1. NR 509 Week 2 Shadow Health: HEENT Physical Assessment 2. NR 509 Week 2 Shadow Health: Respiratory Physical Assessment 3. NR 509 Week 3 Shadow Health: Musculoskeletal Physical Assessment 4. NR 509 Week 3 Shadow Health: Neurological Physical Assessment 5. NR 509 Week 4 Shadow Health: Cardiovascular Physical Assessment 6. NR 509 Week 5 Shadow Health: Gastrointestinal Physical Assessment 7. NR 509 Week 6 Shadow Health: Mental Health Physical Assessment NR 509 Week 2 Shadow Health: HEENT Physical Assessment Suppose you had found that Tina’s pupils were reactive to both direct and consensual light, yet unequal in size. Which condition would you suspect? Correct: Anisocoria is condition in which the pupils are unequal in size. Anisocoria can be found in about 20% of normal individuals. • Unequal visual acuity • Optic neuritis • Glaucoma • Anisocoria (Correct Response) Imagine that, during your physical exam with Tina, you had palpated an enlarged left supraclavicular lymph node. What would this finding have indicated? Correct: Malignancies originating in the pelvis or abdomen are likely to metastasize to the left supraclavicular lymph node, also known as Virchow's node. • Nothing, because this is a normal variant • A serious pathology (Correct Response) • A previous infection of the throat • An active infection of the throat If you had observed Arteriovenous (AV) nicking during the retinal exam on Tina, what would you have seen? Correct: AV nicking is the compression of the vein at arteriovenous crossings due to arterial stiffening. This results in bulging of the vein on either side of the artery making the vein appear to stop on either side of the artery. AV nicking is usually a result of chronic hypertension. • Transparent arterial walls • Opaque arterial walls • Tortuous arteries and veins • Vein stops on either side of the artery (Correct Response) Suppose that you had detected a click while palpating Tina’s temporomandibular joint (TMJ). What could have been the cause? Student Response: TMJ syndrome Model Note: Crepitus, limited mobility, and pain in the jaw are probable indicators of temporomandibular joint dysfunction (TMJ syndrome). The clicking noises are most likely caused by displacement of the disc between the condyle and fossa (ball and socket) at the temporomandibular joint. If Tina had reported new onset ear pain, what would have been the most useful finding to determine otitis media? Student Response: lack of mobility of the tympanic membrane during insufflation Model Note: A useful diagnostic finding that suggests otitis media is the lack of mobility of the tympanic membrane during insufflation. This immobility is caused by increased pressure of the middle ear when air or fluid is trapped due to infection and impairment of the Eustachian tube. Imagine that you inspected Tina’s throat and noted that her tonsilstouched each other. How would you grade her tonsils on the tonsillar hypertrophy grading scale? Student Response: 4+ Model Note: Using the standardized tonsillar hypertrophy grading scale, the tonsils are graded 4+ because they touch one another and, therefore, occupy more than 75% of the space between the posterior pillars of the throat. NR 509 Week 2 Shadow Health: Respiratory Physical Assessment 1. If Tina had mentioned that she was just diagnosed with pneumonia, what would you have expected to find during percussion? • Hyperresonance • Tympany • Resonant • Dullness (Correct Response) Correct: Dull percussion sounds are expected over the areas of diffuse infiltrate (accumulation of fluid and by products of inflammation) in a patient with pneumonia. 2. If the results of Tina’s pulse oximetry had been 97%, which of the following would have been true? • Partial pressure O2 = 97% • Unbound oxygen level = 97% • PaO2 = 97% • Arterial hemoglobin saturation = 97% (Correct Response) Correct: Pulse oximetry measures the percent of hemoglobin molecules that are filled with oxygen. Oxygen-saturated hemoglobin absorbs light wavelengths differently than unsaturated hemoglobin. The oximeter emits a light and reads the extent of wavelength absorption. 3. Suppose that, during your lung exam on Tina, you had heard bronchial breath sounds in the left lower lung posteriorly. What would you have suspected based on this finding? • Normal lung exam • Atelectasis • Fluid filled region of the lung (Correct Response) • Narrowed upper airways secondary to asthma Correct: Increased breath sounds are indicative of lung consolidation (fluid-filled alveoli) or pleural effusion (fluid accumulation in the pleural space) because fluid transmits sounds better than air. This finding is usually accompanied by abnormal transmitted voice sounds and increased tactile fremitus. 4. Suppose that while auscultating, you assessed a few scattered expiratory wheezes. Why would this be an expected finding for a patient with Tina’s history? • Scattered wheezes are to be expected because of Tina’s history of asthma. Asthma is a chronic condition in which hyperreactive airways become narrowed by recurring inflammation and excess mucus production which results in wheezing. 5. When you observe a patient like Tina throughout an exam, there are many ways to determine whether a patient is experiencing respiratory distress. Identify one indicator of respiratory distress that can be assessed through observation alone. • Observable signs of respiratory distress include accessory muscle use, audible respirations, grunting or wheezing, increased respiratory rate, bluish coloration around the lips or fingernails, nasal flaring, chest retractions, sweating, tripod body positioning, and inability to speak in full sentences. 6. Describe how you would assess Tina for dyspnea. • Dyspnea is a subjective complaint that must be elicited by asking the patient about her breathing. Ask your patient, “Do you ever have shortness of breath or difficulty breathing?” If dyspnea is detected, be sure to ask about onset, environmental or physical factors related to exacerbations, duration, body positioning, sleep disturbances, and relieving factors.