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NRSG 312EXAMINATION #2 Study Guide OutlineKnow the steps of how to perform each physical assessment examinationKnow anatomy of each systemHEART AND GREAT VESSELSKnow risk factors of heart diseaseAnnual rates of first CVD event increase with ageFor women, comparable rates occur 10 years later in life than for men, but this gap narrows with advancing ageCauses include an interaction of genetic, environmental, and lifestyle factors Modifiable risk factors:High blood pressure – systolic blood pressure of >140mmHg or diastolic blood pressure of >90mmHg, or currently taking antihypertensive medicineA higher percentage of men than women have hypertension until age 45; from age 45 to 64 years, the percentages are similar; after age 64 years, women have a much higher percentage of hypertension than men haveHypertension is 2 to 3 times more common among women taking oral contraceptives Prevalence of hypertension in Blacks is among the highest in the world Smoking – nicotine increases the risk of MI and stroke by causing:Increase in oxygen demand with a concomitant decrease in oxygen supplyActivation of platelets, activation of fibrinogenAdverse change in the lipid profile Serum cholesterol – high levels of LDL gradually add to the lipid core of thrombus formation in arteries, which results in MI and stroke Total cholesterol: >240mg/dL (high risk); 200-239mg/dL (borderline-high risk) Age-adjusted prevalence of total cholesterol levels over 200mg/dL:51.1% Mexican-American men; 49% of Mexican-American women45% of white men; 48.7% of white women40.2% of African American men; 41.8% of African American women Type 2 Diabetes Mellitus – risk of CVD is twofold greater among persons with DM than without DMCauses damage to large blood vessels that nourish the brain, heart, and extremities – results in stroke, coronary artery disease, peripheral vascular disease Obesity – among Americans 20 years and older, the prevalence of overweight of obesity is as follows:74.8% of Mexican American men; 73% of Mexican American women73.7% of African American men; 77.7% of African American women72.4% of white men; 57.5% of white women Review blood flow through the bodyFrom liver to right atrium through inferior vena cavaSuperior vena cava drains venous blood from the head and upper extremitiesFrom RA, venous blood travels through tricuspid valve to right ventricle From right ventricle, venous blood flows through pulmonic valve to pulmonary arteryPulmonary artery delivers unoxygenated blood to lungsLungs oxygenate bloodPulmonary veins return fresh blood to left atriumFrom left atrium, arterial blood travels through mitral valve to left ventricleLeft ventricle ejects blood through aortic valve into aortaAorta delivers oxygenated blood to body Circulation is a continuous loop; the blood is kept moving along by continually shifting pressure gradients; the blood flows from an area of higher pressure to one of lower pressure How to assess carotid arteriesPalpation:Palpate each carotid artery medial to the sternomastoid muscle in the neckAvoid excessive pressure on the carotid sinus area higher in the neckExcessive vagal stimulation here could slow down the heart rate, especially in older adultsTake care to palpate gentlyPalpate only one carotid artery at a time to avoid compromising arterial blood to the brain Feel the contour and amplitude of the pulse Normally the contour is smooth with a rapid upstroke and slower downstrokeNormally the strength is 2+ or moderateFindings should be equal bilaterally Auscultation:For persons middle-aged or older or who show symptoms or signs of cardiovascular disease, auscultate each carotid artery for the presence of a bruit A blowing, swishing sound indicating blood flow turbulenceNormally none present Keep the neck in a neutral positionLightly apply the bell of the stethoscope over the carotid artery at three levels1. The angle of the jaw2. The midcervical area3. The base of the neck Avoid compressing the artery because this could create an artificial bruit and could compromise circulation if the carotid artery is already narrowed by atherosclerosisAsk person to take a breath, exhale, and hold it briefly while you listen so that tracheal breath sounds do not mask or mimic a carotid artery bruitHolding breath on inhalation will also tense the levator scapulae muscles, which makes it hard to hear the carotids Sometimes you can hear normal heart sounds transmitted to the neck; do not confuse these with a bruitWhat is blood flow turbulence over the carotid arteryBlood flow turbulence over the carotid artery (bruit) – due to a local vascular cause, such as atherosclerotic narrowing What are the parameters of the apical impulseMay not see the apical pulseEasier to see in children and in those with thinner chest walls Location: the apical impulse should occupy only one interspace, the fourth or fifth, and be at or medial to the midclavicular lineSize: normally 1 x 2 cmAmplitude: normally a short, gentle tapDuration: short, normally occupies only first half of systole Auscultation sequence of the heartLocate the four valve areas:Aortic valve area – second R interspacePulmonic valve area – second L interspaceTricuspid valve area – L lower sternal borderMitral valve area – fifth interspace at around L midclavicular line Do not limit auscultation to only four locations – sounds produced by the valves may be heard all over the precordium – learn to inch stethoscope in a rough Z pattern, from the base of the heart across and down, then over to the apex Note the Rate and Rhythm:Rate ranges normally from 50 to 90 bpmRhythm should be regular, although sinus arrhythmia occurs normally in young adults and children When you notice any irregularity, check for a pulse deficit by auscultating the apical beat while simultaneously palpating the radial pulse (when different, subtract the radial rate from the apical and record the remainder as the pulse deficit)Identify S1 and S2:This is important because S1 is the start of systole and thus serves as the reference point for the timing of all other cardiac soundsUsually, you can identify S1 instantly because you hear a pair of sounds close together, and S1 is the first of the pair Guidelines to distinguish S1 from S2:S1 is louder than S2 at the apex; S2 is louder than S1 at the base S1 coincides with the carotid artery pulse; feel the carotid gently as you auscultate at the apex; the sound you hear as you feel each pulse is S1S1 coincides with the R wave (the upstroke of the QRS complex) if the person is on an ECG monitor Listen to S1 and S2 Separately:Note whether each heart sound is normal, accentuated, diminished, or splitInch your diaphragm across the chest as you do this First Heart Sound (S1):Caused by the closure of the AV valves, S1 signals the beginning of systoleYou can hear it over the entire precordium, although it is loudest at the apexYou can hear S1 with the diaphragm with the person in any position and equally well in inspiration and expirationA split S1 is normal, but it occurs rarely – means you are hearing the mitral and tricuspid components separately Second Heart Sound (S2): S2 is associated with closure of the semilunar valvesCan hear it with the diaphragm, over the entire precordium, although S2 is loudest at the base Splitting of S2 – normal phenomenon that occurs toward the end of inspiration in some people Focus on Systole, then on Diastole, and listen for any extra heart sounds:Listen with the diaphragm, then switch to the bell, covering all auscultatory areas Usually these are silent periods – when you do detect an extra heart sound, listen carefully to note its timing and characteristics Listen for murmurs: Murmur is a blowing, swooshing sound that occurs with turbulent blood flow in the heart or great vessels Except for the innocent murmurs described, murmurs are abnormalIf you hear a murmur, describe it by indicating the following characteristics:TimingLoudnessPitchPatternQualityLocationRadiationPosture Know S1, S2, S3, and S4—how produced, where heard bestS1 – occurs with closure of the AV valves and this signals the beginning of systole Can hear it over the entire precordium, although it is loudest at the apex The mitral component of the first sound slightly precedes the tricuspid component, but you usually hear these two components fused as one sound S2 – occurs with closure of the semilunar valves and signals the end of systole The aortic component of the second sound slightly precedes the pulmonic componentAlthough it is heard over all the precordium, it is loudest at the base S3 – ventricular filling that creates vibrations that can be heard over the chest Normally diastole is a silent event These vibrations occur when the ventricles are resistant to filling during the early rapid filling phase (protodiastole)S4 – occurs at the end of diastole, at presystole, when the ventricle is resistant to filling The atria contract and push blood into a noncompliant ventricle – creates vibrations just before S1 Differentiate systole from diastoleSystole: the heart’s contractionBlood is pumped from the ventricles and fills the pulmonary and systemic arteries1/3 of the cardiac cycle Ventricular pressure is finally higher than that in the atria, so the mitral and tricuspid valves swing shit Closure of the AV valves contributes to the first heart sound and signals the beginning of systoleThe AV valves close to prevent any regurgitation of blood back up into the atria during contraction Diastole: the ventricles relax and fill with blood2/3 of the cardiac cycle Pressure in the atria is higher than that in the ventricles, so blood pours rapidly into the ventriclesWhat valves—types and names—produce S1 and S2S1: AV vales (mitral and tricuspid) S2: Semilunar valves (aortic and pulmonic) What is a physiological split of S2 and where may it occurA split S2 is a normal phenomenon that occurs toward the end of inspiration in some peopleRecall that closure of the aortic and pulmonic valves is nearly synchronousBecause of the effects of respiration on the heart, inspiration separates the timing of the two valves’ closure, and the aortic valve closes 0.06 second before the pulmonic valveInstead of one DUP, you hear a spit sound – T-DUPDuring expiration, synchrony returns and the aortic and pulmonic components fuse togetherA split S2 is only heard in the pulmonic valve area, the second left interspace When you first hear the split, do not be tempted to ask the person to hold his or her breath so that you can concentrate on the sounds – breath holding will only equalize ejection times in the R and L sides of the heart and cause the split to go awayInstead, concentrate on the split as you watch the person’s chest rise up and down with breathingThe split occurs about every fourth heartbeat, fading in with inhalation and fading out with exhalation Define gallops, murmurs, split soundsGallops: Murmurs: a blowing, swooshing sound that occurs with turbulent blood flow in the heart or great vesselsMay be due to congenital defects and acquired valvular defectsA systolic murmur may occur with a normal heart or with heart diseaseA diastolic murmur always indicates heart disease A murmur of mitral stenosis is rumbling, whereas that of aortic stenosis is harsh Split sounds: What is the electrical stimulus of the cardiac cycleSpecialized cells in the sinoatrial (SA) node near the superior vena cava initiate an electrical impulse (because the SA node has an intrinsic rhythm, it is the “pacemaker”)The current flows in an orderly sequenceFirst across the atria to the AV node low in the atrial septumThere it is delayed slightly so that the atria have time to contract before the ventricles are stimulatedThen the impulse travels to the bundle of His, the R and L bundle branches, and then through the ventricles The electrical impulse stimulates the heart to do its work, which is to contract A small amount of electricity spreads to the body surface, where it can be measured and recorded on the ECGDiscuss hemodynamic changes related to aging processIncrease in systolic blood pressure Due to stiffening of the large arteries, which in turn is due to calcification of vessel walls (arteriosclerosis)Stiffening creates an increase in pulse wave velocity because the less compliant arteries cannot store the volume ejected Left ventricular wall thickness increases (not overall size of the heart)Adaptive mechanism to accommodate the vascular stiffening mentioned earlier that creates an increased workload on the heartNo significant change in diastolic pressure occurs with ageRising systolic pressure with a relatively constant diastolic pressure increases the pulse pressure (the difference between the two)No change in resting heart rate occurs with aging Cardiac output at rest is not changed with aging Decreased ability of the heart to augment cardiac output with exercise Shown by a decreased maximum HR with exercise and diminished sympathetic response Non-cardiac factors also cause a decrease in maximum work performance with aging:Decrease in skeletal muscle performanceIncrease in muscle fatigueIncreased sense of dyspneaChronic exercise conditioning will modify many of the aging changes in cardiovascular function Relate heart/lung symptomsHypertensionHEAD, FACE AND NECKKNOW ANATOMY AND FUNCTIONSFacial nerves—trigeminal Cranial nerve VII: the facial nerveMediates facial expressions made by facial muscles Cranial nerve V: (trigeminal nerve)Mediates facial sensations of pain/touch (by three sensory branches) Describe bells palsyA lower motor neuron lesion (peripheral), producing cranial nerve VII paralysis, which is almost always unilateralIt has a rapid onset and its cause is currently thought to be herpes simplex virus (HSV)Note complete paralysis on one half of the face – the person cannot wrinkle forehead, raise eyebrow, close eye, whistle, or show teeth on one sideUsually presents with smooth forehead, wide palpebral fissure, flat nasolabial fold, drooling, and pain behind the ear Differentiate salivary glands, where located and duct openingsThyroid gland—thyroxine levels—T3 and T4An important endocrine gland with a rich blood supplyStraddles the trachea in the middle of the neckHighly vascular endocrine gland that synthesizes and secretes thyroxine (T4) and triiodothyronine (T3) – hormones that stimulate the rate of cellular metabolismTwo lobes:Both are conical in shapeEach curve posteriorly between the trachea and the sternomastoid muscleLobes are connected in the middle by a thin isthmus lying over the second and third tracheal ringsDifficult to palpateHeadaches—typesTension:Location: usually both sides, across the frontal, temporal, and/or occipital region of head: forehead, sides, and back of headCharacter: bandlike tightness, viselike, non-throbbing Duration: gradual onset, lasts 30 minutes to daysQuantity and severity: diffuse, dull, aching pain; mild to moderate painTiming: Situational, in response to overwork, postureAggravating symptoms or triggers: stress, anxiety, depression, poor postureAssociated symptoms: fatigue, anxiety, stress, sensation of a band tightening around head, of being gripped like a viceRelieving factors, efforts to treat: rest, massaging muscles in area, NSAIDsMigraine:Location: commonly one-sided but may occur on both sides; pain is often behind the eyes, the temples, or forehead Character: throbbing, pulsatingDuration: rapid onset, peaks 1-2 hours, lasts 4hr-72hr, sometimes longerQuantity and severity: moderate to severe painTiming: About 2/month, last 1-3 days Aggravating symptoms or triggers: hormonal fluctuations (premenstrual), foods (alcohol, caffeine, MSG, nitrates, chocolate, cheese); letdown after stress; changes in sleep pattern; sensory stimuli; changes in weather; physical activityAssociated symptoms: often preceded by an aura (visual changes such as blind spots or flashes of light, tingling in an arm or leg, vertigo); N/V, photophobia, abdominal pain; family history of migraineRelieving factors: lie down, darken room, use eyeshade, sleep, take NSAID or narcotic when severeCluster:Location: always one sided; often behind or around the eye, temple, forehead, cheekCharacter: continuous, burning, piercing, excruciating Duration: abrupt onset, peaks in minutes, last 45-90 min.Quantity and severity: can occur multiple times in a day, in “clusters”Timing: 1-2/day, each lasting ? to 2 hours, for 1 to 2 months; then remission for months or yearsAggravating symptoms or triggers: exacerbated by alcohol, stress, wind or heat exposureAssociated symptoms: nasal congestion or runny nose, watery or reddened eye, eyelid drooping, miosis, feelings of agitation Relieving factors; efforts to treat: need to move, pace the floor Differentiate hyperthyroidism and hypothyroidismHyperthyroidism: Overproduction of thyroid hormone Goiter – increase in the size of the thyroid gland (occurs with hyperthyroidism)Grave’s disease is the most common cause of hyperthyroidism, manifested by goiter and exophthalmos (bulging eyes)Symptoms:Weight lossFatigueNervousnessMuscle crampsHeat intoleranceSigns:TachycardiaSOBExcessive sweating Fine muscle tremor Thin silky hair and skinInfrequent blinkingStaring appearance Hypothyroidism: Deficiency of thyroid hormone When severe, causes a Nonpitting edema or myxedemaPuffy, edematous face, especially around the eyes (periorbital edema)Coarse facial featuresDry skinDry, coarse hair and eyebrows Know lymph nodes—names, where located and assessment parametersPreauricular – in front of the earPosterior auricular (mastoid) – superficial to the mastoid processOccipital – at the base of the skullSubmental – midline, behind the tip of the mandible Submandibular – halfway between the angle and the tip of the mandible Jugulodigastric – under the angle of the mandibleSuperficial cervical – overlying the sternomastoid muscle Deep cervical – deep under the sternomastoid muscle Posterior cervical – in the posterior triangle along the edge of the trapezius muscle Supraclavicular – just above and behind the clavicle, at the sternomastoid muscle Using a gentle circular motion of your finger pads, palpate the lymph nodes Beginning with the Preauricular lymph nodes in front of the ear, palpate the 10 groups of lymph nodes in a routine orderMany nodes are closely packed, so you must be systematic and thorough in your examination Use gentle pressure because strong pressure could push the nodes into the neck muscles If any nodes are palpable, note their location, size, shape, delimitation (discrete or matted together), mobility, consistency, and tenderness Cervical nodes often are palpable in health persons, although this palpability decreases with age Normal nodes feel movable, discrete, soft, and nontender What is lymphadenopathy—benign vs infection vs cancer signs/symptomsLymphadenopathy: enlargement of the lymph nodes (>1cm) from infection, allergy, or neoplasm Acute infection: acute onset, <14 days duration, nodes are bilateral, enlarged, warm, tender, and firm but freely movable Chronic inflammation: eg – in TB the nodes are clumpedCancerous nodes: nodes are hard, >3cm, unilateral, nontender, matted, and fixed Nodes with HIV infection are enlarged, firm, nontender, and mobile; occipital node enlargement is common with HIV infectionA single enlarged nontender, hard, L supraventricular node (Virchow’s node) may indicate neoplasm in thorax or abdomen Painless, rubbery, discrete nodes that gradually appear occur with Hodgkin’s lymphoma BREAST/AXILLAHow to teach a BSEHelp each woman establish a regular schedule of self careThe best time to conduct a BSE is right after the menstrual period, or the 4th through 7th day of the menstrual cycle – breasts are the smallest and least congested If not having periods, select a familiar date to examine her breasts each month – same time each monthSelf-examination will familiarize the woman with her own breasts and their normal variationEmphasize the absence of lumps (not the presence of them)Encourage her to report any unusual findings promptlyWhile teaching, focus on the positive aspects of BSE – avoid citing frightening mortality statistics of breast cancer Keep teaching simple – more likely for compliance Teach woman to do this in front of a mirror while she is disrobed to the waistAt home, she can start palpation in the shower, where soap and water assist palpationThen palpation should be performed while lying supine Know quadrants of breast and tail of SpenceUpper inner quadrantUpper outer quadrant – site of most breast tumors Lower inner quadrantLower outer quadrant Tail of Spence – located in the upper outer quadrant; cone shaped breast tissue that projects up into the axilla, close to the pectoral group of axillary lymph nodes Know axillary lymph nodes and where to palpateCentral axillary nodes – high up in the middle of the axilla, over the ribs and serratus anterior muscle; these receive lymph from the other three groups of nodes Pectoral (anterior) – along the lateral edge of the pectoralis major muscle, just inside the anterior axillary fold Subscapular (posterior) – along the lateral edge of the scapula, deep in the posterior axillary fold Lateral – along the humerus, inside the upper arm What is mammographyMammography: the process of using low-energy X-rays (usually around 30 kVp) to examine the human breast, which is used as a diagnostic and screening tool. The goal of mammography is the early detection of breast cancer, typically through detection of characteristic masses and/or microcalcificationsRisks of breast cancerThe genetic contribution to breast cancer involves specific gene mutations at the BRCA1 and BRCA2 locations – women with these mutations are at increased risk for breast cancer and ovarian cancer White women have a higher incidence of breast cancer than African-American women starting at age 45African-American women have a higher incidence before age 45 and they are more likely to die of the disease at every ageWomen from Asian-American, Hispanic, and American-Indian groups have a lower incidence and death rates from breast cancer Diet is an environmental factor in breast cancer risk (noted because breast cancer incidence varies among countries Female gender, age >50 Personal history of breast cancerFirst-degree relative with breast cancerHigh breast tissue densityBiopsy-confirmed atypical hyperplasiaHigh-dose radiation to chestEarly menarche <12 years or late menopause >55 yearsNulliparity of first child after age 30 yearsRecent oral contraceptive useNever breastfed a childRecent and long-term use of estrogen and progestinAlcohol intake of >1 drink dailyObesity (especially after menopause) and high-fat dietPhysical inactivity Steps of a breast exam—when patient believes she felt a breast lumpLocation – using the breast as a clock face, describe the distance in centimeters from the nipple; or diagram the breast in the woman’s record and mark the location of the lumpSize – judge in centimeters in three dimensions: width x length x thickness Shape – state whether the lump is oval, round, lobulated, or indistinct Consistency – state whether the lump is soft, firm, or hardMovable – is the lump freely movable, or is it fixed when you try to slide it over the chest wall?Distinctness – is the lump solitary or multiple?Nipple – is it displaced or retracted?Note the skin over the lump – is it erythematous, dimpled, or retracted?Tenderness – is the lump tender to palpation?Lymphadenopathy – are any regional lymph nodes palpable? BSE in postmenopausal womenInstruct the woman who is not having menstrual periods to select a familiar date to examine her breasts each month – for example, her birth date or the day the rent is due EAR, NOSE, THROAT, MOUTH, PHARYNX/SINUSESDefine 3 parts of the ear and functionsExternal ear (auricle or pinna) – consists of movable cartilage and skin Serves to funnel sound waves into its opening, the external auditory canalThe canal is lined with glands that secrete cerumen (earwax) – helps lubricate and protect the earWax forms a sticky barrier that helps keep foreign bodies from entering and reaching the sensitive tympanic membrane The tympanic membrane (eardrum) separates the external and middle ear Middle ear – a tiny air-filled cavity inside the temporal boneHas several openingsIts opening to the outer ear is covered by the eardrum The openings to the inner ear are the oval window at the end of the stapes and the round window Three functions:Conducts sound vibrations from the outer ear to the central hearing apparatus in the inner earProtects the inner ear by reducing the amplitude of loud soundsIts Eustachian tube allows equalization of air pressure on each side of the eardrum so that the membrane does not rupture (eg: during altitude changes in an airplane) Inner ear – embedded in bone Contains the bony labyrinth, which holds the sensory organs for equilibrium and hearing Within the bony labyrinth, the vestibule and the semicircular canals compose the vestibular apparatus and the cochlea contains the central hearing apparatus Not accessible to direct examinationCerumen –what is it—functionCerumen – earwax A yellow, waxy material that lubricates and protects the earThe wax forms a sticky barrier that helps keep foreign bodies from entering and reaching the sensitive tympanic membrane Migrates out to the meatus by the movements of chewing and talking Differentiate Conductive and Sensorineural hearing losses: Weber and Rinne test findings for eachConductive hearing loss: involves a mechanical dysfunction of the external or middle earIt is a partial loss because the person is able to hear if the sound amplitude is increased enough to reach normal nerve elements in the inner earMay be caused by:Impacted cerumenForeign bodies Perforated tympanic membranePus or serum in the middle earOtosclerosis (a decrease in mobility of the ossicles) Sensorineural (perceptive) hearing loss: signifies pathology of the inner ear, cranial nerve VIII, or the auditory areas of the cerebral cortexA simple increase in amplitude may not enable the person to understand wordsMay be caused by:Prebycusis – a gradual nerve degeneration that occurs with agingOtotoxic drugs – affect the hair cells in the cochlea Cranial nerves involved in hearingCranial nerve VIII – electrical impulses are conducted by the auditory portion of cranial nerve VIII to the brainstem Describe normal tympanic membrane and structuresThe tympanic membrane (eardrum) separates the external and the middle ear and is tilted obliquely to the ear canal, facing downward and somewhat forward It is a translucent membrane with a pearly gray color and a prominent cone of light in the anteroinferior quadrant, which is the reflection of the otoscope light The drum is oval and slightly concave, pulled in at tis center by one of the middle ear ossicles, the malleus Parts of the malleus show through the translucent drumThe umboThe manubrium (handle)The short processThe small, slack, superior section of the tympanic membrane is called the pars flaccida The remainder of the drum, which is thicker and more taut, is the pars tensa The annulus is the outer fibrous rim of the drum What is Eustachian tubeConnects the middle ear with the nasopaharynx Allows passage of airThe tube is normally closed, but it opens with swallowing or yawning Medications that may affect hearingAspirin, when large doses (8 to 12 pills per day) are takenNSAIDsCertain antibiotics, especially aminoglycosides – common in people with kidney disease or already have ear or hearing problems Loop diuretics used to treat high blood pressure and heart failure (Lasix) or bumetanide Medicines used to treat cancer, including cyclophosphamide, cisplatin, and bleomycin Cysts/nodules on earSebaceous cyst: location is commonly behind lobule, in the postauricular foldA nodule with central black punctum indicates blocked sebaceous glandIt is filled with waxy sebaceous material and is painful if it becomes infectedOften are multipleTophi: small, whitish yellow, hard, nontender nodules in or near helix or antihelix; contains greasy, chalky material of uric acid crystals and are a sign of gout Chondrodermatitis Nodularis Helicus: painful nodules develop on the rim of the helix (where there is no cushioning subcutaneous tissue) as a result of repetitive mechanical pressure or environmental trauma (sunlight)Small, indurated, dull red, poorly defined, very painful Keloid: overgrowth of scar tissue, which invades original site of traumaMore common in dark skinned people, although it also occurs in whitesIn the ear it is most common at lobule at the site of a pierced earCarcinoma: ulcerated, crusted nodule with indurated base that fails to healBleeds intermittentlyMust refer for biopsyUsually occurs on the superior rim of the pinna, which has the most sun exposureMay also occur in ear canal and show chronic discharge that is either serosanguineous or bloody Nosebleeds—technique to stop themEpistaxis occurs with trauma, vigorous nose blowing, foreign bodyPerson should sit up with head tilted forward, pinch nose between thumb and forefinger for 5 to 15 minutes S/S that may accompany a strokeFace drooping – one part of the face may be drooping or numbArm weakness – one arm may feel weak or numbSpeech difficulty – speech may be slurred or slow Sudden persistent headache Sudden dizzinessTrouble walking Sudden trouble seeing in one or both eyesSudden confusion or trouble understanding informationCranial nerves ix, x, xi, xii—name, function, how testedCranial nerve IX (Glossopharyngeal Nerve): almost exclusively sensory and supplies five afferent nuclei of the brainstem, providing sensory innervation to the oropharynx and back of the tongue Provides parasympathetic innervation to the parotid gland Can be assessed by asking the patient to say “ah” and observing if during phonation the uvula deviates A positive sign that is indicative of unilateral damage is a finding of an asymmetrically deviating uvula, deviating towards the side, with an intact or healthy nerveCranial nerve X (Vagus Nerve): Loss of function of the vagus nerve (X) will lead to a loss of parasympathetic innervation to a very large number of structures. Major effects of damage to the vagus nerve may include a rise in blood pressure and heart rate. Isolated dysfunction of only the vagus nerve is rare, but can be diagnosed by a hoarse voice, due to dysfunction of the HYPERLINK ""superior laryngeal nerve Testing of function may be performed by assessing ability to drink liquids Choking on either saliva or liquids may indicate neurological damage to the vagus nerve Damage to this nerve may result in difficulties swallowing Cranial nerve XI (Accessory nerve): damage to the accessory nerve may lead to contralateral weakness in the trapezius; supplies the sternomastoid muscle and trapezius muscle Can be tested by asking the subject to raise their shoulders or shrug, upon which the scapula will move out into a winged position if the nerve is damaged Cranial nerve XII: (Hypoglossal nerve): innervates muscles of the tongue Can be tested by asking subject to stick their tongue straight out; if there is a loss of innervation to one side, the tongue will curve toward the affected side, due to unopposed action of the opposite genioglossus muscle 4 sinus areas—names and how examined—2 most common for evaluationFrontal sinuses: in the frontal bone above and medial to the orbitis (one of the most common for evaluation)Palpation: using your thumbs, press the frontal sinuses by pressing up and under the eyebrowsMaxillary sinuses: in the maxilla (cheekbone) along the side walls of the nasal cavity (the other most common for evaluation)Palpation: press over the maxillary sinuses below the cheekbonesEthmoid sinuses: between the orbitisSphenoid sinuses: deep within the skull in the sphenoid bone Nasal mucosa —differentiate –allergies, rhinitis,Allergies (allergic rhinitis): with chronic allergy, mucosa looks swollen, boggy, pale and grey Itching of nose and eyes, lacrimation, nasal congestion, and sneezing are presentNote serous edema and swelling of turbines to fill the air spaceTurbines are usually pale (although may appear violet), and their surface looks smooth and glisteningMay be seasonal or perennial, depending on allergenIndividual has a strong family history of seasonal allergies Rhinitis: nasal mucosa is swollen and bright red with URIDischarge is common with rhinitis and sinusitis, varying from watery and copious to thick, purulent, and green-yellow First sign is clear, watery discharge, rhinorrhea, which later becomes purulent This is accompanied by sneezing and swollen mucosa, which causes nasal obstructionTurbinates are dark red and swollen Lesions of mouth/lip/tongue: differentiate typesAbnormalities of the LipsCleft lip: maxillofacial clefts are the most common congenital deformities of the head and neckHerpes Simplex 1: the sores are groups of clear vesicles with a surrounding indurated erythematous baseEvolve into pustules, which rupture, weep, and crust and heal in 4 to 10 daysMost likely site is the lip-skin junction – infection often recurs in same site Caused by the herpes simplex virus (HSV-1) – lesion is highly contagious and is spread by direct contactRecurrent herpes infections may be precipitated by sunlight, fever, colds, and allergy Angular Cheilitis (Stomatitis, Perleche): erythema, scaling, shallow and painful fissures at the corners of the mouth occur with excess salivation and Candida infectionOften seen in edentulous persons and in those with poorly fitting dentures causing folding in of corners of mouth, creating a warm, moist environment favoring growth of yeastCarcinoma: the initial lesion is round and indurated, and then it becomes crusted and ulcerated with an elevated borderThe majority occur between the outer and middle thirds of lipRetention “Cyst” (Mucocele): a rounded, well-defined, translucent nodule that may be very small or up to 1 to 2 cmA pocket of mucus that forms when a duct of a minor salivary gland rupturesBenign lesion also may occur on the buccal mucosa, the floor of the mouth, or under the tip of the tongue Abnormalities of the Teeth and GumsBaby bottle tooth decay: destruction of numerous deciduous teeth may occur in older infants and toddlers who take a bottle of milk, juice, or sweetened drink to bed and prolong bottle-feeding past the age of 1 year Liquid pools around the upper front teethMouth bacteria act on carbohydrates in the liquid, especially sucrose, forming metabolic acids Acids break down tooth enamel and destroy its proteinMalocclusion: upper or lower dental arches are not in alignment and incisors protrude from developmental problem of mandible or maxilla or incompatibility between jaw size and tooth sizeThe condition increases risk for facial deformity, negativity, body image, chewing problems, or speech dysfluencyDental Caries: progressive destruction of toothDecay initially looks chalky whiteLater it turns brown or black and forms a cavity Susceptible sites are tooth surfaces where food debris, bacterial plaque, and saliva collectEpulis: a nontender, fibrous nodule of the sum, seen emerging between the teeth; an inflammatory response to injury or hemorrhage Gingival Hyperplasia: enlargement of the gums, sometimes overreaching the teethOccurs with puberty, pregnancy, and leukemia and with long therapeutic use of phenytoin (Dilantin) Gingivitis: gum margins are red and swollen and bleed easilyInflammation is usually due to poor dental hygiene or vitamin C deficiencyMay occur in pregnancy and puberty because of changing hormonal balanceMeth Mouth: illicit meth abuse leads to extensive dental caries, gingivitis, tooth cracking, and EndentulismMeth causes vasoconstriction and decreased saliva, and its use increases the urge to consume sugars and starches and to give up oral hygiene Abnormalities of the Buccal Mucosa Apththous Ulcers: a “canker sore” is a vesicle at first and then a small round “punched-out” ulcer with a white base surrounded by a red haloQuite painful and lasts for 1 to 2 weeks Unknown cause, although it is associated with stress, fatigue, and food allergy Koplik Spots: small blue-white spots with irregular red halo scattered over mucosa opposite the molarsAn early sign, and pathognomonic, of measles Leukoplakia: chalky white, thick, raised patches with well-defined bordersThe lesion is firmly attached and does not scape offMay occur on lateral edges of tongue Due to chronic irritation and occurs more frequently with heavy smoking and heavy alcohol useLesions are precancerous, and the person should be referred Candidiasis or Monilial Infection: a white, cheesy, curdlike patch on the buccal mucosa and tongueScrapes off, leaving a raw, red surface that bleeds easilyOpportunistic infection that occurs after the use of antibiotics and corticosteroids and in immunosuppressed persons Abnormalities of the TongueAnkyloglossia: a short lingual frenulum fixing the tongue tip to the floor of the mouth and gumsLimits mobility and will affect speech (pronunciation of a, d, n) if the tongue tip cannot be elevated to the alveolar ridge; congenital defect Geographic Tongue (Migratory Glossitis): pattern of normal coating interspersed with bright red, shiny, circular bald areas with raised pearly bordersPattern resembles a map and changes in a few daysNot significant, and its cause is not knownSmooth, Glossy Tongue (Atrophic Glossitis): the surface is slick and shiny; the mucosa thins and looks red from decreased papillaeAccompanied by dryness of tongue and burningOccurs with vitamin B12 deficiency (pernicious anemia), folic acid deficiency, and iron deficiency anemia Black Hairy Tongue: not really hair but, rather, the elongation of filiform papillae and painless overgrowth of mycelial threads of fungus infection on the tongue Color varies from black-brown to yellowOccurs after use of antibiotics, which inhibits normal bacteria and allow proliferation of fungus Fissured or Scrotal Tongue: deep furrows divide the papillae into small irregular rowsCondition occurs in 5% of the general population and in Down syndromeIncreases with age Carcinoma: an ulcer with rolled edges; indurated Occurs particularly at sides, base, and under the tongueWhen it is in the floor of mouth, it may cause painful movement or limited movement of tongue Risk for early metastasis if present because of rich lymphatic drainageHeavy smoking and heavy alcohol use place persons at greater riskEnlarged Tongue (Macroglossia): tongue is enlarged and may protrude from mouth; condition is not painful but may impair speech developmentCan occur with Down syndrome; also occurs with cretinism, myxedema, acromegaly Also occurs with local infections Abnormalities of tongue (see above)Antibiotic therapy and tongue appearances Black hairy tongue – occurs after use of antibiotics (see above)Turbinates—names—color—acute/rhinitis/sinusitis—differentiateTurbinate: the bony ridges curving down from the lateral walls Superior turbinate will not be in view, but the middle and inferior turbinates appear in the same light red color as the nasal mucosa Turbinates are vascular and tender if touched Allergic Rhinitis: rhinorrhea, itching of nose and eyes, lacrimation, nasal congestion, and sneezing are present Serous edema and swelling of turbinates fill the air space Turbinates are usually pale, and their surface looks smooth and glisteningMay be seasonal or perennial, depending on allergenAcute Rhinitis: first sign is a clear, watery discharge, rhinorrhea, which later becomes purulent Accompanied by sneezing and swollen mucosa, which causes nasal obstructionTurbinates are dark red and swollen Sinusitis: facial pain, after upper respiratory infectionSigns include red, swollen nasal mucosa, swollen turbinates, and purulent dischargePerson also has fever, chills, malaiseWith maxillary sinusitis, dull, throbbing pain occurs in cheeks and teeth on the same side, and pain with palpation is presentWith frontal sinusitis, pain is above the supraorbital ridge ................
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