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Western Clin

S.O.A.P Subjective, Objective, Assessment, Plan
Seven Attributes used under Chief Complaint 1: Location, Quality, Quantity, Onset, Duration, Timing: onset, dureation, frequency, Aggravation/Alleviation, Setting, Associated Symptoms
Body Mass Index (BMI) Normal 18.5-24.9 Overweight 15-29 Obese >30
Normal Heart in Humans Adult 60-100 Peds about 90
Normal Respiratory rate 12-18 rpm
Explain Bradypnea and Tachypnea, Hyperpnea Apnea and Dyspnea slow respiration rate and rapid (shallow) breathing, increase in rate and depth of breathing (hyperventilation), Apnea is no breathing and Dyspnea
Normal body temp and measuring location 98.6, Tympanic, Rectal, Oral, Axillary
What is Hyperpyrexia and Hypothermia temp over 106F and below 95
Blood pressure ratings Normal lower than 120/80 PreHypertensive 120-139/80-89 Stage 1 Hypertension 140-159/90-99 Stage II HTN over 160/100
What organs are affected Eyes: Retinopathy, Kidneys: Nephropathy, Heart: Cardiomyopathy Brain: Stroke
Cranial Nerves Olfactory, Optic, Oculomotor, Trochlear, Trigeminal, Abducens, Facial, A, Vastibularch, G,
Where are the following structures of the eye? Anterior Chamber containing aqueous humor, Posterior Chamber, Sclera, Retina, Optic Nerve
Lacrimal Gland, Lacrimal Sac, Iris, Limbus....EXPLAIN
Terminology and pathology of eye Right eye: OD ---Oculus Dexter Left eye: OS--- Oculus sinister Miosis: contraction of the pupil Mydriasis: dilation of the pupil Myopia: near-sightedness Hyperopia: far-sightedness Presbyopia: aging vision (see far better) Diplopia: double vision
Visual Acuity Means clearness & acuteness of vision. Expressed as fraction (20/20) top number refers to distance u stand from chart. usually 20 feet. bottom number indicates the distance at which person w/ normal eyesight could read the same line you correctly read
Ptosis drooping of the upper eye lid.
Entropian and Ectropion Inward/outward turning of the lid
infections around the eye Horedeolum: acute purulent inflammation of the eyelid, Chalazion: chronic inflammation of the sebaceous meibomian glands, also called a cyst, inflammation of the lachrymal sac
Red eye redness due to hyperemia (increased blood flow)
Conjunctivitis Inflammation of the lining over the sclera, viral, bacterial, allergic, can start unilateral ->both eyes usual benin, can progress to involvement of the cornea = uveitis (refer ASAP if pain , photophobia, decreased vision, or redness touches limbus
Cataracts leading cause of blindness, is clouding of lens that affects vision, most people over 80 have it, cannot spread from one eye to another
glaucoma optic neuropathy- usually assoc. w/ increased inter ocular pressure, leading to decreased peripheral vision & blindness chronic or open angle glaucoma, acute closed-angle
open angle glaucoma silent thief of sight, 2nd leading cause of blindness in the world, usualy ASx, can develop into acute closed angle glaucoma
closed angle glaucoma, most common, decreased or no drainage of fluid from anterior chamber, ACUTE CLOSED OCCURS WHEN ANGLE IS CLOSED, Sx: Severe pain, headaches, haloes, vision loss, nausea and vomiting
ACUTE closed angle
eye - systemic disease HTN: red eyes, retina neovascularization, Diabetes: retinopathy, neovasculaization Hyperthyroidism: exothalmus, lid lag, MS: non responsive pupil, optic nerve atrophy Syphillis: Argyll Robertson pupil, small irregular, non reactive to light
ear nerves VIII - Vestibulacochlear
Hearing and hearing loss Conductive: air and bone Sensorineural:
Ear related symptoms earache: otitis externa (between earlobe and eardrum Otitis media: middle ear Mastoiditis: infection of mastoid
Symptoms of Nose preoblems Rhinorrhea- running of the nose- clear vs. purulent, viral, allergic, foreign body, tumor, pressure and pain in the face - Sinusitis Epistaxis: trauma, dryness, tumor, foreign bodies, HTN
Angular stomatitis, Cheilitis cracks or sores in the corner of mouth
Pharyngitis/Sore throat exudative vs non-exudative Exu: strepthroat, infectious mono,
Thrush/candidiasis yeast infection, with plaques adherent anywhere in mouth, due to steroids, HIV, antibiotics, cancer and chemo
Leukoplakia white patch anywhere in the mouth, unknown etiology, chronic irritation especially in smokers, precancerous, cannot be scraped off
Aphthous ulcer canker sores, painful, round, self limited, stress or tissue injury faulty immune system, nutritional problems - zinc, B12, food allergies, menstrual periods
orthostatic hypotension form of hypotension, a person's blood pressure suddenly falls when standing up stretching. caused by blood pooling in lower extremities upon change in body position common, can occur briefly in anyone although it's prevalent among elderly, low blood press
Hearing loss conductive: air and bone, sensorineural: meds, aspirin, NSAIDS, aminoglycosides, furosemide, anti HTN
Tinnitus in Senile people, meds as aspirin, and NSAIDS, trauma, meniere's disease: hearing loss, vertigo heaviness in ear
Vertigo subjective vs. Objective, inner ear infection, cardiovascular, meds, acoustic neuroma, post stroke
Mouth cancer mostly at base of mouth, not painful, ulcerated (doesn't seem clean)
Parotitis Mumps if viral, inflammation of saliva producing glands. also acute bacterial, chronic recurrent parotitis, and tuberculosis
Sjorgren's Syndrome autoimmune condition in which there is a decrease in activity of exocrine glands, Sx: dry mouth, glands enlargement, dry eyes, vaginal dryness, dry mouth, joint pain. Diagnosed with biopsy and blood test
TMJ syndrome most active joint, mandible and temporal bone, synovial ball and socket joint caused by trauma, grinding, over use, OA or RA
Bells Palsy paralysis or weakness in muscle that controls facial expression CN VII (facial), damage to nerve, mostly post viral URI, associated with Herpes Simplex, autoimmune, diabetes and pregnancy
Sx of Bells Palsy sudden onset, cant smile or close eyes, facial drooping and stiffness, pn around ear, headache, changes in amount of tears and saliva. Onset is abrupt, severity ranges, the faster the onset the higher the severity
Respiratory distress Intercostal retraction, use of accessory muscles, brief fragmented speech, inability to lie supine, sweating, agitation, mental distress, stridor, wheezing
Common cold viral infection in cold season, URI: starts with dryness and stuffiness in the nasopharynx, sore throat, ear plugging, clear watery nasal discharge. Fever chills, body ache, erythema in throat
Duration of common Cold self limited around 7 days if no bacterial super infection.
Tx for common cold rest, water, steam inhalation, OTC drugs, no ABX needed
Sinusitis inflammation and infection of the sinuses, mostly viral, sometimes bacterial or fungal Acute <4weeks sub acute 4-12 weeks Chronic >3 months, recurrent 4+/year DDX for acute is allergic rhinitis and common cold
OTC meds for common cold antipyretic, -antihistamines (can cause dryness, more cough) -decongestant, increase BP, vasoconstriction
Complications of common cold LRI (pneumonia, bronchitis) sinusitis, otitis media
Sx of sinusitis nasal congestion, purulent nasal discharge, tooth discomfort, facial pn, pressure increase when bending over in chronic it is more dull, HA, PND, chronic cough from PND, and bad breath
Complications for Sinusitis facial edema, eye involvement, cellulitis, meningitis, change in vision and mental status, intracranial abscess
Influenza flu is viral, Type A and B (type A is most severe and most common RNA virus
DDX for influenza, contamination could be common cold, strep throat, but influenza is much more severe, is spread through respiratory droplets, virus in very high levels days 2-4 of illness, then gone in days 5-10
Risk groups for influenza Children <2 Adult >65 Pregnant women Immune compromised people morbidly obese nursing home residents, children under 19 with long term aspirin care
Influenza Sx can cause URI, LRI, rapid onset, common onset: fever cough, rhinitis, headache, sore throat, myalgia, malaise and weakness,
Created by: Crstnr