Exam 1

Review of Systems Red Flags

Chest Pain + diaphoresis

Sudden neuro deficit

Unexplained weight loss

Hemoptysis

Syncope

Vitals/Pain Red Flags

Cyanosis

Altered mental status

Hypotension

Severe tachypnea

Toxic appearance

Potential Causes of Tachypnea

Anxiety

Stress

SOB

Astma

Acidosis

Potential causes of bradypnea

Overdose

Decompensation

Low SpO2 Causes

Poor perfusion

Low reading could be due to dark nail polish

Dyshemoglobinemia (ex: CO2 poisoning)

BP Ranges

Normal: <120/80

Elevated: 120-129/<80

Stage 1 HTN: 130-139/<90

Stage 2 HTN: >140/>90

Hypotension Causes

Hypovolemia

Bleeding

Dehydrated

shock

Older age

Hypertension causes

White coat HTN

Masked HTN

Fluid volume overload

Vascular Disease

Considerations if Patient has fever

Consider infection

Immunocompromised

pallor causes

fear, peripheral vasoconstriction, smoking, shock, anemia

cyanosis causes

Lungs: COPD, anaphylaxis, astma, respiratory distress, asphyxia

Central: hypoxia, anemia

Peripheral: Decreased circulation, hypotension

Bulla

circumscribed, fluid, >1 cm

Macula

circular flat, discoloration, <1cm

Nodule

circular, elevated, solid, >1cm

Patch

circumscribed flat, discoloration, >1cm

Papule

superficial solid elevated, <0.5cm, color varies

plaque

superficial elevated solid flat topped, >1cm

pustule

vesicle containing pus

Vesicle

circular collection of free fluid, <1cm

Wheal

edematous, transitory plaque

Skin Cancer ABCDEEF

A: Asymmetry

B: borders are irregular

C: color

D: diameter >6mm

E: elevated

E: evolving

F: firm

G: growing

Jaundice Causes

yellowish, itchy skin

bilirubin problem and liver not functioning properly

Butterfly rash cause

Lupus

Petechiae

small, pinpoint hemorrhages

Petechiae Causes

Bacterial meningitis

Mononucleosis (mono)

Meningococcemia

Cytomegalovirus (CMV)

Flu or Hemorrhagic fevers

NSAIDS

Leukemia

Vasculitis

Thrombocytopenia/DIC

Purpura

Dark, purplish, bruise-like spots that rapidly expand, becoming hardened and turning into black, necrotic (dying) eschars

Sepsis Indicators: High fever, chills, and extremely low blood pressure (shock).

Purpura causes

bleeding disorders, Thrombocytopenic, and capillary fragility in the older adult

Cellulitis S/Sx

Red, swollen area

Tender

Warn

Painful

Induction

Potential fever

Pressure Injury Stages

Stage 1: non-blanchable

Stage 2: broken skin, superficial

Stage 3: into the subcutaneous tissue

Stage 4: through subcutaneous tissue into muscle or bone

Unstageable: covered in eschar

Alopecia causes

often hereditary, hormone changes, chemotherapy, stress, burns, fungal skin infections

Hirsutism causes

Hirsutism might be caused if a client is taking anabolic steroids.

Koilonychia

a malformation of the nails in which the outer surface is concave or scooped out like the bowl of a spoon

Koilonychia causes

nemia, damage, autoimmune

Clubbing causes

long term respiratory issue, COPD

Splinter Hemorrhages causes

endocarditis, damage to the nails

Addisons s/sx (skin)

Hyperpigmentation or oral mucosa

Cushing disease s/sx (skin)

Striae, atrophy, purpuras, ecchymoses, telangiectasias, acne, moon facies, buffalo hump, hypertrichosis

Diabetes S/Sx (skin)

Pruritus, diabetic dermopathy, acanthosis nigricans, candidiasis, neuropathic ulcers, necrobiosis lipoidica, eruptive xanthomas

Hyperthyroidism S/Sx (skin)

Warm, moist, soft, and velvety skin

thin and fine hair

alopecia

vitiligo

pretibial myxedema (in Graves disease)

hyperpigmentation (local or generalized)

Hypothyroidism S/Sx (skin)

Dry, rough, and pale skin

coarse and brittle hair

alopecia (lateral third of the eyebrows to diffuse)

skin cool to touch

thin and brittle nails

Liver disease s/sx (skin)

Jaundice, spider angiomas and other telangiectasias, palmar erythema, Terry nails, pruritus, purpuras, caput medusae

Necrotizing Infection S/Sx (skin)

Erythema that spreads quickly, “boggy” skin, painful

Steven-Johnson Syndrome

Top layer of affected skin dies, sheds, and leaves painful, burn-like blisters

submental lymph nodes

palpate in the midline a few centimeters behind the tip of the mandible.

submandibular lymph nodes

midway between the angle and the tip of the mandible. These nodes are usually smaller and smoother than the lobulated submandibular gland against which they lie

Tonsillar lymph nodes

palpate in front of the ear

preauricular lymph node

palpate in front of the ear

postauricular lymph node

palpate behind the ear and superficial to the mastoid process.

#2 in image

anterior cervical lymph nodes

D in the photo

palpate for these nodes in the midline between the SCM muscles and superior between the hyoid and manubrium.

posterior cervical lymph node

#6 in the photo

palpate along the anterior edge of the trapezius by flexing the patient's neck slightly forward toward the side being examined

Supraclavicular lymph node

palpate deep in the angle formed by the clavicle and the SCM muscle

Infraclavicular lymph nodes

Normal Lymph Nodes

soft, non-tender, moveable

Abnormal Lymph Nodes

hard, fixed, large

Abnormal Supraclavicular node = concern for _______

suggests possible metastasis from a thoracic or an abdominal malignancy.

especially on the left (Virchow's node)

Tracheal deviation causes

mediastinal mass, thyriod mass, atelectasis, large pneumothorax

Generalized lymphadenopathy is seen in multiple infectious, inflammatory, or malignant conditions such as

HIV or AIDS, infectious mononucleosis, lymphoma, leukemia, and sarcoidosis.

Thyroid Normal findings

· Non-palpable

· Palpable <4cm (right lobe may be slightly larger)

· Gland is soft and smooth

· Area is not tender or excessively warm

· No bruit present

Thyroid Abnormal findings

Neck is enlarged, asymmetrical, nodular

Gland does not move during swallowing.

Causes of enlarged Thyroid

Goiter or cancer or hyperthyroidism

Conjunctival infection findings

- diffuse dilatation of conjunctival vessels with redness that tends to be maximal peripherally

- Watery, mucoid, or mucopurulent

- Mild discomfort rather than pain

- Not affected except for temporary mild blurring due to discharge

Significance: Bacterial, viral, and other infections; highly contagious; allergy; irritation

Sclera Hemorrhage Findings + Significance

Leakage of blood outside of the vessels, producing a homogeneous, sharply demarcated, red area that resolves over 2 wks

No pain

Vision unaffected

Not significant

Ciliary injection Findings + significance

Deeper vessels radiating from the limbus are dilated, creating a reddish-violet flush. The eye may also be diffusely red.

Moderate to severe, superficial

Vision Usually decreased

Watery or purulent discharge

Significance: Abrasions, and other injuries; viral and bacterial infections

Acute close angle glaucoma findings + significance

Diffuse redness, often with a steamy cornea and marked circumcorneal flush.

Pain: Severe, aching, deep, severe photophobia

Decreased vision

Pupils dilated and fixed

Cornea Steamy, cloudy

Significance: EMERGENCY Acute increase in intraocular pressure constitutes an emergency (acute close angle glaucoma)

Normal Retina Findings

- four pairs of vessels with arteries smaller than veins

- clear boarder for optic disk

- retina pink-orange

- Macula two disc lengths towards the ears in Relation to Disc

Papilledema signs and significance

Swelling of the optic disc and anterior bulging of the physiologic cup suggest papilledema , which is optic nerve head swelling associated with increased intracranial pressure

EMERGENCY => increased ICP

Superficial Retinal Hemorrhages signs and significance

Small, linear, flame-shaped, red streaks in the fundi, shaped by the superficial bundles of nerve fibers that radiate from the optic disc in the pattern illustrated

Significance: severe hypertension, papilledema, and occlusion of the retinal vein, among other conditions.

Cotton-Wool Spots signs and significance

Cotton-wool spots are white or grayish, ovoid lesions caused by microinfarcts of the retinal nerve fiber layer.

Result from extruded axoplasm from retinal ganglion cells and are seen in conditions such as hypertension, diabetes, HIV, and other viruses.

Retinal Hemorrhages signs and significance

•Bleeding in the retina - can be superficial, preretinal, or deep

•Seen in sudden increases in intracranial pressure, severe hypertension, and diabetes

eyes red flags

Sudden Vision Loss (monocular or binocular)

Flashes and Floaters

"Curtain" or "Shadows" over vision

Eye Pain with Vision changes

Retinal Detachment S/sx

floaters in eye, flashes of light, blurred vision, "curtain or shadown" over vision or blindness in visual field of one eye

Normal Findings in tympanic membrane

slightly concave, translucent, shiny, and pearly gray in color.

Surface should be smooth

Cone of light:

•5:00 in R ear (this is an image of R ear)

•7:00 in L ear

Perforation of the Tympanic Membrane sign and significance

Perforations are holes in the eardrum caused by middle ear infections, strong blast forces (explosion, hit, etc)

Large perforations can result in earache, redness, inflammation, and hearing loss as infections can cause discharge to drain out through the perforated opening

Tympanosclerosis sign and significance

scarring process in the middle ear due to otitis media, which can result in conductive hearing loss. It is characterized by deposition of hyaline, calcium, and phosphate crystals in the tympanic membrane and middle ear

generally not clinically significant

Serous Effusion signs and significance

usually caused by viral upper respiratory infections (otitis media with serous effusion) or by sudden changes in atmospheric pressure as from flying or diving

Symptoms include fullness and popping sensations in the ear, mild conduction hearing loss, and, sometimes, pain.

Acute Otitis Media signs and significance

Symptoms include earache, fever, and hearing loss.

The tympanic membrane reddens, loses its landmarks, and bulges laterally, toward the examiner's eye.

The tympanic membrane appears bulging and erythematous, with a cloudy and opaque appearance.

The normal landmarks, such as the light reflex, are obscured, indicating possible fluid buildup behind the eardrum.

infection

Rinne Test Normal Findings

air conduction (AC) > bone conduction (BC)

Rinne Test Findings in conductive hearing loss

AC < BC

Rinne Test Findings in Sensorineural hearing loss

Normal: AC > BC

Webber test normal findings

sound should be heard equally in both ears

Webber conductive hearing loss findings

sound lateralizes to the impaired ear

Webber Sensorineural hearing loss findings

sound lateralizes to good ear

Sensorineural Hearing Loss S/Sx and Causes

Common in older adults

Rinne Test: AC > BC (normal)

Webber: lateralizes to good ear

Hallmark Sign: “I can hear people talking but I can’t understand them”

Causes: older age

Conductive Hearing Loss S/Sx and Causes

Common in kids

Rinne Test: AC ≤ BC

Webber: sound lateralizes to the impaired ear

Hallmark Signs:

“Everything is muffled”

Causes: cerumen impaction, otitis media, middle ear infection

acute rhinitis

nasal mucosa = red, smooth, moist, irritatedviral cold/infection

allergic rhinitis

pale nasal mucosa

an allergic reaction to airborne allergens that causes an increased flow of mucus

Nasal polyps

are pale saclike growths of inflamed mucosa that can obstruct the air passage or sinuses, seen in allergic rhinitis, aspirin sensitivity, asthma, chronic sinus infections, and cystic fibrosis.

Large Normal Tonsils causes

Normal tonsils may be large without being infected, especially in children. They may protrude medially beyond the pillars and even to the midline. Here they slightly obscure the pharynx. Their color is pink.

Strep Signs

This red throat has thick white exudates on the tonsils. 

This, together with fever and enlarged cervical nodes, increases the probability of group A streptococcal infection or infectious mononucleosis. 

Anterior cervical lymph nodes are usually enlarged in the former, posterior nodes in the latter.

Thrush on the Palate (Candidiasis) S/Sx + Causes

Thrush is a yeast infection from Candida species. 

appear as cream-colored or bluish-white pseudomembranous patches on the tongue, mouth, or pharynx.

Thick, white plaques are somewhat adherent to the underlying mucosa. 

Predisposing factors include prolonged treatment with antibiotics or corticosteroids and immunocompromised status.

Koplik Spots Significance + Appearance

Koplik spots are an early sign of measles (rubeola). 

Search for small white specks that resemble grains of salt on a red background. 

They usually appear on the buccal mucosa near the first and second molars. 

Leukoplakia appearance + significance

A thickened white patch (leukoplakia) may occur anywhere in the oral mucosa.

The extensive example shown on this buccal mucosa resulted from frequent chewing of tobacco, a local irritant.

This benign reactive process of the squamous epithelium may lead to cancer and should be biopsied.

Another risk factor is human papillomavirus infection.

Diphtheria S/Sx + Risk

Diphtheria, an acute infection caused by Corynebacterium diphtheriae, is now rare but still important. 

Prompt diagnosis may lead to life-saving treatment. 

The throat is dull red, and a gray exudate (pseudomembrane) is present on the uvula, pharynx, and tongue. 

The airway may become obstructed.

CN I + Test

Olfactory (S)

usually not tested

CN II + test

optic nerve (S)

Snellen & Direct + Consensual

CN III + Test

Oculomotor (M)

6 Cardinal Fields

CN IV test

Trochlear (motor)

6 Cardinal Fields (side-to-side)

CN V + Test

Trigeminal (S/M)

CN VI + test

Abducens

6 Cardinal Fields (down and in eye movement)

CN VII

facial nerve (M)

make different facial expressions