Maryville 612 Exam 1 Questions with 100% Correct Answers 2023, Exams of Community Corrections

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Maryville 612 Exam 1 Questions with 100%

Correct Answers 2023

Claudication - Correct answer a condition in which cramping pain in the leg is induced by exercise, typically caused by obstruction of the arteries. May be characterized as a dull ache with accompanying muscle fatigue and cramps. Usually appears with sustained exercise. Site of pain is distant to narrowing. How do you test EOM? - Correct answer Eye movement is controlled by 6 extraocular muscles and 3 cranial nerves, III, IV, and VI. To evaluate eye movement, use 4 techniques. ● First have the patient watch your finger move through the 6 cardinal fields of gaze. Jerking or sustained nystagmus is abnormal. A few beats of horizontal nystagmus may occur. ● Second have the patient follow your finger vertically from the ceiling to the floor.The globes and the upper eyelids should move smoothly without eyelid lag or exposure of the sclera. ● Third, test extraocular muscle balance using the corneal light reflex. WIth the patient looking at a nearby object, shine a light on the nasal bridge. The eyes should converge and reflect the light symmetrically. ● Fourth, if the corneal light reflex is imbalanced, perform the cover-uncover test. As the patient stares at a fixed point nearby, cover one eye and observe the uncovered eye. Then remove the cover and observe that eye as it focuses on the object. Note any eye movement. Your patient should be able to follow your finger with full, smooth extraocular movements and without nystagmus, or "shaky" eye motion. Normal extraocular movements indicate intact cranial nerves III, IV, and VI. *******What is the difference between objective and subjective data? What components of the health history are objective and subjective? *********** - Correct answer Seidel pg 618: objective: "direct observation, what you see, hear, and touch". This includes vital signs and actual assessment. Subjective: "information patients offer about their condition or feelings." This includes chief complaint, past medical history, history or present illness, family history, and review of symptoms. Erb's point - Correct answer Erb's point is the auscultation location for heart sounds and heart murmurs located at the third intercostal space and the left lower sternal border. Erb's point, found two interspaces below the pulmonic area, does not reflect sound from one particular heart valve, but is a common listening post, lying halfway between the base and the apex of the heart. Tonsil assessment - Correct answer • Enlargement; Acute infection, 2+, 3+, or 4+ o 1+ - visible o 2+ halfway between tonsillar pillars

o 3+ touching uvula o 4+ touching each other Order physical assessment is done - Correct answer Inspection, Palpation, Percussion, Auscultation Proper use of Otoscope on adult or child - Correct answer Adult- straighten the external auditory canal by pulling auricle up and back Child- face child sideways with one arm around parents waist. Pull auricle either downward and back or upward and back to gain best view of tympanic membrane. How do you assess for sensoineural hearing loss - Correct answer air conduction heard longer than bone conduction with Rinne Test; lateralization to unaffected ear; loss of high-frequency sounds How do you assess for conductive hearing loss - Correct answer bone conduction heard longer than air conduction with Rinne Test; lateralization to affected ear with Weber Test; loss of low frequency sounds; loss of 11-30 decibels on audiometry with cerumen impaction. Rinne Test***** - Correct answer helps distinguish whether patient hears better by air or bone conduction. Place the tuning fork at base of vibrating tuning fork against the patient's mastoid bone and ask patient to tell you when the sound is no longer heard. Time this interval of bone conduction noting number of seconds. Continue timing the interval of sound due to by air conduction heard by the patient. Compare # of seconds air vs. bone. Air conducted should be heard twice as long as bone conducted sounds. (If bone conducted heard for 15 seconds, air conducted should be heard for additional 15 seconds). Weber Test - Correct answer helps assess unilateral hearing loss. Place base of fork on mid-line of patient's head. Ask patient if sound heard equally in both ears or in one ear (lateralization of sound). Should hear sound equally. Presbyopia - Correct answer Progressive weakening of accommodation (focusing power). The major physiologic change that occurs after the age of 45 years; the lens becomes more rigid, and the ciliary muscle becomes weaker. Strabismus - Correct answer a condition in which both eyes do not focus on the object simultaneously, although either eye can focus independently; may be paralytic or non-paralytic.

Photopsia - Correct answer presence of perceived flashes of light. (Most commonly associated with posterior vitreous detachment, migraine with aura, retinal break, or detachment). Amblyopia - Correct answer also called lazy eye; is disorder of sight d/t eye and brain not working well together. Results in decreased vision in an eye that otherwise typically appears normal. Most common cause of decreased vision in a single eye among children and younger adults. Macular Degeneration - Correct answer is caused when part of the retina deteriorates; dry (atrophic) from gradual breakdown of cells in macula resulting in gradual blurring of central vision and wet (exudative or neovascular)- new abnormal vessels grow under the center of the retina; the blood vessels leak, bleed, and scar the retina, distorting or destroying central vision. In contrast to dry, vision loss may be rapid. Is leading cause of blindness in older than 55 years of age in U.S. Xanthelasma - Correct answer condition characterized by elevated plaque of cholesterol; commonly found on the nasal portion of the eyelid. Snellen Test***** - Correct answer The optic nerve is assessed by testing for visual acuity and peripheral vision. Visual acuity is tested using a snellen chart, for those who are illiterate and unfamiliar with the western alphabet, the illiterate E chart, in which the letter E faces in different directions, maybe used. The chart has a standardized number at the end of each line of letters; these numbers indicates the degree of visual acuity when measured at a distance of 20 feet. The numerator 20 is the distance in feet between the chart and the client, or the standard testing distance. The denominator 20 is the distance from which the normal eye can read the lettering, which correspond to the number at the end of each letter line; therefore the larger the denominator the poorer the version. Measurement of 20/20 vision is an indication of either refractive error or some other optic disorder. In testing for visual acuity you may refer to the following:

1. The room used for this test should be well lighted.
2. A person who wears corrective lenses should be tested with and without them to check fro the adequacy of correction.

3. Only one eye should be tested at a time; the other eye should be covered by an opaque card or eye cover, not with client's finger.
4. Make the client read the chart by pointing at a letter randomly at each line; maybe started from largest to smallest or vice versa.
5. A person who can read the largest letter on the chart (20/200) should be checked if they can perceive hand movement about 12 inches from their eyes, or if they can perceive the light of the penlight directed to their yes. Rosenbaum Test - Correct answer The Rosenbaum near vision card is intended to measure near acuity at a distance of 14" ( 36 cm) from the patient. Preparation:

• Be sure the Rosenbaum is evenly illuminated.
• Have the patient wear their current Rx (contacts or glasses) Recommended Process:

1. Occluder the patient's left eye (to examine the right eye).
2. Starting with the side that has the large '95' on the top, ask the patient to select the smallest line and read out loud each number (E or O,X,O). Challenge the patient to see if they can read the next smallest line correctly until mistakes are made.
3. Document the Snellen (Jaeger or Point) value as appropriate for that line (if read correctly). Record as the right eye.
4. Change which eye is occluded and repeat for the left eye.
5. If the patient cannot read the '95', repeat the process at half the distance and record the results.
6. If they are still unable to read the largest number, see if they can count your fingers at 5 feet, of detect the direction of your hand motion at 2 ft and record the results. Pediatric Testing: The reverse side of the card provides the Lea Symbols for near testing of children in the 3 to 5 year old range.

Confrontation Test**** - Correct answer Examine visual fields by confrontation by wiggling fingers 1 foot from pt's ears, asking which they see move.

• Keep examiner's head level with patient's head. Test of peripheral vision. Papillary Reaction - Correct answer ● observe the pupils' size and shape. They should be round, regular, and equal in size. ● test the pupils' response to light directly and consensually. The pupils should constrict simultaneously. ● perform the swinging flashlight test. Shine the light in one eye and then rapidly swing it to the other eye. If the second eye to be tested continues to dilate rather than constrict, an afferent pupillary defect is present, which suggests optic nerve disease. ● test for accommodation. After looking at a distant object and then focusing on an object 10 cm from the nose, the pupils should constrict to focus on near. Abnormal documentation: ● Miosis (pupillary constriction to less than 2mm) ● Mydriasis (pupillary dilation) ● Failure to respond (constrict) with increased light stimulus ● Argyll Robertson pupil (irregularly shaped pupils that fail to constrict light but retain constriction with convergence) ● Anisocoria (unequal size of pupils) ● Iritis constrictive response ● Oculomotor nerve CN III damage (pupil dilated and fixed, eye deviated laterally and downward; ptosis) ● Adie pupil (tonic pupil). The affected pupil dilated and reacts slowly or fails to react to light; responds to convergence Accommodation******* - Correct answer The accommodation reflex of the eye is a response that automatically occurs when you switch focus from an object that's far away to one that's closer. This response enables you to switch between objects and still maintain focus (meaning neither object appears blurry when you're looking at it). They should dilate with far gaze and constrict with near gaze. Accommodation (response to looking at something moving toward the eye). Accommodation is impaired in lesions of the ipsilateral optic nerve, the ipsilateral parasympathetics traveling in CN III, or the pupillary constrictor muscle, or in bilateral lesions of the pathways from the optic tracts to the visual cortex. Accommodation is spared in lesions of the pretectal area.

• If MG suspected: pt. gazes upward at Dr's finger to show worsening ptosis.

Which valves closing and opening make which sounds? - Correct answer The heart tone "lub," or S1, is caused by the closure of the mitral and tricuspid atrioventricular (AV) valves at the beginning of ventricular systole. The heart tone "dub," or S2 ( a combination of A2 and P2), is caused by the closure of the aortic valve and pulmonary valve at the end of ventricular systole. The splitting of the second heart tone, S2, into two distinct components, A2 and P2, can sometimes be heard in younger people during inspiration. During expiration, the interval between the two components shortens and the tones become merged. Murmurs are a "whoosh" or "slosh" sound that indicate backflow through the valves. S3 and S4 are a "ta" sound that indicates ventricles that are either too weak or too stiff to effectively pump blood. Incompetent heart valve - Correct answer Another valvular heart disease condition, called valvular insufficiency (or regurgitation, incompetence, "leaky valve"), occurs when the leaflets do not close completely, letting blood leak backward across the valve. This backward flow is referred to as "regurgitant flow." Sclerotic Heart Valve - Correct answer Aortic sclerosis--a marker of coronary atherosclerosis. ... Aortic valve sclerosis is defined as calcification and thickening of a trileaflet aortic valve in the absence of obstruction of ventricular outflow. Its frequency increases with age, making it a major geriatric problem. Stenotic Heart Valve - Correct answer when leaflets, which are thickened/narrow---> restricts blood flow Regurgitation - Correct answer when valves lose competency/leak, blood flows backwards What causes leg edema? - Correct answer Right side heart failure What causes murmurs? - Correct answer Caused by some disruption of blood flow, through, or out of the heart. Diseased valves are a common cause, not opening or closing well. Where do you hear murmurs? - Correct answer Aortic stenosis: Murmur: Harsh late-peaking crescendo-decrescendo systolic murmur Heard best- left 2nd ICS Radiation to the carotids.

Possible associated findings: Abnormal carotid pulse Diminished and delayed ("pulsus parvus and tardus") Sustained Apical impulse Calcified aortic valve on CXR Murmur: Blowing holosystolic murmur Heard best at the apex Radiation to the axilla and inferior edge of left scapula. Possible associated findings: S2: wide physiologic splitting S Murmur: Soft blowing early diastolic decrescendo murmur Heard best at the left 2nd ICS without radiation May also hear systolic flow murmur and diastolic rumble (Austin Flint) Possible associated findings: Dilated apical impulse Abnormal and collapsing arterial pulses Murmur: Soft holosystolic murmur Heard best at the LLSB without radiation

Intensity increases with inspiration or pressure over liver Possible associated findings: Elevated neck veins Systolic regurgitant neck vein Systolic retraction of apical pulse Edema, Ascites or both Pulmonic Insufficiency Murmur: High frequency early diastolic decrescendo murmur Heard best at 2nd-3rd ICS Increases with inspiration Associated findings: Abnormal S2 splitting Sustained pulmonary hypertension Pulmonary stenosis Murmur: Harsh crescendo-decrescendo systolic murmur Heard best sternal border bat 2nd or 3rd intercostal spaces Increases with inspiration Associated findings: Ejection sounds heard at sternal edge, 2nd or 3rd intercostal space Wide physiological splitting of S Prominent A wave of the jugular venous pulse

Mitral stenosis Murmur: Low frequency rumbling mid-diastolic murmur, with presystolic component possible Heard best at apex Accentuated in left lateral decubitus position Associated findings: Apical impulse absent or small Irregular pulse ( atrial fibrillation) Loud S Elevated neck veins with exaggerated A wave Hypertrophic cardiomyopathy Murmur: Harsh quality midsystolic murmur Heard best LSB Increases with decreased venous return Possible associated findings: Sustained apical beat to palpation S4 (50% of the time) Grades of murmurs?******* - Correct answer Systolic Murmur Grades I/VI: Barely audible II/VI: Faint but easily audible III/VI: Loud murmur without a palpable thrill IV/VI: Loud murmur with a palpable thrill

V/VI: Very loud murmur heard with stethoscope lightly on chest VI/VI: Very loud murmur that can be heard without a stethoscope Systolic Murmurs are the most common in children. Holosystolic (regurgitant) murmurs start at the beginning of S1 and continue to S2. Examples: ventricular septal defect (VSD), mitral valve regurgitation, tricuspid valve regurgitation. Systolic ejection murmurs (SEM, crescendo-decrescendo) result from turbulent blood flow across the aortic and pulmonary valves. Blood flow across these valves starts after adequate pressure has built up in the ventricle to overcome the pressure in the aorta or pulmonary artery. Examples: aortic and pulmonary stenosis. A murmur with similar characteristics may be heard in coarctation of the aorta. Diastolic murmurs are usually abnormal, and may be early, mid or late diastolic. Early diastolic murmurs immediately follow S2. Examples: aortic and pulmonary regurgitation. Mid-diastolic murmurs due to increased flow through the mitral or the tricuspid valves. Examples: VSD and ASD. Late diastolic murmurs due to pathological narrowing of the AV valves. Example: rheumatic mitral stenosis. What do murmurs sound like?****** - Correct answer The quality and shape of the murmur is then noted. Common descriptive terms include rumbling, blowing, machinery, scratchy, harsh, or musical. The intensity of the murmur is next, graded according to the Levine scale: I - Lowest intensity, difficult to hear even by expert listeners II- Low intensity, but usually audible by all listeners III - Medium intensity, easy to hear even by inexperienced listeners, but without a palpable thrill IV - Medium intensity with a palpable thrill V - Loud intensity with a palpable thrill. Audible even with the stethoscope placed on the chest with the edge of the diaphragm VI - Loudest intensity with a palpable thrill. Audible even with the stethoscope raised above the chest. Normal vs abnormal murmurs - Correct answer Box 14-9 Pg 317 Siedel--> innocent murmurs example are still murmurs that are a result of vigorous myocardial contraction, the consequent stronger blood flow in early systole or midsystole, and the rush of blood from the larger chamber of the heart into the smaller bore of a blood vessel. The thinner chests of young make these sounds easier to hear, particularly with a

lightly held bell. They are usually a grade I or II, usually midsystolic with radiation, medium pitch, blowing, brief, and often accompanied by splitting of S2. They are often located 2 nd ICS near the left sternal border. Such murmurs heard in a recumbent position may disappear when the patient sits or stands becuase of the tendency of the blood to pool. Abnormal murmurs---> ● Aortic Stenosis- detection- heard over aortic area; ejection sound at second right of intercostal border. Description-Calcification of valve cusps restricts forward flow; forceful ejection from ventricle into systemic circulation. Caused by congenital bicuspid (rather than usual tricuspid) valve, rheumatic heart disease, atherosclerosis. Mitral Stenosis- detection- heard with bell at apex, patient in left lateral decubitus position. Description- narrowed valve restricts forward flow; forceful ejection into ventricle. Often occurs with mitral regurgitation. Caused by rheumatic fever or cardiac infection. ● Subaortic stenosis- Detection-heard at apex and along left sternal border. Description- Fibrous ring, usually 1 to 4 mm below aortic valve; most pronounced on ventricular septal side; may become progressively severe with time; difficuMay be the cause of sudden death, particularly in children and adolescents, either at rest or during exercise; risk apparently related to degree of stenosis. ● lt to distinguish from aortic stenosis on clinical grounds alone. ● Pulmonic stenosis- detection- heard over pulmonic area radiating to the left into the neck; thrill in second and third left intercostal spaces. Description- valve restricts forward flow; forceful ejection from ventricle into pulmonary circulation. Cause is almost always congenital. ● Tricuspid stenosis- detection- heard with the bell over the tricuspid area. Description- Calcification of valve cusps restricts forward flow; forceful ejection into ventricles. Usually seen with mitral stenosis, rarely occurs alone. Caused by rheumatic heart disease, congenital defect, endocardial fibroelastosis, right atrial myxoma. ● Mitral Regurgitation- detection- heard best at apex; loudest there, transmitted into left axilla. Description- valve incompetence allows backflow from ventricle to atrium. Caused by rheumatic fever, myocardial infarction, myxoma and rupture of chordae. ● Aortic regurgitation- detection- heard with the diaphragm, patient sitting and leaning forward; Austin Flint murmur heard with bell; ejection click heard in second intercostal space. Description- Valve incompetence allows backflow from aorta to ventricle. Caused by rheumatic heart disease, endocarditis, aortic diseases (Marfan syndrome, medial necrosis) syphilis, ankylosing spondyMitral Valve Prolapse- detection- heard at apex and left lower sternal border; easily missed in supine position; also listen with patient upright. Description- Valve is competent early in systole but prolapses into atrium later in systole; may become progressively severe, resulting in a holosystolic murmur; often concurrent with pectus excavatum. ● litis, dissection and cardiac trauma. ● Pulmonic regurgitation-detection- difficult to distinguish from aortic regurgitation on physical exam. Description- Valve incompetence allows backflow from pulmonary artery to ventricle. Secondary to pulmonary hypertension or bacterial endocarditis.

● Tricuspid regurgitation- detection- heard at left lower sternum, occasionally radiating a few centimeters to the left. Description- Valve incompetence allows backflow from ventricle to atrium. Caused by congenital defects, bacterial endocarditis (especially in IV drug users), pulmonary hypertension and cardiac trauma. Peripheral vision or visual fields - Correct answer Peripheral Vision or visual fields The assessment of visual acuity is indicative of the functioning of the macular area, the area of central vision. However, it does not test the sensitivity of the other areas of the retina which perceive the more peripheral stimuli. The Visual field confrontation test, provide a rather gross measurement of peripheral vision. The performance of this test assumes that the examiner has normal visual fields, since that client's visual fields are to be compared with the examiners. Follow the steps on conducting the test:

1. The examiner and the client sit or stand opposite each other, with the eyes at the same, horizontal level with the distance of 1.5 - 2 feet apart.
2. The client covers the eye with opaque card, and the examiner covers the eye that is opposite to the client covered eye.
3. Instruct the client to stare directly at the examiner's eye, while the examiner stares at the client's open eye. Neither looks out at the object approaching from the periphery.
4. The examiner hold an object such as pencil or penlight, in his hand and gradually moves it in from the periphery of both directions horizontally and from above and below.
5. Normally the client should see the same time the examiners sees it. The normal visual field is 180 degress. What does OLDCARTS mean?****** - Correct answer History of Present Illness: details about the chief complaint (OLD CARTS) •Onset —when did it start? •Location/Radiation —where is it located? •Duration —how long has this gone on?

•Character —does it change with any specific activities? Does the patient use any descriptive words to describe the quality of the symptom? •Aggravating factors -what makes it worse? •Relieving factors -what makes it better? •Timing —is it constant, cyclic, or does it come and go? •Severity —how bothersome, disruptive, or painful is the problem? Sinus, oral, and throat exam - Correct answer. Nose and Sinuses Inspection External: inflammation, deformity, discharge or bleeding Internal: colour of mucosa, edema, deviated or perforated septum, polyps, bleeding Observe nasal versus mouth breathing Palpation Sinus and nasal tenderness Percussion Sinus and nasal tenderness Mouth and Throat Inspection Lips: color, lesions, symmetry Oral cavity: breath odour, color, lesions of buccal mucosa Teeth and gums: redness, swelling, caries, bleeding

Tongue: colour, texture , lesions, tenderness of floor of mouth Throat and pharynx: colour, exudates, uvula, tonsillar symmetry and enlargement , masses Risk factors for heart disease - Correct answer Gender (men are more at risk; women are at more increased risk in postmenopausal years and with oral contraceptive use) Hyperlipidemia Elevated Homocysteine level Smoking Family hx of CVD, DM, HLD, HTN, or sudden death in young adults DM, Obesity, Sedentary lifestyle without exercise, Fatigue Associated symptoms: dyspnea on exertion, chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnea, anorexia, N/V Medications: beta blockers What does left, thrill, heave mean? - Correct answer Lift or heaves- these are forceful cardiac contractions that cause a slight to vigorous movement of sternum and ribs. Thrills- these are the vibrations of loud cardiac murmurs. They feel like the throat of a purring cat. Thrills occur with turbulent blood flow. Auscultation of the heart - Correct answer 1. Aortic Area 2nd right interspace close to the sternum.

2. Pulmonic Area 2nd left interspace.
3. ERB's Point 3rd left interspace.
4. Tricuspid Area 5th left interspace close to the sternum.
5. Mitral Area (Apical) 5th left interspace medial to the MCL

Inspection and palpation- cardiac (aortic, pulmonic, erb's, tricupsid, mitral - Correct answer 1. Aortic Area (second interspace to the right of the sternum). a pulsation could indicate an aortic aneurysm. a thrill could indicate aortic stenosis.

2. Pulmonic Area (second interspace to the left of the sternum). a pulsation could indicate pulmonary hypertension. a thrill could indicate pulmonic stenosis.
3. ERB's Point (third interspace to the left of the sternum). findings similar to that of aortic and pulmonic areas.
4. Tricuspid Area (Right Ventricular Area) (4-5th interspace; lower half of the sternum). a sustained systolic lift could indicate right ventricular enlargement. a systolic thrill could indicate a ventricular septal defect. in patients with anemia, anxiety, hyperthyroidism, fever, pregnancy, or increased cardiac output, a brief pulsation may be felt.
5. Mitral Area (Left Ventricular Area) (5th intercostal space at the midclavicular line). This is where you can find the Apical Pulse and usually can find the Point of Maximum Intensity (PMI). identify the PMI by location, diameter, amplitude, duration, and rate. To help identify it, have patient exhale completely and hold breath or have the patient lean forward. Normal is a light tap, 1-2 cm in diameter at the 5th interspace at the left midclavicular line. PMI could be displaced down and to the left with ventricular hypertrophy, pregnancy, and CHF. normally seen in less than half the population. increased pulsation could indicate increased cardiac output, anemia, anxiety, fever, or pregnancy. a thrill could indicate mitral regurgitation, or mitral stenosis.

Listening to heart sounds: - Correct answer 1. With your stethoscope, identify the first and second heart sounds (S1 and S2). at the aortic and pulmonic areas (base). S2 is normally louder than S1. S2 is considered the dub of 'lub- DUB.' S2 is caused by the closure of the aortic and pulmonic valves. at the tricuspid and mitral area (apex) S1 is often, but not always louder than S2. S1 is considered the lub of 'LUB-dub.' S1 is caused by the closure of the mitral and tricuspid valves. S1 is synchronous with the onset of the apical impulse.

2. Identify the heart rate. tachycardia bradycardia
3. Identify the rhythm. if it is irregular, try to identify the pattern. Do early beats appear on a regular rhythm? Does the irregularity vary consistently with respiration? Is rhythm totally irregular?
4. Listen to S1 first, then S2 at the previously mentioned areas using the diaphragm and then the bell. note its intensity. are there any splitting sounds check during inspiration where S2 usually splits at pulmonic and ERB's point. a thick chest wall or increased AP diameter may make S2 inaudible.

Alterations in S a. S1 is accentuated in exercise, anemia, hyperthyroidism, and mitral stenosis. b. S1 is diminished in first degree heart block. c. S1 split is most audible in tricuspid area (T-lub-dub). Alterations in S a. Normal physiological splitting of S2 is best heard at pulmonic area. It occurs on inspiration (lub-T-dub, lub-dub). b. Splitting of S2 can indicate pulmonic stenosis, atrial septal defect, right ventricular failure, and left bundle branch block (lub-T-dub).

5. Listen for S3 (ventricular gallop). a physiologic S3 is frequently heard in children and in pregnant women. it occurs early in diastole during rapid ventricular filling. It is heard best at the apex in the left lateral decubitus position. it is heard best using the bell. a pathologic S3 occurs in people over the age of 40. Cause is usually myocardial failure. sounds like lub-dub-dee (or 'Kentucky').
6. Listen for an S4 (atrial gallop). it occurs before S it is low pitched and best heard with the bell. often normal in older adults. it is heard best at the apex in the left lateral decubitus position.

it may be caused by coronary artery disease, hypertension, myocardiopathy, or aortic stenosis. sounds like dee-lub-dub (or 'Tennessee').

7. Listen for murmurs. CHECK TIMING. Are they systolic or diastolic? (systolic murmurs may be benign. Diastolic murmurs are never benign). LOCATION OF MAXIMAL INTENSITY. Where is the murmur best heard? FREQUENCY (pitch). This varies from low-pitched, caused by slow velocity of blood flow, to high pitched, caused by a rapid velocity of blood flow. INTENSITY. the loudness of a murmur is described on a scale of 1 to 6: Grade Intensity/ Sounds 1 very faint, easily missed 2 quiet, barely audible 3 moderately loud but easily heard. Same intensity as S1 or S2. 4 loud but usually no thrill present 5 very loud- thrill present 6 heard with stethoscope off of chest. Thrill present. RADIATION. some murmurs radiate in the direction of the blood stream by which they are produced. Listen over neck, back, shoulders, and left axilla.

• QUALITY. musical blowing harsh rumbling aortic murmurs are heard best in full expiration with patient leaning forward. mitral murmurs are heard best after exercise in left side lying position.

Assessment of Extra Heart Sounds

• ejection click
• opening snap
• midsystolic click Normal tympanic membrane appearance - Correct answer The tympanic membrane is translucent, permitting the middle ear cavity and malleus to be visualized. Its oblique position to the auditory canal and its conical shape account for the triangular light reflex. Most of the tympanic membrane is tense (the pars tensa), but the superior portion (pars flaccida) is more flaccid. Here is a short video I viewed to be able to recognize the structures a little better. https://www.youtube.com/watch?v=krNXVWa8QTg What is xanthelasma? Seidel page 210 figure 11-6 photo - Correct answer Flat to slightly raised, oval, irregularly shaped, yellow-tinted lesions on the periorbital tissues that represent deposits of lipids. This may suggest that your patient has an abnormality of lipid metabolism. These lesions are caused by an elevated plaque of cholesterol deposited in macrophages, most commonly in the nasal portion of the upper or lower eyelid. The link is to another photo that shows a very nice example. http://www.medicinenet.com/image-collection/xanthelasma_picture/picture.htm Cardinal fields of gaze? Seidel page 214-215. Figure 11-22 - Correct answer There are six cardinal fields of gaze. I found the description in the book very difficult to follow on how to perform an assessment of the six fields.This video is a great example of how you should perform the test. https://www.youtube.com/watch?v=64KyR8lkInI I used this video of a previous maryville student's AHA exam to see how she performed test. The ENT exam begins at 3:19 with the six fields being tested at 5:33 and concluding at 5:50. She does not explain how to do the test but you can watch her perform the test. Then when you read through the text it makes much more sense. https://www.youtube.com/watch?v=KlMujEKugi
• Starting in the center of the patient's visual field, move your finger up and to the right, then back to midline, than laterally to the right, then midline, and finally down and to the right and back to midline. Repeat this on the left side. Normal movement through the 6 cardinal signs means intact CN III, IV, and VI.

What does 6 cardial fields of gaze assess for? - Correct answer Cranial nerves III (oculomotor) IV (trochlear) and VI (abducens) and the six extraocular muscles. What does 20/30 mean? Seidel pages 43-44 Snellen Alphabet Chart********* - Correct answer The patient can read letters while standing 20 feet from the chart that the average person could read at 30 feet. The term 20/20 refers to a patient's visual acuity which is measured utilizing the Snellen's Alphabet Chart. The numerator (the first number) is the distance the patient stands from the chart when performing the test. An adult should stand at the distance of 20 feet, children should stand 10 feet away (age is not specified) The denominator(the second number) denotes the distance from which a person with normal vision could read the lettering. So a bottom number more than 20 would indicate either a refractive error or an optic disorder. This link is a video of a great explanation. https://www.youtube.com/watch?v=48XD7Z9_XXs How does smoking affect eyesight. Seidel pg 208 - Correct answer • smoking increases risk for cataract formation, glaucoma, macular degeneration, and thyroid eye disease

. Pulse grades. Seidel page 340****** - Correct answer 0: Absent, not palpable 1: Diminished, barely palpable 2: Expected 3: Full, increased 4: Bounding, aneurysmal Valves - stenotic, regurgant, incompetent, sclerotic Seidel page 311 - Correct answer Stenosis: When leaflets are thickened and the passage narrowed, forward blood flow is restricted Regurgitation: When valve leaflet lose competency and leak, blood flows backward. Incompetent: An incompetent valve allows blood to leak back into the chamber it previously existed Sclerotic: thickening and calcification of the leaflets Murmur grades- Seidel page 313******** - Correct answer Grade I: Barely audible in quiet room Grade II: Quiet but clearly audible Grade III: Moderately loud Grade IV: Loud, associated with thrill Grade V: Very loud, thrill easily palpable Grade VI: Very loud, audible with stethoscope not in contact with chest, thrill palpable and visible

How do you take a history and physical? Seidel page 6 and 32****** - Correct answer Identifiers: Name, date, time, age, gender, race, occupation, referral source Chief concern (CC) History of present illness or problem (HPI) Past medical history (PMH) Family history (FH) Personal and social history (SH) Review of systems (ROS) Physical conducted using inspection, palpation, percussion and auscultation

. Tonsil grading- Siedel's pg. 253 - Correct answer Enlarged tonsils are graded to describe their size. 1+- Visible 2+- Halfway between tonsillar pillars and the uvula 3+- Nearly touching the uvula 4+- Touching each other https://www.youtube.com/watch?v=EbNoWFm0JLY Assessment of apical PMI and indications Siedel's pg 305-306 - Correct answer Point of maximal impulse (PMI) is the point at which the apical impulses are most readily seen or felt. This is usually on the left 5th ICS, midclavicular line in adults. It can be obscured by obesity, large breast, and muscularity. It can sometimes be noted in the 4th ICS in some adults. In children it is located 4th ICS medial to the nipple. Normal-1cm diameter, gentle, brief, not lasting longer than systole. Abnormal- Heave or lift (this is when apical pulse outside the above normal parameters). If apical pulse is more forceful and widely distributed, fills systole, or displaced laterally and downward may indicate increased cardiac output or left ventricular hypertrophy. If a lift is noted along the left sternal border it may be right ventricular hypertrophy. A loss of thrust may be related to overlying fluid, air, or displacement under the sternum. Displacement of the apical pulse to the right without a loss or gain in thrust, suggest dextrocardia, diaphragmatic hernia, distended stomach, or pulmonary abnormality. Thrill- Palpable murmur, vibration. Most often over the base of the heart in the area of the right or left second intercostal space. Indicated turbulence or disruption of the expected blood flow related to aortic or pulmonic valve abnormalities. https://www.youtube.com/watch?v=nHBKZbAuttA

S3 and S4 are created by what? Characteristics? Seidel chapter 14 - Correct answer S3 -As the ventricle pressure falls below the atrial pressure, the mitral and tricuspid valves open to allow the blood collected in the atria to refill the relaxed ventricles. Diastole is relatively passive interval until ventricular filling is almost complete. This filling sometimes produces a third heart sound S3. (Seidel, pg. 298) S3 - characteristics-Quiet, low pitched, often difficult to hear (Seidel, pg. 310). When heard resembles the rhythm of pronouncing the word Ken-TUCK-y. S4 - The atria contract to ensure ejection of any remaining blood. This can produce the fourth heart sound (S4). S4- characteristics - Quite, difficult to hear. When heard resembles the rhythm of pronouncing the word TEN-nes-see. (Seidel, 310).

. Heart sounds are created by what?- Seidel 307-310 - Correct answer • S1- closure of mitral and tricuspid valves indicating beginning of systole o heard loudest over the apex o synchronous with carotid pulse

• S2- closure of aortic and pulmonic valves indicating initiation of diastole
• splitting- occurs when the valves do not close simultaneously Assessing sinus tenderness how? Seidel page 243 - Correct answer Inspect the frontal and maxillary sinus areas for swelling. To palpate the frontal sinuses, use your thumbs to press up under the bony brow on each side of the nose. Then press up under the zygomatic processes, using either your thumbs or your index fingers to palpate maxillary sinuses. Expect no tenderness or swelling over the soft tissue. Swelling, tenderness, and pain over the sinuses may indicate infection or obstruction. Oral cancer - assessment and common location- Goolsby & Grubbs pages 148 & 152-153 - Correct answer Patient may present with a "mouth sore." It is necessary to determine if it is painful, when the patient first noticed the lesion, whether the lesion was preceded by other symptoms, or if there was a history of other lesions in the past medical history. Identify any associated symptoms such as fever, malaise, joint pain, SOB, n/v/d, photosensitivity, etc. Also, check for any chronic or coexisting conditions or OTC meds taken. Check the patient's VS, paying close attention to any fever. Note the type of lesion (ulcer, papule, etc) as well as the dimensions, coloring, shape, discoloration, and other details. Check surrounding tissues for any edema, erythema, or pallor. Assess the entire oral mucosa for indurations, thickenings, nodules, or palpable changes. The most common form of oral cancer is Squamous Cell Carcinoma. Most lesions occur on the lips or along the lateral aspects of the tongue. However, other forms of malignancy, including malignant

melanoma, do affect the oral mucosa, and any of the tissue in the oral cavity can be involved. Because many oral cancers are not diagnosed until they are quite advanced, the prognosis can be poor.

. Rinne's test - how is it performed - Goolsby & Grubbs pages 127-128 - Correct answer Rinne test - uses a tuning fork to assess bone and air conduction The vibrating tuning fork is placed on the patient's mastoid bone (bone conduction). When the patient indicates the vibration is no longer heard, then move the tines of the fork in front of the ear (air conduction) until the patient states that the vibration is no longer heard. The amount of time the vibrations are heard in both positions is noted. Intended result: Air conduction should be twice as long as bone, and the results should be similar in both ears. Assess ears in child? Adult?**** - Correct answer Pediatric Goolsby & Grubbs pages 529-530 Ask about hearing ability or difficulties, or drainage. The general appearance and placement of the ears is important in the pediatric assessment. Low set ears may indicate genitourinary or chromosomal abnormalities or a multisystem syndrome such as Turner syndrome. Assess for preauricular sinuses. To exam the inner ear in an infant or young child, pull the pinna down and out. For examination in the older child, pull the pinna up and back. The tympanic membrane should be mobile and intact, thin, smooth, and pearly gray with bright light reflexes. Although, crying will cause erythema of the TMs, the light reflexes and mobility should remain intact. Observe for any bubbles or an obvious fluid level line behind the tympanic membrane, which indicates middle ear effusion. A child continually asking for questions to be repeated should be assessed for hearing deficit. Middle ear effusions and acute otitis media may also cause hearing deficits. Otoscope should always be used last - since it is not favored with kids. Red Flags with Peds:

• Pain over the mastoid process (may indicate mastoiditis)
• Foreign bodies - consider this if the child ℅ strange sounds or sensations in one ear or if there is an obvious blockage or odd color noted on otoscopic exam
• Hearing deficit Common diagnoses made with ears in peds:
• Acute otitis media
• Middle ear effusions
• Otitis externa
• Wax impaction
• Foreign body

Adults Goolsby & Grubbs pages 618-619 / Seidel's page 238-240 Begin with examination of the external ear. Note placement and symmetry of ears. The otoscope is then used to examine the canal and middle ear. Hold the handle of the otoscope between the thumb and index finger supported on the middle finger. Use the ulnar side of your hand to rest against the patient's head for stability. Tilt the patient's head toward the opposite shoulder, pull the auricle upward and back to straighten the auditory canal for best view. If symptoms are unilateral, assess the asymptomatic ear first. Inspect for patency, erythema, tenderness, exudate, deformity, and drainage. Noting the integrity of the tympanic membrane and quality of light reflex. Evaluate the tympanic membrane for inflammation, retraction, or bulging. Tympanic membrane signs and associated conditions: TM bulging with no mobility=middle ear effusion due to pus or fluid TM retracted with no mobility=obstruction of eustachian tube with or without middle ear effusion TM mobility with negative pressure only=obstruction of eustachian tube with or without middle ear effusion TM excess mobility in small areas=healed perforation, atrophic tympanic membrane TM amber or yellow=serous fluid in middle ear (otitis media with effusion) TM blue or deep red=blood in middle ear TM chalky white=infection in middle ear (acute otitis media) TM redness=infection in middle ear (acute otitis media) or prolonged crying TM dullness=fibrosis, otitis media with effusion TM white flecks, dense white plaques=healed inflammation TM air bubbles=serous fluid in middle ear Test for peripheral vision - Goolsby & Grubbs p. 100**** - Correct answer Peripheral vision is tested very grossly through confrontation by the examiner who has the patient count fingers or indicate appearance of a colored object from the upper and lower temporal and nasal quadrants. Carefully identify the location of any visual defects. Seidels page 209 Peripheral vision can be estimated by the confrontation test. To perform this the examiner should sit or stand opposite the patient at eye level at a distance of about 3 feet. Ask the patient to cover the right eye while you cover your left eye, so the open eyes are directly opposite each other. Fully extend your arm midway between the patient and yourself and then move your arm slowly centrally. Have the patient tell you when the fingers are first seen. Compare the patient's response to the time you first note the fingers. Test the nasal, temporal, superior, and inferior fields. The confrontation test is imprecise and can be considered significant only when it is abnormal.

Myopia - Correct answer Nearsightedness caused by light refractive error placing light in front of retina. What is astigmatism? - Correct answer it refers to the refractive condition in which a warped corneal surface causes light rays entering the eye along different planes to be focused unevenly. What is macular degeneration? - Correct answer caused by the deterioration of the central portion of the retina, the inside back layer of the eye that records the images we see and sends them via the optic nerve from the eye to the brain. What would be subjective data if bacterial infection of one or more paranasal sinuses?*** - Correct answer patient complains of nasal stuffiness and facial pain. Patient noted she/he is having yellowing discharge from the nose. frontal headache, facial pain; persistent cough, worse at night; URI that worsens or persists after 7-10 data What would objective data be for bacterial paranasal sinus infection?**** - Correct answer Turbunates are swollen and red. Sinus area are tender to palpation. Noted to have focal pain when the patient bends over. May have no physical findings Purulent Nasal discharge from middle meatus, may be unilateral Tenderness over frontal or maxillary sinuses Sinus does not trans illuminate How do you use the otoscope in an adult*** - Correct answer ave pt tilt head to opposite shoulder, gently pull auricle up and back while inserting speculum Inspect auditory canal, noting any discharge, redness, lesions, FB, or cerumen. expect to see minimal cerumen, uniform pinkness, and hairs in outer thirds if the canals. Third, inspect tympanic membrane for landmarks, color, contour, and perforations. the umbo, handle of malleus, and light reflex should be visible. The TM should be translucent, person grey, and conical with no perforations. 4th assess TM mobility using otoscope pneumatic attachment. The TM should move in and out with pressure changes, causing the cone of light to Change appearance What is a thrill? - Correct answer Fine, palpable sensation.