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.<\/p>\n\n\n\n
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.
\u25cf 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.
\u25cf 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.
\u25cf 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.
\u25cf 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.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
Tonsil assessment<\/p>\n\n\n\n
Order physical assessment is done
Inspection, Palpation, Percussion, Auscultation<\/p>\n\n\n\n
Proper use of Otoscope on adult or child
Adult- straighten the external auditory canal by pulling auricle up and back<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
Rinne Test*<\/strong> Weber Test Presbyopia Strabismus Photopsia Amblyopia Macular Degeneration Xanthelasma Snellen Test*<\/strong> 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.<\/p>\n\n\n\n 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.<\/p>\n\n\n\n Measurement of 20\/20 vision is an indication of either refractive error or some other optic disorder.<\/p>\n\n\n\n In testing for visual acuity you may refer to the following:<\/p>\n\n\n\n Rosenbaum Test Confrontation Test**** Papillary Reaction Accommodation*<\/em><\/strong> Which valves closing and opening make which sounds? Incompetent heart valve Sclerotic Heart Valve Stenotic Heart Valve Regurgitation What causes leg edema? What causes murmurs? Where do you hear murmurs? Murmur:<\/p>\n\n\n\n Harsh late-peaking crescendo-decrescendo systolic murmur Possible associated findings:<\/p>\n\n\n\n Abnormal carotid pulse Murmur:<\/p>\n\n\n\n Blowing holosystolic murmur Possible associated findings:<\/p>\n\n\n\n S2: wide physiologic splitting Murmur:<\/p>\n\n\n\n Soft blowing early diastolic decrescendo murmur Possible associated findings:<\/p>\n\n\n\n Dilated apical impulse Murmur:<\/p>\n\n\n\n Soft holosystolic murmur Possible associated findings:<\/p>\n\n\n\n Elevated neck veins Pulmonic Insufficiency<\/p>\n\n\n\n Murmur:<\/p>\n\n\n\n High frequency early diastolic decrescendo murmur Associated findings:<\/p>\n\n\n\n Abnormal S2 splitting Pulmonary stenosis<\/p>\n\n\n\n Murmur:<\/p>\n\n\n\n Harsh crescendo-decrescendo systolic murmur Associated findings:<\/p>\n\n\n\n Ejection sounds heard at sternal edge, 2nd or 3rd intercostal space Mitral stenosis<\/p>\n\n\n\n Murmur:<\/p>\n\n\n\n Low frequency rumbling mid-diastolic murmur, with presystolic component possible Associated findings:<\/p>\n\n\n\n Apical impulse absent or small Hypertrophic cardiomyopathy<\/p>\n\n\n\n Murmur:<\/p>\n\n\n\n Harsh quality midsystolic murmur Possible associated findings:<\/p>\n\n\n\n Sustained apical beat to palpation Grades of murmurs?*<\/em><\/strong> I\/VI: Barely audible Systolic Murmurs are the most common in children.<\/p>\n\n\n\n Holosystolic (regurgitant) murmurs start at the beginning of S1 and continue to S2. Examples: ventricular septal defect (VSD), mitral valve regurgitation, tricuspid valve regurgitation.<\/p>\n\n\n\n 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.<\/p>\n\n\n\n Diastolic murmurs are usually abnormal, and may be early, mid or late diastolic.<\/p>\n\n\n\n Early diastolic murmurs immediately follow S2. Examples: aortic and pulmonary regurgitation. What do murmurs sound like? I – Lowest intensity, difficult to hear even by expert listeners Normal vs abnormal murmurs 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.<\/p>\n\n\n\n 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.<\/p>\n\n\n\n Follow the steps on conducting the test:<\/p>\n\n\n\n What does OLDCARTS mean? Sinus, oral, and throat exam Nose and Sinuses External: inflammation, deformity, discharge or bleeding<\/p>\n\n\n\n Internal: colour of mucosa, edema, deviated or perforated septum, polyps, bleeding<\/p>\n\n\n\n Observe nasal versus mouth breathing Sinus Sinus and nasal tenderness Lips: color, lesions, symmetry<\/p>\n\n\n\n Oral cavity: breath odour, color, lesions of buccal mucosa<\/p>\n\n\n\n Teeth and gums: redness, swelling, caries, bleeding<\/p>\n\n\n\n Tongue: colour, texture Throat and pharynx: colour, exudates, uvula, tonsillar symmetry and enlargement Risk factors for heart disease Hyperlipidemia<\/p>\n\n\n\n Elevated Homocysteine level<\/p>\n\n\n\n Smoking<\/p>\n\n\n\n Family hx of CVD, DM, HLD, HTN, or sudden death in young adults<\/p>\n\n\n\n DM, Obesity, Sedentary lifestyle without exercise, Fatigue<\/p>\n\n\n\n Associated symptoms: dyspnea on exertion, chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea, anorexia, N\/V<\/p>\n\n\n\n Medications: beta blockers<\/p>\n\n\n\n What does left, thrill, heave mean? Thrills- these are the vibrations of loud cardiac murmurs. They feel like the throat of a purring cat. Thrills occur with turbulent blood flow.<\/p>\n\n\n\n Auscultation of the heart<\/p>\n\n\n\n Inspection and palpation- cardiac (aortic, pulmonic, erb’s, tricupsid, mitral<\/p>\n\n\n\n a pulsation could indicate an aortic aneurysm. a pulsation could indicate pulmonary hypertension. findings similar to that of aortic and pulmonic areas.<\/p>\n\n\n\n a sustained systolic lift could indicate right ventricular enlargement.<\/p>\n\n\n\n a systolic thrill could indicate a ventricular septal defect.<\/p>\n\n\n\n in patients with anemia, anxiety, hyperthyroidism, fever, pregnancy, or increased cardiac output, a brief pulsation may be felt.<\/p>\n\n\n\n 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.<\/p>\n\n\n\n normally seen in less than half the population.<\/p>\n\n\n\n increased pulsation could indicate increased cardiac output, anemia, anxiety, fever, or pregnancy.<\/p>\n\n\n\n a thrill could indicate mitral regurgitation, or mitral stenosis.<\/p>\n\n\n\n Listening to heart sounds:<\/p>\n\n\n\n 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.<\/p>\n\n\n\n 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.<\/p>\n\n\n\n S1 is synchronous with the onset of the apical impulse.<\/p>\n\n\n\n tachycardia<\/p>\n\n\n\n bradycardia<\/p>\n\n\n\n if it is irregular, try to identify the pattern.<\/p>\n\n\n\n Do early beats appear on a regular rhythm?<\/p>\n\n\n\n Does the irregularity vary consistently with respiration?<\/p>\n\n\n\n Is rhythm totally irregular?<\/p>\n\n\n\n note its intensity.<\/p>\n\n\n\n are there any splitting sounds check during inspiration where S2 usually splits at pulmonic and ERB’s point.<\/p>\n\n\n\n a thick chest wall or increased AP diameter may make S2 inaudible.<\/p>\n\n\n\n Alterations in S1 b. S1 is diminished in first degree heart block.<\/p>\n\n\n\n c. S1 split is most audible in tricuspid area (T-lub-dub).<\/p>\n\n\n\n Alterations in S2 b. Splitting of S2 can indicate pulmonic stenosis, atrial septal defect, right ventricular failure, and left bundle branch block (lub-T-dub).<\/p>\n\n\n\n a physiologic S3 is frequently heard in children and in pregnant women.<\/p>\n\n\n\n it occurs early in diastole during rapid ventricular filling. It is heard best at the apex in the left lateral decubitus position.<\/p>\n\n\n\n it is heard best using the bell.<\/p>\n\n\n\n a pathologic S3 occurs in people over the age of 40. Cause is usually myocardial failure.<\/p>\n\n\n\n sounds like lub-dub-dee (or ‘Kentucky’).<\/p>\n\n\n\n it occurs before S1<\/p>\n\n\n\n it is low pitched and best heard with the bell.<\/p>\n\n\n\n often normal in older adults.<\/p>\n\n\n\n it is heard best at the apex in the left lateral decubitus position.<\/p>\n\n\n\n it may be caused by coronary artery disease, hypertension, myocardiopathy, or aortic stenosis.<\/p>\n\n\n\n sounds like dee-lub-dub (or ‘Tennessee’).<\/p>\n\n\n\n CHECK TIMING. Are they systolic or diastolic?<\/p>\n\n\n\n (systolic murmurs may be benign. Diastolic murmurs are never benign).<\/p>\n\n\n\n LOCATION OF MAXIMAL INTENSITY. Where is the murmur best heard?<\/p>\n\n\n\n FREQUENCY (pitch). INTENSITY. the loudness of a murmur is described on a scale of 1 to 6:<\/p>\n\n\n\n Grade Intensity\/ Sounds RADIATION. some murmurs radiate in the direction of the blood stream by which they are produced. Listen over neck, back, shoulders, and left axilla.<\/p>\n\n\n\n musical blowing harsh rumbling<\/p>\n\n\n\n aortic murmurs are heard best in full expiration with patient leaning forward.<\/p>\n\n\n\n mitral murmurs are heard best after exercise in left side lying position.<\/p>\n\n\n\n Assessment of Extra Heart Sounds<\/p>\n\n\n\n Normal tympanic membrane appearance What is xanthelasma? Seidel page 210 figure 11-6 photo Cardinal fields of gaze? Seidel page 214-215. Figure 11-22 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<\/p>\n\n\n\n What does 6 cardial fields of gaze assess for? What does 20\/30 mean? Seidel pages 43-44 Snellen Alphabet Chart* 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. How does smoking affect eyesight. Seidel pg 208<\/p>\n\n\n\n . Pulse grades. Seidel page 340 Valves – stenotic, regurgant, incompetent, sclerotic Seidel page 311 Murmur grades- Seidel page 313 How do you take a history and physical? Seidel page 6 and 32 . Tonsil grading- Siedel’s pg. 253 Assessment of apical PMI and indications Siedel’s pg 305-306 S3 and S4 are created by what? Characteristics? Seidel chapter 14 . Heart sounds are created by what?- Seidel 307-310<\/p>\n\n\n\n Assessing sinus tenderness how? Seidel page 243 Oral cancer – assessment and common location- Goolsby & Grubbs pages 148 & 152-153 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.<\/p>\n\n\n\n . Rinne’s test – how is it performed – Goolsby & Grubbs pages 127-128 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.<\/p>\n\n\n\n Assess ears in child? Adult?**** Red Flags with Peds:<\/p>\n\n\n\n Common diagnoses made with ears in peds:<\/p>\n\n\n\n Adults Goolsby & Grubbs pages 618-619 \/ Seidel’s page 238-240 Tympanic membrane signs and associated conditions: Test for peripheral vision – Goolsby & Grubbs p. 100**** 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.<\/p>\n\n\n\n Myopia What is astigmatism? What is macular degeneration? What would be subjective data if bacterial infection of one or more paranasal sinuses?*** What would objective data be for bacterial paranasal sinus infection?**** How do you use the otoscope in an adult*** 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.<\/p>\n\n\n\n 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.<\/p>\n\n\n\n 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<\/p>\n\n\n\n What is a thrill? What is regurgitation? What is PMI? What diseases indicates S4 heart sound?*<\/strong> What does OLD CARTS stand for in HPI?**** where do auscultate the tricuspid? 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. 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.<\/p>\n\n\n\n What abnormalities might you see in the eye with a diabetic patient?*<\/strong> What abnormalities might you see in the eye with a hypertensive patient?****<\/p>\n\n\n\n What would you look for on exam with the opthalmoscope? Retina\/Fundus What is a lift and heave? What findings would you see with oral cancer? The feeling of a lump or object stuck in your throat<\/p>\n\n\n\n Swellings that make wearing dentures uncomfortable<\/p>\n\n\n\n Numbness, pain or tenderness anywhere in your mouth, including your tongue<\/p>\n\n\n\n Pain in one of your ears but without any loss of hearing<\/p>\n\n\n\n Trouble moving your jaw or tongue, or problems with chewing, swallowing or speaking<\/p>\n\n\n\n Loose teeth with no apparent dental cause<\/p>\n\n\n\n Lingering sore throat or hoarseness<\/p>\n\n\n\n How do you perform the Weber test? How do you perform the Rinne test? What is conductive hearing loss? What is sensorineural 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:<\/p>\n\n\n\n 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. Pt with Chronic cough You have a patient with an acute exacerbation of asthma. Describe the following: When do you perform the cover test for eyes? What is accommodation?*** Confrontation test** The confrontation visual field test measures only the outer edge of the visual field, and it is not very exact.<\/p>\n\n\n\n Which of the following will best facilitate the interview During a history, the patient indicates he has an uncle Which approach is recommended at the onset of an Which of the following questions may lead to an Repeating a patient’s answer is an attempt to During an interview, your patient admits to feeling Jerry, a 26-year-old homosexual man, is having a When questioning a patient regarding a sensitive Direct questions are designed to Interviewers should identify and assess their own During an interview, a patient describes abdominal Developing cultural sensitivity is vital in order for the The balance of hot and cold and its relationship to Developing a knowledge base about cultural groups Which of the following is an example of a cultural A young mother brings her infant to the emergency A common mistake made by health care professionals All of the following are cultural considerations that Which of the following is an example of a physical, Despite repeated instruction over a period of 3 years, Which mode of communication may be offensive to Which of the following infection control guidelines A patient presents with multiple raised lesions on her In an outpatient setting such as a clinic, how should In which of the following situations is transillumination Which of the following instruments is used in conjunction On first meeting, the examiner notices that the patient Focused visual attention obtains data from Which technique is applied throughout the entire As a component of palpation, which surface is most How deep should the examiner’s hands press while The term intensity, when used in relation to percussion The examiner has detected a superficial mass in the Ideally, auscultation should be carried out last, except Which of the following techniques is incorrect and Which of the following is true regarding the correct In which of the following situations is use of a While performing an internal eye examination, the An ophthalmoscope has positive and negative magnification in order to According to the Centers for Disease Control and Unless a life-threatening situation exists, the best When determining a need for additional examination, After an examiner has identified and confirmed a The use of a computer could potentially be detrimental To identify problems based on clinical examination, Each of the following could become a barrier to the Which statement best characterizes a belief that supports a sound decision-making process? Laboratory tests should be used to EBP is defined as Which of the following examples illustrates a vague or nondescriptive term How are “normal findings” best documented Which of the following statements is true regarding use of abbreviations? 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 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 Before instilling a mydriatic eyedrop, the examiner should The examiner screens a 5-year-old child for nystagmus by Which of the following correctly describes the method to assess accommodation? Which of the following should be used to test for near vision? To visualize the macula, the examiner should ask the patient to 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? Which examination finding may be indicative of a retro-orbital tumor? 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? Which of the following would be applicable to a family history? Mrs. Carter has vision that, at best, is 20\/210. Which of the following is the correct technique while performing an ophthalmoscopic examination? A cobblestone appearance of the conjunctiva is most likely related to 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 Which of the following cranial nerves innervate the six muscles that control eye movement? When you are examining the eyelid, you note ptosis on the right side. Which cranial nerve innervates the muscle that elevated the upper eyelid? 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 When performing a Weber test, which of the following is considered a normal finding? 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? Which of the following situations is an indication for transillumination? The examiner notes that a patient’s tonsils are enlarged and that they touch the uvula. This is documented as Which of the following statements made by a 72-year-old patient would indicate a normal process of aging? Chronic sniffling, nasal congestion, nosebleeds, mucosal scabs, and septum perforation are signs of 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 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? The most important clinical signs for sinusitis in adults includes which of the following? Normal findings in elderly mouth\/pharynx General findings in elderly mouth\/pharynx Abnormal findings in elderly mouth\/pharynx Initial symptoms are cracking sound when yawning or swallowing, discomfort, feeling of fullness (no drainage) Exam shows conductive loss as ears fills with fluid, retracted or bulging TM, impaired mobility, yellowish air-fluid level and bubbles Initial symptoms of Abrupt onset, fever, feels blocked, anorexia, irritability, deep-seated ear ache, if TM ruptured foul-smelling discharge Exam shows conductive loss as ears fills with pus, TM with distinct erythema, thickened or clouding; bulging, impaired mobility, air-fluid level and bubbles Exam shows Meatus inflamed, tender and weeping, extreme pain, nothing can be seen of interior canal. What tests are done to test hearing? expected findings of Weber test expected findings for the Rinne test Abnormal findings with elderly Conjunctiva What is disease that progressively destroys the macula, impairing central vision gradual blurring of central vision, and increased difficulty reading fine print, recognizing faces or seeing street signs rapid loss of central vision, with metamorphopsia (images that appear distorted What is Glaucoma? characterized by a progressive series of abnormal changes in the retinal microvasculature, proliferative retinopathy, dilated fundoscopy Subjective Data for Open-angle glaucoma what you might see in Acute glaucoma presbyopia, decrease in dim light sight, decreased ability to adjust to change in lighting What is being looked at with ophthalmoscope if someone of a different culture comes in with pain how would you address that? 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? If language is a barrier how should it be handled What do open-ended questions allow? What do direct questions allow? What tests would you use to check vision acuity? Know some red flags of the eye (send to ED or eye doctor) When a patient has retinal detachment what is their main complaint? How do you check for glaucoma? how to identify bacterial conjunctivitis vs allergic conjunctivitis What is first thing visualized with ophthalmascope 12 inchs away? What will be the first thing seen with ophthalmascope as you approach 3-5 cm away? If your patient is myopic (nearsighted) what lens will be used with ophthalmascope If patient is hyperoptic (farsighted) or aphakic (lacks a lens) what lens will be used with ophthalmascope? When doing an ear exam what do you start out looking at? If you look at the outside of the ear and you see drainage, is this normal or abnormal? What is your differential diagnoses if you see drainage outside of the ear? What kind of patients get Otitis Externa? When you exam the ear what things are you looking for? what is palpated while examining external ear? What is the worst differential diagnosis for a patient that comes in with an ear infection? How is the Rinne test performed? 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)<\/p>\n\n\n\n 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? What are some tests that you would run if you see a patient with oral ulcers that are not resolving What is the number one virus that causes oral ulcers with fever? if a patient comes in with any complaints of mouth problems whats an important question to ask? 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? What is the number one thing that you should document on a sinusitis patient? How would you diagnose a patient with an allergy? What placement should the uvula have? What if the uvula is not midline? What differential diagnoses would you think of if the uvula is deviated? When you are taking a history on a patient is it best to ask straight forward questions or open ended questions? An integral part of the overall effort to respond adequately to a person in need is What diseases are associated with periodontal disease? If the eye is very firm when palpated what disease should be considered markedly asymmetric cupping between the 2 eyes can indicate? What is usually observed before visual field losses appear in Glaucoma? If you do not see a red reflex what could that indicate If you see white flakes, or dense plaques in the ear what could that indicate? What type of glaucoma is caused by a decrease in absorption of the aqueous humor? What does a chalky white TM or redness mean? What causes peripheral cataracts? Pathophysiology of cataracts When assessing the mouth what are some things that you should be looking for? What else would you want to know on a history of a patient that comes in with lesions or mouth sores? What does a Herpes lesion look like? 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? A patient has xanthelasma on their eyes what is this caused by? Differential diagnosis of thickened white patch on the lateral or ventral surface of the tongue in a pt with HIV? Claudicationa 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 […]<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"site-sidebar-layout":"default","site-content-layout":"","ast-site-content-layout":"default","site-content-style":"default","site-sidebar-style":"default","ast-global-header-display":"","ast-banner-title-visibility":"","ast-main-header-display":"","ast-hfb-above-header-display":"","ast-hfb-below-header-display":"","ast-hfb-mobile-header-display":"","site-post-title":"","ast-breadcrumbs-content":"","ast-featured-img":"","footer-sml-layout":"","ast-disable-related-posts":"","theme-transparent-header-meta":"","adv-header-id-meta":"","stick-header-meta":"","header-above-stick-meta":"","header-main-stick-meta":"","header-below-stick-meta":"","astra-migrate-meta-layouts":"default","ast-page-background-enabled":"default","ast-page-background-meta":{"desktop":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"ast-content-background-meta":{"desktop":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"tablet":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""},"mobile":{"background-color":"var(--ast-global-color-5)","background-image":"","background-repeat":"repeat","background-position":"center center","background-size":"auto","background-attachment":"scroll","background-type":"","background-media":"","overlay-type":"","overlay-color":"","overlay-opacity":"","overlay-gradient":""}},"footnotes":""},"categories":[25],"tags":[],"class_list":["post-114924","post","type-post","status-publish","format-standard","hentry","category-exams-certification"],"_links":{"self":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/114924","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/comments?post=114924"}],"version-history":[{"count":0,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/posts\/114924\/revisions"}],"wp:attachment":[{"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/media?parent=114924"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/categories?post=114924"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.learnexams.com\/blog\/wp-json\/wp\/v2\/tags?post=114924"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}
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).<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
presence of perceived flashes of light. (Most commonly associated with posterior vitreous detachment, migraine with aura, retinal break, or detachment).<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
condition characterized by elevated plaque of cholesterol; commonly found on the nasal portion of the eyelid.<\/p>\n\n\n\n
The optic nerve is assessed by testing for visual acuity and peripheral vision.<\/p>\n\n\n\n\n
The Rosenbaum near vision card is intended to measure
near acuity at a distance of 14″ ( 36 cm) from the patient.
Preparation:<\/p>\n\n\n\n\n
glasses)
Recommended Process:<\/li>\n<\/ul>\n\n\n\n\n
eye).<\/li>\n\n\n\n
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.<\/li>\n\n\n\n
appropriate for that line (if read correctly). Record as the
right eye.<\/li>\n\n\n\n
eye.<\/li>\n\n\n\n
at half the distance and record the results.<\/li>\n\n\n\n
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.<\/li>\n<\/ol>\n\n\n\n
Examine visual fields by confrontation by wiggling fingers 1 foot from pt’s ears, asking which they see move.<\/p>\n\n\n\n\n
\u25cf observe the pupils’ size and shape. They should be round, regular, and equal in size.
\u25cf test the pupils’ response to light directly and consensually. The pupils should constrict simultaneously.
\u25cf 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.
\u25cf 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:
\u25cf Miosis (pupillary constriction to less than 2mm)
\u25cf Mydriasis (pupillary dilation)
\u25cf Failure to respond (constrict) with increased light stimulus
\u25cf Argyll Robertson pupil (irregularly shaped pupils that fail to constrict light but retain constriction with convergence)
\u25cf Anisocoria (unequal size of pupils)
\u25cf Iritis constrictive response
\u25cf Oculomotor nerve CN III damage (pupil dilated and fixed, eye deviated laterally and downward; ptosis)
\u25cf Adie pupil (tonic pupil). The affected pupil dilated and reacts slowly or fails to react to light; responds to convergence<\/p>\n\n\n\n
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.<\/p>\n\n\n\n\n
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.<\/p>\n\n\n\n
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.”<\/p>\n\n\n\n
Aortic sclerosis–a marker of coronary atherosclerosis. \u2026 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.<\/p>\n\n\n\n
when leaflets, which are thickened\/narrow—> restricts blood flow<\/p>\n\n\n\n
when valves lose competency\/leak, blood flows backwards<\/p>\n\n\n\n
Right side heart failure<\/p>\n\n\n\n
Caused by some disruption of blood flow, through, or out of the heart. Diseased valves are a common cause, not opening or closing well.<\/p>\n\n\n\n
Aortic stenosis:<\/p>\n\n\n\n
Heard best- left 2nd ICS
Radiation to the carotids.<\/p>\n\n\n\n
Diminished and delayed (“pulsus parvus and tardus”)
Sustained Apical impulse
Calcified aortic valve on CXR<\/p>\n\n\n\n
Heard best at the apex
Radiation to the axilla and inferior edge of left scapula.<\/p>\n\n\n\n
S3<\/p>\n\n\n\n
Heard best at the left 2nd ICS without radiation
May also hear systolic flow murmur and diastolic rumble (Austin Flint)<\/p>\n\n\n\n
Abnormal and collapsing arterial pulses<\/p>\n\n\n\n
Heard best at the LLSB without radiation
Intensity increases with inspiration or pressure over liver<\/p>\n\n\n\n
Systolic regurgitant neck vein
Systolic retraction of apical pulse
Edema, Ascites or both<\/p>\n\n\n\n
Heard best at 2nd-3rd ICS
Increases with inspiration<\/p>\n\n\n\n
Sustained pulmonary hypertension<\/p>\n\n\n\n
Heard best sternal border bat 2nd or 3rd intercostal spaces
Increases with inspiration<\/p>\n\n\n\n
Wide physiological splitting of S2
Prominent A wave of the jugular venous pulse<\/p>\n\n\n\n
Heard best at apex
Accentuated in left lateral decubitus position<\/p>\n\n\n\n
Irregular pulse ( atrial fibrillation)
Loud S1
Elevated neck veins with exaggerated A wave<\/p>\n\n\n\n
Heard best LSB
Increases with decreased venous return<\/p>\n\n\n\n
S4 (50% of the time)<\/p>\n\n\n\n
Systolic Murmur Grades<\/p>\n\n\n\n
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<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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:<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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—> \u25cf 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.
\u25cf 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.
\u25cf lt to distinguish from aortic stenosis on clinical grounds alone.
\u25cf 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.
\u25cf 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.
\u25cf 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.
\u25cf 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.
\u25cf litis, dissection and cardiac trauma.
\u25cf 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.
\u25cf 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.<\/p>\n\n\n\n
Peripheral Vision or visual fields<\/p>\n\n\n\n\n
History of Present Illness: details about the chief complaint
(OLD CARTS)
\u2022Onset
\u2014when did it start?
\u2022Location\/Radiation
\u2014where is it located?
\u2022Duration
\u2014how long has this gone on?
\u2022Character
\u2014does it change with any specific activities? Does the patient
use any descriptive words to describe the quality of the symptom?
\u2022Aggravating factors
-what makes it worse?
\u2022Relieving factors
-what makes it better?
\u2022Timing
\u2014is it constant, cyclic, or does it come and go?
\u2022Severity
\u2014how bothersome, disruptive, or painful is the problem?<\/p>\n\n\n\n
.<\/p>\n\n\n\n
Inspection<\/p>\n\n\n\n
Palpation<\/p>\n\n\n\n
and nasal tenderness
Percussion<\/p>\n\n\n\n
Mouth and Throat
Inspection<\/p>\n\n\n\n
, lesions, tenderness of floor of mouth<\/p>\n\n\n\n
, masses<\/p>\n\n\n\n
Gender (men are more at risk; women are at more increased risk in postmenopausal years and with oral contraceptive use)<\/p>\n\n\n\n
Lift or heaves- these are forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs.<\/p>\n\n\n\n\n
\n
a thrill could indicate aortic stenosis.<\/p>\n\n\n\n\n
a thrill could indicate pulmonic stenosis.<\/p>\n\n\n\n\n
\n
\n
\n
\n
\n
\n
a. S1 is accentuated in exercise, anemia, hyperthyroidism, and mitral stenosis.<\/p>\n\n\n\n
a. Normal physiological splitting of S2 is best heard at pulmonic area. It occurs on inspiration (lub-T-dub, lub-dub).<\/p>\n\n\n\n\n
\n
\n
This varies from low-pitched, caused by slow velocity of blood flow, to high pitched, caused by a rapid velocity of blood flow.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n\n
\n
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<\/p>\n\n\n\n
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<\/p>\n\n\n\n
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<\/p>\n\n\n\n\n
Cranial nerves III (oculomotor) IV (trochlear) and VI (abducens) and the six extraocular muscles.<\/p>\n\n\n\n
The patient can read letters while standing 20 feet from the chart that the average person could read at 30 feet.<\/p>\n\n\n\n
This link is a video of a great explanation. https:\/\/www.youtube.com\/watch?v=48XD7Z9_XXs<\/p>\n\n\n\n\n
0: Absent, not palpable
1: Diminished, barely palpable
2: Expected
3: Full, increased
4: Bounding, aneurysmal<\/p>\n\n\n\n
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<\/p>\n\n\n\n
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<\/p>\n\n\n\n
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<\/p>\n\n\n\n
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<\/p>\n\n\n\n
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<\/p>\n\n\n\n
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).<\/p>\n\n\n\n\n
o heard loudest over the apex
o synchronous with carotid pulse<\/li>\n\n\n\n
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.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
Rinne test – uses a tuning fork to assess bone and air conduction<\/p>\n\n\n\n
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.<\/p>\n\n\n\n\n
\n
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.<\/p>\n\n\n\n
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<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
Nearsightedness caused by light refractive error placing light in front of retina.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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<\/p>\n\n\n\n
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<\/p>\n\n\n\n
ave pt tilt head to opposite shoulder, gently pull auricle up and back while inserting speculum<\/p>\n\n\n\n
Fine, palpable sensation.<\/p>\n\n\n\n
it is when the leaflet lose competency and started to leak, making the blood flow backward.<\/p>\n\n\n\n
Location where apocalypse pulse is most readily seen or felt.<\/p>\n\n\n\n
May indicate decreased left ventricular compliance<\/p>\n\n\n\n
onset, location, duration, characteristic, aggravating factors, relieving factors, temporal factors, severity<\/p>\n\n\n\n
4th left ICS to sternal border<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
Hemorrhages, Cotton wool spots<\/p>\n\n\n\n
Cotton wool spots, hemorrhage, narrowed retinal arteries, AV nicking<\/p>\n\n\n\n
Lift or heaves- these are forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs.<\/p>\n\n\n\n
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<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
This type of hearing loss is sometimes referred to as sensory, cochlear, neural or inner ear hearing loss.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
-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<\/p>\n\n\n\n
-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.<\/p>\n\n\n\n
To evaluate eye fixation if you find imbalance with corneal light reflex test<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
when obtaining a history for a deaf patient who
can read lips?
speaking slowly<\/p>\n\n\n\n
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.<\/p>\n\n\n\n
interview?
Use an open-ended approach; let the patient explain the problem or reason for the visit.<\/p>\n\n\n\n
inaccurate patient response?
“That was a horrible experience, wasn’t it?”<\/p>\n\n\n\n
confirm an accurate understanding.<\/p>\n\n\n\n
worthless and having a sleep disturbance for the
past 3 weeks. These are clues that warrant the exploration
of
risk for suicide<\/p>\n\n\n\n
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<\/p>\n\n\n\n
issue, such as drug use, it is best to
be direct, firm, and to the point<\/p>\n\n\n\n
obtain or clarify specific details about an answer<\/p>\n\n\n\n
feelings, such as hostility and prejudice, in order to
reduce communication barriers<\/p>\n\n\n\n
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.”<\/p>\n\n\n\n
examiner to be successful in
recognizing and accepting health beliefs that differ from his or her own beliefs.<\/p>\n\n\n\n
wellness is a concept that
is believed by members of many cultures, including
Arabs, Asians, Filipinos, and Hispanics.<\/p>\n\n\n\n
allows the practitioner to
understand the behaviors, practices, and problems observed<\/p>\n\n\n\n
characteristic?
shared belief<\/p>\n\n\n\n
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?<\/p>\n\n\n\n
is to?
stereotype individuals based on color or ethnic group<\/p>\n\n\n\n
affect health care except
eye color, temperature, and visual acuity<\/p>\n\n\n\n
as opposed to a cultural, characteristic?
Skin color<\/p>\n\n\n\n
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<\/p>\n\n\n\n
a patient whose cultural perspective differs from that
of the practitioner
maintaining firm and direct eye contact<\/p>\n\n\n\n
are currently recommended by the Centers for Disease
Control and Prevention (CDC)?
standard precautions<\/p>\n\n\n\n
skin. Which instrument should be used to examine
these lesions
ruler<\/p>\n\n\n\n
infection control practice differ from that in the acute care
setting?
Infection control practice is applicable in all healthcare settings.<\/p>\n\n\n\n
an appropriate examination technique
Detection of fluid within the sinuses<\/p>\n\n\n\n
with a simple nasal speculum to visualize the lower and middle turbines of the nose?
penlight<\/p>\n\n\n\n
has an obvious odor. Which examination technique is the examiner using in this scenario?
Inspection<\/p>\n\n\n\n
inspection<\/p>\n\n\n\n
examination and interview process
inspection<\/p>\n\n\n\n
sensitive to vibration
ulnar surface of the hand<\/p>\n\n\n\n
performing deep palpation?
4 cm<\/p>\n\n\n\n
tones, refers to
the loudness of the tone.<\/p>\n\n\n\n
skin. What part of the hand is best to use to palpate
this mass?
fingertips<\/p>\n\n\n\n
when examining the
abdomen<\/p>\n\n\n\n
affects the accuracy of auscultation?
Auscultating through clothing<\/p>\n\n\n\n
use of a stethoscope?
The bell is pressed lightly against the skin to
detect low-frequency sounds<\/p>\n\n\n\n
Doppler indicated
Auscultation of a nonpalpable pulse in a patient with peripheral vascular disease<\/p>\n\n\n\n
examiner observes a fundal lesion. What feature
on the ophthalmoscope permits the examiner to
estimate the size and location of the lesion?
grid light<\/p>\n\n\n\n
compensate for myopia or hyperopia in the
examiner’s or the patient’s eyes.<\/p>\n\n\n\n
Prevention, the health care provider should apply
infection control measures when caring for which
group of patients?
All patients regardless of their infectious status<\/p>\n\n\n\n
guide to determining the priority for the patient’s
condition should be based on
intuition<\/p>\n\n\n\n
testing, or procedures, the examiner knows that these
should be done
if they relate to the examiner’s hypothesis<\/p>\n\n\n\n
problem, the next step is to
determine the managment plan<\/p>\n\n\n\n
to the examiner because
it may become a substitute for critical thinking.<\/p>\n\n\n\n
the examiner should organize the data
by body systems<\/p>\n\n\n\n
critical thinking process, except for the examiner’s
objectivity (feelings, attitudes, and values could be barriers)<\/p>\n\n\n\n
Common problems occur commonly, and rare ones occur rarely<\/p>\n\n\n\n
develop a list of potential problems<\/p>\n\n\n\n
the best available scientific evidence to clinical
decision making.<\/p>\n\n\n\n
“skin color is normal”<\/p>\n\n\n\n
Document what was actually assessed in specific terms.<\/p>\n\n\n\n
Use only universally accepted abbreviations for documentation<\/p>\n\n\n\n
past 5 or 6 months. This would be documented in
Review of symptoms<\/p>\n\n\n\n
characteristic<\/p>\n\n\n\n
observe the eye with focused light tangentially<\/p>\n\n\n\n
inspecting movement of the eyes to the six cardinal fields of gaze<\/p>\n\n\n\n
Constriction should be noted as gaze shifts from across the
room to an object 6 inches away.<\/p>\n\n\n\n
Rosenbaum chart<\/p>\n\n\n\n
look directly into the light of the ophthalmoscope.<\/p>\n\n\n\n
“Although it can’t be prevented, regular screening
and testing assist in early detection.”<\/p>\n\n\n\n
Unilateral exophthalmos<\/p>\n\n\n\n
glaucoma<\/p>\n\n\n\n
Retinoblastoma<\/p>\n\n\n\n
Mrs. Carter is considered
legally blind<\/p>\n\n\n\n
Examine the patient’s right eye with your right eye and the pt’s left eye with your left eye<\/p>\n\n\n\n
allergic or infectious conjunctivitis<\/p>\n\n\n\n
lipemia retinalis<\/p>\n\n\n\n
III, IV, VI<\/p>\n\n\n\n
CN III<\/p>\n\n\n\n
anisocoria<\/p>\n\n\n\n
The patient hears the tone equally in both ears.<\/p>\n\n\n\n
“Have you been taking antibiotics lately?”<\/p>\n\n\n\n
The patient complains of pain over sinuses with palpation.<\/p>\n\n\n\n
3+<\/p>\n\n\n\n
“Food does not taste the same as it used to.”<\/p>\n\n\n\n
cocaine abuse<\/p>\n\n\n\n
riboflavin deficiency<\/p>\n\n\n\n
Class II malocclusion<\/p>\n\n\n\n
Maxillary toothache, purulent nasal drainage, poor response to decongestants<\/p>\n\n\n\n
Oral tissues may be dryer (xerostomia)<\/p>\n\n\n\n
xerostomia, Periodontal disease, Oral cancer, Aspiration pneumonia, fully edentulous<\/p>\n\n\n\n
Gingivitis, periodontal disease, dental caries, teeth may appear longer, Dental malocclusion<\/p>\n\n\n\n
Otitis media with effusion<\/p>\n\n\n\n
Otitis media with effusion<\/p>\n\n\n\n
Acute Otitis Media<\/p>\n\n\n\n
Acute Otitis Media<\/p>\n\n\n\n
Otitis Externa (Swimmer’s ear)<\/p>\n\n\n\n
Whisper, Weber, & Rinne<\/p>\n\n\n\n
sound heard equally in both ears<\/p>\n\n\n\n
air conduction (AC) greater than bone conduction (BC); 2:1 ration<\/p>\n\n\n\n
Cataracts
Age related macular degeneration
Diabetic retinopathy
Glaucoma<\/p>\n\n\n\n
Age related macular degeneration (AMD):<\/p>\n\n\n\n
Dry AMD progression\u2026<\/p>\n\n\n\n
Wet AMD<\/p>\n\n\n\n
progressive, chronic optic neuropathy in which intraocular pressure (IOP), disease of optic nerve where the nerve cells die<\/p>\n\n\n\n
Diabetic retinopathy<\/p>\n\n\n\n
symptoms are absent except for a gradual loss of peripheral vision over a period of years<\/p>\n\n\n\n
intense ocular pain, blurred vision, halos around lights, a red eye, and a dilated pupilo Occasionally: stomach pain, nausea, & vomiting<\/p>\n\n\n\n
Normal findings with elderly Conjunctiva<\/p>\n\n\n\n
Red reflex, vascular supply of the retina, optic disc and macula<\/p>\n\n\n\n
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<\/p>\n\n\n\n
examples of patient-centered questions<\/p>\n\n\n\n
professional interpreter, rather than a family member, should be used<\/p>\n\n\n\n
gives the patient discretion
about the extent of an answer<\/p>\n\n\n\n
to seeks specific information<\/p>\n\n\n\n
Rosenbaum (near vision) & Snellen (far vision)<\/p>\n\n\n\n
uneven pupils with HA, sudden loss of vision, floaters\/flashers<\/p>\n\n\n\n
“curtain” feeling, floaters or flashes<\/p>\n\n\n\n
Check intraocular pressure (tonometry); optic disc assessment, peripherial vision exam, whether intraocular drainage system is “open” or “closed” (gonioscopy)<\/p>\n\n\n\n
Bacterial- starts in one eye and spreads to the other, yellow\/ crusty drainage
Allergic- both eyes, puffy and\/ or runny<\/p>\n\n\n\n
red reflex<\/p>\n\n\n\n
blood vessel<\/p>\n\n\n\n
minus (red) len<\/p>\n\n\n\n
plus (green) lens<\/p>\n\n\n\n
Look at the outer structures of the ear then palpate<\/p>\n\n\n\n
Abnormal<\/p>\n\n\n\n
Otitis Externa, Otitis Media, Ear effusion, or foreign body in the ear<\/p>\n\n\n\n
Swimmers, breast\/ bottle fed children<\/p>\n\n\n\n
TM (whether it is perforated or not), cone of light, look at the canal (whether it is swollen or red, look for cerumen impaction)<\/p>\n\n\n\n
the preauricular and post auricular lymph nodes and mastoid area<\/p>\n\n\n\n
Mastoid infection or meningitis<\/p>\n\n\n\n
Place the base of the tuning fork against patients mastoid bone, ask patient to tell you when sound is no longer heard (bone conduction)<\/p>\n\n\n\n
Ear infection, Meniere’s disease, vertigo; Dix Hallpike maneuver (Head tilt and lay back maneuver)<\/p>\n\n\n\n
Check for HIV, syphilis, imunosuppression<\/p>\n\n\n\n
Herpes Simplex<\/p>\n\n\n\n
if they are a smoker or not<\/p>\n\n\n\n
optic neuritis<\/p>\n\n\n\n
Length of symptoms (to know whether to treat viral or bacterial)<\/p>\n\n\n\n
Clear rhinorrhea as opposed to purulent, throat irritation, POST NASAL DRIP<\/p>\n\n\n\n
midline<\/p>\n\n\n\n
Suspect a problem on the opposite side that the uvula deviates<\/p>\n\n\n\n
Peritonsillar abscess<\/p>\n\n\n\n
Start with open-ended and then narrow it down with straight forward questions<\/p>\n\n\n\n
cultural awareness<\/p>\n\n\n\n
DM, PVD and CV disease<\/p>\n\n\n\n
Glaucoma<\/p>\n\n\n\n
Glaucoma<\/p>\n\n\n\n
optic disc cupping<\/p>\n\n\n\n
Retinoblastoma<\/p>\n\n\n\n
healed inflammation<\/p>\n\n\n\n
Open angle<\/p>\n\n\n\n
middle ear infection (Acute otitis media)<\/p>\n\n\n\n
hypoparathyroidism<\/p>\n\n\n\n
denaturation of lens protein caused by aging<\/p>\n\n\n\n
color, lesions, tonsils, uvula, erythema, oral ulcers, teeth, tongue<\/p>\n\n\n\n
tobacco use, if immunocompromised, stress levels<\/p>\n\n\n\n
vesicular lesion<\/p>\n\n\n\n
retinal detachment<\/p>\n\n\n\n
abnormality of lipid metabolism<\/p>\n\n\n\n
sarcoma<\/p>\n","protected":false},"excerpt":{"rendered":"