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NR 509 Final Study Guide
Chapter 1 - Foundations for Clinical Proficiency
- Know what should be listed under adult illnesses in health history (p.10) Medical, Surgical, OBGYN, Psychiatric -Know what is listed under present illness (p.9) Problems prompting the patients visit, including the onset of the problem, the setting in which it developed, its manifestations, and any treatments to date
- Know what makes up the health history (subjective) (p.7) Identifying data and source of the history; reliability Chief complaint(s) Present Illness Past history Family history Personal and social history Review of Systems
- Know how to prioritize patient complaints (p.37) List most active & serious problems first and their date of onset Problems can be symptoms, signs, past health events such as a hospital admission or surgery or diagnoses
- Be able to figure out what is missing in an HPI (p.9) O.L.D.C.A.R.T -Know what subjective information is (p.6) What patient tells you
- Know what objective information is (p.6) Examination findings, vital signs, laboratory data -Know the c-sections should be listed in surgeries (p.10) Surgical history- make sure you include date, indication, type of surgery. -Subjective info (ROS) (p.12) Goes under the review of systems Chapter 2 - Evaluating Clinical Evidence
- Evaluating Clinical Evidence
- Critical Thinking and Clinical Reasoning
- Differential Diagnoses
- Pathological and Physiological Processes
- Problem List
- Problem Prioritization Chapter 3 - Interviewing and the Health History -Know how to get a patient to open up when they seem upset (p.72) Effective reassurance-identifying and acknowledging patients feelings Meaningful reassurance-deal openly with concerns Validate the legitimacy of his or her emotional experience Moving closer or making physical contact -Know that you need permission of the patient to carry out the visit if someone is in the room (p.75) Whenever visitors are present, you are obligated to maintain the patients confidentiality -Know how to make a pelvic exam less intimidating (p.76) Avoid interviewing patient when she is already positioned for a pelvic exam -Know that if a patient returns from a country with malaria you still need to be selective of which patients you screen for malaria (p.66) Review page -Where to sit when interpreter in the room (p.90) Arrange seating so that you have eye contact with the patient, have the interpreter sit close or behind you (keeps you from turning your head back and forth) -Know the order of meeting a patient and conducting an interview (p.73)
Chapter 4 - Beginning the Physical Examination: General Survey, Vital Signs, and Pain -Know what can cause falsely high BP (p.127) Cuff too small BP will read high; cuff too large BP will read low on small arm and high on large arm Brachial artery below heart, BP will be higher, if brachial artery is above heart, reading will be lower
- Know what is included in constitutional symptoms (p.112) Fatigue, weakness, fever/chills, night sweats, weight changes or pain -BMI interpretation (p.122) The BMI incorporates estimated but more accurate measures of body fat than weight alone Chapter 6 - The Skin, Hair, and Nails -Know that cherry angiomas are benign (p.196 & 205) Benign tumors that result from overgrowth of capillaries -Know risk factors of melanoma (p.177) -Know what acanthosis nigricans can clue into (p.207) Diabetes -Know labs to check with vitiligo (p.191) Thyroid panel/CBC -Know how psoriasis presents (p.192) Scattered erythematous; raised on skin, over 1 cm; plaque- Raised papule- rough, dry, silver, grey. Found most often over joints. -Know what onychomycosis looks like (p.212)
-Know how to interpret visual acuity results (p.231) First number is distance of patient from chart (20 feet) Second, distance which a normal eye can read line Bigger the second number, the worse the vision -Know what visual acuity means 20/100 (p.231) At 20 ft. the patient can read a print that a person with normal vision can read at 100ft -Know what can cause epistaxis (p.220) Trauma (nose picking), inflammation, drying, tumors, and foreign bodies -Know the signs of otitis externa (swimmer's ear) (p.245) Painful movement of the tragus (tug test)
- Know red flags for headaches (p.216) -Know what cotton wool patches look like (p.241) -Know how a subconjunctival hemorrhage presents (p.270) Leakage of outside blood vessels in the eye, absent of pain; vision not affected -Know where the cricoid cartilage is (p.258)
NR 509 Final Study Guide -Know where lymph nodes should be with strep Anterior cervical for strep and posterior cervical for mono -Know what chalazion is (p.275) -Know what a retracted tympanic membrane with effusion looks like (p.288) -Glaucoma (p.270) Severe, aching, deep pain; decreased vision; pupil dilated/fixed Chapter 8 - The Thorax and Lungs -Know the signs of respiratory distress (p.318) tachypnea, cyanosis or pallor, stridor, contraction of accessory muscles -Know the signs of pneumonia (p.322 339) Dullness replaces resonance; dyspnea, pleuritic pain, cough, fever; localized bronchophony/egophony -Know the signs of asthma (p.326 & 334)
NR 509 Final Study Guide -Know why venous insufficiency causes edema, swelling and ulceration (p.533) Chronic obstruction and incompetent valves in the deep venous system. -Know that the Buerger test is for chronic arterial insufficiency (p.530 & 531): patient’s LE color changes with first raising the LE while supine, then having patient sit up. Normal= return of pinkness in <10 sec, filling of veins in <15 sec Chapter 16 - The Musculoskeletal System -Know the sources of joint pain (p.630) Joint pain: articular or extra-articular, acute or chronic, inflammatory or noninflammatory, localized or diffuse Joint pain: associated constitutional symptoms and systemic manifestations from other organ systems -Know what causes saddle numbness and urinary retention (p 635) Cauda equina syndrome
- Know where the acromion process is (p.646) -Know the signs of degenerative pain (p.696) Weakness, fatigue, malaise -Know how a rotator cuff tear presents (p.655 & 700) Weakness during drop arm test
-Know what joints are condylar (p.629) -Know how RA presents (p.703) Acute: tender, painful, stiff joints usually with symmetric involvement Chronic: swelling and thickening of joints. ROM limited; swan neck deformities -Know were pain from lateral epicondylitis presents (p.702) Pain and tenderness develop 1 cm distal to the lateral epicondyle and possibly in the extensor muscles closest Chapter 17 - The Nervous System -Know what the word obtunded means (p.769) Opens eyes and looks at you but responds slowly and is somewhat confused. Alertness and interest in the environment are decreased -Know how to check for nystagmus (p.737 & 785) Gait ataxia, dysarthria (increases with retinal fixation), vestibular (decreases with retinal fixation), internuclear ophthalmoplegia; identified by involuntary jerking eye movement -Know what absence seizures are (p.781) Sudden brief lapse of consciousness with momentary blinking, staring or movements of the lips and hands but no falling. Typical-less than 10 sec and stops abruptly; atypical-may last more than 10 sec. -Know the physical signs of meningitis (p.765) Neck stiffness with resistance to flexion (won't be able to touch chin to chest). Inflammation in the subarachnoid space causes resistance to movement that stretches the spinal nerves (neck flexion), the femoral nerve (Brudzinski sign), and the sciatic nerve (Kernig sign) Brudzinski Sign. As you flex the neck, watch the hips and knees in reaction to your maneuver. Normally they should remain relaxed and motionless. Kernig Sign. Flex the patient’s leg at both the hip and the knee, and then slowly extend the leg and straighten the knee. Discomfort behind the knee during full extension is normal but should not produce pain. -Know signs of subarachnoid hemorrhage (p.216 & 268) Severe and sudden headache; N/V; neck stiffness with resistance to flexion -Know which cranial nerve you assess when you touch the soft palate and view of the uvula (p.257) Cranial nerve X (10) Vagus -Know signs of increased intracranial pressure (p.280) Papilledema of optic disc; headache, blurred vision, vomiting, change in LOC, weakness -Olfactory CN I (p.736) -Accessory CN XI (p.740)- test shoulder shrug against resistance -Know what cranial nerve you're assessing when checking lateral gaze (p.716) Cranial nerve VI (6) Abducens
- Vasovagal syncope causes (p.778) Reflex withdrawal of sympathetic tone and increased vagal tone causing drop in BP and HR -Pronator Drift: hold hands out, watch for drifting downwards or pronation over time; indicates an upper motor neuron issue (ie stroke or spinal cord problem)
Chapter 5 - Behavior and Mental Status
-Know what perseveration is when talking about using words repeatedly (p.162)
o Excessive worry persisting over a 6-month period suggests a possible anxiety disorder, one of the most prevalent psychiatric conditions in the United States, with a lifetime prevalence of approximately 3%. -Screening for depression: o For patients with depression or thought disorders such as schizophrenia, take a careful history of their symptoms and course of illness. Watch for mood changes or symptoms such as fatigue, unusual tearfulness, appetite or weight changes, insomnia, and vague somatic complaints. Two validated screening questions for depression are: “Over the past 2 weeks, have you felt down, depressed, or hope- less?” and “Over the past 2 weeks, have you felt little interest or pleasure in doing things?”85 If the patient seems depressed, always ask about suicide: “Have you ever thought about hurting yourself or ending your life?” As with chest pain, you must evaluate severity—both depression and angina are potentially lethal. o High yield screening questions for depression include: Over the past 2 weeks, have you felt down, depressed, or hopeless? Over the past 2 weeks, have you felt little interest or pleasure in doing things (anhedonia)? o A positive test response has a sensitivity of 83% and a specificity of 92% for detecting major depression. 45 All positive screening tests warrant full diagnostic inter-views. Failure to diagnose depression can have fatal consequences—the presence of an affective disorder is associated with an 11-fold increased risk for suicide. -Depressive Disorders: o Depressive and bipolar disorders affect over 9% of the U.S. population. About 16 million adult Americans, or almost 7%, have major depression, often with coexisting anxiety disorders and substance abuse. Depression is nearly twice as common in women as men; the prevalence of postpartum depression is 7% to 13%. Depression frequently accompanies chronic medical illness. High-risk patients may have subtle early signs of depression, o including low self-esteem, loss of pleasure in daily activities (anhedonia), sleep disorders, and difficulty concentrating or making decisions. -Schizophrenia: -Mental status exam:
Chapter 10 - The Breasts and Axillae
-When performing a breast exam, know what abnormal masses should do when the arm moves (p.444) o Fibroadenoma: very mobile o Cysts: Mobile o Cancer: May be fixed to skin or underline tissues; may cause dimpling of skin or retraction when arms are lifted over head or hands are pressed against hips -Know that a high proportion of breast masses are noted during self-exams (p.441) o Most often found by women during self-examination -Know the characteristics of a breast cyst (p.423) o Usually soft to firm, round, mobile and often tender. Most common between the ages of 25- -Know the risk factors for breast cancer (pg. 425) (age is the largest factor) o ***Age: (65+ vs <65 years although risk increases across all ages until age 80) o Biopsy- confirmed atypical hyperplasia o Certain inherited genetic mutations for breast cancer (BRCA1 and/or BRCA2) o Ductal carcinoma in situ o Lobular carcinoma in situ o Personal hx of early onset breast cancer (<40 years) o Two or more 1 st^ degree relatives diagnosed with breast cancer at an early age o Late age of first full term pregnancy o Late menopause o Breast tissue density o Modifiable risk factors: breastfeeding for less than 1year, postmenopausal obesity, use of HRT, cigarette smoking, alcohol ingestion, physical inactivity, and type of contraception. -Know that age is a big risk factor for breast cancer (p.425) o The most important risk factor for breast cancer is age.
-Know what causes dark, blood emesis (p.458) o Hematemesis may accompany esophageal or gastric varices, Mallory-Weiss tears, or peptic ulcer disease. Epistaxis can present as hematemesis due to swallowing blood from nasopharynx.
- Know the differentials for epigastric pain (pg. 455) o GERD, pancreatitis, and perforated ulcers, myocardial ischemia o RUQ and upper abdominal pain are common in cholecystitis and cholangitis o Causes of dk. bloody emesis o Hematemesis may accompany esophageal or gastric varices, Mallory-Weiss tears, or peptic ulcer disease. - Know what to do if you feel an abdominal mass (pg. 487) o Occasionally there are masses in the abdominal wall rather than inside the abdominal cavity. Ask the patient either to raise the head and shoulders or to strain down, thus tightening the abdominal muscles. Feel for the mass again. o Intraabdominal mass is obscured by muscle contraction -Modification of assessment for age: -GERD: o Complaints of heartburn, dysphagia, regurgitation, and epigastric pain. If patients report heartburn and regurgitation together more than once a week, the accuracy of diagnosing GERD is over 90%. These symptoms or mucosal damage on endoscopy are the diagnostic criteria for GERD. Risk factors include reduced salivary flow, which prolongs acid clearance by damping action of the bicarbonate buffer; obesity; delayed gastric emptying; selected medications; and hiatal hernia. o Some patients with GERD have atypical respiratory symptoms such as chest pain, cough, wheezing, and aspiration pneumonia. Others complain of pharyngeal symptoms, such as hoarseness chronic sore throat, and laryngitis. -IBS: o A functional syndrome with a cluster of symptoms, no found cause. Symptoms include: Intermittent pain for 12 weeks of the preceding 12 months with relief from defecation, change in frequency of bowel movements, or change in form of stool (loose, watery, pellet-like), linked to luminal and mucosal irritants that alter motility, secretion, and pain sensitivity. -Ulcerative colitis: o Caused by : Mucosal inflammation typically extending proximally from the rectum (proctitis) to varying lengths of the colon (colitis to pancolitis), with microulcerations and, if chronic, inflammatory polyps. o - Stool: Frequent, watery, often containing blood o - Timing : Onset typically abrupt; often re-current, persisting, and may awaken at night o - Associated Symptoms: Cramping, with urgency, tenesmus; fever, fatigue, weakness; abdominal pain if complicated by toxic megacolon; may include episcleritis, uveitis, arthritis, erythema nodosum o - Population at Risk: Often young adults, Ashkenazi Jewish descendants; linked to altered CD4+ T-cell Th2 response; increases risk of colon cancer -Know the sequence of the abdomen (p.22) o Inspect, auscultate, percuss, palpate o Palpate lightly, then deeply. Assess the liver and spleen by percussion and then palpation. Try to palpate the kidneys. Palpate the aorta and its pulsations. If you suspect kidney infection, percuss posteriorly over the costovertebral angles.
Chapter 13 - Male Genitalia and Hernias
-Know that in a 47-year-old man, erectile dysfunction is usually psychologic rather than testosterone (p.546) o Erectile dysfunction may be from psychogenic causes, especially if early morning erection is preserved. Can also reflect decreased testosterone, decreased flow, impaired neural innervation, and DM. -Know how syphilis presents genitally (p.557)
half will report symptoms such as urinary hesitancy, dribbling, and incomplete emptying. These symptoms can often be traced to other causes like coexisting disease, use of medications, and lower urinary tract abnormalities. -Conditions of penis and testicles: -Tanner staging:
NR 509 Final Study Guide
Chapter 14 - Female Genitalia
-Know what the HPV vaccine protects against (p.577,578) o Prevents infection from HPV subtypes 16, 18, 6 & 11 which cause 90 % of genital warts o The bivalent vaccine prevents infection from subtypes 16 and 18. o Recommended for prevention of cervical, vulvar, and vaginal cancers and precancers in females as well as anal cancer, precancers, and genital warts in both female and males o Vaccinated women should still get cervical cancer screening because vaccines do not prevent all HPV subtypes o Condoms do not eliminate the risk of cervical HPV infection o Recommended for those with compromised immune systems including HIV -Know what bleeding between periods is called (p.570) o Abnormal uterine bleeding, Intermenstrual bleeding o Metrorrhagia -Know types of vaginosis (p.598) o Trichomonal vaginitis : o Cause : Trichomonas vaginalis (a protozoan), often but not always acquired sexually. o Discharge : yellowish, green, or gray, possibly frothy. Often profuse and pooled in the vaginal fornix; may be malodorous. o Other symptoms : Pruritus (not usually as severe as with candida), pain on urination, dyspareunia. o Vuvlva and vaginal mucosa : Vestibule and labia minora may be erythematous; the vaginal mucosa may be diffusely reddened, with small red granular spots or petechiae in the posterior fornix. In mild cases the mucosa looks normal. o Lab eval : Scan saline wet mount for trichomonads o Candidal Vaginitis:
NR 509 Final Study Guide surrounding skin are often inflamed and sometimes swollen to a variable extent. The vaginal mucosa is often reddened with tenacious patches of white discharge -Know the signs of ectopic pregnancy (pg. 603) o Clinical presentations of ectopic pregnancy range from subacute, approx. 80-89%, to shock from rupture and intraperitoneal hemorrhage (10-30% of cases). Most common clinical features: abdominal pain, adnexal tenderness, and abnormal uterine bleeding. In more than half there is a palpable adnexal mass that is typically large, fixed, and ill-defined at times with adherent omentum or small or large bowel. In milder cases, there may be a prior history of amenorrhea or other symptoms of pregnancy. -Female STI: pg 574, 579 o Local symptoms or findings on physical examination may raise the possibility of STIs (also referred to as sexually transmitted diseases [STDs]). After establishing the seven attributes of any symptoms, elicit the patient’s sexual history. Inquire about sexual contacts and establish the number of sexual partners in the past 3 to 6 months. Ask if the patient has concerns about human immunodeficiency virus (HIV) infection, desires HIV testing, or has current or past partners at risk. Also ask about oral and anal sex and, if indicated, about symptoms involving the mouth, throat, anus, and rectum. Review the past history of STIs. -Cervical disorders: pg 600 -Cervical cancer screening (pg 576)
Chapter 15 - The Anus, Rectum, and Prostate
-Know what to be concerned about if you note an irregular rectal mass (p.618) o Any masses with irregular borders suspicious for rectal cancer o A tender purulent reddened mass with fever or chills suggests an anal abscess. Abscesses tunneling to the skin surface from the anus or rectum may form a clogged or draining ano-rectal fistula. Fistulas may ooze blood, pus, or feculent mucus. Consider anoscopy or sigmoidoscopy for better visualization. -Know the signs of proctitis (p.609) o Anorectal pain, itching, tenesmus , or discharge or bleeding from infection or rectal abscess suggest proctitis o anal fissures -Know the sign factors for of prostate cancer (p.610) o Risk factors: age: rare in ages below 40 but incidence rates begin increasing rapidly after age 50. Median age at diagnosis is 66. o Ethnicity: African American men have the highest incidence and mortality rates. Compared to white men, a higher percentage of African American men are diagnosed with prostate cancer before age
- They are also more likely to present with advanced-stage cancer. o Family history: Genetics appear to play an important role in prostate cancer risk. For men with one affected first degree relative (father, brother) risk of developing prostate cancer increases two-fold. For men with 2 or 3 affected first degree relatives, risk increases 5-11-fold. The BRCA1 and BRCA mutations also appear to confer increased risk of prostate cancer. o Other risk factors: Agent Orange exposure among Vietnam veterans, diets high in animal fat, obesity, and cigarette smoking. BPH is NOT a risk factor -Know the signs of prostatitis (pg. 623)
