Advanced PA Exam 1

what are common concerning symptoms?

fatigue

weakness

fever

chills

night sweats

weight gain or loss

pain

what is one of the most common presenting symptoms in office practice?

pain

what are the most frequent causes of pain?

lower back pain

headache or migraine

knee pain

neck pain

what affects prevalence of pain?

ethnicity

socioeconomic status

what's included in the general survey?

physical appearance

body structure

mobility

behavior

what's included in general survey of physical appearance?

age

gender

LOC

skin color

facial features

what's included in general survey of body structure?

stature

nutrition

symmetry

posture

position

what's included in general survey of mobility?

gait

ROM

what's included in general survey of behavior?

facial expression

mood & affect

speech

dress

personal hygiene

what are the headache warning signs?

progressively frequent or severe over 3-month period

sudden onset like thunderclap or worst headache ever

new onset over age 50

aggravated or relieved by change in position

precipitated by Valsalva or exertion

recent head trama

change in pattern from past headaches

associated papilledema neck stiffness or focal neurological deficits

presence of cancer HIV or pregnancy

what are the 2 most important headache warning signs?

thunderclap

papilledema

what does a "thunderclap" headache usually mean?

subarachnoid hemorrhage

what is vertigo?

spinning sensation accompanied by nystagmus & ataxia

what does vertigo often reflect?

vestibular disease usually from peripheral causes in inner ear

what is diplopia?

double vision

what is dysarthria?

difficulty forming words

what is ataxia?

problems with gait or balance

what are suspicious for vertebrobasilar TIA or stroke?

ataxia

diplopia

dysarthria

vertrigo (investigate central cause)

where is trigeminal neuralgia located?

cheeks

jaws

lips

gums

how does trigeminal neuralgia present?

• abrupt onset

• sharp brief lightning like jabs

• transient but very severe

• pain comes and goes but is uncommon at night

what typically triggers trigeminal neuralgia?

touching certain areas of lower face or by chewing/ talking/ brushing teeth

what is giant cell arteritis?

chronic inflammation of cranial arteries often associated with polymyalgia

where is giant cell arteritis localized?

near involved artery but may become generalized

how does giant cell arteritis present?

• gradual or rapid onset of aching throbbing or burning

• often severe & has variable duration

• recurrent or persistent over weeks to months

• other s/sx

  • tenderness of adjacent scalp

  • fever, malaise, fatigue and anorexia

  • muscular aches, stiffness

  • visual loss of blindness

s/sx of giant cell arteritis

tenderness of adjacent scalp

fever malaise fatigue

anorexia

muscular aches & stiffness

visual loss or blindness

how does hair appear in hyperthyroidism?

fine

how does hair appear in hypothyroidism?

coarse

what is scalp psoriasis?

raised reddish or silver often scaly patches

what is a soft benign nevus?

benign hyperpigmented growth on scalp

how does herpes zoster of the scalp present?

bright red rash on base of scalp/top of neck

what are nits?

lice eggs adhering to hair

what is alopecia areata?

hair loss

what do you examine the face for?

symmetry

expression

abnormal movements or structures

what is cranial nerve VII?

facial movement

what is Bells' Palsy?

damage to facial nerve that causes paralysis

how does Bells' Palsy present?

• drooping on entire side of face with damaged nerve

  • both upper and lower portions of face

• eyes won’t close

• eyebrows cannot move

For a CVA, what side of the face is affected

Opposite

what is acromegaly?

abnormal growth of hands feet & face

(caused by overproduction of growth hormone by pituitary gland)

how does residual muscle weakness present?

drooping of just bottom side of face that is opposite injury

what is a main symptom of hyperthyroidism?

Exophthalmos

how does Parkinson's disease present in the face?

stare

decreased mobility

(Caused by loss of dopamine)

what is a common sign of Cushing's syndrome?

moon face

(Caused by excess adrenal cortisol)

what is myxedema?

Severe hypothyroidism (puffy face, hands, and feet)

what causes glaucoma?

increased intraocular pressure

You are examining a 55 yo male in your office who is complaining of a progressively worsening headache. He reports the pain being present for about a month. It is in the same location each time at the back of his head. He reports the pain as aching, it started as a 2/10 and has increased to a 6/10. He has experienced nausea and vomitting in the past few days. No light or sound sensitivity. He feels like it is worse when he sneezes or moves his head suddenly. He denies fever, chills, anorexia, weight change, recent injury or stiff neck.

Based on his history you are concerned his pain is related to:

A. Migraine

B. Cluster HA

C. Meningitis

D. Increased ICP

Increased ICP

You are assessing a 16 yo patient with head injuries from a recent motor vehicle accident. Which of the following statements indicates the most important reason for assessing for any drainage from the ear canal?

A. Bloody or clear watery drainage can indicate a basal skull fracture.

B. The drum has ruptured and there will be purulent drainage.

C. His auditory canal may be occluded from increased cerumen.

D. There may be an occlusion of the canal secondary to a foreign body from the accident.

Bloody or clear watery drainage can indicate a basal skull fracture

Mrs. J is a 38 yo female with a chief complaint "I've had bad headaches for 4 months." HPI: Began 4 months ago with a unilateral throbbing over right eye and temple, accompanied by photophobia and nausea. Since that time, the pain has recurred about 3x a month sometimes affecting the right eye/temple & other times the left. It occurs in the late morning or afternoon. Two aspirin provide minimal relief & she needs 3-4 hrs in a dark room to lie down. She has regular menstrual periods & the HA are not conscientious with any particular time in her cycle. Based on this info, which HA type is Mrs. J most likely to have?

A. TMJ dysfunction

B. Migraine

C. Sinus infection

D. Temporal arteritis

Migraine

Common or concerning symptoms to inquire about in the General Survey and vital signs include all of the following except:

A) Changes in weight

B) Fatigue and weakness

C) Cough

D) Fever and chills

Cough

what is the most common cause of ptosis?

damage to oculomotor nerve

what is a pinguecula?

harmless yellowish triangular nodule in bulbar conjunctiva on either side of iris

what is conjunctivitis?

inflammation of conjunctiva (pink eye)

what is cranial nerve V?

trigeminal nerve

subjective questions for eyes

vision difficulty

pain

strabismus

diplopia

redness

swelling

watering/discharge

past history of ocular problems

glaucoma

use of glasses/contacts

what is included in vision difficulty?

decreased acuity

blurring

blind spots (scotoma)

floaters

halos with glaucoma

Gradual or sudden vision loss: cataracts

gradual

Gradual or sudden vision loss: glaucoma

Gradual

Gradual or sudden vision loss:

optic nerve compression

Gradual

Gradual or sudden vision loss:

macular degeneration

Gradual

Gradual or sudden vision loss:

increased intraocular pressure

Gradual

Gradual or sudden vision loss:

cortical blindness

Gradual

Cortical blindness

• irreversible vision loss

• can result from stroke

Gradual or sudden vision loss:

presbyopia

Gradual

Gradual or sudden vision loss:

diplopia

Gradual

Gradual or sudden vision loss:

eye pain

Gradual

Gradual or sudden vision loss:

photophobia

Gradual

Gradual or sudden vision loss:

amaurosis fugax

Sudden

Gradual or sudden vision loss:

migraine headaches

Sudden

S/sx of migraines

• transient vision loss in one or both eyes

• HA

• tinnitus

• dizziness

• flashes of light

Gradual or sudden vision loss:

retinal detachment

Sudden

Gradual or sudden vision loss:

vitreous hemorrhage

Sudden

Gradual or sudden vision loss:

central retinal artery occlusion

Sudden

Gradual or sudden vision loss:

uveitis

Sudden

which ocular occurrences are medical emergencies?

• amaurosis fugax

• retinal detachment

• vitreous hemorrhage

• central retinal artery occlusion

what is a pterygium?

• triangular thickening of bulbar conjunctiva growing slowly across outer surface of cornea

• reddening may occur

• may interfere with vision

where does macular degeneration occur?

center of eye (macula)

what is hyperopia?

far-sightedness

what is a subconjunctival hemorrhage?

• sudden unilateral bright red eye that may cause elevated cornea resulting from blood vessel rupture

• red patch with sharp edges over the sclera, resulting from rupture

  of a blood vessel

• may be slight stinging in eye but should resolve without treatment

what is amaurosis fugax?

• monocular visual loss

• appears like curtains closing that lasts 5-15 minutes

what can cause amaurosis fugax?

• carotid stenosis

  • need to cardiac work up!!

• stroke

• retinal detachment

how does vision loss appear with migraines?

sudden transient loss

retinal detachment s/sx

• painless monocular blindness

• Sudden loss of vision

• Pt reports flashing lights, floaters, halos, and blurring — precedes vision loss

• Need intervention to preserve vision loss in that eye

what sudden vision loss cause always has ocular pain?

uveitis

what is uveitis?

• inflammation of uvea

• accompanied by ocular pain

• not an emergency but needs urgent follow-up

how do cataracts present?

• opacities in lens

  • can be peripheral or nuclear

• halos around lights, blurred vision

• vision is worse in bright lights

What is presbyopia?

inability to see things close up, common with old age

what is included in the physical exam of the eyes?

• assess visual acuity

• inspect lids lashes conjunctiva sclerae iris & cornea

• shape & size of pupils

• direct & consensual reflex

• extraocular movements

• accommodation (convergence)

• visual fields

• funduscopic

how do you assess visual acuity?

using snellen chart

what is legal blindness?

20/200 in best eye

what is myopia?

• eye is too long

• near-sightedness

what is the eye shape with hyperopia?

• too short

• far-sighted

what is astigmatism?

• abnormality with either cornea or lens

• Affects looking at near & far vision (objects in vision don't align)

How might the eyebrow present in hypothyrodism?

outer third may start to go away

what is ptosis?

drooping of eyelid below limbal margin

what are the causes of ptosis?

• congenital

• Myasthenia gravis

• damage to oculomotor nerve III

• Horner's syndrome

• herniated fat

what is cranial nerve III?

oculomotor

how does herniated fat cause ptosis?

pushes down on eyelid

what is entropion?

inward folding of lower eyelid (most common in pts 60+)

symptoms of entropion

• redness & pain around eye

• sensitivity to light & wind

• sagging skin around eye

• excessive tearing

• decreased vision (especially if cornea is damaged)

• discomfort (from eyelashes constantly rubbing against the cornea)

what is ectropion?

outward turning of lower eyelid (most common in age, can be repaired surgically)

causes of ectropion

• congenital

• aging

• scarring

• mechanical

• allergic

• facial nerve palsy