PA Hematology Exam 1

hematology

the study of blood

includes the study and treatment of blood disorders and malignancies

branch of internal med

common hematology conditions

anemia

clotting disorders

leukemias

lymphomas

cancers

types of anemias

sickle cell anemia, thalassemias, aplastic anemia, hemolytic anemia

types of clotting disorders

hemophilias- A & B, Von Willebrands

types of lymphomas

hodgkins and non-hodgkins

other cancers

myeloma, myelodysplastic syndromes

key concepts in physical exam - Respect and empathy

gender identity, cultural, modesty, temperature of the room/hands, patient, abilities, and who is with them

Key Concepts in physical exam - safety

provider safety, patient safety, clean hands, and safe environment

key concepts in physical examination

approach patients from the patients right side, IPPA - inspection, percussion, palpation, auscultation, and special test as applicable

IPPA

four common parts of the physical exam - inspection, percussion, palpation, and auscultation

may not always need to percuss and auscultate

should be routine and performed and documented in this order

exception of IPPA

abdominal exam which is IAPP

inspection

refers to focused inspection/different from general inspection

where you will be inspecting the body part of the patient pertaining to their complaint/symptom

clothing should be removed from area

still inspect for painless problems, ex. shortness of breath

compare if bilateral, ex. one knee hurts, compare to the other

percussion

this is done to elicit sound waves through various organs and tissues

the denser the surface the more muffled the sound. The more air-filled an area is, the louder and more high-pitched the sound

tympanitic

loudest, air filled, ex. gastric bubble

hyperresonant

second loudest, ex. lungs with emphysema

resonant

middle loudness, ex. normal lungs

dull

second softest, ex. liver tissue

flat

softest, ex. muscle tissue

how to percuss

involves striking the distal interphalangeal joint of your non-dominant middle finger with the first two fingertips of your dominant hand, all while in firm contact with the patient

perform the finger strikes with rapid, repetitive motions, moving only at your wrists

palpation

involves using your hands to press on various regions of the patient’s body to gather objective information regarding-

• presence or absence of masses

• texture of skin

• position of abnormalities or even normal organs

• size of organs or masses

• consistency

• elicit tenderness or confirm the lack of

how to palpate

pads of the fingers are more sensitive

ulnar aspect for vibration

dorsal aspect for general temperature

start with gentle, light palpation and then transition to more firm/deep pressure

always start away from painful areas

warm hands and short nails

auscultation

involves listening for sounds made by various body organs using a stethoscope

never listen through clothing

adipose tissue decreases the sound quality

quiet room is crucial

listening for-

• pitch

• duration

• intensity

• quality

initial physical exam

general inspection, height/weight/BMI, blood pressure, pulse, respirations and O2 saturation

General inspection

head-to-toe overview of the patient

process using your four senses- sight, smell, sound (hearing), and touch (handshake)

hear when you listen and notice when you see

begins as soon as you enter the room and continues throughout the encounter

examples of things noted in a general inspection

is the patient hearing you alright

are they anxious or in an anxious position

is there eye contact

what is at their bedside table or what did they bring with them

how difficult is it for the patient to move

do they look sick

general inspection components

state of awareness, level of consciousness

apparent state of health

signs of distress

stature and habitus, sexual development (age appropriate)

nutritional state

posture, gait, body movements

dress, grooming, personal hygiene

body/breath ordors

facies and facial expression

manner, affect

speech

awareness, consciousness

general overview

is the patient awake

are they alert or drowsy

are they arousable - to verbal stimuli, to painful stimuli

are they orientated- to person (name), to place (building, city, state), to time (day, month, year), to situation

do they understand your questions

are they answering your questions appropriately

apparent state of health

do they appear frail, robust, etc

do they appear their stated age

does the patient appear ill - acute or chronic

signs of distress - cardiorespiratory distress

labored breathing- dyspnea

nasal flaring in infants - dyspnea

wheezing

persistent cough

cyanosis- lips and nail beds

sitting forward in char

retraction of chest wall or use of accessory muscles in breathing

possibly anxious

sings of distress- pain

facial expression such as wincing, frowning

sweating- diaphoresis, chills - febrile

protectiveness of a painful area- guarding

posture- writhing on table v. very still

obvious moaning, yelling, crying

holding a body part to aid in respiration or movement- splinting

signs of distress -emotional

facial expressions

eye contact

motions of hands or extremities in general

crying

fidgety movements

cold moist palms during handshake

shakiness in speech

stature

height- always measure without shoes

is the patient unusually short or tall

is the patients hieght very different from their genetic potential

marfan syndrome

tall with long extremities

klinefelter syndrome

tall males, XXY

rickets

short

bowed legs

turner syndrome

short

XO

achondroplasia

short

habitus

body build

habitus terms

slender

stocky

petite

lanky

musuclar

symmetry

general body proportions

deformities

exogenous fat

generalized and associated with increased caloric intake

endogenous fat

distributed to the trunk with sparing of extremities such as cushings disease - truncal obesity

edema

accumulation of fluid in the interstitial spaces that appears as swelling and causes increased weight

dependent edema

appears in lowest body parts such as feet and legs

ascites

fluid within the peritoneal cavity

anasarca

diffuse edema throughout the entire body

pitting edema

depression of the skin created by palpation, ideally over a boney prominence

graded severity of pitting edema

1+ is depression up to 2 mm

2+ is depression from 2-4 mm

3+ is depression from 4-6 mm

4+ is depression from 6-8 mm

sexual developement

for pubertal and prepubertal children

breast and secondary sexual hair in females

genital growth and secondary sexual hair in males

arrives at a sexual maturity rating

sexual maturity rating

tanner staging

nutritional status

some overlap with body habitus

normal, cachexia, overweight, obese

cachexia

profound malnutrition

not anorexia

causes unintentional weight loss: malignancy, diabetes, hyperthyroidism, tuberculosis, depression, AIDs,

a state of general ill health and malnutrition, marked by emaciation

anorexia

the lack or loss of appetite, resulting in the inability to eat

anorexia nervosa

refers to the diagnosis of an eating disorder

posture

general posture

sitting up and leaning forward: COPD, pericarditis

supine and motionless: peritonitis

orthopnea: inability to breathe supine, congestive heart failure

nuchal rigidity, meningitis

slouching, consider low tone

gait

does the patient walk easily with confidence and good balance

is there a limp, paint, unsteadiness, or loss of balance

are walking aids required

body movements

is the patient restless or quiet, how often do they move about, how fast are the movements

involuntary movements, what parts of the body are involved, do they stop when the patient relaxes

bradykinesia

fast movements: kids, thyroid disease

bradykinesia

slow movement with age, parkinsons disease, hypothyroidism

types of involuntary movements

tics

convulsive movements

tremors

fasciculations

tics

brief, repetitive, movements occurring at irregular intervals

ex. tourette’s syndrome

convulsive movements

seizure disorders

clonic and tonic

clonic

sudden brief jerks of the trunk or limbs

tonic

muscle contractions producing rigidity

tremors

rhythmic oscillatory movements

fasciculations

fine flickering

smooth muscle groups

types of tremors

resting tremors

intention tremors

postural tremors

familial tremors

resting tremors

only occur at rest such as the pill-rolling tremor of parkinsons

intention tremors

only occur with activity as a target is reach such as in MS

postural tremors

occur when the affected part is actively maintaining posture such as hyperthyroidism, anxiety, fatigue

familial tremors

inherited, ex. essential tremor

abnormal movements

asterixis

athetosis

chorea

asterixis

flapping tremor is a postural tremor by flapping movements of wide amplitude

liver failure, renal failure

athetosis

slower, writhing, twisting such as cerebral palsy

chorea

brief, rapid, jerky, irregular, unpredictable movements that may occur at rest or during activity

dressing, grooming, hygiene

is clothing appropriate for weather, age

is clothing properly buttoned, matched, zipped

do clothes/shoes fit properly

use of cosmetics

is patient properly groomed or enkempt

dress, grooming, hygiene clues to

thyroid dysfunction

depression

dementia

abuse

trying to hide lesions or rashes

financial difficulties and many more

odors

poor hygiene

homeless

occupation

breathe odors from alcohol, cigarettes, acetone, strep, sinus drainage, poor dentition

feces/urine from infrequent diaper changes or incontinence

wounds, foreign bodies

halitosis

bad breath

facies, facial expressions

expression or appearance of face often associated with certain disease states

acromegaly, moon facies, nephrotic syndrome, parkinson’s, myxedema

acromegaly

exaggerated, coarse features

moon facies

seen with cushing’s disease and chronic steroid use

nephrotic syndrome

edematous facies

parkinson’s

decreased mobility, mask like

myxedema

severe hypothyroidism with dull, puffy appearance

affect

an outward, observable manifestation of a persons feelings or emotions

what we observe about their mood

flat, blunted, bright

mood

a prolonged subjective emotional state that influences one’s whole personality and perception of the world

sadness, anger, elation

speech

speed- rapid, slow

effort and flow- hesitant, labored, broke, fluid, fluent, smooth, articulate, slurred

hoarseness

general inspection

should be located at the beginning of the physical exam portion of the write up, preceding the vital signs

should be written as a concise paragraph in complete sentences

temperature

a measure of sensible heat associated with the metabolism of the human body

reflects body’s ability to measure homeostasis

normal temp

98.3 F or 36.8 C

varying body temperature

temperature varies from morning to evening (cortisol) with the body’s circadian rhythm or with a woman’s menstrual cycle (estrogen and proestrogen)

how is temperature assessed

electronic sensor

infrared technology

mercury in glass thermometer

infrared technology

measures infrared radiation

convert it to electric signal

measures surface temperature

general infrared

scans from inches away

temporal thermometers

touches forehead

better

where is temperature assessed

pulmonary artery

oral

rectal

tympanic

axillary

temporal

pulmonary artery

gold standard

invasive

oral

standard

reference

hot, cold liquids, and smoking can affect perforations

rectal

core temperature (one degrees more than reference)

closest reflection of core temperature

associated with rectal perforations

tympanic

1 degree lower than reference

most variable

accuracy depends on correct technique as well as other factors- provider technique, hot environment, wiggly kids

the ear canal has temperature gradients

proper placement of thermometer is key

temporal artery

one degree lower, also variable

uses infrared technology

start center of forehead and move to temporal artery

highly impacted by environment