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500 Cards in this Set
- Front
- Back
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Observations vs. Interpretation
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Try not to confuse the two when taking history. Observation is Primary Data collected. Interpretation is your own conclusion.
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the ability to detect an actual case of the disease in history intake
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sensitivity
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the ability to rule out (R/O) a disease in history intake
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specificity
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"Why have you come in today?" Example of what type of question?
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OPEN-ended
*require a non-directed response |
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"Where exactly is it located?" "What does it feel like?" Examples of what type of question?
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Direct questions
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"How old are you?"
"What do you do for a living? Examples of what types of questions? |
Closed-ended questions
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non-directive cues like "Yes," and "And what else..." are examples of?
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minimal facilitations
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When non-directive approach fails, use "How would you describe the pain? Sharp? Burning? Dull?" examples are?
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Laundry lists/menus
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"Does the pain increase upon breathing?" example of what type of question?
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Yes/no question
*NOT good for sensitive issues like drugs, sex and rock & roll. Focuses on DX |
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What types of questions are confusing and should not be used?
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Multiple/complex questions requiring more than one answer
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What is a good technique of interchangeable responses to show the patient you listened/understood?
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Restate the patient's words using a combination of their words and your words (interchangeable response)
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Besides multiple/complex questions, what type of questions should you, like a lawyer, avoid?
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Leading the witness! Don't use phrases that reveal the answer you expect or desire
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Dr. Finn consistently uses the techniques of feedback positives. What is this?
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"It sounds as though you have been coping really well, despite the pain. Now let's talk about what happened yesterday..."
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The patient's own words
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Chief Complaint
(Hello! I am Chief Complaint.) |
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Gives a clear, chronological account of how each SX developed and what events related (MNOPQRSTA)
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Present illness
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LMNOPQRSTUVWXYZ:
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Location/Mechanism/Neuro/Onset/Provocative~Palliative/Quality/Radiation/Scale/Temporal/ Universal/Various other Rx methods/Worker's comp/You think?/Zzzz's (pt sleep)
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In present illness, don't forget to include any significant _________
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Negatives!
*Pt denies any night sweats |
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What do we ask whenever there is a diagnosis of some type in the history?
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Dx'd by whom? How? When? Any complications? Any recurrences? Any effect on ADL?
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Rx means?
Tx means? |
treatment
tractioned |
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carpal tunnel and weight gain are two cardinal signs of this endocrine disease
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hypothyroidism
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Family history questions: always ask what when a family member had a disease or condition?
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Who? What age? Dx? Rx? Current age and health status? Age and cause of death?
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One of the most glaring indicators of systemic STREP is ?
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migratory joint pain
*Think dental work, scalpel, then strep) |
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Richest center of proprioreceptors in human body?
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Upper cervical spine
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2nd richest center of proprioreceptors in human body (after upper cervs)?
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TMJ
*so think vertigo, ankles are 3rd richest proprio |
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If patient had a sprained ankle with no rehab, why may vertigo result?
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Ankles are chock full of proprioreceptors
*Upper cervs, TMJ, ankles |
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myopia
hyperopia presbyopia |
nearsighted = myopia
farsighted = hyperopia "old"sighted = presbyopia |
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Lupus, MS and Reiter's all have a change in ______ as one sign.
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vision
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epistaxis
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nosebleed
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a description that captures important information about the patient as a person
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Personal/social history
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If suspect patient may have alcohol problem, what questionnaire helps?
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CAGE
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EtOH
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shorthand for Ethanol (alcohol)
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If EtOH, use CAGE
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Cut down
Annoyed Guilty Hair of the dog/Hangover |
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R.O.S.
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Review Of Systems
*review of patient's body with regard to ea. system |
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paroxysmal
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surprise!
*paroxysmal nocturnal dyspnea |
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paroxysmal nocturnal dyspnea may indicate?
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congestive heart failure so edema pools in feet, S.O.B. on laying down after ~2hrs. due to excess heart strain
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unexplained weight gain with carpal tunnel...suspect?
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hypothyroid
*protenaceous deposits in wrist b/c smaller areas accrue them first |
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qualitative measurements taken to ascertain clinical life status
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vital signs
*temperature, pulse, respiration, height,weight, blood pressure |
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the balance/net between the heat produced by the body and the heat lost from the body
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temperature
(aka: core temp, body temp) |
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Temperature receptor locations
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body core and hypothalamus
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sweating and vasodilation occur when body wants to
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drop temperature
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what does the body do when it wants to warm up?
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shiver and inhibit sweating
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Normal range of temperature
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98.6 *F
96.4 - 99.1 oral n. range |
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normal rectal temperature and axillary temperature ranges?
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0.7 - 0.9*F higher rectal
0.7 - 0.9*F lower axillary (than 96.4 - 99.1 avg oral) |
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Tympanic temps are somewhere between what two types of temperature?
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Between oral and rectal (how unfortunate!)
*Tympanic are unreliable |
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How does AGE affect normal body temperature?
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children: higher BMR so higher temp
elderly: lower BMR, low thermoreg efficiency, low H2O intake so low temp |
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What can raise or lower a temperature by 2*F?
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diurnal/circadian variation
(night and day) |
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What can raise a temperature by 3*F?
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Exercise!
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Hormones, Stress and Environment can change temperature. Why environment?
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Extreme ambient temperatures prolonged over time
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pyrexia
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fever state
*a body temperature above normal range 96.4-99.1 |
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why would a patient appear cold or shiver when pyrexic?
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Higher set point reached by promotion of peripheral vasoconstriction
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After a patient appears to shiver and is cold, they may feel flushed, dry, and hot. Why?
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Hypothalamus adapted to vasoconstriction of pheriphery and is using new, higher set point
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When patient appears flushed, sweaty (fever broke), what does this indicate?
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Hypothalamus returns to normal set point and marked vasodilation & diaphoresis in 'fever crisis'
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How long should you wait after ingestion of hot or cold liquids before taking pt. temp?
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10-15 min
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Always shake a glass thermometer down below 95-96*F. Wait time for oral, axillary, rectal?
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Oral 3-5 min
Axillary 9 min (5 for child) Rectal 3 min |
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a wave of blood created in an artery, synchronized with the contraction of the LEFT ventricle
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pulse
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pulse is the synchronized wave of blood through the _____ ventricle
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LEFT
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usually synchronous with the heart rate; measured in beats per min
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pulse rate
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increased pulse rate
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tachycardia
* over 100 bpm |
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decreased pulse rate
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bradycardia
* less than 60 bpm |
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name for a normal pulse rate
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Eucardia
* 60-100 bpm is Eucardia |
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after puberty, males have a slightly __________ blood pressure than females.
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lower
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For every 1* of fever, bpm increases by
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10
*because your body is doing aerobics lying down when you have a fever |
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Is blood pressure higher or lower when sitting?
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higher
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describe pulse qualities:
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4 = bounding
3 = full, increased 2 = expected, normal 1 = diminished, barely palp., thready 0 = absent, not palpable |
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If radial pulse rhythm is regular (and the rate appears to be normal), count the rate for _______ and multiply that number by _____.
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15 sec x 4
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If pulse rhythm is irregular (and/or the rate appears high or low), what to do?
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Count the rate for a FULL MINUTE and note if the irregular rhythm is regular or irregular
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the rate at which a patient externally respirates (ie, breathes).
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Respirations
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units for respirations
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cpm
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tachypnea
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an increase in the respiratory rate
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bradypnea
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a decrease in the respiratory rate
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dyspnea
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difficulty breathing
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Eupnea
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normal breathing 12-20 cpm
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Apnea
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NO breathing
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normal respiratory range
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12-20 cpm
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name 4 factors that can affect respiratory rates:
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exercise
stress high altitude (2* hypoxia) high temperature (ambient or core) |
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marked rhythmic waxing and waning of respiratory rate and depth with periods of apnea
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Cheyne-Stokes respirations
(Grandma right before she passed away) |
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What is a good description of Cheyne-Stokes respiration?
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regularly irregular
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Marked rhythmic waxing and waning of respiratory rate and depth (Cheyne-Stokes' regularly irregular), is associated with what pathologies?
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High intracranial pressure (trauma, tumor, toxin, infection)
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an increase in respiratory rate and depth, aka hyperventilation
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Kussmaul Respirations (hypervent)
*aka "kiss mouth" breathing like a fish |
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In Kussmaul respiration, one is ventilating fine but not __________, meaning not much CO2 or O2 exchange)
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ventilating but not respirating, so they have air hunger, starved for air
*hence assoc. with panic attacks |
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Kussmaul respirations are associated with what pathologies or incidents?
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~metabolic [keto]acidosis
~panic attacks ~pulmonary emboli ~exercise |
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Irregularly shallow and deep breaths interrupted by periods of apnea
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Biot's Respirations
*"She's such and unpredictable Biot!" |
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"irregularly irregular"
"She's such an unpredictable _____!" |
Biot's respirations
*respiratory depression, brain damage (esp. medulla) |
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Pathologies associated with Biot's respirations?
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respiratory depression
brain damage (esp. @ medulla) |
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Name some observations to note during patient respiration
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ease
depth use of accessory muscles wheezes Cheyne-Stokes, Biot's, Kussmaul |
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lay definition of blood pressure
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pressure in you arterial beds when your heart contracts and relaxes
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a peripheral measurement of cardiovascular function
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blood pressure
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amount of pressure in the arteries during contraction
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systole
(S for Squeeze and Systole) |
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amount of pressure in the arteries during relaxation
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diastole
[D for Down/Diastole] |
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Blood pressure regulation:
Brain to ____________ Kidneys to __________ (NTQ) |
baroreceptors
perfusion rates |
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normal blood pressure ranges
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90/60 to 140/90
with 120/70 prehypertensive |
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A patient's blood pressure will _____ if they go into severe shock.
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drop
(think of Dr. Finn breaking her arm, walking home, calling 911 & going into shock) |
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If the cuff is too small, you can get a falsely high reading. If the cuff is too large, you can get a falsely low read. What IS the right size cuff?
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bladder inside should be about 70-80% of the arm circumference - use the ranges indicated on cuff!
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Where should the cuff be positioned in relation to the antecubital crease?
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2 fingersbreadths
*and make sure the cuff is snug b/c loose cuff will give falsely low reading |
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What are we listening for as we deflate the cuff 2-3 mmHg per second?
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Karotoff sounds:
K1 = 1st faint clear tapping sound (SYSTOLE!) K5 = total absence of sound (DIASTOLE!) |
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The skin has no blood vessels and therefore no _____ system of its own.
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nutritional
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hair distribution, hair presence and hair loss patterns are ____________ determined and therefore need to be assessed with this in mind
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genetically
*Native American males have relatively little face/body hair |
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onych
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word fragment relating to nails
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color due to tissues removing O2 as it 'drives by' (ie, passes through capillary bed), an increase of which causes cyanotic coloring (blue)
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deoxyhemaglobin
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widely distributed sweat glands that open directly onto skin surface and help control body temperature
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Eccrine
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found mostly in axillary and genital region, these sweat glands usually open to hair follicles and are stimulated by emotional stress or heat (stink)
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apocrine (make you smell like an ape)
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what kind of glands secrete PROTECTIVE fatty substances?
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Sebaceous
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Name the 4 pigments of skin color
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1. melanin
2. carotene 3. oxyhemoglobin 4. deoxyhemoglobin |
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What kind of medications might affect skin color?
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antibiotics (tricyclins)
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CYANOSIS light skin
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BLUE TINGE, esp. in palpebral conjunctiva, nail bed, earlobes, lips, oral mucosa, soles and palms
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CYANOSIS dark skin
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ASHEN GREY lips and tongue
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PALLor light skin
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LOSS of rosy glow in skin, esp. face
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PALLor dark skin
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ASHEN GREY (black skin)
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ERYTHEMA light skin
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REDNESS seen anywhere on body
(expensive word for inflammation appearance of redness) |
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ERYTHEMA dark skin
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YELLOWish-BROWN in brown skin
**rely on PALPATION! Feel for warm. |
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EcchyMOSES light skin
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Moses wore a purple robe...
PURPLE to yellowish green means bruise; may be seen anywhere on skin |
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EcchyMOSES dark skin
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Moses wore a purple robe...
Very difficult to see - look in MOUTH or CONJUNCTIVA for PURPLE. |
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Petechiae light skin
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Purple PINPOINTS most easily seen on buttocks, abdomen, inner surface of arms and legs
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Petechiae dark skin
*Petechia/Pupura {Bates' Textbook) |
Usually invisible (purple pinpoints) except in ORAL mucosa, CONJUNCTIVA of eyes, and conjunctiva COVERING EYEBALL
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JAUNDICE light skin
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YELLOW STAIN seen in sclera of eyes, skin, fingernails, soles, palms, oral mucosa
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JAUNDICE dark skin
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YELLOW STAIN most reliably assessed in sclera of eyes, HARD PALATE, soles and SUBLINGUAL
(capitialized words are different from light skin presentation) |
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erythema means
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red
*due to fever, viral exanthems, urticaria, inflammation, polycythemia |
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yellow means
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bile = liver disease
carotene = carotenoid intake no oxyhemoglobin = anemia, chronic renal disease |
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blue means
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hypoxia w/ unsaturated hemoglobin = cardiovascular & pulmonary disease
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brown means
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melanin = pituitary, adrenal, liver
Nevus (a mole with an ominous notch - cancer of skin) , neurofibromatosis |
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white means
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no melanin = albinism, vitiligo
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myxedema
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hypothyroidism
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intertriginous area
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in-ter-tri-ginous area...chubb rub.
Skin folds touching and rubbing |
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Cushing's disease may present purple ______ on skin
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striae
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turgor of the skin
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skin remains "tented" where you picked it up under the clavicle to test for dehydration, local edema or elderly
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if mobility of skin is low
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skin feels adhered to underlying layers under clavicle where you picked it up to test for CT diseases (scleroderma) or palpable mass (CA)
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tenderness of the skin may be signs of (3)
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~cellulitis
~CT disease (scleroderma) ~peritonitis (skin over abdomen becomes hypersensitive to touch) |
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name for light used to detect fungal infection of skin
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Wood's light (UV) for fungus
*fungi are found in the Wood |
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light used to detect fluid filled lesion vs. solid lesion
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TRANSILLUMINATOR
*to illuminate through |
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a flat, hard transparent lens pressed over a skin lesion to elicit blanching
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Diascope
+ blanching: vascular congestion --no blanching: RBC extravasation or chronic venous stasis (Kaposi's) |
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Clubbing of fingers
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distal phalanx rounded/bulbous and nail plate angled to 180* or more
*causes: chronic HYPOXIA (COPD, CHF) and lung CA |
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Paronychia
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inflammation of proximal and lateral nail folds - red, swollen, tender
*causes: WATER IMMERSION |
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Onycholysis
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Onycho-lysis...painless separation of nail plate from nail bed
*causes: varied (psoriatic arthritis) |
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Terry's nails
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whitish nails with distal band of red-brown. Lunulae may/not be visible.
*causes: chronic disease (CIRRHOSIS, CHF, NIDDM) |
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acronym N.I.D.D.M.
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Non-Insulin Dependent Diabetes
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acronym CHF
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Congestive Heart Failure
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Leukonychia
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white spots that grow out slowly following trauma to nail
*causes: overly vigorous manicure, trauma |
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Mee's lines
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transverse lines on nails that emerge after an illness
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Beau's lines
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depressions in nails following severe illness
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Nail pitting
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seen in psoriasis (w/ Onycholysis and oil spots)
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Koilonychia
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spoon nails -thin and concave from side to side
*IDA but also maybe with Raynaud's |
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Splinter hemorrhages of nail
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longitudinal bleeding under fingernail
*cause: SBE |
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Pathology of nail for PA II exam PALPATION
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Delayed Capillary Refill: blanching to pink takes longer than 3 seconds
Nail Bed Adherence: psoriasis, trauma, candida, pseudomonas Boggyness: chronic hypoxia |
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Psoriatic arthritis nail presentation
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pitting and oil stains with nail bed adherence lacking -
order x-rays and send to rheumatologist |
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Hair examination for 5 things:
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quantity
parasites (pediculosis) surface characteristics texture color |
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alopecia
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loss of hair
*causes: areata (patchy, well defined loss of hair), traction, systemic disorders like SLE |
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hirsuitism
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excessive body hair in masculine distribution pattern
*causes: hereditary, hormones, porphyria, iatrogenic (med side effect) |
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Presence of parasites is called
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pediculosis
a. capitis: scalp b. corporis: skin c. palpebrarum: eyelids/eyelashes d. pubis: pubic hair |
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a flat circumscribed area of color change - no elevation or depression
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Macule
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solid elevation of skin -
less than 0.5 cm diameter |
Papule
(acne) |
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Solid elevation of skin 0.5-1cm diameter. Extends DEEPER into dermis than papule.
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Nodule
(pigmented nevi) |
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example of macule
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freckle, vitiligo, age spots - all flat with no depression or elevation
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solid mass larger than a nodule and larger than 1cm
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TUMOR
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Flat, elevated surface found where papules, nodules or tumors CLUSTER together
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Plaque
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Type of plaque - Urticaria! on the baby due to drug reaction pg 112 Bates
result is transient EDEMA in dermis |
Wheal
*somewhat flat, localized collection of edema fluid (mosquito bite) |
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Small blister - fluid within or under epidermis
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Vesicle - may contain serous or blood
(herpes zoster, chickenpox) |
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Larger fluid-filled vesicle
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Bulla
(2nd degree burns) |
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Dried exudate on skin
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Crust
(eczema) |
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Flakes of cornified skin
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Scale
(psoriasis) |
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Cracks in the skin
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Fissure
(chapped fingertips and knuckles) |
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Loss of epidermis that does NOT extend into the dermis
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Erosion
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Area of destruction of entire epidermis, which may extend deeply into corium and subcutaneous tissue
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Ulcer
(chancre) |
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Excess collagen production and replacement of destroyed tissue
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Scar
(post op, keloid) |
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Loss of some portion of the skin
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Atrophy
(no etiology given...) |
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localized, fine red lines due to dilated blood vessels that may be venules, capillaries or arterioles.
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Telangiectasia
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presentation of glaucoma on optic CUP
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vitreous humor flattens out optic CUP and makes it look huge!
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How to test if patient born without canal of Schlemm and what is presentation?
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Born without vents for the anterior chamber fluid so eye bulges. Use anterior chamber pen light test.
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The optic cup should be ___ the size of the optic disc.
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1/2
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examination of the retina using an ophthalmoscope
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fundoscopic exam
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Why is it called a fundoscopic exam of the eye?
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Because a Fundus is part of a hollow organ furthest from its opening (ie, the retina)
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Loss of ability to accommodate due to loss of elasticity of the lens. Frequent in elderly.
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presbyopia
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an increase in the curvature of the lens in NEAR vision due to contraction of CILIARY muscles, pulling the ciliary process and choroid forward toward the lens.
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accommodation
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History of blurry vision D/Dx
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Central macular degeneration
Peripheral glaucoma (post chamber) |
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History of recent changes in vision D/Dx
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Reiter's, MS, Diabetes
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Night vision problems D/Dx
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Glaucoma
Vitamin A deficiency Retinitis Pigmentosa (congenital - can't see crazy pigs at night) |
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Halos or colored lights in vision D/Dx
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glaucoma
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Redness or discharge of eye may indicate CONJUNCTIVITIS. What are 3 etiologies of conjunctivitis?
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1. allergic (bilateral, watery, injection)
2. viral (unilateral, watery, mild inj.) 3. bacterial (unilateral, purulent/pus, mild injection to gross erythema/red) |
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Dalrymple's sign
(pathological and non-pathological) |
Normal white visible above and below iris in African descent patients. In whites, may indicate Grave's disease (hyperthyroid -eyes bulge)
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When unable to determine jaundice from sclera, where to look?
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under tongue
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If sclera is not very visible, what possibles?
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~Myxedema (hypothyroid)
~Renal disease ~Ptosis (Horner's) *anything with -neph... |
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Check to see if the iris colors are ________ and without albinism.
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homogenous
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What is the appropriate pupil size in a lighted room?
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3-5 mm
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Exophthalmos
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Graves' disease - hyperthyroidism
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If the pupils are shaped like a cat's eye, what might you suspect?
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Tertiary Syphillis!
(or trauma) |
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What test can be used to detect OVERT strabismus?
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corneal light reflection
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What test can be used to detect COvert strabismus?
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Cover/Uncover test
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Presence of lid lag suggests
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hypERthyroidism
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Patient X presents in your office with fine tremors, hyperreflexia and lid lag (lag ophthalmos). Suggestive of?
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Hyperthyroidism = Graves'
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cover/uncover test to detect
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covert strabismus
(COVer/uncover for COVert strabis) |
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corneal light reflection to detect
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overt (really friggin' obvious) strabismus
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Co-presentation of carpal tunnel (due to fatty deposits in periphery), hyporeflexia and missing lateral 1/3 of eyebrows...
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hypothyroidism
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hyperadreocorticotropism
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Cushing's disease (too much cortisol)
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pain
pallesthesia pulselessness down 1 arm |
Horner's syndrome: ptosis, Miosis (constricted pupil), anhydrosis, TOS (due to Horner's compression of NV bundle)
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mydriasis
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'blown pupils'
*drugs like coke and acid often cause this |
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D/Dx PTOSIS:
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myasthenia gravis
CN III damage Horner's syndrome ** congenital elderly weakened muscles |
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Why would a tumor cause Horner's syndrome?
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A tumor pressing on cervical sympathetic chain on ipsi side
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pure muscle disease of the muscles innervated by the cranial nerves, "Ondine's curse,"
|
Myasthenia gravis
(Ondine's curse is pirmary alveolar hypoventilation/forgetting to breathe) |
|
|
D/dx for ptosis: myasthenia gravis
|
muscle disease of nerves innervating muscles, may involve Ondine's curse, ptosis
|
|
|
D/dx for ptosis: CN III damage
|
direct/consensual light response test, cardinal fields of gaze, ptosis, miosis (constricted pupils), anhydrosis
|
|
|
D/dx for ptosis; Horner's syndrome
|
"Pain, Pallesthesia, Pulselessness down one arm" = ptosis, miosis, anhydrosis, TOS
|
|
|
D/dx for ptosis: congenital
|
wouldn't be able to smile or shrug shoulders, always doing the 'winking' at you, ptosis
|
|
|
Asians have prominent folds over their nasal -side orbits called?
|
Epicanthus/epicanthal fold: vertical fold of skin over medial canthus of eye. Seen in Down's syndrome and other congenital conditions. *do not assume convergent strabismus
|
|
|
Ectropion
|
outward turning of lower lid margin, exposing the conjunctiva and often leads to excessive tearing (like inbred/purebred dogs). Common in elderly.
|
|
|
eNtropion
|
inward turn of lower lid, common in elderly population
|
|
|
Difference between periorbital edema and herniated fat around the eyes?
|
Periorbital edema: swelling of tissues underlying lids. Allergies, myxedema, nephrotic syndrome/fluid retention. Can't see eyes well.
Herniated fat: bags under eyes due to gravity, common in elderly |
|
|
To observe sclera, ask patient to look up or down first?
|
Up, as you traction down on lower lid. THEN look down, as you traction up on upper lid. Do not perform on patient with contacts.
|
|
|
What two exams are not performed on patients wearing contact lenses?
|
Sclera observation and corneal reflex w/ cotton for trigeminal and facial nerve
|
|
|
Name a few reasons you might find yellowing of sclera (scleral icterus):
|
alcohol, jaundice as in bilirubin disorder (either hepatic or not).
|
|
|
If yellow sclera is present but yellowing of skin is NOT, suggests?
|
Vitamin A TOXCICITY
|
|
|
When might you see scleral injection?
|
allergies, local inflammation (conjunctivitis), trauma. Scleral injection comes from below. If CILIARY, then may be CORNEAL injury, acute irititis or glaucoma.
|
|
|
triangular thickening of bulbar conjunctiva, growing across cornea.
|
pterygium
*MAY INTERFERE W/ VISION |
|
|
yellowish, irregular nodule on either side of iris like your Native Am. friend has (normal in that race).
|
Pinguecula
* harmless, usually appears on nasal side first |
|
|
Which one is bad, pinguecula or pterygium?
|
pterygium (a giant pterydactal taking over you eyesight)
pings are just things |
|
|
Local, non-infectious inflammation of superficial sclera. Redness, injection, nodular. Benign.
|
EPIscleritis (an 'itis on top of the sclera)
|
|
|
What kind of lighting to view cornea and lens
|
oblique lighting
|
|
|
a thin, grey circle not quite at the edge of the cornea
|
Arcus senillis/corneal ARCUS
*normal variant in blacks and those over age 55 but suggests hyperlipidemia |
|
|
Do not confuse this superficial greyish white opacity with the opaque lens of a cataract
|
Corneal scar! This is superficial!
|
|
|
Grey cloudiness/opacity of lens seen THROUGH (not on) the pupil. 2 types.
|
CATARACT:
1. Nuclear- partial in nucleus/center, fuzzy. RLR only shows peripherally. Grey opacity surr. by black rim. 2. Peripheral- spoke shadows like on a bicycle wheel |
|
|
Nuclear cataract
|
called so because located in the center (nucleus) of lens
|
|
|
Peripheral cataract
|
called peripheral because spoke-like shadows from outside rim pointing inward, as in a bicycle tire and spokes
|
|
|
Lighting to examine iris
|
tangential lighting focused at limbus of eye
*Iris likes to drink a tangential and do the limbus! |
|
|
The ophthalmoscope/fundoscope will NOT reveal anything if patient has this type of cataract?
|
FULL-BLOWN
|
|
|
crescent-shaped shadow on nose when penlight is shown through anterior chamber could mean?
|
Narrow angle/Acute angle glaucoma = Iris anterior chamber test
|
|
|
Normal pupil size in standard room lighting
|
3-5 mm
|
|
|
Normal diaphragmatic excursion
|
3-5 cm
|
|
|
This gal likes her gin & tonic, making one of her pupils look large and slow to react to light (drunk eye/walleyed!)
|
Adie's tonic pupil
*problem with pupillary muscle, affects accommodation, convergence and direct/consensual |
|
|
Tonic/Adie's (gin & tonic) sluggish pupil is considered to be a pathology of the?
|
pupillary muscle
*not the cranial nerves, but it does present pathology during cranial nerve tests |
|
|
Why does Horner's syndrome affect the pupil?
|
Because something's pressing on the cervical sympathetic chain (pancoast tumor, apical lung tumor, any TOS patient). Unilateral miosis, ptosis and anhydrosis
|
|
|
Gr. meaning "to close the eyes"
|
miosis
|
|
|
When meeting someone for the first time, you should check their epitrochlear nodes and look into their eyes for ?
|
CNS tertiary syphillis sign of ARGYLL-ROBERTSON PUPILS ---small, irregular pupils wh/ don't react to light but DO accommodate
|
|
|
general term for pupils of two different sizes
|
anisicoria
*Adie's tonic, Horner's, CN or sympathetic n. pathology |
|
|
EOM
|
ExtraOcular Muscles
|
|
|
Name 4 techniques to assess integrity of EOM (ExtraOcular Muscles):
|
1. corneal light reflection (overt stra)
2. cover/uncover test (covert stra) 3. cardinal fields of gaze (LR6SO4)3 {patho of muscle or CN) 4. convergence (patho in medial rectus or CN III) |
|
|
Where is a sty located? What is it?
|
painful, tender red infection at the very EDGE of lid
*hordeolum |
|
|
Chalazions are easily confused with stys, but are different because of their etiology and location:
|
Chalazion - due to meibomian gland inflammation. Located in center of lid, pointing inside the lid. NOT an infection but a blocked gland.
|
|
|
Slightly raised, yellow plaques around the eyes (periorbital) usually along nasal side
|
Xanthelasma!
|
|
|
Inflammation of the lacrimal sac
|
Dacrocystitis
*tearing, expressed discharge |
|
|
dakryon means tear. What is Dacrocystitis?
|
Inflammation of tear (dakryon) duct/lacrimal sac
|
|
|
xanthos means yellow. What is Xanthelasma?
|
Yellow deposit (cholesterol) around eyes, common on nose side in Asians & Mediterranean folk
|
|
|
If the nose is fine but the patient has "raccoon eyes," you can bet they are from Trauma! Use an ophthalmoscope to check for
|
brain swelling
|
|
|
Increased light reflection (due to expansion of lumen b/c of pressure) gives this arteriole a bright metallic luster when viewing the retina.
|
Copper Wire arterioles
*tortuous, due to HTN |
|
|
HTN
|
HyperTenNsion
|
|
|
narrow arteriole seen in retina leading to total opacity so no blood visible within it
|
Silver wire arteriole
*due to HTN |
|
|
Arterioles in the eye are light red and 2/3 smaller than eye venules. What makes venules different regarding reflection?
|
Venules don't reflect at all! while arterioles brightly reflect (hence copper and silver wire names are shiny metal)
|
|
|
an abrupt cut off of venule in retina as it crosses artery.
|
AV nicking
*seen with HTN |
|
|
a tapering down of the venule in retina
|
AV tapering
*seen with HTN |
|
|
All arteriole (shiny metal) and venule (dull, nicks and tapers) retina pathologies are due to ?
|
HTN
|
|
|
light colored "debris build-up" in retina
|
Drusen bodies
*aging. May distort optic disc margin |
|
|
Irregular white patches with feathered margins in the retina
|
Myelinated (Medullated) NERVE fibers
*white myelin, normal variant |
|
|
white or black border parallel to optic disc, usually on temporal side
|
Rings & Crescents
*normal variant |
|
|
white or greyish ovoid lesions with IRREGULAR BORDERS in retina (soft, like ______)
|
cOttOn wOOl spOts-sOft exudates
~due to infarcted nerve fibers secondary to HTN ~IRREGULAR white smaller than disc |
|
|
creamy or yellowish lesions with WELL-DEFINED borders
|
Hard exudates... have hard, well-defined borders
*HTN and DM |
|
|
formation of new vessels which are more numerous, tortuous and narrower than local others.
|
Neovascularization
Diabetes Mellitus! |
|
|
small, linear FLAME-shaped red streaks on the retina. Seen with the usual HTN but also with __________
|
Flame Hemorrhages - papilledema
|
|
|
The physiologic 'blind spot' we view through the ophthalmoscope
|
optic disc
|
|
|
Describe papilledema presentation in the eye
|
Flame hemorrhages (red streak retina)
Blurred optic disc margins (not clear) Hyperemic disc (engorged & red like the sun!) SMALL CUP |
|
|
How should the optic disc appear in healthy eye?
|
Clear disc margin
Yellow-orange to creamy pink Cup should be HALF the size of disc Cup should be Yellowish- WHITE |
|
|
Enlarged, pale optic CUP, suggests?
|
glaucoma
*due to increase in vitreous humor pressure, which is not funny |
|
|
Avascular area of central vision containing only CONE cells.
|
Macula and fovea
*highly photosensitive because cones only detect bright colors/light |
|
|
How do we assess the macula and fovea, which are HIGHLY photosensitive?
|
Since we don't chemically dilate the pupil, we ask patient to look DIRECTLY INTO THE LIGHT at end of exam.
|
|
|
What does the macula and fovea look like?
|
dark, pigmented area towards the temporal (lateral) side of optic disc. It's about 1/4 size of disc ~2 disc diameters away going towards temple
|
|
|
emmetropia
|
perfect, normal vision
(won an emme!) |
|
|
ametropia
|
refractive error leading to myopia or hyperopia (nearsighted or farsighted)
*didn't get no emme award:-( |
|
|
With myopia, the image falls ___________ of the retina.
|
in front of
*think RIGHT IN FRONT OF is necessary to see with myopia |
|
|
With hyperopia, the image falls ____________the retina.
|
behind the retina
*think STAND FARRRR AWAY BEHIND ME to see it |
|
|
irregularity in curve of the lens or contour of the cornea
|
a-stigmatism
|
|
|
hyperopia due to aging
|
presbyopia
old people opia |
|
|
How far away does patient stand for Snellen eye chart?
|
20ft
|
|
|
Refer out Snellen test patient who has vision over ?
|
20/40 corrected
|
|
|
Harmon distance
|
patient reads eye chart with chin on fist and chart at elbow length.
*hyperopia and hypermetropia screen |
|
|
A-stigmatism is an irregular curve of lens or shape of cornea. When testing with the wheel, it's a positive if?
|
distorted = irregular = astigmatism
*patient sees DISTORTED (due to their irregularity) lines instead of parallel lines |
|
|
Amsler grid
|
dark spot on checkerboard
*+ is distortion or defect on grid (glaucoma) |
|
|
Examiner compares patient's peripheral vision with her own using the
|
Confrontation test (face your patient!)
(CN II sensory for peripheral - glaucoma) |
|
|
consists of dilation of the ipsilateral pupil in response to pain applied to the neck, face, and upper trunk. If the right side of the neck is subjected to a painful stimulus, the right pupil dilates (increases in size 1-2mm from baseline). This reflex is absent in Horner's syndrome and lesions involving the cervical sympathetic fibers.
|
The ciliospinal reflex (pupillary-skin reflex)
|
|
|
Name 3 disorders that might be discovered during an eye exam
|
1. HTN
2. endocrine disorders 3. trauma |
|
|
DM
Serum lipid disturbances Endocrine disturbances |
lab tests for eye
|
|
|
"Do you ever feel dizzy? Has anyone in your family suffered dizziness or vertigo, fainting spells, etc.?"
|
Meniere's disease questions for ear
|
|
|
When interviewing your patient about her ears, note if?
|
the patient is tilting head towards one side or asking you to repeat questions
|
|
|
scar on earlobe as result of piercing
|
keloid
*more common on darker skinned peeps |
|
|
How to observe alignment of auricle
|
line from outer canthus to EOP (auricle should touch or be above this line), Auricle should be verticle w/ no more than 10 deg. lateral + posterior angle
|
|
|
Low set or unusual auricle angle may indicate
|
chromosomal aberrations (Down's) or Renal disorders but may just mean the external acoustic meatus is not in the right place
|
|
|
benign, firm mobile sac that lies in the dermis forming a DOME-shaped lump
|
Cutaneous (sebaceous) cyst
*a pimple, basically, on the ear |
|
|
thickening along upper ridge of helix; benign normal variant
|
Darwin's tubercle
|
|
|
small indurations found in front of ear where upper auricle originates; benign normal variant
|
Preauricular PITS
*more common in blacks |
|
|
unusual contour of auricle due to blunt force trauma & necrosis of underlying tissue
|
Cauliflower ear
* think MMA! |
|
|
deposit of uric acid crystals on helix or antihelix
|
tophi
*hyperuremic as in gout |
|
|
lumps on helix or anti helix which may ulcerate
|
Rheumatoid nodules
*look for RA on other areas to distinguish these from tophi/gout |
|
|
hemorrhagic spot behind ear suggestive of skull base fx (in presence of Hx of head trauma)
|
Battle's sign
*haha, no shit! |
|
|
infection of mastoid, usually secondary to __________; mastoid appears erythematous and edematous and pinna displaces anteriorly & inferiorly
|
MASTOIDITIS
secondary to otitis media |
|
|
ear discharge suggestive of skull fx in presence of Hx of head trauma
|
blood or serous discharge
|
|
|
ear discharge suggestive of otitis media
|
purulent
|
|
|
ear discharge suggestive of otitis associated with FB
|
purulent and foul smelling
*FB does not mean FaceBook |
|
|
Tenderness of auricle and/or tragus upon external palpation suggests
|
otitis media
|
|
|
Lymph nodes associated with ears
|
preauricular, postauricular, anterior cervical chain (superficial?)
|
|
|
Tenderness of lymph nodes associated with ear suggests infection. In postauricle area, palpate mastoid. If very tender, then?
|
mastoiditis
|
|
|
Should you use the largest or smallest speculum the EAM can accommodate during an otoscopic exam?
|
Largest!
*right hand/right ear rule |
|
|
option to Toynbe maneuver
|
insufflator bulb
|
|
|
normal cerumen in EAM color
|
brown or creamy
*red/grey/black is older |
|
|
hearing loss, episodic vertigo, tinnitus then check?
|
cervical spine, TMJ and ankles for proprioreception - could be Meniere's disease or old injury to 1 of the 3 proprioreceptive centers
|
|
|
edema of EAM is associated with
|
otitis media
|
|
|
chalky white patch on TM (tympanic membrane) following otitis media
|
TympanoSCLEROSIS
|
|
|
hole in the TM usually assoc. with purulent otitis media
|
TM perforation
|
|
|
Does tympanosclerosis impair hearing?
|
no
|
|
|
fluid trapped behind TM secondary to otitis media or barotrauma; pt. complains of popping, mild hearing loss and possible otalgia.
|
Serous effusion (fluid behind TM)
May see a fluid line and bubbles |
|
|
outward bulge of TM into EAM due to otitis media
|
TM bulge
|
|
|
induration of TM into middle ear due to otitis media
|
TM retraction
*saran wrapped look |
|
|
induration =
|
retraction of TM
|
|
|
myringotomy tubes
|
drainage tubes in TM into middle ear due to otitis media
|
|
|
tuning fork for Weber technique
|
512
|
|
|
Describe Weber technique
|
Hearing test: place 512 fork at vertex or forehead, ask pt. if sound lateralizes. Indicates either nerve injury or obstruction
|
|
|
Describe Rinne technique
|
After performing Weber's and determining side of localization, hold fork on mastoid. When pt. can no longer hear, hold fork parallel to EAM. Pt. should hear that sound 2x as long as heard mastoid. (air to bone conduction ratio of 2:1)
|
|
|
Air to bone conduction less than 2:1 in Rinne's test suggests:
|
air conduction loss due to obstruction or nerve damage
|
|
|
Test for profound deafness
|
Schwabach - vibrating 512 on pt.'s mastoid OPPOSITE lateralization side. Go back and forth between your mastoid and theirs. Normal if both of you can't hear it at about same time.
|
|
|
Watch-tick test for hearing
|
doc holds ticking watch equidistant from both EAM's of patient - should hear at same distance on both sides. Can rub fingers together instead of using a watch.
|
|
|
Caloric test (Barany-Caloric test)
|
C.O.W. = Nystagmus opposite cold and same side warm, Listing same side cold and opposite warm are NORMAL findings. Vomiting is okay, too! Abnormal is all else.
|
|
|
Rhomberg's for balance
|
If pt. grossly sways, suggestive of vestibular or dorsal column lesion. (must do babinski-weil walking test to differentiate)
|
|
|
test where pt. will walk in a circle in direction of vestibular lesion
|
Mittlemeyer march
|
|
|
Obstructed ear in Weber test
|
lateralizes to blocked ear then obstruction; lateralizes to other ear then nerve damage
|
|
|
gag reflex nerves
|
9 senses, 10 moves it
|
|
|
Color of inferior conchae allergy indications?
|
Pale, Pale, Pale...grey, pink or blue = all indicate allergy because PALE
*bright is normal |
|
|
Affected nerve when patient cannot differentiate one smell from another
|
CN I Olfactory
|
|
|
Frequent nosebleeds (epitaxis) in an adult may indicate
|
hypertension
*or deviated septum |
|
|
allergic salute
|
transverse nasal crease -
at jcn of cartilage and bone. Due to chronic nasal itching from allergies |
|
|
Rhinophyma
"rhino" nose |
rinophyma--prominent hypertrophy of sebaceous glands of nose with overgrowth of soft tissue
|
|
|
sign of fetal alcohol syndrome in children seen upon nose inspection
|
flattened/absent filtrum
|
|
|
nasal septum displaced to one side; nares unequal in size
|
Deviated septum
* may predispose to epitaxis |
|
|
Green nasal discharge
|
bacterial
|
|
|
White nasal discharge
|
viral
|
|
|
Clear nasal discharge
|
allergy
|
|
|
foul odored nasal discharge
|
FB, esp. if unilateral
|
|
|
normal color of inferior nasal turbinate/concha
|
deep pink like nasal mucosa
|
|
|
tenderness upon palpation of nose?
|
trauma or infection
*crepitus suggests fracture |
|
|
Function of sinuses (arguably)
|
PHONATES the voice (#1)
warms inspired air lightens the head |
|
|
presentation of sinusitis
|
edema/swelling and erythema
|
|
|
just about every test for inspection/palpation/percussion indicates
|
sinusitis
|
|
|
It's not a flashlight or otoscope light against the patient's sinuses but a ?
|
transilluminator!
|
|
|
Why should you transilluminate a well-patient's sinuses?
|
so you will have a litmus test for when they are sick - a "well baseline" exam
|
|
|
Absence of red glow upon sinus transillumination could mean mucous filled sinus or?
|
non-developed sinues
|
|
|
tuning fork for sinus exam
|
128 (the big one!)
|
|
|
Mouth and oropharynx surfaces to examine
|
buccal and lingual surfaces
|
|
|
metallic taste in patient's mouth might indicate
|
lead poisoning
|
|
|
ill-fitting dentures, malocculusion of teeth both might lead to vertigo.
WHY |
proprioreceptors in TMJ (2nd greatest aggregation)
|
|
|
major dental work could be associated with what fever?
|
rheumatic
|
|
|
chewing tobacco can predispose pt to ?
|
oral cancer
|
|
|
name 4 structures you can see in the oropharynx
|
uvula, posterior pillar, palatine tonsil, anterior pillar, soft palates
|
|
|
duct that squirts gleet at the dentist
|
Stenson's duct
|
|
|
Sjogren's
|
dried up Stenson's duct (gleet squirter) + migratory joint pain
|
|
|
recurrent, painful vesicular eruption of the lips and surrounding skin. Begins as a small cluster of vesicles, break, form yellow brown crust. Very attractive.
|
Herpes simplex (aka: cold sore, fever blister)
*heals in 10-14 days |
|
|
softening of the skin around the corners of the mouth followed by cracks/fissures at corners of mouth. What and why?
|
ANGULAR Cheilitis
*VITAMIN B deficiency or NO TEETH (edentulous) |
|
|
loss of redness and a thickening, scaling and eversion of lower lip
|
ACiTiNiC cheilitis
*sun overexposure |
|
|
BUTTON-like lesion, ulcerates and crusts over. Use gloves for this one.
|
Chancre of SYPHILLIS
|
|
|
scaly plaque or ulcer w/ or w/o crust or a nodular lesion usually on lower lip. Risk factors are sun exposure and fair skin...
|
Squamous cell carcinoma
|
|
|
diffuse, tense swelling of the dermis and squamous tissue of lip, usually develops and disappears in hours or days due to ALLERGIES
|
Angio-edema (fat lip from allergy!)
*pt will not c/o angioedema is pruritic (look it up - I had to) |
|
|
pigmented spots on the lips MORE PROMINENT than freckles
|
Peutz-Jeghers syndrome
|
|
|
exudative pharyngitis means
|
pus pockets = mono! (or strep)
|
|
|
bilateral herpes
|
herpes simplex - cold sore on either side of mouth
*h. zoster is unilateral |
|
|
acitinic means
|
from the sun
*acintinic cheilitis is loss of color on lower lip due to sun exposure |
|
|
tanning beds vs. "I sleep around."
|
Squamous cell carcinoma
vs. Syphillitic chancre (button-like) |
|
|
angioedema means
|
allergy! (leukotrienes)
|
|
|
Peutz-Jeghers syndrome markers
|
pigmented spots that are more prominent than freckles and also found on Buccal surfaces. Macule type polyps also prone to in colon.
|
|
|
Oral pigmentation syndrome associated with intestinal polyps
|
Peutz-Jeghers pigments around mouth and on inside cheek (buccal)
|
|
|
One of the best predictors of heart attacks made by the teeth
|
MARGINAL gingivitis!
*non-flossers, inflammation of interdental papillae. Tooth brushing makes gums bleed. |
|
|
Sudden onset of bleeding gums, fever, malaise, lymphadenopathy, greyish pseudomembrane along gum margins and foul breath
|
NECROTIZING gingivitis -get thee to a dentist now.
|
|
|
overgrowth of gums onto teeth
|
gingival hyperplasia
*Dilantin, puberty, pregnancy, leukemia |
|
|
localized gingival enlargement which forms a red, tumor-like mass that bleeds easily -
|
Pregnancy tumor (EPULIS, pyogenic granuloma)
-1% pregnancies -origin is interdental papillae so began as gingival hyperplasia |
|
|
purplish to brown discoloration and enlargement of gums due to AIDS/HIV
|
Kaposi's sarcoma
|
|
|
bluish black line 1mm from gum margin, follows along gumline
|
Lead Line
*seen in plumbism, metallic taste in mouth |
|
|
plumbism
|
lead poisoning
|
|
|
wearing down CHEWING tooth surfaces so yellow-brown dentin exposed. From grinding teeth or just getting old
|
Attrition of teeth
|
|
|
exposed roots of teeth
|
gum recession (long in the tooth)
|
|
|
Dilantin therapy causes
|
gingival hyperplasia, Osteomalacia (softening of bones)
*Dilantin is anti-seizure med |
|
|
EROSION of enamel of teeth on LINGUAL surfaces
|
Erosion of teeth
*due to regurgitation i.e. Bulimia |
|
|
small, widely spaced teeth that are NOTCHED on biting surfaces.
|
Hutchinson's teeth
due to congenital syphilis |
|
|
Are large tonsils normal?
|
yep, so long as they are normally colored
|
|
|
thick, cheesy plaques that adhere to underlying mucosa of palate and oral mucosa - yeast infection of the mouth
|
candidasis/THRUSH
|
|
|
midline, benign bony growth in the MID-PALATE
|
TORUS palatinus
*split like bull horns/tora!tora! |
|
|
Kaposi's sarcoma finding on the palate and oral mucosa
|
raised or flat lesions, deep purple
*Kaposi's is dark purple spots on gingiva, particularly of interdental papillae and darkening gums due to AIDS |
|
|
small, white specks on buccal mucosa near 1st and 2nd molars. First sign of MEASLES.
|
Koplik's spots
*Ted Koppel got the measles in his mouth! |
|
|
yellowish spots that normally appear in buccal mucosa
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Fordyce spots - normal sebaceous glands you can see through the thin skin of the mucosa
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the PRE-CANCEROUS white spot in the mouth
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leukoplakia
*bad, bad white plaque in mouth |
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possible causes of thrush/candidasis of mouth
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diabetes-antibiotics-AIDS
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Torus palatinus, the bony growth hanging from the roof of the mouth, is also called a
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chandelier
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****High, arched palate*****
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******MARFAN'S syndrome******
***do NOT adjust this person P-A!!!!! Vascularly compromised. |
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benign formation of furrows in the tongue associated with aging
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Scrotal tongue (furrowed tongue)
*your balls are so big, even your OLD tongue looks like your sac. Cool. |
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If any of my flashcards offend you
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feel free to type your own for each class and stop using mine. It takes 20-40 hours per class so giddyup!
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benign areas of denuded papillae + normal papillae that come and go on the tongue
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GEO tongue
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yellow to brown tongue with elongation of papillae. Often due to antibiotics, but may occur spontaneously.
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Hairy tongue
*acupuncturists are always looking for this! (heat and stomach) |
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*****Vitamin B12 deficiency tongue - no papillae/smooth tongue
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Beefy tongue/Glossitis/atrophic glossitis
****BEEFY b/c no B12 |
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small red round ulcer on tongue
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Apthous ulcer
*canker sore on tongue |
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caviar lesions on lingual tongue surface
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varicose veins
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extra bone under tongue growing from mandible - under your bottom molars, looks like an extra set of molars stuck in the jaw
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Tori Mandibulares
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reddening of oropharynx, with or without exudate
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Pharyngitis
*strep or mono will cause this along with several kinds of bacteria and viruses. See with fever and swollen lymph nodes plus exudate... |
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dull erythema and grey exudate in oropharynx. Airway obstruction - membranous. They killed George Washington shoving a hot poker down his throat to break this membrane.
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Diptheria Pseudomembrane
*George Washington |
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Regarding tongue ROM, what should you check to make sure the tongue has adequate ability to move freely?
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Frenulum
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Motor to muscles of mastication
Motor to muscles of facial expression |
V
VII |
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Reflex to Palatine
Reflex to Gag Reflex to Jaw |
V, X
IX, X V |
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Sensory to olfaction
Taste to anterior 2/3 tongue Taste to posterior 1/3 tongue Taste to uvula |
I
VII (anterior 2/3) IX (posterior 1/3) X (uvula) |
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Touch to anterior 2/3 of tongue and palate
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V
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Touch to posterior 1/3 of tongue and oropharynx
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IX (same for touch and taste to posterior 1/3 of tongue)
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regulates the BMR
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T3, T4, T7 Thyroid
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regulates serum calcium levels
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calcitonin puts the bone in
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When doing a thyroid exam, be certain your stethoscope is not
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above the thyroid!
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Some causes of low energy
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endocrine (thyroid), neoplastic, nutritional, psych
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paradoxical weight gain
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thyroid, DM
*unexplained (cancer, AIDS) |
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increase in bowel habits regarding thyroid
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hyperthyroid
*ergo, decrease is hypo (+ carpal tunnel) |
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Prefers heat regarding thyroid
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HYPOthyroid (can't get warm)
*likes it cold is hyperthyroid cause they are always running hot |
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hair falling out or getting thinner, pain or numbness in hands/fingers (carpal tunnel), unexplained hoarseness
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HYPOthyroid
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HYPOthyroid symptoms
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hair falling out or getting thinner, pain or numbness in hands/fingers (carpal tunnel), unexplained hoarseness, decreased bowel, stays cold
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Failure of thyroid to move upon swallowing is suggestive of
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cancer
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local enlargement of thyroid suggests
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tumor
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symmetrical enlargement of thyroid
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goiter
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multinodular enlargements of thyroid
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multinodular goiter
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Describe hyperthyroidism with regard to the overall affect/body of patient:
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a. agitation/NERVOUS
b. light weight clothing even in cool weather c. Dalrymple's sign, lid lag or ex-ophthalmus, **EARLIEST, most persistent signs of hyperthyroid d. fine PERIPHERAL TREMOR e. PRETIBIAL myxedema (protein deposits on both anterior tibiae) f. generally THIN |
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Describe hypothyroidism with regards to patient affect/body:
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a. SLOWed mentition
b. heavy clothes even when hot out c. HAIR LOSS or thinning d. loss of lateral 1/3 EYEBROW e. peri-ORBITAL edema/puffy face f. macroGLOSSIA g. xanthelasma (yellow fat deposits) h. HOARSENESS i. general OVERWEIGHT/fat |
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Name of hyperthyroidism (hallmark of Dalrymple's sign and Pretibial myxedema)
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Graves' disease
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paper test
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place piece of paper on suspected hyperthyroid pt's hand. Paper bounces due to fine peripheral tremor
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thyroid findings upon palpation
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normal
diffuse enlargement multinodular singular node |
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percussive sound on angle of Louis for thyroid will sound dull if there is a ______________________ present.
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retrosternal enlargement in inferior direction (vs. lateral enlargement of goiter)
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abnormal venous hum heard with diaphragm of stethoscope
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hyperdynamic circulation of thyroid
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Achilles of hypothyroid patient
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delayed relaxation/tendon recoil phase of foot (not clonus) rates a +1
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DTR of hyperthyroid
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+3 or +4
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tapping facial muscles over parotid gland produces a spasmodic contraction of ipsilateral facial muscles
|
CHVOSTEK'S SIGN = hypocalcemia
(presence of tetany/spasm may or may not be thyroid origin) |
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how to elicit Chvostek's sign
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tap facial muscles over parotid gland in cheek. If tetany/spasm of ipsi facial muscles, then suspect thyroid b/c means hypOcalcemia (calcitonin or parathyroid hormone)
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facial or periorbital edema with pregnancy hyperthyroidism
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ER! sign of preclampsia or ecclampsia (kidney failure)
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thyroid enlargement or bruits with pregnancy
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normal
|
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STD
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VERTICAL chain lymph nodes swell
Cat's eye (uneven pupils) Epitrochlear node inflammation |
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Lymph nodes not involved in STD
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horizontal
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Virchow's node
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SENTINAL NODE of left supraclavicular area which may suggest abdominal cancer if enlarged
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collar of lymph nodes around neck
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Hodgkin's lymphoma
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engorgement of chest veins
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Superior Vena Cava Syndrome (SVCS) - jugular vein on right that drains head is blocked by ENLARGED LYMPH NODE sitting on it. Backed up veins bulge in chest.
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How could Horner's syndrome be caused by a lymph node?
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Inflammed node pressing on cervical sympathetic chain
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If your patient has TOS, what should you do to c.y.a.?
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look up - do they have Horner's syndrome (pain - pallor - paresthesia down one arm - ptosis, miosis, anhydrosis)
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Besides a lymph node pressing down on the superior cervical chain, what else could cause TOS besides muscle?
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Pancoast tumor, Superior sulcus tumor, Apical lung tumor
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accumulation of lymph in soft tissue with swelling due to obstruction of drainage. Breast Cancer. Lymph tissue feels like a sandbag.
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Lymph-edema (NON-PITTING)
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accumulation of soft fluid because of a VENOUS channel obstruction. RIGHT sided heart failure!
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Venous {PITTING} edema - feet and ankles swell.
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4 features of cancerous lymph node
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1. contour = irregular
2. consistency = matted 3. mobility = fixed 4. tenderness = absent |
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irregular, matted, fixed, absent
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the contour, consistency, mobility and tenderness of CANCEROUS lymph node
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a mole with an ominous notch
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nevus
*skin cancer does not transilluminate |
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migratory joint pain
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lupus
|
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loose skin, vascular fragility
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Ehlers-Danlos syndrome
|
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joint pain with telangiectasia
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scleroderma
|
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You can hear ventilation of a lung but not
|
respiration
|
|
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Gals on birth control are ___________ so a hit/kick/damage may cause deep vein thrombosis!
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hyper-coagulable
*at level of internal respiration |
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S.O.B.
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short of breath
|
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reasons for SOB
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asthma, COPD, cancer anxiety
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reasons for a cough
|
infection, asthma, cancer
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High risk hyper-coaguable patients
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pregnancy, BCP, smokers, cancer, immobile, long bone fx (fatty marrow in bld), atrial fibrillation (vegetation from clots)
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____________ are more likely to throw clots
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hypercoagulable
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sunken chest - sternum taking up AP chest diameter
|
pectus excavatum
* may affect organ fcn by compromising inner dimension of thoracic cage` |
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pectus carinatum
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pigeon chest/chicken breast
*projection of sternum beyond abdominal frontal plane |
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AP dimension of chest is larger than lateral dimension - seen with COPD but is a NORMAL variant
|
Barrel chest
*Normal after 55, suggests COPD before that |
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******sharp, short kyphosis due to 2* collapse of vertebral spine in response to TB
|
******Gibbus formation = angular fx
*TB and staph in bones |
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*******using scalenes, SCM's and shoulder girdle muscles to breathe
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Use of Accessory Muscles to breathe
NO MOTION OF THORACIC CAGE *COPD or chronic Hypoxia |
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lateral displacement of trachea due to pleural effusion, pulmonary mass, pneumothorax, atelectasis
|
displacement of trachea
*usually to the right suggests tumor. |
|
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Blue Bloater
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Right sided CHF due to CHRONIC BRONCHITIS
|
|
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Pink puffer
|
Kissmaul and thin, pursed lips. Smoking, hypercapneac, emphysema
|
|
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central cyanosis
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Right sided heart fail due to SYSTEMIC HYPOXIA - blue tongue and lips
|
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clubbing of fingernails
|
due to longstanding hypoxia (smoker)
|
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UNILATERAL chest expansion upon palpation
|
PNEUMOTHORAX, HEMOTHORAX, PLEURAL EFFUSION, HEMIPARESIS
(manual says: pleural effusion, unilateral bronchial obstruction, splinting or guarding, hemiparesis) |
|
|
NO BILATERAL movement of diaphragm suggests
|
COPD
Ankylosing spondylitis Sarcoidosis (constrictive disorders) |
|
|
Vocal fremitus (tactile fremitus) is ________ over area of pneumonia
|
Louder! Vibrates more!
|
|
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Vocal fremitus/tactile fremitus would be ________ over an area of evacuation.
|
lesser (ALL air so even fainter - remember...sound travels best through a solid medium. Pneumothorax, Atelectasis, airway obstruction, asthma and COPD are all air!)
|
|
|
3 normal notes found in thorax upon lung percussion
|
Resonance (over lungs, hollow sound)
Tympany (drum sound over stomach) Dullness (liver) |
|
|
Normal lung
|
resonance
vesicular diaphragm excursion 3-5cm |
|
|
trauma is an entity that makes the lung go away so it makes ________ go away, as well
|
fremitus
|
|
|
RML pneumonia
|
_dull thud over pneumonia area
_no vesicular sounds - only CRACKLE _Large fremitus sound/vibration RML _Normal diaphramatic excursion |
|
|
Hemothorax (pleural effusion of blood)
|
~NO fremitus BELOW where blood has accumulated because there is no lung there anymore - just blood.
~No vesicular sounds (breath) ~Expansion on good side only (+5) ~resonance over blood is DULL, like over a drum full of blood |
|
|
Pneumothorax
|
1. Like hemothorax, NO vesicular sound (breath) b/c just free air bubbles
2. Like hemothorax, NO fremitus because no lung but ABOVE 3. Like hemothorax, NO diaphragmatic excursion on bad side but +5 on good side 4. DIFFERENCE: resonance is very HYPERresonant over upper because all air. Very TYMPANIC |
|
|
COPD lungs
|
fully inflated! Huge! EVACUATED.
a. NO expansion (already expanded) b. HYPERresonance generally because lungs are just bags of air c. DISTANT vesicular (breath) sounds d. NO diaphragmatic excursion. Already fully 'excursed' |
|
|
How to diagnose hemo- vs. pneumo-thoraxi on a field
|
History = trauma
Inspection = unilateral Hemo = no fremitus, no resonance, no vesicular sounds, DULL thud - all BELOW at area of pooled blood Pneumo = no fremitus, no resonance, no vesicular sounds, HYPERESONANCE - all UPPER where air bubble collected. |
|
|
When determining a lung pathology through resonance, tympany, etc., what do we want to know?
|
What happens to the EVACUATED area only.
|
|
|
normal note of lung percussion
|
resonance
|
|
|
Describe normal sounds over heart, stomach, liver, scapulae
|
heart and liver = dull
stomach = tympanic (full of air) scaps = dull |
|
|
When you percuss the lung, your plexer must strike your pressure pleximeter over an ___________
|
intercostal space
|
|
|
When do we hear hyperesonance?
|
COPD (generalized)
Pneumothorax (upper) Atelectasis |
|
|
When do we hear tympany?
|
Pneumothorax
*all air in that one space upper so hyperresonant and tympanic |
|
|
When do we hear dullness?
|
Hemothorax (drum full of blood below)
Pneumonia (density) Tumor (density) Pleural effusion (density) |
|
|
extent to which the diaphragm moves when going from full exhalation to full inhalation
|
excursion
|
|
|
unilateral loss of diaphragmatic excursion suggests
|
Hemiparesis
Ipsilateral FLAIL, PNEUMO, EFFUSE |
|
|
bilateral loss of diaphragmatic excursion
|
COPD
|
|
|
How long does the examiner listen to each lung spot
|
a full respiration cycle
|
|
|
What to do if adventitious lung sound heard?
|
Have patient REALLY cough, then listen again. If cough cleared it, then bronchitis.
|
|
|
This sound is:
1:1 inspiratory to expiratory Loud intensity High in pitch Harsh! |
Tracheal
*extrathoracic trachea location |
|
|
This sound is:
1:3 inspiratory to expiratory (heard mostly on EXPIRATION) Loud intensity High in pitch Tubular sound (wind tunnel) |
Bronchial
*located in manubrium |
|
|
This sound is:
1:1 inspiratory to expiratory Moderate intensity Moderate in pitch Rustling sound, but still tubular |
Bronchovesicular
*over mainstem of bronchi |
|
|
This sound is:
3:1 so INSPIRATION Soft intensity Low in pitch Gentle rustling |
Vesicular
*peripheral lung |
|
|
high pitched, discrete continuous sounds at end of inspiration (reverse atelectasis)
|
Fine crackles
****not cleared by coughing. This is end stage pneumonia. |
|
|
SONOROUS wheeze sound like a SNORE which IS cleared by coughing
smoker's cough in morning |
Rhonchi
*cleared by cough |
|
|
SIBIILANT, musical noise like a squeaker
|
Wheeze
Heard continuously but if on Expiration, suggests narrowed airways like COPD, asthma, bronchitis |
|
|
dry rubbing or grating sound heard during inspiration or expiration
|
Pleural Friction Rub
inflammation of pleural surfaces |
|
|
If '99' or '1,2,3' heard louder in one area when performing bronchophany, suggests
|
consolidation of pneumonia
|
|
|
During ascultatory percussion, how do we assess the anterior lung fields?
|
percuss directly over T3
|
|
|
While performing whispered pectoriloquy, the whisper will sound ___________over an area of consolidation.
|
louder
*same as broncophany - louder! |
|
|
describe Schepelmann's test for rib fracture
|
As a crush fracture or involved nerve, it will hurt when patient leans TO AFFECTED SIDE
|
|
|
describe Schepelmann's test for pleurisy of the lung
|
will hurt like hell WHEN LEANING AWAY because they are stretching the shit out of the inflamed nociceptic bag
|
|
|
How do we know if there is both pleurisy of the lung AND a rib fx.
|
Hurts both ways!
Lean towards fx ouch! Lean away pleurisy ouch! |
|
|
For chiropractors, why is TOS important
|
lymph node
apical tumor pancoast tumor = do supraclavicular area lung exam on ipsilateral side for percussive dullness Horner's syndrome! |
|
|
Mi Tri Regurges on SYS!
|
If you are on the tricuspid valve and you hear a murmur on systole, the name of the murmur is mitral regurgitation.
|
|
|
Mnemonic for Stenosis and Regurgitation of valves...(4)
|
Mi Tri Stenosis on diastole
Mi Tri Regurges on SYS A P Stenosis on SYS A P Regurges on diastole |
|
|
Mi Tri Regurges on SYS
do the rest of them... |
Mi Tri Stenosis on diastole
Mi Tri Regurges on SYS A P Stenosis on SYS A P Regurges on diastole |
