- Onset - When did the symptoms and/or signs begin, what was the mechanism of injury
- Chronology - episodic, variable, constant, etc
- Quality - sharp, dull, ache, sudden, insidious
- Severity - pain rating, 0-10 pain scale, interferes with daily activities
- Modifying factors - aggravating and alleviating factors
- Additional symptoms - unrelated or significant symptoms
- Treatment - medications, herbs, "home remedies", rest, activity, splint, etc
- Use "OLDCART" to assist you (Onset, Location, Duration, Character , Aggravating factors, Relieving factors, Treatments"
Allergies - list of allergies to food, medication, and products with type of reaction
- Medical - past and present medical conditions (i.e. asthma, hypertension, malaria, etc.)
- Surgical - past surgeries (i.e. appendectomy, CABG, craniotomy, etc.)
- Family - mother, father, siblings, etc. - Social - occupation, alcohol, drug, tobacco use, risky behavior
- Immunizations - current and past received with dates
- Screenings/Health Promotion - mammography, testicular exams, dental, vision
- Review of Systems - systemic symptoms related to the current problem(s) including pertinent positives and negatives
General - fever (subjective) with chills and sweats, denies fatigue, weakness, weight loss, or malaise
- Skin - denies rashes, lesions, discolorations
- HEENT - positive for generalized headache, sore throat, pain with swallowing and rhinorrhea. Denies difficulty swallowing saliva, earache, sinus congestion, sinus pain, visual or auditory aura
- Neck - denies lump, pain, stiffness, or decreased range of motion
- Cardiac - denies chest pain, pressure, tightness, palpitations
- Pulmonary - denies cough, wheeze, hemoptysis
- GI - denies nausea, vomiting, abdominal pain
- GU - denies missed menses, urinary frequency, urgency or hematuria
- MS - denies cramping, pain,
- Neuro - denies unilateral weakness, numbness, tingling
• General -Well nourished and hydrated 28 yo female. Awake, alert and orient; appropriately dressed for season. Pleasant and cooperative.
*Skin - hot, dry and pink. No rashes or lesions including petechiae noted
• HEENT - normocephalic, symmetric face features. No tenderness in scalp, face, ethmoid/maxillary/frontal sinuses. Negative transillumination. External ears without deviations, ear canal clear bilaterally, tympanic membranes pearly grey with cone of light, bony landmarks visualized bilaterally. Nasal mucosa pink and moist turbinates with no edema or erythema. Oral mucosa pink and moist, dentition without obvious caries; no lesions oral cavity. Pharynx with moderate erythema tonsillar pillars ¼ bilaterally. No exudate. Uvula midline gag reflex present.
• Neck - supple. Anterior cervical lymphadenopathy with mobile, tender nodes bilaterally all less than 1 cm diameter. No JVD
- Cardiac - S1 S2 with no murmurs, gallops, or clicks. PMI 5th ICS mid-clavicular line
- Pulmonary - lungs clear to auscultation bilaterally in all fields. Negative tactile fremitus, egophony, bronchophony, and whispered pectoriloquy
- GI - no masses or pulsations. Bowel sounds normoactive all 4 quadrants. No organomegaly no bruits.
-GU- denies missed menses, urinary frequency, urgency or
- MS - Strength 4/5 bilateral upper and lower extremities. Gait steady
- Neuro - awake, alert, and oriented to name, place, date, and surroundings. No nuchal rigidity, Kernigs or Brudzinski signs
Symptom Analysis including
onset, progression, trigger, aggravating or alleviating factors;
How has it changed since first appearance; and all associated symptoms-itching, malaise, and so on.
Ask about dryness, pruritis, sores, rashes, lumps, unusual odor or perspiration, changes in moles or warts, lesions that do not heal, or areas of chronic irritation.
Any changes in skin coloration or texture
Skin care habits • Cleansing routine, soaps, oils, lotions • Cosmetics, home remedies, sun screens • Recent changes in skin care habits • Exposure to sunlight or tanning beds • Skin self-examination • Nail care habits • Exposure to environmental or occupational hazards • Recent psychological or physical stress • Use of alcohol, tobacco, or recreational drugs
Previous history of skin diseases or problems
Allergies to food, plants, animals, drugs
Familial predisposition Allergies, hay fever, psoriasis, eczema, acne
Rash or lesions OTC, anxiety, self-esteem, sexually transmitted, tickborne
Change in color Warning signs -ABCDE, itching, burning, bleeding
Excessive bruising, Falls, medication, abuse
• The Hair- quantity, distribution, texture, and pattern of loss • Scalp- check for scales, lumps, or lesions • Skull- size and contour; observe suture line • Face- facial expressions; look for symmetry, masses, or involuntary movements • Skin- color, pigment, texture, hair distribution Wear gloves and apply antiseptic gel
Inspect lips, oral mucosa, gums, teeth, floor and roof of mouth, tongue, soft and hard palate, pharynx, uvula and tonsils for symmetry, color, lesions, exudate .
Palpate 10 Lymph nodes : note size, shape, discrete or matted together, mobility, consistency, tenderness.
Normal characteristics of normal lymph node: small, round, mobile, discrete, non-tender.
Practice technique for locating and palpating all nodes. Know location for
Preauricular, Posterior Auricular, Occipital, Tonsillar, Submental, Submandibular, Superficial Cervical, Posterior Cervical, Deep Cervical Chain, Supraclavicular Bates' textbook page 259. Abnormal node characteristics: enlarged, tender, fixed to underlying tissue.
Tender could indicate inflammation or infection
Fixed nodes could indicate malignancy
•External Examination: - Inspect eyebrows for size, extension, and hair texture - Inspect orbital area for edema, puffiness, and sagging tissue below orbit • Eyelid inspection - Inspect closed lid for fasciculations and tremors - Check ability to close completely/open widely - Observe margin for flakiness, redness, and swelling - Look for eyelashes - Note eye opening • Ptosis - Note any eversion or inversion of lids
Eyelid palpation - Palpate for nodules - Palpate the eye itself through closed lids • Conjunctivae inspection - Usually unapparent, clear, and free of erythema - Inspect lower portion by pulling down lower lid - Upper lid is inspected only if foreign body is in the eye. - Look for redness/exudate - Look for pterygium • Abnormal growth of conjunctiva that extends over the cornea from the limbus
*Cornea -Examine clarity of the cornea by shining light on it. • Cornea is normally avascular; blood vessels should not be present. -Test sensitivity (cranial nerve V) by touching the cornea with a cotton wisp to elicit blink (cranial nerve VII). -Inspect for corneal arcus (arcus senilis). • Composed of lipids deposited in the periphery of the cornea
*Iris and pupil -Inspect iris for pattern, color, and shape -Test for direct/consensual light response -Test pupils for accommodation •The pupils should constrict when the eyes focus on the near object -Estimate pupil size and compare for equality
• Lens -Inspect for transparency/clarity • Sclera -Examine to ensure that it is white -Inspect for senile hyaline plaque • Lacrimal apparatus - Inspect lacrimal gland - Palpate lower orbital rim near inner canthus
External ear: - Angle of attachment and position - Inspect the auricles and mastoid area for size, shape, symmetry, landmarks, color, position, and deformities or lesions, or inflammation - Drainage: clear, blood, or purulent •External ear canal: - Color, drainage, lesions, lumps, and foreign objects - Inflammation - Swelling
External ear: - Consistency and tenderness •External ear canal: - Patency - Palpate tragus, mastoid, and helix for tenderness, swelling, nodules
• Lips - Note color, moisture, lumps, ulcers, cracking, or scaliness • Oral Buccal Mucosa - Note color, moisture, ulcers, and nodules - Stenson ducts, Fordyce spots • Gums and teeth - Note color, presence, and position of teeth, occlusion, alignment
Roof of mouth - Note color • Tongue and floor of mouth - Note color and texture, ulcers, nodules, coating, lesions - Ask patient to extend; deviation, tremor, limitation of movement - Frenulum
• Oropharynx: - Soft palate - Anterior and posterior pillars - Uvula - Tonsils - Pharynx • Note color, symmetry, presence of exudate, swelling, ulceration, or tonsillar enlargement • Elicit gag reflex (cranial nerves IX and X)
• Chest pain
- Initial questions should be as broad as possible, such as, "Do you have any discomfort or unpleasant feelings in your chest?"
- Ask the patient to point to the location of the pain
- Use OLDCART • Onset and duration • Associated symptoms • Efforts to treat • Other medications • Recreational drugs (e.g., cocaine)
Chest pain - Aside from lung conditions, chest pain may arise from cardiac, vascular, gastrointestinal, musculoskeletal, or skin pathology; it is also commonly associated with anxiety
- Lung tissue itself has no pain fibers; pain in lung conditions usually arises from inflammation of the adjacent parietal pleura
- Other surrounding structures may also irritate the parietal pleura, causing pain
• Shortness of breath (Dyspnea)
- Non-painful but uncomfortable awareness of breathing that is inappropriate to the level of exertion
- Begin assessment with a broad question, such as, "Have you had any difficulty breathing?"
- Determine the severity of dyspnea based on the patient's daily activities
• Shortness of breath (Dyspnea) - Onset - Pattern - Position most comfortable, number of pillows used - Related to extent of exercise, certain activities, time of day, eating - Harder to inhale or exhale - Severity - Associated symptoms - Efforts to treat
- Wheezes are musical respiratory sounds that may be audible to the patient and to others
- Airway obstruction form secretions, inflammation or foreign body
- Reflex response to stimuli that irritate receptors in the larynx, trachea, or large bronchi
- May be cardiovascular in origin; left sided failure
• Cough Ask the patient to describe the volume of any sputum and its color, odor, and consistency - Onset - Nature of cough; dry or produces sputum, or phlegm - Sputum production: frequency and amount in 24 hours - Sputum characteristics; mucoid, foul smelling - Pattern - Severity - Associated symptoms - Efforts to treat
• Hemoptysis • Hemoptysis is the coughing up of blood from the lungs; it may vary from blood-streaked phlegm to frank blood - Ask the patient to describe the volume of blood produced as well as other sputum attributes - Try to confirm the source of the bleeding by history and examination before using the term "hemoptysis"; blood may also originate from the mouth, pharynx, or gastrointestinal tract
• Examination of the anterior and posterior chest in sitting and supine positon - Proceed in an orderly fashion: inspect, palpate, percuss, and auscultate - Anteriorally with percussion, the heart normally produces an area of dullness to the left of the sternum from the 3rd to 5th rib interspaces - Supraclavicular retraction is often present
• Inspect the chest; front and back, noting thoracic landmarks, for the following: - Size and shape (anteroposterior diameter compared with the lateral diameter) - Symmetry - Color - Superficial venous patterns - Prominence of ribs
• Evaluate respirations for the following: - Rate - Rhythm or pattern • Inspect chest movement with breathing for the following: - Symmetry - Use of accessory muscles • Note any audible sounds with respiration
• Palpate the chest for the following: - Symmetry - Thoracic expansion - Sensations such as crepitus, grating vibrations - Tactile fremitus
• Percuss on the chest, comparing sides, for the following: - Diaphragmatic excursion - Percussion tone intensity, pitch, duration, and quality
• Auscultate the chest with the stethoscope diaphragm, from apex to base; comparing sides for the following: - Intensity, pitch, duration, and quality of breath sounds - Adventitious breath sounds (crackles, rhonchi, wheezes, friction rubs) - Vocal resonance
• General techniques - Examine the posterior thorax and lungs while the patient is sitting - Examine the anterior thorax and lungs with the patient supine - Compare one side of the thorax and lungs with the other, so the patient serves as his or her own control - Proceed in an orderly fashion: inspect, palpate, percuss, and auscultate
• Initial survey (Inspection) of respiration and the thorax - Observe the rate, rhythm, depth, and effort of breathing - Inspect for any signs of respiratory difficulty o Assess the patient's color o Listen to the patient's breathing o Inspect the patient's neck - Observe the shape of the chest
• Observe for peripheral clues may suggest pulmonary or cardiac difficulties: - Breath: odor - Skin, nails, and lips: cyanosis or pallor - Fingers: clubbing - Lips: pursing - Nostrils: flaring
• Examination of the posterior chest - Inspection o From a midline position behind the patient, note the shape of the chest and the way in which it moves
• Palpation of the thoracic muscles/skeleton - Pulsations - Tenderness - Bulges/depressions - Masses - Unusual movement/positions - Elasticity of rib cage - Immovability of sternum - Rigidity of thoracic spine • Position of the trachea (head & neck exam)
• Percuss chest -Anterior -Lateral -Posterior • Compare tones bilaterally
Examination of the posterior chest - Percussion o Perform from side to side to assess for asymmetry o Strike using the tip of your tapping finger o Use the lightest percussion that produces a clear note o Percussion helps establish whether the underlying tissues (5-7 cm deep) are air-filled, fluid-filled, or solid o Percussion notes Flatness, dullness, resonance, hyperresonance, tympany
• Percussion tone indicators for lungs -Resonance is normal. -Hyperresonance indicates hyperinflation. -Dullness indicates diminished air exchange
- Palpation o Assess any observed abnormalities and identify any tender areas
Feel for tactile fremitus, or palpable vibrations as the patient is speaking
o Chest expansion o Place thumbs at the level of the 10th rib with fingers loosely grasping and parallel to the lateral rib cage; watch the distance between the thumbs as they move apart during inspiration
• Auscultation with a stethoscope provides important clues to the condition of the lungs and pleura • All sounds can be characterized in the same manner as the percussion notes: - Intensity - Pitch - Quality - Duration
• Posterior chest - Auscultation o Auscultation of the lungs is the most important examination technique for assessing air flow through the tracheobronchial tree o Together with percussion, it also helps to assess the condition of the surrounding lungs and pleural space o Listen to the breath sounds with the diaphragm of a stethoscope after instructing the patient to breathe deeply through an open mouth o Use the pattern suggested for percussion, moving from one side to the other and comparing symmetric areas of the lungs o Listen to at least one full breath in each location
o Characteristics of normal breath sounds (pg. 303) Vesicular: soft and low pitched, low intensity; usually heard over most of both lungs Bronchial: louder and higher in pitch and intensity; usually heard over the manubrium Bronchovesicular: intermediate intensity and pitch; usually heard over the 1st and 2nd interspaces (major bronchi) Tracheal: very loud and high pitched, heard over trachea and neck
o Adventitious (added) sounds: Crackles (formerly called rales) • Abnormal respiratory sound heard more often during inspiration and characterized by discrete discontinuous sounds • Fine: high pitched, and relatively short in duration • Coarse: low pitched, and relatively longer in duration
o Adventitious (added) sounds: Rhonchi (sonorous wheezes) • Deeper, more rumbling, more pronounced during expiration, more likely to be prolonged and continuous, and less discrete than crackles • Caused by the passage of air through an airway obstructed by thick secretions, muscular spasm, new growth, or external pressure
o Adventitious (added) sounds: Wheezes (sibilant wheeze) • Continuous, high-pitched, musical sound (almost a whistle) heard during inspiration or expiration • Caused by a relatively high-velocity air flow through a narrowed or obstructed airway • May be caused by the bronchospasm of asthma (reactive airway disease) or acute or chronic bronchitis
• Examination of the posterior chest - Auscultation o Adventitious (added) sounds: Friction Rub • Occurs outside the respiratory tree • Dry, crackly, grating, low-pitched sound and is heard in both expiration and inspiration • Caused by inflamed, roughened surfaces rubbing together
o Adventitious (added) sounds: Mediastinal Crunch (Hammam Sign)) • Dry, crackly, grating, low-pitched sound and is heard in both expiration and inspiration • Caused by inflamed, roughened surfaces rubbing together • Occurs outside the respiratory tree
• Asthma (reactive airway disease) - Reversible small airway obstruction due to inflammation and hyperreactive airways • Atelectasis - Incomplete expansion of the lung at birth or the collapse of the lung parenchyma at any age • Bronchitis - Inflammation of the large airways
• Pleurisy - Inflammatory process involving the visceral and parietal pleura, which becomes edematous and fibrinous • Pleural effusion - Excessive nonpurulent fluid in the pleural space • Empyema - Purulent exudative fluid collected in the pleural space
• Lung abscess - Well-defined, circumscribed mass defined by inflammation, suppuration, and subsequent central necrosis • Pneumonia - Inflammatory response of the bronchioles and alveoli to an infective agent (bacterial, fungal, or viral)
• Influenza - Viral infection of the lung - Normally an upper respiratory infection, but due to alterations in the epithelial barrier, the infected host is more susceptible to secondary bacterial infections. • Tuberculosis - Chronic infectious disease that most often begins in the lung but may then have widespread manifestations
• Pneumothorax - Presence of air or gas in the pleural cavity • Hemothorax - Presence of blood in the pleural cavity • Lung cancer - Generally refers to bronchogenic carcinoma, a malignant tumor that evolves from bronchial epithelial structures
• Cor pulmonale - Acute or chronic condition involving right-sided heart failure • Pulmonary embolism - Embolic occlusion of pulmonary arteries - Relatively common condition - Difficult to diagnose
• Older Adults • Chronic obstructive pulmonary disease - COPD is a nonspecific designation that includes a group of respiratory problems in which cough, chronic and often excessive sputum production, and dyspnea are prominent features. - Not limited to older adults, smokers at greatest risk - Emphysema, bronchiectasis, and chronic bronchitis are the main conditions that are included in this group
• Emphysema - Condition in which the lungs lose elasticity and alveoli enlarge in a way that disrupts function • Bronchiectasis - Chronic dilation of the bronchi or bronchioles is caused by repeated pulmonary infections and bronchial obstruction. • Chronic bronchitis - Large airway inflammation, usually a result of chronic irritant exposure; more commonly, a problem for patients older than 40
• Inspection • Apical impulse - Should be visible at about the midclavicular line in the fifth left intercostal space • In some patients, it may be visible in the fourth left intercostal space • It should not be seen in more than one space if the heart is healthy • Obscured by obesity, large breasts, or muscularity
Palpating the Chest Wall
• Using the finger pads, palpate for heaves or lifts from abnormal ventricular movements: forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs. • Using the ball of the hand, palpate for thrills, or turbulence/ vibrations transmitted to the chest wall surface by a damaged heart valve • Examples: 1. Sustained lift at the Tricuspid area: RV 2. Systolic thrill at tricuspid area: VSD 3. Thrill at the Mitral area: MR or MS
• Palpation • Apical impulse - If it is more vigorous than expected, characterize it as a heave or lift. - Point of maximal impulse (PMI) • Point at which the apical impulse is most readily seen or felt - Thrill: a fine, palpable, rushing vibration, a palpable murmur • Carotid artery palpation
Assessing the Point of Maximal Impulse (PMI)
• Inspect the left anterior chest for a visible PMI • Using your finger pads, palpate at the apex for the PMI • The PMI may be: - Tapping — normal - Sustained — suggests LV hypertrophy from hypertension or aortic stenosis - Diffuse — suggests a dilated ventricle from congestive heart failure or cardiomyopathy • Locate the PMI by interspace and distance in centimeters from the midsternal line • Assess location, amplitude, duration, and diameter
Assessing the Carotid Pulse
• Keep the patient's head elevated to 30° • Place your index and middle fingers on the right then the left carotid arteries, and palpate the carotid upstroke • Never palpate right and left carotid arteries simultaneously • The upstroke may be: - Brisk - normal - Delayed - suggests aortic stenosis - Bounding - suggests aortic insufficiency • Listen with the stethoscope for any bruits - Bruits - turbulent blood flow outside the heart due to flow through narrowed or dilated vessel
* Of limited value in defining borders of heart or determining its size
Chest radiograph is far more useful in defining the heart borders
Listening to the Heart — Auscultation
• Listen in all 6 listening areas for S1 and S2 using the diaphragm of the stethoscope • Then listen at the apex with the bell • The diaphragm and the bell - The diaphragm is best for detecting high-pitched sounds like S1, S2, and also S4 and most murmurs - The bell is best for detecting low-pitched sounds like S3 and the rumble of mitral stenosis
• Auscultation • Assess overall rate and rhythm • Frequency • Intensity • Duration • Pathology
• Auscultation • Basic heart sounds - S1 or S2 most distinct - Splitting - S3 and S4 difficult to hear • Extra heart sounds - Gallops - Mitral snaps - Ejection clicks - Friction rubs
Patient may present with one of the 5 warning signs of BCC
Persistent, non-healing sore that bleeds/oozes, especially on sun-exposed area (face, chest, arms, legs, shoulders)
A red patch or "irritated" area that is painful or itchy (may also be without pain)
A shiny nodule or bump (can be pink, red, white, tan, black, brown)
A pink growth with elevated/rolled border and central, crusted indentation; may note telangiectasias
A white or yellow area that is shiny/taut and has the appearance of a scar (this may indicate invasive BCC)
Ask patients if they have noticed any changes in their skin
If patient reports a change/new growth, further explore if patient has personal OR family history of skin cancer (type, treatment)
During skin exam, carefully inspect/palpate any skin lesions (may require magnifying glass)
Note and describe: type of lesion, color, texture, size, shape, location, number
Diagnosis is confirmed with biopsy
Treatment based on location, size, depth of tumor (curettage and electrodessication; Mohs procedure; excision; pharmacologic, etc.)
Assessment- onset, duration, *any knowledge of previous level of function, new medications or any medications likely to cause toxicity.
Mental Status changes notable to a specific time of day
Environmental factors- do they reside in an institution- recent outbreaks of respiratory infections, influenza, pneumonia
Physical exam- possible causes of sepsis, skin infections, UTI
Mini COG Assessment Instrument for Dementia- Specificity 89-96%
MMSE- Specificity 92-99%
Memory Impairment screen-Specificity 96-97%
Montreal Cognitive Assessment
Geriatric Depression Scale-
Labwork- Basic metabolic profile, Serum B12 and folic acid, CBC with differential, urinalysis with culture and sensitivity, FTA-ABS, Lyme serology, ESR, pulse oximetry, chest xray
Procedures- 24 hour urine, EEG, Lumbar puncture for CSF
Seek to rule out:
Drug side effects
Obtain a history of the redness and it's progression. Ask about other symptoms, such as eye itching, pain, swelling, discharge, or photophobia. Ask about exposures to chemical agents. Ask about systemic symptoms such as general malaise, skin rashes, and cold or allergy symptoms. Ask about family history of eye conditions. If the patient had eye trauma or abrasion, find out patient's tentanus status.
Determine patient's corrected visual acuity, then observe general characteristics of the redness, and finishing with a rapid assessment to rule out signs of trauma. Note if there is any photophobia and adjust the light to patient's comfort if possible. Assess the outer and appendage structures, looking for swelling, redness, discharge, or lesions. Next, focus on the eye itself, observing the cornea and conjunctiva for redness and noting the degree of pattern, and location of the redness. Identify any shadowing by passing oblique lighting over the anterior chamber. Assess the palpebral and tarsal conjunctiva beneath the lids; observe for foreign bodies or lesions. Assess the size, shape, and responsiveness of the pupils. If tolerated, perform a funduscopic examination. Depending on the history and examination of the eyes, it may be necessary to extend the assessment to the skin, ears, nose, throat and joints to assess for infections, allergy, or rheumatic disorders.
Diagnostic tests are helpful in assessing conjunctivitis. Studies can include viral and bacterial cultures of the conjunctiva or tests for atopy.
Respiratory Virus - HA, fever, chills, malaise, accompanied by rhinitis, cough, conjunctivitis
Herpes Pharyngitis - Malaise and fever with inflamed ulcerative lesions
Hand-foot-and-mouth disease - malaise, ulcerative lesions in mouth, hands, feet, buttocks, or genitalia
Diptheria - HA, rhinitis, fever, chills, dysphagia, difficulty breathing; pharynx inflamed with thick, gray membrane
Inspect the external aspects of the ear, such as the auricle, lobule, tragus, and entrance to the ear canal
Assess for lumps, deformities, lesions, erythema, and discharge
Perform the tug test; move the auricle up and down, press the tragus, and press behind the ear firmly. If pain is felt during movement of the auricle and tragus, it is suggestive of otitis externa. If the pain is felt during firmly pressing behind the ear it is suggestive of otitis media
Use an otoscope to inspect the ear canal. To straighten the ear canal pull the auricle upward, then backward, and the away from the head.
Note any odor, discharge, erythema, foreign objects, swelling, and assess cerumen color and consistency.
No further diagnostic testing needed. If discharge is seen, may send for culture and sensitivity. If patient fails to respond to treatment, refer to ENT specialist.
There are other diagnostic tests if there is any doubt about a diagnosis. Alternatives are pursued if the condition hasn't responded to previous treatments, or if there are other persistent or serious problems.
Tympanometry. This test measures the movement of the eardrum. The device, which seals off the ear canal, adjusts air pressure in the canal, thereby causing the eardrum to move. measures of pressure within the middle ear.
Tympanocentesis. Rarely, a doctor may use a tiny tube that pierces the eardrum to drain fluid from the middle ear - Tests to determine the infectious agent in the fluid may be beneficial if an infection hasn't responded well to previous treatments.
For persistent ear infections or persistent fluid buildup in the middle ear, a patient can be referred to an audiologist, speech therapist for tests of hearing, speech delays, and language comprehension.
Endoscopy view nasal passages and adenoids
CT scan for detailed images of the sinus cavity and adenoids
MRI for imaging of the anatomy as well
In order to confirm diagnosis of otitis media
Physical inspection of the ear canal
Labs (labwork helps to reveal if the patient's health status in declining and this is the first sign of the problem, ex rule out septsis...)
Mental Status- Mini Mental Status Exam page 733 Bates'
CN1 through Xll
Motor System: Muscle bulk, tone, strength ,coordination, gait, stance
Sensory System: pain and temperature, position, and vibration, light touch, discrimination sensation
Deep tendon, abdominal, and plantar reflexes
Definition: Pneumonia is a bacterial, viral, or fungal infection of one or both sides of the lungs that causes the air sacs, or alveoli, of the lungs to fill up with fluid or pus. (NHLBI, 2016)
Bacterial PNA: Sputum is mucoid or purulent; may be blood-streaked, diffusely pinkish, or rusty. Common pathogens are S. pneumoniae, Haemophilus influenza, and Moraxella catarrhalis.
Myocoplasma and viral PNA: Dry hacking cough that may become productive of mucoid sputum. Acute febrile illness, often with malaise, headache, and possibly dyspnea.
Community Acquired PNA (CAP): Most common form, occurs outside of hospital or other health care facilities. Infection by breathing in germs (especially while sleeping).
Hospital Acquired PNA (HAP): Hospitalized patients develop. Usually more serious due to already being sick and germs more resistant to typical antibiotics that treat bacterial PNAs.
Ventilator-assisted PNA (VAP): Patients on ventilators are at increased risk.
Atypical Pneumonia: Usually community acquired, infections with less common bacteria: Legionella pneumphila, Mycobacterium pneumoiae, Chlamydia pneumoniae
Aspiration PNA: Inhalation of food, drink, vomit or saliva into lungs. Disruptions to gag reflex (brain injury, stroke) or excessive alcohol/drug intake can cause.
Inspection: observe respirations, use of accessory muscles, symmetry of chest movement.
Palpation: any area of discomfort or pain; tactile fremitus (palpable vibrations felt when patient is speaking, uneven with unilateral PNA)
Percussion: dullness is found with PNA.
Auscultation: general lung fields, pay close attention to areas where abnormalities were already detected. Bronchial breath sounds over the infected area often w/crackles. Bronchophony "ninety-nine", egophony "ee", & whispered pectoriloquy "one-two-three" are positive in area of consolidation.
Fever & cough with the presence of bronchial breath sounds and egophony more than triples the likelihood of PNA.
Have patient take a deep breath and cough to clear the airway if adventitious sounds are heard (can eliminate or change the quality of sounds)
*Always compare bilateral lungs in each area of assessment
Vital signs: include SPO2
CBC: WBC often elevated
CURB-65 to determine if hospitalization needed
Confusion, BUN > 20mg/dl, RR >30 bpm, SBP <90 or DBP < 60, age 65 or older (1 pt awarded for each factor present)
*can perform sputum if able to produce but usually reserved for hospitalized patients.
Catarrhal stage: can last 1-2 weeks and includes a runny nose, sneezing, low-grade fever, and a mild cough (all similar symptoms to the common cold).
Paroxysmal stage: usually lasts 1-6 weeks, but can persist for up to 10 weeks. The characteristic symptom is a burst, or paroxysm, of numerous, rapid coughs. At the end of the cough paroxysm, the patient can suffer from a long inhaling effort that is characterized by a high-pitched whoop (hence the name, "whooping cough"). Infants and young children often appear very ill and distressed, and may turn blue and vomit. "Whooping" does not necessarily have to accompany the cough.
Convalescent stage: usually lasts 2-6 weeks, but may last for months. Although the cough usually disappears after 2-3 weeks, paroxysms may recur when- ever the patient suffers any subsequent respiratory infection. The disease is usually milder in adolescents and adults, consisting of a persistent cough similar to that found in other upper respiratory infections. However, these individuals are still able to transmit the disease to others, including unimmunized or in completely immunized infants.
Intermittent sensation of chest tightness, cough (typically non-productive), shortness of breath, and/or wheezing
Symptoms may become relatively persistent and effect quality of life
Symptoms worsen with activity, viral infection, or exposure to allergens
Symptoms are a large part of asthma staging; night time symptoms, use of SABA, and interference with activities
Wheezing, deep respiratory effort triggers paroxysmal cough, use of accessory muscles, tachypnea
Patients with asthma often have other signs of atopy (AR, atopic dermatitis)