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seven attributes to a symptom
- Onset
- Precipitating factors
- Quality
- Radiation
- Severity
- Timing
- associated sx
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Foreign body in eye
Dx testing
tearing, visualization of foreign body, relief of pain after thorough irrigation with tarsal plates everted. Eyes should be everted during irrigation
Fluoresceinstain, examination with cobalt blue light, slit lamp exam
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Signs and symptoms of glaucoma
- Presents with eye pain, photophobia and halos, possibly headache.
- Cupping may be observed using ophthalmoscope. Cupping is a result of increased intraocular pressure.
- Asymmetry of the cup bilaterally also suggests glaucoma.
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Acute narrow angle glaucoma
DX:
Severe eye pain may indicate acute narrow-angle glaucoma. Increased intraocular pressure diminishes normal spatial relationship between the iris and cornea.Painful eye appears “steamy” and is usually unilateral.
DX: Crescent shadow indicates increased intraocular pressure (Exam by shining penlight on the iris laterally).
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Open angle glaucoma
Dx testing:
- Open angle glaucoma: more common
- Often asymptomatic.
- May cause decreased vision.
- DIAGNOSTIC TESTING: intraocular pressure.
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Corneal abrasion
Dx testing
- Eye pain (especially following known foreign body or injury), tearing, photophobia, corneal defect
- DIAGNOSTIC TESTING: Fluorescein stain (will be yellow-orange), examination with cobalt blue light, slit lamp exam
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Hyphema
- Eye pain and history of trauma
- Blood in the anterior chamber
- DIAGNOSTIC TESTING: Observation and referral to Ophthalmologist
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Herpetic Lesion
DX testing:
- Eye pain, herpetic rash on face may be present, no history of trauma.
- Vesicular rash seen in the distribution of the first division of CN V.
DX: Fluorescein stain, examination with cobalt blue light, ophthalmic or slit light exam. Epithelial dendrite stains green with fluorescent dye.
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Retinal detachment
absence of red reflex
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Viral conjunctivitis
Lid swelling, and conjunctival redness
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Bacterial conjunctivitis
Lid swelling, conjuctival redness, and discharge
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Near sighted
Test
myopia
Hand held card, hold 14 inches from patients eye
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Snellen eye chart
position patient 20 feet from chart
Patient should wear contacts or glasses
One eye at a time
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Check patient vision to make sure they have _______ cardinal directions of gaze
6
Normal conjugate movements
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nystagmus
eyes jerk back and forth
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lid lag
- eyes don't go in right direction
- Associated with thyroid disease
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Ophthalmoscope
- hold in right hand if going to view right eye.
- stand 15 inches away and start at an angle of 15 degrees and move in toward eye
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Extraoccular movements cranial nerves
- III, IV, VI
- occulomotor, trigeminal, abducens
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steps to performing fundoscopic exam
- observe red reflex bilaterally created by light illuminating retina- absent= detached retina
- inspect optic disc for shape and color
- MOve in four directions from the disc noting relative sizes and charateristics at arteriovenous crossings
- Inspect retinal background for hemorrhages, exudates, and lesions
- Inspect macula for color and surface by having patient focus directly on light.
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Allen chart
to check kids vision
begin these tests when children are 3
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Ped patient vision
2-3 months
8 months
9 months
6 years old
voluntary control eye muscles
distinguish between colors
can perceive single image
adult visual acuity at age 6
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presbyopia
decrease in power of accommodation with aging, is suggested when the person moves the card further away
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Auditory acuity
- test one ear at a time
- whisper test- stand 1-2 feet behind patient softly say nine-four, baseball
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Air bone conduction tests
x2
- weber- hold tuning fork on top of head. Lateralization of sound (tone should be heard equally in both ears), unilateral hearing loss.
- If not heard in both ears, indicates conductive hearing loss.
- Rinne- tuning fork behind ear, compare air/bone conduction. Place behind ear and have patient tell you when they can not hear it anymore, then move it one inch away from ear (without changing vibration) to check air conduction and ask again when they stop hearing it. Do this in both ears. Air conduction should be heard two times longer, if it is then it is positive which is normal. If negative it is conductive hearing loss.
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Fx of Eustachian tube
allows air into the middle ear to replace air absorbed by the mucous membrane lining by opening.
equalizes pressure changes
drains normal secretions or the middle ear, and allows secretions t ordain into the nasopharynx
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Vestibular system of ear
most important system, interprets motion and position of the head
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Three component of middle ear
Malleus (____), incus (_____), stapes (______).
hammer, anvil, stirrup
from a movable link that connects the tympanic membrane to the oval window.
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Primary ear pain
infection and inflammation of middle and external ear
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Secondary ear pain
referred to ear from other regions
- TMJ problems (temporal mandibular joint)
- lesions of tongue, cervical musculoskeletal problems, neuralgias.
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conductive hearing loss
poor transmission of sound waves through external and middle ear
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sensorineural
sound waves not conducted to cranial nerve
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If child has ear problems you may want to check _____ as well
kidneys
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Otitis media
- an infection or inflammation of the middle ear.
- These can be viral or bacterial infections.
- SX: Amber-yellow drum
- Air/fluid level with fine black dividing line or air bubbles visible behind drum
- Feeling of fullness, transient hearing loss, popping sound with swallowing
- Fluid in middle ear can become infected, resulting in redness and bulging, along with earache and fever.
- Then fiery red bulging drum.
- Red, bulging tympanic membrane that is intact with no visible landmarks or light reflex.
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Mastoiditis
- usually caused by a middle ear infection (acute otitis media).
- The infection may spread from the ear to the mastoid bone of the skull.
- The mastoid bone fills with infected materials and its honeycomb-like structure may deteriorate. Mastoiditis usually affects children.
- SX: Swelling behind ear, may cause ear to stick out, redness, Drainage, Pain, Fever, may be high, Headache, Hearing loss
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LEMON for assessing airway
- look
- evaluate 3-3-2 rule
- mallampati
- obstruction
- neck mobility
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Risk factors associated with oral cancer
- Risk is increased with family history.
- Use of Alcohol can predispose to oral cancer Tobacco is a carcinogen, use of oral tobacco products is related to increased risk of oral cancer.
- > 40 y/o,
- poor nutrition,
- immuno-suppressed.
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Viral pharyngitis
- Usually associated with non productive cough, rhinorrhea, conjunctivitis, systemic symptoms. More gradual onset and longer
- Sore throat less painful than bacterial infection
- No diagnostic tests
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bacterial pharyngitis
- Occur abruptly
- Usually accompanied by fever > 101.
- Very sore and may interfere with swallowing. Erythema of the pharynx or tonsils with white to yellow exudates.
- If gargles or OTC pain relievers helps, may indicate possible infection.
- Test: Culture and sensitivity, quick beta strep.
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allergic pharyngitis
- Associated with scratchy, irritated, itchy Irritation related to postnasal drip, congestion, boggy nasal turbinates.
- Occur seasonally (seasonal allergies) or as a result to environmental allergen.
- No diagnostic tests.
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These nodes, both superficial and deep, lie above and beneath the sternocleidomastoid muscles. They drain the internal structures of the throat as well as part of the posterior pharynx, tonsils, and thyroid gland.
anterior
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These nodes extend in a line posterior to the sternocleidomastoids but in front of the trapezius, from the level of the Mastoid portion of the temporal bone to the clavicle. They are frequently enlarged during upper respiratory infections.
posterior
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§ These nodes are located just below the angle of the mandible. They drain the tonsillar and posterior pharyngeal regions.
tonsillar
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§ These nodes run along the underside of the jaw on either side. They drain the structures in the floor of the mouth.
sub mandibular
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These nodes are just below the chin. They drain the teeth and intra-oral cavity
submental
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§ These nodes are in the hollow above the clavicle, just lateral to where it joins the sternum. They drain a part of the thoracic cavity and abdomen. Virchow's node is a left supraclavicular lymph node which receives the lymph drainage from most of the body (especially the abdomen) via the thoracic duct and is thus an early site of metastasis for various malignancies.
supraclavicular
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Parotid glands
- Located in the cheek area below and in front of the ear
- Secrete saliva via Stensen’s ducts.
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submandibular glands
- Located in the floor of the oral cavity
- Secrete saliva into the mouth via Wharton’s ducts
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sublingual glands
Found under the tongue
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Common site for aspiration
right main bronchus
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pores of Kohn
pores of connective tissue that hold 2 alveoli together
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visceral pleura
covers the surface of the lungs and the fissures between the lungs
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parietal pleura
attached to the thoracic cavity, lines the inner rib cage and the upper surface of the diaphragm.
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COPD alone should not cause clubbing, patient needs ....
work up to see if there is another cause
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surface air filled
resonance
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surface fluid/tissue filled
dullness
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emphysema percussion sound
hyper-resonance- because of hyperinflation
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Breath sounds in pleural effusion
absent
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Heard over healthy lung tissue
Low in pitch and intensity
vesicular
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Heard over major bronchi; abnormal if heard over peripheral lung base
Moderate in pitch and intensity
bronchiovesicular
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bronchial lung sounds
- Heard over trachea;
- abnormal if over peripheral lung base
- High pitch and intensity
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crackles
- Caused by air flowing by fluid.
- Heard more often during inspiration.
- Crackles are fine, high or low pitched, short in duration, coarse, and last a few milliseconds
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rales
are scratchy sounds that occur in association with processes that cause fluid to accumulate within the alveolar and interstitial spaces. The sound is similar to that produced by rubbing strands of hair together close to your ear. Pulmonary edema is the most common causeWill not disappear after coughing
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Caused by inflammation of the pleural or pericardial tissue (pericarditis or pleurisy). Occurs most commonly outside the airways and are dry, crackling, rubbing, low pitched sounds that are heard in both inhalation and exhalation. Will disappear when breath is held.
friction rub
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egophony
have patient say eee if it sounds like aaa
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tachypnea
greater than 25 breaths per minute
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kussmaul
associated with metabolic acidosis, breathing rapid, shallow, as acidosis becomes worse and labored
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cheyne stokes
periods of apnea, deep fast then apnea, very irregular
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sigh
- abnormal
- neurological-hard to tx
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biot
- caused by brain damage to medulla
- associated with strokes, trauma, fast and irregular
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bronchitis
Cough, fever, muscle aches, nasal congestion, sore throat, sputum production. Normal breath sounds or diffuse crackles, injected pharynx, mild dyspnea
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lobar pnemonia
Cough, fever, pleuritic chest pain. Flushed appearance; confusion; crackles over the affected lung, rhonchi, increased breath sounds; dullness on percussion over the affected lung, increased tactile fremitus, broncophony, egonphony, grunting, nasal flaring, tachypnea, productive cough.
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asthma
Hyperresonance or dullness on percussion, barrel chest (when chronic), audible wheeze. Possible use of accessory muscles for breathing. Cyanosis, apprehension, retraction of intercostals spaces, expiration labored and prolonged
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pleural effusion
Absent tactile fremitus, dullness on percussion, breath sounds absent
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cardiac chest pain
- Chest pain of an MI may have radiation down the arm or in the neck.
- Chest pain associated with MI is sudden onset.
- SOB associated with cardiac may also present with N/V
- Dry cough can be due to ACE inhibitor.
- PND (paroxysmal nocturnal dyspnea)§ Sudden onset of SOB after a period of sleep. Seen often in pts with CHF or pulmonary HTN.
- Ankle edema suggests cardiac cause; CHF.
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Cardiac chest pain is not associated with
inspiration
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signs of DVT
Tenderness and warmth over the deep calf veins, swelling with minimal ankle edema, and unexplained fever. Diagnosed with Doppler flow studies.
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ØPeriumbilical or epigastric pain. Starts colicky, then localizes to RLQ.ØPain precedes vomiting by a few hours
appendicitis
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ØSevere epigastric or RUQ pain that is referred to the shoulder.
cholecystitis
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ØEpigastric pain that radiates to the left side of the abdomen, especially after eating.
diverticulitis
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ØSevere, abrupt, spasm-like pain that is referred to the umbilicus and epigastrium. Described as “gripping”.ØBiliary vomitus first, then followed by fecal-smelling fluid
bowel obstruction
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Murphys sign
Palpate below the right costal margin. Ask patient to take a deep breath. · Positive if patient stops breathing mid inspiration because of pain. Acute cholecystitis, hepatitis, hepatomegaly
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McBurneys sign
Rebound tenderness present in the RLQ.· Appendicitis
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Obturator sign
- rotate the patients leg internally and externally
- checks for appendicitis, and pelvic inflammation
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Psoa sign
pull pt knee up toward abdomen if hurts it is positive
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Rovsings sign
Pushing on pt left quadrant increases pain in right quad. This could indicate appendicitis
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What condition causes exophthalmos
hyperthyroidism- bulging of eyes
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Cushing syndrome
- excess production of cortisol (glucocorticoid)
- -central body obesity, glucose intolerance, hypertension, excess hair growth, osteoporosis, kidney stones, menstrual irregularity, and emotional liability,
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Acromegaly
- pituitary gland produces too much growth hormone during adulthood.
- Bones increase in size, including hands feet and face.
- usually effects middle age
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hypothyroidism
dry hair, thin eyebrows, periorbital edema, puffy face with dry skin.
Fatigue, tired, weight gain
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Hyperthyroidism
nervous, palpitations, weight loss,
If elderly has arrhythmia check TSH level
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Low TSH levels
<0.001
hyperthyroidism
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high TSH levels
4-5
hypothyroidism
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The closer to 1 the TSH is
the better the pt feels
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