Health Assessment Exam 1 2022

Health Assessment Exam 1 2022 Episcleritis - -Superficial -Idiopathic, but R/o collagen vascular disorder. -Asymptomatic, mild pain -Self-limiting or topical treatment -H/o recurrent episodes is common Sub-conjunct ...

Health Assessment Exam 1 2022 Episcleritis - -Superficial -Idiopathic, but R/o collagen vascular disorder. -Asymptomatic, mild pain -Self-limiting or topical treatment -H/o recurrent episodes is common Sub-conjunctival Hemorrhage - -Diffuse or localized area of blood under conjunctiva. -Asymptomatic -Idiopathic, trauma, cough, sneezing, aspirin, HT -Resolves within 10-14 days Hordeolum - (stye) red, painful pustule that is a localized infection of hair follicle at eyelid margin. most often caused by staph. If it does not drain and heal it can become a chalazion Chalazion - Eyelid sebaceous gland obstruction and inflammation but w/o infection. S/S: slow growing, non-tender, hard, localized swelling w/o redness or heat **Key factor: single lesion paranasal sinuses - · 4 pairs of air-filled cavities located on each side of the nasal cavity o Maxillary § Located just below the orbit of the eye in maxillary bone (cheek area) o Frontal § Located n the frontal bone just above the eyebrows o Ethmoidal § Located in the ethmoid bone lying behind the eyes and nose o Sphenoidal § Located in the sphenoid bone lying behind the eyes and nose · Each sinus is lined with cilia and mucous membrane that help to trap foreign particles and move them to the outside · Connect with the nasal cavity via the meatus · Often sites for infection due to the opening in the nasal cavity and can become easily blocked. Paranasal Sinus Exam Adult - Palpate the sinuses (Rhoads, 183). Place thumb on forehead at the orbital ridge and press upward on the eyebrow to palpate the frontal sinuses Move thumbs to each side of the patient's cheeks and apply gentle pressure upward just below the cheekbones, on maxillary area Tenderness on palpation may indicate allergic rhinitis or sinus infection Note evidence of crackling sensation during palpation Suggests accumulation of large amount of exudate Percuss the sinuses Lightly tap over frontal and maxillary sinuses for tenderness Should be resonant on percussion and tenderness should be absent Tenderness/dullness may indicate allergic rhinitis or sinusitis If tenderness is noted on palpation and percussion of the sinuses, transilluminate the sinuses to gather additional information Darken the room Transillumination of frontal sinuses Shine strong, narrow stream of light closely under the eyebrow. Use other hand to shield the light and compare the glow of light through bilateral sinuses Transillumination of maxillary sinuses Shine light directly over maxillary sinus (cheekbone area) Have patient open their mouth and look for the glow of light on the hard palate and compare each side Transillumination→ clear sinuses (air-filled) will see a red glow→ no light seen, they are filled with fluid or purulent drainage Paranasal Exam pediatric - · Inspection o Assess flaring of the nares § Indication for concern o Check nasal patency § Close mouth and occlude one nostril at a time · Not difficulty or distress o Assess for foreign body o DO NOT use nasal speculum to inspect nasal cavity. Use light to visualize · Palpation o DO NOT palpate over sinuses in infants and young children § Sinuses are not fully developed and therefore not palpable § Frontal sinuses fully mature around age 6 Corneal Inflammation or Infection - -May have decrease visual acuity and photophobia. -Often c/o severe pain -Epithelial defect may be evident on slit lamp examination or may require staining with fluorescein. -ANY opacification of the cornea in a red eye is an infection of the cornea until proven otherwise. -THIS IS AN OPHTHALMOLOGIC EMERGENCY. -Refer within 24 hours when to refer to ophthalmologist - Bad signs - REFER Decrease visual acuity Abnormalities with Fluorescein staining. Unequal size or unreactive pupil. Proptosis Ciliary flush Corneal opacities Limited or painful EOM Increase IOP Cases requiring prolonged treatment or who do not respond as expected to the treatment. iritis - involves branches of the anterior ciliary arteries and indicates inflammation of the cornea, iris, or ciliary body. typical of iritis ciliary flush - Violaceous hyperemia of vessels surrounding the cornea Photophobia, ciliary flush and sluggishly reactive pupil --> Iritis corneal abrasion - Surface epithelium sloughed off -stains with fluorescein -usually due to trauma -Pain, foreign body sensation, tearing, redeye Corneal Ulcer - a local inflammation of the cornea caused by infection, trauma, or chemical (Alkali injuries worse than acid) Conjunctivitis (pink eye) - Inflammation or infection of the conjunctiva, characterized by redness and often discharge causes of "red eye" - NO pain and normal vision -likely to be self limiting -conjunctivitis _episcleritis -subconjunctival hemorrhage Pain With or w/o blurring of vision -likely to have sight threatening condition -acute glaucoma -iritis -corneal infections scleritis - Deep, idiopathic, painful, gradual onset of red eye -insidious decrease in vision -deep violet discoloration may be observed Acute Angle-closure Glaucoma - Blurred Vision Headache Halos around lights Nausea Vomiting Another ocular emergency Severe ocular pain with nausea and vomiting, pupil mid-dilated and oval Blurred vision, colored haloes around lights due to corneal edema Treatment: emergency referral to ophthalmologist Pilocarpine, Pressure lowering eyedrops Hyperosmotic agents - glycerol, mannitol Cafe au lait spots - · Caused by increased melanin content and are associated with neurofibromatosis · Lesions vary in appearance and size · Color ranging from tan to dark brown · Borders are uniform · Flat, NOT raised macule spider angioma (telangiectasia) - dilated radiating capillaries surrounding a central arteriole on the face, forearms, and hands radiating telangiectases blanch under diascopy, the center does not red in color f>m liver disease, young children, hyperestrogenic states treat with electrocautery and laser surgery up to 1.5cm Port Wine Stains (Nevus Flammeus) - · Capillary malformation in the skin · Seen at birth and persist throughout life · The area of skin affected grows in proportion to general growth Nevus vasculosus (strawberry mark) - Raised dark red rough surface. Grows rapidly for several months and then begins to fade. Usually disappears by 7 yr old. Papilledema - optic disc swollen with blurred edges due to ICP basal cell carcinoma (BCC) - · Most common form of skin cancer (80%) · Involves sun-exposed skin · Very slow growing o Rarely metastasizes: Can become invasive and destructive if not diagnosed and treated in a timely manner · Signs and symptoms o Non-healing sore on face, ear, other sun-exposed area o Appearance is waxy/pearly appearance with central indentation o Over time central area becomes crusty o Edges typically appear rolled o "PUT ON" § P- pearly papule § U- ulcerating § T- Telangiectasia § O- on the face, scalp, penne of the ear § N- Nodules = Slow growing BCC photo - squamous cell carcinoma (SCC) - Squamous Cell Carcinoma • Second most common • Involves sun-exposed skin: upper layer of epidermis • Grow more rapidly and can become invasive over time • Signs and symptoms o Nonhealing lesion that is growing in size o Often tender o May have a watery appearance, a pink colored plaque, a nodule, or a papule with eroded surface o Size is usually 0.5-1.5 cm in diameter o "NO SUN" N- Nodular O- Opaque S- Sun exposed area U- Ulcerating N-Non distinct borders • Can metastasize SCC photo - Melanoma - · Malignancy that arises from melanocytes · Deadly; can metastasize · Risk factors o Personal or family hx o Greater than 50 common moles present o Atypical or large moles o Red or light hair o Solar lentigines (acquired brown macules on sun exposed areas) o Freckles (inherited brown macules) o UV radiation from heavy sun exposure, sun lamps, or tanning beds o Light skin color or eye color, especially skin that freckles or burns easily o Severe blistering sunburns in childhood o Immunosuppression from HIV or chemo o Personal hx of non-melanoma skin cancer · Screening tool: ABCDE o A- asymmetric with non-matching sides o B- borders are irregular o C- color is not uniform; brown, black, red, white, blue o D- diameter usually larger than 6mm, the size of a pencil eraser o E- evolving lesions; either new or changing (most manifest as new lesions) melanoma photo - What are primary skin lesions? - Primary lesions are those that develop as a direct result of, and therefore are most characteristic of the disease process Macule - o A circumscribed flat area of change in color < 1cm in diameter o EXA: Café au lait freckles, flat moles, port-wine stains, rashes of rickettsial infections, rubella, and measles. papule - o A small solid elevation of the skin < 1cm in diameter o Exa: nevi, warts, insect bites, seborrheic keratosis, actinic keratoses, some lesions of acne, and skin cancers Plaque - o A large flatter elevation of the skin, sometimes found by papules coalescing o EXA: lesions of psoriasis Vesicle - Blister o Small circumscribed elevation of the epidermis containing clear fluid < 1cm in diameter o Exa: herpes infections, acute allergic contact dermatitis Bulla - o Same as a vesicle but >1 cm in diameter Wheal - o Circumscribed raised lesion consisting of dermal edema o AKA: hives or urticaria o Typically, last < 24 hours Burrow - o Linear lesions produced by infestation of the skin and formation of tunnels o EXA: scabies physical presentation of psoriasis - • Chronic immune-mediated skin disorder caused accelerated mitosis and rapid cell turn over leading to decreased maturation and keratinization o This process prevents cells from sticking together, allowing for a shedding of cells in the for of characteristic silvery scales and leaving an underlying red plaque • Genetic and immunological factors • More common in women • Clinical presentation o Typically found on extensor surfaces (elbows and knees most common) o Occasionally on scalp and other surfaces (lumbosacral, genitals, umbilical, and retro auricular o ** has a well-demarcated border with a silvery scale overlying an area of obvious erythema o May be itchy o Nail pitting and onycholysis frequently present o May be associated with debilitating arthritis psoriasis photo - Lichen Planus physical presentation - • Believed to be a cell-mediated response • Highest incidence in winter months • Symptoms 6 p's o Pruritic o Planar (flat) o Purple o Polygonal o Papules o Plaques • Lesions emerge initially on the extremities and become generalized over days to weeks and persist for months • May involve skin overlaying all body parts • Lesions are red to purple papules of 1cm or greater in diameter • Occur individually or in clusters • Presence and severity of pruritis is variable • May have a link with Hep C lichen planus photo - seborrheic dermatitis - • Combination of oil production and immune response to yeast Malassezia • Chronic recurrent inflammatory skin condition found in areas of high concentration of sebaceous glands (scalp, eyelid margins, nasolabial folds, ears, and upper trunk) • Clinical presentation: o Lesions can be distributed over the oily hair bearing area of head, neck, and chest o Lesions can range from mild, patchy scaling to widespread distribution with thick, adherent crusts o Scaling can be present over red, inflamed skin with hypopigmentation, oozing, and crusting seborrheic dermatitis photo - atopic dermatitis - • AKA eczema • Manifestation of a type I hypersensitivity reaction. First occurs during infancy or early childhood; associated with other atopic diseases like asthma and rhinitis/hay fever • Presentation o KEY Symptom is itching!! o Patient presents with complaint of recurrent, itchy skin rash o Common sites are flexor surfaces of the extremities behind the knees and elbow creases in adults o More commonly on neck and face of children and infants o Erythematous, scaley patches and plaque o Sites are prone to infection o Criteria for diagnosis include presence of itching and subsequent scratching (leading to lichenification) dry skin (xerosis) red or inflamed rash Presences of excessive dryness and scaling Located in skinfolds of arms and legs With severe outbreaks, vesicles may be present atopic dermatitis photo - Tinea corporis (ringworm) - • Dermatophyte infection • Begins as a small Annular lesion with a raised erythematous, scaley border and central clearing that appears with growth after infection of the fungus. o Itchy o The edge may develop vesicles, is scaly and remains palpable and reddened so it presents as a ring o May be localized or difuse • The patient may recall exposure to another individual or object Tinea Capitis (Scalp Ringworm) - · Ring worm on the head · Scaling crusting and hair loss seen on the scalp · Painful plaque (Kerion) and occipital lymph node** key feature** Alopecia presentation of hair loss - Clearly demarcated round/oval patches of hair loss Usually affecting young adults and children No visible scaling or inflammation Trichotillomania presentation of hair loss - o From pulling, plucking, or twisting hair o Shafts are broken and varying lengths o More common in children o Often seen in settings of family or psychosocial stress tenia capitis presentation of hair loss - Round scaling patches of alopecia Hairs are broken off close to the surface of the scalp Usually caused by fungal infection from Trichophyton tonsurans from humans Less commonly from microsporum canis from dogs/cats Mimics seborrheic dermatitis physical findings of Otitis media - · Infection of the fluid in the middle ear space o Usually associated with recent upper resp infection · Symptoms o Often unilateral ear pain which may radiate to the neck or jaw o Fever o hearing loss on affected side · Presentation o The tympanic membrane reddens, looses its landmarks, and bulges laterally, towards the examiners eye o The external ear has a normal appearance unless there is drainage from the perforated Tympanic membrane (TM) o The TM is usually dull, may be inflamed, and bulges so that the posterior landmarks are obscured o The light reflex is distorted or obscured o If myringitis (inflammation of the TM) is present, the TM is reddened o Purulent or yellow fluid may be evident posterior to the TM, with diminished TM mobility o With eustachian tube dysfunction, otitis media with effusion (OME) AKA serous otitis, may result Otitis media TM vs normal TM - Otitis Externa - • Inflammation of the external auditory canal, the auricle, or both • Usually associated with swimming or trauma (cleaning the ear with q-tips), or cerumen impaction retaining moisture • Symptoms o Often painful o Itching o Depending on amount of edema and exudate, there may be a sensation of stuffiness and/or decreased hearing o Exam can be uncomfortable; pain is increased at the tragus when manipulated o Canal is often swollen, narrowed, moist, pale, and tender, can be reddened o Drainage or exudate may be present Ranging from cheesy to serous o Depending on amount of swelling and exudate, distal portion of the canal may not be visible o May have an odor Otitis externa photo - physical findings of strep throat - · large red beefy tonsils usually covered with exudate; can be foul smelling · pharyngeal edema · inflamed uvula · palatal petechiae · bilateral anterior cervical lymphadenopathy · strawberry tongue · SS of cough, nasal discharge, conjunctivitis, and hoarseness are usually related to a viral infection rather than GABHS Strep throat - Low grade hypertensive retinopathy physical findings - · Retinal vascular damage caused by hypertension o Symptoms occur late in disease and include blurred vision or visual field deficits · Funduscopic exam shows o Arteriolar constriction o Arteriovenous nicking o Vascular wall changes o Flame shaped hemorrhages o Cotton-wool spots (retinal ischemia) o Yellow hard exudates o Optic disk edema What happens during papilledema - • Swelling of the optic disk with blurred disk margins and anterior bulging of the physiologic cup o Optic nerve head swelling associated with increased ICP • Signals serious disorders of the brain such as meningitis, subarachnoid hemorrhage, trauma, and mass legions • Priority in assessment during fundoscopic exams describe a normal looking Optic Disc - · A round, yellow orange to creamy pink structure with a pink neuroretinal rim and central depression · Disk margins should appear sharp and distinct Weber Exam - · Tests for adequacy of bone conduction · Holding it only by the stem, place the base of the vibrating tuning fork firmly against the skull in the center of the forehead · Ask the patient to identify if the tone is heard equally loud in both ears or louder in only one ear o If not equal; identify which ear is heard the loudest · The tone should be heard equally in both ears · Lateralization of the intensity of the tone to either side is abnormal o Indicates conductive hearing loss in the better hearing ear o OR sensorineural heard loss in the poor-hearing ear Rhinne test - · Tests for comparison of air conduction to bone conduction in each ear separately · Holding only the stem of the fork, apply the stem to the base of the mastoid bone on one side o Enquire if tone is heard § Note length of time the tone is heard · On the same side, hold the tines about 1 inch from the same ear (do not re strike fork) o Enquire if the tone is heard § Note length of time tone is heard · Compare the noted times for bone conducted sound and the air conducted sound o Which time is longer? · If air conducted time is longer, note weather it is at least twice as long o Indicates a POSITIVE test (this is the normal finding) · Repeat in the opposite ear · **in simpler exam the patient is simply asked which sound is louder (air vs. bone) o If the air sound is louder the test is positive · A Negative test is indicative of a conductive hearing loss in the affected ear o Bone conduction tone intensity is louder or heard longer than air conduction tone intensity · Sensorineural hearing loss in a affected ear is manifested by a positive Rinne test o BUT both intensity of both bone and air conduction is reduced, compared with normal intensity Snellen Eye Chart Test - · Assess for visual acuity (wear glasses for exam) · Position patient 20ft from chart (distance denotes top number) o A patient who can not read the first letter can be placed closer to the chart o Note the intervening distance · Cover one eye and read smallest time of print possible · Visual acuity expressed as two number o Distance of patient to chart/the distance at which a normal eye can read the line of letters o The larger the 2nd number, the worse the vision · Inability to test or decreased visual acuity requires immediate referral to an opthalmologist Types of SOAP notes - comprehensive or focused/episodic Components of a SOAP note - o Subjective § CC § HPI § PMI § Medications § Allergies § LMP § Family history § Social history § Nutritional assessment § ROS o Objective § Information gained by the provider on exam § Labs and diagnostic testing o Assessment § Refers to the final assessment; it pulls together subjective and objective data to form a diagnosis o Plan CONTINUES......