UNIT 1 STUDY GUIDE: NU-518, Advanced Nursing Assessment | Already Graded A+

UNIT 1 STUDY GUIDE: NU-518, Advanced Nursing Assessment Bates’ Guide to Physical Examination, 12th edition Chapters 1 – 5, 18 – 20 (selected readings) Edited by: Jessica L. Santos ...

UNIT 1 STUDY GUIDE: NU-518, Advanced Nursing Assessment Bates’ Guide to Physical Examination, 12th edition Chapters 1 – 5, 18 – 20 (selected readings) Edited by: Jessica L. Santos SECTION I: INDEX Question Page Number, Reference Information 1. History and physical exam: comprehensive vs focused. (pp. 5-7; key search term: “focused for patients”) 4 2. Subjective vs. objective data. (pp. 6-7; key search term: “data as you”) 4 – 5 3. Components of health history. (pp. 7-13; key search term: “systems as you”) 5 – 7 4. Cardinal techniques of examination. (pp. 18-19; key search term: “techniques inspection”) 7 – 8 5. Clinical reasoning, assessment, and plan. (pp. 25-28; key search term: “follows think about”) 8 – 9 6. Generating the problem list. (p. 37; key search term: “complete the clinical”) 9 7. Sensitivity and specificity. (p. 48; key search term: “sensitivity is the”) 9 – 10 8. Different types of health histories: comprehensive vs focused. (p. 67; key search term: “concerns your goals”) 10 9. Skilled interviewing techniques; sequence and context of the interview. (pp. 68- 10 – 13 77; key search terms: “progress over time” and “paradigm now”) 10. Seven attributes of a symptom. (p. 79; key search term: “quality what”) 13 11. Cultural humility. (pp. 82-86; key search term: “paradigm communicating”) 13 12. Advanced interviewing. (pp. 86-98; key search term: “patient as you spend”) 13 – 16 13. Ethics and professionalism – building blocks. (p. 100; key search term: “building blocks of professional”) 16 14. The health history – common and concerning symptoms. (p. 112; key search term: “weakness fatigue is”) 17 – 18 15. Eating disorders and excessively low BMI. (p. 140; key search term: “disorders the lifetime”) 18 16. Health promotion and counseling. (pp. 114-119; key search term: “diet fewer”) 18 – 19 17. BMI (underweight, normal, overweight, obese). (p. 116; key search term: “pursue weight”) 19 18. Safe goal for weight loss. (p. 117; key search term: “goals experts”) 19 19. The general survey. (pp. 120-122; key search term: “survey the general”) 19 – 21 20. Proper technique for accurate blood pressure measurement. (p. 127; key search term: “measurements take the”) 21 21. Heart rate and rhythm, respiratory rate and rhythm, temperature. (pp. 132- 21 – 22 134; key search term: “rhythm examine”) 22. Types of pain. (p. 137; key search term: “pain is linked”) 23 23. Personality disorders. (p. 152-153; key search term: “with personality disorders”) 23 – 24 24. Components of the mental status examination (MSE). (pp. 154-156, 158-168; key search term: “complex changes in”) 24 – 27 25. Variations and abnormalities in thought processes. (pp. 161-163; key search term: “processes assess”) 27 26. Abnormalities of perception. (p. 163; key search term: “perceptions pursue”) 27 27. Mood. (p. 156; key search term: “suicide mood”) 27 28. Assessing the infant – development. (p. 809; key search term: “development physical growth”) 28 29. Examination tips – infants. (p. 810; key search term: “noise tips”) 28 30. Techniques of examination - infant, school-age children. (pp. 813-853; key search term: “signs measure the infant’s”) 29 – 41 31. Assessing young and school-aged children – development. (p. 854; key search term: “development after infancy”) 41 – 42 32. Developmental milestones during early childhood. (p. 853; key search term: “development after infancy”) 42 33. Examination tips – young children. (p. 855; key search term: “avoiding a physical”) 43 34. Assessing adolescents - health history. (p. 891; key search term: “environment this makes”) 43 – 44 35. Anatomic changes. (pp. 928-930; key search term: “changes changes”) 44 – 45 36. Gestational age versus expected date of delivery. (p. 934; key search term: “effectively triaging”) 46 37. Substance abuse. (p. 938; key search term: “abuse abstinence”) 46 38. Immunizations. (p. 937; key search term: “immunizations given”) 46 39. Examination techniques – height, weight, and vital signs. (p. 942; key search term: “weight calculate”) 47 40. Vital signs. (pp. 957-958; key search term: “frailty vital”) 47 41. Activities of daily living versus instrumental activities of daily living. (pp. 970- 971; key search term: “living the daily”) 47 – 48 42. Clinical clues to alcohol-related problems. (p. 974; key search term: “watch for clues”) 48 43. Household safety and fall prevention. (p. 979; key search term: “prevention in 2013”) 48 – 49 44. Immunizations. (pp. 979-980; key search term: “immunizations recommend”) 49 – 50 45. Examination techniques – assessing functional status. (pp. 985-997; key search term: “sixth vital sign is”) 50 46. Assessment for preventing falls – algorithm. (pp. 987-988; key search term: “assessment STEADI”) 51 SECTION II: STUDY GUIDE Chapter 1 (Foundations for Clinical Proficiency) 1. History and physical exam: comprehensive vs focused. (pp. 5-7; key search term: “focused for patients”) For patients you are seeing for the first time in the office or hospital, you will usually choose to conduct a comprehensive assessment, which includes all the elements of the health history and the complete physical exam. Provides a complete basis for assessing patient concerns and answering patient questions. Comprehensive examinations are: • Sources of fundamental and personalized knowledge about the patient that strengthens the clinician-patient relationship • Provides a more complete basis for assessing patient concerns and answering patient questions A more flexible focused or problem-oriented assessment is appropriate for patients you know well who are returning for routine office care, or for patients with specific “urgent care” concerns, like sore throat or knee pain. For the focused examination, you will: • Select methods relevant to thorough assessment of the targeted problem • Use the patient’s symptoms, age, and health history to determine the scope of the examination You will adjust the scope of your history and physical examination to the situation at hand, keeping several factors in mind: the magnitude and severity of the patient’s problems; the need for thoroughness; and the clinical setting – inpatient or outpatient, primary or subspecialty care, and the time available. 2. Subjective vs. objective data. (pp. 6-7; key search term: “data as you”) ▪ Subjective data: includes symptoms (what the patient tells you). ▪ Objective data: includes signs (what you observe). 3. Components of health history. (pp. 7-13; key search term: “systems as you”) Health History Component Key Aspects Notes, Examples Identifying Data ▪ Identifying data includes age, gender, occupation, marital status. ▪ Also includes source of the history (e.g., patient, family member, friend, letter of referral, or clinical record). ▪ If appropriate, establish the source of the referral. Identifying the source of referral helps you assess the quality of the referral information, and any questions you may need to address in your assessment and written response. Reliability ▪ Varies according to patient’s memory, trust, mood. Examples: ▪ “The patient is vague when describing symptoms, and the details are confusing.” ▪ “The patient is a reliable historian.” Chief ▪ One or more symptoms or concerns Make every attempt to quote the patient’s own words. Complaint(s) causing the patient to seek care. Examples: ▪ “My stomach hurts and I feel awful.” ▪ “I have come for my regular check-up.” ▪ “I’ve been admitted for a thorough evaluation of my heart.” Present Illness ▪ Describes how each symptom developed. ▪ Includes patient’s thoughts and feelings about the illness. ▪ Pulls in relevant portions of the ROS (called “pertinent positives and negatives”). ▪ May include medications, allergies, and tobacco/alcohol use which are pertinent to present illness. Each principal symptom should be well characterized, with its own paragraph and full description, and should include the seven attributes of a symptom: 1. Location 2. Quality 3. Quantity or severity 4. Timing (including onset, duration, and frequency) 5. The setting in which it occurs 6. Factors that aggravate or relieve the symptom 7. Associated manifestations Past History ▪ Lists childhood illnesses. ▪ Lists adult illnesses with dates for events in at least four categories (medical, surgical, OB/GYN, psychiatric). ▪ Includes health maintenance practices, such as immunizations, screening tests, lifestyle issues, and home safety. Immunizations to assess: ▪ Tetanus ▪ Pertussis ▪ Diphtheria ▪ Polio ▪ Measles ▪ Rubella ▪ Mumps ▪ Influenza ▪ Varicella ▪ Hepatitis B virus ▪ Human papilloma virus ▪ Meningococcal disease ▪ Haemophilus influenzae type B ▪ Pneumococci ▪ Herpes zoster For screening tests, assess: ▪ Tuberculin tests ▪ Pap smears ▪ Mammograms ▪ Stool tests for occult blood ▪ Colonoscopy ▪ Cholesterol Family History ▪ Outlines age and health, or age and cause of death, of siblings, parents, and grandparents. ▪ Documents presence or absence of specific illnesses in family, such as HTN, diabetes, or type of cancer. Review each of the following condition and record whether they are present or absent in the family: HTN, CAD, elevated cholesterol levels, stroke, diabetes, thyroid or renal disease, arthritis, tuberculosis, asthma or lung disease, headache, seizure disorder, mental illness, suicide substance abuse, allergies, history of breast/ovarian/colon/prostate cancer, and any genetically transmitted diseases. Personal and Social History ▪ Describes educational level, family of origin, current household, personal interests, and lifestyle. This should include occupation, last year of schooling, home situation, significant others, sources of stress, important life experiences (e.g., military service, job history, financial situation, retirement), leisure activities, religious affiliation/spiritual believes, ADLs, baseline level of function, lifestyle habits that promote health or create risk (e.g., exercise and diet, safety measure use), sexual orientation and practices, and alternative health care practices. Review of Systems (ROS) ▪ Documents presence of absence of common symptoms related to each of These “yes-no” questions should come at the end of the interview. Ask these series of questions by going from the major body systems “head to toe.” These questions may be drawn upon while eliciting the present illness section of the assessment. Start with general questions, then shift to more specific questions about systems that may be of concern. Major health events discovered during the ROS should be move to the present illness or past history section. 4. Cardinal techniques of examination. (pp. 18-19; key search term: “techniques inspection”) Inspection: close observation of the details of the patient’s appearance, behavior, and movement such as facial expression, mood, body habitus and conditioning, skin conditions such as petechiae or ecchymoses, eye movements, pharyngeal color, symmetry of thorax, height of jugular venous pulsations, abdominal contour, lower extremity edema, and gait. Palpation: tactile pressure from the palmar fingers or fingerpads to assess areas of skin elevation, depression, warmth, or tenderness, lymph nodes, pulses, contours and sizes of organs and masses, and crepitus in the joints. Percussion: use of the striking or plexor finger, usually the third, to deliver a rapid tap or blow against the distal pleximeter finger, usually the distal third finger of the left hand laid against the surface of the chest or abdomen, to evoke a sound wave such as resonance or dullness form the underlying tissue or organs. This sound wave also generates a tactile vibration against the pleximeter finger Auscultation: use of the diaphragm and bell of the stethoscope to detect the characteristics of heart, lung, and bowel sounds, including location, timing, duration, pitch, and intensity. For heart, this involves sounds from closure of the four valves, extra sounds from blood flow into the atria and ventricles, as well as murmurs. Auscultation also permits detection of bruits or turbulence over arterial vessels. 5. Clinical reasoning, assessment, and plan. (pp. 25-28; key search term: “follows think about”) Identify abnormal findings ▪ Make a list of patient’s symptoms, signs you observed during exam, and lab results available. Localize findings anatomically ▪ Find the area of concern related to patient’s statements. ▪ Be as specific as your data allows, but you may have to settle for a body region (e.g., chest) or body system (e.g., musculoskeletal system). ▪ Some symptoms and signs are constitutional and cannot be localized, such as fatigue or fever. Cluster the clinical findings ▪ If there is a relatively long list of symptoms and signs, and an equally long list of potential explanations, one approach is to tease out separate clusters of observations and analyze one cluster at a time. Several clinical characteristics may help: o Patient age: younger adults are more likely to have a single disease, whereas older adults tend to have multiple diseases. o Timing of symptoms: to use timing effectively, you need to know the natural history of various diseases and conditions. o Involvement of different body systems: if symptoms and signs occur in a single system, on disease may explain them. Problems in different, apparently unrelated, systems often require more than one explanation. Knowledge of disease patterns is necessary! o Multisystem conditions: with experience, you will become increasingly adept at recognizing multisystem conditions and building plausible explanations that link manifestations that are seemingly unrelated. o Key questions: you can ask a series of key questions that may steer your thinking in one direction and allow you to temporarily ignore the others. A series of discriminating questions helps you analyze the clinical data and reach logical explanations. Search for the probable cause of the findings ▪ Pathologic processes are commonly classified as congenital, inflammatory or infectious, immunologic, neoplastic, metabolic, nutritional, degenerative, vascular, traumatic, or toxic. ▪ Other problems, pathophysiologic problems, reflect derangements of biologic functions, such as heart failure or migraine headache. ▪ Still other problems are psychopathologic, such as disorders of mood, like depression or headache as an expression of a somatic symptom disorder. Generate hypotheses about the causes of the patient’s problem ▪ Select the most specific and critical findings to support your hypothesis. ▪ Using your knowledge about the structures and processes involved, match your findings against all the conditions you know that can produce them. ▪ Eliminate the diagnostic possibilities that fail to explain the findings. ▪ Weigh the competing possibilities and select the most likely diagnosis among the conditions that might be responsible for the patient’s findings. The statistical probability of a given disease in a patient of this age, sex, ethnic group, habits, lifestyle, and locality should greatly influence your selection. The timing of the patient’s illness also makes a difference! ▪ As you develop possible explanations from the patient’s problem, give special attention to potentially life-threatening and treatable conditions. Always include the “worst case scenario” in your differential diagnosis and make sure you have ruled out this possibility based on your findings and patient assessment. Test the hypotheses ▪ Now that you have made a hypothesis about the patient’s problem, you are ready to test it. You are likely to need further history, additional maneuvers on physical examination, or laboratory studies or x-rays to confirm or rule out your tentative diagnosis or to clarify which of two or three possible diagnoses are most likely. Establish a working diagnosis ▪ Now can establish a working definition of the problem at the highest level of explicitness and certainty that the data allow. 6. Generating the problem list. (p. 37; key search term: “complete the clinical”) ▪ Summarizes the patient’s problems for the front of the office or hospital chart. ▪ Lists the most active and serious problems first, with their dates of onset. ▪ Provides a quick summary of the patient’s clinical history and a reminder to review the status of problems the patient may not mention. ▪ Helps in follow-up visits to check the status of problems the patient may not mention. ▪ Allows better population management of patients, by using EHRs to track patients with specific problems, recall patients who are behind on appointments, and follow-up on specific issues. ▪ Allows other members of the health care team to review patient’s health status at a glance. ▪ Problems can be symptoms, signs, past health events (e.g., hospital admission or surgery), or diagnoses. ▪ Good lists vary in emphasis, length, and detail, depending on the clinician’s philosophy, specialty, and role as a provider. ▪ Problem lists with too many relatively insignificant items are distracting. Chapter 2 (Evaluating Clinical Evidence) 7. Sensitivity and specificity. (p. 48; key search term: “sensitivity is the”) The initial step in evaluating a diagnostic test is to determine whether it provides valid results. This involves comparing the test against a gold standard – the best measure of whether a patient has a disease. The first test statistics to estimate are sensitivity and specificity. Knowing the sensitivity and specificity of a test does not necessarily help you make clinical decisions because they are statistics based on knowing whether the patient has a disease. However, there are two exceptions: ▪ A negative result from a test with a high sensitivity (i.e., a very low false-negative rate) usually excludes disease (represented by the acronym SnNOUT – “a sensitive test with a negative result rules out disease”). ▪ A positive result in a test with high specificity (e.g., a very low false-positive rate) usually indicates disease (represented by the acronym SpPIN – “a specific test with a positive result rules in disease”). Chapter 3 (Interviewing and the Health History) 8. Different types of health histories: comprehensive vs focused. (p. 67; key search term: “concerns your goals”) ▪ For new patients, in most settings, you will do a comprehensive health history. ▪ For patients seeking care for specific concerns, a more limited interview tailored to that specific problem may be indicated; this is sometimes known as a focused or problem-oriented history. 9. Skilled interviewing techniques; sequence and context of the interview. (pp. 68-77; key search terms: “progress over time” and “paradigm now”) Skilled Interviewing Technique Explanation Active Listening Closely attending to what the patient is communicating, connecting to the patient’s emotional state, and using verbal and nonverbal skills to encourage the patient to expand on his or her feelings and concerns. Empathic Responses Empathy has been described as the capacity to identify with the patient and feel the patient’s pain as your own, then respond in a supportive manner. Empathy requires a willingness to suffer some of the patient’s pain in the sharing of suffering that is vital to healing. To express empathy, you must first recognize the patient’s feelings, then actively move toward and elicit emotional content. For a response to be empathic, it must convey that you feel what the patient is feeling. Guided Questioning Your goal is to facilitate full communication, in the patient’s own words, without interruption. Guided questions show your sustained interest in the patient’s feelings and deepest disclosures. Techniques of guided questioning include: ▪ Moving from open-ended to focused questions: questions should flow from general to specific, and leading questions should be avoided. ▪ Using questioning that elicits a graded response: ask questions that require a graded response rather than a yes or no; e.g., “How many steps can you climb before you get short of breath?” instead of “Do you get short of breath climbing stairs?” ▪ Asking a series of questions, one at a time: pause and establish eye contact as you ask one question at a time. ▪ Offering multiple choices for answers: to minimize bias, offer multiple choice answers when patients need help describing their symptoms. ▪ Clarifying what the patient means: acknowledge any confusion by requesting clarification; this reassures the patient that you want to understand his or her story and builds your therapeutic relationship. ▪ Encouraging with continuers: without even speaking, you can use posture, gestures, or words to encourage the patient to say more (e.g., pausing and nodding your head, remaining silent, leaning forward/making eye contact, etc.). ▪ Using echoing: simply repeating the patient’s last words encourages the patient to elaborate on details and feelings. This also demonstrates careful listening and a subtle connection with the patient by using the same words. Nonverbal Communication Being sensitive to nonverbal cues allows you to “read the patient” more effectively and send messages of your own. Pay close attention to eye contact, facial expression, posture, head position and movement such as shaking or nodding, interpersonal distance, and placement of the arms of legs. Matching your position to the patient’s can transmit increase rapport. You can also mirror the patient’s paralanguage, or qualities of speech, such as pacing, tone, and volume. The first step to using this important technique is to notice nonverbal behaviors and bring them to conscious level. Validation Another way to affirm the patient is to validate the legitimacy of his or her emotional experience. Reassurance The first step to effective reassurance is simply identifying and acknowledging the patient’s feelings. This promotes a feeling of connection. Meaningful reassurance comes later, after you have completed the interview, the physical examination, and perhaps some laboratory tests. At that point, you can explain what you think is happening and deal openly with any concerns. Reassurance is more appropriate when the patient feels that problems have been fully understood and are being addressed. Partnering Express your commitment to an ongoing relationship – make patients feel that no matter what happens, you will continue to provide their care. Summarization Giving a capsule summary of the patient’s story during the course of the interview communicates that you have been listening carefully, identifies what you do and don’t know, and lets the patient add other information and correct any misunderstandings. You can use summarization at different points in the interview to structure the visit, which allows you to organize your clinical reasoning and convey your thinking to the patient, making the relationship more collaborative. Transitions To put patients more at ease, tell them when you are changing directions during the interview. Make clear what the patient should expect or do next. Empowering the Patient The clinician-patient relationship is inherently unequal. Ultimately, however, patients are responsible for their own care. When you empower patients to ask questions, express their concerns, and probe your recommendations, they are most likely to adopt your advice, make lifestyle changes, or take medication as prescribed. Techniques for empowering the patient include: ▪ Evoke the patient’s perspective. ▪ Convey interest in the person, not just the problem. ▪ Follow the patient’s leads. ▪ Elicit and validate emotional content. ▪ Share information with the patient, especially at transition points during the visit. ▪ Make your clinical reasoning transparent to the patient. ▪ Reveal the limits of your knowledge. Sequence of the interview: ▪ Preparation: includes reviewing the medical record, setting goals for the interview, reviewing your clinical behavior and appearance, and adjusting the environment. ▪ The sequence of the interview: o Greeting the patient and establishing rapport: the initial moment of your encounter lay the foundation for your ongoing relationship. Greet the patient by name and introduce yourself, giving your own name. If possible, shake hands with the patient. If this is the first contact, explain your role, your status, and how you will be involved in the patient’s care. In addition: ▪ Whenever visitors are present, you are obligated to maintain the patient’s confidentiality; let the patient decide if visitors or family members should stay in the room. ▪ Always be attuned to the patient’s comfort. ▪ Consider the best way to arrange the room (e.g., sit at eye level with patient, move physical barriers such as bed railings or bedside tables, and take lighting into account). o Taking notes: do not let note taking distract you from the patient; maintain good eye contact. o Establishing the agenda: now you are ready to to pursue the patient’s reason for seeking care (chief complaint, or “presenting problem(s)”), begin with open-ended questions that allow full freedom of response. Note that the first problem the patient mentions may not be the one that is most important. o Inviting the patient’s story: now you can invite the patient’s story by asking about the foremost concern; e.g., “Tell me more about…” Encourage patients to tell their stories in their own words, using an open-ended approach. Use active listening skills, and train yourself to follow the patient’s leads. o Exploring the patient’s perspective: the disease/illness distinction model helps elucidate the different yet complementary perspectives of the clinician and the patient; disease is the explanation the clinician uses to organize symptoms that leads to a clinical diagnosis, and illness is a construct that explains how the patient experiences the disease (e.g., effects on relationships, function, and sense of well-being). The clinical interview needs to incorporate both these views of reality. To understand the patient’s perspective, the clinician needs to explore these four domains: ▪ F-I-F-E = Feelings, Ideas, effect on Function, Expectations o Identifying and responding to emotional cues: illness is often accompanied by emotional distress; 30% to 40% of patients have anxiety and depression in primary care practices. Learn to respond attentively to emotional cues using techniques like reflections, feedback, and “continuers” that convey support. A mnemonic for responding to emotional cues is NURSE: Name, Understand (or legitimize), Support, Respect, Explore. o Expanding and clarifying the patient’s story: as you elicit the patient’s story, you must diligently clarify the attributes of each symptom (including context, associations, and chronology). Understanding the seven attributes of a symptom is critical; two mnemonics are used to help remember them: ▪ OLD CARTS: Onset, Location, Duration, Character, Aggravating/Alleviating factors, Radiation, and Timing ▪ OPQRST: Onset, Palliating/Provoking Factors, Quality, Radiation, Site, and Timing o Generating and testing diagnostic hypotheses: you will generate and test diagnostic hypotheses about which disease process might be present. Identifying all the features of each symptom is fundamental to recognizing patterns of disease and to generating the differential diagnosis. It is helpful to visualize the process of evoking a full description of each symptom as “the cone:” (1) ask open-ended questions to hear “the story of the symptom” in the patient’s own words, (2) then ask more specific questions to elicit “the seven features of every symptom,” and (3) finally, ask yes-no questions or “pertinent positives and negatives” from the relevant sections of the review of systems. o Sharing the treatment plan: shared decision-making has been called the pinnacle of patient- centered care. Experts recommend a three-step process: ▪ Introducing choices and describing options using patient decision support tools when available. ▪ Exploring patient preferences. ▪ Moving to a decision, checking that the patient is ready to make a decision and offering more time, if needed. o Closing the interview and the visit: let the patient know that the end of the interview or the visit is approaching to allow time for any final questions. Make sure the patient understands the mutual plans you have developed. A useful technique is to assess the patient’s understanding is to “teach back,” whereby you invite the patient to tell you, in his or her own words, the plan of care. o Taking time for self-reflection: because we bring our own values, assumptions, and biases to every encounter, we must look inward to see how our own expectations and reactions affect what we hear and how we behave. Self-reflection is a continual part of professional development in clinical work. 10. Seven attributes of a symptom. (p. 79; key search term: “quality what”) 11. Cultural humility. (pp. 82-86; key search term: “paradigm communicating”) ▪ Communicating effectively with patients from every background has always been an important professional skill. To moderate the disparities present in healthcare, clinicians are increasingly urged to engage in self-reflection, critical thinking, and cultural humility as they experience diversity in their clinical practices. ▪ Cultural humility is defined as a “process that requires humility as individuals continually engage in self-reflection and self-critique as lifelong learners and reflective practitioners.” ▪ It is a process that includes “the difficult work of examining cultural beliefs and cultural systems of both patients and providers to locate the points of cultural dissonance or synergy that contribute to patients’ health outcomes.” ▪ Three dimensions of cultural humility: 1. Self-awareness: learn about your own biases; we all have them. 2. Respectful communication: work to eliminate assumptions about what is “normal.” Let your patients be the experts on their own unique cultural perspectives. 3. Collaborative partnerships: build your patient relationships on respect and mutually acceptable plans. 12. Advanced interviewing. (pp. 86-98; key search term: “patient as you spend”) Challenging Patient Type Interview Techniques The “Silent Patient” (p. 86) ▪ Silence can mean: patient is collecting their thoughts, trying to remember details, or deciding if they can trust you with certain information. Technique: be attentive and respectful and encourage the patient to continue when ready. Watch the patient closely for nonverbal cues, such as difficulty controlling emotions. ▪ Patients with depression or dementia may seem subdued, giving only short answers and then failing silent. Technique: try guided questioning, or try shifting to more direct inquiry about symptoms, or begin an exploratory mental status examination. ▪ Assess your questioning style, as silence may be the patient’s response to how you are asking questions. The “Confusing Patient” ▪ The patient’s story may be confusing because: it may just be the patient’s style, or possibly an underlying issue interfering with communication. (p. 87) ▪ Patient’s may present a confusing array of multiple symptoms. Technique: focus on the context of the symptom, emphasizing the patient’s perspective, and guide the interview into a psychosocial assessment. ▪ If you suspect a psychiatric or neurologic disorder, gathering a detailed history can frustrate both you and the patient. Technique: shift to the mental status examination, focusing on LOC, orientation, memory, and capacity to understand. The “Patient with Altered Cognition” (p. 87) ▪ Altered cognition may be due to: delirium, dementia, or mental health condition, or being unable to remember certain parts of the history (e.g., events related to a febrile illness/seizure). Technique: obtain historical information from other sources (e.g., family member, caregiver). ▪ Some patients can provide a history, but lack the ability to make informed health care decisions – you then need to determine whether a patient has decision-making capacity. Elements of decision-making capacity include the ability to: understand the relevant information about proposed diagnostic tests or treatment, appreciate their situation, use reason to make a decision, and communicate their choice. The “Talkative Patient” (p. 89) ▪ Technique: give the patient free rein for the first 5 or 10 minutes, while listening closely. Focus on what seems important to the patient, and show your interest by asking questions in those areas, interrupting only if necessary. Set limits when needed. A brief summary may help you change the subject, yet validate concerns. If time runs out, explain the need for a second visit and prepare the patient by setting a time limit. The “Crying Patient” (p. 89) ▪ Crying signals strong emotions. Technique: pausing, gentle probing, or responding with empathy. Offer a tissue and wait for the patient to recover. Make supportive remarks. The “Angry or Disruptive Patient” (p. 89) ▪ Anger may be due to many reasons, including justified anger toward the clinician. Technique: Acknowledge the situation and try to make amends. ▪ Anger is more often a reflection of frustration or pain, however. Technique: accept angry feelings without getting angry in return or retreating. Avoid reinforcing criticism of other clinicians/clinical settings/hospitals. Validate the patient’s feeling without agreeing with their reasons. After the patient has calmed, help the patient work through his or her feelings and move on to other concerns. ▪ Some patients can become disruptive, belligerent or out of control. Technique: before approaching such patients, alert security; ensuring a safe environment is one of your responsibilities. Stay calm and avoid being confrontational. Keep your posture relaxed and nonthreatening. Listen carefully and try to understand what they are saying. Once you have established rapport, gently suggest moving to a more private location. The “Patient with a Language Barrier” (p. 90) ▪ Technique: if your patient speaks another language, make every effort to find a trained interpreter. When you work with an interpreter, begin by establishing rapport and reviewing the information that will be most useful. Ask the interpreter to translate everything, not to condense or summarize. Make your questions clear, short, and simple. Help the interpreter by outlining your goals for each segment of the history. Speak directly to the patient. When available, bilingual written questionnaires are invaluable – and make sure patients can read in their language. Guidelines for working an interpreter can be remembered using the mnemonic INTERPRET: Introductions, Note goals, Transparency, Ethics, Respect beliefs, Patient focus, Retain control, Explain, Thanks. The “Patient with Low Literacy/Low Health Literacy” (p. 91) ▪ Technique: to detect low literacy, you can ask about years completed in school, or check how well the patient reads written instructions. One rapid screen is to hand the patient a written text upside down – most patients will the page around immediately. The “Patient with Hearing Loss” (p. 92) ▪ Factors that must be considered with this population include degree of hearing loss, age of onset of loss, preferred language, and psychological issues. Technique: find out the patient’s preferred method of communication, and learn whether the patient belongs to the deaf culture or the hearing culture, when the hearing loss occurred relative to the development of speech and language, and the kinds of schools the patient attended. ▪ Partial hearing deficits vary. Technique: if the patient has a hearing aid, find out if the patient is using it, and if so, make sure it is working. If the patient has unilateral hearing loss, sit on the hearing side. If the patient is hard of hearing, eliminate background noise. Face patients who can read lips directly, in good light. Patients should put on their glasses to see cues that help them understand you. Speak at a normal volume and rate. Avoid letting your voice trail off at the ends of sentences, covering your mouth or looking down while speaking. Emphasize key points first. When closing, write out your instruction for them to take home. The “Patient with Impaired Vision” (p. 92) ▪ Technique: with blind patients, shake hands to establish contact and explain who you are and why you are there. If the room is unfamiliar, orient the patient to the surroundings and report if anyone else is present. If helpful, adjust the light. Encourage visually impaired patients to wear glasses whenever possible. Spend more time on verbal explanation because postures and gestures are unseen. The “Patient with Limited Intelligence” (p. 92) ▪ Technique: if you suspect a disability, pay special attention to the patient’s school record and ability to function independently. If you are unsure about the patient’s level of intelligence, transition to mental status examination and assess simple calculations, vocabulary, memory, and abstract thinking. For patients with severe mental retardation, turn to family or caregivers for the history, but always show interest in the patient first. Establish rapport, make eye contact, and engage in simple conversation. Avoid “talking down” or condescending behavior. The “Patient with Personal Problems” (p. 93) ▪ Technique: instead of responding to advice-seeking questions that fall outside of your clinical expertise, ask about what alternatives the patient has considered, related pros and cons, and others who have provided advice. Let the patient talk through the problem without giving your own opinions. The “Seductive Patient” (p. 93) ▪ Technique: if you become aware of feelings toward a patient, bring them to a conscious level; denial can heighten the risk of responding inappropriately. Any sexual contact or romantic relationship with patients is unethical. When patients are seductive, calmly but firmly set clear limits that your relationship is professional, not personal. If necessary, leave the room and find a chaperone before you continue the visit. Think carefully about your own behavior (e.g., clothing, demeanor, being overly warm). Sensitive Topics Sexual History (p. 93) ▪ Technique: an orienting sentence is often helpful, explaining that you need to ask about sexual health and practices in order to assess for risk for various diseases, or that patients are routinely asked about sexual function. If you are matter-of-fact, the patient is more likely to follow your lead. Use specific language regarding genitalia, and use words that are understandable. Ask questions that make no assumptions about marital status, sexual preference, or attitudes about pregnancy or contraception. Mental Health History (p. 95) ▪ Technique: ask open-ended questions initially, then move to more specific questions. Two validated screening questions for depression are: 1) “Over the past two weeks, have you felt down, depressed, or hopeless”, and 2) “Over the past two weeks, have you felt little interest or pleasure in doing things?” If the patient seems depressed, always ask about suicide. Alcohol and Prescription/Illici t Drugs (p. 96) ▪ Technique: for alcohol, asking “Tell me about your use of alcohol” is an opening query that avoid the easy yes-no response. Positive answers to two questions are highly suspicious for problem drinking: 1) “Have you ever had a drinking problem?”, and “When was your last drink?”, especially if the night before. The most widely used screening questions are the CAGE questions: Cutting down, Annoyance when criticized, Guilty feelings, and Eye- openers. Two or more affirmative answers to the CAGE questionnaire suggest alcohol misuse. For illicit drugs, ask, “How many times in the past year have you used an illegal drug or used a prescription medication for non-clinical reasons?” If there is a positive response, ask specifically about non-clinical use of illicit and prescription drugs: “In your lifetime, have you ever used: marijuana; cocaine; prescriptions stimulants; methamphetamines; sedatives or sleeping pills; hallucinogens like LSD, ecstasy, mushrooms, etc.; street opioids like heroin or opium; prescription opioids like fentanyl, oxycodone, hydrocodone, etc.; or other substances?” Intimate Partner Violence and Domestic Violence (p. 97) ▪ Technique: routine screening is recommended for all women of childbearing age for intimate partner violence and providing or referring those who screen positive for intervention services. Sensitive interviewing is essential, beginning with normalizing statements. Disclosure is more likely when probing questions lead and then in-depth direct questions follow. When you suspect abuse, it is important to spend part of the visit alone with the patient, but do not force the situation. Following disclosure, empathic validating and nonjudgmental responses are critical. ▪ To screen for child abuse, begin asking the parents about their approach to discipline, and ask how they cope with a baby who will not stop crying or a child who misbehaves. ▪ Cues to physical and sexual abuse: injuries that are unexplained, seem inconsistent with the patient’s story, are concealed, or cause embarrassment; delay in getting treatment for trauma; history of repeated injuries/accidents; presence of alcohol or drug abuse in patient or partner; partner tries to dominate the visit, will not leave the room, or seems unusually anxious/solicitous; pregnancy at a young age and multiple partners; repeated vaginal infections and STIs; difficulty walking or sitting; vaginal lacerations or bruises; fear of pelvic exam or physical contact; fear of leaving the exam room. Pregnancy or somatic symptom disorders are diagnoses with higher association with abuse. Death and the Dying Patient (p. 98) ▪ Technique: working through your own feelings about death and dying and acquiring basic skills to ensure good communication are important. Clinician interventions that improve symptoms and avoid hospitalization reduce grief and bereavement, improve outcomes and quality of care, reduce costs, and sometimes even prolong survival. Offer openings for patients and family members to talk about their feelings and ask questions. Provide the information requested and demonstrate your commitment to support and coordinate the patient’s care throughout the illness. Clarifying the patient’s wishes about treatment at the end of life is an important responsibility. Educate patients about the likely success of CPR, and assure them that relieving pain and taking care of their spiritual and physical needs will be a priority. Encourage patients to establish a health proxy. Explore the patient’s religious or spiritual beliefs so that you and the patient can make the most appropriate decisions about health care. 13. Ethics and professionalism – building blocks. (p. 100; key search term: “building blocks of professional”) Chapter 4 (Beginning the Physical Examination: General Survey, Vital Signs, and Pain) 14. The health history – common and concerning symptoms. (p. 112; key search term: “weakness fatigue is”) Common or Concerning Symptom Notes Fatigue and weakness ▪ Fatigue: sense of weariness or loss of energy that patients describe in various ways. ▪ Fatigue unrelated to hard work, sustained stress, or grief requires further investigation. ▪ Use open-ended questions to encourage the patient to fully describe what he or she is experiencing (elicit the life circumstances in which fatigue occurs). ▪ Requires a good psychosocial history, exploration of sleep patterns, and thorough review of systems. ▪ Common symptoms of depression and anxiety, but also consider: infections, endocrine disorders, heart failure, chronic disease of the lungs/kidneys/liver, electrolyte imbalances, moderate-to-severe anemia, malignancies, nutritional deficits, and medications. ▪ Not to be confused with weakness, which denotes a demonstrable loss of muscle power, and can be indicative of possible neuropathy or myopathy. Fever, chills, night sweats ▪ Fever: abnormal elevation in body temperature. ▪ Ask about fever if patient has acute or chronic illness. Try to distinguish between feeling cold and a shaking chill – recurrent shaking chills suggest more extreme swings in temperature and systemic bacteremia. ▪ Feeling cold/goosebumps/shivering = rising temperature. ▪ Feeling hot/sweating = falling temperature. This can accompany menopause. Night sweats occur in tuberculosis and malignancy. ▪ Inquire about travel, contact with sick people, or other unusual exposures. Even medications may cause fever. ▪ In immunocompromised patients with sepsis, fever may be absent, low-grade, or drop below normal (hypothermia). Weight change ▪ Weight change results from either: 1) changes in body tissues, or 2) changes in body fluids. Rapid changes in weight, over a few days, suggest changes in body fluid, not tissue. ▪ If weight gain or loss appears to be a problem, ask about the amount of change, its timing, the setting in which it occurred, and any associated symptoms. ▪ Weight gain  can reflect calorie intake in excess of expenditure (with resultant increase in body fat), or abnormal accumulation of body fluids. Edema from extravascular fluid retention is visible in heart failure, nephrotic syndrome, liver failure, and venous stasis. ▪ BMI  25 to 29: overweight. ▪ BMI  30: obese. ▪ Many drugs are associated with weight gain, including: tricyclic antidepressants, insulin/sulfonylurea, contraceptives, glucocorticoids, progestational steroids, mirtazapine/paroxetine, gabapentin/valproate, and propranolol. ▪ Clinical significant weight loss = loss of 5% or more of usual body weight over a 6-month period. Mechanisms  decreased food intake due to anorexia, depression, dysphagia, vomiting, abdominal pain, financial difficulties, defective GI absorption or inflammation, and increased metabolic requirements. Causes include: GI diseases, endocrine disorders, chronic infections, HIV/AIDS, malignancy, chronic cardiac/pulmonary/renal failure, depression, and anorexia nervosa or bulimia. ▪ Weight loss with relatively high food intake suggests: DM, hyperthyroidism, or malabsorption. Consider binge eating with clandestine vomiting. ▪ Be alter for signs and symptoms of malnutrition. They may be subtle and non-specific, including weakness, easy fatigability, cold intolerance, flaky dermatitis, and ankle swelling. Poverty, old age, social isolation, physical disability, emotional/mental impairment, lack of teeth, ill- fitting dentures, alcoholism, and drug abuse increase risk of malnutrition. ▪ Drugs associated with weight loss include: anticonvulsants, antidepressants, levodopa, digoxin, metformin, and thyroid medication. Pain ▪ Most frequent causes of pain are low back pain, headache/migraine, and knee/neck pain. ▪ Localizing symptoms, using the seven attributes of every symptom, and the psychosocial history are essential. 15. Eating disorders and excessively low BMI. (p. 140; key search term: “disorders the lifetime”) 16. Health promotion and counseling. (pp. 114-119; key search term: “diet fewer”) There are three important topics for health promotion and counseling, including 1) optimal weight, nutrition, and diet, 2) blood pressure and dietary sodium, and 3) exercise. Topic Recommendations Optimal weight, nutrition, and diet ▪ Use the four-pronged approach: 1) measure BMI and waist circumference, or for those older than 75 years, measure the waist-to-hip ratio, 2) assess dietary intake, 3) assess the patient’s motivation to change, and 4) provide counseling about nutrition and exercise. ▪ For men with BMI  25 kg/m2 and waist circumference > 40 inches = increased risk for heart disease and obesity-related diseases. ▪ For women with BMI  25 kg/m2 and waist circumference > 35 inches = increased risk for heart disease and obesity-related diseases. ▪ Patients with a BMI over 25 kg/m2 and two or more risk factors (HTN, high LDL cholesterol, low HDL cholesterol, high triglycerides, high blood glucose, family history of premature heart disease, physical inactivity, and cigarette smoking) should pursue weight loss – especially if the waist circumference is elevated. ▪ A safe goal for weight loss is 0.5 to 2 lbs. per week. Encourage patients to walk a total of at least 150 minutes per week. A total calorie deficit goal of 500 to 1,000 kilocalories per day is more important than the type of diet. Consider low-fat diets for those with dyslipidemias. Blood pressure and dietary sodium ▪ Excess sodium intake can lead to HTN, a major risk factor for cardiovascular disease. ▪ 2,300 mg of sodium is the tolerable upper intake level for adults, though reduing sodium intake to 1,500 mg provides better blood pressure control. ▪ Advise patients to read the Nutrition Facts panel on food labels closely to help them adhere to the 2,300-mg/day guideline, and urge them to consider the Dietary Approaches to Stop HTN (DASH) diet. Exercise ▪ To achieve health benefits, adults should do at least 150 minutes (2 hours and 30 minutes) of moderate intensity cardiorespiratory activity each week. ▪ Patients can increase exercise by parking further away from their place of work, or using stairs instead of elevators; or, adults can engage in vigorous intensity aerobic activity, such as jogging or running, for 75 minutes (1 hours and 15 minutes) each week. ▪ Those who weigh more will use more calories during exercise, and those who weight less will use fewer. 17. BMI (underweight, normal, overweight, obese). (p. 116; key search term: “pursue weight”) 18. Safe goal for weight loss. (p. 117; key search term: “goals experts”) A key element of effective counseling in weight loss is working with the patient to set reasonable goals. A 5% to 10% weight loss is realistic and still proven to reduce the risk of DM and other obesity-related health problems. Educate your patient about common roadblocks to sustained weight loss: hitting a plateau due to feedback physiologic systems that maintain body homeostasis; poor adherence to diet due to increasing hunger over time as weight declines; and inhibition of leptin, a protein cytokine secreted and stored in fat cells that modulates hunger. A safe goal for weight loss is 0.5 to 2 lbs. per week. 19. The general survey. (pp. 120-122; key search term: “survey the general”) The general survey of the patient’s appearance, height, and weight begins with the opening moments of the patient encounter. As you talk with and examine the patients, heighten your focus on the patient’s mood, build, and behavior. Your goal is to describe the distinguishing features of the patient so clearly that colleagues can spot the patient in a crowd of strangers, avoiding clichés like “middle-aged gentleman” and “in no acute distress.” GENERAL SURVEY General Appearance Apparent state of health Is patient acutely or chronically ill, frail, or fit and robust? LOC Is the patient awake, alert, responsive to you or others/environment? Signs of distress ▪ Cardiac or respiratory distress: clutching chest, pallor, diaphoresis, labored breathing, wheezing, coughing? ▪ Pain: wincing, diaphoresis, protectiveness of painful area, grimacing, or unusual posture favoring one limb or region of the body? ▪ Anxiety or depression: anxious facial expressions, fidgety movements, cold moist palms, inexpressive or flat affect, poor eye contact, or psychomotor slowing? Skin color and obvious lesions Inspect for any changes in skin color, scars, plaques, or nevi; any pallor, cyanosis, jaundice, rashes, bruises, or mottling of the extremities should be pursued. Dress, grooming, and personal hygiene ▪ How the patient is dressed: clothing may reflect the cold intolerance of hypothyroidism, hide skin rash or needle marks, mask anorexia, or signal personal lifestyle preferences. ▪ The patient’s shoes: holes or slippers suggest gout, bunions, edema, or other painful foot conditions, and run-down shoes can contribute to foot and back pain, calluses, falls, and infection. ▪ Jewelry: copper bracelets suggest joint pain; tattoos and piercings can be associated with alcohol and drug use. ▪ Hair, fingernails, make-up: “grown-out” hair and nail polish suggest the length of a possible illness; bitten fingernails may reflect stress. ▪ Personal hygiene and grooming: neglected appearance may appear in depression and dementia, but should be compared with the patient’s norm. Facial expression ▪ Look for the stare of hyperthyroidism. ▪ Immobile face: parkinsonism. ▪ Flat/sad affect: depression. ▪ Decreased eye contact: may be cultural or suggest anxiety, fear, or sadness. Odors of the body and breath ▪ Fruity odor: diabetes. ▪ Scent of alcohol: never assume that alcohol on a patient’s breath explain changes in mental status; these changes can have serious but treatable causes, such as hypoglycemia, subdural hematoma, or postictal state. ▪ Can be indicative of pulmonary infections, uremia, or liver failure. Posture, gait, and motor activity ▪ Preferred posture: patients often prefer sitting upright in left-sided heart failure, and leaning forward with arms brace in COPD. ▪ Anxious patients appear agitated and restless. ▪ Patients in pain often avoid movement. ▪ Examine gait – an impaired gait increases risk of falls. Height and weight ▪ Measure the height and weight with shoes removed to determine the BMI. Note any changes in height and weight over time. ▪ Very short stature: Turner syndrome, childhood renal failure, achondroplastic and hypopituitary dwarfism. ▪ Long limbs in proportion to the trunk: hypogonadism and Marfan syndrome. ▪ Height loss: osteoporosis and vertebral compression fractures. ▪ Fat distribution: distribution is generalized in simple obesity; and truncal (with thin limbs) in Cushing syndrome and metabolic syndrome. ▪ Weight loss: causes include malignancy, DM, hyperthyroidism, chronic infection, depression, diuresis, and successful dieting. Calculating the BMI Waist circumference If the patient’s BMI  35 kg/m2, measure the patient’s waist circumference just above the hips. If the waist circumference is: ▪  35 inches in women, the risk for diabetes, HTN, and cardiovascular disease increases significantly. ▪  40 inches in men, the risk for diabetes, HTN, and cardiovascular disease increases significantly. 20. Proper technique for accurate blood pressure measurement. (p. 127; key search term: “measurements take the”) The accuracy of blood pressure measurements varies according to how these measurements are taken. Numerous studies show that ambulatory and home blood pressure monitoring are more predictive of cardiovascular disease and end organ damage than manual and automated measurements in the office. Proper technique is important and reduces the inherent variability arising from the patient or examiner, the equipment, and the procedure itself: 1. The patient should avoid smoking, caffeine, or exercise for 30 minutes prior. 2. Exam room should be quiet and comfortably warm. 3. Ask patient to sit quietly for 5 minutes in a chair with feet on the floor. 4. Make sure the arm selected is free of clothing, fistulas for dialysis, scars from brachial artery cutdowns, or lymphedema from axillary node dissection or radiation therapy. 5. Palpate the brachial artery to confirm that it has a viable pulse and position the arm so that the brachial artery, at the antecubital crease, is at heart level – roughly level with the 4th interspace at its junction with the sternum. 6. If the patient is seated, rest the arm on the table a little above the patient’s waist; if standing, try to support the patient’s arm at the midchest level. 7. With arm at heart level, center the inflatable bladder over the brachial artery. The lower border of the cuff should be about 2.5 cm above the antecubital crease. Secure the cuff snugly. Arm should be slightly flexed at the elbow. 8. First estimate the systolic pressure by palpation. Palpate the radial pulse with the fingers of one hand, then rapidly inflate the cuff until the radial pulse disappears. Read this pressure on the manometer and add 30 mmHg to it. Using this sum for subsequent inflations prevents discomfort from unnecessarily high cuff pressures. Deflate the cuff promptly and completely and wait 15 to 30 seconds. 9. Now place bell of the stethoscope lightly over the brachial artery, taking care to make an air seal with the full rim. Korotkoff sounds are relatively low in pitch and generally heard better with the bell. 10. Inflate the cuff rapidly to the target level, and then deflate the cuff slowly at a rate of about 2 to 3 mmHg per second. Note the level when you hear the sounds of at least two consecutive beats. This is the systolic pressure. 11. Continue to lower the pressure until sound the sound becomes more muffled and then disappears. To confirm the disappearance point, listen as the pressure falls another 10 to 20 mmHg. Then deflate the cuff rapidly to zero. The disappearance point, which is usually only a few mmHg below the muffling point, provides the best estimate of diastolic pressure. 12. Read both the systolic and diastolic levels to the nearest 2 mmHg. Wait 2 or more minutes and repeat. Average the readings. If the first two readings differ by more than 5 mmHg, then take additional readings. 13. BP should be taken in both arms. Normal fluctuations can be between 5 to 10 mmHg difference between arms. Use the arm with the higher pressure. Note: a pressure difference of more than 10 to 15 mmHg between arms occurs in subclavian steal syndrome, supravalvular aortic stenosis, and aortic dissection, and should be investigated. 21. Heart rate and rhythm, respiratory rate and rhythm, temperature. (pp. 132-134; key search term: “rhythm examine”) Heart rate: with the pads of your middle and index fingers, compress the radial artery until a maximal pulsation is detected. If the rhythm is regular and the rate seems normal, count the rate for 30 seconds and multiply by 2. If the rate is unusually fast or slow, count for 60 seconds. The normal range is 60 to 90-100 beats per minute. Heart rhythm: begin by palpating the radial pulse. If there are any irregularities, assess the rhythm at the apex by listening with your stethoscope. If irregular, try to identify a pattern, including whether: ▪ Early beats appear in a basically regular rhythm ▪ Irregularity varies consistently with respiration ▪ The rhythm is totally irregular Respiratory rate and rhythm: observe the rate, rhythm, depth, and effort of breathing. Count the number of respirations in 1 minute, either by visual inspection or by subtly listening over the patient’s trachea with stethoscope during examination of the head and neck or chest. Normal rate is 20 breaths per minute in a quiet, regular pattern. An occasional sigh is normal. Check to see if expiration is prolonged as is common in COPD. Temperature: the core body temperature measured internally is 98.6°F. Temperature is lowest in the early morning and highest in the afternoon and evening (and women have a wider range of normal than men). Temperature Measurement Modalities Notes Oral ▪ Generally lower than the core body temperature, and lower than rectal temperature by an average of 0.4 to 0.5°C (0.7 to 0.9°F), and higher than axillary temperatures by approximately 1°. ▪ Correlates more closely with the pulmonary artery temperature, but is about 0.5°C lower. ▪ Come in glass and electronic thermometers. ▪ Electronic thermometer: carefully place the disposable cover over the probe and insert the thermometer under the tongue; ask the patient to close both lips, then watch closely for the digital readout. ▪ Glass thermometer: shake the thermometer down to 35°C or below, insert it under the tongue, and instruct the patient to close both lips, waiting 3 to 5 minutes. Then read the thermometer, reinsert for 1 minute, and read it again. If the temperature is still rising, repeat this procedure until the reading remains stable. ▪ Hot/cold liquids or smoking can alter the temperature reading. In these situation, delay taking the temperature for 10 to 15 minutes. Axillary ▪ Takes 5 to 10 minutes to register and is considered less accurate than other measurements. Rectal ▪ Ask the patient to lie on one side with the hip flexed, lubricate the tip of the thermometer, and insert about 3 cm to 4 cm into the anal canal, in a direction pointing toward the umbilicus. ▪ Rapid respiratory rates tend to increase the discrepancy between oral and rectal temperatures; in these situations, rectal temperatures are more reliable. Tympanic membrane ▪ Can be more variable than oral or rectal temperatures; however, the tympanic membrane shares the same blood supply as the hypothalamus, where temperature regulation occurs in the brain. ▪ Make sure the external auditory canal is free of cerumen, which can lower temperature readings. Position the probe in the canal so that the infrared beam is aimed at the tympanic membrane, or otherwise the measurement will be invalid. Temporal artery ▪ Correlates more closely with the pulmonary artery temperature, but is about 0.5°C lower. ▪ Takes advantage of the location of the temporal artery, which branches off the external carotid artery and lies within a millimeter of the skin surface of the forehead, cheek, and behind the ear lobes. ▪ Place the probe against the center of the forehead, depress the infrared scanning button, and brush the device across the forehead, down the cheek, and behind an earlobe. The display will show the highest measured temperature. Combined forehead and behind-the ear contact may be more accurate. 22. Types of pain. (p. 137; key search term: “pain is linked”) Type of Pain Information Nociceptive (somatic) ▪ Linked to tissue damage in the skin, musculoskeletal system, or viscera. ▪ Medicated by the afferent A-delta and C-fibers of the sensory system. ▪ The afferent nociceptors can be sensitized by inflammation, or modulated by psychological processes or neurotransmitters (e.g., endorphins, histamines, acetylcholine, serotonin, norepinephrine, and dopamine). ▪ The sensory nervous system is intact. ▪ May be acute or chronic. Neuropathic ▪ Direct consequence of a lesion or disease affecting the somatosensory system. Over time, the pain may become independent of the inciting injury. ▪ Different postulated mechanisms include: CNS injury from stroke or trauma, PNS disorders causing entrapment or pressure on spinal nerves/plexuses/peripheral nerves, or referred pain syndromes with increased/prolonged responses to stimuli. These triggers appear to induce pain changes in pain signal processing through neuronal plasticity. ▪ May become burning, lancinating, or shock-like in quality. Central sensitization ▪ Alteration of CNS processing of sensation, leading to amplification of pain signals, with a lower pain threshold to nonpainful stimuli. ▪ Response to pain may be more severe than expected. ▪ Example: fibromyalgia. Psychogenic ▪ Involves the many factors that influence the report of pain, such as psychiatric conditions, personality, coping style, cultural norms, and social support systems. Idiopathic ▪ Nobody knows where this pain is coming from – it’s a true question for the ages. The story so far: In the beginning, the Universe was created. This has made a lot of people very angry and been widely regarded as a bad move. Chapter 5 (Behavior and Mental Status) 23. Personality disorders. (p. 152-153; key search term: “with personality disorders”) Characterized by an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early childhood, is stable over time, and leads to distress or impairment. These patients have dysfunctional interpersonal coping styles that disrupt and destabilize their relationships, including those with health care providers. Personality disorders co-occur at high frequencies with alcohol and substance abuse and with depression, anxiety disorders, bipolar disorder, ADHD, autism spectrum disorders, anorexia nervosa, bulimia nervosa, and schizophrenia. Personality Disorders: DSM-5 – “Weird, Wild, Worried” Cluster/ Personality Type Characteristic Behavior Patterns A: Odd or Eccentric disorders Paranoid Distrust and suspiciousness. Schizoid Detachment from social relations with a restricted emotional range. Schizotypal Eccentricities in behavior and cognitive distortions; acute discomfort in close relationships. B: Dramatic, Emotional, or Erratic disorders Antisocial Disregard for, and violation of, the rights of others. Borderline Instability in interpersonal relationships, self-image and affective regulation; impulsivity. Especially challenging group. Recognition of borderline features is essential for patient understanding, reduction of patient self-harm, and referral for expert evaluation. Histrionic Emotional emotionality and attention seeking. Narcissistic Persisting grandiosity, need for admiration and lack of empathy. C: Anxious or Fearful Disorders Avoidant Social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation. Dependent Submissive and clinging behavior related to an excessive need to be taken care of. Obsessive- compulsive Preoccupation with orderliness, perfectionism, and control. 24. Components of the mental status examination (MSE). (pp. 154-156, 158-168; key search term: “complex changes in”) The MSE is central to assessment in psychiatric practice, and is also a critical element in the assessment of the nervous system and the first segment of the nervous system write-up. The MSE consists of five components: appearance and behavior; speech and language; mood; thoughts and perceptions; and cognitive function. Mental Status Examination (MSE) Component Major Points Notes Appearance and Behavior Level of consciousness Posture and motor behavior ▪ Does the patient sit or lie quietly, or prefer to walk around? Observe posture and ability to relax. ▪ Not the pace, range, and types of movements. Are movements voluntary and spontaneous? Are any limbs immobile? What about posture and motor activity? Dress, grooming, and personal hygiene ▪ How is the patient dressed? Is the clothing clean and presentable? Is it appropriate for the patient’s age and social group? ▪ Note the grooming of the patient’s hair, nails, teeth, skin, and if present, beard. How do the grooming and hygiene compare with peers of comparable age/lifestyle/socioeconomic group? ▪ Compare one side of the body with the other (one-sided neglect may result from a lesion in the opposite parietal cortex, usually the nondominant side). Facial expression ▪ Observe the face both at rest and during conversation. ▪ Watch for changes in expression. Are they appropriate for the topics being discussed? Manner, affect, and relationship to people and things ▪ Assess the patient’s affect (external expression of the inner emotional state). Is it appropriate to the topics being discussed? ▪ Observe the patient’s openness, approachability, and reactions to others and the surroundings. Does the patient hear or see things not present, or converse with someone who is not there? Speech and Language Quantity ▪ Is the patient talkative or unusually silent? ▪ Are comments spontaneous, or limited to direct questions? Rate ▪ Is speech fast or slow? Volume ▪ Is speech loud or soft? Articulation of words ▪ Are the words clear and distinct? Does the speech have a nasal quality? ▪ Dysarthria: defective articulation. ▪ Aphasia: disorder of language. ▪ Dysphonia: impaired volume, quality, or pitch of voice. Fluency ▪ Reflects the rate, flow, and melody of speech, and the content and use of words. ▪ Suggestive of aphasia: abnormalities such as hesitancies and gaps in flow and rhythm, disturbed inflections (e.g., monotone), circumlocutions (phrases or sentences are substituted for a word the person cannot think of), paraphasias (in which words are malformed, wrong, or invented). ▪ If patient’s speech lacks meaning or fluency, proceed with further testing. ▪ A person who can write a correct sentence does not have aphasia. Mood Ask the patient to describe mood ▪ Include usual mood level and fluctuations related to life events. ▪ How long has the mood lasted? ▪ Is it appropriate to the patient’s situation? ▪ If you suspect depression, assess its severity and any risk of suicide. It is your responsibility to ask directly about suicidal thoughts. Thoughts and Perceptions Thought processes ▪ Assess the logic, relevance, organization, and coherence of the patient’s thought processes throughout the interview. ▪ Circumstantiality: (mildest) consisting of speech with unnecessary detail, indirection, and delay in reaching the point. ▪ Derailment (loosening of associations): “tangential” speech with shifting topics that are loosely connected or unrelated; the patient is unaware of the lack of association. ▪ Flight of ideas: an almost continuous flow of accelerated speech with abrupt changes from one topic to the next. Changes are based on understandable associations, plays on words, or distracting stimuli, but the ideas are not well- connected. Most frequently seen in manic episodes. ▪ Neologisms: invented or distorted words, or words with new and highly idiosyncratic meanings. ▪ Incoherence: speech that is incomprehensible and illogical, with lack of meaningful connections, abrupt changes in topic, or disordered grammar or word use. Usually seen in schizophrenia. ▪ Blocking: sudden interruption of speech in midsentence or before the idea is completed, attributed to “losing the thought.” ▪ Confabulation: fabrication of facts or events in response to questions, to fill in the gaps from impaired memory. ▪ Perseveration: persistent repetition of words or ideas. ▪ Echolalia: repetition of words and phrases of others. ▪ Clanging: speech with choice of words based on sound, rather than meaning, as in rhyming and punning. Thought content ▪ To assess thought content, follow the patient’s leads and cues rather than asking direct questions. ▪ Compulsions: repetitive behaviors that the person feels driven to perform in response to an obsession, aimed at preventing or reducing anxiety or a dreaded event or situation. ▪ Obsessions: recurrent persistent thoughts, images, or urges experienced as intrusive and unwanted that the person tries to ignore, suppress, or neutralize with other thoughts or actions. ▪ Phobias: persistent irrational fears, accompanied by a compelling desire to avoid the provoking stimulus. ▪ Anxieties: apprehensive anticipation of future danger or misfortune accompanied by feelings of worry, distress, and/or somatic symptoms of tension. ▪ Feelings of unreality: a sense that the environment is strange, unreal, or remote. ▪ Feelings of depersonalization: a sense that one’s self or identity is different, changed, unreal, lost, or detached from one’s mind or body. ▪ Delusions: false fixed personal beliefs that are not amenable to change in light of conflicting evidence. Perceptions ▪ Pursue false perceptions. ▪ Illusions: misinterpretations of real external stimuli. ▪ Hallucinations: perception-like experiences that seem real, but unlike illusions, lack actual external stimulation. May be auditory, visual, olfactory, gustatory, tactile, or somatic. Insight ▪ Questions that yield information about insight: “What brings you to the hospital?” and “What do you think is wrong?” ▪ Note whether the patient is aware that a particular mood, thought, or perception is abnormal or part of an illness. Judgment ▪ Assess by noting the patient’s responses to family situations, jobs, use of money, and interpersonal conflicts. ▪ Note whether decisions and actions are based on reality or impulse, wish fulfillments, or disordered thought content. ▪ Because judgment reflects maturity, it may be variable and unpredictable during adolescence. Cognitive Functions Orientation ▪ Assess orientation to person, time, place. Attention ▪ Tests of attention include: digit span, serial 7s, and spelling backward. Remote memory ▪ Inquire about birthdays, anniversaries, social security number, names of schools attended, jobs held, or past historical events. Recent memory ▪ Ask questions with answers you can check against other sources to see if the patient is confabulating. These can involve the events of the day. New learning ability ▪ Give the patient three or four words, ask the patient to repeat them, so you know the information has been heard and registered. The proceed to other parts of the examination, asking the patient to repeat the words after 3-5 minutes. Information and vocabulary ▪ If observed clinically in the context of cultural and educational background, information and vocabulary provide a rough estimate of the patient’s baseline abilities. ▪ Ask about work, hobbies, reading, favorite television programs, or current events (e.g., name of president, five large cities in the country). Note the person’s grasp of information, complexity of ideas, and choice of vocabulary. ▪ Intellectual impairment  information and vocabulary are limited ▪ Mild or moderate dementia  information and vocabulary are fairly well preserved. Calculating ability ▪ Start with simple addition and multiplication, the proceed to more difficult tasks using two-digit numbers. ▪ Poor performance suggests dementia or aphasia (taking into account the patient’s knowledge and education). Abstract thinking ▪ Two different ways to test: proverbs (ask what different ones mean) and similarities (explain how two items are alike). ▪ Note the relevance of the answers and their degree of concreteness or abstractness. Constructional ability ▪ Have the patient copy figures of increasing complexity onto a piece of blank, unlined paper. Show each figure one at a time and ask the patient to copy it as well as possible. ▪ Or, have the patient draw a clock face complete with numbers and hands. Mini-mental state examination (MMSE): useful in screening for cognitive dysfunction or dementia, and for following their course over time. MMSE Sample Items Orientation to Time What is the date? Registration “Listen carefully. I am going to say three words. You say them back after I stop. Ready? Here they are… APPLE (pause), PENNY (pause), TABLE (pause). Now repeat those words back to me.” [Repeat up to 5 times, but score only the first trial.] Naming “What is this?” [Point to pen or pencil.] Reading “Please read this and do what it says.” [Show words to the patient – CLOSE EYES.] 25. Variations and abnormalities in thought processes. (pp. 161-163; key search term: “processes assess”) Please see question #23. 26. Abnormalities of perception. (p. 163; key search term: “perceptions pursue”) Please see question #23. 27. Mood. (pp. 156, 161; key search term: “suicide mood” – please see question #24 for additional information) ▪ Depressive and bipolar disorders affect over 9% of the US population. ▪ Depression is nearly twice as common in women as men. ▪ Depression frequently accompanies chronic medical illness. ▪ Subtle early signs of depression include low self-esteem, loss of pleasures in daily activities, sleep disorders, and difficulty concentrating or making decisions. ▪ Look carefully for symptoms of depression in vulnerable patients, especially those who are young, female, single, divorced or separated, seriously or chronically ill, bereaved, or have other psychiatric disorders, including substance abuse. ▪ The presence of an affective disorder is associated with an 11-fold increased risk for suicide. Chapter 18 (Assessing Children: Infancy through Adolescence) 28. Assessing the infant – development. (p. 809; key search term: “development physical growth”) ▪ Physical growth during infancy is faster than at any other age – by 1 year, the infant’s birth weight should have tripled and height increased by 50% from weight and height at birth. ▪ Neurologic development progresses centrally to peripherally. ▪ Two months: coos. ▪ Three months: lifts head, clasps the hands. ▪ Six months: babbles, rolls over, reaches for objects, turns to voices, and possibly sits with support. ▪ Nine months: recognizes the examiner as a stranger deserving wary cooperation, seeks comfort from parents during examinations, and actively manipulates reachable objects. ▪ One year: stands and puts objects in the mouth. 29. Examination tips – infants. (p. 810; key search term: “noise tips”) ▪ When examining infants and children, the sequence should vary according to the child’s age and comfort level. ▪ Perform less invasive maneuvers early and potentially distressing maneuvers near the end of the examination. Examine any areas with reported pain last. ▪ Approach the infant gradually, using a toy or object for distraction. If you cannot distract the infant or engage the awake infant with an object, your face, or a sound, consider a possible visual or hearing deficit. ▪ Perform as much of the examination as possible with the infant in the parent’s lap. ▪ Speak softly to the infant or mimic the infant’s sounds to attract attention. ▪ If the infant is cranky, make sure he or she is well fed before proceeding. ▪ Ask a parent about the infant’s strengths to elicit useful developmental and parenting information. ▪ Don’t expect to do a head-to-toe exam in a specific order. Work with what the infant gives you and save the mouth and ear examination for last. 30. Techniques of examination - infant, school-age children. (pp. 813-853; key search term: “signs measure the infant’s”) Techniques of Examination INFANT General Survey and Vital Signs Examination Domain Notes Special Information Somatic growth Measurement of growth is one of the most important indicators of infant health. Deviations may provide an early indication of an underlying problem. TOOL: growth charts by the CDC National Center for Health Statistics (ages 2 to 19)/World Health Organization (0 to 23 months). ▪ Length ▪ Weight ▪ Head circumference Variations beyond two standard deviations for age or above the 95th percentile or below the 5th percentile are indications for more detailed evaluation. ▪ Failure to thrive = < 5th percentile for age, drop > 2 quartiles in 6 months, or weight for length < 5th percentile. ▪ Small head  premature closure of the sutures, microcephaly (familial or due to chromosomal abnormalities, congenital infections, maternal metabolic disorders, or neurologic insults). ▪ Large head  macrocephaly (due to hydrocephalus, subdural hematoma, or brain tumor or inherited syndromes). Vital signs ▪ Blood pressure: obtaining accurate BP reading in infants is challenging, but is important for some high-risk infants, ▪ Sustained HTN  renal artery disease, congenital renal malformations, or coarctation of the and should be routinely performed after age 3. The Doppler method is the easiest way of obtaining the systolic blood pressure in infants. ▪ Pulse: the heart rate of infants is more sensitive to the effects of illness, exercise, and emotion than adults. Palpate the femoral arteries in the inguinal area or the brachial arteries in the antecubital fossa, or auscultate the heart. ▪ Respiratory rate: more response to illness, exercise, and emotion than adults or older children. May vary considerably from moment to moment in the newborn, with alternating rapid and slow breathing (a.k.a, “periodic breathing”). The sleeping respiratory rate is the most reliable. Should be observed for at least 60 seconds. ▪ Temperature: rectal temperatures are the most accurate for infants (auditory canal temperatures are also accurate). The average rectal temperature is higher in infancy and early childhood, usually about 99°F until after age 3 years. aorta. ▪ Pulse rate > 180/min  paroxysmal supraventricular tachycardia. ▪ Bradycardia  may be due to drug ingestion, hypoxia, intracranial/neurologic conditions, or cardiac dysrhythmia (e.g., heart blockage). ▪ Extremely rapid and shallow respiratory rates  cyanotic cardiac disease, right-to-left shunting, or metabolic acidosis. ▪ Tachypnea  > 60 breaths/min (birth to 2 months); > 50 breaths/min (2 to 12 months); signs of lower respiratory disease. ▪ Fever  can raise respiratory rates up to 10 respirations per minute for each degree centigrade of fever; > 38°C or 100.4°F in infants younger than after 2-3 months may be a sign of serious infection or disease. ▪ Temperature instability in newborn  sepsis, metabolic abnormality, etc. Skin ▪ Inspection: texture is soft and smooth due to thinner skin. First 10 minutes after birth: progresses from generalized cyanosis to pinkness. First 8 to 24 hours after birth: “boiled lobster” (erythematous flush) appearance. At birth, there is a fine, downy growth of hair called lanugo over the entire body, and is shed within the first few weeks. You should be able to identify four common dermatologic conditions in newborns: miliaria rubra (results from obstruction of the sweat gland ducts and disappears spontaneously within weeks), erythema toxicum (are of unknown etiology, but disappear within 1 week of birth), pustular melanosis (more common in black infants and can last for several months), and milia (due to retention of sebum in the openings of sebaceous glands, usually disappear over several weeks), none of which are clinically significant. Also assess for jaundice and vascular markings. ▪ Polycythemia  “ruddy” or reddish purple complexion. ▪ Cutis marmorata  bluish mottled appearance that is prominent in premature infants, congenital hypothyroidism, Down syndrome. May also last for months in normal infants. ▪ Acrocyanosis  blue cast to the hands and feet when expose to cold, is very common in newborns for the first few days and may recur throughout early infancy, though if it does not disappear within 8 hours or with warming, cyanotic congenital heart disease should be considered. ▪ Slate blue patches  dark or bluish pigmentation over the buttocks, lower lumbar regions, common in newborns of African, Asian, and Mediterranean descent. Document these areas to avoid later concern or confusion about bruising. ▪ Central cyanosis  any age should raise suspicions of congenital heart disease (look for this in the tongue or ▪ Palpation: palpate the newborn or infant’s skin to assess the degree of hydration or turgor. The skin in well- hydrated infants returns to normal position immediately upon release; delay in return is called “tenting” and usually occurs in children with significant dehydration. oral mucosa). ▪ Café-au-lait spots  light brown lesions (< 1 to 2 cm at birth); multiple lesions with sharp borders or more than five spots may suggest neurofibromatosis. ▪ Skin desquamation  normal in full- term newborns, and often noticeable 24 to 36 hours after birth, and can last for 7 to 10 days, but may rarely be a sign of placental circulatory insufficiency or congenital icthyosis. ▪ Midline hair tufts over the lumbosacral spine region  suggest a possible spinal cord defect. ▪ Jaundice  normal jaundice occurs in half of all newborns and usually appears on the second or third day, peaks the fifth day, and usually disappears within a week, and progresses from head to toe, with more intense jaundice on the upper body; jaundice within the first 24 hours of birth may be from hemolytic disease of the newborn; late-appearing jaundice or jaundice that persists beyond 2 to 3 weeks may indicate biliary obstruction or liver disease. ▪ Nevus simplex (“salmon patch,” “flame nevi,” telangiectatic nevus, capillary hemangioma)  flat/irregular/light pink patches most often seen on the nape of the neck, upper eyelids, forehead, or upper lip that result from distended capillaries and often disappear by 1 year of age. ▪ Port wine stain  unilateral dark, purplish lesion over the distribution of the ophthalmic branch of the trigeminal nerve may be a sign of Sturge-Weber syndrome. ▪ Significant edema in the hands/feet of a newborn girl  may suggest Turner syndrome. Head ▪ Sutures: feels like ridges ▪ Fontanelles: feel like soft concavities. Anterior fontanelle: 4 to 6 cm at birth, and closes between 2 and 26 months, and feels soft and flat upon palpation. Posterior fontanelle: 1 to 2 cm at birth, and closes by 2 months. ▪ Scalp veins: inspect for dilation. ▪ Skull symmetry ▪ Head circumference ▪ Facial symmetry: examine the face for an overall impression of the facies; it is helpful to compare with the face of ▪ Enlarged posterior fontanelle  congenital hypothyroidism. ▪ Bulging/tense fontanelle  IICP (caused by CNS infections, neoplastic disease, hydrocephalus). ▪ Depressed anterior fontanelle  sign of dehydration. ▪ Early closure of fontanelles  developing microcephaly, craniosynostosis (raised, bony ridge at a suture line suggests this), or some metabolic abnormalities. ▪ Delayed closure of fontanelles  the parents. ▪ Chvostek sign: percuss at the top of the cheek just below the zygomatic bone in front of the ear, using the tip of your index or middle finger. Positive: produces facial grimacing and is noted in cases of hypocalcemic tetany, tetanus, and tetany due to hyperventilation. usually normal, though can be due to hypothyroidism, megalocephaly, IICP, or rickets. ▪ Dilated scalp veins  indicative of long-standing IICP. ▪ Caput succedaneum  swelling over the occipital region, due to capillary distension and extravasation of blood and fluid resulting from the vacuum effect of rupture of the amniotic sac; typically crosses suture lines and resolves in 1 to 2 days. ▪ Cephalohematoma  localized swelling of the scalp caused by subperiostal hemorrhage from the trauma of birth, does not cross over suture lines and resolves within 3 weeks. ▪ Positional plagiocephaly (asymmetry of cranial vault)  occurs when infant lies mostly on one side, resulting in flattening of the parieto-occipital region on the dependent side and a prominence of the frontal region on the ipsilateral side; may also reflect pathology such as torticollis from injury to the sternocleidomastoid muscle at birth or lack of stimulation of the infant. ▪ Craniotabes  cranial bones feel springy, and can result from IICP, metabolic disturbances, and infection. ▪ Micrognathia  head is flexed on the sternum, with resulting shortened chin; may be part of the Pierre Robin syndrome. ▪ Abnormal shape or length of palpebral fissures  upslanting (Down syndrome); downslanting (Noonan syndrome); short (fetal alcohol effects) Eyes ▪ Inspection: examine the sclerae, pupils, irises, and extraocular movements. During the first 10 days of life, the eyes may stare in one direction if just the head is turned without moving the body (doll’s eye reflex). During the first few months, some infants have intermittent crossed eyes or laterally deviated eyes. Subconjunctival hemorrhages are common in neonates born via vaginal delivery. Eyes may be edematous. There may be initial asymmetry in the size of pupils, over time they should be equal in size and reaction to light. You cannot measure visual acuity of newborns or infants, though you can ▪ Newborn who cannot open an eye even when awake and alert  may have congenital ptosis, due to birth trauma or third cranial nerve palsy. ▪ Nystagmus (wandering/shaking eye movements) persisting after a few days or after examination  may indicate poor vision or CNS disease. ▪ Failure to gaze at your or follow your face during alert periods  may have visual impairment from congenital cataracts, or other disorders. ▪ Alternating convergent or divergent strabismus beyond 3 months (or persistent strabismus of any type)  may indicated ocular motor weakness, or another abnormality in the visual use visual reflexes to indirectly assess vision (direct and consensual pupillary constriction in response to light, blinking in response to bright light, and blinking in response to quick movement of an object toward the eye). ▪ Opthalmoscopic examination: with the newborn awake and eyes open, examine the red retinal (fundus) reflex by setting the opthalmoscope at 0 diopters and viewing the pupil from about 10 inches. Normally, a red or orange color is reflected from the fundus through the pupil. Cornea can ordinarily be seen at +20 diopters, the lens at +15 diopters, and the fundus at 0 diopters. Examine the optic disc area. system. ▪ Colobomas  may be seen with the naked eye and represent defects in the iris. ▪ Brushfield spots  (seen with ophthalmoscope) ring of white specks; though sometimes present normally, these strongly suggest Down syndrome. ▪ Persistent ocular discharge/tearing beginning at birth  may be from dacryocystitis or nasolacrimal duct obstruction. ▪ Cloudiness of cornea  may be congenital glaucoma. ▪ Dark light reflex  may result from cataracts, retinopathy of prematurity, or other disorders. ▪ White retinal reflex (leukokoria)  may result from cataracts, retinal detachment, chorioretinitis, or retinoblastoma. ▪ Occlusion of lens  may represent a cataract. ▪ Extensive retinal hemorrhages  suggest severe anoxia, subdural hematoma, subarachnoid hemorrhage, or trauma. Ears ▪ Determine position, shape, and features: an imaginary line drawn across the inner and outer canthi of the eyes should cross the pinna or auricle; if the pinna is below this line, the infant has low-set ears. ▪ Otoscopic examination: can only detect patency of the ear canal due to accumulated vernix caseosa, which obscures the tympanic membrane for the first few days of life. The infant’s ear canal is directed downward from the outside; therefore, pull the auricle gently downward for the best view of the eardrum. ▪ Acoustic blink reflex: blinking of the infant’s eyes in response to a sudden sharp sound, which you can produce by snapping your fingers or using a bell, etc., approximately 1 foot from the infant’s ear. ▪ Small, deformed, low-set auricles  may indicated congenital defects, especially renal disease. ▪ Small skin tab/cleft/pit just forward of the tragus  usually normal, though may be associated with renal disease and acquired hearing loss. Nose and Sinuses ▪ Test for patency of the nasal passages by gently occluding each nostril alternately while holding the infant’s mouth closed – this usually will not cause stress because most infants are nasal breathers (though some are obligate nasal breathers). ▪ Inspect to ensure the nasal septum is ▪ Nasal passage obstruction  may be obstructed in choanal atresia. midline. ▪ At birth, maxillary and ethmoid sinuses are present; palpation of the sinuses of newborns is not helpful. Mouth and Pharynx ▪ Normal findings include: smooth alveolar mucosa with finely serrated borders, pearl-like retention cysts along alveolar ridges, petechiae on soft palate, Esptein pearls (tiny white/yellow cysts located along posterior midline of hard palate), cysts on tongue or mouth, thyroglossal duct cysts, little saliva (under 3 months), a lot of saliva and drool (over 3 months). Whitish covering on tongue from milk. Strong, lusty cry. ▪ Inspection with a tongue depressor and flashlight. Pharynx is best seen while crying, as tongue depressor produces a strong gag reflex. Do not have prominent lymphoid tissue, so may not visualize the tonsils. ▪ Palpation: upper hard palate to make sure intact. ▪ Teeth: rule of thumb is that a child will have 1 tooth for each month of age between 6 and 26 months, up to a maximum of 20 primary teeth. ▪ Supernumerary teeth  rare, usually dysmorphic, and are shed within days, but are removed to prevent aspiration. ▪ Prominent, protruding tongue  congenital hypothyroidism or Down syndrome. ▪ Limited protrusion of tongue  ankyloglossia (tongue tie). ▪ Thrush  common, white plaques that are difficult to wipe away and have an erythematous raw base. ▪ Macroglossia  possibly associated with hypoglycemia and omphalocele (which is found in Beckwith- Wiedmann syndrome). ▪ Congenital fissure of median line  cleft palate. ▪ Inspiratory stridor beginning at birth  suggests a congenital abnormality, such as upper airway obstruction from various lesions, a small larynx, or a delay in the development of the cartilage in the tracheal rings. ▪ Stridor that appears following birth  can be due to infections such as croup, a foreign body, or GERD. ▪ Shrill/high-pitched cry  IICP, or in newborns born to narcotic-addicted mothers. ▪ Hoarse cry  hypocalcemic tetany or congenital hypothyroidism. ▪ Absence of cry  severe illness, vocal cord paralysis, profound brain damage. Neck ▪ Palpate the lymph nodes, assess for masses. ▪ Best to palpate while infants are lying supine, as their necks are short. Older children are best examined while sitting. ▪ Check the position of the thyroid cartilage and trachea. ▪ In newborns, palpate the clavicles to look for evidence of fracture (may feel a break in the contour of the bone, tenderness, crepitus at the fracture site, or limited movement of the arm on the affected side). ▪ Branchial cleft cysts  appear as small dimples or openings anterior to the midportion of the sternocleidomastoid muscle, and may be associated with a sinus tract. ▪ Preauricular cysts and sinuses  common, pinhole-size pits usually located anterior to the helix of the ear; may be associated with hearing deficits and renal disorders. ▪ Thyroglossal duct cysts  located at midline of neck, just above thyroid cartilage, and are small, firm, and mobile masses that move upward with tongue protrusion or with swallowing; usually seen after 2 years of age. ▪ Congenital torticollis  from bleeding into the sternocleidomastoid muscle during the stretching process during delivery; felt as a frim, fibrous mass within the muscle 2 to 3 weeks after birth and generally disappears over months. Thorax and Lungs ▪ Infant’s thorax is more rounded. Thin chest wall has little musculature. Tend to be obligate nose breathers. Inward movement of the chest and outward movement of the abdomen during inspiration (thoracoabdominal paradox) is normal in newborns, but not older infants. ▪ Inspection: assess respirations and breathing patterns. Newborn demonstrate “periodic breathing” with 30 to 40 breaths/minute. Observe for 30 to 60 seconds, noting general appearance, respiratory rate, color, nasal component of breathing, audible breath sounds, and work of breathing. ▪ Hoover sign: paradoxical (seesaw) breathing, in which the abdomen moves outward while the chest moves inward during inspiration. Caused by airway obstruction or lower respiratory tract disease. ▪ Palpation: assess tactile fremitus. Feel for symmetry in transmitted vibrations. Percussion is not typically helpful, as is hyperresonant throughout. ▪ Auscultation: breath sounds are usually louder and harsher, and loudest near the neck. Wheezes and rhonchi are common in infants. ▪ Pectus excavatum  funnel chest. ▪ Pectus carinatum  chicken breast. ▪ Apnea  cessation of breathing for more than 20 seconds; often accompanied by bradycardia and may indicate respiratory disease, CNS disease, or cardiopulmonary condition. Also a high-risk factor for SIDS. ▪ Nasal flaring  URIs, or may be caused by pneumonia or other serious respiratory infections. ▪ Respiratory distress  indicated by grunting, audible wheezing, lack of breath sounds, nasal flaring, retractions. ▪ Acute stridor  croup, epiglottitis, bacterial tracheitis, foreign body, hemangioma, or a vascular ring. ▪ Abnormal work of breathing + abnormal findings on auscultation  best signs for ruling in pneumonia (though absence of tachypnea is best sign for ruling out pneumonia). ▪ Asymmetric chest movement  possible space-occupying lesion. ▪ Increased abdominal breathing  indicator of pulmonary disease before 2 years of age. ▪ Biphasic sounds  severe obstruction from intrathoracic airway narrowing or severe obstruction from extrathoracic airway narrowing. ▪ Diminished unilateral breath sounds  unilateral lesions. ▪ Wheezes  asthma and bronchiolitis. ▪ Rhonchi  URIs. ▪ Crackles (rales)  pneumonia and bronchiolitis. Heart ▪ Inspection: observe for cyanosis (central cyanosis: inside of mouth, tongue, or conjunctivae). True strawberry pink is normal, whereas any hint of raspberry red suggests desaturation and requires urgent evaluation. Noncardiac findings commonly present in infants with cardiac disease include: poor feeding, failure to thrive, irritability, tachypnea, hepatomegaly, clubbing, poor overall appearance, weakness, and fatigue. An increase in respiratory effort is ▪ Central cyanosis without acute respiratory symptoms  cardiac disease; often involve right-to-left shunting and can be caused by a variety of congenital cardiac lesions. expected from pulmonary disease, whereas in cardiac disease, there may be tachypnea without increased work of breathing. ▪ Palpation: helps assess volume changes within the heart. Point of maximal cardiac impulse is not always palpable in infants. Thrills are easiest to feel with your palm of the base of your fingers. ▪ Pulses: major branches of the aorta can be assessed by evaluation of the peripheral pulses. In neonates and infants, the brachial artery pulse in the antecubital fossa is easier to feel than the radial artery pulse at the wrist. Palpate: brachial, femoral, and lower extremity pulses. ▪ Measure BP carefully. ▪ Auscultation: common have a normal sinus dysrhythmia, with the heart rate increasing on inspiration and decreasing on expiration. May have premature atrial or ventricular beats (skipped beats) that are usually benign. Evaluate the S1 and S2 heart sounds; you will detect a split S2 in a quiet or sleeping infant. Third heart sounds are often normal. Apparent gallop (widely split S2 that varies) is also normal. ▪ Heart murmurs: note specific location, timing, intensity, and quality. Benign murmurs have no associated abnormal ▪ Tachypnea + tachycardia + hepatomegaly  suggestive of heart failure. ▪ Diffuse bulge outward of left side of chest  suggests long-standing cardiomegaly. ▪ Rolling heave at the left sternal border  increase in right ventricular work. ▪ Rolling heave closer to the apex  increase in left ventricular work. ▪ Hyperdynamic precordium + bounding distal pulses  associated with PDA. ▪ Visible and palpable chest pulsations  suggest a hyperdynamic state from either increased metabolic rate or inefficient pumping as a result of an underlying cardiac defect. ▪ Absence/diminution of femoral pulses  coarctation of the aorta. ▪ Weak or thread, difficult-to-fell pulse  myocardial dysfunction and heart failure, especially is associated with tachycardia. ▪ Full pulses in feet of neonates  PDA or truncus arteriosus. ▪ Distant heart tones  pericardial effusion. ▪ Mushy, less distinct heart sounds  myocardial dysfunction. ▪ Louder-than-normal pulmonic component (particularly when louder than aortic sound) in S2 splitting  pulmonary HTN. ▪ Persistent splitting of S2  right ventricular volume load (e.g., atrial septal defect, anomalies or pulmonary venous return, or chronic anemia). ▪ Fourth heart sounds (S4)  low- frequency, late diastolic sounds, occurring just before the first heart sound, and suggest heart failure. ▪ True gallop rhythm  tachycardia + loud S3, S4, or both, indicates heart failure. ▪ Pulmonary flow murmur with other signs of disease  likely to be findings. Most children will have one or more functional (benign) heart murmurs before reaching adulthood – e.g., peripheral pulmonary flow murmur. pathologic, possibly caused by Williams syndrome, congenital rubella syndrome, and Alagille syndrome. ▪ Heart murmur + central cyanosis  congenital heart disease; requires urgent cardiac evaluation. Breasts In males and females, often enlarged due to maternal estrogen effect, and may last for several months. ▪ Premature thelarche  breast development occurs between 6 months and 2 years of age. Abdomen ▪ Inspection: typically protuberant with poorly developed musculature. Examine the umbilical cord and surrounding area. May have diastasis recti, and is benign in most cases. ▪ Auscultation: tinkling bowel sounds. ▪ Percussion and palpation: greater tympanitic sounds. Hold the legs flexed at the knees and hips with one hand and palpate the abdomen with the other. You should be able to feel the liver edge in most infants, 1 to 3 cm below the right costal margin. Spleen is moveable and rarely extends more than 1 to 2 cm below the left costal margin. Pulsations in the epigastrium caused by the aorta is normal. ▪ Single umbilical artery  associated with congenital abnormalities or may be an isolated anomaly. ▪ Umbilical hernia  detectable by a few weeks of age, caused by a defect in the abdominal wall; most will disappear by 1 year, and nearly all by 5 years. ▪ Increase in pitch or frequency of bowel sounds  gastroenteritis, or intestinal obstruction. ▪ Silent, tympanic, distended, tender abdomen  peritonitis. ▪ Enlarged, tender liver  heart failure, or storage diseases (in newborns, this may be due to hepatitis, storage diseases, vascular congestion, or biliary obstruction). ▪ Splenomegaly  infections, hemolytic anemia, infiltrative disorders, inflammatory or autoimmune diseases, and portal HTN. ▪ Abnormal abdominal masses  associated with kidney, bladder, bowel, or tumors. ▪ Deep palpation in RUQ or midline that reveals a 2 cm firm mass (“olive”)  pyloric stenosis; may see visible peristaltic waves pass across abdomen during feeding, followed by projectile vomiting. Male Genitalia ▪ Inspect: note appearance of penis, testes, and scrotum. The foreskin is nonretractable at birth, though you may be able to retract it enough to visualize the external urethral meatus. Rugae on the testes should be present by 40 weeks’ gestation. Scrotal edema may be present for several days following birth due to maternal estrogen effect. ▪ Palpate: testes in scrotal sacs should be about 10 mm in width and 15 mm in length and should lie in the scrotal sacs most of the time. Examine for swelling. ▪ Hypospadias  abnormal location of urethral orifice to some point along the ventral surface of the glans or shaft of the penis. ▪ Fixed, downward bowing of penis  chordee; may accompany a hypospadias. ▪ Undescended testicle (cryptochordism)  scrotum appears underdeveloped and tight, and palpation reveals an absence of the scrotal contents; in 2/3rd of these cases, both testes will descend by 1 year of age. ▪ Hydrocele  often coexists with inguinal hernia; more common on right side; overlie the testes and spermatic cord, are not reducible, and can be transilluminated; most resolve by 18 months. ▪ Inguinal hernia  often coexists with hydrocele; more common right side; separate from the testes, usually reducible, often do not transilluminate. They do not resolve. Female Genitalia ▪ Genitalia will be prominent due to the effects of maternal estrogen. ▪ During the first few weeks of life, there is often a milky white vaginal discharge that may be blood tinged and is not cause for concern. ▪ Inspect: size of clitoris, color and size of labia majora, any rashes/bruises/lesions, separate the labia majora, inspect the urethral orifice and labia minora, assess the hymen, and note any discharge. ▪ Ambiguous genitalia  rare, caused by endocrine disorders (e.g., congenital adrenal hyperplasia). ▪ Labial adhesions  occur frequently, tend to be thin, and often disappear without treatment. Rectum ▪ Generally not performed for infants or children unless there is a question of patency of the anus or an abdominal mass. ▪ If needed, flex the infant’s hips and fold the legs to head. ▪ Blood in stool  common cause is anal fissure (superficial break in the surface of the anus), observable with naked eye. Musculoskeletal System Focus on detection of congenital abnormalities, particularly in the hands, spine, hips, legs, and feet. ▪ Newborn’s hands are clenched (palmar grasp reflex). ▪ Palpate along the clavicle, noting any lumps, tenderness, or crepitus (looking for fracture). ▪ Inspect the spine, looking for pigmented spots, hairy patches, or deep pits. If present within 1 cm of the midline, they may overlie openings of sinus tracts that extend to the spinal canal. Do not probe these, due to risk of introducing infection. ▪ Examine the hips, assessing for signs of dislocation: Ortolani (posterior dislocation) and Barlow (intact but unstable hip) tests. ▪ Assess for femoral shortening: Galeazzi or Allis sign. Place the feet with knees flexed and sacrum flat on table together, and note any difference in knee heights. ▪ Examine legs and feet, looking as symmetry, bowing, and torsion. Most newborns are bowlegged, and some normal infants exhibit twisting or torsion of the tibia inwardly or outwardly on its longitudinal axis. Tibial torsion usually corrects itself during the 2nd year of life (after months of weight bearing). ▪ Examine the feet – at birth, they may appear deformed, often turned inward. You should be able to correct the feet ▪ Skin tags, remnants of digits, polydactyly (extra fingers), syndactyly (webbed fingers)  congenital defects. ▪ Soft audible “click” with Ortolani or Barlow tests  does not prove dislocation, but should prompt a careful examination. ▪ Feel a “clunk” as the femoral head enters the acetabulum, and a palpable movement of the femoral head back into place  positive Ortolani test (may indicate developmental dysplasia of the hip). ▪ Feel the head of the femur slipping out onto the posterior lip of the acetabulum  positive Barlow sign (indicates laxity and potentially dislocatable hip). ▪ Limited abduction after 3 months of age  concerning for developmental dysplasia of hip. ▪ Severe bowing of knees  can be normal, but can also be due to rickets or Blount disease. to the neutral, and even to an overcorrected position. Appear flat. Some may have adduction of the forefoot (metatarsus adductus) – this requires close follow-up. All variants tend to resolve within 1 to 2 years. Nervous System Techniques are specific to the age of the child. Neurologic abnormalities in infants often present as developmental abnormalities, such as failure to do age appropriate tasks. Therefore, the neurologic and developmental examinations need to proceed together. ▪ Assessment should include mental status, gross and fine motor function, tone, cry, deep tendon reflexes, and primitive reflexes. ▪ More detailed examination of cranial nerve and sensory function are indicated if you suspect any abnormalities. ▪ Motor tone: note any spasticity or flaccidity. ▪ Sensory function: flick the infant’s palm or sole – observe for withdrawal, arousal, and change in facial expression ▪ Deep tendon reflexes: present in newborns, but may be difficult to elicit, and may vary in intensity. Their exaggerated presence or their absence has little diagnostic significance. ▪ Triceps, brachioradialis, abdominal reflexes: difficult to elicit before 6 months of age. ▪ Anal reflex: present at birth and important to elicit if a spinal cord ▪ Signs of severe neurologic disease include: extreme irritability, persistent asymmetry of posture, persistent extension of extremities, constant turning of the head to one side, marked extension of the head/neck/extremities, severe flaccidity, and limited response to pain, and sometimes seizures. ▪ Fine tremors, irritability, and poor self- regulation  may indicate withdrawal from nicotine if the mother smoked during pregnancy. ▪ Persistent irritability  sign of neurologic insult, or may reflect metabolic, infectious, or other constitutional abnormalities, or environmental conditions (e.g., withdrawal from drugs). ▪ Persistent irritability (with jitteriness, tremors, hypertonicity, and hyperactive reflexes)  may have drug withdrawal. ▪ Increased or decreased tone  intracranial disease. ▪ Hypotonia  CNS abnormalities and disorders of the motor unit. ▪ Changes in facial expression or cry following a painful stimulus without withdrawal  weakness or paralysis may be present. ▪ Abnormalities in cranial nerves  intracranial lesions (e.g., hemorrhage, congenital malformation). ▪ Dysphagia  can be due to injury to cranial nerves IX, X, and XII. ▪ Progressive increase in deep tendon reflexes during the first year of life  may indicate CNS disease (e.g., cerebral palsy). ▪ Asymmetric reflexes  suggest a lesion of the peripheral nerves or spinal segment. ▪ Absent anal reflex  suggests a loss of innervation of the external sphincter muscle caused by a spinal cord abnormality (e.g., tumor, injury, spina bifida). ▪ Sustained ankle clonus while performing the Babinski test  possible CNS disease. lesion is suspected. ▪ Babinski response: positive with dorsiflexion of big toe and fanning of other toes in response to plantar stimulation – may persist for several months after birth. ▪ Primitive reflexes: assess the developing CNS by examining infantile automatisms. ▪ Persistence of palmar grasp reflex beyond 4 months  pyramidal tract dysfunction. ▪ Persistence of clenched hand beyond 2 months  CNS damage, especially if fingers overlap thumb. ▪ Persistence of plantar grasp reflex beyond 8 months  pyramidal tract dysfunction. ▪ Absence of rooting  severe generalized or CNS disease. ▪ Persistence of Moro reflex beyond 4 months  neurologic disease; beyond 6 months  strong suggests neurologic disease. ▪ Asymmetric Moro reflex  suggests fracture of clavicle or humerus or brachial plexus injury. ▪ Persistence of asymmetric tonic neck reflex beyond 2 months  asymmetric CNS system development and sometimes predicts the development of cerebral palsy. ▪ Absence of trunk incurvation reflex  transverse spinal cord lesion or injury. ▪ Persistence of trunk incurvation reflex  indicates delayed development. ▪ Persistence of Landau reflex  indicates delayed development. ▪ Delay in appearance of parachute reflex  may predict future delays in voluntary motor development. ▪ Lack of positive support reflex  suggests hypotonia or flaccidity. ▪ Fixed extension and adduction of legs during positive support reflex  suggest spasticity from neurologic disease (e.g., cerebral palsy). ▪ Absence of placing and stepping reflexes  may indicate paralysis. ▪ Note: newborns born by breech delivery may not have a placing reflex. ▪ Development: a normative measure of development is the development quotient. Please see questions #30, #31, and #32 for additional information. 31. Assessing young and school-aged children – development. (p. 854; key search term: “development after infancy”) Early Childhood: 1 to 4 Years ▪ Rate of physical growth slows by approximately half. o After 2 years, toddlers gain about 2 to 3 kg and grow 5 cm per year. ▪ Gross motor skills develop quickly. ▪ Fine motor skills develop through neurologic maturation and environmental manipulation. ▪ Toddlers move from sensorimotor learning (through touching and looking) to symbolic thinking, solving simple problems, remembering songs, and engaging in imitative play. ▪ Language develops with extraordinary speed. ▪ Remain preoperational, without sustained logical though processes. ▪ Emerging drive for independence. ▪ Impulsive with poor self-regulation, so temper tantrums are common. Middle Childhood: 5 to 10 Years ▪ Marked by goal-directed exploration, increased physical and cognitive abilities, and achievements by trial and error. ▪ Grow steadily but more slowly. ▪ Strength and coordination improve dramatically. ▪ When children with physical disabilities or chronic illnesses become more aware of their limitations. ▪ More concrete operational – capable of limited logic and more complex learning. o Remain rooted in present with little ability to understand consequences or abstractions. ▪ Develop self-efficacy, or the ability to thrive in different situations. ▪ Language becomes increasingly complex. ▪ Progressively more independent. ▪ Family and environment contribute enormously to the child’s self-image. ▪ Moral development remains simple and concrete with a clear sense of right and wrong. 32. Developmental milestones during early childhood. (p. 853; key search term: “development after infancy”) 33. Examination tips – young children. (p. 855; key search term: “avoiding a physical”) More tips for examining the young child: • The child should remain dressed during the interview to minimize the child’s apprehension. • Toddlers aged 9 to 15 months may have stranger anxiety – do not approach these toddlers quickly; play can help them warm up to you. • If a child is shy, turn your attention to the parent to allow the child to warm up gradually; conversely, helping the parent relax can help everyone relax. • For those who resist undressing, expose only the body part being examined. • When examining siblings, begin with the oldest child, who is more likely to cooperate and set a good example. • Plan the examination to start with the least distressing procedures and end with the most distressing ones. • Use a reassuring voice throughout the examination. • Let the child see and touch the examination tools you will be using. • Avoid asking permission to examine a body part because you will do the examination anyway. Instead, ask the child which ear or which part of the body he or she would like you to examine first. • Examine the child in the parent’s lap. Let the parent undress the child. • If unable to console the child, give the child a short break. • Make a game out of the examination! For example, “Let’s see how big your tongue is!” or “Is Elmo in your ear? Let’s see!” 34. Assessing adolescents - health history. (p. 891; key search term: “environment this makes”) The key is a comfortable, confidential environment. Consider the teen’s cognitive and social development when deciding issues of privacy, parental involvement, and confidentiality. Adolescents usually respond positively to anyone demonstrating a genuine interest in them. Adolescents are more likely to open up when the interview focuses on them rather than on their problems. In contrast to most other interviews, start with specific questions to build trust and rapport and get the conversation going. Additional tips include: ▪ Using silence is usually not a good idea. ▪ Use summarization and transitional statements. ▪ Explain what you are going to do during the physical examination. ▪ Once you have established rapport, return to more open-ended questions. ▪ Because adolescents are often reluctant to ask their most important questions, ask if the adolescent has anything else to discuss; e.g., “Tell me what other questions you have” or “Other kids your age often have questions about…” ▪ Behavior is related to the developmental stage, not necessarily to chronologic age or physical maturation. ▪ The clinician should start asking the parent to leave the room for part of the interview when the child is aged 11 years. ▪ Never make confidentiality unlimited – always state explicitly that you may need to act on information that makes you concerned about safety. ▪ Encourage adolescents to discuss sensitive issues with their parents and offer to be present and help. It is important to carefully assess the parents’ perspective prior to further discussion, and to obtain the explicit consent of the young person. ▪ Modesty is important – leave the room while the patient puts on a gown, and ask younger adolescents and their parents about preferences about being in the room during examination. ▪ Clinicians should have a chaperone in the room when examining an adolescent of a different gender. ▪ Some issues are unique to adolescents, including: puberty, growth, development, family and peer relationships, sexuality, healthy decision making, and high-risk behaviors. Chapter 19 (The Pregnant Woman) 35. Anatomic changes. (pp. 928-930; key search term: “changes changes”) Anatomic Changes of Pregnancy Breasts ▪ Become moderately enlarged due to hormonal stimulation that causes increased vascularity and glandular hyperplasia. ▪ Nipples become larger and more erectile, with darker areolae and more pronounced Montgomery glands. ▪ Venous pattern over breasts becomes visibly more prominent. ▪ Breast tenderness may make them more sensitive during examination. ▪ 3rd month gestation: more nodular. ▪ 2nd and 3rd trimesters: some women secrete colostrum. Uterus ▪ Uterus growth due to muscle cell hypertrophy, increases in fibrous and elastic tissue, and development of blood vessel and lymphatics. ▪ Increases in weight from 70 g at conception to nearly 1,100 g at delivery. ▪ 1st trimester: confined to pelvis and shaped like inverted pear. ▪ 12 to 14 weeks: becomes externally palpable as it expands into a globular shape beyond the pelvic brim. ▪ 2nd trimester: enlarging fetus pushes the uterus into an anteverted position that encroaches into the space usually occupied by the bladder, triggering frequent voiding. Intestines are displaced laterally and superiorly. Stretches its own supporting ligaments, causing round ligament pain in the lower quadrants. Slight dextrorotation leads to greater discomfort on the right side as well as increased right-sided hydronephrosis. Vagina ▪ Appear deeply rugated due to thicker mucosa, loosening of connective tissue, and hypertrophy of smooth muscle cells. ▪ Secretions may become thick, white, and more profuse, known as leukorrhea of pregnancy. ▪ Lower vaginal pH due to proliferation of Lactobacillus acidophilus resulting from increased glycogen stores in the epithelium. May be protective, though may also contribute to higher rates of vaginal candidiasis. Cervix ▪ Soon after conception: copious secretions fill the cervical canal with a mucus plug that protects that uterine environment from outside pathogens and is expelled as bloody show at delivery. ▪ 1 month after conception: softens and turns bluish or cyanotic due to increased vascularity, edema, and glandular hyperplasia. ▪ Hegar sign: palpable softening of the cervical isthmus. Adnexae ▪ Corpus luteum may be prominent enough to be felt on the affected ovary as a small nodule, and disappears by midpregnancy. External Abdomen ▪ Striae gravidarum (“stretch marks”): purplish marks. ▪ Linea nigra: a brownish-black pigmented vertical stripe along the midline. ▪ Diastasis recti: rectus abdominis muscles may separate with advancing pregnancy. If this is severe, especially in multiparous women, only a layer of skin, fascia, and peritoneum may cover the anterior uterine wall, and fetal parts may be palpable through this muscular gap. 36. Gestational age versus expected date of delivery. (p. 934; key search term: “effectively triaging”) ▪ Gestational age: the number of weeks and days from the first day of the LMP. Counting this menstrual age from the LMP, although biologically distinct from date of conception, is the standard means of calculating fetal age, yielding an average pregnancy length of 40 weeks. ▪ Expected date of delivery: 40 weeks from the first day of the LMP. The expected date of delivery can be estimated by taking the LMP, adding 7 days, subtracting 3 months, and adding 1 year. Patient recall of LMP is highly variable. Even when the date is accurate, the LMP can be affected by hormonal contraceptives, menstrual irregularities, or variations in ovulation that result in atypical cycle lengths. LMP dating should be checked against physical examination markers such as fundal height, an anyd wide discrepancies should be clarified by ultrasound evaluation. 37. Substance abuse. (p. 938; key search term: “abuse abstinence”) Provide universal screening, which can uncover subtle issues and help you address substance abuse in a neutral and constructive manner. ▪ Tobacco: implicated in 13% to 19% of all low-birth weight babies and many other poor pregnancy outcomes, including a twofold risk of placenta previa, placental abruption, and preterm labor, and increased risk of spontaneous abortion, fetal death, and fetal digit anomalies. Cessation is the goal but any decrease in use is favorable. ▪ Alcohol: fetal alcohol syndrome is the leading cause of preventable mental retardation in the US. No safe dose of alcohol has been established. Women should abstain throughout pregnancy. ▪ Illicit Drugs: women should be referred for immediate treatment, and screened for HIV and hepatitis C infection. ▪ Abuse of Prescription Drugs: ask about unusual use of narcotics, stimulants, benzodiazepines, and other commonly abused prescriptions drugs. ▪ Herbal and Unregulated Supplements: review and discuss any intake of supplements and consider pregnancy toxicology to determine specific risks related to the timing of ingestion and the extent of fetal exposure. Unregulated supplements, especially if formulated outside the US, may contain lead and other toxins. 38. Immunizations. (p. 937; key search term: “immunizations given”) ▪ Tdap should be administered during each pregnancy, ideally at 27 to 36 weeks of gestation, regardless of prior immunization history (caretakers in direct contact with the infant should also receive Tdap). ▪ Inactivated influenza vaccination is indicated in any trimester during the influenza season. ▪ Safe during pregnancy includes: pneumococcal, meningococcal, and hepatitis B. ▪ Not safe during pregnancy includes: measles/mumps/rubella, polio, varicella; however, all women should have rubella titers drawn during pregnancy and be immunized after birth if found to be nonimmune. ▪ Anti-D immunoglobulin should be given to all Rh-negative women at 28 weeks’ gestation and again within 3 days of delivery to prevent sensitization is the infant is Rh-D positive. 39. Examination techniques – height, weight, and vital signs. (p. 942; key search term: “weight calculate”) Measure the height and weight: calculate BMI with standard tables, using 19 to 25 as normal for the prepregnant state. Losses in excess of 5% of prepregnancy weight are considered excessive, representing hyperemesis gravidarum, and may lead to adverse pregnancy outcomes. Measure the BP at every visit: baseline prepregnancy readings are important for determining the patient’s usual range. In the second trimester, BP normally drops below the nonpregnant state. ▪ Chronic HTN  systolic BP > 140 or diastolic BP > 90 that predates pregnancy. ▪ Gestational HTN  SBP > 140 or DBP > 90 first documented after 20 weeks, without proteinuria or preeclampsia, that resolves by 12 weeks postpartum. ▪ Preeclampsia syndrome  SBP ≥ 140 or DBP ≥ 90 after 20 weeks on two occasions at least 4 hours apart in a woman with a previously normal BP or BP ≥ 160/110 confirmed within minutes AND proteinuria ≥ 300 mg/24 hours, protein:creatinine ≥ 0.3, or dipstick 1+ OR new onset HTN without proteinuria and any of the following: o Thrombocytopenia (platelets < 100,000/L) o Impaired liver function (liver transaminase levels more than twice normal) o New renal insufficiency (creatinine > 1.1 mg/dL or doubles in the absence of renal disease) o Pulmonary edema o New onset cerebral or visual symptoms Chapter 20 (The Older Adult) 40. Vital signs. (pp. 957-958; key search term: “frailty vital”) Blood Pressure: in Western societies, systolic blood pressure tends to rise with aging. As the aorta becomes less distensible, a given stroke volume causes a greater rise in systolic blood pressure; systolic hypertension with a widened pulse pressure often ensues. Diastolic blood pressure stops rising at approximately the sixth decade. At the other extreme, many older adults develop orthostatic (“postural”) hypotension—a sudden drop in blood pressure when rising to a standing position. Heart Rate and Rhythm: in older adults, resting heart rate remains unchanged, but there are declines in the pacemaker cells of the sinoatrial node and the maximal heart rate, which affect the response to exercise and physiologic stress. Older adults are more likely to have abnormal heart rhythms such as atrial or ventricular ectopy. Asymptomatic rhythm changes are generally benign. However, some rhythm changes cause syncope, which is a temporary loss of consciousness. Respiratory Rate and Temperature: respiratory rate and temperature are unchanged, but changes in temperature regulation lead to a susceptibility to hypothermia. 41. Activities of daily living versus instrumental activities of daily living. (pp. 970-971; key search term: “living the daily”) The daily activities of older adults, especially those with chronic illness, provide an important baseline for future evaluations. First, ask about how well the patient performs the ADLs, which consist of six basic self-care abilities. Then, move on to higher level functions, the instrumental activities of daily living (IADLs). 42. Clinical clues to alcohol-related problems. (p. 974; key search term: “watch for clues”) Recommended drinking limits are lower for adults over age 65, due to physiologic changes that alter alcohol metabolism, frequent comorbid illness, and risk of drug interactions. No more than three drinks on any occasion or seven drinks a week are recommended. Despite the high prevalence of alcohol-related problems, rates of detection and treatment are low. Screening all older adults for harmful alcohol use is especially important due to adverse interactions with most medications and exacerbation of comorbid illnesses, including cirrhosis, GI bleeding or reflux disease, gout, HTN, diabetes, insomnia, gait disorders, and depression. Watch for clues of excess alcohol consumptionespecially in elders with recent bereavement or losses, pain, disability or depression, or a family history of alcohol disorders. Use the CAGE questions to uncover problem drinking. Although symptoms and signs are subtler in older adults, making early detection more difficult, the four CAGE questions remain sensitive and specific in this age group, using the conventional cutoff score of 2 or more. 43. Household safety and fall prevention. (p. 979; key search term: “prevention in 2013”) Emergency room visits and deaths were most likely to involve yard and garden equipment, ladders and stepstools, personal-use items like hair dryers and flammable clothing, and bathroom and sports injuries. Encourage older adults to adopt corrective measures for poor lighting, chairs at awkward heights, slippery or irregular surfaces, and environmental hazards. 44. Immunizations. (pp. 979-980; key search term: “immunizations recommend”) Recommend vaccination for influenza; pneumonia (both PPSV23 and PCV12); herpes zoster (shingles); and tetanus/diphtheria and pertussis (Tdap and Td). Vaccination rates still lag for Hispanics and African Americans. Influenza vaccine. The following groups should receive the influenza vaccine each year: *All adults ≥ 50 years *Adults with chronic pulmonary and cardiovascular disorders including asthma (but excluding hypertension), and renal, hepatic, neurologic, hematologic or metabolic disorders including diabetes *Adults who are immunosuppressed from medication or HIV *Residents of nursing homes and other long-term care facilities; adults with morbid obesity (BMI ≥ 40) *Household contacts and caregivers of children under 5 years and adults ≥ 50 years, especially those with medical conditions placing them at risk for severe complications from influenza Pneumococcal vaccine: *All adults ≥ 65 years; older adults who have not previously received PCV13 should receive PCV13 first, followed 6 to 12 months later by PPSV23. Those who have already received one or more doses of PPSV23 should receive PCV13 at least 1 year after the most recent dose of PPSV23. *Adults ages 19–64 years should also be vaccinated as above if they have the following conditions: HIV infection, long-term immunosuppressive therapy, chronic renal failure, nephrotic syndrome, functional or anatomic asplenia, cochlear implants, sickle cell disease (or other hemoglobinophathies), congenital or acquired immunodeficiencies, generalized malignancy, Hodgkin disase, leukemia, multiple myeloma, solid organ transplant, or CSF leaks. Zoster vaccine: *All adults ≥ 60 years, regardless of whether they have already had either chicken pox or shingles. *Contraindications: the vaccine should not be given to adults with a history of a primary or acquired immunodeficiency state, including leukemia, lymphoma, or other malignant neoplasm affecting the bone marrow or lymphatic system, or with HIV/AIDS or to those receiving immunosuppressive therapy, including high-dose corticosteroids. Tetanus/diphtheria and Tetanus/diphtheria/pertussis (Td and Tdap) vaccine: *All adults ≥ 19 years, including those aged ≥ 65 years: all adults ≥ 19 years who have not been vaccinated with Tdap should receive a single dose of Tdap regardless of the time interval since last receiving Td. After receiving Tdap, they should receive Td boosters at 10-year intervals. For adults aged ≥ 65 years, this will reduce the likelihood of transmission to infants aged < 12 months. 45. Examination techniques – assessing functional status. (pp. 985-997; key search term: “sixth vital sign is”) Establishing functional status provides a baseline for making interventions to optimize the patient’s level of function and for identifying geriatric syndromes that can be treated or delayed, such as cognitive impairment, falls, incontinence, low BMI, dizziness, and impaired vision and hearing. Deficits in function are now recognized as better predictors of patient outcome and mortality after hospitalization than the admitting diagnoses. The 10-Minute Geriatric Screener is brief, has high interrater agreement, and can be easily used by office staff. It covers three important areas: cognitive, psychosocial, and physical function. It includes vision, hearing, and questions about urinary incontinence, an often hidden source of social isolation. For identifying causes of incontinence, two mnemonics may be helpful: DIAPERS (Delirium, Infection, Atrophic urethritis/vaginitis, Pharmaceuticals, Excess urine output from conditions like hyperglycemia or heart failure, Restricted mobility, and Stool impaction) and DDRRIIPP (Delirium, Drug side effects, Retention of feces, Restricted mobility, Infection of urine, Inflammation, Polyuria, and Psychogenic). 46. Assessment for preventing falls – algorithm. (pp. 987-988; key search term: “assessment STEADI”)