Bates reading for APM exam Spring 2014

Written Exam: 5/15/14

• 100 points—75% to pass, 50 questions, 90 minutes in ODOWD
• multiple choice with case vignettes
o First Aid, BLS, Communication Skills, Influenza exam, Wound care
o PE findings: chapter 6, 17, 9, 12, 8
Heminopsia-! learn all this stuff!!

Components of 1. Identifying data

adult health history a. Age, gender, occupation, marital status
b. Sources of history: patient usually
c. Sources of referral if needed
2. Reliability: varies according to patient’s memory, trust, mood
3. Chief compliant
4. Present illness
a. ROS
b. Medications, allergies, smoking, alcohol
5. Past history:
a. Childhood illnesses
b. Adult illnesses
c. Immunizations (including flu), screening tests
d. Lifestyle issues
e. Home safety
6. Family history:
a. Age, health, age of death: siblings, parents, grandparents
7. Personal and social history
a. Education level, family origin, current household, personal interests, lifestyle
8. ROS
Cardinal 1. Inspection
techniques of the 2. Palpation
PE 3. Percussion
4. Auscultation
Steps in clinical 1. Identify abnormal findings
reasoning 2. Localize findings anatomically
3. Interpret findings in terms of probable process
4. Make hypotheses about the nature of the patient’s problem
5. Test the hypotheses and establish a working diagnosis
6. Develop a plan agreeable to the patient##
Checklist for a clear 1. Is the order clear?
and accurate 2. Do the data included contribute directly to the assessment?
record 3. Are pertinent negative specifically described
4. Are there overgeneralizations or omissions of important data?
5. Is there too much detail?
6. Are phrases and short words used appropriately. Is there unnecessary repetition of data?
7. Is the written style succinct? Are there excessive abbreviations?
Sequence of 1. Greet#patient#and#establish#rapport#
medical interview 2. Establish#agenda#for#interview#
3. Invite#patient#story#
4. Identify#and#respond#to#emotional#cues#
5. Expand#and#clarify#story#
6. Generate#and#test#diagnostic#hypotheses#
7. Create#shared#understanding#of#problem#
8. Negotiate#plan—further#evaluation,#treatment,#patient#education#and#support,#prevention#
 9. Plan#follow#up#and#closing##
Attributes of a Location, quality, quantity/severity, timing, setting in which it occurs, remitting or exacerbating factors,
symptom associated manifestations
Broaching sensitive Be nonjudgemental. Explain why you need to know the info. Find opening questions for sensitive
topics topics. Consciously acknowledge the discomfort.
Blood pressure Don’t smoke or drink caffeine for 30 min.
Sit quietly for 5 minutes with feet on floor.
Classification BP Category Systolic Diastolic
Normal <120 <80
Prehypertension 120-139 80-90
Hypertension stage 1 140-159 90-99
Hypertension stage 2 >160 >100
Hypertension goal with <130 <80
diabetes, renal probs
Heart rate Radial pulse. Count for 30 seconds than multiple by 2.
Normal: 50-90 beats/min
Flu shot 1. Inactivated#vaccine:#killed#virus#
2. Nasal#spray#vaccine:#live#attenuated#virus,#for#5L49#year#old#healthy#people.##
Who to get:
• Adults#with#chronic#pulmonary#conditions#or#medical#illnesses#or#immunosuprressed#
• Residents#of#nursing#homes#
• Heath#care#personnel#
• Caregivers#of#age#5#and#younger#or#50#and#holder.##
Pupillary light A light beam shining onto one retina causes pupillary constriction in both that eye, termed the direct
reaction reaction to light, and in the opposite eye, the consensual reaction. The initial sensory pathways are
similar to those described for vision: retina, optic nerve, and optic tract. The pathways diverge in the
midbrain, however, and impulses are transmitted through the oculomotor nerve, CN III, to the
constrictor muscles of the iris of each eye.
Pupillary near When a person shifts gaze from a far object to a near one, the pupils constrict. This response, like
reaction the light reaction, is mediated by the oculomotor nerve (CN III). Coincident with this pupillary
constriction, but not part of it, are (1) convergence of the eyes, an extraocular movement; and (2)
accommodation, an increased convexity of the lenses caused by contraction of the ciliary muscles.
This change in shape of the lenses brings near objects into focus but is not visible to the examiner.
Visual acuity Vision of 20/200 means that at 20 feet the patient can read print that a person with normal vision
could read at 200 feet. The larger the second number, the worse the vision. “20/40 corrected” means
the patient could read the 40 line with glasses (a correction).
Myopia is impaired far vision.
Presbyopia is impaired near vision, found in middle-aged and older people. A presbyopic person
often sees better when the card is farther away.
In the United States, a person is usually considered legally blind when vision in the better eye,
corrected by glasses, is 20/200 or less. Legal blindness also results from a constricted field of vision:
20 degrees or less in the better eye.
Pupils Miosis refers to constriction of the pupils, mydriasis to dilation.
Red reflex absence of a red reflex suggests an opacity of the lens (cataract) or possibly of the vitreous. Less
commonly, a detached retina or, in children, a retinoblastoma may obscure this reflex. Do not be
fooled by an artificial eye, which has no red reflex.
When the lens has been removed surgically, its magnifying effect is lost. Retinal structures then look
much smaller than usual, and you can see a much larger expanse of the fundus.
Papilledema Papilledema describes swelling of the optic disc and anterior bulging of the
physiologic cup. Increased intracranial pressure is transmitted to the optic
nerve, causing stasis of axoplasmic flow, intra-axonal edema, and swelling of
the optic nerve head. Papilledema often signals serious disorders of the brain,
such as meningitis, subarachnoid hemorrhage, trauma, and mass lesions, so
searching for this important disorder is a priority during all your funduscopic
examinations.
Hearing loss Hearing disorders of the external and middle ear cause conductive hearing loss. External ear causes
include infection (otitis externa), trauma, squamous cell carcinoma, and benign bony growths such as
exostoses or osteomas. Middle ear disorders include congenital conditions, benign cholesteatomas
and otosclerosis, tumors, and perforation of the tympanic membrane.

Disorders of the inner ear cause sensorineural hearing loss from congenital and hereditary
conditions, presbycusis, viral infections such as rubella and cytomegalovirus, Ménière's disease,
noise exposure, and acoustic neuroma.[44]
Swinging flashlight If left-sided optic nerve damage is present, the pupils usually react as follows: When the light beam
test shines into the normal right eye, there is brisk constriction of both pupils (direct response on the right
and consensual response on the left). When the light swings over to the abnormal left eye, partial
dilation of both pupils will occur. The afferent stimulus on the left is reduced so the efferent signals to
both pupils are also reduced and a net dilation occurs. This demonstrates an afferent pupillary defect,
sometimes termed as a Marcus Gunn pupil, the most common pupillary abnormality.
Deep tendon Ankle reflex: sacral 1
reflexes Knee reflex: lumbar 2,3,4
Brachioradialis reflex: cervical 5,6
Biceps reflex: cervical 5,6
Triceps reflex: cervical 6,7
Beaumont flu policy mandatory flu vaccine for all employees, physicians and volunteers. Health Care Workers (HCWs)
and physicians have an obligation to promote the health and safety of our patients. Anyone working
within the hospitals, clinical settings or any patient care areas are required to receive the vaccine
unless medically contraindicated.
Giving flu shot Before giving the vaccine you MUST obtain a signed consent form from the patient or their legal
guardian
Given IM in the deltoid (best absorbed in the deltoid)
Use 23 gauge, 1” to 1-1/2” needle
Who should not Children younger than 6 months
get a shot People with a severe allergy to chicken eggs resulting in anaphylactic reaction or angio-edema
If patient has had a severe reaction to the flu vaccination in the past
People who have developed (GBS) Guillian-Barre syndrome with in 6 weeks of getting the flu vaccine
in the past
If ill with a fever > 101 F postpone getting the vaccine
Review with Drug allergies?
patients before shot !Allergies to eggs? Latex? Thimerosal?
Hx of (GBS) Guillain-Barre Syndrome
Ask the patient if they have had the flu vaccine previously and if there were any reactions
If they are presently ill and running a temp > 101F you may want to delay administering the vaccine
until they feel better
The five rights Right Medication
Right Dose
Right Time
Right Route
Right Patient
Muscle tone
disorders

Responsible for voluntary

muscle movement

Muscle strength 0—No muscular contraction detected

scale 1—A barely detectable flicker or trace of contraction
2—Active movement of the body part with gravity eliminated
3—Active movement against gravity
4—Active movement against gravity and some resistance
5—Active movement against full resistance without evident fatigue. This is normal muscle strength.
Grading reflexes 4+ brisk, hyperactive with clonus
3+ brisker than average
2+ normal
1+ diminished or low normal
0 no response
Brudzinksi Flex the neck and watch the hips and knees.
If they both flex! positive (meningitis)
Kernig’s sign Flex the leg at both the hip and knees then straighten the knee.
Pain and increased resistance to extending the knee is positive.
Thorax landmarks 2nd intercostal space for needle insertion for tension pneumothorax; 4th intercostal space for chest
tube insertion; T4 for lower margin of endotracheal tube on a chest x-ray.
Thoracentesis Note the T7–8 interspace as a landmark for thoracentesis
Lungs

Dyspnea Most patients relate shortness of breath to their level of activity. Anxious patients present a different
picture. They may describe difficulty taking a deep enough breath, a smothering sensation with
inability to get enough air, paresthesias, or sensations of tingling or “pins and needles” around the
lips or in the extremities.

Anxious patients may have episodic dyspnea during both rest and exercise, and also
hyperventilation, or rapid, shallow breathing.

Wheezes are musical respiratory sounds that may be audible to the patient and to others.
 Wheezing occurs in partial airway obstruction from secretions and tissue inflammation in asthma, or
from a foreign body.
Cough ough can be a symptom of left-sided heart failure.

For complaints of cough, a thorough assessment is in order. Duration of the cough is important: is the
cough acute, lasting less than 3 weeks; subacute, lasting 3 to 8 weeks; or chronic, more than 8
weeks?

Viral upper respiratory infections are the most common cause of acute cough. Also consider acute
bronchitis, pneumonia, left ventricular heart failure, asthma, or a foreign body. Postinfectious cough,
bacterial sinusitis, asthma occur in subacute cough; postnasal drip, asthma, gastroesophageal reflux,
chronic bronchitis, bronchiectasis in chronic cough.[4]–[6]

Ask whether the cough is dry or produces sputum, or phlegm.

Mucoid sputum is translucent, white, or gray; purulent sputum is yellow or green

Ask the patient to describe the volume of any sputum and its color, odor, and consistency.

Foul-smelling sputum is present in anaerobic lung abscess; tenacious sputum in cystic fibrosis
Sticky
To help patients quantify volume, try a multiple-choice question. “How much do you think you cough
up in 24 hours: a teaspoon, tablespoon, quarter cup, half cup, cupful?” If possible, ask the patient to
cough into a tissue; inspect the phlegm and note its characteristics. The symptoms associated with a
cough often lead you to its cause.

Large volumes of purulent sputum are present in bronchiectasis or lung abscess

Diagnostically helpful symptoms include fever, chest pain, dyspnea, orthopnea, and wheezing.
Lung abnormalities • sAymmetric expansion in pleural effusion
• Abnormal retraction of the interspaces during inspiration. Retraction is most apparent in the lower
interspaces.
• Retraction occurs in severe asthma, COPD, or upper airway obstruction
• Impaired respiratory movement on one or both sides or a unilateral lag (or delay) in movement.
• Unilateral impairment or lagging indicates pleural disease from asbestosis or silicosis; it is also
seen in phrenic nerve damage or trauma#
Fremitus Fremitus is decreased or absent when the voice is higher pitched or soft or when the transmission of
vibrations from the larynx to the surface of the chest is impeded by a thick chest wall, an obstructed
bronchus, COPD, or pleural changes from effusion, fibrosis, air (pneumothorax), or an infiltrating
tumor.
Asymmetric decreased fremitus occurs in unilateral pleural effusion, pneumothorax, neoplasm due to
decreased transmission of low frequency sounds; asymmetric increased fremitus occurs in unilateral
pneumonia from increased transmission through consolidated tissue.[22]
Percussion Dullness replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the
pleural space beneath your percussing fingers. Examples include: lobar pneumonia, in which the
alveoli are filled with fluid and blood cells; and pleural accumulations of serous fluid (pleural effusion),
blood (hemothorax), pus (empyema), fibrous tissue, or tumor. Dullness makes pneumonic and
pleural effusion 5 and 18 times more likely, respectively.[22]

Generalized hyperresonance may be heard over the hyperinflated lungs of COPD or asthma.
Unilateral hyperresonance suggests a large pneumothorax or possibly a large air-filled bulla in the
lung.
Crackles, wheezes • Crackles#may#be#from#abnormalities#of#the#lungs#(pneumonia,#fibrosis,#early#heart#failure)#or#of#the#
rhonchi airways#(bronchitis,#bronchiectasis)#
• Wheezes#suggest#narrowed#airways,#as#in#asthma,#COPD,#or#bronchitis.#
 • Rhonchi#suggest#secretions#in#large#airways.#
Egophony If “ee” sounds like “A,” an E-to-A change, or egophony, is present, seen in lobar consolidation from
pneumonia. The “A” has a nasal bleating quality, and should be localized. In patients with fever and
cough, the presence of bronchial breath sounds and egophony more than triples the likelihood of
pneumonia.[22]
PMI A PMI greater than 2.5 cm is evidence of left ventricular hypertrophy (LVH), or enlargement, seen in
hypertension and aortic stenosis.
Similarly, displacement of the PMI lateral to the midclavicular line or greater than 10 cm lateral to the
midsternal line also suggests LVH.
White coat effect A growing literature suggests that in office practice automated blood pressure measurement, taken
BP when the patient rests alone in a quiet room, is the most accurate way to eliminate the “white coat”
effect and correlates best with the current standard, 24-hour blood pressure monitoring.
JVP A hypovolemic patient may have to lie flat before you see the neck veins. In contrast, when jugular
venous pressure is increased, elevating the patient's head to 60 degrees or even 90 degrees may be
required. In all these positions, the sternal angle usually remains about 5 cm above the right atrium,
as diagrammed above.

Increased jugular venous pressure is highly correlated with both acute and chronic right and left-
sided heart failure.[16],[84]–[87] It is also seen in tricuspid stenosis, chronic pulmonary hypertension,
superior vena obstruction, and pericardial disease such as tamponade and constrictive
pericarditis.[88]–[91]

In patients with obstructive lung disease, venous pressure may appear elevated on expiration only;
the veins collapse on inspiration. This finding does not indicate heart failure.

Venous pressure measured at >3 cm, or possibly 4 cm, above the sternal angle, or more than 8 cm
or 9 cm in total distance above the right atrium, is considered elevated above normal.

An elevated JVP is 98% specific for an increased left ventricular end diastolic pressure and low left
ventricular ejection fraction, and increases risk of death from heart failure.[16],[86]
Basic life support Circulation: providing an adequate blood supply to tissue, especially critical organs, so as to deliver
oxygen to all cells and remove metabolic waste, via the perfusion of blood throughout the body.
Airway: the protection and maintenance of a clear passageway for gases (principally oxygen and
carbon dioxide) to pass between the lungs and the atmosphere.
Breathing: inflation and deflation of the lungs (respiration) via the airway
CAB
BLS sequence • Do not preform blind finger sweep!
1. If patient is not breathing ! assess pulse at the carotid on your side for an adult, at the brachial
for a child and infant for 5 seconds and not more than 10 seconds;
2. Begin immediately with chest compressions at a rate of 30 chest compressions in 18 seconds
followed by two rescue breaths in 5 seconds each lasting for 1 second.
3. Continue chest compression at a rate of 100 compressions per minute for all age groups,
allowing chest to recoil in between.
o For adults push up to 5 cm and for child up to 4 cm.
o For infants up to 3 cm or 1/3 of the chest diameter antero-posteriorly.
o Keep counting aloud.
o Press hard and fast maintaining the rate of at about 100/minute. Allow recoil of chest fully
between each compression.
o After every 30 chest compressions give two rescue breaths in adult and child victim,
Continue for five cycles or two minutes before re-assessing pulse.
4. Attempt to administer two artificial ventilations using the mouth-to-mouth technique, or a bag-
valve-mask (BVM). The mouth-to-mouth technique is no longer recommended, unless a face
shield is present. Verify that the chest rises and falls; if it does not, reposition (i.e. re-open) the
airway using the appropriate technique and try again. If ventilation is still unsuccessful, and the
victim is unconscious, it is possible that they have a foreign body in their airway. Begin chest
 compressions, stopping every 30 compressions, re-checking the airway for obstructions,
removing any found, and re-attempting ventilation.
5. If the ventilations are successful, assess for the presence of a pulse at the carotid artery. If a
pulse is detected, then the patient should continue to receive artificial ventilations at an
appropriate rate and transported immediately. Otherwise, begin CPR at a ratio of 30:2
compressions to ventilation's at 100 compressions/minute for 5 cycles.
6. After 5 cycles of CPR, the BLS protocol should be repeated from the beginning, assessing the
patient's airway, checking for spontaneous breathing, and checking for a spontaneous pulse as
per new protocol sequence C-A-B. Laypersons are commonly instructed not to perform re-
assessment, but this step is always performed by healthcare professionals (HCPs).
7. If an AED is available it should be activated immediately and its directives followed and (if
indicated), call for clearance before defibrillation/shock should be performed. If defibrillation is
performed, begin chest compression immediately after shock.
8. BLS protocols continue until (1) the patient regains a pulse, (2) the rescuer is relieved by another
rescuer of equivalent or higher training (see patient abandonment), (3) the rescuer is too
physically tired to continue CPR, or (4) the patient is pronounced dead by a medical doctor.[2]
9. At the end of five cycles of CPR, always perform assessment via the AED for a shockable
rhythm, and if indicated, defibrillate, and repeat assessment before doing another five cycles.
10. The CPR cycle is often abbreviated as 30:2 (30 compressions, 2 ventilations or breaths). CPR
for infants and children uses a 15:2 cycle when two rescuers are performing CPR, but still uses a
30:2 if there is only one rescuer. Two person CPR for an infant also requires the "two hands
encircling thumbs" technique for the rescuer performing compressions.
Wheezes and When air flows rapidly through bronchi that are narrowed nearly to the point of closure. They are
rhonchi wheezes often audible at the mouth as well as through the chest wall. Causes of wheezes throughout the
chest include asthma, chronic bronchitis, COPD, and heart failure (cardiac asthma).
In asthma, wheezes may be heard only in expiration or in both phases of the respiratory cycle.
Rhonchi suggest secretions in the larger airways. In chronic bronchitis, wheezes and rhonchi often
clear with coughing.
Occasionally in severe obstructive pulmonary disease, the patient is unable to force enough air
through the narrowed bronchi to produce wheezing. The resulting silent chest is ominous and
warrants immediate attention.
Persistent localized wheezing suggests partial obstruction of a bronchus, seen with a tumor or
foreign body. It may be inspiratory, expiratory, or both.
Stridor A wheeze that is entirely or predominantly inspiratory is called stridor. It is often louder in the neck
than over the chest wall. It indicates a partial obstruction of the larynx or trachea, and demands
immediate attention.
Pleural rub Inflamed and roughened pleural surfaces grate against each other as they are momentarily and
repeatedly delayed by increased friction. These movements produce creaking sounds known as a
pleural rub (or pleural friction rub), usually during expiration.
Pleural rubs resemble crackles acoustically, although they are produced by different pathologic
processes. The sounds may be discrete, but sometimes are so numerous that they merge into a
seemingly continuous sound. A rub is usually confined to a relatively small area of the chest wall, and
typically is heard in both phases of respiration. When inflamed pleural surfaces are separated by
fluid, the rub often disappears.
Mediastinal Crunch A mediastinal crunch is a series of precordial crackles synchronous with the heart beat, no with
(Hamman’s Sign) respiration. Best heard in the left lateral position, it is due to mediastinal emphysema
(pneumomediastinum).
Patterns of Hearing Loss

Conductive Loss Sensorineural Loss

Pathophysiology External or middle ear disorder impairs sound Inner ear disorder involves cochlear nerve and
conduction to inner ear. Causes include foreign neuronal impulse transmission to the brain.
body, otitis media, perforated eardrum, and Causes include loud noise exposure, inner ear
otosclerosis of ossicles. infections, trauma, acoustic neuroma,

Usual Age of Onset Childhood and young adulthood, up to age 40
Ear Canal and Drum Abnormality usually visible, except in otosclerosis
Effects • Little effect on sound
• Hearing seems to improve in noisy
environment
• Voice remains soft because inner ear and
cochlear nerve are intact
Weber Test (in • Tuning fork at vertex
unilateral hearing • Sound lateralizes to impaired ear—room
loss) noise not well heard, so detection of
vibrations improves.
Rinne Test • Tuning fork at external auditory meatus;
then on mastoid bone
• Bone conduction longer than or equal to
air conduction (BC ≥ AC). While air
conduction through the external or middle
ear is impaired, vibrations through bone
bypass the problem to reach the cochlea.
congenital and familial disorders, and aging.
Middle or later years
Problem not visible
• Higher registers are lost, so sound
may be distorted
• Hearing worsens in noisy environment
• Voice may be loud because hearing is
difficult
• Tuning fork at vertex
• Sound lateralizes to good ear—inner
ear or cochlear nerve damage impairs
transmission to affected ear.
• Tuning fork at external auditory
meatus; then on mastoid bone
• Air conduction longer than bone
conduction (AC > BC). The inner ear
or cochlear nerve is less able to
transmit impulses regardless of how
the vibrations reach the cochlea. The
normal pattern prevails.