NURS 6512 Advanced Health Assessment midterm exam questions and answers/2023/2024

NURS 6512 Advanced Health Assessment midterm exam questions and answers
NURS-6512F-23-Advanced Health Assessment midterm

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Question 1

Percussing at the right midclavicular line, below the umbilicus, and continuing upward is the correct technique for locating the:

descending aorta.
lower liver border.
upper right kidney ridge.
medial border of the spleen.
B

Question 2

Mrs. G. reports an increase in her alcohol intake over the past 5 years. To screen her for problem drinking, you would use the:

PACES assessment.
Miller Analogies Test.
Glasgow Coma Scale.
CAGE questionnaire.
D

Question 3

A brief statement of the reason the patient is seeking health care is called the:

chief complaint.
diagnosis.
medical history.
assessment.
A

Question 4

A 5-year-old child presents with nasal congestion and a headache. To assess for sinus tenderness you should palpate over the:

sphenoid and frontal sinuses.
maxillary and frontal sinuses.
sphenoid sinuses only.
maxillary sinuses only.
D

Question 5

Which statement is true regarding the relationship of physical characteristics and culture?

To be a member of a specific culture, an individual must have certain identifiable physical characteristics.
Physical characteristics should be used to identify members of cultural groups.
Gender and race are the two essential physical characteristics used to identify cultural groups.
There is a difference between distinguishing cultural characteristics and distinguishing physical characteristics.
D

Question 6

Inspection of the abdomen should begin with the patient supine and the examiner:

standing at the foot of the table.
seated on the patient’s right.
walking around the table.
standing at the patient’s left.
B

uestion 7

Ms. Otten is a 45-year-old patient who presents with a complaint of weight gain. Which medication is frequently associated with weight gain?

Steroids
Laxatives
Oral hypoglycemics
Diuretics
A

Question 8

During physical examination of a 30-year-old Chinese man, you notice slight asymmetry of his face. The cranial nerve examination is normal. Your best action is to:

B. perform monofilament testing on the face.
D. record the finding in the patient’s chart.
A. ask the patient if this characteristic runs in his family.
C. consult with the physician regarding laboratory tests needed.
C

Question 9

A fixed image of any group that rejects its potential for originality or individuality is known as a(n):

norm.
acculturation.
stereotype.
ethnos.
C

Question 10

Tangential lighting is best used for inspecting skin:

exudates.
color.
contour.
symmetry.
C

Question 11

Mrs. Britton is a 34-year-old patient who presents to the office with complaints of skin rashes. You have noted a 4′ 3-cm, rough, elevated area of psoriasis. This is an example of a:

B. patch.
D. papule.
C. macule.
A. plaque.
D

Question 12

During an interview, tears appear in the patient’s eyes and his voice becomes shaky. Initially, you should:

ask the patient what he is upset about.
ask him if he would like some time alone.
offer a tissue and let him know it is all right to cry.
explain to the patient that you will be able to help him more if he can control his emotions.
C

Question 13

When communicating with older children and teenagers, you should be sensitive to their:

typical reluctance to talk.
natural urge to communicate.
need for verbal instructions.
desire for adult companionship.
A

Question 14

Expected hair distribution changes in older adults include:

increased terminal hair follicles to the tragus of men’s ears.
more prominent axillary and pubic hair production.
increased terminal hair follicles on the scalp.
more prominent peripheral extremity hair production.
A

Question 15

The examiner’s evaluation of a patient’s mental status belongs in the:

physical examination.
review of systems.
history of present illness.
patient education.
Aa

Question 16

When examining the skull of a 4-month-old baby, you should normally find:

D. overlap of cranial bones.
A. closure of the anterior fontanel.
C. ossification of all sutures.
B. closure of the posterior fontanel.
D

Question 17

You are using an ophthalmoscope to examine a patient’s inner eye. You rotate the lens selector clockwise, then counterclockwise to compensate for:

astigmatism.
strabismus.
amblyopia.
myopia.
D

Question 18

The most superior part of the stomach is the:

pyloric orifice.

body.
pylorus.
fundus.
D

Question 19

Brittle nails are typical findings in:

D. older adults.
C. pregnant women.
A. adolescents.
B. infants.
Older adults

Question 20

Which of the following is the most vital nutrient?

Fat
Protein
Water
Carbohydrate
C

Question 21

A tool used to screen adolescents for alcoholism is the:

HITS.
CAGE.
CRAFFT.
PACES.
C

Question 22

When taking a history, you should:

use a holistic and eclectic structure.
start the interview with the patient’s family history.
ask the patient to give you any information they can recall about their health.
use a chronologic and sequential framework.
D

Question 23

Ms. G. is being seen for her routine physical examination. She is a college graduate and president of a research firm. Although her exact salary is unknown, she has adequate health insurance. Most of the above information is part of Ms. G.’s _ history.

past medical
family
personal and social
present problem
C

Question 24

Mr. Williams, age 25, has recovered recently from an upper and lower respiratory infection. He describes a long-standing nasal dripping. He is seeking treatment for a mild hearing loss that has not gone away. Information concerning his chronic postnasal drip should be documented within which section of his history?

Past medical data
Age-specific data
Social history
Past surgical data
A

Question 25

Mr. Jones is a 45-year-old patient who presents for a physical examination. On examination, you note costochondral beading, enlarged skull, and bowed legs and diagnose him with rickets. A deficiency of which fat-soluble micronutrient can result in rickets?

Vitamin K
Vitamin E
Vitamin A
Vitamin D
D

Question 26

Mrs. Grace is a 58-year-old patient who has a diagnosis of pernicious anemia. Which B vitamin is deficient in patients with pernicious anemia?

B1
B2
B6
B12
D

Question 27

After thorough inspection of the abdomen, the next assessment step is:

percussion.
palpation.
rectal examination.
auscultation.
D

Question 28

You are examining a pregnant patient and have noted a vascular lesion. When you blanche over the vascular lesion, the site blanches and refills evenly from the center outward. The nurse documents this lesion as a:

A. telangiectasia.
C. petechiae.
B. spider angioma.
D. purpura.
C

Question 29

Which of the following is the most accurate reflection of an individual’s food intake?

Serum protein assays
Food diary
Twenty-four-hour diet recall
Computerized nutrient analysis
B

Question 30

Mr. Abdul is a 40-year-old Middle Eastern man who presents to the office for a first visit with the complaint of new abdominal pain. You are concerned about violating a cultural prohibition when you prepare to do his rectal examination. The best tactic would be to:

ask a colleague from the same geographic area if this examination is acceptable.
inform the patient of the reason for the examination and ask if it is acceptable to him.
forego the examination for fear of violating cultural norms.
refer the patient to a provider more knowledgeable about cultural differences.
B

Question 31

Tracheal tug suggests the presence of a(n):

enlarged thyroid.
thoracic carcinoma.
swallowing disorder.
aortic aneurysm.
D

Question 32

As you explain your patient’s condition to her husband, you notice that he is leaning toward you and pointedly blinking his eyes. Knowing that he is from England, your most appropriate response to this behavior is to:

tell him that you understand his need to be alone.
ask whether he would prefer to speak to the clinician.
tell him that it is all right to be angry.
ask whether he has any questions.
D

Question 33

When hearing is evaluated, which cranial nerve is being tested?

IV
VIII
III
XII
B

Question 34

Nuchal rigidity is most commonly associated with:

A. thyroiditis.
C. Down syndrome.
D. cranial nerve V damage.
B. meningeal irritation.
D

Question 35

The attitudes of the health care professional:

are difficult for the patient to sense.
are largely irrelevant to the success of relationships with the patient.
do not influence patient behavior.
are culturally derived.
D

Question 36

Macronutrients are so named because they:

form long chemical chains.
have high molecular weights.
are required in large amounts.
tend to increase waist measurements.
C

Question 37

White, rounded, or oval ulcerations surrounded by a red halo and found on the oral mucosa are:

aphthous ulcers.
Fordyce spots.
leukoedema.
Stensen ducts.
A

Question 38

Which type of speculum should be used to examine a patient’s tympanic membrane?

The shortest speculum available
The smallest speculum that will illuminate the ear
Any speculum that will fit the otoscope head
The largest speculum that will fit comfortably in the ear
D

uestion 39

To correctly document absent bowel sounds, one must listen continuously for:

5 minutes.
1 minute.
30 seconds.
3 minutes.
A

Question 40

Which part of the information contained in the patient’s record may be used in court?

Objective information only
All information
Diagnostic information only
Subjective information only
B

Question 41

A flat, nonpalpable lesion is described as a macule if the diameter is:

greater than 1 cm.
less than 1 cm.
3 cm exactly.
too irregular to measure.
B

Question 42

Knowledge of the culture or cultures represented by the patient should be used to:

help make the interview questions more pertinent.
draw conclusions regarding individual patient needs.
form stereotypical categories.
form a sense of the patient.
A

The review of systems is a component of the:

health history.
assessment.
physical examination.
past medical/surgical history.
A

Question 44

Mr. Akins is a 78-year-old patient who presents to the clinic with complaints of hearing loss. Which of the following are changes in hearing that occur in the elderly? Select all that apply.

a. Progression is slow
b. Bone conduction heard longer than air conduction
c. Results from cranial nerve VII
d. Loss of high frequency
e. Sounds may be garbled and difficult to localize
f. Unable to hear in a crowded room
D

E

F

Question 45

Which of the following is an expected change in the assessment of the thyroid during pregnancy?

A bruit is auscultated.
Inspection reveals a goiter.
The gland is tender upon palpation.
Palpation of the gland becomes difficult.
A

Question 46

A 17-year-old girl presents to the clinic for a sports physical. Physical examination findings reveal bradycardia, multiple erosions of tooth enamel, and scars on her knuckles. She appears healthy otherwise. You should ask her if she:

is cold intolerant.
binges and vomits.
has constipation frequently.
has regular menstrual periods.
Bb

Question 47

Mr. Walters, a 32-year-old patient, tells you that his ears are “stopped up.” An objective assessment of this complaint is achieved by using the:

otoscope with pneumatic attachment.
tympanometer.
reflex hammer.
tuning fork.
B

Question 48

During an interview, you have the impression that a patient may be considering suicide. Which action is essential?

Ask whether the patient has considered self-harm.
Avoid directly confronting the patient regarding your impression.
Record the impression in the patient’s chart and refer the patient for hospitalization.
Ask whether the patient would like to visit a psychiatrist.
A

Question 49

When are open-ended questions generally most useful?

During the initial part of the interview
While designing the genogram
During the review of systems
After several close-ended questions have been asked
A

Question 50

When assessing abdominal pain in a college-age woman, one must include:

history of interstate travel.
food likes and dislikes.
the first day of the last menstrual period.
age at completion of toilet training.
C

Question 51

Regardless of the origin, discharge is described by noting:

color and consistency.
associated symptoms in alphabetic order.
a grading scale of 0 to 4.
demographic data and risk factors.
A

Question 52

Spasmodic muscular contractions of the head, face, or neck are called:

D. webbing.
B. tics.
A. torticollis.
C. dimpling.
B

Question 53

Before performing an abdominal examination, the examiner should:

don double gloves.
have the patient empty his or her bladder.
ascertain the patient’s HIV status.
completely disrobe the patient.
B

Question 54
The recommended minimum daily protein requirement for the normal adult is __

14-20%

Question 55

Subjective and symptomatic data are:

not mentioned in the legal chart.
recorded with the examination technique.
placed in the history section.
documented with the examination findings.
C

Question 56

Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical. This visit would be documented by creating a(n):

accident report.
progress note.
triage note.
problem-oriented medical record.
B

Question 57

Which of the following formats would be used for visits that address problems not yet identified in the problem-oriented medical record (POMR)?

Progress note
Brief SOAP note
Referral note
Comprehensive health history
B

Question 58

You are collecting a history from an 11-year-old girl. Her mother is sitting next to her in the examination room. When collecting history from older children or adolescents, they should be:

ignored while you address all questions to the parent.
mailed a questionnaire in advance to avoid the need for her to talk.
given the opportunity to be interviewed without the parent at some point during the interview.
allowed to direct the flow of the interview.
C

Question 59

A 51-year-old woman calls with complaints of weight loss and constipation. She reports enlarged hemorrhoids and rectal bleeding. You advise her to:

use topical over-the-counter hemorrhoid treatment for 1 week.
eat six small meals a day.
exercise and eat more fiber.
come to the laboratory for a stool guaiac test.
D

Question 60

Mr. Marks is a 66-year-old patient who presents for a physical examination to the clinic. Which question has the most potential for exploring a patient’s cultural beliefs related to a health problem?

“What are your age, race, and educational level?”
“What types of symptoms have you been having?”
“Why do you think you are having these symptoms?”
“How often do you have medical examinations?”
C

Question 61

Which cranial nerves innervate the face?

A. II and V
B. III and VI
D. VIII and IX
C. V and VII
D

Question 62

Peritonitis produces bowel sounds that are:

absent.
high pitched.
hypoactive.
hyperactive.
C

Question 63

Mrs. Raymonds is a 24-year-old patient who has presented for a routine concern over her current weight. In your patient teaching with her, you explain the importance of macronutrients. Which of the following is a macronutrient?

Fat
Calcium
Iron
Thiamin
A

Question 64

Nasal symptoms that imply an allergic response include:

small, atrophied nasal membranes.
firm consistency of turbinates.
purulent nasal drainage.
bluish gray turbinates.
D

Question 65

Mr. Johnson presents with a freely movable cystic mass in the midline of the high neck region at the base of the tongue. This is most likely a:

D. thyroglossal duct cyst.
A. parotid gland tumor.
B. branchial cleft cyst.
C. Stensen duct stone.
A

Question 66

Pigmented, raised, warty lesions over the face and trunk should be assessed by an experienced practitioner who can distinguish:

C. sebaceous hyperplasia from eczema.
D. seborrheic keratoses from actinic keratoses.
B. furuncles from folliculitis.
A. cutaneous tags from lentigines.
B

Question 67

When you are questioning a patient regarding alcohol intake, she tells you that she is only a social drinker. Which initial response is appropriate?

“I’m glad that you are a responsible drinker.”
“If you only drink socially, you won t need to worry about always having a designated driver.”
“Do the other people in your household consume alcohol?”
“What amount and what kind of alcohol do you drink in a week?”
D

Question 68

Mrs. Kinder is a 39-year-old patient who presents to the office with complaints of an earache. In explaining to the patient about the function of her ears, which ear structure would you tell her is responsible for equalizing atmospheric pressure when swallowing, sneezing, or yawning?

Eustachian tube
Triangular fossa
Inner ear
Pars flaccida
A

Question 69

What finding is unique to the documentation of a physical examination of an infant?

Thyroid position
Prostate size
Liver span
Fontanel sizes
D

Question 70

A blood pressure cuff bladder should be long enough to:

cover 75% to 80% of the arm circumference.
completely encircle the arm.
cover 20% to 25% of the arm circumference.
cover 45% to 50% of the arm circumference.
D

Question 71

Mr. and Mrs. Johnson have presented to the office with their infant son with complaints of ear drainage. When examining an infant’s middle ear, the nurse should use one hand to stabilize the otoscope against the head while using the other hand to:

hold the speculum in the canal.
pull the auricle down and back.
distract the infant.
stabilize the chest.
B

Question 72

To perform the Rinne test, place the tuning fork on the:

preauricular area.
mastoid bone.
top of the head.
forehead.
B

Question 73

Mrs. Britton brings her 16-year-old son in with a complaint that he is not developing correctly into adolescence. Which structures disproportionately enlarge in the male during adolescence?

C. Mandible and maxilla bones
B. Hyoid and cricoid cartilages
D. Nose and thyroid cartilages
A. Coronal sutures
C

Question 74

Mr. Donalds is a 45-year-old roofer. Your inspection to determine color variations of the skin is best conducted:

B. under fluorescent lighting.
D. using a Wood’s light.
C. with illumination provided by daylight.
A. using an episcope.
C

Question 75

Mr. Kevin Marks is a new health care provider. What is the best method to develop cultural competence?

Realize that all members of a cultural group behave in the same way.
Ignore one’s own cultural beliefs.
Realize that cultural values are difficult to change and must be respected.
Attempt to convince the patient to accept institutional mores.
C

Question 76

Ms. Davis is a 27-year-old patient with a BMI of 33. Based on her BMI, your diagnosis would be:

extremely obese.
overweight.
obese.
normal body weight.
C

Question 77

The most common form of birth trauma of the scalp is:

cranial bossing.
torticollis.
caput succedaneum.
cephalhematoma.
C

Question 78

Mr. L. presents to the clinic with severe groin pain and a history of kidney stones. Mr. L.’s son tells you that, for religious reasons, his father wishes to keep any stone that is passed into the urine filter that he has been using. What is your most appropriate response?

“The stone must be sent to the lab for examination and therefore cannot be kept.”
“We don’t know yet if your father has another kidney stone, so we must analyze this one.”
“With your father’s permission, we will examine the stone and request that it be returned to him.”
“We cannot let him keep his stone because it violates our infection control policy.”
C

Question 79

Your patient is complaining of acute, intense sharp epigastric pain that radiates to the back and left scapula with nausea and vomiting. Based on this history, your prioritized physical examination should be to:

inspect for ecchymosis of the flank.
auscultate for abdominal bruits.
assess for rebound tenderness.
percuss for ascites.
A

Question 80

Mr. Black is a 44-year-old patient who presents to the clinic with complaints of neck pain that he thinks is from his job involving computer data entry. As the examiner, you are checking the range of motion in his neck and note the greatest degree of cervical mobility is at:

B. C2 to C3.
D. C4 to C5.
A. C1 to C2.
C. C3 to C4.
B

stion 81

Which of the following organs is part of the alimentary tract?

Gallbladder
Pancreas
Stomach
Liver
C

uestion 82

You are completing a general physical examination on Mr. Rock, a 39-year-old man with complaints of constipation. When examining a patient with tense abdominal musculature, a helpful technique is to have the patient:

sit upright.
hold his or her breath.
flex his or her knees.
raise his or her head off the pillow.
C

estion 83

Mrs. Berger is a 39-year-old woman who presents with a complaint of epigastric abdominal pain. You have completed the inspection of the abdomen. What is your next step in the assessment process?

Deep palpation
Auscultation
Percussion
Light palpation
B

Question 84

Placing the base of a vibrating tuning fork on the midline vertex of the patient’s head is a test for:

lateralization of sound.
air conduction of sound.
bone versus air conduction.
mallear auditory ability.
A

uestion 85

Before performing an abdominal examination, the examiner should:

have the patient empty his or her bladder.
completely disrobe the patient.
don double gloves.
ascertain the patient’s HIV status.
C

George Michaels, a 22-year-old patient, tells the nurse that he is here today to “check his allergies.” He has been having “green nasal discharge” for the last 72 hours. How would the nurse document his reason for seeking care?

G. M. is a 22-year-old male here for “allergies.”
G. M. came into the clinic complaining of green discharge for the past 72 hours.
G. M., a 22-year-old male, states he has allergies and wants them checked.
G.M. is a 22-year-old male here for having “green nasal discharge” for the past 72 hours.
D

Question 87

Your patient presents with symptoms that lead you to suspect acute appendicitis. Which assessment finding is least likely to be associated with this condition early in its course?

Rebound tenderness
Consistent right lower quadrant (RLQ pain)
Positive McBurney sign
Positive psoas sign
A

Question 88

Bulging of an amber tympanic membrane without mobility is most often associated with:

repeated and prolonged crying cycles.
middle ear effusion.
healed tympanic membrane perforation.
impacted cerumen in the canal.
B

Question 89
Recommended carbohydrate content of total dietary intake (% total calories) is __%.

50

uestion 90

Unusual white areas on the skin may be due to:

B. polycythemia.
A. adrenal disease.
D. Down syndrome.
C. vitiligo.
D

uestion 91

Auscultation should be carried out last, except when examining the:

lungs.
abdomen.
heart.
neck area.
Bb

Question 92

Penicillin is considered a

“cold” medicine.
“hot” medicine.
“lukewarm” oil.
“cold” herb.
Bbb

uestion 93

In examining the neck of a 34-year-old female patient, you note that the uppermost ridge of the tracheal cartilage is at the:

sternocleidomastoid.
thyroid.
hyoid.
cricoid.
D

Question 94

When assessing abdominal pain in a college-age woman, one must include:

age at completion of toilet training.
the first day of the last menstrual period.
history of interstate travel.
food likes and dislikes.
B

Question 95

A detailed description of the symptoms related to the chief complaint is presented in the:

general patient information section.
differential diagnosis.
assessment.
history of present illness.
D

Question 96

Periods of silence during the interview can serve important purposes, such as:

providing time for reflection.
increasing the length of the visit.
promoting calmness.
allowing the clinician to catch up on documentation.
D

Question 97

A guideline for history taking is for caregivers to:

ask direct questions before open-ended questions so that data move from simple to complex.
ask for a complete history at once so that data are not forgotten between meetings.
make notes sparingly so that patients can be observed during the history taking.
write detailed information as stated by patients so that their priorities are reflected.
C

Question 98

Tuning forks with a frequency of 500 to 1000 Hz are most commonly used to measure:

hearing range of normal speech.
buzzing or tingling sensations.
noise above the threshold level.
buzzing from bone conduction.
A

Question 99

Which is the best way to position a patient’s neck for palpation of the thyroid?

B. Flexed directly forward
C. Flexed toward the side being examined
A. Flexed away from the side being examined
D. Hyperextended directly backward
B

Question 100

Which question would be considered a leading question?

“You don’t get headaches often, do you?”
“At what time of the day are your headaches the most severe?”
“On a scale of 1 to 10, how would you rate the severity of your headaches?”
“What do you think is causing your headaches?”
A

What are the concepts of developing a relationship with the patient?
See the patient as a unique individual
Let them know that you really want to know all that is needed
Be open and flexible
Explain boundaries
Be honest

What is the primary objective when developing a relationship with the patient?
To discover the details about a patient’s concern, explore expectations, display interest, and partnership

What does establishing a positive relationship with the patient depend on?
Communication built on courtesy, comfort, connection, and confirmation.

What are effective communication strategies when obtaining a health history?
Using open-ended questions, direct questions, rarely leading questions. Facilitate by encouraging patient to say more. Reflect by repeating what you heard. Clarify. Empathize by showing understanding and acceptance. Confront by discussing disturbing behavior. Interpret by repeating what you heard to confirm.

What are open-ended questions?
Those that give the patient discretion about the extent of the answer. Such as “How have you been feeling?” or “What brings you in today?”

What are direct questions?
Those that seek specific information. Such as “How long ago did that happen?” or “Where does it hurt?”

What are leading questions?
Those that are prompting the patient toward the desired answer and these are the most risky.

What is a patient centered question?
One that respects and responds to a patient’s wants, needs, preferences so that they can make choices in their care that best fit their individual circumstances. Such as “How would you like to be addressed?”, “What would you like us to do today?”, “How are you coping with your illness?”.

What are potential barriers of patient and provider communication?
When the patient is curious about you, anxiety, silence, depression, crying/compassionate moments, physical & emotional intimacy, seduction, anger, avoiding the full story, financial considerations.

What is the structure and components of the patient history?
Patient identifiers, chief complaint, history of present illness, past medical history, family history, personal/social history, review of systems

What kind of patient information is obtained in the patient identifier component of the patient history?
name, age, gender, race, occupation, date, time, and referral source

What kind of patient information is obtained in the chief complaint component of the patient history?
a brief statement about why the patient is seeking care while probing for underlying concerns.

What kind of patient information is obtained in the HPI component of the patient history?
a chronological order of events leading up to the presenting problem, health status prior to the onset, a complete description of first symptoms, symptom analysis (onset, location, description, duration, intensity, character, aggravating factors, alleviating factors), impact on patients lifestyle, medications or treatments tried

What kind of information is obtained in the PMH component of the patient history?
general health/strength
childhood illnesses
major adult illnesses and chronic diseases
immunization
surgeries (dates, hospital, diagnosis, complications)
serious injuries resulting in disability
limitation of ability to function d/t past events
medications
allergies (meds, environment, seasonal, food)
transfusions
recent screening tests
emotional status

What kind of information is obtained in the family history component of the patient history?
Any relevant medical problems for both immediate and non-immediate family members

What kind of information is obtained in the personal/social history section of the patient history?
home environment and conditions (pets, economic)
where was the patient raised
education
position in family
marital status
life satisfaction
hobbies/interests
source of stress
habits (nutrition, sleep, drugs, etoh, ADL’s, and smoking)
self-care (self breast exams, exercise, home remedies)
sexual history
environmental (travel, exposure to diseases)
religious and cultural preferences
access to care

What information is necessary when obtaining sexual health information?
number of partners, concerns, birth control, protection from STI’s

What kind of information is obtained for the ROS component of the patient history?
those that identify presence or absence of health related issues in each body system

What is subjective data?
it is information collected during the patient interview with the patient or significant other. it is their words. It can include symptoms, sensations, feelings, perceptions, desires, preferences, beliefs, ideas, values, personal information, ROS, complete health history

What is objective data?
it is the information that can be physically seen by the provider and tested against. It can include the physical exam, lab analysis, x rays, and professional consults.

How do you approach sensitive issues when interviewing a patient?
Provide privacy, be direct and firm, don’t ask leading questions, use open-ended questions, don’t apologize for asking questions, don’t preach, avoid confrontation, use understandable language, watch medical jargon, document carefully using the patient’s words.

What does it mean to be culturally aware?
It is the deliberate self-examination and in depth exploration of one’s own biases, stereotypes, prejudices, assumptions that one holds about people different than them.

What does it mean to be culturally competent?
It requires the provider to be sensitive to a patient’s heritage, sexual orientation, socioeconomic situation, ethnicity, and cultural background

What are examples of questions that explore the patient’s culture?
“what do you call your problem?”
“What do you think caused it?”
“What does your sickness do to you?”
“Why do you think it started when it did?”
“What should be done to get rid of it?”
“Who else or what else might help you get better?”

What are the components of a cultural response to a patient?
the response should include modes of communication to include speech, space, and body language, awareness of the the patients health beliefs, diet and nutritional practice, and the nature of relationships with their family

How do you measure visual acuity and test CN II
by measuring distance, near vision , and peripheral vision

What is CN II?
optic nerve

How do you measure distance vision for visual acuity?
by using a snellen chart and having the patient cover one eye and read the lowest line that he can see clearly and then alternate eyes

How do you document distance vision?
the numerator is 20 and the denominator is the distance at which the average eye can read the line.

How do you measure near vision?
by using a rosenbaum pocket screener and have the patient hold it about 14 inches from eyes and read the smallest line possible with one eye and then the other

How do you measure peripheral vision?
by using the confrontation test. Have the patient sit directly across from you and look directly at you. Have them cover their left eye and your cover your right eye. Then test nasal, temporal, superior, and inferior fields. Have the patient tell you as soon as they see your finger in each of those fields.

What may be some causes of abnormal results from the confrontation test?
stroke, retinal detachment, optic neuropathy, pituitary tumor, central retinal vascular occlusion

How would you perform an external examination of the eyes?
Systematically beginning with appendages and move inward
eyebrows
orbits/periorbital area
eyelids

What is being assessed when looking at the patient’s eyebrows?
size, extension beyond temporal canthus, texture of hair

If the eyebrows do not extend beyond the temporal canthus or are course what may be the cause?
hypothyroidism

What is being assessed when looking at the patient’s orbits/periorbital area?
edema, puffiness, sagging tissue below orbit

What can cause periorbital edema?
thyroid disease, allergies, or nephrotic syndrome (children)

What are xanthelasma?
yellowish deposits on the periorbital tissue most often on the nasal side that represents a lipid metabolism disorder

What is being assessed with looking at the patient’s eyelids?
have the patient close lids lightly to look for tremors
inspect ability of eyelids to close completely and open wide
check for flakiness, crusting, redness, or swelling
check eyelashes to make sure that they curve away from the eye
when eye is open the superior eyelid should cover a portion of the iris but not cover pupil

What can be a cause of fasciculations of the eyelid when a patient lightly closes eye?
hyperthyroidism

What is ptosis?
when the upper eyelid covers more than the top of the iris or pupil and indicates congenital weakness of levator muscle or paresis of a branch of CN III

What is CN III
oculomotor nerve

How do you document a finding of ptosis?
by recording the difference between the two eyelids in millimeters (the average lid is 2 mm below the border of the cornea and sclera. average lower lid is at the lower limbus)

What is ectropion?
it is when the lower eyelid turns away from the eye and may result in excessive tearing because the tear collecting system can’t collect the secretions

What is entropion?
it is when the eyelid turns toward the globe which can cause corneal and conjunctival irritation and risk for secondary infection

What is a hordeolum?
it is an acute suppurative inflammation of an eyelash follicle which causes an erythematous or yellowish lump

What may be the cause of crusting along eyelashes?
blepharitis caused by blockage of tiny oil glands or by bacteria, seborrhea, psoriasis, rosacea, allergic response

What is lagophthalmos?
it is when the eyelids to not meet completely when closed and can be caused by thyroid disease, bell’s palsy, aggressive ptosis, blepharoplasty

When you palpate the eyes what are you assessing for?
eyelids for nodules
orbit for intraocular pressure

If the patient complains of pain when you palpate the orbit what can be the cause?
scleritis, orbital cellulitis, cavernous sinus thrombosis

If the eye is very firm or resists palpation what does this indicate?
it can be a sign of severe glaucoma or retrobulbar tumor

How do you inspect the lower conjunctiva?
have the patient look up while you draw the lower eyelid down and note the translucency and vascular pattern, erythema, exudate

How do you inspect the upper conjunctiva?
this is only done when there is a foreign object present. Evert the upper lid one a cotton swab

What can cause erythema or cobblestone appearance to conjunctiva?
allergic or infections conjunctivitis

What is a subconjunctival hemorrhage?
it is seen as bright red blood in a sharply defined area that is surrounded by healthy conjunctiva which may occur spontaneously in pregnancy or labor

What is a pterygium?
it is the abnormal growth of conjunctiva tissue over the cornea and more common on the nasal side. This is more common in persons exposed to UV light.

How do you examine the cornea for clarity?
check for clarity by shining a light tangentially on it. blood vessels should not be present

What is corneal arcus?
it is lipid deposits in the periphery of the cornea and common after age 60. If they present in persons less than 40 it may indicate a lipid disorder

How do you check corneal sensitivity (CN V)
by touching a cotton wisp to the cornea which should make the patient blink. This indicates an intact CN V and motor fibers of CN VII (facial nerve)

What is CN IV?
trochlear nerve

What is decreased corneal sensitivity caused by?
diabetes, herpes simplex, herpes zoster, after trigeminal neuralgia surgery

How do you inspect the iris?
check it for visibility and uniform color

How do you inspect the pupil?
note irregularities in shape of pupil, they should be round, regular, and equal in size

How do you test the pupil?
check the pupils response to light and accomodation

How do you test pupil accommodation?
have the patient look at a distant object and then a test object held 10 cm from bridge of nose. Expect the pupils to constrict when eyes focus on the near object

If pupils fail to respond to light but retains constriction during accommodation, what can be the cause?
sometimes seen with diabetes or syphilis

What is miosis?
it is pupil constriction of less than 2 mm with causes of miotic eyedrop use, drug abuse

What is mydriasis?
it is pupil dilation of more than 6 mm with causes including mydriatic drops, midbrain lesions, hypoxia, CN III damage, drug abuse, acute angle glaucoma

What is argyll robertson pupil?
it is a bilateral, miotic, irregular shaped pupils that fail to constrict to light and caused by syphilis, DM, midbrain lesions

What is anisocoria?
unequal pupil sizes which may be normal in about 20% of the population

What is iritis?
constrictive response, acute uveitis with pain and red eye

What can occur to pupils with damage to CN III (oculomotor)
pupil dilated and fixed with eye deviated lateral and down with ptosis

What is an Adie pupil?
a tonically dilated pupil that reacts slowly or fails to react to light but does respond to convergence. due to destruction of postganglionic nerve innervation to the eye by an infection.

What are normal finding when inspecting the lens?
it should be clear and transparent

What are normal findings when inspecting the sclera?
it is white and visible above the iris only when eyes are wide open

What are some abnormal findings when inspecting the sclera?
pigmentation of yellow or green. Senile hyaline plaque is a dark, slate gray anterior to insertion of medial rectus muscle

How do you inspect and palpate the lacrimal apparatus?
inspect it by palpating the lower orbital rim near the inner canthus and the upper temporal orbit.

What do you do if the temporal aspect of the upper eyelid feels full?
then evert the superior eyelid and inspect the lacrimal gland which is normally non-palpable with no tenderness and no regurgitation of fluid from the nasolacrimal duct

What can cause lacrimal gland enlargement?
tumors, lymphoid infiltration, sarcoid disease, sjogrens syndrome

How do you test the extraocular movements of CN II, CN IV, CN VI?
hold the patient’s chin and ask them to watch your finder as it moves through the 6 cardinal fields of gaze. Then have the patient follow your finger in a vertical plane from ceiling to floor. Movement should be smooth.

What are the six cardinal fields of gaze?
*Lateral to the left (left eye lateral rectus, CN IV; right eye medial rectus CNIII)
*Left eye looking laterally and then up (left eye uses superior rectus and right eye uses inferior oblique)
*Left eye looking laterally and then down (left eye uses inferior rectus and right eye uses superior oblique
*Lateral to the right (right eye lateral rectus, CN VI; left eye medial rectus CNIII
*right eye looking laterally and then up (right eye uses superior rectus and left eye uses inferior oblique)
*right eye looking laterally and then down (right eye uses inferior rectus and left eye uses superior oblique

Abnormal findings when testing extraocular movements?
if lid lag occurs or sclera is seen above the iris it may indicate thyroid disease

How to test balance of extraocular muscles?
by using the corneal light reflex. direct the light at nasal bridge from 30 cm and ask patient to look at a nearby object. Look for convergence of eyes. if abnormal then do the cover uncover test

Abnormalities when doing the cover uncover test?
eye moves outward from the midline (exotropic)
eye moved inward toward the nose (esotropia)

What is the proper technique to examine the interior of the eye with an ophthalmoscope?
examine patient’s right eye with your right eye and patient’s left eye with your left eye. Change the lens with your index finger starting with the setting at 0. get in close to the patient and stabilize yourself and the patient by placing your free hand on the patient’s shoulder or head. Have the patient look at a distant fixed point and direct light at pupil from about 12 in away, visualize red reflex, then approach eye slowly and look for retina.

What structures are visualized in the interior eye with the ophthalmoscope?
*red reflex of retina first
*retina is red/pink or yellow background and depends on amount of melanin in skin
*blood vessel will probably be the first structure seen when 3-5 cm from patient. You will see branching of blood vessels.
*use the branching blood vessels to fing optic disc
*then look at vascular supply of retina
*venous pulsations may be seen on disc and must be noted
*look at arterioles which are smaller and light reflected from them are brighter red

• then examine optic disc in which margins should be sharp and well defined with color of yellow to creamy pink and 1.5cm in diameter
  then examine macula by asking patient to look directly at the light and it will appear as a lighter dot surrounded by an avascular area

What may vessels look like with someone who has HTN?
they may be narrowing, increased vascular tortuosity, copper wiring (diffuse red brown reflex), retinal hemorrhage, arteriovenous nicking

How is a lesion expressed?
for example, being 2 DD from optic disc at the 2 o clock position and is 2/3 DD long and 1/3 DD wide

What do myelinated nerve fibers look like in the eye?
they appear as white area with soft, ill defined peripheral margins and have no significance

What is papilledema?
it is the loss of definition of the optic disc margin, vessels are pushed forward and veins dilate. Caused by increased ICP

What is glaucomatous optic head cupping?
optic disc margins are raised with lower central area , blood vessels may disappear. Caused by increased intraocular pressure with loss of nerve fibers and death of ganglion cells

What is a cotton wool spot?
they are ill defined yellow areas that are caused by infarction of nerve layer of the retina and due to HTN and diabetes

What are drusen bodies?
they are small, discrete spots that are slightly more yellow than the retina and most commonly a consequence of aging and may be a precursor to macular degeneration. *use Amsler grid to determine macular degeneration

what is exophthalmos?
it is the bulging of the eye anteriorly out of the orbit

What is the pathophysiology of exophthalmos?
occurs from an increase in volume of orbital contents. It is most cause is graves disease due to abnormal connective tissue deposits in the orbit and extraocular muscles. It can be bilateral or unilateral. If unilateral then consider a retro-orbital tumor

Subjective data of exopthalmos?
reports of trauma that can cause a complete or partial disclocation of they eye

Objective data of exopthalmos?
apparent eye protrusion, lids do not reach the iris. Measurement of the degree of exopthalmos is performed using an exophthalmometer, usually be an opthalmologist

What is episcleritis?
it is inflammation of the superficial layers of the sclera anterior to the insertion of the rectus muscles

Pathophysiology for episcleritis?
simple, intermittent episodes of moderate to severe inflammation that recur to 1-3 month intervals and lasting 7-10 days. Or nodular with prolonged attacks of inflammation that are typically more painful. Most cases are idiopathic but may have underlying causes such as automimmune, RA, SLE, gout, atopy, foreign bodies, chemical exposure or infection

Subjective data for episcleritis?
reports of a sudden onset of mild to moderate discomfort or photophobia. Painless injection of redness and or water discharge without crusting.

Objective data for episcleritis?
there is diffuse or localized redness that can be seen of the bulbar conjunctiva. Purplish elevation of a few millimeters. Watery discharge.

What is band keratopathy?
it is the deposition of calcium in the superficial cornea

Pathophysiology for keratopathy?
this is most common with patients with chronic corneal disease. It may occur with hypercalcemia, hyperparathyroidism, and occasionally in trauma, renal failure sarcoidosis, or syphilis.

Subjective data for keratophathy?
reports of decreased vision as the deposits progress. A foreign body sensation and irritation

Objective data for keratopathy?
the line can be seen just below the pupil and passes over the cornea with horizontal grayish bands that are interspersed with dark areas that look like holes.

What is a corneal ulcer?
it is the disruption of the corneal epithelium and stroma

Pathophysiology of a corneal ulcer?
causes can include rheumatologic disorder, connective tissue disease such as RA, sjogren syndrome, or SLE, infection like herpes simplex or bacterial, extreme dryness such as with incomplete lid close or lacrimal gland dysfunction

Subjective data for corneal ulcer?
reports of pain, photophobia, hx of wearing contact lenses, blurry vision, feeling like something is in the eye

Objective data for corneal ulcer?
visual acuity may be affected but depends on the location, inflammation and erythema of the eyelids and conjunctiva, purulent exudates, and an ulcer that is round or oval with sharply demarcated borders and base appearing gray

What is strabismus?
it is when both eyes do not focus on an object simultaneously

Pathophysiology of strabismus?
it can be caused due to paralysis from impairment of one or more extraocular muscles. It can be non-paralytic with no primary muscle weakness. It may be a sign of ICP because CN III is vulnerable to damage from brain swelling.

Subjective data of strabismus?
reports of poor vision, may have sudden onset of double vision, eye deviation

Objective data of strabismus?
If an extraocular muscle becomes impaired the eye can be seen as not moving in the direction controlled by that muscle. This can be detected by the cover-uncover test

What is Horner syndrome?
it is an interruption of the sympathetic nerve innervation of the eye which results in ipsilateral miosis, mild ptosis, and loss of hemifacial swelling

Pathophysiology of Horner syndrome?
the condition can be congenital, acquired, or hereditary. It may result from a lesion of the primary neuron, stroke, trauma to the brachial plexus, tumors, dissecting carotid aneurysm, or operative trauma.

Subjective data of Horner syndrome?
reports symptoms that are dependent on underlying cause

Objective data of Horner syndrome?
the ptosis can be seen as subtle and pupil may be round and constricted. Anisorocia can be seen as the difference in pupil size and is greater in darkness. The affected pupil dilates slowly and dry skin occurs on the same side of face as the affected pupil

What are cataracts?
it is an opacity of the lens

Pathophsyiology of cataracts?
the protien of the lens denaturates with age and are usually central but may occur peripherally due to hypoparathyroidism. Medications can cause them as well as genetic defects, maternal rubella, and other fetal insults during the first trimester

Subjective data of cataracts?
patient reports cloudy or blurry vision, faded colors, lights and headlights appearing too bright, halo around lights, poor night vision or double vision, frequent prescription changes.

Objective data of cataracts?
cloudiness of the lens can obviously be seen without special viewing equipment

What is non-proliferative diabetic retinopathy?
it is dot hemorrhages or microaneurysms and the presence of hard and soft exudates

Subjective data of non-proliferative diabetic retinopathy?
the initial stages patients are asymptomatic. Later stages the patient reports blurred vision, distortion, or visual acuity loss in more advanced stages

Objective data of non-proliferative diabetic retinopathy?
On an opthalmoscopic exam, blood vessels with balloon-like sacs (microaneurysms), blots of hemorrhages on the retina, and tiny yellow patches of hard exudates

What is proliferative diabetic retinopathy?
it is the development of new vessels as a result of anoxic stimulation

Pathophysiology for proliferative diabetic retinopathy?
vessels grow out of the retina toward the vitreous humor. It may occur in peripheral retina or on optic nerve. The new vessels lack supporting structure so they may hemorrhage. The bleeding caused by this is a major cause of blindness in diabetics. Laser therapy can often control it to prevent blindness.

Subjective data of proliferative diabetic retinopathy?
the patient reports seeing floaters, blurred vision, or progressive visual acuity loss in advanced stages. Early stages are asymptomatic.

Objective data of proliferative diabetic retinopathy?
during opthalmascope exam, the settings for the lens may be necessary in order to visualize the vessels. Vitreous hemorrhage may also be seen which can obstruct the view of the retina

What is lipemia retinalis?
it is a creamy white appearance of the retinal vessels that occurs with excessively high serum triglyceride levels

Pathophysiology of lipemia retinalis?
it occurs when the serum triglyceride level exceeds 2000 mg/dl and seen in most hyperlipidemic states

Subjective data of lipemia retinalis?
reports of elevated serum triglycerides and no vision symptoms

Objective data of lipemia retinalis?
during the early stages the peripheral fundus is salmon pink in color but as the triglyceride levels rise they turn white colored.

What is retinitis pigmentosa?
it is an autosomal recessive disorder in which the genetic defects cause cell death in the rod photoreceptors

Pathophysiology of retinitis pigmentosa?
it is caused by a genetic defect that causes apoptosis of the photoreceptors. Associated conditions include deafness, paralysis of one or more of the extraocular muscles, dysphagia, ataxia, intellectual delay, peripheral neuropathy, acanthotic (spiked) RBC’s, absence of VLDL

Subjective data of retinitis pigmentosa?
reports of night blindness as the earliest symptom, tunnel vision, bumping into furniture, loss of vision is painless and progressive over years to decades

Objective data of retinitis pigmentosa?
the exam is normal in the early stages. In later stages waxy pallor, narrowing of the arterioles, and peripheral bone spicule pigmentation are seen in the mid periphery with retinal atrophy

What is glaucoma?
it is a disease of the optic nerve where the nerve cells die, usually due to excessively high intraocular pressure

Pathophysiology of glaucoma?
acute angle may occur acutely with dramatically elevated intraocular pressure if the iris blocks the exit of aqueous humor from the anterior chamber. Open angle is caused by decreasing aqueous humor absorption that leads to increased resistance and painless build up of pressure in the eye. This may also be congenital as a result of improper development of the eye’s aqueous outflow system.

Subjective data of glaucoma?
with chronic disease the symptoms may be asymptomatic with the exception of a gradual loss of peripheral vision over a period of years. an acute onset is accompanied by intense ocular pain, blurred vision, halos around lights, red eye, and a dilated pupil. Patients may also report stomach pain and N/V

Objective data of glaucoma?
optic nerve damage can be seen clearly during a dilated eye exam and produces a characteristic appearance of the optic nerve cupping. Visual field tests may be decreased

What is chorioretinitis?
it is an inflammatory process involving both the choroid and retina

Pathophysiology of chorioretinitis?
the most common cause is laser therapy for diabetic retinopathy but may also be seen with histoplasmosis, CMV, toxoplasmosis, or congenital rubella infection

Subjective data of chorioretinitis?
reports of a history of cleaning cat litter box, laser surgery, pain, reduced visual acuity, floaters, photophobia.

Objective data of chorioretinitis?
a sharply defined lesion that is generally whitish yellow and becomes stippled with dark pigment in later stages ending with a chorioretinal scar. Visual field defects can be detected with large lesion, may be single or multiple, feathery margins contrast with myelinated retinal fibers.

What are visual field defects?
it is defective vision or blindness

Pathophysiology of visual field defects?
it may be a consequence of degenerative changes within the eye such as a cataract or from a lesion of the optic nerve. The most common cause is interruption of the vascular supply to the optic nerve. Bitemporal hemianopia is caused by a lesion most commonly a pituitary tumor and homonymous hemianopia can be caused by lesions of the optic nerve radiation on either side of the brain occurring after the optic chiasm.

Subjective data of visual field defects?
reports of defective vision or blindness

Objective data of visual field defects?
visual field defects found on exam

What is a retinoblastoma?
it is an embryonic malignant tumor arising from the retina

Pathophysiology of retinoblastoma?
it usually develops in the first 2 years of life and is transmitted by autosomal dominant or a chromosomal mutation and is the most common retinal tumor in children

Subjective data of retinoblastoma?
family history of it and reports of a white reflex on photographs

Objective data of retinoblastoma?
the initial sign that can be seen is leukocoria, and then an ill defined mass arising from the retina on fundoscopic exam and chalky white areas of calcification can be seen

What is macular degeneration?
it is age related and is caused when part of the retina deteriorates

Pathophysiology of macular degeneration?
There are two types. The dry type is atrophic and occurs from the gradual breakdown of cells in the macula which results in gradual blurring of central vision. The wet (exudative) type is when new abnormal blood vessels grow under the center of the retina then leak and scar the retina which distorts or destroys central vision and may be rapid. It is the leading cause of legal blindness

Subjective data of macular degeneration?
reports of blurred or decreased central vision, blind spots or scotomas, straight lines looking irregular or bent, objects appearing a different color or shape in each eye, or objects appearing smaller in one eye (micropsia)

Objective data of macular degeneration?
with the dry form, Drusen bodies (multiple spots in the macular region) can be seen with thinning and loss of the retina and choroid. The wet form can cause exudates, blood, scarring, and new blood vessels membranes below the retina that can be seen

How do you inspect the external ear?
First visually inspect the auricles for size, shape, symmetry, color, position on on head

How do you inspect the position of the auricles?
By drawing an imaginary line between the inner canthus of the eye and the most prominent part of the top of auricle which should be above or at the top of this line

What can cause a low set position or unusual angle of the auricles?
either a chromosome abnormality or renal disease

What are normal findings while inspecting the auricles?
they should be the same color as facial skin without moles, cysts, lesions deformities, nodules, skin tags, openings or discharges. A darwin tubercle which is a thickening of the upper ridge of the helix is normal. Pre-auricle skin tags and pits in front of the ear where the upper auricle originates may be normal.

What are abnormal findings while inspecting the auricles?
blue color may mean cyanosis, pallor or extreme redness may result from vasomotor instability, frostbite can cause extreme pallor, unusual size or shape may be d/t family trait or abnormality, cauliflower ear is d/t blunt trauma with necrosis of underlying cartilage, tophi are small white uric acid crystals on peripheral margins of auricle and may indicate gout, sebaceous cysts

How do you inspect the auditory canal?
visually inspect it for any discharge and note any odor

What are some abnormal findings while inspecting the auditory canal?
purulent foul smelling discharge is associated with otitis externa, perforated acute otitis media, or foreign bodies. Bloody or serous discharge with a head trauma is indicative of a head fracture

Describe palpating the auricles and mastoid area?
palpate both of them for any tenderness, swelling, or nodules

What are normal findings when palpating the auricles and mastoid area?
auricles should be firm, mobile and without nodules. If folded forward it should readily recoil to its usual position. Pulling on the lobule should not illicit pain.

What are abnormal findings when palpating the auricles and mastoid area?
if pain is present when pulling on the lobule then external auditory canal inflammation may be present. If there is tenderness or swelling in the mastoid area it may indicate mastoiditis.

How would you perform an otoscopic examination of an adult ear?
Select the largest speculum that will fit comfortably in the patients ear.
Hold the handle of the otoscope between the thumb and little finger supported on the middle finger.
Use the ulnar side of your hand to rest it against the patients head, stabilizing the otoscope as it is inserted into the canal .
Use a firm/gentle grasp and tilt the patients head toward the opposite shoulder as the speculum is inserted.
Pull the auricle up and back to straighten auditory canal
Insert the speculum 1/2 inch and inspect from meatus to tympanic membrane (landmarks, color, contour, perforations

How do you evaluate the patients hearing using a whispered voice?
Have the patient put a finger is one ear while you stand about 1-2 feet away from the opposite ear out of the line of vision from the patient. Then whisper a combination of letter and numbers into the ear and ask them to repeat it. They should be able to repeat 50% of the sounds.

How do you perform the Weber test?
This is done to assess for unilateral hearing loss. Place the base of a vibrating tuning ford on the midline of the patients head and ask them if the sound is heard equally in both ears or just one.

Abnormal findings of Weber test?
if the sound is better in the affected ear then the patient has conductive hearing loss. If the sound lateralizes to the better ear then it is sensorineural loss.

How do you perform the Rinne test?
This is done to distinguish between air and bone hearing conduction. First place the base of a tuning fork against the patients mastoid bone and ask them to say when the sound is no longer heard. The time in seconds is the interval of bone conduction. Then quickly move the tuning fork 1/2 inch from the auditory canal and ask them again to say when it is no longer heard. The time in seconds is the air conduction interval. Normal should be longer hearing for air conduction (2:1).

What are abnormal findings of the Rinne test?
if bone conduction is heard fro longer in the affected ear then it is a conductive loss. if the air conduction is heard longer but less than the 2:1 ratio then it a sensorineural loss

How do you inspect the external nose?
Look for any deviations in shape, size, or color, discharge, flaring or narrowing or nares. Columnella should be midline and width should not exceed the diameter of the nares.

Abnormal findings of external nose exam?
a depression of the nasal bridge can result from a fracture of nasal bone or previous nasal cartilage inflammation , a transverse crease at the junction between the cartilage and the nose bone may indicate chronic itching and allergies, discharge

What can cause nasal discharge?
allergies (watery), epistaxis or trauma (bloody), rhinitis or URI (purulent), foreign body (unilateral, purulent, odor), CSF (unilateral, watery after head trauma)

How do you palpate the external nose?
place finger tips on both sides of nose and then palpate from bridge of nose to tip checking for any displacement of bone, tenderness, or masses (structures should be firm and stable)

How do you evaluate nasal patency?
by occluding one nares and ask the patient to breathe in and out with mouth closed. Then repeat on the other side. Breathing should be noiseless and easy.

How do you inspect the nasal cavity?
use the nasal speculum and a light, hold speculum in palm of one hand and use other hand to change the patients head position, insert speculum and inspect nasal mucosa for color, discharge, masses, lesions, and turbinate swelling. Inspect septum for alignment, perforation, bleeding, crusting. Keep patients head erect as you look at the inferior turbinate and then tilt the head back to look at the middle meatus and middle turbinate, then move speculum to look at septum

Normal findings of nasal mucosa and septum?
mucosa should be deep pink and glistening, film or clear discharge on septum is often present, hairs may be present on vestibule, turbinates firm and same color as surrounding area, septum should be straight and midline

Abnormal findings of nasal mucosa and septum?
purulent discharge may be d/t URI, sinusitis, foreign body. Increased redness of mucosa my occur due to infection, localized redness in vestibule may indicate a furncicle, turbinates that are blue, gray, pale, pink, swollen, boggy may indicate allergies, a polyp may be seen as a round, elongated mass that is protruding into the nasal cavity from boggy mucosa

How do you test cranial nerve I (sense of smell)?
have patient close eyes and occlude one naris then hold and opened vial of a familiar aromatic odor under the other naris and have them inspire deeply and identify the odor. Repeat on the other side using a different odor.

How do you inspect and palpate the sinuses?
inspect both areas for and swelling, palpate by using thumbs to press up under the bony burrow on each side of the nose. Then press up under the zygomatic process to palpate the maxillary.

Abnormal findings of palpating the sinuses?
swelling or tenderness over them upon palpation may indicate infection or obstruction

How do you inspect and palpate the lips?
have the patient close their mouth and inspect and palpate for symmetry, color, edema, surface abnormalities. Lips should be pink, no lesions, symmetrical, smooth surface.

Abnormal findings of lips?
dry and cracked/ cheilitis (dehydration, wind, dentures, braces, lip licking)
deep fissures at corners of mouth/ cheilosis (riboflavin deficiency, overclosure of mouth)
swelling (allergy)
pallor (anemia)
circumoral pallor (scarlet fever)
round, oval, irregular blue/gray moles (Puetz-Jeghers syndrome)
lesions, plaques, nodules, ulceration (infections, skin cancer)

How do you inspect and palpate the buccal mucosa, gums, and teeth?
first have the patient clench teeth and smile to determine that upper molars fit into the grooves of lower molars and the premolars and canines interlock fully. Then remove any dental hardware and using a tongue blade and light inspect the buccal mucosa, gums, and teeth. Then using gloves, palpate the gums for lesions, induration, thickening or masses.

Normal findings of buccal mucosa, gums, and teeth?
Gingiva should be pink
Mucous membranes should be pink/red smooth and moist
Stensen duct can be seen as a yellow.white protrusion in Alignment with the 2nd upper molar
Fordyce spots are ectopic sebaceous glands on buccal mucosa and seen as raised yellow white lesions
Patchy pigmented skin mucosa is found in dark skinned
Ginvival enlargement can occur with pregnancy

Abnormal findings of buccal mucosa, gums, and teeth?
Whitish/pink scars may be seen due to trauma from poor tooth alignment.
A red spot on stensen duct is associated with mumps
Epulis is a local swelling of gingiva
Gingival swelling which can occur due to vitamin C deficiency, certain meds
Gingivitis (bleeding, swollen gums, enlarged crevices between teeth and gum margins, pockets containing debris

Describe how you examine the oral cavity by inspection, testing CN XII, inspecting floor of mouth , tongue, palate, uvula, and soft palate?
Inspect dorsum of tongue for swelling, size, color, coating, ulceration.
Ask patient to extend tongue and check for deviation, tremor, limited movement (CN XII hypoglossal nerve)
Then ask the patient to touch tongue to tip of palate and inspect floor of mouth and ventral surface of tongue, frenulum, SL ridge, and wharton ducts
Then wrap the tongue with a piece of guaze and gently pull it to each side and inspect
Palpate tongue and floor and floor of mouth for lumps, nodules, ulceration
Lastly have the patient tilt their head back and look at the palate and uvula, have patient say “ah” to see if the uvula rises

What are normal tongue findings of oral cavity?
The tongue should be midline when protruded with no atrophy, no fasiculations, tongue should be pink, dorsal side rough surface of tongue with small fissures, ventral surface pink and smooth with large veins

Abnormal findings of oral cavity?
Smooth tongue with slick appearance is glossitis and due to vitamin B12 deficiency
Hairy tongue with yellow/brown black papillae can be due to abx
Ranula (mucocele) may be seen on the floor of the mouth when duct of a SL gland is obstructed
Any ulceration, nodule, thick white patch on lateral or ventral side of tongue may be a malignancy
Deviation of uvula may indicate vagus nerve paraylis
Bifid uvula may be common in Native Americans

How do you inspect the oropharynx including the tonsils and tonsillar pillars and test CN IX and CN X?
First use a tongue blade to depress the tongue and observe the size and shape of tonsillar pillars and the integrity of the retropharyngeal wall. Then prepare the patient for gag reflex check and touch posterior wall to elicit gag reflex and test CN IX and CN X

Normal findings of oropharynx?
tonsils should be smooth, glistening, with pink mucosa, orpharynx may have some small irregular spots of lymphatic tissue with blood vessels,

Abnormal findings of oropharynx?
red, hypertrophied, exudate tonsils indicate infection, red bulge adjacent to tonsil and extending beyond midline may be a peritonsilar abscess, yellowish mucoid film indicates postnasal drip

What is otitis media with effusion and acute otitis media?
An inflammation of the middle ear resulting in the collection of serous, mucoid, or purulent fluid when tympanic membrane is intact. Can be seen as a bulging of tympanic membrane, or red bulging and distorted light reflex and effusion can be seen with yellowish air bubbles.

What is otitis externa?
An inflammation of the auditory canal and external surface of tympanic membrane which can be caused by water retained in the ear and can cause inflammation of the pinna also. Ear canal is red, edematous, and tympanic membrane is obscured.

What is a cholesteatoma?
It is trapped epithelial tissue behind the tympanic membrane that is often the result of untreated or chronic otitis media. Spherical white cyst behind intact tympanic membrane can be seen, or if it is perforated there may be foul smelling discharge and conductive hearing loss

What is conductive hearing loss?
It is reduced transmission of sound to the middle ear due to a type of obstruction like cerumen, otitis media with effusion, infection, foreign body, cholesteatoma, stiffening of ossicles, and otoscerosis. The person hears better in noisy environments, speaks softly, turns TV up louder. The bone conduction is heard longer than air. Lateralization with Weber test.

What is sensorineural hearing loss?
It is the reduced transmission of sound in the inner ear and is caused by inner ear disorder, systemic disease, ototoxic medications, trauma, tumors, prolonged exposure to loud noise , presbycusis in older adults. The person is unable to hear in a crowded room, speaks more loudly. Air conduction is hear longer than bone conduction. Lateralization to unaffected ear with Weber test. Loss of high frequency sounds.

What is meniere disease?
A disorder of progressive hearing loss that in some cases is hereditary.

What is vertigo?
It causes the illusion of rotational movement by the patient due to inner ear disorders

What is sinusitis?
It is a bacterial infection of one or more of the paranasal sinuses due to inflammation, allergies, infection and cause URI that worsens after 7-10 days, frontal headache, facial pain or pressure, purulant nasal discharge, persistent cough may be worse at night

What is acute pharyngitis?
It is an infection of tonsils or posterior pharynx by microorganisms most commonly by group A beta hemolytic strep, gonorrhea, mycoplasma pneumoniae. Symptoms include sore throat, referred pain to ears, fever, fetid breath, may have abd pain and headache. Tonsils are red and swollen, crypts filled with purulent exudate, enlarged anterior cervical lymph nodes, palate petechiae

What is a peritonsillar abscess?
it is a deep infection in the space between the soft palate and tonsil caused by inflammation or obstruction of the weber gland. The patient may have drooling, sever sore throat with pain radiating to the ear, malaise, fever. Unilateral red swollen tonsil, may have displaced uvula, trismus or spasm of masticator muscles may occur, muffled voice, cervical lymphadenopathy

What is a retropharyngeal abscess?
It is a life threatening infection in the lateral pharyngeal space the has the potential to occlude the airway and most common in children. It may occur due to trauma to posterior pharyngeal wall, dental infection, group a strep. The patient is acutely ill with drooling, irritable, anxious, pain in neck and jaw, will not move neck. Lateral neck movement makes pain worse, lateral pharyngeal wall is distorted medially, trismus, resp distress, muffled voice

What are the normal findings when inspecting the precordium?
the apical impulse is generally visible at the 5th intercostal space midclavicular line, it may be visible instead at the 4th, but it should only be visible in 1 intercostal space

What other systems/organs can you check to assess the cardiac status?
skin to check for cyanosis or venous distention, nail beds for cyanosis, capillary refill, clubbing

How do you palpate the precordium?
This can be done with the patient supine. use the proximal halves of 4 fingers or the whole hand,using light touch and beginning at the apex then inferior sternal border, up the sternum to the base, then down the right sternal border to epigastric area.

What are normal findings when palpating the precordium?
The apical impulse is felt at the 5ht intercostal space midclavicular line and will be brief.

What are abnormal findings when palpating the precordium?
if the PMI is more vigorous than expected then it may indicate increased cardiac output or left ventricular hypertrophy. A lift along the left sternal border may be caused by right ventricular hypertrophy. A loss of thrust be may be due to air or fluid beneath the sternum. A displacement of impulse to the right side may indicate dextrodardia, diaphragmatic hernia, distended stomach, or pulmonary abnormality.

How do you palpate the carotid artery?
Use the opposite hand from the one palpating the precordium and place a finger to the neck just medial to and below the angle of the jaw, pressing lightly. Do not check both sides at once. S1 and carotid pulse should be synchronous.

How do you percuss the heart?
begin by tapping anterior axillary line and move medially along the intercostal spaces toward the sternal border. A change from resonant to dull marks the cardiac border and note these points with a pen.

What is the most accurate way to estimate the size of the heart?
by chest xray

How do you auscultate the 5 cardiac areas on the chest?
Use the diaphragm on the stethoscope to hear high pitched sounds with firm pressure and use the bell with light pressure to hear the low frequency sounds. Listen to the aortic valve area which is the 2nd right intercostal space at the right sternal border. Listen to the pulmonic valve area which is the 2nd left intercostal space at the left sternal border. Listen to the second pulmonic area at the 3rd left intercostal space left sternal border. Listen to the tricuspid area at the 4th left intercostal space along lower left sternal border. And listen to the mitral area which is the apex of the heart at the 5th left intercostal space midclavicular line

What does S1 indicate in the cardiac cycle?
it is the sound produced by the initiation of systole due to the closing of the mitral and tricuspid valves. It should be synonymous with the carotid pulse.

What does S2 indicate in the cardiac cycle?
it is the sound produced by the initiation of diastole due to the closure of the pulmonic and aortic valves

What is S3 heart sound?
it may occur during passive filling of the ventricles due vibration on the ventricular walls and is a low-pitched sound (kentucky)

What is S4 heart sound?
it may occur during the second phase of ventricular filling when the atria contracts due to vibration in the valves, papillae, and ventricular walls (Tennessee). If it is loud it may indicate increased resistance to ventricular filling

Abnormalities of S1
a loud sound may be due to the snapping shut of the mitral valve, increased blood viscosity, fever, anemia, anxiety, exercise and intensity may be increased with heart block. Decreased intensity may be due to overlying tissue fat, fluid, pulmonary hypertension, fibrosis, or calcification of mitral valve

Abnormalities of S2
an increased intensity may indicate systemic HTN, syphilis of aortic valve, exercise, excitement, pulmonary HTN, mitral stenosis, CHF. A decreased intensity may indicate shock, immobile valves, aortic stenosis, pulmonic stenosis, overlying tissue, fat or fluid

What is a pericardial friction rub?
inflammation of the pericardial sac that produces a rubbing/machine like sound during systole and diastole, heard widely but more distinct over the apex

What position is best for hearing high pitch murmurs?
lying supine or sitting erect and leaning forward during expiration

What position is best for hearing low pitch filling sounds in diastole?
left lateral recumbent

What position is best for hearing a rotated heart with dextrocardia?
right lateral recumbent

Chief Complaint / Reason for Seeking Care
A subjective statement made by a patient describing the most significant or serious symptoms or signs of illness or dysfunction that caused him or her to seek health care. It is used most often in a health history. Also called presenting symptom.

Client (patient) Profile
A form that patient fills out that allows the physicians to keep track of important medical information such as health changes, surgeries, current prescribed meds, previous doctor visits, immunizations, special instructions, insurance information, as well as general information about the patient.

Database
Medical information that can be processed/accessed by a computer; Comprises of the collected subjective/objective data, patient’s records, and lab studies.

4 types of data:
1) Complete total health database
2) Episodic / Problem-centered database
3) Follow-up database
4) Emergency database

Subjective Data
What a patient SAYS about him/herself during history taking.

Objective Data
What the physician OBSERVES when inspecting, percussing, palpating, and auscultating the patient during physical examination.

Medical History
(aka Health History)
A collection of information obtained from the patient and from other sources concerning the patient’s physical status as well as his or her psychological, social, and sexual function.

The first part describes the chief complaint and history of present illness or injury. The second part lists any/all allergies, immunizations, as well as previous illnesses, surgeries, screenings, hospitalizations, and transplants.

Family History
A crucial part of the patient’s medical history, in which he or she is asked about the health of members of the immediate family in a series of specific questions to discover any (possibly hereditary) disorders to which the patient may be particularly vulnerable to. Other questions, such as those concerning the age, sex, relationships of others in the household, and marital history of the patient, may also be asked.

Precipitating Factor
An element that causes or contributes to the occurrence of a disorder.

Predisposing Factor
Any conditioning factor that influences both the type and the amount of resources that the individual can elicit to cope with stress. It may be biological, psychological, genetic, or sociocultural.

Remission
A temporary or permanent recovery from the clinical and subjective characteristics of a chronic or malignant disease.

Risk
Something that causes a person or a group of people to be particularly susceptible to an unwanted, unpleasant, or unhealthful event.

Sign
An objective finding as perceived by an examiner; something measurable or physically seen.

(e.g. a rash, a 101ºF fever, dilation of the eyes)

Review of Systems (ROS)
A detailed assessment of each body system, performed to ascertain the presence of deviations from normal (aka discover any dysfunctions/diseases).

Techniques of Communication
1) Introducing the Interview

• Keep introduction short and formal
• Let patient address chief complaint
  2) The Working (Data-Gathering) Phase
• Open Ended Questions
• Closed/Direct Questions
  3) Verbal Responses- Assisting the Narrative
• Facilitation, silence, reflection, empathy, clarification, confrontation, interpretation, explanation, summary
  4) 10 Traps of Interviewing
• False hope, unwanted advice, authority, avoidance, professional jargon, using biased questions, talking too much, interrupting, using “why” questions
  5) NonVerbal Skills
• Physical appearance, posture, gestures, facial expressions, eye contact, tone of voice, touch,
  6) Closing the Interview
• Making sure patient doesn’t have unanswered questions or unaddressed concerns

The Interview: Definition & Goal
-Definition: The interview is a meeting between you and your patient
-Goal: to collect a complete health history and to achieve optimal health for the patient

Results of a successful interview
-Gather complete and accurate data about the person’s health state including the description and chronology of any symptoms of illness
-Establish rapport and trust so the person feels accepted and thus free to share all relevant data
-Teach the person about the health state so that the person can participate in identifying problems
-Build rapport for a continuing therapeutic relationship; this rapport facilitates future diagnoses, planning, and treatment.
-Begin teaching for health promotion and disease prevention

Health History you collect in an interview is? (Also importance and collects what type of data and how?)
-Important in beginning to identify health strengths and problems as a bridge to physical examination.
-First and most important part of data collection
-Collects subjective data:

• What the person says about his or her perceived health state
• The interview is the first and the best chance a person has to tell you about what he or she perceives the health status to be
• The patient knows everything about his or her own health state, and YOU KNOW NOTHING!!

-Consider the interview a (1) between you and your patient?

2. This consists of?
3. (contract)
4. The contract consists of spoken and unspoken rules for behavior

• What the person needs and expects from health care and what the health professional has to offer
• Mutual goal is optimal health for the patient

Terms of the contract

• Time and place of interview and physical examination
• Introduction of and explanation of health care provider’s role
• Purpose of interview
• How long it will take
• Expectation of participation for each person
• Presence of others, e.g., family, etc.
• Confidentiality and to what extent it may be limited
• Any costs that the patient must pay

Confusion could produce?
Any confusion could produce resentment and anger rather than the openness and trust you need to facilitate the interview.

The Process of Communication

1. Sending: (Verbal and Nonverbal Communication)
2. Receiving: (Taking in by the other person)

Definitions of Communication
-Communication is exchanging information so that each person clearly understands the other
-Communication is behavior (conscious and unconscious), verbal and nonverbal.
-All behavior has meaning and be aware of what the message is that you’re sending to the patient

Process of Communication: (Sending)
-Verbal communication:

• Words spoken, vocalizations, tone of voice
  -Nonverbal communication:
• Body language – posture, gestures, facial expression, eye contact, foot tapping, touch, even where you place your chair
• Because nonverbal communication is under less conscious control than verbal communication, nonverbal communication probably is more reflective of your true feelings

Process of Communication: (Receiving)
-Awareness of messages you send is only part of process
-Words and gestures must be interpreted in a specific context to have meaning
-The patient comes to you with a history – the receiver attaches meaning determined by his or her past experiences, culture, self-concept, and current physical and emotional state
-Successful communication requires mutual understanding by sender and receiver
-Patients’ health problems intensify communication because patients depend on you to get better
-Communication can be learned and polished when you are a beginning practitioner
-Communication is a tool, as basic to quality health care as tools of inspection or palpation

To maximize your communication skills, you need to be aware of (1.) and (2.) and their influence.

1. Internal factors
2. External Factors

Internal Factors
What you, as an examiner, bring into the interview

Three important internal factors

1. Liking others:
   -A generally optimistic view of people – an assumption of their strengths and a tolerance for their weakness
   -The patient must feel accepted unconditionally
   -Goal is NOT to make patient dependent on you, but to help them to be increasingly responsible for themselves
2. Empathy:
   -Viewing the world from the other person’s inner frame of reference while still remaining yourself
   -Feeling WITH the person rather than feeling LIKE the person
   -To understand with the person how he or she perceives the world
3. The ability to listen:
   -Listening is not passive – it is active and demanding and requires your complete attention!
   -Active listening:

• Listen to WHAT the person says
• Listen to the WAY the person tells the story – this may give diagnostic cues

External factors: In any location, the following conditions are important to have a smooth interview: (1-7)

1. Ensure Privacy
2. Refuse Interruptions
3. Physical Environment
4. Dress
5. Note-Taking
6. Tape and Video Recording
7. Electronic Health Recording (EHR)

External Factors: (Ensure Privacy)
If physical privacy is not available, try to provide “psychological privacy” such as curtained partitions that will help the patient feel confident that no one can overhear the conversation or interrupt

External Factors: (Refuse Interruptions)
-Most people resent interruptions except in cases of emergency
-Inform support staff of your interview and ask that they not interrupt you

External Factors: (Physical Environment)
-Comfortable temperature
-Sufficient lighting (especially not facing patient directly into a light source)
-Reduce noise
-Remove distracting and unnecessary objects (the room should look professional)
-Place the distance between you and the patient at 4 to 5 feet
-Appropriate eye contact with the patient
-Arrange equal-status seating

• Both patient and examiner seated at eye level with each other
• Do not speak from behind a desk
• DO NOT STAND – it communicates haste and assumes superiority
• Bed-ridden patients should be arranged at a face-to-face position

External Factors: (Dress)
-Patient should remain in street clothes except in emergencies
-Collect history BEFORE asking the patient to change into the paper examination gown
-Your appearance should be appropriate to setting and should meet conventional professional standards without placing a distance between you and the patient because of your fancy 3-piece suit

External Factors: (Note-Taking)
-May be unavoidable:

• Cannot rely completely on memory for details of previous illnesses or review of body systems
• Keep note taking to a minimum and try to focus your attention on the patient
  -Challenges of note taking:
• Breaks eye contact too often
• Shifts attention away from person, diminishing his or her sense of importance
• Interrupts patient’s narrative flow
• Impedes observation of patient’s nonverbal behavior
• May be threatening to patient’s discussion of sensitive issues

External Factors: (Tape and Video Recording)
-A tape or video is an excellent teaching tool to study objectively your performance as an interviewer
-Ethical considerations:

• Explain to the patient the purpose of the recording, exactly who will hear it, and that it will then be destroyed (if that is the case)
• Obtain consent BEFORE your start

External Factors: (Electronic Health Recording (EHR))
-Benefits:

• Eliminates handwritten data
• Provides access to patient education materials and internet searches
  -However, it may seem to the patient that they sit idly by while you fumble around silently with the computer.

Techniques of Communication: Introducing the interview
-Keep this part short
-Address the person using their last name and shake hands if that feels appropriate

• Except for a child or adolescent, avoid using first names in this interview
  -Introduce yourself, state your role, and provide the reason for the interview

Techniques of Communication: The Working Phase
-Data-gathering phase
-Verbal skills include questions to patient and your responses to what is said
-Two types of questions (each has its own function and place in the interview):

1. Open-Ended Questions
2. Closed/Direct Questions

Techniques of Communication: The Working Phase: (Open-Ended Questions)
-Open-ended questions ask for narrative information and state the topic to be discussed ONLY in general terms.
-Ask for narrative responses – “Tell me, how did your labor go yesterday?”

• Opens up the conversation
• Establishes the rapport with the patient
• Can help correct misconceptions that the patient has/had about a particular topic
• Also helps you establish if the patient is upset about a certain aspect of the healthcare provider and/or system
  -State topic only in general terms
  -Use them:
• To begin interview
• To introduce a new section of questions
• Whenever the patient introduces new topic

Techniques of Communication: The Working Phase: (Closed/Direct Questions)
-Ask for specific information
-Elicit short, one-or-two word answers, a yes or no answer, or a forced choice
-Use them:

• After opening narrative to fill in details person may have left out
• When you need many specific facts about past health problems, or during review of systems
• To move the interview along – the interview is not a social event!
  -Guidelines for closed/direct questions:
• Ask only one question at a time and avoid bombarding the patient with questions
• Choose language the patient understands (example: “running off”)

Techniques of Communication: The Working Phase: (Responses)

• Assisting the narrative in an interview.
• You responses help the patient amplify their story
• The first Five responses (Facilitation, Silence(Attentiveness), Reflection, Empathy, and Clarification) involve you reactions to the facts or feelings the person has communicated.
  -Your response focuses on the patient’s frame of reference.
  -Your own frame of reference does not enter into the response.
  -The patient leads this part.
• The last Four responses (Confrontation, Interpretation, Explanation, and Summary), you start to express your own thoughts and feelings
  -The frame of reference shifts from the patient’s perspective to yours – you lead this part!

Techniques of Communication: The Working Phase: Responses: (Facilitation)
-Facilitation encourages patients to say more and shows you are interested and will listen further
-Also called “general leads”
-Simply maintain eye contact, shift forward in your seat with increased attention, nodding yes, or using hand gestures to encourage the patient to continue talking

Techniques of Communication: The Working Phase: Responses: (Silent Attentiveness)
-Gives patient time to think and organize what to say without interruption from you
-Gives you a chance to observe person unobtrusively and note nonverbal cues

Techniques of Communication: The Working Phase: Responses: (Reflection)
-Echoes patient’s words, repeating what person has just said
-Focuses further attention on a specific phrase
-Helps person continue in his or her own way, expressing the feeling behind a person’s words

Techniques of Communication: The Working Phase: Responses: (Empathy)
-Recognizes a feeling and puts it into words
-Names the feeling and allows expression of it

• Patient feels accepted and can deal with feeling openly

Techniques of Communication: The Working Phase: Responses: (Clarification)
-Use when person’s words are ambiguous or confusing
•Used to summarize person’s words and to simplify them to make them clearer
-You are asking for agreement, and the person can then confirm or deny your understanding
-“I have low blood. ” “What does low blood mean to you?”

Techniques of Communication: The Working Phase: Responses: (Confrontation)
-Frame of reference shifts from patient’s perspective to yours
-May focus on discrepancy or inconsistency in person’s narrative
-You have observed a certain action, feeling, or statement and now focus person’s attention on it
-You give honest feedback about what you see or feel

Techniques of Communication: The Working Phase: Responses: (Interpretation)
-Based on your inference or conclusion
-It links events, makes associations, implies cause, ascribes feelings
-Helps person understand his or her own feelings in relation to the verbal message
-If your inference is incorrect, the patient may correct it, and thus prompt further discussion of topic

Techniques of Communication: The Working Phase: Responses: (Explanation)
-These statements inform the person – you share factual and objective information offering reasons for requirements or actions
-“The reason you cannot eat or drink before your blood test is that food will change the test results.”

Techniques of Communication: The Working Phase: Responses: (Summary)
-Final review of what person has said – it condenses facts and presents your view of health problem
-Is a type of validation that person can agree with or correct; both you and patient should participate
-Occurring at the end of the interview, it signals that termination of the interview is near

Things to remember about Responses
-These responses now include your own thoughts and feelings
-Use the last four responses only when merited by the situation – if you use them too often, you take over at the patient’s expense

Ten Traps of Interviewing

1. Providing false assurance or reassurance
2. Giving unwanted advice
3. Using authority
4. Using avoidance language
5. Engaging in distancing
6. Using professional jargon
7. Using leading or biased questions
8. Talking too much
9. Interrupting
10. Using “why” questions

Ten Traps of Interviewing: (Providing false assurance or reassurance)

• Correct responses acknowledge the feelings of the patient and open the door for more communication.
• You can reassure patients that you are listening to them, that you understand them, that you have hope for them, and that you will take good care of them.
• This type of reassurance makes a commitment to the patient, and it can have a powerful impact.

Ten Traps of Interviewing: (Giving unwanted advice)

• Know when to give advice and when to avoid giving it.
• Instead of giving opinion, try to allow an opportunity for the patient to reflect on the problem at hand. Through this process the patient is likely to learn and to change his or her behavior.

Ten Traps of Interviewing: (Using authority)

• Although you and the patient cannot have equality to professional skill and experience, you do have equally worthy roles in the health process, which each respecting the other.
• Talking down to the patient promotes dependency and inferiority

Ten Traps of Interviewing: (Using avoidance language)

• People use euphemisms such as “passed on” to avoid reality or to hide their feelings. They think that if they actually use the word “death” it might actually happen. To protect themselves, they evade the issue
• Not talking about fear does not make it go away – it suppresses it.
• Direct language is the best way to deal with frightening topics

Ten Traps of Interviewing: (Engaging in distancing)

• Distancing is the use of impersonal speech to put space between a threat and the self.
• Does not work because it communicates to the other person that you are also afraid of the procedure.
• The use of blunt specific terms actually is preferable to defuse anxiety.

Ten Traps of Interviewing: (Using professional jargon)

• If a patient uses medical jargon, do not assume he or she always knows the correct meaning.

Ten Traps of Interviewing: (Using leading or biased questions)

• If a person wants to please you, either he is forced to answer in a way corresponding to you values of he feels guilty when he must admit the other answer.

Ten Traps of Interviewing: (Talking too much)
Listen more than you talk, so your able to get all information needed/looking for.

Ten Traps of Interviewing: (Interrupting)

• Often, when you think that you know what the person will say, you interrupt and cut the person off. This does not show that you are clever; it signals that you are impatient or bored with the interview.
• Aim for a second of silence between the person’s statement and your next response.

Ten Traps of Interviewing: (Using “why” questions)

• The adult’s use of “why” questions usually imply blame and condemnation and puts the patient on the defensive.
• Using “why” questions make you sound whining, accusatory, and judgmental and the patient must then come up with an excuse to rationalize.
• “I see you started to have chest pains early in the day. What was happening between the time the pains started and the time you came into the ER?”

Non-Verbal Skills
-Learn to listen with your eyes as well as your ears.
-Nonverbal messages provide clues to understanding feelings.
-When verbal and nonverbal messages are congruent, the verbal is reinforced
-When verbal and nonverbal are incongruent, the nonverbal message tends to be the true one because it is under less conscious control.

Nonverbal modes of communication: (1-7)

1. Physical appearance
2. Posture
3. Gestures
4. Facial Expression
5. Eye Contact
6. Voice
7. Touch

Nonverbal modes of communication: (Physical Appearance)
-Hans Selye “The Stress of Life”

• Some patients just “look sick” before you have a chance to collect any other data than simply looking at them.
• The same goes for you, too, as a nurse…
  -Whatever your personal choice in clothing or grooming, the aim should be to convey a competent, professional image.

Nonverbal modes of communication: (Posture)
-Open versus closed body language
-If a person in a relaxed position suddenly tenses, it suggests discomfort with a new topic
-Your own calm, relaxed posture creates a feeling of warmth and trust and conveys interest in the person.

Nonverbal modes of communication: (Gestures)
-Gestures send messages, such as nodding or an open turning out of the hand shows acceptance, attention, or agreement.

• Wringing hands = anxiety
• Pointing a finger = anger and vehemence
  -Hand gestures also can reinforce a person’s description of pain, such as holding a clinched fist in front of the sternum with crushing substernal chest pain or pointing with one finger to signify “this is where it hurts!”

Nonverbal modes of communication: (Facial Expression)
-Relevant emotions or conditions, and physical conditions such as pain or shortness of breath may show on the face
-Your own expression should reflect a professional who is attentive, sincere, and interested in the patient.
-Any expression of boredom, distraction, disgust, criticism, or disbelief is picked up on by the patient and any rapport you have established with dissolve.

Nonverbal modes of communication: (Eye Contact)
-Lack of eye contact suggests that the person is shy, withdrawn, confused, bored, intimidated, apathetic, or depressed – this applies to you as an examiner, too!
-Do not have a fixed, penetrating look but rather, an easy gaze toward the person’s eyes, with occasional glances away.
-Exception: patients from a culture that avoids direct contact

Nonverbal modes of communication: (Voice)
-Besides spoken words, meaning comes through the tone of voice, the intensity and rate of speech, the pitch, and any pauses.
-Examples:

• Sarcasm versus disbelief versus sympathy versus hostility
• Anxious = loud and fast voice
• Whining = high-pitched, wavering quality with long drawn-out syllables
• Soft voice = fear or shyness
• Hearing impaired = loud voice
  -Pauses:
• When questioning is easy and straightforward, a patient’s long, unexpected pause indicates the person is taking time to think of an answer and raises some doubt as to the honesty of the answer.
• Usually frequent and long pauses, when combined with speech that is slow and monotonous and a weak, breathy voice, indicate depression.

Nonverbal modes of communication: (Touch)
-The meaning of physical touch is influenced by the person’s age, gender, cultural background, past experience, and current setting
-The meaning of touch is easily misinterpreted – do not use touch during the interview unless you know the person well and are sure how it will be interpreted
-When appropriate, touch communicates effectively, such as a touch of the hand or arm to signal empathy.

Closing the Interview
-The session should end gracefully – and abrupt or awkward closing can destroy rapport and leave the patient with a negative impression of the whole interview.
-To ease into the closing ask:

• Is there anything else you would like to mention?
• Are there any questions you would like to ask?
• Are there any other areas I should have asked about?
• We have covered a number of concerns today. What would you most like to accomplish?
  -This gives the patient the final opportunity for self-expression.
  -After all of the above, indicate that closing is imminent by saying something like, “Our interview is just about over.”
  -This is a good time to give your summary or recapitulation of what you have learned during the interview
• Summary = a final statement of what you and that patient agree the health state to be, it should include
  o Positive health aspects
  o Any health problems that have been identified
  o Any plans for action
  o And explanation of the following physical examination
  -As you leave, thank the patient for the time spent and for their cooperation.

Developmental Competence: (The adolescent)
-Puberty is a time of dramatic physiologic change – a changing body affects a patient’s self-concept.
-Adolescents are between the childhood and adult stages in life; therefore, they are capable of both mature and immature actions (especially during times of stress).
-Adolescents love their friends and believe that no adult can understand them

• Leads to monosyllabic answers and/or telling you only what they think you want to hear
• Assume that health professionals have similar values and standards of behavior as most of the other authority figures in their lives and therefore are reluctant to share information.

Guidelines for successful communication with adolescents

1. Have a respectful attitude, which is the most important thing you can communicate to an adolescent.
2. Communication must be totally honest.
3. Stay in your professional character – do not try to be his or her peer.
4. Use icebreakers – focus first on the adolescent and not their problem.

• “How are things at school?”
• “Are you in any sports?”
• “Any activities?”
• “Do you have any pets at home?”

1. Remember that adolescents are more sensitive to nonverbal communication than adults. They are more sensitive to any comment they take to mean criticism from you and will withdraw.
2. Take every opportunity for positive reinforcement regarding healthy lifestyle choices.

• For bad choices – discussion is not enough – five them a small achievable goal and encourage another visit in a few weeks for follow-up on the behaviors of concern.

Developmental Competence: The adolescent= (Things to Avoid)

• Silent periods, as used with adults, are not appropriate and may be seen as threatening.
• Reflection – they do not have the cognitive skills to respond to that indirect mode of questioning.
• Do not assume that adolescents know anything about a health interview or a physical examination. Explain every step and give the rationale.

Developmental Competence: The Older Adult: (Developmental Tasks)

• Finding the meaning of life and the purpose of his or her own existence
• Adjusting to the inevitability of death

Developmental Competence: The Older Adult: (Points to Remember)

• Always address the older adult by their last name
• Avoid all “elderspeak” which consists of
• Diminutives
• Inappropriate plural pronouns
• Tag questions
• Shortened sentences, slow speech rate, and simple vocabulary that sounds like baby talk
• Adjust the pace of the interview to the aging person – the older person has a great amount of background material to sort through and this takes time and energy.
• Avoid hurrying the interview – this only affirms their stereotype that people are merely interested in numbers of patients and filling out forms.
• Touch is important, especially if other senses have dulled. Also it communicated empathy and an effort to understand.

Interviewing Patients with Special Needs: (Hearing-Impaired People)
-Ask, “How can I best communicate with you?”
-Don’t shout – this distorts your words and the reception of hearing aids.
-Speak slowly and supplement your voice with appropriate hand gestures/pantomime.
-Be aware of nonverbal communication
-Written communication is efficient in sections such as past health history or review of systems.

Interviewing Patients with Special Needs: (Acutely ill people)
-“Deferred secondary to patient vomiting.” When you may skip over a part of the interview – do not leave anything blank!
-Although life-support measures may be paramount, still try to interview the patient as much as possible.
-Establish a priority and find out immediately what parts of the history are the most relevant.

Interviewing Patients with Special Needs: (People under the influence of street drugs or alcohol)
-Ask simple and direct questions while maintaining a nonthreatening and nonjudgmental demeanor.
-Avoid scolding or disgust – this may lead to belligerent behavior.
-Top priority: the time of the last drink/drug and how much was taken at this episode as well as the name and amount of other substances taken.
-Once sober: assess for the extent of the problem and the meaning of the problem for the person and family.

Interviewing Patients with Special Needs: (Personal Questions “to you”)
-You don’t have to answer every question
-You may supply brief information when you feel it is appropriate but be aware that there may be a motive behind personal questions such as loneliness or anxiety.
-Direct your response back to the patient’ frame of reference.
-“No I don’t have children; I wonder if your question is related to how I can help you care for little Jimmie?”

Interviewing Patients with Special Needs: (Sexually Aggressive People)
-Some patients experience serious or chronic illness as a threat to their self-esteem and sexual adequacy that creates anxiety that makes them act out in sexually aggressive ways.
-You may need to stop your interview and get another healthcare provider to do it

Interviewing Patients with Special Needs: (Crying)
-You may need to defer parts of the interview – again note that something prevented that aspect of the interview and why.
-If crying occurs, do not go on to a new topic, just let the person cry and express feelings fully.
-If someone is on the verge of tears, acknowledge the expression by saying, “You look sad.” The person may cry but will be relieved, and you will have gained insight to a serious concern.

Interviewing Patients with Special Needs: (Anger)
-The patient is showing aggression as a response to feelings of anxiety or hopelessness.
-Do not ask about the anger and hear the person out (let them vent).
-An angry person cannot be an effective participant in a health interview.
-If YOU are angry, say so and tell the patient that you are angry at something or someone else. Otherwise the patient will think that you are angry with him or her.

Interviewing Patients with Special Needs: (Threat of Violence)
-Fist clenching, pacing back and forth, vacant stare, confusion, statements out of touch with reality, statements that don’t make sense, history of recent drug use, recent history of intense bereavement
-Trust your instincts – leave the exam room door open and position yourself between the person and the door.
-Avoid taking any risks.

Interviewing Patients with Special Needs: (Anxiety)
-Nearly all sick people have some anxiety – this is a normal response to being sick.

Cross-cultural communication
-Probability of miscommunication increases with two people from different cultural backgrounds
-Cultural backgrounds of both health care professional and patient influence verbal and nonverbal communications

Cross-cultural communication: (Cultural perspectives on professional interactions)
-Asians expect those in authority (us…) to be authoritarian, directive, and detached
-Appalachians have close family relationships and may expect to have the same closeness with their healthcare provider
-Latin-American and Mediterranean expect an even greater level of intimacy than Appalachians

Cross-cultural communication: (Etiquette)
-Etiquette refers to the conventional code of good manners that governs behavior and varies cross-culturally.
-When meeting a patient for the first time, it is best to be formal, respectful, and polite.

Cross-cultural communication: (Space and Distance)
-Spatial distance is significant throughout the interview and physical examination, with culturally appropriate distance zones varying widely

Cross-cultural communication: (Cultural Considerations on Gender)
-Arab Americans – an adult male is never alone with a female (except his wife) and is generally accompanied by one or more other males when interacting with females.
-When gender differences are important to the patient, try strategies such as offering to have a third person present.
-Ensure proper modesty procedures are in place (use common sense).

Cross-cultural communication: (Cultural Considerations on Sexual Orientation)
-Never assume the sexual orientation of a patient
-Heterosexism – the institutionalized belief that heterosexuality is the only natural choice and assumes it is the norm.

Overcoming Communication Barriers
-Working with (and without) an interpreter

• Remember from Dr. Scott’s class…
  -Nonverbal cross-cultural communication
• 5 types of nonverbal behaviors that convey information about the person

1. Vocal cues

• Pitch, tone, and quality of voice
• Includes moaning, crying, and groaning

1. Action cues

• Posture, facial expression, and gestures

1. Object cues

• Clothing, jewelry, and hair styles

1. Use of personal and territorial space

• Interpersonal transactions and care of belongings

1. Touch

• Touching patients is a necessary component of comprehensive assessment
• Physical contact with patients conveys various meanings cross-culturally

Things to remember about overcoming communication barriers
-Patients’ significant others may exert pressure on nurses by enforcing culturally meaningful norms in health care setting
-In some cultures, it is considered an acceptable expression of friendship and affection to openly and publicly hold hands with or embrace members of same gender with no sexual connotation
-You may find that a patient displays similar behaviors and should feel free to discuss cultural differences and similarities openly with the person

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