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50 Cards in this Set

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When is a comprehensive assessment of the patient necessary?
- new patients
- provides fundamental and personalized knowledge about the patient
- strengthens the clinician-patient relationship
- helps to identify and rule our physical causes related to patients concerns
- provides baseline
- provides platform for patient education
- develops proficiency in the skills of physical examination
When is a focused assessment appropriate?
- for established patients, especially during routine or urgent care visits
- addresses focused concerns or symptoms
- assesses symptoms restricted to a certain body system
- applies specific body system exam methods
What are the most important physical exam techniques?
BP, assessment of central venous pressure from the jugular venous pulse, listening to the heart for valvular disease, breast exam, detection of hepatic or spleen enlargement, Pap smear
What is subjective data?
- what the patient tells you
- the history, from chief complaint through review of symptoms
What is objective data?
What you detect during the examination
- all physical findings
What are the 7 components of Comprehensive Adult Health History
- Identifying data and Source of the History
-Chief Complaint
- Present Illness
- Past History
- Family History
- Personal and Social History
- Review of systems
What is identifying data?
age, gender, occupation
Source of history -- usually the patient but can be a friend, family, or medical referral
Present Illness
- amplifies chief complaint- explains how each symptom developed
- includes patients thoughts and feelings about the illness
- pulls in relevant portions of ROS
- may include meds, allergies, smoking/alchol
Review of Symptoms
documents presence or absence of common symptoms related to each body system
When describing the symptoms what is important to note?
1) location
2) quality
3) quantity or severity
4) timing, including onset, duration, and frequency
5)setting in which it occurs
6) factors that aggravated or relieved the symptoms
7) associated manifestations
What are the functions of skin?
1. Protection
2. Prevents penetration
3. Perception
4. Temperature regulation
5. Identification
6. Wound repair
7. Absorption and excretion
8. Synthesizes vitamin D
What are the layers of the skin?
there are three layers of the skin
- epidermis, dermis, and subcutaneous tissue
Epidermis
Avascular thin outermost layer
- it is nourished by blood vessels in the dermis
Composed of two important strata:
1) The stratum corneum- dead keratinized cells that normally separate (Keratin)
2) The stratum Germinativum- basal cell layer is made up of rapidly proliferating living cells that slowly migrate upward, keratinize and are shed from the stratum corneum (4 week process)
Keratin
Keratin- insoluble protein that provides the skin with its protective properties
What are the two major cell types in the basal cell layer?
Keratin-
Melanocytes
Melanocytes
produce melanin- the number of melanocytes are roughly the same in all people -- what differs is the amount of melanin in the melanocytes
What affects skin color?
Skin is derived from 3 sources:
- the mainly brown pigment is melanin
- the yellow orange pigment is carotene
- the red purple tones come from the underlying vascular bed
Dermis
makes up the bulk of the skin
- dense connective tissue
- chiefly collagen and elastin
- the nerves, lymphatics, blood vessels, and sensory receptors lay in the dermis
- hair follicles- invaginations intot he dermis
Collagen
tough fibrous protein that enables the skin to resist tearing
Elastin
a resilient tissue that allows the skin to stretch with movement
What are appendages of the skin?
Hair, nails, sweat and sebaceous glands
- the hair and nails are made of dead keratinized cells
Subcutaneous layer
the 3rd layer mostly made of adipose tissue
Adipose layer
thermal regulator as well as a protection over bony prominences
- stores fat for energy
Sebaceous glands
produces sebum- protective lipid substances -- oil and lubricates teh skin and hair and forms an emulsion with water that slows water loss from the skin
- they are everywhere except the palms and soles
Sweat glands
Two kinds
Eccrine- open directly onto the skin surface and produce a dilute saline solution that we called sweat- widely distributed and mature by the time we are two months old
Apocrine- found in close association with hair follices-- occur mostly in the axillae, areolae, the navel, the pubis, and the perineum and secrete a mily stick secretion into the hair follicles
What sweat gland is involved in BO?
Apocrine- become active during puberty and sexual stimulation
- bacterial flora residing on teh skin reacts with apocrine sweat toe create BO
Subjective data- SKIN
- previous history of skin disease
- change in pigmentation
- change in mole
- excessive dryness or moisture
- pruritus
- excessive bruising
- rash or lesion
- medications
- hair loss
- change in nails
- environmental or occupational hazards
- self care behaviors
What is the difference between skin of very young, older adult, and healthy adult skin?
- skin in very young is unable to effectively prevent fluid loss or function in temp regulation
- the stratum corneum of older skin thins and flattens allowing chemicals easier access into the body
Why does wrinkling occur?
- loss of elastin, collagen, and subcutaneous fat, as well as reduced muscle tone
Physical Exam for skin
Perparation- reduce external variable
Equipment needed- direct lighting, penlight, centimeter ruler, gloves for open
For special procedures- Wood's light, magnifying glass, materials for lab tests
Examples of color affected by variables?
Temporary pallor- fear, exam room is too cold
Temporary erythema- embarrassment, exam room too hot
What are some examples of widespread color change?
pallor, erythema, cyanosis, jaundice, increased pigmentation
Pallor
when red pink tones from oxygenated hemoglobin is lost, the skin takes the color of the connective tissue which is mostly white
- in tan people the person will look more yellowish brown color or ashen
- can be observed in mucous membranes, lips, and nail beds
- common in anxiety, great from vasoconstriction
- can be seen in anemia- check in palpebral conjuctiva and nail beds
- fainted, poor areterial flow in the feet
Raynaud’s phenomenon
skin color changes in response to cold temperature- primary raynaud's is when you see it in their hands
- secondary raynaud's phenomenon can be because of a connective tissue disease
Erythema
intense redness of skin due to excess blood in superficial capillaries, expected with fever, or localized infection, or emotional
- occurs in carbon monoxide poisoning and venous stasis
Jaundice
exhibited by yellow color, indicated a rise in bilirubin in the blood
- first noted in junction of hard and soft palate or in sclera
- seen in severe mononucleosis hepatitis, cirrhosis, sickle celled anemia, newborns
Cyanosis
bluish mottled color that signifies decreased perfusion of tissues with oxygenated blood
- Anemic person will not look cyanotic because there is no Hgb present
- polyythemia (increased RBC) will look ruddy blue all the time
- occurs with heart failure, shock, chronic bronchitis
Vitiligo
decreased pigmentation
Increased pigmentation
- when we see it around the neck it is called nigricans-- indicative of diabetes
- we see it around the lips too
Mongolian spot
- common variation of hyperpigmentation in black, asian, native american, and hispanic newborns
- blue black to purple macular area at the sarum or buttocks
- fades during the 1st year of life
- 90% of black, 80% of asians and native americans, and 9% of whites
Comedonal Acne
- increase activity in sebaceous glands increased oiliness
- mild may have white and blackheads
- severe has papules, pustules, and nodules
What happens to older adults skin?
- more wrinkling
- senile purpura- bruising in old people
- dry skin (xerosis)- changes in keratin and reduction in sweat and sebum
- senile lentigines- small flat brown macules that are a cluster of melanocytes that appear after sun exposure
- aged skin repairs itself more slowly and wound healing can be as 4x as long-- this contributes to infections and ulcers
Keratoses and skin tags
Keratoses-
raised, thickness areas of pigmentation- looks crusted, scaly and warty- sebhorrheic lookds dark, greasy and stuck on
Skin tags (acrochordons)
overgrowth of normal skin forms a stalk and polyplike (occurs on eyelids, cheeks, neck axillae, and trunk)
Temperature of skin
- check bilaterally with dorsa of hands
- skin should be warm and the temperature should be equal and bilateral
- hands and feet might be slightly cooler
Moisture of skin
- perspiration is normal on face, hands, axilla, and skinfolds
Edema
fluid in intercellular spaces and should not be present
4 is the worst
- congestive heart failure, kidney and liver failure
What to check for on skin?
color, temperature, moisture, texture, thickness, edema, mobility and turgor, any lesions
Primary skin lesions diagnosis
- distrubtion, localized, primary or secondary, color, sharpness of edges, surface contour, geometric shape
PRimary skin lesions
1) Macule
2) Patch
3) Papule
4) Plaque
5) Nodule
6) Tumor
7) Wheal
8) Urticaria
9) Vessicle
10) Bulla
11) Pustule
12) Cyst