EXAM 1 Review NUR 590 2023 with verified questions and answers

Comprehensive Vs. Focused History Comprehensive: performed on all nonemergent, new patient who will be receiving ongoing primary care Focused: - performed in an emergency situation - performed when the patient is already under ongoing care and presents with a specific problem-oriented compaint ex: pt is specifically coming in for a rash or UTI sx Importance of open ended questions Elicit personal descriptions of symptoms and concerns - Use guided questioning - Encourage with continurers - Echoing - Clarify what the patient means HPI Elements - OLDCARTS - Contains key pertinent data - for provider and other healthcare professionals - inclues if patient has extensive recent history - document signs and symptoms - include pertinent test results and test dates Comprehensive ROS vs Focused ROS Comprehensive ROS: - conducted when a patient presents for general health maintenance/disease prevention care - their first visit to establish with the provider Focused ROS: - conducted when a patient presents with specific chief complaint Components of Comprehensive Physical Exam - CC - HPI - PMH - FH - SH - ROS - Physical examination - Laboratory data - Assessment - Differential diagnoses - Plan Comprehensive Physical Exam - Head to toe examination - performed on all non-emergent new patients receiving ongoing primary care - performed on all new patients Focused Physical Exam - Performed when the patient presents with a specific problem-oriented complaint - Performed in emergency situations SOAP Note S: subjective O: objective A: assessment P: plan Documentation order for Objective Data of SOAP note - Vital signs - General Assessment - Skin - HEENT - Neck - Chest - Abdomen - GU/Gyn - Extremities - Musculoskeletal - Neurologic Which side do you examine a patient from? Right side - you can feel the spleen better Setting the Stage for the Physical Exam - Reflect on your appraoch to the patient - Adjust the lighting and the environemnt - make sure both you and the patient are comfortable - Check your equiptment - observe standard precautions - drape patient appropriately, keep doors and curtains drawn or closed Patient positioning Physical Exam Sequence 1. General Assessement 2. Vital signs 3. Skin 4. HEENT 5. Neck 6. Respiratory 7. Cardiovascular 8. Abdomen 9. GU/Gyn 10. Musculoskeletal 11. Neuro What is a Differential Diagnosis - conditions that are being considered and may require more work up - When documenting DD, list in order of most likely to least likely - List does not need to be all inclusive but should demonstrate thoughtful analysis - may need to document in plan what is being done to rule out certain DD Diagnostic Process 1. Identify 2. Frame 3. Organize 4. Rank Assessment Section of SOAP note - Careful analysis and interpretation of subjective and objectiveinformation should lean to logical assessment (diagnosis) - assessment, diagnosis and impression are terms used interchangably - first assessment listed should correlate with plan of care - assessment and plan can be in the same section of the note or separate sections - as you uncover other diagnoses, list them in order of importance or impact on CC Plan section of SOAP note - includes documentation/ interpretation of diagnostic studies that were ordered or will be ordered - includes referrals so specialists, therapeutic interventions, education and disposition of the patient - always include follow up visits - include health promotion/disease prevention - pharmacologic and nonpharmacologic treatment CAGE questions/ TACE model Screening tools for alcohol use/abuse C- cutting down A- Annoyance G- Guilty feeling E- Eye opener T- how many drinksk does it Take when you feel intoxicated? what do you prefer? more than 2 drinks is red flag A- Have people Annoyed you by criticizing your drinking? C- Have you ever felt. you should Cut down your drinking? E- Have you ever needed to have an Eye opener first thin in the morning to steady your nerves or get rid of a hangover? A patient smokes 1.5 packs of cigarettes a day for 10 years. What is the pack year history? 15 Interviewing Pointers - Ask patient if it is okay if you take brief notes - Use open ended questions - Give adequate time to respond - think about what responses by patient requires follow up questioning (verify and follow up!) Objective data Measurable and Verifiable - test results, examination findings - things you measure - Should include: - Physical examination which should match ROS - Diagnostic tests (laboratory findings) Subjective data Information provided during the health history by the patient - based on patient's perception - Less quantifiable and open to interpretation Past Medical History (PMH) - Previous or current illnesses - Hospitalizations - Surgeries - Injuries - Immunizations - Medications - Allergies - Transfusions - Transfusion reactions - Results of any screening examinations Social History (SH) - Nutritional History (diet) - Marital Status - Highest level of Educatin - Use of Alcohol, tobacco, recreational drugs - Sleep habits - Exercise habits - Religious preferences avoid being judgemental Family History (FH) - Major illnesses and health status of relatives - Genetic Defects - Deaths - Ethnicity - make sure you go back two generations Factors determining the systems explored in ROS - Patient's chief complaint - List of comorbidities - Whether the examination is a comprehensive history and physical or a focused history and physical Categories of Final assessment - All new diagnoses (including any preexisting ones) - Differential diagnoses - Diagnoses that requrie further testing - A problem list Components of Plan - Nonpharmacological interventions - Pharmacological interventions - Educational needs for both the patient and his/her family (what did you teach them and how did they tell you they understood this information) - Follow-up - Referrals Documentation to avoid legail problems regarding patient education - What was taught or explained - To whom it was told - If the patient/family stated they understood the information presented - Format: written and or verbal instructions Plan: Follow up Instructions - important to document at every visit - Should include: - when they should return for follow up - s/s that could indicate worsening of condition and what to do if those symptoms develop - determine time frame for routine follow up, when do you want to see the patient back? Elements of a Comprehensive Health History - Patient identifiers - Reliability - Chief complaint (CC) - History of present illness (HPI) - Past medical history (PMI) - Family history (FH) - Social history (SH) - Review of systems (ROS) Comprehensive Review of Systems (ROS) - General/Constitutional - Skin - Eyes - Ears - Nose - Mouth/throat - Cardiovascular - Respiratory - Gastrointestinal - Genitourinary - Breast - Musculoskeletal - Neurologic - Mental/psychiatric - Lymphatic - Hematologic - Endocrine Constitutional Questions - Unintentinal weight loss/gain - Fever - Night sweats - Chills - Fatigue - Weakness Cheif Complaint (CC) Record the patient's response using his/her own words - their own reason for seeking care or what is wrong - use quotations History of Present Illness (HPI) Use PQRST to ensure all patient data is obtained - use mnemonic CLIENT OUTCOMES to provide culturally congruent care - OLDCARTS PQRST Precipitating factor - what provokes the symptom? Quality - describe the character and location of symptoms? Radiation - Does the symptom radiate to other areas of the body? Severity - ask patient to quantify symptoms on scale 0-10 Timing - inquire about onset, duration, frequency, etc. Focused Health History - Identifying Data - CC - HPI - Data from patient's PMH, FH and SH pertinent to the chief complainet - Problem-oriented ROS Sensitivity vs. Specificity Sensitivity: true positives, specificity: true negatives Example was given about ultrasound test for DVT having a sensitivity of 96% and specificity of 98%. - be able to look at data and determine sensitivity and specificity for that data! Determine if screening is appropriate Burden of disease must be sufficient to warrent screening - screen only for diseases that can cause severe disease, disability or death Valid sources of recommended screening tests and schedules for men, women and special populations US Preventative Services Task Force (USPSTF) or professional/specialty associations Prostate Cancer Screening - Men ages 55-59 clinicians should discuss risk/benefit with each patient - age 50 with at least 10 years of life expectancy who are at average risk for prostate cancer - age 45 for men at high risk - age 40 for men with more than one first degree relative diagnosed before 65 - Screening is not recommended beyond age 70 Colon Cancer Screening Guidelines - Every 10 years starting at age 50 until age 70 (or 10 years before a 1st degree relative was diagnosed if earlier) - Recommends against screening adults older than 85 Cervical Cancer Screening Guidelines 21 - none 21-29 - cytology q3y 30-65 - cytology q3y OR cytology PLUS HPV q5y 65 - none if prior screens negative Breast Cancer Screening Guidelines - 40-49: decision to start screening is individualized - 50-74: screen every 2 years - 75+: insufficient evidence to screen older than 75 some say to continue as long as life expectancy is at least 10 years ACS Lung Cancer Screening Guidelines Annual low dose CT scan for adults aged 55-80 with 30 year smoking history who currently smoke or have quit in the past 15 years -screeing can be d/c once a person has not smoked for 15 years or develops a health problem limiting life expectancy Osteoporosis screening - DEXA - women 65+ - younger women at high risk Diabetes screening Guidelines As part of the cardiovascular risk assessment in adults 40-70 years who are overweight or obese Blood Pressure Screening Guidelines Adults 18 or older, USPSTF recommends obtaining measurements outside the clinical setting for diagnostic confirmation before starting treatment Vital signs - BP, HR, RR, Temp - Considered baseline indicators of health Temperature - regulated by hypothalamus - body generates heat by shivering, conserves heat by vasoconstriction - normal body temp: approx 37 degrees celcius or 98.6 F - gold standard for measurment is a blood temp taken in pulmonary artery Heart Rate (HR) - Best palpated over an artery close to surface of body that lies over bones - ex: carotid, brachial, radial, femoral, popliteal, dorsalis pedis, posterior tibial - examine Rate and rhythm How to count HR - count 30 s x 2 - if rate is too slow or too fast... count for full 60 sec Normal rate: 60-100 If rhythm is abnomal check with stethoscope Oral temperature - generally lower than core body temp - higher than axillary temp Primary muscles of respiration diaphragm and intercostal muscles Categories of Blood pressure levels for adults Orthostatic Vital signs Monitor HR and BP in 2 positions - positive orthostatic when SBP drops 20 mm/Hg or diastolic drop 10 mm/Hg within 3 minutes of reading Infants Vital Signs - more susceptible to hypothermia - higher HR and RR - Count RR for one minute - Have lower BP than adults Children Vital signs - HR of kids are more variable when compared to adults and react with wider swings r/t fever or exercise - BP standards are provided for gender, age and height percentile - HR can increase with fever How many BPM can 1 degree celsius affect HR of a child HR can increase 10-14 BPM for each degree of temperature elevation (in celsius) Kids normal resting HR less than 1 yr: 128-130 1 yr: 116-119 2-3: 106-108 4-5: 94-97 6-11: 77-88 12-19: 72-80 Kids normal RR newborn: 24-50 1 yr: 20-40 3: 20-30 6: 16-22 10: 16-20 17: 12-20 Changes with pregnancy - BP decreases at 8 wks - HR gradually increases 10-30% Assessment of pain Needs to be thorough, reliable and accurate - nocioceptive - neuropathic - central sensitization - psychogenic pain - idiopathic pain - acute pain - chronic pain Include: - onset - quality - intensity - location - associated symptoms Pain Scales - Wong-Baker - Visual Analog Pain Scale - Numeric Pain Scale - Premature infant pain profile (PIPP) - Neonatal infant pain scale - CRIES scale Palpate thyroid Gland Note size, shape, configuration, consistency, tenderness, nodules Stiffness or sponginess of thyroid gland Often seen with toxic goiter Normal thyroid gland has consistency of what? Muscle tissue Unusual hardness of thyroid gland associated with scaring or cancer Tenderness of thyroid gland associated with -acute infections - hemorrhage into the gland If you note enlargement in thyroid - perform auscultation - place bell over lobes of thyroid while listening for bruit - suggestive of a toxic goiter Toxic Goiter Hyperthyroid condition resulting from hyperactivity of thyroid gland - areas of enlargement and nodules Sensitivity True Positives - ability of the test to correctly identify patients who have a given disease - if a test is highly sensitive and patient has a positive restult... there is a high certainty the patient does have the disease tests with high sensitivity have low false-negative result (true positive) / (true positive + false negaive) Specificity True Negative - the ability of a test to correctly identify those who DO NOT have a given disease - tests with a high specificity have a low percentage of false-positive results; a positive result is likely a true positive (True negative)/(false positive + True negative) tonsil grading scale 1+: visible 2+: halfway b/w tonsillar pillars and uvula 3+: touching uvula 4+: touching each other Lymph nodes Anatomy of the Ear Outer ear: pinna (auricle) and ear cannal Middle ear: tympanic cavity - contains malleus, incus, stapes Inner ear: structures for balance and hearing Normal light reflex in ear Function of outer ear collecting sound and sending it to the eardrum through the auditory canal - begins hearing process Function of middle ear - conduit for hearing - Regulator of ventilation pressure in middle ear How to hold an otoscope for infant ear exam - hold otoscope scope side down so you can steady the infants head with your hand - use ulnar side of hand for stabilization Conductive hearing loss Caused by disorders of the external and middle ear causes external ear: - trauma, squamous cell carcinoma, benign bony growth such as exostosis or osteoma Causes Middle ear: - otitis media, congenital conditions, cholesteatomas, otosclerosis, tympanosclerosis, tumors and perforations of tympanic membrane Sensorineural hearing loss Hearing loss caused by disorders of the inner ear causes: - presbycusis, viral infections like rubella, cytomegalovirus, menieres disease, noise exposure, ototoxic drug exposure and acoustic neuromas Function of inner ear contains the organs of hearing and balance Four para nasal sinuses 1. Maxillary 2. Ethmoid 3. Frontal 4. Sphenoid - air filled cavities within the bones of the skull that are lined with mucous membranes. Function of the sinuses - lighten weight of the head - humidify/heat inhaled air - increase resonance of speech - serve as "crumple zone" to protect vital structures in event of facial trauma - posssible role in immune defense Transillumination of the sinuses • Performed in a darkened room. Bring light placed in patient's mouth on one side of hard palate or against cheek. Light passes through maxillary sinus, appears as a crescent-shaped dull glow inferior to orbit. If sinus contains excess fluid/mass/thickened mucosa, glow is decreased. Frontal sinuses may be illuminated by directing light superiorly under medial aspect of eyebrow, producing glow superior to orbit. Pattern/extent of illumination varies from person to person. Allergic rhinitis - congestion of the nasal mucosa triggered by an allergen Nonallergic rhinitis - same sx as allergic rhinitis but not seasonal and not triggered by allergens - occurs during stressful times - results in venous engorgement, resulting in obstruction - can be caused by nasal spray abuse (afrin) What are the only sinuses accessible on clinical examination? - frontal and maxillary Normal Tympanic Membrane pinkish gray, shiny, translucent, intact, small flutter or moves with swallowing Otitis Media (OM) Sx: earache, fever and hearing loss. - tympanic membrane is reddened , loses its landmarks and bulges laterally toward the examiners eye. - often have pain behind the ear Otitis externa (OE) - canal is often swollen, narrowed, moist, erythematous or pale and tender - frequently, canal is so tender and swollen adequate visualization is impossible - movement of tragus or auricle is painful - most often caused by pseudomonas aeruginosa Tympanosclerosis Scarring process of middle ear from otitis media that involves deposition of hyaline and calcium and phosphate crystals in the tympanic membrane and middle ear. - when severe it may entrap the ossicles and cause conductive hearing loss Perforation of the tympanic membrane Holes in the eardrum that usually result from purulent infections of the middle ear Ruptured Tympanic Membrane - Spontaneous rupture may result from increased pressure with discharge of the mucopurulent exudate into external canal - Marginal perforations are more serious then central - predisposes to the development of a cholesteatoma - avoid instilling water or irrigating when perforation is present - can lead to erosion of the ossicles and expansion into the mastoid antrum Cholesteatoma - trapped epithelial tissue behind tympanic membrane - result of untreated or chronic revurrent otitis media - surgical excision is usually indicated-- referral is necessary Exostosis Nontender nodular swellings covered by normal skin deep in the ear canals suggest osteomas or exostoses nonmalignant overgrowths which may obscure the tympanic membrane Mastoiditis - infection of mastoid bone - almost always a complication of AOM - S/S: radiating ear pain and fever, persistent pain for weeks, severe, deep, and often worse at night. hearing is affected Exam: swelling, erythema, and tenderness over mastoid bone complications can include paralysis from facial nerve involvement, infection of the labyrinth or CSF causing meningitis or brain abscess Prebycusis Age-related cuase of sensorineural hearing loss - diminished fxn of cochlea and decreased elasticity of the TM - Gradual onset Serous Effusion Usually caused by viral URI. or by sudden changes in atmospheric pressure such as flying or diving. The eustachian tube cannot equalize the air pressure in the middle ear and outside air. air is absorbed from the middle ear into the bloodstream and serous fluid accumulates in the middle ear instead. symptoms: fullness and popping sensation in the ear, mild conduction hearing loss and sometimes pain Bullous Myringitis Painful hemorrhagic vesicles appear on the tympanic membrane, the ear canal or both. Eardrum is reddened, landmarks are obscured. sx: earache, blood-tinged discharge from the ear and conductive hearing loss. When examining an adult ear, what direction do you pull the auricle? Upward and backward slightly away from the head when examining a infant ear what direction do you pull the auricle? Down and back Webber test & Rinne test Tests that use a tuning fork to distinguish between conductive and sensorineural hearing losses Rinne Test Air conduction vs Bone conduction Place the base of a lightly vibrating tuning fork on the mastoid bone, behind the ear an level with the canal - when the pt can no longer hear the sound, quickly place the prongs of the fork close to teh ear canal and ask if the pt hears a vibration normally sound is heard longer through air than through bone ( AC BC) Webber Test Tests for adequacy of bone conduction Test for lateralization - set the fork into light vibration - Place the base of the lightly vibrating tuning fork firmly on top of the patient's head or on the midforehead - Ask where the patient hears the sound best "on one side or both sides" Normally vibrations are heard in the midline or equally in both ears unilateral conductive hearing loss weber test Sound is heard in (lateralized to) the impaired ear Conductive hearing loss Unilateral sensorineural hearing loss weber test Sound will be heard in the good ear Hyperthyroidism (grave's disease) sx: nervousness, weight loss - excessive sweating and heat intolerance - palpitations - frequent bowel movements - tremor and proximal muscle weakness Conductive hearing loss Rinne Sound is heard through bone as long as or longer than it is through air Sensorineural Hearing loss Rinne Sound is heard longer through air function of eustachian tube -allows air into the middle ear - replace air absorbed by mucous membrane lining opening - equalize pressure change in the middle ear that are a result of altitude or depth change - drains normal secretions of the middle ear - mucociliary transport system - repeated active tubal opening and closing - allows secretions to drain into nasopharynx Cochlea a coiled, bony, fluid-filled tube in the inner ear through which sound waves trigger nerve impulses Dedicated to hearing Semicircular canals and Otolith organs Dedicated to balance Hypothyroidism Sx: Fatigue, lethargy, modest weight gain with anorexia - dry, coarse skin and cold intolerance - swelling of face, hands and legs - constipation - weakness, muscle cramps, arthralgias, parasthesias, impaired memory and hearing - often have "hung" reflexes Types of Ear Pain and Their Sources Primary: originating within the ear structure Secondary: originating from other regions Primary Ear Pain - Originating within ear structures - infections, inflammation of middle and external ear structures and mastoid issues Secondary Ear Pain - Originating from other regions - TMJ, dental and periodontal problems - infections in the sinuses and nasopharyngeal areas - lesions of the tongue - cervical musculoskeletal problems - neuralgias Acute Otitis Media Treatment - "Watchful waiting" - Antibiotics (amoxicillin) - Tympanic membrane tubes Whisper test A hearing test in which the examiner stands 28-24 inches from one of the patient's ears, has the person block sound in one ear and whispers a random set of 3 numbers and letters (or three non-related words) into the other ear, asking the person to repeat what was heard. What is a positive Rinne test? -air conduction is greater than bone conduction (normal) What is a negative Rinne test? -air conduction is less than bone conduction (abnormal) Where is the opening of the parotid gland opening located? Stensen's Ducts Inspection of mouth and throat - Observe for parotid gland openings - Inspect tongue - Observe position, color, number of teeth - inspect the hard and soft palates - Observe the movement of the uvula - Inspect posterior of throat Tonsillitis Infection of the tonsils - usually Group A streptococcus, though can be viral in very young children S/S: sever throat pain and difficulty swallowing. Fever often present and patient appears ill Exam: Usually mouth breathing and deepened voice due to pain with speaking - tonsils edematous and may have exudate - lymphadenopathy is present Viral Pharyngitis Gradual onset Low-grade fever Cold sx after 1-2 days of fever Slight erythema and enlargement of tonsils May have tender cervical lymph nodes Moderately ill for 1-5 days Salivary glands Three major glands - parotid gland (largest) - submandibular - sublingual Parotid Gland - largest salivary gland - 7th CN- facial travels through gland - Stenson's duct enters the oral cavity opposite the first or second upper molar tooth Submandibular gland - second largest salivary gland - located below and in front of the angle of the mandible - wharton's duct terminates on either side of the frenulum, at the base of the tongue Sublingual gland - smallest salivary gland - located in the floor of the mouth, beneath the tongue - numerous ducts, some of which opens into Wharton's ducts Peritonsillar Abscess -may develop as a complication of tonsillitis - Sore throat, fever, malaise, over time throat pain becomes unilateral with increasing difficulty moving the neck, speaking and swallowing - Trismus may be present, area adjacent to tonsil is swollen, tonsil is often displaced with uvular deviation, voice may be muffled - hot potato voice Retropharyngeal Abscess Life threatening infection in the lateral pharyngeal space that has the potential to occlude the iar way. - most commonly occurs in children - GAS and Staph aureus are common causes - S/S: fever, irritability, pain in neck and jaw, may be referred to ear, refusal to move neck - trismus and muffled voice may be present Risks of melanoma - personal or family hx of previous melanoma - 50 common moles - Atypical or large moles, especially if dysplastic - red or light hair color - light eye or skin color - burns easily - Solar lentigines - Feckles - UV radiation from heavy sun exposure - severe blistering sunburns in childhood - immunosuppression from HIV or chemotherapy - Personal hx of nonmelanoma skin cancer - large congenital nevus (15 cm) Tori Abnormal growths of bone in a specific area - benign finding ABCDEFG of malignant melanoma Assymetry Border Color Diameter larger than 6mm Evolving/elevated Firm to palpation Growing progressively over several weeks Most common skin cancer 1: Basal Cell Carcinoma (BCC) 2: Squamous Cell Carcinoma (SCC) 3: Melanoma General Skin Principles - Moisture - Turgor - Texture - Temperature Preparing for skin exam: - Good lighting - Tape measure - Gloves - Patient should be in a gown - allow for chaperone to be present - seated or lying position, then prone - plan to do the same order every time so you are less likely to miss/skip a part of the examination Anatomy of the nail Note the body of the nail (nail plate), lunula, and cuticle Function of the nail Protect the tips of fingers and toes against trauma Male Pattern hair loss Frontal hairline regression and thinning on posterior vortex Female pattern hair loss Crown down without hairline regression Telogen effluvium Temporary hair loss that usually happens after stress, shock or traumatic event Anagen effluvium Hair shedding during the growth stage of the hair cycle alopecia areata an autoimmune disorder that attacks the hair follicles, causing well-defined bald areas on the scalp or elsewhere on the body - sudden onset of clearly demarcated, localized, round or oval patches of hair loss Tinea Capitis "ring worm" - round scalinng patches of alopecia found on the scalp Scarring alopecia Shiny skin, complete loss of hair follicles and discoloration Hair shaft disorders Abnormal hair shaft from birth - this requires referral to dermatology Primary lesion lesions arising from previously normal skin - most characteristic of disease process Beau's lines (transferse linear depressions) Transverse depressions of the nail plates - usually bilateral - resulting from temporary disruptions of proximal nail growth from sysstemic illness - seen with severe illness, trauma and cold exposure - Timing of illness can be estimated by measuring distance from the line to the nailbed. - nails grow approximately 1 mm every 6-10 days - most common in toe and thumb nail