ADVANCED HEALTH ASSESSMENT FINAL EXAM VERSION A COMPLETE 200 QUESTIONS AND VERIFIED CORRECT DETAILED ANSWERS ||ALREADY GRADED A+

ADVANCED HEALTH ASSESSMENT FINAL EXAM VERSION A COMPLETE 200 QUESTIONS AND VERIFIED CORRECT DETAILED ANSWERS ||ALREADY GRADED A+ A circumscribed, elevated lesion, >1 cm I diameter and containing clear serous fluid is best described as - CORRECT ANSWERS - Bulla The history and physical of a client indicates paste occurrences of lichenification. The NP identifies this as: - CORRECT ANSWERS - Rough, thickened epidermis, accentuated skin markings On examination of a client's skin, the nurse practitioner finds a lesion that is about 0.75 cm in diameter, brown, and circumscribed. Correct term for this lesion is: - CORRECT ANSWERS - Macule In performing a skin assessment, the NP understands that the following characteristic of a mole would need intervention: - CORRECT ANSWERS - A new 2mm mole that is brown with a red, irregular border, and occasionally pruritic The NP describes an annular skin lesion as usually arranged in - CORRECT ANSWERS - A circle or ring shape An NP educating patients realizes that risk factors for skin cancer include all except: - CORRECT ANSWERS - Dark eyes Which of the following in a client's history would place the patient most at risk for melanoma? - CORRECT ANSWERS - Intense, intermittent sun exposure An elderly retired farmer presents with a rolled border, pearly, firm nodule with telangiectasia on his nose. This is: - CORRECT ANSWERS - Basal cell carcinoma An adult female presents with an irregular, variegated nevus on her left lower back that has doubled in size the past ?. The NP should: - CORRECT ANSWERS - Refer immediately to a dermatologist The ABCDs of melanoma identification include all of the following EXCEPT: - CORRECT ANSWERS - B (bridging): connection across sides Your patient is 2 weeks old. During your assessment, you note that she has pinhead sized, smooth, white, raised areas. You document this as: - CORRECT ANSWERS - Milia Which skin lesions are directly related to chronic sun exposure and photo damage? - CORRECT ANSWERS - Actinic keratosis In your assessment you note Ms. Angel has white nail syndrome, you order: - CORRECT ANSWERS - BUN & Creatinine Mary D. an 84 y.o F has multiple solar lentils <1 cm. These are not uncommon for her age. You would describe these - CORRECT ANSWERS as: Macules Lou, a 50 yo homeless man is diagnosed with tinea capitis. You realize this is cause by a(n): - CORRECT ANSWERS - Dermatophyte Ron R presents with dependent edema. You assess he has a >1 inch indentation up to mid-tibia bilaterally. You document this as: - CORRECT ANSWERS - +4 edema The most common type of melanoma is the: - CORRECT ANSWERS - Superficial You are assessing Arlene C's skin complaint. You get a +Auspitz sign. This aides you in the diagnosis of: - CORRECT ANSWERS - Psoriasis As you gather you history from a patient with atopic dermatitis what other items in the personal or family history would you expect with this patient? - CORRECT ANSWERS - Asthma Which of the following statements best describes squamous cell carcinoma? - CORRECT ANSWERS - Often has a keratinous horn You are assessing a newborn and note the baby is jaundiced. He is 3 days old. You realize that for this to be a normal finding it must be gone within: - CORRECT ANSWERS - 1 week What are the major components to be documented for a skin lesion? - CORRECT ANSWERS - -Distribution -Configuration -Palpable features -Pattern -All of the above Which of the following presentations suggests a diagnosis of a malignant melanoma? - CORRECT ANSWERS - Lesion with border irregularity All of the following statements concerning basal cell carcinoma are true EXCEPT? - CORRECT ANSWERS - It is most often found on abdomen or trunk The NP denotes a bruit above and to the left of the umbilicus. This finding is consistent with: - CORRECT ANSWERS - History of HTN As you palpate the abdomen, + rebound tenderness at McBurney's point would alert you to: - CORRECT ANSWERS - Appendicitis Which of the following is true regarding colorectal cancer? - CORRECT ANSWERS - Later disease presentation often includes iron deficiency anemia You assess for Cullen sign in Dan, age 62, after surgery. Cullen sign may indicate: - CORRECT ANSWERS - Intra-abdominal bleeding When percussing the abdomen, you document hyper-resonance. This most likely represents: - CORRECT ANSWERS - Gaseous distention A positive fluid wave test may occur with all of the following conditions EXCEPT – CORRECT ANSWERS - Inflammation of the spleen Harold Williams abdominal exam includes a liver span of 3.0 MCL. Your assessment reveals: - CORRECT ANSWERS - Liver atrophy To test for a positive obturator sign in a client with abdominal pain, the NP: - CORRECT ANSWERS - Passively rotates the right hip from the 90 degree hip/knee flexion position A middle-aged woman who is overweight had RUQ pain that radiates to her R subscapular area. If there is a positive , the patient has - CORRECT ANSWERS - Murphy's sign, cholecystitis A clients complains of extreme pain in his abdomen and points to the RLQ. In examining the acute abdomen, the NP would: - CORRECT ANSWERS - Palpate the left side of the abdomen, then the right side, noting guarding and tenderness The most important goal of assessing a client with abdominal pain is - CORRECT ANSWERS - Rule out emergent conditions While examining the abdomen of a post-op patient, you note that the bowel sounds are noted within 20 seconds. You. document that this is: - CORRECT ANSWERS - a normal finding During your abdominal assessment you note purple striae. Your next step would be to: - CORRECT ANSWERS - Ask about cold/heat intolerance Ruay Smith is a 27 yo M diagnosed with ulcerative colitis at age 18. He needs a colonoscopy by age - CORRECT ANSWERS - 30 When palpating the abdomen of an infant, the NP realizes that the spleen is easily palpable: - CORRECT ANSWERS - True In your examination of Gordon, age 29, you elicit L costa-vertebral angle tenderness. What do you expect? - CORRECT ANSWERS - Pyelonephritis When auscultating a patient's abdomen, the NP hears a systolic bruit in the epigastric area. It occurs at a fixed interval, most likely source of this bruit is: - CORRECT ANSWERS - abdominal aorta Jay Smith presents with abdominal pain. As you assess him you chat +AWT. This leads you to what possible diagnosis - CORRECT ANSWERS - Muscle strain Mr Java is an 85 yo M, you realize that abdominal disorders in the older patient are more difficult to diagnose because - CORRECT ANSWERS - Vague symptoms and often little to no pain Mrs Jones is a female patient with history of ETOH abuse. Your abdominal exam should include: - CORRECT ANSWERS - The scratch test When examining the eyes, the NP realizes that the pupils change in size when the client focuses from a close object to a far object. This is: - CORRECT ANSWERS - Normal visual accommodation On ophthalmic examination, there appears to be narrowing or blocking of the vessels. Significance of this finding is: - CORRECT ANSWERS - The client should be evaluated for chronic hypertension Mr Smith has a +bruit upon examination of the thyroid. This most likely indicates: - CORRECT ANSWERS - Hyperthyroidism As you are getting your patients history you notice bilateral lid lag of the eye. You make a note to yourself to assess for problems with: - CORRECT ANSWERS - thyroid 70 yo comes to clinic c/o blurred vision, problems w glare, no pain. NP should check first for - CORRECT ANSWERS - cataract At what age do you approximate adult vision? - CORRECT ANSWERS - 4 years old The purpose of conducting the Rinne test is to determine the conduction of sound through bone and auditory canal to determine that: - CORRECT ANSWERS - Air conduction is twice as long as bone conduction Sally, age 19, presents with pain and pressure over her cheeks and discolored nasal discharge. You cannot transilluminate. Which sinus is affected? - CORRECT ANSWERS - Maxillary Zeke Gilbert, age 72, retired factory worker, has hearing loss in the right ear due to excessive cerumen. The NP would expect to find during the weber test - CORRECT ANSWERS - Sound materializes to the Right ear What is the correct procedure for palpation of a client's thyroid gland? - CORRECT ANSWERS - Have a client lower chin and lean slightly toward the side being evaluated you are giving an 85 yo nursing home resident her annual physical exam. History of HTN. Margin of lower lid is turned outward and conjuctiva is exposed - CORRECT ANSWERS - Ectropion 56 yo salesman evaluated area on the tongue that has been present for 3 , unable to scrape off. White painless plaques. What is the likely diagnosis? - CORRECT ANSWERS - Leukoplakia Client presents with conjunctivitis. Which lymph nodes would you expect to find enlarged? - CORRECT ANSWERS - Pre-auricular and anterior cervical Conducting an ophthalmic exam on a patient with chronic hypertension. What would you expect to see? - CORRECT ANSWERS - cotton wool patches and flame hemorrhages When Judy, age 15, asks you to explain what 20/50 vision means you respond: - CORRECT ANSWERS - You can see at 20 feet what normal people can see at 50 feet Ms Ins presents with eye pain. The external eye is red, tender, swollen, raised area, pointing outward on the lash border. This is: - CORRECT ANSWERS - Hordeolum firm, painless, relatively fixed submandibular node would most likely be seen in the diagnosis of : - CORRECT ANSWERS - oral caner As an APN, you believe strongly in anticipatory guidance and prevention education. You explain this to your patient that the development of screening and prevention guidelines is based on: - CORRECT ANSWERS - increased in average life expectancy ted who is 15 yo just moved into the community and is staying in a foster home temporality without any record of immunizations. Which immunizations does he need? - CORRECT ANSWERS - -meningococcal -mmr -tdap -all of the above*** the client tells you that he takes aspirin daily. What question should you ask next? - CORRECT ANSWERS - Why do you take aspirin daily? Mr. Bill presents to your office for a physical. You note that his BMI is 27. You inform him that this is considered - CORRECT ANSWERS - overweight You are evaluating an elderly man who was brought by his distraught daughter. You explain that many physical changes occur as we age that affect nutrition. Including all of the following except? - CORRECT ANSWERS - total caloric needs increase Mr P complains of a "pain in his stomach". In your note you document that he is c/o pain in the LLQ, radiating with worsening intensity towards the umbilicus. Pain is 6/10. Denies n/v/d. HPI should include- - CORRECT ANSWERS - When did it begin? During a routine physical exam of a 44 yo woman you note she has an inverted left nipple. You decide to investigate because: - CORRECT ANSWERS - The inversion may be a recent change A 30 yo F is in the office c/o palpiations and some lightheadedness for the past ?, random episodes, no detectable pattern. NP notes a mid systolic click with a late systolic murmur heard best in the apical area. You suspect - CORRECT ANSWERS - Mitral valve prolapse (MVP) All of the following tests require the patient's voice to perform correctly except: - CORRECT ANSWERS - -egophany -tactile fremitus -whispered pectoriloquy *auscultation* 59 yo M with history of COPD presents with worsening dyspnea. Patient is afebrile, breath sounds are decreased bilaterally, noted to have JVD and pitting edema of lower extremities. What is the most likely cause of his dyspnea? - CORRECT ANSWERS - CHF James Jones 55 yo M smoker presents with thick sputum producing cough. Exam: +tactile fremitus, resonant percussion, and normal voice transmission. You suspect: - CORRECT ANSWERS - bronchitis During the breast exam of a 30 year old nulliparous female. The NP palpates several rubbery areas of the breast tissue. They are slightly tender to palpation and present in both breasts. Expecting menses in 5 days. Which intervention is best? - CORRECT ANSWERS - Tell her to recheck 1 week after her menses All of the following symptoms associated with chest pain are likely to represent CAD except? - CORRECT ANSWERS - pain with inspiration 60 yo landscaper presents to your office to establish care, history of CHF controlled with medications. Denies cp, edema. Early diastolic ? with opening snap . You suspect? - CORRECT ANSWERS - Mitral stenosis When performing a H&P on a pediatric patient. Which important factor affects the outcome the most: - CORRECT ANSWERS - Child's developmental level The most important question to ask as you build your HPI is - CORRECT ANSWERS - Have you ever had this before? Which of the following patients is least likely to become an alcohol abuser? - CORRECT ANSWERS - 50 yo construction worker who drinks 1 beer nightly You are describing a lesion noted on Mr Smith a 55 yo M. It is flat, nonpalpable, <1cm. You describe this as a - CORRECT ANSWERS - macule A patient states that she has had a rash on her breast for about 2 weeks. In order to determine if it is pagets disease you would expect to have all of the following on physical exam EXCEPT - CORRECT ANSWERS - inverted nipple You notice a medium-pitched harsh systolic murmur during a routine exam or R upper border of the sternum. Which of the following is most likely? - CORRECT ANSWERS - Aortic stenosis Which of the following statements in NOT typical of the murmur it is describing? - CORRECT ANSWERS - Grade II/Grade VI murmur is associated with a thrill? you realize that as an APN you must ask sensitive questions, the most important thing is to be: - CORRECT ANSWERS - nonjudgemental cultural competence is best enhanced when the healthcare provider - CORRECT ANSWERS - uses self awareness and reflection you are assessing Jenna's broken arm in the ER and you suspect she may be a victim of violence. What statement triggered your concern? - CORRECT ANSWERS - I hurt it about 4 days ago You organize a BP screening for a fair at the mall. You are involved in which type of prevention? - CORRECT ANSWERS - secondary prevention Mr Smith presents with RLQ pain, you document in the HPI that he also c/o nausea. This is considered: - CORRECT ANSWERS - An associated symptom Jill Basket's daughter is explaining to you why her mother is here. This is an example of: - CORRECT ANSWERS - Subjective information You have administered a CAGE questionnaire and the patient answers "yes" to questions 2 & 4. What significance is this? - CORRECT ANSWERS - patient has physical dependence and needs intervention You are meeting a 14 yo pt for the first time. You would want to include the following in your exam - CORRECT ANSWERS - HEADS and RAFFT As the NP you are giving your patient a mini-mental status examination. The patient scores 29. This is considered - CORRECT ANSWERS - A normal finding Which of the following is NOT one of the adult health history - CORRECT ANSWERS - Physical exam Mr Jones is a new patient with history of diabetes. You realize that in order to get reimbursed at a higher level for the diabetic education you must document at least what % with the patient? - CORRECT ANSWERS - 55% Susie Lee presents for check up to your office, she was seen by your partner two years ago. According to CPT definition she is - CORRECT ANSWERS - Established Keys to select for the right level of billing includes - CORRECT ANSWERS - History, exam, decision making Key element for all levels of CPT code is - CORRECT ANSWERS - Chief complaint When obtaining health history from an older client must be taken into consideration? - CORRECT ANSWERS - Auditory acuity is the most common sensory loss in the aged population and may hinder the interview 70 yo Mr Willians is a new patient, has no complaints, requesting a physical. His physical is unremarkable but which of the following puts him at risk: - CORRECT ANSWERS - Waits of 42 inches Limiting public smoking is an example of secondary prevention. True or false - CORRECT ANSWERS - FALSE James is a 17yo patient who presents for school physical. Based on the leading cause of mortality for this age group, you should discuss: - CORRECT ANSWERS - Seat belt use Lisa is a 53 yo F who presents for a physical. According to ABCDE approach to preventing cardiology: the items to assess for the "A" include all EXCEPT - CORRECT ANSWERS - -assessment of risk -antiplatelet use -*apple shape* -anticoagulation Larry 25 yo M presents to have TB test read. Should be billed at - CORRECT ANSWERS - 99211 Learning how to drive with a therapist after a stroke is called - CORRECT ANSWERS - Tertiary prevention NP evaluating an 85 yo M NP instructs the patient to remember words and repeat them in 10 minutes. Which of the tests are being described? - CORRECT ANSWERS - MMSE A charitable foundation plans to build a community youth center in a large urban area with history of gang violence. What type of prevention is being done? - CORRECT ANSWERS - Primary prevention All of the following are true about domestic abuse EXCEPT? - CORRECT ANSWERS - No delay in seeking treatment The SCOFF screening tool is used to diagnose eating disorders - CORRECT ANSWERS - False A 58 yo dentist presents for routine check up. He has been healthy. Non smoker, does not drink alcohol. You hear a moderately loud murmur, no palpable thrill. What is the appropriate grade for this murmur? - CORRECT ANSWERS - Grade 3 57 yo college professor is hospitalized for SOB. As you examine her in ER, JVP of 45 degrees 8 cm above the clavicle. finding is most consistent with which of the following diagnoses? - CORRECT ANSWERS - Right sided heart failure What technique should be used to best auscultate the 2nd heart sounds? - CORRECT ANSWERS - Diaphragm of the stethoscope at 2nd intercostal space at the base of the heart You hear a split s2 on auscultation of a 25 yo client. What is your best action? - CORRECT ANSWERS - Tell them to hold their breath and repeat The clinet has been told he has a heart murmur. He asks you what this means. You explain - CORRECT ANSWERS - It is the rushing sound blood makes moving through narrow places. Some are harmless and others indicate problems Where would you expect to hear best an abnormal sound with mitral valve insufficiency? - CORRECT ANSWERS - 5th ICS at MCL when auscultating the heart sounds of a 72 yo client with history of HTN. NP notes an S4. This finding could indicate - CORRECT ANSWERS - An increased resistance to ventricular filling As you assess Ms Jones you recall that the most prevalent cardiac symptom is - CORRECT ANSWERS - Fatigue Joe Tiger presents with complaints of pain in his leg when walking that is relieved with rest. You perform ABI. Which result would be consistent with physical symptoms? - CORRECT ANSWERS - 0.6 As you assess your patient you document Osler's nodes. You realize that this could be a sign of? - CORRECT ANSWERS - Endocarditis During the physical exam of 72 yo Mary Rose you note a BP of 140/90. According to JNC 8, what would you do first? - CORRECT ANSWERS - Calculate cardiac risk When auscultating a clients heart you note short, high-frequency click (opening snap) after S2 during the beginning of diastole. What could this indicate? - CORRECT ANSWERS - Mitral stenosis NP upon exam notes a bilateral gray ring around the irises of the 80 yo patient. Denies vision changes or pain. What is the possible diagnosis? - CORRECT ANSWERS - Arcus senilis To rule out middle lobe pneumonia you would make sure to auscultate - CORRECT ANSWERS - Under the right axillae In assessing a patient with a positive cardiac history, you utilize CHADS scoring. What are the elements of this scoring system? - CORRECT ANSWERS - HTN, DM, CHF The NP is aware that acute bronchitis is characterized by? - CORRECT ANSWERS - Paroxyms of coughing that is dry or productive of mucoid sputum 21 year old college senior to clinic c/o SOB x 3 days. Hx asthma, controlled with medications. S/s URI with fever. Increased use of rescue inhaler. What would you expect her lung sounds to be? - CORRECT ANSWERS - Wheezes during inspiration and expiration All of these are abnormal breathing in the infant EXCEPT - CORRECT ANSWERS - louder, harsher sounds A positive clinical sign on the physical exam indicating pneumonia is - CORRECT ANSWERS - Dullness on percussion Lung sounds that have low pitch and soft in intensity and are heard better on inspiration - CORRECT ANSWERS - Vesicular When auscultating for vocal resonance in a client with possible consolidation of lung tissue. The NP hears "a-a-a" when the client says "e-e-e". This is called: - CORRECT ANSWERS - Positive egophany The NP understands the following about hyperresonance in percussion of the lungs - CORRECT ANSWERS - It is expected finding with emphysema 55 yo client tells you she smoked 2ppd since age 14. How many pack years? - CORRECT ANSWERS - 82 During pulmonary assessment, you observe the client to have diaphragmatic excursion of 4 cm bilaterally. What is your best action? - CORRECT ANSWERS - Document the observation As you assess Ms L you understand that her dyspnea is basically a dysfunction with external respiratory physiology. Due to her - CORRECT ANSWERS - emphysema You review a chart of a patient seen 2 days ago by your collegue. You see a positive whispered pectoriliquy test, you understand this is - CORRECT ANSWERS - Abnormal - loud & clear finding To ease their breathing, clients with COPD often position themselves in a tripod position which can result in which finding? - CORRECT ANSWERS - Dahl's sign Which is NOT a risk factor for breast cancer? - CORRECT ANSWERS - - History of maternal breast cancer -1st pregnancy after age 35 -*asymmetric breast development* -late menopause after 54 Which description is most characteristic of breast cancer? - CORRECT ANSWERS - Single, firm, nontender, ill-defined breast lump You are assessing a neonate and note breast engorgement. You document this as an abnormality. True or false - CORRECT ANSWERS - FALSE With which of the following clients having a breast lump are you alerted to the possibility of a fibroadenoma? - CORRECT ANSWERS - 25 yo woman with a single firm rubbery lump When performing a clinical breast exam, you take special care to examine the upper outer quadrants and axilla because - CORRECT ANSWERS - Most frequent location of breast cancer Which of the following statements is true regarding the internal structures of the breast? - CORRECT ANSWERS - The breast is composed of fibrous, glandular, and adipose tissue In an older man, gynecomastia may be secondary to: - CORRECT ANSWERS - A change in testosterone Which of the following statements is most suggestive of a fibrocystic breast condition? - CORRECT ANSWERS - I feel a lump in my breast before my periods Which of the following statements is the best way to promote breast self- examination? - CORRECT ANSWERS - "breast self-examination on a monthly basis will help you to become familiar with your breast tissue and its normal variations" a 34 yo woman noted that she had nipple discharge for two months. Pregnancy test was negative. Which of the following characteristics of the discharge would be most concerning? - CORRECT ANSWERS - Bloody 52 yo F palpable breast lump. Fine needle aspiration does not bring any fluid. .. . What is the next step? - CORRECT ANSWERS - Refer for biopsy You have noted a thrill at the apex during systole during a physical exam on the patients anterior chest. This could indicate - CORRECT ANSWERS - Mitral regurge Mr Bear presents c/o excessive daytime sleepiness. Exam reveals flushed face, SOB ambulating into the room. BMI>30 , +JVD, +HJR, HTN. Your possible list of diagnoses include all EXCEPT - CORRECT ANSWERS - - pickwickian syndrome -CHF -*Atrial fibrillation* -Metabolic syndrome In assessing for pneumonia, you would expect to find in tactile vocal fremitus - CORRECT ANSWERS - Increase Lilly age 3 months was seen for a cold. Which physical finding is most common in the infant? - CORRECT ANSWERS - Wheeze An abnormal symmetric expansion would most likely be noted on which of the following patients? - CORRECT ANSWERS - Pneumonia You are assessing a pediatric patient with croup. What clinical finding would you expect to discover? - CORRECT ANSWERS - croup Mr Random is being seen for SOB you are assessing his neck veins and need to distinguish the jugular from the carotid. You understand that there is a change in respiration with the . - CORRECT ANSWERS - Jugular You are doing a physical on a male patient when he tells you he is concerned about breast cancer. All of the following are risk factors EXCEPT: - CORRECT ANSWERS - -Testosterone -*45-55 years old* -Low level of physical activity -History of bone fracture after 45 Breast cancer in men is similar to women and the provider should be suspicious of the Tail of Spence. True or false - CORRECT ANSWERS - FALSE What is the most common cause of left ventricular hypertrophy in the US? - CORRECT ANSWERS - Chronic HTN patient tells you they are taking ASA everyday. What do you ask next? - CORRECT ANSWERS - Why are you taking ASA daily? what is the most important rule as an APN regarding sensitive topics - CORRECT ANSWERS - be nonjudgmental still have to be succinct, focused, and direct too cultural competence is best enhanced when the HCP? - CORRECT ANSWERS - uses self-awareness and reflection you assess a patients broken arm and you suspect she may be a victim of violence. which statement triggers your concern? - CORRECT ANSWERS - I hurt it about 4 days ago=delay of treatment you are going to organize a BP screening fair at the mall. you are involved in what type of prevention? - CORRECT ANSWERS - secondary prevention secondary prevention - CORRECT ANSWERS - screening means you are looking for a disease thats already there patients presents with RLQ pain, as you document his HPI you note his c/o nausea. In your symptom analysis this would be considered: - CORRECT ANSWERS - associated symptom Pt's daughter is explaining why her mother is at the office. This is an example of: - CORRECT ANSWERS - subjective information Pt has a BMI of 27. Is this normal, underweight, or overweight? - CORRECT ANSWERS - overweight You administered the CAGE questionnaire as part of a screening policy and the patient answers yes to 2 and 4. what is the significance of this if any? - CORRECT ANSWERS - he has physical dependence and needs intervention what does question 4 on the CAGE questionnaire ask? what is the significance of it? - CORRECT ANSWERS - do they need an eye opener? it indicates physical dependence you are meeting for the first time a 14 y/o female patient. you would want to include the what in her exam? - CORRECT ANSWERS - HEADS & RAFFT what does HEADS & RAFFT assess - CORRECT ANSWERS - behavior of the teenager patient scores a 29 on the mini-mental exam. what do you document this as? - CORRECT ANSWERS - a normal finding what are the components of the adult health history? - CORRECT ANSWERS - 1. identifying data 2. history of present illness 3. review of systems NOT physical exam what does the CAGE questionnaire look for - CORRECT ANSWERS - alcoholism coronary artery disease risk factors (4) - CORRECT ANSWERS - 1. smoking 2. HTN 3. family history 4. age you have a new patient and in order to get reimbursed at a higher level for education you provide, you must document the time spent on this education at least what percentage of the visit - CORRECT ANSWERS - at least 55% of the visit how do you define an established patient - CORRECT ANSWERS - patient presents for a checkup in your office. you have not seen her before but she was last seen by the MD in your group 2 years ago how long would it be since a patient has been seen in the same practice for them to be considered a new patient - CORRECT ANSWERS - 3 years ago as you review your note for your patient you realize that the keys to select the right level of billing include what 3 things - CORRECT ANSWERS - history exam decision making when performing a history & physical on a pediatric patient, which important factor affects the outcome the most: - CORRECT ANSWERS - child's development level the key element for all levels of CPT code documentation is: - CORRECT ANSWERS - chief complaint when obtaining a health history from an older client, which characteristics of the older client must be taken into consideration? - CORRECT ANSWERS - auditory acuity is the most common sensory loss in the aged population and may hinder the interview what's the most important question to ask as you build your HPI - CORRECT ANSWERS - have you ever had this before? the development of screening and prevention guidelines is based on? - CORRECT ANSWERS - increase in average life expectancy limiting public smoking is what type of prevention? - CORRECT ANSWERS - primary prevention-trying to prevent disease what is the leading cause of mortality in teenagers - CORRECT ANSWERS - motor vehicle accidents according to the ABCDE approach to preventive cardiology, the items to assess for the "A" include: (3 Things) - CORRECT ANSWERS - 1. assessment of risk 2. antiplatelet therapy 3. anticoagulation therapy NOT apple shape patients presents to have a TB test read. how is this billed? - CORRECT ANSWERS - 99211 b/c it doesn't have to be seen as a provider teenager moved to the community and doesn't have any immunization records. what do you do - CORRECT ANSWERS - repeat vaccines learning how to drive with a therapist after a stroke is considered what type of prevention - CORRECT ANSWERS - tertiary prevention already have the disease and the manifestation of the disease adding a community youth center to an area with a history of gangs is what type of prevention - CORRECT ANSWERS - primary prevention trying to prevent more gangs the SCOFF screening too is used to diagnose eating disorders: true or false - CORRECT ANSWERS - False no screening tool diagnoses affects of aging on our body - CORRECT ANSWERS - 1. fat replaces muscle 2. decrease in lean body mass 3. lowered protein reserves slow the body's response 4. total caloric needs decrease you do a physical exam of a healthy 58 y/o patient and you hear a moderately loud murmur and there is no palpable thrill. what is the appropriate grade of this murmur? - CORRECT ANSWERS - grade 3 what's the difference between a grade 3 and grade 4 murmur? - CORRECT ANSWERS - grade 4 has a thrill you exam a patient in the ER who presents with SOB. Her JVP at 45 degrees is 7cm above the clavicle. Understanding the formula for determining JVP in relation to the right atria, this finding is most consistent with what diagnosis? - CORRECT ANSWERS - right-sided heart failure where can you best auscultate the 2nd heart sound? - CORRECT ANSWERS - place the diaphragm of the stethoscope at the 2nd ICS at the base of the heart you hear a split S2 on auscultation of a 25 y/o client. what is your best action? - CORRECT ANSWERS - ask the client to hold their breath and repeat physiology S2 is related to respirations where would you expect to hear best an abnormal heart sound when the client has mitral valve insufficiency? - CORRECT ANSWERS - 5th ICS, left MCL what does an S3 heart sound indicate - CORRECT ANSWERS - volume what does an S4 heart sound indicate - CORRECT ANSWERS - stiffness you hear an S4 on a 72 y/o client with a history of HTN. What could this finding indicate? - CORRECT ANSWERS - an increased resistance to ventricular filling which result for an ABI would be consistent with physical symptoms? patient c/o of pain in his leg when walking that is relieved with rest - CORRECT ANSWERS - ABI of 0.6 what is the normal ABI - CORRECT ANSWERS - 1.0 what could oslers nodes be a sign of - CORRECT ANSWERS - endocarditis During the physical exam of a 72 y/o you note a BP of 140/90. According to the JNC 8, what would you do first? - CORRECT ANSWERS - calculate cardiac risk pulsus paradoxus is more likely to be associated with: - CORRECT ANSWERS - status asthmaticus what is arcus senilis - CORRECT ANSWERS - bilateral gray ring around the irises of older patients. pt will deny visual changes bilateraly gray ring around the iris NOT in an elderly patient - CORRECT ANSWERS - hyperlipidemia to r/o middle lobe pneumoia where would you auscultate? - CORRECT ANSWERS - under the right axillae 30 y/o patient c/o palpitations and some light-headedness for past 6 months. NP notices a mid-systolic click with a late systolic murmur heard best in the apical area. what would you suspect? - CORRECT ANSWERS - mitral valve prolapse what is acute bronchitis characterized by - CORRECT ANSWERS - paroxysms of coughing that is dry or productive of mucoid sputum a positive clinical sign on physical exam indicating pneumonia is: - CORRECT ANSWERS - dullness on percussion when auscultating for vocal resonance in a client with possible consolidation of lung tissue, the NP hears "a" when the client says "e". this is called: - CORRECT ANSWERS - positive egophony what does hyperresonance in percussion of the lungs indicate? - CORRECT ANSWERS - an expected finding with emphysema b/c of air trapping as you assess a client you understand that their dyspnea is basically a dysfunction with external respiratory physiology due to her: - CORRECT ANSWERS - emphysema happens at the lung where does external respiration happen - CORRECT ANSWERS - at the lung where does internal respiration happen - CORRECT ANSWERS - at the tissue level assess a 55 y/o smoker with a thick sputum producing cough. on exam you notice a positive tactile fremitus, resonant percussion, and normal voice sounds. you suspect: - CORRECT ANSWERS - bronchitis you review a chart of a patient with positive whispered pectoriloquy. you understand this to be: - CORRECT ANSWERS - abnormal-loud and clear finding what does the presence of increased tactile fremitus indicate - CORRECT ANSWERS - fluid or solid mass within the lungs what are 3 risk factors for breast cancer? - CORRECT ANSWERS - ry of maternal breast cancer (premenopausal onset) 2. first pregnancy after age 35 3. late menopause after 54 is asymmetric breast development a risk factor for breast cancer - CORRECT ANSWERS - no what is a good description of a breast cancer lump - CORRECT ANSWERS - single, firm, non-tender, ill-defined what is the classic description of a fibroadenoma? - CORRECT ANSWERS - single, firm, rubbery lump what types of tissues compose the internal structures of the breast - CORRECT ANSWERS - fibrous, glandular, and adipose tissue in an older man, gynecomastia may be secondary to: - CORRECT ANSWERS - a change in testosterone what would you expect to find on physical exam in a patient with Paget's disease? (3 things) - CORRECT ANSWERS - 1. c/o itching and crusting 2. scaly appearance of nipple 3. redness & thickening of areola NOT an inverted nipple in assessing a patient with a positive cardiac history you utilize the CHADS scoring. what are the elements that this scoring system is based on to determine risk? - CORRECT ANSWERS - 1. HTN 2. DM 3. CHF you noticed a thrill at the apex during systole. this could indicate: - CORRECT ANSWERS - mitral regurg patient c/o excessive daytime sleepiness, flushed fash. SOB ambulating to the room, BMI>30, +JVD, +HJR, HTN. what are 3 possible list of diagnoses: - CORRECT ANSWERS - 1. Pickwician syndrome 2. CHF 3. metabolic syndrome not AFib! what would you expect to find with tactile fremitus in a patient with pneumonia - CORRECT ANSWERS - increased tactile fremitus would symmetric expansion be normal or abnormal in pneumonia - CORRECT ANSWERS - abnormal how would you interpret this murmur: 5th ICS, timing of diastole with radiation to axilla - CORRECT ANSWERS - mitral stenosis 3 risk factors for men to get breast cancer - CORRECT ANSWERS - 1. testosterone level 2. low levels of physical activity 3. h/o bone fracture after 45 NOT 45-55 y/o a circumscribed, elevated lesion >1 cm in diameter and containing clear serous fluid is best described as what: - CORRECT ANSWERS - bulla the history and physical of a client indicates past occurrences of lichenification. The NP identifies the characteristics of this lesion as: - CORRECT ANSWERS - rough, thickened epidermis; accentuated skin markings the NP finds a lesion that is about 0.75 cm in diameter, brown, circumscribed, flat and nonpalpable. the correct term for this lesion is: - CORRECT ANSWERS - macule description of a possible melanoma - CORRECT ANSWERS - a new 2-mm mole that is brown with a red, irregular border, and is occasionally pruritic an annular skin lesion is usually arranged in what kind of shape - CORRECT ANSWERS - a circle or ring shape when educating patients about the risk factors for skin cancer you list 3 risk factors - CORRECT ANSWERS - 1. genetic predisposition 2. high mole count 3. high altitude NOT dark eyes elderly retired farmer presents with a rolled border, pearly, firm nodule with telangiectasia on his nose. what would you list in his differential diagnosis? - CORRECT ANSWERS - basal cell carcinoma an adult female presents with an irregular variegated nevus on her lower left back that has doubled in size. what should the NP do? - CORRECT ANSWERS - refer immediately to a dermatologist sounds like a possible melanoma and DO NOT want to do a punch biopsy your patient is 2 weeks old and has pinhead size, smooth, white raised areas across the nose and forehead. How do you document this? - CORRECT ANSWERS - milia what type of skin lesion is directly related to chronic sun exposure and photo damage - CORRECT ANSWERS - actinic keratoses what labs do you order if your patient has white nail syndrome - CORRECT ANSWERS - BUN & Creatinine sign of renal insufficiency what term would you use to describe an elderly patient with multiple solar lentingos <1cm. These are not uncommon for their age. - CORRECT ANSWERS - macules flat against the skin, like very large freckles what is tinea capitis caused by? - CORRECT ANSWERS - dermatophyte how would you document a patient with dependent edema with <1" indentation up to the mid-tibia bilaterally - CORRECT ANSWERS - 4+ what is the most common type of melanoma - CORRECT ANSWERS - superficial assessment of a patients skin reveals a positive Auspitzs sign. What diagnosis does this help you with? - CORRECT ANSWERS - psoriasis you note a history of atophic dermatitis in a patient. what other items in the personal or family history would you look for? - CORRECT ANSWERS - asthma what do the A's stand for in the triad of A's? - CORRECT ANSWERS - 1. atopic dermatitis 2. asthma 3. allergic rhinitis how would you best describe squamous cell carcinoma? - CORRECT ANSWERS - often has a keratinous horn how long should it take for jaundice to resolve in a newborn in order for it to be normal? - CORRECT ANSWERS - 1 week what are the 4 major components to be documented for a skin lesion? - CORRECT ANSWERS - 1. distribution 2. configuration 3. palpable features 4. pattern what is the most common cutaneous malignancy - CORRECT ANSWERS - basal cell carcinoma where do you most commonly find basal cell carcinoma - CORRECT ANSWERS - in sun exposure areas a bruit above and to the left of the umbilicus is most consistent with: - CORRECT ANSWERS - history of HTN as you palpate the abdomen, +rebound tenderness at McBurney's point would alert you to what? - CORRECT ANSWERS - appendicitis what sign would you see in a patient with cholecystitis - CORRECT ANSWERS - + Murphy's sign what do you typically see in later disease presentation of colorectal cancer - CORRECT ANSWERS - often includes iron deficiency anemia A cullen's sign after surgery may indicate: - CORRECT ANSWERS - intra- abdominal bleeding what does hyperresonance while percussing the abdomen most likely represent? - CORRECT ANSWERS - gaseous distention what 3 conditions might you see a positive fluid wave test - CORRECT ANSWERS - 1. congestive heart failure 2. portal hypertension 3. cirrhosis NOT inflammation of the spleen a liver span of 3.0 cm MCL would indicate: - CORRECT ANSWERS - liver atrophy small liver span for a male how would you test for a positive obturator sign in a client with abdominal pain? - CORRECT ANSWERS - passively rotate the right hip from the 90 degree hip/knee flexion position a client complains of extreme pain in his abdomen and points to the RLQ. In examining the acute abdominal pain the NP would: - CORRECT ANSWERS - palpate the left side of the abdomen, then gently palpate the right side, noting guarding and tenderness what is the most important goal of assessing a client with abdominal pain - CORRECT ANSWERS - rule out emergent conditions what could purple striae on an abdominal assessment imply - CORRECT ANSWERS - Cushing's disease ask about heat/cold intolerance how long after a diagnosis of ulcerative colitis do you need a colonoscopy? how frequent - CORRECT ANSWERS - every 10 years is the spleen easily palpable in an infant - CORRECT ANSWERS - yes what do you suspect if you elicit let costo-vertebral angle tenderness - CORRECT ANSWERS - pyelonephritis when listening to a patients abdomen you hear a systolic bruit in the epigastric area. It occurs at a fixed interval after the apical impulse. what do you suspect is the most likely source of the bruit - CORRECT ANSWERS - the abdominal aorta patient presents with abdominal pain. You note +AWT (abdominal wall tenderness). This leads you to what possible diagnosis - CORRECT ANSWERS - muscle strain abdominal disorders in the older patient are more difficult to diagnose because they usually present with: - CORRECT ANSWERS - vague symptoms & often little or no abdominal pain female patient with a history of ETOH abuse. your abdominal exam should include what test? - CORRECT ANSWERS - scratch test-looks at liver size pupils change in size when the client focuses from a close object to a distant object. this is interpreted as: - CORRECT ANSWERS - normal visual accomodation on ophthalmic exam, there appears to be a narrowing or blocking of the vessels. the significant of this finding is: - CORRECT ANSWERS - the client needs to be evaluated for chronic hypertension positive bruit on exam of the thyroid most likely indicates: - CORRECT ANSWERS - hyperthyroidism you notice patients history shows a bilateral lid lag of the eye. you should ask the patient about what other problems? - CORRECT ANSWERS - thyroid client is older (70 y/o) c/o blurred vision that has been getting increasingly worse over past 2 years and has a problem with glare but no pain. What would you first check for? - CORRECT ANSWERS - cataract what age do children approximate adult vision - CORRECT ANSWERS - 4 y/o how would you describe a normal Rinne test - CORRECT ANSWERS - air conduction twice as long as bone conduction which sinus is most likely affected if patient presents with pain and pressure over her cheeks and discolored nasal discharge. you cannot transilluminate the sinuses - CORRECT ANSWERS - maxillary 72 y/o retired factory worker has hearing loss in his right ear due to excessive cerumen (means theres no air conduction). what would you expect when performing a Weber test - CORRECT ANSWERS - sound lateralizes to the right ear how do you correctly palpate the thyroid gland - CORRECT ANSWERS - have the client lower their chin and lean head slightly toward the side being evaluated patient has dipped tobacco for past 35 years. when examining the tongue there is an area of white painless plaques that he cannot get off with brushing. what is the most likely diagnosis - CORRECT ANSWERS - leukoplakia which lymph nodes would you expect to find enlarged with conjunctivitis - CORRECT ANSWERS - pre-auricular & anterior cervical patient has chronic hypertension. what would you expect to visualize on funduscopic exam - CORRECT ANSWERS - cotton wool patches & flame hemorrhages patient presents with eye pain. when you examine the external eye you note a red, tender, swollen, raised area pointing upward from along the lower lash border. what would you document this as? - CORRECT ANSWERS - hordeolum what two things are important when getting your history involving an injury - CORRECT ANSWERS - 1. how the injury occurred (activity, trauma) 2. if and how the patient has self treated what are 7 risk factors for musculoskeletal problems - CORRECT ANSWERS - 1. obesity 2. poor nutrition 3. low calcium intake 4. medication history 5. chronic illness 6. age 7. gender what does a 4/5 on muscle strength mean - CORRECT ANSWERS - full ROM/some resistance what does a 3/5 on muscle strength mean - CORRECT ANSWERS - full ROM w/ gravity what does a 2/5 on muscle strength mean - CORRECT ANSWERS - full ROM gravity removed what does a 1/5 on muscle strength mean - CORRECT ANSWERS - slight contraction what does a muscle strength test of a grade 3 or less indicate - CORRECT ANSWERS - disability what would a positive drop arm test indicate - CORRECT ANSWERS - rotator cuff tear what would a positive arc test indicate - CORRECT ANSWERS - bursitis what 2 hand deformities do you see with rheumatoid arthritis? - CORRECT ANSWERS - 1. swan neck deformity 2. boutonniere deformity what 2 hand deformities do you see with oseoarthritis? - CORRECT ANSWERS - 1. Heberdon's 2. Bouchard's what does a positive Tinnels and a positive Phalens tell you - CORRECT ANSWERS - carpal tunnel syndrome what does the ortolani test look for - CORRECT ANSWERS - development dysplasia of the hip when should you refer someone for scoliosis based on their scoliometer test - CORRECT ANSWERS - >5-7 what do locking episodes of the knee suggest - CORRECT ANSWERS - meniscal tear what does the bulge sign on the knee indicate - CORRECT ANSWERS - effusion what is ballotment of the patella reliable for - CORRECT ANSWERS - large amounts of fluid where is the location of the most common meniscal tear - CORRECT ANSWERS - medial (3x more likely than a lateral tear) what injury often co-exists with meniscal tears - CORRECT ANSWERS - ACL tears how do people with meniscal injuries present - CORRECT ANSWERS - may hear a "pop" painful locking what does a positive McMurray test indicate - CORRECT ANSWERS - if a click is heard or felt indicates a torn medial meniscus is an ACL or PCL tear most likely to happen - CORRECT ANSWERS - ACL (2nd most common knee injury) patient has chronic hypertension. what would you expect to visualize on funduscopic exam - CORRECT ANSWERS - Arterio-Venous (AV) Nicking BMI Classifications - CORRECT ANSWERS - Underweight: <18.5 Normal: 18.5-24.9 Overweight: 25.0-29.9 Obesity class • I: 30.0-34.9 • II: 35.0-39.9 • III: at or over 40 How do you calculate BMI? - CORRECT ANSWERS - Stages of HTN - CORRECT ANSWERS - Normal: under 120/80 Prehypertension: 120-139/80-89 Stage 1: 140-159/90-99 Stage 2: over 160/100 If diabetes or renal disease: goal is under 130/80 Waist Circumference - CORRECT ANSWERS - Risk if over 35in for women Risk if over 40in for men Cranial Nerves - CORRECT ANSWERS - 1. Olfactory: Sensory 2. Optic: Sensory 3. Occulomotor: Motor 4. Trochlear: Motor 5. Trigeminal: Both 6. Abducens: Motor 7. Facial: Both 8. Acoustic: Sensory 9. Glossopharyngeal: Both 10. Vagus: Both 11. Spinal Accessory: Motor 12. Hypoglossal: Motor Romberg Test - CORRECT ANSWERS - Stand with hands to the sides and eyes closed, observe swaying Pronator Drift - CORRECT ANSWERS - Stand with arms out, eyes closed, and hands supine -- watch for hands pronating. Graphesthesia - CORRECT ANSWERS - The inability to recognize numbers written on the hand. Suggests a lesion in the sensory cortex. Astereognosis: - CORRECT ANSWERS - Inability to recognize objects placed in the hand Kernig - CORRECT ANSWERS - Flex patient's leg at hip and knee, then straighten the knee. Discomfort behind the knee during full extension should not cause pain. Brudzinski - CORRECT ANSWERS - Pt supine, your hands behind pt's head and flex the neck forward, until chin touches the chest if possible. Neck stiffness with resistance and flexion of hips and knees is a positive sign. May be a sign of acute bacterial meningitis or subarachnoid hemorrhage Straight Leg Raising - CORRECT ANSWERS - Lift the straight leg, if pt has low back pain with nerve pain that radiates down the leg = sciatica from compression of the spinal nerve root as it passes through the vertebral foramen Plantar (Babinski) Reflex - CORRECT ANSWERS - Dorsiflexion of the big toe is a positive Babinski response from a CNS lesion in the corticospinal tract Finkelstein Test - CORRECT ANSWERS - Pt grabs thumb with hand and you pull down to see if there is tendon tenderness - if positive, might mean tendonitis Tinel's Sign - CORRECT ANSWERS - Tap on the Median Nerve Phalen's Test - CORRECT ANSWERS - Bend wrists at 90 degrees and put back of hands against each other for 1 minute and see if there is numbness/tingling Ballotment - CORRECT ANSWERS - Leg extended, compress the suprapatellar pouch and then push the patella sharply against the femur, watching for fluid returning to the pouch Bulge Sign - CORRECT ANSWERS - Knee extended, hand on knee above the patella and milk downward. Apply medial pressure and tap laterally. Watch for a fluid wave Drawer Sign - CORRECT ANSWERS - Pt supine with knee flexed, your thumbs at the medial/lateral joint line and fingers wrapped around. Then sharply push/pull, watching for laxity McMurray Test - CORRECT ANSWERS - Pt supine with knee flexed, one hand medial knee and the other medial ankle. Extend the leg and laterally rotate, watching for clicking Directions for Self-Breast Exam - CORRECT ANSWERS - 5-7 days after period OR same time every month for menopausal women. Lawn Mower pattern What Abdominal locations do you listen for bruits with the Bell of the stethoscope? - CORRECT ANSWERS - Aoritc, Illiac, Femoral What Abdominal locations do you listen for bruits with the diaphragm of the stethoscope? - CORRECT ANSWERS - Epigastric and Renal Murphey's Sign - CORRECT ANSWERS - Assessing gallbladder, pt will stop breathing d/t pain when pushing up on the liver if positive. Rovsing's Sign - CORRECT ANSWERS - Pressure on LLQ causes referred pain in RLQ Rebound Tenderness - CORRECT ANSWERS - Pain in RLQ increases when pressure is released quickly Psoas Sign - CORRECT ANSWERS - Place hand just above right knee and ask pt to raise that thigh against your hand and turn onto the left side. then extend the right leg at the hip.Flexion of th leg at the hip makes the psoas muscle contract; extension stretches it. Increased abd pain with either maneuver constitutes a positive sign Obturator Sign - CORRECT ANSWERS - Flex pt's right thigh at the hip, with knee bent, and rotate the leg internally at the hip. It stretches the internal obturator muscle. Right hypogastric pain = positive sign Normal size of aorta - CORRECT ANSWERS - under 3 cm Spleen percussion/palpation - CORRECT ANSWERS - Normally the lowest interspace in the left anterior axillary line is tympanitic. After a deep breath, if percussion changes from tympanitic, enlargement is suspected and you'll need to palpate the spleen, but be careful not to cause rupture Feeling the liver edge - CORRECT ANSWERS - Normally feels smooth, soft, sharp, and regular. Normally about 3 cm below the right costal margin in the midclavicular line Grading of Heart Murmurs - CORRECT ANSWERS - •Grade I -barely audible •Grade 2-clearly audible but faint •Grade 3-moderately loud, easy to hear •Grade 4- Loud, associated with thrill •Grade 5- Very loud- partly off chest •Grade 6- Loudest can be heard with stethoscope lifted off chest S3 - CORRECT ANSWERS - low frequency heard best at the apex, use bell and lay on the left side. Ventricular gallop - means that ventricular compliance is low. Heard at the beginning of diastole. Blood flowing into overfilled non- compliant left ventricle rapidly decelerates. Sound of it "popping" open quickly. Ken-tuc-ky S4 - CORRECT ANSWERS - low frequency, heart best at the apex, use bell and lay on left side. Atrial gallop, pericardial friction rub. Heard at the end of diastole. Atrial contraction trying to push blood to the ventricle, but it is stiff. Ten-ness-ee. Murmurs - CORRECT ANSWERS - Caused by a flow of blood across a partial obstruction (valve stenosis) or valve irregularity (leaks...) or increased flow through normal structures (pregnancy and anemia), flow into a dilated chamber (aneurysm), backward flow, shunting of blood out of a high pressure area through a hole Heart conditions that accompany systolic murmurs - CORRECT ANSWERS - •Aortic Stenosis: pressure or gradient that the blood has to flow through due to a smaller valve. Increased pumping pressure of Left ventricle •Pulmonary Stenosis: same as above, heard with diaphragm at 2nd and 3rd intercostal space, medium or rough quality, radiates to left shoulder and neck •Tricuspid Insufficiency: supposed to be closed during systole, so causes a backward flow of blood. Diaphragm at 5th intercostal space at the sternal border, radiates to left anterior sternal line •Mitral Insufficiency: loudest at the apex, 5th intercostal space, high pitched and blowing quality Heart conditions that accompany Diastolic murmurs - CORRECT ANSWERS - •Aortic Insufficiency: most common, Marfan syndrome, retrograde blood flow into left ventricle. Diaphragm at 2nd and 4th intercostal along sternal border, sit up and lean forward and hold breath •Pulmonary Insufficiency: high pitched, diaphragm, 2nd or 3rd intercostal, enhanced during inspiration. •Mitral Stenosis: most common, bell at 5th intercostal, low pitched rumbling, left lateral position •Tricuspid Stenosis: forward blood flow from right atrium though stenosed tricuspid valve, bell at 4th intercostal along sternal border. Allen Test - CORRECT ANSWERS - Occlude radial and ulnar arteries and then release one and visualize blood return Presbycusis - CORRECT ANSWERS - Hearing loss associated with age Sarcopenia - CORRECT ANSWERS - loss of lean body mass and strength with aging Axillary Lymph Nodes - CORRECT ANSWERS - Lateral Pectoral (Anterior) Subscapular (Posterior) Supraclavicular Infraclavicular Self Breast Exam Instructions - CORRECT ANSWERS - 5-7 days after period for women still menstruating or can choose a time of month if menopausal. Vaginal Speculum Exam - CORRECT ANSWERS - lubricate with water so that sample is not contaminated, insert two fingers first and then speculum vertically, putting pressure on the posterior vaginal wall Obtaining Vaginal Specimens - CORRECT ANSWERS - Pap Smear: Rotate 5X and obtain sample before any other test samples Then any swabs for infection Skene's Glands - CORRECT ANSWERS - Near urethra- can milk to see if there is discharge. Bartholin's Glands - CORRECT ANSWERS - 5 and 7 Do you listen for Epigastric and Renal Bruits with the bell or the diaphragm? - CORRECT ANSWERS - Diaphragm Do you listen for aortic, illiac, and femoral bruits? - CORRECT ANSWERS - Bell Shifting Dullness - CORRECT ANSWERS - Shifting Dullness: Indicates ascites - fluid shifts dependently when the patient lies supine vs laying on the side. Percuss to determine or look for fluid wave Do you listen for carotid Bruits with the bell or the diaphragm? - CORRECT ANSWERS - Both Cardiac Landmarks - CORRECT ANSWERS - Epitrochlear Nodes - CORRECT ANSWERS - Inguinal Nodes - CORRECT ANSWERS - Ankle-Brachial Index - CORRECT ANSWERS - Arterial Vs. Venous - CORRECT ANSWERS - Cervical Lymph Nodes - CORRECT ANSWERS - Pre-auricular Post-auricular Tonsillar Occipital Submental Submandibular Posterior cervical Superficial cervical Deep cervical chain Supraclavicular Retinal Structures - CORRECT ANSWERS - Macula/Fovea Optic Disc Red Reflex Vessels Convergence - CORRECT ANSWERS - Eye converge symmetrically at the nose Accommodation - CORRECT ANSWERS - Look far away and then close up, pupils will constric Direct light reflex - CORRECT ANSWERS - Light goes into the eye and that eye's pupil constricts Corneal Light reflex - CORRECT ANSWERS - Light shone from the side, and watch for shadowing on the iris - shadowing might mean lesions Consensual light reflex - CORRECT ANSWERS - Light goes into one eye and the opposite eye's pupil constrict Weber Test - CORRECT ANSWERS - Place base of tuning fork on top of the head and see if the patient hears it equally in both ears. If not, this is considered conductive hearing loss and they will hear the sound in the impaired ear. Rinne Test - CORRECT ANSWERS - Base of the tuning fork is placed on the mastoid bone, count how long they hear it. Then move it in front of the ear and count how long they hear that. Normally the sound is heard longer through air than through bone. In conductive hearing loss, sound is heard through bone as long as or longer than it is through air (BC>AC). In sensorineural hearing loss, sound is heard longer through air (AC>BC). Tonsil Grades - CORRECT ANSWERS - Parotid Glands- Stenson's Duct - CORRECT ANSWERS - Side of cheek Submaxillary- Wharton's duct - CORRECT ANSWERS - Under the tongue Diaphragmatic excursion - CORRECT ANSWERS - percuss after breathing in and holding it, then same for breathing out and holding it - then look at the distance between the two. Normal is 3-5.5cm Dullness on respiratory percussion - CORRECT ANSWERS - fluid or solid tissue replaces air containing lung or occupies the pleural space beneath your fingers Generalized hyperresonance on respiratory percussion - CORRECT ANSWERS - hyperinflated lungs of COPD or asthma Vesicular Sounds - CORRECT ANSWERS - soft, low pitched. Heard through inspiration, continue without pause through expiration, and then fade away about one third of the way through expiration Bronchovesicular Sounds - CORRECT ANSWERS - with inspiratory and expiratory sounds about equal in length, at times separated by a silent interval. Detecting differences in pitch and intensity is often easier during expiration. Bronchial Sounds - CORRECT ANSWERS - louder, harsher, and higher in pitch, with a short silence between inspiratory and expiratory sounds. Expiratory sounds last longer than inspiratory sounds.. Egophony - CORRECT ANSWERS - "ee" sounds like "A". This sound is present with consolidation/pneumonia Bronchophony - CORRECT ANSWERS - "ninety-Nine" - if louder than normal Whispered pectoriloquy - CORRECT ANSWERS - whisper "ninety-nine" or "one-two-three" and if louder, clearer whispered sounds, then whispered pectoriloquy Light palpation - CORRECT ANSWERS - use one hand and press 1cm - think kneading dough Deep palpation - CORRECT ANSWERS - use two hands and press 2-3cm Methods for assessing cognitive functioning - CORRECT ANSWERS - •A&O: person, time, place •Remote, immediate, and recent memory •Cognitive function: tell me what a proverb means, "if you found an envelope on the ground, what would you do", calculations ABCDE of skin assessment - CORRECT ANSWERS - •A: Asymmetry •B: Irregular Borders •C: changes in color •D: Diameter over 1/4in or 6mm •E: evolving/changing How do you interpret a Snellen Chart? - CORRECT ANSWERS - Vision of 20/200 means that at 20 ft the pt can read print that a person with normal vision could read at 200ft. The larger the second number, the worse the vision. Exopthalamus - CORRECT ANSWERS - protrusion of the eyeball, a common feature of Graves', triggered by autoreactive T lymphocytes. Xanthelasma - CORRECT ANSWERS - slightly raised, yellowish, well- circumscibed plaques that appear along the nasal portions of one or both eyelids. May accompany lipid disorders Lid Lag - CORRECT ANSWERS - the eyelid should follow the eye if it moves down, almost always covering a little bit of the iris. Perforated ear drum - CORRECT ANSWERS - -Central perforation: don't extend to the margin of the drum -Marginal perforations: involve the margin -Reddened internal ear, might have drainage, no cone of light Serous effusion of the ear - CORRECT ANSWERS - -Usually caused by viral URI or by sudden changes in atmospheric pressure as from flying or diving. Eustachian tube can't equalize the air pressure in middle ear and outside air. Air absorbed from middle ear into the bloodstream, and serous fluid accumulated there instead. -Symptoms: fullness and popping sensation in the ear, mild conduction hearing loss, ,and sometimes pain -Amber fluid behind the eardrum. Air bubbles can be seen, but not always Acute otitis media with purulent effusion-ear - CORRECT ANSWERS - - Commonly caused by bacterial infection with S. penumoniae and H. influenza -s/s: earache, fever, hearing loss. Eardrum reddens, loses its landmarks, and bulges laterally toward the examiner -hearing loss is conductive Bullous Myringitis - CORRECT ANSWERS - -Painful hemorrhagic vesicles appear on TM or ear canal or both -s/s earache, blood-tinged discharge from the ear and conductive hearing loss -caused by mycoplasma, viral, or bacterial otitis media Torus Palatinus - CORRECT ANSWERS - Midline bony growth in hard palate that is fairly common in adults. Size and lobulation vary. Harmless Kaposi's sarcoma in AIDs - CORRECT ANSWERS - Deep purple lesions. A low grade vascular tumor associated with human herpesvirus 8. Lesions may be raised or flat. Antiretroviral therapy can reduce prevalence Thrush on the palate - CORRECT ANSWERS - Yeast infection. Thick, white plaques are somewhat adherent to underlying mucosa. Predisposing factors: prolonged Tx with antibiotics or corticosteroids and AIDS Diptheria - CORRECT ANSWERS - -Acute infection caused by Corynebacterium diptheriae; rare -Throat is dull red and grey exudate is present on uvula, pharynx, and tongue. Airway may become obstructed. Pharyngitis - CORRECT ANSWERS - -Redness and vascularity of pillars and uvula -s/s sore, scratchy throat - no fever, exudate or enlargement of cervical lymph nodes -causes: viral and bacterial Exudative tonsillitis - CORRECT ANSWERS - -Red throat with white exudate on tonsils -Fever, enlarged cervical nodes = Group A strep or mono Nummular Lesions - CORRECT ANSWERS - Round (coin-shaped) lesions. Also known as discoid. Linear Lesions - CORRECT ANSWERS - A linear shape to a lesion often occurs for some external reason such as scratching. Also striate. Target Lesion - CORRECT ANSWERS - Concentric rings like a dartboard. Also known as iris lesion Gyrate Rash - CORRECT ANSWERS - A rash that appears to be whirling in a circle. Annular Lesions - CORRECT ANSWERS - Lesions grouped in a circle Lichenification - CORRECT ANSWERS - Lichenification is caused by chronic rubbing, which results in palpably thickened skin with increased skin markings and lichenoid scale. It occurs in chronic atopic eczema and lichen simplex. Crusting - CORRECT ANSWERS - Crust occurs when plasm