NR 509 Midterm Exam Study Guide Advanced Physical Assessment – Chamberlain
Latest 2023 / 2024
• Articular structures include joint capsule and articular cartilage, the synovium and synovial fluid, intra-articular ligaments and juxta-articular bone
o Articular disease involves:
▪ Swelling ▪ Tenderness of the joint ▪ Crepitus ▪ Instability “locking” ▪ Deformity ▪ Limits active and passive range of motion due to stiffness or pain • Extra-articular structures include periarticular ligaments, tendons, bursae, muscle, fascia, bone, nerve and overlying skin
o Extra-articular disease involves:
▪ “point of focal tenderness in regions adjacent to articular structures ▪ Limits active range of motion ▪ RARELY causes swelling, instability, joint deformity
• Nonarticular conditions: trauma/fracture, fibromyalgia, polymyalgia rheumatica, bursitis, tendinitis
• Intra-articular (acute, < 6 weeks): acute arthritis
- infectious arthritis
- gout
- pseudogout
- Reiter syndrome
• Intra-articular (chronic, > 6 weeks): chronic inflammatory arthritis vs chronic noninflammatory arthritis
o Chronic inflammatory arthritis with 1-3 joints involved:
▪ Indolent infection ▪ Psoriatic arthritis ▪ Reiter syndrome ▪ Periarticular JA
o Chronic inflammatory arthritis with >3 joints involved:
▪ Psoriatic arthritis or Reiter syndrome (no symmetry) ▪ rheumatoid arthritis if not RA then systemic lupus, scleroderma, polymyositis
• CES (cauda equina syndrome) most commonly results from a massive herniated disc in the lumbar region.• Asingle excessive strain or injury may cause a herniated disc.Knowrthersources rof rjoint rpainr(pg. r627 ralgorithm) *Knowrwhat rcausesrsaddle rnumbness randrurinaryrretentionr(pg. r678?) 1 / 4
Knowrhowrretinal rdetachment rpresentsr(p.217) Knowrwhat rcranial rnerve ryou’rerassessingrwhen rcheckingrlateral rgaze r(p. r237) Knowrhowroptic rneuritis rpresents r(p.r217) • However, disc material degenerates naturally as a person ages, and the ligaments that hold it in place begin to weaken. As this degeneration progresses, a relatively minor strain or twisting movement can cause a disc to rupture.
The following are other potential causes of CES:
• Spinal lesions and tumors • Spinal infections or inflammation • Lumbar spinal stenosis • Violent injuries to the lower back (gunshots, falls, auto accidents) • Birth abnormalities • Spinal arteriovenous malformations (AVMs) • Spinal hemorrhages (subarachnoid, subdural, epidural) • Postoperative lumbar spine surgery complications • Spinal anesthesia
• Sudden, painless vision loss that is unilateral
• The obtunded patient opens eyes and looks at you but responds slowly and is somewhat confused. Alertness and interest in the environment are decreased.
• Cranial nerve VI: abducens
• 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
• Absence of red reflex suggests an opacity of the lens (cataract), or possibly the vitreous (or even an artificial eye).• Less commonly, a detached retina, or in children a retinoblastoma may obscure this reflex.
• itching, watery eyes, sneezing, ear congestion, postnasal drainage
• Sudden visual loss that is unilateral and can be painful, associated with multiple sclerosis
• Oval lesions on trunk, in older children often in a Christmas tree pattern, sometimes a Harold patch (a large patch that appears first) Knowrthersigns rof rseasonal rallergies r(p.r27) Knowrwhat rtherwordrobtunded rmeansr(p. r769) Knowrwhat rshould rbe rlisted runderradult rillnesses rin rhealth rhistoryr(pg. r10) Knowrwhat rconditionsrdo rnot rhave rred rreflexes r(p. r239) Knowrhowrpityriasis rrosacea rpresents r(p. r912) 2 / 4
Knowrwherertheracromionrprocess risr(berable rtoridentifyrit ron ra rpicture) Knowrwhat rcanrcause rfalselyrhigh rBP’s r(p. r127) Knowrhowrto rcheck rfor rnystagmus r(p. r737)
• 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)
• Located between the clavicle and the shoulder
• 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
• Nystagmus is seen in cerebellar disease especially with
- gait ataxia
- dysarthria (increases with retinal fixation
- vestibular disorders (decreases with retinal fixation)
- internuclear ophthalmoplegia
• Identify any nystagmus, an involuntary jerking movement of the eyes with quick and slow components.3r 0) *Knowrwhat rto rdo rif ryou rhave ra r+ rfindingron rphysical rexamrbut rotherwise rnegative rwork-upr(p.Knowrwhat risrlistedrunder rpresentrillness r(p. r9) 3 / 4
Knowrwhat ryellowrsclera rindicatesr(p. r234) Pg. r72 r- rKnowrhowrtorgetrarpatientrtoropenruprwhenrherseemsrupset Pg. r27 r- r Know rthe rsigns rof rdegenerative rpain Pg. r289 r-rKnowrhowrotosclerosisrpresentsrwithrWeberrandrRinnertest • 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.
• A yellow sclera indicates jaundice
• The first step to effective reassurance is simply identifying and acknowledging the patient’sfeelings. 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 isrmore 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.Perhapsthat explains why you still feel upset,” validates the patient’s response as legitimate andrunderstandable • 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.
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Otosclerosis condition that affects the tiny middle ear bone known as the stapes.• Stapes can become stuck, limiting its ability to vibrate (vibrations are crucial for hearing) • Conductive hearing loss • Weber test
- Tuning fork at vertex
- Sound is heard in the impaired ear
- Room noise not well heard, so detection of vibrations improves
- 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
- The sound is heard longer through bone than air
- / 4
• Rinne test
through bone bypass the problem to reach the cochlea