PCS 3 Exam 2

At a well visit, you would measure length and height and weight how often?

every visit

When do you start measuring length and height of a child standing ?

at 2 years old

For what aged patients do you measure head circumference?

birth to 36 months old

How to measure length/hieght of a child under 2

-Measure the crown-heel length using a recumbent stadiometer.(shown below) Ask a parent or assistant to hold the baby's head stilland stretch out the legs until the baby is fully extended.

-Most places wont have this though, so just lay them on the exam table and mark it off on the paper

A patient's height is related to

average of their parents' height centile ± 2 standard deviations

How to weigh an infant

fully undressed on an electronic scale accurate to 5g

how to measure head circumference

Measure at greatest circumference -> place tape measure slightly above points just above the eyebrows and the pinna and around the occipital prominence.

To nearest millimeter, measure 3 times and take largest .

Plot on appropriate growth chart.

failure to thrive

a condition in which the baby does not grow and develop properly

learn to use a growth chart

fine

preterm infants

Those born before the completion of 37 weeks of gestation (the time between fertilization and birth).

premmie growth chart rules

use preterm growth charts

can use regular chart once they hit 40 weeks

for first 2 years of life, adjust age to expected date of delivery instead of DOB

Ortolani maneuver

the hip is abducted and gentle pressure isapplied to the proximal thigh from behind. Here, the examiner attemptsto relocate an already dislocated femoral head back into theacetabulum. If the joint is dislocated, a palpable "clunk" is noticed asthe head slides back into place.

Barlow maneuver

The examiner grasps the infant's thigh near the hip and with gentleposterior/lateral pressure, attempts to dislocate the femoral head fromthe acetabulum. Normally, there is no motion in this direction. If the hipis dislocatable, a distinct "clunk" may be felt as the femoral heads popsout of joint.

between length/weight/height, what is least reproducible

length

6 most significant behaviors affecting adolescents

• Inadequate physical activity

• Poor nutrition

• Sexuality-related behaviors•

Substance use and abuse (including tobacco products)

• Unintentional injury

• Intentional injury

Acronym for Adolescent Social Hx taking

S Strengths*

S School

H Home

A Activities

D Drugs

E Emotions

S Sexuality

S Safety

Failing grades can indicate

an underlying learning or attention disorder and also correlates withpsychosocial issues.

Home questions can help identify

protective and risk factors in their home environment

working more than 20 hours a week while in school associated with

-lower grades, less investment in education

-substance use:alcohol and drug use

-delinquency and distress

7 Ps Framework of Sexuality

• Partners

• Practices

• Protection from STIs

• Past History of STIs

• Prevention of pregnancy

• Permission

• Personal gender identify

Being bullied is associated with

-negative coping and significant more medical problems or complaints

-Also associated with poorer quality relationships and loneliness

two potential harms to performing a psychosocial screening

• It can contextualize a person's life through a lens of brokenness or risk. By starting with the highlighted strengths, the SSHADESS screening is designed to address this.

• It holds potential of retraumatizing a young person by triggering memories.

It is important to be what in an adolescent interview

nonjudgemental and flexible

Clear mucois sputum associated with

COPD/bronchiectasis without current infection/rhinitis.

Yellow (mucopurulent) sputum associated with

acute lower respiratory tract infection/asthma

Green (purulent) sputum associated with

current infection - acute disease or exacerbation of chronicdisease, such as COPD

Red/brown (rusty) sputum associated with

pneumonccocal pneumoniae

Foul-smelling sputum is present in

anaerobic lung abscess, thick tenacious sputum in cystic fibrosis.

Large volumes of sputum are present in

bronchiectasis and lung absecces

hemoptysis

the coughing up of blood from the lower respiratory tract

For patients reporting hemoptysis:

o Quantify the volume of blood produced

o The setting and activity

o Any associated symptoms.

causes of hemoptysis include

severe, forceful cough, infections, pulmonary embolism, cancer,vasculitis

Massive hemoptysis (>200 cm3) may be life-threatening

How to determine severity of SOB

based on a patient's daily activity

a family history of atopy is relevant in

rhinitis

In patients with epistaxis, it is important to

establish a family history of hereditary hemorrhagic telangiectasia or inherited bleeding disorders. Heavy alcohol intake is also relevant to this

history of COPD at a young age indicative of

Alpha 1 antitrypsin deficiency

classic allergic salute

allergic shiners

dark circles under eyes

aka me constantly

Pale, boggy turbinates

allergic rhinitis

Jugular venous pressure is raised in patients with

pulmonary hypertension and maybe acutely raised in those with tension pneumothorax or large pulmonary embolism

Tracheal deviation away from the affected side is seen acutely in

tension pneumothorax

Chronic tracheal deviation towards the affected side occurs with

loss of lung volume in upper lobe fibrosis or collapse and following lobectomy or pneumonectomy.

Surgical emphysema

palpation of the chest wall can indicate this, air trapped in the subcutaneous tissue

crepitus commonly complicates

pneumothorax with chest drainage or rib fracture and feels like a palpable crackling under the skin of the upper thorax and neck

Consolidation indicates

filling of the alveoli and bronchioles with pus(pneumonia), fluid (pulmonary edema), blood, or neoplastic cells.

A solitary wheeze that is present consistently with each breath and does not clear with coughing suggests

a possible fixed bronchial obstruction and can be an important sign of underlying cancer

Crackles that persist after several breaths and do not clear with a deliberate cough are

pathological

fine crackles

fine crackles during inspiration, resembling the sound made by peeling a Velcro fastener, are characteristic of interstitial pulmonary fibrosis, and are most commonly heard atthe lung bases posteriorly and laterally.

coarse crackles

generally heard in patients with significant purulent airway secretionssuch as those with bronchopneumonia or bronchiectasis. (Rhonchi)

bronchophony

• Have the patient repeat "99" as you auscultate

• An area of increased sound transmission suggests consolidation

Egophony

• Ask the patient to say "Eeeee" as you auscultate

• If consolidation is present the "E" will be heard as "A"

whispered pectoriloquy

• Ask your patient to whisper "1, 2, 3"

• Normally whispering produces a muffled sound

.• In an area of consolidation, the words will be louder.

Tactile Fremitus

• Place the ulnar surface of your hands against the chest wall and ask the patient to repeat "99" as you move your hands down the chest wall. (You can also use the palmar surface of your hand.)

• Tactile fremitus (vibrations) o Increased in consolidation o Decreased in conditions that decrease transmission of sound such as increased fat, an air-fluid level, or over expansion from emphysema. (seevideo!)

#1 preventable cause of mortality in the US

smoking

The use of appropriate skills to address smoking is not associated with longer visits.

nice

how quick does nicotine reach the brain

less than 10 seconds after inhalation, and achieves max concentrations within 1 minute

Fagerstrom Tolerance questionnaire

meausres dependence

Heaviness of Smoking Index

-How soon after you wake up do you smoke your first cigarette?

-On average how many cigarettes do you smoke per day?

5 A's of tobacco counseling

- Advise: importance of quitting

- Assess: level of readiness to quit

-Agree: on goals and methods , based on willingness

- Assist: let me know when ready to quit

- Arrange: follow up

Stages of Change Model

The Stages of Change Model:

1. Precontemplation- Patient has no interest in quitting in the foreseeable future.

2. Contemplation- Patient is ambivalent about quitting and not willing to make a commitment to change.

3. Preparation- Patient intends to quit within the next month, or has made recent changes in smoking behavior,

4. In action- Patient has recently quit and is using strategies to remain abstinent.

5. Maintenance- Patient has quit for at least 6 months

Relapse

occurs frequently in smokers trying to quit, almost 80 % sometimes

importance

what patients believe about the importance of giving up smoking

confidence

how patients feel about their ability to quit despite obstacles

even brief advice increases quit rates!

true

dancing with discord can elicit

patient "change talk" that reflects movement towards considering quitting

The outcome goal patients agree to choose is rarely

abstinence now and forever

Assure that you and patients agree on goals that are based on

patient's past experience

other pearls to consider

Agreeing on an achievable goal is far better than persuading patients to assent to an "optimal" goal which they neither want nor are capable of reaching.

• A sensible goal encourages small successes instead of big failures and enhances the likelihood of successful change

• For patients with high levels of nicotine dependence suggest

nicotine replacement therapy

The combination of counseling and pharmacotherapy is more effective than ether modality alone

okie

essential aspect of the smoking intervention

patient follow up

Effective telephone counseling or texting can be conducted by

clinical staff or a community resource,including the national quit line and texting programs available at https://smokefree.gov/

quitting is not an event, it is a

stepwise process

tobacco dependence is a

chronic and relapsing disorder

Successful clinical intervention depends on

appropriate assessment, a trusting relationship, and skillful informing and advising of patients

myth or fact? smokers do not want to quit

MYTH

About 70% of smokers want to quit smoking, and almost half make a serious attempt to quiteach year

Why is nicotine optimal for development of physical dependence

instantly enters the neurons, and impacts brain function

what percent of smokers trying to quit experience significant withdrawal sx?

50 %

what are some smoking withdrawal symptoms and concerns ?

craving, increased hunger, dreaming about smoking, concern of weight gain, (more in women)

What smokers may have a higher level of nicotine dependence

smoking withing 30 minutes of arising, or 25 or more a day

what is associated with higher prevalence of smoking and harder to quit

psychiatric comorobidity like anxiety or mood disorders

how to address confidentiality to parents and pateint in adolescent interview

-Will need to explain the transition to allow more autonomy and privacy for the adolescent, may invovle asking the parent to leave

-give a confidentiality statement

-explain confidentiality with the goal of promoting open communication with the family

-reassure parent that they will be brought back in

vague answers in a teen like "just hanging out" may need to be probed at further because...

could be a sign of engaging in risky behavior and activities the adolescent is reluctant to discuss

how to ask adolescents about suidical idealations

-dont use vague terms like "harming yourself"

-open with a statement that normalizes thoughts of suicide to help them open up

-use clear language

if an adolescent expresses suicidal idealations...

-determine if there is a specific plan

-determine if they have the ability to carry it out

**ONE OF THE EXCEPTIONS TO CONfIDENTIALITY

where else can hemoptysis come from thats not lungs?

nose bleeds, vomitus

Anxious patients may have episodic dyspnea both during exercise and at rest, as well as ____, or rapid, shallow breathing.

hyperventilation

family hx of clots may indicate risk for

PE

barrel chest

a condition characterized by increased anterior-posterior chest diameter caused by increased functional residual capacity due to air trapping from small airway collapse. A barrel chest is frequently seen in patients with chronic obstructive diseases, such as chronic bronchitis and emphysema.

wheeze

high-pitched, musical, squeaking adventitious lung sound, usually expiratory and of smaller airways

polyphonic wheeze is common in

asthma, bronchitis, COPD exacerbation

indications for pulmonary function tests

- pt with dyspnea duh

-evaluating disease severity and monitoring tx response

-determing if fit for surgery (thoracic/lung resection)

Tidal Volume (TV)

amount of air inhaled or exhaled with each breath under resting conditions

peak flow meter measures

peak expiratory flow

nasal cannula

A device that delivers low concentrations of oxygen through two prongs that rest in the patient's nostrils.

24-40% oxygen, delivery rate is 1-6 L/min

Simple face mask flow rate

6-10L/min

40-60% oxygen

Non-rebreather mask

allows higher levels of oxygen to be added to the air taken in by the patient

60-80% oxygen

10-15 L/min

non rebreather risks

-Risk of suffocation if the gas flow is interrupted. The bag should never totally deflate

• Risk of hyper-oxygenation

• Difficult to eat with mask on. Mask may beconfining for some patients, who may feel claustrophobic with the mask on.

Venturi mask flow rate

24-60% O2 at 4-12 L/min

bag-valve mask (BVM)

A device with a one-way valve and a face mask attached to a ventilation bag; when attached to a reservoir and connected to oxygen, it delivers more than 90% supplemental oxygen.

dont use if patient is conscious duh