Chronological order of events, state of health, complete description of the symtoms. - OLDCART

Onset - When did the fatigue start?

Location

Duration - How often does it occur?

Character - What does it feel like?

Aggravating factors - What factors have made it worse?

Relieving Factors - What factors have made it improve?

Temporal Factors

Severity - How severe is the fatigue?

Talk about their general health - good, fair, poor? 

Childhood illnesses, immunizations, surgeries and allergies.

In relation to the patient, what family member may have died.

Especially siblings, parents, grandparents.

Age?

Cause?

Pedigree or genogram - drawing of different symbols to symbolize the patients. 

Personal status - married

Tobacco, alcohol use

Diet, nutritional issues

Sexual history

Religious preference

Take into account the patient's point of view

Remember this is subjective data

Example: From the patient's standpoint r/t abdominal pain, are they having nausea, vomiting, or fever?

Systems to include: General, skin, chest, cardiovascular, hematologic, diet, endocrine

Complete - 1st time seeing patent, includes their PMH, Surgical history, and social history

Problem or focus - problem is acute or life threatning

Interim- details events that have occurred since the last meeting with the patient - i.e. f/u visit - what events have happened since last visit?

How do patients perform their ADLs? Need assistance?

Able to take and buy medicine?

• Speak slowly
• Use open-ended approach; let the patient explain the problem or reason for visit
• Ensure confidentiality regarding information discussed
• CRAFFT - questionanaire for drug/alcohol use
• Long silence - time needed to gain courage to discuss painful topic
• Sensitive issue - Be direct, firm, and to the point
• Direct questions -Obtain or clarify specific details about an answer
• Provider personal life - answer briefly then refocus
• Patient begins to cry - allow the patient to cry and then resume when patient is ready.

Week 2: Concepts in Assessment

(Immediate) Direct - Striking the finger or hand directly againsts the body

Blunt (fist) - used to elicit tenderness arising from the liver, gallbladder, or kidneys. Use ulnar aspect of the fist to deliver a firm blow. 

Indirect - place nondominant hand on the surface of the body. Tap the interphalangeal join of the finger that is on the body surface

The more dense the medium, the quieter is the percussion tone. The percussion tone over air is loud, over fluid is less loud, and over solid areas soft. 

Tympany is loudest and flatness is quietest. 

Percussion 

Table 3-4 Pg. 52

Tympanic - gastric bubble, stmoach

Hyperresonant - emphysematous lungs

Resonant - lung of health patient

Dull - over liver, patient with pneumonia, abdomen with large tumor

Flat - over muscle, sternum

Ruler - examine multiple raised lesions on skin

Transillumination - detection of fluid within the sinuses - source of light with a narrow beam differentiates tissue, fluid, air in body cavity. 

Penlight - used to visualize lower/middle turbines of nose

Amsler Grid - used to assess for macular degeneration

Percussion Hammer - test deep tendon reflexes

Rosenbaum/Jaeger chart - assess near vision

Lange/Harpenden capliers - measures skinfold thickness

Wood's lamp - black light - detect fungal infections or corneal abrasion

Tympanometer - used to assess function of the inner ear

Correct size of cuff - adult: be 40% of the circumference of the arm or widith that is one-third to one-half the circumfrence of the limb.

Adult cuff on child = reading falsely low

Cuffs that are too wide will underestimate blood pressure

Those that are too narrow will give an artificially high measurement.

Indicated for auscultation of a nonpalpable puse in a patient with PVD.

Detect systolic blood pressure - patients in shock, infants, obese persons

Auscultate fetal heart activity, locate vessels, take weak pulses, assess vessel patency. 

Patient has obvious odor - exam techinique -inspection

Inspection - applied throughout entire exam

Surface most sensitive to vibration - ulnar surface

Surface most sensitive to temperature - dorsal surface

Deep palpation - 4cm

Percussion intensity - refers to loudness

UTI - assess tenderness using firm fist percussion

Superficial mass - fingertips to palpate

Measure length of infant - crown to heel

Stethoscope - less than 18in long - reduce distortion

Bell - pressed lightly to detect low-frequency sounds

Red numbers on lens selector dal of ophthalmoscope - negative magnification

Positive and negative magnification - compensate for myopia and hyperopia

Very important to obtain a history

Nearsightedness - can't see far away

Farsightedness - can't see up close

Strabismus - both eyes do not focus on an object at the same time; but can focus with either eye (CN III - oculomotor, IV - trochlear, VI - abducens)  

Amblyopia - lazy eye - loss of one eye's ability to see details common in children. 

Testing cranial nerve II - optic nerve

Snellen chart - essentially a measurement of central vision

Read line from right to left to reduce the chance of recall influencing response.

Numerator - distance from chart

Denominator - distance at which the avergae eye can read

20/200- pt can read at 20 ft what the average person can read to 200 ft - smaller fraction = worse

Vision not correctable to better than 20/200 = legal blind

Test near vision - Rosenbaum or Jaeger Chart - which is 15 inches away - from arm length to the patient

- Always test vision without glasses first

Confrontation test - stand at opposite side of patient; pt cover right eye; provider cover left eye. open eyes are opposite of each other. Move arm slowly to center.

Compare the patients response to the time you first note the fingers. 

Nose can interfere with testing - tests nasal, temporal, superior, inferior fields.

Can also be done by cover/uncover test

Controlled by CN III - ocular motor

CN IV - trochlear

CN VI - abducens

6 extraocular muscle

Six Cardinal Fields of Gaze

Horizontal rhythmic movements = nystagmus - a few are normal, but more than that would be abnormal.

Jerking nystagmus to right - eye moves rapidly to the right and then slowly drifts leftward

Thyroid eye disease - lag lid - ask to move from ceiling to floor (vertical).

Corneal light reflex - used to test balance of eye muscles 

Both eyes should converge

Imbalance found with corneal light reflex test - perform  cover-uncover test

Ask patient to stare straight ahead at near fixed object. Cover one eye and observe the uncovered eye for movement as it focuses on teh point. Then remove the cover and watch the movement of the newly uncovered eye as it fixes on the object. 

Straight eye is being tested = no movement

Movement of the covered or uncovered eye - mandates referral to opthalmologist. 

Confrontation test

cover-uncover test

corneal light test

caused by the light illuminating the retina.

Any opacities will stand out as black densities. 

Absence of the red reflex = improperly positioned or indicate total opacity of the pupil by a cataract or hemorrhage. 

Loose red reflex = reposition

Myopic = use minus red lens

hyperopic or lacks lens = use plus black lens

optic disc = yellow to creamy pink - differ by race

papillar edema - loss of definition of the optic disc margin- due to incresaed IOC pressure. 

Child's vision - ask about academic performance

Assess eye with pen light before giving mydriatic drops

Nystagumus - fast, uncontrollable movements of the eyes - use six cardinal fields of gaze. 

Test accomodation - note constriction as gaze shifts from across the room to an object 6 inches away

Near vision - use rosenbaum chart

Newborn assessment - assess red reflex

Retro-orbital tumor  - unilateral exophthalmos

Outer half of each eye - vision loss - pituitary tumor

Family history - retinoblastoma - failure to elicit red reflex in child

20/210 = legally blind - visual acuity lower than or equal to 20/200 in the better eye, with best correction

Loss of peripheral vision = cataracts

Loss of central vision - macular degeneration

Cloudiness of lens = cataracts

If the right 6th nerve is damaged - the right eye does not move temporarily - strabisumus

gradual loss of peripheral vision = glaucoma; r/t increased intraocular pressure; optic nerve damage can be clearly seen during a dilated eye exam.

Lift up tongue to rule out oral cancer

Otoscope - usee the largest speculum that is comfortable for the patient. 

Adult - pull up the pinna and pull back

Ear - color - pearly gray

Contour - concave - indicates some fluid

Convex - indicates no fluid - clear

Severe otitis media - use pneumatic otoscopy - insert air t see if there's fluid behind membrane

CN 9 - Glossopharyngeal

& 10 - Vagus nerves

+1 - visible

+2 - halfway between tonsillar pillars and the uvula

+3 - nearly touching the uvula

+4 - touching each other

A tonsil pushed backward or foward, possibly displacing the uvula suggests a peritonsillar abscess or other mass.

Hearing - Testing cranial nerve 8 - Vestibulocholear

Whisper test - cover ear that is not being tested, whisper word about 5 feet way and have pt repeat - should hear a minimum of 3 to 6 sounds in each ear.

Weber test - assess unilateral hearing loss - tuning fork to compare hearing by bone conduction vs air conduction.

vibration heard equally? laterlize to affected side? normal - should hear sound equally in both ears 

Rinne test - distinguish if hears better by air or bone conduction. air-conducted sound heard twice as long as bone conducted sound - AC > BC 2:1 ratio (Rinne +)

Weber - expected finding - no lateralization, but will lateralize to ear occuled by patient. ability to hear sound bilaterally 

Conducive hearing loss - lateralization of affected ear

Senorineural hearling loss - lateralization to better ear

Rinne - air conduction heard longer than bone conduction by 2:1 ratio (Rinne positive)

Conductive hearing loss - bone conduction heard longer than AC in affected ear (Rinne negative)

Sensorineural hearing loss - AC heard longer than BC in affected ear, but less than 2:1 ratio.

No movement is expected when the tympanic membrane is perforated. 

No movement with positive or negative pressure may be a sign of acute otitis media or otitis media with effusion.

CN VII - Facial nerve - ask patient to clench his or her teeth and smile to observe the occlusion of the teeth. 

Proper tooth occlusion is apparent when the upper molars interdigitate with the groove on the lower molars and the premolars and canines interdigitate fully. 

Hearing decreases due to conductive hearing loss after age 50. 

Saliva may decrease, smell, taste sensation also start to decrease after age 45. 

Weber test - normal finding - tone equally in bone ears

Indication for transillumination - complains of pain over sinuses with palpation.

Tonsils touch uvula - 4+

Ruptured tympanic membrane - bloody, yellowish-looking stuff out of ear

Normal aging process- food does not taste like it used to.

Hearing problem - "my 4 month old baby does not seem to respond to loud noises"

infant weighing less than 1500 grams = risk for hearing loss

6 week old - normal finding - lacks conical appearance with diffuse light reflex

tend to run in male gender

high risk in African Americans

decreased kidney function, dm, htn, family history of CAD

Risk factors for venous disease are different

Inspecting the neck, pg. 442

Table 15-2

Patient reclining in 45 degree angle - Inspect for jugular venous pulsations and distention. 

Pt initially placed in supine position. HOB gradually raised until jugular venous pulsations become evident. 

Jugular pulse can only be visualized; it cannot be palpated.

Three positive waves in NSR

Increased level of pulse on expiration

Gentle pressure easily eliminates pulse wave

abdominal pressure - increased prominince in well person or with R-sided HF 

Carotid - one wave, more brisk, otherwise no effects with respiration, venous compression, or abd. pressure. 

Palpate one at a time. 

Use the distal pads of the second and third finger. 

You want to palpate firmly but not occlude the artery.

Excessive carotid massage can lead to lower HR and drop in BP.

Normal documentation is 2+

Except femoral popliteral is usually 1+ 

Carotid pulse and S1 are practically synchronous; if not = abnormal finding.

Measure BP in both arms, supine first

Postural lightheadedness - blood pressure in arm should also be measured with the patient standing

Expect to see a significant drop in systolic pressure (> 15mmHG) and a drop in diastlic pressure. There is also frequently an increase in heart rate. 

Less than 2 sec

Environmental influences, such as temp can prolong cap refill time. 

Normal finding - no bruit - do not hear anything

Use bell of stethoscope, usually sounds are low pitched. 

Ventricular contraction raises the pressure in the ventricles and forces the mitral and tricuspid valve closed (preventing backflow). 

Known as S₁, "lubb" sound

S_{2 correlates with the beginning of diastol.} 

Ventricles are almost empty, allows the aortic and pulmonic valves to close

Sound of S2 - "dubb" - closure of aortic and pulmonic valves

S1 - marks the beginning of systole and coincides with the rise of the carotid pulse - closure of AV valves; best heard at the apex - louder than S2

S2 - marks the initiation of diastole; closure of semilunar valves; indicates end of systole; best heard in aortic and pulmonic areas; higher pitch and shorter duration than S1.

S2 is louder than S1 at the base of the heart.  

Abnormal finding - structural valve defects, increased blood viscocity, abnormal chamber openings

Makes a swishing noise

Cuff size too small, smoking within past 10-15 min, had caffeine, more stressed

Bring in home b/p cuff to compare to office reading. make sure it is accurate. 

More vigorous than expected

Apical impulse that is more forceful = increased cardiac output or left ventricular hypertrophy

Apical impulse may become more visible when patient sits up - this is a normal finding - midclavicular line in the 5th intercostal space. - known as the PMI

Lift along left sternal border = right ventricular hypertrophy.

Indicative of defect in closure of the semilunar valves - generally aortic or pulmonic stenosis, pulmonary htn, or atrial septal defect.

Vibration at the 2nd or 3rd intercostal space

Increasing venous return (asking pt to raise leg) or arterial pressure (asking pt to grip hand vigorously and repeatedly) make S3 and S4 easier to hear. 

S3 - stimulates a gallop when it becomes intense

S3 may be louder if filling pressure is increased or if ventricular compliance is reduced - heard best in left lateral decubitus recumbent position.

S4 - commonly heard in older patients, increased resistance to filling, r/t loss of compliance to ventricular walls - i.e. htn disease and cad, or increased stroke volume - profound anemia, pregnancy, and thyrotoxicosis

S3 - Ken-TUCK-y

S4 - TEN-nes-see

A loud S4 sound always suggests pathology. 

Fixed when it is unaffected by respiration. Occurs with delayed closure of the pulmonic valve when output of the right ventricle is greater than that of the left. 

Occurs in large atrial septal defects, a ventricular septal defect with left-to-right shunting, or Right ventricular failure. 

Caused by peripheral atherosclerosis

Risk factors - DM, HTN, dyslipidemia, and tobacco

Result of vascular trauma, radiation therapy, or vasculitis

MOST COMMON SYMPTOM OF ARTERIAL INSUFFICIENCY is Claudication - This is pain that results from muscle ischemia - USUALLY THE 1st SYMPTOM! 

Described as a dull ache with muscle fatigue and crampiness

Appears during sustained exercise; HOWEVER, relieved with REST!

Pulses may be weak or absent. 

Pain comes during exercise

Quickly relieved by rest

Likely increases with induration and duration of exercises

Claudication most common symptom

Comes on during or often several hours after exercises

Relieved with rest, but only after SEVERAL HOURS OR DAYS.

Pain tends to be more constant. 

A constant pain is one of the first symptoms. 

Site of pain is distal to the stenosis

Slight pallor on elevation and a return to full color as soon as the leg becomes dependent are the expected findings. 

Venous hum

BOX 15-2; pg 437

Usually of no clinical significance

Often confused with carotid bruit. 

The Ps

Pallor

Pain

Pulselessness

Paresthesias (if the major artery is occluded)

Paralysis (rare)

Calf - consider the superficial femoral artery

Thigh - consider common femoral artery or external iliac artery obstruction

Buttocks - common iliac artery or distal aorta obstruction. 

Want the patient to lie supine, elevate the extremity, note degree of blanching of the distal extremity, note the time from maximal return of color when the extremity is elevated.

If there is a delay of many seconds or even minutes before the extremity regains full color, arterial sufficiency is present!!!

WHen return to full color takes as long as 2 minutes, the problem is severe. 

Consider redness, thickening, and tenderness along superficial vein.

Thrombophlebitis is SUPERFICIAL!

Cannot be confirmed by physical exam alone.

compliant of calf pain

Positive sign = thrombosis

Keep knees slightly flexed while dorsiflexing the foot. 

Absence of homan sign does not preclude venous thrombosis. 

1+ slight pitting, no visible distortion, disappears rapidly

2+ deeper pit, no readily detectable distortion, disappears within 10 to 15 sec

3+ noticeably deep pit that may last more than a minute; dependent extremities look fuller and swollen

4+ very deep pit that lasts as long as 2 to 5 minutes and is grossly distorted. 

If edema is unilateral = suspect occlusion of a major vein

If edema is bilateral = consider CHF

If edema occurs without pitting - suspect arterial insufficiency or lymphedema. 

S1 Intensity Diagnostic Clues

Beginning of systole - MV snaps shut more vigorously producing a louder S1 sound. This occurs in the following situations:

Blood velocity is increased - anemia, fever, hyperthyroidism, anxiety, during exercise

or 

The mitral valve is stenotic

If the MV is not completely open, ventricular contraction forces it shut. Loudness produced by valve closure depends on the degree of opening. The intensity of S1 varies in these following situations:

Complete heart block present

Gross disruption of rhythm occurs, i.e. fibrillation

THe intensity of S1 is decreased  in the following situations:

Increased overlying tissue, fat, or fluid - obsures sound

systemic or pulmonary htn is present

fibrosis and calcification

Their presence does not necessarily indicate a pathological condition.

Indicates increased venous return 

Can assess by asking patient to raise leg or arterial pressure by asking patient ot grip your hand vigorously and repeatedly.

Beginning of systole. 

These events surround mitral and tricuspid valve closure. 

Nearly simultaneous with the upstroke of the carotid.

Best can be heard towards the apex of the heart and mitral valve area.

S1 is louder at the apex than S2

S1 Lubb

closure of the aortic and pulmonic semilunar valves

Indicates end of systole. 

best heard in the aortic and pulmonic areas of the precordium

S2 is louder than S1 at the base

S2 - Dub

benign in patient under age 30, best heard in the pulmonic valve area

Louder on inspiration 

Splitting of S2 is an expected event

No change in intensity when patient inspires 

May indicate septal defect - fixed splitting

or

left bundle branch block - paradoxic (reversed) splitting

Intensity of S2 increases -

Systemic htn, syphilis of aortic valve, exercise, or excitement

Pulmonary htn, mitral stenosis, CHF

Diseased valves

Intensity of S2 decreases -

arterial hypotension (shock)

immobile valves - thickened, calcified

aortic stenosis affects A2

Pulmonic stenosis affects P2

Overlying tissue, fat

It's early, it's passive blood flow and its an early diastolic sound

increasing venous pressure - raise his/her leg

increase aterial pressure - grip your hand vigorously and repeatedly

This makes cardiac sounds more evident

Best heard at the apex

Second phase of ventricular filling

Late diastolic sound (presystolic)  

Best heard at apex

hear more vigorous muslcar ejection with poor myocardial compliance - causes vibration in the valves 

Indicative of hearing the Tennessee Sound

S4 always suggests pathology!

inflammation of the pericardiac sac

Sounds like a grating, machine-like sound

Occupies both systole and diastole

heard more toward the apex

indicative of turbulent blood flow

most often heard with the bell of stethoscope

Characteristics depend on adequacy of valve function, size of opening, rate of blood flow, vigor of the mycardium, thicness and consistency of overlying tissue.

do not adequately open, valve are thickened, passage is narrowed and forward blood flow is restricted. 

Regurg - when valves don't close well - valve leaflets are loose or incompetent - allow backward flow of blood

Diseased valves are a common cause of murmurs

systolic - usually benign or pathologic

diastolic - always pathologic - diseased valves are a common cause of murmurs!

Grade I - barely audible in quiet room

Grade II - quiet but clearly audible

Grade III - moderately loud

Grade IV - loud, associated with thrill

Grade V - very loud, thrill easily palpable

Grade VI - very loud, audible with stethoscope not in contact with chest, thrill palpable and visble. 

Best heard at PMI - Usually common in children, adolescents, and especially young athletes. Systolic murmur in someone without any significant history

Grade 4-6

have a thrill or heave, PMI is displaced

Indicative of hypertrophic cardiomyopathy

Not chest pain when the following occurs

There is a constant achiness that lasts all day.

It does not radiate

It is made worse by pressing on the precordium

It is a fleeting, needle-like jab that lasts only a second or two

It is situated in the shoulders or between the shoulder blades in the back. 

Acute - less than 4 weeks

Chronic - more than 4 weeks

a ratio of 1.0 or even greater - most often a chronic condition present.

Expected ratio 0.70 to 0.75 - thoracic ratio

The AP diameter should be less than the lateral diameter (1 to 2)

Side of patient - would be 1

front of patient - would be 2

COPD - increased ratio - 1 to 1

thoracic expansion - Put hands on T10 -- moves equally on both sides.

COPD - may not demonstrate expansion - barrel chest

Ulnar or palmar surface of both hands

dullness to percussion and tactile fremitus are the two most useful findings for pleural effusion 

Decreased fremitus or absent fremitus - cause by excess air in lungs - COPD, emphysema, pleural thickening or effusion, pulm edema

Increased fremitus - presence of fluids, a solid mass within the lungs; lung consolidation. When pt says 99, there is increased fremitus, could be indicative of consolidation

Use one side as control for the other

Resonance, the expected sound, can usually be heard over all areas of the lungs

Hyperresonance - hyperinflation - COPD, asthma, emphesema, pneumothorax, possible atelectasis

Dullness or flatness - pneumonia, atelectasis, pleural effusion, pneumothorax, asthma

Vesicular - soft, low pitched, normally heard over most of the lungs

Bronchovestiuclar - intermediate in intensity - heard 1st and 2nd interspaces of anterior chest

Bronchial - are normal - loud and high pitched - heard over the manubrium and also the trachea. 

Bronchovesicular and bronchial sounds are abnormal if heard over the peripheral lung tissue

heard outside the respiratory tree

Dry, crackly, grating, low-pitched sound

heard on inspiration and expiration

caused by inflamed, roughened surfaces rubbing together over heart/lungs.

Over the pericardium, this sound suggets pericarditis

Over the lungs, pleurisy

The respiratory rub disappears when the breath is held; the cardiac rub does not!

have the patient whipser - the sound should be muffled

If clear, then indicates possible consolidation or fluid

have the patient say 99 99, should be muffled. 

Abnormal is that you would hear 99 clearly - indicates presence of consolidation in the lungs

have the patient say E, E, E. Normal to have a muffled sound

But if it's A, the A changes would be an abnormal finding and indicate consolidation or fluid

Expected Findings

Box 13-9, pg. 359

On inspection - symmetry of movement on expansion and absence of retractions

On palpation - midline trachea without a tug and symmetric, unaccentuated tactile fremitus

On percussion, range of 3 to 5 cm in the decent of the diaphragm and resonant and symmetric percussion notes

On auscultation, absence of adventitious sounds, vesicular breath sounds, except for bronchovesicular sounds beside the sterum and the more prominent bronchial components in the area of the larger bronchi. 

Posterior-anterior (PA) chest x-ray is perferred and more accurate. 

Much more clear and sharper images

Usually the AP are done portably, not as accurate

usually assess for pneumonia, CHF, or abnormalities of the chest cavity.

Order - XRAY, CT, MRI, PET Scan

Lateral chest x-ray - visual abnormalities behind the heart

Obese - heart sounds softer and more distant

unable to palpate apical pulse and heart sounds faint - consider pleural or pericardial fluid

increased maternal blood volume - heart is shifted more horizontal orientation

Pulmonary hypertension - decreased intensity of S1 increased intensity of S2

Heave, lateral displacement of apical pulse - left ventricular enlargement

Thrill usually indicates a distruption of blood flow r/t defect of closure of semilunar valves

left ventricular size - determined by locating PMI

Easily mistaken for cardiac generated sounds - pericardial friction rub

Aortic stenosis - midsystolic murmur, medium pitch, coarse thrill

S2 - of higher pitch and shorter duration than S1

Splitting of heart sounds - greatest during inspiration

low pitched filling sounds - left lateral recumbent position

apical pulse more difficult to locate in older adults

Carotid artery - most accessible artery close to heart

Spider telangectasis - periperhal vasodilation with decreased vascular resistance

suspect dvt - dorsiflexes patient's foot which elicits pain - homans sign

3+ amplitude pulse = full

korotkoff sounds - produced by turblence of blood flow in an artery

determine jugular venous pressure - use light to supply tangetial illumination across the neck

progressive ischemia caused by insufficient perfusion - peripheral atherosclerotic disease

Jugular venous hum expected - in children

prominent jugular vein with significant pulsations - right sided heart failure

common cause of venous thrombosis in children - placement of venous access device

HTN in children - most common cause - renal disease

Distiguishes musculoskeltal pain from vascular insufficiency - may occur several hours after activity

highest risk factor for respiratory disability - paraplegia

expect costal angel to be > 90 degress - COPD pt

diaphragmatic excursion of 4cm on right and 8 cm on left = possible pleural effusion

unusual finding for a newborn - coughing

hyperresonance - associated with normal age-reated changes of chest 

hamman sign - heard best lying on left side

pneumothorax - tracheal deviation away from midline position

respiratory rate to heart rate ratio

1:4

tumor - dminished or absent breath sounds

emphesema - decreased tactile fremitus

testing of facial features

Facies - expression or appearance of the face and features of the head and neck, that when considered together, is a characteristic of a clinical condition or syndrome.

entire side of face is affected

 Bells palsy - cranial nerve VII

general round or roatary movement from front to back. 

Hypothyroidism - coarse, dry, brittle hair

Hyperthyroidism - fine, silky hair

a bruit is highly suggestive of a vascular anoly

C/o eye pain

Note coarseness, thickness, and hardness upon palpation of the temporal artery

Gently grasping the cricoid cartilage and applying upward pressure while the patient stands with his/her chin extended upward. 

A downward tug of the trachea may be felt if an aneurysm is present. 

observe for erythema, edema, red streaking - indicate infected lymph node or lymphadenitis. 

Start at head and neck

Next axilla, palpate the left axilla by holding the left arm in the examiners left arm. Use fingertips to palpate in a circular motion. 

Three physical signs

1. enlarged lymph nodes (lymphadenopathy)

2. red streaks in the skin (lymphangitis)

3. lymphedema

The harder, more discrete - more likely it is malignancy

More tender - is inflammation

Supraclavicular node on left - significant clue to thoraic or abdominal malignancy

Slow nodal enlargement over weeks to months = benign process

Rapid enlargement = malignancy

BOX 9-2 TERMS

Page 224

smaller than 0.5cm not cause for concern

nodes with a diameter of 1cm or less in the cervical and inguinal chains do not always indicate a problem. 

Cervical nodes present - usually posterior in childhood diseases - rubella, rubeola, and varicella

Hepatitis A and B and infectious mononucelosis have the same tendency

Preauricular - above and behind the ear

postauricular - superficial to the mastoid process

occipital - base of skull

submental - behind the tip of mandible

submandibular - halfway between the angle and tip of the mandible

superficial cervical - overlying the sternomastoid muscle

deep cervical - deep under the sternomastoid muscle

posterior cervical - posterior triangle along the edge of the trapezius muscle

supraclavicular - ablve and behind the clavical

easily palpable lympth nodes are generally not found in health adults

cause for concern - the lymph node is fixed in its settings

enlarged lymph node and c/o pain - an inflammatory process

differentiate lymph node from a cyst - transillumination

assess supraclavicular lymph node - palpate deeply behind the clavicles as the patient takes a deep breath

differentiate mumps from cervical adenitis - palpating the angle of the jaw. 

Head (Study Guide) 

Hypertensive headache - begins in the morning and decreases as day progresses

Classic migraine - associated with a well-prodromal event

muscular tension - may be brought on by anger

Temporal arteritis - occurs more in older adult

cluster headache - brought on by alcohol consumption

Week 7  - Primary Skin lesions

Refer to Table 8-4; pg 166

Primary skin lesions - occur as initial spontaneous manifestations of a pathologic process

Developed on previously unaltered skin and are an immediate result of a specific causative factor

Usually not clinically significant as far as something abnormal

I.e. freckle, birthmark

Examples of Primary skin lesions

Macule

Macule - flat circumscribed lesion that changes in color and is less than one centimeter in diameter

Example - freckle, flat mole, measules

Papule - solid circumscribed area less than one centimeter in diameter

Example - wart, an elevated mole

Vesicle - an elevated circumscribed, superficial to the dermis lesions that's filled with serous fluid; less than 1 cm in diameter

Examples - chicken pox, varicella; herpes zoster (shinges)

Pustule - similar to vesicle, but filled with purulent fulid 

Examples - impetigoor acne

Patch - flat, non-palpable, irregular shaped macule that's greater than one centimeter. 

Example - port wine stains, Mongolian spot, vitiligo

Bullae - fluid filled lesions - greater than one centimeter

so it's a big vesicle!

Example - blister; pemphigus vulgaris

Cyst - a raised encapusulated fluid filled lesion that is usually on the dermis of subcutaneous layer of the skin

Could be filled with liquid, or semi-solid material

Good example - sebaceous cyst or cystic acne

Wheal - elevated irregular shaped area of the cutaneous layer that could be edematous, solid, transient, or variable in diameter. 

It's also circumscribed on the skin

Example - an insect bite, urticaria, or an allergic reaction

Nodule - elevated, firm, a circumscribed lesion that can be deeper in the dermis, and larger than a papule. It could be one to two centimeters in diameter

Example - lipoma

Table 8-6 - Characterisitics 

Pg. 171

Localized - leasion appears in one small area

Examples - impetigo, herpes simplex (labialis), fungal infection - tinea corporis (ringworm)

Regional - lesions involve a specific region of the body

Example - acne vulgaris, dermatome distribution like with herpes zoster, in the skin folds like with psoriasis

Generalized - lesions appear widely distributed or in numerous areas simultaneously

Examples - urticaria, hives, disseminated drug eruptions

Shape/Arrangement 

Round/discoid

Round/discoid - coin shaped (no central clearing)

Example - nummular eczema

Oval - ovoid shape

Example - Pityriasis rosea - it's a round, red circle with the inside being plae or skin coloured. 

Annular - Round, active margins with central clearing

Example - Tinea corporis (ringworm), sarcoidosis

Polycyclic - interlocking or has surrounding circles that overlap forming an enlargement or an annular lesions

Examples - psoriasis or urticaria

Target lesion - pink macules with purple central papules

Very commonly seen with erythema multi-form

Iris is the same reference as a target lesions

Star shaped like

Example -  meningcoccoal septicaemia

Discrete border - well defined - Psoriasis

Indistinct borders - poorly defined - papules or eczema

Active border  - marginal lesion that shows greater activity than the center - tinea eruptions or fungal eruptions

Irregular borders - non-smooth or notched margins - malignant melanoma

Border raised above - the center or center of center of lesions are depressed compared to the edges - basal cell carcinoma

Advancing border - expanding margins - cellulitis

Happen secondary to what the diagnosis is

Those that result from later evolution of or external trauma to a primary lesion

Examples - crusting seen with dandruff, scaling, excoriation, lichenification, erosion, actual openings or fissures

Skin (Study Guide)

Chicken pox - vesicle

insect bite -wheal

impetigo -  pustule

chronic dermatitis - lichenification

lipoma - nodule

blister -bulla

wart - papule

port wine stain - patch

petechiae - macule

Milia - finding in newborns

skin cancer - symptom - bleeds easily when touched

freckles - type of macule

dark-skinned patient - hypoxic - inspect for ashen-gray color to mucous membranes

infants develop yellow skin tone on 3rd and 4th day of life - red blood cells that hemolyze after birth may cause a yellow hue

Cholasma - expected finding in pregnant women

Tenting - loss of adipose tissue and loss of elasticity

Presence of clubbing - eamine angle of the nail base

lesion sometimes grows out of a present nevus - malignant melanoma

young/school-aged children - most common skin lesions are due to communicable disease and bacterial infection

Cafe au lait spots - r/t neurofibromatosis or pulm. stenosis

Cherry angioma - expected finding in older adults

Hyperkeratosis on palms and soles - systemic disorder

Odor of rotting apples - Clostridium perfringens