Health assessment test 3

2) Objective assessment: exam order

1. inspect 2. auscultate 3. percuss 4. palpate **so we don't alter presence or absence of bowel sounds -use all senses but taste -prep- adequate lighting, everything covered but abdomen, measures to enhance abdominal wall relaxation (urinate, bend knees, soft voice) -stethoscope, small cm ruler, marking pen, alch pad

sources of pain

somatic pain- originates from musculoskeletal tissues or body surface-usually well localized, easy to pinpoint deep somatic pain- blood vessels, joints, tendons, muscles, bone-aching, throbbing cutaneous-from skin or subq tissues-superficial, sharp, burning visceral pain-originates from large internal organs (stomach, intestine, gallbladder, pancreas)-dull, squeezing, cramping

chorea

sudden rapid, jerky, purposeless mvmt involving limbs, trunk, or face -regular intervals, NOT RHYTHMIC OR REPETITIVE -more convulsive than a tic -spontaneous or initiated -all accentuated by voluntary acts -disappears w/ sleep *Sydenham chorea and Huntington disease

polydactyly- extra fingers/toes

syndactyly- webbing fingers/toes

spinal nerve dermatomes

thumb= c6 middle finger= c7 fifth finger= c8 axilla= t1 nipple=t4 umbilicus= t10 groin=L 1 knee= L4

Seizure disorder

time-limited even caused by excessive, hyper synchronous discharge of neurons in brain -may be from cerebral trauma, structural lesions (tumor, blood clot, infection), hyponatremia, acute alch withdrawal, med overdose

skin color, marks on skin of abdomen

-should appear smooth, even color -common pigment variation is striae (stretch marks) silvery, white, jagged marks 1-6cm long -occurs following rapid/prolonged stretching-such as pregnancy and excess weight gain

Special Cases: Altered LOC

-A change in LOC is the EARLIEST and most SENSITIVE indicator of alterations in brain function -Glascow Coma Scale (GCS) The GCS is a quantitative tool that standardizes patient's responses with a numerical value

cranial nerve VI (right and left sides-lateral)

-Abducens -Motor -located in pons/medulla junction -lateral movement of eye (outward) -check 6 cardinal fields of gaze, PERRLA -paralysis of nerve causes inward turning of eye (INTERNAL STRABISMUS) leading to DOUBLE VISION, diplopia on lateral gaze -d/t brainstem tumor/trauma/fracture of orbit

midline

-aorta -small intestine -bladder (if distended) -uterus (if enlarged) -spine

trigeminal neuralgia (tic douloureux) "suicide disease"

-most painful excruciating pain -intense pain along trigeminal nerve often from trauma/infection, but may have unknown etiology -neurontin helps w/pain as well as amitriptyline

extinction

-the ability to recognize only one of the stimuli (when stimuli on both arms) occurs w/ sensory cortex lesion, the stimulus is EXTINGUISHED on the side OPPOSITE TO CORTEX LESION Point location--w/ this type of lesion, light touch sensation may be intact, even though the person can't localize the sensation accurately

abdominal distention- ascites (FLUID)

-single curve, everted umbilicus. Bulging flanks when supine, Taut, glistening skin; recent weight gain, increase in abdominal girth -normal bowel sounds over intestines. Diminished over ascitic fluid -tympany at top where intestines float. Dull over fluid, produces FLUID WAVE and shifting dullness -taut skin and increased intra-abdominal pressure limit palpation

abdominal distention-pregnancy (FETUS)

-single curve, umbilicus protruding. Breasts engorged -fetal heart tones. Bowel sounds diminshed -tympany over intestines, dull over enlarging uterus -fetal parts, fetal movements upon palpation

abdominal distention- air or gas (FLATUS)

-single round curve -depends on cause of gas (decreased or absent bowel sounds w/ ileus or lack of mvmt along bowel); hyperactive w/early intestinal obstruction -tympany over large area -may have muscle spasms of abdominal wall

Left upper (LUQ)

-stomach -left kidney/adrenal gland -spleen -splenic flexure of colon and part of (transverse and descending) -body of pancreas

Lasegue test

-straight leg raising test -reproduce back pain and leg pain and help confirm presence of herniated nucleus pulposus

brachioradialis reflex (C5-C6)

-strike forearm directly 2-3 cm above styloid process of radius -normal= flexion and supinationof forearm

quadriceps reflex (knee jerk)- L2-L4

-strike just below knee -extension of lower leg is expected

triceps reflex (C7-C8)

-strike triceps just above elbow normal response is extension of forearm

Increased ICP

-sudden, unilateral, dilated, nonreactive pupil, papilledema

infant- Allis test

-tests for hip dislocation -compares knee lengths. -flex knees up and scan if tops of knees are at same elevation -if not suggests hip dislocation

infant- ortolani's sign

-tests if hip is dislocated -adduct legs and then gently abduct this normally feels smooth and has no sound -with dislocated hip head of femur is not in acetabulum and sound heard is a "clunk"

The Glasgow Coma Scale (GCS) minimizes the ambiguity of level of consciousness

*Assessment Areas: Eye-opening (1-4) Verbal response (1-5) Motor response (1-6) Total = 3-15 (higher score = higher functioning)

cranial nerves

- Only Optimistic Octopus Tentacles Try And Feel Very Good Vaginally Accessible Hymens -Some Say Money Matters But My Brother Says Big Boobs Matter More

1) first always do SUBJECTIVE DATA (health history questions)

-10% weight gain or weight loss? -appetite -dysphagia...if so what ? -food intolerance -abdominal pain (PQRST) -nausea/vomiting (emesis)-(amount, consistency, odor, appearance/character) -bowel habits-how often? No set healthy bowel movement -abdominal history -medication reconciliation -nutritional assessment

cranial nerve XI (back, neck muscles)

-Accessory (spinal accessory) -motor -located in superior spinal cord -movement of trapezius (moves scapula, turns facet to opp side/pull head back) and sternomastoid muscles (turns head) (neck muscle movement) -test trapezius strength by having pt. shrug shoulders against resistance -test sternocleidomastoid by turning head to each side against resistance -peripheral lesions produce ipsilateral (same side) weakness of SCM, trapezius -central lesions-produce ipsilateral SCM weakness and contralateral trapezius weakness. -paralysis of nerve=prevents rotation of head away from the affected side and drooping of shoulder d/t neck injury, torticollis(neck muscles contract/head twists to one side)

Level of Consciousness (LOC)

-Alert: Easily awakened with minimal stimulation -Lethargic: Drowsy- vigorous stimulation necessary for brief, but appropriate response -Stupor: Sluggish response to aggressive verbal, visual, or painful stimuli -Comatose: Response of reflex motor activity only to painful stimuli -Sternal Rub: Painful Stimuli used with a stuporous or comatose patient

Peripheral nervous system function

-Carries sensory messages TO the central nervous system's sensory receptors -Transmits messages FROM the CNS to the muscles and glands throughout the body Reflex arc Cranial nerves

CNS Pathways

-Crossed representation Left controls right Right controls left -Sensory pathways Spinothalamic tract (anterolateral)- PAIN, TEMP, CRUDE/LIGHT TOUCH Posterior columns- POSITION (PROPRIOCEPTION), VIBRATION, FINE LOCALIZED TOUCH (STEREOGNOSIS) -Motor pathways Corticospinal tract-skilled, purposeful mvmts. Extrapyramidal tracts-subcortical motor fibers maintain muscle tone and control body movements-gross/automatic mvmts like walking Cerebellar system-coordinates movement, equilibrium, posture (occurs at subconscious level)

cranial nerve VII (taste, facial expression)

-Facial (2 facial nerves one for each side of face) -Both -located in Pons/ medulla junction Motor-facial muscles, close eye, labial speech, close mouth Sensory-taste (sweet, salty, sour, bitter) on anterior 2/3 of tongue -saliva and tear secretion -Test by observing bilateral mvmt= smile, frown, show teeth, close eyes tightly, raise eyebrows, puffs cheeks. Press puffed cheeks for equal, bilat evacuation of air -test ability to identify sweet and salty on both sides of tongue -Bell's palsy -loss of taste d/t UMN lesions

cranial nerve IX (taste, throat sensation, gag/swallow)

-Glossopharyngeal (supplies tongue, throat, parotid gland) -both -located in medulla motor-pharynx (phonation or speech sounds and swallowing) sensory-taste on posterior 1/3 of tongue, pharynx (gag reflex) -identify taste on posterior 1/2 of tongue -have client open mouth and say ah -touch back of tongue w/tongue blade-gag reflex problems-result in taste/swallowing

cranial nerve XII (tongue mvmts)

-Hypoglossal -motor -located at brainstem/medulla -movement of tongue (tongue muscles) -inspect tongue in mouth and while protruded for symmetry, tremors, atrophy. Inspect tongue mvmt toward nose and chin -test tongue strength w/ index finger when tongue is pressed against cheek. Evaluate quality of lingual speech sounds (L, T, D- light, tight, dynamite)-should be clear and distinct -paralysis=impairs speech (sounds thick) and causes tongue to deviate toward paralyzed side w/ cranial lesion such as stroke. In time tongue atrophies in size= LMN lesion -wiggle tongue from side to side, @slowed rate- bilateral UMN lesion

Nervous system

-PNS- 12 pairs of cranial nerves, 31 pairs of spinal nerves -CNS-brain and spinal cord

parietal lobe

-POST CENTRAL gyrus-primary center for sensation -

plantar assessment reflex

-Plantar reflex (neg. Babinski)- a curling at the toes pathological response--Babinski sign- absence of descending inhibition-normal in infants, pathological in adults= big toe extends, toes fan out/flex. -indicates Corticospinal (pyramidal tract) disease i.e. stroke, trauma

cerebellar functioning-coordination/skilled movements

-Rapid altering movements (RAM) -Romberg test -tandem walking -Finger-to-finger test and finger-to-nose test, heal-to-shin test

Autonomic Nervous System (regulates the body's internal environment)

-Sympathetic Arises from thoracolumbar segments of spinal cord "Fight-or-flight response" Increase BP, HR Vasoconstricting peripheral blood vessels Inhibiting gastrointestinal peristalsis Dilates bronchi Controls body's response during a perceived threat -Parasympathetic Arises from craniosacral segments "Rest and Digest" Decreases HR, BP, respiratory rate Stimulates gastrointestinal peristalsis Muscles relax Pupils constrict Restores body to a calm state

cranial nerve X (gag/swallow, parasympathetic activity)

-Vagus -both -located in medulla motor- pharynx and larynx (talking and swallowing) sensory- general sensation from carotid body, carotid sinus, pharynx, viscera -carotid reflex (pressure regulation of body) -nerve fibers to pharynx (throat), larynx (voicebox), trachea (windpipe), lungs, heart, esophagus, most of intestinal tract. Brings sensory info back from ear, tongue, pharynx, larynx problems w/ nerve= back of soft palate droops on affected side, gag reflex lost on that side -voice hoarse and nasal= soft palate weakness -vocal cord on affected side is immobile=dysphagia and dysphonia (trouble swallowing w/ risk for aspiration and trouble speaking) -vagal stimulation=heart rate drop

cranial nerve VIII (hearing and balance)

-Vestibulocochlear (acoustic) -sensory -located in pons/medulla junction -hearing and equilibrium -test sense of hearing w/ whisper test while pushing on tragus intermittently. Compare bone and air conduction of sound using tuning fork. Weber's test- LATERALIZATION vibrate fork on top of patient's head, where do you hear sound coming from? Normal=midline Rinne's test: Air vs. bone conduction Vibrate fork on mastoid behind ear, ask when stop hearing. When stop hearing move to pts. ear normal= air conduction (ear) > bone conduction (mastoid) problems w/ nerve- DEAFNESS, TINNITUS (ringing in nose or ears), DIZZINESS, VERTIGO, VOMITING

uterus

-a pelvic organ -if GRAVID- uterus enlarged, comes up into abdomen -fibroids=uterus enlarged...myoectomy

Bells palsy (cnerve 7-facial)

-acute unilateral paralysis of facial nerve, 80 percent clients fully recover -d/t unknown or viral infection -antivirals may help-acyclovir or prednisone-steroids -facial reconstruction "smile surgery"

hollow viscera

-allows passageway of fluid (bowel,urine,blood,feces,air) -stomach -gallbladder -small intestine -colon (bowl)=large intestine -bladder

cerebellar functioning (Balance-cranial VIII)- Romberg test

-assesses balance, an extension of CNS/cerebellum fx -inner ear provides info regarding body position (proprioception). If inner ear is inflamed, incorrect info is transmitted (via PNS) to brain (CNS), causing sensation of vertigo/unsteady gait -EQUILIBRIUM AND VERTIGO can be assessed using Romberg test GAIT- have pt. walk 10-20 feet, turn, and walk back. Gait should be smooth, rhythmic, effortless w/ coordinated swing in opposing arm and 15 inch from heal to heal TANDEM WALKING- walk in straight line in a heal-to-toe fashion. If intact, the person will walk straight and maintain balance, even w/ decreased support base ROMBERG TEST (eliminate sensory compensation of the eyes)-feet together, arms at side, and eyes closed, and hold 20 seconds No swaying=negative test (: -positive test can occur w/intoxication, multiple sclerosis, loss of proprioception, loss of vestibular function

kinesthesia

-awareness of position and mvmt. of the parts of the body by means of sensory organs (proprioceptors) in the muscles and joints

reflex arc- a STIMULUS activates sensory nerve which carries message from receptor to dorsal root of spinal cord and synapse w/motor neuron in anterior cord. Motor neurons leave and travel to muscle stimulating a sudden contraction

-basic defense mechanisms of nervous system that are involuntary, operating below LOC -help maintain body balance and muscle tone -four types of reflexes 1) deep tendon (myotatic or stretch)- patellar/knee jerk reflex, biceps, triceps, brachioradialis, achilles tendon 2)superficial- corneal reflex, abdominal reflex 3) visceral (organic)- pupillary response to light and accommodation 4) pathologic (abnormal) Babinski (extensor plantar) reflex

temporal lobe

-behind the ear -has the primary auditory reception center, with functions of HEARING, TASTE, and SMELL -Wernicke's area located in temporal lobe= associated w/ language comprehension -when damaged in the person's dominant hemisphere, RECEPTIVE APHASIA results (the person hears sound, but it has no meaning)

auscultate bowel sounds

-caused by mvmt of air and fluid through the small and large intestines -high pitched, gurgling, irregular occurence btw 5-30x per minute -start w/ RLQ (b/c ileocecal valve is there) AND CONTINUE IN SYSTEMATIC WAY -hyperactive, normative, hypoactive, hyperperistalsis (growling stomach)- BORBORYGMUS -to say no bowel sounds are present, one must auscultate for a full 5 minutes (uncommon)

right lower (RLQ)

-cecum -appendix -colon (ascending) -right ureter ( R fallopian tube or spermatic cord) -major vein and artery to right leg

brain stem

-central core of the brain consisting of mostly nerve fibers -cranial nerves III through XII originate from nuclei in brainstem (3 areas-midbrain, pons, medulla) 1) midbrain- most anterior part, still has basic tubular sturcture of spinal cord- merges into the hypothalamus and thalamus. 2) Pons- ascending/descending motor tracts. 2 respiratory centers (pneumotaxic and apneustic) that coordinate w/ the main respiratory center in medulla 3) Medulla-continuation of spinal cord in brain (contains all ascending/descending fiber tracts) -it has vital autonomic centers (respiration, heart, gastrointestinal fx) and nuclei for cranial nerves VIII through 12 -pyramidal decussation (crossing of motor fibers) occurs here -breathing -blood pressure -heartbeat -swallowing

left lower (LLQ)

-colon (a part of descending) -sigmoid colon -L ureter (L fallopian/spermatic) -major vein and artery to left leg

ABNORMAL POSTURE- Flaccid quadriplegia

-complete loss of muscle tone and paralysis of all four extremities, indicating COMPLETELY non-functional brainstem.

inspect abdomen

-contour (flat, rounded, scaphoid, protuberant-pregnant, obesity) -symmetry -umbilicus (inverted, everted) -skin (usually pale) -pulsation/mvmt (from aorta) -hair distribution- Male pubic hair (diamond) female (upside down triangle) -demeanor of face-grimacing?

abdominal distention- ovarian cyst (large) (FIBROID)

-curve in lower half of abdomen, midline. Everted umbilicus -normal bowel sounds over upper abdomen where intestines pushed superiorly -top dull over fluid, intestines pushed superiorly. -Large cyst produces fluid wave and shifting dullness -****transmits aortic pulsation, whereas ascites does not

Anosmia

-decrease or loss of smell occurs bilaterally w/ tobacco smoking, allergic rhinitis, cocaine use -unilateral loss in absence of nasal disease is neurogenic anosmia*

flaccidity

-decreased resistance, hypotonia (decreased muscle tone)= occur w/ peripheral weakness -muscle feels limp, soft, flabby; muscle is weak and easily fatigued, limb feels like a rag doll -occurs w/ LMN injury (anterior horn to peripheral nerve)- peripheral neuritis, poliomyelitis, Guillain-Barre, early stroke/spinal cord injury are flaccid at first

scorbutic gums

-deficiency of vitamin C -gums swollen/ulcerated/bleeding

Kwashiorkor (protein-malnutrition)

-diets high in calories but low in protein -may appear well nourished or obese/ edema*

concussion

-direct blow that causes brain to shift rapidly back/forth inside skull -teens more susceptible due to thinner cranial bones, larger head-to-body ratio, immature CNS, larger subarachnoid space in which brain can rattle

deformities

-dislocation-loss of contact btw bones and joint -subluxation- alignment is off, bones in contact -contracture- shortening of a muscle leading to limited ROM -ankylosis- stiffness or fixation of a joint

hallux valgus

-distal part of great toe directed away from body

hepatomegaly splenomegaly

-enlarged liver -mononucleosis infection (enlarged spleen)- may be palpable, 3x larger -usually not

palpate for size, location, consistency, abnormal masses/tenderness

-muscle guarding -rigidity=stiff and boardlike -large masses -tenderness types: -light palpation-keep four fingers together, depress skin in rotary motion approx. 1 cm in depth -deep palpation- press down in rotary motion w/ depth of 5-8 cm -bimanual palp.-using 2 hands, bottom hand senses, while top pushes=use w/ larger or obese persons -palpate and then lift up fingers fully -assess aortic pulsation (upper abdomen slightly left of midline)- (using opposing thumbs and fingers, palpate aortic pulsation. Generally 2.5-4 cm

ptosis

-myasthenia gravis, dysfunction of cranial nerve 3 (oculomotor), Horner syndrome

referred abdominal pain

-felt in one spot but not originated there, pain referred to site where organ was located in fetal development. Examples: Liver-dull, mild-moderate pain in RUQ Esophagus- mid-epigastrium, behind lower sternum that radiates upward Gallbladder- sudden pain in RUQ that may radiate to R/L scapula (after ingestion of fatty foods, alch, caffeine). Associated w/positive Murphy sign or sudden stop in inspiration w/RUQ palpation Pancreas-acute, mid-epigastric pain radiating to back and sometimes to L scapula Duodenum- dull, aching, gnawing pain; doesn't radiate, may be relieved by food, awaken person from sleep Stomach- dull, aching, gnawing epigastric pain, usually brought on by food and radiates to back or sub-sternal area. Perforated ulcer- sudden epigastric pain radiates to possibly both shoulders Appendix- starts as dull, diffuse pain in peri-umbilical region that later shifts to severe, sharp, persistent pain/tenderness localized in RLQ (McBurney point) Kidney- sudden severe colicky flank/lower abdominal pain Small intestine- diffuse, generalized abd. pain Colon- moderate, colicky pain of gradual onset in lower abdomen, and bloating. Sharp burn/cramping pain over wide area-does not radiate

PATHOLOGICAL REFLEXES- Gordon

-firmly squeeze calf muscles -ab response- extension of great toe, fanning of toes -indicates corticospinal tract disease

Aging adult

-general atrophy w/steady loss of neuron structure in brain and spinal cord -decrease in weight volume w/thinning of cortex, reduced subcortical structures, enlarged ventricles -general muscle bulk loss (dorsal hand muscles), loss of muscle tone in face, impaired fine coordination/agility, loss of vibratory sense at ankle, decreased/absent achilles reflex, loss of sense of position at big toe, small pupils -muscle tremors, dyskinesias (facial grimacing) -in good health=walk slower and more consciously

damage to cortical functions of brain results from

-highly specialized neurological cells are deprived of their blood supply such as when a cerebral artery becomes occluded (ischemic stroke) or when vascular bleeding occurs (hemorrhagic stroke)

spinothalamic testing-pain (sharp or dull) and light touch

-hypoalgesia- decreased pain sensation -analgesia-absent pain sensation -hyperalgesia-increased pain sensation -hypoesthesia-decreased touch sensation -anesthesia-absent touch sensation -hyperanesthesia-increased touch sensation

PATHOLOGICAL REFLEXES- Kernig

-in flat lying supine position raise leg straight or flex thigh on abdomen and extend knee -ab response- resistance to straightening (b/c of hamstring spasm, pain down posterior thigh -d/t meningeal irritation (meningitis, infections)

DYSMETRIA (incoordination)

-inability to control the distance, power, and speed of a muscular action -clumsy, or cerebellar disorders, acute alch. intoxication -past-pointing= a constant deviation to one side

marasmus (protein-calorie malnutrition)

-inadequate intake of protein/calories or prolonged starvation -anorexia, bowel obstruction, cancer cachexia, chronic illness can lead to this -starved appearance

spasticity, rigidity and cogwheel rigidity

-increased muscle tone or hypertonia ; increased resistance to passive lengthening, then may give way to sudden (clasp-knife phenomenon) like a pocket knife sprung open -constant state of resistance (lead-pipe rigidity); resists passive movement in any direction, dystonia (invol. muscle contractions) -type of rigidity in which increased tone is released by degrees during passive range of motion so it feels like small, regular jerks -cause is Upper motor neuron injury- (corticospinal motor tract i.e. paralysis w/stroke develops spasticity days/weeks after incident) -injury to extrapyramidal motor tracts (basal ganglia w/parkinsonism) -parkinsonism

cancer pain- chronic malignant

-infiltration of lesion, nerve injury from periphery or CNS -dependent on underlying pathology -bone metastases, neuropathy -symptom control

basal ganglia (located in forebrain)

-large bands of gray matter buried deep within the two cerebral hemispheres and that form the subcortical-associated motor system (the extrapyramidal system) -help to initiate and coordinate intentional movement and control automatic associated movements of the body- i.e. arm swing alternating w/ legs during walking

cervical spine, neck ROM (pivot joint)

-lateral bending -flexion 45 degrees -extension-55 degrees -rotation against resistance

solid viscera

-liver -pancreas -spleen -adrenal glands (on top of kidneys) -kidneys -ovaries -uterus (allows fetus to grow within and menstrual flow) its so thick and muscular so its considered solid**

Right upper (RUQ)

-liver (a portion goes in LUQ) -right kidney/adrenal gland -gallbladder -duodenum -colon (ascending), transverse -head of pancreas

abdominal distention-tumor (FATAL)

-localized distention -normal bowel sounds -dull over mass if reaches up to skin surface -define borders, distinguish from enlarged or normally palpable structures

abdominal distention-FECES

-localized distention -normal bowel sounds -tympany predominates. Scattered dullness over fecal mass -plastic-like or rope-like mass w/ feces in intestines

cerebellum

-located under occipital lobe -balance/equilibrium (postural balance of body) -motor coordination of voluntary movements -muscle tone (fine muscle control) -DOESN'T INITIATE movement but coordinates and smoothes it (i.e. for piano, swimming, juggling) -automatic pilot on airplane b/c it adjusts and corrects voluntary movements (entirely below the conscious level)

thalamus

-main relay station where sensory pathways of spinal cord, cerebellum, basal ganglia, and brainstem form synapses (sites of contact btw neurons) on their way to the cerebral cortex -integrating center w/ connections crucial to human emotion and creativity -relays all of the senses (98%) except smell (olfaction) to cerebral cortex for interpretation

hypothalamus

-major repsiratory center w/ basic vital functions: temperature, appetite, sex drive, heart rate, and blood pressure control; sleep center; anterior and posterior pituitary gland regulator*; coordinator of autonomic nervous system activity and stress response

spinal cord

-mediates reflexes of postural control, urination, and pain response -lumbar cistern inside vertebral column is favored for withdrawal of CSF

two point discrimination (distinguishing the separation of two simultaneous pin points on the skin) i.e. apply two points of an opened paper clip lightly to skin in ever-closing distances

-note the distance at which the person no longer perceives two separate points -varies w/ each region tested -fingertips are most sensitive (2 to 8 mm) and least sensitive on upper arms, thighs, back (40 to 75 mm) -an increase in distance it normally takes to identify two separate points occurs w/sensory cortex lesions

abdominal distention (7 F's)

-obesity or FAT -air or gas or FLATUS/FLATULENCE -ascites or FLUID -ovarian cyst or FIBROID -pregnancy (ectopic pregnancy) FETUS -FECES -tumor or FATAL

SEIZURES

-occur w/epilepsy, a paroxysmal disease characterized by altered or loss of consciousness, involuntary muscle mvmts, sensory disturbances AURA-subjective sensation that precedes seizure; auditory, visual, or motor

dysdiadonchokinesia

-occurs w/cerebellar disease -impaired ability to perform rapid, alternating mvmts

vibration testing w/tune fork over bony prominences

-often first sensation lost w/ diabetic neuropathy and alcoholism *peripheral neuropathy is worse at the feet and gradually improves as you move up the leg - as opposed to a specific nerve lesion, which has a clear zone of deficit for its dermatome

-coffee ground emesis -bright red stool

-old blood, GI bleed -fresh blood, GI bleed

adrenal glands

-on top of kidneys -adrenalin, cortisone, aldosterone

referred pain

-pain originating in organs that can't be "felt" i.e. heart, liver, spleen -pain is felt by "proxy" -pain in heart is referred to chest, shoulder, left arm (which were it's neighbors in fetal development) -pain in spleen felt on top of left shoulder

Bell's palsy

-paralysis of facial nerve of unknown cause -thought to be caused by viral infection (i.e herpes simplex virus) -when whole side of face is paralyzed=peripheral lesion -forehead is spared on side of paralysis=central lesion (i.e stroke)

Paresis

-partial or incomplete paralysis

reinforcement of reflexes

-perform isometric exercise in a muscle group away from one being tested -i.e. as person to lock fingers and then try patellar reflex -biceps response= ask pt. to clench teeth or grasp thigh w/opp hand

neuro assessment of older adult

-personal hygiene, appearance, dress -may have naturally slowed responses/reflexes -general atrophy -nerve conduction velocity decreases 5-10%

frontal lobe

-personality -behavior -emotions -intellectual functions -Broca's area located in frontal lobe= mediates MOTOR SPEECH. When injured in dominant hemisphere EXPRESSIVE APHASIA results (the person cannot talk but can understand the language)-only can produce a garbled sound

pellagra

-pigmented keratotic scaling lesions due to deficiency of niacin (vitamin B3)

achilles reflex (ankle jerk)- L5 to S2

-position person w/ knee flexed and hip externally rotated, hold foot in dorsiflexion and strike achilles directly Normal=foot plantar flexes

(ulnar surface, tapping, ulnar surface in fist) Percuss for density of abdominal contents, to locate organs, screen for abnormal fluid or masses (12 spots)

-predominant sound in abdomen is tympany d/t air rising to surface when patient is supine -dullness-occurs over organs (liver), distended bladder, adipose tissue, fluid, or a mass -hyperresonance- present w/gaseous distention Liver span-generally btw 6-12 cm (usual tech), scratch test -start at lungs, when feel dull is liver=mark -start at abdomen, when feel dull is liver=mark -splenic dullness Flank pain-Costovertebral angle tenderness (CVA)-angle off of ribs (direct method, ulnar fist=thud)... assess for pain. Inflammation of kidneys (pyelonephritis)

occipital lobe

-primary visual receptor center

ABNORMAL POSTURE- opisthotonos

-prolonged arching of back, w/ head and heels bent backward. -indicates meningeal irritation

Fasciculations

-rapid, continuous twitching of resting muscle or or part of muscle w/o movement of the limb TYPES: fine- occurs with LMN disease associated w/atrophy and weakness coarse- cold exposure/fatigue=not significant

myoclonus

-rapid, sudden jerk or a short series of jerks at fairly regular intervals A HICCUP IS A MYOCLONUS OF DIAPHRAGM -single arm/leg jerk normal when person is falling asleep -severe w/grand mal seizures

special procedures for A.P

-rebound tenderness-deep palpation, deep in abdomen and let go quickly= indicator of appendicitis.- BLUMBERG'S SIGN -inspiratory arrest- MURPHY'S SIGN- Take a deep breath while hold border of liver- indicative of cholecystitis -Iliopsoas muscle test -obturator test

rectum prolapse

-red on outside of anus, folded in on itself

nociceptive pain (somatic/visceral)

-response to damaging stimuli -inflammation Somatic-well localized, dull, aching- NSAID, opioid Visceral- poorly localized, deep/squeezing pressure-muscle relaxant, corticosteroid, bi- phosphonate Somatic- post-op pain, arthritis, sports injury VIsceral- liver, pancreatic cancer

magenta tongue

-riboflavin deficiency (vitamin B2) beefy red color tongue vs. pale tongue (iron deficiency)

test Oculomotor (III), Trochlear(IV), and Abducens(VI) together

-rotation of eyeball up, down, pupil constriction, upward and outward mvmt., -assess for strabismus (cross-eyed) and nystagmus (lazy eye-involuntary back, forth, cyclic mvmt of eye) -Test pupils with (PERRLA) Pupils Equal Round React to Light and Accommodation) ***

infant-motor activity under control of spinal cord/medulla until cerebral cortex develops

-sensation is also not fully there at birth, newborn needs a strong stimulus and the response is whole body movements. As myelinization occurs-able to localize a stimulus more precisely and make an accurate motor response

cranial nerve V (jaw mvmts, facial sensation)

-trigeminal -both -located in pons motor- muscles of mastication sensory- pain and touch sensation of face and scalp, cornea, mucous membranes of mouth and nose (feel light touch, dull, sharp?) -Palpate jaw muscles (temporal muscles) for tone and strength while pt. clenches teeth. Attempt to push down chin to separate jaws. *inspect face for muscle atrophy and tremors -sensation: opthalmic, maxillary, mandibular touch cotton wisp to bilateral areas of FOREHEAD, CHEEK, and CHIN and request patient to state when sensation felt. -Corneal reflex -problems w/ motor= deviation of jaw toward affected side and trouble chewing, no blink =unilateral weakness=CN 5 lesion, bilateral=UMN/LMN -problems w/sensory- pain/loss of sensation in face= trauma, tumor, pressure from aneurysm,

cranial nerve IV (down, inward mvmt)

-trochlear -motor -located in midbrain -some eye movement (superior, oblique)-down and inward movement of eye -check for accommodation- bring penlight towards client -paralysis results in rotation of eyeball upward and outward (therefore-DOUBLE VISION) ABNORMAL- failure to turn eye down or out d/t fracture of orbit, brainstem tumor

ABNORMAL POSTURE- decerebrate rigidity

-upper extremities stiffly extended, adducted; internal rotations, palms pronated -lower extremities- stiffly extended, plantar flexion, teeth clenched, hyperextended back -more ominous (threatening) than decorticate rigidity -indicates lesion in brainstem at midbrain or upper pons

ABNORMAL POSTURE- decorticate rigidity

-upper extremities-flexion of arm, wrist, fingers; adduction of arm (i.e. tight against thorax) -lower extremities- extension, internal rotation, plantar flexion. Hemispheric lesion of cerebral cortex

auscultate for vascular sounds (5 spots)

-use bell for bruit, especially in patient w/hypertension. Generally bruit not present -use firmer pressure over aorta, renal arteries, iliac/femoral arteries -AAA (abdominal aortic aneurysm)- needs to be clipped immediately before it ruptures

Deep tendon reflexes (DTR)

-use reflex hammer and use a short, snapping flow to muscle insertion tendon -use pointed end for smaller targets, flat end on wider targets or to prevent pain and compare bilateral responses -Grading 4+ Hyperactive, with clonus (exaggerated muscle mvmt, involuntary rapid rhythmic series of contrac/relax) Indicates presence of disease process 3+ Brisker than average; may indicate need for further workup 2+ active, normal, expected response 1+ diminished, low-normal, sluggish 0 no response Proprioception (sensory cortex issues) Stereognosis- familiar object identification (astereognosis-inability to identify object correctly) Graphesthesia- familiar writing identification 1. intact sensory nerve (afferent) 2. functional synapse in the cord 3. an intact motor nerve fiber (efferent) 4. neuromuscular junction 5. competent muscle

note if sensory loss over hands and feet is in a "glove and stocking" distribution (hands/feet) or over a specific dermatome

-use unbiased directions for sensory tests- "tell me what you feel" vs. "can you feel this pinprick" which suggests the sensation

percussion-fluid wave

-used when ascites suspected -place pts. hand firmly on abd. midline -place left hand on pt. right flank -use right hand, give left flank a strike -fluid moves according to shifting=shifting dullness

PATHOLOGICAL REFLEXES- Oppenheim

-using heavy pressure w/ thumb and index finger, stroke anterior medial tibial muscle -abnormal response- extension of great toe, fanning of toes -indicates corticospinal tract disease (i.e. stroke, trauma)

subjective for bowel

-usual bowel routine -change in bowel habits -rectal bleeding, blood in stool? -self care behaviors- WIPE FROM FRONT TO BACK -family history-rectal conditions- itching (pruritis ani), hemorrhoids (shiny, blue sac-look w/ mirror), fissure (linear crack with abrupt edges), fistula-abnormal opening -medications-stool softener frequently? Enema?(perforation of rectum risk) iron-can cause constipation, turn stool black...peptobismol can turn stool black

rickets

-vitamin D and calcium deficits

PATHOLOGICAL REFLEXES- Brudzinski

-w/ one hand under neck and other hand on persons chest, sharply flex chin on chest and watch hips and knees -ab response-- resistance w/ pain in neck, w/flexion of hips and knees -d/t meningeal irritation

PATHOLOGICAL REFLEXES- Hoffman

-with pts. hand relaxed, wrist dorsiflexed, and fingers slightly flexed, sharply flick nail of distal phalanx of middle/index finger -ab response- clawing of fingers and thumb -indicates corticospinal tract disease

Upper motor neurons

-within CNS -convey impulses from motor areas of the cortex to lower motor neurons in anterior horn -diseases=stroke, cerebral palsy, multiple sclerosis

lower motor neurons

-within PNS -in anterior gray column-mvmts. must be translated by LMN fibers -i.e. cranial nerves, spinal nerves -diseases=spinal cord lesions, poliomyelitis, amyotrophic lateral sclerosis

1) newborns 2)infants/children

1)-visual inspec. of anus -confirm patent rectum w/ meconium passing meconium:greenish stool passed the first 24-48 hrs after birth** meconium stained amnio-fluid=distress 2) buttocks firm/rounded, no masses or lesions Meningocele mongolian spots diaper rash *OMIT PALPATION unless symptoms warrant if necessary- child on back, legs flexed-use FIFTH finger due to size

objective-palpation of anus

1)place pad of index finger gently against anal verge 2) feel for tightening of spinchter, then relaxation; as it relaxes, flex the tip of finger and insert slowly in direction of umbilicus 3) never use 90 degree angle- can perforate rectum 4) rotate examning finger, palpate entire muscular ring *assess spinchter tone 5) canal should feel smooth/even 6) ask person to tighten evenly around finger 7) bi-digital palpation- use thumb against the perianal tissue. Press examining finger; assess swelling or tenderness Also, assess bulbourethral glands (Cowper's glands, in males only) when palpate rectal wall-can palpate prostate recto-vaginal fistula- assess patency of wall

Assessing the Cerebral Cortex: Begin with subjective data and history.

1. Orientation: Person, Place, Time, Situation 2. Headache 3. Head Injury 4. Dizziness/Vertigo 5. Seizures 6. Tremors 7. Weakness 8. Incoordination 9. Numbness or tingling 10. Difficulty swallowing (Dysphagia) 11. Difficulty speaking (Dysphasia) 12. Significant Past History 13. Environmental or occupational hazards 14. Review medications: anticonvulsants, antitremors, antivertigos, and pain medications

superficial (cutaneous) reflexes abdominal upper- T8-10 abd lower- T10-T12

normal response is ipsilateral contraction of abdomen muscle with observed deviation of umbilicus toward stimulus... absent w/diseases of pyramidal tract (contralateral side w/stroke) -cremasteric reflex (L1-L2) on male-stroke inner aspect of thigh. normal=ipsilateral elevation of testicle...absent in both UMN and LMN lesions -plantar reflex (L4-S2)-except in infancy, abnormal is dorsiflexion of big toe and fanning of all toes* occurs w/UMN or corticospinal (pyramidal) tract

biceps reflex (C5-C6)

normal=flexion of forearm and contraction of biceps muscle

Cerebral Cortex: Outer layer of cerebrum

Gray Matter (lacks myelin) -composed of the cell bodies -Area of highest functioning: thought, memory, reasoning, sensation, and voluntary movement

ABNORMAL INSPECTION FINDINGS

HERNIA in umbilical or epigastric region, incisional site, diastastis recti (separation of rectus abdomenis muscles)-obese, preg women at risk -lying supine, have pt. raise up like doing crunches=area revealed

deeper into

IVC, aorta, ureter

chronic pain

pain continues for 6 months or longer (can last years) Malignant (cancer-related) vs. non-malignant -non malignant= arthritis, low back pain, fibromyalgia -creates depression feelings -does not respond well to meds -chronic pain intensity doesn't correspond to physical findings -no change in vital signs

paresis or weakness is DIMINISHED STRENGTH

paralysis or plegia is ABSENCE of strength

infant reflexes (go away as infant learns purposeful movements)

Moro/startle reflex- birth to 4 months Suckling-birth to 4 mo Palmar grasp- birth to 3-4 months Rooting response- birth to 3-4 months Tonic neck (ipsilateral extension, flexion of one side)= birth to 4-6 months Plantar grasp- birth to 8-10 mo Step in place- leaves when starts to walk Babinski's- leaves at birth to 24 mo- 2 year Clonus Myelinization is cephalocaudal (Head to toe) proximodistal (inwards to outwards) i.e. lifts head, lifts head and shoulders, rolls over, moves whole arm, uses hands, walks

atrophy occurs w/ disease such as

polio, diabetic neuropathy (LMN disorders)

neuropathic pain

primary lesion (neuroma) or dysfunction in nervous system causing ectopic charges within nervous system -constant dull ache, burning, stabbing, electric shock-like, numbness, tingling, hyperalgesia, hyperpathia -distal neuropathy (diabetes, HIV), herpes zoster, trigeminal neuralgia, neuropathic pain -treat- tricyclic antidepressant, anticonvulsant, antineuroleptic, local anesthetic, corticosteroid, opioid

cranial nerve III (up, down)

Oculomotor -motor -located in midbrain -most eye movement (up/down), elevation of eyelids(eye lid opening), pupillary reflex, lens shape -paralysis of oculomotor nerve results in drooping eyelid (PTOSIS), deviation of the eyeball outward and slightly down (and therefore DOUBLE VISION) and a DILATED(wide-open) pupil -failure to move eye up,in,down -absent light reflex -causes-paralysis of CN III from internal carotid artery d/t aneurysm, tumor, inflamm lesions -ptosis from myasthenia gravis, oculomotor nerve palsy, horner syndrome, blindness, drug influence, syphilis

cranial nerve I

Olfactory -sensory -located in the telencephalon -smell-special sense Occlude one nares at a time, ask pt. to sniff=establish patency and baseline -test w/eyes closed and aromatic substance easily identifiable ABNORMAL=anosmia -upper resp. infection (temporary) -tobacco/cocaine use -fracture of cribriform plate or ethmoid area; frontal lobe lesion; tumor in olfactory bulb/tract

cranial nerve II *a part of both the eye and brain*

Optic -sensory -located in diencephalon -vision-special sense -test "near sighted" via Snellen chart 20 ft away (pocket chart 14) cover one eye and read the lowest line possible -test peripheral vision via confrontation -fundoscopic exam for direct visualization of optic nerve -test "far sighted" via Jaeger card ABNORMAL- defect in or absent central vision, defect in peripheral vision, hemianopsia(decreased vision in half of visual field), absent light reflex, papilledema, optic atrophy, retinal lesions -increased ICP, glaucoma, diabetes

Cerebrum (CNS)

Right and Left hemispheres Left dominant in 95% of people: Right handed Four lobes per hemisphere: - Frontal - Parietal - Temporal - Occipital

Pain assessment tools

Self report is subjective=best indicator -Initial pain assessment tool-8 questions concerning location, quality, duration, intensity -verbal descriptor scale-use words to describe feelings/meanings of pain -brief pain inventory- rate pain over past 24 hr, graduated scale 0-10. Looks at pain impact on mood, activity, sleep, etc -short-form McGill pain questionnaire- rank a list of descriptors in terms of intensity and overall intensity rating to his/her pain -numeric pain scale rating for children -Wong-baker faces (0-5) Faces pain scale (FPS-R) (0-10) -FLACC behavioral pain scale- face, legs, activity, crying, consolability -CRIES neonatal post-op pain score crying, requires O2 sat, increased vital signs, expression, sleepless

anus, rectum, prostate

rectum-distal portion of large intestine, 12 cm long; from sigmoid colon-3rd sacral vertebra ileostomy-liquid colostomy in ascending colon- liquid transverse colon-more solidified descending- almost all formed sigmoid- can gain control of bowel mvmts, all formed closer it gets to the end-more formed it is** anus- outlet of GI tract, 3.8 cm long, 2 spinchters that control passage= internal-involuntary, external=voluntary (end stage AIDS, bowel incontinence) prostate-him lies in front of anterior wall of rectum secretes thin, milky alkaline fluid that helps sperm viability for her-uterine cervix lies in front of anterior wall may be palpated through

acute pain

short term and self-limiting -d/t surgery, trauma, kidney stones -creates anxiety -responds well to meds -voices c/o pain -moaning -change in vital signs -agitated

athetosis

slow, twisting, writhing, continuous mvmt.- like a snake or a worm -involves the distal part more than proximal part of limb -athetoid hand-some fingers flexed, some extended

SYNCOPE-sudden loss of strength, a temporary loss of consciousness (a faint) caused by lack of cerebral blood flow i.e. low bP

VERTIGO-rotational spinning caused by neurologic disease in vestibular apparatus in ear or vestibular nuclei in brainstem

umbilical region

near umbilicus

epigastric pain

above stomach, below xiphoid region

colorectal screening

after age 50... (now age 40) or earlier if family history -digital rectum exam annually -fecal occult blood test annually sigmoidoscopy every 5 years colonoscopy every 10 years *prostate cancer screening: after age 45 in black males; after age 50 all others prostate-specific antigen (PSA) annually

paresthesia

an abnormal sensation (burning, tingling)

TREMOR

any involuntary shaking, vibrating, or trembling

shoulder hip joint

ball and socket

hypogastric (suprapubic)

below umbilicus

reflex abnormalities (for adequate response limb should be relaxed and the muscle partially stretched)

clonus- a set of rapid, rhythmic contractions of the same muscle hyperreflexia- exaggerated reflex seen when monosynaptic reflex arc is released from the usually inhibiting influence of higher cortical levels *occurs with UMN lesions-such as a stroke Hyporeflexia- absence of a reflex, LMN problem- occurs w/interruption of sensory afferents or destruction or destruction of motor efferents and anterior horn cells (spinal cord injury)

hearing loss

conductive- mechnaical dysfunction of external/internal ear resulting in partial hearing loss due to impacted cerumen, foreign bodies, perforated tympanic membrane, inner ear pus, otosclerosis (hardening of ear) sensorineural- pathology associated w/ inner ear, gradual nerve degeneration (Prebycusis) b/c of aging, ototoxic meds (Lasix) that affect cochlear hair cells

DYSARTHRIA

difficulty forming words

DYSPHASIA

difficulty w/ language comprehension or expression

hinge joint

fingers and toes knees-bulge sign-occurs w/ small amounts of effusion. Stroke medial aspect of knee, tap lateral aspect and watch for fluid wave ballottement- larger amts of fluid present. press patella up against femur McMurray test- tests for torn meniscus of knee elbows ankle

Nutrition screening is

first step in nutritional assessment -if screening identifies risks patient should undergo comprehensive nutritional assessment which includes 1) dietary history/clinical info 2) physical exam, anthropometric measures 3) routine lab data dietary intake- 24-hr diet recall, food diary, food freq questionnaire, direct observation

bitot spots

foamy plaques of cornea-sign of vitamin A deficiency -severe depletion may lead to conjunctival xerosis (drying)

Abnormal findings-palpation

if identify a mass, distinguish from a normally palpable structure or enlarged organ -location (midline-3 regions, not midline use 4 Q) -size -shape -consistency (soft, firm, hard) -surface (smooth, nodular) -mobility (including w. respirations) -pulsatility (liver edge) -tenderness

musculoskeletal exam

inspection palpation ROM muscle testing (0-5) Temporomandibular joint

objective assessment: anus

inspection: color- moist, more pigmented skin than perianal skin surface-coarse folded skin hair-none (around but not on) hemorrhoids- flabby skin sac, shiny blue skin sac: thrombosed hemorrhoid -dimpling, inflammation, swelling, hair tuft, tenderness at tip of coccyx=may indicate pilonidal cyst-dimple area (results from inflammation from ingrown hair, debris)-use clock 12,3,6,9 O.R -incision and drainage positioning: females-left lateral left lateral, right knee flexed (Sim's)-rectal suppository lithotomy(if examining genitalia also) males- left lateral, standing

tremor

involuntary contraction of opposing muscle groups. Results in rhythmic, back and forth mvmt of one or more joints. -may occur at rest or w/ voluntary mvmt -disappear while sleeping -tremors may be slow (3-6/sec) or rapid (10-20/sec) rest tremor-occurs when hand is supported, coarse and slow, partly/completely disappears w/ voluntary mvmt intention tremor- rate varies- worse w/voluntary mvmt. Occurs w/ cerebellar disease and M.S. essential(familial)-tremor w/older people benign- no associated disease can be helped w/ alcohol

tic

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

genu varum genu valgum

knees apart knees together

abdomen

largest cavity in body extends from diaphragm to brim of pelvis

paralysis

loss of motor function caused by a lesion in neurologic or muscular system, or loss of sensory innervation *HEMIPLEGIA- one side paralysis of body/extremities PARAPLEGIA-symmetrical paralysis of both lower extremities QUADRIPLEGIA- paralysis in all 4 extremities PARESIS- weakness rather than paralysis

Assess IX and X together

motor assess= depress tongue w/ tongue blade: watch for pharyngeal mvmt when pt. says "ahh" or yawns- uvula and soft-palate should rise midline, tonsillar pillars should move medially -touch posterior pharyngeal walls w/ tongue blade: gag reflex, voice clear sensory= posterior 1/3 of tongue: bitter taste * 20% normal individuals have absent/minimal gag reflex -NO GAG REFLEX-could be vocal cord weakness

stool assessment

type 1- separate hard lumps, like nuts (hard to pass) type 2- sausage-shaped but lumpy type 3- like a sausage but w/cracks on its surface type 4- like a sausage or a snake, smooth and soft type 5- soft blobs w/ clear-cut edges (passed easily) type 6- fluffy pieces with ragged edges, a mushy stool type 7- watery, no solid pieces, entirely liquid Occult blood (hidden blood)- test may vary by agency or institution -positive is abnormal finding -false-positive may be caused by eating after large amts. of red meat in past 3 days lower GI-red up higher-dark, hidden (dark, tarry) color

abdominal distention- Obesity (FAT)

uniformly rounded. Umbilicus sunken (it adheres to peritoneum, layers of fat are superficial to it) -normal bowel sounds -tympany. Scattered dullness over adipose tissue

seizures occur in infants and toddlers....

w/ high fever or may be a sign of neurological disease

gliding joint

wrist