health assessment 2 test 2

Articular disease (inside the joint capsule [e.g., arthritis])

produces swelling and tenderness around the whole joint, and it limits all planes of ROM in both active and passive motion

Extra-articular disease (injury to a specific tendon, ligament, nerve)

produces swelling and tenderness to that one spot in the joint and affects only certain planes of ROM, especially during active (voluntary) motion

adults and aging adult developmental competence male gen system

production of sperm begins to decrease around 40 years, although it continues into the 80s and 90s. Testosterone production declines after age 30 but very gradually, so resulting physical changes are not evident until later in life. aging male the amount of pubic hair decreases and turns gray. Penis size decreases. Because of decreased tone of the dartos muscle, the scrotal contents hang lower, the rugae decrease, and the scrotum looks pendulous. The testes decrease in size and are less firm to palpation. The prostate gland surrounding the upper urethra undergoes an expected tissue hyperplasia in about 80% of men over 60 years declining testosterone production leaves the older male with a slower and less intense sexual response, and an erection takes longer to develop and is less full or firm. Ejaculation is shorter and less forceful, and the volume of seminal fluid is less than when the man was younger. After ejaculation, rapid detumescence (return to the flaccid state) occurs, especially after 60 years.

two seminal vesicles

project like rabbit ears above the prostate. They secrete a fluid that is rich in fructose, which nourishes the sperm and contains prostaglandins

coracoid process

projects anteriorly and laterally from the neck of the scapula. These surround the deeply situated joint.

uterine cervix

projects into the vagina. In the nulliparous female the cervix appears as a smooth doughnut shape with a small circular hole, or os. After childbirth the os is slightly enlarged and irregular

adults dev comp bowels

prostate gland commonly starts to enlarge during the middle adult years, but this is NOT cancer

Symptomatic hemorrhoids:

pruritus, painless rectal bleeding, red blood on tissue or in bowl

tanners developmental stage 2

pubic hair: Few straight, slightly darker hairs at base of penis; hair is long and downy penis: Little or no enlargement scrotum: Testes and scrotum begin to enlarge; scrotal skin reddens and changes in texture

tanner stage 1 preadolescent

there is only a small elevated nipple present

skeletal, or voluntary, muscles—

those under control. is composed of bundles of muscle fibers or fasciculi. is attached to bone by a tendon

Hammertoes

toes move into a claw-like position

point location

touch skin and withdraw stimulus promptly; ask person to put finger where you touched

spina bifida

tuft of hair over a dimple in the midline may indicate

the median sulcus.

two lateral lobes are separated by a shallow groove called

spasticity and rigidity

types of increased resistance that occur with central weakness

ataxia

uncoordinated or unsteady gait

Cryptorchidism—

undescended testes (those that have never descended). Undescended testes are common in premature infants. They occur in 3% to 4% of term infants, although most have descended by 3 months of age. Age at which child should be referred differs among clinicians

clitoris.

urethral meatus appears as a dimple 2.5 cm posterior to the

dark gray urine

urine contains melanin, melanuria

Straining

using extreme effort to do urinate.

Glandular structures accessory to the genital organs

(the prostate, seminal vesicles, and bulbourethral glands)

Corns

(thickening of soft tissue) develop on the dorsum over the bony prominence from prolonged pressure from shoes.

subluxation

(two bones in a joint stay in contact, but their alignment is off)

Genu varum

"Bowlegs", defined as a medial displacement of the distal end of the distal bone in the joint. it is present when you measure a persistent space of more than 2.5 cm between the knees when the medial malleoli are together. Genu varum is normal for 1 year after the child begins walking. The child may walk with a waddling gait. This resolves with growth; no treatment is indicated.

Hallux valgus,

a common deformity from RA, is a lateral or outward deviation of the great toe with medial prominence of the head of the 1st metatarsal.

musculoskeletal system functions

(1) for support to stand erect (2) for movement (3) to encase and protect the inner vital organs (e.g., brain, spinal cord, heart) (4) to produce the red blood cells, white blood cells, and platelets in the bone marrow (hematopoiesis) (5) as a reservoir for storage of essential minerals such as calcium and phosphorus in the bones

Use the Ottawa knee rules for any knee pain with injury for referral for imaging:

(1) isolated pain of patella or head of fibula; (2) age ≥55 years; (3) cannot flex knee to 90 degrees; (4) cannot bear weight for 4 steps

inguinal ligament

(Poupart ligament).

fracture

(a break in a bone)

dislocation

(complete loss of contact between the two bones in a joint)

Signs of physical or sexual abuse

(e.g., anal abrasions, perianal tears)

Genu valgum

(knock-knees) are present when there is more than 2.5 cm between the medial malleoli when the knees are together It occurs normally between 2 and years. Treatment is not indicated.

Coccygeal mass. Meningocele

(sac containing meninges that protrude through a defect in the bony spine).

contracture

(shortening of a muscle leading to limited ROM of joint)

ankylosis

(stiffness or fixation of a joint)

fine fasciculation

- occurs with lower motor neuron disease, associated with atrophy and weakness

plantar grasp

- touch your thumb at the ball of baby foot -note that the toes cur down tightly -present at birth disappears at 8 to 10 months

upper motor neuron lesion

-Weakness/paralysis: In muscles corresponding to distribution of damage in *pyramidal tract lesion*; *usually in hand grip, arm extensors, leg flexors* -Location: Descending motor pathways that originate in motor areas of cerebral cortex and carry impulses to anterior horn cells of spinal cord -Example: *Stroke (brain attack)* -Muscle tone: Increased tone; *spasticity* -Bulk: May have *some atrophy from disuse; otherwise normal* -Abnormal movements: None -Reflexes: *Hyperreflexia, ankle clonus; diminished or absent superficial abdominal reflexes; positive Babinski sign* -Possible nursing diagnoses: Risk for contractures; impaired physical mobility

lower motor neuron lesion

-weakness/paralysis: In specific muscles served by damaged *spinal segment, ventral root, or peripheral nerve* -location: *Nerve cells that originate in anterior horn of spinal cord or brainstem and carry impulses by spinal or cranial nerves to muscles, the "final common pathway"* -example: *Poliomyelitis, herniated intervertebral disk* -muscle tone: Loss of tone; *flaccidity* -bulk: *Atrophy (wasting), may be marked* -abnormal movements: *Fasciculations* -reflexes: *Hyporeflexia or areflexia; no Babinski sign, no pathologic reflexes* -possible nursing diagnoses: Impaired physical mobility

Scrotal swelling (edema) may be taut and pitting

. This occurs with heart failure, renal failure, or local inflammation

Functional Assessment. of aging adult musculoskeletal

1. Walk (with shoes on). Shuffling pattern; swaying; arms out to help balance; broader base of support; person may watch feet. 2. Climb up stairs. Person holds handrail; may haul body up with it; may lead with favored (stronger) leg. 3. Walk down stairs. Holds handrail, sometimes with both hands. If person is weak, he or she may descend sideways, lowering weaker leg first. If person is unsteady, he or she may watch feet. 4. Pick up object from floor. Person often bends at waist instead of bending knees; holds furniture to support while bending and straightening. 5. Rise up from sitting in chair. Person uses arms to push off chair arms, upper trunk leans forward before body straightens, feet planted wide in broad base of support. 6. Rise up from lying in bed. May roll to one side, push with arms to lift up torso, grab bedside table to increase leverage.

Tophi With Chronic Gout

Hard nodules (tophi) most often in the metatarsophalangeal joint of first toe. Tophi are collections of sodium urate crystals caused by chronic gout in and around the joint. Crystals are stong inflammation triggers that cause extreme painful swelling and joint deformity. They may erode through skin with a chalky discharge

(also called peau d'orange)

Edema exaggerates the hair follicles, giving a "pigskin" or "orange-peel" look results from skin infiltration of cancer and skin edema. Lymphatic obstruction produces edema. This thickens the skin and exaggerates the hair follicles, giving a pigskin or orange-peel look. Edema usually begins in the skin around and beneath the areola, the most dependent area of the breast.

urethritis

Edges that are red, everted, edematous, along with purulent discharge, suggest occurs with gonorrhea and/or chlamydia infection.

essential tremor

A type of involuntary, rhythmic contraction of muscles producing the appearance of trembling or quivering; occurs generally in persons older than 70 years old; is often confused with the resting tremor associated with Parkinson's Disease.

pattern of motor system dysfunction

A-cerebral palsy B-muscular dystrophy C-hemiplegia D-parkinsonism E-cerebellar F-paraplegia G-MS

two ovaries

are located one on each side of the uterus at the level of the anterior superior iliac spine. Each is oval shaped, 3 cm long by 2 cm wide by 1 cm thick, and serves to develop ova (eggs) and the female hormones.

spinous processes of C7 and T1

are prominent at the base of the neck

Hypertrophy:

Enlargement of muscle due to strengthening

• E

= examine, check for changes, report changes immediately

• S

= shower, warm water relaxes scrotal sac

T

= timing, once a month

weakness of the shoulder muscles

A baby who starts to "slip" between your hands shows

Fecal Impaction (FI)

A complete colon blockage by hard, desiccated immovable stool, which presents as constipation or overflow incontinence. FI is common, potentially serious, and not routinely discussed.10 At highest risk are children, incapacitated patients (spinal cord injuries, stroke), aging adults, and those in institutions. Causes of constipation and FI are many, including immobility, low fiber, dehydration, neurologic diseases, opioids and other medications. Exams of some aging people may lead to confusion, agitation. Inspect abdominal distention with tympany, palpable cord in left lower quadrant; may not palpate stool on rectal exam if higher impaction. Warrants radiologic imaging. Complications are bowel obstruction, perforation, peritonitis. Treatment is disimpaction with endoscopy (manual can cause perforation, rectal bleeding, and vagal stimulation), then distal colon cleansing with enemas, and a bowel regimen to prevent recurrence.10 Usually treated in outpatient setting, but between 2006 and 2011, the frequency of constipation visits in Emergency Departments increased by 41.5%

Hypospadias

A congenital disorder of the urethra (1 in 300 baby boys) in which the urethral meatus opens on the ventral (under) side of the glans or shaft. About 90% of openings are on or near the head of the penis with a groove extending from the meatus to the expected location at the tip. Shiny tissue extends from the meatus to the tip and the foreskin is not fully developed, leaving the ventral side of the glans uncovered. Circumcision can proceed if parents desire this; surgical correction of hypospadias can be at age 3 months or older

Tinea Cruris

A fungal infection in the crural fold, not extending to scrotum, occurring in postpubertal males ("jock itch") after sweating or wearing layers of occlusive clothing. It forms a red-brown half-moon shape with well-defined borders.

Pilonidal Cyst or Sinus

A hair-containing cyst or sinus located in the midline over the coccyx or lower sacrum. Often opens as a dimple with visible tuft of hair and possibly an erythematous halo. Or may appear as a palpable cyst. When advanced, has a palpable sinus tract. Although a congenital disorder, it is first diagnosed between 15 and 30 years.

Abscess

A localized cavity of pus from infected anorectal gland. Characterized by persistent throbbing rectal pain, and appears red, hot, swollen, indurated, and tender. In internal abscess may be palpated as boggy area on rectal exam. Must be incised and drained to prevent spread, recurrence, and formation of fistula

Carcinoma

A malignant neoplasm in the colon or rectum is asymptomatic; thus the importance of routine imaging by colonoscopy and DRE. An early lesion may be a single firm nodule, may have an ulcerated center with rolled edges. As the lesion grows it has an irregular cauliflower shape and is fixed and stone-hard. Refer a person with any rectal lesion for cancer screening. Suggest screening guidelines: careful family history, fecal occult blood tests annually, and colonoscopy every 10 years, starting at age 50 years for those at average risk, earlier for those at high risk

Ingrown Toenail

A misnomer; the nail does not grow in, but the soft tissue grows over the nail and obliterates the groove. It occurs almost always on the great toe on the medial or lateral side. It is caused by trimming the nail too short or toe crowding in tight shoes. The area becomes infected when the nail grows and its corner penetrates the soft tissue.

Rectal Polyp

A protruding growth from the rectal mucous membrane is fairly common. The polyp may be pedunculated (on a stalk) or sessile (a mound on the surface, close to the mucosal wall). The soft nodule is difficult to palpate. Colonoscopy, removal, and biopsy screen for a malignant growth. Removal of adenomatous polyps has been shown to prevent deaths from colorectal cancer. Particularly larger sizes of polyps increase risk of cancer

Breast Abscess

A rare complication of generalized infection (e.g., mastitis) if untreated. A pocket of pus that feels hard, looks red, and is quite tender accumulates in one local area. Here there is extensive nipple edema, and abscess is "pointing" at 3 o'clock position on areolar margin. May breastfeed depending on location of abscess, associated pain, and type of medicine. Continue to nurse on unaffected side. Treat with antibiotics, surgical incision, and drainage.

polyp

A soft, slightly movable mass may be a

Osgood-Schlatter disease

Enlargement of the tibial tubercles with tenderness suggests

Specimens for stool cultures:

Obtain using medical asepsis while wearing gloves. Label the specimen, and promptly send it to the laboratory.

vagina,

a flattened, tubular canal extending from the orifice up and backward into the pelvis It is 9 cm long and sits between the rectum posteriorly and the bladder and urethra anteriorly Its walls are in thick transverse folds, or rugae, enabling the vagina to dilate widely during childbirth.

Calluses

a hardened thickened place on the skin

inguinal canal,

a narrow tunnel passing obliquely between layers of abdominal muscle. It is 4 to 6 cm long in the adult. Its openings are an internal ring, located 1 to 2 cm above the midpoint of the inguinal ligament, and an external ring, located just above and lateral to the pubis.

Peyronie Disease

Hard, nontender, subcutaneous plaques on dorsal or lateral surface palpated by stretching the penis. May be single or multiple and asymmetric. They are associated with painful bending of the penis during erection. Usually occurs after age 45 years. Its cause is trauma to the penis with resulting scar, deformity, and often erectile dysfunction. More common in men with diabetes, gout, and Dupuytren contracture of the palm

positional deformities,

a residual of fetal positioning

Gray, tan stool—

Absent bile pigment (e.g., obstructive jaundice).

nipple

a rough, round, usually protuberant its surface looks wrinkled and indented with tiny milk duct openings

generalized seizure

a seizure that involves most of the brain, as contrasted with a partial seizure, which remains localized

colostrum

a thick, yellow fluid is the precursor for milk that contains the same amount of protein and lactose but practically no fat produced for the first few days after birth and is rich with antibodies that protect the newborn against infection

reflexes

are basic defense mechanisms of nervous system and are involuntary operating below the level of conscious control and permitting a quick reaction to potentially painful or damaging situations help the body maintain balance and appropriate muscle tone 3 types: stretch/deep tendon, superficial (cutaneous), and visceral (organic)

Black stool—

Also occurs with ingesting iron or bismuth preparations.

Fissure

An exquisitely painful longitudinal tear in the superficial mucosa at the anal margin. Most (>90%) occur in the posterior midline area. Pain with passing stool is described as passing "shards of glass"; may have bright red blood in the stool. Inspection shows an acute fissure as having sharp edges and a chronic fissure as indurated and accompanied by a papule of skin, sentinel tag, on the anal margin below or a polyp above. Fissures are caused by trauma, ischemia, and elevated anal pressure. Occurs with constipation, obesity, and hypothyroidism.16 Medical treatments are stool softeners, nitroglycerin ointment, topical nifedipine or diltiazem cream, but injection of botulinum toxin into internal anal sphincter is slightly more effective.8

epididymitis

An indurated, swollen, and tender epididymis indicates

Deviation in Nipple Pointing

An underlying cancer causes fibrosis in the mammary ducts, which pulls the nipple angle toward it. Here note the swelling behind the right nipple and that the nipple tilts laterally.

Anorectal Fistula

Anorectal abscess starts from an infected anorectal gland; the infection channels through the perianal tissues to form a fistula, a connection between the infected gland and the outside perineum.8 Fistulae also occur with Crohn disease or radiation therapy. Persistent pain and swelling occur with abscess; fistulae are sometimes painful and itch. The fistula track feels like an indurated cord on bidigital palpation; may drain purulent or serosanguineous matter.

Retraction signs

are caused by fibrosis in the breast tissue, usually caused by growing neoplasms. The fibrosis shortens with time, causing contrasting signs with the normally loose breast tissue.

aging adult dev comp anal/rectum

As an aging person performs the Valsalva maneuver, you may note relaxation of the perianal musculature and decreased sphincter control. Otherwise the full examination proceeds as that described earlier for the younger adult

Phalen test

Ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand

Migratory testes (physiologic cryptorchidism)

are common because of the strength of the cremasteric reflex and the small mass of the prepubertal testes.

Subcutaneous nodules

are raised, firm, and nontender, and overlying skin moves freely. Common sites are in the olecranon bursa and along the extensor surface of the ulna. These nodules occur with RA

Fixation

Asymmetry, distortion, or decreased mobility with the elevated arm maneuver. As cancer becomes invasive, the fibrosis fixes the breast to the underlying pectoral muscles. Here note that the right breast is held against the chest wall.

Coxa Plana (Legg-Calvé-Perthes Syndrome)

Avascular necrosis of the femoral head, occurring primarily in males between 3 and 12 years of age, with peak at age 6 years. In initial inflammatory stage interruption of blood supply to femoral epiphysis occurs, halting growth. Revascularization and healing occur later, but significant residual deformity and dysfunction may be present.

Frequency.

Average adult voids 5-6 times/day, varying with fluid intake, individual habits

Breast mass, Retraction, Edema, Axillary mass, Scaly nipple, Tender breast.

BREAST lists physical signs associated with more advanced cancer:

mons pubis

is a round, firm pad of adipose tissue covering the symphysis pubis. After puberty it is covered with hair in the pattern of an inverted triangle.

penis Carcinoma

Begins as red, raised, warty growth or as an ulcer with watery discharge. As it grows, may necrose and slough. Usually painless. Almost always on glans or inner lip of foreskin and following chronic inflammation. Enlarged lymph nodes are common.

Syphilitic Chancre

Begins within 2 to 4 weeks of infection as a small, solitary, silvery papule that erodes to a red, round or oval, superficial ulcer with a yellowish serous discharge. Palpation reveals a nontender indurated base that can be lifted like a button between the thumb and the finger. Lymph nodes enlarge early but are nontender. This is an STI easily treated with penicillin G; but untreated it leads to cardiac and neurologic problems and blindness. Almost eradicated in the United States in 1957; epidemics recur cyclically every 7 to 10 years.

Fibroadenoma

Benign mass, most commonly self-detected in late adolescence and early adulthood. Solitary nontender mass that is solid, firm, rubbery, and elastic. Round, oval, or lobulated; 1 to 5 cm. Freely movable, slippery; fingers slide it easily through tissue. Usually no axillary lymphadenopathy but frequently painful. Diagnose by palpation, ultrasound, and needle biopsy. Because of risk of deformity of surgery to a growing breast, excisional surgery is reserved for masses >5 cm; for continuously enlarging, well-circumscribed, multiple masses; or with suspicious ultrasound findings.

Melena.

Black stools may be tarry due to occult blood from GI bleeding or non-tarry from ingestion of iron medications.

upper GI bleeding with blood partially digested

Black tarry stool with distinct malodor indicates

Strangulated—

Blood supply to hernia is shut off. Accompanied by nausea, vomiting, and tenderness.

Carcinoma

Bloody nipple discharge that is unilateral and from a single duct requires further investigation. Although there was no palpable lump associated with the discharge shown here, mammography revealed a 1-cm, centrally located, ill-defined mass.

colonic bleeding.

Bright red blood mixed with feces indicates possible

rectal bleeding

Bright red blood on stool surface indicates

rooting reflex

Brush the infant's cheek near the mouth. Note whether the infant turns the head toward that side and opens the mouth. Appears at birth and disappears at 3 to 4 months.

Dysuria.

Burning when urinating is common with acute cystitis, prostatitis, urethritis.

Tear of Rotator Cuff

Characteristic "hunched" position and limited abduction of arm. Occurs from traumatic adduction while arm is held in abduction or from fall on shoulder, throwing, or heavy lifting. Positive drop arm test: if the arm is passively abducted at the shoulder, the person is unable to sustain the position and shrugs or hitches the shoulder forward to compensate with remaining intact muscles. Needs ultrasound imaging, possibly MRI.

Talipes Equinovarus (Clubfoot)

Congenital, rigid, and fixed malposition of foot, including (1) inversion, (2) forefoot adduction, and (3) foot point ing downward (equinus). A common birth defect, with an incidence of 1 : 1000 to 3 : 1000 live births. Males are affected twice as frequently as females

fibromyalgia syndrome

Chronic axial skeletal pain occurs with

Epicondylitis—Tennis Elbow

Chronic disabling pain at lateral epicondyle (LE) of humerus; radiates down extensor surface of forearm. Pain can be located with one finger. Resisting extension of the hand increases the pain. Inflammation along flexor and extensor tendons of elbow joint with overuse.15 Occurs with excessive pronation and supination of forearm with an extended wrist (e.g., racquet sports or using a screwdriver)

Dupuytren Contracture

Chronic hyperplasia of the palmar fascia causes flexion contractures of the digits, first in the 4th digit, then the 5th digit, and then the 3rd digit. Note the bands that extend from the midpalm to the digits and the puckering of palmar skin. Common in men older than 40 years and is usually bilateral. It occurs with diabetes, epilepsy, and alcoholic liver disease and as an inherited trait. The contracture is painless but impairs hand function

Fibromyalgia Syndrome

Chronic widespread musculoskeletal pain lasting >3 months, associated with fatigue, insomnia, and psychosocial distress. Most (90%) are adult women. The pain is amplified centrally in the brain. Because it is not a peripheral pain condition, medications for peripheral pain (NSAIDs) will not help. The 2010 revised criteria stopped the tender point on the body count and substituted interview criteria. These include a widespread pain index or a 0-19 count of the person's report of the number of painful body regions. The 2010 criteria also assess characteristic symptoms (fatigue, nonrefreshed sleep, cognitive problems, somatic symptoms) on a 0-3 severity scale.

Rectal prolapse

Circular red doughnut of tissue—

clonus

is a set of rapid, rhythmic contractions of the same muscle

Genital Herpes—HSV-2 Infection

Clusters of small vesicles with surrounding erythema, which are often painful and erupt on the glans, foreskin, or anus. These rupture to form superficial ulcers. May have mild tingling before outbreak or shooting pain in buttock or leg. An STI, the initial infection lasts 7 to 10 days and is treated with oral antivirals. The virus remains dormant indefinitely; recurrent infections last 3 to 10 days with milder symptoms

Fissure—

Common cause of constipation or rectal bleeding in child. (Painful, so the child does not defecate.)

Reducible—

Contents will return to abdominal cavity by lying down or gentle pressure.

Osteoporosis

Decrease in skeletal bone mass leading to low bone mineral density (BMD) and impaired bone density. The weakened bone state increases risk for fractures, especially at wrist, hip, and vertebrae. Occurs primarily in postmenopausal white women. risk also is associated with smaller height and weight, younger age at menopause, lack of physical activity, and lack of estrogen in women physical exercise increases skeletal mass and helps prevent or delay osteoporosis

Premature thelarche

is early breast development with no other hormone-dependent signs (pubic hair, menses).

Osteoarthritis (OA)

Different from RA, OA is characterized by hard, nontender, noninflammatory nodules, 2 to 3 mm or more. These osteophytes (bony overgrowths) of the DIP joints are called Heberden nodes. Those of the PIP joints are called Bouchard nodes and are less common

Oliguria—

Diminished, <400 mL/24 hours

Tinel Sign

Direct percussion of the location of the median nerve at the wrist produces no symptoms in the normal hand

Epispadias—

Dorsal location of meatus

enlarging prostate

Early symptoms of may be tolerated or ignored. Later symptoms are more dramatic: hematuria, urinary tract infection

palpate the anus and rectum

Drop lubricating jelly onto your gloved index finger. Instruct the person that palpation is not painful but may feel like needing to move the bowels. Ask the man to take a deep breath and hold it. Place the pad of your index finger gently against the anal verge. You will feel the sphincter tighten and then relax. As it relaxes ask the man to exhale and flex the tip of your finger and slowly insert it into the anal canal in a direction toward the umbilicus. Never approach the anus at right angles with your index finger extended. Such a jabbing motion causes sphincter tightening and is painful. Rotate your examining finger to palpate the entire muscular ring. The canal should feel smooth and even. Note the intersphincteric groove circling the canal wall. To assess tone, ask the person to tighten the muscle. The sphincter should tighten evenly around your finger with no pain to the person. Use a bidigital palpation with your thumb against the perianal tissue. Press your examining finger toward it. This maneuver highlights any swelling or tenderness and helps assess the bulbourethral glands. Above the anal canal the rectum turns posteriorly, following the curve of the coccyx and sacrum. Insert your finger farther and explore all around the rectal wall. It normally feels smooth with no nodularity. Promptly report any mass you discover for further examination.

Ostomy care

EQUIPMENT ● Pouch system (skin barrier and pouch) ● Pouch closure clamp ● Barrier pastes (optional) ● Gloves ● Washcloths ● Towel ● Warm water ● Scissors ● Pen PROCEDURE ● If a wound ostomy continence nurse is not available, educate the client about stoma care. ● Perform hand hygiene. ● Put on gloves. ● Remove the pouch from the stoma. ● Inspect the stoma. It should appear moist, shiny, and pink. The peristomal area should be intact, and the skin should appear healthy. ● Use mild soap and water to cleanse the skin, then dry it gently and completely. Moisturizing soaps can interfere with adherence of the pouch. ● Apply paste if necessary. ● Measure and mark the desired size for the skin barrier. ● Cut the opening 0.15 to 0.3 cm (1 ⁄18 to 1 ⁄8 in) larger, allowing only the stoma to appear through the opening. ● If necessary, apply barrier pastes to creases. ● Apply the skin barrier and pouch. ● Fold the bottom of the pouch and place the closure clamp on the pouch. ● Dispose of the used pouch. Remove the gloves and perform hand hygiene.

, the tunica vaginalis

Each testis is covered by a double-layered membrane , which separates it from the scrotal wall

Paget Disease (Intraductal Carcinoma)

Early lesion has unilateral, clear yellow discharge and dry, scaling crusts, friable at nipple apex. Spreads outward to areola with erythematous halo on areola and crusted, eczematous, retracted nipple. Later lesion shows nipple reddened, ulcerated with bloody discharge, and an erythematous plaque surrounding the nipple. Symptoms include tingling, burning, itching. Except for the expected redness and occasional cracking from initial breastfeeding, any other dermatitis of the nipple area must be explored carefully and referred immediately.

Steatorrhea

is excessive fat in stool: malabsorption as in celiac disease, cystic fibrosis, chronic pancreatitis, Crohn disease

Psychosocial factors

Emotional distress increases peristalsis and exacerbates chronic conditions (colitis, Crohn's disease, ulcers, irritable bowel syndrome) Depression can lead to decreased peristaltic activity and constipation

Self-Care—Testicular Self-Examination (TSE)

Encourage self-care by teaching every male (from 13 to 14 years old through adulthood) how to examine his own testicles. Testicular cancer is not common, but it has no early symptoms. When detected early and treated before metastasis, the cure rate is almost 100%. Therefore include the teaching but adjust your message to emphasize familiarity with the young man's own body rather than only cancer detection as the goal.

tennis elbow

Epicondyles, head of radius, and tendons are common sites of inflammation and local tenderness, or

Get Up and Go Test.

Evidence shows that this timed test helps to identify older adults at increased risk of falling. Watch the time it takes the person to rise from an armchair, walk 10 feet, turn, walk back, and sit down again. A healthy adult over 60 years can manage this test in fewer than 10 seconds.

Polyuria—

Excessive quantity

inflammation

Heat, redness, and swelling in nonlactating and nonpostpartum breasts indicate

Male Breast Cancer

Less than 1% of breast cancers occur in men.2 It presents as a painless palpable mass—hard, irregular, nontender, fixed to the area; may have nipple retraction. Nipple discharge, is a significant warning of early breast cancer. Note retraction and ulceration shown here. Early spread to axillary lymph nodes occurs because of minimal breast tissue. Because of lack of screening and general awareness, men are diagnosed 5 years later than women and at later stages, with the mean age at 67 years.

prolapsed hemorrhoids

Mucoid discharge and soiled underwear occur with

true deformity

is fixed and assumes a right angle only with forced manipulation or not at all

palmar grasp

place baby's head midline to ensure symmetric response; offer finger from baby's ulnar side, away from thumb; note tight grasp of all baby's fingers Present at birth; strongest at 1 to 2 months; disappears at 3 to 4 months

Dislocated Shoulder

Glenohumeral dislocation is the most frequent type of joint dislocation. Anterior dislocation (95%) shows when hunching the shoulder forward and the tip of the clavicle dislocates. It occurs with trauma involving abduction, extension, and rotation (e.g., falling on an outstretched arm or diving into a pool), showing obvious deformity and severe pain. Needs radiography. At risk for further dislocations due to injury to ligaments.

Pigeon toes (i.e., toeing in)

are demonstrated when the child tends to walk on the lateral side of the foot and the longitudinal arch looks higher than normal. It often starts as a forefoot adduction, which usually corrects spontaneously by 3 years of age as long as the foot is flexible.

thumb, middle finger, and fifth finger

are each in the dermatomes of C6, C7, and C8

two bulbourethral (Cowper) glands

are each the size of a pea and are located inferior to the prostate on either side of the urethra secrete a clear, viscid mucus

Renal Calculi

Renal stones (crystals of calcium oxalate or uric acid) form in kidney tubules and then migrate and become urgent when they pass into ureter, become lodged, and obstruct urine flow, causing hydronephrosis. Cause abrupt severe flank pain with radiation to the groin or abdomen, nausea and vomiting, restlessness, gross or microscopic hematuria

intervertebral discs

are elastic fibrocartilaginous plates that constitute one-fourth of the length of the column center has a nucleus pulposus cushion the spine like a shock absorber and help it move

Ligaments

are fibrous bands running directly from one bone to another bone that strengthen the joint and help prevent movement in undesirable directions

suspensory ligaments (Cooper ligaments)

are fibrous connective tissue extending vertically from the skin surface to attach on chest wall muscles these support breast tissue

Age

INFANTS ● Breast milk stools: watery and yellow brown ● Formula stools: pasty and brown TODDLERS: Bowel control at 2 to 3 years old ADOLESCENTS ● Increased secretion of gastric acids ● Accelerated growth of the large intestine OLDER ADULTS: Decreased peristalsis, relaxation of sphincters

abnormality with ballottement of the patella

If fluid has collected, your tap on the patella moves it through the fluid, and you will hear a tap as the patella bumps up on the femoral condyles

Scoliosis

Lateral curvature of thoracic and lumbar segments of the spine, usually with some rotation of involved vertebral bodies abnormal lateral curvature of the spine Inequality of bony landmarks occurs

Polydactyly

Extra digits are a congenital deformity, usually occurring at the 5th finger or the thumb. Surgical removal is considered for cosmetic appearance. The 6th finger shown here was not removed because it had full ROM and sensation and a normal appearance.

herniated nucleus pulposus

Lateral tilting and forward bending occur with a

Diet

Fiber requirement: 25 to 38 g/day ● Difficulty digesting foods (lactose intolerance) can cause watery stools. ● Certain foods can increase gas (cabbage, cauliflower, apples), have a laxative effect (figs, chocolate), or increase the risk for constipation (pasta,cheese, eggs).

Frozen Shoulder—Adhesive Capsulitis

Fibrous tissues form in the joint capsule, causing stiffness, progressive limitation of motion, and pain, especially unilateral nocturnal pain. Motion limited in abduction and external rotation; unable to reach overhead. It may lead to atrophy of shoulder girdle muscles. Gradual onset; prevalence in 20% of diabetics. Also associated with prolonged bed rest or shoulder immobility

is a positive indication of Allis sign and suggests hip dislocation

Finding one knee significantly lower than the other

Hypokalemia:

Leg cramps, muscle weakness, nausea, vomiting, cardiac dysrhythmias

Ulnar Deviation or Drift

Fingers drift to the ulnar side because of stretching of the articular capsule and muscle imbalance. Also note subluxation and swelling in the joints and muscle atrophy on the dorsa of the hands. This is caused by chronic RA

gordon reflex

Firmly squeeze calf muscles. Abnormal: Extension of great toe, fanning of toes. Indicates corticospinal (pyramidal) tract disease.

epididymis,

First the testis is capped by the __which is a markedly coiled duct system and the main storage site of sperm. It is a comma-shaped structure, curved over the top and the posterior surface of the testis Occasionally (in 6% to 7% of males), the epididymis is anterior to the testis

hemorrhoid

Flabby skin sac—

cystic fibrosis or celiac syndrome

Flattened buttocks in

Swan-Neck and Boutonnière Deformity

Flexion contracture resembles curve of a swan's neck, as in metacarpophalangeal joint. Then hyperextension of the PIP joint, and flexion of the DIP joint. It occurs with chronic RA, often accompanied by ulnar drift of the fingers. In boutonnière deformity the knuckle looks as if being pushed through a buttonhole. It is a common deformity.

rom of knee

Flexion of 130 to 150 degrees A straight line of 0 degrees in some people; a hyperextension of 15 degrees in others Duck walk shows intact ligaments and no effusion or arthritis.

decorticate rigidity

Flexion of arm, wrist, and fingers; adduction of arm, tight against thorax; extension, internal rotation, plantar flexion, indicates hemispheric lesion of cerebral cortex.

Fluid intake

Fluid requirement: 2 L/day for females and 3 L/day for males from fluid and food sources

infant and children dev comp anal/rectum

For the newborn, hold the feet with one hand and flex the knees up onto the abdomen. Note the presence of the anus. Confirm a patent rectum and anus by noting the first meconium stool passed within 24 to 48 hours of birth. To assess sphincter tone, check the anal reflex. Gently stroke the anal area and note a quick contraction of the sphincter. For each infant and child, note that the buttocks are firm and rounded with no masses or lesions. Recall that the mongolian spot is a common variation of hyperpigmentation in black, American Indian, Mediterranean, and Asian newborns. The perianal skin is free of lesions. However, diaper rash is common in children younger than 1 year and is exhibited as a generalized reddened area with papules or vesicles. Omit palpation unless the history or symptoms warrant. When internal palpation is needed, position the infant or child on the back with the legs flexed and gently insert a gloved, well-lubricated finger into the rectum. Use your gloved and lubricated pinky finger; its smaller size is more comfortable for the infant or child. Inspect the perianal region of the school-age child and adolescent during examination of the genitalia. Internal palpation is not performed routinely.

Paraphimosis

Foreskin is retracted and fixed. Once retracted behind glans, a tight or inflamed foreskin cannot return to its original position. Constriction impedes circulation, so glans swells. A medical emergency; the constricting band prevents venous and lymphatic return from the glans and compromises arterial circulation.

rickets, poliomyelitis, and syphilis.

Genu valgum also occurs with

Incarcerated—

Herniated bowel cannot be returned to abdominal cavity.

hip rom results

Hip flexion of 90 degrees Hip flexion of 120 degrees. The opposite thigh should remain on the table Internal rotation of 40 degrees. External rotation of 45 degrees Abduction of 40 to 45 degrees. Adduction of 20 to 30 degrees Hyperextension of 15 degrees when stabilized

This is a positive Ortolani sign and warrants referral.

Hip instability feels like a clunk as the head of the femur pops back into place.

frog position

Hips abducted and almost flat against the table, externally rotated (normal only after breech delivery)

The motions of the vertebral column

are flexion (bending forward), extension (bending back), abduction (to either side), and rotation

McMurray test is positive for a torn meniscus.

If you hear or feel a "click," This must be referred to orthopedics for imaging and possible surgical repair

testis,

In each scrotal half is a which produces sperm has a solid oval shape, which is compressed laterally and measures 4 to 5 cm long by 3 cm wide in the adult. left testis is lower than the right because the left spermatic cord is longer. Each testis is covered by a double-layered membrane, the tunica vaginalis, which separates it from the scrotal wall

kernig reflex

In flat-lying supine position, raise leg straight or flex thigh on abdomen, then extend knee. Abnormal: Resistance to straightening, pain down posterior thigh. Indicates meningeal irritation.

Acute Urinary Retention and Urinary Tract Infection

Inability to pass urine with bladder distention and lower abdominal pain. Common in older men due to bladder outlet obstruction of BPH This can cause UTI, owing to stasis and turbulent flow. UTI incidence increases among men ages ≥60 years and presents with dysuria, frequency, urgency, nocturia, suprapubic pain, occasionally gross hematuria, possibly fever. Treat with antibiotics and address underlying problem.

Spina Bifida

Incomplete closure of posterior part of vertebrae results in a neural tube defect. Seriousness varies from skin defect along the spine to protrusion of the sac containing meninges, spinal fluid, or malformed spinal cord. The most serious type is myelomeningocele (shown here), in which the meninges and neural tissue protrude. In these cases the child is usually paralyzed below the level of the lesion.

Pale yellow, greasy stool—

Increased fat content (steatorrhea), as occurs with malabsorption syndrome.

Urethritis (Urethral Discharge and Dysuria)

Infection of urethra causes painful, burning urination or pruritus. Meatus edges are reddened, everted, and swollen with purulent discharge. Urine is cloudy with discharge and mucus shreds. Cause determined by urine screen: (1) gonococcal urethritis has thick, profuse, yellow or gray-brown discharge; (2) nongonococcal urethritis (NGU) may have similar discharge but often has scanty, mucoid discharge. Of these, about 40% are caused by chlamydia infection. Guidelines are to treat for both infections if either are found.

Achilles Tenosynovitis

Inflammation of a tendon sheath near the ankle (here the Achilles tendon) produces a superficial linear swelling and a localized tenderness along the route of the sheath. Movement of the involved tendon usually causes pain.

pilonidal cyst

Inflammation or tenderness, swelling, tuft of hair, or dimple at tip of coccyx may indicate

anal columns (or columns of Morgagni)

are folds of mucosa. These extend vertically down from the rectum and end in the anorectal junction anal column contains an artery and a vein

the labia minora.

Inside the labia majora are two smaller, darker folds of skin, These are joined anteriorly at the clitoris where they form a hood, or prepuce.

columnar epithelium

Inside the os the endocervical canal is lined with ___ that looks red and rough.

Pruritus Ani

Intense itching and burning in the perineum has myriad causes: soaps, restrictive clothing, fecal soiling or hemorrhoids, eczema or psoriasis, STIs (herpes, condylomata), candida infection from moist or sweaty folds of skin in obese or aging persons, systemic causes (such as diabetes, liver disease), and pinworm infestation in children. Persistent scratching makes an inflammatory response and shows as red, raised, thickened, excoriated skin; may be swollen and moist. Careful history leads to treatment of underlying cause. Urge not to scratch, to avoid scented soap, prepared wipes, tight underclothing.

Nocturnal enuresis—

Involuntarily urinating at night after age 5 to 6 years.

Reflex Urinary Incontinence

Involuntary loss of urine occurring at somewhat predictable intervals when patient reaches specific bladder volume related to spinal cord damage between C1 and S2

Urge incontinence—

Involuntary urine loss from overactive detrusor muscle in bladder.

Stress incontinence—

Involuntary urine loss with physical strain, sneezing, or coughing caused by weakness of pelvic floor.

femoral canal.

It is a potential space located 3 cm medial to and parallel with the femoral artery. You can use the artery as a landmark to find this space.

rest tremor

It occurs when muscles are quiet and supported against gravity (hand in lap). Coarse and slow (3 to 6 per second); partly or completely disappears with voluntary movement (e.g., "pill rolling" tremor of parkinsonism, with thumb and opposing fingers).

inflammation

Jellylike mucus shreds mixed in stool indicate

Arthritis

Joint effusion or synovial thickening, seen first as bulge or fullness in grooves on either side of olecranon process. Redness and heat can extend beyond area of synovial membrane. Soft, boggy, or fluctuant fullness to palpation. Limited extension of elbow. Occurs with RA, gout, OA, trauma.

rheumatic fever

Joint pain 10 to 14 days after an untreated strep throat suggests

Olecranon Bursitis

Large, soft knob, or "goose egg," and redness from swelling and inflammation of olecranon bursa. Localized and easy to see because bursa lies just under skin. Occurs with trauma, gout, or RA.

rom of spine

Lateral bending of 35 degrees Hyperextension of 30 degrees. Rotation of 30 degrees, bilaterally

Fissure

Linear split—

Swelling of Menisci

Localized soft swelling from cyst in lateral meniscus shows at the midpoint of the anterolateral joint line. Semiflexion of the knee makes swelling more prominent. Other meniscal injuries present as a sharp acute pain at lateral or medial joint line together with catching, locking, or popping. Tears in the menisci occur with severe ligament injury and present with joint instability, swelling, and pain. Suspected tears are referred to orthopedics due to future increased risk of osteoarthritis

Prepatellar Bursitis

Localized swelling on anterior knee between patella and skin. A tender, fluctuant mass indicates swelling; infection may spread to surrounding soft tissue. The condition is limited to the bursa, and the knee joint itself is not involved. Overlying skin may be red, shiny, atrophic, or coarse and thickened.

when urine stream is weakened

Loss of force and decreased caliber

Atrophy

Loss of muscle mass is exhibited as a lack of fullness surrounding the deltoid muscle, here in left shoulder from brachial plexus injury. also occurs from disuse, muscle tissue damage, or motor nerve damage.

Mild Synovitis

Loss of normal hollows on either side of the patella, which are replaced by mild distention. Occurs with synovial thickening or effusion (excess fluid) as in RA. Also note mild distention of the suprapatellar pouch.

Gait:

Manner or style of walking

Range of motion (ROM):

Maximum amount of movement of a joint - sagittal (left or right), transverse (side to side), and frontal (front to back)

Absent testis—

May be a temporary migration or true cryptorchidism

Epispadias

Meatus opens on the dorsal (upper) side of glans or shaft above a broad, spadelike penis. Rare; less common than hypospadias but more disabling because of associated urinary incontinence and separation of pubic bones.

snout reflex

Method of testing: Gently percuss oral region Abnormal response (reflex is present): Puckers lips Indications: Frontal lobe disease, cerebral degenerative disease (Alzheimer), amyotrophic sclerosis, corticobulbar lesions

Abnormal Tibial torsion

More than 20 degrees of deviation; or if lateral malleolus is anterior to medial malleolus, it indicates tibial torsion

9. Eversion—

Moving the sole of the foot outward at the ankle

Benign ("Fibrocystic") Breast Disease

Multiple tender masses that occur with numerous symptoms and physical findings: (1) swelling and tenderness (cyclic discomfort), (2) nodularity (significant lumpiness, both cyclic and noncyclic), (3) dominant lumps (including cysts and fibroadenomas), (4) nipple discharge (including intraductal papilloma and duct ectasia), and (5) infections and inflammations (including subareolar abscess, lactational mastitis, breast abscess, and Mondor disease) Many women have some form of benign breast disease. Nodularity occurs bilaterally; regular, firm nodules are mobile, well demarcated, and feel rubbery like small water balloons. Pain may be dull, heavy, and cyclic as nodules enlarge. Some women have nodularity but no pain. Cysts are discrete, fluid-filled sacs. Dominant lumps and nipple discharge must be investigated carefully. Nodularity itself is not premalignant but produces difficulty in detecting other cancerous lumps

Hypernatremia:

Muscle weakness, lethargy, swollen red tongue

Stricture—

Narrowed opening

Phimosis—

Narrowed opening of prepuce so cannot retract the foreskin

warrant ultrasound imaging

Nodules on testes or epididymides

Colles Fracture (not illustrated)

Nonarticular fracture of distal radius, with or without fracture of ulna at styloid process. Usually from a fall on an outstretched hand; occurs more often in older women. Wrist looks puffy with "silver fork" deformity, a characteristic hump when viewed from the side.

Osteoarthritis (OA) (Degenerative Joint Disease)

Noninflammatory, localized, progressive disorder involving deterioration of articular cartilages (cushion between the ends of bones) and subchondral bone remodeling, synovial inflammation, and formation of new bone (osteophytes) at joint surfaces. Increased risk occurs with older age, females, and Caucasians. Obesity increases risk and progression, especially in the knee. Asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. Affected joints have stiffness; swelling with hard, bony protuberances; pain with motion; and limitation of motion is worse later in the day

Phimosis

Nonretractable foreskin forming a pointy tip with a tiny orifice. Foreskin is advanced and so tight that it is impossible to retract over glans. May be congenital or acquired from adhesions secondary to infection. Poor hygiene leads to retained dirt and smegma, which increases risk for inflammation, calculus formation, obstructive uropathy.

Synovial joints

are freely movable because their bones are separated from one another and enclosed in a joint cavity a layer of resilient cartilage covers the surface of opposing bones

Muscle tone:

Normal state of balanced muscle tension allowing one to maintain positions (sitting or standing)

infants musculoskeletal system

Often the newborn's feet are not held straight but instead in a varus (apart) or valgus (together) position. It is important to distinguish whether this position is flexible (and thus usually self-correctable) or fixed. Scratch the outside of the bottom of the foot. If the deformity is self-correctable, the foot assumes a normal right angle to the lower leg. Or immobilize the heel with one hand and gently push the forefoot to the neutral position with the other hand. If you can move it to neutral position, it is flexible. Note the relationship of the forefoot to the hindfoot. Commonly the hindfoot is in alignment with the lower leg, and just the forefoot angles inward. This forefoot adduction is metatarsus adductus. It is usually present at birth and usually resolves spontaneously by age 3 years Check for tibial torsion, a twisting of the tibia. Place both feet flat on the table and push to flex up the knees. With the patella and the tibial tubercle in a straight line, place your fingers on the malleoli. In an infant note that a line connecting the four malleoli is parallel to the table. may originate from intrauterine positioning and then be exacerbated at a later age by continuous sitting in a reverse tailor position, the "TV squat" (i.e., sitting with the buttocks on the floor and the lower legs splayed back and out on either side). Check the hips for developmental dysplasia of the hip (DDH). The most reliable method is Ortolani maneuver. Allis test. Note the gluteal folds. Normally they are equal on both sides. However, some asymmetry may occur in healthy children. Unequal gluteal folds may accompany hip dislocation after 2 to 3 months of age Inspect the hands, noting shape, number, and position of fingers and palmar creases. Palpate the length of the clavicles because the clavicle is the bone most frequently fractured during birth. The clavicles should feel smooth, regular, and without crepitus. Also note equal ROM of arms during Moro reflex. Lift the infant and examine the back. Note the normal single C-curve of the newborn's spine. By 2 months the infant can lift the head while prone on a flat surface. This builds the concave cervical spinal curve and indicates normal forearm strength. Inspect the length of the spine for any tuft of hair, dimple in midline, cyst, or mass. Normally none are present Test muscle strength by lifting the infant with your hands under the axillae. A baby with normal muscle strength wedges securely between your hands.

palpate the prostate gland

On the anterior wall in the male, note the elastic, bulging prostate gland. Find the median sulcus and palpate the entire prostate in a systematic manner, but note that only the superior and part of the lateral surfaces are accessible to examination. Press into the gland at each location because when a nodule occurs, it will not project into the rectal lumen. The surface should feel smooth and muscular; search for any distinct nodule or diffuse firmness. Note these characteristics: Size—2.5 cm long by 4 cm wide; should not protrude more than 1 cm into the rectum Shape—Heart shape, with palpable central groove Surface—Smooth Consistency—Elastic, rubbery Mobility—Slightly movable . Sensitivity—Nontender to palpation In the female palpate the cervix through the anterior rectal wall. It normally feels like a small, round mass. You also may palpate a retroverted uterus or a tampon in the vagina. Do not mistake the cervix or a tampon for a tumor. Withdraw your examining finger; normally no bright red blood or mucus is on the glove. To complete the examination, offer the person tissues to remove the lubricant and help him or her to a more comfortable position.

Preschool-Age and School-Age Children musculoskeletal

Once the infant learns to crawl and then walk, the waking hours show perpetual motion. This is convenient for your musculoskeletal assessment; you can observe the muscles and joints during spontaneous play before a table-top examination. Most young children enjoy showing off their physical accomplishments. For specific motions coax the toddler: "Show me how you can walk to Mom" or "Climb the step stool." Ask the preschooler to hop on one foot or jump While the child is standing, note the posture. From behind you should note a "plumb line" from the back of the head, along the spine, to the middle of the sacrum. Shoulders are level within 1 cm, and scapulae are symmetric. From the side lordosis is common throughout childhood, appearing more pronounced in children with a protuberant abdomen. Often parents tell you that they are concerned about the child's foot development. The most common questions are about "flatfeet" and "pigeon toes."Pronation beyond 30 months is abnormal Pigeon toes abnormal with Toeing in from forefoot adduction that is fixed or lasts beyond age 3 years. Toeing in from tibial torsion Check the child's gait while walking away from and returning to you. Let him or her wear socks because a cold tile floor distorts the usual gait. From 1 to 2 years expect a broad-based gait, with arms out for balance. Weight-bearing falls on the inside of the foot. From 3 years the base narrows, and the arms are closer to the sides. Inspect the shoes for spots of greatest wear to aid your judgment of the gait. Normally the shoes wear more on the outside of the heel and the inside of the toe. The child may sit for the remainder of the examination. Start with the feet and hands of the child from 2 to 6 years because he or she is happy to show these off and proceed through the examination described earlier Particularly check the arm for full ROM and presence of pain. Look for subluxation of the elbow (head of the radius). This occurs most often between 2 and 4 years as a result of forceful removal of clothing or dangling while adults suspend the child by the hands Palpate the bones, joints, and muscles of the extremities as described in the adult examination.

plugged duct

One section of the breast surface appearing red and tender indicates a

This is the foreskin or prepuce.

Over the glans, the skin folds in and back on itself, forming a hood or flap. Often it is surgically removed shortly after birth by circumcision.

Carpal Tunnel Syndrome With Atrophy of Thenar Eminence

Pain along thumb and index and middle fingers and atrophy occur from interference with motor function from compression of the median nerve inside the carpal tunnel. Caused by chronic repetitive motion; occurs between 40 and 60 years and is more common in women. Symptoms of carpal tunnel syndrome include pain, nighttime pain, burning and numbness, positive findings on Phalen test, positive Tinel sign, and often atrophy of thenar muscles.

Dyschezia.

Pain due to local condition (hemorrhoid, fissure) or constipation

Paraphimosis—

Painful constriction of glans by retracted foreskin

Acute Rheumatoid Arthritis

Painful swelling and stiffness of joints, with fusiform or spindle-shaped swelling of the soft tissue of PIP joints. Fusiform swelling is usually symmetric, the hands are warm, and the veins are engorged. The inflamed joints have a limited range of motion

Osgood-Schlatter Disease

Painful swelling of the tibial tubercle just below the knee, from overuse injury that places traction and microtrauma on the bone. Occurs most in puberty during rapid growth and before closure of the growth plate. Pain increases with kicking, running, bike riding, volleyball, basketball, soccer. It is usually self-limited, and symptoms resolve with rest

Mammary Duct Ectasia

Pastelike matter in subareolar ducts produces sticky, purulent discharge that may be cream-colored, green, or bloody. A single duct discharge is shown here. Caused by stagnation of cellular debris and secretions in the ducts, leading to obstruction, inflammation, and infection. Itching, burning, or drawing pain occurs around nipple. May have subareolar redness and swelling. Ducts are palpable as rubbery, twisted tubules under areola. May have palpable mass, soft or firm, poorly delineated. Not malignant but needs biopsy.

infants and children dev. compt. male gu sys

Penis size is usually small in infants (2 to 3 cm) A common scrotal finding in the boy younger than 2 years is a hydrocele

Transillumination.

Perform this maneuver only if you note a swelling or mass. Darken the room. Shine a strong flashlight from behind the scrotal contents. Solid scrotal contents do not transilluminate.

Measure Leg Length Discrepancy

Perform this measurement if you need to determine whether one leg is shorter than the other

Mcmurray Test.

Perform this test when the person has reported a history of trauma followed by locking, giving way, or local pain in the knee. Position the person supine as you stand on the affected side. Hold the heel and flex the knee and hip. Place your other hand on the knee with fingers on the medial side. Rotate the leg in and out to loosen the joint. Externally rotate the leg, and push a valgus (inward) stress on the knee. Slowly extend the knee. Normally the leg extends smoothly with no pain test for meniscal tear

rickets.

Severe bowing or unilateral bowing also occurs with

carpal tunnel syndrome

Phalen test reproduces numbness and burning in a person with

Urethral Stricture

Pinpoint, constricted opening at meatus or inside along urethra. Occurs congenitally or secondary to urethral injury. Gradual decrease in force and caliber of urine stream is most common symptom. Shaft feels indurated along ventral aspect at site of stricture

, MSM

Sexual minority also includes men having settled themselves into same-sex relationships men having sex with men.

Thrombosed hemorrhoid.

Shiny blue skin sac—

rom of ankle and foot

Plantar flexion of 45 degrees Dorsiflexion of 20 degrees Eversion of 20 degrees. Inversion of 30 degrees

Alignment:

Position of the joints, tendons, muscles, and ligaments while sitting, standing, and lying

aging adult musculoskeletal

Postural changes include a decrease in height, more apparent in the 70s and 80s. The expression "lengthening of the arm-trunk axis" describes this shortening of the trunk with comparatively long extremities. Kyphosis is common, with a backward head tilt to compensate. This creates the outline of a figure 3 when you view this older adult from the left side. Slight flexion of hips and knees is also common Contour changes include a decrease of fat in the body periphery and fat deposition over the abdomen and hips. The bony prominences become more marked. For most older adults ROM testing proceeds as described earlier. ROM and muscle strength are much the same as with the younger adult, provided no musculoskeletal illnesses or arthritic changes are present. Get Up and Go Test. abnromal if Performance >10 seconds together with history of falls and mobility problems increases risk for future falling. Functional Assessment.

infants developmental competence male gen system

Prenatally the testes develop in the abdominal cavity near the kidneys. testes migrate, pushing the abdominal wall in front of them and dragging the vas deferens, blood vessels, and nerves behind. descend along the inguinal canal into the scrotum before birth At birth each testis measures 1.5 to 2 cm long and 1 cm wide. Only a slight increase in size occurs during the prepubertal years

pregnant women musculoskeletal

Proceed through the examination described in the adult section. Expected postural changes in pregnancy include progressive lordosis and, toward the third trimester, anterior cervical flexion, kyphosis, and slumped shoulders. When the pregnancy is at term, the protuberant abdomen and relaxed mobility in the joints create the characteristic "waddling" gait

adolescents musculoskeletal

Proceed with the musculoskeletal examination that you provide for the adult, except pay special note to spinal posture. Kyphosis is common during adolescence because of chronic poor posture. Be aware of the risk for sports-related injuries with the adolescent because sports participation and competition often peak with this age-group. The U.S. Preventive Services Task Force32 does not support the routine screening of asymptomatic adolescents for idiopathic scoliosis. They found that most cases detected through screening did not progress to clinically significant scoliosis. In addition, the harm of unnecessary imaging, follow-up visits, and psychological adverse effects of brace wear did not offset any potential benefits of screening. However, when idiopathic scoliosis is discovered incidentally or when the teen or parent expresses concern, clinicians should be prepared to evaluate. Screen for scoliosis with the forward bend test.

Priapism

Prolonged painful erection of penis without sexual stimulation and unrelieved by intercourse or masturbation. When lasting 4 hours or longer can cause ischemia of penis, fibrosis of tissue, erectile dysfunction. Can occur as a rare side effect of drugs for erectile dysfunction and street drugs; with sickle-cell trait or disease; with leukemia in which excess white blood cells produce engorgement; with malignancy; from local trauma; or as a result of spinal cord injuries with autonomic nervous system dysfunction

Cathartics:

Promote peristalsis

supernumerary breast

Rarely additional glandular tissue, called a

acute cystitis

Recurrent episodes of uti's with

tanner stage 2 breast bud stage

a small mound of breast and nipple develops the areola widens

tendon

a strong fibrous cord

Post-Polio Muscle Atrophy

Right leg and foot muscle atrophy as a result of childhood polio. Poliomyelitis epidemics peaked in the United States in the 1940s and 1950s. The development of the oral polio vaccine (1962) has almost eradicated the disease. However, thousands of polio survivors have this muscle atrophy.

Ganglion Cyst

Round, cystic, nontender nodule overlying a tendon sheath or joint capsule, usually on dorsum of wrist. Flexion makes it more prominent. The fluid-filled mass is more common in women ages 30 to 60 years.37 Nonpainful ganglion cysts are a cosmetic concern; painful ones may compress the median or ulnar nerve, causing numbness and tingling or weakness

Small Testis

S: (None) O: Palpation—Small and soft (rarely may be firm) A: Small testis Small and soft (<3.5 cm) indicates atrophy as with cirrhosis or hypopituitarism, following estrogen therapy, or as a sequelae of orchitis. Small and firm (<2 cm) occurs with Klinefelter syndrome (hypogonadism).

Orchitis

S: Acute or moderate pain of sudden onset, swollen testis, feeling of weight, fever O: Inspection—Enlarged, edematous, reddened; does not transilluminate Palpation—Swollen, congested, tense, and tender; hard to distinguish testis from epididymis A: Tender swelling of testis Acute inflammation of testis. Most common cause is mumps; can occur with any infectious disease. May have associated hydrocele that does transilluminate

Varicocele

S: Dull pain; constant pulling or dragging feeling; or may be asymptomatic O: Inspection—Usually no sign; or bluish color through light scrotal skin Palpation—When standing, feel soft, irregular mass posterior to and above testis; collapses when supine, refills when upright; feels distinctive, like a "bag of worms" Testis on side of varicocele may be smaller due to impaired circulation A: Soft mass on spermatic cord A varicocele is dilated, tortuous internal spermatic varicose veins caused by incompetent valves, which permit reflux of blood; 90% left-sided because left spermatic vein inserts at a right angle into left renal vein. Occurs in 15% by age 15 years. Screen at early adolescence; obtain scrotal ultrasound; early treatment important to prevent potential infertility when an adult

Absent Testis, Cryptorchidism

S: Empty scrotal half O: Inspection—In true maldescent, atrophic scrotum on affected side Palpation—No testis A: Absent testis

Diffuse Tumor

S: Enlarging testis (most common symptom). When enlarges, has feel of increased weight O: Inspection—Enlarged, does not transilluminate Palpation—Enlarged, smooth, ovoid, firm Important—Firm palpation does not cause usual sickening discomfort as with normal testis A: Nontender swelling of testis Diffuse tumor maintains shape of testis.

Testicular Torsion

S: Excruciating unilateral pain in testicle of sudden onset, often during sleep or following trauma; may also have lower abdominal pain, nausea and vomiting, no fever O: Inspection—Red, swollen scrotum, one testis (usually left) higher owing to rotation and shortening Palpation—Cord feels thick, swollen, tender; epididymis may be anterior; cremasteric reflex absent on side of torsion Sudden twisting of spermatic cord. Occurs in late childhood, early adolescence; rare after age 20 years. Torsion usually on left side; faulty anchoring of testis on wall of scrotum allows testis to rotate. The anterior testis rotates medially toward the other testis. Blood supply is cut off, resulting in ischemia and engorgement. An emergency requiring surgery; testis can become gangrenous in a few hours

Prostatitis

S: Fever, chills, malaise, urinary frequency and urgency, dysuria, urethral discharge; dull, aching pain in perineal and rectal area. O: An exquisitely tender enlargement is acute inflammation, yielding a swollen, slightly asymmetric gland. With a chronic inflammation the signs can vary from tender enlargement with a boggy feel to isolated firm areas caused by fibrosis. Or the gland may feel normal.

Carcinoma

S: Frequency, nocturia, hematuria, weak stream, hesitancy, pain or burning on urination; continuous pain in lower back, pelvis, thighs. O: A malignant neoplasm often starts as a single hard nodule on the posterior surface, producing asymmetry and a change in consistency. As it invades normal tissue, multiple hard nodules appear, or the entire gland feels stone-hard and fixed. The median sulcus is obliterated.

Hydrocele

S: Painless swelling, although person may complain of weight and bulk in scrotum O: Inspection—Enlarged mass does transilluminate with a pink or red glow (in contrast to a hernia) Palpation—Nontender mass; able to get fingers above mass (in contrast to scrotal hernia) A: Nontender swelling of testis Cystic. Circumscribed collection of serous fluid in tunica vaginalis surrounding testis. May occur following epididymitis, trauma, hernia, tumor of testis, or spontaneously in the newborn. Usually resolves during first year; if large or enlarging, may need surgical decompression.

Early Testicular Tumor

S: Painless, found on examination; may have history of undescended testicle or familial testicular cancer. O: Palpation—Firm nodule or harder-than-normal section of testicle; testicular swelling occurs in most A: Solitary nodule Most testicular tumors occur between ages 18 and 35; practically all are malignant. More common in whites; must biopsy to confirm. Most important risk factor is undescended testis, even those surgically corrected. Early detection important in prognosis, but practice of testicular self-examination is low.

Spermatocele

S: Painless, usually found on examination O: Inspection—Does transilluminate higher in the scrotum than a hydrocele, and the sperm may fluoresce Palpation—Round, freely movable mass lying above and behind testis; if large, feels like a third testis A: Free cystic mass on epididymis Retention cyst in epididymis; cause unclear but may be obstruction of tubules. Filled with thin, milky fluid that contains sperm. Most spermatoceles are small (<1 cm); occasionally they may be larger and mistaken for hydrocele.

Epididymitis

S: Severe pain of sudden onset in scrotum, relieved by elevation (positive Prehn sign); also rapid swelling, fever O: Inspection—Enlarged scrotum; reddened Palpation—Exquisitely tender; epididymis enlarged, indurated; hard to distinguish from testis. Overlying scrotal skin may be thick and edematous Laboratory—White blood cells and bacteria in urine A: Tender swelling of epididymis Acute infection of epididymis commonly caused by prostatitis; after prostatectomy because of trauma of urethral instrumentation; or from chlamydia, gonorrhea, or other bacterial infection. Often difficult to distinguish between epididymitis and testicular torsion

Scrotal Hernia

S: Swelling, may have pain with straining O: Inspection—Enlarged, may reduce when supine, does not transilluminate Palpation—Soft, mushy mass; palpating fingers cannot get above mass. Mass is distinct from testicle that is normal A: Nontender swelling of scrotum Scrotal hernia usually caused by indirect inguinal hernia Requires surgery. Teach patient or boy's parents signs of incarcerated hernia; proceed to ED if these occur before planned surgery.

Scrotal Edema

S: Tenderness O: Inspection—Enlarged, may be reddened (with local irritation) Palpation—Taut with pitting. Probably unable to feel scrotal contents A: Scrotal edema Accompanies marked edema in lower half of body (e.g., congestive heart failure, renal failure, and portal vein obstruction). Occurs with local inflammation: epididymitis, torsion of spermatic cord. Also, obstruction of inguinal lymphatics produces lymphedema of scrotum.

Benign Prostatic Hypertrophy (BPH)

S: Urinary frequency, urgency, hesitancy, straining to urinate, weak stream, intermittent stream, sensation of incomplete emptying, nocturia. O: A symmetric nontender enlargement; commonly occurs in males beginning in the middle years. The prostate surface feels smooth, rubbery, or firm (like the consistency of the nose), with the median sulcus obliterated.

Screen for scoliosis with the forward bend test.

Seat yourself behind the standing child and ask him or her to stand with the feet shoulder-width apart and bend forward slowly to touch the toes. Expect a straight vertical spine while standing and also while bending forward. Posterior ribs should be symmetric, with equal elevation of shoulders, scapulae, and iliac crests.

diastasis recti

Separation of the longitudinal muscles of the abdomen (rectus abdominis) during pregnancy.

inspect the perineal area

Spread the buttocks wide apart with both gloved hands and observe the perianal region. The anus normally looks moist and hairless, with coarse, folded skin that is more pigmented than the perianal skin. The anal opening is tightly closed. No lesions are present. Inspect the sacrococcygeal area. Normally it appears smooth and even Instruct the person to hold the breath and bear down by performing a Valsalva maneuver. No break in skin integrity or protrusion through the anal opening should be present. Describe any abnormality in clock-face terms, with the 12 o'clock position as the anterior point toward the symphysis pubis and the 6 o'clock position toward the coccyx.

Heberden and Bouchard nodules

are hard and nontender and occur with osteoarthritis

Atrophied testes—

Small and soft

Fistula

Small round opening in anal area

Genital Warts

Soft, pointed, moist, fleshy, painless papules may be single or multiple in a cauliflower-like patch. Color may be gray, pale yellow, or pink in white males and black or translucent gray-black in black males. They occur on shaft of penis, behind corona, or around the anus where they may grow into large, grapelike clusters. These are caused by the human papillomavirus (HPV) and are one of the most common STIs. The HPV infection is correlated with early onset of sexual activity, infrequent use of contraception, and multiple sexual partners. The vaccine Gardasil is indicated for prevention of genital warts; approval was re-confirmed in 2014 for boys and men ages 9 to 26 years. It also reduces HPV-related disease in women, such as cervical cancer.

Cancer

Solitary, unilateral, 3-dimensional, usually nontender mass. Solid, hard, dense, and fixed to underlying tissues or skin as cancer becomes invasive. Borders are irregular and poorly delineated. Grows constantly. Requires diagnostic mammogram for those over age 30 years and at average risk.13 Most common in upper outer quadrant. Found in women 30 to 80 years of age; increased risk across all ages until age 80 years. As cancer advances, signs include firm or hard irregular axillary nodes; skin dimpling; nipple retraction, elevation, and discharge.

hemiplegia

Spastic or flaccid paralysis of one side (right or left) of body and extremities.

Plugged Duct

This is common when milk is not removed completely because of poor latching, ineffective suckling, infrequent nursing, or switching to second breast too soon. There is a tender lump that may be reddened and warm to touch. No infection. It is important to keep breast as empty as possible and milk flowing. The woman should nurse her baby frequently on affected side first to ensure complete emptying and manually express any remaining milk. A plugged duct usually resolves in less than 1 day.

squamocolumnar junction

point where these two tissues meet is the___ and is not visible

paraurethral (Skene) glands.

Surrounding the urethral meatus are the tiny, multiple Their ducts are not visible but open posterior to the urethra at the 5 and 7 o'clock positions.

Joint Effusion

Swelling from excess fluid in the joint capsule, here from rheumatoid arthritis. Best observed anteriorly. Fluctuant to palpation. Considerable fluid must be present to cause a visible distention because the capsule normally is so loose.

prostatitis.

Tender. Swollen, exquisitely tender gland accompanies

True cryptorchidism—

Testes that have never descended. Incidence at birth is 3% to 4%; one-half of these descend in first month. Incidence with premature infants is 30%; in the adult, 0.7% to 0.8%. True undescended testes have a histologic change by 6 years, causing decreased spermatogenesis and infertility. Also increases risk for testicular cancer.

very small amounts of effusion,

The bulge sign occurs with ___ 4 to 8 mL, from fluid flowing across the joint

Mastitis

This is uncommon; an inflammatory mass before abscess formation. Usually occurs in single quadrant. Area is red, swollen, tender, very hot, and hard, here forming outward from areola upper edge in right breast. The woman also has a headache, malaise, fever, chills, sweating, increased pulse, flulike symptoms. May occur during first 4 months of lactation from infection or from stasis from plugged duct. Treat with rest, local heat to area, antibiotics, and frequent nursing to keep breast as empty as possible. Must not wean now, or the breast will become engorged, and the pain will increase. Mother's antibiotic not harmful to infant. Usually resolves in 2 to 3 days.

anorectal junction (also called the dentate line).

This junction is not palpable, but it is visible on proctoscopy

Rectal Prolapse

The complete rectal mucous membrane protrudes through the anus, appearing as a moist red doughnut with radiating lines. When prolapse is incomplete, only the mucosa bulges. When complete, it includes the anal sphincters. Occurs following a Valsalva maneuver such as straining at stool or with exercise. Caused by weakened pelvic support muscles and requires surgery.

Herniated Intervertebral Disc

The nucleus pulposus (the center of the disc) ruptures into the spinal canal and puts pressure on the local spinal nerve root, causing pain and inflammation. Usually occurs from strenuous activities (lifting, twisting, continuous flexion with lifting, fall on buttocks), mostly in men 20 to 45 years of age, more in smokers. Lumbar herniations occur mainly in interspaces L4 to L5 and L5 to S1. NOTE: Sciatic pain, numbness, and paresthesia of involved dermatome; listing away from affected side; decreased mobility; low back tenderness; and decreased motor and sensory function in leg. Straight leg raising tests reproduce sciatic pain

Sudden locking—

The person is unable to extend the knee fully. This usually occurs with a painful and audible "pop" or "click."

stratified squamous epithelium

The vagina and cervix are covered with smooth, pink,

Intraductal Papilloma

These are discrete benign tumors that arise in a single or multiple papillary duct(s). May have serous or serosanguineous discharge. Often there is a palpable nodule in underlying duct (highlighted here). Most common in women ages 40 to 60 years. Most are benign, although multiple papillomas have a higher risk of subsequent cancer than do solitary ones. Requires core needle biopsy and possible excision.

Hemorrhoids

These common, flabby papules are a varicosed vein. An external hemorrhoid starts below the anorectal junction covered by anal skin. When thrombosed, it contains clotted blood and becomes a painful, swollen, shiny blue mass that itches and bleeds with defecation. When resolved, it leaves a painless, flabby skin sac around the anal orifice. An internal hemorrhoid starts above the anorectal junction covered by mucous membrane. Hemorrhoids result from increased pressure: with straining at stool, chronic constipation, pregnancy, obesity, or a low-fiber diet. Accompanied by painless rectal bleeding, red blood on tissue or toilet bowl, pruritus, anal swelling and pain, fecal soilage, mucus discharge. Treat with fiber supplement, laxative, decreased time on toilet, rubber band ligation.8,12

Rheumatoid Nodules

These raised firm nodules are granulomatous lesions that grow along small blood vessels in people with RA. Can be tender or nontender, movable or fixed; skin slides freely over nodules. Develop over pressure points such as extensor surface of arm (ulna) and olecranon.

cloudy urine

UTI, kidney stones

thyroid dysfunction, stilbestrol ingestion, or ovarian or adrenal tumor

precocious development of breasts before age 8 years. It is usually normal but also occurs with

oppenheim reflex

Using heavy pressure with your thumb and index finger, stroke anterior medial tibial muscle. Abnormal: Extension of great toe, fanning of toes. Indicates corticospinal (pyramidal) tract disease.

1. Location— 2. Size— 3. Shape 4. Consistency— 5. Movable— 6. Distinctness— 7. Nipple— 8. Note the skin over the lump— 9. Tenderness— 10. Lymphadenopathy—

Using the breast as a clock face, describe the distance in centimeters from the nipple (e.g., "7:00, 2 cm from the nipple"). Or diagram the breast in the woman's record and mark in the location of the lump. Judge in centimeters in 3 dimensions: width × length × thickness. State whether the lump is oval, round, lobulated, or indistinct. State whether the lump is soft, firm, or hard. Is the lump freely movable, or is it fixed when you try to slide it over the chest wall? Is the lump solitary or multiple? Is it displaced or retracted? Is it erythematous, dimpled, or retracted? Is the lump tender to palpation? Are any regional lymph nodes palpable?

Plantar Wart

Vascular papillomatous growth is caused by human papillomavirus and occurs on the sole of the foot, commonly at the ball and has small dark spots. Although it looks like a callus, it is extremely painful. The wart is tender if you pinch it side to side, whereas a callus is tender to direct pressure

Hypospadias—

Ventral location of meatus

Syndactyly

Webbed fingers are a congenital deformity requiring surgical separation. The metacarpals and phalanges of the webbed fingers are different lengths and the joints do not line up. To leave the fingers fused would thus limit their flexion and extension

Developmental Dysplasia of the Hip

With a dislocated hip the head of the femur is displaced out of the cup-shaped acetabulum. The degree varies; subluxation may occur as stretched ligaments allow partial displacement of femoral head, and acetabular dysplasia may develop because of excessive laxity of hip joint capsule. Occurrence is 1 : 500 to 1 : 1000 births; common in girls by 7 : 1 ratio. Signs include limited abduction of flexed thigh (illustration A), positive indications of Ortolani sign, asymmetric skin creases or gluteal folds, unequal knee elevation (illustration B), limb length discrepancy, and positive indication of Trendelenburg sign in older children.

tonic neck reflex

With baby supine, turn head to one side with chin over shoulder, note ipsilateral extension of arm and leg, and flexion of opposite arm and leg The "fencing" position, turning head to opposite side, positions will reverse Appears by 2 to 3 months, decreases at 3 to 4 months, disappears by 4 to 6 months

brudzinski reflex

With one hand under the neck and other hand on person's chest, sharply flex chin on chest, watch hips and knees. Abnormal: Resistance and pain in neck, flexion of hips and knees. Indicates meningeal irritation.

hoffman reflex

With pts hand relaxed, wrist dorsified, fingers slightly flexed, sharply flick nail of distal phalanx of middle or index finger. Abnormal: clawing of fingers and thumbs. Indicates corticospinal (pyramidal) tract disease.

Ankylosis

Wrist in extreme flexion with ruptures of wrist and finger extensors, caused by severe rheumatoid arthritis (RA). This is a functionally compromised hand because, when the wrist is palmar flexed, a good deal of power is lost from the fingers, and often the thumb cannot oppose the fingers

stress incontinence

a 59 year old patient has been diagnosed with prostatitis and is being seen at a clinic for complaints of burning and pain during urination what is he experiencing

grand mal seizure

a type of generalized epileptic seizure in which nerve cells fire in high-frequency bursts, usually accompanied by involuntary rhythmic contractions of the body and affects loss of consciousness, tonic phase with muscular rigidity/opening of mouth and eyes/tongue biting/high pitched cry, clonic phase with violent muscular contractions/facial grimacing/increased heart rate, postictal phase with deep sleeping/disorientation/confusion

Graphesthesia

ability to "read" a number by having it traced on the skin

two point discrimination

ability to distinguish the separation of two simultaneous pinpricks on the skin

galactorrhea

abnormal flow of milk from the breasts can be caused by medications: oral contraceptives, phenothiazines, diuretics, digitalis, steroids, methyldopa, calcium channel blockers

lordosis

abnormal increase in the forward curvature of the lumbar spine which compensates for the enlarging fetus; otherwise the center of balance would shift forward. compensates by shifting the weight farther back on the lower extremities. This shift in balance in turn creates strain on the low back muscles, which in some women is felt as low back pain during late pregnancy

atrophy

abnormally small muscle with a wasted appearance, occurs with disuse, injury, LMN disease like polio, diabetic neuropathy

Internal hemorrhoid

above anorectal junction is not palpable unless thrombosed.

Hyporeflexia

absence of a reflex and is a lower motor neuron problem

analgesia

absent pain sensation

anesthesia

absent touch sensation

mammary glands

accessory organs of the female reproductive system specialized to secrete milk following pregnancy

Muscles

account for 40% to 50% of body weight. contract they produce movement three types: skeletal, smooth, and cardiac

Metatarsus varus—

adduction and inversion of forefoot

lateral node

along the humerus, inside the upper arm

pectoral (anterior) node

along the lateral edge of the pectoralis major muscle, just inside the anterior axillary fold

subscapular (posterior) node

along the lateral edge of the pectoralis major muscle, just inside the anterior axillary fold

Allis test

also is used to check for hip dislocation by comparing leg lengths Place the baby's feet flat on the table and flex the knees up. Scan the tops of the knees; normally they are at the same elevation

vertebrae

are 33 connecting bones stacked in a vertical column can feel their spinous processes in a furrow down the midline of the back. furrow has paravertebral muscles mounded on either side down to the sacrum, where it flattens. Humans have 7 cervical, 12 thoracic, 5 lumbar, 5 sacral, and 3 or 4 coccygeal

Pinworms

are a common cause of intense itching and irritated anal skin

nipple

are at the level of T4

groin

are at the region of L1

Cartilaginous joints

are separated by fibrocartilaginous discs and are only slightly movable (e.g., the vertebrae). is avascular; it receives nourishment from synovial fluid that circulates during joint movement very stable connective tissue with a slow cell turnover. has a tough, firm consistency yet is flexible cushions the bones and gives a smooth surface to facilitate movement

montgomery glands

are small elevated sebaceous glands found in the areola that secrete a protective lipid material during lactation

cartilage

are specialized forms of connective tissue

fallopian tubes

are two pliable, trumpet-shaped tubes, 10 cm in length, extending from the uterine fundus laterally to the brim of the pelvis. There they curve posteriorly, their fimbriated ends located near the ovaries.

labia majora

are two rounded folds of adipose tissue extending from the mons pubis down and around to the perineum. After puberty hair covers the outer surfaces of the labia, whereas the inner folds are smooth and moist and contain sebaceous follicles.

decerebrate rigidity

arms stiffly extended, adducted, internally rotated; legs stiffly extended, plantar-flexed

spermatic cord

ascends along the posterior border of the testis and runs through the tunnel of the inguinal canal into the abdomen.

DTR 2

average, normal

Hematuria—

blood in urine or for a color change lasting longer than a day, seek health care A danger sign that warrants further workup may signal glomerulonephritis or cancers of prostate or bladder

red urine

blood in urine; nephritis, cystits; cancer; following prostate surgery

DTR 3

brisker than average, may indicate disease

Chronic pain

can increase anxiety symptoms

abrupt twisting

can injure anterior cruciate ligament

outside injury

can strain or rupture lateral ligament

Inside knee injury

can strain or rupture medial ligament

benign prostatic hyperplasia (BPH)

causes an obstructed urine stream and risk for urinary tract infection (UTI)

Fracture

causes sharp pain that increases with movement

spastic hemiparesis

characteristic appearance: arm is immobile against the body, with flexion of the shoulder, elbow, wrist and fingers and adduction of shoulder, does not swing freely. leg is stiff and extended and circumducts with each step possible causes: UMN lesion of the corticospinal tract (stroke, trauma)

scissors

characteristic appearance: knees cross or are in contact like holding an orange between the thighs. the person uses short steps, and walking requires effort possible causes: paraparesis of legs, MS

short leg

characteristic appearance: leg length discrepancy > 2.5 cm, vertical telescoping of affected side which dips as person walks, appearance of gait varies, depending on amount of accompanying muscle dysfunction possible causes: congenital dislocated hip, acquired shortening from disease trauma

parkinsonian (festinating)

characteristic appearance: posture is stooped, trunk is pitched forward, elbows/hips/knees are flexed, steps are short and shuffling, hesitation to begin walking and difficult to stop suddenly, the person holds the body rigid, walks and turns body as one fixed unit, difficulty with any change in direction possible causes: parkinsonism

steppage or footdrop

characteristic appearance: slapping quality looks as if walking up stairs and finding no stair there. lifts knee and foot high and slaps it down hard and flat to compensate for footdrop possible causes: weakness of peroneal and anterior tibial muscles, caused by LMN lesion at spinal cord (poliomyelitis)

cerebellar ataxia

characteristic appearance: staggering, wide based gait, difficulty with turns, uncoordinated movement with positive romberg sign possible causes: alcohol or barbiturate effect on cerebellum, cerebellar tumor, MS

wadding

characteristic appearance: weak hip muscles so when the person take a step the opposite hip drops which allows compensatory lateral movement of pelvis. often the person also has marked lumbar lordosis and a protruding abdomen possible causes: hip girdle muscle weakness caused by muscular dystrophy dislocation of hips

acute compression of the spinal cord

characteristics: acute spinal cord compression yields symmetric loss of sensation under a circumferential boundary possible causes: fractured vertebrae or movement of bone fragments, disk herniation, and movement of vertebral bodies

cortex lesion

characteristics: because pain, vibration, and crude touch are mediated by the thalamus little loss of these sensory function occurs with a cortex lesion possible causes: cerebral cortex, parietal lobe lesion (stroke)

Spinal Cord Hemisection (Brown-Sequard Syndrome)

characteristics: injury to one half of the cord causing contralateral loss of pain and temperature starting one to two segments below level of lesion. possible causes: meningioma, neurofibroma, cervical spondylosis, MS

thalamus

characteristics: loss of all sensory modalities on the face, arm, and leg on side contralateral to lesion also pupil miosis and aphasia possible causes: vascular occlusion (stroke)

individual nerves or roots

characteristics: radiculopathy causes a decrease or loss of all sensory modalities in a dermatome pattern. area of sensory loss corresponds to distribution of involved nerve possible causes: cervical radiculopathy, carpal tunnel syndrome, trauma, vascular occlusion

hemorrhoid.

chronic increased venous pressure, the vein may enlarge, forming a

pale yellow urine

clear, watery with excess liquids; acute viral hepatitis, cirrhosis

cyclic pain

common with normal breasts, oral contraceptives, and benign breast (fibrocystic) disease

flaccid quadriplegia

complete loss of muscle tone and paralysis of all four extremities, indicating completely nonfunctional brainstem

Bulge Sign

confirms the presence of small amounts of fluid as you try to move the fluid from one side of the joint to the other. Firmly stroke up on the medial aspect of the knee 2 or 3 times to displace any fluid. Tap the lateral aspect. Watch the medial side in the hollow for a distinct bulge from a fluid wave. Normally none is present

The collateral ligaments

connect the joint at both sides; they give medial and lateral stability and prevent dislocation.

glandular tissue

contains 15 to 20 lobes radiating from the nipple and these are composed of lobules in each are clusters of alveoli that produce milk each empties into a lactiferous duct which form a collecting system converging toward the nipple where the ducts can form ampullae or lactiferous sinuses behind the nipple to serve as a reservoir for storing milkd

rectum

contains only autonomic nerves, numerous somatic sensory nerves are present in the anal canal and external skin; therefore a person feels sharp pain from any trauma to the anal area. rectum, which is 12 cm long, is the distal portion of the large intestine. It extends from the sigmoid colon, at the level of the 3rd sacral vertebra, and ends at the anal canal. Just above the anal canal dilates and turns posteriorly, forming the rectal ampulla

elbow joint

contains the three bony articulations of the humerus, radius, and ulna of the forearm. hinge action moves the forearm (radius and ulna) on one plane, allowing flexion and extension. muscles are the biceps and brachioradialis for flexion, and the triceps and brachialis for extension

cremaster muscle

controls the size of the scrotum by responding to ambient temperature. to keep the testes at 3° C below abdominal temperature, the best temperature for producing sperm. When it is cold, the muscle contracts, raising the sac and bringing the testes closer to the body to absorb heat necessary for sperm viability. When it is warmer, the muscle relaxes, the scrotum lowers, and the skin looks smoother.

Direct Inguinal hernia

course: Directly behind and through external inguinal ring, above inguinal ligament; rarely enters scrotum clinical symptoms and signs: Usually painless; round swelling close to the pubis in area of internal inguinal ring; easily reduced when supine frequency: Less common; occurs most often in men older than 40 years, rare in women cause: Acquired weakness; brought on by heavy lifting, muscle atrophy, obesity, chronic cough, or ascites

Indirect Inguinal hernia

course: Sac herniates through internal inguinal ring; can remain in canal or pass into scrotum clinical symptoms and signs: Pain with straining; soft swelling that increases with increased intra-abdominal pressure; may decrease when lying down frequency: Most common; 60% of all hernias More common in infants <1 year and males 16 to 20 years of age cause: Congenital or acquired

Femoral hernia

course: Through femoral ring and canal, below inguinal ligament, more often on right side clinical symptoms and signs: Pain may be severe; may become strangulated frequency: Least common, 4% of all hernias; more common in women cause: Acquired; due to increased abdominal pressure, muscle weakness, or frequent stooping

peritoneum

covers only the upper two-thirds of the rectum. male the anterior part reflects down to within 7.5 cm of the anal opening, forming the rectovesical pouch and then covers the bladder female this is termed the recto-uterine pouch and extends down to within 5.5 cm of the anal opening.

he prostatic growth

creates bladder outlet obstruction because it constricts the urethra. This impedes urine output like putting a clamp on a garden hose.

The cruciate ligaments (not shown)

crisscross within the knee; they give anterior and posterior stability and help control rotation.

hypoalgesia

decreased pain sensation

hypoesthesia

decreased touch sensation

hammertoe

deformities in the 2nd, 3rd, 4th, and 5th toes that include hyperextension of the metatarsophalangeal joint and flexion of the proximal interphalangeal joint.

hormonal failure, anorexia nervosa, or severe malnutrition.

delayed development of breasts is seen with

grade 5

description: Full ROM against gravity, full resistance % normal: 100 assessment: normal

grade 4

description: Full ROM against gravity, some resistance % normal: 75 assessment: good

grade 3

description: Full ROM with gravity % normal: 50 assessment: fair

grade 2

description: Full ROM with gravity eliminated (passive motion) % normal: 25 assessment: poor

grade 0

description: No contraction % normal: 0 assessment: zero

grade 1

description: Slight contraction % normal: 10 assessment: trace

rigidity

description: constant state of resistance (lead pipe rigidity); resists passive movement in any direction; dystonia associated with: injury to extrapyramidal motor tract (basal ganglia with parkinsonism)

fibrous joints

the bones are united by interjacent fibrous tissue or cartilage and are immovable (e.g., the sutures in the skull).

flaccidity

description: decreased muscle tone, muscle feels limp/soft/and flabby, muscle is weak and easily fatigued; feels like a rag doll associated with: lower motor neuron injury anywhere from the anterior horn cell in the spinal cord to the peripheral nerve (peripheral neuritis, poliomyelitis, Guillain Barre syndrome); early stroke and spinal cord injury are flaccid at first

spasticity

description: increased tone; increased resistance to passive lengthening; then may suddenly give way (clasp-knife phenomenon) like a pocket knife sprung open associated with: upper motor neuron injury to corticospinal motor tract (paralysis with stroke develops spasticity days or weeks after incident) is an early sign of cerebral palsy after releasing flexed knees, legs will quickly extend and adduct even to a scissoring motion when present

cogwheel rigidity

description: type of rigidity in which the increased tone is released by degrees during passive range of motion so it feels like small, regular jerks associated with: parkinsonism

Hesitancy

difficulty starting urination

DTR 1

diminished, low normal, or occurs with reinforcement

Solid tissue and blood

do not transilluminate (e.g., hernia, epididymitis, or tumor)

Serous fluid

does transilluminate and shows as a red glow (e.g., hydrocele or spermatocele)

pyimosis

during a physical examination the nurse finds that a male patients foreskin is fixed and tight and will not retract over the glans. the nurse recognizes that this condition is

gynecomastia

during adolescence it is common for the breast tissue to enlarge temporarily and may reappear in the aging male resulting from testosterone deficiency also occurs with use of anabolic steroids, some medications, cirrhosis, and other diseases

rectal prolapse

during an examination a nurse asks the patient to perform the valsalva maneuver and notices that the patient has a moist, red , doughnut shaped protrusion from the anus. the nurse knows that this finding is consistent with a

elevate her head and

during the examination portion of a patients visit she will be it lithotomy position. which statement reflects something that the nurse can do to make this position more comfortable for the female patient?

kyphosis

excessive outward curvature of the spine, causing hunching of the back.

corpus spongiosum

expands into a cone of erectile tissue, the glans.

tail of spence

extension of breast tissue into the axilla

the vulva, or pudendum

external genitalia are called

supernumerary nipple

extra nipple

urgency

feeling the need to urinate immediately

infants dev comp bowels

first stool passed by the newborn is dark green meconium and occurs within 24 to 48 hours of birth, indicating anal patency. From that time on the infant usually has a stool after each feeding infant passes stools by reflex. Voluntary control of the external anal sphincter cannot occur until the nerves supplying the area have become fully myelinated, usually around 1.5 to 2 years of age. Toilet training usually starts after age 2 years. male puberty the prostate gland undergoes a very rapid increase to more than twice its prepubertal size. During young adulthood its size remains fairly constant.

bladder cancer

fourth most common cause of cancer in men Smoking is the most common risk factor, Other risk factors include occupational exposure to aniline dyes and other chemicals used in the textile, paint, plastic, printing, and rubber industries initial sign is painless hematuria

Fluid retention

from mild heart failure or varicose veins produces nocturia because recumbency at night mobilizes fluid.

tanner stage 3

the breast and areola enlarge the nipple is flush with the breast surface

amber urine

gold or concentrated with dehydration; some laxatives; food or supplements with b complex vitamins

Clostridium difficile

has explosive diarrhea.

Fissure"

has painful bowel movements like "shards of glass.

opisthotonos

head arched back, stiffness of neck, and extension of arms and legs occurs with meningeal or brainstem irritation and kernicterus

subacromial bursa

helps during abduction of the arm so that the greater tubercle of the humerus moves

Abnormalities in the scrotum:

hernia, tumor, orchitis, epididymitis, hydrocele, spermatocele, varicocele

central acillary nodes

high up in the middle of the axilla, over the ribs and serratus anterior muscle. these receive lymph from the other three groups of nodes

plane of movement

horizontal, vertical, rotary or combination

Straight Leg Raising or Lasègue Test is positive

if it reproduces or worsens sciatic pain and if person resists further leg elevation. This strongly suggests herniated disc and more so if person has increased pain on dorsiflexion of the foot.

(Ottawa knee rules)

if pain is experienced at fibula head or patella, or if patient is over age 55 years obtain x-ray if the patient is unable to flex knee to 90 degrees or unable to bear weight for 4 steps

L4

imaginary line connecting the highest point on each iliac crest crosses

the sacrum

imaginary line joining the two symmetric dimples that overlie the posterior superior iliac spines crosses

Cloudy urine

in urinary tract infection

astereognosis

inability to identify object correctly occurs in sensory cortex lesions (stroke)

dysdiadochokinesia

inability to perform rapid alternating movements that occurs with cerebellar disease

Colorectal cancer (CRC)

incidence rates are higher in Alaska Natives and African Americans when compared to whites, and lower in Asian/Pacific Islanders. Also, rates are 30% to 40% higher in men than in women. more effective screening, early detection, and treatment helped to increase 5-year survival rates. relate to screening and treatment differences that occur along racial/ethnic lines and to insurance status. CRC incidence in those over 50 years has declined by about 5% but increased in those under 50 years by 22%. Similarly, death rates decreased by 34% in those over 50 years but increased by 13% in those under 50 years. Recommendations include beginning screening at age 50 for those at average risk but earlier with a family history of CRC. Hereditary factors that increase CRC risk include family history, as mentioned, inherited genetic Lynch syndrome (hereditary nonpolyposis colorectal cancer [HNPCC]), and familial adenomatous polyposis (FAP), as well as a personal history of chronic inflammatory bowel disease (ulcerative colitis or Crohn disease) or type 2 diabetes.

male genital structures

include the penis and scrotum externally and the testis, epididymis, and vas deferens internally.

"Sexual minority"

includes those who self-identify as gay if male; lesbian if female; bisexual when sexually attracted to both males and females; transgender when having an innate, deep-seated knowledge that their own orientation differs from their birth assignment

hyperalgesia

increased pain sensation

hypertrophy

increased size and strength that occurs with isometric exercise

hyperesthesia

increased touch sensation

Smoking

increases bone loss and risk of fracture in older women; moderate-to-heavy alcohol drinking increases falls risk

strict program of regular high-dose exercises

increases bone strength and reduces fracture risk

Pustules

indicate secondary infection of diaper rash

Clay color

indicates absent bile pigment: biliary cirrhosis, gallstones, alcoholic or viral hepatitis

Proteinuria

indicates glomerular disease in the nephron.

Tendonitis

inflammation of a tendon is worse in the morning, improves during the day.

pregnancy

inspection: single curve, umbilicus protruding, breasts engorged auscultation: fetal heart tones, bowel sounds diminished percussion: tympany over intestines, dull over enlarging uterus palpation: uterine fundus, fetal parts, fetal movements

tic

involuntary, compulsive, repetitive twitching of a muscle group (wink, grimace, head movement, shoulder shrug) due to neurologic cause (tardive dyskinesias, Tourette syndrome) or a psychogenic cause (habit tic)

Plantar Fasciitis

is a band of connective tissue that extends lengthwise from the medial tubercle of the heel to the metatarsal heads and the five proximal phalanges of the toes. An inflammatory response to repetitive microtrauma to this fascia is the most frequent cause of heel pain. Risk factors include obesity, high-arched foot, running, standing long periods on hard flooring, or recent activity changes. Pain is unilateral, "throbbing, searing, or piercing," and is localized to the plantar medial part of the heel; it is worse in the morning or after periods of long rest. Ultrasound imaging often aids in diagnosis. It is self-limiting; treatments include rest and oral pain medications or steroids, a 2- to 4-month stretching program, orthotics for shoes, or night splints

shoulder girdle

is a belt of three large bones (humerus, scapula and clavicle), joints, and muscles

Rheumatoid Arthritis (RA)

is a chronic inflammatory pain condition that is possibly started by an autoimmune response, inflammatory event, or infection. It occurs 2.5 times more in women than in men; its peak is ages 30 to 60 years although it can occur at any age. The inflammation of synovial tissues, hyperplasia, and swelling lead to fibrosis, cartilage and bone destruction, which limit motion and show as deformity. Joint involvement is symmetric and bilateral, with heat, redness, swelling, and painful motion of affected joints. symptoms include fatigue, weakness, anorexia, weight loss, low-grade fever, and lymphadenopathy. carries increased cardiovascular risk of heart attack and stroke. pain is worse in the morning when arise in which movement decreases pain stiffness occurs in the morning and after rest periods

urethra

is a conduit for both the genital and the urinary systems. transverses the corpus spongiosum, and its meatus forms a slit at the glans tip

past-pointing

is a constant deviation to one side

hydrocele

is a cystic collection of serous fluid in the tunica vaginalis, surrounding the testis.

frenulum

is a fold of the foreskin extending from the urethral meatus ventrally.

scrotum

is a loose protective sac, which is a continuation of the abdominal wall. After adolescence the scrotal skin is deeply pigmented and has large sebaceous follicles.

Acute Gout

is a painful inflammatory arthritis characterized by excess uric acid in the blood and deposits of urate crystals in the joint space. Acute episodes are triggered by surgery, trauma, diuretics, alcohol intake. Episodes are characterized by redness, swelling, heat, and extreme pain such as a continuous throbbing. Increased prevalence in obesity, metabolic syndrome, hypertension, hyperlipidemia

single transverse crease

is a palmar crease that occurs with Down syndrome, accompanied by short broad fingers, incurving of little fingers, and low-set thumbs.

uterus

is a pear-shaped, thick-walled, muscular organ. It is flattened anteroposteriorly, measuring 5.5 to 8 cm long by 3.5 to 4 cm wide and 2 to 2.5 cm thick. It is freely movable, not fixed, and usually tilts forward and superior to the bladder

groin

is a potential spot for hernia

hallux valgus

the distal part of the great toe is directed away from the body midline

Dimpling The shallow dimple (also called a skin tether)

is a sign of skin retraction. Cancer causes fibrosis, which contracts the suspensory ligaments. The dimple may be apparent at rest, with compression, or with lifting of the arms. Also note the distortion of the areola here as the fibrosis pulls the nipple toward it.

clitoris

is a small, pea-shaped erectile body, homologous with the male penis and highly sensitive to tactile stimulation.

aura

is a subjective sensation that precedes a seizure and it could be auditory, visual, or motor

hymen

is a thin, circular or crescent-shaped fold that may cover part of the vaginal orifice or may be absent completely.

combined length of the anal canal and the rectum

is about 16 cm in the adult. The average length of the examining finger is from 6 cm to 10 cm, bringing many rectal structures within reach.

paresthesia

is an abnormal sensation such as tingling and burning

Crepitation

is an audible and palpable crunching or grating that accompanies movement. It occurs when the articular surfaces in the joints are roughened, as with RA

Circumcision

is an elective surgical procedure to remove all or part of the foreskin (prepuce) from the penis Medical benefits of male circumcision include a reduced risk of acquiring HIV infection through heterosexual contact. reduced risk of urinary tract infections in infancy and in adults a reduced risk of STIs such as human papillomavirus (HPV) infection, herpes simplex virus, and genital ulcer disease in men, and a decreased risk of bacterial vaginosis and trichomoniasis in female partners Most risks are minor and treatable: pain, bleeding, swelling, or inadequate skin removal. These include dorsal penile nerve block and a lidocaine-prilocaine cream (EMLA)

bursa

is an enclosed sac filled with viscous synovial fluid, much like a joint are located in areas of potential friction (e.g., subacromial bursa of the shoulder, prepatellar bursa of the knee) and help muscles and tendons glide smoothly over bone.

nuchal rigidity

is an extreme resistance to any direction of head movement and occurs with inflammation of the meninges due to meningitis, bleeding, or tumor

hyperplasia

is an imbalance between cell proliferation and programmed cell death (apoptosis)

Paralytic ileus

is an intestinal obstruction caused by reduced motility following bowel manipulation during surgery, electrolyte imbalance, wound infection, or by the effects of medication

Reinforcement

is another technique to relax the muscles and enhance the response

Incontinence

is any involuntary leaking of urine.

Ankylosing Spondylitis (AS)

is chronic inflamed vertebrae (spondylitis) that in extreme form leads to bony fusion of vertebral joints (ankyloses). It affects the spine, pelvis, and thoracic cage, and is characterized by inflammatory back pain that is dull and deep in lower back or buttocks. It also has morning back stiffness that lasts ≥30 minutes and decreases with activity, nighttime awakening with pain, age at onset ≤45 years. It affects males by a 2 : 1 ratio, beginning in late adolescence or early 20s. Spasm of paraspinal muscles pulls spine into forward flexion, obliterating cervical and lumbar curves. Thoracic curve exaggerated into single kyphotic rounding. Also includes flexion deformities of hips and knees as they compensate for spinal flexion

Normal urine

is clear and slightly acidic with a pH range of 4.5 to 8.0. There is little or no protein, no glucose, and fewer than 5 red blood cells (RBCs) or white blood cells (WBCs) per high-powered field in the microscope.

penis

is composed of three cylindric columns of erectile tissue: the two corpora cavernosa on the dorsal side and the corpus spongiosum ventrally

Constipation

is decrease in BM frequency, with difficult passing of very hard, dry stools

Chronic kidney disease (CKD)

is determined by blood tests, urinalysis, and imaging studies that show decreased kidney function or kidney damage lasting 3 months or longer. can lead progressively and irreversibly to end-stage renal disease (ESRD), when the person survives only by kidney transplant or dialysis. two main causes, hypertension and diabetes there was a higher proportion of adverse health-related behaviors (current smoking, high alcohol intake, high sedentary time, unhealthy diet), a higher proportion of comorbid conditions (diabetes, hypertension, obesity, hypercholesterolemia), as well as more people having no health insurance and no routine health care visits in the past year.

Structural scoliosis

is fixed; the curvature shows both on standing and on bending forward. Note rib hump with forward flexion. When the person is standing, note unequal shoulder elevation, unequal scapulae, obvious curvature, and unequal hip level

Functional scoliosis

is flexible; appears with standing and disappears with forward bending. It may compensate for other abnormalities (leg length discrepancy).

Bone

is hard, rigid, and very dense. are specialized forms of connective tissue. Its cells are continually turning over and remodeling

Fecal incontinence

is leaking of solid or liquid stool involuntarily.

positive romberg sign

is loss of balance that occurs when closing the eyes. occurs with cerebellar ataxia (MS, alcohol intoxication), loss of proprioception, and loss of vestibular function

MTF

is males transitioning to females.

Lordosis

is marked with muscular dystrophy and rickets

Serum analysis of kidney function

is measured with creatinine, an end-product of muscle metabolism Normal levels range from 0.7 to 1.5 mg/dL and are fairly constant from day to day

Noninflammatory diarrhea

is milder and usually viral

inflammatory

is more severe and bacterial; associated with travel, foodborne illness, fever, abdominal pain. Check for dehydration (decreased urine, thirst, dizziness, change in mental status)

E. coli

is most frequent cause of traveler's diarrhea.

sigmoid colon

is named from its S-shaped course in the pelvic cavity. It extends from the iliac flexure of the descending colon and ends at the rectum. It is 40 cm long and is accessible to examination only through the colonoscope. The flexible fiberoptic scope provides a view of the entire mucosal surface of the sigmoid and the colon.

Encopresis

is persistent passing of stools into clothing in a child older than 4 years, at which age continence would be expected

vaginal orifice

is posterior to the urethral meatus. It appears either as a thin median slit or a large opening with irregular edges, depending on the presentation of the membranous hymen.

Flatfoot (pes planus)

is pronation, or turning in, of the medial side of the foot. The young child may look flatfooted because the normal longitudinal arch is concealed by a fat pad until age 3 years. When standing begins, the child takes a broad-based stance, which causes pronation. Thus pronation is common between 12 and 30 months. You can see it best from behind the child, where the medial side of the foot drops down and in.

Ballottement of the Patella

is reliable when larger amounts of fluid are present. Use your left hand to compress the suprapatellar pouch to move any fluid into the knee joint. With your right hand push the patella sharply against the femur. If no fluid is present, the patella is already snug against the femur.

inability to tandem walk

is sensitive for an upper motor neuron lesion such as MS and for acute cerebellar dysfunction such as alcohol intoxication

Poor stream

is significant because it may indicate a stricture or neurogenic bladder

Pathologic discharge

is spontaneous, unilateral, has blood, or is clear, serous; it is sometimes associated with a mass

hip joint

is the articulation between the cup-shaped acetabulum and the head of the femur. has somewhat less ROM than the shoulder, but it has more stability as befits its weight-bearing function. stability is the result of powerful muscles that spread over the joint, a strong fibrous articular capsule, and the very deep insertion of the head of the femur. muscles include the anterior flexor (iliopsoas), the posterior extensor (gluteus maximus), adductor muscles that swing the thigh toward the midline, and abductor muscles that swing it away.

midcarpal joint

is the articulation between the two parallel rows of carpal bones. It allows flexion, extension, and some rotation

wrist, or radiocarpal joint,

is the articulation of the distal radius (on the thumb side) and a row of 8 carpal bones. condyloid action permits movement in two planes at right angles: flexion and extension, and side-to-side deviation.

glenohumeral joint

is the articulation of the humerus with the glenoid fossa of the scapula ball-and-socket action allows great mobility of the arm on many axes, more than any other joint. joint is enclosed by a group of four powerful muscles and tendons that support and stabilize it. Together these are called the rotator cuff. four muscles are the SITS muscles (supraspinatus, infraspinatus, teres minor, and subscapularis). form a cover around the head of the humerus. They rotate the arm laterally and stabilize the head of the humerus against the shallow glenoid fossa of the scapula.

The temporomandibular joint (TMJ)

is the articulation of the mandible and the temporal bone feel it in the depression anterior to the tragus of the ear. permits jaw function for speaking and chewing allows three motions: (1) hinge action to open and close the jaws; (2) gliding action for protrusion and retraction; and (3) gliding for side-to-side movement of the lower jaw.

The ankle, or tibiotalar joint,

is the articulation of the tibia, fibula, and talus. is a hinge joint, limited to flexion (dorsiflexion) and extension (plantar flexion) on one plane. Landmarks are two bony prominences on either side: the medial malleolus and the lateral malleolus. Strong, tight medial and lateral ligaments extend from each malleolus onto the foot. These help the lateral stability of the ankle joint, although they may be torn in eversion or inversion sprains of the ankle. calcaneus (heel) is under the talus and points posteriorly

knee joint

is the articulation of three bones—the femur, the tibia, and the patella (kneecap)—in one common articular cavity. largest joint in the body and is complex. It is a hinge joint, permitting flexion and extension of the lower leg on a single plane. There is no overlying fat or muscle; only the ligaments hold the tibia and femur in place, making the knee vulnerable to injury. synovial membrane is the largest in the body. It forms a sac at the superior border of the patella, called the suprapatellar pouch (or bursa), which extends up as much as 6 cm behind the quadriceps muscle. Two wedge-shaped cartilages, called the medial and lateral menisci, cushion the tibia and femur. joint is stabilized by two sets of ligaments. The cruciate ligaments and The collateral ligaments they give medial and lateral stability and prevent dislocation. large quadriceps muscle, which you can feel on your anterior and lateral thigh

hyperreflexia

is the exaggerated reflex seen when the monosynaptic reflex arc is released from the usually inhibiting influence of higher cortical levels. This occurs with upper motor neuron lesions (e.g., a brain attack).

bunion

is the inflamed bursa that forms at the pressure point. The great toe loses power to push off while walking; this stresses the 2nd and 3rd metatarsal heads, and they develop calluses and pain. Chronic sequelae include corns, calluses, hammertoes, and joint subluxation

inguinal area, or groin,

is the juncture of the lower abdominal wall and the thigh

spinal cord

is the long, cylindric structure of nervous tissue ad big around as your little finger occupies the upper 2/3 of the vertebral canal from the medulla to lumbar vertebrae L1-L2 mediates reflexes of posture control, urination, and pain response its nerve cell bodies are arranged in a butterfly shape with anterior and posterior horns

Prostate cancer (PC)

is the most frequently diagnosed cancer in men. are heterogeneous; many are indolent, nonlethal and slow growing; some are aggressive. Known risk factors include increasing age, African ancestry, a family history of PC (brother or father), and inherited mutations of BRCA1 and BRCA2 genes. The risk of PC is 74% higher in African-American and African-Caribbean men. may be related to inherited genetic factors. Other risk factors affect prostate cancer progression once it occurs and is treated. Not smoking, keeping a healthy body weight, and maintaining regular vigorous exercise seem to delay prostate cancer progression. some foods (tomatoes rich in the antioxidant lycopene, broccoli, cauliflower, and other cruciferous vegetables) and healthy sources of vegetable fats (olive oil and nuts) may reduce the risk of cancer progression. Obesity is strongly associated with an increased risk of aggressive PC and is associated with PC progression and mortality. Mechanisms here may be insulin and insulin-like growth factors, change in levels of sex hormones, or fat cell (adipokine) signaling. Men with metastatic PC are more likely to have a lower socioeconomic status (SES), to lack insurance or have Medicaid, and to be of black or Hispanic race/ethnicity. associated with lack of access to preventive PSA screening, lack of high-quality insurance coverage, and barriers to full evaluation. he American Urological Association recommends that men of African ancestry and men with a family history of prostate cancer should be offered the blood test of PSA screening. Further, they recommend that men between ages 55 to 69 years of average risk and with a life expectancy of >10 years should have counseling with their provider on the risks and benefits of PSA screening; then they may have the test if they so choose.

anal canal

is the outlet of the gastrointestinal (GI) tract; it is about 3.8 cm long in the adult. It is lined with modified skin (having no hair or sebaceous glands) that merges with rectal mucosa at the anorectal junction.

joint (or articulation)

is the place of union of two or more bones. are the functional units of the musculoskeletal system because they permit the mobility needed for activities of daily living (ADLs)

Polydactyly

is the presence of extra fingers or toes.

internal sphincter

is under involuntary control by the autonomic nervous system

Myalgia

is usually felt as cramping or aching muscle pain

Syndactyly

is webbing between adjacent fingers or toes

the frenulum, or fourchette

labia minora are joined posteriorly by a transverse fold,

termed the vestibule

labial structures encircle a boat-shaped space, or cleft,

cerebellar disease

lack of coordination, heel falls off shin occurs with

adipose tissue

layers of subcutaneous and retromammary fat actually provide most of the bulk of the breast

breats

lie anterior to the pectoralis major and serratus anterior muscles located bw 2nd and 6th ribs

female the uterine cervix

lies in front of the anterior rectal wall and may be palpated through it

prostate gland

lies in front of the anterior wall of the rectum and 2 cm behind the symphysis pubis. It surrounds the bladder neck and urethra and has 15 to 30 ducts that open into the urethra

fibroadenoma

likely age: 15-30 years, can occur up to 55 years shape: round, lobular consistency: usually firm, rubbery demarcation: well demarcated, clear margins number: usually single mobility: very mobile, slippery tenderness: usually none skin retraction: none pattern of growth: grows quickly and constantly risk to health: benign-diagnose by ultrasound and biopsy; may spontaneously resolve in women <20 years

benign breast disease

likely age: 30 - 55 years; decreases after menopause shape: round, lobular consistency: firm to soft, rubbery demarcation: well demarcated number: usually multiple, may be single mobility: mobile tenderness: tender; usually increases before menses; may be noncyclic skin retraction: none pattern of growth: size may increase or decrease rapidly; cyclic with menstrual periods risk to health: benign, although general lumpiness may mask other cancerous lump

cancer

likely age: 30 - 80 years, risk increases after 50 years shape: irregular, star shaped consistency: firm to stony hard demarcation: poorly defined number: single mobility: fixed tenderness: usually none, can be tender skin retraction: usually pattern of growth: grows contantly risk to health: serious, needs early treatment

tea urine

liver disease, especially with pale stools, jaundice myoglobinuria some medications or food dyes blood in urine

Nipple Retraction.

looks flatter and broader, like an underlying crater. A recent suggests cancer, which causes fibrosis of the whole duct system and pulls in the nipple. It also may occur with benign lesions such as ectasia of the ducts. Do not confuse with the normal long-standing type of nipple inversion, which has no broadening and is not fixed.

the anal valve

lower end of each column is a small crescent fold of mucous membrane,

the vas deferens.

lower part of the epididymis is continuous with a muscular duct, This duct approximates with other vessels (arteries and veins, lymphatics, nerves) to form the spermatic cord

nucleus pulposus

made of soft, semifluid, mucoid material that has the consistency of toothpaste in the young adult

Swelling

may be excess joint fluid (effusion), thickening of the synovial lining, inflammation of surrounding soft tissue (bursae, tendons), or bony enlargement

Pop

may mean tear in ligament or fracture

ulceration

may produce a stricture, shown by a pinpoint meatus and a narrow stream.

Fecal impaction

may warrant rectal palpation by an experienced clinician

true leg length,

measure between fixed points, from the anterior iliac spine to the medial malleolus, crossing the medial side of the knee

apparent leg length,

measure from a nonfixed point (the umbilicus) to a fixed point (medial malleolus) on each leg.

Creatinine

measures glomerular filtration rate (GFR). The GFR is the product of filtration pressure in the glomeruli, normally 125 mL/min. When the GFR decreases by half the serum creatinine level doubles, indicating decreased kidney function

Specific gravity

measures the concentration of urine, from very dilute at 1.003 to concentrated at 1.030

Blood urea nitrogen (BUN)

measures urea, an end-product of protein metabolism. It measures 10 to 20 mg/dL and rises with dehydration or an increase in protein intake. rises with decreased kidney function but is less specific.

blue urine

medication side effect (amitriptyline, indocin); foods: asparagus; dye after prostate surgery

orange urine

medications rifampin for meningitis, pyridium, warfarin/coumadin; some foods, food dyes, laxatives; dehydration; jaundice (bilirubinemia)

sucking reflex

method of testing: touch oral region abnormal response (reflex is present): sucking movement of lips, tongue, jaw, swallowing indications: same as for snout reflex

linea alba

midline tendinous seam joining the abdominal muscles

yellow urine

natural yellow is urochrome excretion, a pigment in blood; bright neon yellow with vitamin supplements;

called witch's milk.

neonates may secrete a clear or white fluid This is not significant and is resolved within a few days to a few weeks.

DTR 0

no response

inferior angle of the scapula

normally is at the level of the interspace between T7 and T8

inframammary ridge

normally you may feel a firm transverse ridge of compressed tissue in the lower quadrants it is especially noticeable in large breasts.

dislocated hip

the head of the femur is not cupped in the acetabulum but rests posterior to it

Increased WBCs

occur with UTI

increased RBCs

occur with UTI, glomerulonephritis, renal calculi, trauma, and cancer.

seizures

occur with epilepsy, a paroxysmal disease characterized by altered or loss of consciousness, involuntary muscle movements, and sensory disturbances

Male hypogonadism (testosterone deficiency)

occurs in 40% of men after age 45 years and may present as depression, fatigue, loss of muscle mass or strength, or decreased libido, although these symptoms occur also with obesity, diabetes, metabolic syndrome

Nocturia

occurs together with frequency and urgency in urinary tract disorders. Other origins: cardiovascular, habitual, diuretic medication. or fluid ingestion 3 hours before bedtime; coffee and alcohol especially have a diuretic effect.

Red blood

occurs with GI bleeding, local bleeding around the anus, with colon and rectal cancer.

coarse fasciculation

occurs with cold exposure or fatigue and is not significant

Low back pain

occurs with degenerative discs, osteoporosis, lumbar stenosis, or is nonspecific

loss of vibration

occurs with diabetes and alcoholism

Diarrhea

occurs with gastroenteritis, colitis, irritable colon syndrome. Risks include: child-care center, eating raw shellfish, undercooked meat or eggs, contaminated water Check for dehydration (decreased urine, thirst, dizziness, change in mental status) is a side effect of antibiotics

Urethral discharge

occurs with infection

Increased tone

occurs with inflammation and anxiety

Sudden buckling, or "giving way,"

occurs with ligament injury, which causes weakness and instability

Flatulence

occurs with some medications, nutritional supplements, Crohn disease, certain foods

malstalgia

occurs with trauma, inflammation, infection, and benign breast disease

Swelling and redness

of olecranon bursa are localized and easy to observe because of the close proximity of the bursa to skin

Sublaxation

of the elbow shows the forearm dislocated posteriorly

lymphatics

of the penis and scrotal surface drain into the inguinal lymph nodes, whereas those of the testes drain into the abdomen

tanner stage 5 mature breast

only the nipple protrudes the areola is flush with the breast contour (the areola may continue as a secondary mound in some normal women)

quadriplegia

paralysis in all four extremities

In carpal tunnel syndrome

percussion of the median nerve produces burning and tingling along its distribution, which is a positive Tinel sign

metacarpophalangeal (MCP) and the interphalangeal joints (DIP and PIP)

permit finger flexion and extension. The flexor tendons of the wrist and hand are enclosed in synovial sheaths

subtalar joint

permits inversion and eversion of the foot. The foot has a longitudinal arch, with weight-bearing distributed between the parts that touch the ground—the heads of the metatarsals and the calcaneus (heel). Muscles include the gastrocnemius and toe flexors for plantar flexion and the anterior tibialis and toe extensors for dorsiflexion.

tanners developmental stage 5

pubic hair: Growth spread over medial thighs, although not yet up toward umbilicus; after puberty, pubic hair growth continues until the mid-20s, extending up the abdomen toward the umbilicus penis: Adult size and shape scrotum: Adult size and shape

tanners developmental stage 1

pubic hair: No pubic hair; fine body hair on abdomen (vellus hair) continues over pubic area penis: Preadolescent, size and proportion the same as during childhood scrotum: Preadolescent, size and proportion the same as during childhood

tanners developmental stage 3

pubic hair: Sparse growth over entire pubis; hair is darker, coarser, and curly penis: Penis begins to enlarge, especially in length scrotum: Further enlarged

tanners developmental stage 4

pubic hair: Thick growth over pubic area but not on thighs; hair coarse and curly as in adult penis: Penis grows in length and diameter, with development of glans scrotum: Testes almost fully grown; scrotum darker

visceral (organic) reflex

pupillary response to light and accommodation

radioulnar joints,

radius and ulna articulate with one another at two one at the elbow and one at the wrist. These move together to permit pronation and supination of the hand and forearm.

fasciculation

rapid, continuous twitching of resting muscle or part of muscle without movement of limb which can be seen by clinicians or felt by patient types: fine, coarse

myoclonus

rapid, sudden jerk or a short series of jerks at fairly regular intervals single is normal when the person is falling asleep severe with grand mal seizures

intention tremor

rate varies, worse with voluntary movement as in reaching toward a visually guided target. occurs with cerebellar disease and multiple sclerosis

valves of Houston.

rectal interior has 3 semilunar transverse folds called the These cross one-half the circumference of the rectal lumen. Their function is unclear, but they may serve to hold feces as the flatus passes. The lowest is within reach of palpation, usually on the person's left side—do not mistake for an intrarectal mass.

Straight Leg Raising or Lasègue Test

reproduce back and leg pain and help confirm the presence of sciatica and a herniated nucleus pulposus. Straight leg raising while keeping the knee extended normally produces no pain. Raise the affected leg just short of the point where it produces pain. Then dorsiflex the foot Raise the unaffected leg while leaving the other leg flat. Inquire about the involved side.

the gastrocolic reflex.

response to eating is a wave of peristalsis called

embolic strokes

result from a traveling clot caused by atrial fibrillation or flutter, recent heart attack, growth around prosthetic heart valves, and endocarditis

thrombotic strokes

result from atherosclerotic plaque formation

Denver II test to

screen the fine and gross motor skills for the child's age.

Functional assessment

screens the safety of independent living, the need for home health services, and quality of life

, or rugae

scrotal wall consists of thin skin lying in folds, and the underlying cremaster muscle.

prostate

secretes a thin, milky, alkaline fluid that supports sperm. It is a bilobed structure with a round or heart shape. It measures 2.5 cm long and 4 cm in diameter

intersphincteric groove

separates the internal and external sphincters and is palpable

strength

shoulder abduction, elbow extension, wrist extension, finger abduction, hip flexion, knee flexion, ankle dorsiflexion

corona.

shoulder where the glans joins the shaft is the

urinalysis

shows a color of pale yellow to amber caused by the presence of urochrome pigments

Idiopathic scoliosis

shows at 10 years of age through adolescence during the peak of the growth spurt; usually not progressive and more common in girls

Effusion or synovial thickening

shows first as a bulge or fullness in groove on either side of the olecranon process, and it occurs with gouty arthritis and bursitis

pin worms

the mother of a 5 year old tells the nurse that she noticed her daughter "scratching at her bottom a lot the last few days" during the assessment the nurse finds redness and raised skin in the anal area this is most likely from

adolescent developmental competence male gen system

signs of puberty in the United States begin now at an average of age 9 for African-American boys and age 10 for Caucasians and Hispanics. first sign is enlargement of the testes. Next pubic hair appears, and then penis size increases Tanner's sexual maturity ratings onset of Tanner stage 2 (testes enlargement and pubic hair growth) is now about 2 years earlier for African-American boys and abo1.5 t years earlier for Caucasians may relate to environmental factors such as chemical exposure, diet changes, and less physical activity. sexual minority, mtf, msm Those who lack this support experience high-risk sexual behaviors, drug behaviors, and mental health concerns.

extinction

simultaneously touch both sides of body at same point normally both sensations are felt

anal canal

slants forward toward the umbilicus, forming a distinct right angle with the rectum, which rests back in the hollow of the sacrum

athetosis

slow, twisting, writhing, continuous movement, resembling a snake or worm involves the distal more than the proximal part of the limb occurs with cerebral palsy disappears with sleep

—suggests dermoid sinus

small dimple in the midline—anywhere from the head to the coccyx.

athetoid hand

some fingers are flexed and some are extended

the anal crypt

space above the anal valve (between the columns) is a small recess,

moro reflex

startle infant by jarring crib making a loud noise or supporting head and back in semi sitting position and quickly lowering infant to 30 degrees baby looks as if he or she is hugging a tree; symmetric abduction and extension of arms and legs; fanning fingers and curling of index finger and thumb to C position; infant then brings in both arms and legs present at birth disappears at 1 to 4 months

motor function

strength, coordination, and gait

chorea

sudden, rapid, jerky, purposeless movement involving limbs, trunk, or face. occurs at regular intervals, not rhythmic or repetitive, more convulsive than a tic some are spontaneous, and some initiated all are accentuated by voluntary acts disappears with sleep common with Sydenham chorea and huntington disease

Glycosuria .

suggests hyperglycemia occurring with diabetes

Cloudiness

suggests presence of WBCs, bacteria, casts. Certain drugs or foods can change urine color

the sphincters

surrounded by two concentric layers of muscle,

external sphincter

surrounds the internal sphincter but also has a small section overriding the tip of the internal sphincter at the opening. It is under voluntary control. Except for the passing of feces and gas, the sphincters keep the anal canal tightly closed.

areola

surrounds the nipple for a 1 to 2 cm radius has smooth muscle fibers that cause nipple erection when stimulated

paraplegia

symmetric paralysis of both lower extremities

acute ischemic stroke

symptoms include unilateral facial droop, arm drift, weakness or paralysis on one half of the body, difficulty speaking or understanding speech, confusion, sudden onset of dizziness, loss of balance, clouding of vision

stereognosis

test person's ability to recognize objects by feeling their forms, sizes, and weights

adolescent dev comp male gu sys

the SMR charts, note: (1) enlargement of the testes and scrotum, (2) pubic hair growth, (3) darkening of scrotal color, (4) roughening of scrotal skin, (5) increase in penis length and width, and (6) axillary hair growth.

tanner stage 4

the areola and nipple form a secondary mound over the breast

thelarche

the beginning of breast development that precedes the beginning of menarche by about 2 years

menarche

the beginning of menstruation

DTR 4

very brisk, hyperactive with clonus, indicative of disease

paresis

weakness of muscles rather than paralysis

hemiparesis

weakness on one side of the body

glandular tissue, fibrous tissue, and adipose tissue

what type of tissue makes up breasts tissue

ejaculatory duct

where it joins the duct of the seminal vesicle to form the This duct empties into the urethra

upper outer quadrant

which areas of the breast are most breast tumors located

bone remodeling ,

which is the cyclic process of bone resorption and deposition responsible for skeletal maintenance at sites that need repair or replacement.

two vestibular (Bartholin) glands,

which secrete a clear lubricating mucus during intercourse. Their ducts are not visible but open in the groove between the labia minora and the hymen.

Ortolani maneuver,

which should be done at every professional visit until the infant is 1 year old. With the infant supine, flex the knees holding your thumbs on the inner midthighs and your fingers outside on the hips touching the greater trochanters. Adduct the legs until your thumbs touch. hen gently lift and abduct, moving the knees apart and down so their lateral aspects touch the table. This normally feels smooth and has no sound.

Young MSM

who report unprotected anal intercourse in the previous 6 months are at increased risk for gonorrhea, chlamydia, syphilis, and HIV.

pink urine

with menses; some foods like beets, berries, food dyes; some laxatives; kidney stones; UTI

1. Flexion

—Bending a limb at a joint

14. Depression

—Lowering a body part

12. Retraction

—Moving a body part backward and parallel to the ground

11. Protraction

—Moving a body part forward and parallel to the ground

3. Abduction

—Moving a limb away from the midline of the body

4. Adduction

—Moving a limb toward the midline of the body

7. Circumduction

—Moving the arm in a circle around the shoulder

10. Rotation

—Moving the head around a central axis

8. Inversion

—Moving the sole of the foot inward at the ankle

13. Elevation

—Raising a body part

2. Extension

—Straightening a limb at a joint

5. Pronation

—Turning the forearm so the palm is down

6. Supination

—Turning the forearm so the palm is up

Rome III criteria for constipation:

≤3 stools/wk, straining, lumpy or hard stools, incomplete evacuation, sensation of blockage Risks: older age, women, inactivity.

Expected curvatures (posteriorly)

● Concave cervical spine ● Convex thoracic spine ● Concave lumbar spine ● Convex sacral spine

Pregnancy

● Growing fetus compromising intestinal space ● Slower peristalsis ● Straining increasing the risk of hemorrhoids

OSTOMIES

● Some bowel disorders prevent the expected elimination of stool from the body. Bowel diversions through ostomies are temporary or permanent openings (stomas) surgically created in the abdominal wall to allow fecal matter to pass. ● Ostomies are created in either the large intestine or the small intestine. Colostomies end in the colon, and ileostomies end in the ileum. ◯ End stomas are a result of colorectal cancer or some types of bowel disease. ◯ Loop colostomies help resolve a medical emergency and are temporary. In a loop colostomy, a loop of bowel is supported on the abdomen with a proximal stoma draining stool and a distal stoma draining mucus. It is usually constructed in the transverse colon. ◯ Double-barrel colostomies consist of two abdominal stomas: one proximal and one distal. The proximal stoma drains stool and the distal stoma leads to inactive intestine. After the injured area of the intestine heals, the colostomy is often reversed by reattaching the two ends