PERDUE NFPE: Tongue
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1 NFPE: Tongue
2 NFPE: Nail Reference Guide Techniques: Inspection: Inspect the shape of the nails for - spooning - abnormal color or color patterns - splinter hemorrhages - white spots - presence of the lunula Palpation: Palpate the nail by - rubbing your finger over the nail plate - feeling for the presence of any vertical or horizontal ridging - gently applying light pressure to the tip of the nail to determine nail strength - lightly pressing the tip of the nail to observe capillary refill Nail Plate Nail Groove Lunula Eponychium (cuticle)
3 NFPE: Nail Reference Guide Lindsay s Nails: most of nail light pink or white with a red, pink, or brown band covering 20%-60% of distal nail; suggestive of chronic kidney disease. Mees Lines: one + transverse white bands running parallel to lunula; move with nail growth; don t disappear w/ pressure. Assoc. w/ malnutrition, arsenic poisoning; systemic stress. Meuhrcke s Lines: paired, white, transverse lines going across the entire nail; associated with alb < 2.2 g/dl. Beau s Lines: transverse linear depressions in the nail plate; assoc. w/ systemic injury/illness (severe infection, malnutrition, MI, hypotension, shock, surgery, chemotherapy). Terry s Nails: most of nail light pink/white with distal pink/brown band mm; does not move forward with nail growth; color difference fades with pressure; associated w/ cirrhosis. Onychorrhexis: longitudinal striations/ridges, sometimes brittle and splitting on distal end; assoc. w/ iron, folate or protein deficiency, severe malnutrition, esp. with a central ridge. Splinter Hemorrhages: longitudinal thin red/brown lines below nail plate; located in distal 1/3 of the nail; assoc. with Vit. C def.; specific indicator of endocarditis if proximal vs. distally. Koilonychia: thin, spoon shaped, concave nails typically involving iron deficiency, protein deficiency (especially sulfur containing amino acids cysteine, methionine). Leukonychia Striae: non-uniform white spots on one or more nails. Nutrient of Concern: zinc; differential includes trauma. Pallor of Nail Bed: Apply light pressure to the tip of the nail. Nail should blanch temporarily. Observe color when pressure is removed. Assoc. w/ iron, B12, and/or folate deficiency.
4 NFPE: Upper/Lower Extremities - Skin
5 NFPE Vitamin B12 NFPE: Nutrition-Related Neuropathies Technique: With the patient s eyes closed, strike the tuning fork and place it over the following locations: 1) metatarsal phalangeal joint, medial malleolus, and tibial tuberosity. If the sensation is felt distally, there is not point to proceeding proximally. Check that the patient feels the vibration not just the contact of the tuning fork. Strike the tuning fork, stop vibrating immediately and repeat the test. If the patient reports that they feel the vibration, demonstrate the test again, Compare right side with the left side. Technique: Vibratory Sense Evaluation With pt s eyes closed, lightly strike 128 Hz tuning fork, place over the location being evaluated (tibial tuberosity, medial malleolus, or metatarsal phalangeal joint), & ask pt if they feel the vibration. If pt answers positively, strike the tuning fork but immediately stop vibration. Repeat the test at lowest site where vibration was noted. If pt reports feeing the vibration, demonstrate test again & repeat. Compare right & left sides. Tips: Make sure the pt feels the vibration and not just the contact of the tuning fork. If the vibrating sensation is felt distally, there is no need to proceed proximally. Restrike the tuning fork when moving from one location of the body to the next. Technique: Test position sense by having pt, with eyes closed, report if their large toe is up or down as the examiner manually moves pt s toe in the respective direction. Repeat on opposite foot & compare. Tips: Proprioception Evaluation Be sure to hold the toe on its sides, as holding it by the top or bottom provides the pt with pressure cues, rendering the test invalid. Fuller, Geraint (1999) Neurological examination made easy 2 nd ed. Churchill Livingstone, London, p.159 Kurtz 2016
6 Vibratory & Proprioception Evaluation NFPE Vitamin B12 NFPE: Nutrition-Related Neuropathies Technique: With the patient s eyes closed, strike the tuning fork and place it over the following locations: 1) metatarsal phalangeal joint, medial malleolus, and tibial tuberosity. If the sensation is felt distally, there is not point to proceeding proximally. Check that the patient feels the vibration not just the contact of the tuning fork. Strike the tuning fork, stop vibrating immediately and repeat the test. If the patient reports that they feel the vibration, demonstrate the test again, Compare right side with the left side. Vibratory Sense {Present (+) / Absent (-) } Left Right Great Toe Metatarsal Phalangeal Joint Medial Malleolus Tibial Tuberosity Proprioception {Present (+) / Absent (-)} Left Right Great toe up (1/2/3) / / / / Great toe down (1/2/3) / / / / Notes: Tibial Tuberosity Medial Malleolus Metatarsal Phalangeal Joint Tip of Great Toe Fuller, Geraint (1999) Neurological examination made easy 2 nd ed. Churchill Livingstone, London, p.159 Kurtz 2016
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