Physical Assessment Final Total

Three types of joints?


Bone is made of what kind tissue?

modified connective

joint definition

articulation of two bones

synovial articulation

The bones do not touch each other, and the joint articulations are freely moveable.

Synovial joint structure

Bones are covered by articular cartilage and separated by a synovial cavity that cushions joint movement.A synovial membrane lines the synovial cavity and secretes a small amount of viscous lubricating fluid�the synovial fluid.
Surrounding the synovial me

Cartilagenous joint structure

Slightly moveable.
Fibrocartilaginous discs separate the bony surfaces.
At the center of each disc is the nucleus pulposus, fibrocartilaginous material that serves as a cushion or shock absorber between bony surfaces.

Fibrous joint structure

The bones are almost in direct contact, which allows no appreciable movement.


synovial sacs that allow adjacent muscles or muscles and tendons to glide over each other during movement.


ropelike bundles of collagen fibrils that connect bone to bone.


collagen fibers connecting muscle to bone. Another type of collagen matrix forms the cartilage that overlies bony surfaces.

Muscle 40-50% weight

what percent weight are muscles of body


bending at a joint


Strightening limb at a joint


moving away from the body


moving towards midline of body


turning forearm so palm down


turning forearm so palm up


Moving arm in circle around shoulder


Moving sole of foot inward at angle, lifting big toe up


Moving sole of foot out at ankle, moving little tow up


moving body part forward parallel to ground


moving body part backwards parallel to ground

Elevation and depression

Up and down in relation to ground


Moving head on its central axis

If synovial membrane inflammed feel?



Crunch or grating sound when articular surfaces roughened eg osteoarthritis as age

Muscle strength grading 0

no contraction, complete paralysis, no visible or palpable movement

Muscle strength grading 1

slight contraction, but very severe weakness, weak contraction visible but extremity doesn't move

Muscle strength grading 2

full ROM with gravity eliminated (passive motion)

Muscle strength grading 3

full ROM with gravity but not against resistance (moderate weakness)

Muscle strength grading 4

full ROM against gravity, with some resistance

Muscle strength grading 5

full ROM against gravity, with full resistance (normal muscle strength)

Shoulder joint name?

Glenohumerol joint, articulation of humerous and scapula


Outward extension of the shoulder blade forming the point of the shoulder.

Hyperextension of arm

Is normal and should be seen on phys exam of shoulder

Hands behind head demonstrates

external rotation

hands behnd back demonstrates

internal rotation

lateral epicondyl

bony articulation at elbow away from body

medial epicondyl

bony articulation at elbow near body

Which forearm bone is medial at elbow?


Which forearm bone is lateral at elbow?


Oleacranon bursa in which joint?


1/2 206 bones where?

hands and feet

Three digit joints from wrist to finger tip?


Wernecke's area

associated with auditory reception. IF damaged in domnant side person can hear words but can't make sense.

Brock's area

if damaged perosn knows what wants to say but can;t get words to come out right.

Cerebral Cortex

Frontal lobe
Temporal lobe
Parietal lobe
Occipital lobe
Wernicke's area
Broca's area


Basal ganglia



Frontal lobe

associated with reasoning, planning, parts of speech, movement, emotions, and problem solving

Temporal lobe

portion that lies below the frontal lobe, responsible for hearing, taste, and smell

Parietal lobe

portion posterior to the frontal lobe, responsible for sensations such as pain, temperature, and touch

Occipital lobe

portion posterior to the parietal and temporal lobes, responsible for vision

Cerebral damage due to vasospasm?

even in migraine can have altered speech, anything that will diminish the blood supply there, stroke is MI in cerebral cortex= CVA.

Basal ganglia

controls automatic associative movements like's arms swinging when walk. If parkinsons and basal ganglia affected don't swing arms when walk, shuffle.


main relay station for NS, processes sensory impulases and relays up to the cerebral cortex for definition.


maintains homeostatis. HR temp and BP. Also effects endocrine system by secreting hormones that act on pituitary gland, also some emotions like anger and sexual drive.


continuation of spinal cord that has ascend and descend nerve tracts, is where decusation eg crossing over to other side, occurs.


ascending and descending nerve fiber tracts


the "little brain" attached to the rear of the brainstem; its functions include processing sensory input and coordinating movement output and balance

Spinal cord extends

from brain to L1 or L2. That's why lumbar puncture below level of spinal cord. Helps mediate reflexes. Has grey matter as well, arrranged in butterfly, H shape, posterior horn is nerve impulses, anterior is efferent impulses.

Posterior horn sends ____ impulses?


Anterior horn sends _____ impulses?


Where do the peripheral nerves synapse?

axons synapse in brain stem for cranial nerves and in spinal cord for other peripheral nerves.

Intention tremors cause?

Benign, run in families


drooping of the upper eyelid caused by muscle paralysis and weakness

In Bell's palsy observe?

total paralysis of one side face

With unilateral facial paralysis need to rule out?

herpes zoster, lyme's disease, or bell's palsy

What causes Bell's palsy?


If a patient can wrinkle forehead and close eyes bilaterally, but right bottom of face paralyzed caused?

Lesion in LEFT CENTRAL CN VII at motor cortex


increased resistance to passive movement, from damage to corticospinal tract


damage to extrapyramidal tract eg parkinsons, cog wheel resistance.


Repetitive twitch at inappropriate time


Rapid constant twitch when muscle at rest


inability to arrest abruptly one motor impulse and substitute its opposite


improper coordinated function of given muscle groups


inability to gauge properly the distance between two points or objects

What are the components of the PNS?

12 Cranial nerves
31 spinal nerves + branches

Which hemisphere is dominant in almost everyone?

Left, regardless of handedness

Which region of the brain as the greatest amount of brain tissue?
How is this tissue divided?

cerebral cortex:
grey (outer): highest human functions
white (inner): neuronal axons coded with myelin

Where is Wernicke's area located and what does it do?

Wernicke's area is located in the temporal lobe.
Fxn: comprehension of speech

Where is the primary motor area located?

frontal lobe

What are the functions of the frontal lobe?

1. intellectual fxns
2. emotions
3. behaviors
4. personality

Where is the primary sensory area located?

parietal lobe

Where is Broca's area located? What is its function?

Frontal lobe
fxn: (motor) speech formation

What is the function of the cerebellum?

2. equilibrium
3. muscle TONE
**does NOT initiate movement

What is the spinal cord and where is it located?

A mass of nerve tissue

Which NS is associated with the spinal column?


Which NS is associated with the spinal nerves?


What is the function of the basal ganglia?

Controls automatic body movements (normal arm swing while walking)

What is the function of the thalamus?

Main relay system for the NS; the synapes go to the CORTEX for finite determination

What does the hypothalamus regulate?

1. T
2. sleep center
3. pituitary
4. emotional status

What is the midbrian composed of?

nerve fibers that merge with the thalamus

Which nerve fibers are assoiciated with the pons?

ascending/descending nerve fibers

Which nerve tracts are associated with the medulla?

all motor/sensory tracts go here

What is the function of the medulla?

1. Vital autonomic centers (vitals, respiration, heart beat)
2. motor fibers CROSS here (pyramidal decussation)

Name 3 major motor pathways.

MOTOR pathways:
1. Corticospinal (pyramidal) tract
2. Extrapyramidal tract
3. Cerebellar system

Describe the pathway of the corticospinal (pyramidal) tract.

motor fibers originate in the cortex-->brainstem (cross over)-->spinal column-->synapse with lower motor neuron or spinal nerve

What is the function of the corticospinal tract?

controls VOLUNTARY movement (ie skilled, descrete skills like writing)

Where do extrapyramidal tracts originate?

motor cortex

What does the extrapyramidal tract control?

controls gross body movements (walking)

What are the functions of the cerebellum?

1. coordinate arm movement
2. maintain equilibrium, posture

What are the 2 major sensory pathways?

SENSORY pathways:
1. spinothalamic tract
2. posterior (dorsal) column

What does the spinothalamic tract sense?

1. pain
2. T
3. crude/light touch

What is the pathway of the spinothalamic tract?

fibers enter the POSTERIOR root of the spinal cord-->synapse&crossover-->goes up to the thalamus (tells you if good/bad)-->cortex (tells you what's going on)

What are the functions of the posterior (dorsal) column?

1. proprioception (sensation of position)
2. vibrations
3. fine localized touch
4. discriminatory touch

Anterior portion of spinal nerves consist of __, Posterior portion consists of __.

motor fibers, sensory fibers

What are the requirements for a reflex arc?

1. intact sensory nerve
2. functional synapse in spinal cord
3. intact motor nerve
4. intact NMJ (neuromuscular junction)
5. competent muscle
*relay of structures across the CNS-PNS

What type of problem is Parkinson's?

cerebellar; shaking at rest

If you are concerned about a patient's attention, whould should you do to assess their attention level?

ask them to repeat words/numbers 6-7 forward & 4 backwards

What are 3 types of memory?

1. Immediate recall
2. short term (demented people have problems here)
3. long term

How do you test immediate and short term recall?

tell the patient 3 words to remember. For immediate, ask them to repeate it right back. For short term, ask them to repeat words in 3-5 min

How do you test the vestibular portion of CN VIII?

Rhomberg test: feet together, arms to the side, eyes closed. See if they can keep their balance

Describe spastic tone.

increased tone (which increases resistance to passive lengthening; the more you move it, the tighter it gets)
(injury to corticospinal motor tract)

Describe rigid tone

constant state of resistance (cogwheel rigidity)
*from parkinson's, damage to the extrapyramidal tract

What is fasiculation?

rapid twitching of a flaccid muscle

What are tremors?

at rest (pill rolling movement, such as in parkinson's)

What does the spinothalamic tract mediate?

1. pain
2. T
3. light/crude tough

How do you test tactile discrimination?

1. sereognosis
2. graphesthesia
3. 2-point discrimination
4. extinction

If someone has no coordination, what dz may this indicate?


What might cause a positive babinski in adults?

upper motor neuron problem:
1. drugs, alcohol
2. seizure


Area surrounding the introitus, within the labia minora


entrance to vagina

Skene's glands

next to urethral meatus, if see pus = gonnorhea or chlamydia


folds of mucosa within vagina


anterior and posterior top of vaginal canal


Ovaries, fallopian tubes and supporting ligaments.


Palpable before menopause, nonpalpable after menopause

Pap should be at?

squamocolumnar junction

What are the 2 types of epithelium in the cervix?

-Squamous: shiny pink, continuous with the vagina
-Columnar: deep red, resembles interior of the uterus

Where do most cervical cancers occur?

At the Transformation zone (small area just surrounding the os)

What defines menopause?

No menses for 12 months

What is the average age for menopause?


What is the common range of menarche in the US?


When would it be normal to see a prolapse of the urethra?

Before menses and after menopause
-would appear dark pink/red

What is Cystosil?

Prolapse of the bladder

What is rectusil?

rectum protruding into the vagina

Are hernias thought to be a male or female problem?

Primarily male, but can also be in females

Where do hernias occur?

in the groin

What position must men and women be in to conduct a hernia exam?


How do you palpate for female hernias?

-Palpate the labia majora just upward and lateral to the pubic tubercles

What is urethritis?

Inflammation of the paraurethral glands

How do you examine for urethritis?

-insert index finer into the vagina and mile the urethra gently from inside outward
-culture any discharge that has been "milked out

What columns of vascular erectile tissue form the shaft of the penis?

1 corpus spongiosum (contains urethra)
- 2 corpora cavernosa

What tissue forms the bulb of the penis?

Corpus spongiosum

What is the corona of the penis?

The expanded base of the glans

What are the secretions of the glans called?


What is the epididymis and where is it?

- soft, comma-shaped structure (carries sperm)
-On the posterolateral surface of testes

What are the landmarks of the groin?

-anterior superior iliac spine
-pubic tubercle
-inguinal ligament

What are we feeling during a hernia examination?

The external inguinal ring

What should you inspect the scrotum for?

Tortuous veins

How do you evaluate a possible scrotal hernia?

- if large scrotal mass is found, ask the pt to lie down. If the mass disappears it is a hernia
-If the mass remains:
-listen to the mass with a stethoscope. If BOWEL sounds are heard it is a hernia

What is an incarcerated hernia?

One that does not go away when not bearing down. (not reducable)
-No blood supply
-can become gangrene

What is the most common type of hernia

Indirect hernia

What are indirect hernias?

Come down through the scrotum sac
-Have pain with straining
-Will feel at external ring
'-Can be congenital or aqcuired
-Most common in infants and 16-20 yrs old

What is the direct hernia?

Intestine comes from behind inguinal canal
-Rarely go into the scrotum
-Less common but seen in OVER 40 yrs old

What is the most common hernias in women?

The femoral hernia and indirect

What is the most painful hernia?


Describe Femoral hernias

-More common the right side of the body
-Come from the femoral canal
-often extrenuated and incarcerated

What are hemorrhoids?

When columns in the anus become varicosed.

Describe the prostate gland

-Bilobed, heart shaped gland
-surrounds the bladder and extra ducts
-Lies in front of the anterior wall of the rectum, 2cm behind symphysis pubis

Describe a Rectal Polyp.

-Polyp: very movable (but still needs biopsed)

What does rectal ulcer feel like?

-Cancer will usually have ulcerated area with raised edges and the be FIRM!

How would you have your pt positioned for a prostate exam?

Bent over with toes pointing toward eachother.

Cerebral Lobes

Frontal: personality, behavior, higher functions
Temporal: hearing, tasting, smelling
Parietal: sensation
Occipital: vision


Basal Ganglia: unconscious movement, control of fine movement
Thalamus: processing of sensory input; relay of sensory info to cortex
Hypothalamus: homeostasis


Midbrain (superior, anterior)
Pons (medial)
Medulla (inferior, posterior)->site of pyramidal decussation.


Muscle Tone--coordinated, smooth movements
Unconscious control

Major Motor Pathways in CNS

Pyramidal (corticospinal) tract
Extrapyramidal tracts
Cerebellar system

Major Sensory Pathways

Spinothalamic Tract
Dorsal (posterior) Column

Requirements for a Deep Tendon Reflex

1. Intact sensory nerve
2. Functional synapse
3. Intact motor nerve
4. Intact NMJ
5. Competent Muscle

LOC terms

Alert, lethargic, obtunded, stuporous, comatose


Ability to identify person, place, and time.

Assessment of Language (neuro)

Speech should be fluent, non-hesitant, and make sense. Person should be able to follow commands.

Memory assessment

Immediate recall; Short-term (3 minutes); Long-term (20+ minutes)

Name two tests for CN VIII (vestibulocochlear)

Vestibular: Romberg's Test
Cochlear: Whisper (finger rub) test

Which cranial nerve innervates the masseter muscle?

CN V (trigeminal)


Muscle weakness that results from disuse, injury, or lower motor neuron peripheral disease

Significance of muscular rigidity

Indicates extrapyramidal tract injury
ex) Cog Wheel Rigidity in Parkinson's Disease.

When a child breaks or fractures their arm, why is proper assessment especially important?

Damage to the epiphyseal plate of a long bone can inhibit growth of that bone.

Breech babies are at risk for this complication

Hip dysplasia

Signs of Prolonged QT Syndrome in kids

dizziness, syncope, chest pain, shortness of breath


Missing a finger (or toe) or two

Tests for Hip Dysplasia

Barlow Test
Ortolani Test

Genu Varum

Bowleggedness. Normal in kids until they start walking.

Genu Algum

Knock-kneed, with greater than a 2 cm gap between ankles when knees are together. Normal up to 3.5 years old.

Nursemaid's Elbow

Dislocation of the radial head. Common injury in 2-4 year olds, often because of being lifted by arm. Very common normally, but can also be a sign of abuse.

Adams Forward-Bend Test

Tests for scoliosis in adolescents.

Why are young children at a risk for brain and spine injury?

Thin dura attached to skull--easily torn. Poorly developed neck muscles, heavy head.

One of the first signs of childhood abnormality

Failure to meet a milestone

What can pregnant women take to prevent a neural tube defect in the fetus?

Folic acid

Palmar grasp reflex

Reflexive grasp in response to palmar stimulation in infants under 2 months of age

Rooting reflex

When infant's cheek is stroked, infant turns head in that direction

Plantar grasp

pressure applied to foot makes toes curl in.

Babinski reflex

pressure applied to foot, toes fan out. Normal under 2 years.

Cri du Chat

High-pitched, shrill cry of infant. Indicated neural damage.

Gower's Sign

Child uses wall or rolling to get up from seated position. Indicated muscular dystrophy.

Which EKG lead is most commonly read? Why?

Lead II. The flow of electricity from I-->II moves in the same direction as the flow of impulses through the heart; that is, to the left and down.

Sinus arrythmia

A normal arrhythmia characterized by regularly irregular heartbeats, generally following patterns of inspiration.

Premature Atrial Beat

A ventricular response to atrial irritation or hyperactivity. Can be caused by digoxin toxicity, hyperthyroidism, or stimulants.

Atrial Flutter

Ectopic focus in atria starts to beat rapidly. Impulse partially blocked by AV node, so flutter occurs in the atria instead of ventricles. QRS rhythm still regular.

Atrial Fibrillation

Multiple weak ectopic foci in atria, which create lots of tiny P waves. Characterized by irregularly irregular rhythm.

Supraventricular Tachycardia

Ectopic focus above ventricles but below SA Node. Normal QRS but rapid rate.

Premature Ventricular Contraction

Widened QRS interval. Caused by low O2, poor cardiac output, and/or low potassium.

Ventricular Tachycardia

Emergency! Ventricles are so irritated that one of the foci takes over and starts beating. Crazy-looking fast rhythm.

Ventricular Fibrillation

Mega-emergency! You can't live with this. Immediate fibrillation required. On EKG, rapid fibrillation below middle line.

1st degree AV Heart Block

PR interval greater than 0.20 seconds
Consistent in each cycle.

2nd degree AV Heart Block

2 Types:
Mobitz Type I: PR interval gets gradually longer until it's gone (no more QRS)
Mobits Type II: 2 P waves or 3 P waves for every 1 QRS

3rd degree AV Heart Block

Very wide QRS, with no relationship between P and QRS. AV node completely blocked, heart beats at the ventricular rate.

Sympathetic neurotransmitter to the heart

norepinephrine to alpha and beta adrenergic receptors

Parasympathetic neurotransmitter to the heart

acetylcholine to muscarinic type 2 receptors.

What part of the heart do the coronary arteries supply?

The myocardium (heart muscle). Site of myocardial infarction.

Skene's Glands

Tiny exocrine glands that open just under the urethra in females.


End of the vagina around the cervix.


Ovaries, fallopian tubes, and supporting tissues


External central surface of the cervix, comprised of columnar epithelium.

Body of cervix

Outer ring of cervical tissue made up of squamous cell epithelium. This is what is swabbed during a Pap smear.

What might swollen testicles be a sign of?

Congestive heart failure

What increases your risk of testicular cancer?

Testicles that weren't descended at birth, being white, ages 15-34.

Common hernia in women

Femoral hernia

Most common hernia in young men

Indirect hernia

Mostcommon hernia in obese men

direct hernia

Liquid-filled pads within synovial joints


Connective tissue between bones


Tissue that connects bone to muscle


Fluid within joints such as the shoulder

Synovial fluid--lubricates joint

Elbow joint type

Synovial hinge

Skull bone joint type

Fibrous suture joint

Shoulder and hip joint type

Synovial ball-and-socket

Carpal joint type

Synovial Gliding (planar) joints

Knee joint type

Synovial Compound Joint (modified hinge)

Temporomandibular joint type

Synovial condyloid joint

Vertebral joint type

Cartilaginous symphysis

SA intrinsic rate?


AV node rate?


Bundle of his and bundle branch rate?


AV node function?

Acts as a gatekeeper and briefly delays impulses from the SA node, to allow the atria to contract completely and empty the blood into the ventricles.

What does SA node depolarization look like on EKG?

The SA node is very small and you do not see its electrical activity on the EKG.

P wave

represents the electrial activity (depolarization ) of both atria and the simultaneous contraction of the atria. Path ofi

Path of impulse after SA node?

The AV node further conducts impulses to the bundle of His.
The bundle of His carries the impulses to the right and left bundle branches and eventually to the Purkinje fibers

Ventricular conduction?

it conducts very rapidly through the Bundle of His and the left and right bundle branches and their subdivisions.
The terminal filaments of the Purkinje fibers distribute the depolarization stimulus to the ventricular myocardial cells.
Depolarization of t

QRS complex?

depolarization of ventricular myocardium

ST interval

Following the QRS complex, there is a segment of horizontal baseline known as the ST segment which represents the plateau phase of repolarization.

T wave

Then a broad T wave appears.
The T wave represents the final rapid phase of ventricular repolarization (becomes negatively charged).


total ventricular contraction

QT interval significance?

Ventricular contraction (systole) begins with the QRS and persists until the end of the T wave.
So ventricular contraction spans depolarization and repolarization of the ventricles.
Thus the QT interval has clinical significance.
A long QT interval often

PR interval? time

<0.20 sec

QRS interval? time

<0.08 sec

QT interval? time

<0.4 sec

Cardiac Cycle

HR from EKG per large box


Direction on EKG leads?

from negative to positive electrodes

Small box and large box on EKG represent?

0.04 sec, 0.2 sec

Regularly irregular sinus arrhythmia?

Normal with inspiration and expiration

What happens if atrial foci to become irritable?

Atria can but put an extra beat = Premature Atrial Beat

What does PAB look like on EKG?

odd P, too close to previous QRS, is less serious than atrial irritability

Atrial flutter

a single strong ectopic focus in an atria start to beat fast 240-360 beats per minute. The AV node acts as the gatekeeper, blocking some of the impulses to the ventricles, so ventricular rate not that crazy fast

Appearance of atrial flutter on EKG

looks like saw tooth, multiple P waves between venrticular

A fib

many weak ectopic foci in the atria beat in an uncoordinated pattern, resulting in an uneven baseline of many tiny P waves.
Eventually the ventricles receive enough electrical stimulation to contract or they contract on their own.Irregularly irregular.

A fib is risk for?

Stroke, that's why cumadin. Blood static in atria because quivering not contracting, little clots can form.

Premature Ventricular Contractions

A ventricular focus can be made irritable by low O2 (airway obstruction, absence of air, low O2 content, reduced cardiac output, poor to absent coronary blood supply due to infarction or insufficiency) and low K (hypokalemia)
= premature ventricular contr

Ventricular Tachycardia

is the result of one strong ventricular ectopic focus that hijacks the conduction system of the heart. About 200 bpm
This rhythm cannot sustain life for long.

Ventricular Fibrillation

is the beating of many weak ectopic foci in the ventricles, resulting in uncoordinated contractions.
It is a rhythm that cannot circulate blood and is not compatible with life.

Conduction Abnormalities

Second-Degree Atrioventricular Block, Type I =

First-Degree Atrioventricular Block

PR interval > 0.20, regular

Second-Degree Atrioventricular Block, Type I

Mobitz type 2 wencheback = Note progressively longer PR duration until non-conducted QRS
Going, going, gone!!!

Second-Degree Atrioventricular Block, Type II

Mobitx type II = consistently normal PR interval but then a normal, punctual P wave with no QRS response
There can be 2:1 or 3:1 Mobitz II block

Third-Degree Atrioventricular Block

complete heart block/ AV dissociation = No relationship between the P waves and QRS complexes. PR intervals hugely varied, need pacemaker.

Sympathetic cardiac stim

Norepinephrine secreted to B1 adrenergic receptors in the heart to elicit an excitatory response
Increases SA node pacing
Increases force of myocardial contraction
Constricts arteries - Increases B/P

Parasympathetic cardiac stim

Acetylcholine activate cholinergic receptors to produce an inhibitory effect
Decreases SA node pacing
Decreases force of contraction
Dilates arteries - Decreases B/P36

Coronary arteries

Supply blood to myocardium, heart muscle

What is a normal percussion note over peripheral lung fields?


In COPD with large AP diameter called?

Barrel chest

Trachea bifurcates anteriorly at?

Manubriosternal angle/ angle of Louis

Unequal chest expansion occurs when?

part of the lung is obstructed or collapsed

When auscultating over adult posterior lower lobes of lungs, what would be normal?

Low pitches, soft lung sounds with inspiration > expiration.

Bronchophony associated with?

Pulmonary consolidation/ pneumonia

Percussion over an area of atelactasis would sound?



collapse of lung tissue

While auscultating hear EE as AA indicates?

Pulmonary consolidation/ pneumonia

Benign lesion characteristics in breast?

Soft, mobile, well defined edges.

Retraction phenomena are seen with benign or malignant lesions?


Which two heart chambers are most anterior in the chest?

Right atrium and ventricle.


coincides carotid artery pulse, louder apex, closure of mitral and tricuspid


louder base, closure of aortic and pulmonic


resistance in arteries against which ventricle must contract to pump out blood

A murmur between S1 and S2

Systolic mitral regurg


Rumbling heart sound because ventricle resistant to turbulent blood flow from atrial kick

Physiologic Split S2

On inspiration heard at 2nd left intercostal space

PMI in child <7?

4th intercostal midclavicular

Pediatric innocent murmurs?

Do not effect growth, disappear with change in position, are systolic.

Varicose veins are?

Dilated, twisted, tortuous

Before obtaining arterial blood gas?

Allen test

Allen test

Determining the patency of the radial and ulnar arteries by compressing one artery site and observing return of skin color as evidence of patency of the other artery

In venous stasis see?

Brown discoloration and hardened skin (brawny)

In obese patient, alternative to liver percussing?

Liver scratch test

Aortic aneurysms

May hear a bruit, may rupture, 95% above umbilicus, femoral pulses decreased.

Complaint of tenderness along posterior costovertebral angle indicates?

Kidney inflammation


Loud, gurgling bowel sounds

Bladder full, on percussion?

suprapubic dullness

Murphy's sign?

Palpation of right subcostal area while client takes a deep breath - extreme pain indicates acute cholecystitis (inflammation gall bladder)

Illiopsoas sign?

hyperextention of right hip causing abdominal pain =

Rebound tenderness?

a sign of inflammation of the peritoneum or appendicitis in which increased pain is elicited by the sudden release of the fingertips pressing on the abdomen.

Differences in the Child and Adult

Brain tissue is thinner, softer, and more flexible.
Dura is more firmly attached to the skull and more likely to be torn.
Motor and sensory development: mostly reflexive at birth.
Cephalocaudal Motor development: proceeds bilaterally in head-to-toe fashio

Why more head injuries for kids?

Thin carnial bones, up to 18 mo open sutures, weaker neck, incomplete ossification of vertebra = risk C1 and 2 injuries

Neurological abnormalities present?

Milestone not met
Adults is more assymetrical symptom

Prenatal care concern?

Did take folic acid because concerned neural tube defects

Infant assessment points?

Milestones are meet
Primitive reflexes are eliminated when they are expected to
Behavioral assessment

Infant Motor Function & Postural Tone

Assessment of voluntary muscles
Head control
Postural tone: Tested by evaluating the resistance to gravity.
It is best tested by the traction response (pull-to-sit maneuver)

Full head control?

By 4 months


Most common abnormality in infant neuro exam


stiff baby, sign of neuro damage

Infant cranial nerve tests

Palmar grasp timeline?

Gone by 2 mos or so

Rooting reflex timeline?

Gone by 3-4 mos

Moro reflex timeline?

Gone by 4-6 mos

Atonic neck reflex?

Extension arm on SAME side as turn, contract on opposite side Gone by 4-6 mo

Plantar grasp

Push under toes and get curl, Gone by 10-12 mos

Babinski reflex

Faniing toes, big toes up. After 2 yo should reverse

Abnormal findings infant +

Failure to attain a skill by expected time.
Persistence of reflex behavior beyond normal time.
A high-pitched shrill cry or cat sounding screech.
A weak, groaning cry.
Lethargy, hyporeactivity, hyperirritability.
Hypotonia or Hypertonia
Twithching, tremor

Deep tendon reflexes

Are difficult to assess in children under the age of 5.
Conducted in the same sequence as the adult.

Abnormal Findings in the Pre-School & School Aged Child

Staggering, falling
Weakness climbing up or down stairs
Failure to hop after the age of 5
Gower's sign - weak pelvic muscles. muscular dystrpohy, rolling and wall to get up
Sensory loss
Hypo or Hyper activity of Deep Tendon Reflexes

Neuro "soft signs

Short attention span
Unusual body movement, mirroring
Poor coordination and sense of position
Excessive, purposeful movement (hyperactivity)
Labile emotions
No established handedness
Language articulation problems
Perceptual deficits (space,

Differences child and adult bones

More bones in the child's skeleton than the adult.
Incompletely calcified bones are more pliable and porous than the adult.
Bones stop growing in length near the end of adolescents.
Bone thickening continues into the early 20's.

Childhood growth of bones

In childhood bone growth is based on hormonal regulation.
During puberty sex hormones are released and contribute to the growth spurt seen in adolescence.
Testosterone and estrogen also account for the masculinization/feminization of specific parts of the

Growth plate

between epiphysis and diaphysis of LONG bone = epiphyseal plate where growth occurs. If injure before have closed can have shortening of the limb.

Pediatric Spine

At birth the spine has a single C shaped curve.
3-4 months the anterior curve in the cervical region develops.
1-18 months anterior curve in the lumbar region develops.

Pediatric muscle growth

Muscle fibers reach maximum diameter in girls at around age 10 and 14years in boys.
Muscle strength continues to increase until 25 to 30 years of age.
Ligaments and tendons are stronger than bone until puberty.
Muscles and fat are significant for weight i

Infant/Toddler Health History

Was the child full-term?
Was there any trauma associated with the labor and delivery? anoxic event = poor muscle tone
What was the presentation of the child at birth? breech = hip dysplasia
Where there any defects noted along the spinal column? Tufts of h

School Age health History

Has the child been screened for scoliosis?
Is the child involved in sports? How frequently (times/week)?
What does the child's diet consist of?
Is there any joint pain, swelling? = juvenile rheumatoid arthritis

Sport Physical

Do you display signs or symptoms of early fatigue, dizziness, syncope, chest pain, shortness of breath or palpitations with exercise? = Prolonged QT syndrome, sudden death, congenital, ventricular tachy arrhythmias
Is there a family history of sudden deat

Infant physical assessment

Count fingers and toes polydactyly and syndactyly extra or fusing digits
Inspect the spine for abnormalities, spina bifida neural tube defect, sac with CSF and portion spine = mylomenigeseal.

Infant exam palpation

Palpate clavicles.
Hip exam NEWBORN <8-12 wks: Barlow and ortalani tests
Assess feet for metatarsus adductus and or Talipes equinovarus.

Barlow maneuver and Ortolani test

Listen for clunk = abnormal

Club foot test

Incurving of feet in newborn, if can put in neutral position is normal from womb.

Joint test in children?

Don't need functional joint by joint test in child
Look normal coordination and milestones

Preschool and school age inspection spine

Shoulder level within 1cm
Scapula symmetric
Lordosis common in childhood


anterior curvature of the lumbar spine (sway-back condition)

schoool age and preschool Assess legs.

Genu varum (bowlegged) >2.5 cm between knees, common til 1 yr and walking
Genu algum (Knock kneed) >2.5cm gap ankles, normal 2-3.5 yo

Pesplanus (Flatfoot)

pronate foot inward, foot pad

Pigeon toes or toeing in

longitudinal arch higher than normal, usually corrects by 3yo, concerned if tibial torsion

Hanging arm

Assess subluxation of the radial head.
Nursemaid's elbow. Arm hanging, can't grasp object, lax ligaments.
Most common upper extremity injury in this age child that presents to the ED. 2-4yo

Adolescent screening for scoliosis

Most common during the preadolescent growth spurt
Treatment depends on severity.
girls 10-12, boys 13-14
forward bend test, scoiliometer 7 degree +, refer orthopedist

Systemic veins are _______, pulmonary arteries are______, pulmonary veins are _______, systemic arteries are_______.

deoxygenated, deoxygenated, oxygenated, oxygenated.


area on the anterior chest overlying the heart and great vessels


the part of the thoracic cavity between the lungs that contains the heart and aorta and esophagus and trachea and thymus....2nd to 5th intercostal


5th intercostal space at midclavicular line, pulsation of apex maximally visible, loud.

Internal position heart and great vessels

Heart rotated so right ventricle most ____. Left ventricle mostly _____,

anterior, posterior

Rotation of heart anteriorly

Relationship aorta to carotid arteries?

Aorta behind heart, branches that come off to be common carotid artery, left and right. Carotid artery pulse only miliseconds different to actual contraction of the heart.

Which vein is used to assess central venous pressure?

Internal jugular vein is one look at for central venous pressure, very deep, medial to sternomastoid muscle, behind it and come through.


protective layer of connective tissue. Part lies next to mayocardium little bit fat


thick middle muscle layer of the heart; pumps blood through the circulatory system. little connective tissue in there as wel as well as lymph blood and nerve.

order of blood flow

Right side pumps deox at very low pressure, goes thorugh tricuspid valve into right ventricle when contracts, tricuspid valve closes, goes out pulmoary artery though pulmonic valve to the lungs.
From lungs in pulmonary veins into left atrium, through the

Heart sounds and valve locations

Atrioventricular valves between atria and ventricels (tricuspid on left, bi on right)
Semi lunar valves between ventricel and great vessel, right is colonic left is aortic
When valves close lub dub
Lub = atrioventriculcar closing = S1
S2 = semilunar closi


If have hypertension perssure in arteries ventricle has to do isometric contraction that much more to compensate for pressure. Aortic valve opens at 82 here = bp 120 over 82. If 130/90 ventricle has to make that much more isometric contraction to get up t

S3 and S4

abnormal sounds. Both occur during diastole. Cause by ventricle that not accepting turbulent blood flow. Normally during diastole blood flwoing in silently, if for some reason ventricle rigid or tight and doesn't like blood pouring in = trubulent will mak

Where hear heart soudns best?

Hear S1 better at apical because tri and bi cuspid near apex of heart, bottom of heart.
S2 closesur aortic pulmonic, heard bet at the base, the top.

Split S2

Split S2, aortic pukmonic close sepearately hear two sounds, remember more to the right, less to the left = little less blood in left side heart during inspiration because sequestered in lung taking in oxygen, little bit more in right side. Stroke volume

Cardiac Output and BP

Resting adult cardiac output 4-6 L blood per min = volume blood that in each systole (stroke volume) times heart rate.
BP = cardiac output time systemic vascular resistance.


Preload is length to which ventricle muscle stretches at end of diastole. If exercise ventricles will stretch more than at rest, and greater stretch = greater will contract is Starlings law.
If volume overlaod have a prelaod problem = give diuretic


Afterload is the opposing pressure the ventricle has to generate to open the aortic valve. If too much pressure have an afterload problem, give an antihypertensive?

Subjective Cardiac data

Dyspnea = shortness of breath
Orthopnes = how many pillows need to be comfortable
Cough can be associated cardiac disease, right sid eheart failure fluid back to lungs.
Men more at risk until menopause then evens out,
Race, blacks have twice the rate as c

Aortic stenosis

narrowing of the aorta. Can lead to different BPs in each arm.

Hypertension is a result of

Hypertension caused difference cardiac output (heart rate stroke volume) periperhapl vascular resistance (blood viscosity or rigid walls) or both.

Venous Pressure

Can see pulsation in sternal notch but if touch no pulse, because when blood into ventricel atrial kick moves backward, jugular venous pulsation. That's why check the internal jugular vein, closer to heart, and right one for same reason.
Right atrium at a

The female breast lies between?

The 2nd and 6th rib, sternal edge to midaxillary line

Tail of spence

extension of breast tissue that extends into the axilla, malignancies often seen here

Thre three types of breast tissue?

Glandular, fibrous and adipose

Glandular breast tissue

located into 15-20 lobes surrounding the nipple

Fibrous breast tissue

bands of tissue including suspensory ligaments (Cooper's), which support the glandular tissue

Adipose breast tissue

surrounds the breast and predominates the breast tissue

Central axillary nodes

the lymph nodes that are found high up in the middle of the axillae. they receive lymph from the other three groups of nodes

Pectoral nodes

3 to 5 nodes just deep to pectoralis muscles along medial wall of axilla. receives lymph from anterior thoracic wall. Drains into central node

Subscapular nodes

located along the lateral edge of the scapula just inside posterior axillary fold; drainage from the posterior chest wall and arm

Lateral axillary nodes

lymph from ducts and nodes in arm pass into these nodes, and ultimately to the subclavian lymph trunk

Parasternal nodes

medial breast lymph drain nodes

Lymph nodes and drainage associated with breast

Breast cancer risk _____with age, cervical cancer _____with age.

increases, decreases

Risk factors for breast cancer

childbearing after 30
late menopause
female relatives with cancer

More veins in one breast can mean?

Feeding a tumor

Where do men and women most often get cancer?

Men deep behind nipple and women axillary and tail of spence


benign slow growing tumor. Most common breast lesion in young women.
Round or ovioid, rubbery, discrete and mobile non tender 1-3 cm mass. Usually solitary but may be multiple.
Dultrasound to see if cyst, Sometimes removed, sometimes just watched.

Fibrocystic breast disease

Age 30-50, regress after menopause except with estrogen therapy, Single or multiple, Round, Soft to firm, usually elastic, Well delineated, Mobile, Often tender. More tender from caffeine and chocolate, Non cancerous, but slight cancer risk increase.

Breast cancer

Age 30 and older, most common over 50
Usually single, although may coexist with other nodules
Irregular or stellate
Firm or hard
Not clearly delineated form surrounding tissues
May be fixed t skin or underlying tissues
Usually nontender

peau d'orange


5 Tanner stages


enlargement of male breast tissue, normal during puberty and temporary
seen in anabolic steroids or liver disease

order of axillary palpation

deep central , pectoral, lateral, subscapular, epitrochlear lymphnode

Suprasternal notch

Hollow, U-shaped depression just above the sterum, in between clavicles

Angle of Louis

Manubriosternal angle, at second rib, above first bifurcation of traechea, upper border of atria of heart

Costal angle

found between the right and left costal margins meeting at the level of the xiphoid process; should be less than 90 degress; greater than 90 degrees indicates emphysema

Vertebra Prominens

the spinous process of the seventh cervical vertebra (C7)

Spinous Processes

Knobs on the vertebrae to T4.

The inferior border of the scapula is located...

at the 7th or 8th rib

Location of the 5 lobes of the lungs anterior

Location of the 5 lobes of the lungs posterior

Lung base rests on diaphragm near which rib?

6th rib

Apex of lungs marked in back by?


From deflated to inflated lung moves from?

T10 to T12


the part of the thoracic cavity between the lungs that contains the heart and aorta and esophagus and trachea and thymus


a double-layered sac surrounding each lung consisting of parietal pleura & visceral pleura (lubricated by pleural fluid); help divide the thoracic cavity into central mediastinum & 2 lateral pleural compartments

If choke or aspirate goes into which lung and why?

Right because bronchial tree on right is shorter and straighter.

Costodiaphragmatic recess

-a potential space formed by the extension of the pleurae 3 cm below the level of the lungs
-compromises lung expansion when it fills with air or fluid


membranous tube with cartilaginous rings that conveys inhaled air from the larynx to the bronchi

Bronchial tree

branched airways that lead from the trachea to the alveoli

Where does the traechea bifurcate?

The 2nd rib


difficult or labored respiration


coughing up blood

Respiratory excursion

Rough measurement of chest expansion on inspiration

tactile fremitus

99", vibratory tremors felt through the chest wall by palpation

Diaphragmatic excursion

percussing to map out the lower lung border during expiration and inspiration

Thorax front to side ratio should be?


The costal angle should be?

90 degrees

People sit in "tripod" because?

Need to expand chest cavity eg in COPD


a phase, or cyclic, type of breathing in response to hypercapnia (carbon-dioxide buildup) in the system. The cycle starts with a smooth increase, or crescendo effect, in the rate and depth of respirations followed by a gradual smooth decrease, or decresce

Difference between tachypnea and hyperventilation?

Tachypnea fast and shallow, hyperventilation fast and deep.

Difference between bradypnea and hypoventilation?

Bradypnea slow and deep, hypoventilation slow and shallow


irregular respirations with irregular periods of apnea. There is no cyclic nature to them as in Cheyne-Stokes breathing. Breaths are generally of equal depth (also distingishing them from Cheyne-Stokes).

Kussmaul respirations

deep, rapid respirations and indicate the body is trying to compensate for severe metabolic acidosis (blow off the excess carbon dioxide in the system). They have an increased rate, very large tidal volumn and no expiratory pause. Typically seen in diabet

barrel chest

a condition characterized by increased anterior-posterior chest diameter caused by increased functional residual capacity due to air trapping from small airway collapse. A barrel chest is frequently seen in patients with chronic obstructive diseases, such

What does tactile fremitus test for?

Sound is conducted better through a dense or solid structure than porous so anything that increase density of lung will increase fremitus

Test for symmetric expansion where?

at 9th or 10th rib

Expected Percussion Notes - Posterior Chest

3 kinds of normal breath sounds

Locations of 3 breath sounds

Vesicular is majority of breath sounds, bronchovesicular over main stem of bronchus and bronchial over menubrium.


upper portion of the sternum


Abnormal transmission of sounds from the lungs or bronchii. Pathology that increases lung density will enhance transmission of voice sounds ex// you hear a clear "nighty-nine". Pneumonia test


a change in the voice sound of a patient with pleural effusion or pneumonia as heard on auscultation. When the patient is asked to make /?-?-?/ sounds, they are heard over the peripheral chest wall as /�-�-�/, particularly over an area of consolidated or

Whispered Pectoriloquy

condition in which the words "one-two-three" whispered by the patient are heard distinctively and clearly through a stethoscope placed over the lungs; possibly indicitive of consolidation and pleural effusions. In a normal test, words would sound faint an

Expected sounds on anterior percussion of chest

Normal Lung

Trachea - midline
Tactile Fremitus - normal
Percussion - resonant
Breath sounds - vesicular except perhaps over large bronchi or trachea
Adventitious sounds -none

Atelectasis- Lobar Obstruction on assessment

Trachea - may be shifted towards involved side
Tactile Fremitus - usually absent
Percussion - dull over airless area
Breath sounds - usually absent when bronchial plug.
Adventitious sounds -none


collapse of lung tissue

Consolidation-Pneumonia on assessment

Trachea - midline
Tactile Fremitus - increased over involved area with bronchophony, egophony, whispered pectoriloquy
Percussion - dull over airless area
Breath sounds - bronchial over involved area
Adventitious sounds - late inspiratory crackles over inv

Bronchitis on assessment

Trachea - midline
Tactile Fremitus - normal
Percussion - resonant
Breath sounds - vesicular except perhaps over large bronchi or trachea
Adventitious sounds -none or scattered coarse crackles in early inspiration and perhaps expiration; or wheezes and rho

Emphysema on assessment

Trachea - midline
Tactile Fremitus - decreased
Percussion - hyperresonant
Breath sounds - decreased to absent
Adventitious sounds -none or scattered coarse crackles in early inspiration and perhaps expiration; or wheezes and rhonchi associated with chroni

Asthma on assessment

Trachea - midline
Tactile Fremitus - decreased
Percussion - resonant to hyperresonant
Breath sounds - often obscured by wheezes
Adventitious sounds - wheezes, possibly crackles

Pleural Effusion on assessment

Trachea - shifted toward opposite side in large effusion
Tactile Fremitus - decreased to absent
Percussion - dull to flat over fluid
Breath sounds - decreased to absent, but bronchial sounds may be heard near top of large effusion
Adventitious sounds - no

Pneumothorax on assessment

Trachea - shifted toward opposite side if much air
Tactile Fremitus - decreased to absent over pleural air
Percussion -hyperresonant to tympanic over pleural air
Breath sounds - decreased to absent over pleural air
Adventitious sounds - none, except a pos

Congestive Heart Failure on assessment

Trachea - midline
Tactile Fremitus - decreased
Percussion - resonant Breath sounds - vesicular
Adventitious sounds - late inspiratory crackles in the dependent portions of lungs; possibly wheezes.


alveoli filled with fluid or blood cells, as in pneumonia


inflammation of the membranes lining the bronchial tubes


obstructive pulmonary disease characterized by overexpansion of the alveoli with air, with destructive changes in their walls resulting in loss of lung elasticity and gas exchange


chronic bronchial inflammatory disorder with airway obstruction due to bronchial edema and constriction and increased mucus production

pleural effusion

accumulation of fluid within the pleural cavity


air in the pleural cavity caused by a puncture of the lung or chest wall

congestive heart failure

Failure of the left ventricle to pump an adequate amount of blood to meet the demands of the body, resulting in a "bottleneck" of congestion in the lungs that may extend to the veins, causing edema in lower portions of the body

Cranial Nerve I


Cranial Nerve II

(visual acuity, visual fields, ocular fundi)

Cranial Nerve II, III

Optic, Oculomotor
(Pupillary reactions)

Cranial Nerve III, IV, VI

Oculomotor , Trochlear, Abducens
(Extraocular movements)

Cranial Nerve V

(Corneal reflexes, facial sensation, and jaw movements)

Cranial Nerve VII

(Facial movements)

Cranial Nerve VIII


Cranial Nerve IX, X

Glossopharyngeal, Vagus
(Raising of soft palate, swallowing, gag reflex)

Cranial Nerve XI

(Movement of trapezius muscles)

Cranial Nerve XII (with V, VII, X)

Hypoglossal, with Trigeminal, Facial, Vagus
(Voice and speech, tongue movement)

Medial rectus innervation?

Oculomotor (III)

Inferior rectus innervation?

Oculomotor (III)

Superior rectus innervation?

Oculomotor (III)

Lateral rectus innervation?

Abducens (VI)

Inferior oblique innervation?

Oculomotor (III)

Superior oblique innervation?

Trochlear (IV)

Medial rectus function?

Adduction (eye moves nasally)

Lateral rectus function?

Abduction (eye moves towards lateral canthus, temporally away from nose)

Superior rectus function?

Elevation (eye moves upward)
Abduction (eye moves towards lateral canthus, temporally away from nose)

Inferior rectus function?

Depression (eye moves downward)

Superior oblique function?

Intorsion (top of the eye towards nose)

Inferior oblique function?

Extorsion (top of the eye away from nose)

Oculomotor (III) nerve palsy

Results in ptosis and inability to elevate or adduct the eyes. Common causes include diabetes, aneurysms and midbrain lesions.

Nerve palsy of abducens (VI)

Affected eye cannot cross the midline on lateral gaze

Skin Warning Signs

Borders (irregular)
Color (mottled, brown/black/grey/red/white)
Diameter (>6mm, pencil eraser)

Eye muscle diagnostic positions


A circumscribed, flat, nonpalpable change in skin color.
Up to 1cm

Freckles, flat nevi, hypopigmentation, petechiae, measles, scarlet fever are examples of?



A macule larger than 1cm

Mongolian spot, vitiligo, cafe au lait spot, chloasma, measles rash are examples of?



A palpable, elevated, circumscribed, solid mass; caused by superficial thickening in the epidermis. <0.5cm

Elevated nevus, lichen planus, molluscum, wart are examples of?



A flat, elevated surface larger than 0.5 cm., often formed by the coalescence of papules.


A solid, elevated, firm or soft mass larger than 0.5 cm. May be firmer and extend deeper into the dermis than a papule.

Psoriasis, lichen planus, xanthoma are examples of?



A solid, elevated, firm or soft mass larger than 1 - 2 cms., extending even deeper into dermis; may be benign or malignant.

Lipoma, hemangioma are examples of?



A superficial, raised, erythematous, transient!!!, lesion with somewhat irregular borders due to localized edema (fluid held diffusely in the tissues).

Mosquito bite, allergic reaction, dermographism are examples of?



Wheals coalescing to form an extensive reaction; intensely pruritic (itchy).

Hives are examples of?



A circumscribed, superficial, elevated cavity containing free fluid; clear fluid flows if wall is ruptured. Up to 1cm.

Herpes simplex, early varicella (chicken pox), herpes zoster (shingles), contact dermatitis are examples of?



A larger vesicle (>1cm); usually single chambered (unilocular); superficial in epidermis; it is thin walled, so it ruptures easily.

Friction blister, pemphigus, burns, contact dermatitis are examples of?



A circumscribed, superficial, elevated cavity containing turbid fluid (pus) <1cm

Impetigo, acne are examples of?



An encapsulated, fluid- or pus-filled cavity in dermis or subcutaneous layer, tensely elevating the skin.>1cm

Primary lesions

Develop on previously unaltered skin. They are the immediate result of a specific causative factor.

Secondary lesions

Result from the evolution of a primary lesion, scratching, or a secondary infection.


The thickened, dried residue of burst vesicles, pustules, or blood. Can be red-brown, honey-colored, or yellow, depending on the fluid's origin.

Eczema, impetigo, scab following an abrasion are examples of?



Compact, desiccated flakes of skin, dry or greasy, silvery or white, from shedding of dead excess keratin cells; visible exfoliation of the dermis.

Post-scarlet fever or drug reaction (laminated sheets of skin), psoriasis (silvery), seborrheic dermatitis (yellow, greasy), dandruff, dry skin are examples of?



A scratch mark; superficial; can be a self-inflicted abrasion secondary to intense itching.

Scratches from a foreign body, insect bites, scabies, dermatitis, varicella are examples of?



A linear crack with abrupt edges; extends into the dermis; can be dry or moist

Cheilosis (at corners of mouth), athlete's foot, anal ____ are examples of?



A superficial, circumscribed loss of epidermis; leaves a scooped-out, but shallow depression; moist but no bleeding; heals without a scar because it does not extend into the dermis.

Stage 2 decubitis ulcer is an example of what kind fo secondary skin lesion?



A circumscribed depression extending into the dermis; irregular shape; may bleed; leaves a scar when it heals.

Stasis ___, pressure sore, chancre, malignant growth are examples of?



Replacement of destroyed normal skin tissue by fibrous connective tissue; a permanent change.


A hypertrophic scar. The resulting skin level is elevated by excess scar tissue, which is invasive beyond the site of original injury.


Depressed skin level resulting from loss of tissue; a thinning of the epidermis with loss of normal skin furrows, resulting in shiny, translucent skin.

Striae, senile skin, arterial insufficiency are examples of?



Thickening and roughening of the skin, usually as a result of intense scratching. Results from a tightly packed set of papules; causes increased visibility of the superficial skin markings.

Long-standing eczema, atopic dermatitis can result in?


Papulosquamous, maculopapular, vesiculopustular, or papulovesicular are examples describing what?

Combinations of primary and secondary lesions that coexist in the same person.

Functions of the skin

Prevents penetration
Temperature regulation
Wound repair
Absorption and excretion
Synthesizes vitamin D

Visualize the anatomy of the skin


The thin, outermost layer of skin

The two layers of the epidermis

The stratum corneum and stratum germinativum

Stratum corneum

Horny cell layer of dead keratinized cells

Stratum germinativum

Inner basal cell layer made up of rapidly proliferating living cells that slowly migrate upward, keratinize and are ultimately shed form the stratum corneum, (process takes about 4 weeks).


Dense connective tissue layer forming the bulk of the skin

Location and differences between appocrine and exocrine sweat glands

Eccrine- open directly skin surface, produce sweat. Widely distributed in the body and are mature in the 2-month old.
Apocrine- glands found in close association with hair follicles. Mostly in the axillae, areolae, the navel, the pubis and the perineum, s

The two major cell types in the basal cell layer ?

keratin and melanocytes

Skin color is derived from which 3 sources?

The mainly brown pigment melanin
The yellow-orange pigment carotene
The red-purple tones in the underlying vascular bed.

The names and functions of the main 2 types of tissue in the dermis.

Chiefly collagen, a tough, fibrous protein that enables skin to resist tearing and elastin- a resilient tissue that allows the skin to stretch with movement.

The nerves, lymphatics, blood vessels and sensory receptors reside?

In the dermis

Subcutaneous layer

The 3rd layer, chiefly composed of adipose (fatty connective ) tissue

The skin of the very young is unable to...

effectively prevent fluid loss or function in temperature regulation

Wrinkling occurs because of loss of 3 things....

elastin, collagen and subcutaneous fat

Hypothyroid skin is...


Hyperthyroid skin is...


To assess the critical aspects of a reported symptom

Provocative and palliative?
Quality and quantity?
Region and radiation?
Severity scale?
Understanding patient perception

Reynaud's phenomenon

Severe vasoconstriction of fingers and toes leading to extreme color changes in these areas

Preferred sites for assessing pallor from anemia

The palpebral conjunctiva and nail beds

Causes of jaundice

hepatitis, cirrhosis, sickle-cell disease

Jaundice first seen in...

Junction of hard and soft palate or in sclera


Intense redness of skin due to excess blood in superficial capillaries

Increased pigment around neck called nigracans indicates

Diabetes, hyper-insulin, anemia

Comedonal acne

Increased activity in sebaceous glands increased oiliness, both whiteheads and blackheads.

Pustular acne

Deeper and bigger lesions than in comedonal

5 changes in skin of older adults

Senile purpura (bruises from loss blood flow and subq fat)
Xerosis (dry skin)
Senile letigines (liver spots, small, flat brown macules cluster of melanocytes from sun exposure, not malignant)
Slower healing
Keratoses (raised, thickened areas of

Ratings for edema

1= mild pitting slight indentation, no leg swelling
2= moderate, indentation subsides rapidly
3= deep, indentation remains for a short time leg looks swollen
4+= very deep, indentation lasts a long time leg is swollen


Ease of skin rising


Ease of skin returning to its place after being raised

Cherry angiomas

Small, smooth, slightly raised bright red dots increase with age.


On stalk


Circular as in ringowrm


Lesions run together (hives)


distinct individual lesions (molluscum)


Clusters of lesions (contact dermatitis)


Twisted, coiled spiral, snakelike.

Target or iris

resembles iris of eye (erythema multiforme)


A scratch, streak, line or stripe


Annular lesions grow together (Lichen planus, psoriasis)


Linear arrangement along a nerve route - herpes zoster


Pin sized macules of blood in the skin


Larger macule of blood in the skin, does not blanch


Larger extravasations of blood into skin

Spider angioma

Stellate telangiectases radiating from central feeding vessel. If press center lesion will disappear. If many on trunk check liver function


Chronic dilation of groups of capillaries causing elevated dark red blotches on the skin (niefdrine causes)

Nevus flammeus, port wine stain

Present at birth, caused by dilated dermal capillaries.

4 types of herpes virus

Herpes simplex 1 (mouth, cold sore)
Herpes simplex 2 (genital)
Herpes zoster (shingles)

Three types of skin cancer

Basal cell carcinoma
Squamous cell carcinoma

Basal cell carcinoma

Most common
Locally invasive
Rarely metastasizes
Translucent dome shaped papule with overlying telangiectasia

Squamous cell carcinoma

De novo, on its own, or arising from actinic keratoses
"Sore that never heals"
On sun exposed areas


deadliest skin cancer, malignant nevi


abnormal excess body hair growth in women resulting from polycystic ovarian syndrome and diabetes

Picture the structure of the nail

Problem Oriented Records are arranged


The 4 regions of the skull and their locations



Immovable joints that ossify during childhood.

Anterior fontanel

Diamond shaped, closes between 4 and 26 months

Posterior fontanel

Triangular shaped, closes by two months

Palpebral fissures

openings between eyelids

Sensory portion of Cranial nerve V (trigeminal) innervates 3 areas...

Ophtalmic (forehead, near eyes)
Maxillary (cheeks)
Mandibular (chin and jaw)

Decreased ROM in jaw indicates


Click in the jaw movement indicates

Synovial swelling, tear in meniscus or poor occlusion (upper and lower jaw coming together)

Temporal artery is a small branch of the...

carotid artery

Temporal artery should NOT be...

indurated (hard)
tortuous (twisting)

Picture eye structure


corner of the eye (both sides- medial and lateral) - the angle where the lids meet


A small fleshy mass containing sebaceous glands in inner canthus


Transparent front part of the eye that covers the iris, pupil, and anterior chamber, continuous with the sclera


whitish fibrous membrane that with the cornea forms the outer covering of the eyeball


Colored muscular diaphragm that controls the size of the pupil


The adjustable opening in the center of the eye through which light enters


the border between the cornea and the sclera


the light-sensitive membrane covering the back wall of the eyeball

Tarsal plate

strip of connective tissue gives shape to the upper lid.

Meibomian glands

modified sebaceous glands that secrete an oily lubricating material onto the lids and help with airtight seal when lids are closed


mucous membrane that lines the eyelids and outer surface of the eyeball

Palpebral conjunctiva

the part of the conjunctiva that coats the inside of the eyelids

Bulbar conjunctiva

the part of the conjunctiva that overlays the eyeball with the white sclera showing through - merges with cornea at limbus.

Path of tears from lacrimal gland to nose


middle layer of internal eye - darkly pigmented, highly vascular delivers blood to the retina. Continuous with ciliary body and the iris. Lens divides eye into anterior and posterior, keeps viewed objects in continual focus on retina

Cilliary Body

Controls the thickness of the lens. Lens bulges for focus on near objects and flattens for far object.

Pupil contracts

Bright light, near vision

Pupil dilates

Dim light, far vision

Anterior compartment

Behind the cornea and in front of the iris and lens, contains a clear liquid called aqueous humor

Aqueous humor is produced...

by the cilliary body

Optic disc

most prominent structure - head of optic nerve located toward the medial or nasal side of the eye
creamy yellow-orange to pink
round or oval
margins are distinct and sharply demarcated especially on temporal side

physiologic cup

visualized as a light area near center or disc.inside disc where vessels enter and exit,


site of central vision -about same size as disc and is visualized as an area with increased pigmentation without a distinct margin. May be identified by a reflection of light- located two disc diameters temporal to the disc review and transduces light for

fovea centralis

the center of the macula and is highly concentrated with cones. This is the areas of highest visual resolution and color vision.

visual fields

the entire areas seen by an eye when it looks at a central point, are normally limited by the brows above, by the cheeks below, and by the nose medially.
When a person is using both eyes, the two overlap in an area of binocular vision. Laterally, vision i

Trace the visual pathways

for an image to be seen, light reflected from it must pass through the pupil and be focused on sensory neurons in the retina.
The image projected there is upside down and reversed right to left. An image from the upper nasal visual field thus strikes the

Pupillary light reflex

normal constriction of the pupils when bright light shines on retina - the afferent link is CN II (optic nerve) - the efferent link is CNIII (oculomotor)
When one eye exposed to bright light, a direct light reflex occurs (constriction of pupil) as well as


reflex directing eye to object - image is fixed in center of visual field


very rapid ocular movements to place object in center of vision - impaired with drugs alcohol fatigue etc.


adaptation of eye for near vision. - accomplished by increasing curvature of the lens through movement of ciliary muscles - observe through convergence of the axes of the eyeballs and pupillary constriction.


abnormal alignment of one or both eyes


visual impairment in which an object is seen as two objects


increased pressure in the eyeball due to obstruction of the outflow of aqueous humor

corneal light reflex

Reflections of light noted at same location on both eyes

snellen chart use

Position patient 20 feet from chart, shield one eye, read smallest line possible, encourage to read the next line as well- leave glasses on
Record fraction noted at last line read with mistakes or glasses ie. OD 20/30 -1 with glasses
Normal is 20/20 top n


occurs when the anterior-posterior diameter of the eye is too long relative to the refracting power of the cornea and lens


anterior posterior diameter is too short relative to the refracting power of the eye


beginning in the fifth decade, ability of lens to accommodate decreases, resulting in progressive difficult in reading fine print


drooping of eyelid


abnormal constriction with narcotic, paralysis of sympathetic nerves, iritis


abnormal dilation seen with III nerve palsy, increased IOP, midbrain lesions, deep coma, brain death and some drugs like atropine


unequal pupils- if pupillary reactions are normal is considered normal

test which will detect a small degree of deviated alignment by interrupting the reflex that normally keeps the 2 eyes parallel.

Have patient stare ahead at your nose, cover one eye, watch uncovered eye, - normal response is a stead fixed gaze.- covered eye will relax - uncover, watch for movement - if it jumps = eye muscle weakness


fine oscillating movement- ok at lateral gaze - bad otherwise, cerebellar problem (ms) ear, semicircular canal or drug toxicity

bitemporal hemianopsia

from cut in optical chiasm (where optic nerves cross over nasally) so lose temporal vision on both side

left homonymous hemianopsia

lesion in right optic tract leads to disruption left eye temporal and right eye nasal fields

AV nicking

A vascular abnormality in the retina of the eye, in which a vein is compressed by an arteriovenous crossing. The vein appears "nicked" as a result of constriction or spasm. It is a sign of hypertension, arteriosclerosis, or other vascular conditions.


swelling and inflammation of the optic nerve at the point of entrance into the eye through the optic disk

name and locate structures of auricle/pinna

name and locate structures inside ear


the outermost bone in the ossicular chain. One end is attached to the tympanic membrane; the other is connected to the Incus.


anvil; middle of the three auditory ossicles of the middle ear


the stirrup-shaped ossicle that transmits sound from the incus to the cochlea


the snail-shaped liquid filled tube (in the inner ear coiled around the modiolus) where sound vibrations are converted into nerve impulses by the Organ of Corti

semicircular canals

three loops of the fluid-filled tubes that are attached to the cochlea; They help us with our sense of balance

eustachean tube

connects ear to nasopharynx, and is responsible for pressure equalization. gets more slanted as you age, which is why children are much more likely to get ear infections.


hardening of the spongy bone of the ear, leads to deafness

tympanic membrane structure and names


age related hearing loss

pathways of hearing

Rinne test

hearing test using a tuning fork; checks for differences in bone conduction and air conduction

Weber test

Test done by placing the stem of a vibrating tuning fork on the midline of the head and having the patient indicate in which ear the tone can be heard.


a small cartilaginous flap in front of the external opening of the ear


when impacted causes partial deafness, tinnitus or dizziness


Discreet, hard, round or oval outcropping
formation of new bone on the surface of a bone
Seen in swimmers and surfers
develop over many years and can result in infections, pain, plugging and hearing loss.

otitis externa

Scaling or crusting, inflammation and discharge in canal
pain on movement of tragus especially
may have palpable nodes
ask about swimming, frequent cleaning of ear

serous otitis media

TM is retracted and has decreased mobility
Thin serous effusion give a yellowish appearance
Bubbles apparent if eustachian tube is blocked

bacterial otitis media

bacteria can migrate into eustachian tube from resp tract, multiply and infect. most commonly caused by strep pneumoniae

salivary glands and neck vessels

neck muscles

Sternomastoid and trapezius muscles innervated by cranial nerve XI, spinal accessory.
Anterior and posterior triangles are important landmarks for describing abnormalites.

Lymph node names and locations


Endocrine gland with rich blood supply
Straddles trachea with lobe on each side
Isthmus lies over the trachea at 2nd or 3rd tracheal ring
Just above isthmus is cricoid cartilage with thyroid cartilage above that (Adam's apple)

Location of thyroid

palpate trachea

Normally midline - palpate for shift
Place index finger in sternal notch and slip off to each side - should be symmetrical

How to Examine CN XI: Spinal Accessory - trapezius muscle

How to Examine CN XI spinal accesory - Sternocleidomastoid Muscle

palpation of the thyroid

Ask to bend head slightly forward and to right.
Use fingers of left hand to push trachea slightly to right.
Then feel with right finger between trachea and muscle.
Ask to swallow the thyroid moves up under your finger with the trachea and larynx .


enlargement of the thyroid gland caused by thyroid dysfunction, tumor, lack of iodine in the diet, or inflammation



Keisselbach region

anteroinferior part of the nasal septum, where four arteries anastomose


the division of the two nares and is continuous inside with the nasal septum

ala nasi

expanded outer wall of cartilage on each side of the nose

lateral wall turbinates

Superior meatus - ethmoid cells
Middle meatus - sinuses
Inferior meatus - tears

structures of the nasal cavity

Paranasal sinuses




inspection of a cavity or organ by passing light through its walls

oral cavity structures

salivary glands names and location


difficulty swallowing

assessing CN XII - hypoglossal nerve

stick tongue out
Should protrude midline
Note any tremors or deviation
Deviates towards paralyzed side

Grading tonsils

1+ = visible
2+ = halfway between pillars and uvula
3+ = touching uvula
4+ = touching each other

bacterial pharyngitis

red throat with exudate on tonsil.
fever and enlarged cervical nodes, increases the causal probabilities of group A streptococcal infection or infectious mononucleosis.