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127 Cards in this Set
- Front
- Back
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Most important points about health history and physical exam of the integumentary system. |
hair loss rash/itch growths |
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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) |
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central cyanosis |
depends on the oxygen in the arterial blood Diseases-advanced lung disease COPD and pulmonary edema, congential heart disease. |
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peripheral cyanosis |
blood/oxygen pulled from extremities to more central areas. Causes: heart failure. |
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Sebaceous glands |
produce a fatty substance secreted onto the skin surface through hair follicles |
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Sweat glands eccrine apocrine |
e-widely distrubuted a-in axillary and genital regions |
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Causes of itching without rash |
dry skin, pregnancy, uremia, lymphomas, leukemia, drug reaction, lice, less common diabetes and thyroid diease |
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Causes of changes in skin-Color changes Addison's diease |
Widespread increased in melanin causes darker skin |
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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. |
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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. |
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Causes of changes in skinColor changes Vitiligo |
dipigmented macules appear on the face, hands, feet. Non harmful. |
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Causes of changes in skinColor changes Cyanosis |
Blueish color skintone |
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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. |
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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. |
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Causes of changes in skinColor changes Erythema |
Red hue, increased blood flow. Example-slapped cheeks in 5th diease. |
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Causes of changes in skinColor changes Heliotrope |
Violaceous patches over the eyelids in the collagen vascular diease dermatomyositis. |
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Skin dryness |
hypothroidism |
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Temperature changes-warmth |
fever, hyperthyroidism local-cellulitis/inflammation |
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Temperature changes-coolness |
hypothyroid |
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skin roughness texture |
hypothyroid |
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skin velvety texture |
hyperthyroid |
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Skin decreased mobility |
edema, scleroderma |
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Skin decreased turgor |
dehydration Poor skin turgor is noting if "tenting" is observed or skin slowly recedes back. |
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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) |
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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. |
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Primary skin lesion-Macule |
Small flat spot up to 1 cm Example-hemagioma, freckles , vitiligo(bates book), flat mole, petchaie, measles, scarlet fever (evolve) |
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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 |
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Primary skin lesion-Papule |
An elevated, firm lesion up to 1 cm Examples: Wart, elevated moles, cherry angioma, skin tag |
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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. |
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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 |
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Primary skin lesion-Tumor |
Knot like lesion, elevated and greater than 2cm |
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Primary skin lesion-Cyst |
Nodule filled with expressible material, either liquid or semisolid Example: epidermal inclusion cyst |
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Primary skin lesion-Wheal |
A somewhat irregular, superficial area of localized skin edema Example: urticaira(hives) from drug or allergic reactions. |
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Primary skin lesion-Vesicle |
Up to 1cm filled with serous filled Example: herpes simplex, herpes zoster, shingles, impetigo |
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Primary skin lesion-Bulla |
1 cm or larger filled with serous fluid (blister) Example: insect bites |
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Primary skin lesion-pustule |
Filled with pus Examples: Acne, small pox |
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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 |
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Primary skin lesion-crust |
Dried residue of skin exudates such as serum, pus or blood. |
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Secondary skin lesion-scale |
Thin flake of dead epidermis Examples, dry skin, ichthyosis vulgarism |
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Secondary skin lesion-liechenification |
Visible thickening of the epidermis and roughing of the skin with skin furrows often from rubbing. Examples: neurodermatitis |
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Secondary skin lesion-scar |
Increased connective tissue that arises from injury or disease. |
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Secondary skin lesion-keloids |
Hypertrophic scaring that extends beyond the borders of the initial injury. |
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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. |
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Secondary skin lesion-Excoriation |
Linear hollowed out crust area Example: abrasion or scratch |
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Fissure |
A linear crack resulting from excessive dryness. Example: athlete's foot |
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Ulcer |
Loss of epidermis and dermis, may bleed and scar Example: pressure ulcer, stasis ulcer, syphillis chancre |
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Stage 1 pressure ulcer |
Presence of reddened area that fails to blanche with pressure and changes in temperature. |
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Stage 2 pressure ulcer |
Partial thickness skin loss involving the epidermis/dermis or both. Usually appears as a blister or abrasion. |
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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. |
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Stage 4 pressure ulcer |
Full thickness skin loss with tissue necrosis and damage to the underlying muscle. |
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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. |
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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 |
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HA-sudden onset |
subarachnoid hemorrhage, meningitis |
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Hair Fine is a sign of ___________ Course is a sign of _________ Tiny white ovoid granules in the hair_______ |
hypothyroid hyperthyroid lice |
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Exam of head parotid gland |
superficial to and behind the mandible (visible and palpable when enlarged). Open into the oral cavity |
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Exam of head Submandibular gland |
located deep to the mandible. Open into the oral cavity. |
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Hyperopia |
Difficulty with close work (far-sighted) |
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Presbyopia |
Aging vision |
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Myopia |
Difficulty with distance vision (nearsighted) |
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Unilateral vision loss that is painless |
vitreous hemorrhage from diabetes or trauma macular degeneration retinal detachment retinal vein occlusion central retinal artery occlusion |
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Unilateral vison loss that is painful |
corneal ulcers acute glaucoma optic neuritis from MS Immediate referral is warranted |
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Sudden Bilateral and painless vision loss |
Consider mediations such as cholinergics and steroids |
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Gradual bilateral vision loss |
Cataracts macular degeneration glaucoma |
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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. |
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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. |
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Pupillary reaction consensual reaction |
A light beams shining onto one retina causes pupillary reactions in both eyes. Cranial nerve III, oculomotor nerve |
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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 |
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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. |
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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) |
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Deviated eye |
weak or paralyzed eye muscle examined by the 6 cardinal positions of gaze. |
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Nystagmus |
A fine rhythmic oscillation of the eyes. A few beats of the extreme lateral gaze are normal. |
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Pupillary enlargement |
Mydriasis-associated with the ingestion of sympathetic agents (cough and cold meds) and glaucoma dilating drops. |
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Pupillary constriction |
Miosis-seen with ingestion of parasympathetic agents (beta blockers, epinephrine) |
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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. |
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Normal conjunctiva |
C-should be pink |
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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. |
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Pain with blinking |
Corneal abrasions. Corneal diseases are painful due to the cornea having so many nerves. |
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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. |
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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. |
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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. |
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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. |
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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. |
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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. |
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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.) |
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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 |
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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 |
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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. |
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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. |
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Position and alignment of the eyes |
Inward or outward deviation of the eyes. |
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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. |
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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. |
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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. |
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AV nicking |
Indentations of pinched appearances where veins and arteries cross with hypertension. |
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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. |
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Entropion |
Common in elderly. Inward turning of the lid margin. The lower lashes are often invisible. |
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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. |
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Cataracts |
Opacities of the lenses visible through the pupil. Risk factors older age, smoking, diabetes, corticosteroid use. |
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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 |
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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) |
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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. |
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Otoscope insertion |
Insert the speculum gently into the ear canal, directing it somewhat down and forward and though the hairs. |
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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. |
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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 |
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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. |
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Older adults with presbycusis |
Have higher frequency hearing loss, making them more likely to miss consonants, which have high frequencies than vowels. |
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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 |
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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. |
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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. |
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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 |
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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. |
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Nasal septum-abnormal |
Septal perforation-causes trauma, surgery, cocaine use. Polyps-pale sac like growths |
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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. |
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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 |
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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 |
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Hypoglossal nerve CN XII |
Ask patient to stick out tongue. Asymmetric profusion such a lesion on CN7 |
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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. |
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Neck exam lymph nodes |
Pre auricular Posterior auricular Occipital Tonsillar Submandibular Submental Superficial cervical Posterior cervical Deep cervical chain Supraclavicular |
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Shotty lymph nodes |
Small, discrete, mobile, nontender nodes are frequently found in normal people. |
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Palpation of lymph nodes |
Using the pads of the 2nd and 3rd fingers, palpate with a gentle rotary motion. |
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tonsillar node that palpates |
really the carotid artery |
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Location of thyroid |
located above the suprasternal notch. The thyroid isthmus spans the 2nd, 3rd and 4th tracheal rings just below the cricoid cartilage |
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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. |
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Abnormal thyroid |
Enlarged, soft, firm, tender Diffuse enlargement Single nodule enlargement Multi nodular enlargment |
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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. |
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Leukoplakia |
A thickened, whitish raised areas that cannot be scraped off in the oral mucosa. May lead to cancer. |
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Fordyce Spots/granules |
Normal sebaceous glands that appear as small yellowish spots on the buccal mucosa or on the lips. |
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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. |
