NR509 Mid-Term Study Guide GRADED A VERIFIED

NR509 Mid-Term Study Guide Know the sources of joint pain (pg. 627 algorithm) Nonarticular conditions: trauma/fracture, fibromyalgia, polymyalgia rheumatica, bursitis, tendinitis Intra-articular (acute): acute arthritis (infectious arthritis, gout, pseudogout, reiter syndrome Inta-articular (chronic, > 6 weeks): chronic inflammatory arthritis vs chronic noninflammatory arthritis, rheumatoid arthritis, systemic lupus, scleroderma, polymyositis *Know what causes saddle numbness and urinary retention (pg. 678?) Know how retinal detachment presents (p.217) Sudden, painless vision loss that is unilateral Know what the word obtunded means (p. 769) The obtunded patient opens eyes and looks at you but responds slowly and is somewhat confused. Alertness and interest in the environment are decreased. Know what cranial nerve you’re assessing when checking lateral gaze (p. 237) Cranial nerve VI: abducens Know what should be listed under adult illnesses in health history (pg. 10) Medical illnesses: such as diabetes, hypertension, hepatitis, asthma, and HIV. Also hospitalizations, number and gender of sexual partners, and risk-taking sexual practices Surgical: dates, indications, and types of operations Obstetric/Gynecologic: obstetric history, menstrual history, methods of contraception, and sexual function Psychiatric: illness and timeframe, diagnoses, hospitalizations, and treatments Know what conditions do not have red reflexes (p. 239) Absence of red reflex suggests an opacity of the lens (cataract), or possibly the vitreous (or even an artificial eye). Less commonly, a detatched retina, or in children, a retinoblastoma may obscure this reflex. *Know the signs of seasonal allergies (p. 27) Know how optic neuritis presents (p. 217) Sudden visual loss that is unilateral and can be painful, associated with multiple sclerosis Know how pityriasis rosacea presents (p. 912) Oval lesions on trunk, in older children often in a Christmas tree pattern, sometimes a harold patch (a large patch that appears first) Know what is listed under present illness (p. 9) Complete, clear, and chronologic description of the problems prompting the patient’s visit, including the onset of the problem, the setting in which it developed, it’s manifestation and any treatments to date. (OLDCART) Onset, Location, Duration, Characteristics, Aggravating factors, Relieving factors, Treatments (past) Know where the acromion process is (be able to identify it on a picture) Located between the clavicle and the shoulder *Know what to do if you have a + finding on physical exam but otherwise negative work-up (p. 30) Know what can cause falsely high BP’s (p. 127) If the brachial artery is below the heart level, the blood pressure reading will be higher. If the cuff is too small (narrow) the blood pressure will read high. If the cuff is too large (wide) the BP will read high on a large arm Know how to check for nystagmus (p. 737) Identify any nystagmus, an involuntary jerking movement of the eyes with quick and slow components. Note the direction of the gaze in which it appears, the plane of the nystagmus (horizontal, vertical, rotary, or mixed), and the direction of the quick and slow components. Nystagmus is named for the direction of the quick component. Ask the patient to fix his or her vision on a distant object and observe if the nystagmus increases or decreases. Know what yellow sclera indicates (p. 234) A yellow sclera indicates jaundice Midterm Study Guide Pg. 72 - Know how to get a patient to open up when he seems upset • The first step to effective reassurance is simply identifying and acknowledging the patient’s feelings. For example, you might simply say, “You seem upset today.” This promotes a feeling of connection. Meaningful reassurance comes later, after you have completed the interview, the physical examination, and perhaps some laboratory tests. At that point, you can explain what you think is happening and deal openly with any concerns. Reassurance is more appropriate when the patient feels that problems have been fully understood and are being addressed. • Another way to affirm the patient is to validate the legitimacy of his or her emotional experience. Saying something like, “Your accident must have been very scary. Car accidents are always unsettling because they remind us how vulnerable we are. Perhaps that explains why you still feel upset,” validates the patient’s response as legitimate and understandable • Moving closer or making physical contact like placing your hand on the patient’s shoulder conveys empathy and can help the patient gain control of upsetting feelings. The first step to using this important technique is to notice nonverbal behaviors and bring them to conscious level. Pg. 27 - Know the signs of degenerative pain Pg. 289 - Know how otosclerosis presents with Weber and Rinne test • Weber test • Tuning fork at vertex • Sound is heard in the impaired ear • Room noise not well heard, so detection of vibrations improves • Rinne test • Tuning fork at external auditory meatus; then on mastoid bone • BC longer than or equal to AC (BC > AC or BC = AC) • While air conduction through the external or middle ear is impaired, vibrations through bone bypass the problem to reach the cochlea • The sound is heard longer through bone than air Pg. 183 - Know that cherry angiomas are benign Pg. 231 - Know how to interpret visual acuity results • Visual acuity is expressed as two numbers (e.g., 20/30): the first indicates the distance of the patient from the chart, and the second, the distance at which a normal eye can read the line of letters • 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. • The larger the second number, the worse the vision. • “20/40 corrected” means the patient could read the 20/40 line with glasses (a correction). • A patient who cannot read the largest letter should be positioned closer to the chart; note the intervening distance. Pg. 73 - Know the order of meeting a patient and conducting an interview • Preparation • Reviewing the Clinical Record • Provides important background information and suggests areas you need to explore • Setting goals • Before you talk with the patient, clarify your goals for the interview • The clinician must balance these provider-centered goals with patient-centered goals, weighing multiple agendas arising from the needs of the patient, the patient’s family, and health care agencies and facilities. • Reviewing your clinical behavior and appearance • Posture, gestures, eye contact, and tone of voice all convey the extent of your interest, attention, acceptance, and understanding. • Adjusting the environment • Private and comfortable • Sequence of Interview • Greeting the patient and establishing rapport • How you greet the patient and other visitors in the room, provide for the patient’s comfort, and arrange the physical setting all shape the patient’s first impressions. • Greet the patient by name and introduce yourself, giving your own name. If possible, shake hands with the patient. • Use a formal title to address the patient, • If you are unsure how to pronounce the patient’s name, don’t be afraid to ask. • When visitors are in the room, acknowledge and greet each one in turn, inquiring about each person’s name and relationship to the patient. • Let the patient decide if visitors or family members should stay in the room, and ask for the patient’s permission before conducting the interview in front of them • Always be attuned to the patient’s comfort. • Establishing the agenda • Begin with open-ended questions that allow full freedom of response: “What are your special concerns today?”, “How can I help you?” • Identifying all the concerns at the outset allows you and the patient to decide which ones are most pressing and which ones can be postponed to a later visit. • Identifying the full agenda protects time for the most important issues. • Inviting the patient's story • Invite the patient’s story by asking about the foremost concern, “Tell me more about...” • Do not inject new information or interrupt. Instead, use active listening skills • After the patient’s initial description, explore the patient’s story in more depth. Ask, “How would you describe the pain?”, “What happened next?”, or “What else did you notice?” • Exploring the patient’s perspective • The disease/illness distinction model helps elucidate the different yet complementary perspectives of the clinician and the patient • Disease is the explanation that the clinician uses to organize symptoms that leads to a clinical diagnosis. • Illness is a construct that explains how the patient experiences the disease, including its effects on relationships, function, and sense of well-being • The clinical interview needs to incorporate both these views of reality. • The melding of these two perspectives forms the basis for planning evaluation and treatment. • FIFE • The patient’s Feelings, including fears or concerns, about the problem • The patient’s Ideas about the nature and the cause of the problem • The effect of the problem on the patient’s 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 • Check on these clues and feelings by asking, “How did you feel about that?” or “Many people would be frustrated by something like this.” • Clues to patient’s perspective on illness • Direct statement(s) by the patient of explanations, emotions, expectations, and effects of the illness • Expression of feelings about the illness without naming the illness • Attempts to explain or understand symptoms • Speech clues (e.g., repetition, prolonged reflective pauses) • Sharing a personal story • Behavioral clues indicative of unidentified concerns, dissatisfaction, or unmet needs such as reluctance to accept recommendations, seeking a second opinion, or early return appointment • Learn to respond attentively to emotional cues using techniques like reflection, feedback, and “continuers” that convey support. • A mnemonic for responding to emotional cues is NURSE: • Name—“That sounds like a scary experience”; • Under- stand 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”; • Explore—“How else were you feeling about it? • Expanding and clarifying the patient’s story • You must diligently clarify the attributes of each symptom, including context, associations, and chronology. • For pain and many other symptoms, understanding these essential characteristics, summarized as the seven attributes of a symptom, is critical. • OLD CARTS, or Onset, Location, Duration, Character, Aggravating/ Alleviating Factors, Radiation, and Timing, or • OPQRST, or Onset, Palliating/Provoking Factors, Quality, Radiation, Site, and Timing • Whenever possible, repeat back the patient’s words and expressions • Generating and testing diagnostic hypotheses • You will generate and test diagnostic hypotheses about which disease process might be present. • Identifying all the features of each symptom is fundamental to recognizing patterns of disease and to generating the differential diagnosis. • It is important to fully flesh out the patient’s story. This avoids the common trap of premature closure, or shutting down the patient’s story too quickly • Each symptom has its own “cone” • Sharing the treatment plan • Shared decision-making has been called the pinnacle of patient-centered care • Experts recommend a three-step process: introducing choices and describing options using patient decision support tools when available; exploring patient preferences; and moving to a decision, checking that the patient is ready to make a decision and offering more time, if needed. • 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. • “Ask” open-ended questions—invite the patient to consider how and why they might change. • “Listen” to understand your patient’s experience—“capture” their account with brief summaries or reflective listening statements such as “quitting smoking feels beyond you at the moment”; these express empathy, encourage the patient to elaborate, and are often the best way to respond to resistance. • “Inform”—by asking permission to provide information, and then asking what the implications might be for the patient. • Closing the interview and the visit • Let the patient know that the end of the interview or the visit is approaching to allow time for any final questions. • Make sure the patient understands the mutual plans you have developed. • As you close, summarizing plans for future evaluation, treatments, and follow-up is helpful. • 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. An example would be: “Could you please tell me what you understand is our plan of care? • The patient should have a chance to ask any final questions, but the last few minutes are not a good time to bring up new topics. 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 • Taking the time for self-reflection • “purposefully and nonjudgmentally attentive to [one’s] own experience, thoughts, and feelings. • Because we bring our own values, assumptions, and biases to every encounter, we must look inward to see how our own expectations and reactions affect what we hear and how we behave Pg. 75 - Know that you need permission of the patient to carry out the visit if someone is in the room with them • When visitors are in the room, acknowledge and greet each one in turn, inquir- ing about each person’s name and relationship to the patient. Whenever visitors are present, you are obligated to maintain the patient’s confidentiality. Let the patient decide if visitors or family members should stay in the room, and ask for the patient’s permission before conducting the interview in front of them. For exam- ple, “I am comfortable with having your sister stay for the interview, Mrs. Jones, but I want to make sure that this is what you want” or “Is it better if I speak to you alone or with your sister present?” For sensitive questions, you may need to arrange another time to be with the patient alone. Pg. 7 - Know what makes up the health history (subjective info) • Identifying data • Identifying data - such as age, gender, occupation, marital status • Source of the history - usually the patient, but can be a family member or friend, letter of referral, or clinical record • If appropriate, establish the source of referral, because a written report may be needed • Reliability • Varies according to the patient’s memory, trust, mood • Chief complaints • The one or more symptoms or concerns causing the patient to seek care • Present illness • Complete, clear, and chronologic description of the problems prompting the patient’s visit • Onset of the problem, the setting in which it developed, its manifestations, and any treatments to date. • Each principal symptom should be well characterized, and should include the seven attributes of a symptom: (1) location; (2) quality; (3) quantity or severity; (4) timing, including onset, duration, and frequency; (5) the setting in which it occurs; (6) factors that have aggravated or relieved the symptom; and (7) associated manifestations. • Risk factors may be relevant • The Present Illness should reveal the patient’s responses to his or her symptoms and what effect the illness has had on the patient’s life • Amplifies the chief complaint; describes how each symptom developed • Includes patient’s thoughts and feelings about the illness • Pulls in relevant portions of the Review of Systems, called “pertinent positives and negatives” • May include medications, allergies, and tobacco use and alcohol, which are frequently pertinent to the present illness • Past history • Childhood illnesses • Adult illnesses with dates for events in at least 4 categories: medical, surgical, OB/GYN, and psychiatric • Includes health maintenance practices such as immunizations, screening tests, lifestyle issues, and home safety • Family history • Outlines or diagrams age and health, or age and cause of death, of siblings, parents, grandparents, children, and grandchildren • Documents present or absence of specific illnesses in family, Review each of the following conditions and record whether they are present or absent in the family: hypertension, coronary artery disease, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide, substance abuse, allergies, or type of cancer • Personal and social history • Describes educational level, family of origin, current household, personal interests, and lifestyle • Review of systems • Documents presence or absence of common symptoms related to each of the major body systems Pg. 649, 655, 700 - Know how a rotator cuff tear presents • Patients complain of chronic shoulder pain, night pain, or catching and grating when raising the arm overhead • Look for atrophy of the deltoid, supraspinatus, or infraspinatus muscles. • Palpate anteriorly over the anterior greater tuberosity of the humerus to check for a defect in muscle attachment and below the acromion for crepitus during arm rotation. • In a complete tear, active abduction and forward flexion at the glenohumeral joint are severely impaired, producing a characteristic shrug of the shoulder and a positive “drop arm” test Pg. 37 - Know how to prioritize patient complaints • List the most active and serious problems first • Problems can be symptoms, signs, past health events such as a hospital admission or surgery, or diagnoses. Pg. 629 - Know what joints are condylar • Knee • Temporo-mandibular joint Pg. 703 - Know how RA presents • Acute • Tender, painful, stiff joints in RA, usually with symmetric involvement on both sides of the body. • The distal interphalangeal (DIP), metacarpophalangeal (MCP), and wrist joints are the most frequently affected. • Note the fusiform or spindle-shaped swelling of the PIP joints in acute disease • Chronic • In chronic disease, note the swelling and thickening of the MCP and PIP joints. • Range of motion becomes limited, and fingers may deviate toward the ulnar side. • The interosseous muscles atrophy. • The fingers may show “swan neck” deformities (hyperextension of the PIP joints with fixed flexion of the distal interphalangeal [DIP] joints). • Less common is a boutonnière deformity (persistent flexion of the PIP joint with hyperextension of the DIP joint). • Rheumatoid nodules are seen in the acute or the chronic stage. Pg. 9 - Be able to figure out what is missing in an HPI (scenario, OLDCART method) • Onset • Location • Duration • Characteristics • Aggravating factors • Relieving factors • Treatment Pg. 6 - Know what subjective information is • What the patient tells you • The symptoms and history, from chief complaint through review of systems Ex: Mrs. G is a 54 year old hairdresser who reports pressure over her left chest “like an elephant sitting there,” which goes into her left Know risk factors of melanoma (pg. 177) Personal or family hx of previous melanoma Greater than or equal to 50 common moles Atypical or large moles, especially if dysplatic Red or light hair Solar lentigines (acquired brown macules on sun-exposed areas) Freckles (inherited brown macules) Ultraviolet radiation from heavy sun exposure, sun lamps, or tanning beds Light eye or skin color, especially skin that freckles or burns easily Severe blistering sunburns in childhood Immunosuppression from HIV or from chemotherapy Personal history of non-melanoma skin cancer Know signs of subarachnoid hemorrhage (pg. 216) Severe and sudden “worst headache of my life!” Nausea and vomiting can be present. Neck stiffness with resistance to flexion is present in 21-86% of patients Know how to make a pelvic exam less intimidating (pg. 76) Avoid interviewing a patient when she is already positioned for a pelvic exam Know that if 1 patient returns from a country with malaria you still need to be selective of which patients you screen for malaria. (pg. 66?) Know what absence seizures are. (pg. 781) A sudden brief lapse of consciousness, with momentary blinking, staring, or movements of the lips and hands but no falling. Two subtypes are typical absence (lasts less than 10 sec and stops abruptly) and atypical absence (may last more than 10 sec). Post ictal state: no aura recalled. In typical absence, there is a prompt return to normal and in atypical there might be some postictal confusion. Know which cranial nerve you assess when you touch the soft palate and view the uvula (pg. 275). Cranial nerve X (Vagus) Know signs of increased intracranial pressure (pg. 280). Headache, blurred vision, feeling less alert than usual, vomiting, changes in behavior, weakness or problems with moving or talking, lack of energy or sleepiness Know the signs or respiratory distress (p. 318) Tachypnea: greater than or equal to 25 breaths/mim Cyanosis or pallor (signals hypoxia) Audible sounds of breathing: audible whistling during inspiration over the neck or lungs (stridor signals upper airway obstruction in the larynx or trachea) Contraction of the accessory muscles of the neck or supraclavicular retraction, contraction of the intercostal or abdominal oblique muscles Is the trachea midline? Know what objective information is (pg. 6) What you detect during the examination, laboratory information, & test data. All physical exam findings, or signs. Know what can cause epistaxis (p. 220) Trauma (especially nose picking), inflammation, drying and crusting of the nasal mucosa, tumors, and foreign bodies Know the signs of otitis externa (swimmer’s ear) (pg. 245) Painful movement of the auricle and tragus (tug test) Know the signs of pneumonia (pg. 322-340) Dullness replaces resonance, crackles can arise from abnormalities of the lung parenchyma, pleural rubs, localized bronchophony and egophony (in patients with fever and cough the presence of bronchial breath sounds and egophony more than triples the likelihood of pneumonia. Pleuritic pain: sharp, knifelike, aggravated by deep inspiration, coughing, movements of the trunk. Often persistent and severe. Pg 333: dyspnea, pleuritic pain, cough, sputum, fever. Pg. 339 goes over physical findings in lobar pneumonia Know the physical signs of meningitis (pg. 765) Neck stiffness with resistance to flexion is present in approx. 84% of patients with acute bacterial meningitis (won’t be able to touch chin to chest) Know the signs of asthma (p. 326, 334) Cough at times with this mucoid sputum, especially near the end of an attack. Episodic wheezing and dyspnea, but cough may occur alone, often with a history of allergies. In the advanced airway obstruction of severe asthma, wheezes and breath sounds may be absent due to low respiratory airflow (the “silent chest” which is a clinical emergency). Abnormal retraction occurs in severe asthma. Know the signs of lyme disease (pg. 208) Rash, often in a bull’s-eye pattern (erythema migrans) and flu-like symptoms, fever, headache, fatigue Know what acanthosis nigricans can clue into (pg. 207 & 440) Diabetes mellitus Know red flags for headaches (p. 216) Progressively frequent or severe over a 3-month period Sudden onset like a “thunderclap” or “the worst headache of my life” New onset after age 50 Aggravated or relieved by change in position Precipitated by Valsalva maneuver or exertion Associated symptoms of fever, night sweats, or weight loss Presence of cancer, HIV infection, or pregnancy Recent head trauma Change in pattern from past headaches Lack of similar headache in the past Associated papilledema, neck stiffness, or focal neurologic deficits Know labs to check with vitiligo (pg. 191) Thyroid panel: TSH, free T3 and free T4 C-section (pg. 10) Know that it should be listed under surgeries, make sure you include date indication and type of surgery Subjective info (p. 12) Goes under the review of systems, includes items that the patient reports to you Where to sit when interpreter in the room (p. 90) Arrange sitting so that you have easy eye contact with pt , have the interpretor sit close or behind you (keeps you from turning your head back and forth) Know what is included in constitutional symptoms (pg. 112) Concerning s/s fatigue, weakness, fever, chills, night sweats, weight change and pain. (pg. 192) know how psoriasis presents If you run ur fingers over a lesion and its palpable above the skin – its raised, over one cm its PLAGUE under one cm its PAPULE (pg. 231)know what visual acuity means, 20/100 Means that at 20 feet the patient can read a print that a person with normal vision could read at 100 ft, the larger the second number the worse the vision First # indicates the distance from the chart (pg. 241) see the picture and know what cotton whool patches look like, Its irregular patches seen at diabetic and hypertensive retinopathy (pg. 270) Know how a subconjunctival hemorrhage presents Benign, no treatment required, resolves in 2 weeks , Leakage of blood outside the vessel producing homogenous red area. , no ocular discharge, vision not affected, Usually resulting from trauma, or sudden increase in venous pressure (pg. 310) Know to consider Angina Pectoris as a differentia with CP. It can be a cause for pain in the myocardium. A clenched fist over the sternum suggest angina pectoris Olfactory CN I (pg. 736) The decreased sense of smell is normal in elderly patients, head trauma, smoking, cocaine use and parkinsosn d/e. Shoulder shrug (pg. 740) Testing the CN XI Spinal Accessory nerve. Put your hands on pt shoulder and ask them to shrug against your hands- asses for strength and contraction of trapezii. Weakness noted with atrophy and points to a peripheral nerve disorder. Vasovagal syncope causes (pg. 778) Reflex withdrawal of sympathetic tone and increased vagal tone causing a drop in BP and HR. Usually precipitated by strong emotions such as fear or pain, prolonged standing or hot humid environment. Predisposing factors – fatigue, hunger, dehydration, diuretics, vasodilators