Three types of joints?
Bone is made of what kind tissue?
articulation of two bones
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
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
hands behnd back demonstrates
bony articulation at elbow away from body
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?
MCP, PIP, DIP
associated with auditory reception. IF damaged in domnant side person can hear words but can't make sense.
if damaged perosn knows what wants to say but can;t get words to come out right.
associated with reasoning, planning, parts of speech, movement, emotions, and problem solving
portion that lies below the frontal lobe, responsible for hearing, taste, and smell
portion posterior to the frontal lobe, responsible for sensations such as pain, temperature, and touch
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.
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?
A PERIPHERAL lesion at CN VII
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?
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?
What are the functions of the frontal lobe?
1. intellectual fxns
Where is the primary sensory area located?
Where is Broca's area located? What is its function?
fxn: (motor) speech formation
What is the function of the cerebellum?
1. COORDINATION of VOLUNTARY movements
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?
2. sleep center
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.
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?
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?
1. spinothalamic tract
2. posterior (dorsal) column
What does the spinothalamic tract sense?
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)
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?
3. light/crude tough
How do you test tactile discrimination?
3. 2-point discrimination
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
Area surrounding the introitus, within the labia minora
entrance to vagina
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?
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?
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
What are we feeling during a hernia examination?
The external inguinal ring
What should you inspect the scrotum for?
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
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.
Frontal: personality, behavior, higher functions
Temporal: hearing, tasting, smelling
Basal Ganglia: unconscious movement, control of fine movement
Thalamus: processing of sensory input; relay of sensory info to cortex
Midbrain (superior, anterior)
Medulla (inferior, posterior)->site of pyramidal decussation.
Muscle Tone--coordinated, smooth movements
Major Motor Pathways in CNS
Pyramidal (corticospinal) tract
Major Sensory Pathways
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
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.
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
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
Bowleggedness. Normal in kids until they start walking.
Knock-kneed, with greater than a 2 cm gap between ankles when knees are together. Normal up to 3.5 years old.
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?
Palmar grasp reflex
Reflexive grasp in response to palmar stimulation in infants under 2 months of age
When infant's cheek is stroked, infant turns head in that direction
pressure applied to foot makes toes curl in.
pressure applied to foot, toes fan out. Normal under 2 years.
Cri du Chat
High-pitched, shrill cry of infant. Indicated neural damage.
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.
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.
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.
Multiple weak ectopic foci in atria, which create lots of tiny P waves. Characterized by irregularly irregular rhythm.
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.
Emergency! Ventricles are so irritated that one of the foci takes over and starts beating. Crazy-looking fast rhythm.
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
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.
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
Most common hernia in young men
Mostcommon hernia in obese men
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
Skull bone joint type
Fibrous suture joint
Shoulder and hip joint type
Carpal joint type
Synovial Gliding (planar) joints
Knee joint type
Synovial Compound Joint (modified hinge)
Temporomandibular joint type
Synovial condyloid joint
Vertebral joint type
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.
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
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
depolarization of ventricular myocardium
Following the QRS complex, there is a segment of horizontal baseline known as the ST segment which represents the plateau phase of repolarization.
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
QRS interval? time
QT interval? time
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
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
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
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.
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.
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
Supply blood to myocardium, heart muscle
What is a normal percussion note over peripheral lung fields?
In COPD with large AP diameter called?
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?
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
May hear a bruit, may rupture, 95% above umbilicus, femoral pulses decreased.
Complaint of tenderness along posterior costovertebral angle indicates?
Loud, gurgling bowel sounds
Bladder full, on percussion?
Palpation of right subcostal area while client takes a deep breath - extreme pain indicates acute cholecystitis (inflammation gall bladder)
hyperextention of right hip causing abdominal pain =
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
Infant Motor Function & Postural Tone
Assessment of voluntary muscles
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
Push under toes and get curl, Gone by 10-12 mos
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
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
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
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)
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
between epiphysis and diaphysis of LONG bone = epiphyseal plate where growth occurs. If injure before have closed can have shortening of the limb.
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
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
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
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
pronate foot inward, foot pad
Pigeon toes or toeing in
longitudinal arch higher than normal, usually corrects by 3yo, concerned if tibial torsion
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 _____,
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, 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
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.
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
3 to 5 nodes just deep to pectoralis muscles along medial wall of axilla. receives lymph from anterior thoracic wall. Drains into central node
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
medial breast lymph drain nodes
Lymph nodes and drainage associated with breast
Breast cancer risk _____with age, cervical cancer _____with age.
Risk factors for breast cancer
childbearing after 30
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.
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
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
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
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
the spinous process of the seventh cervical vertebra (C7)
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?
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.
-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
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
Rough measurement of chest expansion on inspiration
99", vibratory tremors felt through the chest wall by palpation
percussing to map out the lower lung border during expiration and inspiration
Thorax front to side ratio should be?
The costal angle should be?
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).
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
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
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
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
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
Cranial Nerve III, IV, VI
Oculomotor , Trochlear, Abducens
Cranial Nerve V
(Corneal reflexes, facial sensation, and jaw movements)
Cranial Nerve VII
Cranial Nerve VIII
Cranial Nerve IX, X
(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?
Inferior rectus innervation?
Superior rectus innervation?
Lateral rectus innervation?
Inferior oblique innervation?
Superior oblique innervation?
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
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
Develop on previously unaltered skin. They are the immediate result of a specific causative factor.
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
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
Horny cell layer of dead keratinized cells
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
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?
Understanding patient perception
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
Increased activity in sebaceous glands increased oiliness, both whiteheads and blackheads.
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)
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
Small, smooth, slightly raised bright red dots increase with age.
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
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
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.
Diamond shaped, closes between 4 and 26 months
Triangular shaped, closes by two months
openings between eyelids
Sensory portion of Cranial nerve V (trigeminal) innervates 3 areas...
Ophtalmic (forehead, near eyes)
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...
Temporal artery should NOT be...
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
strip of connective tissue gives shape to the upper lid.
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
the part of the conjunctiva that coats the inside of the eyelids
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
Controls the thickness of the lens. Lens bulges for focus on near objects and flattens for far object.
Bright light, near vision
Dim light, far vision
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
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
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
the center of the macula and is highly concentrated with cones. This is the areas of highest visual resolution and color vision.
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
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
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
three loops of the fluid-filled tubes that are attached to the cochlea; They help us with our sense of balance
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
hearing test using a tuning fork; checks for differences in bone conduction and air conduction
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.
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
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
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
anteroinferior part of the nasal septum, where four arteries anastomose
the division of the two nares and is continuous inside with the nasal septum
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
inspection of a cavity or organ by passing light through its walls
oral cavity structures
salivary glands names and location
assessing CN XII - hypoglossal nerve
stick tongue out
Should protrude midline
Note any tremors or deviation
Deviates towards paralyzed side
1+ = visible
2+ = halfway between pillars and uvula
3+ = touching uvula
4+ = touching each other
red throat with exudate on tonsil.
fever and enlarged cervical nodes, increases the causal probabilities of group A streptococcal infection or infectious mononucleosis.