BMI Classifications
Underweight: <18.5
Normal: 18.5-24.9
Overweight: 25.0-29.9
Obesity class
� I: 30.0-34.9
� II: 35.0-39.9
� III: at or over 40
How do you calculate BMI?
Stages of HTN
Normal: under 120/80
Prehypertension: 120-139/80-89
Stage 1: 140-159/90-99
Stage 2: over 160/100
If diabetes or renal disease: goal is under 130/80
Waist Circumference
Risk if over 35in for women
Risk if over 40in for men
Cranial Nerves
1. Olfactory: Sensory
2. Optic: Sensory
3. Occulomotor: Motor
4. Trochlear: Motor
5. Trigeminal: Both
6. Abducens: Motor
7. Facial: Both
8. Acoustic: Sensory
9. Glossopharyngeal: Both
10. Vagus: Both
11. Spinal Accessory: Motor
12. Hypoglossal: Motor
Romberg Test
Stand with hands to the sides and eyes closed, observe swaying
Pronator Drift
Stand with arms out, eyes closed, and hands supine -- watch for hands pronating.
Graphesthesia
The inability to recognize numbers written on the hand. Suggests a lesion in the sensory cortex.
Astereognosis:
Inability to recognize objects placed in the hand
Kernig
Flex patient's leg at hip and knee, then straighten the knee. Discomfort behind the knee during full extension should not cause pain.
Brudzinski
Pt supine, your hands behind pt's head and flex the neck forward, until chin touches the chest if possible. Neck stiffness with resistance and flexion of hips and knees is a positive sign. May be a sign of acute bacterial meningitis or subarachnoid hemorrhage
Straight Leg Raising
Lift the straight leg, if pt has low back pain with nerve pain that radiates down the leg = sciatica from compression of the spinal nerve root as it passes through the vertebral foramen
Plantar (Babinski) Reflex
Dorsiflexion of the big toe is a positive Babinski response from a CNS lesion in the corticospinal tract
Finkelstein Test
Pt grabs thumb with hand and you pull down to see if there is tendon tenderness - if positive, might mean tendonitis
Tinel's Sign
Tap on the Median Nerve
Phalen's Test
Bend wrists at 90 degrees and put back of hands against each other for 1 minute and see if there is numbness/tingling
Ballotment
Leg extended, compress the suprapatellar pouch and then push the patella sharply against the femur, watching for fluid returning to the pouch
Bulge Sign
Knee extended, hand on knee above the patella and milk downward. Apply medial pressure and tap laterally. Watch for a fluid wave
Drawer Sign
Pt supine with knee flexed, your thumbs at the medial/lateral joint line and fingers wrapped around. Then sharply push/pull, watching for laxity
McMurray Test
Pt supine with knee flexed, one hand medial knee and the other medial ankle. Extend the leg and laterally rotate, watching for clicking
Directions for Self-Breast Exam
5-7 days after period OR same time every month for menopausal women. Lawn Mower pattern
What Abdominal locations do you listen for bruits with the Bell of the stethoscope?
Aoritc, Illiac, Femoral
What Abdominal locations do you listen for bruits with the diaphragm of the stethoscope?
Epigastric and Renal
Murphey's Sign
Assessing gallbladder, pt will stop breathing d/t pain when pushing up on the liver if positive.
Rovsing's Sign
Pressure on LLQ causes referred pain in RLQ
Rebound Tenderness
Pain in RLQ increases when pressure is released quickly
Psoas Sign
Place hand just above right knee and ask pt to raise that thigh against your hand and turn onto the left side. then extend the right leg at the hip.Flexion of th leg at the hip makes the psoas muscle contract; extension stretches it. Increased abd pain with either maneuver constitutes a positive sign
Obturator Sign
Flex pt's right thigh at the hip, with knee bent, and rotate the leg internally at the hip. It stretches the internal obturator muscle. Right hypogastric pain = positive sign
Normal size of aorta
under 3 cm
Spleen percussion/palpation
Normally the lowest interspace in the left anterior axillary line is tympanitic. After a deep breath, if percussion changes from tympanitic, enlargement is suspected and you'll need to palpate the spleen, but be careful not to cause rupture
Feeling the liver edge
Normally feels smooth, soft, sharp, and regular. Normally about 3 cm below the right costal margin in the midclavicular line
Grading of Heart Murmurs
�Grade I -barely audible
�Grade 2-clearly audible but faint
�Grade 3-moderately loud, easy to hear
�Grade 4- Loud, associated with thrill
�Grade 5- Very loud- partly off chest
�Grade 6- Loudest can be heard with stethoscope lifted off chest
S3
low frequency heard best at the apex, use bell and lay on the left side. Ventricular gallop - means that ventricular compliance is low. Heard at the beginning of diastole. Blood flowing into overfilled non-compliant left ventricle rapidly decelerates. Sound of it "popping" open quickly. Ken-tuc-ky
S4
low frequency, heart best at the apex, use bell and lay on left side. Atrial gallop, pericardial friction rub. Heard at the end of diastole. Atrial contraction trying to push blood to the ventricle, but it is stiff. Ten-ness-ee.
Murmurs
Caused by a flow of blood across a partial obstruction (valve stenosis) or valve irregularity (leaks...) or increased flow through normal structures (pregnancy and anemia), flow into a dilated chamber (aneurysm), backward flow, shunting of blood out of a high pressure area through a hole
Heart conditions that accompany systolic murmurs
�Aortic Stenosis: pressure or gradient that the blood has to flow through due to a smaller valve. Increased pumping pressure of Left ventricle
�Pulmonary Stenosis: same as above, heard with diaphragm at 2nd and 3rd intercostal space, medium or rough quality, radiates to left shoulder and neck
�Tricuspid Insufficiency: supposed to be closed during systole, so causes a backward flow of blood. Diaphragm at 5th intercostal space at the sternal border, radiates to left anterior sternal line
�Mitral Insufficiency: loudest at the apex, 5th intercostal space, high pitched and blowing quality
Heart conditions that accompany Diastolic murmurs
�Aortic Insufficiency: most common, Marfan syndrome, retrograde blood flow into left ventricle. Diaphragm at 2nd and 4th intercostal along sternal border, sit up and lean forward and hold breath
�Pulmonary Insufficiency: high pitched, diaphragm, 2nd or 3rd intercostal, enhanced during inspiration.
�Mitral Stenosis: most common, bell at 5th intercostal, low pitched rumbling, left lateral position
�Tricuspid Stenosis: forward blood flow from right atrium though stenosed tricuspid valve, bell at 4th intercostal along sternal border.
Allen Test
Occlude radial and ulnar arteries and then release one and visualize blood return
Presbycusis
Hearing loss associated with age
Sarcopenia
loss of lean body mass and strength with aging
Axillary Lymph Nodes
Lateral
Pectoral (Anterior)
Subscapular (Posterior)
Supraclavicular
Infraclavicular
Self Breast Exam Instructions
5-7 days after period for women still menstruating or can choose a time of month if menopausal.
Vaginal Speculum Exam
lubricate with water so that sample is not contaminated, insert two fingers first and then speculum vertically, putting pressure on the posterior vaginal wall
Obtaining Vaginal Specimens
Pap Smear: Rotate 5X and obtain sample before any other test samples
Then any swabs for infection
Skene's Glands
Near urethra- can milk to see if there is discharge.
Bartholin's Glands
5 and 7
Do you listen for Epigastric and Renal Bruits with the bell or the diaphragm?
Diaphragm
Do you listen for aortic, illiac, and femoral bruits?
Bell
Shifting Dullness
Shifting Dullness: Indicates ascites - fluid shifts dependently when the patient lies supine vs laying on the side. Percuss to determine or look for fluid wave
Do you listen for carotid Bruits with the bell or the diaphragm?
Both
Cardiac Landmarks
Epitrochlear Nodes
Inguinal Nodes
Ankle-Brachial Index
Arterial Vs. Venous
Cervical Lymph Nodes
Pre-auricular
Post-auricular
Tonsillar
Occipital
Submental
Submandibular
Posterior cervical
Superficial cervical
Deep cervical chain
Supraclavicular
Retinal Structures
Macula/Fovea
Optic Disc
Red Reflex
Vessels
Convergence
Eye converge symmetrically at the nose
Accommodation
Look far away and then close up, pupils will constric
Direct light reflex
Light goes into the eye and that eye's pupil constricts
Corneal Light reflex
Light shone from the side, and watch for shadowing on the iris - shadowing might mean lesions
Consensual light reflex
Light goes into one eye and the opposite eye's pupil constrict
Weber Test
Place base of tuning fork on top of the head and see if the patient hears it equally in both ears. If not, this is considered conductive hearing loss and they will hear the sound in the impaired ear.
Rinne Test
Base of the tuning fork is placed on the mastoid bone, count how long they hear it. Then move it in front of the ear and count how long they hear that. Normally the sound is heard longer through air than through bone. In conductive hearing loss, sound is heard through bone as long as or longer than it is through air (BC>AC). In sensorineural hearing loss, sound is heard longer through air (AC>BC).
Tonsil Grades
Parotid Glands- Stenson's Duct
Side of cheek
Submaxillary- Wharton's duct
Under the tongue
Diaphragmatic excursion
percuss after breathing in and holding it, then same for breathing out and holding it - then look at the distance between the two. Normal is 3-5.5cm
Dullness on respiratory percussion
fluid or solid tissue replaces air containing lung or occupies the pleural space beneath your fingers
Generalized hyperresonance on respiratory percussion
hyperinflated lungs of COPD or asthma
Vesicular Sounds
soft, low pitched. Heard through inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration
Bronchovesicular Sounds
with inspiratory and expiratory sounds about equal in length, at times separated by a silent interval. Detecting differences in pitch and intensity is often easier during expiration.
Bronchial Sounds
louder, harsher, and higher in pitch, with a short silence between inspiratory and expiratory sounds. Expiratory sounds last longer than inspiratory sounds..
Egophony
ee" sounds like "A". This sound is present with consolidation/pneumonia
Bronchophony
ninety-Nine" - if louder than normal
Whispered pectoriloquy
whisper "ninety-nine" or "one-two-three" and if louder, clearer whispered sounds, then whispered pectoriloquy
Light palpation
use one hand and press 1cm - think kneading dough
Deep palpation
use two hands and press 2-3cm
Methods for assessing cognitive functioning
�A&O: person, time, place
�Remote, immediate, and recent memory
�Cognitive function: tell me what a proverb means, "if you found an envelope on the ground, what would you do", calculations
ABCDE of skin assessment
�A: Asymmetry
�B: Irregular Borders
�C: changes in color
�D: Diameter over 1/4in or 6mm
�E: evolving/changing
How do you interpret a Snellen Chart?
Vision of 20/200 means that at 20 ft the pt can read print that a person with normal vision could read at 200ft. The larger the second number, the worse the vision.
Exopthalamus
protrusion of the eyeball, a common feature of Graves', triggered by autoreactive T lymphocytes.
Xanthelasma
slightly raised, yellowish, well-circumscibed plaques that appear along the nasal portions of one or both eyelids. May accompany lipid disorders
Lid Lag
the eyelid should follow the eye if it moves down, almost always covering a little bit of the iris.
Perforated ear drum
-Central perforation: don't extend to the margin of the drum
-Marginal perforations: involve the margin
-Reddened internal ear, might have drainage, no cone of light
Serous effusion of the ear
-Usually caused by viral URI or by sudden changes in atmospheric pressure as from flying or diving. Eustachian tube can't equalize the air pressure in middle ear and outside air. Air absorbed from middle ear into the bloodstream, and serous fluid accumulated there instead.
-Symptoms: fullness and popping sensation in the ear, mild conduction hearing loss, ,and sometimes pain
-Amber fluid behind the eardrum. Air bubbles can be seen, but not always
Acute otitis media with purulent effusion-ear
-Commonly caused by bacterial infection with S. penumoniae and H. influenza
-s/s: earache, fever, hearing loss. Eardrum reddens, loses its landmarks, and bulges laterally toward the examiner
-hearing loss is conductive
Bullous Myringitis
-Painful hemorrhagic vesicles appear on TM or ear canal or both
-s/s earache, blood-tinged discharge from the ear and conductive hearing loss
-caused by mycoplasma, viral, or bacterial otitis media
Torus Palatinus
Midline bony growth in hard palate that is fairly common in adults. Size and lobulation vary. Harmless
Kaposi's sarcoma in AIDs
Deep purple lesions. A low grade vascular tumor associated with human herpesvirus 8. Lesions may be raised or flat. Antiretroviral therapy can reduce prevalence
Thrush on the palate
Yeast infection. Thick, white plaques are somewhat adherent to underlying mucosa. Predisposing factors: prolonged Tx with antibiotics or corticosteroids and AIDS
Diptheria
-Acute infection caused by Corynebacterium diptheriae; rare
-Throat is dull red and grey exudate is present on uvula, pharynx, and tongue. Airway may become obstructed.
Pharyngitis
-Redness and vascularity of pillars and uvula
-s/s sore, scratchy throat - no fever, exudate or enlargement of cervical lymph nodes
-causes: viral and bacterial
Exudative tonsillitis
-Red throat with white exudate on tonsils
-Fever, enlarged cervical nodes = Group A strep or mono
Nummular Lesions
Round (coin-shaped) lesions. Also known as discoid.
Linear Lesions
A linear shape to a lesion often occurs for some external reason such as scratching. Also striate.
Target Lesion
Concentric rings like a dartboard. Also known as iris lesion
Gyrate Rash
A rash that appears to be whirling in a circle.
Annular Lesions
Lesions grouped in a circle
Lichenification
Lichenification is caused by chronic rubbing, which results in palpably thickened skin with increased skin markings and lichenoid scale. It occurs in chronic atopic eczema and lichen simplex.
Crusting
Crust occurs when plasma exudes through an eroded epidermis. It is rough on the surface and is yellow or brown in color. Bloody crust appears red, purple or black.
Excoriation
An excoriation is a scratch mark. It may be linear or a picked scratch (prurigo). Excoriations may occur in the absence of a primary dermatosis.
Erosion
Erosion is caused by loss of the surface of a skin lesion; it is a shallow moist or crusted lesion.
Fissure
A fissure is a thin crack within epidermis or epithelium, and is due to excessive dryness.
Ulcer
An ulcer is full thickness loss of epidermis or epithelium. It may be covered with a dark-coloured crust called an eschar
Hypertrophy
Some component of the skin such as a scar is enlarged or has grown excessively. The opposite is atrophy or thinned skin.
Percussion Sounds for Respiratory
Murmur Grades