NR 509 Midterm

Basic Interviewing Techniques

O Active listening: Active listening means closely attending to what the patient is communicating, connecting
to the patient's emotional state, and using verbal and nonverbal skills to encourage the patient to expand
on his or her feelings and concerns.
O Empathic responses: Empathy has been described as the capacity to identify with the patient and feel the
patient's pain as your own, then respond in a supportive manner.
O Guided questioning: Guided questions show your sustained interest in the patient's feelings and deepest
disclosures and allows the interviewer to facilitate full communication, in the patient's own words, without
interruption.
O Nonverbal communication: Nonverbal communication includes eye contact, facial expression, posture,
head position and movement such as shaking or nodding, interpersonal distance, and placement of the
arms or legs—crossed, neutral, or open.
O Validation: Validation helps to affirm the legitimacy of the patient's emotional experience.
O Reassurance: Reassurance is an appropriate way to help the patient feel that problems have been fully
understood and are being addressed.
O Partnering: When building rapport with patients, express your commitment to an ongoing relationship.
O Summarization: Giving a capsule summary of the patient's story during the course of the interview to
communicate that you have been listening carefully.
O Transitions: Inform your patient when you are changing directions during the interview.
O Empowering the patient: Empower patients to ask questions, express their concerns, and probe your
recommendations in order to encourage them to adopt your advice, make lifestyle changes, or take
medications as prescribed.
 Determine scope of assessment:
Focused vs. Comprehensive:
O Comprehensive: Used patients you are seeing for the first
time in the office or hospital. Includes all the elements of
the health history and complete physical examination.
O Focused: For patients you know well returning for routine
care, or those with specific “urgent care” concerns like
sore throat or knee pain. You will adjust the scope of your
history and physical examination to the situation at hand,
keeping several factors in mind: the magnitude and
severity of the patient’s problems; the need for
thoroughness; the clinical setting—inpatient or outpatient,
primary or subspecialty care; and the time available.
Adaptive Questioning ( pg. 69-
71)
O Adaptive questioning also known as guided
questioning
O Techniques of Guided Questioning
O ●Moving from open-ended to focused questions
O Using questioning that elicits a graded response
O ●Asking a series of questions, one at a time
O ●Offering multiple choices for answers ●Clarifying
what the patient means
O ●Encouraging with continuers
O ●Using echoing
 Articular structures
O include joint capsule and articular cartilage, the
synovium and synovial fluid, intra-articular
ligaments and juxta-articular bone
O Articular disease involves:
O Swelling
O Tenderness of the joint
O Crepitus
O Instability “locking”
O Deformity
O Limits active and passive range of motion due to stiffness
or pain
Extra-articular structures
O include periarticular ligaments, tendons,
bursae, muscle, fascia, bone, nerve and
overlying skin
O Extra-articular disease involves:
O “point of focal tenderness in regions adjacent to
articular structures
O Limits active range of motion
O RARELY causes swelling, instability, joint
deformity
Nonarticular conditions
O trauma/fracture, fibromyalgia, polymyalgia
rheumatica, bursitis, tendinitis
Intra-articular (acute, < 6
weeks): acute arthritis
O infectious arthritis
O gout
O pseudogout
O Reiter syndrome
Intra-articular (chronic, > 6 weeks): chronic inflammatory arthritis vs chronic
noninflammatory arthritis

O Chronic inflammatory arthritis with 1-3 joints

involved:
O Indolent infection
O Psoriatic arthritis
O Reiter syndrome
O Periarticular JA
O Chronic inflammatory arthritis with >3 joints
involved:
O Psoriatic arthritis or Reiter syndrome (no symmetry)
O rheumatoid arthritis if not RA then  systemic lupus,
scleroderma, polymyositis
what causes saddle numbness and urinary retention
(pg. 678?)

O CES (cauda equina syndrome) most commonly

results from a massive herniated disc in the
lumbar region.
O A single excessive strain or injury may cause a
herniated disc.
O However, disc material degenerates naturally as a
person ages, and the ligaments that hold it in place
begin to weaken. As this degeneration progresses,
a relatively minor strain or twisting movement can
cause a disc to rupture
The following are other potential causes of CES:

O Spinal lesions and tumors

O Spinal infections or inflammation
O Lumbar spinal stenosis
O Violent injuries to the lower back (gunshots, falls, auto
accidents)
O Birth abnormalities
O Spinal arteriovenous malformations (AVMs)
O Spinal hemorrhages (subarachnoid, subdural, epidural)
O Postoperative lumbar spine surgery complications
O Spinal anesthesia
retinal detachment (p.217)
O Sudden, painless vision loss that is unilateral
what the word obtunded means
(p. 769)
O The obtunded patient opens eyes and looks at
you but responds slowly and is somewhat
confused. Alertness and interest in the
environment are decreased.
O 
what cranial nerve you’re assessing when
checking lateral gaze (p. 237)

O Cranial nerve VI: abducens

O 
what should be listed under adult
illnesses in health history (pg. 10)
O Medical illnesses: such as diabetes, hypertension,
hepatitis, asthma, and HIV. Also hospitalizations,
number and gender of sexual partners, and risk-
taking sexual practices
O Surgical: dates, indications, and types of operations
O Obstetric/Gynecologic: obstetric history, menstrual
history, methods of contraception, and sexual
function
O Psychiatric: illness and timeframe, diagnoses,
hospitalizations, and treatments
what conditions do not have red
reflexes (p. 239
O Absence of red reflex suggests an opacity of
the lens (cataract), or possibly the vitreous (or
even an artificial eye).
O Less commonly, a detached retina, or in
children a retinoblastoma may obscure this
reflex.
 signs of seasonal allergies (p. 27)

O itching, watery eyes, sneezing, ear congestion,

postnasal drainage
O 
optic neuritis presents (p. 217)

O Sudden visual loss that is unilateral and can be

painful, associated with multiple sclerosis
pityriasis rosacea presents (p. 912)

O Oval lesions on trunk, in older children often

in a Christmas tree pattern, sometimes a
Harold patch (a large patch that appears first)
 what is listed under present
illness (p. 9)
O Complete, clear, and chronologic description
of the problems prompting the patient’s visit,
including the onset of the problem, the setting
in which it developed, it’s manifestation and
any treatments to date.
O (OLDCART) Onset, Location, Duration,
Characteristics, Aggravating factors,
Relieving factors, Treatments (past)
where is the acromion process
O Located between the clavicle and the shoulder
O 
what can cause falsely high BP’s
(p. 127)
O If the brachial artery is below the heart level,
the blood pressure reading will be higher. If
the cuff is too small (narrow) the blood
pressure will read high.
O If the cuff is too large (wide) the BP will read
high on a large arm
 how to check for nystagmus (p. 737)

O Nystagmus is seen in cerebellar disease especially with

O gait ataxia
O dysarthria (increases with retinal fixation
O vestibular disorders (decreases with retinal fixation)
O internuclear ophthalmoplegia
O Identify any nystagmus, an involuntary jerking movement of the eyes with
quick and slow components.
O Note the direction of the gaze in which it appears, the plane of the
nystagmus (horizontal, vertical, rotary, or mixed), and the direction of the
quick and slow components.
O Nystagmus is named for the direction of the quick component.
O Ask the patient to fix his or her vision on a distant object and observe if the
nystagmus increases or decreases.
what yellow sclera indicates (p.
234)
O A yellow sclera indicates jaundice
how to get a patient to open up
when he seems upset
O The first step to effective reassurance is simply
identifying and acknowledging the patient’s feelings.
For example, you might simply say, “You seem upset
today.” This promotes a feeling of connection.
Meaningful reassurance comes later, after you have
completed the interview, the physical examination, and
perhaps some laboratory tests. At that point, you can
explain what you think is happening and deal openly
with any concerns. Reassurance is more appropriate
when the patient feels that problems have been fully
understood and are being addressed.
 how otosclerosis presents with Weber and
Rinne test
O Otosclerosis condition that affects the tiny middle ear bone known as the
stapes.
O Stapes can become stuck, limiting its ability to vibrate (vibrations are crucial
for hearing)
O Conductive hearing loss
O 
O Weber test
O Tuning fork at vertex
O Sound is heard in the impaired ear
O Room noise not well heard, so detection of vibrations improves
O Rinne test
O Tuning fork at external auditory meatus; then on mastoid bone
O BC longer than or equal to AC (BC > AC or BC = AC)
O While air conduction through the external or middle ear is impaired, vibrations
through bone bypass the problem to reach the cochlea
O The sound is heard longer through bone than air
 cherry angiomas
O are benign
 how to interpret visual acuity results
O Visual acuity is expressed as two numbers (e.g., 20/30):
O First indicates the distance of the patient from the chart
(20 feet),
O Second, the distance at which a normal eye can read the
line of letters
O 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.
O The larger the second number, the worse the vision.
O “20/40 corrected” means the patient could read the 20/40
line with glasses (a correction).
O A patient who cannot read the largest letter should be
positioned closer to the chart; note the intervening distance.
you need permission of the patient to carry out the visit if
someone is in the room with them

O When visitors are in the room, acknowledge

and greet each one in turn, inquiring about each
person’s name and relationship to the patient.
O Whenever visitors are present, you are
obligated to maintain the patient’s
confidentiality. Let the patient decide if visitors
or family members should stay in the room, and
ask for the patient’s permission before
conducting the interview in front of them.
what makes up the health
history (subjective info)
O Identifying data
O Identifying data - such as age, gender,
occupation, marital status
O Source of the history - usually the patient, but
can be a family member or friend, letter of
referral, or clinical record
O If appropriate, establish the source
of referral, because a written report
may be needed
Pg. 649, 655, 700 - how a rotator cuff tear presents

O Patients complain of chronic shoulder pain,

night pain, or catching and grating when
raising the arm overhead
O Weakness or tears of the tendons usually
start in the supraspinatus tendon and
progress posterior and anterior
O Look for atrophy of the deltoid,
supraspinatus, or infraspinatus muscles.
O Palpate anteriorly over the anterior greater
tuberosity of the humerus to check for a
defect in muscle attachment and below the
acromion for crepitus during arm rotation.
Rotator Cuff Tear
Atrophy of the supraspinatus and infraspinatus with increased prominence of scapular
spine can appear within 2 to 3 weeks of a rotator cuff tear; infraspinatus atrophy has a
positive likelihood ratio (LR) of 2 for rotator cuff disease
Drop Arm Test
how to prioritize patient
complaints
O List the most active and serious problems first
and their date of onset
O Problems can be symptoms, signs, past health
events such as a hospital admission or surgery, or
diagnoses.
what joints are condylar
O Articulating surfaces that are convex or
concave
O These joins allow flexion, extension, rotation
and motion in the coronal plane
O Movement of two articulating surfaces not
dissociable
O Knee
O Temporo-mandibular joint
how RA presents pg 703
O Acute
O Tender, painful, stiff joints in RA, usually with symmetric involvement on
both sides of the body.
O The distal interphalangeal (DIP), metacarpophalangeal (MCP)
O wrist joints are the most frequently affected
O Note the fusiform or spindle-shaped swelling of the PIP joints in acute
disease
O Chronic
O In chronic disease, note the swelling and thickening of the MCP and PIP
joints.
O Range of motion becomes limited, and fingers may deviate toward the
ulnar side.
O The interosseous muscles atrophy.
O The fingers may show “swan neck” deformities (hyperextension of the
PIP joints with fixed flexion of the distal interphalangeal [DIP] joints).
O Less common is a boutonnière deformity (persistent flexion of the PIP
joint with hyperextension of the DIP joint).
Rheumatoid nodules are seen in the acute or
the chronic stage
subjective information
O What the patient tells you
O The symptoms and history, from chief complaint
through review of systems
O Ex: Mrs. G is a 54 year old hairdresser who
reports pressure over her left chest “like an
elephant sitting there,” which goes into her left
risk factors of melanoma (pg.
177)
 Melanoma Clinicians should apply the ABCDE rule. (page 178)

O ABCDE Rule:
O Asymmetry: (compare one side to the other)
O Border irregularity: look for ragged, notched or blurred
O Color variations: more than 2 colors(blue black) (brown red), loss of
pigment, or redness
O Diameter >6 mm: size of pencil eraser
O Evolving: changing rapidly in size, symptoms, or morphology (usually
asymmetrical)
O Also look for elevation, firmness to palpate, growing progressively over
several weeks.
O Self skin exams are recommended by the ACS and AAD. They should be
done in a well lit room with a full length mirror. Patients with a family
history of melanoma, prior history of melanoma, or history of high sun
exposure should do exams more frequently. Teach patient the appearance
of different skin cancers and provide internet reliable resources for
patients. Usually seen in fair colored patients.
signs of subarachnoid hemorrhage (pg. 216)

O Severe and sudden “worst headache of my

life!” Nausea and vomiting can be present.
Neck stiffness with resistance to flexion is
present in 21-86% of patients
Assessing patient with Possible
Malaria
O if 1 patient returns from a country with
malaria you still need to be selective of
which patients you screen for malaria. (pg.
66?)
what are absence seizures (pg. 781)

O A sudden brief lapse of consciousness, with

momentary blinking, staring, or movements of the
lips and hands but no falling.
O Two subtypes are typical absence (lasts less than
10 sec and stops abruptly)
O And atypical absence (may last more than 10 sec).
O Post ictal state: no aura recalled. In typical
absence, there is a prompt return to normal and in
atypical there might be some postictal confusion.
which cranial nerve you assess when you touch
the soft palate and view the uvula (pg. 257).

O Cranial nerve X (Vagus)

signs of increased intracranial pressure (pg. 280).

O Papilledema of the optic disc  elevated ICP causes

intraaxonal edema along the optic nerve leading to
engorgement and swelling on the optic disc
O pink, hyperemic, loss of venous pulsations, disc
more visible, disc swollen with blurred margins,
physiologic cup not visible)
O Headache, blurred vision, feeling less alert than
usual, vomiting, changes in
O behavior, weakness or problems with moving or
talking, lack of energy or sleepiness
signs of respiratory distress (p.
318)
O Tachypnea: greater than or equal to 25 breaths/min 
pneumonia and cardiac disease
O Cyanosis or pallor (signals hypoxia)
O Audible sounds of breathing: audible whistling during
inspiration over the neck or lungs
O stridor signals upper airway obstruction in the larynx or trachea
O Contraction of the accessory muscles of the neck or
supraclavicular retraction, contraction of the intercostal
or abdominal oblique muscles
O Is the trachea midline?
objective information
O What you detect during the examination,
laboratory information, & test data. All
physical exam findings, or signs.
what can cause epistaxis (p. 220)

O Trauma (especially nose picking),

inflammation, drying and crusting of the nasal
mucosa, tumors, and foreign bodies
signs of otitis externa (swimmer’s ear) (pg. 245)

O Painful movement of the auricle and tragus (tug test)

O Movement of the auricle and tragus (the “tug test”) is

painful in acute otitis externa (inflammation of the ear
canal), but not in otitis media (inflammation of the middle
ear). Tenderness behind the ear occurs in otitis media.

O in acute otitis externa (Fig. 7-43), the canal is often

swollen, narrowed, moist, pale, and tender. It may be
reddened.
signs of pneumonia (pg. 322-340)

O Dullness replaces resonance, crackles can arise from

abnormalities of the lung parenchyma, pleural rubs,
localized bronchophony and egophony (in patients with
fever and cough the presence of bronchial breath sounds
and egophony more than triples the likelihood of
pneumonia.
O Pleuritic pain: sharp, knifelike, aggravated by deep
inspiration, coughing, movements of the trunk. Often
persistent and severe.
O Pg 333: dyspnea, pleuritic pain, cough, sputum, fever.
Pg. 339 goes over physical findings in lobar pneumonia
physical signs of meningitis
(pg. 765)
O Neck stiffness with resistance to flexion is present in approx. 84% of
patients with acute bacterial meningitis (won’t be able to touch chin
to chest)

O Inflammation in the subarachnoid space causes resistance to

movement that stretches the spinal nerves (neck flexion), the femoral
nerve (Brudzinski sign), and the sciatic nerve (Kernig sign).

O Neck stiffness with resistance to flexion is found in ∼84% of patients

with acute bacterial meningitis and 21% to 86% of patients with
subarachnoid hemorrhage. It is most reliably
O present in severe meningeal inflammation but its overall diagnostic
accuracy is low.
Meningitis
signs of asthma (p. 326, 334)

O Cough at times with this mucoid sputum,

especially near the end of an attack. Episodic
wheezing and dyspnea, but cough may occur
alone, often with a history of allergies. In the
advanced airway obstruction of severe asthma,
wheezes and breath sounds may be absent due
to low respiratory airflow (the “silent chest”
which is a clinical emergency).
O Abnormal retraction occurs in severe asthma.
the signs of lyme disease (pg. 208)

O Rash, often in a bull’s-eye pattern (erythema

migrans) and flu-like symptoms, fever,
headache, fatigue
what acanthosis nigricans can clue into
(pg. 207 & 440)

O Diabetes mellitus

O Shadow Health Tina Jones

what Mongolian spots are pg. 816

O A dark or bluish pigmentation over the buttocks and

lower lumbar regions  common in newborns of
African, Asian and Mediterranean descent,
O Also called slate blue patches
O Result from pigmented cells in the deep layers
on the skin
O Less noticeable with age and disappear during
childhood
O Document these pigmented areas to avoid later
concern about bruising
red flags for headaches (p. 216)
O Progressively frequent or severe over a 3-month period
O Sudden onset like a “thunderclap” or “the worst headache of my
life”
O New onset after age 50
O Aggravated or relieved by change in position
O Precipitated by Valsalva maneuver or exertion
O Associated symptoms of fever, night sweats, or weight loss
O Presence of cancer, HIV infection, or pregnancy
O Recent head trauma
O Change in pattern from past headaches
O Lack of similar headache in the past
O Associated papilledema, neck stiffness, or focal neurologic
deficits
What labs to check with vitiligo (pg. 191)

O Thyroid panel: TSH, free T3 and free T4, CBC

 C-section (pg. 10)

O Know that it should be listed under surgeries,

make sure you include date indication and
type of surgery
 Subjective info (p. 12
O Goes under the review of systems, includes
items that the patient reports to you
how psoriasis presents
O If you run your fingers over a lesion and its
palpable above the skin – its raised, over one
cm its PLAGUE under one cm its PAPULE
what visual acuity means, 20/100

O Means that at 20 feet the patient can read a

print that a person with normal vision could
read at 100 ft, the larger the second number
the worse the vision First # indicates the
distance from the chart
what cotton whool patches look like,
subconjunctival hemorrhage
O Benign, no treatment required, resolves in 2
weeks , Leakage of blood outside the vessel
producing homogenous red area. , no ocular
discharge, vision not affected, Usually
resulting from trauma, or sudden increase in
venous pressure
Conjunctivitis and Subconjunctival
Hemmorhage
Angina Pectoris versus chest
pain
O It can be a cause for pain in the myocardium.
A clenched fist over the sternum suggest
angina pectoris
O A clenched fist over the sternum suggests
angina pectoris; a finger pointing to a tender
spot on the chest wall suggests
musculoskeletal pain; a hand moving from the
neck to the epigastrium suggests heartburn.
 Olfactory CN I (pg. 736)

O The decreased sense of smell is normal in

elderly patients, head trauma, smoking,
cocaine use and Parkinson’s d/e.
 Shoulder shrug (pg. 740)

O Testing the CN XI Spinal Accessory nerve.

Put your hands on pt shoulder and ask them to
shrug against your hands- asses for strength
and contraction of trapezii. Weakness noted
with atrophy and points to a peripheral nerve
disorder.
Shoulder Shrug
Vasovagal syncope causes (pg. 778)

O Reflex withdrawal of sympathetic tone and

increased vagal tone causing a drop in BP and
HR.
O Usually precipitated by strong emotions such
as fear or pain, prolonged standing or hot
humid environment.
O Predisposing factors – fatigue, hunger,
dehydration, diuretics, vasodilators
how to distinguish jugular venous pulsation vs
carotid pulse (pg. 377)

O Jugular: rarely palpable, soft bi-phasic undulating quality

(usually with 2 elevations and characteristic inward
deflection), pulsations eliminated by light pressure on the
vein just above the sternal end of the clavicle, height of
pulsation changes with position (normally dropping as the
patient becomes more upright), height of pulsations usually
falls with inspiration
O Carotid: palpable, a more vigorous thrust with a single
outward component, pulsations not eliminated by pressure
on veins at sternal end of clavicle, height of pulsations
unchanged by position, height of pulsations not affected by
inspiration
where the cricoid cartilage is
(pg. 258)
atrium or ventricle you feel when
you palpate the chest (pg. 385-389)

O Left ventricular area: the apical pulse or point

of maximal impulse (PMI)- best palpated with
the patient lying supine in the left lateral
decubitus position which displaces the apical
pulse to the left. Locate the interspaces,
usually the 5th or 4th which give the vertical
location and the distance in cm from the
midclavicular line which gives the horizontal
location.
 aortic regurgitation pg. 392

O Ask the patient to sit up, lean forward, exhale

completely, and briefly stop breathing after
expiration.
O Press the diaphragm on your stethoscope on
the chest and listen along the left sternal border
and at the apex, pause periodically so the
patient may breathe
O You may miss the soft diastolic decrescendo
unless you listen at this position
 what valve you are listening to
when you listen to the apex of the
heart Pg. 391
O Mitral valve
O Have the patient roll onto left lateral decubitus
position which brings the left ventricle closer
to the chest wall
O Place bell of your stethoscope lightly on the
apical impulse  S3 & S4, mitral murmurs
& mitral stenosis