounds, including p, b, and m 10- 12 mos. - imitates different speech sounds, has 1 or 2 words, such as "mama," "dada," "bye-bye," but sounds may not be clear 12- 24 mos. - increases words each month, 2-word questions or phrases (e.g., "Where baby?" and "Want cookie") 24-36 mos. - uses two- to three-word sentences to ask for things or talk about things, large vocabulary, speech understood by family members most of time, asks why 36-48 mos. - answers simple questions, uses pronouns like I, me, you Sentences have four or more Objective finding - Information from direct observation - what you see, hear, touch, smell Subjective finding - What the patient tells you Organs, masses, lesions - Describe what was found during inspection and palpation including texture, consistency, size, shape, mobility, tenderness, induration, heat, color, location, 'action' - oozing bleeding, discharge, scab formation, scarring, excoriation, etc. Macule - flat, circumscribed area w/color change; less than 1 cm in diameter Macule - freckles, flat moles (nevi), petechiae, measles Papule - elevated, firm, circumscribed area; less than 1 cm in diameter Papule ex - wart (verruca), elevated moles, lichen planus Patch - flat, nonpalpable, irregularly shaped macule greater than 1 cm in diameter Patch ex - vitiligo, port-wine stains, café au lait Plaque - elevated, firm, and rough lesion with flat top surface greater than 1 cm in diameter Plaque ex - psoriasis, seborrheic, and actinic keratosis Wheal - elevated, irregular-shaped area of cutaneous edema; solid, transient, variable diameter Wheal - insect bites, urticaria, allergic Nodule - elevated, firm, circumscribed lesion; deeper in dermis than a papule; 1-2 cm in diameter Nodule ex - erythema nodosum, lipoma Mass - elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis; greater than 2 cm in diameter Mass ex - Neoplasms, benign tumor, lipoma Vesicle - elevated, circumscribed, superficial, not into dermis; filled with serous fluid; less than 1 cm in diameter Vesicle ex - Varicella (chickenpox), herpes zoster (shingles) Bulla - vesicle greater than 1 cm in diameter Bulla ex - blister, pemphigus vulgaris Skin changes to investigate - ABCDE - asymmetry, irregular borders, color not uniform diameter 6mm or growing, evolution of existing lesions, esp. in non-uniform/asymmetric way; not healing, crusting, bleeding Staph infection - causes faruncle, tender, hot, red nodule, purulent (pus) core, may rupture Strep infection - causes cellulitis; red, hot, tender, and indurated; borders are not well demarcated; Lymphangitic streaks and regional lymphadenopathy may be present Herpes - grouped vesicles, erode, form crust, type 1 and 2, crossover becoming common, HSV Basal cell - most common skin cancer, from epidermis; shiny sore, crusting, bleeding, poor healing Malignant melanoma - lethal, forms from melanocyte; ABCDE Seborrheic keratosis - pigmented, raised, warty lesions, usually appearing on the trunk. These must be distinguished from other growths such as nevi or actinic keratoses, which may have malignant potential. Eczematous dermatitis - most common skin prob; contact, allergic, atopic (childhood, skin folds, plaques) Skin lesions of older adult - cherry angioma, seborrheic keratosis, sebaceous hyperplasia, cutaneous tags, cutaneous horns, solar lentigines, Signs of lymph system disorder - enlarged lymph nodes (lymphadenopathy), red streaks on the overlying skin (lymphangitis), and lymphedema Easily palpable lymph nodes - generally are not found in healthy adults Shotty nodes - small, movable, discrete, small, multiple nodes that feel like BBs or buckshot under the skin) less than 1 cm in diameter that move under your fingers. Generally not consequential, usually represent enlargement after viral infection Enlarged epitrochlear or supraclavicular nodes - require additional evaluation Lymph node fixed to surrounding tissues - cause for concern Palpating lymph nodes (expectations) - always there, doesn't transilluminate, solid, not clearly defined, symmetrical, should not be easily palpable, fixed or tender Malignant node - Hard, fixed, painless node, rapid enlargement w/out signs of inflammation Inflamed nodes - Very tender Palpable supraclavicular node on the left - Virchow node; significant clue to thoracic or abdominal malignancy. Benign node - Slow enlargement over weeks and months Need investigation - nodes that are hard, fixed/matted, inflamed, tender Sign of malignancy - Supraclavicular node anterior to the sternocleidomastoid muscle Tuberculosis - nodes felt in the cervical chains, are usually body temperature, soft, matted, and not tender or painful Cyst transilluminates, is discrete, is transient, fluid filled - Thyroid palpation - should be small, smooth, and free of nodules, should rise freely with swallowing. Broadest part approx. 4 cm, right lobe is often 25% larger than left. Should be firm yet pliable. Coarse tissue/gritty thyroid - suggests an inflammatory process. Thyroid nodule - should be characterized by number, smooth vs. irregular, soft or hard Thyroiditis findings - enlarged, tender; should auscultate for vascular sounds with the bell of the stethoscope; hypermetabolic = vascular bruit (a soft rushing sound) Hypothyroid findings from H&P - subj - weight gain, constipation, fatigue, cold introlerance; obj - weight gain, lethargy, dry skin/hair, thick nails, puffy periorbital area, no goiter Primary hypothyroidism - Thyroid gland produces insufficient amounts of thyroid hormone Secondary hypothyroidism - Insufficient thyroid hormone secretion due to inadequate secretion of either thyroid-stimulating hormone (TSH) from the pituitary gland or thyrotropin-releasing hormone (TRH) from the hypothalamus Hyperthyroid findings - Weight loss, tachycardia, diarrhea, heat intolerance, normal size thyroid, goiter or nodule, fine hair Migraine hx findings - starts in childhood, unilateral or generalized, hours to days, prodromes - vague neurologic changes, personality change, fluid retention, appetite loss to well-defined neurologic event, scotoma, aphasia, hemianopsia, aura, precip events - females, period, bcp, following stress, can cause nausea/vomiting, Tension headache hx findings - adulthood, uni- or bilateral, hours to days, any time, bandlike/constricting, prodromes - none, precip - anger, bruxism, stress, daily, male or female Cluster headache hx findings - adulthood, unilateral, .5 to 2 hours, night, intense/boring/searing/knifelike, prodromes - personality changes, ETOH use, several x nightly, several days, then none, males, tearing/nasal discharge Pain - various scales, physical manifestations - guarding, groaning, sweating, VS changes, writhing, pupil dilation, pallor, dry mouth, restlessness Pain - patient self-report Pain in child - Wong-Baker, Oucher. Pain in child - when to use pain scale Abnormal changes in older adult - cognitive, personality Amsler grid - used to evaluate macular degeneration, central vision; distortion shows problem 140/90 - hypertension in older adult Underweight BMI - below 18.5 Normal BMI - 18.5-24.9 Overweight BMI - 25-29.9 Obese BMI - 30+ Signs of nutritional deficiency - Iron: Fatigue, anemia, decreased cognitive function, headache, glossitis, and nail changes Iodine: Goiter, developmental delay, and mental retardation Vitamin D: Poor growth, rickets, and hypocalcemia Physiologic jaundice in newborn normal - Day 1-8/10 Physiologic jaundice in newborn abnormal - longer than 2 weeks - suggests liver disease, a hemolytic process, or severe, overwhelming infection Infant skull transillumination findings normal - suspected intracranial lesions or a rapidly increasing head circumference - ring of 2 cm or less beyond the rim of the transilluminator is expected with all regions of the head except the occiput, where the ring should be 1 cm or less. Infant skull transillumination findings abnormal - Illumination beyond 2 cm (or 1 cm at occiput) suggests excess fluid or decreased brain tissue in the skull. Skin changes in pregnancy normal - Striae gravidarum (stretch marks), telangiectasias, which may be found on the face, neck, chest, and arms; usually resolve after delivery. Hemangiomas may increase in size, or new ones may develop. Cutaneous tags (molluscum fibrosum gravidarum) from from epithelial hyperplasia and are not inflammatory. Hyperpigmentation (nipples), melasma. Palmar erythema, linea Negra, itching from stretched skin Skin changes in pregnancy abnormal - itching w/ rash, generalized itching (palms, soles) d/t decreased bile flow, jaundice, Exam order - Identifiers, Chief Concern, History of Present Illness, Medical History, Personal/Social History Skull bones - 7 total (2 frontal, 2 parietal, 2 temporal, and 1 occipital) fused together and covered by the scalp, helpful in identifying landmarks on the head Face - fused frontal, nasal, zygomatic, ethmoid, lacrimal, sphenoid, and maxillary bones and the movable mandible; has cavities for the eyes, nose, and mouth.