NRSG 312
EXAMINATION #2 Study Guide Outline
Know the steps of how to perform each physical assessment examination
Know anatomy of each system
HEART AND GREAT VESSELS
Know risk factors of heart disease
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Annual rates of first CVD event increase with age
o For women, comparable rates occur 10 years later in life than for men, but this gap
narrows with advancing age
Causes include an interaction of genetic, environmental, and lifestyle factors
Modifiable risk factors:
o High blood pressure – systolic blood pressure of >140mmHg or diastolic blood pressure
of >90mmHg, or currently taking antihypertensive medicine
 A higher percentage of men than women have hypertension until age 45; from
age 45 to 64 years, the percentages are similar; after age 64 years, women have
a much higher percentage of hypertension than men have
 Hypertension is 2 to 3 times more common among women taking oral
contraceptives
 Prevalence of hypertension in Blacks is among the highest in the world
o Smoking – nicotine increases the risk of MI and stroke by causing:
 Increase in oxygen demand with a concomitant decrease in oxygen supply
 Activation of platelets, activation of fibrinogen
 Adverse change in the lipid profile
o Serum cholesterol – high levels of LDL gradually add to the lipid core of thrombus
formation in arteries, which results in MI and stroke
 Total cholesterol: >240mg/dL (high risk); 200-239mg/dL (borderline-high risk)
 Age-adjusted prevalence of total cholesterol levels over 200mg/dL:
 51.1% Mexican-American men; 49% of Mexican-American women
 45% of white men; 48.7% of white women
 40.2% of African American men; 41.8% of African American women
o Type 2 Diabetes Mellitus – risk of CVD is twofold greater among persons with DM than
without DM
 Causes damage to large blood vessels that nourish the brain, heart, and
extremities – results in stroke, coronary artery disease, peripheral vascular
disease
o Obesity – among Americans 20 years and older, the prevalence of overweight of obesity
is as follows:
 74.8% of Mexican American men; 73% of Mexican American women
 73.7% of African American men; 77.7% of African American women
 72.4% of white men; 57.5% of white women
Review blood flow through the body
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From liver to right atrium through inferior vena cava
Superior vena cava drains venous blood from the head and upper extremities
From RA, venous blood travels through tricuspid valve to right ventricle
From right ventricle, venous blood flows through pulmonic valve to pulmonary artery
Pulmonary artery delivers unoxygenated blood to lungs
Lungs oxygenate blood
Pulmonary veins return fresh blood to left atrium
From left atrium, arterial blood travels through mitral valve to left ventricle
Left ventricle ejects blood through aortic valve into aorta
Aorta delivers oxygenated blood to body
Circulation is a continuous loop; the blood is kept moving along by continually shifting pressure
gradients; the blood flows from an area of higher pressure to one of lower pressure
How to assess carotid arteries
Palpation:
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Palpate each carotid artery medial to the sternomastoid muscle in the neck
Avoid excessive pressure on the carotid sinus area higher in the neck
Excessive vagal stimulation here could slow down the heart rate, especially in older adults
Take care to palpate gently
Palpate only one carotid artery at a time to avoid compromising arterial blood to the brain
Feel the contour and amplitude of the pulse
o Normally the contour is smooth with a rapid upstroke and slower downstroke
o Normally the strength is 2+ or moderate
o Findings should be equal bilaterally
Auscultation:
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For persons middle-aged or older or who show symptoms or signs of cardiovascular disease,
auscultate each carotid artery for the presence of a bruit
o A blowing, swishing sound indicating blood flow turbulence
o Normally none present
Keep the neck in a neutral position
Lightly apply the bell of the stethoscope over the carotid artery at three levels
o 1. The angle of the jaw
o 2. The midcervical area
o 3. The base of the neck
Avoid compressing the artery because this could create an artificial bruit and could compromise
circulation if the carotid artery is already narrowed by atherosclerosis
Ask person to take a breath, exhale, and hold it briefly while you listen so that tracheal breath
sounds do not mask or mimic a carotid artery bruit
o Holding breath on inhalation will also tense the levator scapulae muscles, which makes
it hard to hear the carotids
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Sometimes you can hear normal heart sounds transmitted to the neck; do not confuse these
with a bruit
What is blood flow turbulence over the carotid artery
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Blood flow turbulence over the carotid artery (bruit) – due to a local vascular cause, such as
atherosclerotic narrowing
What are the parameters of the apical impulse
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May not see the apical pulse
Easier to see in children and in those with thinner chest walls
Location: the apical impulse should occupy only one interspace, the fourth or fifth, and be at or
medial to the midclavicular line
Size: normally 1 x 2 cm
Amplitude: normally a short, gentle tap
Duration: short, normally occupies only first half of systole
Auscultation sequence of the heart
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Locate the four valve areas:
o Aortic valve area – second R interspace
o Pulmonic valve area – second L interspace
o Tricuspid valve area – L lower sternal border
o Mitral valve area – fifth interspace at around L midclavicular line
Do not limit auscultation to only four locations – sounds produced by the valves may be heard
all over the precordium – learn to inch stethoscope in a rough Z pattern, from the base of the
heart across and down, then over to the apex
Note the Rate and Rhythm:
o Rate ranges normally from 50 to 90 bpm
o Rhythm should be regular, although sinus arrhythmia occurs normally in young adults
and children
o When you notice any irregularity, check for a pulse deficit by auscultating the apical
beat while simultaneously palpating the radial pulse (when different, subtract the radial
rate from the apical and record the remainder as the pulse deficit)
Identify S1 and S2:
o This is important because S1 is the start of systole and thus serves as the reference point
for the timing of all other cardiac sounds
o Usually, you can identify S1 instantly because you hear a pair of sounds close together,
and S1 is the first of the pair
o Guidelines to distinguish S1 from S2:
 S1 is louder than S2 at the apex; S2 is louder than S1 at the base
 S1 coincides with the carotid artery pulse; feel the carotid gently as you
auscultate at the apex; the sound you hear as you feel each pulse is S1
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S1 coincides with the R wave (the upstroke of the QRS complex) if the person is
on an ECG monitor
Listen to S1 and S2 Separately:
 Note whether each heart sound is normal, accentuated, diminished, or split
 Inch your diaphragm across the chest as you do this
 First Heart Sound (S1):
 Caused by the closure of the AV valves, S1 signals the beginning of
systole
 You can hear it over the entire precordium, although it is loudest at the
apex
 You can hear S1 with the diaphragm with the person in any position and
equally well in inspiration and expiration
 A split S1 is normal, but it occurs rarely – means you are hearing the
mitral and tricuspid components separately
 Second Heart Sound (S2):
 S2 is associated with closure of the semilunar valves
 Can hear it with the diaphragm, over the entire precordium, although S2
is loudest at the base
 Splitting of S2 – normal phenomenon that occurs toward the end of inspiration
in some people
Focus on Systole, then on Diastole, and listen for any extra heart sounds:
 Listen with the diaphragm, then switch to the bell, covering all auscultatory
areas
 Usually these are silent periods – when you do detect an extra heart sound,
listen carefully to note its timing and characteristics
Listen for murmurs:
 Murmur is a blowing, swooshing sound that occurs with turbulent blood flow in
the heart or great vessels
 Except for the innocent murmurs described, murmurs are abnormal
 If you hear a murmur, describe it by indicating the following characteristics:
 Timing
 Loudness
 Pitch
 Pattern
 Quality
 Location
 Radiation
 Posture
Know S1, S2, S3, and S4—how produced, where heard best
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S1 – occurs with closure of the AV valves and this signals the beginning of systole
o Can hear it over the entire precordium, although it is loudest at the apex
o The mitral component of the first sound slightly precedes the tricuspid component, but
you usually hear these two components fused as one sound
S2 – occurs with closure of the semilunar valves and signals the end of systole
o The aortic component of the second sound slightly precedes the pulmonic component
o Although it is heard over all the precordium, it is loudest at the base
S3 – ventricular filling that creates vibrations that can be heard over the chest
o Normally diastole is a silent event
o These vibrations occur when the ventricles are resistant to filling during the early rapid
filling phase (protodiastole)
S4 – occurs at the end of diastole, at presystole, when the ventricle is resistant to filling
o The atria contract and push blood into a noncompliant ventricle – creates vibrations just
before S1
Differentiate systole from diastole
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Systole: the heart’s contraction
o Blood is pumped from the ventricles and fills the pulmonary and systemic arteries
o 1/3 of the cardiac cycle
o Ventricular pressure is finally higher than that in the atria, so the mitral and tricuspid
valves swing shit
o Closure of the AV valves contributes to the first heart sound and signals the beginning of
systole
o The AV valves close to prevent any regurgitation of blood back up into the atria during
contraction
Diastole: the ventricles relax and fill with blood
o 2/3 of the cardiac cycle
o Pressure in the atria is higher than that in the ventricles, so blood pours rapidly into the
ventricles
What valves—types and names—produce S1 and S2
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S1: AV vales (mitral and tricuspid)
S2: Semilunar valves (aortic and pulmonic)
What is a physiological split of S2 and where may it occur
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A split S2 is a normal phenomenon that occurs toward the end of inspiration in some people
Recall that closure of the aortic and pulmonic valves is nearly synchronous
Because of the effects of respiration on the heart, inspiration separates the timing of the two
valves’ closure, and the aortic valve closes 0.06 second before the pulmonic valve
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Instead of one DUP, you hear a spit sound – T-DUP
During expiration, synchrony returns and the aortic and pulmonic components fuse together
A split S2 is only heard in the pulmonic valve area, the second left interspace
When you first hear the split, do not be tempted to ask the person to hold his or her breath so
that you can concentrate on the sounds – breath holding will only equalize ejection times in the
R and L sides of the heart and cause the split to go away
o Instead, concentrate on the split as you watch the person’s chest rise up and down with
breathing
The split occurs about every fourth heartbeat, fading in with inhalation and fading out with
exhalation
Define gallops, murmurs, split sounds
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Gallops:
Murmurs: a blowing, swooshing sound that occurs with turbulent blood flow in the heart or
great vessels
o May be due to congenital defects and acquired valvular defects
o A systolic murmur may occur with a normal heart or with heart disease
o A diastolic murmur always indicates heart disease
o A murmur of mitral stenosis is rumbling, whereas that of aortic stenosis is harsh
Split sounds:
What is the electrical stimulus of the cardiac cycle
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Specialized cells in the sinoatrial (SA) node near the superior vena cava initiate an electrical
impulse (because the SA node has an intrinsic rhythm, it is the “pacemaker”)
The current flows in an orderly sequence
o First across the atria to the AV node low in the atrial septum
o There it is delayed slightly so that the atria have time to contract before the ventricles
are stimulated
o Then the impulse travels to the bundle of His, the R and L bundle branches, and then
through the ventricles
The electrical impulse stimulates the heart to do its work, which is to contract
A small amount of electricity spreads to the body surface, where it can be measured and
recorded on the ECG
Discuss hemodynamic changes related to aging process
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Increase in systolic blood pressure
o Due to stiffening of the large arteries, which in turn is due to calcification of vessel walls
(arteriosclerosis)
o Stiffening creates an increase in pulse wave velocity because the less compliant arteries
cannot store the volume ejected
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Left ventricular wall thickness increases (not overall size of the heart)
o Adaptive mechanism to accommodate the vascular stiffening mentioned earlier that
creates an increased workload on the heart
No significant change in diastolic pressure occurs with age
Rising systolic pressure with a relatively constant diastolic pressure increases the pulse pressure
(the difference between the two)
No change in resting heart rate occurs with aging
Cardiac output at rest is not changed with aging
Decreased ability of the heart to augment cardiac output with exercise
o Shown by a decreased maximum HR with exercise and diminished sympathetic response
o Non-cardiac factors also cause a decrease in maximum work performance with aging:
 Decrease in skeletal muscle performance
 Increase in muscle fatigue
 Increased sense of dyspnea
o Chronic exercise conditioning will modify many of the aging changes in cardiovascular
function
Relate heart/lung symptoms
Hypertension
HEAD, FACE AND NECK
KNOW ANATOMY AND FUNCTIONS
Facial nerves—trigeminal
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Cranial nerve VII: the facial nerve
o Mediates facial expressions made by facial muscles
Cranial nerve V: (trigeminal nerve)
o Mediates facial sensations of pain/touch (by three sensory branches)
Describe bells palsy
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A lower motor neuron lesion (peripheral), producing cranial nerve VII paralysis, which is almost
always unilateral
It has a rapid onset and its cause is currently thought to be herpes simplex virus (HSV)
Note complete paralysis on one half of the face – the person cannot wrinkle forehead, raise
eyebrow, close eye, whistle, or show teeth on one side
Usually presents with smooth forehead, wide palpebral fissure, flat nasolabial fold, drooling, and
pain behind the ear
Differentiate salivary glands, where located and duct openings
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Thyroid gland—thyroxine levels—T3 and T4
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An important endocrine gland with a rich blood supply
Straddles the trachea in the middle of the neck
Highly vascular endocrine gland that synthesizes and secretes thyroxine (T4) and
triiodothyronine (T3) – hormones that stimulate the rate of cellular metabolism
Two lobes:
o Both are conical in shape
o Each curve posteriorly between the trachea and the sternomastoid muscle
o Lobes are connected in the middle by a thin isthmus lying over the second and third
tracheal rings
Difficult to palpate
Headaches—types
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Tension:
o Location: usually both sides, across the frontal, temporal, and/or occipital region of
head: forehead, sides, and back of head
o Character: bandlike tightness, viselike, non-throbbing
o Duration: gradual onset, lasts 30 minutes to days
o Quantity and severity: diffuse, dull, aching pain; mild to moderate pain
o Timing: Situational, in response to overwork, posture
o Aggravating symptoms or triggers: stress, anxiety, depression, poor posture
o Associated symptoms: fatigue, anxiety, stress, sensation of a band tightening around
head, of being gripped like a vice
o Relieving factors, efforts to treat: rest, massaging muscles in area, NSAIDs
Migraine:
o Location: commonly one-sided but may occur on both sides; pain is often behind the
eyes, the temples, or forehead
o Character: throbbing, pulsating
o Duration: rapid onset, peaks 1-2 hours, lasts 4hr-72hr, sometimes longer
o Quantity and severity: moderate to severe pain
o Timing: About 2/month, last 1-3 days
o Aggravating symptoms or triggers: hormonal fluctuations (premenstrual), foods
(alcohol, caffeine, MSG, nitrates, chocolate, cheese); letdown after stress; changes in
sleep pattern; sensory stimuli; changes in weather; physical activity
o Associated symptoms: often preceded by an aura (visual changes such as blind spots or
flashes of light, tingling in an arm or leg, vertigo); N/V, photophobia, abdominal pain;
family history of migraine
o Relieving factors: lie down, darken room, use eyeshade, sleep, take NSAID or narcotic
when severe
Cluster:
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Location: always one sided; often behind or around the eye, temple, forehead, cheek
Character: continuous, burning, piercing, excruciating
Duration: abrupt onset, peaks in minutes, last 45-90 min.
Quantity and severity: can occur multiple times in a day, in “clusters”
Timing: 1-2/day, each lasting ½ to 2 hours, for 1 to 2 months; then remission for months
or years
Aggravating symptoms or triggers: exacerbated by alcohol, stress, wind or heat
exposure
Associated symptoms: nasal congestion or runny nose, watery or reddened eye, eyelid
drooping, miosis, feelings of agitation
Relieving factors; efforts to treat: need to move, pace the floor
Differentiate hyperthyroidism and hypothyroidism
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Hyperthyroidism:
o Overproduction of thyroid hormone
o Goiter – increase in the size of the thyroid gland (occurs with hyperthyroidism)
o Grave’s disease is the most common cause of hyperthyroidism, manifested by goiter
and exophthalmos (bulging eyes)
o Symptoms:
 Weight loss
 Fatigue
 Nervousness
 Muscle cramps
 Heat intolerance
o Signs:
 Tachycardia
 SOB
 Excessive sweating
 Fine muscle tremor
 Thin silky hair and skin
 Infrequent blinking
 Staring appearance
Hypothyroidism:
o Deficiency of thyroid hormone
o When severe, causes a Nonpitting edema or myxedema
o Puffy, edematous face, especially around the eyes (periorbital edema)
o Coarse facial features
o Dry skin
o Dry, coarse hair and eyebrows
Know lymph nodes—names, where located and assessment parameters
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Preauricular – in front of the ear
Posterior auricular (mastoid) – superficial to the mastoid process
Occipital – at the base of the skull
Submental – midline, behind the tip of the mandible
Submandibular – halfway between the angle and the tip of the mandible
Jugulodigastric – under the angle of the mandible
Superficial cervical – overlying the sternomastoid muscle
Deep cervical – deep under the sternomastoid muscle
Posterior cervical – in the posterior triangle along the edge of the trapezius muscle
Supraclavicular – just above and behind the clavicle, at the sternomastoid muscle
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Using a gentle circular motion of your finger pads, palpate the lymph nodes
Beginning with the Preauricular lymph nodes in front of the ear, palpate the 10 groups of lymph
nodes in a routine order
Many nodes are closely packed, so you must be systematic and thorough in your examination
Use gentle pressure because strong pressure could push the nodes into the neck muscles
If any nodes are palpable, note their location, size, shape, delimitation (discrete or matted
together), mobility, consistency, and tenderness
Cervical nodes often are palpable in health persons, although this palpability decreases with age
Normal nodes feel movable, discrete, soft, and nontender
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What is lymphadenopathy—benign vs infection vs cancer signs/symptoms
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Lymphadenopathy: enlargement of the lymph nodes (>1cm) from infection, allergy, or neoplasm
o Acute infection: acute onset, <14 days duration, nodes are bilateral, enlarged, warm,
tender, and firm but freely movable
o Chronic inflammation: eg – in TB the nodes are clumped
o Cancerous nodes: nodes are hard, >3cm, unilateral, nontender, matted, and fixed
o Nodes with HIV infection are enlarged, firm, nontender, and mobile; occipital node
enlargement is common with HIV infection
o A single enlarged nontender, hard, L supraventricular node (Virchow’s node) may
indicate neoplasm in thorax or abdomen
o Painless, rubbery, discrete nodes that gradually appear occur with Hodgkin’s lymphoma
BREAST/AXILLA
How to teach a BSE
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Help each woman establish a regular schedule of self care
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The best time to conduct a BSE is right after the menstrual period, or the 4th through 7th
day of the menstrual cycle – breasts are the smallest and least congested
o If not having periods, select a familiar date to examine her breasts each month – same
time each month
Self-examination will familiarize the woman with her own breasts and their normal variation
Emphasize the absence of lumps (not the presence of them)
Encourage her to report any unusual findings promptly
While teaching, focus on the positive aspects of BSE – avoid citing frightening mortality statistics
of breast cancer
Keep teaching simple – more likely for compliance
Teach woman to do this in front of a mirror while she is disrobed to the waist
At home, she can start palpation in the shower, where soap and water assist palpation
Then palpation should be performed while lying supine
Know quadrants of breast and tail of Spence
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Upper inner quadrant
Upper outer quadrant – site of most breast tumors
Lower inner quadrant
Lower outer quadrant
Tail of Spence – located in the upper outer quadrant; cone shaped breast tissue that projects up
into the axilla, close to the pectoral group of axillary lymph nodes
Know axillary lymph nodes and where to palpate
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Central axillary nodes – high up in the middle of the axilla, over the ribs and serratus anterior
muscle; these receive lymph from the other three groups of nodes
Pectoral (anterior) – along the lateral edge of the pectoralis major muscle, just inside the
anterior axillary fold
Subscapular (posterior) – along the lateral edge of the scapula, deep in the posterior axillary fold
Lateral – along the humerus, inside the upper arm
What is mammography
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Mammography: the process of using low-energy X-rays (usually around 30 kVp) to examine the
human breast, which is used as a diagnostic and screening tool. The goal of mammography is
the early detection of breast cancer, typically through detection of characteristic masses and/or
microcalcifications
Risks of breast cancer
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The genetic contribution to breast cancer involves specific gene mutations at the BRCA1 and
BRCA2 locations – women with these mutations are at increased risk for breast cancer and
ovarian cancer
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White women have a higher incidence of breast cancer than African-American women starting
at age 45
African-American women have a higher incidence before age 45 and they are more likely to die
of the disease at every age
Women from Asian-American, Hispanic, and American-Indian groups have a lower incidence and
death rates from breast cancer
Diet is an environmental factor in breast cancer risk (noted because breast cancer incidence
varies among countries
Female gender, age >50
Personal history of breast cancer
First-degree relative with breast cancer
High breast tissue density
Biopsy-confirmed atypical hyperplasia
High-dose radiation to chest
Early menarche <12 years or late menopause >55 years
Nulliparity of first child after age 30 years
Recent oral contraceptive use
Never breastfed a child
Recent and long-term use of estrogen and progestin
Alcohol intake of >1 drink daily
Obesity (especially after menopause) and high-fat diet
Physical inactivity
Steps of a breast exam—when patient believes she felt a breast lump
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Location – using the breast as a clock face, describe the distance in centimeters from the nipple;
or diagram the breast in the woman’s record and mark the location of the lump
Size – judge in centimeters in three dimensions: width x length x thickness
Shape – state whether the lump is oval, round, lobulated, or indistinct
Consistency – state whether the lump is soft, firm, or hard
Movable – is the lump freely movable, or is it fixed when you try to slide it over the chest wall?
Distinctness – is the lump solitary or multiple?
Nipple – is it displaced or retracted?
Note the skin over the lump – is it erythematous, dimpled, or retracted?
Tenderness – is the lump tender to palpation?
Lymphadenopathy – are any regional lymph nodes palpable?
BSE in postmenopausal women
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Instruct the woman who is not having menstrual periods to select a familiar date to examine her
breasts each month – for example, her birth date or the day the rent is due
EAR, NOSE, THROAT, MOUTH, PHARYNX/SINUSES
Define 3 parts of the ear and functions
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External ear (auricle or pinna) – consists of movable cartilage and skin
o Serves to funnel sound waves into its opening, the external auditory canal
o The canal is lined with glands that secrete cerumen (earwax) – helps lubricate and
protect the ear
o Wax forms a sticky barrier that helps keep foreign bodies from entering and reaching
the sensitive tympanic membrane
o The tympanic membrane (eardrum) separates the external and middle ear
Middle ear – a tiny air-filled cavity inside the temporal bone
o Has several openings
o Its opening to the outer ear is covered by the eardrum
o The openings to the inner ear are the oval window at the end of the stapes and the
round window
o Three functions:
 Conducts sound vibrations from the outer ear to the central hearing apparatus
in the inner ear
 Protects the inner ear by reducing the amplitude of loud sounds
 Its Eustachian tube allows equalization of air pressure on each side of the
eardrum so that the membrane does not rupture (eg: during altitude changes in
an airplane)
Inner ear – embedded in bone
o Contains the bony labyrinth, which holds the sensory organs for equilibrium and hearing
o Within the bony labyrinth, the vestibule and the semicircular canals compose the
vestibular apparatus and the cochlea contains the central hearing apparatus
o Not accessible to direct examination
Cerumen –what is it—function
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Cerumen – earwax
o A yellow, waxy material that lubricates and protects the ear
o The wax forms a sticky barrier that helps keep foreign bodies from entering and
reaching the sensitive tympanic membrane
o Migrates out to the meatus by the movements of chewing and talking
Differentiate Conductive and Sensorineural hearing losses: Weber and Rinne test findings for each
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Conductive hearing loss: involves a mechanical dysfunction of the external or middle ear
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It is a partial loss because the person is able to hear if the sound amplitude is increased
enough to reach normal nerve elements in the inner ear
o May be caused by:
 Impacted cerumen
 Foreign bodies
 Perforated tympanic membrane
 Pus or serum in the middle ear
 Otosclerosis (a decrease in mobility of the ossicles)
Sensorineural (perceptive) hearing loss: signifies pathology of the inner ear, cranial nerve VIII, or
the auditory areas of the cerebral cortex
o A simple increase in amplitude may not enable the person to understand words
o May be caused by:
 Prebycusis – a gradual nerve degeneration that occurs with aging
 Ototoxic drugs – affect the hair cells in the cochlea
Cranial nerves involved in hearing
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Cranial nerve VIII – electrical impulses are conducted by the auditory portion of cranial nerve VIII
to the brainstem
Describe normal tympanic membrane and structures
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The tympanic membrane (eardrum) separates the external and the middle ear and is tilted
obliquely to the ear canal, facing downward and somewhat forward
It is a translucent membrane with a pearly gray color and a prominent cone of light in the
anteroinferior quadrant, which is the reflection of the otoscope light
The drum is oval and slightly concave, pulled in at tis center by one of the middle ear ossicles,
the malleus
Parts of the malleus show through the translucent drum
o The umbo
o The manubrium (handle)
o The short process
The small, slack, superior section of the tympanic membrane is called the pars flaccida
The remainder of the drum, which is thicker and more taut, is the pars tensa
The annulus is the outer fibrous rim of the drum
What is Eustachian tube
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Connects the middle ear with the nasopaharynx
Allows passage of air
The tube is normally closed, but it opens with swallowing or yawning
Medications that may affect hearing
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Aspirin, when large doses (8 to 12 pills per day) are taken
NSAIDs
Certain antibiotics, especially aminoglycosides – common in people with kidney disease or
already have ear or hearing problems
Loop diuretics used to treat high blood pressure and heart failure (Lasix) or bumetanide
Medicines used to treat cancer, including cyclophosphamide, cisplatin, and bleomycin
Cysts/nodules on ear
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Sebaceous cyst: location is commonly behind lobule, in the postauricular fold
o A nodule with central black punctum indicates blocked sebaceous gland
o It is filled with waxy sebaceous material and is painful if it becomes infected
o Often are multiple
Tophi: small, whitish yellow, hard, nontender nodules in or near helix or antihelix; contains
greasy, chalky material of uric acid crystals and are a sign of gout
Chondrodermatitis Nodularis Helicus: painful nodules develop on the rim of the helix (where
there is no cushioning subcutaneous tissue) as a result of repetitive mechanical pressure or
environmental trauma (sunlight)
o Small, indurated, dull red, poorly defined, very painful
Keloid: overgrowth of scar tissue, which invades original site of trauma
o More common in dark skinned people, although it also occurs in whites
o In the ear it is most common at lobule at the site of a pierced ear
Carcinoma: ulcerated, crusted nodule with indurated base that fails to heal
o Bleeds intermittently
o Must refer for biopsy
o Usually occurs on the superior rim of the pinna, which has the most sun exposure
o May also occur in ear canal and show chronic discharge that is either serosanguineous
or bloody
Nosebleeds—technique to stop them
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Epistaxis occurs with trauma, vigorous nose blowing, foreign body
Person should sit up with head tilted forward, pinch nose between thumb and forefinger for 5 to
15 minutes
S/S that may accompany a stroke
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Face drooping – one part of the face may be drooping or numb
Arm weakness – one arm may feel weak or numb
Speech difficulty – speech may be slurred or slow
Sudden persistent headache
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Sudden dizziness
Trouble walking
Sudden trouble seeing in one or both eyes
Sudden confusion or trouble understanding information
Cranial nerves ix, x, xi, xii—name, function, how tested
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Cranial nerve IX (Glossopharyngeal Nerve): almost exclusively sensory and supplies five afferent
nuclei of the brainstem, providing sensory innervation to the oropharynx and back of the tongue
o Provides parasympathetic innervation to the parotid gland
o Can be assessed by asking the patient to say “ah” and observing if during phonation the
uvula deviates
 A positive sign that is indicative of unilateral damage is a finding of an
asymmetrically deviating uvula, deviating towards the side, with an intact or
healthy nerve
Cranial nerve X (Vagus Nerve): Loss of function of the vagus nerve (X) will lead to a loss of
parasympathetic innervation to a very large number of structures. Major effects of damage to
the vagus nerve may include a rise in blood pressure and heart rate. Isolated dysfunction of only
the vagus nerve is rare, but can be diagnosed by a hoarse voice, due to dysfunction of the
superior laryngeal nerve
o Testing of function may be performed by assessing ability to drink liquids
 Choking on either saliva or liquids may indicate neurological damage to the
vagus nerve
 Damage to this nerve may result in difficulties swallowing
Cranial nerve XI (Accessory nerve): damage to the accessory nerve may lead to contralateral
weakness in the trapezius; supplies the sternomastoid muscle and trapezius muscle
o Can be tested by asking the subject to raise their shoulders or shrug, upon which the
scapula will move out into a winged position if the nerve is damaged
Cranial nerve XII: (Hypoglossal nerve): innervates muscles of the tongue
o Can be tested by asking subject to stick their tongue straight out; if there is a loss of
innervation to one side, the tongue will curve toward the affected side, due to
unopposed action of the opposite genioglossus muscle
4 sinus areas—names and how examined—2 most common for evaluation
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Frontal sinuses: in the frontal bone above and medial to the orbitis (one of the most common
for evaluation)
o Palpation: using your thumbs, press the frontal sinuses by pressing up and under the
eyebrows
Maxillary sinuses: in the maxilla (cheekbone) along the side walls of the nasal cavity (the other
most common for evaluation)
o Palpation: press over the maxillary sinuses below the cheekbones
Ethmoid sinuses: between the orbitis
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Sphenoid sinuses: deep within the skull in the sphenoid bone
Nasal mucosa —differentiate –allergies, rhinitis,
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Allergies (allergic rhinitis): with chronic allergy, mucosa looks swollen, boggy, pale and grey
o Itching of nose and eyes, lacrimation, nasal congestion, and sneezing are present
o Note serous edema and swelling of turbines to fill the air space
o Turbines are usually pale (although may appear violet), and their surface looks smooth
and glistening
o May be seasonal or perennial, depending on allergen
o Individual has a strong family history of seasonal allergies
Rhinitis: nasal mucosa is swollen and bright red with URI
o Discharge is common with rhinitis and sinusitis, varying from watery and copious to
thick, purulent, and green-yellow
o First sign is clear, watery discharge, rhinorrhea, which later becomes purulent
o This is accompanied by sneezing and swollen mucosa, which causes nasal obstruction
o Turbinates are dark red and swollen
Lesions of mouth/lip/tongue: differentiate types
Abnormalities of the Lips
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Cleft lip: maxillofacial clefts are the most common congenital deformities of the head and neck
Herpes Simplex 1: the sores are groups of clear vesicles with a surrounding indurated
erythematous base
o Evolve into pustules, which rupture, weep, and crust and heal in 4 to 10 days
o Most likely site is the lip-skin junction – infection often recurs in same site
o Caused by the herpes simplex virus (HSV-1) – lesion is highly contagious and is spread by
direct contact
o Recurrent herpes infections may be precipitated by sunlight, fever, colds, and allergy
Angular Cheilitis (Stomatitis, Perleche): erythema, scaling, shallow and painful fissures at the
corners of the mouth occur with excess salivation and Candida infection
o Often seen in edentulous persons and in those with poorly fitting dentures causing
folding in of corners of mouth, creating a warm, moist environment favoring growth of
yeast
Carcinoma: the initial lesion is round and indurated, and then it becomes crusted and ulcerated
with an elevated border
o The majority occur between the outer and middle thirds of lip
Retention “Cyst” (Mucocele): a rounded, well-defined, translucent nodule that may be very
small or up to 1 to 2 cm
o A pocket of mucus that forms when a duct of a minor salivary gland ruptures
o Benign lesion also may occur on the buccal mucosa, the floor of the mouth, or under the
tip of the tongue
Abnormalities of the Teeth and Gums
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Baby bottle tooth decay: destruction of numerous deciduous teeth may occur in older infants
and toddlers who take a bottle of milk, juice, or sweetened drink to bed and prolong bottlefeeding past the age of 1 year
o Liquid pools around the upper front teeth
o Mouth bacteria act on carbohydrates in the liquid, especially sucrose, forming metabolic
acids
o Acids break down tooth enamel and destroy its protein
Malocclusion: upper or lower dental arches are not in alignment and incisors protrude from
developmental problem of mandible or maxilla or incompatibility between jaw size and tooth
size
o The condition increases risk for facial deformity, negativity, body image, chewing
problems, or speech dysfluency
Dental Caries: progressive destruction of tooth
o Decay initially looks chalky white
o Later it turns brown or black and forms a cavity
o Susceptible sites are tooth surfaces where food debris, bacterial plaque, and saliva
collect
Epulis: a nontender, fibrous nodule of the sum, seen emerging between the teeth; an
inflammatory response to injury or hemorrhage
Gingival Hyperplasia: enlargement of the gums, sometimes overreaching the teeth
o Occurs with puberty, pregnancy, and leukemia and with long therapeutic use of
phenytoin (Dilantin)
Gingivitis: gum margins are red and swollen and bleed easily
o Inflammation is usually due to poor dental hygiene or vitamin C deficiency
o May occur in pregnancy and puberty because of changing hormonal balance
Meth Mouth: illicit meth abuse leads to extensive dental caries, gingivitis, tooth cracking, and
Endentulism
o Meth causes vasoconstriction and decreased saliva, and its use increases the urge to
consume sugars and starches and to give up oral hygiene
Abnormalities of the Buccal Mucosa
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Apththous Ulcers: a “canker sore” is a vesicle at first and then a small round “punched-out”
ulcer with a white base surrounded by a red halo
o Quite painful and lasts for 1 to 2 weeks
o Unknown cause, although it is associated with stress, fatigue, and food allergy
Koplik Spots: small blue-white spots with irregular red halo scattered over mucosa opposite the
molars
o An early sign, and pathognomonic, of measles
Leukoplakia: chalky white, thick, raised patches with well-defined borders
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The lesion is firmly attached and does not scape off
May occur on lateral edges of tongue
Due to chronic irritation and occurs more frequently with heavy smoking and heavy
alcohol use
o Lesions are precancerous, and the person should be referred
Candidiasis or Monilial Infection: a white, cheesy, curdlike patch on the buccal mucosa and
tongue
o Scrapes off, leaving a raw, red surface that bleeds easily
o Opportunistic infection that occurs after the use of antibiotics and corticosteroids and in
immunosuppressed persons
Abnormalities of the Tongue
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Ankyloglossia: a short lingual frenulum fixing the tongue tip to the floor of the mouth and gums
o Limits mobility and will affect speech (pronunciation of a, d, n) if the tongue tip cannot
be elevated to the alveolar ridge; congenital defect
Geographic Tongue (Migratory Glossitis): pattern of normal coating interspersed with bright red,
shiny, circular bald areas with raised pearly borders
o Pattern resembles a map and changes in a few days
o Not significant, and its cause is not known
Smooth, Glossy Tongue (Atrophic Glossitis): the surface is slick and shiny; the mucosa thins and
looks red from decreased papillae
o Accompanied by dryness of tongue and burning
o Occurs with vitamin B12 deficiency (pernicious anemia), folic acid deficiency, and iron
deficiency anemia
Black Hairy Tongue: not really hair but, rather, the elongation of filiform papillae and painless
overgrowth of mycelial threads of fungus infection on the tongue
o Color varies from black-brown to yellow
o Occurs after use of antibiotics, which inhibits normal bacteria and allow proliferation of
fungus
Fissured or Scrotal Tongue: deep furrows divide the papillae into small irregular rows
o Condition occurs in 5% of the general population and in Down syndrome
o Increases with age
Carcinoma: an ulcer with rolled edges; indurated
o Occurs particularly at sides, base, and under the tongue
o When it is in the floor of mouth, it may cause painful movement or limited movement of
tongue
o Risk for early metastasis if present because of rich lymphatic drainage
o Heavy smoking and heavy alcohol use place persons at greater risk
Enlarged Tongue (Macroglossia): tongue is enlarged and may protrude from mouth; condition is
not painful but may impair speech development
o Can occur with Down syndrome; also occurs with cretinism, myxedema, acromegaly
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Also occurs with local infections
Abnormalities of tongue (see above)
Antibiotic therapy and tongue appearances
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Black hairy tongue – occurs after use of antibiotics (see above)
Turbinates—names—color—acute/rhinitis/sinusitis—differentiate
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Turbinate: the bony ridges curving down from the lateral walls
o Superior turbinate will not be in view, but the middle and inferior turbinates appear in
the same light red color as the nasal mucosa
o Turbinates are vascular and tender if touched
Allergic Rhinitis: rhinorrhea, itching of nose and eyes, lacrimation, nasal congestion, and
sneezing are present
o Serous edema and swelling of turbinates fill the air space
o Turbinates are usually pale, and their surface looks smooth and glistening
o May be seasonal or perennial, depending on allergen
Acute Rhinitis: first sign is a clear, watery discharge, rhinorrhea, which later becomes purulent
o Accompanied by sneezing and swollen mucosa, which causes nasal obstruction
o Turbinates are dark red and swollen
Sinusitis: facial pain, after upper respiratory infection
o Signs include red, swollen nasal mucosa, swollen turbinates, and purulent discharge
o Person also has fever, chills, malaise
o With maxillary sinusitis, dull, throbbing pain occurs in cheeks and teeth on the same
side, and pain with palpation is present
o With frontal sinusitis, pain is above the supraorbital ridge