Exam 1 Review (week 1-3)

MOUTH:

Normal findings in elderly mouth/pharynx:

■ The lips have increased vertical markings and appear dryer.
■ The buccal mucosa is thinner, less vascular, and less shiny
■ Tongue may appear more fissures, and veins on its ventral surface
■ Oral tissues may be dryer (xerostomia) especially with medications
■ Natural teeth may be worn down, shortening the crown, and altering enamel thickness.

General findings in elderly mouth/pharynx:

▪ Chronic disease increases the burden of oral disease, predisposing older adults to oral
microbial infections, pain, altered taste, difficulty chewing and speaking, and dysphagia.
▪ Poor oral health can lead to weight loss
○ Periodontal disease is the 6th leading complication of diabetes and can inhibit glycemic
control and poor glycemic control can contribute to periodontal disease
○ Xerostomia (dry mouth) impairs oral function, promotes tooth decay, exacerbates periodontal
disease which can be caused by many medications.
○ Oral cancer is the 8th most common cancer in men and 7x more likely in older adults
○ Aspiration pnumonia is a major cause of hospitalization and results in 20-50% mortality, oral
hygiene can decrease this incidence.
○ 23% have untreated cavities and 70 % periodontal disease
○ 1/3 are fully edentulous (missing all their natural teeth) or average 19 or less remaining teeth
○ 17% have orofacial pain, facial, oral sores, burning mouth, and toothache

Abnormal findings in elderly mouth/pharynx:

■ Gingivitis: which is associated with plaque, hormonal changes, or foreign-body response
■ Periodontal disease is associated with DM, PVD, cerebrovascular disease, & CV disease which
could be due to inflammation. This is marked by loss of alveolar bone around teeth: Oral abx
and chlorhexidine can slow it but may need root surface debridement.
■ 59% of those 60-69 and 72% of those 70+ have less than 20 teeth remaining which can impact
nutritional status. Dentures does not decrease the malnutrition.
■ Dental caries is an infection. This can spread to other organs. The use of high-fluoride
toothpaste can be beneficial. Dental caries may be present or deterioration of dental
restorations present.
■ Teeth may appear longer due to reabsorption of the gum and bone progresses which reveals the
teeth root.
■ Dental malocclusion may be caused by the migration of remaining teeth after extractions.
 EARS:

Otitis Media with Effusion:

■ Initial symptoms: sticking or cracking sound on yawning or swallowing; no signs of

dizziness
■ Pain: discomfort, feeling of fullness
■ Discharge: none
■ Hearing: conductive loss as middle ear fills with fluid
■ Inspection: tympanic membrane retracted or bulging, impaired mobility, yellowish; air-fluid
level and/or bubbles
Acute Otitis Media :

■ Initial symptoms: abrupt onset, fever, feeling of blockage, anorexia, irritability

■ Pain: deep-seated earache that interferes with activity or sleep, pulling at ear (pediatric
patients)
■ Discharge: only if tympanic membrane ruptures or through tympanostomy tubes; foul-
smelling
■ Hearing: conductive loss as the middle ear fills with pus
■ Inspection: tympanic membrane with distinct erythema, thickened or clouding; bulging;
limited or absent movement to positive or negative pressure, air-fluid level and/or bubbles

Otitis Externa: infection of ear canal/ “swimmers ear”

Whisper test and how you would perform it?

▪ Whisper test is used to check the patient’s response to your whispered voice, one ear at a
time.
o Have the patient mask the hearing in the untested ear by having them occlude the
non-tested ear with their finger
o Stand behind and to the side of a seated patient at arm’s length from the patient’s non-
tested ear
o Soften the whisper by exhaling fully
o Then whisper 3-6 letter and numbers at random; ask the patient to repeat them
 o Repeat the process with other letters/numbers on the other ear
o Patient should be able to repeat more than 50% of the letters/numbers and if not they
should be referred for a formal auditory evaluation.
▪ Exams to test hearing : Weber (midline tuning fork), Rinne Test (Bone conduction), whisper
test

The way the ear looks related to when its healing, perforated, fungi, etc…..this information
is in the text within its own box
Signs Associated conditions/causes

Bulging with no mobility Middle ear effusion due to pus or fluid

Retracted with no mobility Obstruction of eustachian tube with or without middle ear effusion

Mobility with negative pressure only Obstruction of eustachian tube with or without middle ear effusion

Excess mobility in small areas Healed perforation, atrophic tympanic membrane

Color: amber or yellow Serous fluid in middle ear (otitis media with effusion)

Blue or deep red Blood in the middle ear

Chalky white Infection in the middle ear (acute otitis media)

Redness Infection in middle ear (acute otitis media), prolonged crying

Dullness Fibrosis, otitis media with effusion

White flecks, dense white plaques Healed inflammation

Air bubbles Serous fluid in the ear

 EYES:

Abnormal findings with elderly Conjunctiva

Cataracts
Age related macular degeneration
Diabetic retinopathy
Glaucoma

Cataracts: a clouding of the lens Cataracts: opacity in lens

▪ gradual onset of blurred vision and increased sensitivity to glare (especially when driving at
dusk or night)
▪ sight-limiting cataract is an insensitivity to subtle color differences such as those caused by
food stains on clothing in an otherwise neatly dressed patient
▪ white haze in the pupil during pupil testing suggests a moderate or worse cataract
▪ With the pupil dilated, the red eye reflex may exhibit focal or diffuse areas of darkness when
viewed with the direct ophthalmoscope or a slit lamp
Cataracts Pathophysiology:
o Most commonly from denaturation of lens protein caused by aging
 o With aging, cataracts are generally central
o Peripheral cataracts may occur in hypoparathyroidism
o Medications such as steroids can cause cataracts
o Congenital cataracts can result from a number of genetic defects, maternal infections
such as rubella, or other fetal insults during the first trimester of pregnancy
Subjective Data:
o Cloudy or blurry vision
o Faded colors
o Headlights, lamps, or sunlight may appear too bright
o Halo may appear around lights
o Poor night vision or double vision
o Frequent prescription changes
Objective Data:
o Cloudiness of the lens, often obvious without special viewing equipment

Age related macular degeneration (AMD): disease that progressively destroys the macula,
impairing central vision

▪ In its early stages, AMD has no symptoms

▪ As dry AMD progresses, patients note a gradual blurring of central vision, and increased
difficulty reading fine print, recognizing faces or seeing street signs
○ In dry AMD, drusen—cream colored lesions that represent a build-up of metabolic waste
products within the retina—are seen in the macula
▪ wet AMD often presents as a rapid loss of central vision, with metamorphopsia (images
that appear distorted) or central scotomas
○ In wet AMD, abnormal blood vessels grow and hemorrhage, causing macular swelling,
loss of retinal function and scarring
▪ Other signs include pigmentary changes or chorioretinal atrophy of the macula
Diabetic retinopathy: is characterized by a progressive series of abnormal changes in the retinal
microvasculature

■ may be asymptomatic in its early more treatable stages

■ Blurred vision may occur if there is macular edema, but if the contralateral eye is unaffected
or the vision loss is subtle, patients may not notice changes
■ proliferative retinopathy, new blood vessels can bleed extensively, causing blurred vision, or
visual field scotomas, extensive laser photocoagulation for treatment of proliferative disease
may have an overall constriction of the visual field
■ dilated fundoscopy, and can include hemorrhages, exudates or neovascularization; fundus
photographs reviewed via telemedicine can be a sensitive and effective screening tool for
identifying patients with diabetic retinopathy who need to be prioritized for referral to
specialty eye care
■ Specialty diabetic eye examinations typically include retinal examination for subtle signs of
macular edema, assessing the location and amount of hemorrhages and assessing the vascular
abnormalities that help stage the severity of either nonproliferative or proliferative
retinopathy.
Glaucoma: is a progressive, chronic optic neuropathy in which intraocular pressure (IOP) and
other currently unknown factors contribute to a characteristic acquired atrophy of the optic
nerve that, if left to progress, leads to visual field loss. Glaucoma: disease of the optic nerve
wherein the nerve cells die, usually due to exclusively high intraocular pressure

■ because glaucoma is often asymptomatic, most patients fail to notice changes in vision until
end-stage disease
■ Clinical examination for glaucoma includes measurement of IOP (tonometry), optic disc
assessment, visual field assessment and gonioscopy to assess whether the intraocular
drainage system is “open” or “closed.”
■ Intra-occular pressure (IOP) normally ranges from 10–21 mm Hg; however, IOP outside of
this range is not pathognomonic for glaucoma—it is simply a risk factor associated with the
development and/or progression of the disease
■ Glaucomatous atrophy causes increased optic nerve cupping; markedly asymmetric cupping
between the 2 eyes can indicate glaucoma. optic disc findings are usually observed before
visual field losses appear
Glaucoma Pathophysiology
o Acute angle may occur acutely with dramatically elevated intraocular pressure if the
iris blocks the exit of aqueous humor from the anterior chamber
o Open angle caused by decreasing aqueous humor absorption leads to increased
resistance and painless buildup of pressure in the eye
o May also be congenital as a result of improper development of the eye’s aqueous
outflow system
Subjective Data:
o Open-angle glaucoma: symptoms are absent except for a gradual loss of peripheral
vision over a period of years
o Acute glaucoma: intense ocular pain, blurred vision, halos around lights, a red eye,
and a dilated pupil
o Occasionally: stomach pain, nausea, & vomiting
Objective Data:
 o During dilated eyes there is an increased cupping of the optic nerve
o Visual field tests may show loss of peripheral vision

Normal findings with elderly Conjunctiva

■ The prevalence of cataract, age-related macular degeneration, glaucoma, and need for
corrective lenses increases with advancing age
■ the crystalline lens gradually becomes less flexible and less able to change its curvature
(accommodate). This results in the condition known as presbyopia, in which patients lose the
ability to focus their eyes on near objects
■ The ability to see well in dim light also becomes diminished in older adults as a result of a
combination of decreases in pupil size and progressive increases in the light absorption of the
lens. This age-related reduction in retinal illumination is substantial.
■ typical 60-year-old’s retina receives only about one-third of the light that a typical 20-year-
old receives. As a result of the tendency for opacities to form in the aging lens and cornea,
older adults are increasingly sensitive to glare caused by scattered light in the eye
■ because of neural changes in the retina, there is an age-related reduction in the ability to
adapt to sudden changes in illumination.

Proper way to use an Ophthalmoscope

1. Examine the patient’s right eye with your right eye and the left with your left to reduce
unintentional nose to nose contact.
2. Hold the ophthalmoscope in the hand that corresponds to the examining eye
3. Change the lens of the ophthalmoscope with your index finger; start with the lens at 0, and
stabilize yourself and the patient by placing your free hand on the patient’s shoulder or head
4. The focus wheel is adjusted by your thumb
5. With the patient looking at a distant fixation point, direct the light of the ophthalmoscope at
the pupil from about 12 in away and visualize the red reflex first.
6. As you approach the eye the retinal details should become apparent. With a blood vessel
being the 1st thing you see at 3-5 cm from the patient.
7. If your patient is myopic (nearsighted) use the minus (red) lens
8. If patient is hyperoptic (farsighted) or aphakic (lacks a lens) use the plus lens
9. Look at the optic disc
10. Next look at the vascular supply of the retina
11. Now inspect the optic disc
12. Next examine the macula (fovea centralis) which may not be visible because of pupillary
response.
 GENERAL PATIENT CARE:

Know how to ask culturally sensitive questions…..if someone of a different culture comes in
with pain how would you address that? By asking them what questions?
RESPECT MODEL:
▪ Rapport:
o Connect on a social level
o See the patient’s point of view
o Consciously suspended judgement; recognize and avoid making assumptions
▪ Empathy:
o Remember the patient has come to you for help
o Seek out and understand the patient’s rationale for his/her behaviors and illness
o Verbally acknowledge and legitimize the patient’s feelings
▪ Support:
o Ask about and understand the barriers to care and compliance
o Help the patient overcome barriers; Involve family members if appropriate
o Reassure the patient you are and will be available to help
▪ Partnership:
o Be flexible
o Negotiate roles when necessary
o Stress that you are working together to address health problems
▪ Explanations:
o Check often for understanding
o Use verbal clarification techniques
▪ Cultural competence:
o Respect the patient’s cultural beliefs
o Understand that the patient’s view of you may be defined by ethnic and cultural
stereotypes
o Be aware of your own cultural biases and preconceptions
o Know your limitations in addressing health issues across cultures
o Understand your personal style and recognize when it may not be working with a
given patient
▪ Trust:
o Recognize that self-disclosure may be difficult for some patients; Consciously work
to establish trust

▪ Do you express your pain to your loved ones?

▪ Does the pain cause you to be afraid?
▪ How do you cope with the pain?
▪ How do you want others to respond to your pain?
▪ What ways do you treat your pain usually?
▪ Do you have any cultural beliefs that will affect how we need to treat your pain?
 Dr. Parajuli Tips
(From soundcloud (Summer 19’) & dropbox (Fall 19’) :

Exam layout: 20 questions (10 MC & 10 SA (some ?s have 2 part))- 60 minutes to complete
Do MC first and then SA
• Focus on how you would collect health history data
o Talking to patients from different cultures
o Talking to patients where there is a language barrier
EYES
Know normal and abnormal: example redness or swelling to eyelids
Assess eye: assess congunctiva and sclerea
What tests would you use to check vision acuity?
o Rosenbaum (near-sighted vision)
o Snellen (Far-sighted vision)
Know some red flags of the eye (send to ED or eye doctor):
o Uneven pupils (especially with HA)
o Sudden loss of vision
o Floaters/ flashes (retinal detachment possible)
When a patient has retinal detachment what is their main complaint? “curtain” feeling,
floaters or flashes
How do you check for glaucoma? Check extraocular pressure/ (can use Tonipen to measure)
• Know how to do an external exam of the eyes
o Know how to identify bacterial conjunctivitis vs allergic conjunctivitis
▪ Bacterial- starts in one eye and spreads to the other, yellow/ crusty
drainage
▪ Allergic- both eyes, puffy and/ or runny
What are you looking for when you have a patient follow your finger with their eyes?
o Cardinal fields of gaze (testing cranial nerves 3,4, & 6)
• When completing an eye exam you want to look at the outside of the eye? Look at
eyelids and make sure not swollen, look at the conjunctiva/ sclera, then use
ophthalmoscope to look at the inside of the eye, check cardinal gazes (checks cranial
nerves 3,4, & 6)
• How to use the Ophthalmoscope:
o Examine the patient’s right eye with your right eye and the left with your left to
reduce unintentional nose to nose contact.
o Hold the ophthalmoscope in the hand that corresponds to the examining eye
o Change the lens of the ophthalmoscope with your index finger; start with the lens
at 0, and stabilize yourself and the patient by placing your free hand on the
patient’s shoulder or head
o The focus wheel is adjusted by your thumb
o With the patient looking at a distant fixation point, direct the light of the
ophthalmoscope at the pupil from about 12 in away and visualize the red reflex
first.
o As you approach the eye the retinal details should become apparent. With a blood
vessel being the 1st thing you see at 3-5 cm from the patient.
▪ If your patient is myopic (nearsighted) use the minus (red) lens
 ▪ If patient is hyperoptic (farsighted) or aphakic (lacks a lens) use the plus
lens
o Look at the optic disc
o Next look at the vascular supply of the retina
o Now inspect the optic disc
o Next examine the macula (fovea centralis) which may not be visible because of
pupillary response.
EARS:
Know normal and abnormal findings
Know differences between Otitis Externa and Otitis Media
• Otitis media- middle ear
• Otitis externa/ “swimmers ear”- ear canal
When doing an ear exam what do you start out looking at? Look at the outer structures of the
ear then palpate
If you look at the outside of the ear and you see drainage, is this normal or abnormal?
ADNORMAL
What is your differential diagnoses if you see this? Otitis Externa, Otitis Media, Ear effusion,
or foreign body in the ear
• What kind of patients get Otitis Externa? Swimmers, breast/ bottle fed children
• When you do ear tests, what are other things that you look for? Look at the TM
(whether it is perforated or not), look at the light, look at the canal (whether it is swollen
or red, look for cerumen impaction)
• Exam external ear→ pull tragus and palpate the preauricular and post auricular lymph
nodes and mastoid area

• What is the worst differential diagnosis for a patient that comes in with an ear
infection? Mastoid infection or meningitis
o Mastoid is bone that connects the ear canal with the skull, people with chronic ear
infections can get mastoid infections. If patient comes in saying that ear pain has
been over 2 weeks make sure that you palpate the mastoid area to make sure that
there is no erythema)
• What tests do you do to test hearing?
o Whisper/ watch test
 o Rinne test - tuning fork over mastoid process and then placed in front of the ear-
tests Bone conduction – bone conduction should be longer than bone conduction
o Weber- tuning fork midline of skull→ hearing should be the same in both ears
• Vertigo
o You have a 42 y/o female that comes in to you saying “I have dizziness”
▪ What are some of your differential diagnoses? Ear infection,
Meniere’s disease, vertigo
▪ What are some of the tests that you can do to decide if it is vertigo
or not? Dix Hallpike maneuver (Head tilt and lay back maneuver)→ used
to diagnosis benign postural vertigo.
MOUTH:

When assessing the mouth what are some things that you should be looking for? Color,
lesions, tonsils, uvula, erythema, oral ulcers, teeth
What are some tests that you would run if you see a patient with oral ulcers that are not
resolving? Check for HIV and syphilis
What is the number one virus that causes oral ulcers with fever? Herpes Simplex
• Make sure if a patient comes in with any complaints of mouth problems that you
ask if they are a smoker or not!!
• What else would you want to know on a history of a patient that comes in with
lesions or mouth sores? Tobacco use, stress, immunocompromised (cancer,
transplant hx, HIV/AIDs, or on immunosuppressant drugs)
• What are some other types of mouth sores that you will see in a clinic on
patients? Herpes lesions
• What does a Herpes lesion look like? Vesicular lesion
• If a patient comes in with a herpes lesion or shingles in face, what is the number
one thing that you would think of and send this patient to the emergency
department? Make sure that you examine and assess the patient’s eyes and ears!!! (If
they have lesions so close to the eyes then they can get shingles in their eye and it can
affect their optic nerve)→ can cause optic neuritis!!!
• What is the number one thing that you should document on a sinusitis patient?
o Length of symptoms (to know whether to treat viral or bacterial)
o Document assessment: purulent rhinorrhea, pharyngeal symptoms, maxillary and
frontal sinus tenderness
o Educate:
▪ Take Flonase, do sinus rinse, take allergy medications.
▪ Reassure them that they don’t need an antibiotic unless it has been 7-10
days with infection of febrile.
• How would you diagnose a patient with an allergy? Clear rhinorrhea as opposed to
purulent, throat irritation, post nasal drip
• Where do you want the uvula to be? Midline
• What if the uvula is not midline? Suspect a problem on the opposite side that the
uvula deviates
• What differential diagnoses would you think of if the uvula is deviated?
Peritonsillar abscess
 Eyes: know the difference between cataracts/ retinal detachment and glaucoma
• When you are taking a history on a patient is it best to ask straight forward
questions or open ended questions? Start with open-ended and then narrow it down
as to closed .

Dr. Parajuli on sound cloud last semester:

https://soundcloud.com/neha-jain-484325487/parajuli-exam-1?in=jip-g-641624466/sets/ass
Dr. Parajuli fall 2019:
https://www.dropbox.com/s/gsobsuqt7z286cy/aha%20fall%202019%20exam%201%20.m4a?dl
=0&fbclid=IwAR1Yfcmjoe52bsfXwh1vdFd2ehCke1bG-jEVxzMME7XAAYu-nq7HFNWAb8g

Other Resources:

https://quizlet.com/186412053/maryville-612-exam-1-advanced-health-assessment-flash-cards/

https://quizlet.com/267830165/maryville-612-exam-1-flash-cards/

https://www.studyblue.com/notes/note/n/aha-test-1/deck/21116607

https://www.youtube.com/watch?v=Es4oSQjNvCI

https://quizlet.com/315329216/maryville-612-exam-1-workbook-multiple-choice-flash-
cards/?i=518qs&x=1jqq

https://www.khanacademy.org/science/health-and-medicine/circulatory-system-diseases/heart-
valve-diseases/v/systolic-murmurs-diastolic-murmurs-and-extra-heart-sounds-part-1

https://soundcloud.com/taylor-rae-loudermilk/aha-nurs-612-exam-1-possible-short-answer-
questions

https://soundcloud.com/taylor-rae-loudermilk/aha-nurs-612-exam-1-possible-short-answer-questions
https://soundcloud.com/taylor-rae-loudermilk/aha-nurs-612-exam-1-1

https://soundcloud.com/taylor-rae-loudermilk/aha-nurs-612-exam-1-2

https://soundcloud.com/taylor-rae-loudermilk/aha-nurs-612-exam-1-3

https://soundcloud.com/taylor-rae-loudermilk/aha-nurs-612-exam-1-heart-sound-locations