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Cyanosis

- blue or purple coloration of the skin or mucous membranes due to the tissues near the skin surface being low on oxygen
- dark skinned = ashen gray
- light skinned = grayish blue tone, lips & face (worst), extremities

- common causes: Hypoxia, Anemia, Hypotension

Jaundice

- yellowish pigmentation of the skin, the conjunctival membranes over the sclera, and other mucous membranes caused by hyperbilirubinemia (increased levels of bilirubin in the blood)
- liver or GB disease
- transcutaneous or blood/serum bilirubin testing

Erythema

- redness of skin

Pallor

- skin appears a pale color which can be caused by illness, emotional shock or stress, stimulant use, lack of exposure to sunlight, anemia, hypotension

Skin Turgor

- elasticity of skin

- to test for dehydration

- elderly have poor turgor so not an accurate test for dehydration in elderly

- to test: pick up skin and slightly pinch the skin on the forearm or clavicle. Skin should easily move when lifted & should return to place immediately

Pitting Edema Scale

1+ A barely perceptible pit, 2mm
2+ A deeper pit, rebounds in a few seconds, 4mm
3+ A deep pit, rebounds in 10-20 seconds, 6mm
4+ A deeper pit, rebounds in >30 seconds, 8mm

Petechiae

- caused by tiny hemorrhages w/i the dermal or submucosa due to intravascular defects and infection

- less than 0.5cm in diameter

Ecchymosis

- caused by trauma to the blood vessel resulting in bleeding under the tissue

- variable in size

- bruising

Hematoma

- mass of extravasated blood confined to a space

- caused by a break in a blood vessel

Skin lesion ABCDE rule

A-asymmetry (irregular)
B-border (not intact)
C-color (red,black,gray,pink) - different from surround
D-diameter (change in size)
E-elevation and enlargement (change in elevation)

-is it smooth? / has it changed?

Primary Skin Lesions

─ Macule
─ Urticaria
─ Papule (hives)
─ Patch
─ Vesicle
─ Plaque
─ Cyst
─ Nodule
─ Bulla
─ Wheal
─ Pustule
─ Tumor

Secondary Skin Lesions

─ Crust
─ Scale
─ Fissure
─ Erosion
─ Ulcer
─ Excoriation
─ Scar
─ Atrophic scar
─ Lichenificat ion
─ Keloid

Macule

- flat, round area, that's a change in color of skin

- less than 1 cm

-ex; freckles, flat moles

Papule

- 1° elevated, firm, round area

- fluid or blood filled

- less than 1 cm

- wart, elevated moles, skin tags

Reflex Scoring

0=no response
1+=slugglish or diminished response
2+=active or expected response
3+=slightly hyperactive
4+=brisk, hyperactive w/intermittent clonus
5+=sustained clonus (tremors/seizure disorder)

(2 normal / 3 may also be normal)

Babinski Response

- run object lightly across later side of sole of foot starting at heel and ending at the big toe

-normal: toes curve inward & foot everts

-abnormal: big toe dorsal flexes & other toes fan out. Normal in infants. Indicates damage to CNS.

Kernig's Sign

- Meningitis Test:

- Have pt. lay supine. Lift leg at hip, bend at knee, then extend at knee.

normal: no pain

abnormal: pain along length of spine

Brudzinski"s Sign

- Meningitis Test:

- Have pt. lay supine. Bring pt's head upwards so chin is close to chest

normal: no pain or resistance

abnormal: pt. flexes hip & knee in response to this & reports pain in spine

Pustules

- elevated, superficial lesion

-similar to a vesicle but filed with purulent fluid

- infection

- ex: impetigo, acne, herpes, folliculitis

Wheals

- 1° elevated irregular-shaped area of cutaneous edema; solid, transient

- ex: insect bites, allergic reaction, lupus

Spinal cord levels related to reflexes

Brachioradial = C5, C6
Biceps = C5, C6
Triceps = C6, C7, C8
Quad = L2, L3
Patellar = L2, L3, L4
Achillies = S1, S2

Adduction

movement of limb towards the body

Abduction

movement of limb away from the body

S/S of Syphilis (3 stages)

- Primary: single painless genital lesion 10 days to 3 months after exposure

- Secondary: Generalized skin rash, enlarged lymph nodes, red macules on hands & feet, round and gray lesions may appear, fever may appear 2-4 weeks after appearance of lesions; may last for several years

- Latent: Usually no clinical signs present for as long as 20 years; may continue to involve & damage neurologic & cardiac organs; dementia, confusion, paralysis may occur

S/S of Gonorrhea

- Men: purulent penile discharge, dysuria, frequency of urination

- Women: Dysuria, abnormal menses, yellow or green discharge, PID, vaginal burning & itching may be severe

- Oral sex can lead to symptoms of pharyngitis

- gram negative

Cranial Nerves and Functions

1 - Olfactory (Smell)
2 - Optic (Vision)
3 - Oculomotor (Eyeball Movement)
4 - Trochlear (Eyeball Movement)
5 - Trigeminal (Chewing/Teeth Clenching)
6 - Abducens (Eyeball Movement)
7 - Facial (Smiling)
8 - Acoustic (Hearing)
9 - Glossopharyngeal (taste)
10 - Vagus (taste)
11 - Spinal accessory (trapezius & sternocleidomastoid)
12 - Hypoglossal (taste/tongue movement)

McMurray's test

- Used to evaluate pt. for tears in the meniscus of the knee.

- Medial Meniscus Assessment: internally rotate leg so the toes point inward. Flex the pt's knee then extend while still having the leg internally rotated.

- Lateral Meniscus Assessment: Externally rotate leg so the toes point outward. Flex the pt's knee then extend while still having the leg externally rotated.

- Normal: Pt should experience no pain or have no "clicking" noise present when performing the test

- medial meniscus tear is more common than lateral

Romberg test

- test for balance

- pt stands with feet together, arms rested at the side, and eyes closed

- Normal: Slight swaying but maintained upright position and foot position

-Abnormal: A loss of balance indicating cerebellar disorder or vestibular dysfunction

PERRLA

P=Pupils are
E=Equal
R=Round and
R=React to
L=Light and
A=Accommodation

Accommodation

- Have pt stare at an object across the room (about 20 ft away)

- Have pt shift their gaze to your finger which should be 6 inches from their nose

- distance=pupils dilate
- close=pupils constrict

Confrontation

- test for peripheral vision

- Have pt close one eye & you close opposite eye. have the pt stand looking at you.

- Move hands from 50, 60, 70 , & 90 degrees from side into line of vision

- Have pt tell you when they first see the pen

- Normal=pt see's object when you do

S/S of HPV

- most common STD

-Pale, soft papally lesions found around the internal & external genitalia & perianal & rectal areas of body

- Profuse watery vaginal discharge, dyspareunia (painful intercourse), intense pruritus & vulvar itching

- Women have risk for cervical cancer

- Men may or may not have lesions

Symptoms of Menopause (9)

- Irregular periods
- Decreased fertility
- Vaginal dryness
- Hot flashes
- Sleep disturbances
- Mood swings
- Increased abdominal fat
- Thinning hair
- Loss of breast fullness

Pupillary light reflex

- Dim lights in room, have pt hold eye open & gaze at an object across the room

- Approach with a penlight beam from the side & shine directly into pupil (Repeat w/ other eye)

- Findings should be PERRLA - size=2-6mm

Cataract

- opacity of the crystalline lens

- Comes from denaturation of lens protein or trauma

- Pt reports cloudy or blurred vision

- Cloudy lens can be observed. Red reflex is absent & light cannot penetrate the opacity.

Muscle Strength

- Ask pt to flex the muscle being evaluated & then resist when you apply opposing force against the muscle

- There are 3 scales to test: Lovett scale, grading, & percent of normal

- Muscle strength should be a 5, bilaterally symmetric, w/ full resistance to opposition. Documentation of 5/5

Muscle strength scale

0=no evidence of contractility
1=evidence of slight contractility
2=complete ROM w/ gravity eliminated
3=complete ROM w/ gravity
4=complete ROM against gravity w/ some resistance
5=complete ROM against gravity w/ full resistance

Risk factors for CVA (Cerebrovascular Accident)

- Age
- Gender (men have greater risk than women)
- Family history
- Race (African American have greater risk)
- Previous CVA
- smoking
- Diabetes Mellitus
- Atherosclerosis / obesity / high cholesterol
- Excessive alcohol / cocaine usage

What are you looking for when you trans-illuminate the scrotum?

masses / testicular cancer

S/S of testicular torsion

- sudden & severe onset of pain & swelling of the scrotum

- caused by twisting of the testicles & spermatic cord, cutting off blood supply (surgical emergency)

- testicles become tender, not associated w/ trauma or physical activity

Vibratory sense is most frequently affected in cases of?

Diabetes

Which area of the brain is most likely affected if the pt is having trouble w/ the finger-to-nose test?

Cerebellum

Cerebrospinal fluid

- should be colorless & odorless

- clear with a little halo of red

- cloudy = bacterial meningitis

Superficial Reflexes

- Upper Abd (T7, T8, T9)
- Lower abd (T10, T11)
- Cremasteric (T12, L1, L2)
- Plantar (L4, L5, S1, S2)

Lower Extremity for Vibratory Neuropathy

- have pt lay supine & close eyes

- place vibratory uning fork on medial or lateral malleolus (ankle)

- ask pt to describe the sensation & where is felt at & when vibration is no longer felt

Normal=pt should feel vibration & distinguish the change in sensation

Abnormal=unequal to decreased vibration (diabetes/stroke/spinal cord injury)

Goniometer

used to measure joint ROM

Phalen's Sign

- test for carpal tunnel syndrome

- have pt flex both wrist & press the dorsum of the hands against each other for a minute

- abnormal=numbness, pain or tingling over the palmar surface of hand at first 3 fingers/possibly part of fourth

Tinel's Sign

- test for carpal tunnel syndrome

- tap on the median nerve where it passes through the carpal tunnel under the carpal ligament

- abnormal=tingling sensation or pain from the wrist to the hand along the median nerve

- if pain occurs right away probably arthritis not carpal tunnel

Thomas Test

- have pt lay supine w/ one leg fully extended and the other knee up to chest as far as possible

- normal: extended leg remains on the table when the other is flexed

- abnormal: lifting of extended leg indicates a hip flexion contracture

Weber's Test

- test for hearing loss

- strick tuning fork & place on midline of skull & ask pt which ear sound is heard best in or if equal

- normal: heard equally in both ears

- abnormal: sound heard better in one side

Rinne Test

- test for sensory or conductive hearing loss

- place tuning fork on mastoid bone & then move next to external ear / have pt tell you when they can no longer hear the sound

- Normal: pt hears the vibration longer & louder when tuning fork is held next to ear not mastoid bone (AC>BC)

- Abnormal: pt hears a louder & longer tone when tuning fork is on mastoid bone (AC<BC) / indicates hearing loss / referred to as reversed Rinne

(TMJ) Temporomandibular Joint

- using pads of fingers in front of the tragus of each ear, gently palpate the TMJ while pt is opening & closing their mouth.

Normal: no pain / mandible moves smoothly/ clicking w/o other symptoms may be normal

Abnormal: pain & locking or popping

Glasgow Coma Scale

Test: Motor response, Verbal response, & Eye Opening

add up points & compare to scale to see how severe brain injury is (3 lowest, 15 highest)
- eye opening response=spontaneous to no response
- best verbal response=oriented X4 to no response
- best motor response=obeys commands to no respond

Lower Extremities Coordination Test

- have pt lay supine & place heel of one foot to the knee of the other leg and life down the shin

- Abnormal: pts w/ cerebellar disease may overshoot the knee & oscillate back & forth

Two Point Discrimination

- to test for injured nerves

- have pt close eyes & gently press a paperclip against its skin, alternating between one & two points

- inability to distinguish between two points

Extraocular Muscle Movement

- test CN 3, 4, & 6

- hold pen 12 in away from pt's face. Move pen in several directions & have pt follow pen w/o moving their head

- Normal: both eyes should move together

- Abnormal: weakness in one or more muscles typically results in double vision. (brain tumor or other brain injury)

Hirschberg Corneal Light Reflex Test

- test for Strabismus (crossed eyes) / usually done on a child by 3rd grade

- hold object 12in away & place penlight on top of object & have child focus on object

- Light should reflect centered in the pupil of each eye

Abnormal: reflection doesn't appear centered=indicates strabismus

What are the normal changes to genitalia in an elderly male patient?

- scrotal skin thins
- prostate enlarges
- pubic hair thinner & less abundant
- scrotal sags / penis shrinks

Gravida / Para

Gravida - number of pregnancies

Para - number of pregnancies that reached 20 weeks or longer

Acromegaly

disease characterized by enlarged features, especially the face and hands, caused by hypersecretion of the pituitary hormone after puberty, when normal bone growth has stopped; most often caused by a pituitary tumor

Tonsil Grading

1+ : Visible
2+ : halfway between tonsilar pillars & uvula
3+ : nearly touching the uvula
4+ : touching each other

What are the steps for a musculoskeletal physical exam?

1. - inspection = redness, swelling, skin & contour of joint, skin & tissues over joint
2. - palpation = warmth, clicking and tenderness of joints, skin temperature
3. - range of motion = general, can they walk/move arms
4. - Muscle testing (muscle strength) = grip strength, apply opposing force, grading muscle strength (0-5)

Subjective Hx w/ Musculoskeletal Assessment?

- Joints: pain/stiffness/swelling

- Muscles: pain/weakness

- Bones: pain/deformity/trauma

- Activities of daily living

- Self-care behaviors

Functional Assessment

able to do normal daily activities to balancing check book

Lateral Epicondylitis

tennis elbow, over use, repetitive injury

Ankylosis

stiffness or fixation of a joint

What direction do you pull the ear canal in when using an otoscope?

- up for an adult

- down for a child

Frontal Lobe

- motor
- behavior
- speech
- change in personality

Occipital Lobe

primary visual cortex

Temporal Lobe

primary auditory cortex

Cerebral cortex

balance / coordination

Light touch sensation

- with pts eyes closed, touch them with a cotton ball to forehead, cheeks, & chin. Ask the pt to tell you when they feel you touch them & where

- tests all 3 divisions of nerve ophthalmic, maxillary, & mandibular

- cranial nerve 5

(can also be done on corneal reflex)

Cranial Nerve 11

- shrug shoulders / neck movement

- some speech

Cranial Nerve 1

Olfactory - sensory

smell reception & interpretation

Cranial Nerve 3

Oculomotor - motor/parasympathetic

raise eyelids / most extraocular movements

Cranial Nerve 4

- downward, inward eye movement

Cranial Nerve 6

- lateral eye movement

Cranial Nerves 3, 4, & 6

- test together / fields of gaze

- parallel tracking is normal

- extra ocular movement

- accommodation

Cranial Nerve 2

- visual acuity using snellen chart

- confrontation

Cranial Nerves 5 & 7

- face movement/sensation

- light touch/sharp touch

- clench teeth / symmetric facial features

- chewing / taste anterior 2/3 of tongue / secretion of saliva & tears

Cranial Nerve 8

- Acoustic

- Rinne / Weber

- hearing equilibrium

Cranial Nerve 7 & 9

- Taste

- Posterior / Anterior tongue

Cranial Nerve 9 & 10

- movement of soft palate / speech sounds

- say "ahh" (vagus nerve)

- gag reflex / swallowing

Cranial Nerve 12

- Hypoglossal

- Tongue movement for speech sounds

- swallowing

Kinesthetic sensation

- move finger/toe up/down

- eyes closed / can they tell if it is moving

Stereognosis

identification of familiar objects in hand

Graphesthesia

identification of numbers/letters drawn on hand, back and other area

Subluxation

partial dislocation / incomplete dislocation - joint will pop back in, not requiring it to be put back into place

Contracture

- Stiffening of a body joint to the extent that the joint cannot be moved through normal range of motion

- Stiffening, causing it to shorten and/or stay bent. Permanent contraction of muscle.

Dislocation

Occurs when bones in a joint become displaced or misaligned. Often caused by sudden impact to the joint. Ligaments always become damaged as result.

Lymph Nodes

1-Preauricular
2-posterior auricular
3-occipital
4-submental
5-submandibular
6-jugulodigastric
7-superficial cervical
8-deep clavicle pain
9-posterior cervical
10-supraclavicle

flexion

movement that brings a joint into bent position

extension

movement that brings a joint into a straight position

pronation

to turn the forearm so that the palm faces downward or to rotate the leg or foot inward

supinate

to turn the forearm so that the palm faces upward, or to rotate the foot and leg outward

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