CMS100 Practical Exam Guide PDF

CMS100 PRACTICAL EXAM GUIDE HEART AND BLOOD PRESSURE TEST USAGE/NORMAL Heart rate Used for: assessing heart rate, rhythm and amplitude *Left side preferred* Normal Rate = 60-100 bpm (95% of healthy population have between 50-95 bpm) - For fast HR – using stethoscope at apex is more accurate - For ir...

CMS100 PRACTICAL EXAM GUIDE HEART AND BLOOD PRESSURE TEST USAGE/NORMAL Heart rate Used for: assessing heart rate, rhythm and amplitude *Left side preferred* Normal Rate = 60-100 bpm (95% of healthy population have between 50-95 bpm) - For fast HR – using stethoscope at apex is more accurate - For irregular rhythm or children – counting 60s is recommended Pulse rhythm = regular; even tempo and even intervals Heart auscultation Amplitude = strength; assess volume of blood, heart functioning and artery elasticity; can be absent, diminished, normal or bounding o Four-point scale: o 0 - absent or not palpable o 1+ difficult to palpate, thready, weak or easily obliterated with pressure o 2+ easy to palpate or not easily obliterated with pressure (normal) o 3+ full, bounding or not obliterated with pressure Used for: observation of heart sounds *Left side* Normal HOW TO 1. Have patient comfortably seated and arms relaxed 2. Locate radial pulse and count beats for 15 seconds (x4) or 30 seconds (x2) PATHOLOGY FINDINGS Bradycardia: heart rate less than 50bpm Tachycardia: heart rate greater than 100bpm Pulse deficit: difference of 2bpm or more between the radial pulse rate and the apical pulse rate (apical rate always being greater - Associated with atrial fibrillation Regularly irregular rhythm – predictable pattern of missed beats/variation = sinus arrhythmia Irregularly irregular rhythm – chaotic and no pattern = atrial fibrillation Pulse equality – pulse amplitude is similar on both sides of the body 1. Have patient lying supine, bikini drape to have access to upper and lower ribs 2. 5 locations to apply stethoscope Loud S1 = hyperdynamic state (fever, exercise) or pathology of mitral stenosis 1st heart sound (S1, lub) - Marks beginning of systole and closure of mitral and tricuspid valves - LOUDEST at apex of heart (mitral area) 2nd heart sound (S2, dub) - Marks beginning of diastole with closure of aortic and pulmonary valves - LOUDEST at base of heart (aortic or pulmonic areas; Erb’s) 3. Aortic (A) - 2nd intercostal space on right sternal border 4. Erb's point (E; no specific valve) - 3rd intercostal space on left sternal border; useful for quick/general assessment as all heart sounds are audible here 5. Tricuspid (T) - in 4th intercostal space on left lower sternal border 6. Mitral (M) - 5th intercostal space on the midclavicular line Wide S2 splitting= pulmonic stenosis, mitral regurgitation Wide and fixed S2 splitting = atrial septal defect, right ventricular failure Paradoxical S2 splitting = aortic stenosis, ischemic heart disease S3 hear sounds (in early diastole; ventricular gallop) can be suggestive of congestive heart failure (elderly) or regurgitation/shunts S4 heart sounds (in late diastole; atrial gallop) is always pathologic = hypertension, ischemic cardiomyopathy, hypertrophic cardiomyopathy, aortic stenosis Blood pressure (brachial) *Left arm preferred* Used for: determine pressure within 1. Have patient seated, ensure right arterial system size of BP cuff 2. Find estimated systolic number Normal = systolic/diastolic = by finding radial pulse and 120/80 mmHg finding at which point the pulse - Min. acceptable is 90/60 disappears. Add 20 to this - Korotkoff sounds: represents number and this is your starting sudden deceleration of the value for finding BP rapidly opening arterial 3. Deflate cuff and have patient walls which causes a hold arm up and pump hand for snapping or tapping sound 15 seconds - Should not differ more than 4. Place bell over brachial artery 10 mmHg between arms; and make an air seal >15mmHg difference may 5. Inflate cuff indicate obstruction on one 6. Open valve slowly and listen for side Korotkoff sounds *heart murmurs chart at below* Hypotension – low blood pressure (<90/60mmHg) - Dehydration, decreased cardiac output, can be fatal with those in ICU/myocardial infarction Hypertension – high blood pressure - Elevated: 120-129/<80 - Stage 1: 130-139/80-89 - Stage 2: >140/>90 - Crisis: >180/120 Obstruction of flow in subclavian artery – should not differ more Jugular venous pressure *right side* Sequence of Korotkoff Sounds Obtained during BP: Phase I. Sudden appearance of sharp tapping sounds (systolic) Phase II. Swishing sounds Phase III. Regular, louder sounds Phase IV. Abrupt muffling of sounds Phase V. Loss of all sounds (diastolic) Used for: estimating pressure in right atrium Normal = top of neck vein less than 3cm above sternal angle CHEST AND LUNGS TEST Respiration rate USAGE/NORMAL Used for: evaluating # breaths/min (frequency) Normal = 12 to 20 breaths per minute - Babies – up to 44 breaths/min 7. Pressure at which sounds first become audible = systolic pressure 8. Record three sounds – when sound appeared/muffled/disappeared 9. Average the muffling 10. Perform on both arms (for initial visit) and repeat on higher arm (for future visits) than 10 mmHg between arms; >20mmHg difference may indicate obstruction on one side - Subclavian steal syndrome, aortic dissection 1. Patient lying down on back examine right side neck 2. Raise head off table so head is elevated where neck veins are revealed (30-45 degrees) 3. Place first ruler at sternal angle in upright position 4. Using a penlight (or not), find the point at which you can no longer see the jugular vein pulse (flutter). 5. Use the other ruler and lay it horizontally so it lines up with this point, and creates a perpendicular angle with the first ruler Abnormal => top of neck vein more than 3 cm above sternal angle HOW TO 1. Patient seated; arms relaxed – stand to side of patients with one hand on shoulder and assess breathing movement 2. Do not let patient know; say doing HR for 60 seconds 3. Rate, rhythm, depth and effort - Pathologies that increase diastolic pressure – ex. heart or lung disease where ascites or edema is present PATHOLOGY FINDINGS Tachypnea: increased rate; CNS stimulation as compensation for resp. problems Bradypnea: decreased rate; could be hypothyroidism, resp. failure Kussmaul breathing (hyperpnea): deep, sighing respiratory pattern due to increased tidal volume with/without - Chest auscultation – posterior and anterior Women have higher than men Used for: assessing breath sounds Normal Vesicular – low pitched, softer, heard at most fields Bronchial – 1st and 2nd intercostal of anterior chest; high pitched, hollow, heard over manubrium Bronchovesicular – 1st and 2nd intercostal of anterior chest and between scapulae posteriorly, intermediate pitch Tracheal – over trachea, high pitched, loud Chest percussion – posterior and anterior Used for: diagnostic of lung abnormalities 4. If rate is fast or slow, count breaths for full 60 seconds increased resp. rate (can cause acidosis); due to diabetes, toxic ingestion - Cheyne-Stokes breathing: crescendodecrescendo respirations then period of apnea (heart failure; during sleep) Anterior chest – supine If bronchial heard in location away from 1. Have patient draped with manubrium and bronchovesicular sound access to ribs/abdomen heard away from first and second 2. Auscultation one full breath intercostal spaces anteriorly => suggests at each location consolidation (mass, fluid, etc.) 3. Use ladder pattern to auscultate lungs bilaterally Wheezing – high-pitch, hissing, continuous (asthma, COPD) Posterior chest – sitting 1. Have patient seated with Rhonchi – low-pitch, continuous, snoring gown open at the back quality, (secretion in airway; clears with 2. Instruct patient to cross coughing in chronic bronchitis) arms over their chest (hug themselves) Crackles (rales) – discontinuous, short, 3. Instruct patient to breathe intermittent through their mouth - Late = congestive heart failure or 4. Auscultate one full breath interstitial lung disease cycle at each location - Early = chronic bronchitis 5. Avoid auscultation over the - Mid = bronchiectasis scapula - Fine crackles – high-pitched; soft; shorter - Coarse crackles – low pitched; loud; longer Use same pattern and set up as lung auscultation Pleural friction (rub) – pleural surfaces rubbing against each other due to inflammation (resemble crackling) Dullness - Can occur when percussing over solid tissue = masses, tumour, blood, organs (heart, liver, spleen, etc.) Egophony, bronchophony and/or whispered pectoriloquy (bilateral) Normal = resonant (tympanitic) 1. Begin above the clavicle and percussion sound; lungs filled above scapulae to make sure to with air and not solid reach the apex of the lung 2. Continue to percuss bilaterally at all locations – avoiding bones Used for: not routine test; done Use same pattern and set up as when abnormally located lung auscultation bronchovesicular/bronchial sounds are heard Egophony 1. Ask patient to say “E” at each Normal location = should hear “E” 2. If “A” is heard = suggests - Should hear “E” consolidation - Should hear spoken words Should faintly Bronchophony hear whispered words 1. Ask patient to say “99” at each location 2. If you hear spoken words louder and clearer in an area of lung tissue comparatively = suggests consolidation - Pleural effusion, lung tumours, pneumonia Hyperresonance – abnormally long and low-pitched; can be caused by emphysema, pneumothorax, COPD When consolidation is present in lungs --> causes transmission of higher-frequency vocal vibrations --> which enhances the clarity and resonance of the words that are spoken Whispered pectoriloquy 1. Ask patient to whisper “99” at each location 2. If you hear the spoken words louder and clearer in an area of the lung tissue comparatively = suggests consolidation REFLEXES AND CEREBELLAR FUNCTION TEST USAGE/NORMAL HOW TO DTR – biceps, Used for: testing spinal nerve roots and Using the reflex hammer and with brachioradialis, associated reflex arcs patient seated and relaxed triceps (bilateral) Biceps – C5 and C6 Brachioradialis PATHOLOGY FINDINGS Absent = can be due to lower motor neuron lesions and spinal nerves Brachioradialis – C5, C6 (sometimes C7) Triceps – C7 and C8 1. Strike using the wider side of the hammer – tap on tendon (not so much on muscle) Biceps reflex 1. Place thumb on biceps tendon 2. Use narrow side of hammer to tap on thumb directly DTR – patellar, Achilles/ankle (bilateral) Used for: testing function of spinal nerves Patellar – spinal nerves from L2-L4 (involves quadriceps femoris) Achilles (ankle) – spinal nerves S1-S2 (involves gastrocnemius and soleus) Plantar reflex Used for: CNS function and corticospinal function (identify disease of spinal cord or brain) Normal = downward flexion of toes upon cutaneous stimulation of reflex Cerebellar – rapid Used for: testing the cerebellar system alternating movements that is part of the motor system to help (upper and lower) coordinate muscle movement Triceps reflex 1. Suspend arm up in 90-degree angle 2. Strike using the wider side of hammer 1. Have patient sitting with legs freely hanging off edge of exam table 2. Patellar – strike using wide edge of hammer just below patella 3. Achilles – have patient relax foot and passively dorsiflex the foot with the palm of your hand; strike back of Achille’s tendon with hammer (foot should plantarflex) 1. Can have patient sitting or lying down 2. Stroke skin on sole of foot with a blunt instrument starting from lateral heel and moving upward in curved pattern to the ball of the foot 3. Toes should downward flex Upper limbs 1. Have patient seated 2. Ask patient to repeatedly tap their palm on their thigh, flip over and Absent = can be due to lesions of spinal nerves Babinski’s sign = positive plantar reflex - Big toe dorsiflexes and other toes fan out - Sign of upper motor lesion (CNS – corticospinal tract) Dysdiadochokinesis: slow, irregular, awkward movements that may indicated cerebellar/basal ganglia Normal = rapid, rhythmic, smooth coordinated movement Cerebellar – point-topoint (finger to nose and heel to shin) Gait assessment – walk, tandem/heel-totoe, toes, heels tap back of hand on thigh as fast as possible Lower limbs 1. Have patient seated 2. Ask patient to tap palms of your hands with the ball of each foot repeatedly Used for: testing the cerebellar system Finger to nose that is part of the motor system to help 1. Have patient seated coordinate muscle movement 2. Ask patient to use index finger to alternate between touching nose Normal = smooth, accurate movements and touching your index finger 3. Move finger to different positions to switch directions and extend arm fully 4. Test bilaterally Used for: observing balance, posture, coordination Normal = regular swinging of arms, ability to maintain balance, Heel to shin 1. Have patient seated with legs hanging off chair/bed 2. Ask patient to slide heel down their opposite shin and back up – test bilaterally Ask patient to: 1. Walk across the room, turn around and come back 2. Heel-to-toe in a straight line (tandem walking) 3. Walk on tippy toes 4. Walk on heels disease or upper motor neuron weakness Abnormal – clumsy, unsteady movements that vary in speed, force or direction Dysmetria – finger undershoots, or overshoots targets OR heel may overshoot/undershoot target - Heel may also oscillate from side to side when running down shin Intention tremor – involuntary rhythmic oscillatory muscle contractions during a directed and purposeful motor movement - - Hemiplegic gait – weakness or paralysis on one side; circumduction movement of affected limb Diplegic gait – bilateral and symmetrical leg movement (ex. cerebral palsy) Neuropathic gait – high-stepping with foot drop/instability (PNS damage) Myopathic gait – muscle disorders; waddling, wide-based stance Choreiform gait – irregular and involuntary movements (ex. Huntington’s disease) - Ataxic gait – dysfunction in cerebellum; instability wide steps and tendency to veer off course - Parkinsonian gait – Parkinson’s; small shuffle steps, reduced arm swing and difficulty stopping movement - Sensory gait – sensory deficits; cautious, wide-based gait Positive Romberg sign = patient loses balance when eyes are closed - Can indicate sensory ataxia; can be caused by conditions that affect the dorsal column (ex. Tabes dorsalis) - Romberg test Used for: proprioception or position sense Normal = patient remains upright posture with minimal swaying Pronator drift Used for: assessing upper motor neuron function (corticospinal tract) Normal = maintain position of their arms (supinated and in horizontal plane) Use DTR scale to note your findings  0 - No response; reflex is absent  1+ - Trace/decreased response (hypoactive)  2+ - Normal response  3+ - Exaggerated/brisk response (hyperactive)  4+ - Sustained response (hyperactive with clonus) Always compare response of one side to another 1. Ask patient to stand unsupported with feet together and eyes open for 30-60 seconds then with eyes closed for 30-60 seconds 2. Stand close to the patient with arms outstretched behind and in front of patient 1. Ask patient to stand for 20-30 seconds with feet shoulderwidth apart, arms outstretched straight forward, palms facing up (supinated) and eyes closed 2. Observe arms for drifting Pronator drift = arms pronate and/or drift downwards - Can indicate motor neuron lesion in corticospinal tract CRANIAL NERVE FUNCTION AND EAR TEST USAGE/NORMAL Extraocular movements – H-test Used for: testing movements of the eye controlled by CN III (oculomotor), CN IV (trochlear nerve) and CN VI (abducens nerve) Pupillary response to light and accommodation Used for: assessing function of CN II (optic nerve) and CN III (oculomotor nerve) Normal = pupils are symmetric and should constrict to light and dilate to dark; should constrict to near object and dilate to far object HOW TO 1. Have patient seated and ask them to follow your pen or finger 2. Start in center and move in H-shape 3. Make sure eyes can get to full range of motion and stay in spot for at least one second Light response 1. Have patient seated with the lights dim and ask them to look into the distance 2. Shine light at oblique angle into each pupil 3. Look for direct response first – when pupil constricts in response to direct illumination 4. Allow pupils to dilate again then look for consensual response – when opposite pupil constricts Near accommodation 1. Hold finger or penlight about 10cm away from patient 2. Ask patient to look into the distance, then at penlight 3. Pupils should constrict when looking at near object and dilate looking into the distance PATHOLOGY FINDINGS Dysconjugate gaze Nystagmus Lid lag Anisocoria: asymmetric pupil size; benign if pupillary reactions are normal Relative afferent pupillary defect (RAPD, Marcus Gunn Pupil): defect in direct response; damage inoptic nerve or severe retinal disease Adie's (Tonic) Pupil: no or sluggish response to light (both direct and consensual responses; common in women in 30's-40's; potentially due to denervation in the postganglionic parasympathetic nerve Argyll Robertson Pupil: hallmark of tertiary neurosyphilis; pupils will not constrict to light but will constrict with accommodation Ophthalmoscopic exam (bilateral) Used for: allows visualization of the retina, optic disc and vasculature Should be able to visualize: - Red reflex - Background of retina - Optic disc and physiologic cup - Arteries and veins - Fovea and macula Otoscopic exam (bilateral) Used for: visualizing the external ear canal and tympanic membrane Normal = canal should be skin colour, the eardrum should be a light-gray or shiny pearly-white colour 1. Dim lights in room, use left hand and eye to examine patient’s left eye and vice versa for right 2. Adjust focus of ophthalmoscope 3. Ask patient to look into the distance above your shoulder 4. Hold thumb of opposite hand above patient’s eyebrow 5. Start around 15 inches away and approach patient at 15degree angle from patient’s line of vision 6. Shine light beam into pupil and look for red reflex (orange glow) 7. Once you find red reflex move closer to see retina 1. Have patient seated 2. Use pencil grip on otoscope – use left hand for left ear and right hand for right ear 3. Pull ear up, out and back with other hand and insert otoscope Horner's syndrome: loss of sympathetic innervation causing triad of ptosis, miosis, anhidrosis Pathological findings can include:  Pathological optic cupping – abnormal enlargement of central area of disc (often glaucoma)  Optic disc edema – swelling of optic disc (intracranial pressure)  Arterio-venous (AV) nicking – compression of veins at crossings )hypertensive retinopathy)  Cotton wool spots – white fluffy lesions on retina (ischemia)  Emboli and infarcts – dislodged debris in vessels (reduced blood flow)  Roth spot – retinal hemorrhage with white or pale center (usually systemic cause; anemia) Pathological findings can include:  Acute otitis media – infection of fluid accumulation in middle ear  Otitis media with effusion – accumulated fluid in middle ear without inflammation/infection  Cholesteatoma – abnormal collection of keratinized squamous epithelium  Foreign body ABDOMINAL TEST Abdominal auscultation Abdominal percussion Abdominal palpation – light and deep USAGE/NORMAL Used for: detection of altered bowel sounds (limited diagnostic) HOW TO 1. Patient lying down, drape over lower body, pull up gown to belly button and lower drape Normal = clicks, gurgles and just below ASIS rumbling 2. Can also have knees bent or pillow under to relax patient - 5-35 sounds/minute; 1 sound/53. Start in RLQ  RUQ  LUQ 12 seconds  LLQ 4. Spend minimum 2-5 seconds at each location PATHOLOGY FINDINGS Hypoactive – less than 5 sounds/minute = constipation Hyperactive – more than 35 sounds/minute = diarrhea, gastroenteritis, IBD, laxative, GI bleeding, bowel obstruction Absent – use 5 minutes for required duration; emergent conditions (obstruction, peritonitis, intestinal ischemia, paralytic ileus) ** ask about this** Used for: reveal abnormal tenderness, masses or organomegaly Normal = soft and firm without pain or tenderness on light palpation; consistency - Guarding: voluntary contraction; generally over entire abdomen - Rigidity: involuntary tightening; underlying inflammation Light 1. Lying down, knees bent or pillow under, hands by sides 2. With pads of fingers depress abdomen 1-2cm and move in circular motions 3. If ticklish, use sandwich method (hand over hand) Deep 1. Lying down, knees bent or pillow under, hands by sides 2. With palmar surface of fingers depress abdomen If tenderness on light palpation – describe depth, patient’s response (severity), which quadrant If masses found on deep palpation – describe location, size, shape, consistency (soft/firm), pain or tenderness McBurney’s point tenderness *Right side* Used for: cases of appendicitis or inflammation of the ileocecal area - Point in lower right quadrant 1. 2. 3. Shifting dullness (ascites) Used for: assessing if ascites is present; requires changing of position 1. 2. 3. 4. 5. 6. Fluid wave (ascites) Used for: assessing ascites 1. Normal: no impulse or thrill felt through receiving hand 2. 3. 4. 4-5cm (can use two hands Patient lying down, gown pulled up to expose abdomen Locate point by drawing line between umbilicus and ASIS – divide into thirds Point is meeting place of 1 third up from ASIS (~5cm or 2in from ASIS) – push down Percuss abdomen starting at center or most protuberant part Move laterally toward flank for transition to dullness Mark location Have patient roll onto side so dull area is most superior Repeat percussion in that location after a few seconds (15s) With ascites – area that was dull will become tympanic and dullness will shift to dependent side Patient lying supine, gown raised Have patient place hands firmly in the center down midline to block transmission Hands on both sides of flank Tap or flick one side and feel for impulse on other With acute abdominal pain => point will increase tenderness = increases likelihood of appendicitis - If pain absent in this point = decreases likelihood of appendicitis Heart failure, liver disease, nephrotic syndrome, malignancy First clue => observing rounded, symmetrical contour of abdomen with bulging flanks - Can be tense - Doughy or fluctuant Positive fluid or thrill finding => ascites; will feel impulse in receiving hand after almost no lag LIVER AND SPLEEN TEST Liver percussion and liver span *Right side* Liver palpation *Right side* Spleen percussion (Castell’s sign) *Left side* USAGE/NORMAL Used for: assessing size of liver (liver span) Normal = dull sound where liver is - Dull = solid structure or fluid - Tympanitic (drum) = air-filled structure - Normal liver span on midclavicular line is 6-12cm - Normal liver span on midsternal line is 4-8cm HOW TO Midclavicular liver span 1. Lying down, bikini drape 2. Find 3rd intercostal space on midclavicular line and percuss – should be over lungs 3. Percuss inferiorly until dullness noted (usually ~5th space) 4. Start percussing just below belly button 5. Continue percuss superiorly until dullness; inferior border of liver 6. Use measuring tape to measure between upper and lower marks Midsternal liver span 1. Lying down, bikini drape 2. Repeat above – starting from 3rd intercostal space 3. Use measuring tape to measure between upper and lower marks Used for: assessing size and feeling for 1. Lying down, bikini drape tenderness and masses 2. Start in right lower quadrant, pressing lateral to rectus Normal = slightly tender or abdominis nonpalpable; healthy liver has soft, 3. Ask patient to take a deep breath; sharp, regular and smooth edge on inspire try to feel liver’s edge 4. Move superiorly by 1-2 cm increments Used for: detecting splenomegaly 1. Have patient lying down, gown pulled up and draped on lower legs PATHOLOGY FINDINGS Increased tenderness => inflammation (ex. hepatitis) or congestion (ex. congestive heart disease) Firm, irregular, rounded/blunted edge => diseased liver; cirrhosis Palpable mass on inferior border could be distended gallbladder Dullness when patient takes deep breath => positive Castelle’s sign and suggests splenomegaly Normal = percussion should remain tympanitic as you percuss over the same spot Spleen palpation Used for: detecting splenomegaly *Left (upper) side Normal = not usually palpable (unless thin); lower edge may be slightly palpable THYROID TEST Thyroid inspection USAGE/NORMAL Used for: looking for enlargement of the thyroid Normal = no enlargement, symmetrical, moves with swallowing 2. Find lowest intercostal space on left anterior axillary line 3. Start percussing continuously (should be tympanitic) and ask patient to take deep breath in 4. Inspiration will move diaphragm inferiorly and push spleen inferiorly as well = might push spleen down under finger if enlarged 1. Have patient lying down supine, stand on right side 2. Reach over patient, support left lower rib cage with left hand 3. Start palpating spleen below left costal margin with right hand (keep hand stationary but apply some pressure) 4. Ask patient to take a deep breath and on inspiration, spleen should move towards palpating hand 5. On exhale move your hand towards left costal margin and ask them to repeat; continue steps until hand is under left costal margin 6. If you can’t palpate spleen move patient to their right side HOW TO 1. Ask patient (seated) to extend neck slightly 2. Use penlight to shine tangentially on thyroid from angle of chin 3. Thyroid gland located inferiorly to cricoid cartilage Some causes of splenomegaly: - Hematologic malignancies - HIV infection - Mononucleosis - Portal hypertension - Splenic hematoma - Splenic infarct PATHOLOGY FINDINGS Enlarged thyroid (goiter) => will move upwards with swallowing and goes back to resting after - If mass does not move = likely not enlarged thyroid 4. Ask patient to swallow – note rise and fall, symmetry and contour, any enlargements, scars 5. If enlargement seen – note location (uni or bilateral) and size Thyroid palpation Used for: determining shape, texture, gland size and any enlargements Normal = no enlargement, symmetrical, moves with swallowing **add in what texture feels like SKIN AND LYMPH NODES TEST USAGE/NORMAL Skin examination of Used for: assess skin lesions and skin lower limb characteristics 1. Patient is seated to flex neck forward and tilt head to one side (10-15 degrees) to relax SCM 2. Place pads of fingers from each hand on right and left lobes 3. Ask patient to swallow 4. Palpate thyroid and feel it as patient swallows 5. Push trachea on one side to the side you are palpating 6. Move in circular motions with palpating fingers Enlarged thyroid could be due to: - Iodine deficiency – thyroid hormone dysfunction - Hyperthyroidism - Hypothyroidism - Hashimoto’s - Thyroid cancer HOW TO Have patient lie down supine and have lower body draped Ask patient to raise gown as far as comfortable and uncover drape one leg at a time Examine leg skin, feet and toes After done both legs, ask patient to stand and raise gown to observe back of legs PATHOLOGY FINDINGS Inspect and palpate:  Skin colour a. Pigmentation b. Redness c. Pallor - lips, fingernails, mucous membranes d. Cyanosis (blue) - lips, oral mucosa and tongue; can also be nails, hands and feet e. Yellowing (jaundice) sclera, palpebral conjunctiva, lips, hard palate, under tongue, 1. 2. 3. 4. Cervical lymph node palpation (bilateral) Used for: detecting lymphadenopathy 1. Have patient sitting on table 2. Use fingers in small circular motions Normal = should not be able to palpate to start palpating the following areas lymph nodes significantly  Preauricular – in front of ears  Posterior auricular – behind ears - Shotty nodes: small mobile, soft, by mastoid process non-tender and discrete lymph node  Occipital – back of skill that can be a normal finding  Tonsillar – just below angle of mandible  Submandibular – move forward halfway between tip and angle  Submental – directly below chin  Superficial cervical – over sternocleidomastoid muscle  Posterior cervical – posterior to SCM muscle and anterior to trapezius  Supraclavicular – superior to clavicles near border of SCM  Infraclavicular – along inferior border of clavicles tympanic membrane, skin f. Moisture - dry, sweat, oil  Temperature  Texture - rough, smooth  Mobility and turgor lifting skin on dorsum of hand, sub-clavicular fossa or anterior thigh for 3 seconds; observe ability to go back to normal (decreased turgor = remains elevated)  Skin lesions*  Palpate fingernails and toenails - note colour and shape If node is palpable – note location, size, shape, mobility, consistency, pain/tenderness, delamination Hard and fixed = red flag Supraclavicular small palpable lymph node can indicate malignancy in abdominal cavity Lymphadenopathy: swelling of lymph node - Can be due to infection or malignancies - Diffused lymphadenopathy = could suggest HIV infection Skin Lesion Description  macule, a flat, nonpalpable circumscribed area (up to 1 cm) of color change that's brown, red, white, or tan  patch, a flat, nonpalpable lesion with changes in skin color, 1 cm or larger  papule, an elevated, palpable, firm, circumscribed lesion up to 1 cm  plaque, an elevated, flat-topped, firm, rough, superficial lesion 1 cm or larger, often formed by coalescence of papules  nodule, an elevated, firm, circumscribed, palpable area larger than 0.5 cm; it's typically deeper and firmer than a papule  cyst, a nodule filled with an expressible liquid or semisolid material  vesicle, a palpable, elevated, circumscribed, superficial, fluid-filled blister up to 1 cm  bulla, a vesicle 1 cm or larger, filled with serous fluid  pustule, which is elevated and superficial, similar to a vesicle, but is filled with pus  wheal, a relatively transient, elevated, irregularly shaped area of localized skin edema. Most wheals are red, pale pink, or white.  scale, a thin flake of dead exfoliated epidermis  crust, the dried residue of skin exudates such as serum, pus, or blood  lichenification, visible and palpable thickening of the epidermis and roughening of the skin with increased visibility of the normal skin furrows (often from chronic rubbing)  excoriation, linear or punctuate loss of epidermis, usually due to scratching. Heart Murmurs