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127 Cards in this Set

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Most important points about health history and physical exam of the integumentary system.

hair loss


rash/itch


growths

Skin- 4 pigments

1)melanin-brownish pigment of skin


2)carotene-golden yellow in SQ tissue




2 types of hemoglobin-circulates RBC


3) oxyhemoglobin(bright red) and 4) deoxyhemoglobin (bluer)



central cyanosis

depends on the oxygen in the arterial blood




Diseases-advanced lung disease COPD and pulmonary edema, congential heart disease.

peripheral cyanosis

blood/oxygen pulled from extremities to more central areas.




Causes: heart failure.

Sebaceous glands

produce a fatty substance secreted onto the skin surface through hair follicles

Sweat glands


eccrine


apocrine

e-widely distrubuted


a-in axillary and genital regions

Causes of itching without rash

dry skin, pregnancy, uremia,


lymphomas, leukemia, drug reaction,


lice,




less common diabetes and thyroid diease

Causes of changes in skin-Color changes




Addison's diease

Widespread increased in melanin causes darker skin

Causes of changes in skin- Color changes




Cafe-Au-Lait Spot

A slightly but uniformly pigmented macule or patch with a somewhat irreg boarder.




Greater than >1.5cm suggests


neurofibromatosis.

Causes of changes in skinColor changes




Tinea Versicolor

Fungal infection of the skin causes hypo or


hyper pigmented, scaly macules on the trunk, neck and upper arms.




In lighter skin, macules may look reddish or tan instead of pale.

Causes of changes in skinColor changes




Vitiligo

dipigmented macules appear on the face, hands, feet.




Non harmful.

Causes of changes in skinColor changes




Cyanosis

Blueish color skintone

Causes of changes in skinColor changes




Jaundice

Yellow skin




Jaundice also occurs in the palpebral conjunctiva, lips, hard palate, and the undersurface of the tongue.




Causes liver disease and hemolysis of RBC.

Causes of changes in skinColor changes




Carotenemia

yellow skin causes by a diet high in carrots and yellow vegetables/fruit.




Unlike jaundice it does not affect sclera.




Not harmful.

Causes of changes in skinColor changes




Erythema

Red hue, increased blood flow.




Example-slapped cheeks in 5th diease.

Causes of changes in skinColor changes




Heliotrope

Violaceous patches over the eyelids in the


collagen vascular diease dermatomyositis.

Skin dryness

hypothroidism

Temperature changes-warmth

fever, hyperthyroidism




local-cellulitis/inflammation

Temperature changes-coolness

hypothyroid

skin roughness texture

hypothyroid

skin velvety texture

hyperthyroid

Skin decreased mobility

edema, scleroderma

Skin decreased turgor

dehydration




Poor skin turgor is noting if "tenting" is observed or skin slowly recedes back.

Describe the ABCD's of examining a mole for possible melanoma

A-asymmetry (not round or oval)


B-Border (poorly defined or irreg border)


C-Color-(uneven)


D-Diameter(usually greater than 6mm)


E-Evolution (recent change from flat to raised lesion)(change in size, symptoms or morphology)




F-Feeling (sensation of itching, tingling, or stinging within the lesion)

Risk factors for Melanoma

History of previous melanoma


Age over 50


Regular dermatologist absent


mole changing


male gender


red or light hair


atypical moles


solar lentigines(macules on sun-exposed areas)


freckles


UV radiation from sun exposure/sun lamps


skin that freckles or burns easily


severe blistering sunburn as a child


immunosuppression from HIV or chemotherapy


family hx of melanoma


Changing nevi may have a new swelling or redness beyond the border, scaling, oozing, or blessing or sensations such as itching, burning or pain.




On darker skin, look for melanomas under the nails and on the hands and soles of the feet.




Early detection of melanoma when macular or less than 1mm deep greatly improves prognosis.

Primary skin lesion-Macule

Small flat spot up to 1 cm




Example-hemagioma, freckles , vitiligo(bates book), flat mole, petchaie, measles, scarlet fever (evolve)

Primary skin lesion-Patch

A flat spot up to 1 cm or large




Example-cafe-au-lait spot (bates book) port wine stains, mongolian spots

Primary skin lesion-Papule


An elevated, firm lesion up to 1 cm




Examples: Wart, elevated moles, cherry angioma, skin tag

Primary skin lesion-Plaque

An elevated lesion greater than 1 cm(sometimes formed by a group of papules)




Example: psoriasis (bates book) seborrheic keratosis, actinic keratosis.

Primary skin lesion-Nodule

Knot like lesion, elevated, firm 1-2 cm, goes deeper and firmer into dermis than a papule.




Example: dermatofibroma (bates book) , melanoma, hemiangioma

Primary skin lesion-Tumor

Knot like lesion, elevated and greater than 2cm

Primary skin lesion-Cyst

Nodule filled with expressible material, either liquid or semisolid




Example: epidermal inclusion cyst

Primary skin lesion-Wheal

A somewhat irregular, superficial area of localized skin edema




Example: urticaira(hives) from drug or allergic reactions.

Primary skin lesion-Vesicle

Up to 1cm filled with serous filled




Example: herpes simplex, herpes zoster, shingles, impetigo

Primary skin lesion-Bulla

1 cm or larger filled with serous fluid (blister)




Example: insect bites

Primary skin lesion-pustule

Filled with pus




Examples: Acne, small pox

Primary skin lesion-Burrow

A slightly raised tunnel in the epidermis. With a magnifying lens, look for the burrow of the mite that causes scabies.




Example: scabies

Primary skin lesion-crust

Dried residue of skin exudates such as serum, pus or blood.

Secondary skin lesion-scale

Thin flake of dead epidermis




Examples, dry skin, ichthyosis vulgarism

Secondary skin lesion-liechenification

Visible thickening of the epidermis and roughing of the skin with skin furrows often from rubbing.




Examples: neurodermatitis

Secondary skin lesion-scar

Increased connective tissue that arises from injury or disease.

Secondary skin lesion-keloids

Hypertrophic scaring that extends beyond the borders of the initial injury.

Secondary skin lesion-erosion

Non-scarring loss of the superficial epidermis, surface is moist but does not bleed




Example: aphthous stomatitis, moist after the rupture of a vesicle as in chickenpox.

Secondary skin lesion-Excoriation

Linear hollowed out crust area




Example: abrasion or scratch

Fissure

A linear crack resulting from excessive dryness.




Example: athlete's foot

Ulcer

Loss of epidermis and dermis, may bleed and scar




Example: pressure ulcer, stasis ulcer, syphillis chancre

Stage 1 pressure ulcer

Presence of reddened area that fails to blanche with pressure and changes in temperature.

Stage 2 pressure ulcer








Partial thickness skin loss involving the epidermis/dermis or both. Usually appears as a blister or abrasion.

Stage 3 pressure ulcer

Full thickness skin loss involving damage to or necrosis of subcutaneous tissue that make extend to the muscle but NOT through the muscle.

Stage 4 pressure ulcer

Full thickness skin loss with tissue necrosis and damage to the underlying muscle.

Clubbing of the nails

The angle of the nail base exceeds 180 degrees and the nail bed feels spongy or floating.




Involves vasodilatation of the nail bed.




Seen in congenital heart disease, interstitial lung disease, lung cancer, inflammatory bowel disease and malignancies.

Health history of the head and face

HA


changes in vision, hyperopia, presbyopia, myopia


double vision or diplopia


hearing loss, ear ache, tinnitus


vertigo


nosebleed or epistaxis


sore throat or hoarseness


swollen glands


goiter

HA-sudden onset

subarachnoid hemorrhage, meningitis

Hair


Fine is a sign of ___________


Course is a sign of _________


Tiny white ovoid granules in the hair_______



hypothyroid


hyperthyroid


lice

Exam of head


parotid gland

superficial to and behind the mandible


(visible and palpable when enlarged).


Open into the oral cavity

Exam of head


Submandibular gland

located deep to the mandible. Open into the oral cavity.

Hyperopia

Difficulty with close work (far-sighted)

Presbyopia

Aging vision

Myopia

Difficulty with distance vision (nearsighted)

Unilateral vision loss that is painless

vitreous hemorrhage from diabetes or trauma


macular degeneration


retinal detachment


retinal vein occlusion


central retinal artery occlusion

Unilateral vison loss that is painful

corneal ulcers


acute glaucoma


optic neuritis from MS




Immediate referral is warranted

Sudden Bilateral and painless vision loss

Consider mediations such as cholinergics and steroids

Gradual bilateral vision loss

Cataracts


macular degeneration


glaucoma

Flashing light or new vitreous floaters

Dark specks or strands between the funds and lens.




Suggest detachment of vitreous from retina.




Prompt eye consultation is indicated.

Diplopia

Can result from faulty eye alignment or a


lesion seen the brain or weakness or paralysis of one or more extra ocular muscle.




The patient may close one eye to relieve this or elevate the chin to overcome vertical deviation.

Pupillary reaction


consensual reaction

A light beams shining onto one retina causes


pupillary reactions in both eyes.




Cranial nerve III, oculomotor nerve

Pupillary reaction


pupillary constriction




direct reaction


consensual reaction

When a person shifts gaze from a far object to a near one, the pupils constrict.




Cranial nerve III, oculomotor nerve




D-pupillary constiction in the same eye


C-pupillary constriction in the oppositie eye

accommodation




Fixation

A-adaptation of the eye for near vision (convergence & convergence)


*an increased convexity of the lenses caused by contraction of the ciliary muscles.


F-reflex direction of the eye towards an object attacking a person's attention.

Extraocular movements of the eye

6 cardinal position of gaze-have person follow you fingers and make an H in the air. Normal-eyes follow the finger smoothly.




When person looks at the most distal point in the lateral and vertical fields, note eyeball movement for normal movements and nystagmus.




Cranial nerves 3, 4, 6 (oculomotor, trochlear,


abducens)

Deviated eye

weak or paralyzed eye muscle


examined by the 6 cardinal positions of gaze.

Nystagmus

A fine rhythmic oscillation of the eyes.


A few beats of the extreme lateral gaze are normal.

Pupillary enlargement

Mydriasis-associated with the ingestion of sympathetic agents (cough and cold meds) and glaucoma dilating drops.

Pupillary constriction

Miosis-seen with ingestion of parasympathetic agents (beta blockers, epinephrine)

Inspect iris for color, nodules and vascularity

Normally iris blood vessels cannot be seen with the naked eye.




The markings should be clearly defined. With your light shining directly from the temporal side, look for a crescentic shadow on the medial side of the iris. Because the iris is normally fairly flat and forms a relatively open angle with the cornea, this lightly casts no shadow.

Normal conjunctiva





C-should be pink

Hirschberg test-corneal light reflux

Tests for strabismus (imbalance of eye muscles, one eye can't focus). Patient stares straight ahead at your nose. Stand in front of the patient and shine a penlight at the bridge of the patient's nose. Note where the light relfects on the cornea of each eye. Light reflection should be the same in both eyes.




If the light falls in the corneal center in one eye and is displaced in the corneal center in the other eye a deviation of the eye exists.

Pain with blinking

Corneal abrasions. Corneal diseases are painful due to the cornea having so many nerves.

Cover -uncover test-


Test for strabismus

Perform this test if the corneal light is asymmetric. Used to determine whether the eyes are straight or a deviated eye is present due to muscle weakness.




The patient is asked to focus on a distant target. One eye is covered with a 3x5 card. The examiner should observe the uncovered eye. Remove the card from the covered eye, if this due moves to focus, it is the weaker eye. It should not move.

Snellen Chart

The person stands 20 feet from the chart. Ask the person to shield one eye. Ask them to read the letters as you point to progressively smaller printer. Note the last line they read accurately. The numerator indicates the distance the person stands from the chart. The denominator is the distance at which a normal eye can read the letters.




If a person wears glasses, it should be noted.

ophthalmoscope exam

Held in the right hand in front of the right eye of the patient. Opposite for left.




Place against the forehead of the examiner while the left thumb elevates the patients right upper eyelid.




The light should shine on the pupil, a red glow, can be seen in the pupil.



ophthalmoscope exam


Anterior chamber, lens, chamber and vitreous body,

Note any opacities. The anterior chamber is transparent, any visible material is abnormal.




Look at the blood vessels of the retina, look for the optic disc. From a side view the iris should appear flat and should not be bulging forward.

ophthalmoscope exam


Optic disc\physiologic cup

Disc sharpness-


Color of the disc-normally yellows orange to creamy pink. White or pigmented crescents may ring the disc, a normal finding


Size of the physiologic cup-yellowish-white. The horizontal diameter is usually less than half the horizontal diameter of the disc.






The physiologic cup is a small depression to the disc center that does not extend to the border. The size and placement should be the same in both eyes. It is the entry point for retinal vessels,




papilledema-swelling of the optic disc and anterior bulging of the physiologic cup which is caused by increased intracranial pressure along the optic nerve. Signals serious disorders of the brain.

ophthalmoscope exam


Retinal vessels and retina

The retina normal appears transparent but the diffuse orange red color of the choroid layer shows through, the pigmentation may be darker in black persons. Spotty color alterations such as white patches may be abnormal.




Extremely narrow arteries are abnormal. Indentations on pinched appearances where veins and arteries cross occur with hypertension and are termed Arteriovenous nicking.

ophthalmoscope exam


Macula/fovea

The macula appears darker than the surrounding fundus and is relatively avascular. In young people the tiny bright reflection at the center of the fovea helps you to orient. Shimmering light reflections in the macular area are common.




(macular degeneration-cause of poor central vision in older adults.)

Name the 3 basic tests used to assess the movement of the extraocular muscles

1. Corneal light reflex (Hirschberg test) 2. The Cover Test 3. The Cardinal Fields of Gaze

Someone with 20/20 vision can read at 20 feet what the normal eye can read at 20 feet. Therefore what does 20/60 mean.

You can read at 60 feet what someone can read at 20

Static finger wiggle test

Patient looks into your eyes. Place your hands 2 feet apart, lateral to patient's ears. Wiggle both your fingers simultaneously and bring them slowly forward. Ask if patient can see the movement. If they cannot see your finger until they have crossed the line of gaze a temporal hemianopsia is present.

Kinetic red target test

Facing the patient, move a 5mm red topped pin inward from beyond the boundary of each quadrant. Ask the patient when the pin first appears to be red.




An enlarged blind spot occurs in conditions affecting the optic nerve such as glaucoma, optic neuritis and papilledema.

Position and alignment of the eyes

Inward or outward deviation of the eyes.





Vision changes of older adults

*decreased lacrimal production-dry eyes


*pupils become smaller and slightly irreg but they should respond to light and near/far.


*Near vision becomes blurry.


*Lens losses elasticity and the eye grows progressively less able to accommodate and focus on near objects.


*Thickening and yellowing of lens requires more reading light.


*Increased risk for cataracts, glaucoma, and macular degeneration.

Six cardinal fields of gaze

Ask pt to follow your finger as you sweep through the 6 cardinal fields of gaze.


Abnormal-Asymmetry or unconjugate gaze.

Convergence test

Ask the patient to follow your finger or pencil as you move it in toward the bridge of the nose. The converging eyes normally follow the object within 5 cm to 8 cm of the nose.





AV nicking

Indentations of pinched appearances where veins and arteries cross with hypertension.

Abnormal findings of the eye

Dilation of the conjunctival vessels with redness or a reddish violet flush around the limbus.




Other clues of serious disorders are pain, decreased vision, unequal pupils and a clouded cornea.

Entropion

Common in elderly.




Inward turning of the lid margin. The lower lashes are often invisible.

Ectropion

Common in the elderly.




The lower margin of the lid is turned outward, exposing the palpebral conjunctiva. When this happens, the eye no longer drains well, and tearing occurs.

Cataracts

Opacities of the lenses visible through the pupil. Risk factors older age, smoking, diabetes, corticosteroid use.

Abnormal Fundi


(The fundus of the eye is the interior surface of the eye, opposite the lens, and includes the retina, optic disc, macula and fovea)

*Red spots and streaks-cause hemorrhages


*Tiny dots/microaneuysms


*tortuous retinal vessels


*Cotton-wool patches-ovoid lesions with irreg soft borders.


*Hard exudates-creamy/yellow well defined lesions.


*Drusen-yellow round spots



External ear exam


Auricle


*look for deformities, lumps or lesions


*if ear pain, d/c or inflammation-move the auricle up and down, press the tragus and press firmly just behind the ear (tug test)


*Tug test is painful in otitis externa(inflammation of the ear canal)


Ear exam


What size speculum to use?


Adult vs. child


How to hold a otoscope?

Use an otoscope with the largest speculum that the ear canal with accommodate.




Adult-pull upward and backward on the ear.


Child-pull down and back




Hold otoscope between you thumb and fingers, brace your hand against the patient's face.

Otoscope insertion

Insert the speculum gently into the ear canal,


directing it somewhat down and forward and though the hairs.

Inspect the ear canal


Normal wax color


Abnormal ear canal?

Note any discharge, foreign bodies, color of the ear canal.


Ear wax-yellow and flaky to brown and sticky




Abnormal-swollen, narrowed, moist, pale, tender, thick, itchy and may be reddened.





Inspect the eardrum (TM)

Note color, and contour and cone of light. Small blood vessels along the handle of the malleous are normal.


Normal-pinkish gray




Abnormal-


red bulging ear drum-otitismedia,


amber drum-serous effusion


short process and a prominent handle-retracted


eardrum.


Perforated drum


Chalky white patches


blood-tinged d/c

Whisper test

1-Stand 2 feet behind patient.


2-Occlude the nontest ear with a finger


3-Exhale a full breath before whispering to ensure a quiet voice.


4-Whisper a combo of 3 numbers/letters. Use a different combo in the other ear.


Normal-pt repeats initial sequence correctly


Normal-pt responds incorrectly so test a 2nd time, pt repeats at least 3 out of the 6 numbers and letter correctly.


Abnormal-4 out of 6 possible numbers and letters are incorrect.




Conduct further testing by audiometry.

Older adults with presbycusis

Have higher frequency hearing loss, making them more likely to miss consonants, which have high frequencies than vowels.

Conductive hearing loss

affects the passage of sound between the ear drum and the inner ear. Sound passes down the ear canal to the ear drum and through the middle ear, where the sound is transmitted across the middle ear by the three bones called the ossicles to the inner ear.




Hearing improves in a noisy environment.


Voice remains soft because inner ear and coclhear nerve are intact.


Little effect on sound.




Childhood up to age 40

sensorineural hearing loss

is defined as damage to the hair cells in the cochlea (this is the sensory hearing organ) or damage to the neural pathways of hearing (nerves).




Hearing worsens in a noisy environment.


Voice may become loud because hearing is difficult.


Higher registers are lost, so sound may be distorted.




Middle or later years.

Weber test

Test for lateralization


Ask where the patient hears the sound? On one or both sides. Normally the vibration is hear equally in both ears.




Abnormal


Conductive hearing loss-sound lateralizes to the affected ear.


Sensorineural hearing loss-sound lateralizes to the unaffected ear.

Rhine test

Normally the sound is heard longer through the air than bone AC>BC.




Conductive hearing loss- sound is heard through the bone as long as longer than it is through air.


BC>/=AC


Sensorineural hearing loss-sound is heard long through the air AC>BC

Nasal examination


Steps?


Abnormal?

1-Inspect the anterior and inferior surface of the nose with a otoscope. Use the largest ear speculum available.


2-Tilt the head back a bit and insert the speculum gently into the vestibule of each nostril, avoiding contact with the sensitive nasal septum.


3-Direct the speculum posteriorly, then upward in small steps, try to see the inferior and middle turbinates. Some asymmetry is normal.




Abnormal-red and swollen or pale, bluish or red.

Nasal septum-abnormal

Septal perforation-causes trauma, surgery, cocaine use.




Polyps-pale sac like growths

How to assess for sinus tenderness

1-Press up on the frontal sinuses and the maxillary sinuses.




Abnormal-Local tenderness, pain, fever, nasal d/c




Transillumination may be helpful in diagnosing.

Lips

Observe their color and moisture, note any lumps, ulcers, cracking or scaliness.




Abnormal-


Fissures, blisters, angioedema, multiple small red spots, small brown spots, ulcers

mouth/throat

Normal-Pink tonsils may be slightly enlarged.


Abnormal


red throat with exudate


dull red, gray exudate


thick white plaques


deep purple lesions


bony growth on hard palate


gingivitis


hairy tongue

Hypoglossal nerve CN XII

Ask patient to stick out tongue.


Asymmetric profusion such a lesion on CN7

Vagus nerve X

With the patient's mouth open but the tongue not protruded, ask the patient to say "Ah" or yawn. You may need to press a tongue blade on the tongue to visualize the pharynx. Note the rise of the soft palate.




In CNX paralysis the soft palate fails to rise and the uvula deviates to the opposite side.

Neck exam lymph nodes

Pre auricular


Posterior auricular


Occipital


Tonsillar


Submandibular


Submental


Superficial cervical


Posterior cervical


Deep cervical chain


Supraclavicular



Shotty lymph nodes

Small, discrete, mobile, nontender nodes are frequently found in normal people.

Palpation of lymph nodes

Using the pads of the 2nd and 3rd fingers, palpate with a gentle rotary motion.

tonsillar node that palpates

really the carotid artery

Location of thyroid

located above the suprasternal notch.


The thyroid isthmus spans the 2nd, 3rd and 4th tracheal rings just below the cricoid cartilage


Steps to palpating the thyroid gland


(posterior approach)

1-Ask pt to flex neck slightly forward


2-place the fingers of both hands on the pt.'s neck so your index fingers are just below the cricoid.


3-Ask patient to take a sip and swallow water. Feel the thyroid isthmus rising up under your finger pads. It is often but not always palpable.


4-Displace the trachea to the right with fingers of the left hand; with the right-hand fingers, palpate laterally for the right lobe of the thyroid in the space between the displaced trachea and the sternomastoid.


*Note the size, shape and consistency of the gland and identify any nodules or tenderness.


*If the thyroid is enlarge, listen over the lateral lobes with a stethoscope to detect a bruit.

Abnormal thyroid

Enlarged, soft, firm, tender




Diffuse enlargement


Single nodule enlargement


Multi nodular enlargment



Candidiasis

Fungal infection caused by moisture, immunosuppression or abx. It is white plaque covering the mucous membranes or in warm moist body areas. It can be scraped off.

Leukoplakia

A thickened, whitish raised areas that cannot be scraped off in the oral mucosa.




May lead to cancer.

Fordyce Spots/granules

Normal sebaceous glands that appear as small yellowish spots on the buccal mucosa or on the lips.

Leukoedema

Edema of the oral mucosa that may clinically mimic early leukoplakia.




bluish-white opalescence of the buccal mucosa that becomes the normal mucosal color on stretching the tissue; may be considered a normal anatomic variation.