Claudication
a condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries. May be characterized as a dull ache with accompanying muscle fatigue and cramps. Usually appears with sustained exercise. Site of pain is distant to narrowing.
How do you test EOM?
Eye movement is controlled by 6 extraocular muscles and 3 cranial nerves, III, IV, and VI. To evaluate eye movement, use 4 techniques.
● First have the patient watch your finger move through the 6 cardinal fields of gaze. Jerking or sustained nystagmus is abnormal. A few beats of horizontal nystagmus may occur.
● Second have the patient follow your finger vertically from the ceiling to the floor.The globes and the upper eyelids should move smoothly without eyelid lag or exposure of the sclera.
● Third, test extraocular muscle balance using the corneal light reflex. WIth the patient looking at a nearby object, shine a light on the nasal bridge. The eyes should converge and reflect the light symmetrically.
● Fourth, if the corneal light reflex is imbalanced, perform the cover-uncover test. As the patient stares at a fixed point nearby, cover one eye and observe the uncovered eye. Then remove the cover and observe that eye as it focuses on the object. Note any eye movement.
Your patient should be able to follow your finger with full, smooth extraocular movements and without nystagmus, or “shaky” eye motion. Normal extraocular movements indicate intact cranial nerves III, IV, and VI.
What is the difference between objective and subjective data? What components of the health history are objective and subjective? **
Seidel pg 618: objective: “direct observation, what you see, hear, and touch”. This includes vital signs and actual assessment. Subjective: “information patients offer about their condition or feelings.” This includes chief complaint, past medical history, history or present illness, family history, and review of symptoms.
Erb’s point
Erb’s point is the auscultation location for heart sounds and heart murmurs located at the third intercostal space and the left lower sternal border. Erb’s point, found two interspaces below the pulmonic area, does not reflect sound from one particular heart valve, but is a common listening post, lying halfway between the base and the apex of the heart.
Tonsil assessment
- Enlargement; Acute infection, 2+, 3+, or 4+
o 1+ – visible
o 2+ halfway between tonsillar pillars
o 3+ touching uvula
o 4+ touching each other
Order physical assessment is done
Inspection, Palpation, Percussion, Auscultation
Proper use of Otoscope on adult or child
Adult- straighten the external auditory canal by pulling auricle up and back
Child- face child sideways with one arm around parents waist. Pull auricle either downward and back or upward and back to gain best view of tympanic membrane.
How do you assess for sensoineural hearing loss
air conduction heard longer than bone conduction with Rinne Test; lateralization to unaffected ear; loss of high-frequency sounds
How do you assess for conductive hearing loss
bone conduction heard longer than air conduction with Rinne Test; lateralization to affected ear with Weber Test; loss of low frequency sounds; loss of 11-30 decibels on audiometry with cerumen impaction.
Rinne Test*
helps distinguish whether patient hears better by air or bone conduction. Place the tuning fork at base of vibrating tuning fork against the patient’s mastoid bone and ask patient to tell you when the sound is no longer heard. Time this interval of bone conduction noting number of seconds. Continue timing the interval of sound due to by air conduction heard by the patient. Compare # of seconds air vs. bone. Air conducted should be heard twice as long as bone conducted sounds. (If bone conducted heard for 15 seconds, air conducted should be heard for additional 15 seconds).
Weber Test
helps assess unilateral hearing loss. Place base of fork on mid-line of patient’s head. Ask patient if sound heard equally in both ears or in one ear (lateralization of sound). Should hear sound equally.
Presbyopia
Progressive weakening of accommodation (focusing power). The major physiologic change that occurs after the age of 45 years; the lens becomes more rigid, and the ciliary muscle becomes weaker.
Strabismus
a condition in which both eyes do not focus on the object simultaneously, although either eye can focus independently; may be paralytic or non-paralytic.
Photopsia
presence of perceived flashes of light. (Most commonly associated with posterior vitreous detachment, migraine with aura, retinal break, or detachment).
Amblyopia
also called lazy eye; is disorder of sight d/t eye and brain not working well together. Results in decreased vision in an eye that otherwise typically appears normal. Most common cause of decreased vision in a single eye among children and younger adults.
Macular Degeneration
is caused when part of the retina deteriorates; dry (atrophic) from gradual breakdown of cells in macula resulting in gradual blurring of central vision and wet (exudative or neovascular)- new abnormal vessels grow under the center of the retina; the blood vessels leak, bleed, and scar the retina, distorting or destroying central vision. In contrast to dry, vision loss may be rapid. Is leading cause of blindness in older than 55 years of age in U.S.
Xanthelasma
condition characterized by elevated plaque of cholesterol; commonly found on the nasal portion of the eyelid.
Snellen Test*
The optic nerve is assessed by testing for visual acuity and peripheral vision.
Visual acuity is tested using a snellen chart, for those who are illiterate and unfamiliar with the western alphabet, the illiterate E chart, in which the letter E faces in different directions, maybe used. The chart has a standardized number at the end of each line of letters; these numbers indicates the degree of visual acuity when measured at a distance of 20 feet.
The numerator 20 is the distance in feet between the chart and the client, or the standard testing distance. The denominator 20 is the distance from which the normal eye can read the lettering, which correspond to the number at the end of each letter line; therefore the larger the denominator the poorer the version.
Measurement of 20/20 vision is an indication of either refractive error or some other optic disorder.
In testing for visual acuity you may refer to the following:
- The room used for this test should be well lighted.
- A person who wears corrective lenses should be tested with and without them to check fro the adequacy of correction.
- Only one eye should be tested at a time; the other eye should be covered by an opaque card or eye cover, not with client’s finger.
- Make the client read the chart by pointing at a letter randomly at each line; maybe started from largest to smallest or vice versa.
- A person who can read the largest letter on the chart (20/200) should be checked if they can perceive hand movement about 12 inches from their eyes, or if they can perceive the light of the penlight directed to their yes.
Rosenbaum Test
The Rosenbaum near vision card is intended to measure
near acuity at a distance of 14″ ( 36 cm) from the patient.
Preparation:
- Be sure the Rosenbaum is evenly illuminated.
- Have the patient wear their current Rx (contacts or
glasses)
Recommended Process:
- Occluder the patient’s left eye (to examine the right
eye). - Starting with the side that has the large ’95’ on the top,
ask the patient to select the smallest line and read out
loud each number (E or O,X,O). Challenge the patient to
see if they can read the next smallest line correctly until
mistakes are made. - Document the Snellen (Jaeger or Point) value as
appropriate for that line (if read correctly). Record as the
right eye. - Change which eye is occluded and repeat for the left
eye. - If the patient cannot read the ’95’, repeat the process
at half the distance and record the results. - If they are still unable to read the largest number, see
if they can count your fingers at 5 feet, of detect the
direction of your hand motion at 2 ft and record the
results.
Pediatric Testing:
The reverse side of the card provides the Lea Symbols
for near testing of children in the 3 to 5 year old range.
Confrontation Test****
Examine visual fields by confrontation by wiggling fingers 1 foot from pt’s ears, asking which they see move.
- Keep examiner’s head level with patient’s head. Test of peripheral vision.
Papillary Reaction
● observe the pupils’ size and shape. They should be round, regular, and equal in size.
● test the pupils’ response to light directly and consensually. The pupils should constrict simultaneously.
● perform the swinging flashlight test. Shine the light in one eye and then rapidly swing it to the other eye. If the second eye to be tested continues to dilate rather than constrict, an afferent pupillary defect is present, which suggests optic nerve disease.
● test for accommodation. After looking at a distant object and then focusing on an object 10 cm from the nose, the pupils should constrict to focus on near.
Abnormal documentation:
● Miosis (pupillary constriction to less than 2mm)
● Mydriasis (pupillary dilation)
● Failure to respond (constrict) with increased light stimulus
● Argyll Robertson pupil (irregularly shaped pupils that fail to constrict light but retain constriction with convergence)
● Anisocoria (unequal size of pupils)
● Iritis constrictive response
● Oculomotor nerve CN III damage (pupil dilated and fixed, eye deviated laterally and downward; ptosis)
● Adie pupil (tonic pupil). The affected pupil dilated and reacts slowly or fails to react to light; responds to convergence
Accommodation*
The accommodation reflex of the eye is a response that automatically occurs when you switch focus from an object that’s far away to one that’s closer. This response enables you to switch between objects and still maintain focus (meaning neither object appears blurry when you’re looking at it).
They should dilate with far gaze and constrict with near gaze. Accommodation (response to looking at something moving toward the eye). Accommodation is impaired in lesions of the ipsilateral optic nerve, the ipsilateral parasympathetics traveling in CN III, or the pupillary constrictor muscle, or in bilateral lesions of the pathways from the optic tracts to the visual cortex. Accommodation is spared in lesions of the pretectal area.
- If MG suspected: pt. gazes upward at Dr’s finger to show worsening ptosis.
Which valves closing and opening make which sounds?
The heart tone “lub,” or S1, is caused by the closure of the mitral and tricuspid atrioventricular (AV) valves at the beginning of ventricular systole.
The heart tone “dub,” or S2 ( a combination of A2 and P2), is caused by the closure of the aortic valve and pulmonary valve at the end of ventricular systole.
The splitting of the second heart tone, S2, into two distinct components, A2 and P2, can sometimes be heard in younger people during inspiration. During expiration, the interval between the two components shortens and the tones become merged.
Murmurs are a “whoosh” or “slosh” sound that indicate backflow through the valves.
S3 and S4 are a “ta” sound that indicates ventricles that are either too weak or too stiff to effectively pump blood.
Incompetent heart valve
Another valvular heart disease condition, called valvular insufficiency (or regurgitation, incompetence, “leaky valve”), occurs when the leaflets do not close completely, letting blood leak backward across the valve. This backward flow is referred to as “regurgitant flow.”
Sclerotic Heart Valve
Aortic sclerosis–a marker of coronary atherosclerosis. … Aortic valve sclerosis is defined as calcification and thickening of a trileaflet aortic valve in the absence of obstruction of ventricular outflow. Its frequency increases with age, making it a major geriatric problem.
Stenotic Heart Valve
when leaflets, which are thickened/narrow—> restricts blood flow
Regurgitation
when valves lose competency/leak, blood flows backwards
What causes leg edema?
Right side heart failure
What causes murmurs?
Caused by some disruption of blood flow, through, or out of the heart. Diseased valves are a common cause, not opening or closing well.
Where do you hear murmurs?
Aortic stenosis:
Murmur:
Harsh late-peaking crescendo-decrescendo systolic murmur
Heard best- left 2nd ICS
Radiation to the carotids.
Possible associated findings:
Abnormal carotid pulse
Diminished and delayed (“pulsus parvus and tardus”)
Sustained Apical impulse
Calcified aortic valve on CXR
Murmur:
Blowing holosystolic murmur
Heard best at the apex
Radiation to the axilla and inferior edge of left scapula.
Possible associated findings:
S2: wide physiologic splitting
S3
Murmur:
Soft blowing early diastolic decrescendo murmur
Heard best at the left 2nd ICS without radiation
May also hear systolic flow murmur and diastolic rumble (Austin Flint)
Possible associated findings:
Dilated apical impulse
Abnormal and collapsing arterial pulses
Murmur:
Soft holosystolic murmur
Heard best at the LLSB without radiation
Intensity increases with inspiration or pressure over liver
Possible associated findings:
Elevated neck veins
Systolic regurgitant neck vein
Systolic retraction of apical pulse
Edema, Ascites or both
Pulmonic Insufficiency
Murmur:
High frequency early diastolic decrescendo murmur
Heard best at 2nd-3rd ICS
Increases with inspiration
Associated findings:
Abnormal S2 splitting
Sustained pulmonary hypertension
Pulmonary stenosis
Murmur:
Harsh crescendo-decrescendo systolic murmur
Heard best sternal border bat 2nd or 3rd intercostal spaces
Increases with inspiration
Associated findings:
Ejection sounds heard at sternal edge, 2nd or 3rd intercostal space
Wide physiological splitting of S2
Prominent A wave of the jugular venous pulse
Mitral stenosis
Murmur:
Low frequency rumbling mid-diastolic murmur, with presystolic component possible
Heard best at apex
Accentuated in left lateral decubitus position
Associated findings:
Apical impulse absent or small
Irregular pulse ( atrial fibrillation)
Loud S1
Elevated neck veins with exaggerated A wave
Hypertrophic cardiomyopathy
Murmur:
Harsh quality midsystolic murmur
Heard best LSB
Increases with decreased venous return
Possible associated findings:
Sustained apical beat to palpation
S4 (50% of the time)
Grades of murmurs?*
Systolic Murmur Grades
I/VI: Barely audible
II/VI: Faint but easily audible
III/VI: Loud murmur without a palpable thrill
IV/VI: Loud murmur with a palpable thrill
V/VI: Very loud murmur heard with stethoscope lightly on chest
VI/VI: Very loud murmur that can be heard without a stethoscope
Systolic Murmurs are the most common in children.
Holosystolic (regurgitant) murmurs start at the beginning of S1 and continue to S2. Examples: ventricular septal defect (VSD), mitral valve regurgitation, tricuspid valve regurgitation.
Systolic ejection murmurs (SEM, crescendo-decrescendo) result from turbulent blood flow across the aortic and pulmonary valves. Blood flow across these valves starts after adequate pressure has built up in the ventricle to overcome the pressure in the aorta or pulmonary artery. Examples: aortic and pulmonary stenosis. A murmur with similar characteristics may be heard in coarctation of the aorta.
Diastolic murmurs are usually abnormal, and may be early, mid or late diastolic.
Early diastolic murmurs immediately follow S2. Examples: aortic and pulmonary regurgitation.
Mid-diastolic murmurs due to increased flow through the mitral or the tricuspid valves. Examples: VSD and ASD.
Late diastolic murmurs due to pathological narrowing of the AV valves. Example: rheumatic mitral stenosis.
What do murmurs sound like?
The quality and shape of the murmur is then noted. Common descriptive terms include rumbling, blowing, machinery, scratchy, harsh, or musical. The intensity of the murmur is next, graded according to the Levine scale:
I – Lowest intensity, difficult to hear even by expert listeners
II- Low intensity, but usually audible by all listeners
III – Medium intensity, easy to hear even by inexperienced listeners, but without a palpable thrill
IV – Medium intensity with a palpable thrill
V – Loud intensity with a palpable thrill. Audible even with the stethoscope placed on the chest with the edge of the diaphragm
VI – Loudest intensity with a palpable thrill. Audible even with the stethoscope raised above the chest.
Normal vs abnormal murmurs
Box 14-9 Pg 317 Siedel–> innocent murmurs example are still murmurs that are a result of vigorous myocardial contraction, the consequent stronger blood flow in early systole or midsystole, and the rush of blood from the larger chamber of the heart into the smaller bore of a blood vessel. The thinner chests of young make these sounds easier to hear, particularly with a lightly held bell. They are usually a grade I or II, usually midsystolic with radiation, medium pitch, blowing, brief, and often accompanied by splitting of S2. They are often located 2 nd ICS near the left sternal border. Such murmurs heard in a recumbent position may disappear when the patient sits or stands becuase of the tendency of the blood to pool. Abnormal murmurs—> ● Aortic Stenosis- detection- heard over aortic area; ejection sound at second right of intercostal border. Description-Calcification of valve cusps restricts forward flow; forceful ejection from ventricle into systemic circulation. Caused by congenital bicuspid (rather than usual tricuspid) valve, rheumatic heart disease, atherosclerosis. Mitral Stenosis- detection- heard with bell at apex, patient in left lateral decubitus position. Description- narrowed valve restricts forward flow; forceful ejection into ventricle. Often occurs with mitral regurgitation. Caused by rheumatic fever or cardiac infection.
● Subaortic stenosis- Detection-heard at apex and along left sternal border. Description- Fibrous ring, usually 1 to 4 mm below aortic valve; most pronounced on ventricular septal side; may become progressively severe with time; difficuMay be the cause of sudden death, particularly in children and adolescents, either at rest or during exercise; risk apparently related to degree of stenosis.
● lt to distinguish from aortic stenosis on clinical grounds alone.
● Pulmonic stenosis- detection- heard over pulmonic area radiating to the left into the neck; thrill in second and third left intercostal spaces. Description- valve restricts forward flow; forceful ejection from ventricle into pulmonary circulation. Cause is almost always congenital.
● Tricuspid stenosis- detection- heard with the bell over the tricuspid area. Description- Calcification of valve cusps restricts forward flow; forceful ejection into ventricles. Usually seen with mitral stenosis, rarely occurs alone. Caused by rheumatic heart disease, congenital defect, endocardial fibroelastosis, right atrial myxoma.
● Mitral Regurgitation- detection- heard best at apex; loudest there, transmitted into left axilla. Description- valve incompetence allows backflow from ventricle to atrium. Caused by rheumatic fever, myocardial infarction, myxoma and rupture of chordae.
● Aortic regurgitation- detection- heard with the diaphragm, patient sitting and leaning forward; Austin Flint murmur heard with bell; ejection click heard in second intercostal space. Description- Valve incompetence allows backflow from aorta to ventricle. Caused by rheumatic heart disease, endocarditis, aortic diseases (Marfan syndrome, medial necrosis) syphilis, ankylosing spondyMitral Valve Prolapse- detection- heard at apex and left lower sternal border; easily missed in supine position; also listen with patient upright. Description- Valve is competent early in systole but prolapses into atrium later in systole; may become progressively severe, resulting in a holosystolic murmur; often concurrent with pectus excavatum.
● litis, dissection and cardiac trauma.
● Pulmonic regurgitation-detection- difficult to distinguish from aortic regurgitation on physical exam. Description- Valve incompetence allows backflow from pulmonary artery to ventricle. Secondary to pulmonary hypertension or bacterial endocarditis.
● Tricuspid regurgitation- detection- heard at left lower sternum, occasionally radiating a few centimeters to the left. Description- Valve incompetence allows backflow from ventricle to atrium. Caused by congenital defects, bacterial endocarditis (especially in IV drug users), pulmonary hypertension and cardiac trauma.
Peripheral vision or visual fields
Peripheral Vision or visual fields
The assessment of visual acuity is indicative of the functioning of the macular area, the area of central vision. However, it does not test the sensitivity of the other areas of the retina which perceive the more peripheral stimuli. The Visual field confrontation test, provide a rather gross measurement of peripheral vision.
The performance of this test assumes that the examiner has normal visual fields, since that client’s visual fields are to be compared with the examiners.
Follow the steps on conducting the test:
- The examiner and the client sit or stand opposite each other, with the eyes at the same, horizontal level with the distance of 1.5 – 2 feet apart.
- The client covers the eye with opaque card, and the examiner covers the eye that is opposite to the client covered eye.
- Instruct the client to stare directly at the examiner’s eye, while the examiner stares at the client’s open eye. Neither looks out at the object approaching from the periphery.
- The examiner hold an object such as pencil or penlight, in his hand and gradually moves it in from the periphery of both directions horizontally and from above and below.
- Normally the client should see the same time the examiners sees it. The normal visual field is 180 degress.
What does OLDCARTS mean?
History of Present Illness: details about the chief complaint
(OLD CARTS)
•Onset
—when did it start?
•Location/Radiation
—where is it located?
•Duration
—how long has this gone on?
•Character
—does it change with any specific activities? Does the patient
use any descriptive words to describe the quality of the symptom?
•Aggravating factors
-what makes it worse?
•Relieving factors
-what makes it better?
•Timing
—is it constant, cyclic, or does it come and go?
•Severity
—how bothersome, disruptive, or painful is the problem?
Sinus, oral, and throat exam
.
Nose and Sinuses
Inspection
External: inflammation, deformity, discharge or bleeding
Internal: colour of mucosa, edema, deviated or perforated septum, polyps, bleeding
Observe nasal versus mouth breathing
Palpation
Sinus
and nasal tenderness
Percussion
Sinus and nasal tenderness
Mouth and Throat
Inspection
Lips: color, lesions, symmetry
Oral cavity: breath odour, color, lesions of buccal mucosa
Teeth and gums: redness, swelling, caries, bleeding
Tongue: colour, texture
, lesions, tenderness of floor of mouth
Throat and pharynx: colour, exudates, uvula, tonsillar symmetry and enlargement
, masses
Risk factors for heart disease
Gender (men are more at risk; women are at more increased risk in postmenopausal years and with oral contraceptive use)
Hyperlipidemia
Elevated Homocysteine level
Smoking
Family hx of CVD, DM, HLD, HTN, or sudden death in young adults
DM, Obesity, Sedentary lifestyle without exercise, Fatigue
Associated symptoms: dyspnea on exertion, chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea, anorexia, N/V
Medications: beta blockers
What does left, thrill, heave mean?
Lift or heaves- these are forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs.
Thrills- these are the vibrations of loud cardiac murmurs. They feel like the throat of a purring cat. Thrills occur with turbulent blood flow.
Auscultation of the heart
- Aortic Area 2nd right interspace close to the sternum.
- Pulmonic Area 2nd left interspace.
- ERB’s Point 3rd left interspace.
- Tricuspid Area 5th left interspace close to the sternum.
- Mitral Area (Apical) 5th left interspace medial to the MCL
Inspection and palpation- cardiac (aortic, pulmonic, erb’s, tricupsid, mitral
- Aortic Area (second interspace to the right of the sternum).
a pulsation could indicate an aortic aneurysm.
a thrill could indicate aortic stenosis.
- Pulmonic Area (second interspace to the left of the sternum).
a pulsation could indicate pulmonary hypertension.
a thrill could indicate pulmonic stenosis.
- ERB’s Point (third interspace to the left of the sternum).
findings similar to that of aortic and pulmonic areas.
- Tricuspid Area (Right Ventricular Area) (4-5th interspace; lower half of the sternum).
a sustained systolic lift could indicate right ventricular enlargement.
a systolic thrill could indicate a ventricular septal defect.
in patients with anemia, anxiety, hyperthyroidism, fever, pregnancy, or increased cardiac output, a brief pulsation may be felt.
- Mitral Area (Left Ventricular Area) (5th intercostal space at the midclavicular line). This is where you can find the Apical Pulse and usually can find the Point of Maximum Intensity (PMI).
identify the PMI by location, diameter, amplitude, duration, and rate. To help identify it, have patient exhale completely and hold breath or have the patient lean forward. Normal is a light tap, 1-2 cm in diameter at the 5th interspace at the left midclavicular line. PMI could be displaced down and to the left with ventricular hypertrophy, pregnancy, and CHF.
normally seen in less than half the population.
increased pulsation could indicate increased cardiac output, anemia, anxiety, fever, or pregnancy.
a thrill could indicate mitral regurgitation, or mitral stenosis.
Listening to heart sounds:
- With your stethoscope, identify the first and second heart sounds (S1 and S2).
at the aortic and pulmonic areas (base). S2 is normally louder than S1. S2 is considered the dub of ‘lub-DUB.’ S2 is caused by the closure of the aortic and pulmonic valves.
at the tricuspid and mitral area (apex) S1 is often, but not always louder than S2. S1 is considered the lub of ‘LUB-dub.’ S1 is caused by the closure of the mitral and tricuspid valves.
S1 is synchronous with the onset of the apical impulse.
- Identify the heart rate.
tachycardia
bradycardia
- Identify the rhythm.
if it is irregular, try to identify the pattern.
Do early beats appear on a regular rhythm?
Does the irregularity vary consistently with respiration?
Is rhythm totally irregular?
- Listen to S1 first, then S2 at the previously mentioned areas using the diaphragm and then the bell.
note its intensity.
are there any splitting sounds check during inspiration where S2 usually splits at pulmonic and ERB’s point.
a thick chest wall or increased AP diameter may make S2 inaudible.
Alterations in S1
a. S1 is accentuated in exercise, anemia, hyperthyroidism, and mitral stenosis.
b. S1 is diminished in first degree heart block.
c. S1 split is most audible in tricuspid area (T-lub-dub).
Alterations in S2
a. Normal physiological splitting of S2 is best heard at pulmonic area. It occurs on inspiration (lub-T-dub, lub-dub).
b. Splitting of S2 can indicate pulmonic stenosis, atrial septal defect, right ventricular failure, and left bundle branch block (lub-T-dub).
- Listen for S3 (ventricular gallop).
a physiologic S3 is frequently heard in children and in pregnant women.
it occurs early in diastole during rapid ventricular filling. It is heard best at the apex in the left lateral decubitus position.
it is heard best using the bell.
a pathologic S3 occurs in people over the age of 40. Cause is usually myocardial failure.
sounds like lub-dub-dee (or ‘Kentucky’).
- Listen for an S4 (atrial gallop).
it occurs before S1
it is low pitched and best heard with the bell.
often normal in older adults.
it is heard best at the apex in the left lateral decubitus position.
it may be caused by coronary artery disease, hypertension, myocardiopathy, or aortic stenosis.
sounds like dee-lub-dub (or ‘Tennessee’).
- Listen for murmurs.
CHECK TIMING. Are they systolic or diastolic?
(systolic murmurs may be benign. Diastolic murmurs are never benign).
LOCATION OF MAXIMAL INTENSITY. Where is the murmur best heard?
FREQUENCY (pitch).
This varies from low-pitched, caused by slow velocity of blood flow, to high pitched, caused by a rapid velocity of blood flow.
INTENSITY. the loudness of a murmur is described on a scale of 1 to 6:
Grade Intensity/ Sounds
1 very faint, easily missed
2 quiet, barely audible
3 moderately loud but easily heard. Same intensity as S1 or S2.
4 loud but usually no thrill present
5 very loud- thrill present
6 heard with stethoscope off of chest. Thrill present.
RADIATION. some murmurs radiate in the direction of the blood stream by which they are produced. Listen over neck, back, shoulders, and left axilla.
- QUALITY.
musical blowing harsh rumbling
aortic murmurs are heard best in full expiration with patient leaning forward.
mitral murmurs are heard best after exercise in left side lying position.
Assessment of Extra Heart Sounds
- ejection click
- opening snap
- midsystolic click
Normal tympanic membrane appearance
The tympanic membrane is translucent, permitting the middle ear cavity and malleus to be visualized. Its oblique position to the auditory canal and its conical shape account for the triangular light reflex. Most of the tympanic membrane is tense (the pars tensa), but the superior portion (pars flaccida) is more flaccid. Here is a short video I viewed to be able to recognize the structures a little better. https://www.youtube.com/watch?v=krNXVWa8QTg
What is xanthelasma? Seidel page 210 figure 11-6 photo
Flat to slightly raised, oval, irregularly shaped, yellow-tinted lesions on the periorbital tissues that represent deposits of lipids. This may suggest that your patient has an abnormality of lipid metabolism. These lesions are caused by an elevated plaque of cholesterol deposited in macrophages, most commonly in the nasal portion of the upper or lower eyelid. The link is to another photo that shows a very nice example. http://www.medicinenet.com/image-collection/xanthelasma_picture/picture.htm
Cardinal fields of gaze? Seidel page 214-215. Figure 11-22
There are six cardinal fields of gaze. I found the description in the book very difficult to follow on how to perform an assessment of the six fields.This video is a great example of how you should perform the test. https://www.youtube.com/watch?v=64KyR8lkInI
I used this video of a previous maryville student’s AHA exam to see how she performed test. The ENT exam begins at 3:19 with the six fields being tested at 5:33 and concluding at 5:50. She does not explain how to do the test but you can watch her perform the test. Then when you read through the text it makes much more sense. https://www.youtube.com/watch?v=KlMujEKugi8
- Starting in the center of the patient’s visual field, move your finger up and to the right, then back to midline, than laterally to the right, then midline, and finally down and to the right and back to midline. Repeat this on the left side. Normal movement through the 6 cardinal signs means intact CN III, IV, and VI.
What does 6 cardial fields of gaze assess for?
Cranial nerves III (oculomotor) IV (trochlear) and VI (abducens) and the six extraocular muscles.
What does 20/30 mean? Seidel pages 43-44 Snellen Alphabet Chart*
The patient can read letters while standing 20 feet from the chart that the average person could read at 30 feet.
The term 20/20 refers to a patient’s visual acuity which is measured utilizing the Snellen’s Alphabet Chart. The numerator (the first number) is the distance the patient stands from the chart when performing the test. An adult should stand at the distance of 20 feet, children should stand 10 feet away (age is not specified) The denominator(the second number) denotes the distance from which a person with normal vision could read the lettering. So a bottom number more than 20 would indicate either a refractive error or an optic disorder.
This link is a video of a great explanation. https://www.youtube.com/watch?v=48XD7Z9_XXs
How does smoking affect eyesight. Seidel pg 208
- smoking increases risk for cataract formation, glaucoma, macular degeneration, and thyroid eye disease
. Pulse grades. Seidel page 340
0: Absent, not palpable
1: Diminished, barely palpable
2: Expected
3: Full, increased
4: Bounding, aneurysmal
Valves – stenotic, regurgant, incompetent, sclerotic Seidel page 311
Stenosis: When leaflets are thickened and the passage narrowed, forward blood flow is restricted
Regurgitation: When valve leaflet lose competency and leak, blood flows backward.
Incompetent: An incompetent valve allows blood to leak back into the chamber it previously existed
Sclerotic: thickening and calcification of the leaflets
Murmur grades- Seidel page 313
Grade I: Barely audible in quiet room
Grade II: Quiet but clearly audible
Grade III: Moderately loud
Grade IV: Loud, associated with thrill
Grade V: Very loud, thrill easily palpable
Grade VI: Very loud, audible with stethoscope not in contact with chest, thrill palpable and visible
How do you take a history and physical? Seidel page 6 and 32
Identifiers: Name, date, time, age, gender, race, occupation, referral source
Chief concern (CC)
History of present illness or problem (HPI)
Past medical history (PMH)
Family history (FH)
Personal and social history (SH)
Review of systems (ROS)
Physical conducted using inspection, palpation, percussion and auscultation
. Tonsil grading- Siedel’s pg. 253
Enlarged tonsils are graded to describe their size.
1+- Visible
2+- Halfway between tonsillar pillars and the uvula
3+- Nearly touching the uvula
4+- Touching each other
https://www.youtube.com/watch?v=EbNoWFm0JLY
Assessment of apical PMI and indications Siedel’s pg 305-306
Point of maximal impulse (PMI) is the point at which the apical impulses are most readily seen or felt. This is usually on the left 5th ICS, midclavicular line in adults. It can be obscured by obesity, large breast, and muscularity. It can sometimes be noted in the 4th ICS in some adults.
In children it is located 4th ICS medial to the nipple.
Normal-1cm diameter, gentle, brief, not lasting longer than systole.
Abnormal-
Heave or lift (this is when apical pulse outside the above normal parameters). If apical pulse is more forceful and widely distributed, fills systole, or displaced laterally and downward may indicate increased cardiac output or left ventricular hypertrophy. If a lift is noted along the left sternal border it may be right ventricular hypertrophy. A loss of thrust may be related to overlying fluid, air, or displacement under the sternum.
Displacement of the apical pulse to the right without a loss or gain in thrust, suggest dextrocardia, diaphragmatic hernia, distended stomach, or pulmonary abnormality.
Thrill- Palpable murmur, vibration. Most often over the base of the heart in the area of the right or left second intercostal space. Indicated turbulence or disruption of the expected blood flow related to aortic or pulmonic valve abnormalities.
https://www.youtube.com/watch?v=nHBKZbAuttA
S3 and S4 are created by what? Characteristics? Seidel chapter 14
S3 -As the ventricle pressure falls below the atrial pressure, the mitral and tricuspid valves open to allow the blood collected in the atria to refill the relaxed ventricles. Diastole is relatively passive interval until ventricular filling is almost complete. This filling sometimes produces a third heart sound S3. (Seidel, pg. 298)
S3 – characteristics-Quiet, low pitched, often difficult to hear (Seidel, pg. 310). When heard resembles the rhythm of pronouncing the word Ken-TUCK-y.
S4 – The atria contract to ensure ejection of any remaining blood. This can produce the fourth heart sound (S4).
S4- characteristics – Quite, difficult to hear. When heard resembles the rhythm of pronouncing the word TEN-nes-see. (Seidel, 310).
. Heart sounds are created by what?- Seidel 307-310
- S1- closure of mitral and tricuspid valves indicating beginning of systole
o heard loudest over the apex
o synchronous with carotid pulse - S2- closure of aortic and pulmonic valves indicating initiation of diastole
- splitting- occurs when the valves do not close simultaneously
Assessing sinus tenderness how? Seidel page 243
Inspect the frontal and maxillary sinus areas for swelling. To palpate the frontal sinuses, use your thumbs to press up under the bony brow on each side of the nose. Then press up under the zygomatic processes, using either your thumbs or your index fingers to palpate maxillary sinuses. Expect no tenderness or swelling over the soft tissue. Swelling, tenderness, and pain over the sinuses may indicate infection or obstruction.
Oral cancer – assessment and common location- Goolsby & Grubbs pages 148 & 152-153
Patient may present with a “mouth sore.” It is necessary to determine if it is painful, when the patient first noticed the lesion, whether the lesion was preceded by other symptoms, or if there was a history of other lesions in the past medical history. Identify any associated symptoms such as fever, malaise, joint pain, SOB, n/v/d, photosensitivity, etc. Also, check for any chronic or coexisting conditions or OTC meds taken. Check the patient’s VS, paying close attention to any fever. Note the type of lesion (ulcer, papule, etc) as well as the dimensions, coloring, shape, discoloration, and other details. Check surrounding tissues for any edema, erythema, or pallor. Assess the entire oral mucosa for indurations, thickenings, nodules, or palpable changes.
The most common form of oral cancer is Squamous Cell Carcinoma. Most lesions occur on the lips or along the lateral aspects of the tongue. However, other forms of malignancy, including malignant melanoma, do affect the oral mucosa, and any of the tissue in the oral cavity can be involved. Because many oral cancers are not diagnosed until they are quite advanced, the prognosis can be poor.
. Rinne’s test – how is it performed – Goolsby & Grubbs pages 127-128
Rinne test – uses a tuning fork to assess bone and air conduction
The vibrating tuning fork is placed on the patient’s mastoid bone (bone conduction). When the patient indicates the vibration is no longer heard, then move the tines of the fork in front of the ear (air conduction) until the patient states that the vibration is no longer heard. The amount of time the vibrations are heard in both positions is noted. Intended result: Air conduction should be twice as long as bone, and the results should be similar in both ears.
Assess ears in child? Adult?****
Pediatric Goolsby & Grubbs pages 529-530
Ask about hearing ability or difficulties, or drainage. The general appearance and placement of the ears is important in the pediatric assessment. Low set ears may indicate genitourinary or chromosomal abnormalities or a multisystem syndrome such as Turner syndrome. Assess for preauricular sinuses. To exam the inner ear in an infant or young child, pull the pinna down and out. For examination in the older child, pull the pinna up and back. The tympanic membrane should be mobile and intact, thin, smooth, and pearly gray with bright light reflexes. Although, crying will cause erythema of the TMs, the light reflexes and mobility should remain intact. Observe for any bubbles or an obvious fluid level line behind the tympanic membrane, which indicates middle ear effusion. A child continually asking for questions to be repeated should be assessed for hearing deficit. Middle ear effusions and acute otitis media may also cause hearing deficits. Otoscope should always be used last – since it is not favored with kids.
Red Flags with Peds:
- Pain over the mastoid process (may indicate mastoiditis)
- Foreign bodies – consider this if the child ℅ strange sounds or sensations in one ear or if there is an obvious blockage or odd color noted on otoscopic exam
- Hearing deficit
Common diagnoses made with ears in peds:
- Acute otitis media
- Middle ear effusions
- Otitis externa
- Wax impaction
- Foreign body
Adults Goolsby & Grubbs pages 618-619 / Seidel’s page 238-240
Begin with examination of the external ear. Note placement and symmetry of ears. The otoscope is then used to examine the canal and middle ear. Hold the handle of the otoscope between the thumb and index finger supported on the middle finger. Use the ulnar side of your hand to rest against the patient’s head for stability. Tilt the patient’s head toward the opposite shoulder, pull the auricle upward and back to straighten the auditory canal for best view. If symptoms are unilateral, assess the asymptomatic ear first. Inspect for patency, erythema, tenderness, exudate, deformity, and drainage. Noting the integrity of the tympanic membrane and quality of light reflex. Evaluate the tympanic membrane for inflammation, retraction, or bulging.
Tympanic membrane signs and associated conditions:
TM bulging with no mobility=middle ear effusion due to pus or fluid
TM retracted with no mobility=obstruction of eustachian tube with or without middle ear effusion
TM mobility with negative pressure only=obstruction of eustachian tube with or without middle ear effusion
TM excess mobility in small areas=healed perforation, atrophic tympanic membrane
TM amber or yellow=serous fluid in middle ear (otitis media with effusion)
TM blue or deep red=blood in middle ear
TM chalky white=infection in middle ear (acute otitis media)
TM redness=infection in middle ear (acute otitis media) or prolonged crying
TM dullness=fibrosis, otitis media with effusion
TM white flecks, dense white plaques=healed inflammation
TM air bubbles=serous fluid in middle ear
Test for peripheral vision – Goolsby & Grubbs p. 100****
Peripheral vision is tested very grossly through confrontation by the examiner who has the patient count fingers or indicate appearance of a colored object from the upper and lower temporal and nasal quadrants. Carefully identify the location of any visual defects.
Seidels page 209 Peripheral vision can be estimated by the confrontation test. To perform this the examiner should sit or stand opposite the patient at eye level at a distance of about 3 feet. Ask the patient to cover the right eye while you cover your left eye, so the open eyes are directly opposite each other. Fully extend your arm midway between the patient and yourself and then move your arm slowly centrally. Have the patient tell you when the fingers are first seen. Compare the patient’s response to the time you first note the fingers. Test the nasal, temporal, superior, and inferior fields. The confrontation test is imprecise and can be considered significant only when it is abnormal.
Myopia
Nearsightedness caused by light refractive error placing light in front of retina.
What is astigmatism?
it refers to the refractive condition in which a warped corneal surface causes light rays entering the eye along different planes to be focused unevenly.
What is macular degeneration?
caused by the deterioration of the central portion of the retina, the inside back layer of the eye that records the images we see and sends them via the optic nerve from the eye to the brain.
What would be subjective data if bacterial infection of one or more paranasal sinuses?***
patient complains of nasal stuffiness and facial pain. Patient noted she/he is having yellowing discharge from the nose. frontal headache, facial pain; persistent cough, worse at night; URI that worsens or persists after 7-10 data
What would objective data be for bacterial paranasal sinus infection?****
Turbunates are swollen and red. Sinus area are tender to palpation. Noted to have focal pain when the patient bends over.
May have no physical findings
Purulent Nasal discharge from middle meatus, may be unilateral
Tenderness over frontal or maxillary sinuses
Sinus does not trans illuminate
How do you use the otoscope in an adult***
ave pt tilt head to opposite shoulder, gently pull auricle up and back while inserting speculum
Inspect auditory canal, noting any discharge, redness, lesions, FB, or cerumen. expect to see minimal cerumen, uniform pinkness, and hairs in outer thirds if the canals.
Third, inspect tympanic membrane for landmarks, color, contour, and perforations. the umbo, handle of malleus, and light reflex should be visible. The TM should be translucent, person grey, and conical with no perforations.
4th assess TM mobility using otoscope pneumatic attachment. The TM should move in and out with pressure changes, causing the cone of light to Change appearance
What is a thrill?
Fine, palpable sensation.
What is regurgitation?
it is when the leaflet lose competency and started to leak, making the blood flow backward.
What is PMI?
Location where apocalypse pulse is most readily seen or felt.
What diseases indicates S4 heart sound?*
May indicate decreased left ventricular compliance
What does OLD CARTS stand for in HPI?****
onset, location, duration, characteristic, aggravating factors, relieving factors, temporal factors, severity
where do auscultate the tricuspid?
4th left ICS to sternal border
CLINICAL CASE STUDY PRACTICE: Patient D.C. is a 67-years-old homeless man who is brought to the ER. after being found intoxicated in a local park. After 6 hours in the ER, D.C. is awake and cooperative. The nurse noticed grimacing as he eats. List possible subjective and objective data.
S: patient also stated he does not have an insurance. He have 8/10 pain to his mouth as he eat. He stated that he have a poorly fitted dentures on the upper teeth which was giving him pain.
O: Patient’s gums are red and swollen, buccal mucosa with no lesions. Molars have black spot/hole. Tonsil pillars +2, no redness or exudate.
What abnormalities might you see in the eye with a diabetic patient?*
Hemorrhages, Cotton wool spots
What abnormalities might you see in the eye with a hypertensive patient?****
What would you look for on exam with the opthalmoscope? Retina/Fundus
Cotton wool spots, hemorrhage, narrowed retinal arteries, AV nicking
What is a lift and heave?
Lift or heaves- these are forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs.
What findings would you see with oral cancer?
Sores, swellings, lumps or thick patches anywhere in or around your mouth or throat
Areas of red or white lesions in your mouth or lips
The feeling of a lump or object stuck in your throat
Swellings that make wearing dentures uncomfortable
Numbness, pain or tenderness anywhere in your mouth, including your tongue
Pain in one of your ears but without any loss of hearing
Trouble moving your jaw or tongue, or problems with chewing, swallowing or speaking
Loose teeth with no apparent dental cause
Lingering sore throat or hoarseness
How do you perform the Weber test?
A normal weber test has a patient reporting the sound heard equally in both sides. In an affected patient, if the defective ear hears the Weber tuning fork louder, the finding indicates a conductive hearing loss in the defective ear.
How do you perform the Rinne test?
Normal test: Air conduction should be greater than bone conduction and so the patient should be able to hear the tuning fork next to the pinna (outer ear) after they can no longer hear it when held against the mastoid.
What is conductive hearing loss?
Conductive hearing loss is the result of sounds not being able to pass freely to the inner ear. This usually results from a blockage in the outer or middle ear, such as a build-up of excess ear wax or fluid from an ear infection (especially common in children). It can also happen as a result of some abnormality in the structure of the outer ear, ear canal or middle ear – or be due to a ruptured eardrum.
What is sensorineural hearing loss?
This type of hearing loss is sometimes referred to as sensory, cochlear, neural or inner ear hearing loss.
A permanent sensorineural hearing loss is the result of damage to the hair cells within the cochlea or the hearing nerve (or both). Damage to the cochlea occurs naturally as part of the ageing process (age-related hearing loss is known as presbycusis) – but there are many things that cause sensorineural hearing loss, or add to it, such as:
Regular and prolonged exposure to loud sounds. These sounds do not necessarily have to be unpleasant – for example, exposure to loud music can be just as harmful as exposure to loud machinery. Even short term exposure to loud sound can cause temporary deafness.
Ototoxic drugs – some medicines are harmful to the cochlea and/or hearing nerve. These include drugs that are used in the treatment of serious diseases such as cancer but also include certain types of antibiotics
Certain infectious diseases, including Rubella
Complications at birth
Injury to the head
Benign tumours on the auditory nerve – although rare, these can cause hearing loss
Genetic predisposition – some people are especially prone to hearing loss.
Sensorineural hearing loss not only changes our ability to hear quiet sounds, but it also reduces the quality of the sound that is heard, meaning that individuals with this type of hearing loss will often struggle to understand speech. Once the cochlea hair cells become damaged, they will remain damaged for the rest of a person’s life. Therefore sensorineural hearing loss is irreversible and cannot be cured – at least at the present time.
Pt with Chronic cough
-List two pertinent questions you would want to ask in the PMH
-Describe two abnormal findings on focused exam of chest and lungs.
Dyspnea may be present but not severe; cough and sputum production Subjective and Objective: Wheezing and crackles; hyperinflation with decreased BS and flattened diapgrahm
You have a patient with an acute exacerbation of asthma. Describe the following:
-Wheezing
-Stridor
Wheezing: continuous high pitched, musical sound heard during inspiration and expiration.; Stridor:abnormal, high-pitched sound produced by turbulent airflow through a partially obstructed airway at the level of the supraglottis, glottis, subglottis, or trachea.
When do you perform the cover test for eyes?
To evaluate eye fixation if you find imbalance with corneal light reflex test
What is accommodation?***
Test pupillary response to acommodation; Ask pt to look at distant object and then test object (finger or pen) held 10 cm from bridge of nose. Expect pupils to constrict when the eyes focus on a near object.
Confrontation test**
The term “confrontation” in this test just means that the person giving the test sits facing the patient, about 3 or 4 feet away. The tester holds his or her arms straight out to the sides. The patient looks straight ahead, and the tester moves one hand or the other inward. The patient gives a signal as soon as the hand is seen.
The confrontation visual field test measures only the outer edge of the visual field, and it is not very exact.
Which of the following will best facilitate the interview
when obtaining a history for a deaf patient who
can read lips?
speaking slowly
During a history, the patient indicates he has an uncle
and a brother with sickle cell disease. Which of the
following is an appropriate method to document this
information?
Include it in the family history.
Which approach is recommended at the onset of an
interview?
Use an open-ended approach; let the patient explain the problem or reason for the visit.
Which of the following questions may lead to an
inaccurate patient response?
“That was a horrible experience, wasn’t it?”
Repeating a patient’s answer is an attempt to
confirm an accurate understanding.
During an interview, your patient admits to feeling
worthless and having a sleep disturbance for the
past 3 weeks. These are clues that warrant the exploration
of
risk for suicide
Jerry, a 26-year-old homosexual man, is having a
health history taken. Which question regarding sexual
activity would most likely hamper trust between
Jerry and the interviewer?
Are you married or do you have a girlfriend
When questioning a patient regarding a sensitive
issue, such as drug use, it is best to
be direct, firm, and to the point
Direct questions are designed to
obtain or clarify specific details about an answer
Interviewers should identify and assess their own
feelings, such as hostility and prejudice, in order to
reduce communication barriers
During an interview, a patient describes abdominal
pain that often awakens him at night. Which of the
following responses by the interviewer would facilitate
the interviewing process?
“Tell me what you mean by often.”
Developing cultural sensitivity is vital in order for the
examiner to be successful in
recognizing and accepting health beliefs that differ from his or her own beliefs.
The balance of hot and cold and its relationship to
wellness is a concept that
is believed by members of many cultures, including
Arabs, Asians, Filipinos, and Hispanics.
Developing a knowledge base about cultural groups
allows the practitioner to
understand the behaviors, practices, and problems observed
Which of the following is an example of a cultural
characteristic?
shared belief
A young mother brings her infant to the emergency
department with a high temperature and dehydration.
Which of the following questions asked by an examiner
demonstrates cultural awareness?
What do you think is causing the illness?
A common mistake made by health care professionals
is to?
stereotype individuals based on color or ethnic group
All of the following are cultural considerations that
affect health care except
eye color, temperature, and visual acuity
Which of the following is an example of a physical,
as opposed to a cultural, characteristic?
Skin color
Despite repeated instruction over a period of 3 years,
the mother of three young children has still not had
her children immunized. Which of the following
questions would help the health care provider understand
this situation?
What are your beliefs about immunizations
Which mode of communication may be offensive to
a patient whose cultural perspective differs from that
of the practitioner
maintaining firm and direct eye contact
Which of the following infection control guidelines
are currently recommended by the Centers for Disease
Control and Prevention (CDC)?
standard precautions
A patient presents with multiple raised lesions on her
skin. Which instrument should be used to examine
these lesions
ruler
In an outpatient setting such as a clinic, how should
infection control practice differ from that in the acute care
setting?
Infection control practice is applicable in all healthcare settings.
In which of the following situations is transillumination
an appropriate examination technique
Detection of fluid within the sinuses
Which of the following instruments is used in conjunction
with a simple nasal speculum to visualize the lower and middle turbines of the nose?
penlight
On first meeting, the examiner notices that the patient
has an obvious odor. Which examination technique is the examiner using in this scenario?
Inspection
Focused visual attention obtains data from
inspection
Which technique is applied throughout the entire
examination and interview process
inspection
As a component of palpation, which surface is most
sensitive to vibration
ulnar surface of the hand
How deep should the examiner’s hands press while
performing deep palpation?
4 cm
The term intensity, when used in relation to percussion
tones, refers to
the loudness of the tone.
The examiner has detected a superficial mass in the
skin. What part of the hand is best to use to palpate
this mass?
fingertips
Ideally, auscultation should be carried out last, except
when examining the
abdomen
Which of the following techniques is incorrect and
affects the accuracy of auscultation?
Auscultating through clothing
Which of the following is true regarding the correct
use of a stethoscope?
The bell is pressed lightly against the skin to
detect low-frequency sounds
In which of the following situations is use of a
Doppler indicated
Auscultation of a nonpalpable pulse in a patient with peripheral vascular disease
While performing an internal eye examination, the
examiner observes a fundal lesion. What feature
on the ophthalmoscope permits the examiner to
estimate the size and location of the lesion?
grid light
An ophthalmoscope has positive and negative magnification in order to
compensate for myopia or hyperopia in the
examiner’s or the patient’s eyes.
According to the Centers for Disease Control and
Prevention, the health care provider should apply
infection control measures when caring for which
group of patients?
All patients regardless of their infectious status
Unless a life-threatening situation exists, the best
guide to determining the priority for the patient’s
condition should be based on
intuition
When determining a need for additional examination,
testing, or procedures, the examiner knows that these
should be done
if they relate to the examiner’s hypothesis
After an examiner has identified and confirmed a
problem, the next step is to
determine the managment plan
The use of a computer could potentially be detrimental
to the examiner because
it may become a substitute for critical thinking.
To identify problems based on clinical examination,
the examiner should organize the data
by body systems
Each of the following could become a barrier to the
critical thinking process, except for the examiner’s
objectivity (feelings, attitudes, and values could be barriers)
Which statement best characterizes a belief that supports a sound decision-making process?
Common problems occur commonly, and rare ones occur rarely
Laboratory tests should be used to
develop a list of potential problems
EBP is defined as
the best available scientific evidence to clinical
decision making.
Which of the following examples illustrates a vague or nondescriptive term
“skin color is normal”
How are “normal findings” best documented
Document what was actually assessed in specific terms.
Which of the following statements is true regarding use of abbreviations?
Use only universally accepted abbreviations for documentation
You are taking a health history on your patient. When you are asking about problems in other body systems, your patient reports constipation over the
past 5 or 6 months. This would be documented in
Review of symptoms
Your patient presents to the office with a chief complaint of shoulder pain that he reports as stabbing. In using the mnemonic OLDCARTS, this is noted as
characteristic
Before instilling a mydriatic eyedrop, the examiner should
observe the eye with focused light tangentially
The examiner screens a 5-year-old child for nystagmus by
inspecting movement of the eyes to the six cardinal fields of gaze
Which of the following correctly describes the method to assess accommodation?
Constriction should be noted as gaze shifts from across the
room to an object 6 inches away.
Which of the following should be used to test for near vision?
Rosenbaum chart
To visualize the macula, the examiner should ask the patient to
look directly into the light of the ophthalmoscope.
A 51-year-old patient tells the examiner, “My mother had glaucoma. What can I do to prevent myself from getting it?” Which of the following responses is most appropriate?
“Although it can’t be prevented, regular screening
and testing assist in early detection.”
Which examination finding may be indicative of a retro-orbital tumor?
Unilateral exophthalmos
A patient tells the examiner, “I have a loss of vision in the outer half of each eye.” Which of the following underlying problems should the examiner consider?
glaucoma
Which of the following would be applicable to a family history?
Retinoblastoma
Mrs. Carter has vision that, at best, is 20/210.
Mrs. Carter is considered
legally blind
Which of the following is the correct technique while performing an ophthalmoscopic examination?
Examine the patient’s right eye with your right eye and the pt’s left eye with your left eye
A cobblestone appearance of the conjunctiva is most likely related to
allergic or infectious conjunctivitis
Mr. Barclay is a 48-year-old patient who presents to the office for follow up. On his eye examination, you note peripheral fundus changes and vessels that appear whitish. The most likely cause for these findings is
lipemia retinalis
Which of the following cranial nerves innervate the six muscles that control eye movement?
III, IV, VI
When you are examining the eyelid, you note ptosis on the right side. Which cranial nerve innervates the muscle that elevated the upper eyelid?
CN III
Mr. Kasey is a 57-year-old patient who presents to your office. During the eye examination, you note that his pupils are not equal in size; however, they react to light and accommodation. This is called
anisocoria
When performing a Weber test, which of the following is considered a normal finding?
The patient hears the tone equally in both ears.
The examiner observes a blackish lesion on the top surface of the tongue of an adult patient. The patient indicates that his tongue is painful. Which question by the examiner would be helpful in explaining this finding?
“Have you been taking antibiotics lately?”
Which of the following situations is an indication for transillumination?
The patient complains of pain over sinuses with palpation.
The examiner notes that a patient’s tonsils are enlarged and that they touch the uvula. This is documented as
3+
Which of the following statements made by a 72-year-old patient would indicate a normal process of aging?
“Food does not taste the same as it used to.”
Chronic sniffling, nasal congestion, nosebleeds, mucosal scabs, and septum perforation are signs of
cocaine abuse
Mrs. Williams presents to the office for a follow-up visit. On examination, you note deep fissures at the corners of her mouth and identify this as cheilosis. You know this is a result of
riboflavin deficiency
Mr. Cruz presents for a physical examination. On examination, you note that the lower molars are distally positioned in relation to the upper molars. How would you classify this malocclusion?
Class II malocclusion
The most important clinical signs for sinusitis in adults includes which of the following?
Maxillary toothache, purulent nasal drainage, poor response to decongestants
Normal findings in elderly mouth/pharynx
Oral tissues may be dryer (xerostomia)
General findings in elderly mouth/pharynx
xerostomia, Periodontal disease, Oral cancer, Aspiration pneumonia, fully edentulous
Abnormal findings in elderly mouth/pharynx
Gingivitis, periodontal disease, dental caries, teeth may appear longer, Dental malocclusion
Initial symptoms are cracking sound when yawning or swallowing, discomfort, feeling of fullness (no drainage)
Otitis media with effusion
Exam shows conductive loss as ears fills with fluid, retracted or bulging TM, impaired mobility, yellowish air-fluid level and bubbles
Otitis media with effusion
Initial symptoms of Abrupt onset, fever, feels blocked, anorexia, irritability, deep-seated ear ache, if TM ruptured foul-smelling discharge
Acute Otitis Media
Exam shows conductive loss as ears fills with pus, TM with distinct erythema, thickened or clouding; bulging, impaired mobility, air-fluid level and bubbles
Acute Otitis Media
Exam shows Meatus inflamed, tender and weeping, extreme pain, nothing can be seen of interior canal.
Otitis Externa (Swimmer’s ear)
What tests are done to test hearing?
Whisper, Weber, & Rinne
expected findings of Weber test
sound heard equally in both ears
expected findings for the Rinne test
air conduction (AC) greater than bone conduction (BC); 2:1 ration
Abnormal findings with elderly Conjunctiva
Cataracts
Age related macular degeneration
Diabetic retinopathy
Glaucoma
What is disease that progressively destroys the macula, impairing central vision
Age related macular degeneration (AMD):
gradual blurring of central vision, and increased difficulty reading fine print, recognizing faces or seeing street signs
Dry AMD progression…
rapid loss of central vision, with metamorphopsia (images that appear distorted
Wet AMD
What is Glaucoma?
progressive, chronic optic neuropathy in which intraocular pressure (IOP), disease of optic nerve where the nerve cells die
characterized by a progressive series of abnormal changes in the retinal microvasculature, proliferative retinopathy, dilated fundoscopy
Diabetic retinopathy
Subjective Data for Open-angle glaucoma
symptoms are absent except for a gradual loss of peripheral vision over a period of years
what you might see in Acute glaucoma
intense ocular pain, blurred vision, halos around lights, a red eye, and a dilated pupilo Occasionally: stomach pain, nausea, & vomiting
presbyopia, decrease in dim light sight, decreased ability to adjust to change in lighting
Normal findings with elderly Conjunctiva
What is being looked at with ophthalmoscope
Red reflex, vascular supply of the retina, optic disc and macula
if someone of a different culture comes in with pain how would you address that?
ask if they any cultural beliefs that will affect how you need to treat the pain, does the pain frighten you, how do you cope with pain, what ways do you usually treat pain
How would you like to be addressed?; How are you feeling today?; What would you like for us to do today?; What do you think is causing your symptoms?; What is your understanding of your diagnosis?
examples of patient-centered questions
If language is a barrier how should it be handled
professional interpreter, rather than a family member, should be used
What do open-ended questions allow?
gives the patient discretion
about the extent of an answer
What do direct questions allow?
to seeks specific information
What tests would you use to check vision acuity?
Rosenbaum (near vision) & Snellen (far vision)
Know some red flags of the eye (send to ED or eye doctor)
uneven pupils with HA, sudden loss of vision, floaters/flashers
When a patient has retinal detachment what is their main complaint?
“curtain” feeling, floaters or flashes
How do you check for glaucoma?
Check intraocular pressure (tonometry); optic disc assessment, peripherial vision exam, whether intraocular drainage system is “open” or “closed” (gonioscopy)
how to identify bacterial conjunctivitis vs allergic conjunctivitis
Bacterial- starts in one eye and spreads to the other, yellow/ crusty drainage
Allergic- both eyes, puffy and/ or runny
What is first thing visualized with ophthalmascope 12 inchs away?
red reflex
What will be the first thing seen with ophthalmascope as you approach 3-5 cm away?
blood vessel
If your patient is myopic (nearsighted) what lens will be used with ophthalmascope
minus (red) len
If patient is hyperoptic (farsighted) or aphakic (lacks a lens) what lens will be used with ophthalmascope?
plus (green) lens
When doing an ear exam what do you start out looking at?
Look at the outer structures of the ear then palpate
If you look at the outside of the ear and you see drainage, is this normal or abnormal?
Abnormal
What is your differential diagnoses if you see drainage outside of the ear?
Otitis Externa, Otitis Media, Ear effusion, or foreign body in the ear
What kind of patients get Otitis Externa?
Swimmers, breast/ bottle fed children
When you exam the ear what things are you looking for?
TM (whether it is perforated or not), cone of light, look at the canal (whether it is swollen or red, look for cerumen impaction)
what is palpated while examining external ear?
the preauricular and post auricular lymph nodes and mastoid area
What is the worst differential diagnosis for a patient that comes in with an ear infection?
Mastoid infection or meningitis
How is the Rinne test performed?
Place the base of the tuning fork against patients mastoid bone, ask patient to tell you when sound is no longer heard (bone conduction)
Place the still vibrating tines (1-2 cm) in from the auditory canal and ask patient to tell you when sound is no longer heard (air conduction)
You have a 42 y/o female that comes in to you saying “I have dizziness” what differential diagnoses could be and what test can you do to check if it is vertigo?
Ear infection, Meniere’s disease, vertigo; Dix Hallpike maneuver (Head tilt and lay back maneuver)
What are some tests that you would run if you see a patient with oral ulcers that are not resolving
Check for HIV, syphilis, imunosuppression
What is the number one virus that causes oral ulcers with fever?
Herpes Simplex
if a patient comes in with any complaints of mouth problems whats an important question to ask?
if they are a smoker or not
If a patient comes in with a herpes lesion or shingles on face close to eyes, what is the number one thing that you would think of and send this patient to the emergency department?
optic neuritis
What is the number one thing that you should document on a sinusitis patient?
Length of symptoms (to know whether to treat viral or bacterial)
How would you diagnose a patient with an allergy?
Clear rhinorrhea as opposed to purulent, throat irritation, POST NASAL DRIP
What placement should the uvula have?
midline
What if the uvula is not midline?
Suspect a problem on the opposite side that the uvula deviates
What differential diagnoses would you think of if the uvula is deviated?
Peritonsillar abscess
When you are taking a history on a patient is it best to ask straight forward questions or open ended questions?
Start with open-ended and then narrow it down with straight forward questions
An integral part of the overall effort to respond adequately to a person in need is
cultural awareness
What diseases are associated with periodontal disease?
DM, PVD and CV disease
If the eye is very firm when palpated what disease should be considered
Glaucoma
markedly asymmetric cupping between the 2 eyes can indicate?
Glaucoma
What is usually observed before visual field losses appear in Glaucoma?
optic disc cupping
If you do not see a red reflex what could that indicate
Retinoblastoma
If you see white flakes, or dense plaques in the ear what could that indicate?
healed inflammation
What type of glaucoma is caused by a decrease in absorption of the aqueous humor?
Open angle
What does a chalky white TM or redness mean?
middle ear infection (Acute otitis media)
What causes peripheral cataracts?
hypoparathyroidism
Pathophysiology of cataracts
denaturation of lens protein caused by aging
When assessing the mouth what are some things that you should be looking for?
color, lesions, tonsils, uvula, erythema, oral ulcers, teeth, tongue
What else would you want to know on a history of a patient that comes in with lesions or mouth sores?
tobacco use, if immunocompromised, stress levels
What does a Herpes lesion look like?
vesicular lesion
If the patient presents with sudden vision disturbances, “curtains”, floaters, or flashing lights with a wrinkled and grey retina following a trauma what would you suspect?
retinal detachment
A patient has xanthelasma on their eyes what is this caused by?
abnormality of lipid metabolism
Differential diagnosis of thickened white patch on the lateral or ventral surface of the tongue in a pt with HIV?
sarcoma