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Chapter 1

Basic and Advanced Interviewing Techniques
Basic maximize patient's comfort, avoid unnecessary changes in position, enhance
clinical efficiency, move head to toe, examine the patient from their right side
Active listening, empathic responses, guided questioning, nonverbal communication, validation,
reassurance, partnering, summarization, transitions, empowering the patient
Active Listening- closely attending to what the patient is communicating, connecting to the
patient’s emotional state and using verbal and nonverbal skills to encourage the patient to
expand on his or her feelings and concerns
...

Guided Questioning- show your sustained interest in the patient’s feelings and deepest
disclosures and allows the interviewer to facilitate full communication, in the patient’s own
words, without interruption
...

Validation- helps to affirm the legitimacy of the patient’s emotional experience
...

Partnering- building rapport with patients, express your commitment to an ongoing relationship
...

Transitions- inform your patient when you are changing directions during the interview
...

Advanced: Determine scope of assessment: Focused vs
...

Includes all the elements of the health history and complete physical examination
...

●
Is appropriate for new patients in the office or hospital
●
Provides fundamental and personalized knowledge about the
patient
●
Strengthens the clinician–patient relationship
●
Helps identify or rule out physical causes related to patient
concerns
●
Provides a baseline for future assessments

●
Creates a platform for health promotion through education
and counseling
●
Develops proficiency in the essential skills of physical
examination
Flexible Focused or problem-oriented assessment: For patients you know well returning for
routine care, or those with specific ―urgent care‖ concerns like sore throat or knee pain
...

● Is appropriate for established patients, especially during
routine or urgent care visits
● Addresses focused concerns or symptoms
● Assesses symptoms restricted to a specific body system
● Applies examination methods relevant to assessing the
concern or problem as thoroughly and carefully as possible
Tangential lighting: JVD, thyroid gland, and apical impulse of heart
...
Can be: a family member or friend, letter of referral, or clinical
record
...

Chief Complaint
Chief Complaint- Make every attempt to quote the patient’s own words
...
A list of potential causes for
the patients problems
...


-Each symptom needs its own paragraph and a full description
...
Home remedies, nonprescriptions drugs, vitamins, minerals or herbal supplements, oral contraceptives, or borrowed
medications
...
If someone has quit, note for how long
-Alcohol and drug use should always be investigated and is often pertinent to the Presenting
Illness
...
Also include any chronic childhood illness
-Adult illnesses: Provide information in each of the 4 areas:
● Medical: diabetes, hypertension, hepatitis, asthma and HIV;
hospitalizations; number and gender of sexual partners; and risk
taking sexual practices
...

●
Psychiatric: Illness and time frame, diagnoses,
hospitalizations, and treatments
...

Review Tb tests, pap smears, mammograms, stool tests for occult blood, colonoscopy,
cholesterol levels etc
...

Ask about history of breast, ovarian, colon, or prostate cancer
Ask about Genetically transmitted diseases
Personal or social history
Describes educational level, occupation, family of origin, current household, personal interests,
and lifestyle

Capture the patients personality and interests, sources of support, coping style, strengths, and
concerns
Includes lifestyle habits that promote health or create risk, such as exercise and diet, safety
measures, sexual practices, and use of alcohol, drugs, and tobacco
Expanded personal and social history personalizes your relationship with the patient and builds
a rapport
Review of systems pg 11-13
Documents presence or absence of common symptoms related to each of the major body
systems
Understanding and using Review of Systems questions may seem challenging at first
...
Think about asking a series of
questions going from ―head to toe
...
‖
Most Review of Systems questions pertain to symptoms, but on occasion, some clinicians
include diseases like pneumonia or tuberculosis
...

For example, after a full description of chest pain, you may ask, ―Do you have any history of
high blood pressure
...
shortness of breath
...
Significant health events, such as past
surgery, hospitalization for a major prior illness, or a parent’s death, require full exploration
...

Remember that major health events discovered during the Review of Systems should be moved
to the Present Illness Past History in your write-up
...
If the patient has only a few symptoms, this
combination can be efficient
...
12-13 ROS Chart Copied from online book
General: Usual weight, recent weight change, clothing that fits more tightly or loosely than before;
weakness, fatigue, or fever
...


Head, Eyes, Ears, Nose, Throat (HEENT): Head: Headache, head injury, dizziness,
lightheadedness
...

Ears: Hearing, tinnitus, vertigo, earaches, infection, discharge
...
Nose and sinuses: Frequent colds, nasal stuffiness, discharge, or

itching, hay fever, nosebleeds, sinus trouble
...

Neck: ―Swollen glands,‖ goiter, lumps, pain, or stiffness in the neck
...

Respiratory: Cough, sputum (color, quantity; presence of blood or hemoptysis), shortness of
breath (dyspnea), wheezing, pain with a deep breath (pleuritic pain), last chest x-ray
...

Cardiovascular: ―Heart Trouble‖; high blood pressure; rheumatic fever; heart murmurs; chest
pain or discomfort; palpitations; shortness of breath; need to use pillows at night to ease
breathing (orthopnea breathing (paroxysmal nocturnal dyspnea); swelling in the hands, ankles,
or feet (edema); results of past electrocardiograms or other cardiovascular tests
...
Bowel move-ments, stool
color and size, change in bowel habits, pain with defecation, rectal bleeding or black or tarry
stools, hemorrhoids, constipation, diarrhea
...
Jaundice, liver, or gallbladder trouble; hepatitis
...
Urinary: Frequency of urination,
polyuria, nocturia, urgency, burning or pain during urination, blood in the urine (hematuria),
urinary infections, kidney or flank pain, kidney stones, ureteral colic, suprapubic pain,
incontinence; in males, reduced caliber or force of the urinary stream, hesitancy, dribbling
...
Sexual habits,
interest, function, satisfaction, birth control methods, condom use, and problems
...

Female: Age at menarche, regularity, frequency, and duration of periods, amount of bleeding;
bleeding between periods or after intercourse, last menstrual period, dysmenorrhea,
premenstrual tension
...
If
the patient was born before 1971, exposure to diethylstilbestrol (DES) from maternal use during
pregnancy (linked to cervical carcinoma)
...
Number of pregnancies, number and type of deliveries,
number of abortions (spontaneous and induced), complications of pregnancy, birth-control
methods
...
Concerns about HIV infection
...
If present, describe the
location of affected joints or muscles, any swelling, redness, pain, tenderness, stiffness,
weakness, or limitation of motion or activity; include timing of symptoms (e
...
, morning or
evening), duration, and any history of trauma
...
Joint pain with systemic
symptoms such as fever, chills, rash, anorexia, weight loss, or weakness
...
Past counseling, psycho-therapy, or psychiatric admissions
...


Subjective vs Objective Data
Subjective- symptoms or what the patient tells you
...
Cannot be directly observed
and can be discovered only asking questions
...

Objective- signs or what you observe
...
Examples: blood pressure,
heart rate, wound appearance, lung sounds, ambulation description
...

-think order and readability, amount of detail
...
The FNP should draw on a full range of knowledge
and experience, and read widely
...
By consulting the clinical literature, you are embarking on evidence-based
decision making and clinical practice
...

2
...

4
...


Select the most specific and critical findings to support your hypothesis
Match findings against all the conditions that can produce them
...

Weigh the competing possibilities and select the most likely diagnosis
Give special attention to potentially life-threatening conditions

Once the hypothesis is made it should be tested, this may include further history taking, testing or
physical examination
...
The final step is developing a plan
...
It is important to discuss your assessment with the patient prior to
finalizing the plan to ensure the patient is onboard
...
The main critical thinking skills in which nursing students should
be exercised during their studies are critical analysis, introductory and concluding justification,
valid conclusion, distinguish between facts and opinions, evaluation the credibility of information
sources, clarification of concepts and recognition of conditions
...
The nursing education programs
should adopt attitudes that promote critical thinking and mobilize the skills of critical reasoning
...
In nursing, critical thinking for clinical decision-making is the ability to think in a
systematic and logical manner with openness to question and reflect on the reasoning process
used to ensure safe nursing practice and quality care
...

Differential Diagnoses (obtained from book and week 1 review) - A list with potential causes of
patient specific problem/CC
-A chief complaint must be identified first
...

-The differential diagnosis list should begin with the most likely explanation or etiology for the
problem/CC
...
Peptic ulcer 2
...
Acute hemorrhagic gastritis
-Differential diagnostic procedures are used by clinicians to diagnose the specific disease in a
patient, or, at least, to eliminate any imminently life-threatening conditions
...


-The differential diagnosis includes all of the medical diseases that may possibly explain the
patient’s chief complaint or principal problem
-A differential diagnosis list is focused on providing an explanation for a specific complaint
...
Each differential diagnosis should offer an explanation or etiology for the same chief
complaint
...
Common Classified: congenital, inflammatory or infectious,
immunologic, neoplastic, metabolic, nutritional, degenerative, vascular, traumatic, and toxic
...


Problem List
-After you complete the clinical record, it is good clinical practice to generate a
problem list that summarizes the patient’s problems that can be placed in the
front of the office or hospital chart
...

- Helps to individualize the patient’s care
...

-An accurate Problem List allows better population management of patients, by
using EHRs to track patients with specific problems, recall patients who are
behind on appointments, and follow up on specific issues
...

For example, in a patient who is vomiting blood and is known to have migraines and to be
diabetic, the problem list might read:
1
...

3
...

5
...
Prioritize which complaints/problems are highest priority (urgent) for this visit
...
e
...
Patient-centered
interviews recognize the importance of patients' expressions of personal concerns, feelings, and
emotions and evoke the personal context of the patient's symptoms and disease
Sensitivity- true positive
...

Specificity- True negative
...

Kappa score- reproductivity
...

Precision-reproductivity
...


Logical Sequence pg 73
In general, an interview moves through several stages
...
As a student, you will concentrate primarily on eliciting the patient’s story and
creating a shared understanding of the patient’s concerns
...
Whether the interview
is comprehensive or focused, pay close attention to the patient’s feelings and affect, always working on
strengthening the relationship as you move through the typical sequence that follows
...

1
...

The initial moments of your encounter lay the foundation for your ongoing relationship
...

Use a formal title to address the patient
...
Don’t be afraid to clarify how to pronounce a patient’s name
...
Whenever visitors
are present, YOU ARE OBLIGATED TO MAINTAIN THE PATIENT'S CONFIDENTIALITY
...
ALWAYS BE ATTUNED TO THE PATIENT'S
COMFORT
...
Give
the patient your undivided attention
...


Taking Note

As a novice, you may need to write down much of what you learn during the interview
...
Jot down short phrases, specific dates,
or words, but do not let note taking or the laptop screen distract you from the patient
...
If the patient is talking about disturbing material, put your pen down and look away from the
computer
...

Look up from the computer as often as possible, readjusting your position as needed
...

Establishing the Agenda=chief complaint
Once you have established rapport, you are ready to pursue the patient’s reason for seeking care,
traditionally called the chief complaint
...
One benefit to this phrase is that
it does not characterize the patient as a complainer
...
Note that the first problem the patient mentions may
not be the one that is most important
...
For some visits, patients do not have a specific concern and only ―want a check-up‖
...
Using questions such as, ―Is there anything else?‖, ―Have we got
everything?‖, or ―Is there anything we missed?‖, can help to uncover the patient’s full agenda and ―the
real reason‖ for the visit
...
Even
negotiating the agenda at the outset doesn’t avert ―oh by the way‖ concerns that suddenly emerge at the
end of the visit
...

Inviting the Patient’s story
Once you have prioritized the agenda, invite the patient’s story by asking about the foremost concern,
―Tell me more about
...
Avoid biasing the patient’s story—do not inject new information or interrupt
...
‖ Train yourself to follow the patient’s leads
...
Studies show that
clinicians wait only 18 seconds before they interrupt
...
After the patient’s initial description, explore the patient’s story in more depth
...

5
...
Disease is the explanation that the clinician uses to organize the symptoms that
leads to a clinical diagnosis
...

FIFE
The Patient’s Feelings, including fears or concerns, about the problem
The patients Ideas about the nature and cause of the problem
The effect of the problem on the patients’ life and Function
The patient’s Expectations of the disease, of the clinician, or of health care, often based on prior personal
or family experiences
...

Identifying and Responding to the Patient’s emotional Cues
...
Visits tend to be longer when clinicians miss emotional clues
...
g
...
A mnemonic for responding to emotional cues is NURSE: Name- ―that
sounds like a scary experience for you‖; Understand or legitimize- ―It’s understandable that you feel that
way‖; Respect- ―you’ve done better than most people would with this‖; Support- ―I will continue to work
with you on this‖; and Explore- ―How else were you feeling about it‖
...
Generating and Testing Diagnostic Hypotheses
As you gain experience listening to patient concerns, you will deepen your skills of clinical reasoning
...

Identifying all the features of each symptom is fundamental to recognizing patterns of disease and to
generate the differential diagnosis
...
This avoids the
common trap of premature closure, or shutting down the patient’s story too quickly, which can lead to
errors in diagnosis
...

Questions about clusters of symptoms in common clinical entities are also found in ―The Health History‖
section of each of the regional physical examination chapters
...
The challenge is to avoid a clinician- centered
agenda, letting focused questions take over that obscure the patient’s perspective and limit your
opportunity to create an empathic therapeutic connection
...

Sharing the treatment plan
Learning about the disease and conceptualizing the illness allow you and the patient to create a shared
picture of the patient’s problems
...
g
...

Shared decision-making has been called the pinnacle of patient-centered care
...

10
...


Many of your patient visits will close with a discussion of behavior changes needed to optimize health or
treat illness
...
38 Advanced techniques
such as motivational interviewing and the therapeutic use of the clinician–patient relationship are beyond
the scope of this book
...
39 Motivational interviewing helps patients ―to say why and how they might
change, and is based on the use of a guiding style‖ of inter- viewing, rather than direct advice
...
40 Motivational interviewing makes the
assumption that many patients already know what is best for them and helps them con- front their
ambivalence to change
...

The Guide Style of Motivational Interviewing: 1
...
2
...
3
...

11
...

You may find that ending the health history interview, and later concluding the visit, are difficult
...
Let the patient know that the end of the interview or the visit is approaching to allow time
for any final questions
...
For
example, before gathering your papers or standing to leave the room, you can say, ―We need to stop now
...
A useful technique to assess the patient’s understanding
is to ―teach back,‖ whereby you invite the patient to tell you, in his or her own words, the plan of care
...
If this happens and the concern is not life threatening, simply assure the patient of
your interest and make plans to address the problem at a future time
...

Why don’t you make an appointment for next week so we can dis- cuss it?‖ Reaffirming your ongoing
commitment to the patient’s health shows your involvement and esteem
...
Taking Time for Self-Reflection The role of self-reflection, or mindfulness, in developing clinical
empathy cannot be overemphasized
...
‖44 As you encounter people
of diverse ages, gender identities, social class, race, and ethnicity, being consistently respectful and open
to individual differences is an ongoing challenge of clinical care
...
Self-reflection is a continual part of professional
development in clinical work
...
This
personal awareness is one of the most rewarding aspects of patient care
...
Location 2
...
Quantity or severity 4
...
The setting in which it occurs 6
...
Associated manifestations

Adaptive Questioning
Guided Questioning: 1
...
Using questioning that
elicits a graded response 3
...
Offering multiple choices for answers 5
...
Encouraging with
continuers 7
...
Reflect on your approach to the patient: When greeting the patient identify
yourself as a student, beginners spend more time in certain areas and that is ok but

just warn the patient that you may want to listen to their heart a little longer but that
does not mean anything is wrong
■ Avoid interpreting your findings, you are not the patients primary care
provider
■ Avoid negative reactions or showing distaste when finding abnormalities
○
2
...
Check your equipment: The following equipment is needed:
■
An ophthalmoscope and an otoscope
...

■
●A flashlight or penlight
■
● Tongue depressors
■
A ruler and a flexible tape measure, preferably marked in centimeters
■
●Often a thermometer
■
●A watch with a second hand
■
●A sphygmomanometer
■
●A stethoscope with the following characteristics:
■
●Ear tips that fit snugly and painlessly
...

■
●Thick-walled tubing as short as feasible to maximize the
transmission of sound: ∼30 cm (12 inches), if possible, and no longer than 38
cm (15 inches)
■
●A bell and a diaphragm with a good changeover mechanism
■
●A visual acuity card
■
●A reflex hammer
■
●Tuning forks, both 128 Hz and 51
■
Cotton swabs, safety pins, or other disposable objects for testing
sensation and two-point discrimination
■
●Cotton for testing the sense of light touch
■
●Two test tubes (optional) for testing temperature sensation
■
●Gloves and lubricant for oral, vaginal, and rectal examinations
■
● Vaginal specula and equipment for cytologic and bacteriologic
studies
■
●Paper and pen or pencil, or desktop or laptop computer
○
4
...
Show sensitivity to privacy and patient
modesty; this conveys respect for the patients vulnerability
○
5
...

○
6
...
123: Blood pressure, heart rate, RR, and temperature

Begin by measuring the blood pressure and heart rate
...
Count respirations at this time to avoid the patient becoming
alerted=change in pattern
...

Gold Standard: Ambulatory blood pressure monitoring: automated
...
Shows nocturnal blood pressure ―dips‖ (normal) or stays elevated
(Cardiovascular disease risk factor)
...

Types of hypertension:
1
...
Masked hypertension office blood pressure <140/90, but
elevated daytime blood pressure >135/85
...
Nocturnal hypertension- ―dipping occurs‖ in most
patients at night as they shift from wakefulness to sleep
...
Cuff too large= readings LOW
Brachial Artery: brachial artery below heart= BP readings HIGHER
...

Definitions of Hypertension
● Make sure patients understand all the steps needed to ensure accurate readings at home, as
detailed in this section
...
The patient should avoid smoking, caffeine, or exercise for 30 minutes prior to measurement
...
The examining room should be quiet and comfortably warm
...
The patient should sit quietly
for 5 minutes in a chair with feet on the floor, rather than on the examining table
...
The arm
selected should be free of clothing, fistulas for dialysis, scars from brachial artery cutdowns, or
lymphedema from axillary node dissection or radiation therapy
...
Palpate the brachial artery to
confirm a viable pulse and position the arm so that the brachial artery, at the antecubital crease,
is at heart level—roughly level with the fourth interspace at its junction with the sternum
...
If the
patient is seated, rest the arm on a table a little above the patient’s waist; if standing, try to
support the patient’s arm at the mid-chest level

Estimate the Systolic Pressure and Add 30 mm Hg : To decide how high to raise the cuff
pressure, first estimate the systolic pressure by palpation
...
Read this
pressure on the manometer and add 30 mm Hg
...
It also avoids the occasional error
caused by an auscultatory gap—a silent interval that may be present between the systolic and
diastolic pressures (Fig
...
Deflate the cuff promptly and completely and wait for 15 to 30
second
Identify the Systolic Blood Pressure Inflate the cuff again rapidly to the target level, and then
deflate the cuff slowly at a rate of about 2 to 3 mm Hg per second
...

Identify the Diastolic Blood Pressure Continue to deflate the cuff slowly until the sounds become
muffled and disappear
...
Then deflate the cuff rapidly to zero
...
Wait 2 or more minutes and repeat
...
If the first two readings differ by
more than 5 mm Hg, take additional readings
...
Avoid slow or repetitive inflations of the cuff because the resulting
venous congestion can cause false readings
Measure Blood Pressure in Both Arms At Least Once
...
Subsequent readings should be made
on the arm with the higher pressure
...


Orthostatic Hypotension
If indicated, assess orthostatic hypotension, common in older adults
...
Normally, as the patient rises from the horizontal to
the standing position, systolic pressure drops slightly or remains unchanged, whereas diastolic
pressure rises slightly
...

Causes of orthostatic hypotension include drugs, moderate or severe blood loss, prolonged bed
rest, and diseases of the autonomic nervous system
...

Coarctation of the aorta arises from narrowing of the thoracic aorta, classically presents
with systolic hypertension greater in the arms than the legs
...

To determine blood pressure in the leg, use a wide, long thigh cuff that has a bladder size of 18
× 42 cm, and apply it to the midthigh
...
If possible, the patient should be prone
...

Palpate the radial or brachial and femoral pulses at the same time, and compare their volume
and timing
...

Temperature The core body temperature, measured internally, is approximately 37°C (98
...
It is lowest in the early morning
and highest in the afternoon and evening
...
Although the research gold standard for core body temperature is the blood
temperature in the pulmonary artery, clinical practice relies on noninvasive oral, rectal, axillary,
tympanic membrane, and temporal artery measurements
...
Oral temperatures are generally
lower than the core body temperature
...
4 to 0
...
7 to 0
...
Axillary temperatures take 5 to 10 minutes to register and are considered less accurate than
other measurements
...

Studies vary in methodology, but suggest that in adults, oral and temporal artery
temperatures correlate more closely with the pulmonary artery temperature, but are about
0
...
54–56 Oral Temperatures
...
Then read the

thermometer, reinsert it for a minute, and read it again
...
Note that hot or cold liquids, and even smoking,
can alter the temperature reading
...

-Rectal Temperatures
...
Select a rectal thermometer with a stubby tip, lubricate it, and insert it about 3 cm to 4
cm (1
...
Remove it after 3
minutes, then read
...
Wait about 10 seconds for the digital temperature recording to appear
-Tympanic Membrane Temperatures
...
Accurate temperature
readings require access to the tympanic membrane
...
Position the probe in the canal so that
the infrared beam is aimed at the tympanic membrane, or otherwise the measurement will be
invalid
...

-Temporal Artery Temperatures This method takes advantage of the location of the temporal
artery, which branches off the external carotid artery and lies within a millimeter of the skin
surface of the forehead, cheek, and behind the ear lobes
...
Read the display, which records the highest measure
temperature
...
Other causes include reduced movement
as in paralysis, interference with vasoconstriction from sepsis or excess alcohol, starvation,
hypothyroidism, and hypoglycemia
...

-Unable to Korotkoff sounds= use alternative methods using a doppler probe or direct arterial
pressure tracings
...
Abnormal Findings and Interpretation
Melanoma pg 176
- Least common skin cancer but most lethal
- Melanoma risk tool: 5 year risk of developing melanoma based on geographic location,
gender, race, age, history of blistering sunburns, complexion, number of size of moles,
freckling, and sun damage
...

-Diameter > 6mm (size of a pencil eraser)
-Evolving (or changing rapidly in size, symptoms, or morphology) THE MOST
SENSITIVE of CRITERIA
-Elevated, Firm to palpation, Growing progressively over several weeks
-HIGH RISK: a personal or family history of multiple or dysplastic nevi or pervious
melanoma

Primary and Secondary Skin Lesion Nomenclature
Skin Lesions: flat, raised, vesicle, bulla, erosions, ulcers, nodules, ecchymoses,
petechiae, palpable purpura
...

● Macule: Lesion is flat and <1 cm
...

● Raised: You can palpate the lesion with eyes closed
...

● Plaque: Lesion is raised, >1 cm, but not fluid filled
...

● Bulla: Lesion is raised, >1 cm, and fluid filled
...
If multiple, record how many
...

Size: Measure with a ruler in millimeters or centimeters
...

Shape: Some good words to learn are "circular," "oval," "annular" (ring-like,
with central clearing), "nummular" (coin-like, no central clearing), and
"Polygonal
...
Refer to a color wheel, if needed
...
Use "skin-colored" to describe a lesion that is the
same shade as the patient’s skin
...

Texture: Palpate the lesion to see if it is smooth, fleshy, verrucous or warty, or
scaly (fine, keratotic, or greasy scale)
...
For single lesions, measure their distance
from other landmarks (e
...
, 1 cm lateral to left oral commissure)
...


Psoriasis pg 192 Table 6-1
If raised spot is small (<1 cm)= papule
If raised spot is larger (>1 cm)=plaque
-Guttate Psoriasis (papules raised, small)- scattered erythematous round drop-like, flat
topped well circumscribed scaling papules and plaques on the trunk

-Plaque psoriasis :Plaques (raised, large)- scattered erythematous to bright pink wellcircumscribed flat-topped plaques on extensor knees and elbows, with overlying silvery
scale

-Tinea versicolor: multiple 2-5 mm hypopigmented, hyperpigmented, or tan round to
oval macules on upper neck and back, upper chest, and arms with slight inducible scale
on scraping

-Tinea Cruris: bilateral erythematous, geographic patches with peripheral scaling, on the
inner thighs bilaterally, sparing the scrotum ―jock itch‖

Pityriasis Rosea pg 193 looks like ringworm
Single, oval, flat topped superficial erythematous to skin-colored plaque on right
abdomen= herald patch of pityriasis
...
The submandibular
nodes lie superficial to the submandibular gland, and should be differentiated
...
The gland is larger and has a
lobulated, slightly irregular surface (see p
...
Note that the tonsillar, submandibular, and submental nodes drain portions of the mouth and throat as well as the face
...

Assessing Lymph Nodes:
1
...
Look for enlargement of the
parotid or submandibular glands, and note any visible lymph nodes
...


Palpate the lymph nodes
...
The patient should be relaxed, with the
neck flexed slightly forward and, if needed, turned slightly toward the side being examined
...

For the submental node, however, it is helpful to feel with one hand while bracing the top of the head
with the other
...
Preauricular—in front of the ear
2
...
Occipital—at the base of the skull posteriorly
4
...
Submandibular—midway between the angle and the tip of the mandible
...

6
...

7
...

8
...

9
...

Hook your thumb and fingers around either side of the sternocleidomastoid muscle to find
them
...


Supraclavicular—deep in the angle formed by the clavicle and the sternocleidomastoid
...
Small, mobile, discrete, nontender nodes, sometimes termed ―shotty,‖ are
frequently found in normal people
...

Also note any overlying skin changes (erythema, induration, drain-age, or breakdown)
...
For preauricular and cervical lymph nodes, adopt the techniques to follow
...
Then examine the posterior auricular and occipital lymph nodes
...
Then palpate the posterior cervical chain along the
trapezius (anterior edge) and along the sternocleidomastoid (posterior edge)
...
Examine the supraclavicular
nodes in the angle between the clavicle and the sternocleidomastoid)
...


Enlargement of
supraclavicular lymph node – especially on the left suggests possible
metastasis from a thoracic or abdominal malignancy
...
Unlike a muscle or an artery, that
**Tender nodes suggest inflammation
...


Cranial Nerves
Cranial Nerves
MNEUMONI
C

CRANIAL NERVE

MOTOR/SENSOR
Y

MNEUMONIC

On

I

Olfactory

Sensory

Some

Old

II

Optic

Sensory

Say

Olympus

III

Occularmotor

Towering

Motor

Marry

IV Trochlear

Motor

Money

Tops

V

Trigeminal

Both

But

A

VI

Abduscens

Motor

My

Frenchman

VII Facial

Both

Brother

And

VIII Acoustic

German

Viewed

Sensory

Says

IX
Glossopharyngeal

Both

Big

X

Both

Brains

Vagus

Some

XI Spinal
Accessory

Motor

Matter

Hops

XII

Motor

Most

Hypoglossal

HEENT Assessment and Modification for Age/Normal vs Abnormal
Findings and Interpretation

HEENT Assessment and Modifications for Age
...

Hair and scalp…Note its quantity, distribution, texture, and any pattern of loss
...
Part the hair in several places and look for
scaliness, lumps, nevi, or other lesions
...
Tiny white ovoid granules that adhere to hairs may be nits (lice
eggs)
...

2
...
Observe the general size and contour of the skull
...
Learn to recognize the irregularities in a normal
skull, such as those near the suture lines between the parietal and occipital bones
...

An enlarged skull may signify hydrocephalus or Paget disease of bone
...

Face…
...
Observe for
asymmetry, involuntary movements, edema, and masses
4
...

Acne is common in adolescents
...

-In the near reaction, when a person shifts gaze from a far object to a near object, the
pupils constrict
...
The coordinated action of six muscles, the four rectus and
two oblique, control the eye
...


Visual acuity To test the acuity of central vision, use a well-lit Snellen eye chart, if
possible
...
Patients who wear glasses other
than for reading should put them on
...
A
patient who cannot read the largest letter should be positioned closer to the chart; note
the intervening distance
...
Record the visual acuity designated at the side of this line,
along with use of glasses, if any
...
If
patients cannot read even the largest letters, test their ability to count your upraised
fingers and distinguish light (such as your flashlight) from dark
...

Myopia (nearsightedness) causes focusing problems for distance vision
...

Presbyopia(farsighted) causes focusing problems for near vision, found in
middle-aged and older adults
...

c
...

Legal blindness also results from a constricted field of vision: 20° or less in the better
eye
...

Vision of 20/200 means that at 20 feet the patient can read print that a person
with normal vision could read at 200 feet
...
―20/40 corrected‖ means the patient could read the 20/40 line with glasses (a
correction)
...

Static finger wiggle test: Position yourself about an arm’s length away from the
patient
...
So, for example, when the patient covers the left eye, to test the visual field of
the patient’s right eye you should cover your right eye to mimic the patent’s field of view
...
While in this position, wiggle your fingers and slowly bring your moving
fingers forward into the patient’s center of view
...
Test each clock hour, or at least each quadrant
...
Note any
abnormal ―field cuts‖
Kinetic Red Target Test
...
Ask the patient when the pin first appears to be red
...


-Graves disease or ocular tumors: Abnormalities include esotropia (inward deviation)
or exotropia (out-ward deviation) of the eyes and also abnormal protrusion

-Seborrheic dermatitis scaliness, lateral sparseness in hypothyroidism
...

- Blepharitis- Red inflamed lid margins, often with crusting
...
Stand in front of the patient and survey the eyes for
position and alignment
...
264)
...
Inspect the eyebrows, noting their fullness, hair distribution,
and any scaliness of the underlying skin
...
Note the position of the lids in relation
to the eyeballs
...
Look for this especially when the eyes are unusually
prominent, when there is facial paralysis, or when the patient is unconscious
...

Lacrimal Apparatus: Briefly inspect the regions of the lacrimal gland and lacrimal sac for
swelling
...

-Dryness from impaired secretion is seen in Sjogren syndrome
...
Ask the patient to look up as you depress both lower lids with
your thumbs, exposing the sclera and conjunctiva
...
Note the vascular pattern against the white scleral background
...
Ask the patient to look to each side and
down
...
For this, you need to evert the lid
...

Note any opacities in the lens that may be visible through the pupil
...
The markings should be clearly defined
...

Because the iris is normally fairly flat and forms a relatively open angle with the cornea,
this lighting casts no shadow
...

Occasionally, the iris bows abnormally far forward, forming a very narrow
angle with the cornea
...
This narrow angle increases the risk for acute narrow-angle glaucoma a
sudden increase in IOP when drainage of the aqueous humor is blocked
...


b
...
Light each eye from the side for inspection
...
Measure the pupils with a card
showing black circles of varying sizes, and test the light reaction
...

-Miosis refers to constriction of the pupils
-Mydriasis to dilation
...

Pupillary sizes
...
4 mm
or greater without a known pathologic cause, is visible in approximately 35% of healthy
people, and rarely exceeds 1 mm
...

d
...
In dim light, test the pupillary reaction to light
...
Both
the distant gaze and the oblique lighting help to prevent a near reaction
...
Note any deviation from
normal, or dysconjugate gaze
...
A few beats of nystagmus on
extreme lateral gaze are normal
...

■ Lid lag as the eyes move from up to down
Test the Six EOMs (Extraocular Muscles): CN 3,4,6 Ask the patient to follow your finger
or pencil as you sweep through the six cardinal directions of gaze
...
7-25): 1
...
to the right
and upward, and 3
...
without pausing in the middle, to the
extreme left, 5
...
down on the left
...
Move your finger or pencil at a comfortable
distance from the patient
...
Some patients move their heads to
follow your finger
...
If you
suspect lid lag or hyperthyroidism, ask the patient to follow your finger again as you
move it slowly from up to down in the midline
...

The Optic Disk
Inspect the optic disc
...
The nasal portion of the disc mar-gin may
be somewhat blurred, a normal finding
...
White or pigmented
crescents may ring the disc, a normal finding
...
It is usually yellowish white
...

● The comparative symmetry of the eyes and findings in the fundi
FINDINGS: In a refractive error, light rays from a distance do not focus on the retina
-In myopia, they focus anterior to the retina
-hyperopia, posterior to it
-Retinal structures in a myopic eye look larger than normal
-An enlarged cup suggests chronic open-angle glaucoma

Detecting Papilledema Swelling of the optic disc and anterior bulging of the physiologic
cup suggest papilledema= increased intracranial pressure
...
Papilledema signals serious
disorders of the brain, such as meningitis, subarachnoid hemorrhage, trauma, and mass
lesions, so searching for this important disorder is a priority during all your funduscopic
examinations
...

-The Retina—Arteries, Veins, Fovea, and Macula
● Inspect the retina, including arteries and veins as they extend
...
Veins are dark red, larger, and inconspicuous or absent
...

-Inspect the fovea and surrounding macula
...
In younger people, the tiny bright reflection at the
center of the fovea helps to orient you; shimmering light reflections in the macular area
are common
...
Types include dry atrophic (more common but less severe) and
wet exudative, or neovascular
...
Vitreous floaters are dark
specks or strands seen between the fundus and the lens
...
The ear has three compartments: the external ear,
the middle ear, and the inner ear
...

The external ear comprises the auricle and ear canal
...
Its prominent curved
outer ridge is the helix
...
Inferiorly is the fleshy projection of the earlobe, or lobule
...
The ear canal curves inward and is approximately 24 mm long
...
In this segment, the skin is hairy and contains glands that
produce cerumen (wax)
...
Pressure on this latter area causes pain—a point to remember when
you when you examine the ear
...
The external ear
captures sound waves for transmission into the middle and inner ear
...

The Middle Ear
...

The proximal end of the eustachian tube connects the middle ear to the nasopharynx
...
7-36)
...
From the umbo, where the
eardrum meets the tip of the malleus, a light reflection called the cone of light fans
down-ward and anteriorly
...
The remainder of the drum is the pars tensa
...
A second ossicle, the incus, can sometimes be seen through the
drum
...

The Inner Ear
...
Movements of the stapes vibrate the perilymph in the labyrinth of the semicircular
canals and the hair cells and endolymph in the ducts of the cochlea, producing electrical
nerve impulses transmitted by the auditory nerve to the brain
...
Assess their condition by
testing auditory function
...

Hearing disorders of the external and middle ear cause conductive hearing loss
...

Middle ear disorders include otitis media, congenital conditions, cholesteatomas and
otosclerosis, tumors, and perforation of the tympanic membrane
...

b
...
An
alternative pathway, known as bone conduction (BC), bypasses the external and middle
ear and is used for testing purposes
...
In those with
normal hearing, AC is more sensitive than BC (AC > BC)
...

Equilibrium
...


EAR ASSESSMENT
1
...
Inspect the auricle and surrounding tissue for deformities, lumps, or
skin lesions
...

Ear Canal and Drum
...
Position the patient’s head so
that you can see comfortably through the otoscope
...
Movement of the auricle and tragus (the ―tug test‖) is painful in acute otitis externa
(inflammation of the ear canal), but not in otitis media (inflammation of the middle ear)
...

-Exostoses Nontender nodular swellings covered by normal skin deep in the ear canals
suggest exostoses (nonmalignant overgrowths which may obscure the eardrums)
...

-Cerumen which varies in color and consistency from yellow and flaky to brown and
sticky or even to dark and hard, may wholly or partly obscure your view
...

-In chronic otitis externa, the skin of the canal is often thickened, red, and itchy
...


Testing Auditory Acuity—Whispered Voice Test
...
The whispered voice test is a reliable
screening test for hearing loss if the examiner uses a standard method of testing and
exhales before whispering
...

Occlude the non-test ear with a finger and gently rub the tragus in a circular motion to
prevent transfer of sound to the non-test ear
...

● Whisper a combination of three numbers and letters, such as 3-U-1
...

● Interpretation:
-Normal: Patient repeats initial sequence correctly
...

-Abnormal: Four of the six possible numbers and letters are incorrect
...

For patients failing the whispered voice test, the Weber and Rinne fork tests may help
determine if the hearing loss is conductive or sensorineural in origin
...

-To conduct these tests, make sure the room is quiet, and use a tuning fork of
512 Hz
...
Set the fork into light vibration by briskly
stroking it between the thumb and index finger ( Note that older adults with presbycusis
have higher frequency hearing loss, making them more likely to miss consonants, which
have higher frequency sounds than vowels
...

-Test for lateralization (Weber test)
...

-In unilateral conductive hearing loss, sound is heard in (lateralized to) the
impaired ear
...

Ask where the patient hears the sound: on one side or both sides? Normally, the
vibration is heard in the midline or equally in both ears
...
Restrict this test to patients with unilateral

hearing loss since patients with normal hearing may lateralize, and patients with
bilateral conductive or sensorineural deficits will not lateralize
...
Place the base of a lightly vibrating tuning fork on
the mastoid bone, behind the ear and level with the canal
...
Here, the ―U‖ of the fork should face forward, which maximizes sound
transmission for the patient
...

In sensorineural hearing loss=sound is heard longer through air (AC > BC)
...
Inspect the anterior and inferior surfaces of the nose
...
Use
a penlight or otoscope light to obtain a partial view of each nasal vestibule
...
Note any
asymmetry or deformity of the nose
...

-Test for nasal obstruction, if indicated, by pressing on each alnasi in turn and
asking the patient to breathe in
...
* Tilt the patient’s head back a bit and insert the speculum gently into the
vestibule of each nostril, avoiding contact with the sensitive nasal septum
...
Some
asymmetry of the two sides is normal
...
Inspect the nasal mucosa, the nasal septum, and any
abnormalities
...
Note its color and
any swelling, bleeding, or exudate
...
The nasal mucosa is normally somewhat redder than the
oral mucosa
...
Note any deviation, inflammation, or perforation of the
septum
...

-In viral rhinitis, the mucosa is reddened and swollen

-allergic rhinitis, it may be pale, bluish, or red
...

-Causes of septal perforation include trauma, surgery, and intranasal use of cocaine or
amphetamines, which also cause septal ulceration
...
Press up on the frontal sinuses from under the bony
brows, avoiding pressure on the eyes
...

-Local tenderness, together with symptoms such as facial pain, pressure or
fullness, purulent nasal discharge, nasal obstructions, and smell disorder, especially
when present for >7 days, suggest acute bacterial rhinosinusitis involving the frontal or
maxillary sinuses
...

If you detect any suspicious ulcers or nodules, put on a glove and palpate any lesions,
noting any thickening or infiltration of the tissues that might suggest malignancy
...
Observe their color and moisture, and note any lumps, ulcers,
cracking, or scaliness
...
Look into the patient’s mouth and, with a good light and the
help of a tongue blade, inspect the oral mucosa for color, ulcers, white patches, and
nodules
...

-The Gums and Teeth
...

Brown patches may be present, especially but not exclusively in dark-skinned
individuals
...
Inspect the teeth
...

-The Roof of the Mouth
...

A
...


Torus palatinus is a startling but benign midline lump
Redness of the gingiva suggests gingivitis, a black line might indicate lead
poisoning
...

C
...
There may be ulcers or papillary granulation tissue
...
Ask the patient to protrude the tongue
...
Inspect the side of the tongue, and then palpate it with your gloved left
hand, feeling for any induration
...
Any persistent nodule or ulcer, red or white, is
suspect, especially if indurated
...
Inspection and palpation remain the standard for
detection of oral cancers
...
This action helps you see the posterior pharynx well
...
Alternatively, you can press a tongue
blade firmly down on the midpoint of the arched tongue—back far enough to visualize
the pharynx but not so far that you cause gagging
...
Note the rise of the soft palate—a test of CN X (the vagal nerve)
...
Inspect the soft palate, anterior and posterior pillars, uvula,
tonsils, and pharynx
...
If possible, palpate any suspicious area for induration or
tenderness
...
Discard your
tongue blade after use
...
Ask the patient to sip some water and to extend the
neck again and swallow
...
The thyroid cartilage, the cricoid cartilage, and the thyroid gland
all rise with swallowing and then fall to their resting positions
-Auscultate breath sounds over the trachea
...
When assessing shortness of breath, always
remember to listen over the trachea for stridor for upper airway etiologies in addition to
examining the lungs
...

-Causes include epiglottitis, foreign body, goiter, and stenosis from placement of
an artificial airway
...
Tip the patient’s head slightly back
...

Confirm your visual observations by palpating the gland outlines as you stand facing the
patient
...


- Palpate the thyroid gland
...
Palpate the thyroid gland
...
If the thyroid gland is retrosternal, below
the suprasternal notch, it is often not palpable
...

● Place the fingers of both hands on the patient’s neck so that your index fingers are
just below the cricoid cartilage
...

Feel for the thyroid rising up under your finger pads
...

● Displace the trachea to the right with the fingers of the left hand; with the right-hand
fingers, palpate laterally for the right lobe of the thyroid in the space between the
displaced trachea and the relaxed sternocleidomastoid
...
In a
similar fashion, examine the left lobe
...
The anterior surface of a lateral lobe is approximately
the size of the distal phalanx of the thumb and feels somewhat rubbery
...
In general, benign (or colloid) nodules tend to be more
uniform, ovoid structures and are not fixed to surrounding tissue
...

-When the thyroid gland is retrosternal, below the suprasternal notch, it is often
not palpable
...

-The thyroid is soft in Graves disease and may be nodular; it is firm in Hashimoto thyroiditis (though not always uniformly) and malignancy
...

-A localized systolic or continuous bruit may be heard in hyperthyroidism from
Graves disease or toxic multinodular goiter
...
g
...

- Larger the number worse the vision

Glaucoma=Optic disc Changes
- Change in color and size of the optic disc
- Leading cause of visual impairment and blindness (gradual loss of peripheral visual
fields) IS TREATABLE
- Loss of retinal ganglion cell axons: exam reveals pallor and increasing the size of the
optic cup
- Risk factors: African American, DM, Myopia, ocular hypertension

Epistaxis

- bleeding from nasal passage, paranasal sinuses or nasopharynx
-Causes: trauma, inflammation, drying or crusting of nasal mucosa, tumors, foreign
bodies, anticoagulants NSAIDS, vascular malformations, coagulopathies
-Assess for hemoptysis and hematemesis

Retinal Issues Cottonwood Patches & Drussen
- Retina is found in the optic fundus
- follow vessels peripherally in each direction (size and characteristics), ID any lesions:
measured in terms of "disc diameters"
- Fovea is the tiny bright reflection at the center: shimmering light reflections are
common
- look for opacities in the vitreous or lens (vitreous floaters are dark specs/strands send
between fundus and lens)
Cottonwood PATCHES: irregular patches= DM & HTN ―Think of Tina‖

HARD DRUSSEN: Lipids and proteins/ older population, can lead to maculardegeneration
...

Arms should be folded across chest with hands resting on opposite shoulders
if possible
...
The ask pt to lie
down
...

This position allows breast to be gently displaced
...

o EXAMINE POSTERIOR CHEST
Inspection (shape of chest and how chest moves)
· Assess for deformities or asymmetry of chest expansion
o Asymmetric expansion occurs in large pleural effusions
· Abnormal muscle retraction of the intercostal space during
inspirations, most visible in the lower intercoastal spaces
o Retraction occurs in severe asthma, COPD, or upper
airway obstruction
...

Palpation (focus on areas of tenderness or bruising, respiratory expansion, and fremitus)
· Intercostal tenderness can develop over inflamed pleurae, costal
cartilage tenderness in costochondritis
· Identify tender areas: palpate tender areas or where there is visible
lesions or bruises
...

o Tenderness, bruising, and bony “step-offs” are common
over a fractured rib
...

· Any skin abnormalities like masses or sinus tracts (blind,
inflammatory, tube-like structures opening onto the skin)
o Although rare, sinus tracts suggest infection of the
underlying pleura and lung (as in tuberculosis or actinomycosis)
...

· Palpate both lungs for symmetric tactile fremitus
o Fremitus refers to the palpable vibrations that are
transmitted through the bronchopulmonary tree to the chest
wall as the patient is speaking and is normally symmetric
...
Easier to detect in the right
lung than the left lung
...

o Ask patient to say ―99‖ or ―1-2-3‖
o
Fremitus is decreased or absent when the voice is higher
pitched or soft or when the transmission of vibrations from the
larynx to the surface of the chest is impeded by a thick chest
wall, an obstructed bronchus, COPD, or pleural effusion,
fibrosis, air (pneumothorax), or an infiltrating tumor
...

Percussion:
· Percussion sets the chest wall and underlying tissues in motion,
producing audible sound and palpable vibrations
...

· Dullness replaces resonance when fluid or solid tissue replaces
air-containing lung or occupies the pleural space beneath your
percussing fingers
...
Dullness makes pneumonic and pleural
effusion three to four times more likely, respectively
· Generalized hyperresonance is common over the hyperinflated
lungs of COPD or asthma
...


Auscultation:
· Before beginning auscultation, ask the patient to cough once or
twice to clear mild atelectasis or airway mucus that can produce
unimportant extra sounds
...
Hair can alter sounds;
press harder or moisten hair on chest hair
...

· Breath sounds usually louder at lower posterior lung fields
...

o EXAMINE ANTERIOR CHEST: If performed with patient supine, arms
should be slightly abducted
...
Persons
with severe COPD may prefer to sit leaning forward, with lips pursed during
exhalation and arms supported on their knees or a table
...

o Tender pectoral muscles or costal cartilages suggest, but
do not prove, that chest pain has a localized musculoskeletal
origin
...

· Assess chest expansion
...
Unless you displace the breast, you may miss
the abnormal percussion note
...
) (p
...
Abnormal alveolar hypoventilation without increased tidal volume can
arise from uremia, drug-induced respiratory depression, and increased intracranial pressure
...
Occasional sighs are normal
...

This pattern is normal in children and older adults during sleep
...


Obstructive Breathing - In obstructive lung disease, expiration is prolonged due to narrowed airways
increase the resistance to air flow
...


Rapid Deep Breathing (Hyperpnea, Hyperventilation) –
·
In hyperpnea, rapid deep breathing occurs in response to metabolic demand from causes
such as exercise, high altitude, sepsis, and anemia
...
Light-headedness and tingling may arise from decreased CO2
concentration
...

·
Kussmaul breathing is compensatory over breathing due to systemic acidosis
...


Ataxic Breathing (Biot Breathing)- Breathing is irregular—periods of apnea alternate with regular
deep breaths which stop suddenly for short intervals
...


Tachypnea: >25 bpm
·
This increases the likelihood of pneumonia and cardiac disease
o

Assess for signs of respiratory distress:
Assess for RR
Inspect patient’s color for cyanosis or pallor
...

· Cyanosis in the lips, tongue, and oral mucosa signals hypoxia
...

· Clubbing of the nails (see p
...

Listen for audible sounds of breathing
...

· Wheezing is either expiratory or continuous
...
Lateral displacement of the trachea occurs
in pneumothorax, pleural effusion, and atelectasis
...


o Forced Expiratory Time: take a deep breath and breathe out
...
Get 3 readings
...

o Identify fracture rib: With one hand on sternum and one on thoracic spine,
squeeze chest
...


LUNG SOUNDS (breath sounds)
o Adventitious (added) lung sounds: Causes and Qualities (p
...
When hearing
crackles that do not clear with coughing, assess: loudness, pitch, and duration (fine or coarse),
number, timing in resp cycle, location in chest wall, persistence of pattern from breath to breath,
and any change after cough or position
...

Heard from mid to late inspiration, especially in the dependent areas of the lung, and change
according to body position
...

o Examples include pulmonary fibrosis (known for ―Velcro rales‖) and interstitial lung
diseases such as interstitial fibrosis and interstitial pneumonitis
...

·
Coarse crackles; appear in early inspiration and last throughout expiration (biphasic),
have a popping sound, are heard over any lung region, and do not vary with body position
...
Coarse crackles appear to result from ―boluses of gas
passing through airways as they open and close intermittently
...

o The crackles of heart failure are usually best heard in the posterior inferior lung fields
...
Wheezes can be inspiratory, expiratory, or
biphasic
...

o Although wheezes are typical of asthma, they can occur in a number of pulmonary diseases
...
Unlike wheezes, rhonchi may disappear with coughing, so
secretions may be involved
...

·
Stridor is a continuous, high-frequency, high-pitched musical sound produced during
airflow through a narrowing in the upper respiratory tract
...
Causes of the underlying airway obstruction include
tracheal stenosis from intubation, airway edema after device removal, epiglottitis, foreign body,
and anaphylaxis
...

·
Stridor and laryngeal sounds are loudest over the neck, whereas true wheezes and
rhonchi are faint or absent over the neck
...
This
nonmusical sound is biphasic, heard during inspiration and expiration, and often best heard in the
axilla and base of the lungs
...

Mediastinal Crunch (Hamman Sign)
·
A mediastinal crunch is a series of precordial crackles synchronous with the heartbeat,
not with respiration
...
It usually produces severe
central chest pain and may be spontaneous
...

Pneumonia
o Pneumococcal Vaccination
Streptococcal pneumonia causes pneumonia, bacteremia, and meningitis
...

Adult who have not received the PPSV23 should 1st be given the PCV13 and then 6-12 months
later, receive the PPSV23
...

Use both vaccines for high-risk groups:
·
Adults >65 years
·
Children and adults from ages 2 to 64 years with chronic illnesses specifically associated
with an increased risk of pneumococcal infection (sickle cell disease, cardiovascular and
pulmonary disease, diabetes, alcoholism, cirrhosis, cochlear implants, and leaks of cerebrospinal
fluid)
·
Any adult aged 19 to 64 years who is a smoker or has asthma
·
Adults and children older than age 2 years who are immunocompromised (including from
HIV infection, AIDS, long-term steroids, Hodgkin disease, lymphoma or leukemia, kidney
failure, multiple myeloma, nephrotic syndrome, organ transplant, damaged spleen or no spleen,
radiation, or chemotherapy)

·
Residents of nursing homes or long-term care facilities
o Lobar Pneumonia (consolidation): alveoli filled with fluid as in pneumonia
...
339)
Percussion note: dull over airless area
Trachea: midline
Breath sounds: bronchial over the involved area
Adventitious sounds: late inspiratory crackles over involved area
Tactile fremitus and transmitted voice sounds: increased over the involved area, with egophony,
bronchophony, and whispered pectoriloquy
o Mycoplasma and viral pneumonias: cough and sputum include dry, hacking cough, may
become productive and mucoid sputum
...
Associated with acute illness with chills, often high
fever, dyspnea, and chest pain
...

Asthma:
o Widespread, usually reversible, airflow obstruction with bronchial hyperresponsiveness and
underlying inflammation
...
(p
...
Associated with
episodic wheezing and dyspnea, but cough may occur alone
...

o In the advanced airway obstruction of severe asthma, wheezes and breath sounds may be
absent due to low respiratory airflow (the “silent chest”), a clinical emergency
...

-The first goal of your evaluation of musculoskeletal disorders is to characterize the
patient’s complaint in terms of four key features
...


Articular disease typically involves swelling and tenderness of the entire joint,
crepitus, instability, ―locking,‖ or deformity, and limits both active and passive
range of motion due to either stiffness or pain
...

Extra-articular disease typically involves ―point or focal tenderness in regions
adjacent to articular structures‖ and limits active range of motion
...

-Age also provides clues to causes of joint pain:
■ If age <60 years, consider repetitive strain or overuse syndromes like tendinitis
or bursitis, crystalline arthritis (gout; crystalline pyrophosphate deposition disease
[CPPD]) (males), rheumatoid arthritis (RA), psoriatic arthritis and reactive (Reiter)
arthritis (in inflammatory bowel disease [IBD]), and infectious arthritis from gonorrhea,
Lyme disease, or viral or bacterial infections
...
Inspect for joint symmetry, alignment, bony deformities, and swelling
2
...

3
...
Assess any areas of inflammation, especially tenderness, swelling, warmth,
redness
...

JOINT PAIN CONSIDERATIONS:
-True pain from the hip joint is typically described in the groin
...

-Trochanteric pain from bursitis occurs on the lateral thigh
...

-Severe pain of rapid onset in a red swollen joint suggests acute septic arthritis or
crystalline arthritis/gout in adults; or osteomyelitis in children
...

-Morning stiffness that gradually improves with activity is more common in
inflammatory disorders like RA
...

-Monoarticular arthritis can be traumatic, crystalline, or septic
...

-Polyarthritis (4 or more joints) may be viral or inflammatory from RA, SLE, or
psoriasis
...

-In inflammatory conditions, order labs: Erythrocyte sedimentation rate (ESR), Creactive protein (CRP), platelet count, and hematocrit
...
85 % of cases are associated with a disc disorder, usually at L4-L5 or L5-S1
-Spinal stenosis- leg pain that resolves with rest and or lumbar forward flexion
-Cauda Equina Syndrome- from an S2-S4 midline disc or tumor if bowel or bladder
dysfunction especially if there is saddle anesthesia or perineal numbness
...

-Achilles tendon rupture: ―like a gunshot‖absent plantar flexion is a positive test, sudden
severe pain, an ecchymosis from the calf into the heel, and a flat footed gait with absent
―toe off‖ may also be present

Elbow Pain :
Olecranon Bursitis:
Swelling and inflammation of the
olecranon bursa may result from
trauma, gout, or rheumatoid arthritis
(RA)
...
Consider aspiration
for both diagnosis and symptomatic
relief
...
They
are firm and nontender
...
They can develop in the
area of the olecranon bursa, but often occur more distally
...
Palpate for a boggy, soft, or fluctuant
swelling and for tenderness
...
Patients report pain, stiffness, and restricted motion
...
Pain and tenderness develop 1 cm distal to
the lateral epicondyle and possibly in the extensor muscles close to it
...
Medial
epicondylitis (pitcher’s, golfer’s, or Little League elbow) follows repetitive wrist
flexion such as throwing
...
Wrist flexion against resistance increases the pain
...

-Common Locations: hands (initially small joints), wrists, knees, elbows, and ankles
-Symmetrically additive: progresses to other joints while persisting in initial joints
-Usually insidious; human leukocyte antigen (HLA) and non-HLA genes account for >50
%of risk of disease, involves proinflammatory cytokines
-Often chronic, with remissions and exacerbations
-Frequent swelling of synovial tissue in joints or tendon sheaths; also subcutaneous
nodules
-Tender, often warm, but seldom red
-Prominent stiffness, often in the mornings, and after inactivity
-Joint contractures and subluxation, bursitis, and tendinopathy
-Generalized symptoms: weakness, fatigue, weight loss, and low fever are common
-Heberden nodes and Bouchard nodes

Lyme Disease
is a bacterial infection you get from the bite of an infected tick
...
But not all people with Lyme
disease have a rash
...
Lyme disease is caused by the bacterium Borrelia burgdorferi and rarely,
Borrelia mayonii
...
Typical symptoms include fever, headache, fatigue, and a characteristic skin rash
called erythema migrans
...
Antibiotics commonly used for oral treatment include
doxycycline, amoxicillin, or cefuroxime
...

Early Signs and Symptoms (3 to 30 Days After Tick Bite)
"Classic" Erythema Migrans Rash
· Fever, chills, headache, fatigue, muscle and joint aches, and swollen lymph nodes may

occur in the absence of rash

· Erythema migrans (EM) rash
o

Begins at the site of a tick bite after a delay of 3 to 30 days (average is about 7
days)
o

Expands gradually over several days reaching up to 12 inches or more (30 cm)
across
o

May feel warm to the touch but is rarely itchy or painful

o

Sometimes clears as it enlarges, resulting in a target or ―bull’s-eye‖ appearance

o

May appear on any area of the body

Later Signs and Symptoms (days to months after tick bite)
Swollen Knee
Facial Palsy
· Severe headaches and neck stiffness
· Additional EM rashes on other areas of the body
· Facial palsy (loss of muscle tone or droop on one or both sides of the face)
· Arthritis with severe joint pain and swelling, particularly the knees and other large joints
...

If age >60 years, look for OA, gout and pseudogout, polymyalgia rheumatica (PMR),
osteoporotic fracture, and septic bacterial arthritis
...
Inspect for joint symmetry, alignment, bony deformities, and swelling
2
...
Assess range of motion and maneuvers to test joint function and stability and the integrity of
ligaments, tendons, bursae, especially if pain or trauma
4
...

o
The two rounded condyles of the femur rest on the relatively flat tibial
plateau
...
This feature, in
addition to the lever action of the femur on the tibia and the lack of padding from
overlying fat or muscle, makes the knee highly vulnerable to injury
...
The knee
should be extended at heel strike and flexed at all other phases of swing and stance
...
Observe any atrophy of the quadriceps muscles
...

> Stumbling or ―giving way‖ of the knee during heel strike suggests quadriceps weakness or
abnormal patellar tracking
...

Swelling over the patella occurs in prepatellar bursitis (housemaid’s knee)
...
In
this position, bony landmarks are more visible, and the muscles, tendons, and ligaments are more

relaxed, making them easier to palpate
...
Pain is a
common complaint in knee problems, and localizing the structure causing pain is important for
accurate evaluation
...

Tenderness over the tendon or inability to extend the knee suggests a partial or complete tear of
the patellar tendon
...
Similar pain may occur when using the stairs or getting up from a chair
...

Findings most diagnostic of the patellofemoral pain syndrome: pain with quadriceps contraction;
pain with squatting; and pain with palpation of the posteromedial or lateral patellar border
...

Prepatellar bursitis is triggered by excessive kneeling
anserine bursitis from running, valgus knee deformity, or OA
popliteal or “Baker” cyst from distention of the gastrocnemius semimembranosus bursa from
under-lying arthritis or trauma
...
Identify the medial and lateral epicondyles and the olecranon
process of the ulna
...
Note any nodules or swelling
...
Palpate the olecranon process and press over the epicondyles for tenderness
...
Normally the synovium and olecranon bursae are not palpable
...
Palpate the epicondyles
...

Abnormal Findings:

Elbow Range of Motion:
Flexion: Biceps brachii, brachialis, brachioradialis
...
―Straighten your elbow‖
...
―Turn your palms up, as if carrying a bowl‖
Pronation: Pronator teres, pronator quadratus
...
‖
*After injury, preservation of active range of motion and full elbow extension makes fracture
highly unlikely
...
Full elbow extension also
makes intra-articular effusion or hemarthrosis unlikely
...
Assess for subcutaneous nodules
...

Process: Chronic inflammation of synovial membranes with secondary erosion of adjacent
cartilage and bone, and damage to ligaments and tendons
Common Locations: Hands—initially small joints (PIP and MCP joints), feet (MTP joints),
wrists, knees, elbows, ankle
Pattern of Spread: Symmetrically additive: progresses to other joints while persisting in initial
joints
Onset: Usually insidious; human leukocyte antigen (HLA) and non-HLA genes account for
>50% of risk of disease; involves proinflammatory cytokine
Progression and Duration: Often chronic (in >50%), with remissions and exacerbations
Acute RA: Tender, painful, stiff joints in RA, usually with symmetric involvement on both sides
of the body
...
Note the fusiform or spindle-shaped swelling of the PIP joints in
acute disease
...

Range of motion becomes limited, and fingers may deviate toward the ulnar side
...
The fingers may show ―swan neck‖ deformities (hyperextension
of the PIP joints with fixed flexion of the distal interphalangeal [DIP] joints)
...

Rheumatoid nodules are seen in the acute or the chronic stage
...
Five pound feature: pulsatile or throbbing, one day
duration or at least 4 to 72 hours if untreated, Unilateral; Nausea or vomiting; Disabling
or intensity causing interruption of daily activity
...

Delirium- a multifactorial syndrome, an acute confusion state marked by sudden onset,
fluctuating course, inattention, and at tome changing levels of consciousness
...
Most common Alzheimer (>65 years old)
...
Loss of smell occurs=head trauma, smoking, aging, use of cocaine, and
Parkinson disease
CN 2- optic: test visual activity
...
Inspect each disc carefully for bulging and blurred margins (papilledema), pallor
(optic atrophy), and cup enlargement (glaucoma)
...

Anisocoria= a difference of >0
...

- Intracranial aneurysm: large pupil reacts poorly to light or aniscoria
worsens in light, the large pupil has abnormal pupillary constriction, and
ptosis and ophthalmoplegia are also present and if the patient is awake
...

CN III, IV, VI- Oculomotor, Trochlear, and Abducens: test the extraocular movements in
the six cardinal directions of gaze and look for loss of conjugate movements in the aby
the six directions, which causes diplopia
CN V- trigeminal- palpate the temporal muscles and masseter muscles and check
sensory
CN VII- Facial, inspect the face both at rest and during conversation with the patient for
symmetry
...

CN VII- Acoustic and Vestibula
...

-Vertigo and hearing loss= Meniere disease

CN XI- Spinal accessory= stand behind the patient, look for atrophy or fasciculations in
the trapezius muscles, and compare one side with the other
...

-Fasciculations= fine flickering irregular movements in small groups of muscle
fibers
...

CNXII- Listen to the articulation of the patient’s words, inspect the tongue as it lies on
the floor of the mouth
...
Some coarser restless
movements are normal
...
As the patient to move the tongue from side to
side, and note symmetry of the movement
...
The patient stand fairly well with eyes open but
loses balance when they are closed= positive test (Ataxia)

Babinski Reponses (Abnormal)- Dorsiflexion of the big toe
...
Occasionally accompanied by reflex flexion at hip and knee
...


Brudzinski Sign- Flexion of both the hip and knees is positive sign
...
Normally they should remain relaxed
and motionless
...
Flex the
patients leg at both the hip and the knee, and the slowly extend the leg and straighten
the knee, discomfort behind the knee during full extension is normal but should not
produce pain
...

Asterixis- metabolic encephalopathy in patients whose mental functions are impaired
...
Test by asking patient to ―stop
traffic‖, observe for 1 to 2 minutes
...

Grotesque, twisted postures
...


Chorea- brief, rapid, jerky, irregular movements, and unpredictable
...

Aphonia- loss of voice that accompanies disease affecting the larynx or its never supply
Dysarthria- defect in muscular control of the speech apparatus
...
Sentences lack meaning and words are
malformed or invented
...

-Broca Aphasia non-fluent or expressive aphasia
...
Inflection and articulation are impaired but words are meaningful, with nouns,
transitive verbs, and important adjectives
...


Seizure Disorder pg 724, 780, 781Jessica
– patient reports ―spells‖ or fainting
- A sudden excessive electrical discharge from cortical neurons
...
Does not always involve loss of consciousness, depends on type
...
More common in infants and older adults, the baseline
neurological exam is frequently normal
...

- Tonic-clonic motor activity, bladder or bowel incontinence, and postictal state
...
Loses consciousness, and the
body stiffness into tonic extensor rigidity
...
A clonic phase of rhythmic muscular contraction follows
...

- Partial- usually adult-onset seizures
- Myclonic (drop attack) - sudden loss of consciousness with falling but no
movements
...
Typical <10 sec
...


Syncope pg 724 Jessica
-Determine if consciousness was lost, external noise or voices throughout the episode,
felt light-headed, or weak
-Syncope= sudden but temporary loss of consciousness and postural tone from
transient global hypoperfusion of the brain
- Causes= seizures, vasovagal syncope, postural tachycardia syndrome, carotid sinus
syncope, orthostatic hypotension, cardiac disease causes arrythmias
...

-Vasovagal Syncope- Most common cause: prodrome nausea, diaphoresis, and
pallor triggered by a fearful or unpleasant event, then vagally mediated
hypotension, often with slow onset and offset
...
Precipitating=
emptying the bladder after getting out of bed
...


Cranial Nerves



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