Physical Assessment of the Child And Adolescent: An Overview of Normal vs. Abnormal Physical Examination Findings
WENDY L. WRIGHT, MS, RN, ARNP, FNP, FAANP, FAAN ADULT/FAMILY NURSE PRACTITIONER OWNER – WRIGHT & ASSOCIATES FAMILY HEALTHCARE @ AMHERST AND @ CONCORD OWNER – PARTNERS IN HEALTHCARE EDUCATION
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Disclosures
Speaker Bureau: Sanofi-Pasteur, Merck, Pfizer, AbbVie, Biohaven Consultant: Sanofi-Pasteur,, Pfizer, Merck, GSK
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Wright, 2021 1 Objectives
Upon completion of this lecture, the participant will be able to:
Describe the essential components of a comprehensive physical examination on a child and adolescent
Identify normal vs abnormal physical examination findings
Identify special maneuvers which can identify pathology in children and adolscent
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Let’s Talk About Some Common Problems
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Wright, 2021 2 Eye Complaint: History
Chief complaint
HPI, including the following associated symptoms:
Pain, itching, discharge, tearing, blurring, visual acuity changes, foreign body sensation, photophobia, halo vision
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History (continued)
Present status of visual function
Corrective lens, glasses and use
Last eye examination Medications
Systemic
Ocular Allergies Past history
Ocular disease
Systemic disease
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Wright, 2021 3 History (continued)
Surgeries (if pertinent) Family History
Ocular diseases
Systemic diseases
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Physical Examination
Eyebrows Note quantity and distribution of hair Note any scaling or lesions
**Eyebrows are symmetrical and evenly distributed; No dryness, scaling, or thinning of the lateral 1/3.
**Thinning of the lateral 1/3 of the eyebrow- hypothyroidism **Scaling-seborrheic dermatitis
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Wright, 2021 4 Eyelids
Lids should close in unison to cover the entire eye Upper lid margin rests on the superior border of the iris Lower lid margin rests on the inferior border of the iris Palpebral fissure: Space between the upper and lower lid
** Lids close in unison to cover entire eye. The upper lid margin is at the superior border of the iris and the lower lid is at the inferior border of the iris.
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Abnormalities of Eyelids
Widening of the palpebral fissure Hyperthyroidism (Exophthalmos) Decrease in palpebral fissure size Dehydration (Enophthalmos) Ptosis Cranial Nerve III Dysfunction Muscular Dystrophy
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Wright, 2021 5 Exophthalmos
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Ptosis
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Wright, 2021 6 Lid Margins
Lid Margins
Skin tone
Inversion or Eversion
Lesions
** The lid margins are appropriately colored; No lesions, edema, inversion or eversion.
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Abnormalities of the Lid Margins
Lesions: Hordeolum, Chalazion Edema: Allergic Conjunctivitis, Crying, Infection Entropion: Inversion of Lid Margin Spasm or scarring of the lid Eyelashes often invert and irritate the conjunctiva and cornea Ectropion: Eversion of Lid Margin Aging Exposes the conjunctiva to bacteria Eye does not drain properly-tearing
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Wright, 2021 7 Entropion
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Ectropion
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Wright, 2021 8 Eyelashes
Note
Color
Distribution
Direction in which they point
Discharge
**Eyelashes are ____ in color, evenly distributed, outward pointing; No discharge or thinning.
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Abnormalities of Eyelashes
Thinning
Make-up
Trichotillomania
Alopecia Discharge
Conjunctivitis
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Wright, 2021 9 Blepharitis
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Dacryocystitis
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Wright, 2021 10 Conjunctiva
Conjunctiva Clear covering over the visible parts of the eye (except the cornea) Protective covering for the eye Bulbar Clear covering and the blood vessels that cover the sclera Palpebral Conjunctiva Thin covering above and below the eyeball Forms deep recesses that fold forward to join the eyelid
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Normal Conjunctiva
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Wright, 2021 11 Conjunctiva
Bulbar and Palpebral Conjunctiva Color Injection Lesions Foreign bodies
**Conjunctiva is clear and appropriately colored; No injection, pallor, lesions, or foreign bodies.
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Abnormalities of the Conjunctiva
Injection Conjunctivitis, Irritation from Contact Lens, Iritis, Glaucoma Pallor Anemia Lesions
Pterygium: An opaque, triangular shaped conjunctival lesion usually seen nasally and able to extend over the cornea. May interfere with vision. Pinguecula: Yellow nodules usually seen at 3 and 9 o’clock on the conjunctiva. No visual changes.
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Wright, 2021 12 Pinguecula
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Pterygium
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Wright, 2021 13 Sclera Sclera White portion of the eye May look buff-colored or pale yellow in the periphery Note Color Texture Lesions
**Sclera are white, smooth; No lesions or icterus.
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Sclera
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Wright, 2021 14 Abnormalities of Sclera
Yellow sclera
Physiologic or pathologic jaundice
Resolving subconjunctival hemorrhage Red appearing sclera
Subconjunctival Hemorrhages
Note: It is actually the bulbar conjunctiva not the sclera that becomes jaundiced or red.
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Excessive Vomitting Causing Subconjunctival Hemorrhages
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Wright, 2021 15 Cornea Cornea Portion of the anterior aspect of the eye which when viewed from the side, protrudes forward Transparent covering that protects the eye Avascular covering over the iris and pupil Note (Use a penlight and view from the side) Appearance Shiny Lesions Corneal Light Reflex
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Cornea
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Wright, 2021 16 Cornea
**Cornea are smooth, transparent, and shiny; No lesions or opacities. Corneal light reflex is symmetric bilaterally.
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Abnormalities of the Cornea
Arc Corneal arcus or arcus senilis Thin gray-white arc or circle that lies close to the edge of the cornea or edge of the iris Causes: aging, african americans, hyperlipidemia Abrasion Mild injury to the cornea Causes include foreign body, trauma, contact lens Symptoms: pain, photophobia, discharge
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Wright, 2021 17 Corneal Abrasion
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Herpes Simplex
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Wright, 2021 18 Abnormalities of the Cornea
Corneal Ulceration Opacities
Scarring Asymmetric Corneal Light Reflex
Strabismus (esotropia or exotropia)
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Corneal Ulcer
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Wright, 2021 19 Asymmetric Corneal Light Reflex
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Exodeviation
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Wright, 2021 20 Iris Iris
Colored portion of the eye
Contains muscle that surround the pupil and control pupillary size
These muscles are innervated by CN III Note
Appearance
Shape
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Iris Note
Color
Detail
Anterior Chamber
** Iris is round, symmetric, ____ in color, and with clear detail. The anterior chamber is without blood or pus.
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Wright, 2021 21 Iris
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Abnormalities of the Iris Hyphema: Blood in the anterior chamber Trauma Hypopion: Pus in the anterior chamber Infection Anterior uveitis (formerly, iritis): Moderate pain, decreased vision, pupil is small and will become irregular over time Becomes irregular because the swelling distorts the pupil Associated with many systemic disorders Rheumatoid arthritis, SLE, Ankylosing spondylitis
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Wright, 2021 22 Abnormalities of the Iris
Iris Color Is Not Identical
Heterochromia Iridis
If this is seen, suspect Horner’s syndrome
Horner’s syndrome: Sympathetic nerve disruption, most often in the neck. Iris is lighter in color, ptosis of eyelid, loss of sweating on forehead, and pupil is smaller (all on the affected side) Brushfield Spots
Down’s Syndrome
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Pupils Pupils
Normally round
Range in size from 3-7 mm
Allow images and light to enter
They change in size to adjust for light and to focus on an image Note
Size
Shape
Regularity
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Wright, 2021 23 Pupils Note
Symmetry
Newborn
Response to direct light
Older child
Response to direct and consensual light
** Pupils are ____mm, round, regular and equal bilaterally and respond briskly to direct and consensual light.
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Abnormalities of the Pupils
Aniscoria: Inequality of the pupils Normal Variation: Respond normally to light Increase in Intracranial Pressure Acute Angle Closure Glaucoma Severe pain Decreased vision Pupil is dilated Cornea is cloudy Increase in intraocular pressure
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Wright, 2021 24 Abnormalities of the Pupils
Miosis
Equally constricted pupils
Drugs, morphine, bright light Mydriasis
Equally dilated pupils
Anticholinergic agents, mushrooms, increased intracranial pressure Inability to accommodate
Cranial nerve defect (III, IV, VI)
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Visual Acuity
Visual Acuity
Test of central vision
Controlled by cranial nerve II (Optic)
Use a Snellen Chart (wall or hand-held)
Stand 20 feet from wall chart
Place hand held Snellen 13 inches from face
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Wright, 2021 25 Visual Acuity
Infants Central vision is present, may just see light Optimum distance for visualization: 8-12 inches Assess by checking direct and consensual response to light, blinking, extending the head in response to a bright light (Optical blink reflex) and blinking in response to a quick movement of an object toward the eye 2-4 weeks, should be able to fixate on objects 5-6 weeks, coordinated eye movements
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Visual Acuity Child Vision: 20/200 at 1 year old, 20/40 at 3, 20/30 at 4-5 years of age No test that accurately measures acuity in child < 3 Can test using a hand-held Snellen chart or a wall chart Letters and Lazy E are the best tests Older Child and Adult Adult visual acuity is reached at approximately 6 years of age
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Wright, 2021 26 Visual Acuity
Visual Acuity is ____OD, ____OS, and ____OU (corrected or uncorrected)
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Abnormalities of Visual Acuity
Absence of a direct or consensual response to light, absence of blinking, negative optical blink reflex, or failure to blink when an object is moved quickly toward the eye: Blindness Asymmetric Visual Acuity: Amblyopia
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Wright, 2021 27 Red Eye
Differential falls into the following categories Infections with or without trauma (conjunctivitis) Inflammation with or without trauma (uveitis) Vascular (subconjunctival hemorrhage) Systemic diseases Allergies Chemical Acute glaucoma
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Non-vision Threatening Causes of Red Eye
Subconjunctival hemorrhage Hordeolum Chalazion Blepharitis Conjunctivitis Dry eyes Corneal abrasions
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Wright, 2021 28 Hordeolum
Etiology
Obstruction of the glands of Zeiss
Staphylococcal aureus is the most common causative organism History
Swollen, red, painful lesion on the lid margin
Itchiness of the eyelid
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Hordeolum
Physical examination
Erythematous, tender nodule on the margin of the eyelid
Surrounding edema Treatment
Warm compresses-20 minutes qid
Antimicrobial ointment or drops
Good eye hygiene and handwashing
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Wright, 2021 29 Hordeola
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Hordeola
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Wright, 2021 30 Internal Hordeola
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Chalazion
Etiology
Obstructed meibomian glands
Chronic inflammatory lesion that grows inward as it enlarges
May become infected History
Lesion on the outside of the eye
May become slightly inflamed
Usually non-tender
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Wright, 2021 31 Chalazion
Physical examination May or may not visualize a nodule on the outside of the eyelid Visible on the inside of the lid May become erythematous, tender and edematous Treatment None Antimicrobial agent if infected Surgical management
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Chalazion
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Wright, 2021 32 Chalazion
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Case Study 1: TM
TM is a 19 y.o.w.m student with a 2 day history of yellow discharge & redness in both eyes. Began approximately 2 weeks after developing a cold Associated with a mild blurring of the vision and itching Denies pain, photophobia, other visual changes, headache Has done nothing to treat Meds: none; Allergies: NKDA, NKEA PMH: Noncontributory PE: Visual acuity 20/20 OD, OS, OU; 4 mm preauricular node
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Wright, 2021 33 Viral Conjunctivitis
Etiology Adenovirus is the most common cause 40 strains available Recent studies have shown that they can remain viable on plastic and metal surfaces for up to 1 month Symptoms Watery discharge, foreign body sensation, redness URI symptoms are common including sore throat and fever Often bilateral
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Viral Conjunctivitis
Signs
Normal visual acuity, PERRLA, EOMI, Fund nl
Mucoid-slightly watery discharge
Mild, diffuse injection
Preauricular lymphadenopathy Treatment
Symptomatic only
Cool compresses
Strict eye hygiene
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Wright, 2021 34 Viral Conjunctivitis
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Viral Conjunctivitis
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Wright, 2021 35 Viral Conjunctivitis
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Bacterial Conjunctivitis
Etiology
Staphylococcal
Streptococcus pneumoniae/pyogenes
Haemophilus influenzae
Neisseria Symptoms
Redness, swelling, purulent discharge, itching
No symptoms until eye complaints began
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Wright, 2021 36 Bacterial Conjunctivitis
Signs
Normal visual acuity, PERRLA, EOMI, Fund nl
Diffuse injection
No ciliary injection
Unilateral at onset Treatment
Topical antimicrobials x 5-7 days
Warm compresses qid x 10-20 minutes
Strict eye hygiene given contagion
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Bacterial Conjunctivitis
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Wright, 2021 37 Bacterial Conjunctivitis
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Vision Threatening Red Eye Disorders
Corneal Infections or Ulcerations Hyphema Hypopion Iritis/Uveitis Acute Angle Closure Glaucoma Orbital Cellulitis Chemical injury (particularly-alkali)
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Wright, 2021 38 Case Study 3: TY TY is a 6 yowm who presents with his mom for an evaluation of (R) pink eye. Began this am. Denies discharge, itching, recent URI. Mom denies trauma but does report strange occurrence yesterday. He failed to respond to her calling. When he finally came, he reported being asleep outside. PE: Absent red reflex-OD; Visual acuity 20/100 (OD); 20/30 (OS); Pupil-slightly constricted (OD). Unable to view the fundus (OD)
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Hyphema
Definition
Bleeding into the anterior chamber of the iris
Causes include trauma or surgery Symptoms
Pain, red eye, blood in anterior chamber
Blurred or Absent vision Signs
Absence of the red reflex
Blood in the anterior chamber
Increased IOP
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Wright, 2021 39 Hyphema
Signs
Decreased visual acuity
Injected conjunctiva (mild-severe)
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Hyphema
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Wright, 2021 40 Complication of Hyphema
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Hyphema
Treatment
Always assume that the globe is ruptured as 25% have other serious ocular injuries
Shield the eye and refer immediately
Can lead to devastating visual complications including blood staining of the cornea, glaucoma, atrophy of the optic nerve
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Wright, 2021 41 Reasons to Refer Immediately
Sudden unilateral loss of vision Lacerations that involve the lid margin or tear duct apparatus Ocular pain, photophobia, ciliary injection Corneal ulceration Hyphema or Hypopion Pupillary distortion Central or deep foreign body Iritis or scleritis
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Blowout Fracture
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Wright, 2021 42 Ears
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John...
John is a 19 year old male who is new to the practice. Presents with a 3-day history of right ear pain, nasal discharge and fever of 102. Decreased sleep and appetite. Last urine-2 hours ago. PE: Ears: Canals pale white. Right TM erythem, edem and without movement. Left TM-slightly retracted. Nasal mucosa pink. Tonsils pink: no exudate. Nodes: nonpalpable, nontender; Lungs: clear bilaterally
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Wright, 2021 43 Ear Canal
Anatomy Overview : The external canal is an S-shaped pathway leading to the middle ear It is approximately 2.5 cm long, covered with a thin layer of very sensitive skin. The canal is protected and lubricated with cerumen, secreted by the sebaceous glands in the distal 1/3 of the canal.
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Otitis Media
Symptoms Fever Pain Discharge from ear Tugging or batting at the ear Irritability, crying, lethargy Decreased appetite Decreased sleep Recent URI
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Wright, 2021 44 Otitis Media
Signs
Red, bulging tympanic membrane
Retracted with pus, fluid or air bubbles
No movement with insufflation
Inability to see normal landmarks
Occasionally-hole in the tympanic membrane
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Ears
Auricles Position Size Lesions **Auricles are level with the outer canthus of the eye and symmetric. They are proportionate in size to the body without lesions or deformities
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Wright, 2021 45 Abnormalities of the Auricle Small or Low-Set Ears: Congenital Defects Accutane exposure in utero Large Protruding Ears: Fragile X Syndrome Protruding Ears: Mastoiditis
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EARS
Ear Canal Before age 6, pull auricle down, back, and out Color Lesions Discharge Foreign body **Ear canals are pale white with a _____amount of hair present. There are no lesions, discharge or foreign bodies
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Wright, 2021 46 Abnormalities of the Ear Canal
Erythema and discharge: Otitis externa Foreign body Cerumen Cholesteatoma
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EARS
Tympanic Membrane Color Appearance Bony Landmarks Cone of Light Insufflation **Tympanic membrane is pearly gray, moveable, and intact AU. The bony landmarks are clearly visible. The cone of light is at 5 o’clock on the right and 7 o’clock on the left. There is no erythema, perforations, or retractions.
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Wright, 2021 47 Variations of Tympanic Membrane Normal TM
Acute OM
Otitis Media with Effusion
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Abnormalities of the Tympanic Membrane
Erythematous, Bulging TM: Otitis Media Retracted TM: Eustachian Tube Dysfunction, Serous OM Bullae on TM: Bullous Myringitis Perforation: Trauma, OM, Flying
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Wright, 2021 48 AOM
S. pneumoniae Gram-positive diplococci => 25% PCN- resistant via altered protein- binding sites Very unlikely to resolve on own Usually the sickest
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Acute OM
H. influenzae
Gram-negative bacilli
=>40% amoxicillin- resistant via beta- lactamase production M. Catarrhalis
90-95% beta-lactamase producing
Likely to resolve on own
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Wright, 2021 49 Bullous Myringitis
Intensely painful Often presents with TM performation
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Duration of Treatment for AOM
Regimens evaluated Numerous treatment options were evaluated Treatment success evaluated at 12–14 days Results Similar response in all patients between short- course (eg, 5 days) and standard-course (eg, 10 days) therapy Patients <2 years old and those in a daycare setting may achieve better results with 10-day therapy
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Wright, 2021 50 Treatment for Otitis Media
Plan
Therapeutic Decongestants/antihistamines: not shown to be effective Auralgam: analgesic for the ear Warm compresses NSAIDs/Tylenol
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Otitis Media
Plan Educational No smoke exposure Finish all medication Consider ventilation tubes
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Wright, 2021 51 Nose and Sinuses
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NOSE AND SINUSES
Skeleton
Structure
Midline
**Skeleton is straight and midline without deformities or deviations.
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Wright, 2021 52 Nose and Sinuses
External
Vestibule
Ala Nasi
Bridge
Tip
Columnella
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NOSE AND SINUSES
Nares
Patency
Foreign Body
**Nares are patent. No foreign bodies
**Discharge from one nare: Foreign body
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Wright, 2021 53 Anatomy and Physiology
Internal Air enters the nasal cavity through the nares bilaterally Air then passes into a widened area known as the vestibule and then on to the nasopharynx Septum Medial wall of the nasal cavity Supported by bone and cartilage Covered with mucous membranes Well supplied with blood
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NOSE AND SINUSES
Septum Position Perforation **Septum is midline and intact without deviations, ulcerations, or perforations. **Deviation may be present in some children, particularly after a nasal fracture or birth process, and may interfere with nasal breathing.
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Wright, 2021 54 NOSE AND SINUSES
Mucosa Color Discharge Edema Polyps **Mucosa is pink and without discharge, edema, erythema, or lesions. **Erythematous Mucosa: Viral or Bacterial Infection: **Pale, Boggy Mucosa or Polyps: Allergic Rhinitis
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Anatomy and Physiology
Turbinates 3 sets: Inferior, middle and superior Located laterally Bony structures Protrude into the nasal cavity Functions Increases surface area of the nose & mucosa Cleans the air Warms the air Humidification
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Wright, 2021 55 NOSE AND SINUSES
Turbinates Color Edema Discharge **Lower and middle turbinates are darker in color than the mucosa and without edema or discharge. **Erythematous, Edematous Turbinates: Sinusitis **Pale, Boggy Turbinates: Allergic Rhinitis
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Sinuses
4 sets of sinuses Maxillary Ethmoid Sphenoid Frontal
**All are present at birth, except the frontal, which develops at 1 year of age
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Wright, 2021 56 Anatomy Slide
Accessed at AAAAI Patient Resource Center. 113
NOSE AND SINUSES
Sinuses Maxillary Frontal
Tenderness
Erythema **Frontal and Maxillary sinuses are nontender and without erythema or edema **Tenderness: Sinusitis **Erythema: Abscess
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Wright, 2021 57 Allergic Rhinitis
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Physical Examination Findings in the Individual With Allergic Rhinitis Pale, boggy mucosa and Watery discharge in nose and eyes turbinates Ulcerations on nasal mucosa Allergic shiners Pharyngeal edema Allergic salute Lymphoid tissue Conjunctival injection Nasal polyps
Cobblestoning Long eye lashes
Allergic facies High arched palate
Dennie’s lines
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Wright, 2021 58 117
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Wright, 2021 59 119
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Wright, 2021 61 123
PHARYNGITIS
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Wright, 2021 62 Pharyngitis
Epidemiology
30 million patients seen yearly in US for pharyngitis
Most often seen in colder months
Peak age: 5-8 years; however with increase in # of children in daycare at younger age, it is occurring in younger children
Tonsils serve as our 1st line of defense against respiratory pathogens
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Pharyngitis
Epidemiology Tonsils are small in infancy Increase in size until approximately 10 years of age and then they regress Pathogens for pharyngitis spread via person to person Pathogen
Group A Beta hemolytic strep
1/3-1/2 of cases in children aged 2 - 14
Non-group A strep
Viral pharyngitis: 1/2 of cases in infants < 2
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Wright, 2021 63 Pharyngitis
Epidemiology
Group A Beta Hemolytic Strep
Most interest because of its association with severe complications
Peritonsillar abscesses, rheumatic fever, post-streptococcal glomerulonephritis - complications
Rheumatic fever: 20/100,000 people in early 1900’s, now 1:100,000
Recent increase in cases
Many cases in individuals without sore throat
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Pharyngitis
Symptoms Group A Beta Hemolytic Strep
Rapid onset of sore throat
Fever 103-104
Swollen glands
Children often complain of abdominal pain
Usually-no URI symptoms
Headache
Decreased appetite
Irritability
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Wright, 2021 64 Pharyngitis
Symptoms
Viral Pharyngitis Usually not a severe sore throat Low grade temp Mild swollen glands Associated with URI symptoms
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MOUTH
Anatomy and Physiology Lips Tongue Mucosa Uvula Tonsils Posterior Pharynx Dentition Gingiva
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Wright, 2021 65 MOUTH
Anatomy and Physiology Lips Tongue Mucosa Uvula Tonsils Posterior Pharynx Dentition Gingiva
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MOUTH
Lips Color Moisture Lesions Abnormalities **Lips are appropriately colored and moist; No lesions or abnormalities
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Wright, 2021 66 Abnormalities of the Lips
Blue: Cyanosis Abnormal Development: Cleft Lip Vesicles: Herpes Simplex, Impetigo Thin Upper Lip: Fetal Alcohol Syndrome
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Mouth
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Wright, 2021 67 MOUTH
Tongue Position Size Deviation Lesions Coating Frenulum **Tongue is straight, appropriate size and midline. It is lightly papillated without lesions or coating. Frenulum is intact.
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Abnormalities of the Tongue
Deviation: Cranial Nerve XII Dysfunction White Coating: Thrush Thick Frenulum: Tongue Tie Protruding Tongue: Angelman Syndrome Ulcerations: Thrush, Apthous Stomatitis, Coxsackie Virus
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Wright, 2021 68 MOUTH
Mucosa Color Lesions Coating Moisture **Mucosa is appropriately colored, smooth, and moist without lesions, masses or coating.
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Abnormalities of Buccal Mucosa
Coating: Thrush Ulcerations: Chewing Tobacco; Apthous Stomatitis; Hand, Foot, and Mouth Disease
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Wright, 2021 69 MOUTH
Hard and Soft Palate Continuity Lesions **Hard and Soft Palate are continuous without lesions or abnormalities. **Incongruous Hard and Soft Palate: Cleft Palate **Ulcerations: Thrush, Apthous Stomatitis, Coxsackie Virus **Coating: Thrush
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MOUTH
Uvula Position Color Lesions **Uvula is midline and smooth. It rises with phonation and is without lesions, erythema, or deviation. Asymmetry: CN X Dysfunction, Tonsillar Abscess Erythema: Viral or Bacterial Pharyngitis
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Wright, 2021 70 MOUTH
Tonsils Anterior and Posterior Pillars Color Edema Exudate **Tonsils are present bilaterally and without edema, erythema, or exudate.
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Abnormalities of the Tonsils
Erythematous, Edematous: Viral or Bacterial Pharyngitis Exudate: Bacterial Pharyngitis, Mononucleosis, Viral pharyngitis Asymmetric Enlargement: Tonsillar Abscess
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Wright, 2021 71 MOUTH
Posterior Pharynx Color Lesions Edema Exudate **Posterior pharynx is pink without lesions, erythema, exudate, or edema. **Lymphoid tissue: Viral or Allergic Illness **Exudate and Edema: Strep Pharyngitis
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Pharyngitis
Signs
Group A Beta Hemolytic Strep
Erythematous, edematous tonsils, uvula
Exudate
Lymphadenopathy
Palatal petecchiae
Fever
Rash-scarletina
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Wright, 2021 72 Pharyngitis
Signs Viral Pharyngitis Slightly erythematous tonsils Can have exudate URI physical exam findings
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Exudative pharyngitis
Exudative pharyngitis Differentials include: Strep pharyngitis Peritonsillar abscess Mononucleosis Viral pharyngitis
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Wright, 2021 73 Scarletina
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Strawberry Tongue
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Wright, 2021 74 Pharyngitis
Plan Diagnostic Throat culture: 24 hour is the gold standard Quick strep: 85-100% specificity; 31-95% sensitivity Must swab both tonsils for best results Consider mononucleosis
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Pharyngitis
Even with a best case scenario, 1/3 - 1/2 of cases of strep pharyngitis are missed or overdiagnosed using history and physical examination only!!!
MUST DO A THROAT CULTURE
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Wright, 2021 75 Remember… Adolescents/Young Adults with mono have strep pharyngitis 50% of the time
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Peritonsillar Abscess
Generally begins as an acute febrile URI or pharyngitis Condition suddenly worsens Increased fever Anorexia Drooling Dyspnea Trismus
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Wright, 2021 76 Peritonsillar Abscess
Physical examination
May appear restless
Irritable
May lie with head hyperextended to facilitate respirations
Muffled or “hot potato voice”
Stridor may be present
Respiratory distress
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Peritonsillar Abscess
Physical examination findings
Fiery red asymmetric swelling of one tonsil
Uvula is often displaced contralaterally and often forward
Large, tender lymphadenopathy
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Wright, 2021 77 Peritonsillar Abscess
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Peritonsillar Abscess
Trismus
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Wright, 2021 78 Peritonsillar Abscess
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Peritonsillar Abscess
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Wright, 2021 79 Cardiac Examination
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Heart Sounds
Auscultate for rate, rhythm and presence of extra heart sounds with the athlete in a supine position The heart should also be auscultated in a sitting and standing position
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Wright, 2021 80 Cardiac Physical
Auscultation Examination
Locations Auscultate in 5 locations with the bell and the diaphragm Aortic - 2nd ics, right sternal border Pulmonic - 2nd ics, left sternal border Erb’s point - 4th ics, left sternal border Tricuspid - 5th ics, left sternal border Mitral - 5th ics, left midclavicular line
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Cardiac Physical
Heart Sounds Examination
S1: Mitral and Tricuspid closure
Abnormally loud: Mitral stenosis
S2: Aortic and Pulmonic closure
Physiologic split: common, widens with inspiration
Fixed split: ASD, pulmonary stenosis
S3: Early diastole
2 types: Physiologic and Pathologic
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Wright, 2021 81 S3 Heart Sound
Physiologic
Heard in about 1/3 of children under 16
Rarely in adults over 30 Pathologic
To differentiate from physiologic, correlate with history and physical examination findings
Sign of poor cardiac output
Seen with CHF
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S4 Heart Sound
Known as an atrial gallop Late diastole Physiologic and Pathologic
Physiologic
Virtually never seen except in exceptionally trained athletes (50% of pro basketball players, runners)
Pathologic
Poor ventricular compliance
Long-standing hypertension, CHF, HCM
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Wright, 2021 82 Click
Systolic in timing Mid-late systolic click: MVP Early systolic click: Mitral stenosis
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Murmur
Sound of turbulent blood flow Blood flowing through the vessels and chambers of the heart is normally silent When blood flow becomes turbulent-a murmur is produced Murmurs are often described using 7 characteristics These help the health care professional to figure out possible causes of the murmur
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Wright, 2021 83 QUALITIES OF A HEART MURMUR
1. Timing
When does it occur?
Systole, diastole or continuous
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Heart Murmurs
Systolic
MR PASS MVP Diastolic
MS ARD
Fitzgerald Health Education Associates, 2000
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Wright, 2021 84 QUALITIES OF A HEART MURMUR
2. Shape
Is there a change in the intensity of the murmur
Crescendo, decrescendo, both 3. Location
Where do you hear it loudest? 4. Radiation
Does it radiate anywhere?
Aortic-neck; mitral-axilla
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QUALITIES OF A HEART MURMUR
5. Intensity
How loud is the murmur?
Graded on a roman numeral scale or I through VI
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Wright, 2021 85 Intensity
Grade I: Very faint, barely audible Grade II: Soft, quiet but easily heard Grade III: Moderately loud; no thrill
Murmur is as loud as S1 and S2 Grade IV: Loud, thrill is present Grade V: Very loud, thrill is present Grade VI: Able to be heard with stethoscope off chest; thrill is present
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Systolic Murmurs
Mitral Regurgitation Physiologic Aortic Stenosis Systolic Mitral Valve Prolapse
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Wright, 2021 86 Additional Systolic Murmurs · Systolic Murmurs ASD, VSD Coarctation of the Aorta Picked up at birth Adult type: 2nd - 3rd I.sp, rad - back, thrill Unequal femoral pulses Tetralogy of Fallot Picked up at birth; baby often in distress
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Physiologic Murmur
Physiologic Murmur
Caused by turbulence around the valves due to a temporary increase in blood flow Etiology
Fever, hyperthyroidism, pregnancy, no cause
50% will have a physiologic murmur at some point in life Timing: Early-mid systole
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Wright, 2021 87 Physiologic Murmur
Location: 2nd-4th interspaces of LSB Radiation: Little Intensity: Grade I - II/VI; Occasionally III/VI Pitch: Medium Quality: Soft, blowing; May occasionally be harsh
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Physiologic Murmur
Aids to Diagnosis
Softens or disappears with sitting or standing
Softens or disappears with inspiration Associated Findings
None unless person has anemia, pregnancy, fever, hyperthyroidism
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Wright, 2021 88 Sudden Cardiac Death
From 1985 - 1995: 158 cases of sudden death during competitive exercise in the US This translates to 1:1,000,000 athletes 4 sports have been associated with more than 5 sudden deaths
Football, soccer, basketball, track
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Mayo Clinic Study
Significant cardiac abnormalities were found in 0.39 percent of 2,739 athletes 95% of all sudden deaths in athletes under 30 years of age have been due to structural heart problems
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Wright, 2021 89 Hypertrophic Cardiomyopathy
Most common cause of sudden cardiac death in the athlete A few well-known sports figures have died from this disease
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HCM
Hypertrophic Cardiomyopathy
Cardiomyopathy: disease of cardiac muscle
Presents in young adulthood
Septal thickening and abnormal movements of the mitral valve; Often is accompanied by outlet obstruction Etiology
Strong genetic component: Autosomal dominant
Often times, family history of individuals dying prematurely as early as in the 20’s
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Wright, 2021 90 Hypertrophic
Clinical SymptomsCardiomyopathy
DOE
Often asymptomatic and die spontaneously during exercise Timing: Mid-systolic Location: Left sternal border Radiation: Down left sternal border; occas. carotids Intensity: Grade II and louder/VI
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Hypertrophic
Quality: blowing,Cardiomyopathy moderately harsh Aids to Diagnosis
Decreases with squatting, hand grip or valsalva
Increases with standing Associated Findings
Rapid upstroke of the carotid impulse
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Wright, 2021 91 Abdominal Examination
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Abdominal Examination
Inspection
Contour of abdomen
Flat
Scaphoid Malnourished
Protuberant Obesity Gas distention from obstruction Tumor
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Wright, 2021 92 Abdominal Examination
Inspection
Skin
Color and moisture
Scars and incision
Striae (Cushing’s syndrome)
Dilated veins
Rashes or lesions (Cherry angiomas, herpes zoster)
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Abdominal Examination
Inspection
Symmetry
Visible Organ Enlargement/Masses
Hernia: defect in the wall of the abdomen through which a mass of tissue and occasionally the intestine protrudes Should be reducible
Lipoma: common, benign fatty tumors in the subcutaneous tissues Pressing down on the edge of it will cause it to slip out from under your finger
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Wright, 2021 93 Abdominal Examination
Auscultation
Bowel sounds
Very unreliable
Can be normal in the setting of serious pathology
Borborygmi: loud, prolonged gurgles that are indicative of hyperperistalsis Intestinal obstruction Gastroenteritis
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Abdominal Examination
Palpation
Essential when assessing the abdomen
Light palpation
Lightly palpate the entire abdomen
Purpose: Identify abdominal tenderness Superficial masses Muscular rigidity or guarding
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Wright, 2021 94 Costovertebral Angle Tenderness
Tap gently on the area above the 10-12th ribs posteriorly Continue tapping as you move downward “What if anything do you feel?” CVAT-pyelonephritis
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Mark…
Mark is a 12 yowm who presents with an 8 hour history of worsening abdominal pain. Woke him from sleep. Epigastric at onset. Now seems lower in right side of abdomen. Associated with nausea and vomiting for the past 2 hours and a temp of 100. Denies bowel changes, urinary symptoms. Meds: none; Allergies: NKDA What is going on with Mark?
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Wright, 2021 95 Appendicitis
Inflammation/Infection of the Appendix
Can lead to ischemia and perforation of the appendix Etiology
Most common age: 10-19 years
Incidence: 1.1/1000 Persons each year
Males>females
Whites>Nonwhites
Summer-most common time of year
Midwest-highest incidence
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Appendicitis
Mortality and morbidity rates remain high Perforation rates: 17-40%
Perforation has been known to occur within 1st 24-48 hours of the infection
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Wright, 2021 96 History of a patient with appendicitis
Careful history is the most important aspect
Individual is usually a teen or young adult Classic presentation: awakens in the night with vague periumbilical pain Worsens over the period of 4 hours Subsides as it migrates to the RLQ Worsened with movement, deep respirations, coughing
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History of a patient with Appendicitis Pain precedes anorexia, nausea or vomiting Nausea and anorexia are very common Vomiting may or may not be present Question the diagnosis if patient is hungry
Low grade fever or none at all Usually seek attention within 12-48 hours Patient will often report feeling constipated
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Wright, 2021 97 Clinical Pearl
The presence of pain before vomiting is highly suggestive of appendicitis.
Diarrhea before pain is more likely to be gastroenteritis.
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Physical Examination
Abdominal Examination
Tenderness at McBurney’s point
1/3 the distance between the anterior iliac spine and the umbilicus
Guarding
Contraction of the abdominal walls
Frequently present
Can be faked or induced
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Wright, 2021 98 Physical Examination
Rigidity
Important predictor of appendicitis
Involuntary spasm of the abdominal musculature
Caused by peritoneal inflammation Markle’s sign
Heel-drop jarring test
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Physical Examination
Rebound tenderness
Press on area above the pain
Suddenly withdraw fingers Rovsing’s Sign
Pain felt in RLQ when examiner presses firmly in the LLQ and suddenly withdraws Psoas Sign
Patient is placed in a supine position
Ask patient to lift thigh against your hand that you have placed above the knee
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Wright, 2021 99 Physical Examination
May be or may not be positive
Patient is positioned in supine position with the right hip and knee flexed
Internally rotate the right leg
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Wendy L. Wright, ARNP Family Nurse Practitioner Owner – Wright & Associates Family Healthcare Amherst, NH email: [email protected]
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