Exam 1 Physical Diagnosis Objectives

From Iusmicm

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*Note, much borrowed from generous, previous IUSM medical students.
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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===
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*Apply the guidelines for using a medical interpreter when a medical interpreter is needed for a patient interview.
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**need to be trained in med. Terminology
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**same sex and age as patient
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**establish an approach with interpreter before talking to patient
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**speak and look at patient
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**do not expect word for word translation
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**ask interpreter about patient fears and expectations
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**use short questions
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**use simple language
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**keep explanations brief
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**avoid using "if", "would" and "could" questions and statements
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**avoid idiomatic expressions
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*Define the “rule of 5 vowels” and use the 5 vowels in a patient interview.
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**AEIOU: audition, evaluation, inquiry, observation, understanding
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**audition: listen to story
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**evaluation: determine what is relevant
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**inquiry: ask appropriate questions
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**observation: importance of non-verbal communication
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**understanding: show empathy and signs that you understand and care
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*Recognize the difference between a “symptom” and a “sign”.
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**A symptom is what a pt feels.
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**A sign is what a physician detects.
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*Select the appropriate terminology and questions to begin a medical interview.
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**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.
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**Start with open ended questions, focus down with direct questions.
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*Apply the use of direct questions when conducting a patient interview.
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**ROS should be demarked with a transition statement explaining that you're not looking for simple yes or no answers.
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**Follow positive ROS responses with open ended and OPQRST questions.
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*Discriminate patient symptoms using the O-P-Q-R-S-T mnemonic.
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**OPQRST:
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***onset (time, activity);
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***provoke / palliate (what makes it worse or better);
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***quality (characteristics like blurry, sharp, burning, deep, etc.);
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***radiation (does the symptom occur anywhere else or associate with any other symptom);
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***severity (1-10);
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***timeline
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**CLOSER:
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***characteristics (quality, severity)
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***location (and radiation)
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***onset (and duration)
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***symptoms associated
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***exacerbating factors
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***relieving factors
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*Discriminate which questions to avoid and not use when interviewing a patient.
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**Avoid rapid-fire questions; "have you lost or gained weight or had any nausea or vomitting?"
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**Avoid medical jargon; "where you tachypnic when the pain started?"
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**Avoid leading or biased questions; "you don't have any heart problems do you?"
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*Describe the parts of the medical history and include each part when writing a medical history.
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**Chief complaint
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**History of Present Illness
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**Past Medical History
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**Social History
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**Family History
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**Psychosocial and Spiritual History
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**Sexual and Reproductive History
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**Review of Systems
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===Chapter 2===
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*Describe the various responses to illness in a patient.
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**There are several major responses to illness, including: anxiety, depression, denial, projection, and regression.
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**Anxiety: characterized by uneasiness and a sense of impending danger
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**Depression: a chronic state of lowered mood
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***The most common reaction to illness and perhaps the most overlooked.
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***20% of pts with major illnesses express depression (especially cancer pts).
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***Noted by brief answers, slow speech, and low volume.
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***Thoughts are negative, with lots of (perceived) inadequacy, defeat, and worthlessness.
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**Denial: acting and thinking a part of reality is not true.
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***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.
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***The more acute the illness, the less room for denial; the more insidious the illness, the more denial.
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***May need to interview a reliable informant when denial is so severe accurate answers cannot be secured.
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**Projection: perceiving one's own emotions in another being
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***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).
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***A danger for the Doctor-Pt relationship.
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**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.
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***Regression is a defense mechanism.
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*Describe the variety of patient types and how to approach them during an interview.
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**Silent
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***Characteristics: shy, insecure, easily embarrassed normally or silent from fear of illness.  May be depressed.
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***Approach: Use directed questions, not open-ended.
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**Over-talkative
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***Characteristics:
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***Approach: use courteous interruption followed by another direct question. Avoid open-ended questions. 
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**Seductive:
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***Characteristics: many have personality disorder and have fantasy of intimacy with doctor.
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***Approach: Keep empathy and reassurance to minimum.  Keep professional distance.
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**Angry
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***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.
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**Paranoid
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***Characteristics: Reassurance tends to be threatening.
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***Approach: Complete questioning and don’t try to convince about false ideations.  Avoid any anger.
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**Insatiable
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***Character: never satisfied.
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***Approach: Handle with firm, noncondescending approach.  Use definite closing statement.
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**Ingratiating
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***Character: attempts to please interviewer.
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***Approach: Try to give “right” answer.  Stress importance of accuracy
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**Aggressive
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***Character: often has personality disorder, easily irritated and can fly into rage.
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***Approach: Stay away from provoking anxiety early and establish rapport.
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**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.
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***Approach: Use strong emotional support and gentile reasoning
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**Demanding
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***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.
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***Approach: Provide firm boundaries, elicit and set clear expectations.
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**Compulsive
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***Character: concerned about every detail, use projection
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***Approach: Provide detailed and specific info in a straight forward way
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**Dependent
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***Character: finds life hard without help.  Need to care for closely, but they can take advantage of doctors by demanding time.
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***Approach: Be direct about limits without leaving rejected.
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**Masochistic
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***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.
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***Approach: Don’t promise cures, attend to all aspects of illness.
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**Borderline
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***Character: personality disorder with instability, splitting, impulsiveness and unstable moods.  Are always afraid, but may mask with anger.
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***Approach: Use lots of reassuring words.
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*Describe how disease can influence the type of patient response.
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**Disabled
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***Theme is mistrust of healthcare; response is assurance.
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***Sort out emotional problems for physical ones.
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***Smile and nice words help them cooperate.
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***Don’t like their routines changed.
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***If hearing impaired sit in front so they can read your lips or speak louder, write things down if needed. 
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***If vision impaired: occasionally touch patient’s arm so they know where you are.  Avoid non-verbals. 
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***Developmentally delayed need guardian to give history.
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**Cancer
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***-5 major concerns: loss of control, pain, alienation, mutilation and mortality.
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***Doctor may be afraid of patient’s questions about death and patient feels rejected.
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***Doctor needs to recognize their limitations.
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***Allow patient to vent and promote dialogue.
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**AIDS
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***Fearful for life and being stigmatized which may result in delay of seeking care.
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***Denial is important and may fear doctors.
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***Fear worsened by anxiety of health care workers who care for them.
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***Unsympathetic rejection of AIDS patients leading to anxiety, hostility and depression.
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***Be supportive with out false sense of hope.
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***Give facts and make sure staff is educated.
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**Dyphasic
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***Impairment of speech and can’t arrange words correctly.
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***Always assume patient is aware if talking with them in the room.
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***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.
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***May have hallucinations and delusions.
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***Remain calm and get assistance if violent episode.
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***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").
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***Fear is common.  Be sensitive and allay their fears.  Avoid question that may seem threatening to them.
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***Need mental status exam.
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***History may not reliable.
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**Acutely Ill
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***Need concise history and physical.
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***May need to interview while doing exam.
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***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.
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***Lack of communication from surgeon makes worse.
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***Depression if loss of body part.
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***Allow time to release tension and feelings of loss during interview
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**Alcoholic
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***Feel castigated and alone.  Alcohol is only friend.
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***Often ready to talk and may have low self esteem.
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***May be self destructive. May have fears of sexual inadequacy or homosexuality.
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**Psychosomatic
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***Psychological problems create physical ailments.
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***May be unaware of emotional distress.
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***Identify disorder, teach patient to cope with psych problems.
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***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.
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***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.
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***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.
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****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.
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# Give a differential diagnosis based on symptoms and/or physical exam findings pertaining to the eye.
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===Chapter 11===
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====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.
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# Interpret the symptoms of diseases of the ear and apply them clinically to a patient.
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# 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.
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# Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings of the ear.
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====Nose====
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# Describe the structure of the nose.
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# Illustrate how the major symptoms of nose diseases are used to identify nose diseases.
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# Interpret the symptoms related to the nose and apply them clinically to a patient.
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# Apply the components of the physical exam of the nose to a patient.
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# Clinically correlate the symptoms and physical exam findings pertaining to the nose for the following disease processes: allergic rhinitis, sinusitis, and nonallergic rhinitis.
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# Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings of the nose.
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===Chapter 12===
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*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.
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***Crusting when bullae break.
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**Chancre
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***Painless, single lesion on lips or tongue.
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***Lesion w/o central necrotic material.
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***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)
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***Erythroplakia of mouth floor and soft palate.
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***Raised border, absence of necrotic material in crater.
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***May have painless lymphadenopathy in neck.
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**Candidiasis
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***Burning tongue, inside of cheek or throat.
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***Whitish pseudomembrane.
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***Peeled off to reveal raw, red area that may bleed.
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**Erythroplakia
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***Painless, red area.
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***Granular, red papules that bleed.
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**Leukoplakia
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***Painless, white area.
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***Hyperkeratinized.  Can’t be scraped off.
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***Looks like flaking white paint.  Often speckled w/ red spots.
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***If associated with adenopathy, could be malignancy.
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**Lipoma
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***Painless mass on inner surface of cheek or tongue.
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***Yellowish, soft, freely mobile.
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**Lichen planus
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***Usually no symptoms.
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***Erosive form causes burning sores on inner cheeks and tongue.
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***White reticulated papules bilaterally in lace-like pattern.
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***Erosive form is hemorrhagic, ulcerated w/ possible white areas or bullae.
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***May have pseudomembrane covering.
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**Mucocele
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***Intermittent painless swelling of lower lip, or inside cheek.
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***Slightly bluish.
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***Dome-shaped, freely-mobile cystic lesion.
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**Hairy Tongue
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***Gagging sensation.
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***Large brown or black painless lesion on top of tongue.
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***Elongation of filiform papillae and color change.
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===Chapter 13===
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#Describe the topographical landmarks of the chest and utilize that knowledge to describe physical findings of the chest.
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#Recognize the main symptoms of pulmonary disease and how these symptoms can identify disease.
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#Interpret the symptoms of pulmonary disease and apply them clinically to a patient.
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#Apply the components of the physical exam of the chest to a patient.
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#Clinically correlate the symptoms and physical exam findings pertaining to the chest:
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##Pulmonary Edema
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##Pneumothorax
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##Asthma
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##Pneumonia
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##Emphysema
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##Pulmonary Embolism
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##Pleural Effusion
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#Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings of the chest.
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===Chapter 17===
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# Describe the topographical landmarks of the abdomen and utilize that knowledge to describe physical findings of the abdomen.
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# Recognize where abdominal structures are located by topographical quadrants of the abdomen.
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# Recognize the main symptoms of abdominal disease and how these symptoms can identify disease.
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# Interpret the symptoms of abdominal disease and apply them clinically to a patient.
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# Apply the components of the physical examination of the abdomen to a patient.
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# Clinically correlate the symptoms and physical exam findings pertaining to the abdomen.
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# Generate a diagnosis and/or differential diagnosis based on symptoms and/or physical exam findings.
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Current revision as of 20:39, 2 September 2015

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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