1
Q
Purposes of the medical interview
A
- establish relationship
- acquire information (subjective) to promote health and well-being of patient
2
Q
Sections and Section Components of a Full Medical History
A
DATE AND TIME, ID (name, gender, age, source), RELIABILITY, CC, HPI (hloride-pac, medications with dose, route, name, indication, compliancy, allergies with specific reaction, smoking, drugs, alcohol - CAGE/TACE), PMH (child, adult, surgical, medical, psychiatric, health maintenance, OB/GYN - G(Pregnancies)P(full)(Preterm)(Abortions)(Living), FH (parents, siblings, kids - living status, genetic or chronic conditions, alcohol abuse), SH (sex, marital, occupation, exercise and diet, religion, access to care, support, race/ethnicity), ROS ( 4 questions per system)
3
Q
ROS Steps
A
General Skin HEENT Neck Breasts Respiratory Cardiovascular Gastrointestingal Peripheral Vascular Urinary Genital Musculoskeletal Psychiatric Neurological Hematologic Endocrine
4
Q
Steps for a successful interview
A
- Time for self-reflection
- review of medical record
- interview goals
- provider’s behavior and appearance
- adjusting the environment
5
Q
Sequence of interview
A
Greeting the patient and establishing rapport. Taking notes. Establishing the agenda for the interview. Inviting the patient’s story and exploring the patient’s perspective (FIFE -feelings, ideas, function, expectations). Identifying and responding to emotional cues. Expanding and clarifying the patient’s story (pursue the 7 attributes of a symptom). Generating and testing diagnostic hypotheses. Sharing the treatment plan. Closing the interview and the visit. Taking time for self-reflection.
6
Q
Active Listening
A
Process of closely attending to what the patient is communicating, awareness of the patient’s emotional state
7
Q
Guided Questioning
A
- move from open-ended to focused questions
- use questioning that elicits a graded response
- ask a series of questions, one at a time
- offer multiple choices for answers
- clarify what the patient means
- encourage with continuers
- use echoing (no bias)
8
Q
Nonverbal communication
A
- read the patient’s nonverbal clues and use these to gage how the patient is reacting to you
9
Q
Empathetic Responses
A
Capacity of the clinician to identify with the patient and feel the patient’s pain as the clinician’s own
10
Q
Validation
A
- affirmation of the patient by acknowledging the legitimacy of his/her emotional experience.
11
Q
Reassurance
A
- identify and acknowledge the patient’s feelings
- make sure the patient feels confident that problems have been fully understood and are being addressed
12
Q
Partnering
A
- be explicit about your commitment to an ongoing partnership/continued care
13
Q
Summarization
A
- summarize at points what you do and do not know
- communicates that you have been listening carefully
- good to do at times of transition
14
Q
Transitions
A
- make transitions clear to the patient during the interview to set them at ease
15
Q
Empowering the Patient
A
- evoke the patient’s perspective
- convey interest in the person, not just the problem
- follow the patient’s leads
- elicit and validate emotional content
- share information with the patient, especially at transition points during the visit
- make your clinical reasoning transparent to patient
- reveal limits of your knowledge
16
Q
Silent Patient
A
- be attentive and respectful, convey encouragement for the patient to continue, watch for nonverbal cues, consider changing your wording
17
Q
Confusing Patient
A
- don’t get frustrated or baffled
- focus on the meaning or function of a symptom
- consider a psychiatric disorder or AMS and instead pause to assess mental status
18
Q
Patient with Altered Capacity
A
- assess capacity to answer questions
- seek substituted consent to help with history/surrogate
19
Q
Talkative Patient
A
- don’t show impatience or exasperation
- give the patient a few minutes to talk, listen carefully, be supportive, and then focus on what seems to be most important to the patient
- can give a brief summary to focus the interview
20
Q
Crying Patient
A
- be supportive
- crying can be therapeutic
- ask if they need privacy if continues
21
Q
Angry/disruptive Patient
A
- accept their feelings and allow them to express (without joining in)
- alert the security staff if necessary
- do not argue or appear confrontational
- stay calm
22
Q
Patient with impaired vision/hearing
A
- impaired vision: shake hands to establish contact, orient to room, adjust light if needed, report anyone else in room
- impaired hearing: find out patient’s preferred method of communication, eliminate background noise, use visual cues
23
Q
Patient with limited literacy or cognitive abilities
A
- low literacy: assess patient’s ability to read, explore why reading is difficult, do not confuse with level of intelligence
- limited cognitive abilities: pay attention to schooling and ability to function independently, important sexual history, can turn to family or caregivers for information
24
Q
Patient that speaks a different language
A
- attempt to find non-family interpreter
- make questions short, clear, and simple
- speak directly to patient
- INTERPRET: introductions, note goals, transparency, ethics, respect beliefs, patient focus, retain control, explain, thanks
25
Three Dimensions of Cultural Humility
- Self-awareness: learn about your own biases
- Respectful communication: Work to eliminate assumptions on what is "normal," learn directly from your patients - they are experts on their culture and illness
- Collaborative partnerships - build your patient relationships on respect and mutually acceptable plans
26
Patient ID
name, age, gender (occupation, marital status)
27
Source
usually patient, can be family member/friend, medical record
28
CC
in patient's own words, what caused them to seek care
29
HPI
- provides a clear, complete, chronologic account of the problems prompting the patient to seek care
- amplifies chief complain and describes how each symptom developed
- includes patient's thoughts and feelings about the illness
- pulls in relevant ROS (pertinent positives and negatives)
- medications, allergies, smoking, alcohol that are frequently pertinent to present illness
30
CHLORIDE-PAC
Character, Location, Onset, Radiation, Intensity, Duration, Exacerbating, Palliative, Associated, Conception/Concerns
31
Significance of PMH and FH
- a good PMH and FH is significant in helping you form DD, identifying risk factors for chronic or inheritable disease, providing clues that may relate to the present illness
32
Social History
- occupation
- smoking (pack years - packs per day for how many years)
- drinking (clarify)
- recreational drug use
- diet and exercise
- sexual history (intimate partner violence - StressAfraidFriendsEmergencyplan), clinical issues relating to sex and sexuality, common medications causing sexual dysfunction
- spiritual history
- access to care
- sleep and rest
- functional assessment (ADLs)
- relationships
33
CAGE vs TACE questions
CAGE: Ever felt you should CUT down drinking? Have you been ANNOYED by criticism of drinking? Felt GUILTY about drinking? Had an EYE OPENER to steady your nerves/get rid of a hangover?
TACE (better for pregnant women): Tolerance, Annoyance, Cut down, Eye opener
34
Techniques for gathering Social and Sexual Histories
- establish report (confidentiality, private environment, reason for questions, timing, language, least to most sensitive, allow for questions)
- common false assumptions (all pts are currently sexually active, younger or older are not sexually active, married person is not have sex solely with spouse, etc.)
35
Extended vs Problem Focused ROS
- complete: all systems (at least 10 systems)
- extended - all related to the HPI plus between 2-9 additional systems
- Problem Focused: just systems reported
36
Purpose of Oral and Written Medical Communication
- communicate information about the patient
- demonstrate clinical reasoning
- utilization review
- quality assurance
- medico-legal record
- coding and billing
- academic instruction
37
Organize comprehensive history and PE as written on medical chart
- Extensive history (id, source, reliability, cc, hpi, pmh, fh, sh)
- ROS
- Assessment/Impression of patients H&P
- Plan of Evaluation/treatment/follow-up
38
General Survey
apparent state of health, level of consciousness, signs of distress, height, weight (body size), dress, grooming and personal hygiene, facial expressions, odors of body and breath, posture, gate, and motor activity
39
Normal and Abnormal Pulse
- normal is 50-90 bpm
| - abnormal: pulsus alternans, pulsus bisferiens, pulsus paradoxus
40
Normal and Abnormal Respirations
- normal: 14-20 per min (adults; up to 44 per min in infants)
- abnormal: bradypnea, sighing respiration, tachypnea, obstructive breathing, Cheyne-Stokes breathing, hyperpnea/hyperventilation, Ataxis breathing (Biot's breathing)
41
Normal and Abnormal Temperature
- oral: 98.6, fluctuates (in morning, low, late afternoon, higher)
- rectal temps .4-.5C or .7-.9F degress higher than oral
- axillary temps lower than oral by 1 degree (less accurate, takes awhile to register)
42
Normal and Abnormal Height and Weight (BMI)
- BMI: weight(kg)/height(m2) or (lbsx700)/inches/inches
- if >35, measure waist - risk for diabetes, hypertension, CV increases if waist is 35+ inches for women and 40+ for men
- underweight: <18.5
- normal: 18.5-24.9
- overweight: 25-29.9
- obesity: I (30-34.9), II (35.0-39.9), III or extreme obesity greater or equal to 40)
43
Abnormalities of the arterial pulse
- small, weak pulse: pulse pressure is diminished, feels thready (dehydration and heart failure)
- large bounding pulse: pulse very strong (anemia, hyperthyroidism, fever)
44
Abnormalities of Heart Rate and Rhythym
- bisferiens pulse: double systolic pulse (aortic regurgitation and L ventricular failure)
- pulsus alternans: variation in pulse amplitude with alternate beats due to changing systolic pressure (L ventricular failure)
- pulsus paradoxus: exaggerated decline in blood pressure during inspiration resulting in negative thoracic pressure (severe lung disease, constrictive pericarditis)
45
Abnormalities of Respiratory Rate and Rhythym
- bradypnea: slow breathing
- sighing respiration: breathing punctuated by frequent sighs (hyperventilation syndrome)
- Tachypnea: rapid shallow breathing
- Cheyne-Stokes Breathing: deep breathing alternate with apnea
- Obstructive breathing: COPD, expiration is prolonged because narrowed airways increase resistance to air flow
- Hyperpnea/hyperventilation: rapid deep breathing
- Biot's Breathing: ataxic breathing, unpredictable irregularity
46
Observations to make in skin, hair, and nail examination
- skin: moisture, texture, turgor, temperature, color, lesions
- hair: quantity, textures, distribution
- nails: growth, shape, thickness, color, texture, abnormalities (lines, clubbing, trauma, pitting)
47
Symptom vs Sign
Symptom: what patient tells you (subjective)
Sign: what you observe or get from labs (objective)
48
Sensitivity vs Specificity
Sensitivity: likelihood of having positive symptom if a particular condition is present
Specificity: if a symptom is absent, likelihood that you don't have the condition
49
Lesions (type, shape, distribution, arrangement, color)
- type: primary or secondary, acne, vascular, purpuric, benign, malignant
- shape: round, oval, polygonal, irregular, annular, serpiginous, iris, polycyclic, umbilicated
- arrangement: disseminated, scattered or diffuse, herpetiformed, linear, serpiginous, reticulated, zosteriform
- distribution: isolated, localized, regional, generally, symmetrical, site of pressure, exposed areas, intertriginous, folicular
- color: cyanosis, erythema, skin color, hypo/hyperpigment, verigated, brown pigmentation, loss of pigmentation, pallor (anemia), yellowing
50
Cyanosis
- increased concentration of deoxyhemoglobin in cutaneous blood vessels
- gives skin bluish cast
51
Erythema
- red hue, increased blood flow
52
Icterus/jaundice
- skin diffusely yellow
| - best seen in sclera
53
Induration
- hardening of an area of body as a reaction to inflammation, hyperemia, or neoplastic infiltration
- an area or part of the body that has undergone such a reaction
54
Turgor
- how quickly the fold of skin returns to place
55
Excoriation
- linear or punctuate erosions cause by scratching
56
Ecchymosis
- purple or purplish blue, fading to green, yellow, and brown with time
- variable in size, larger than petechiae, >3mm
- no effect from pressure
- often secondary to bruising or trauma, also seen in bleeding disorders
57
Hematoma
- central subcutaneous flat nodule seen in ecchymosis
58
Petechiae/Purpura
- deep red or reddish purple, fading away over time
- petechia: 1-3mm
- purpura are larger
- no effect from pressure
- may suggest bleeding disorder
59
Telangiectasia
- small dilated blood vessels on or near surface of skin
60
Macule
- small flat spot, up to 1cm (vs papule, elevated lesion up to 1 cm)
61
Patch
- flat spot, 1cm or larger
62
Plaque
- elevated lesion 1cm or larger
| - often formed by coalescence of papules
63
Cyst
- nodule filled with expressible material, liquid or semisolid
64
Pustule
- palpable elevation filled with pus (yellow proteinaceous fluid filled with neutrophils)
65
Ulcer
- deeper loss of epidermis and dermis, may bleed and scar
| - secondary skin lesion: depressed
66
Scale
- thin flake of dead exfoliated skin
| - secondary skin lesion (seen in overtreatment ,excess scratching, infection of primary lesions)
67
Vesicle
- palpable elevation up to 1cm, filled with serous fluid
68
Bulla
- palpable elevation 1 cm or larger, filled with serous fluid
69
Wheal
- somewhat irregular, relatively transient, superficial area of localized skin edema
70
Nodule
- knot-ilke lesion larger than .5 cm, deeper and firmer than a papule
71
Exudation (dry vs wet)
- fluid leaking into lesions on skin
| - clear, pus, blood, etc.
72
Erosion
- nonscarring loss of superficial epidermis, surface is most but doesn't bleed
- secondary skin lesion: depressed
73
Scar
- increased connective tissue that arises from injury or disease
- secondary skin lesion (seen in overtreatment, excess scratching, infection of primary lesions)
74
Lichenification
- visible and palpable thickening of epidermis and roughening of skin with increased visibility of the normal skin forrows (often from chronic rubbing)
- secondary skin lesion (seen in overtreatment ,excess scratching, infection of primary lesions)
75
Classification of stages of ulcer pressure
Stage I: reddened area that fails to blanche with pressure and changes in temp, consistency, sensation, or color
Stage 2: blister or sore, partial thickness skin loss or ulceration involving epidermis, dermis, or both
Stage 3: crater with full-thickness skin loss and damage to or necrosis of subcutaneous tissue that may extend to, but not through underlying muscle
Stage 4: pressure ulcer deepens, full thickness skin loss with destruction, tissue necrosis, or damage to underlying muscle, bone, and sometimes tendons and joints
76
Clubbing
- bulbous swelling of the soft tissue at the nail base
- loss of normal angle between nail and proximal nail fold
- nail beds feel spongy or floating
- possibly from hypoxia
- changes in innervation
- genetics
- platelet derived growth factor from fragments of platelet clumps
77
Paronychia
- superficial infection of proximal and lateral nail folds adjacent to nail plate
- nail folds are often red, swollen, and tender, usually from Staph aureus and Strep species
78
Onycholysis
- painless separation of the whitened opaque nail plate from the pinker translucent nail bed, starts distally then progresses proximally enlarging the free edge of the nail
- causes include: trauma, psoriasis, fungal infection, allergic reactions, diabetes, anemia, hyperthyroidism, peripheral ischemia, bronchiectasis, syphilis
79
Leukonychia
- trauma to nails followed by non-uniform white spots that grow slowly out with the nail, typically from vigorous manicuring
80
Be able to Identify structures of the eye
lid, conjunctiva, lacrimal ducts, pupil, iris, cornea, sclera, limbus, medial and lateral canthus, anterior chamber, posterior chamber, lens, vitreous body, fundus, optic disc, blood vessels, retina, macula, fovea centralis (see pictures in book)
81
Cranial Nerves that Innervate the Eye
- CN II Optic: SL for direct light reflex and consensual light reflex, SL for near point retraction
- CN III Oculomotor: medial rectus (direct gaze medially), superior rectus (medial and superior), inferior rectus (lateral and superior), leviator palpabrae superiorus (raises eyelids), ciliaris, ML of direct light reflex, consensual light reflex, and near point reaction, sphincter pupillae (parasympathetic control, constricts pupil)
- CH IV Trochlear: superior oblique (medial and inferior)
- CN V Trigeminal: SL for palpebral conjunctiva of upper eyelid, bulbar conjuntiva, corneal epithelium, SL of corneal reflex
- CN VI Abducens: lateral rectus (laterally)
- CN VII Facial: orbicularis oculi (closes eyes), lacrimal gland, ML of corneal reflex
82
Components of the Visual Pathway
retina (occlusion of branch of retinal artery - horizontal defect) --> optic nerve (blind eye ipsalateral to lesion of optic nerve)--> optic chiasm (lesion, bitemporal hemianopsia) --> optic tract (contralateral homonymous hemianopsia)--> optic radiation (contralateral homonymous hemianopsia or homonymous contralateral quadratic defect for partial lesion)--> visual cortex
83
Components and Structures for Assessing Visual Acuity
- Snellen eye chart positioned 20 ft away; determine smallest line of print from which the patient can read more than half the letters
84
Components and Structures for Assessing Visual Fields
- confrontation: static finger wiggle test (pt looks directly into your eyes, place hands 2 feet apart lateral to patient's ears; wiggle fingers while bringing your hands forward and inward; ask patient to tell you when they see your fingers; further testing done covering one eye at a time)
85
Components and Structure for Assessing EOM (extra ocular movements)
- corneal reflection test: shine light into patients eye from 2 ft away and inspect reflections in cornea; both should be slightly nasal to center of pupils (if on temporal side of cornea, may indicate deviation from normal alignment)
- ask patient to follow finger in H formation with their eyes, can't move head
86
Appropriate Technique for assessing direct and consensual reaction
- shine light into one eye, assess pupil for constriction (direct light reflex); repeat in same eye but look at other eye for pupil constriction (consensual light reflex)
- -> repeat for other eye
87
Appropriate Technique for assessing accomodation
- accommodation: adjustment of eye for distance (focus on image of an object on retina by changing curvature of the lens)
- bring object far away and in to patient's nose (lens thickens - changes shape to accommodate for movement of the object)
- convergence: alignment of optic axes, can be observed during accommodation test
88
PERRLA
pupils are equal round and reactive to light and accomodation
89
Findings of the swinging flashlight test
- note size of pupils in dim light
- swing light into one pupil, then other
- in normal eye, have normal consensual light reflex
- in eye with optic nerve damage, when a light shines into the damaged eye, neither pupil will constrict
90
Findings of the cover/uncover test
- assess for strabismus
- cover one eye, look with other eye at something for a minute
- uncover eye, if eye that has been covered deviates, than it has a weakening of the muscle (strabismus)
91
Characteristics of Fundoscopy
- optic disc: yellowish orange to creamy pink oval or round structure that may fill your field of gaze
- margin: should be sharp, nasal portion of the disc margin may be somewhat blurred (normal)
- color: yellowish orange to creamy pink, white or pigmented crescents may ring the disc (normal)
- physiologic cup: if present, yellowish white, horizontal diameter less than half that of the disc, located centrally/somewhat temporally, conspicuous or absent
- blood vessels (arteries are light red, smaller, and bright to light reflex; veins are dark red, larger and inconspicuous or absent to light reflex)
- AV nicking: vein appears to stop abruptly on either side of the arter
92
Red Reflex
- shine ophthalmoscope into a patient's eye when you pass over the pupil - pupil looks read instead of black (with cataracts may look opaque)
93
Light Reflex
- constriction of pupils when a light is shined on them (PERRLA)
94
Corneal Reflex
- tests SL of CN V and ML of CN VII
| - blinking eyes when cornea is stimulated by cotton is normal response
95
Hyperopia
farsightedness
96
Myopia
nearsightedness
97
Presbyopia
- impaired near vision
- middle-aged and elderly
- sees better when testing care is farther away
98
Argyll Robertson Pupil
- small, irregular pupils that accommodate but do not react to light
- central nervous system syphilis
99
Lid Lag
- hyperthyroidism
| - patient follows finer as it moves up and down in the midline - lid will overlap iris during this movement
100
Nystagmus
- fine rhythmic oscillation of the eyes
- few beats are normal on extreme lateral gaze
- associated with disorders of labyrinth or cerebellar systems, drug toxicity, impaired vision in early life
101
Strabismus
- misalignment of eyes due to a weak EOM
102
Ectropion
- margin of lower lid in turned outward
- exposing the palpebral conjunctiva
- eye no longer drains well and tearing occurs
- more common in elderly
103
Entropion
- more common in elderly
| - inward turning of lid margin so that lower lashes irritate conjunctiva and lower cornea
104
Pterygium
- triangular thickening of the bulbar conjunctiva that grows slowly across the outer surface of the cornea, usually from nasal side
- reddening may occur
- may interfere with vision (as it encroaches on pupil)
105
Hordeolum
- aka stye
| - painful, tender, red infection in a gland at the margin of the eyelid
106
Chalazion
- subacute, nontender
| - usually painless nodule involving blocked meibomian gland
107
Pinguecula
- harmless yellow triangular nodule in bulbar conjunctiva on either side of iris
- appears frequently with aging
- first on nasal then on temporal side
108
Papilledema
- swelling of optic disc and anterior bulging of physiologic cup
- caused by elevated intracranial pressure --> traaxonal edema along optic nerve --> engorgement and swelling of the optic disc
109
Glaucoma
- increased pressure within eye --> increased cupping (backward depression of disk) and atrophy
110
Exophthalmos
- protrusion of eyeball
| - common in Grave's Opthalmopathy
111
Arcus Senilis
- thin grayish white arc/circle not quite at the edge of the cornea
- common in older patients
- usually benign
112
Anisocoria
- unequal pupils
| - causes: trauma to eye, glaucoma, Horner's Syndrome, tonic pupil, CN III paralysis
113
Cataracts
opacities of the lens visible through the pupil
114
Retinopathy (diabetic and hypertensive)
- Diabetic: retinal microaneurysms, retinal hemorrhage, cotton wool patches, areas of new vascularization (new arteries and veins) that can become fibrous/put pt at risk for decreased visual acuity
- Hypertensive: marked arteriolar-venous crossings, changes (AV nicking, tapering, banking), copper wiring of the arterioles, cotton-wool spots, punctate exudates that are scattered or can form macular scar
115
Horner's Syndrome
- affected pupil reacts briskly to light and near effort
- ptosis of eyelid present
- perhaps with loss of sweating on forehead
116
Bones of Skull
- frontal, parietal, temporal, occipital, maxilla, mandible, zygomatic
117
Structures of Surface Anatomy of Face
see pictures in Bates
118
Normocephalic
- head of medium length; skull with cephalic index 75-80 and capacity of 1350-1450mL
119
Microcephalic
small head size
120
Macrocephalic
abnormally large shaped head
121
Atraumatic
without trauma
122
Facial asymmetry
non-symmetrical face
123
Bell's Palsy
- lesion of CN VII
- inability to control facial muscles on that side
- diagnosis if no specific cause can be found
124
Ptosis
- drooping of upper lid
- causes: myasthenia gravis, damage to oculomotor nerve, damage to sympathetic nerve supply (Horner's syndrome)
- may be congenital
- weakened muscle, relaxed tissues, and weight of herniated fat may cause senile ptosis
125
Identify External and Internal Ear Structures
auricle, helix, antihelix, lobule, tragus, external canal, short process of malleus, umbo, cone of light, handle of malleus, pars tensa, pars flaccid
126
Functions of the 2 Branches of CN VIII
- Vestibular: balance
| - Cochlear: hearing
127
Weber test
- tests for lateralized hearing loss that is conductive in nature
- conductive loss lateralizes to bad ear
- sensorineural loss lateralizes to good ear
128
Rinne Test
- compares air conduction of sound to bone conduction
- AC > BC in normal conditions
- if BC>AC, sensorineural loss
129
Gross Hearing
- brisk finger rub
- whispered words
- stand two feet away
- Bates suggest pt occludes one ear by briskly rubbing fingers so pt cannot hear whispered voice
130
Anatomy of Nose and Paranasal Sinuses
nasal bridge, ala nasi, anterior nares, vestibule, septum, turbinates, facial, maxillary, ethmoid, mastoid sinuses
131
Techniques to assess nose
Inspection: note asymmetry, redness, swelling, lesions, patency; with otoscope: septal deviation or perforation, polyps, ulcers, bleeding, color, swelling exudate (tilt head slightly back, insert speculum into vestibule avoiding septum)
Palpation: frontal and maxillary sinuses
No percussion
No auscultation
132
Technique to assess olfactory nasal function
- assess bilateral patency
| - occlude one nostril, present familiar irritating odor and ask for identification
133
Patency
open-ness
134
Rhinorrhea
running nose
135
Epistaxis
bloody nose
136
Nasal polyps
pale sac-like growths on inflamed tissue
137
Anatomy of Mouth and Throat
gingiva, buccal mucosa, uvula, anterior pillars, posterior pillars, tonsils, Wharton's duct, Stenson's duct, hard palate, soft palate, pharynx; see Bates
138
Proper techniques to access oral pharyngeal cavity
- open mouth without protruded tongue; use tongue blade on midpoint of arch if necessary; bright light
- "ahh" test for vagus nerve (CN X)
139
Appropriate techniques for assessing CN IX, X, XII
- CN IX and X palsy: uvula deviation away from side of lesion
- CN XII: as ask pt to stick out tongue in midline, move tongue side to side to look for ability to protrude tongue in midline, fre emovment of tongue from side-to-side, fasciculations; palsy: tongue deviates to side of lesion
140
Describe health appearance of mouth and throat
- lips: pink, symmetrical, free of ulcers, fissures, masses
- teeth: 32 adult teeth including wisdom, each rooted in bony socet with enamel crown exposed, free of caries
- gums/gingiva: firmly attached to teeth and maxilla and mandible; lighter people (pale, coral pink, lightly stippled), darker people (diffusely or partly brown); labial frenulum connects lips to gingiva
- oral mucosa: pink, moist, free of ulcers, white patches, nodules; opening on parotid duct on cheek bilaterally
- tongue: symmetrical, papillae intact, pink, lingual frenulum intact, ducts of submandibular present under tongue, note fasciculations, nodules, ulcers
- tonsils: anterior and posterior pillars are curtains around tonsils; pink; free of exudate; crypts in tonrisl are normal and may collect food (or catch in normal exfoliating epithelium); normal size is +1
- oropharynx: pink, uvula midline, no deviations with "ahh," free of exudate, swelling and nodules
141
Anatomy of Neck
sternocleidomastoid muscles, trapezius muscle, trachea, thyroid cartilage, cricoid cartilage, thyroid gland, lymphatics, see Bates
142
Techniques to assess ROM in neck
- flex: chin to chest
- extend: tilt head back
- rotate: look left/right
- lateral bend: touch ear to shoulder
143
Techniques to assess thyroid gland
(posterior technique)
- flex neck slightly
- feel below cricoid cartilage for isthmus (ask pt to swallow to bring isthmus up to fingers)
- displace trachea to R with L hand
- palpate R lobe of thyroid with R hand
- repeat for L lobe
144
Techniques to assess lymphatics
- assess location, size, shape, delimitation, mobility, consistency, presence/absense of tenderness
145
Techniques to assess CN XI
- innervation of trapezius and sternocleidomasatoid
- bilateral muscle strength: trapezius (try to raise shoulders against resistance) and sternocleidomastoid (L/R rotation of neck against resistance)
146
Size, shape, and symmetry of neck and trachea
- size: look for swelling, goiter, abnormally large lymph nodes
- shape: symmetrical, anterior and posterior triangles
- symmetry: trachea at midline, thyroid lobes same size, neck symmetrical
147
Thyroid gland
- size: enlarged thyroid is GOITER (listen for bruit)
- shape: butterfly shaped
- symmetry: spaces between trachea and SCM should be one finger width and should be symmetrical; lobes symmetrical in size (enlargement can be diffuse, single nodule or multinodular)
- tenderness: soft in Grave's disease, firm in Hashimoto's thyroiditis, tenderness in thyroiditis
- nodules: may be benign or malignant
- mobility: will move up with swallowing
148
Lymph nodes
preauricular, post auricular, occipital, submental, submxillary, superficial cervial, posterior cervical, deep cervical, supraclavicular; see Bates
149
5 characteristics to assess lymph nodes
- size
- shape
- delinitation (discrete or matted together)
- consistency
- tenderness
- normal: small, mobile, nontender nodes
150
Keloid
- excessive scar tissue build-up (beyond the sight of injury), feels rubbery and bulbous
- vs sebaceous cyst: firm but water balloon, fluid filled
151
Tophi
- uric acid deposits
- hard nodules/crystals, white, chalky in helix/antihelix
- patients with gout (skin manifestation of gout)
152
Rheumatoid nodules
- chronic rheumatoid arthritis
- small lumps at helix or antihelix
- may appear on hands, along ulnar surface distal to elbow, knees, heels
153
Perforated Ear Drum
- hole in TM
- central vs marginal
- cause: trauma/chronic OM, naturally occurring or on purpose
- hearing can still work, just not work as well
- serves to equalize pressure
154
Tympanosclerosis
- chalky white deposits on TM, irregular margins
- indicates history of chronic ear infections
- can cause conductive hearing loss (if it involves bones - bones can't move)
- can occur within middle ear cavity
155
Serous Effusion
- cause: viral URI or sudden atmospheric changes (flying or diving)
- eustachian tubes can't equalize; air is absorbed from middle ear into bloodstream and serous fluid accumulates
- fullness, popping, sensations, conduction hearing loss, pain
- fluid level and sometimes air bubbles can be seen
156
Otitis Media
- TM is red, loses landmarks, bulges laterally
- most common in children
- no movement with air puff because stuff behind the TM
- usually bacterial infection of middle ear, may be accompanied by purulent effusion
- earache, fever, hearing loss (Conductive)
157
Angular chelitis
- fissuring of angles of mouth
- maybe due to nutritional deficits (often)
- or due to mechanical issues (overclosure, over stretching)
- common to get fungal infections in corners of mouth for immunocompromised
158
Herpes simplex
- due to HSV
- S and S: prodromal pain (little bit of itching before they pop up), small clusters of vesicles
- 7-14 days
- in children can be really bad
159
Angioedema
- subcutaneous or submucosal swelling from edema
1. Allergy: vascular permeability triggered by mast cells in allergic and NSAID reactions, urticaria (hives) and pruritis (itching); benign
2. Bradykinin: from ACE-inhibitors; can be lift threatening if spreads to airway (can develop into anaphylaxis)
160
Syphillis chancre
- ulcerated papule with indurated edge
- resemble carcinoma or crusty cold sole
- heal spontaneously, nonsuppurative (no pus)
- painless ulceration (chancre), unless infected with something else
- the great imitator
- 3-6 week incubating infection
- use gloves
161
Exudative tonsillitis
- red throat, white exudate
- fever, large cervical lymph nodes (group A strep if anterior lymph swollen, mononucleosis if posterior lymph swollen)
- exudates in craters (make sure not food)
- be aware of symptoms
162
Candidiasis
- thrush (yeast infection), may appear anywhere on mouth
- thick, white plaques, adherent
- prolonged treatment of abx or steroids, AIDS
* *differs from leukoplakia in that it has erythematous base and can be scraped off
163
Kaposi Sarcoma
- seen in patients with HIV
- cancerous tumor of endothelium - why it looks purplish
- lesions flat or raised
- don't forget to look on the roof of the mouth
- can be in GI tract and lungs
- antiretrovial therapy has decreased prevalence
164
Geographic tongue
- generally benign
- dorsum has scattered areas of smooth redness (no papillae) and regular pinkness (papillae)
- maplike pattern that can change over time
- may be sensitive in areas where papillae are missing
165
Hairy Tongue
- elongated papillae on dorsum of tongue
- yellowish/black
- sometimes occurs after antibiotics, candida infection, poor hygience
- etiology unknown
166
Tori Mandibulares
- benign bony growths sublingually/inner surfaces of mandible
- bilateral, asymptomatic, harmless
- generally occur in the patients 4th decade
- increase in size is gradual
- patients in their 30s
- looks different from cancer - coloration looks like normal skin, not irritated
167
Carcinoma of the floor of the mouth
- ulcerated lesion
| - surrounding mucosa is erythematous
168
Mental Health and the Interview
- open-ended questions initially
- careful psychiatric history
- if depression, always ask about suicide
169
Flat, non-palpable lesions with change in color
- macule: small flat spot up to 1.0cm
| - patch: flat spot, larger than 1.0cm
170
Palpable Elevations: Solid Bumps
- papule: elevated lesions up to 1cm
- plaque: elevated lesion larger than 1 cm, often merging of papules
- nodule: know like lesion >.5cm, deeper and firmer than papule
- cyst: nodule filled with liquid or semisolid
- wheal: irregular, transient, superficial area of localized skin edema
171
Palpable Elevations: With Fluid
- vesicle: palpable elevation up to 1cm filled with serous fluid
- bulla: larger than 1cm, filled with serous fluid
- pustule: elevated filled with pus
- burrow (scabies): slightly raised tunnel into epidermis, 5-15mm linear or curved gray line ending in a vesicle
172
Secondary Skin Lesions
- scale: thin flake of dead exfoliated epidermis
- crust: dried residue of skin exudates such as pus, blood
- lichenification: palpable thickening/roughening of epidermis, skin furrows
- scars: increased connective tissue arising from injury
- keloid: hypertrophic scarring extending beyond injury
- erosion: non-scarring loss of superficial epidermis, no blood
- excoriation: linear or punctuate erosions caused by scratching
- fissure: linear crack in skin from dryness
- ulcer - deeper loss of epidermis, may bleed and scar
173
Leukoplaki
- thick white patch/plaque (elevated)
- may occur anywhere, often on tongue
- WILL NOT scrape off
- may be due to local irritant
- may lead to cancer
- often seen in smokers
- seen more with HIV/AIDS patients at the beginning
174
Appropriate Techniques for Head Examination
- Inspection (hair - distribution, quantity, pattern of loss, infestation; scalp - lesions; skull - size, shape, proportion; facial - symmetrical movement, involuntary movement, edema, masses; sin - scars, lesions, color)
- NOT percussion
- Palpation (hair for texture and moisture; scalp for masses and tenderness; skull for deformity)
- NOT ascultation
175
Techniques for examining CN V in Head
- motor: muscles of mastication (chewing); palpate temporal and masseter muscles, have pt clench jaw and move side to side - feel for muscle contraction
- sensory: (1) light touch: pt closes eyes, stroke each branch (O,M, M) and ask patient to report if they feel it and if they feel it equally (2) Corneal Reflex (test of SL of V and ML of VII): pt look up and left, touch lateral sclera at edge of cornea using wet cotton; observe blink and repeat for other eye
176
Techniques for examining CN VII in Head
MOTOR: (1) observe mobility and facial asymmetry (2) pt raises eyebrows, smiles, frowns, puff out cheeks (3) Test for strength: pt closes eyes tightly and doesn't let you open them
SENSORY: taste on anterior 2/3 of tongue (we don't do this)
** Facial Nerve Palsy is Bells' Palsy
177
Appropriate Techniques for Assessing External Ear
- Inspection: (1) auricles: check position, size, symmetry, note deformities, nodules, swelling, redness and lesions (2) External Ear Canal: inspect canal patency, quantity of cerumen, note deformities, swelling, redness, lesions (3) inspect behind and around ear
- Palpation: simultaneously with inspection; palpate helix, anti-helix, tragus, lobe, mastoid area; check for tenderness, warmmth, nodules, ear pain with movement of external structures
- No percussion
- No auscultation
178
Appropriate Techniques for Assessing Internal Ear
- Inspection: with otoscope (choose largest speculum possible, pull pinna up back and out from head, insert speculum down and forward, inspect canal for cerumen, lesions, redness, swelling, exudate, TM for color, clarity, position, visibility of landmarks and ID cone of light, handle and short process of malleus, check pars flaccida and pars tensa for perforations)
- No Palpation
- No Perucussion
- No Auscultation
- Special test: pneumatic otoscopy to check for Tympanic Membrane Mobility
179
Proband versus consultand
Consultand: patient, presents for genetic counseling and through whom a family with an inherits disorder comes to medical attention, not necessarily affected
Proband: affected individual through whom family with a genetic disorder is ascertained, May or may not be Consultand
Clinical Assessment
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