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clinical exam 2


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when percussing over an organ like the liver or spleen, what should the sound be?
when percussing over the thigh or a tumor what would the sound be?
when percussing over a gastric air bubble or intestinal air, what would the sound be?
the striking finger in percussion
when percussing over a hyperinflated lung like with emphysema what should the sound be?
when percussing over normal lungs what should the sound be?
at what point in the physical assessment do you take vital sings?
in the general servayy at the begining.
inspecting the internal structures of the eye
inspecting the external auditory canal and tympanic membrane
BMI for adults should be what? ..what is underweight, and what is overweight? What is obese?
should be 20-25. less than 20 is underweight, and 25-29.9 is overweight. Obese is 30 and up.
conjunctiva should be what color?
pink and moist.
how should you palpate skin for temperature?
with the dorsal aspect of your hand
How do you assess turgor,..what might be your finding, and what does it mean?
assess turgor by pinching on the clavicle. You have tenting if it takes teh skin 3 seconds to return to the original position. Decreased turgor is seen with dehydration or normal aging.
how do you assess for edema?
press firmly with your finger for 5 seconds over a bony promonance. it is +1-+4..and there is also trace edema.
tiny collections of sebum usually on the face---found in newborns. It is a normal finding.
skin tags. they may be seen around the neck, axillae, skinfolds or agreas where clothing rubs. they are normal.
age spots in older adults
is acne a normal or abnormal finding?
it is an abnormal finding, though it is common.
when assessing malignant lesions, what does ABCDE stand for?
Asymmetry Borders Color Diameter (should be less than 0.5) Elevation
excess hair -maybe facial or trunk hair
what is the normal angle of the nail plate?
160 degrees
what is a normal finding in nails of older adults?
they grow more slowly, become thicker and tend to split.
what are abnormal nail findings?
thickened, brittle or soft nails, or nails with deep verticle grooves.
how quickly should capillary refil occur?
less than 3 seconds.
when looking for symmetry of the face, where do you look?
in the palpebral fissures and the nosolabial folds. (the eye and nose folds).
how do you assess the eyes of someone who cannot read?
use the snellen E chart.
should corrective lenses be worn durring the eye test? (snellen chart)?
yes, they should be worn.
in 20/20 what does the numerator and denomenator stand for?
the numerator is teh distance that YOU are standing from the chart, adn the denomenator is teh distance that a person with normal vision would stand to read the chart.
when does distance vision reach 20/20?
not until 6 or 7 years of age.
in an eye exam, a smaller fraction (20/100) would indicate what?
myopia --or near sighted ness
in an eye exam a larger fraction would indicate what?
hyperopia--or far sighted ness
on the snellen chart, what line do you stop at to determine their vision?
you record the number at the end of the line that the patient could read with NO MORE than 2 errors. (so two is ok?)
how do you test near vision?
by holding newsprint 14 inches away and having them read it.
On a test for near vision, what would the client holding the paper farther away indicate?
hyperopia or presbyopia
what are the color cards?
glazed eyes may indicate what?
a febrile state
the upper lid should cover how much of the iris?
1/2 of the upper iris
entorpion and ectropion
invererted and everted eyelashes
asymmetry of the eye lids may be the result of what?
damage to cranial nerve III.
how do you assess the palpebral conjunctivae?
have the pt look up as you place a Q-tip on the outside of the eyelid and flip the eyelid outward
how do you assess the bulbar conjunctiva?
pull down the lower lid
what should the sclara look like?
it should be smooth, white and glistening. Dark skinned people may have a yellowish cast to the peripheral sclara or small brown spots more centrally. So yellow sclara is an abnormal finding EXCEPT in dark skinned people.
arcus senillis
its a gray ring in the eyes. it is normal in older adults
unequal pupil size. can be a normal varient if the difference is less than 0.5 mm.
how do you test pupilary reaction?
pen light in from the side, both should react
how do you test pupil accomodation?
have them look straight aghead and bring an object closer to them. The pupils should constrict and eventually cross as the object moves closer.
should you be able to palpate the lacrimal glands?
how you use that thingy to view the eyes (and do the redlight reflex)
what is teh normal angle attatchment of the ear?
less than 10 -- <10
high or low placement of the ear may be a sign of?
a hearing deficit or genetic problems.
how long should the ears be?
4-10 cm
what is an otoscope?
used for the ears
ear wax
to straighten the external ear canal pull the helix:
up and back for an adult. Down and back for a child
you can hear a watch at about :
5 inches away
what to problems with the whisper test indicate?
low tone hearing problems
what do problems with the watch ticking test indicate?
high pitched hearing problems
webber test
tuning fork on top of head
conductive hearing loss
in the webber test the vibration will be louder in the impaired ear. The problems could be caused by a middle ear infection or external bloackage (like excess cerumen) or trauma to the TM
sensorineural hearing loss
sounds will be louder in thte unaffected ear. could be the result of medication or inner ear problems.
AC= 2 X BC
air conduction is twice as long as bone conduction. Used on the Rinne test
Rinne test
tuning fork on side
in the rinne test, what does it mean if the cliet cannon hear the vibrations through bone conduction?
it indicates sensorineural hearing loss
Romberg test
should be negative. ..the cliet stands and has minimal swaying.
what do the following colors of drainage from the nose mean: clear, yellow, green, bloody
clear = allergy yellow or green = infection bloody = trauma or hypertension or bleeding disorder.
how many teeth should you have?
28, or 32 if you have your wizdom teeth. Children have 20 teeth.
in older adults what may it look like under the tongue?
they may have vericosities under the tongue. THis is normal.
what may tonsils look like in kids?
they may extend beyond the palatine arch.
absense of gag reflex
damage to crainial nerves IX and X
in what 3 ways do you inspect the neck?
inspect in the nautral position, when its hyperextended, and when the pt swollows water
what might a normal finding be in infants breasts?
enlargement and watery white discharge from the nipples during the first 2 weeks of life
breast enlargement in males
peau d' orange
dimpled skin texture. if found it may be a lymphatic obstruction or breast cancer
what are the 3 methods you can use for a breast examination?
vertical strip method, pie wedge method, concentric circles method
newborns respiratory rate
infants and children breath ____
abdominally, so you will see little moviement of the chest
respirations in older adults:
the rate doesnt change much, but their breathing may become more shallow
sternal and intercostal retractions are see with?
hypoxia, respiratory distress and airway obstruction
what are some things that may increase someones respiratory rate?
activity, smoking, fever, pain or ANEMIA
what is teh AP lateral ratio of infants? and adults?
infants have equal and adults have 1:2
what would weakening thoracic and diaphragm muscles do? What are some disorders/problems that would cause this?
it would cause the chest to widen and become more barrel shaped (like in COPD). kyphosis and osteoporosis would cause this
what is the normal costal angle?
less than 90 degrees. <90
a greater costal angle than normal is found in?
sternal and intercostal retractions would indicate what?
severe hypoxia or respiratory distress
what might cause a tracheal diviation?
a mass in the neck, or excess pressure in the lungs (like in tension pneumothorax).
where is crepitus most likely to occur?
around wounds, central iv line sites, chest tubes or a tracheostomy
when assessing chest excursion, what might limited chest excursion indicate?
shallow breathing, restricitve clothing or restrictive airway disease
what might asymmetrical chest excursion indicate?
airway obstruction, pleural effusion or pneumothorax.
what 3 things do you follow the same sequence for in assessing the chest?
palpating for fremitus, percussing and auscultating the chest
what does increased fremitus indicate?
fluid in the lungs (like pulmonary edema)
what does decreased or abscent fremitus indicate?
tissue consolidation as in emphysema or asthma.
fremitus SHOULD be deminished in the ___?
mid thorax
when percussing the chest, where is the anterior chest, lateral chest, and posterior chest resonant to?
anterior chest is resonant to the 4th ICS on the right and 2nd ICS on the left. Lateral chest is resonant to the 8th ICS. Posterior chest is resonant to T 12.
what is the normal distance for diaphragmatic excursion?
3-6 cm.
what might decreased diaphragmatic excursion indicate?
paralysis, atelectasis or COPD with overinflated lungs
where are bronchial, bronchiovesicular and vesicular breath sounds heard?
bronchial is over the trachia, bronchiovescicular is over the sternum in the front and between the scapula in the back, and vescicular is heard over most of the lung fields.
infants breath sounds are ____?
louder than adults
when are crackles and rales heard and what do they sound like?
they are heard with atelectasis, pneumonia, or pulmonary edema. They are soft, high pitched, very breif sounds and are usually heard during inspiration.
what is Rhonchi the result of, and what does it sound like?
it is the result of mucus secretions in the large airways and it sounds like snoring, low pitched sounds heard during both inspiration and expiration
what is wheezing the result of and what does it sound like?
it is the result of narrowing of an airway by a spasm (like in asthma), inflammation, mucus or a tumor. It sounds like high pitched musical sounds that are heard during both inspiration and expiration.
what causes stridor and what does it sound like?
it is caused by acute respiratory distress, a foreign body in teh airway or epiglottitis. It sounds like high-pitched continous honking sounds. It is heard throughout the respiratory cycle but is most pronounced during inspiration. It is a MEDICAL EMERGENCY!!!
what is grunting caused by and what does it sound like?
it is caused by emphysema--or retention of air in the lungs, and it sounds like a high pitched tubular sound that is heard on expiration.
how do you assess for bronchophony?
by having the cliet say 1,2,3 as you listen over the lung fields. If you hear it clearly then bronchophony is presnet. this is abnormal
how do you assess for egophany?
client says E...if it sounds like an AH..thats not good.
how do you assess for whispired pectoriloquy?
whisper 1,2,3 and if you hear 1,2,3 clearly, ....thats not good :p
what does significatn jugular venous distention indicate?
right sided heart failure
what is the normal jugular venous pressure?
less than 3 cm
where should you look for the PMI in children?
it is more medially and at about the 4th ICS
what is teh difference between a lift, heave and thrill?
a lift and a heave you can SEE, a thrill you feel. A thrill indicates turbulent blood flow
what are the 5 areas that you should palpate the precordium?
apex, left lateral sternal border, epigastric area, base left and base right
where is the PMI PALPABLE?
at the apex over a 1-2 cm area
if you find a bruit when you are assessing the carotids, what might this indicate?
in adults it means carotid stenosis
is it normal to hear a bruit over the carotid artery of a child?
yes. it may be heard beacuse of a high output state
is it normal to hear a venous hum in a child?
yes. it is normal
describe the difference in children and adults in 1) listening to breath sounds, and 2) listening to heart sounds:
in children breath sounds are louder, but heart sounds are quieter than in adults.
of s3 and s4 which is considered normal in an older adult?
s4 is considered normal.
at the aortic and pulmonic valves (when you are listening to the heart), which is greater, s1 or s2?
s2 is greater than s1
over the mitral and tricuspid valves (when you are listening to the heart) which is greater s1 or s2?
s1 is greater.
when might you hear a split s1?
over the tricuspid valve
a diastolic murmer greater than ____ is never an innocent murmur:
greater than 3/6
how are murmurs graded?
as a fraction out of 6. 1/6 is very faint and 6/6 is the worst.
how would you assess general knowledge of a client?
by asking how many days in a week or months in a year
how do you assess abstract thinking?
interpret a proverb such as a penny saved is a penny earned.
when does the ability to think abstractly develope?
not until 12 years of age.
how do you test spontaneous speech?
show them a picture and have them describe it
how do you test motor speech?
do, re, mi, fa, so , la, ti, do
test automatic speech
recite days of the week
how do you test CN I
it is the olfactory nerve so you want to have them smell something (hopefully something yummy :).
how do you test CN II?
it is the optic nerve so you test their vision with the snellen chart, identify their visual fields and perform a fundoscopic exam
how do you test CN III, IV, and VI
these are the oculomotor, trochlear and abducense nerves. You test the EOM by having the client move throught the 6 cardinal fields of gaze. You also test the pupils for retraction to light accomodation.
how do you test CN V?
this is the trigeminal nerve. it test motor function of the jaw and tongue, (so have them move the jaw from side to side and clench down), sensory function of the face (so touch them on different areas of the face and see if they know where you did it) and corneal reflex (so touch the cornea with a wisp of cotton or puff air onto it)
how do you test CN VII?
this is the facial nerve so have them make faces or whistle. it also has to do with taste, so taste sweet, salty and sour things on the tip of the tongue.
how do you test CN VIII?
this is the acoustic nerve, so have them listen for a watch ticking. Also perform thet weber, rinne and romberg test since these have to do with balance and hearing (both related to your ear).
how do you test CN IX and X?
these are the glossopharyngeal and vagus nerves, so observe ability to talk, swollow and cough. test motor function by haivng them say ahhh and observe the uvula. Test sensory function by produceing the gag reflex and do a taste test on the POSTERIOR aspect of the tongue.
how do you test CN XI
this is the accessory nerve. Have them shrug their shoulders against resistance and turn their head from side to side
how do you test CN XII?
have them say DLNT and move their tongue from side to side.
increased sensation to pain
no pain (think of analgesics--pain meds)
numbness and tingling
the ability to feel an object and identify it
the ability to tell the number "drawn" in your hand
point localization
they close their eyes and identify when you touched them
sensory extinction
touch bilaterally at the same time. have them identify it
babinski response (what is a positive one and a negative one)
positive would be if the toes fan *this is BAD* ....negative would be if the toes curl down or there is no response (this is good).
what is the order that you assess the abdomen?
inspect, auscultate, percuss, palpate
what is the order that you assess everything BUT the abdomen?
inspect, paplate, percuss, auscultate
the cervical and lumbar curves are ___ and the thoracic and sacral curves are _____
cervical and lumbar are concave, and the thoracic and sacral are convex
when is lordosis a normal finding?
before age 5
genu varum
bowlegs. It is normal for a year after the child begins to walk
what is the normal base of support and stride length for an adult?
2-4 inchese apart and 12-14 in length
foreskin on penis cannot be retracted
tinea cruris
jock itch. a rash in "that area" of a male
when is the penal pulse located?
on the dorsal side
nulliparous, parous and parity
nulliparous is someone who has never had kids. Parous is someone who has had kids, and parity is the number of births that you have had.
normal bowel sounds are :
5-15 seconds or 5-30 times a minute

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