NR 509New NR509 study guide Revised 2021/2022 latest update solution GRADED A+, Exams of Nursing

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NR509 Mid-Term Study Guide ¢ Articular structures include joint capsule and articular cartilage, the synovium and synovial fluid, intra-articular ligaments and juxta-articular bone 0 Articular disease involves: @ Swelling Tenderness of the joint Crepitus Instability “locking” Deformity Limits active and passive range of motion due to stiffness or pain ¢ Extra-articular structures include periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve and overlying skin 0 Extra-articular disease involves: m= “point of focal tenderness in regions adjacent to articular structures m Limits active range of motion m RARELY causes swelling, instability, joint deformity ¢ Nonarticular conditions: trauma/fracture, fibromyalgia, polymyalgia rheumatica, bursitis, tendinitis ¢ Intra-articular (acute, < 6 weeks): acute arthritis 0 infectious arthritis oO gout O pseudogout O Reiter syndrome ¢ Intra-articular (chronic, > 6 weeks): chronic inflammatory arthritis vs chronic noninflammatory arthritis 0 Chronic inflammatory arthritis with 1-3 joints involved: @ Indolent infection @ Psoriatic arthritis m Reiter syndrome @ Periarticular JA 0 Chronic inflammatory arthritis with >3 joints involved: m Psoriatic arthritis or Reiter syndrome (no symmetry) m= rheumatoid arthritis if not RA then [] systemic lupus, scleroderma, polymyositis ¢ CES (cauda equina syndrome) most commonly results from a massive herniated disc in the lumbar region. ¢ A single excessive strain or injury may cause a herniated disc. ¢ However, disc material degenerates naturally as a person ages, and the ligaments that hold it in place begin to weaken. As this degeneration progresses, a relatively minor strain or twisting movement can cause a disc to rupture. The following are other potential causes of CES: Spinal lesions and tumors Spinal infections or inflammation Lumbar spinal stenosis Violent injuries to the lower back (gunshots, falls, auto accidents) Birth abnormalities Spinal arteriovenous malformations (AVMs) Spinal hemorrhages (subarachnoid, subdural, epidural) Postoperative lumbar spine surgery complications Spinal anesthesia ¢ Sudden, painless vision loss that is unilateral ¢ The obtunded patient opens eyes and looks at you but responds slowly and is somewhat confused. Alertness and interest in the environment are decreased. * Cranial nerve VI: abducens * Medical illnesses: such as diabetes, hypertension, hepatitis, asthma, and HIV. Also hospitalizations, number and gender of sexual partners, and risk-taking sexual practices ¢ Surgical: dates, indications, and types of operations * Obstetric/Gynecologic: obstetric history, menstrual history, methods of contraception, and sexual function ¢ Psychiatric: illness and timeframe, diagnoses, hospitalizations, and treatments ¢ Absence of red reflex suggests an opacity of the lens (cataract), or possibly the vitreous (or even an artificial eye). ¢ Less commonly, a detached retina, or in children a retinoblastoma may obscure this reflex. * itching, watery eyes, sneezing, ear congestion, postnasal drainage ¢ Sudden visual loss that is unilateral and can be painful, associated with multiple sclerosis ¢ Oval lesions on trunk, in older children often in a Christmas tree pattern, sometimes a Harold patch (a large patch that appears first) ¢ Cherry angioma is a mole-like skin growth made up of small blood vessels or capillaries. * Most common type of angioma ¢ Benign tumors that result from an overgrowth of capillaries ¢ Rare for children to develop these noncancerous lesions ¢ Visual acuity is expressed as two numbers (e.g., 20/30): O First indicates the distance of the patient from the chart (20 feet), O Second, the distance at which a normal eye can read the line of letters m@ Vision of 20/200 means that at 20 feet the patient can read print that a person with normal vision could read at 200 feet. ¢ The larger the second number, the worse the vision. “20/40 corrected” means the patient could read the 20/40 line with glasses (a correction). A patient who cannot read the largest letter should be positioned closer to the chart; note the intervening distance. Preparation + Reviewing the Clinical Record O Provides important background information and suggests areas you need to explore * Setting goals O Before you talk with the patient, clarify your goals for the interview 0 The clinician must balance these provider-centered goals with patient-centered goals, weighing multiple agendas arising from the needs of the patient, the patient’s family, and health care agencies and facilities. * Reviewing your clinical behavior and appearance O Posture, gestures, eye contact, and tone of voice all convey the extent of your interest, attention, acceptance, and understanding. O Adjusting the environment 0 Private and comfortable Sequence of Interview * Greeting the patient and establishing rapport Oo Oo How you greet the patient and other visitors in the room, provide for the patient’s comfort, and arrange the physical setting all shape the patient’s first impressions. Greet the patient by name and introduce yourself, giving your own name. If possible, shake hands with the patient. Use a formal title to address the patient If you are unsure how to pronounce the patient’s name, don’t be afraid to ask. When visitors are in the room, acknowledge and greet each one in turn, inquiring about each person’s name and relationship to the patient. Let the patient decide if visitors or family members should stay in the room, and ask for the patient’s permission before conducting the interview in front of them Always be attuned to the patient’s comfort. + Establishing the agenda Oo Oo Oo Begin with open-ended questions that allow full freedom of response: “What are your special concerns today?”, “How can I help you?” Identifying all the concerns at the outset allows you and the patient to decide which ones are most pressing and which ones can be postponed to a later visit. Identifying the full agenda protects time for the most important issues. + Inviting the patient's story Oo Oo oO Invite the patient’s story by asking about the foremost concern, “Tell me more about...” Do not inject new information or interrupt. Instead, use active listening skills After the patient’s initial description, explore the patient’s story in more depth. Ask, “How would you describe the pain?”, “What happened next?”, or “What else did you notice ?” « Exploring the patient’s perspective Oo Oo The disease/illness distinction model helps elucidate the different yet complementary perspectives of the clinician and the patient Disease is the explanation that the clinician uses to organize symptoms that leads to a clinical diagnosis. Illness is a construct that explains how the patient experiences the disease, including its effects on relationships, function, and sense of well-being The clinical interview needs to incorporate both these views of reality. The melding of these two perspectives forms the basis for planning evaluation and treatment. FIFE ¢ The patient’s Feelings, including fears or concerns, about the problem ¢ The patient’s Ideas about the nature and the cause of the problem ¢ The effect of the problem on the patient’s life and Function . The patient’s Expectations of the disease, of the clinician, or of health care, often based on prior personal or family experiences * Identifying and responding to the patient’s emotional cues Oo Oo Check on these clues and feelings by asking, “How did you feel about that?” or “Many people would be frustrated by something like this.” Clues to patient’s perspective on illness Direct statement(s) by the patient of explanations, emotions, expectations, and effects of the illness Expression of feelings about the illness without naming the illness Attempts to explain or understand symptoms Speech clues (e.g., repetition, prolonged reflective pauses) Sharing a personal story Behavioral clues indicative of unidentified concerns, dissatisfaction, or unmet needs such as reluctance to accept recommendations, seeking a second opinion, or early return appointment O Learn to respond attentively to emotional cues using techniques like reflection, feedback, and “continuers” that convey support. A mnemonic for responding to emotional cues is NURSE: Name—‘“That sounds like a scary experience” Under- stand or legitimize—‘It’s understandable that you feel that way” Respect— “You've done better than most people would with this” Support—‘T will continue to work with you on this” Explore—“How else were you feeling about it? ¢ Expanding and clarifying the patient’s story You must diligently clarify the attributes of each symptom, including context, associations, and chronology. For pain and many other symptoms, understanding these essential characteristics, summarized as the seven attributes of a symptom, is critical. OLD CARTS, or Onset, Location, Duration, Character, Aggravating/ Alleviating Factors, Radiation, and Timing, or OPQRST, or Onset, Palliating/Provoking Factors, Quality, Radiation, Site, and Timing Whenever possible, repeat back the patient’s words and expressions ¢ Generating and testing diagnostic hypotheses You will generate and test diagnostic hypotheses about which disease process might be present. Identifying all the features of each symptom is fundamental to recognizing patterns of disease and to generating the differential diagnosis. It is important to fully flesh out the patient’s story. This First, open-ended questions to i <— hear “the story of the symptom” avoids the common in the patient's own words trap of premature closure, or shutting ‘Then more specific questions to <—— clicit “the seven features of every down the patient’s Sepa story too quickly Finally, the yes-no questions or Each symptom has ‘pertinent positives and negatives" 0 ” from the relevant section of the its own “cone review of systems FIGURE 3-8. Gather a full description of each symptom. . Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety ¢ Family history ¢ Outlines or diagrams age and health, or age and cause of death, of siblings, parents, grandparents, children, and grandchildren ¢ Documents present or absence of specific illnesses in family, Review each of the following conditions and record whether they are present or absent in the family: hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, allergies, or type of cancer ¢ Personal and social history . Describes educational level, family of origin, current household, personal interests, and lifestyle ¢ Review of systems ¢ Documents presence or absence of common symptoms related to each of the major body systems The Review of Systems General: Usual weight, recent weight change, clothing that fits more tightly or loosely than before; weakness, fatigue, or fever. Skin: Rashes, lumps, sores, itching, dryness, changes in color; changes in hair or nails; changes in size or color of moles. Head, Eyes, Ears, Nose, Throat (HEENT): Head: Headache, head injury, dizziness, lightheadedness. Eyes: Vision, glasses or contact lenses, last examination, pain, redness, excessive tearing, double or blurred vision, spots, specks, flashing lights, glaucoma, cataracts. Ears: Hearing, tinnitus, vertigo, earaches, infection, discharge. If hearing is. decreased, use or nonuse of hearing aids. Nose and sinuses: Frequent colds, nasal stuffiness, discharge, or itching, hay fever, nosebleeds, sinus trouble. Throat (or mouth and pharynx): Condition of teeth and gums, bleeding gums, dentures, if any, and how they fit, last dental examination, sore tongue, dry mouth, frequent sore throats, hoarseness. Neck: “Swollen glands,” goiter, lumps, pain, or stiffness in the neck. Breasts: Lumps, pain, or discomfort, nipple discharge, self-examination practices. Respiratory: Cough, sputum (color, quantity; presence of blood or hemoptysis), shortness of breath (dyspnea), wheezing, pain with a deep breath (pleuritic pain), last chest x-ray. You may wish to include asthma, bronchitis, emphy- sema, pneumonia, and tuberculosis. Cardiovascular: “Heart trouble’; high blood pressure; rheumatic fever; heart mur- murs; chest pain or discomfort; palpitations; shortness of breath; need to use pillows at night to ease breathing (orthopnea); need to sit up at night to ease (continued) * Patients complain of chronic shoulder pain, night pain, or catching and grating when raising the arm overhead The Review of Systems (continued) breathing (paroxysmal nocturnal dyspnea); swelling in the hands, ankles, or feet (edema); results of past electrocardiograms or other cardiovascular tests. Gastrointestinal: Trouble swallowing, heartburn, appetite, nausea. Bowel move- ments, stoal color and size, change in bowel habits, pain with defecation, rectal bleeding or black or tarry stools, hemorrhoids, constipation, diarrhea. Abdominal pain, food intolerance, excessive belching or passing of gas. Jaundice, liver, or gallbladder trouble; hepatitis. Peripheral vascular: Intermittent leg pain with exertion (claudication); leg cramps; varicose veins; past clots in the veins; swelling in calves, legs, or feet; color change in fingertips or toes during cold weather; swelling with redness or tenderness. Urinary: Frequency of urination, polyuria, nocturia, urgency, burning or pain during urination, blood in the urine (hematuria), urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain, incontinence; in males, reduced caliber or force of the urinary stream, hesitancy, dribbling. Genital: Male: Hernias, discharge from or sores on the penis, testicular pain or masses, scrotal pain or swelling, history of sexually transmitted infections and their treatments. Sexual habits, interest, function, satisfaction, birth control methods, condom use, and problems. Concerns about HIV infection. Female: ‘Age at menarche, regularity, frequency, and duration of periods, amount of bleeding; bleeding between periods or after intercourse, last menstrual period, dysmenorrhea, premenstrual tension. Age at menopause, menopausal symp- toms, postmenopausal bleeding. If the patient was born before 1971, exposure to diethylstilbestrol (DES) from maternal use during pregnancy (linked to cervical carcinoma). Vaginal discharge, itching, sores, lumps, sexually transmitted infec- tions and treatments. Number of pregnancies, number and type of deliveries, number of abortions (spontaneous and induced), complications of pregnancy, birth-control methods. Sexual preference, interest, function, satisfaction, any problems, including dyspareunia. Concerns about HIV infection. Musculoskeletal: Muscle or joint pain, stiffness, arthritis, gout, backache. If present, describe location of affected joints or muscles, any swelling, redness, pain, tenderness, stiffness, weakness, or limitation of motion or activity; include timing of symptoms (e.g., morning or evening), duration, and any history of trauma. Neck or low back pain. Joint pain with systemic symptoms such as fever, chills, rash, anorexia, weight loss, or weakness. Psychiatric: Nervousness, tension, mood, including depression, memory change, suicidal ideation, suicide plans or attempts. Past counseling, psycho- therapy, or psychiatric admissions. Neurologic: Changes in mood, attention, or speech; changes in orientation, memory, insight, or judgment; headache, dizziness, vertigo, fainting, black- outs; weakness, paralysis, numbness or loss of sensation, tingling or “pins and needles,” tremors or other involuntary movements, seizures. Hematologic: Anemia, easy bruising or bleeding, past transfusions, transfusion reactions. Endocrine: “Thyroid trouble,” heat or cold intolerance, excessive sweating, excessive thirst or hunger, polyuria, change in glove or shoe size. + Weakness or tears of the tendons usually start in the supraspinatus tendon and progress posterior and anterior * Look for atrophy of the deltoid, supraspinatus, or infraspinatus muscles. + Palpate anteriorly over the anterior greater tuberosity of the humerus to check for a defect in muscle attachment and below the acromion The scapulohumeral group rotates the shoul- der laterally (the rotator auff) and depresses and rotates the head of the Axioscapular group Scapulohumeral Levator scapulae homboids Trapezius Supraspinatus i. Infraspinatus Shoulder- shrugging effort humerus (Fig. 16-15) See pp. 653-654 for dis- cussion of rotator cuff injuries, FIGURE 16-15 groups. during arm rotation. Limited abduction Normal abduction ™ Latissimus dorsi ‘Scapulohumeral and axioscapular for crepitus * Ina complete tear, active abduction and forward flexion at the glenohumeral joint are severely impaired, producing a characteristic shrug of the shoulder and a positive “drop arm” test « Atrophy of the supraspinatus and infraspinatus with increased prominence of scapular spine can appear within 2 to 3 weeks of a rotator cuff tear; infraspinatus atrophy has a positive likelihood ratio (LR) of 2 for rotator cuff disease Empty can test. Elevate the arms to 90° and internally rotate the arms with the thumbs pointing down, as if emptying a can. Ask the patient to resist as you place downward pressure on the arms. Drop-arm test. Ask the patient to fully abduct the arm to shoulder level, up to 90°, and lower it slowly. Note that abduction above shoulder level, from go° to 120°, reflects action of the deltoid muscle. Inability of the patient to hald the arm fully abducted at shoulder level or control lowering the arm is a positive test for a suprasinatus rotator cuff tear, with a positive LR of 1.3. Weakness during this maneuver is a positive test for a supraspinatus rota- tor cuff tear or pital tendinitis, with a positive LR of 3.3. Risk Factors for Melanoma Personal or family history of previous melanoma*”> 250 common moles Atypical or large moles, especially if dysplastic Red or light hair Solar lentigines (acquired brown macules on sun-exposed areas) Freckles (inherited brown macules) Ultraviolet radiation from heavy sun exposure, sunlamps, or tanning booths Light eye or skin color, especially skin that freckles or burns easily Severe blistering sunburns in childhood Immunosuppression from human immunodeficiency virus (HIV) or from chemotherapy Personal history of nonmelanoma skin cancer ¢ Severe and sudden “worst headache of my life!” Nausea and vomiting can be present. Neck stiffness with resistance to flexion is present in 21-86% of patients ¢ Avoid interviewing a patient when she is already positioned for a pelvic exam ¢ Asudden brief lapse of consciousness, with momentary blinking, staring, or movements of the lips and hands but no falling. ¢ Two subtypes are typical absence (lasts less than 10 sec and stops abruptly) And atypical absence (may last more than 10 sec). Post ictal state: no aura recalled. In typical absence, there is a prompt return to normal and in atypical there might be some postictal confusion. * Cranial nerve X (Vagus) ¢ Papilledema of the optic disc [] elevated ICP causes intraaxonal edema along the optic nerve leading to engorgement and swelling on the optic disc 0 pink, hyperemic, loss of venous pulsations, disc more visible, disc swollen with blurred margins, physiologic cup not visible) ¢ Headache, blurred vision, feeling less alert than usual, vomiting, changes in behavior, weakness or problems with moving or talking, lack of energy or sleepiness ¢ Tachypnea: greater than or equal to 25 breaths/min [] pneumonia and cardiac disease * Cyanosis or pallor (signals hypoxia) ¢ Audible sounds of breathing: audible whistling during inspiration over the neck or lungs 0 stridor signals upper airway obstruction in the larynx or trachea * Contraction of the accessory muscles of the neck or supraclavicular retraction, contraction of the intercostal or abdominal oblique muscles 0 Is the trachea midline? ¢ What you detect during the examination, laboratory information, & test data. All physical exam findings, or signs. ¢ Trauma (especially nose picking), inflammation, drying and crusting of the nasal mucosa, tumors, and foreign bodies ¢ Painful movement of the auricle and tragus (tug test) Movement of the auricle and tragus (the “tug test”) is painful in acute otitis externa (inflammation of the ear canal), but not in otitis media (inflammation of the middle ear). Tenderness behind the ear occurs in otitis media. in acute otitis externa (Fig. 7-43), the canal is often swollen, narrowed, moist, pale, and tender. It may be reddened. ¢ Dullness replaces resonance, crackles can arise from abnormalities of the lung parenchyma, pleural rubs, localized bronchophony and egophony (in patients with fever and cough the presence of bronchial breath sounds and egophony more than triples the likelihood of pneumonia. ¢ Pleuritic pain: sharp, knifelike, aggravated by deep inspiration, coughing, movements of the trunk. Often persistent and severe. ¢ Pg 333: dyspnea, pleuritic pain, cough, sputum, fever. Pg. 339 goes over physical findings in lobar pneumonia Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers. Examples include: lobar pneumonia, in which the alveoli are filled with fluid and blood cells; and pleural accumulations of serous fluid (pleural effusion), blood (hemothorax), pus (empyema), fibrous tissue, or tumor. Dullness makes pneumonic and pleural effusion three to four times more likely, respectively. Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space beneath your percussing fingers. Examples include: lobar pneumonia, in which the alveoli are filled with fluid and blood cells; and pleural accumulations of serous fluid (pleural effusion), blood (hemothorax), pus (empyema), fibrous tissue, or tumor. Dullness makes pneumonic and pleural effusion three to four times more likely, respectively. Lobar Pneumonia (Consolidation) Alveoli fill with fluid, as in pneumonia Dull over the airless area Adventi Crackles (or Rales) Discontinuous © Intermittent, nonmusical, and brief ° Like dots in time © Fine crackles: soft, high-pitched (650 H2), very brief (5-10 ms) © Coarse crackles: somewhat louder, lower in pitch (~350 Hz), brief (15-30 ms) eecee Midline Bronchial over the involved area ious or Added Breath Sounds Wheezes and Rhonchi Continuous © Sinusoidal, musical, prolonged (but not necessarily persisting throughout the respiratory cycle) © Like dashes in time © Wheezes: relatively high-pitched (2400 Hz) with hissing or shrill quality (>80 ms) Whi © Rhonchi: relatively low-pitched (150-200 Hz) with snoring quality (>80 ms) www Source: Loudon R, Murphy LH. Lungs sounds, Am Rev Respir Dis. 199;130:663; Bohadana A, l2bicki G, Kreman SS. Fundamentals of lung auscultation. N Engl) Med. 2014;370:744. Late inspiratory crackles over the involved area Increased over the in- volved area, with egoph- ony, bronchopiny, and whispered pectoriloquy Crackles can arise from abnormalities of the lung parenchyma (pneumonia, interstitial lung disease, pulmonary fibrosis, atelectasis, heart failure) or of the airways (bronchitis, bronchiectasis). Wheezes arise in the narrowed air- ways of asthma, COPD, and bronchitis. Many clinicians use the term “rhonchi” to describe sounds fram secretions in large airways that may change with coughing. Neck stiffness with resistance to flexion is present in approx. 84% of patients with acute bacterial meningitis (won’t be able to touch chin to chest) Inflammation in the subarachnoid space causes resistance to movement that stretches the spinal nerves (neck flexion), the femoral nerve (Brudzinski sign), and the sciatic nerve (Kernig sign). Neck stiffness with resistance to flexion is found in ~84% of patients with acute bacterial meningitis and 21% to 86% of patients with subarachnoid hemorrhage. It is most reliably present in severe meningeal inflammation but its overall diagnostic accuracy is low. Its irregular patches seen at diabetic and hypertensive retinopathy FIGURE 7-32. Cotton-wool patches. Note the irregular patches, seen in diabetic and hypertensive retinopathy, between 11 and 12 o'clock, 1 to 2 disc diameters from the disc. Each measures about 2 by % disc diameters. ¢ Benign, no treatment required, resolves in 2 weeks , Leakage of blood outside the vessel producing homogenous red area. , no ocular discharge, vision not affected, Usually resulting from trauma, or sudden increase in venous pressure Conjunctivitis Subconjunctival Hemorrhage Pattern of — Conjunctival injection: diffuse dilatation Redness of conjunctival vessels with redness thar tends to be maximal peripherally Pain Mild discomfort rather than pain n Not affected except for temporary mild blurring due ro discharge Ocular ‘Watery, mucoid, or mucopumilent Discharge Pupil Not affected Cornea Clear Significance Racterial, viral, and other infections: highly contagious; allergy; irritation Leakage of blood outside of the vessels, producing a homogencous, sharply demarcated, red area that resolves over 2 weeks Absent Not affected Absent Not affected Clear Often none. May result from trauma, bleeding disorders, or sudden increase in venous pressure, as from cough ¢ It can be a cause for pain in the myocardium. A clenched fist over the sternum suggest angina pectoris A clenched fist over the sternum suggests angina pectoris; a finger pointing to a tender spot on the chest wall suggests musculoskeletal pain; a hand moving from the neck to the epigastrium suggests heartburn. Problem Process Location Quality Severity Cardiovascular Angina Temporary myocardial Retrosternal or across Pressing, squeezing, Mild to moderate, Pectoris ischemia, usually the anterior chest, often tight, heavy, sometimes perceived secondaty lo coronary radiates to the shoulders, occasionally burning — as discomfort rather atherosclerosis arms, neck, lower jaw, or than pain upper abdomen ¢ The decreased sense of smell is normal in elderly patients, head tr use and Parkinson’s d/e. auma, smoking, cocaine ¢ Testing the CN XI Spinal Accessory nerve. Put your hands on pt shoulder and ask them to shrug against your hands- asses for strength and contraction of trapezii. Weakness noted with atrophy and points to a peripheral nerve disorder. Cranial Nerve Xl—Spinal Accessory. Standing behind the patient, look for atrophy or fasciculations in the trapezius muscles, and compare one side with the other. Fasciculations are fine flickering irregular movements in small groups of muscle fibers. Ask the patient to shrug both shoulders upward against your hands (Fig. 17-14). Note the strength and contraction of the trapezii. FIGURE 17-14. Test trapezius strength. Trapezius weakness with atrophy and fasciculations points toa peripheral nerve disorder. In trapezius muscle paralysis, the shoulder droops, and the scapula is displaced downward and laterally. ¢ Reflex withdrawal of sympathetic tone and increased vagal tone causing a drop in BP and HR. ¢ Usually precipitated by strong emotions such as fear or pain, prolonged standing or hot humid environment. Predisposing factors — fatigue, hunger, dehydration, diuretics, vasodilators Vasovagal Syncope (The Common Faint) and Vasodepressor Syncope Mechanism pressure and heart rate Precipitating Factors Fo: vasovagal syncope: reflex withdrawal of sympathetic Stzong emotion such as fear or tone and increased vagal tone causing drop in blood, pair, prolonged standing, hot humid environment For vasodepressor syncope: same mechanism but no. vagal surge or drop in heart rate Baroreflexes normal Jugular: rarely palpable, soft bi-phasic undulating quality (usually with 2 elevations and characteristic inward deflection), pulsations eliminated by light pressure on the vein just above the sternal end of the clavicle, height of pulsation changes with position (normally dropping as the patient becomes more upright), height of pulsations usually falls with inspiration Carotid: palpable, a more vigorous thrust with a single outward component, pulsations not eliminated by pressure on veins at sternal end of clavicle, height of pulsations unchanged by position, height of pulsations not affected by inspiration Distinguishing Internal Jugular and Carotid Pulsations Internal Jugular Pulsations Rarely palpable Soft biphasic undulating quality, usu- ally with two elevations and charac- teristic inward deflection (x descent) Pulsations eliminated by light pressure on the vein(s) just above the sternal end of the clavicle Height of pulsations changes with position, normally dropping as the patient becomes more upright Height of pulsations usually falls with inspiration Carotid Pulsations Palpable Amore vigorous thrust with a single outward component Pulsations not eliminated by pressure on veins at sternal end of clavicle Height of pulsations unchanged by position Height of pulsations not affected by inspiration ¢ Ask the patient to sit up, lean forward, exhale completely, and briefly stop breathing after expiration. ¢ Press the diaphragm on your stethoscope on the chest and listen along the left sternal border and at the apex, pause periodically so the patient may breathe O You may miss the soft diastolic decrescendo unless you listen at this position Pg. 391 * Mitral valve ¢ Have the patient roll onto left lateral decubitus position which brings the left ventricle closer to the chest wall O Place bell of your stethoscope lightly on the apical impulse [] $3 & S4, mitral murmurs & mitral stenosis Aortic valve: sounds are heard in 2° intercostal space at right sternal margin Pulmonary valve: sounds are heard in 2° intercostal space at left sternal margin Mitral valve: sounds are heard over heart apex, in 51 intercostal space in line with middie of clavicle Tricuspid valve: sounds are typically heard in right sternal margin of 5% intercostal ‘space; variations include over sternum or over left ‘sternal margin in 5" intercostal space Perseveration is repetition of the words and phrases of others, occurs in schizophrenia and other psychotic disorders Erectile dysfunction may be from psychogenic causes, especially if early morning erection is preserved; it may also reflect decreased testosterone, decreased blood flow in the hypogastric arterial system, impaired neural innervation, and diabetes ee | ee Fibroadenoma: very mobile Cysts: mobile Cancer: may be fixed to skin or underlying tissues (may cause dimpling of skin or retraction when arms are lifted over head or hands are pressed against hips) Fibroadenoma Cysts Cancer Usual Age (in Years) Number Shape Consistency Delimitation Mobility Tenderness Retraction Signs 15-25 years, usually puberty and young adulthood, but up to age 55 years Usually single, may be multiple Round, disclike, or lobular; typically small (1-2 cm) May be soft, usually firm ‘Well delineated Very mobile Usually nontender Absent 30-50 years, regress after menopause except with estrogen therapy Single or multiple Round Soft to firm, usually elastic ‘Well delineated Mobile Often tender Absent 30-90 years, most common over age 50 years Usually single, although may coexist with other nodules Irregular or stellate Firm or hard Not clearly delineated from surrounding tissues May be fixed to skin or underlying tissues Usually nontender May be present Stage 1: preadolescent- elevation of nipple only Stage 2: breast bud stage- elevation of breast and nipple as a small mound; enlargement of areolar diameter Stage 3: further enlargement of elevation of breast and areola, with no separation of their contours Stage 4: projection of areola and nipple to form a secondary mound above the level of breast Stage 5: mature stage- projection of nipple only; areola has receded to general contour of the breast (although in some individuals the areola continues to form a secondary mound) Sexual Maturity Ratings in Girls: Breasts Stage 1 Preadolescent: elevation of nipple only Stage 2 Stage 3 Breast bud stage: elevation of breast. Further enlargement of elevation of and nipple as a small mound; enlarge- breast and areola, with no separation ment of areolar diameter of their contours Stage 4 Stage 5 Projection of areolaand nippletoform Mature stage: projection of nipple only; asecondary mound above the levelof —_ areola has receded to general contour breast of the breast (although in some normal individuals the areola continues to form a secondary mound) Photos used with permission of the American Academy of Pediatrics, Assessment of Sexual Maturity Stages in Girls, 1995. Acute: epigastric, may radiation straight to the back of other areas of the abdomen; 20% with severe sequelae of organ failure Problem Mechanisms Symptoms Physical Signs Overflow Incontinence Detrusor contractions are insufficient to overcome urethral resistance, causing urinary retention. The bladder is typically flaccid and large, even after an effort to void. Obstruction of the bladder outlet, as in benign prostatic hyperplasia or tumor, Weakness of the detrusor muscle associated with peripheral nerve disease at 524 level. Impaired bladder sensation that interrupts the reflex are, as in diabetic neuropathy ‘When intravesicular pressure ‘overcomes urethral resistance, continuous dripping or dribbling incontinence ensues Decreased force of the urinary stream, Prior symptoms of partial urinary obstruction or other sytaptoms of peripheral nerve disease tay be present Examination often reveals an enlarged, sometimes tender, bladder. Other signs include prostatic enlargement, motor signs of peripheral nerve disease, a decrease it sensation (including perineal sensation), and diminished to absent reflexes Functional Incontinence The patient is functionally unable to reach the toilet in time because of impaired health or environmental conditions. Problems in mobility resulting, from weakness, arthritis, poor vision, or other conditions. Environmental factors such as an unfamiliar setting distant bathroom facilities, bed rails, or physical restraints. Incontinence on the way to the toilet or only in the early morning, The bladder is not detectable on examination, Look for physical or environmental clues as the likely cause. Incontinence Secondary to Medications Drugs may contribute to any type of incontinence listed. scratchy throat Sedatives, tranquilizers, anticholinergics, sympathetic blockers, and potent ditivatioe Variable. A careful history and chart review are important Variable. ?pg 260 + google * Strep throat [Jstreptococcal pharyngitis, bacterial infection that may cause a sore, * Common childhood infection has a classic presentation of erythema of the posterior pharynx and palatal petechiae ¢ Enlarged swollen cervical lymph nodes [] superficial cervical lymph nodes O Superficial cervical[] superficial to the sternocleidomastoid Posterior auricular Tonsillar Occipital Srnec it Submental Posterior cervical ‘Submandibular Supraclavicular =} Deep cervical chain > —» External lymphatic drainage —¥ Internal lymphatic drainage (from mouth and throat) Preauricular nodes: } Drain scalp, skin Differential diagnosis: Scalp infections, “ Submandibular nodes: mycobacterial infection > \ Drain oral cavity Malignancies: f . Differential diagnosis: Skin neoplasm, mehomas, (Qi & Mononucleosis, upper head and neck squamous ~ ow - respiratory infection, cell carcinomas | 0 mycobacterial infection, el — toxoplasma, cytomegalovirus, . _ : dental disease. rubella Posterior cervical nodes: | Wo, ____| Malignancies: Drain scalp, neck, upper = a Squamous cell carcinoma thoracic skin bee 2 @ = of the head and neck Differential diagnosis: —— 9 % J lymphomas, leukemias Same as preauricular nodes | 7 |e — OO 2 Q = Co o Anterior cervical nodes: Drain larynx, tongue, oropharynx, ariterior neck Supraciavicular nod. Differential diagnosis: Same as submandibular nodes Differential diagnosi Thyroid/laryngeal disease, mycobacterial/fungal infections D.Klem Malignancies: Abdominal/thoracic pg. 937 ¢ Tdap during each pregnancy [] 27-36 weeks of gestation regardless of prior immunization history ¢ Influenza vaccine at any trimester during influenza season ¢ Pneumococcal, meningococcal, Hepatitis B * MMR, polio and varicella[] NOT DURING PREGNANCY O Rubella titers drawn during pregnancy and immunized after birth if nonimmune ¢ Check RH(D) and antibody type during first prenatal visit, at 28 weeks and delivery Oo Anti-D immunoglobulin should be given to all Rh-negative women at 28 weeks and again within 3 days of delivery to prevent sensitization if the infant is Rh-D positive Know what to be concerned about if you note an irregular rectal mass Pg. 618 ¢ Any masses with irregular borders suspicious for rectal cancer A tender purulent reddened mass with fever or chills suggests an anal abscess. Abscesses tunneling to the skin surface from the anus or rectum may form a clogged or draining ano-rectal fistula. Fistulas may ooze blood, pus, or feculent mucus. Consider anoscopy or sigmoidoscopy for better visualization. (epithelial cells with stippled borders); sniff for fishy odor after applying KOH (“whiff test”); test the vaginal secretions for pH >4.5. Scattered vesicles on an erythematous base, usually on the face and trunk, result from obstruction of the sweat gland ducts; disappears spontaneously within weeks (refer to pic on pg. 819) Usually soft to firm, round, mobile and often tender. Most common between the ages of 25-50 When tender area is palpated for guarding, early voluntary guarding may be replaced by involuntary muscular rigidity and signs of peritoneal inflammation. There may also be RLQ pain on quick withdrawal or deferred rebound tenderness. See findings suggestive of peritonitis secondary to possible appendicitis pg. 485-486) Left lower quadrant Left lateral decubitus ee | ee Ask questions related to: chest pain, palpitations, shortness of breath, swelling (edema), syncope. Review info on pages 355-358 of text Acutely, the gland appears as a tense, hot, very tender abscess. Possible labial swelling. Look for pus emerging from the duct or erythema around the duct opening. Chronically, a nontender cyst is felt that may be large or small. RLQ pain or pain that migrates from the periumbilical region, combined with abdominal wall rigidity on palpation is suspicious for appendicitis. Female: syphilitic chancre- firm, painless ulcer from primary syphilis, forms approx. 21 days after exposure to Treponema pallidum. It may remain hidden and undetected in the vagina and heals regardless of treatment in 3-6 weeks. Secondary syphilis (Condyloma lantum)- large raised, round or oval, flat-topped gray or white lesions point to condylomata lata. These are contagious and, along with rash and mucus membrane sores in the mouth, vagina, or anus are manifestations of secondary syphilis. Male: Primary syphilis: small red papule that becomes a chancre, a painless erosion up to 2 cm in diameter. Base of chancre is clean, red, smooth, and glistening; borders are raised and indurated. Chancre heals within 3-8 weeks. Anorectal pain, itching, tenesmus, or discharge or bleeding from infection or rectal abscess suggest proctitis. Hematemesis may accompany esophageal or gastric varices, Mallory-Weiss tears, or peptic ulcer disease. In children and young adults, a third heart sound (S3) may arise from rapid deceleration of the column of blood against the ventricular wall. In an older adult, an S3 usually indicates a pathologic change in ventricular compliance. Local swelling, redness, warmth, and a subcutaneous cord signal superficial thrombophlebitis (an emerging risk factor for DVT). A subacute nontender, usually painless nodule caused by a blocked meibomian gland. May become acutely inflamed, but unlike a stye, usually points inside the lid rather than on the lid margin. Pic on pg 275. Chest wall becomes stiffer and harder to move (decrease in chest wall compliance), respiratory muscles may weaken, and the lungs lose some of their elastic recoil. Lung mass and the surface area for gas exchange decline, and residual volume increases as the alveoli enlarge. An increase in closing volumes of small airways predisposes to atelectasis and risk of pneumonia. Diaphragmatic strength declines. As tension on the abdominal wall increases with advancing pregnancy, the rectus abdominus muscles may separate at the midline, called diastasis recti. If diastasis is severe, especially in multiparous women, only a layer of skin, fascia, and peritoneum may cover the anterior uterine wall, and fetal parts may be palpable through this muscular gap. Refer to picture on pg 228 Inspect, auscultate, percuss, palpate (first palpate lightly, then deeply). Assess the liver and spleen by percussion then palpation. Try to palpate the kidneys. Palpate the aorta and its pulsations. If you suspect kidney infection, percuss posteriorly over the costovertebral angles. Acute epididymitis: an acutely inflamed epididymis is indurated, swollen, and notably tender, making it difficult to distinguish from the testis. The scrotum may be reddened and the vas deferens inflamed. (pic on pg. 560) If you feel a testis up in the inguinal canal, gently milk it downward into the scrotum. Need to differentiate between undescended testes (in the inguinal canals) and highly retractile testes. Risk factors: age: rare in ages below 40 but incidence rates begin increasing rapidly after age 50. Median age at diagnosis is 66. Ethnicity: African American men have the highest incidence and mortality rates. Compared to white men, a higher percentage of African American men are diagnosed with prostate cancer before age 50. They are also more likely to present with advanced-stage cancer. Family history: Genetics appear to play an important role in prostate cancer risk. For men with one affected first degree relative (father, brother) risk of developing prostate cancer increases two fold. For men with 2 or 3 affected first degree relatives, risk increases 5-11 fold. The BRCA1 and BRCA2 mutations also appear to confer increased risk of prostate cancer. Other risk factors: Agent Orange exposure among Vietnam veterans, diets high in animal fat, obesity, and cigarette smoking. BPH is NOT a risk factor. Picture located on pg 923, but no description included Discharge that is white and curdy, may be thin but typically thick, not malodorous. Often accompanied by pruritis, vaginal soreness, pain on urination (from skin inflammation) and dyspareunia. Vulva and surrounding skin are often inflamed and sometimes swollen to a variable extent. The vaginal mucosa is often reddened with tenacious patches of white discharge. Know to screen for depression with vague complaints and negative work-up Risk factors for LE Peripheral Artery Disease: 1. Age greater than or equal to 50 with a hx of DM or smoking 2. Leg symptoms with exertion 3. Nonhealing wounds Central nodes (axillary) Personal hx of early onset breast cancer (<40 years) Two or more 1* degree relatives diagnosed with breast cancer at an early age Age of first full term pregnancy Late menopause Breast tissue density Modifiable risk factors: breastfeeding for less than 1 year, postmenopausal obesity, use of HRT, cigarette smoking, alcohol ingestion, physical inactivity, and type of contraception. Symptoms arise from both smooth muscle contraction in the prostate and bladder neck and from compression of the urethra. They may be irritative (urgency, frequency, nocturia), obstructive (decreased stream, incomplete emptying, straining), or both and are seen in more than 1/3 of men by age 65. The affected gland may be normal in size, or may feel symmetrically enlarged, smooth, and firm, though slightly elastic; there may be obliteration of the median sulcus and more notable protrusion into the rectal lumen. Elder mistreatment includes abuse, neglect, exploitation, or abandonment. Prevalence is highest in adults with dementia and depression. COULD NOT FIND SPECIFIC LIST OF SIGNS On straining for a bowel movement, the rectal mucosa, with or without its muscular wall, may prolapse through the anus, appearing as a doughnut or rosette of tissue. A prolapse involving only mucosa is relatively small and shows radiating folds (pic on pg. 621). When the entire bowel is involved, the prolapse is larger and covered by concentrically circular folds. See pic at the top of pg. 212 Gestational is systolic blood pressure (SBP) >140 mm Hg or diastolic blood pressure (DBP) > 90 mm Hg first documented after 20 weeks, without proteinuria or preeclampsia, that resolves by 12 weeks postpartum. *Included on the answer above Occasionally there are masses in the abdominal wall rather than inside the abdominal cavity. Ask the patient either to raise the head and shoulders or to strain down, thus tightening the abdominal muscles. Feel for the mass again. Ask the patient to roll onto the opposite hip, placing her hand on her forehead but keeping the shoulders pressed against the bed or examining table. This flattens the lateral breast tissue. Begin palpation in the axilla, moving ina straight line down to the bra line, then move the fingers medially and palpate in a vertical strip up the chest to the clavicle. Continue in vertical overlapping strips until you reach the nipple, then reposition the patient to flatten the medial portion of the breast. The term functional somatic syndrome has been applied to several related syndromes characterized more by symptoms, suffering, and disability, than by consistently demonstrable tissue abnormality. Examples include IBS, fibromyalgia, chronic fatigue, TMJ disorder, and multiple chemical sensitivity. Functional syndromes have been shown to “frequently co-occur and share key symptoms and selected objective abnormalities.” The co-occurrence rates for common functional syndromes such as IBS, fibromyalgia, chronic fatigue, TMJ disorder, and multiple chemical sensitivity reach 30-90%, depending on the disorders compared. The prevalence of symptom overlap is high in the common functional syndromes, name complaints of fatigue, sleep disturbance, musculoskeletal pain, HA, and GI problems. The common functional syndromes also overlap in rates of functional impairment, psychiatric comorbidity, and response to cognitive and antidepressant therapy. Internal hemorrhoids: enlargements of the normal vascular cushions located above the pectinate line, usually not palpable. May cause bright red bleeding, especially during defecation. They may also prolapse through the anal canal and appear as reddish, moist, protruding masses. Pic on pg. 621 Polyps of the rectum: fairly common and variable in size and number, they can develop on a stalk (pedunculated) or lie on the mucosal surface (sessile). They are soft and may be difficult or impossible to feel even when in reach of the examining finger. Endoscopy and biopsy are needed for differentiation of benign from malignant lesions. Pic on pg. 622 Cancer of the rectum: usually firm, nodular, rolled edge. Pic on pg. 622 During inspiration the right heart filling time is increased, which increases right ventricular stroke volume and the duration of right ventricular ejection compared with the neighboring left ventricle. This delays the closure of the pulmonic valve, P2, splitting S2 into its two audible components. Can be heard at the 2" and 3" left intercostal spaces close to the sternum. Postural color changes of chronic arterial insufficiency: if pain or diminished pulses suggest arterial insufficiency, consider looking for postural color changes using the Buerger test. Raise both legs to about 90 degrees for up to 2 min until there is maximal pallor of the feet. Then ask the patient to sit up with legs dangling down, compare both feeting noting the time required for: Return of pinkness of the skin, normally about 10 sec or less Filling of the veins of the feet and ankles, normally about 15 Elevated JVP is highly correlated with both acute and chronic heart failure. It is also seen in tricuspid stenosis, chronic pulmonary hypertension, SVC obstruction, cardia tamponade, and constrictive pericarditis