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178 Cards in this Set
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- Back
Why learn basic clinical skills?
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70% of diagnoses can be made based on history alone. 90% of diagnoses can be made when the physical exam is added.
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What are the four types of data collection?
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1/ complete/classic (traditional history and physical)
2/ episodic 3/ follow-up 4/ emergency |
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"classic" history and physical
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introductory Information
CC- chief complain HPI- history present of illness PMH- past medical history current health social, occupational, family history functional assessment (ADLs, IADLs) ROS- review of systems PE- physical exam |
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analysis of a symptom
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OPQRSTU- onset, provocation/palliative, quality/quantity, radiation/relief, severity, time, understanding
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PMH
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general health, childhood illnesses, adult illnesses, obestetric/contraceptive history, psych, accidents/injuries
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gravida
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number of pregnancies, regardless of whether they were carried to term
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para
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number of live births
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abortus
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number of pregnancies that were lost for any reasons, i.e. miscarriages and abortions
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current health
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medications, allergies, habits, screening tests, sleep patterns, exercise/leisure, diet, environmental, use of safety measures
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How many generations should a family history include?
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3!
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palpation
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purpose is to confirm points you noticed during inspection; assess texture, moisture, temperature, organ location and size, masses, pulsations, crepitus, tenderness
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Which parts of the hands should you use for fine discriminations, temperature, and vibrations?
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tips, dorsal, palmar aspects of mcp joints or ulnar surface
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What are the four assessment techniques? List in the order of performance.
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1/ inspection
2/ palpation 3/ percussion 4/ auscultation |
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What is the special case for abdominal exams?
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Inspect and listen before you touch!
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percussion
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gently tap part of body w/ finger or instrument
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When would you directly percuss? When would you indirectly percuss?
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The only time you directly percuss is when assessing the thorax of a child's sinuses. Indirect percussion for everything else.
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sounds via percussion
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tympani- found in abdomen
resonance- air-filled lung/organ, is normal dullness- dense organs (e.g. liver, spleen) flatness- bone, tumor |
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Which method yields the most physical signs?
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Inspection: although the least mechanical, it provides an enormous amount of information.
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auscultation
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listening to internal organs of the body
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diaphragm v. bell
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diaphragm- higher pitch sounds v. bell- lower pitch sounds
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vital signs
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-height/weight measurement; head circumference for peds
-temperature -pulse -respiration -BP -pain |
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body mass index (BMI): adults v. peds
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weight (kg) / height (m)2
*always check if patient has weight problem or CHF peds use percentiles (obese > 95) |
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pulse
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measures stroke volume
60-100; <60 is bradycardia; >100 is tachycardia assess for rate, rhythm, quality (force), elasticity listen to heart if rhythm is irregular |
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How to rate quality of pulse?
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1+ thready, e.g. shock
2+ normal pulse 3+ bounding, e.g. s/p exercise |
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influences on temperature
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1/ diurnal cycle- lowest @ AM, highest @ PM
2/ menstrual cycle- 0.5 increase during ovulation 3/ exercise 4/ age- geriatric is usually one degree > adult |
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respiration
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infants: 30-40
adults: 10-20 *usually 1/4 of pulse |
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temperature
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average oral: 37 C or 98.6 F
rectal: 0.5 C or 1F > oral axillary: 0.5 C or 1F < oral tympanic: 0.8 C or 1.4 F > oral |
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BP
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"pressure of blood against the wall"
systolic pressure- max pressure felt on wall during ventricular systole (when heart contracts) diastolic pressure- elastic recoil/resting pressure during diastole |
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influences on blood pressure
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age- BP rises as we get older (thickening of artery)
gender- women < men after puberty until menopause race- blacks are 2x HTN than white diurnal- higher in PM higher in obese, during stress, exercise peripheral vascular resistance & elasticity volume/viscosity or circulating blood cardiac output |
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auscultatory gap
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silent interval that may be present b/w systolic and diastolic pressures
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orthostatic hypotension
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drop in systolic pressure > 20 mmHg
pulse increase >20 bpm *usually occurs when patient is bleeding; should take vitals in supine, sitting, and standing |
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What is the approach for pediatric physicals?
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QUIET TO ACTIVE
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T/F. Adolescents can consent to pregnancy and drug testing.
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True
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What is the approach for adolescents?
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HEADSSS- home, education, activities, drugs, sexuality, safety, suicide
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peds growth curve v. preemies growth curve
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measure height/weight for every well visit
>dropping off curve is bad; starting out on lower end, but following the curve is not as concerning v. preemie growth charts which corrects for age through age 2 |
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When do you start a new growth chart?
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after age 2
< 2, measure length- patient is lying down > 2, measure height- patient is standing up measure head circumference until age 2 |
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peds temperature routes/variations
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*rectal is most accurate
temporal- not accurate under 3 mos tympanic- not accurate under 6 mos |
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peds heart rate
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apical pulse is the most accurate for children younger than 2
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peds BP
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*start measuring @ age 3
BP will get higher as child gets older HTN if child is >95% in height, weight, age, or gender group |
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bones of face and cranium
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bones unite @ sutures (immovable joints)
cranium is supported by C1-C7 |
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facial muscles
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acromegaly
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brow prominent, soft tissues of nose, ears, and lips are enlarged, prominent jaw
*anterior pituitary gland problem |
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fetal alcohol syndrome
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nose: widen bridge, flat, upturned
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bell's palsy
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*damage to facial nerve- lose movement @ top and bottom of face (e.g. close eyes, raise eyebrows)
patients who are unable to close eyes w/ long term bell's palsy have weight placed so they don't get too dry stroke patients can close/open eyes; raise eyebrows |
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temporomandibular joint
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below temporal artery, anterior to tragus
*most active joint in body; decrease ROM- arthritis; click- miniscus tear, poor occlusion or synovial swelling |
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When palpating the temporal artery, what are you assessing for?
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should not feel indurated (hard) or tortuous (wavy)
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external eye structures
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palpebral fissure- opening of upper and lower eye lid
pupil- where light enters iris limbus- border b/w cornea and sclera medial & lateral canthus caruncle- crease of eye |
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anatomy of eye
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tarsal plate- in lids to give structure/shape
meibomian glands- secrete oily substance to clear dust *conjunctiva- >bulbar- goes over sclera, clear but appears white >palpebral- lines the lids, clear but appears pink |
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What does it mean when you see white on top of the eye when it is open?
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Eye is protruding! The upper eye lid is more mobile than lower and should be able to cover the iris.
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lacrimal apparatus
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*provides constant irrigation
secretes tears >> puncta >> nasolacrimal sac >> nose |
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What are the three layers of the eye?
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1/ sclera- outer layer; white; covers iris & pupil
2/ choroid- middle layer; darkly pigmented; extremely vascular- delivers blood to retina 3/ retina- inner layer; visual center |
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ciliary body
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*controls thickness of lens, produces aqueous humor
bulges out for near objects flattens for far objects |
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compartments of the eye
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anterior- aqueous humor, how eye gets nutrients and gets rid of waste
posterior- vitreous humor is "gel-like" substance which can clog together to form "floaters" |
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What are the extraocular muscles?
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straight muscles: superior rectus, inferior rectus, lateral rectus, medial rectus
rotary muscles: superior oblique, inferior oblique *conjugate movement of eye prevents double vision |
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CN VI
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abducens
innervates lateral rectus (look out to side) |
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CN IV
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trochlear
innervates superior oblique (look down and in) |
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CN III
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oculomotor
innervates the rest: superior, medial, and inferior rectus & inferior oblique |
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visual field
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entire area seen by eye while looking at central point
when using both eyes- binocular, overlap when using one eye- monocular vision |
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visual pathway
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for image to be seen, light has to hit pupil and be perceived by sensory neurons @ retina
*images are projected upside down and reversed from right to left |
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visual reflexes
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pupillary light reflex- direct and consensual
light travel through CN II, splits at optic chiasm, sends message to both side of the brain, and response via CN III fixation- when looking straight ahead, fovea/macula is fixated accommodation |
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snellen chart
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20/50; can read at 20 feet what normal eye can read at 50 feet
20/200; legal blindness |
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myopia v. hyperopia
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myopia- nearsighted, eye too long
hyperopia- farsighted, eye too short |
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strabismus
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asymmetrical corneal light reflex
weakness/paralysis of one or more of the extraocular muscles, does not have conjugate vision |
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ptosis
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one eye drooping more than the other; could be CN or congenital problem
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aniscia
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unequal pupils
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optic nerve cut prior to optic chiasm
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unable to see; cannot get to occipital cortex
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optic chiasm cut
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bitemporal hemianopsia- lose vision in both temporal area
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R optic tract cut
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left homonymous hemianopsia- can see temporal w/ R eye and nasal w/ L eye
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papilledema
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inflammation of optic disk (becomes blurry and puffy) due to intracranial pressure
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glaucoma
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increased intraoccular pressure in anterior chamber of eye, cornea will be cloudy
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structure of skin
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epidermis, dermis, subcutaneous layer
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epidermis
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thin, outermost layer, avascular (nourished by dermis)
> stratum corneum- outer most horny cell layer- dead keratin cells > stratum germinativum- inner basal cell layer- living cells: keratin and melanocytes |
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dermis
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dense connective tissue layer forming the bulk of the skin
>chiefly collagen (resistant to tearing), elastin, hair follicles, glands, vascular |
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subcutaneous layer
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chiefly adipose tissue- thermal regulation
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sweat glands
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apocrine- active after adolescence, closely associated w/ hair follicles, coarse air, milky secretions, only active during sexual/emotional situations
eccrine- matures by 2 months, transparent secretion, goes directly to epidermis |
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psoriasis
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skin redness and irritation; most people with psoriasis have thick, red skin with flaky, silver-white patches called scales
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pallor
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loss of color; fear, cold
>anemia? |
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erythema
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redness of skin; excitement, embarrassment, hot
>localized infection >s/p exercise >poisoning >emotional event |
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raynaud's disease
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cold temperatures or strong emotions cause blood vessel spasms that block blood flow to the fingers, toes, ears, and nose
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jaundice
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yellowish pigmentation of skin; usually seen in mouth/eye before skin
>liver disease >hepatitis- sclera turns yellow >sickle cell |
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cyanosis
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decreased perfusion of tissue w/ oxygenated blood: blue
>shock >heart failure >chronic bronchitis |
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vitiligo
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melanocytes are devoid of color (MJ)
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acanthosis nigricans
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increased pigmentation; seen in adolescent/older adults who are insulin resistant
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mongolian spots
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hyper-pigmentation (blue, black, purple), starts to fade after year 1
common in Black, Asians, Native Americans |
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acne
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1/ comedonal- black or white heads
2/ pustular |
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Explain the changes in skin in older adults.
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They have less fat, vessels break easily, less elastin, and longer wound repair
>more wrinkling >senile purpura- easy bruising >xerosis- dry skin >senile lentigines- "liver spots" melanocytes clump together from sun exposure; not cancerous, no treatments |
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edema
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overaccumulation of interstitial fluid
possible affected system >circulatory >cardiovascular >kidney >lymphatic |
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primary skin lesions
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macula, patch
papule, plaque nodule, tumor wheal, urticaria vesicle, bulla cyst pustule |
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macule v. patch
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macule- flat, non palpable change in skin color, up to 1 cm
patch- macule larger than 1 cm |
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papule v. plaque
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papule- palpable, elevated, solid mass caussed by superficial thickening of epidermis, up to 0.5 cm
plaque- coalescence of papules, larger than 0.5 cm |
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nodule v. tumor
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nodule- solid, elevated, soft or firm mass less than 1-2 cm
tumor- larger than 1-2 cm, may extend deeper into dermis |
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wheal v. urticaria
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wheal- superficial, raised, erythematous, transient lesion w/ irregular borders due to localized edema; fluid is held diffusely in the tissues
v. urticaria- wheals coalescing, pruritic |
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vesicles v. bullae
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vesicle- cirumscribed, superficial elevated cavity; contains free fluid, up to 1 cm
bullae- larger than 1 cm; usually single chambered, thin wall, easily ruptured |
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cyst
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encapsulated fluid or pus-filled cavity in dermis or subcutaneous layer, larger than 1 cm
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pustules
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circumscribed, superficial, elevated cavity, contains turbid fluid (pus), up to 1 cm
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secondary skin lesions
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crust
scale fissure erosion ulcer excoriation scar atrophic scar lichenification keloid |
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crust
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thickened dried residue of burst vesicles, pustules or blood; red-brow, honey-colored, or yellow
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scaling
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compact desiccated flakes of skin; visible exfoliation of the dermis; shedding of dead excess keratin cells
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fissures
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linear crack w/ abrupt edges, extends into dermis; dry or moist
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erosion v. ulcer
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erosion- superficial circumscribed loss of epidermis; moist but no bleeding; heals w/o a scar; "stage 2 pressure sore"
ulcer- circumscribed depression extending into dermis; irregular shape; may bleed; scar |
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excoriation
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scratch mark, superficial
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scar
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replacement of destroyed normal skin tissue by fibrous connective tissue
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atrophy
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depressed skin level >> loss of tissue; thinning of epidermis w/ loss of normal skin resulting in shiny translucent skin
*like a scar, but depressed |
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lichenification
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thickening/roughening of skin (usually from scratching); results from tightly packed papules
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keloid scar
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hypertrophic; skin level is elevated by excess scar tissue, which is invasive beyond site of original injury
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common shapes/configurations of lesions
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confluent- coalescing (edges overlap)
grouped- multiple lesions (edges don't overlap) gyrate- angled, tunneling (not straight) polycyclic- multiple round lesions zosteriform- following a dermatome |
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vascular lesions
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petechiae, purpura
ecchymosis cherry angioma spider angioma telangiestasia nevus flammeus "port wine stain" |
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petechiae v. purpura
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petechiae- red, pin sized macules of blood; < 3 mm
purpura- 0.3 to 1 cm *blood filled lesions do not blanch |
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ecchymosis
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escape of blood into tissues from ruptured blood vessels; small hemorrhagic spot in skin; non-elevated, blue/purplish patch; > 1 cm
*larger bruise |
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cherry angioma
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aka Campbell de Morgan spots
bright red papules; benign; common on trunks of middle-aged and elderly |
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spider angioma
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*if many on trunk, check liver function- possible deficiency; may be normal in children and pregnant women
stellate telangiectases radiating from central palpable feeding vessel |
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telangiectasia
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permanently dilated and visible vessels in the skin
*can be caused by nifedipine |
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nevus flammeus
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aka port wine stain, stork bite
present at birth, caused by dilated dermal capillaries; pale pink to purple macules; mostly on face or trunk |
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skin warning signs
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"ABCDE"
asymmetry border- irregular color- mottled diameter- unusually large (> 6 mm) elevation *enlargement |
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basal cell carcinoma
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most common malignancy
locally invasive and destructive slow growing, rarely metastasized translucent, dome-shaped papule with overlying telangiectasias |
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actinic keratosis
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yellowish; can progress into squamous cells
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squamous cell carcinoma
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invasive malignancy; common on head, neck, hands
"sore- heals and opens continuously" |
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melanoma
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superficial spreading or nodular; can be benign or malignant; usually dark from the pigments produced by melanocytes
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What are the two types of hairs?
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1/ vellus- fine faint hair covers most of body
2/ terminal- eyebrows, scalp, pubic, face, chest |
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What happens to the hair as we get older?
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Melanin gets replaced by colorless air bubbles, resulting in gray or white hair.
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alopecia areata v. alopecia totalis
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alopecia areata- non-scarring hair loss; usually an immunological phenomenon
alopecia totalis- total hair loss |
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hirsutism
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excessive hairiness @ sites where terminal hair does not normally occur (hair, face, thigh, abdomen); in women; check for hormones
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What happens to nails as we age?
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Nails are thickened, ridged and split in older adults.
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measurement of nail angle
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check for clubbing; associated w/ cystic fibrosis, cancer, lung disease
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external ear structures
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most skin cancer findings are in helix
tragus gets tender during infection |
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anatomy of ear
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1/ external ear- funnels sound waves to TM
2/ middle ear (MIS)- conducts sound vibrations, reduces amplitude of sound, equalization of air pressure 3/ inner ear- vestibular fx, bony, cochlear |
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Where is the cone of light on the R and L ear on the TM?
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R 5:00
L 7:00 |
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What is the anatomic/developmental difference in the ears of infants?
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Their eustachian tubes are shorter, wider, and more horizontal, making them more prone to infection.
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otosclerosis
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abnormal spongy bone growth in middle ear that causes hearing loss; more common in females than males
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presbycusis
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age-related hearing loss; tiny hairs get lost w/ age
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What is the most efficient hearing pathway?
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Air conduction is more efficient than bone conduction.
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tinnitus
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"ear ringing"
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weber test
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place 512 fork in midline of head; ask if sound is louder in one ear than other
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rinne test
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bone conduction- place on mastoid process
air conduction- outer ear |
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Person with normal hearing ...
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Weber- hear vibration equal bilaterally
Rinne- AC > BC (last longer) |
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Person with conductive hearing lost ...
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Weber- will lateralize to bad ear
Rinne- BC = AC; BC > AC common causes- fluid, ear wax, damage to ear drum |
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Person with sensorineural loss ...
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Weber- will lateralize to good ear
Rinne- AC > BC (decreased amount of time, same ratio) or they may not hear at all |
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If pain when palpating mastoid process, what should you consider?
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otitis media, mastoiditis
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If pain when palpating tragus, what should you consider?
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otitis externa
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kiesselbach region
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anteroinferior part of nasal septum; where four arteries anastomoses
*common site for nose bleeds |
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structures of nasal cavity
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anterior edge is lined w/ coarse nasal hairs- filters air; remainder is lined w/ ciliated mucous membranes to filter dust and bacteria
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T/F. Nasal mucosa is redder than oral mucosa.
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True; it has a larger blood supply
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lateral wall turbinates
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superior meatus- ethmoid cells
middle meatus- sinuses inferior meatus- tears |
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sinuses
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air-filled pockets within cranium to lighten weight of skull; we have for pairs of paranasal sinuses
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epistaxis
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nosebleeds
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polyps
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smooth gray nodules; overgrowth of mucosa; result of chronic allergies; non-tender; often removed b/c of breathing/snoring problems
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perforated septum
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cocaine use, excessive use of nasal spray
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rhinitis
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allergic or acute; pale inside; usually clear fluid, if pusy- possible sinus infection
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palpate sinuses
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get underneath sinus and push up
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transillumination
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shoot light through sinus >> red light if sinus is clear
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oral cavity structure
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tonsils are b/w posterior and anterior pillar
adult- 32 teeth; children- 20 teeth |
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salivary glands
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*moistens food
parotid, submandibular, sublingual |
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stenson's duct
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opening of parotid salivary gland; opposite upper second molar
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wharton's duct
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opening of submandibular salivary glands
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normal findings of the mouth
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fordyce spots- yellow inside cheeks
torus palatinus- roof of mouth scrotal tongue- multiple fissures geographic tongue- areas devoid of papillae |
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CN XII
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hypoglossal
tongue should protrude midline w/o tremors or deviation; if it does deviate >> will go towards paralyzed side |
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CN X
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vagus
"AHH" >> soft palate rises up and uvula stays midline |
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grading tonsils
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1+ visible
2+ halfway b/w pillars and uvula 3+ touching uvula 4+ touching each other |
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viral pharyngitis
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redness and vascularity of pillars and uvula; pt c/o of sore throat or scratchy throat
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bacterial pharyngitis
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red throat w/ exudate (pus) on tonsil; fever and enlarged cervical nodes; could be streptococcal infection
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thyroid gland
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endocrine gland w/ rich blood supply
thyroid cartilage (Adam's apple) cricoid cartilage isthmus lies over trachea at 2nd or 3rd tracheal ring |
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lymph nodes
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*removes impurities; @ interstitial tissue; all over body but can only assess them at neck, under the arm, and groin
palpate w/ tip of finger, soft circular motion swollen, tender- infection, inflammation, < 1 cm hard, unmovable- cancer, > 1 cm |
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CN XI
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spinal accessory; innervates sternomastoid and trapezius muscles (lift up shoulder against pressure)
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List all the lymph nodes!
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preauricular, postauricular, occipital
tonsillar, submandibular, submental superficial cervical, posterior cervical, deep cervical supraclavicular, infraclavicular |
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If patient had the following conditions, where would you expect swollen lymph nodes? (eye infection, ear infection, hair dye, sore throat)
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eye- preauricular
ear- postauricular, preauricular dye hair- occipital sore throat- tonsillar *always draining towards the heart |
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abnormal trachea
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if on one side >> collapse lung
if mass is pushing trachea >> bulge in neck |
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When checking for carotid pulse, which parts do you check?
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Always the lower third or the upper third--there is a sinus in the middle.
Listen for bruit (turbulent blood flow, "whoosh"), can hear if person has 70% occlusion) |
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goiter (enlarged thyroid)
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thickening throughout neck; could be hyperthyroidism, hypothyroidism, or uthyroidism (normal)
>> always feel for nodules; single nodule is more concerning for cancer |
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T/F. Suture lines may not be palpable at birth.
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True
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fontanels
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"soft spots"
*anterior- diamond shaped, 2 cm in term infants posterior- triangular shaped, may or may not be palpable |
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Normal fontanels are soft/flat. What does it mean if it is bulging or sunken?
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swollen- hydrocephaly
sunken- dehydration |
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T/F. Term infant are hyperopic (farsighted) at birth.
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True
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red light reflex (bruchner test)
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to detect disease processes preventing light from entering/exiting pupil
if cataracts >> will see black spots! |
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leukokoria
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whitish opacity of pupil w/ absent/partial red reflex
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Explain the difference in ear assessment b/w peds and adults.
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For peds, pull auricle inferiorly.
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T/F. Sinuses are fully formed in children.
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False; the continue to develop throughout childhood.
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T/F. Children have larger tonsils than adults.
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True
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ankylglossia
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shortened lingual frenulum; not usually repaired b/c it doesn't affect speech/feeding
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