What are the concepts of developing a relationship with the patient?
See the patient as a unique individual
Let them know that you really want to know all that is needed
Be open and flexible
Explain boundaries
Be honest
What is the primary objective when developing a relationship with the patient?
To discover the details about a patient's concern, explore expectations, display interest, and partnership
What does establishing a positive relationship with the patient depend on?
Communication built on courtesy, comfort, connection, and confirmation.
What are effective communication strategies when obtaining a health history?
Using open-ended questions, direct questions, rarely leading questions. Facilitate by encouraging patient to say more. Reflect by repeating what you heard. Clarify. Empathize by showing understanding and acceptance. Confront by discussing disturbing behavior. Interpret by repeating what you heard to confirm.
What are open-ended questions?
Those that give the patient discretion about the extent of the answer. Such as "How have you been feeling?" or "What brings you in today?
What are direct questions?
Those that seek specific information. Such as "How long ago did that happen?" or "Where does it hurt?
What are leading questions?
Those that are prompting the patient toward the desired answer and these are the most risky.
What is a patient centered question?
One that respects and responds to a patient's wants, needs, preferences so that they can make choices in their care that best fit their individual circumstances. Such as "How would you like to be addressed?", "What would you like us to do today?", "How are you coping with your illness?".
What are potential barriers of patient and provider communication?
When the patient is curious about you, anxiety, silence, depression, crying/compassionate moments, physical & emotional intimacy, seduction, anger, avoiding the full story, financial considerations.
What is the structure and components of the patient history?
Patient identifiers, chief complaint, history of present illness, past medical history, family history, personal/social history, review of systems
What kind of patient information is obtained in the patient identifier component of the patient history?
name, age, gender, race, occupation, date, time, and referral source
What kind of patient information is obtained in the chief complaint component of the patient history?
a brief statement about why the patient is seeking care while probing for underlying concerns.
What kind of patient information is obtained in the HPI component of the patient history?
a chronological order of events leading up to the presenting problem, health status prior to the onset, a complete description of first symptoms, symptom analysis (onset, location, description, duration, intensity, character, aggravating factors, alleviating factors), impact on patients lifestyle, medications or treatments tried
What kind of information is obtained in the PMH component of the patient history?
general health/strength
childhood illnesses
major adult illnesses and chronic diseases
immunization
surgeries (dates, hospital, diagnosis, complications)
serious injuries resulting in disability
limitation of ability to function d/t past events
medications
allergies (meds, environment, seasonal, food)
transfusions
recent screening tests
emotional status
What kind of information is obtained in the family history component of the patient history?
Any relevant medical problems for both immediate and non-immediate family members
What kind of information is obtained in the personal/social history section of the patient history?
home environment and conditions (pets, economic)
where was the patient raised
education
position in family
marital status
life satisfaction
hobbies/interests
source of stress
habits (nutrition, sleep, drugs, etoh, ADL's, and smoking)
self-care (self breast exams, exercise, home remedies)
sexual history
environmental (travel, exposure to diseases)
religious and cultural preferences
access to care
What information is necessary when obtaining sexual health information?
number of partners, concerns, birth control, protection from STI's
What kind of information is obtained for the ROS component of the patient history?
those that identify presence or absence of health related issues in each body system
What is subjective data?
it is information collected during the patient interview with the patient or significant other. it is their words. It can include symptoms, sensations, feelings, perceptions, desires, preferences, beliefs, ideas, values, personal information, ROS, complete health history
What is objective data?
it is the information that can be physically seen by the provider and tested against. It can include the physical exam, lab analysis, x rays, and professional consults.
How do you approach sensitive issues when interviewing a patient?
Provide privacy, be direct and firm, don't ask leading questions, use open-ended questions, don't apologize for asking questions, don't preach, avoid confrontation, use understandable language, watch medical jargon, document carefully using the patient's words.
What does it mean to be culturally aware?
It is the deliberate self-examination and in depth exploration of one's own biases, stereotypes, prejudices, assumptions that one holds about people different than them.
What does it mean to be culturally competent?
It requires the provider to be sensitive to a patient's heritage, sexual orientation, socioeconomic situation, ethnicity, and cultural background
What are examples of questions that explore the patient's culture?
what do you call your problem?"
"What do you think caused it?"
"What does your sickness do to you?"
"Why do you think it started when it did?"
"What should be done to get rid of it?"
"Who else or what else might help you get better?
What are the components of a cultural response to a patient?
the response should include modes of communication to include speech, space, and body language, awareness of the the patients health beliefs, diet and nutritional practice, and the nature of relationships with their family
How do you measure visual acuity and test CN II
by measuring distance, near vision , and peripheral vision
What is CN II?
optic nerve
How do you measure distance vision for visual acuity?
by using a snellen chart and having the patient cover one eye and read the lowest line that he can see clearly and then alternate eyes
How do you document distance vision?
the numerator is 20 and the denominator is the distance at which the average eye can read the line.
How do you measure near vision?
by using a rosenbaum pocket screener and have the patient hold it about 14 inches from eyes and read the smallest line possible with one eye and then the other
How do you measure peripheral vision?
by using the confrontation test. Have the patient sit directly across from you and look directly at you. Have them cover their left eye and your cover your right eye. Then test nasal, temporal, superior, and inferior fields. Have the patient tell you as soon as they see your finger in each of those fields.
What may be some causes of abnormal results from the confrontation test?
stroke, retinal detachment, optic neuropathy, pituitary tumor, central retinal vascular occlusion
How would you perform an external examination of the eyes?
Systematically beginning with appendages and move inward
eyebrows
orbits/periorbital area
eyelids
What is being assessed when looking at the patient's eyebrows?
size, extension beyond temporal canthus, texture of hair
If the eyebrows do not extend beyond the temporal canthus or are course what may be the cause?
hypothyroidism
What is being assessed when looking at the patient's orbits/periorbital area?
edema, puffiness, sagging tissue below orbit
What can cause periorbital edema?
thyroid disease, allergies, or nephrotic syndrome (children)
What are xanthelasma?
yellowish deposits on the periorbital tissue most often on the nasal side that represents a lipid metabolism disorder
What is being assessed with looking at the patient's eyelids?
have the patient close lids lightly to look for tremors
inspect ability of eyelids to close completely and open wide
check for flakiness, crusting, redness, or swelling
check eyelashes to make sure that they curve away from the eye
when eye is open the superior eyelid should cover a portion of the iris but not cover pupil
What can be a cause of fasciculations of the eyelid when a patient lightly closes eye?
hyperthyroidism
What is ptosis?
when the upper eyelid covers more than the top of the iris or pupil and indicates congenital weakness of levator muscle or paresis of a branch of CN III
What is CN III
oculomotor nerve
How do you document a finding of ptosis?
by recording the difference between the two eyelids in millimeters (the average lid is 2 mm below the border of the cornea and sclera. average lower lid is at the lower limbus)
What is ectropion?
it is when the lower eyelid turns away from the eye and may result in excessive tearing because the tear collecting system can't collect the secretions
What is entropion?
it is when the eyelid turns toward the globe which can cause corneal and conjunctival irritation and risk for secondary infection
What is a hordeolum?
it is an acute suppurative inflammation of an eyelash follicle which causes an erythematous or yellowish lump
What may be the cause of crusting along eyelashes?
blepharitis caused by blockage of tiny oil glands or by bacteria, seborrhea, psoriasis, rosacea, allergic response
What is lagophthalmos?
it is when the eyelids to not meet completely when closed and can be caused by thyroid disease, bell's palsy, aggressive ptosis, blepharoplasty
When you palpate the eyes what are you assessing for?
eyelids for nodules
orbit for intraocular pressure
If the patient complains of pain when you palpate the orbit what can be the cause?
scleritis, orbital cellulitis, cavernous sinus thrombosis
If the eye is very firm or resists palpation what does this indicate?
it can be a sign of severe glaucoma or retrobulbar tumor
How do you inspect the lower conjunctiva?
have the patient look up while you draw the lower eyelid down and note the translucency and vascular pattern, erythema, exudate
How do you inspect the upper conjunctiva?
this is only done when there is a foreign object present. Evert the upper lid one a cotton swab
What can cause erythema or cobblestone appearance to conjunctiva?
allergic or infections conjunctivitis
What is a subconjunctival hemorrhage?
it is seen as bright red blood in a sharply defined area that is surrounded by healthy conjunctiva which may occur spontaneously in pregnancy or labor
What is a pterygium?
it is the abnormal growth of conjunctiva tissue over the cornea and more common on the nasal side. This is more common in persons exposed to UV light.
How do you examine the cornea for clarity?
check for clarity by shining a light tangentially on it. blood vessels should not be present
What is corneal arcus?
it is lipid deposits in the periphery of the cornea and common after age 60. If they present in persons less than 40 it may indicate a lipid disorder
How do you check corneal sensitivity (CN V)
by touching a cotton wisp to the cornea which should make the patient blink. This indicates an intact CN V and motor fibers of CN VII (facial nerve)
What is CN IV?
trochlear nerve
What is decreased corneal sensitivity caused by?
diabetes, herpes simplex, herpes zoster, after trigeminal neuralgia surgery
How do you inspect the iris?
check it for visibility and uniform color
How do you inspect the pupil?
note irregularities in shape of pupil, they should be round, regular, and equal in size
How do you test the pupil?
check the pupils response to light and accomodation
How do you test pupil accommodation?
have the patient look at a distant object and then a test object held 10 cm from bridge of nose. Expect the pupils to constrict when eyes focus on the near object
If pupils fail to respond to light but retains constriction during accommodation, what can be the cause?
sometimes seen with diabetes or syphilis
What is miosis?
it is pupil constriction of less than 2 mm with causes of miotic eyedrop use, drug abuse
What is mydriasis?
it is pupil dilation of more than 6 mm with causes including mydriatic drops, midbrain lesions, hypoxia, CN III damage, drug abuse, acute angle glaucoma
What is argyll robertson pupil?
it is a bilateral, miotic, irregular shaped pupils that fail to constrict to light and caused by syphilis, DM, midbrain lesions
What is anisocoria?
unequal pupil sizes which may be normal in about 20% of the population
What is iritis?
constrictive response, acute uveitis with pain and red eye
What can occur to pupils with damage to CN III (oculomotor)
pupil dilated and fixed with eye deviated lateral and down with ptosis
What is an Adie pupil?
a tonically dilated pupil that reacts slowly or fails to react to light but does respond to convergence. due to destruction of postganglionic nerve innervation to the eye by an infection.
What are normal finding when inspecting the lens?
it should be clear and transparent
What are normal findings when inspecting the sclera?
it is white and visible above the iris only when eyes are wide open
What are some abnormal findings when inspecting the sclera?
pigmentation of yellow or green. Senile hyaline plaque is a dark, slate gray anterior to insertion of medial rectus muscle
How do you inspect and palpate the lacrimal apparatus?
inspect it by palpating the lower orbital rim near the inner canthus and the upper temporal orbit.
What do you do if the temporal aspect of the upper eyelid feels full?
then evert the superior eyelid and inspect the lacrimal gland which is normally non-palpable with no tenderness and no regurgitation of fluid from the nasolacrimal duct
What can cause lacrimal gland enlargement?
tumors, lymphoid infiltration, sarcoid disease, sjogrens syndrome
How do you test the extraocular movements of CN II, CN IV, CN VI?
hold the patient's chin and ask them to watch your finder as it moves through the 6 cardinal fields of gaze. Then have the patient follow your finger in a vertical plane from ceiling to floor. Movement should be smooth.
What are the six cardinal fields of gaze?
*Lateral to the left (left eye lateral rectus, CN IV; right eye medial rectus CNIII)
*Left eye looking laterally and then up (left eye uses superior rectus and right eye uses inferior oblique)
*Left eye looking laterally and then down (left eye uses inferior rectus and right eye uses superior oblique
*Lateral to the right (right eye lateral rectus, CN VI; left eye medial rectus CNIII
*right eye looking laterally and then up (right eye uses superior rectus and left eye uses inferior oblique)
*right eye looking laterally and then down (right eye uses inferior rectus and left eye uses superior oblique
Abnormal findings when testing extraocular movements?
if lid lag occurs or sclera is seen above the iris it may indicate thyroid disease
How to test balance of extraocular muscles?
by using the corneal light reflex. direct the light at nasal bridge from 30 cm and ask patient to look at a nearby object. Look for convergence of eyes. if abnormal then do the cover uncover test
Abnormalities when doing the cover uncover test?
eye moves outward from the midline (exotropic)
eye moved inward toward the nose (esotropia)
What is the proper technique to examine the interior of the eye with an ophthalmoscope?
examine patient's right eye with your right eye and patient's left eye with your left eye. Change the lens with your index finger starting with the setting at 0. get in close to the patient and stabilize yourself and the patient by placing your free hand on the patient's shoulder or head. Have the patient look at a distant fixed point and direct light at pupil from about 12 in away, visualize red reflex, then approach eye slowly and look for retina.
What structures are visualized in the interior eye with the ophthalmoscope?
*red reflex of retina first
*retina is red/pink or yellow background and depends on amount of melanin in skin
*blood vessel will probably be the first structure seen when 3-5 cm from patient. You will see branching of blood vessels.
*use the branching blood vessels to fing optic disc
*then look at vascular supply of retina
*venous pulsations may be seen on disc and must be noted
*look at arterioles which are smaller and light reflected from them are brighter red
* then examine optic disc in which margins should be sharp and well defined with color of yellow to creamy pink and 1.5cm in diameter
then examine macula by asking patient to look directly at the light and it will appear as a lighter dot surrounded by an avascular area
What may vessels look like with someone who has HTN?
they may be narrowing, increased vascular tortuosity, copper wiring (diffuse red brown reflex), retinal hemorrhage, arteriovenous nicking
How is a lesion expressed?
for example, being 2 DD from optic disc at the 2 o clock position and is 2/3 DD long and 1/3 DD wide
What do myelinated nerve fibers look like in the eye?
they appear as white area with soft, ill defined peripheral margins and have no significance
What is papilledema?
it is the loss of definition of the optic disc margin, vessels are pushed forward and veins dilate. Caused by increased ICP
What is glaucomatous optic head cupping?
optic disc margins are raised with lower central area , blood vessels may disappear. Caused by increased intraocular pressure with loss of nerve fibers and death of ganglion cells
What is a cotton wool spot?
they are ill defined yellow areas that are caused by infarction of nerve layer of the retina and due to HTN and diabetes
What are drusen bodies?
they are small, discrete spots that are slightly more yellow than the retina and most commonly a consequence of aging and may be a precursor to macular degeneration. *use Amsler grid to determine macular degeneration
what is exophthalmos?
it is the bulging of the eye anteriorly out of the orbit
What is the pathophysiology of exophthalmos?
occurs from an increase in volume of orbital contents. It is most cause is graves disease due to abnormal connective tissue deposits in the orbit and extraocular muscles. It can be bilateral or unilateral. If unilateral then consider a retro-orbital tumor
Subjective data of exopthalmos?
reports of trauma that can cause a complete or partial disclocation of they eye
Objective data of exopthalmos?
apparent eye protrusion, lids do not reach the iris. Measurement of the degree of exopthalmos is performed using an exophthalmometer, usually be an opthalmologist
What is episcleritis?
it is inflammation of the superficial layers of the sclera anterior to the insertion of the rectus muscles
Pathophysiology for episcleritis?
simple, intermittent episodes of moderate to severe inflammation that recur to 1-3 month intervals and lasting 7-10 days. Or nodular with prolonged attacks of inflammation that are typically more painful. Most cases are idiopathic but may have underlying causes such as automimmune, RA, SLE, gout, atopy, foreign bodies, chemical exposure or infection
Subjective data for episcleritis?
reports of a sudden onset of mild to moderate discomfort or photophobia. Painless injection of redness and or water discharge without crusting.
Objective data for episcleritis?
there is diffuse or localized redness that can be seen of the bulbar conjunctiva. Purplish elevation of a few millimeters. Watery discharge.
What is band keratopathy?
it is the deposition of calcium in the superficial cornea
Pathophysiology for keratopathy?
this is most common with patients with chronic corneal disease. It may occur with hypercalcemia, hyperparathyroidism, and occasionally in trauma, renal failure sarcoidosis, or syphilis.
Subjective data for keratophathy?
reports of decreased vision as the deposits progress. A foreign body sensation and irritation
Objective data for keratopathy?
the line can be seen just below the pupil and passes over the cornea with horizontal grayish bands that are interspersed with dark areas that look like holes.
What is a corneal ulcer?
it is the disruption of the corneal epithelium and stroma
Pathophysiology of a corneal ulcer?
causes can include rheumatologic disorder, connective tissue disease such as RA, sjogren syndrome, or SLE, infection like herpes simplex or bacterial, extreme dryness such as with incomplete lid close or lacrimal gland dysfunction
Subjective data for corneal ulcer?
reports of pain, photophobia, hx of wearing contact lenses, blurry vision, feeling like something is in the eye
Objective data for corneal ulcer?
visual acuity may be affected but depends on the location, inflammation and erythema of the eyelids and conjunctiva, purulent exudates, and an ulcer that is round or oval with sharply demarcated borders and base appearing gray
What is strabismus?
it is when both eyes do not focus on an object simultaneously
Pathophysiology of strabismus?
it can be caused due to paralysis from impairment of one or more extraocular muscles. It can be non-paralytic with no primary muscle weakness. It may be a sign of ICP because CN III is vulnerable to damage from brain swelling.
Subjective data of strabismus?
reports of poor vision, may have sudden onset of double vision, eye deviation
Objective data of strabismus?
If an extraocular muscle becomes impaired the eye can be seen as not moving in the direction controlled by that muscle. This can be detected by the cover-uncover test
What is Horner syndrome?
it is an interruption of the sympathetic nerve innervation of the eye which results in ipsilateral miosis, mild ptosis, and loss of hemifacial swelling
Pathophysiology of Horner syndrome?
the condition can be congenital, acquired, or hereditary. It may result from a lesion of the primary neuron, stroke, trauma to the brachial plexus, tumors, dissecting carotid aneurysm, or operative trauma.
Subjective data of Horner syndrome?
reports symptoms that are dependent on underlying cause
Objective data of Horner syndrome?
the ptosis can be seen as subtle and pupil may be round and constricted. Anisorocia can be seen as the difference in pupil size and is greater in darkness. The affected pupil dilates slowly and dry skin occurs on the same side of face as the affected pupil
What are cataracts?
it is an opacity of the lens
Pathophsyiology of cataracts?
the protien of the lens denaturates with age and are usually central but may occur peripherally due to hypoparathyroidism. Medications can cause them as well as genetic defects, maternal rubella, and other fetal insults during the first trimester
Subjective data of cataracts?
patient reports cloudy or blurry vision, faded colors, lights and headlights appearing too bright, halo around lights, poor night vision or double vision, frequent prescription changes.
Objective data of cataracts?
cloudiness of the lens can obviously be seen without special viewing equipment
What is non-proliferative diabetic retinopathy?
it is dot hemorrhages or microaneurysms and the presence of hard and soft exudates
Subjective data of non-proliferative diabetic retinopathy?
the initial stages patients are asymptomatic. Later stages the patient reports blurred vision, distortion, or visual acuity loss in more advanced stages
Objective data of non-proliferative diabetic retinopathy?
On an opthalmoscopic exam, blood vessels with balloon-like sacs (microaneurysms), blots of hemorrhages on the retina, and tiny yellow patches of hard exudates
What is proliferative diabetic retinopathy?
it is the development of new vessels as a result of anoxic stimulation
Pathophysiology for proliferative diabetic retinopathy?
vessels grow out of the retina toward the vitreous humor. It may occur in peripheral retina or on optic nerve. The new vessels lack supporting structure so they may hemorrhage. The bleeding caused by this is a major cause of blindness in diabetics. Laser therapy can often control it to prevent blindness.
Subjective data of proliferative diabetic retinopathy?
the patient reports seeing floaters, blurred vision, or progressive visual acuity loss in advanced stages. Early stages are asymptomatic.
Objective data of proliferative diabetic retinopathy?
during opthalmascope exam, the settings for the lens may be necessary in order to visualize the vessels. Vitreous hemorrhage may also be seen which can obstruct the view of the retina
What is lipemia retinalis?
it is a creamy white appearance of the retinal vessels that occurs with excessively high serum triglyceride levels
Pathophysiology of lipemia retinalis?
it occurs when the serum triglyceride level exceeds 2000 mg/dl and seen in most hyperlipidemic states
Subjective data of lipemia retinalis?
reports of elevated serum triglycerides and no vision symptoms
Objective data of lipemia retinalis?
during the early stages the peripheral fundus is salmon pink in color but as the triglyceride levels rise they turn white colored.
What is retinitis pigmentosa?
it is an autosomal recessive disorder in which the genetic defects cause cell death in the rod photoreceptors
Pathophysiology of retinitis pigmentosa?
it is caused by a genetic defect that causes apoptosis of the photoreceptors. Associated conditions include deafness, paralysis of one or more of the extraocular muscles, dysphagia, ataxia, intellectual delay, peripheral neuropathy, acanthotic (spiked) RBC's, absence of VLDL
Subjective data of retinitis pigmentosa?
reports of night blindness as the earliest symptom, tunnel vision, bumping into furniture, loss of vision is painless and progressive over years to decades
Objective data of retinitis pigmentosa?
the exam is normal in the early stages. In later stages waxy pallor, narrowing of the arterioles, and peripheral bone spicule pigmentation are seen in the mid periphery with retinal atrophy
What is glaucoma?
it is a disease of the optic nerve where the nerve cells die, usually due to excessively high intraocular pressure
Pathophysiology of glaucoma?
acute angle may occur acutely with dramatically elevated intraocular pressure if the iris blocks the exit of aqueous humor from the anterior chamber. Open angle is caused by decreasing aqueous humor absorption that leads to increased resistance and painless build up of pressure in the eye. This may also be congenital as a result of improper development of the eye's aqueous outflow system.
Subjective data of glaucoma?
with chronic disease the symptoms may be asymptomatic with the exception of a gradual loss of peripheral vision over a period of years. an acute onset is accompanied by intense ocular pain, blurred vision, halos around lights, red eye, and a dilated pupil. Patients may also report stomach pain and N/V
Objective data of glaucoma?
optic nerve damage can be seen clearly during a dilated eye exam and produces a characteristic appearance of the optic nerve cupping. Visual field tests may be decreased
What is chorioretinitis?
it is an inflammatory process involving both the choroid and retina
Pathophysiology of chorioretinitis?
the most common cause is laser therapy for diabetic retinopathy but may also be seen with histoplasmosis, CMV, toxoplasmosis, or congenital rubella infection
Subjective data of chorioretinitis?
reports of a history of cleaning cat litter box, laser surgery, pain, reduced visual acuity, floaters, photophobia.
Objective data of chorioretinitis?
a sharply defined lesion that is generally whitish yellow and becomes stippled with dark pigment in later stages ending with a chorioretinal scar. Visual field defects can be detected with large lesion, may be single or multiple, feathery margins contrast with myelinated retinal fibers.
What are visual field defects?
it is defective vision or blindness
Pathophysiology of visual field defects?
it may be a consequence of degenerative changes within the eye such as a cataract or from a lesion of the optic nerve. The most common cause is interruption of the vascular supply to the optic nerve. Bitemporal hemianopia is caused by a lesion most commonly a pituitary tumor and homonymous hemianopia can be caused by lesions of the optic nerve radiation on either side of the brain occurring after the optic chiasm.
Subjective data of visual field defects?
reports of defective vision or blindness
Objective data of visual field defects?
visual field defects found on exam
What is a retinoblastoma?
it is an embryonic malignant tumor arising from the retina
Pathophysiology of retinoblastoma?
it usually develops in the first 2 years of life and is transmitted by autosomal dominant or a chromosomal mutation and is the most common retinal tumor in children
Subjective data of retinoblastoma?
family history of it and reports of a white reflex on photographs
Objective data of retinoblastoma?
the initial sign that can be seen is leukocoria, and then an ill defined mass arising from the retina on fundoscopic exam and chalky white areas of calcification can be seen
What is macular degeneration?
it is age related and is caused when part of the retina deteriorates
Pathophysiology of macular degeneration?
There are two types. The dry type is atrophic and occurs from the gradual breakdown of cells in the macula which results in gradual blurring of central vision. The wet (exudative) type is when new abnormal blood vessels grow under the center of the retina then leak and scar the retina which distorts or destroys central vision and may be rapid. It is the leading cause of legal blindness
Subjective data of macular degeneration?
reports of blurred or decreased central vision, blind spots or scotomas, straight lines looking irregular or bent, objects appearing a different color or shape in each eye, or objects appearing smaller in one eye (micropsia)
Objective data of macular degeneration?
with the dry form, Drusen bodies (multiple spots in the macular region) can be seen with thinning and loss of the retina and choroid. The wet form can cause exudates, blood, scarring, and new blood vessels membranes below the retina that can be seen
How do you inspect the external ear?
First visually inspect the auricles for size, shape, symmetry, color, position on on head
How do you inspect the position of the auricles?
By drawing an imaginary line between the inner canthus of the eye and the most prominent part of the top of auricle which should be above or at the top of this line
What can cause a low set position or unusual angle of the auricles?
either a chromosome abnormality or renal disease
What are normal findings while inspecting the auricles?
they should be the same color as facial skin without moles, cysts, lesions deformities, nodules, skin tags, openings or discharges. A darwin tubercle which is a thickening of the upper ridge of the helix is normal. Pre-auricle skin tags and pits in front of the ear where the upper auricle originates may be normal.
What are abnormal findings while inspecting the auricles?
blue color may mean cyanosis, pallor or extreme redness may result from vasomotor instability, frostbite can cause extreme pallor, unusual size or shape may be d/t family trait or abnormality, cauliflower ear is d/t blunt trauma with necrosis of underlying cartilage, tophi are small white uric acid crystals on peripheral margins of auricle and may indicate gout, sebaceous cysts
How do you inspect the auditory canal?
visually inspect it for any discharge and note any odor
What are some abnormal findings while inspecting the auditory canal?
purulent foul smelling discharge is associated with otitis externa, perforated acute otitis media, or foreign bodies. Bloody or serous discharge with a head trauma is indicative of a head fracture
Describe palpating the auricles and mastoid area?
palpate both of them for any tenderness, swelling, or nodules
What are normal findings when palpating the auricles and mastoid area?
auricles should be firm, mobile and without nodules. If folded forward it should readily recoil to its usual position. Pulling on the lobule should not illicit pain.
What are abnormal findings when palpating the auricles and mastoid area?
if pain is present when pulling on the lobule then external auditory canal inflammation may be present. If there is tenderness or swelling in the mastoid area it may indicate mastoiditis.
How would you perform an otoscopic examination of an adult ear?
Select the largest speculum that will fit comfortably in the patients ear.
Hold the handle of the otoscope between the thumb and little finger supported on the middle finger.
Use the ulnar side of your hand to rest it against the patients head, stabilizing the otoscope as it is inserted into the canal .
Use a firm/gentle grasp and tilt the patients head toward the opposite shoulder as the speculum is inserted.
Pull the auricle up and back to straighten auditory canal
Insert the speculum 1/2 inch and inspect from meatus to tympanic membrane (landmarks, color, contour, perforations
How do you evaluate the patients hearing using a whispered voice?
Have the patient put a finger is one ear while you stand about 1-2 feet away from the opposite ear out of the line of vision from the patient. Then whisper a combination of letter and numbers into the ear and ask them to repeat it. They should be able to repeat 50% of the sounds.
How do you perform the Weber test?
This is done to assess for unilateral hearing loss. Place the base of a vibrating tuning ford on the midline of the patients head and ask them if the sound is heard equally in both ears or just one.
Abnormal findings of Weber test?
if the sound is better in the affected ear then the patient has conductive hearing loss. If the sound lateralizes to the better ear then it is sensorineural loss.
How do you perform the Rinne test?
This is done to distinguish between air and bone hearing conduction. First place the base of a tuning fork against the patients mastoid bone and ask them to say when the sound is no longer heard. The time in seconds is the interval of bone conduction. Then quickly move the tuning fork 1/2 inch from the auditory canal and ask them again to say when it is no longer heard. The time in seconds is the air conduction interval. Normal should be longer hearing for air conduction (2:1).
What are abnormal findings of the Rinne test?
if bone conduction is heard fro longer in the affected ear then it is a conductive loss. if the air conduction is heard longer but less than the 2:1 ratio then it a sensorineural loss
How do you inspect the external nose?
Look for any deviations in shape, size, or color, discharge, flaring or narrowing or nares. Columnella should be midline and width should not exceed the diameter of the nares.
Abnormal findings of external nose exam?
a depression of the nasal bridge can result from a fracture of nasal bone or previous nasal cartilage inflammation , a transverse crease at the junction between the cartilage and the nose bone may indicate chronic itching and allergies, discharge
What can cause nasal discharge?
allergies (watery), epistaxis or trauma (bloody), rhinitis or URI (purulent), foreign body (unilateral, purulent, odor), CSF (unilateral, watery after head trauma)
How do you palpate the external nose?
place finger tips on both sides of nose and then palpate from bridge of nose to tip checking for any displacement of bone, tenderness, or masses (structures should be firm and stable)
How do you evaluate nasal patency?
by occluding one nares and ask the patient to breathe in and out with mouth closed. Then repeat on the other side. Breathing should be noiseless and easy.
How do you inspect the nasal cavity?
use the nasal speculum and a light, hold speculum in palm of one hand and use other hand to change the patients head position, insert speculum and inspect nasal mucosa for color, discharge, masses, lesions, and turbinate swelling. Inspect septum for alignment, perforation, bleeding, crusting. Keep patients head erect as you look at the inferior turbinate and then tilt the head back to look at the middle meatus and middle turbinate, then move speculum to look at septum
Normal findings of nasal mucosa and septum?
mucosa should be deep pink and glistening, film or clear discharge on septum is often present, hairs may be present on vestibule, turbinates firm and same color as surrounding area, septum should be straight and midline
Abnormal findings of nasal mucosa and septum?
purulent discharge may be d/t URI, sinusitis, foreign body. Increased redness of mucosa my occur due to infection, localized redness in vestibule may indicate a furncicle, turbinates that are blue, gray, pale, pink, swollen, boggy may indicate allergies, a polyp may be seen as a round, elongated mass that is protruding into the nasal cavity from boggy mucosa
How do you test cranial nerve I (sense of smell)?
have patient close eyes and occlude one naris then hold and opened vial of a familiar aromatic odor under the other naris and have them inspire deeply and identify the odor. Repeat on the other side using a different odor.
How do you inspect and palpate the sinuses?
inspect both areas for and swelling, palpate by using thumbs to press up under the bony burrow on each side of the nose. Then press up under the zygomatic process to palpate the maxillary.
Abnormal findings of palpating the sinuses?
swelling or tenderness over them upon palpation may indicate infection or obstruction
How do you inspect and palpate the lips?
have the patient close their mouth and inspect and palpate for symmetry, color, edema, surface abnormalities. Lips should be pink, no lesions, symmetrical, smooth surface.
Abnormal findings of lips?
dry and cracked/ cheilitis (dehydration, wind, dentures, braces, lip licking)
deep fissures at corners of mouth/ cheilosis (riboflavin deficiency, overclosure of mouth)
swelling (allergy)
pallor (anemia)
circumoral pallor (scarlet fever)
round, oval, irregular blue/gray moles (Puetz-Jeghers syndrome)
lesions, plaques, nodules, ulceration (infections, skin cancer)
How do you inspect and palpate the buccal mucosa, gums, and teeth?
first have the patient clench teeth and smile to determine that upper molars fit into the grooves of lower molars and the premolars and canines interlock fully. Then remove any dental hardware and using a tongue blade and light inspect the buccal mucosa, gums, and teeth. Then using gloves, palpate the gums for lesions, induration, thickening or masses.
Normal findings of buccal mucosa, gums, and teeth?
Gingiva should be pink
Mucous membranes should be pink/red smooth and moist
Stensen duct can be seen as a yellow.white protrusion in Alignment with the 2nd upper molar
Fordyce spots are ectopic sebaceous glands on buccal mucosa and seen as raised yellow white lesions
Patchy pigmented skin mucosa is found in dark skinned
Ginvival enlargement can occur with pregnancy
Abnormal findings of buccal mucosa, gums, and teeth?
Whitish/pink scars may be seen due to trauma from poor tooth alignment.
A red spot on stensen duct is associated with mumps
Epulis is a local swelling of gingiva
Gingival swelling which can occur due to vitamin C deficiency, certain meds
Gingivitis (bleeding, swollen gums, enlarged crevices between teeth and gum margins, pockets containing debris
Describe how you examine the oral cavity by inspection, testing CN XII, inspecting floor of mouth , tongue, palate, uvula, and soft palate?
Inspect dorsum of tongue for swelling, size, color, coating, ulceration.
Ask patient to extend tongue and check for deviation, tremor, limited movement (CN XII hypoglossal nerve)
Then ask the patient to touch tongue to tip of palate and inspect floor of mouth and ventral surface of tongue, frenulum, SL ridge, and wharton ducts
Then wrap the tongue with a piece of guaze and gently pull it to each side and inspect
Palpate tongue and floor and floor of mouth for lumps, nodules, ulceration
Lastly have the patient tilt their head back and look at the palate and uvula, have patient say "ah" to see if the uvula rises
What are normal tongue findings of oral cavity?
The tongue should be midline when protruded with no atrophy, no fasiculations, tongue should be pink, dorsal side rough surface of tongue with small fissures, ventral surface pink and smooth with large veins
Abnormal findings of oral cavity?
Smooth tongue with slick appearance is glossitis and due to vitamin B12 deficiency
Hairy tongue with yellow/brown black papillae can be due to abx
Ranula (mucocele) may be seen on the floor of the mouth when duct of a SL gland is obstructed
Any ulceration, nodule, thick white patch on lateral or ventral side of tongue may be a malignancy
Deviation of uvula may indicate vagus nerve paraylis
Bifid uvula may be common in Native Americans
How do you inspect the oropharynx including the tonsils and tonsillar pillars and test CN IX and CN X?
First use a tongue blade to depress the tongue and observe the size and shape of tonsillar pillars and the integrity of the retropharyngeal wall. Then prepare the patient for gag reflex check and touch posterior wall to elicit gag reflex and test CN IX and CN X
Normal findings of oropharynx?
tonsils should be smooth, glistening, with pink mucosa, orpharynx may have some small irregular spots of lymphatic tissue with blood vessels,
Abnormal findings of oropharynx?
red, hypertrophied, exudate tonsils indicate infection, red bulge adjacent to tonsil and extending beyond midline may be a peritonsilar abscess, yellowish mucoid film indicates postnasal drip
What is otitis media with effusion and acute otitis media?
An inflammation of the middle ear resulting in the collection of serous, mucoid, or purulent fluid when tympanic membrane is intact. Can be seen as a bulging of tympanic membrane, or red bulging and distorted light reflex and effusion can be seen with yellowish air bubbles.
What is otitis externa?
An inflammation of the auditory canal and external surface of tympanic membrane which can be caused by water retained in the ear and can cause inflammation of the pinna also. Ear canal is red, edematous, and tympanic membrane is obscured.
What is a cholesteatoma?
It is trapped epithelial tissue behind the tympanic membrane that is often the result of untreated or chronic otitis media. Spherical white cyst behind intact tympanic membrane can be seen, or if it is perforated there may be foul smelling discharge and conductive hearing loss
What is conductive hearing loss?
It is reduced transmission of sound to the middle ear due to a type of obstruction like cerumen, otitis media with effusion, infection, foreign body, cholesteatoma, stiffening of ossicles, and otoscerosis. The person hears better in noisy environments, speaks softly, turns TV up louder. The bone conduction is heard longer than air. Lateralization with Weber test.
What is sensorineural hearing loss?
It is the reduced transmission of sound in the inner ear and is caused by inner ear disorder, systemic disease, ototoxic medications, trauma, tumors, prolonged exposure to loud noise , presbycusis in older adults. The person is unable to hear in a crowded room, speaks more loudly. Air conduction is hear longer than bone conduction. Lateralization to unaffected ear with Weber test. Loss of high frequency sounds.
What is meniere disease?
A disorder of progressive hearing loss that in some cases is hereditary.
What is vertigo?
It causes the illusion of rotational movement by the patient due to inner ear disorders
What is sinusitis?
It is a bacterial infection of one or more of the paranasal sinuses due to inflammation, allergies, infection and cause URI that worsens after 7-10 days, frontal headache, facial pain or pressure, purulant nasal discharge, persistent cough may be worse at night
What is acute pharyngitis?
It is an infection of tonsils or posterior pharynx by microorganisms most commonly by group A beta hemolytic strep, gonorrhea, mycoplasma pneumoniae. Symptoms include sore throat, referred pain to ears, fever, fetid breath, may have abd pain and headache. Tonsils are red and swollen, crypts filled with purulent exudate, enlarged anterior cervical lymph nodes, palate petechiae
What is a peritonsillar abscess?
it is a deep infection in the space between the soft palate and tonsil caused by inflammation or obstruction of the weber gland. The patient may have drooling, sever sore throat with pain radiating to the ear, malaise, fever. Unilateral red swollen tonsil, may have displaced uvula, trismus or spasm of masticator muscles may occur, muffled voice, cervical lymphadenopathy
What is a retropharyngeal abscess?
It is a life threatening infection in the lateral pharyngeal space the has the potential to occlude the airway and most common in children. It may occur due to trauma to posterior pharyngeal wall, dental infection, group a strep. The patient is acutely ill with drooling, irritable, anxious, pain in neck and jaw, will not move neck. Lateral neck movement makes pain worse, lateral pharyngeal wall is distorted medially, trismus, resp distress, muffled voice
What are the normal findings when inspecting the precordium?
the apical impulse is generally visible at the 5th intercostal space midclavicular line, it may be visible instead at the 4th, but it should only be visible in 1 intercostal space
What other systems/organs can you check to assess the cardiac status?
skin to check for cyanosis or venous distention, nail beds for cyanosis, capillary refill, clubbing
How do you palpate the precordium?
This can be done with the patient supine. use the proximal halves of 4 fingers or the whole hand,using light touch and beginning at the apex then inferior sternal border, up the sternum to the base, then down the right sternal border to epigastric area.
What are normal findings when palpating the precordium?
The apical impulse is felt at the 5ht intercostal space midclavicular line and will be brief.
What are abnormal findings when palpating the precordium?
if the PMI is more vigorous than expected then it may indicate increased cardiac output or left ventricular hypertrophy. A lift along the left sternal border may be caused by right ventricular hypertrophy. A loss of thrust be may be due to air or fluid beneath the sternum. A displacement of impulse to the right side may indicate dextrodardia, diaphragmatic hernia, distended stomach, or pulmonary abnormality.
How do you palpate the carotid artery?
Use the opposite hand from the one palpating the precordium and place a finger to the neck just medial to and below the angle of the jaw, pressing lightly. Do not check both sides at once. S1 and carotid pulse should be synchronous.
How do you percuss the heart?
begin by tapping anterior axillary line and move medially along the intercostal spaces toward the sternal border. A change from resonant to dull marks the cardiac border and note these points with a pen.
What is the most accurate way to estimate the size of the heart?
by chest xray
How do you auscultate the 5 cardiac areas on the chest?
Use the diaphragm on the stethoscope to hear high pitched sounds with firm pressure and use the bell with light pressure to hear the low frequency sounds. Listen to the aortic valve area which is the 2nd right intercostal space at the right sternal border. Listen to the pulmonic valve area which is the 2nd left intercostal space at the left sternal border. Listen to the second pulmonic area at the 3rd left intercostal space left sternal border. Listen to the tricuspid area at the 4th left intercostal space along lower left sternal border. And listen to the mitral area which is the apex of the heart at the 5th left intercostal space midclavicular line
What does S1 indicate in the cardiac cycle?
it is the sound produced by the initiation of systole due to the closing of the mitral and tricuspid valves. It should be synonymous with the carotid pulse.
What does S2 indicate in the cardiac cycle?
it is the sound produced by the initiation of diastole due to the closure of the pulmonic and aortic valves
What is S3 heart sound?
it may occur during passive filling of the ventricles due vibration on the ventricular walls and is a low-pitched sound (kentucky)
What is S4 heart sound?
it may occur during the second phase of ventricular filling when the atria contracts due to vibration in the valves, papillae, and ventricular walls (Tennessee). If it is loud it may indicate increased resistance to ventricular filling
Abnormalities of S1
a loud sound may be due to the snapping shut of the mitral valve, increased blood viscosity, fever, anemia, anxiety, exercise and intensity may be increased with heart block. Decreased intensity may be due to overlying tissue fat, fluid, pulmonary hypertension, fibrosis, or calcification of mitral valve
Abnormalities of S2
an increased intensity may indicate systemic HTN, syphilis of aortic valve, exercise, excitement, pulmonary HTN, mitral stenosis, CHF. A decreased intensity may indicate shock, immobile valves, aortic stenosis, pulmonic stenosis, overlying tissue, fat or fluid
What is a pericardial friction rub?
inflammation of the pericardial sac that produces a rubbing/machine like sound during systole and diastole, heard widely but more distinct over the apex
What position is best for hearing high pitch murmurs?
lying supine or sitting erect and leaning forward during expiration
What position is best for hearing low pitch filling sounds in diastole?
left lateral recumbent
What position is best for hearing a rotated heart with dextrocardia?
right lateral recumbent