Advanced Phs Asses 1

• 1. Mitral and tricuspid - closed
• 2. Aortic and Pulmonic - open

Valve Closure

1. Closure of AV valves

1. Caused by AV valve closure

2. Systole

3. the Apex (mitral); "lub"

1. Aortic and Pulomonic Valve closure

2. Diastole

3. base (Aortic) "dub"

• Aoritic (Base)-2nd ICS on R Sternal Borde
• Pulmonic-2nd ICS on L Sternal Border
• Erbs Point-3rd ICS on L Sternal Border
• Tricuspid - 4th ICS on Sternal Border
• Mitral(Apex)- 5th ICS on L Mid clavicular line

Early Diastole

Due to decreased elasticity from overfilling of ventricle - associated with CHF. "Ketucky"

Late Diastole

Due to stiff ventricles, HTN, CAD, LVH

Sounds like "Tenessee"

L ICS MCL

Closed Valves - Regurgitation

Open valves

• Systole - Mitral Regurg
• Tricuspid Regurg

• Aortic Stenosis
• Pulmonic Stenosis

• Diastoley Mitral Stenosis
• Tricuspid Stenosis

• Aortic Regurg
• Pulmonic Regurg

What age was your father at his time of death?

Vellus - downy body hair

Terminal - scalp hair

fatigue

Left Ventricular Hypertrophy

S2 - Valve closure of Aortic and pulmonic

• a. Grade I Moderately loud
• b. Grade II- soft, readily detected
• c. Grade III
• c. Grade IV- loud and usually palpable
• d. Grade V- very loud
• e. Grade VI- heard w/o stethoscope

Aching, cramping, and possibly numbness or severe fatigue that appear with walking and disappear promptly with rest typify intermittent claudication.

Loss of hair over extremity; cool, shiny skin; pallor or cyanosis; thickened nails; pulses weak or absent; numb/cool temp; ulcers distal

• G=# of pregnancies
• P = Outcomes
• b = # of term
• c = # of preterm
• d = Aborted
• e = Full term

• Primary prevention: focuses on preventing or slowing the onset of disease
• Examples include: counseling and education, immunizations, use of safety measures

Secondary prevention: involves risk assessment and risk reduction for chronic diseases

All screening tests smoking cessation to reduce risk.

Slowing or halting diseases that are already in progress.

• Graded:
• A - High certainty benefit
• B- Moderat certainty benefit
• C- Recommends AGAINST ROUTINE serv., benfit is small
• D- Recommends AGAINST Serv. Risks outweigh
• I - Insufficient evidence to determine

Sensitivity: The proportion of persons with a condition who correctly test positive when screened

Poor sensitivity will miss many cases

False-negative results

Specificity: the proportion of persons without the condition who correctly test negative when screened

Poor specificity incorrectly labels persons as having condition

False-positive

Cut down, Annoyance, guilt, eye-opener

One study found 75% sensitivity and 96% specificity

Normal <120 <80

Pre-HTN 120-139 80-89

Stage I 140-159 90-99

Stage II >160 >100

Start Pap smearing testing 3 years after onset of sexual activity or age 21(USPTF).

4 ng /ml

Epidermis: Most superficial layer, thin, no blood vessels.

Dermis: Well supplied with blood. Contains connective tissue, the sebaceous glands, and some of the hair follicles.

Subcutaeous tissues: Fat and sweat glands, and remaining hair follicles.

Macule: Flat, change in skin color. It is < 1 cm. (freckle)

Patch: Larger than macule. >1 cm. (Vitiligo)

Papule: Firm, raised, up to 1 cm (raised nevus)

Plaque: Flat, elevated surface, > 1 cm. (coalescence of papules)

Nodule: >0.5 cm. Often deeper and firmer than papule.

Tumor: Larger 1-2 cm. A large nodule.

Wheal: Transient, irregular, superficial area of localized skin edema. (hive, mosquito bite)

Vesicle: Up to 1 cm. Filled with serous fluid.

Bulla: 1 cm or greater. Filled with serous fluid.

Pustule: Filled with pus. (Acne, impetigo).

Loss of the epidermis

Lichenification: Thickening and roughening of the skin with increased visibility of the normal furrows, can be caused by scratching.(atopic dermatitis)

Atrophy: Thinning of the skin with loss of furrows. Skin appears shiner and translucent. (arterial insufficiency)

Eschar: Crust and necrosis.

Keloid: Raised, firm, thickened red scar that may grow for a prolonged period of time.

Spider angioma: Very small to 2 cm. Central body surrounded by radiating legs. Face, neck, arms, and upper trunk. (Liver disease, Vit. B def., pregnancy)

Cherry angioma: 1-3 mm, round, flat or sometimes raised. No clinical significance.

Spider vein: Blue in color, size varies. Legs and anterior chest. Accompanies increased pressure on superficial veins.

Petechia: 1-3 mm, emboli to skin

Purpura: Larger than petechia, blood outside the vessels.

Telangiectasias: Chronic dilated small vessels, blanch minimally.

Comedo:(closed) The common blackhead. (open) Whitehead

Symptoms that can be associated with multiple systems such as fever, chills, malaise, weightloss.

1. Meibomian gland: glands that provide oils to the tear film

2. Chalazion - usually painless and points inside not on the margin of the lid.

Entropion: inverted eyelashes

Ectropion: everted eyelashes

Acute Hordeolum (STY) usually painful, looks like a pimple on the margin of the eye lid.

Blepharitis is an inflamation of the eyelids along the lid margins often with crusting or scales.

Dacryocystitis - inflammation of lacrimal sac.

Conjunctiva

Bulbar: covers most of anterior eyeball

Palprebral: lines the eyelids

Pterygium - triangular thickening of the bulbar conjuntiva that grows slowly on the outer surface of the cornea - usually from the nasal side. May interfere with vision as it approaches the pupil.

Pinguecula - A yellowish, somewhat triangular nodule in the bulbar conjuctiva on either side of the iris. Harmless accumulation of protein.

• 20/20
• top #-patient distance from chart;

bottom #-distance at which normal eye can read

A cataract is an opacity of the lens seen through the pupil.

Accommodation:

Convergence of the eyes with constriction of the pupil when focused on a near object.

Dilation of the pupil when looking at a far object.

Direct: pupillary constriction in the same eye

Consensual: pupillary constriction in the opposite eye

Weber test - Strike tuning fork and place on top of head /forehead

Abnormal: “Positive Lateralization” > vibration in one ear over the other.

Conductive hearing loss- lateralization to “impaired” ear

Sensorineural loss- lateralization to “good” ear

Rinne test

Place vibrating tuning fork on mastoid

• Normal :AC>BC
• Conductive loss- sound through bone is as long or longer than through air. (BC=AC or BC>AC)

Sensorineural loss- sound is heard longer through air (AC>BC) (normal pattern prevails because the vibrations reach the cochlea)

Glaucoma

Cone of light (Right: 5 o’clock Left: 7o’clock)

Umbo

Nervousness, weightloss with increased apetit, sweating and heat intolerence.

Hypertension, tachycardia, AFIB, warm moist skin.

Associatedwith GRAVES disease

Fatigue, lethargy, modest weigt gain with anorexia.

Dry course skin, cold intolerance. Hypotension, bradycardia, hypothermia

Grading Scale

• Tonsil 0: Tonsils fit within tonsillar fossa
• Tonsil 1+: Tonsils <25% of space between pillars
• Tonsil 2+: Tonsils <50% of space between pillars
• Tonsil 3+: Tonsils <75% of space between pillars
• Tonsil 4+: Tonsils >75% of space between pillars

• 1. inspection
• 2. palpation
• 3. percussion
• 4. auscultation from the anterior, lateral and posterior approaches