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- | *Note, much borrowed from generous, previous IUSM medical students.
| + | b5muSQ You are my breathing in, I own few web logs and occasionally run out from brand . Analyzing humor is like dissecting a frog. Few people are interested and the frog dies of it. by E. B. White. |
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- | ===Chapter 1===
| + | |
- | *Apply the guidelines for using a medical interpreter when a medical interpreter is needed for a patient interview.
| + | |
- | **need to be trained in med. Terminology
| + | |
- | **same sex and age as patient
| + | |
- | **establish an approach with interpreter before talking to patient
| + | |
- | **speak and look at patient
| + | |
- | **do not expect word for word translation
| + | |
- | **ask interpreter about patient fears and expectations
| + | |
- | **use short questions
| + | |
- | **use simple language
| + | |
- | **keep explanations brief
| + | |
- | **avoid using "if", "would" and "could" questions and statements
| + | |
- | **avoid idiomatic expressions
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- | | + | |
- | *Define the “rule of 5 vowels” and use the 5 vowels in a patient interview.
| + | |
- | **AEIOU: audition, evaluation, inquiry, observation, understanding
| + | |
- | **audition: listen to story
| + | |
- | **evaluation: determine what is relevant
| + | |
- | **inquiry: ask appropriate questions
| + | |
- | **observation: importance of non-verbal communication
| + | |
- | **understanding: show empathy and signs that you understand and care
| + | |
- | | + | |
- | *Recognize the difference between a “symptom” and a “sign”.
| + | |
- | **A symptom is what a pt feels.
| + | |
- | **A sign is what a physician detects.
| + | |
- | | + | |
- | *Select the appropriate terminology and questions to begin a medical interview.
| + | |
- | **Greet with your name, ask their name, make eye contact, shake hands, smile, state your purpose and intent.
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- | | + | |
- | *Apply the use of open-ended questions when conducting a medial interview.
| + | |
- | **Start with open ended questions, focus down with direct questions.
| + | |
- | | + | |
- | *Apply the use of direct questions when conducting a patient interview.
| + | |
- | **ROS should be demarked with a transition statement explaining that you're not looking for simple yes or no answers.
| + | |
- | **Follow positive ROS responses with open ended and OPQRST questions.
| + | |
- | | + | |
- | *Discriminate patient symptoms using the O-P-Q-R-S-T mnemonic.
| + | |
- | **OPQRST:
| + | |
- | ***onset (time, activity);
| + | |
- | ***provoke / palliate (what makes it worse or better);
| + | |
- | ***quality (characteristics like blurry, sharp, burning, deep, etc.);
| + | |
- | ***radiation (does the symptom occur anywhere else or associate with any other symptom);
| + | |
- | ***severity (1-10);
| + | |
- | ***timeline
| + | |
- | **CLOSER:
| + | |
- | ***characteristics (quality, severity)
| + | |
- | ***location (and radiation)
| + | |
- | ***onset (and duration)
| + | |
- | ***symptoms associated
| + | |
- | ***exacerbating factors
| + | |
- | ***relieving factors
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- | | + | |
- | *Discriminate which questions to avoid and not use when interviewing a patient.
| + | |
- | **Avoid rapid-fire questions; "have you lost or gained weight or had any nausea or vomitting?"
| + | |
- | **Avoid medical jargon; "where you tachypnic when the pain started?"
| + | |
- | **Avoid leading or biased questions; "you don't have any heart problems do you?"
| + | |
- | | + | |
- | *Describe the parts of the medical history and include each part when writing a medical history.
| + | |
- | **Chief complaint
| + | |
- | **History of Present Illness
| + | |
- | **Past Medical History
| + | |
- | **Social History
| + | |
- | **Family History
| + | |
- | **Psychosocial and Spiritual History
| + | |
- | **Sexual and Reproductive History
| + | |
- | **Review of Systems
| + | |
- | | + | |
- | ===Chapter 2===
| + | |
- | *Describe the various responses to illness in a patient.
| + | |
- | **There are several major responses to illness, including: anxiety, depression, denial, projection, and regression.
| + | |
- | **Anxiety: characterized by uneasiness and a sense of impending danger
| + | |
- | **Depression: a chronic state of lowered mood
| + | |
- | ***The most common reaction to illness and perhaps the most overlooked.
| + | |
- | ***20% of pts with major illnesses express depression (especially cancer pts).
| + | |
- | ***Noted by brief answers, slow speech, and low volume.
| + | |
- | ***Thoughts are negative, with lots of (perceived) inadequacy, defeat, and worthlessness.
| + | |
- | **Denial: acting and thinking a part of reality is not true.
| + | |
- | ***Recall that denial is a defense mechanism used to guard against an inner tension that causes anxiety. Denial prevents the turmoil from producing overt anxiety.
| + | |
- | ***The more acute the illness, the less room for denial; the more insidious the illness, the more denial.
| + | |
- | ***May need to interview a reliable informant when denial is so severe accurate answers cannot be secured.
| + | |
- | **Projection: perceiving one's own emotions in another being
| + | |
- | ***Recall that projection is a defense mechanism that guards against an inner tension and manifests as the pt perceiving their own emotion in the interviewer (fear, anger, for example).
| + | |
- | ***A danger for the Doctor-Pt relationship.
| + | |
- | **Regression: an unconscious return to an earlier stage of physical or emotional development in which the pt was free from the demands of disease and was often gratified.
| + | |
- | ***Regression is a defense mechanism.
| + | |
- | | + | |
- | *Describe the variety of patient types and how to approach them during an interview.
| + | |
- | **Silent
| + | |
- | ***Characteristics: shy, insecure, easily embarrassed normally or silent from fear of illness. May be depressed.
| + | |
- | ***Approach: Use directed questions, not open-ended.
| + | |
- | **Over-talkative
| + | |
- | ***Characteristics:
| + | |
- | ***Approach: use courteous interruption followed by another direct question. Avoid open-ended questions.
| + | |
- | **Seductive:
| + | |
- | ***Characteristics: many have personality disorder and have fantasy of intimacy with doctor.
| + | |
- | ***Approach: Keep empathy and reassurance to minimum. Keep professional distance.
| + | |
- | **Angry
| + | |
- | ***Approach: Realize reactions are to illness and not personal. Confront about anger and allow to vent, proceed slow, avoid interpretations and ask questions about present illness.
| + | |
- | **Paranoid
| + | |
- | ***Characteristics: Reassurance tends to be threatening.
| + | |
- | ***Approach: Complete questioning and don’t try to convince about false ideations. Avoid any anger.
| + | |
- | **Insatiable
| + | |
- | ***Character: never satisfied.
| + | |
- | ***Approach: Handle with firm, noncondescending approach. Use definite closing statement.
| + | |
- | **Ingratiating
| + | |
- | ***Character: attempts to please interviewer.
| + | |
- | ***Approach: Try to give “right” answer. Stress importance of accuracy
| + | |
- | **Aggressive
| + | |
- | ***Character: often has personality disorder, easily irritated and can fly into rage.
| + | |
- | ***Approach: Stay away from provoking anxiety early and establish rapport.
| + | |
- | **Help-rejecting
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- | ***Character: seen many experts and no one can figure out what is wrong. Return saying suggestions didn’t work. New symptoms appear after one goes away. Blame “illness” for disappointments.
| + | |
- | ***Approach: Use strong emotional support and gentile reasoning
| + | |
- | **Demanding
| + | |
- | ***Character: Use intimidation and guilt to force others to take care of them. See self as neglected, may have outburst of anger and have power struggle with doctor.
| + | |
- | ***Approach: Provide firm boundaries, elicit and set clear expectations.
| + | |
- | **Compulsive
| + | |
- | ***Character: concerned about every detail, use projection
| + | |
- | ***Approach: Provide detailed and specific info in a straight forward way
| + | |
- | **Dependent
| + | |
- | ***Character: finds life hard without help. Need to care for closely, but they can take advantage of doctors by demanding time.
| + | |
- | ***Approach: Be direct about limits without leaving rejected.
| + | |
- | **Masochistic
| + | |
- | ***Character: go thru life suffering mentally, but don’t seek physical abuse or pain. Feel they self-sacrifice and handle illness well, but may feel threatened by recovery.
| + | |
- | ***Approach: Don’t promise cures, attend to all aspects of illness.
| + | |
- | **Borderline
| + | |
- | ***Character: personality disorder with instability, splitting, impulsiveness and unstable moods. Are always afraid, but may mask with anger.
| + | |
- | ***Approach: Use lots of reassuring words.
| + | |
- | | + | |
- | *Describe how disease can influence the type of patient response.
| + | |
- | **Disabled
| + | |
- | ***Theme is mistrust of healthcare; response is assurance.
| + | |
- | ***Sort out emotional problems for physical ones.
| + | |
- | ***Smile and nice words help them cooperate.
| + | |
- | ***Don’t like their routines changed.
| + | |
- | ***If hearing impaired sit in front so they can read your lips or speak louder, write things down if needed.
| + | |
- | ***If vision impaired: occasionally touch patient’s arm so they know where you are. Avoid non-verbals.
| + | |
- | ***Developmentally delayed need guardian to give history.
| + | |
- | **Cancer
| + | |
- | ***-5 major concerns: loss of control, pain, alienation, mutilation and mortality.
| + | |
- | ***Doctor may be afraid of patient’s questions about death and patient feels rejected.
| + | |
- | ***Doctor needs to recognize their limitations.
| + | |
- | ***Allow patient to vent and promote dialogue.
| + | |
- | **AIDS
| + | |
- | ***Fearful for life and being stigmatized which may result in delay of seeking care.
| + | |
- | ***Denial is important and may fear doctors.
| + | |
- | ***Fear worsened by anxiety of health care workers who care for them.
| + | |
- | ***Unsympathetic rejection of AIDS patients leading to anxiety, hostility and depression.
| + | |
- | ***Be supportive with out false sense of hope.
| + | |
- | ***Give facts and make sure staff is educated.
| + | |
- | **Dyphasic
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- | ***Impairment of speech and can’t arrange words correctly.
| + | |
- | ***Always assume patient is aware if talking with them in the room.
| + | |
- | ***Give patient pen and paper and or ask yes / no questions.
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- | **Psychotic
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- | ***Impaired reality testing abilities and can’t communicate effectively.
| + | |
- | ***May have hallucinations and delusions.
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- | ***Remain calm and get assistance if violent episode.
| + | |
- | ***May have Munchausen’s and be malingerers.
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- | ***Many self injure.
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- | **Demented or Delirious
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- | ***Demented are more confused out of their environment especially at night ("sundowning").
| + | |
- | ***Fear is common. Be sensitive and allay their fears. Avoid question that may seem threatening to them.
| + | |
- | ***Need mental status exam.
| + | |
- | ***History may not reliable.
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- | **Acutely Ill
| + | |
- | ***Need concise history and physical.
| + | |
- | ***May need to interview while doing exam.
| + | |
- | ***Finish interview after stable.
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- | **Surgical
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- | ***Frightened even if calm appearance.
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- | ***Feel helpless and out of control.
| + | |
- | ***Lack of communication from surgeon makes worse.
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- | ***Depression if loss of body part.
| + | |
- | ***Allow time to release tension and feelings of loss during interview
| + | |
- | **Alcoholic
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- | ***Feel castigated and alone. Alcohol is only friend.
| + | |
- | ***Often ready to talk and may have low self esteem.
| + | |
- | ***May be self destructive. May have fears of sexual inadequacy or homosexuality.
| + | |
- | **Psychosomatic
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- | ***Psychological problems create physical ailments.
| + | |
- | ***May be unaware of emotional distress.
| + | |
- | ***Identify disorder, teach patient to cope with psych problems.
| + | |
- | ***Somatization is unconscious and patients are really suffering. Acknowledge their suffering is real. Never say problem is in your head.
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- | ***Use open ended questions to get insight.
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- | **Dying
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- | ***Conscious of taking up doctor’s time and will start asking fewer questions.
| + | |
- | ***Don’t avoid dying patients because of own fears.
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- | ***Many fear process of dying more than death.
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- | ***May have anger or guilt or resentment.
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- | ***Envy healthy and deny imminent death.
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- | ***May deny disease even when asked directly.
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- | ***Most reach acceptance which may include apathy and withdraw.
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- | ***Dying patient needs to talk to someone.
| + | |
- | ***Appropriate response to an expression of grief may be period of silence.
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- | | + | |
- | ===Chapter 7===
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- | *Describe the “Four Principles of Physical Examination”, their importance, and clinical application.
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- | **Four principles are inspection, palpitation, percussion, and auscultation.
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- | *Describe what the examiner should observe while taking a history and how to apply clinically when evaluating a patient.
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- | **General appearance: state of consciousness and personal grooming, distress? Groggy? Alert? Clean?
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- | **State of nutrition: sunken eyes, temporal wasting, loose skin, thin, frail
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- | **Body habitus:
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- | ***Asthenic: a condition of weakness, feebleness, or loss of vitality
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- | ***Ectomorphic characterized by a lean slender body build with slight muscular development
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- | ***Mesomorph: intermediate to asthenic and ectomorphic
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- | ***Hypersthenic or endomorphic: is short, round with good muscles, but weight problem
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- | **Symmetry
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- | **Posture and gait: foot drag? Shuffle?, limp?
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- | **Speech: slurred? Appropriate words? Hoarse? High pitched?
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- | *Apply the “preparations for the physical examination” clinically when evaluating a patient.
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- | **Have all necessary equipment and place at bedside
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- | **Close curtains for exam
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- | **Wash hands – lather 10 seconds or use alcohol product in no visible soilage
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- | **Have patient wear gown
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- | **Do in order that requires least movement of patient
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- | **Perform exam from right side of patient
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- | **Expose only areas that are being examined at that time
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- | **Continue speaking to patient during exam
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- | *Discriminate which comments to refrain from when performing the physical examination.
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- | **Avoid using "that's good", "normal", and "that's fine" as they may have unintended consequences with regard the pt's perception.
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- | *Apply the precautionary guidelines for health-care workers from the CDC and OSHA and how to apply them when examining a patient.
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- | **Use gloves when doing physical exam or handling blood soiled or body fluid sheets
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- | **Wear gloves with patients with exudative lesions or weeping dermitis
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- | **Use fluid resistant gowns, masks and eye covers when doing procedures
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- | **Wash hands immediately if accidently soiled with blood or body fluids
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- | **All sharps must be handled with care
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- | **Don’t re-cap needles and dispose in puncture resistant containers
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- | **Use mouthpieces for mouth to mouth
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- | **Handle blood and body fluid samples with gloves
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- | **Clean and decontaminant soiled surfaces with disinfectant
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- | **Process reusable items according to recommendations
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- | **If sharps injury or exposure to blood or body fluid clean area immediately and report
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- | **All heath care workers should have Hep B vaccine
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- | **Responsibility of health care worker not to transmit their disease to patient
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- | ===Chapter 9===
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- | *Describe and recognize common symptoms of diseases involving the neck: neck mass and neck stiffness.
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- | **Two most common physical findings are masses and stiffness.
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- | *Interpret the signs and symptoms of diseases involving the neck: neck mass and neck stiffness.
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- | **If there is associated pain with a mass in the neck, an acute infection is likely.
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- | **Consider the age of the patient:
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- | ***Thyroglossal cyst occurs with patients under the age of 20, while thyroid disease occurs in older patients
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- | **Consider the location of the mass:
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- | ***Lateral masses are more commonly neoplastic
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- | ***Midline masses are not associated with neoplasms but hyperplasia
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- | ***Superior masses correlate with head / neck tumors
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- | ***Inferior masses correlate with breast / stomach masses
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- | **Neck stiffness is usually cause by spasm of the cervical muscles and commonly causes tension headaches.
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- | **Depression is a common symptom of head and neck disease.
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- | *Apply the components of the physical exam of the neck to a patient.
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- | **No special equipment is required, and the patient is seated facing the examiner
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- | **Inspection: position, scalp, masses, eyes, veins, nodularity
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- | **Auscultation for carotid bruits
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- | **Palpation: along muscles and major lymph node tracts using pads of fingers from posterior to anterior; thyroid gland
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- | *Clinically correlate the symptoms and physical findings for the following disease processes: hyperthyroidism, hypothyroidism, thyroid nodules.
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- | **Inspection:
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- | ***Proptosis: forward displacement of the eyes from thyroid dysfunction or orbital mass
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- | ***Thyromegaly: Graves’ disease causes bilateral proptosis and thyromegaly
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- | ***Thyroglossal duct cysts: are smooth, firm and midline
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- | ***Venous distention and nodularity may be associated with a goiter
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- | **Palpation:
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- | ***Tender nodes are associated with inflammation, whereas firm nodes are associated with malignancy
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- | ***Thyroid
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- | ****Two methods for palpating the thyroid: anterior and posterior
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- | ****Rarely felt in it's healthy state.
| + | |
- | ****Hardness is associated with cancer or scarring
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- | ****Tenderness is associated with acute infections or hemorrhage
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- | ****Enlargement warrants auscultation
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- | ****A to-and-fro bruit of the superior pole highly suggests a toxic goiter
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- | ***Supraclavicular nodes: important; enlarged nodes can be felt with inspiration
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- | *Using the symptoms and / or physical exam findings pertaining to the neck, generate a diagnosis and a differential diagnosis.
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- | **Grave’s Disease: proptosis, heat intolerance, hyperhidrosis, anxiety, insomnia, hyperpigmentation, palpitations, sweats, erythema, etc.
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- | **Plummer’s Disease: toxic adenomatous goiter – frequently see atrial fibrillation
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- | **Malignant thyroid nodule: male, one nodule, no FHx, change in voice, prior radiation for H/N
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- | **Benign nodule: female, >1 nodule, FHx of benign thyroid disease, no voice change
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- | **Hypothyroidism: weight gain, fatigue, chilly, lethargy
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- | ===Chapter 10===
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- | # Describe the actions and innervations of the eye and extraocular muscles.
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- | # Identify the major symptoms of eye disease.
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- | # Interpret the symptoms of the major diseases of the eye and apply them clinically to a patient: loss of vision, eye pain, diplopia, tearing or dryness, discharge, and redness.
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- | # Apply the components of the physical examination of the eye to a patient.
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- | # Clinically correlate the symptoms and physical exam findings pertaining to the eye for the following disease processes: visual field defect, red eye (acute conjunctivitis, acute iritis, narrow-angle glaucoma, and corneal abrasion), diabetes, hypertension, and papilledema.
| + | |
- | # Give a differential diagnosis based on symptoms and/or physical exam findings pertaining to the eye.
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- | | + | |
- | ===Chapter 11===
| + | |
- | ====Ear====
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- | # Describe the structure and innervations of the ear.
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- | # Identify the major symptoms of ear disease and how these symptoms can identify diseases involving the ear: hearing loss, vertigo, tinnitus, otorrhea, otalgia, and itching.
| + | |
- | # Interpret the symptoms of diseases of the ear and apply them clinically to a patient.
| + | |
- | # Apply the components of the physical exam of the ear to a patient.
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- | # Clinically correlate the symptoms and physical exam findings pertaining to the ear for the following disease processes: conductive and sensorineural hearing loss, otitis media. Serous otitis media, otitis externa, and vertigo.
| + | |
- | # Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings of the ear.
| + | |
- | ====Nose====
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- | # Describe the structure of the nose.
| + | |
- | # Illustrate how the major symptoms of nose diseases are used to identify nose diseases.
| + | |
- | # Interpret the symptoms related to the nose and apply them clinically to a patient.
| + | |
- | # Apply the components of the physical exam of the nose to a patient.
| + | |
- | # Clinically correlate the symptoms and physical exam findings pertaining to the nose for the following disease processes: allergic rhinitis, sinusitis, and nonallergic rhinitis.
| + | |
- | # Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings of the nose.
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- | ===Chapter 12===
| + | |
- | *Know the structures of the oral cavity and pharynx.
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- | **http://media-3.web.britannica.com/eb-media/91/74891-004-345232AC.jpg
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- | **http://4.bp.blogspot.com/_hL0QrZsPcvY/SaP_z9urWaI/AAAAAAAAAYM/Djf9xDzyaes/s400/or4.gif
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- | | + | |
- | *Know the functions of the pharynx.
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- | **Subdivisions: nasopharynx, oropharynx, hypopharynx.
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- | **Fxn: provides swallowing, speech, and an airway.
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- | | + | |
- | *Know the important symptoms of disease of the oral cavity.
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- | **Ulceration, bleeding, mass, halitosis, xerostomia (dry mouth).
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- | *Apply the components of the physical exam of the oral cavity and pharynx to a patient.
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- | **See cd.
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- | | + | |
- | *Clinically correlate the signs and symptoms of the following conditions:
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- | **Aphthous ulcer
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- | ***Single canker sore. Most common acute oral ulcer.
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- | ***Relatively superficial w/ raised borders. On buccal or labial mucosa.
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- | **Herpetic ulcer
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- | ***acute multiple ulcers, associated w/ vesicles.
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- | ***On mucocutaneous junction, hard palate, or gingivae.
| + | |
- | ***Crusting when bullae break.
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- | **Chancre
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- | ***Painless, single lesion on lips or tongue.
| + | |
- | ***Lesion w/o central necrotic material.
| + | |
- | ***May have tender lymphadenitis.
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- | **Squamous cell carcinoma:
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- | ***Single indurated sore on lips, tongue, mouth floor, or tongue (esp. on lateral borders)
| + | |
- | ***Erythroplakia of mouth floor and soft palate.
| + | |
- | ***Raised border, absence of necrotic material in crater.
| + | |
- | ***May have painless lymphadenopathy in neck.
| + | |
- | **Candidiasis
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- | ***Burning tongue, inside of cheek or throat.
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- | ***Whitish pseudomembrane.
| + | |
- | ***Peeled off to reveal raw, red area that may bleed.
| + | |
- | **Erythroplakia
| + | |
- | ***Painless, red area.
| + | |
- | ***Granular, red papules that bleed.
| + | |
- | **Leukoplakia
| + | |
- | ***Painless, white area.
| + | |
- | ***Hyperkeratinized. Can’t be scraped off.
| + | |
- | ***Looks like flaking white paint. Often speckled w/ red spots.
| + | |
- | ***If associated with adenopathy, could be malignancy.
| + | |
- | **Lipoma
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- | ***Painless mass on inner surface of cheek or tongue.
| + | |
- | ***Yellowish, soft, freely mobile.
| + | |
- | **Lichen planus
| + | |
- | ***Usually no symptoms.
| + | |
- | ***Erosive form causes burning sores on inner cheeks and tongue.
| + | |
- | ***White reticulated papules bilaterally in lace-like pattern.
| + | |
- | ***Erosive form is hemorrhagic, ulcerated w/ possible white areas or bullae.
| + | |
- | ***May have pseudomembrane covering.
| + | |
- | **Mucocele
| + | |
- | ***Intermittent painless swelling of lower lip, or inside cheek.
| + | |
- | ***Slightly bluish.
| + | |
- | ***Dome-shaped, freely-mobile cystic lesion.
| + | |
- | **Hairy Tongue
| + | |
- | ***Gagging sensation.
| + | |
- | ***Large brown or black painless lesion on top of tongue.
| + | |
- | ***Elongation of filiform papillae and color change.
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- | | + | |
- | | + | |
- | ===Chapter 13===
| + | |
- | #Describe the topographical landmarks of the chest and utilize that knowledge to describe physical findings of the chest.
| + | |
- | #Recognize the main symptoms of pulmonary disease and how these symptoms can identify disease.
| + | |
- | #Interpret the symptoms of pulmonary disease and apply them clinically to a patient.
| + | |
- | #Apply the components of the physical exam of the chest to a patient.
| + | |
- | #Clinically correlate the symptoms and physical exam findings pertaining to the chest:
| + | |
- | ##Pulmonary Edema
| + | |
- | ##Pneumothorax
| + | |
- | ##Asthma
| + | |
- | ##Pneumonia
| + | |
- | ##Emphysema
| + | |
- | ##Pulmonary Embolism
| + | |
- | ##Pleural Effusion
| + | |
- | #Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings of the chest.
| + | |
- | | + | |
- | ===Chapter 17===
| + | |
- | # Describe the topographical landmarks of the abdomen and utilize that knowledge to describe physical findings of the abdomen.
| + | |
- | # Recognize where abdominal structures are located by topographical quadrants of the abdomen.
| + | |
- | # Recognize the main symptoms of abdominal disease and how these symptoms can identify disease.
| + | |
- | # Interpret the symptoms of abdominal disease and apply them clinically to a patient.
| + | |
- | # Apply the components of the physical examination of the abdomen to a patient.
| + | |
- | # Clinically correlate the symptoms and physical exam findings pertaining to the abdomen.
| + | |
- | # Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings.
| + | |
b5muSQ You are my breathing in, I own few web logs and occasionally run out from brand . Analyzing humor is like dissecting a frog. Few people are interested and the frog dies of it. by E. B. White.