final exam review

Do not rely solely on this power point for your

Studies. I hope you have your own studying done as
well.
Assessing from Head to Toe
Think about which order you will be
assessing your patient from head to toe
Start by inspecting- you will inspect your
patient head/face
Then palpating lymph nodes
Ascultating lung sounds and heart sounds
Percussing abdomen
And assess patient’s gait
OLD CART
Onset
Location
Duration
Characteristic
Aggravating factors
Relieving factors
Treatment
Subarachnoid Hemorrhage
Severe and Sudden “worst headache of
my life”
Nausea and Vomiting can be present
Cranial Nerve X

Vagus nerve
Used to assess when you touch the soft
palate and view uvula
Signs of Otitis Externa (swimmers Ear)
Painful movement of the auricle and
tragus (page 245)
Review fig 7-43
Physical Signs of Meningitis (pg 765)
Neck stiffness with resistance of flexion.
Won’t be able to touch chin to chest
Red flags for Headaches (pg
216)
Progressively frequent or severe over 3
month period
New onset after 50
Aggravated or relieved by change in
position
Recent head trauma
Labs to check with Vitiligo (pg 191)
Thyroid panel: TSH, free T3 and Free T4,
CBC
Pregnancies and C-sections
C-sections should be listed under surgery
in the patients history
Preservation (162)
Patientuses words repeatedly. Using
words or phrases repeatedly often seen in
schizophrenia
Erectile Dysfunction
Older men in their late 40s that
experience ED is usually psychological
rather than testosterone.
Tanner Staging of breasts in females
(897)
Stage 1: preadolescents-elevation of nipple
Stage 2: Breast bud stage- elevation of breast
and nipple as a small mound.
Stage 3: further enlargement of elevation of
breast and areola
Stage 4: projection of areola and nipple for a
secondary mound above the level of the breast
Stage 5: mature stage- projection of nipple
only.
HPV vaccine (page 577 and 578)
Prevents infection from subtypes 16 and
18.
Measuring tape when measuring uterus in
a pregnant woman pg 944
Place tape measure on pubic symphysis
and place zero end of tape, when you can
firm feel the bone.
Extend the tape measure to the very top
of the uterine fundus and note the number
of cm measured.
The number should equal the number of
weeks of gestation
Bounding pulse (pg 522)
Bounding meaning 2+
On a scale 0-3
Tanner Staging

Females: p. 897
Stage 1: preadolescent (elevation of nipple only)
Stage 2: breast bud stage (elevation of breast and
nipple as a small mound; enlargement of areolar
diameter
Stage 3: further enlargement of elevation of breast
and areola; no contour separation
Stage 4: projection of areola and nipple to form a
second mound above the level of the breast
Stage 5: mature stage (projection of nipple only;
areola has receded to general contour of the breast)
Bacterial Vaginosis-

Discharge: Gray or white, thin,

homogeneous, scant, malodorous Other
Symptoms: Fishy genital odor
Vulva: Usually normal
Vagina: Usually normal
Laboratory Assessment: Saline wet mount
for “clue cells,” “whiff test” with KOH
for fishy odor
Candida vaginitis Discharge

White, curdy, often thick, not malodorous

Other Symptoms: Itching, vaginal
soreness, external dysuria, dyspareunia
Vulva: Often red and swollen
Vagina: Often red with white patches of
discharge
Laboratory Assessment: KOH preparation
for branching hyphae
Erectile Dysfunction

May be a from psychogenic causes,

especially if early morning erection is
preserved; it may also reflect decreased
testosterone, decreased blood flow in the
hypogastric arterial system, impaired
neural innervation, and diabetes.
Rovsing sign:
pain in the RLQ during left sided pressure
Diverticulitis-
Inflammation of the diverticula. Left
lower quadrant pain, especially with a
palpable mass. Deep palpation is usually
required to delineate the liver edge, the
kidneys, and abdominal masses. The pain
may be cramping at first, then steady.
what are absence seizures
A sudden brief lapse of consciousness, with
momentary blinking, staring, or movements of
the lips and hands but no falling.
Two subtypes are typical absence (lasts less than
10 sec and stops abruptly)
And atypical absence (may last more than 10
sec).
Post ictal state: no aura recalled. In typical
absence, there is a prompt return to normal and in
atypical there might be some postictal confusion.
signs of increased intracranial pressure
Papilledema of the optic disc  elevated ICP causes
intraaxonal edema along the optic nerve leading to
engorgement and swelling on the optic disc
◦ pink, hyperemic, loss of venous pulsations, disc more
visible, disc swollen with blurred margins, physiologic
cup not visible)
Headache, blurred vision, feeling less alert than
usual, vomiting, changes in
behavior, weakness or problems with moving or
talking, lack of energy or sleepiness
 
signs of respiratory distress
◦ Tachypnea: greater than or equal to 25
breaths/min  pneumonia and cardiac disease
◦ Cyanosis or pallor (signals hypoxia)
◦ Audible sounds of breathing: audible whistling
during inspiration over the neck or lungs
 stridor signals upper airway obstruction in the larynx
or trachea
◦ Contraction of the accessory muscles of the neck
or supraclavicular retraction, contraction of the
intercostal or abdominal oblique muscles
 Is the trachea midline?
what is objective information
What you detect during the examination,
laboratory information, & test data. All
physical exam findings, or signs.
what can cause epistaxis
Know what can cause epistaxis (p. 220)
Trauma (especially nose picking),
inflammation, drying and crusting of the
nasal mucosa, tumors, and foreign bodies
signs of otitis externa (swimmer’s ear)
Painful movement of the auricle and tragus (tug
test)
Movement of the auricle and tragus (the “tug
test”) is painful in acute otitis externa
(inflammation of the ear canal), but not in otitis
media (inflammation of the middle ear).
Tenderness behind the ear occurs in otitis media.
in acute otitis externa, the canal is often swollen,
narrowed, moist, pale, and tender. It may be
reddened.
the signs of pneumonia
Dullness replaces resonance, crackles can
arise from abnormalities of the lung
parenchyma, pleural rubs, localized
bronchophony and egophony (in patients
with fever and cough the presence of
bronchial breath sounds and egophony more
than triples the likelihood of pneumonia.
 Pleuritic pain: sharp, knifelike, aggravated
by deep inspiration, coughing, movements of
the trunk. Often persistent and severe.
the physical signs of meningitis
Neck stiffness with resistance to flexion is present in approx.
84% of patients with acute bacterial meningitis (won’t be
able to touch chin to chest)
Inflammation in the subarachnoid space causes resistance to
movement that stretches the spinal nerves (neck flexion), the
femoral nerve (Brudzinski sign), and the sciatic nerve
(Kernig sign).
Neck stiffness with resistance to flexion is found in ∼84%
of patients with acute bacterial meningitis and 21% to 86%
of patients with subarachnoid hemorrhage. It is most reliably
present in severe meningeal inflammation but its overall
diagnostic accuracy is low.
Test for Kernig Sign
Signs of Lyme Disease
Rash, often in a bull’s-eye pattern
(erythema migrans) and flu-like
symptoms, fever, headache, fatigue
acanthosis nigricans can clue into
 Diabetes mellitus
Remember Tina Jones in Shadow Health
had this
Mongolian spots
A dark or bluish pigmentation over the buttocks
and lower lumbar regions  common in
newborns of African, Asian and Mediterranean
descent,
Also called slate blue patches
◦ Result from pigmented cells in the deep layers on the
skin
◦ Less noticeable with age and disappear during
childhood
Document these pigmented areas to avoid later
concern about bruising
red flags for headaches

◦ Progressively frequent or severe over a 3-month period

◦ Sudden onset like a “thunderclap” or “the worst headache of
my life”
◦ New onset after age 50
◦ Aggravated or relieved by change in position
◦ Precipitated by Valsalva maneuver or exertion
◦ Associated symptoms of fever, night sweats, or weight loss
◦ Presence of cancer, HIV infection, or pregnancy
◦ Recent head trauma
◦ Change in pattern from past headaches
◦ Lack of similar headache in the past
◦ Associated papilledema, neck stiffness, or focal neurologic
deficits
Cotton Wool Patches
Conjunctivitis vs Subconjunctival Hemorrhage
Olfactory CN I
The decreased sense of smell is normal in
elderly patients, head trauma, smoking,
cocaine use and Parkinson’s d/e.
Cricoid Cartilage
how to listen for aortic regurgitation

Ask the patient to sit up, lean forward,

exhale completely, and briefly stop
breathing after expiration.
Press the diaphragm on your stethoscope
on the chest and listen along the left
sternal border and at the apex, pause
periodically so the patient may breathe
◦ You may miss the soft diastolic decrescendo
unless you listen at this position
When performing a breast exam, identify what
abnormal masses should do when the arm moves

Fibroadenoma: very mobile

Cysts: mobile
Cancer: may be fixed to skin or
underlying tissues (may cause dimpling of
skin or retraction when arms are lifted
over head or hands are pressed against
hips)
hepatitis A
Transmitted through fecal-oral route.
Fecal shedding followed by poor
handwashing contaminates water and
foods leading to infection of household
and sexual contacts
Stress incontinence:
the urethral sphincter is weakened so that
transient increases in intra-abdominal
pressure raise the bladder pressure to
levels that exceed urethral resistance.
Causes include childbirth and surgery,
postmenopausal atrophy of the mucosa,
and urethral infection. May follow
prostate surgery in men.
Urge incontinence:
detrusor contractions are stronger than normal
and overcome the normal urethral resistance.
The bladder is typically small. Mechanisms:
Decreased cortical inhibition of detrusor
contractions from stroke, brain tumor, dementia,
and lesions of the spinal cord above sacral level.
Also hyperexcitability of sensory pathways ie:
bladder infections, tumors, and fecal impaction.
Deconditioning of voiding reflexes ie: frequent
voluntary voiding at low bladder volumes.
Overflow incontinence
detrusor contractions are insufficient to
overcome urethral resistance, causing
urinary retention. The bladder is typically
flaccid and large, even after an effort to void.
Mechanisms: obstruction of the bladder
outlet ie: BPH or tumor. Weakness of the
detrusor muscle associated with peripheral
nerve disease at S2-4 level. Impaired bladder
sensation that interrupts the reflex arc ie:
diabetic neuropathy.
Functional incontinence:
the patient is functionally able to reach the
toilet in time because of impaired health or
environmental conditions. Mechanism:
problems in mobility resulting from
weakness, arthritis, poor vision, or other
conditions. Also environmental factors such
as an unfamiliar setting, distant bathroom
facilities, bedrails, or physical retraints.
 
Where do you palpate the lymph nodes when assessing for
strep?

Strep throat streptococcal pharyngitis,

bacterial infection that may cause a sore,
scratchy throat
Common childhood infection has a classic
presentation of erythema of the posterior
pharynx and palatal petechiae
Enlarged swollen cervical lymph nodes 
superficial cervical lymph nodes
Superficial cervical superficial to the
sternocleidomastoid
Superficial cervical
causes of increased jugular venous
pressure
Elevated JVP is highly correlated with
both acute and chronic heart failure. It is
also seen in tricuspid stenosis, chronic
pulmonary hypertension, SVC
obstruction, cardia tamponade, and
constrictive pericarditis
 
what to do if you feel an abdominal
mass
Occasionally there are masses in the
abdominal wall rather than inside the
abdominal cavity. Ask the patient either to
raise the head and shoulders or to strain
down, thus tightening the abdominal
muscles. Feel for the mass again.