HA2 Final Exam

Breath Sounds

- Anterior and Posterior •Listen for 1 full respiration using diaphragm of stethoscope •Auscultate bilaterally - Three types of breath sound: •Bronchial, sometimes called tracheal or tubular •Bronchovesicular •Vesicular •Note description of characteristics and location of breath sounds •Do not confuse background noise with lung sounds.

Abnormal Findings: Lesions on the Eyelids

- Blepharitis, inflammation of eyelids - Chalazion - Hordeolum, stye - Dacryocystitis, inflammation of lacrimal sac

Abnormal Findings: Opacities in the Lens

- Central gray opacity, nuclear cataract - Star-shaped opacity, cortical cataract

Abnormal Findings:Vascular Disorders of External Eye

- Conjunctivitis - Subconjunctival hemorrhage - Iritis, circumcorneal redness - Acute glaucoma

Occult blood test

A chemical test or microscopic examination for blood, especially in the feces, that is not apparent on visual inspection.

d

A dull percussion note forward of the left midaxillary line is: a. Normal; and expected finding during splenic percussion b. Expected between the 8th and 12th ribs c. Found if the examination follows a large meal d. Indicative of splenic enlargement

d

A female patient has striae on the abdomen. Which color indicates long-standing striae? a. Pink b. Blue c. Purple-blue d. Silvery white

Indirect inguinal hernia

A hernia that protrudes into the membranous sac of the spermatic cord. This condition usually is due to a congenital defect in the abdominal wall.

a

A newborn infant has a dark green stool 2 days after birth. How should you interpret this? a. This type of stool would indicate anal patency b. The dark green color could indicate occult blood in the stool c. Meconium stool can be reflective of distress in the newborn d. The newborn should have passed the first stool within 12 hours after birth

b

A patient has soft, moist, fleshy, painless papules around the anus. The examiner suspects this condition is: a. HSV-2 b. HPV c. Gonorrhea d. Peyronie Disease

a

Which of the following is (are) normal, common finding(s) on inspection and palpation of the vulva and perineum? a. Labia majora that are wide apart and gaping b. Palpable Bartholin glands c. Clear, thin discharge from paraurethral glands d. Bulging an introitus during valsalva maneuver

a

Which of the following would be a normal sensitivity to pressure for the testes? a. Somewhat b. Not at all c. Left more sensitive than the right d. Only when inflammation is present

b

Which of these is the correct technique to assess patency of the anal sphincter? a. Inspect the anus and ask the patient to strain b. Palpate the anus with a gloved finger to elicit sphincter control c. Percuss above the anal canal for dull resonance d. There are no sensory nerves in the anal canal or rectum

b

Which population has the highest incidence of benign prostatic hypertrophy (BPH)? a. European Americans b. African Americans c. Hispanics d. Asians

c

Which symptoms suggest benign prostatic hypertrophy? a. Weight loss and bone pain b. Fever, chills, urinary frequency, and urgency c. Difficulty initiating urination and weak stream c. Dark, tarry stools

Extension

straightening a limb at a joint

Hemorrhoids

swollen, twisted, varicose veins in the rectal region

Flexion

bending a limb at a joint

Vagus

talking, swallowing, and sensory information from pharynx and carotid sinus

optic chiasma

the crossing of the optic nerves from the two eyes at the base of the brain

•Dental caries

cavities

Annular

circular shape to skin lesion

Grouped

clusters of lesions

Mixed hearing loss

combination of conductive and sensorineural types in the same ear

If sound is louder on mastoid process as opposed to air conduction

conductive hearing loss

Bed sores

decubitus ulcers

Bell

deep, hollow cuplike shape, soft pitched sounds

Habit-Tic Dystrophy

depression down middle of nail

Discrete

distinct and separate

Trochlear

down and inward movement of the eye

Culture and genetics: prostate cancer

•Most frequently diagnosed cancer in men Known risk factors: •Increasing age, African ancestry, family history, and inherited mutation of BRCA1 and BRCA2 genes •Incidence higher for black men; mortality rates two times higher for black males •Diets heavy in red meat or high-fat dairy products may be factor •Follow screening recommendations relative to identified risk

Cervical Exam

•Palpate cervix in female through anterior rectal wall. •Withdraw examination finger; normally no bright red blood or mucus is on glove. •To complete examination, offer the person tissues to remove lubricant and help the person to comfortable position.

Beau Line

transverse furrow or groove

Pronation

turning the forearm so that the palm is down

Supination

turning the forearm so that the palm is up

Gyrate

twisted, coiled spiral, snakelike

Eyelids, Lashes, and Eyeballs

uEyelids and lashes uEyeballs uConjunctiva and Sclera uLacrimal Apparatus uCornea and Lens

Most important environmental risk factor for skin cancer is exposure to _______________ both from sun and indoor tanning sources.

ultraviolet (UV) radiation

Profile sign of Nail

view index finger at its profile and note angle of nail base; it should be about 160 degrees

Otosclerosis

§Common cause of conductive hearing loss in young adults between ages of 20 and 40 - Gradual hardening that causes footplate of stapes to become fixed in oval window - Impeding transmission of sound and causing progressive deafness

Developmental Competence:Aging Adults EARS

§In aging persons, cilia lining ear canal become coarse and stiff. §May cause cerumen to accumulate and oxidize, which greatly reduces hearing §Cerumen is drier with aging because of atrophy of apocrine glands. §Impacted cerumen is a common but reversible cause of hearing loss in older people.

Equilibrium in ear

§Labyrinth in inner ear constantly feeds information to brain about body's position in space. §Three semicircular canals §If labyrinth ever becomes inflamed, it feeds wrong information to brain, creating a staggering gait and vertigo.

Conductive hearing loss

§Mechanical dysfunction of external or middle ear §Partial loss because a person is able to hear if sound amplitude is increased enough to reach normal nerve elements in inner ear §May be caused by impacted cerumen, foreign bodies, a perforated TM, pus or serum in middle ear, and otosclerosis

Culture and Genetics: Otitis Media (OM)

§Obstruction of eustachian tube or passage of nasopharyngeal secretions into middle ear §One of the most common illnesses in children §Risk factors to acute OM §Absence of breastfeeding in first 3 months of life, preterm birth, secondhand tobacco smoke exposure, daycare attendance, male sex, pacifier use, seasonality (fall and winter), and bottle-feeding §Increased ambulatory visits §Persistent effusion may lead to hearing loss. §Genetic variation with regard to cerumen development - Dry cerumen: gray, flaky, and frequently forms thin mass in ear canal - Wet cerumen: honey brown to dark brown and moist

Objective Data Ear - Equipment needed:

§Otoscope with bright light, fresh batteries give off white, not yellow light. §Pneumatic bulb attachment, sometimes used with infant or young child §Tuning forks in 512 and 1024 Hz

Sensorineural (or perceptive) hearing loss

§Signifies pathology of inner ear, cranial nerve VIII, or auditory areas of cerebral cortex §Increase in amplitude may not enable a person to understand words. §May be caused by presbycusis and by ototoxic drugs, which affect hair cells in cochlea.

Whispered Voice Test

§Test one ear at a time while masking hearing in other ear by placing one finger on tragus and rapidly pushing it in and out of auditory meatus. §Shield your lips so the person cannot compensate for a hearing loss (consciously or unconsciously) by lip reading or using the "good" ear. §With your head 30 to 60 cm (1 to 2 ft.) from the person's ear, exhale and whisper slowly some two-syllable words. §Normally, the person repeats each word correctly after you say it.

Presbycusis

§Type of hearing loss that occurs with aging, even in people living in quiet environment §Gradual sensorineural loss caused by nerve degeneration in inner ear or auditory nerve §Onset usually occurs in 50s and slowly progresses. §First notice a high-frequency tone loss. §Ability to localize sound is impaired also. §Accentuated when unfavorable background noise is present §Gender and ethnic differences

Subjective Data: Chest Pain with Breathing

•Any chest pain with breathing? Please point to exact location. •onset, timing—constant versus intermittent. •pain characteristics in terms of quality and intensity. •associated clinical symptoms. •treatment interventions used to decrease pain.

Subjective data: nose

•Any nasal drainage or runny nose? •Any unusual or Frequent colds? •Any Sinus pain or sinusitis? •Ever have any Trauma or blow to the nose? •Epistaxis—Any nosebleeds? •Any Allergies or hay fever? •Any changes in smell? •Discharge •Any nasal discharge or runny nose? Continuous? •Is discharge watery, purulent, mucoid, bloody? •Frequent colds •Any unusually frequent or severe colds (upper respiratory infections)? How often do these occur?

Subjective Data Questions: Pain in Breasts

•Any pain or tenderness in breasts? •Onset •Pain location - Localized or diffuse •Is painful spot sore to touch? Do you feel a burning or pulling sensation? •Appearance of pain cyclic? - Any relation to menstrual cycle? •Precipitating factors •Brought on by strenuous activity? •Change in activity? •Sexual manipulation?

History of Respiratory Infections

•Any past history of breathing trouble or lung diseases, such as bronchitis, emphysema, asthma, or pneumonia? - any unusually frequent or unusually severe colds. - any family history of allergies, tuberculosis, or asthma. •Smoking history •Onset, duration. and pattern of smoking •Secondhand exposure to smoke •Smoking cessation •Counseling using the five A's: Ask, Advise, Assess, Assist, and Arrange***

Spermatic cord

•Ascends along posterior border of testis and runs through tunnel of inguinal canal into abdomen •Here, vas deferens continues back and down behind bladder, where it joins duct of seminal vesicle to form ejaculatory duct, which empties into urethra.

Romberg sign (Neurological)

•Ask the person to stand up with feet together and arms at sides; when in stable position, ask the person to close eyes and to hold position for about 20 seconds. - Normally the person can maintain posture and balance even with visual orienting information blocked. •Ask the person to perform shallow knee bend or hop in place, first on one leg, then other. - Demonstrates normal position sense, muscle strength, and cerebellar function - Some individuals cannot hop because of aging or obesity.

Developmental Competence Breasts: Adolescent

•At puberty, estrogen stimulates breast changes •Temporary asymmetry: Occasionally one breast may grow faster than other •Tanner Staging: Five stages of breast development are included as levels of sexual maturity •Thelarche precedes menarche by about 2 years

Abnormal Findings: Common Respiratory Conditions

•Atelectasis, lobar pneumonia, or bronchitis (acute or chronic) •Emphysema or asthma (reactive airway disease) •Pleural effusion (fluid) or thickening •Pneumocystis jiroveci (P. carinii) pneumonia •Tuberculosis •Pulmonary embolism •Acute respiratory distress syndrome (ARDS) •Lung cancer

Aging Adult - CNS

•Atrophy with steady loss of neuron structure in brain and spinal cord •Velocity of nerve conduction decreases making reaction time slower in some older persons. •Increased delay at synapse results in diminished sensation of touch, pain, taste, and smell. •Motor system may show general slowing down of movement, muscle strength, and agility decrease. •Progressive decrease in cerebral blood flow and oxygen consumption may cause dizziness and loss of balance.

Developmental Competence Breasts: Aging Woman

After menopause, ovarian secretion of estrogen and progesterone decreases, causing breast glandular tissue to atrophy - Decreased breast size makes inner structures more prominent - A breast lump may have been present for years but is suddenly palpable Around nipple, the lactiferous ducts are more palpable and feel firm and stringy because of fibrosis and calcification - Axillary hair decreases

T1

Dermatome Landmark: (Identify the Spinal Nerve) Axilla

L1

Dermatome Landmark: (Identify the Spinal Nerve) Groin

L4

Dermatome Landmark: (Identify the Spinal Nerve) Knee

T4

Dermatome Landmark: (Identify the Spinal Nerve) Nipple

T10

Dermatome Landmark: (Identify the Spinal Nerve) Umbilicus

C6, C7, C8

Dermatome Landmark: (Identify the Spinal Nerves) Thumb, middle finger, and fifth finger

Common Skin Lesions in Children

Diaper dermatitis Intertrigo (candidiasis) Impetigo Atopic dermatitis (eczema) Measles (rubeola) German measles (rubella) Chickenpox (varicella)

d

H.T has come to the clinic for a follow up visit. Six months ago, he was started on a new medication that may cause impotence as a side effect; therefore the medication classes explored by the nurse are: a. Antipyretics b. Bronchodilators c. Corticosteroids d. Antihypertensives

Additional History for Aging Adult Lungs

Have you noticed any shortness of breath or fatigue with your daily activities? Ask about: •Tell me about your usual amount of physical activity. •(For those with a history of chronic obstructive pulmonary disease, lung cancer, or tuberculosis): Use Lung Function Questionnaire •How is your energy level? Do you tire more easily? How does your illness affect you at home and at work? •Do you have any chest pain with breathing? •Do you have any chest pain after a bout of coughing or after a fall?

Subjective Data Questions: Lump and Discharge on Breasts

Lump ØLocation: Ever noticed lump or thickening in breast? Where? ØOnset: When did you first notice it? Changed at all since then? ØAppearance: Does lump have any relation to your menstrual period? ØNoticed any change in overlying skin: •Redness, warmth, dimpling, swelling? Discharge ØOnset: Any discharge from nipple? When did you first notice this? ØCharacteristics: •What color is discharge? •Is consistency thick or runny? Odor?

Deep tendon reflexes

•Measurement of stretch reflexes reveals intactness of reflex arc at specific spinal levels and normal override on reflex of higher cortical levels. •Limb should be relaxed and muscle partially stretched. •Stimulate reflex by directing short, snappy blow of reflex hammer onto muscle's insertion tendon. •Bilateral comparison: responses should be equal

Plaques

Papules coalescing to form surface elevation wider than 1 cm

Skin color

•Melanin—brown pigment •Carotene—yellow-orange pigment •Red purple tones in the underlying vascular bed

Steps of neuro assessment

•Mental status •Cranial nerves •Motor system •Sensory system •Reflexes

c

Patients who have Parkinson's disease usually have which of the following characteristic style of speech? a. A garbled manner b. Loud, urgent c. Slow, monotonous d. Word confusion

Tympany

Percussing lightly in all four quadrants of the abdomen should generate this sounds because air in the intestines rises to the surface when the person is supine

Palpate Surface and Deep Areas: Abdomen

Perform palpation. •Judge size, location, and consistency of certain organs and screen for an abnormal mass or tenderness. •Because most people are naturally inclined to protect abdomen, you need to use additional measures to enhance complete muscle relaxation. Begin with light palpation then proceed to deep palpation.

Lichenifications

Prolonged intense scratching leads to thickened skin producing tightly packed set of papules

b

Pronation and supination of the hand and forearm are the result of the articulation of the: a. Scapula and clavicle b. Radius and ulna c. Patella and condyle of the fibula d. Femur and acetabulum

c

Prostatic hypertrophy occurs frequently in older men. The symptoms that may indicate this problem are: a. Polyuria and urgency b. Dysuria and oliguria c. Straining, loss of force, and sense of residual urine d. Foul-smelling urine and dysuria

Visual Reflexes

Pupillary light reflex: normal constriction of pupils when bright light shines on retina Fixation: a reflex direction of eye toward an object attracting person's attention Accommodation: adaptation of eye for near vision

Pustules

Pus in cavity that is circumscribed and elevated.

Developmental Competence: Male Breast

Rudimentary structure consisting of a thin disk of undeveloped tissue underlying nipple. Gynecomastia: during adolescence, it is common for breast tissue to temporarily enlarge. - Condition is usually unilateral and temporary. - Reassurance is necessary for adolescent male, whose attention is riveted on his body image. - May reappear in aging male and may be due to testosterone deficiency.

Abnormalities of the Spine

Scoliosis Herniated nucleus pulposus - Herniated disc

c

Select the best description of the anal canal: a. 12 cm long portion of the large intestine b. Involuntary control of the parasympathetic nervous system c. 3.8 cm long outlet of the gastrointestinal tract d. S-shaped portion of the colon

b

Select the best description of the uterus. a. Anteverted, rounded, asymmetric organ b. Pear-shaped, thick-walled organ flattened anteroposteriorly c. Retroverted, almond-shaped, asymmetric organ d. Midposition, thick-walled, oval organ

c

Select the sequence of techniques used during an examination of the abdomen. a. Percussion, inspection, palpation, auscultation b. Inspection, palpation, percussion, auscultation c. Inspection, auscultation, percussion, palpation d. Auscultation, inspection, palpation, percussion

Excoriations

Self-inflicted abrasion that is superficial

b

Senile tremors may resemble parkinsonism, except that senile tremors do not include: a. Nodding the head as if responding yes or no b. Rigidity and weakness of voluntary movement c. Tremor of the hands d. Tongue protrusion

Strabismus, Diplopia, Redness and Swelling

Strabismus, diplopia: Any history of crossed eyes? - Now or in the past? Does this occur with eye fatigue? - Ever see double? Constant, or does it come and go? In one eye or both? Redness, swelling - Any redness or swelling in eyes? - Any infections? Now or in past? When do these occur? In a particular time of year?

Facial

Tasting anterior two thirds of tongue, closing eyes

Lentigines

Technical term for freckles liver spots

c

Tenderness during abdominal palpation is expected when palpating the: a. Liver edge b. Spleen c. Sigmoid colon d. Kidneys

Jaeger Card

Test Near Vision

Hirsutism

excessive hair growth over the body

Oculomotor

extraocular movement, pupil constriction, down and inward movement of the eye

Diaphragm

flat edge, high pitched sounds

Macule

flat, colored spot on the skin, less than 1cm

Black hairy tongue

fungal infection of the tongue

Acoustic (Vestibulocochlear)

hearing and equilibrium

Urticaria

hives

Reference Lines

Use reference lines to pinpoint finding vertically on chest. - Anterior chest: note midsternal and midclavicular line - Posterior chest: note vertebral (midspinal) line and scapular line Lift up the person's arm 90 degrees, and divide lateral chest by three lines: - Anterior axillary line - Posterior axillary line - Midaxillary line

Spinothalmic Tract

Using pain to assess if the patient can feel a pinprick is a way to assess the function of the __________ tract.

palpebral fissure

opening between eyelids

Gingival hyperplasia

overformation of gum tissue

Keloid

overgrowth of scar tissue

Chondrodermatitis nodularis helicis

painful nodules on rim of helix as a result of trauma

Skin Color

pallor (pale), erythema (red), cyanosis (blue), or jaundice (yellow). Note if color change transient or due to pathology.

Costovertebral Angle Tenderness

What type of tenderness are you assessing for? Place one hand over the 12th rib at the costovertebral angle on the back. Thump that hand with the ulnar edge of your other fist. The person normally feels a thud but no pain

b

When assessing an infant, the examiner completes the ortolani maneuver by: a. Lifting the newborn and noting a C-shaped curvature of the spine b. Gently lifting and abducting the infant's flexed knees while palpating the greater trochanter with the fingers c. Comparing the height of the tops of the knees when the knees are flexed up d. Palpating the length of the clavicles

Achilles

Which Reflex? Hold the foot in dorsiflexion and strike this tendon directly. The foot should plantar flex against your hand

Quadriceps

Which Reflex? Let lower legs dangle freely to flex knee and stretch the tendons. Strike directly below the patella.

Plantar

Which Reflex? Lightly stroke up the sole of the foot and inward across the ball of the foot, like an upside down J. The toes should plantar flex and the forefoot should invert and flex

Cremasteric

Which Reflex? On the male, stroke the inner aspect of the thigh with the reflex hammer. The ipsilateral testicle should rise

Biceps

Which Reflex? Place thumb on biceps tendon and strike a blow on your thumb. A normal response is the contraction of the biceps muscle and flexion of the forearm

Brachioradialis

Which Reflex? Suspend the forearms in relaxation. Strike the forearm directly, about 2-3 cm above the radial syloid process. Normal response is flexion and supination of the forearm

Triceps

Which Reflex? Tell person to let their arm "go dead", and suspend it by holding their upper arm. Strike this tendon directly above the elbow. Normal response is an extension of the forearm

d

Which finding in the prostate gland suggest prostate cancer? a. Symmetric smooth enlargement b. Extreme tenderness to palpation c. Boggy soft enlargment d. Diffuse Hardness

b

Which is a structure that secretes a thin, milky alkaline fluid to enhance the viability of sperm? a. Cowper's gland b. Prostate gland c. Median sulcus d. Bulbourethral gland

a

Which is the most common bacterial sexually transmitted infection in the United States? a. Chlamydia b. Gonorrhea c. Trichomoniasis d. Syphilis e. Bacterial vaginosis

c

Which is true regarding the bulbourethral gland? a. It can be palpated during an examination of a female patient b. It can be palpated during an examination of both male and female patients c. It can be palpated during an examination of a male patient d. It cannot be assessed with a rectal examination

Temporomandibular Joint (TMJ)

Which joint allows these three motions? 1. Hinge action to open and close the jaws 2. Gliding action for protrusion and retraction 3. Gliding for side to side movement of lower jaw

c

Which of the following can be noted through inspection of a patient's abdomen? a. Fluid waves and abdominal rigidity b. Umbilical eversion and Murphy's sign c. Venous pattern, peristaltic waves, and abdominal contour d. Peritoneal irritation, general tympany, and peristaltic waves

6 cardinal fields of gaze

stand in front of pt and have them follow the object; make sure you tell them to follow only with their eyes. patterns include the H-pattern or the wheel pattern; you pause at each area so you can watch their eyes at each of these positions

Palpation of Anterior Chest

•Palpate for symmetric chest expansion. - Any limitation in thoracic expansion is easier to detect on anterior chest because greater range of motion exists here with breathing. •Assess tactile (vocal) fremitus. - Compare vibrations from one side to other as the person repeats "ninety-nine." •Palpate anterior chest wall. - Note any tenderness or lumps. - Note skin mobility, turgor, temperature, and moisture.

Palpation of Inguinal Lymph Nodes

•Palpate horizontal chain along groin inferior to inguinal ligament and vertical chain along upper inner thigh •Normal to palpate an isolated node on occasion; it then feels small, 1 cm, soft, discrete, and movable •Enlarged, hard, matted, fixed nodes are abnormal findings

Abnormalities in muscle movement

•Paralysis •Fasciculations •Tic •Myoclonus •Chorea •Athetosis •Seizure disorder •Tremor •Rest tremor •Intention tremor

Salivary glands

•Parotid •Submandibular •Sublingual •Smallest of the glands; lies within the floor of the mouth

Lesions caused by trauma or abuse:

•Pattern injury •Hematoma •Contusion (bruise)

Percussion and Tympany

•Percuss general tympany, liver, and splenic dullness. - To assess relative density of abdominal contents, to locate organs, and to screen for abnormal fluid or masses - Yields highly variable results therefore not recommended •General tympany - First, percuss lightly in all four quadrants to determine prevailing amount of tympany and dullness in clockwise manner.

Objective data: preparation

•Perform rectal examination on all adults and particularly for those in middle and late years. •Place patient in best position relative to gender. •Males: Left lateral decubitus, standing, or lithotomy** •Females: Lithotomy for examining genitalia or left lateral decubitus for exam of rectum alone**

Autonomic nervous system

•Peripheral nervous system composed of cranial nerves and spinal nerves •Carry fibers divided functionally into two parts: - Somatic fibers innervate skeletal (voluntary) muscles. - Autonomic fibers innervate smooth (involuntary) muscles, cardiac muscle, and glands. •Autonomic system mediates unconscious activity.

Trachea and Bronchial Tree

•Trachea lies anterior to esophagus / 10 to 11 cm long in the adult. •Right main bronchus is shorter/wider/more vertical than the left main bronchus. •Trachea and bronchi transport gases between environment and lung parenchyma. •Constitute dead space, or space that is filled with air but is not available for gaseous exchange—150 ml in adult •Bronchial tree protests alveoli from small particulate matter in inhaled air. •Lined with goblet cells that secrete mucus •Acinus: functional unit consists of bronchioles, alveolar ducts, alveolar sacs and alveoli

Abnormal Findings:Lumps and Lesions on External Ear

•Sebaceous cyst - nodule from blocked sebaceous gland •Tophi - small, whitish yellow, hard, nontender nodules in or near helix •Chondrodermatitis nodularis helicis - painful nodules on rim of helix as a result of trauma •Keloid -overgrowth of scar tissue •Battle sign - bruising behind the ear related to skull fracture Carninoma

Sebaceous glands

•Sebum—secreted lipid substance through hair follicles •Lubricate skin and form emulsion

Sensory pathways CNS

•Sensation travels in afferent fibers in peripheral nerve through posterior (dorsal) root and into spinal cord. •Anterolateral tract - Contains sensory fibers that transmit sensations of pain, temperature, and crude or light touch •Posterior (dorsal) columns - These fibers conduct sensations of position, vibration, and finely localized touch. - Position (proprioception), vibration, and finely localized touch (stereognosis)

Incontinence types

•Urgency incontinence: sudden loss, as in acute cystitis •Stress incontinence: involuntary urine loss with physical strain, sneezing or coughing due to weakness of pelvic floor

Palpation of the Aorta

•Using your opposing thumb and fingers, palpate aortic pulsation in upper abdomen slightly to left of midline. •Normally it is 2.5 to 4 cm wide in adult and pulsates in an anterior direction. Widened in the presence of abdominal aortic aneurysm

Subjective bowel data

•Usual bowel routine •Change in bowel habits •Rectal bleeding, blood in stool •Medications: laxatives, stool softeners, iron •Rectal conditions: pruritus, hemorrhoids, fissure, fistula •Family history •Patient-centered care: diet of high-fiber foods, most recent examinations

Regional structures anus, rectum, etc.

•Uterine cervix, in females, lies in front of anterior rectal wall and may be palpated through it. •Combined length of anal canal and rectum is about 16 cm in adult. •Sigmoid colon, S-shaped course in pelvic cavity

Posterior Thoracic Landmarks

•Vertebra prominens: Flex your head and feel for most prominent bony spur protruding at base of neck. •Spinous processes: Count down these knobs on vertebrae, which stack together to form spinal column. •Inferior border of scapula: Scapulae are located symmetrically in each hemothorax. •Twelfth rib: Palpate midway between spine and a person's side to identify its free tip.

Auscultation of Bowel and Vascular Sounds

•This is done because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds. - Use diaphragm endpiece because bowel sounds are relatively high pitched. - Hold stethoscope lightly against skin; pushing too hard may stimulate more bowel sounds. - Begin in RLQ at ileocecal valve area because bowel sounds are normally always present here.

Hair

•Threads of keratin—hair shaft and bulb matrix •Types of hair—vellus and terminal •Follicle—cyclical with active and resting phases

tongue

•Tongue's ability to change shape and position enhances its functions in mastication, swallowing, cleansing teeth, and the formation of speech. •Functions in taste sensation

Vesicles

Elevated cavity containing fluid up to 1 cm (blister)

Cysts

Encapsulated fluid filled cavity

Male Breast Examination

Examination of male breast can be abbreviated, but do not omit it. Normal male breast has flat disk of undeveloped breast tissue beneath nipple. ØGynecomastia •Benign growth of this breast tissue, making it distinguishable from other tissues in chest wall. •Feels like a smooth, firm, movable disk •Occurs normally during puberty and is temporary ØThe adolescent is acutely aware of his body image. ØReassure him that this change is normal, common, and temporary.

a

Examination of the shoulder includes 4 motions. These are: a. Forward flexion, internal rotation, abduction, and external rotation b. Abduction, adduction, pronation, and supination c. Circumduction, inversion, eversion, and rotation d. Elevation, retraction, protraction, and circumduction

Nodule

solid, raised clump of skin cells, larger than 1cm

Septum

(Divides Nasal Cavity)

Confrontation Test

Gross measure of peripheral vision; compares person's peripheral vision with yours

Culture and Genetics: Kidney Disease and Bladder Cancer

- Kidney disease •Two main causes of ESRD: hypertension and diabetes •Prevalence of diabetes and hypertension is higher in some racial groups: African Americans, American Indians and Hispanics are more likely to be affected •Contributing factors: low socioeconomic status with higher proportion of at-risk behaviors, presence of comorbidities, and limited access to care - Bladder cancer •4th most common cancer in men with ethnic differences •Smoking is the most common risk factor along with occupational exposure to chemicals Assess for painless hematuria.

Abnormal Findings: Abnormalities in the Eyelids

- Periorbital edema - Exophthalmos, protruding eyes - Enophthalmos, sunken eyes - Ptosis, drooping upper lid - Upward palpebral slant - Ectropion - Entropion

Structure and function: Peritoneal reflection

- Peritoneum covers only upper two thirds of rectum. - In male, anterior part of peritoneum reflects down to anal opening, forming rectovesical pouch and then covers bladder. - In female, it is termed the rectouterine pouch.

Major neck muscles and function

- Sternomastoid and trapezius are innervated by cranial nerve XI. ■Sternomastoid - Head rotation and flexion and divides each side of neck into two triangles: anterior and posterior triangles ■Two trapezius muscles - move shoulders and extend and turn head.

Abnormalities in the Pupil

- Unequal pupil size, anisocoria - Constricted and fixed pupils, miosis - Dilated and fixed pupils, mydriasis

Facial expressions formed by facial muscles

-Cranial nerve VII -Reflect mood

Cranial bones

-Frontal -Parietal -Occipital -Temporal

Skull Infants and Children complications

-Molding ■Overriding of the cranial bones during birth process that resolves over a few days or a week -Positional molding (positional plagiocephaly) ■Flattening of the head due to infant sleeping position ■Helmet Baby!

Two pairs of salivary glands accessible to examination on the face:

-Parotid glands are in cheeks over mandible, anterior to and below ear; the largest of salivary glands, they are not normally palpable. -Submandibular glands beneath mandible at angle of jaw

Endocrine galnd

-Straddles trachea in middle of the neck ■Synthesizes and secretes - Thyroxine (T4) and triiodothyronine (T3), which are hormones that stimulate rate of cellular metabolism

Types of headaches:

-Tension, migraine, and cluster

Closure of fontanels

-Triangle-shaped posterior fontanel closes by 1 to 2 months. Diamond-shaped anterior fontanel closes between 9 months and 2 years

Subjective data for eyes

-Vision difficulty: decreased acuity, blurring, blind spots -Pain -Strabismus, diplopia -Redness, swelling -Watering, discharge -History of ocular problems -Glaucoma -Use of glasses or contact lenses -Self-care behaviors

Muscle strength scale

0 - no movement 1 - flicker of muscle 2 - joint movement, not against gravity 3 - moves against gravity, not resistance 4 - moves against resistance, but weak 5 - active movement strong against resistance. *Denominator is always 5.* *Strength is only tested with "normal" movement*

Tonsils grading**

0 no tonsils 1 tonsils are visible 2 tonsils are between the tonsillar pillars and the uvula 3 tonsils are touching uvula 4 tonsils are toughing each other

Subjective Data Abdomen

1. Appetite 2. Dysphagia 3. Food intolerance 4. Abdominal pain 5. Nausea/vomiting 6. Bowel habits 7. Past abdominal history 8. Medications 9. Nutritional assessment

Subjective Data Ears

1. Earache 2. Infections 3. Discharge 4. Hearing loss 5. Environmental noise 6. Tinnitus 7. Vertigo 8. Patient-centered care

c

A 64 year old has come in for a health examination. A normal age-related change in the scrotum would be: a. Testicular atrophy b. Testicular hypertrophy c. Pendulous scrotum d. Increase in scrotal rugae

12 cranial nerves in order

1. Olfactory 2. Optic 3. Oculomotor 4. Trochlear 5. Trigeminal 6. Abducens 7. Facial 8. Vestibulocochlear 9. Glossopharyngeal 10. Vagus 11. Accessory 12. Hypoglossal

Mechanisms of Respiration: Function numbered

1. Supply oxygen to the body for energy production 2. Remove carbon dioxide (CO2) as a waste product of energy reactions 3. Maintain homeostasis (acid-base balance) of arterial blood 4. Maintain heat exchange

a

A 65 year old man has noticed a change in his personality and his ability to understand. He also cries and becomes angry very easily. The cerebral lobe responsible for these behaviors is the __________ lobe. a. Frontal b. Patietal c. Occipital d. Temporal

c

A 70 year old woman has come for a health examination. Which of the following is a common age-related change in the curvature of the spinal column? a. Lordosis b. Scoliosis c. Kyphosis d. Lateral scoliosis

Tuning fork used for CNS eval

128 Hz or 256 Hz

b

A 2 year old child comes to the clinic for a health examination. A common finding for this age group is: a. Kyphosis b. Lordosis c. Scoliosis d. No deviation is normal

b

A 20 year old man has indicated that he does not perform a testicular self-examination. One of the facts that should be shared with him is that testicular cancer, although rare, does occur in men: a. Younger than 15 years b. 15 to 34 years of age c. 35-55 years of age d. 55 years and older

d

The normal range of liver span in the right midclavicular line in the adult is: a. 2 to 6 cm b. 4 to 8 cm c. 8 to 14 cm d. 6 to 12 cm

c

A patient states that he is frequently constipated, and when he has a bowel movement he has rectal bleeding and pain. He does not feel any mass at his anal opening. "Do I have hemorrhoids, or is there something else wrong with me?" The examiner completes a rectal examination and explains that: a. There is an indication of rectal prolapse b. It appears to be a pilonidal cyst c. The symptoms are consistent with internal hemorrhoids d. The problem is probably encopresis

a

A patient states the he has frothy, fowl smelling stools that float on the surface of the water in the toilet bowl. What type of stool is the patient describing? a. Steatorrhea b. Melena c. Dyschezia d. A parasitic infection

a

A positive Babinski sign is: a. Dorsiflexion of the big toe and fanning of all toes b. Plantar flexion of the big toe with a fanning of all toes c. The expected response in healthy adults d. Withdrawal of the stimulated extremity from the stimulus

d

A positive Blumberg sign indicates: a. Possible aortic aneurysm b. Presence of renal artery stenosis c. Enlarged, nodular liver d. Peritoneal inflammation

b

A positive Murphy's sign is best described as: a. The pain felt when the examiner's hand is rapidly removed from an inflamed appendix b. Pain felt when taking a deep breath when the examiner's fingers are on the approximate location of the inflamed gallbladder c. A sharp pain felt by the patient when one hand of the examiner is used to thump the other at the costovertebral angle. d. This is not a valid examination technique

c

A positive Phalen test and Tinel sign are found in a patient with: a. A torn meniscus b. Hallux valgus c. Carpal tunnel syndrome d. Tennis elbow

Rinne Test

A test used for conductive hearing loss. The examiner strikes a tuning fork and places it on the mastoid bone behind one ear

Weber Test

A test used for sensorineural hearing loss. The examiner strikes a tuning for and places it in the middle of the patient's head

Femoral hernia

A type of hernia that causes a bulge in the upper part of the thigh near the groin.

d

A woman has come for a health care reporting a thick white discharge with intense itching. These symptoms are suggestive of: a. Atrophic Vaginitis b. Trichomoniasis c. Chlamydia d. Candidiasis

d

A woman has come for an examination because of a missed menstrual period and a positive home pregnancy test. Examination reveals a cervix that appears cyanotic. This is referred to as the: a. Goodell sign b. Hegar sign c. Tanner sign d. Chadwick sign

a

A young woman has come for her first gynecologic examination. Because she has not had any children, the examiner expects the cervical Os to appear: a. Smooth and circular b. Irregular and slitlike c. Irregular and circular d. Smooth and enlarged

RLQ

Abdominal Quadrant: Ascending colon, appendix, cecum, right ovary and tube, right ureter, right spermatic cord

LLQ

Abdominal Quadrant: Descending colon, sigmoid colon, left ovary and tube, left ureter, left spermatic cord

RUQ

Abdominal Quadrant: Liver, gallbladder, duodenum, head of pancreas, right kidney and adrenal gland, hepatic fissure, transverse colon

LUQ

Abdominal Quadrant: Spleen, stomach, left lobe of liver, body on pancreas, left kidney and adrenal gland, splenic flexure, transverse colon

Abnormalities of the Ankle and Foot

Achilles tenosynovitis Chronic/acute gout Hallux vagus with bunion and hammer toes Callus Plantar wart Ingrown toenail

Vibration

After 65 years of age, the loss of the sensation of _________ at the ankle malleolus is common and usually accompanied by loss of the ankle jerk.

Corneal Light Reflex

Also known as the Hirschberg test

b

An adhesion of the prepuce to the head of the penis, making it impossible to retract, is: a. Paraphimosis b. Phimosis c. Smegma d. Dyschezia

swimmers ear

An infection of the skin covering the outer ear canal

d

An older man asks if he is able to father children. In the aging male, when does infertility occur? a. At age 60, with the sudden decline in sperm production b. At approximately age 55 to 60, when testosterone levels are lower c. When the male is no longer able to achieve an erection d. There is no specific age; men may be fertile into their 80s and 90s

d

Anterior and posterior stability are provided to the knee joint by the: a. Medial and lateral menisci b. Patellar tendon and ligament c. Medial collateral ligament and quadriceps muscle d. Anterior and posterior cruciate ligaments

Aging adult: additional subjective data mouth and throat

Any dryness in the mouth? Are you taking any medications? (Note prescribed and over-the-counter medications.) Have you had any loss of teeth? Can you chew all types of food? Are you able to care for your own teeth or dentures? Have you noticed a change in your sense of taste or smell?

Palpation

Applies sense of touch to assess the following: ØTexture, temperature and moisture ØOrgan location and size ØSwelling, vibration, pulsation or crepitation ØRigidity or spasticity ØPresence of lumps or masses ØPresence of tenderness or pain

Environmental Exposure Lungs

Are there any environmental conditions that may affect your breathing? Ask about: •occupational factors and exposure. •protection from exposure. •monitoring and follow-up to exposure. •awareness of symptoms that might signal breathing problems.

Subjective Data Questions: Patient-Centered Care

Ask about self-breast exam (SBE) ØTeaching moment to review basics of examination Review screening guidelines recommendations based on age and patient history ØAmerican Cancer Society Begin at ages 40 to 44, screening mammography Annual mammography from ages 45 to 54 Biennial mammography over age 55 or continuation of annual

Abnormal Findings Abnormalities of the Shoulder

Atrophy Dislocated shoulder Joint effusion Tear of the rotator cuff Frozen shoulder—adhesive capsulitis Subacromial bursitis

a

Auscultating the abdomen is begun in the right lower quadrant (RLQ) because: a. Bowel sounds are always normally present here b. Peristalsis through the descending colon is usually active c. This is the location of the pyloric sphincter d. Vascular sounds are best heard in this area

a

Auscultation of the abdomen may reveal bruits of the ____________ arteries. a. Aortic, renal, iliac, and femoral b. Jugular, aortic, carotid, and femoral c. Pulmonic, aortic, and portal d. Renal, iliac, internal jugular, and basilic

Celiac disease

Autoimmune disorder Intolerant of gluten

Paroxysmal Nocturnal Dyspnea

Awakens from sleep due to SOB

Cerebellar function tests BALANCE

Balance tests •Gait: observe as the person walks 10 to 20 feet, turns, and returns to starting point •Normally the person moves with a sense of freedom; gait is smooth, rhythmic, and effortless; opposing arm swing is coordinated; the person turns smooth; step length about 15 inches from heel to heel. •Tandem walking: Ask the person to walk straight line in heel-to-toe fashion

Neck

Base of skull and inferior border of mandible above, and by manubrium sterni, clavicle, first rib, and first thoracic vertebra below

c

Before withdrawing the speculum, the examiner swabs the cervix with a swap soaked in acetic acid. This examination is done to assess for: a. Herpes simplex virus b. Contact dermatitis c. Human Papillomavirus d. Carcinoma

Keloids

Benign excess of scar tissue beyond original injury

Risk Profile for Breast Cancer

Breast cancer is second major cause of death from cancer in women. However, early detection and improved treatment have increased survival rates. Review factors associated with "relative risk" ØRR above 1 indicates a higher likelihood of occurrence among exposed than unexposed persons.

Lymphatics of the breast

Breast has extensive lymphatic drainage. Four groups of axillary nodes are present ØCentral axillary nodes ØPectoral (anterior) ØSubscapular (posterior) ØLateral From the central axillary nodes, drainage flows up to infraclavicular and supraclavicular nodes

Subjective Data Breast

Breast: •Pain, lump, and discharge •Rash, swelling, trauma •History of breast disease •Surgery or radiation •Medications •Patient-centered care •Perform breast self-examination/last mammogram Axilla: •Tenderness, lump, or swelling •Rash

PNS

CNS or PNS? Includes the 12 pairs of cranial nerves, the 31 pairs of spinal nerves, and all their branches.

CNS

CNS or PNS? Includes the brain and spinal cord

Mouth - Culture and Genetics

Dental caries - Infectious process leading to tooth decay due to interaction of bacteria is on the rise. Increased risk for dental disease - Due to socioeconomic status, lack of access and comorbidities Complications r/t periodontal disease - Linked to type 2 diabetes Increased incidence of oral cancers - Linked to HPV and changes in sexual norms

Finger to Nose Test

Cerebellar Function Test: Have person close their eyes, outstretch their arms, and have them touch the tip of their nose with each finger.

Rapid Alternating Movements

Cerebellar Function Test: Have person pat knees with both hands, turn hands over, and pat knees with backs of hands. Have the person do this faster.

Heel To Shin Test

Cerebellar Function Test: Test lower extremity coordination by having person lie in a supine position, place heel on opposite knee, and run it down shin from knee to ankle.

Finger to Finger Test

Cerebellar Function Test: With person's eyes open, have them touch their finger to yours, and then have them touch their own nose.

c

Cerebellar function is assessed by which of the following? a. Muscle size and strength assessment b. Cranial nerve examination c. Coordination ----hopping on one foot d. Spinothalamic test

Temporomandibular joint (TMJ)

articulation of mandible and temporal bone

Secondary Skin Lesion

Debris on skin surfaces •Crust—Thickened dried out exudate •Scale—Compact flakes of desiccated skin from shedding of dead excess keratin cells

Abnormal postures

Decorticate rigidity •Upper extremities •Flexion of arm, wrist, and fingers •Adduction of arm: tight against thorax Lower extremities •Extension, internal rotation, plantar flexion; indicates hemispheric lesion of cerebral cortex Decerebrate rigidity •Upper extremities: stiffly extended, adducted, internal rotation, palms pronated •Lower extremities: stiffly extended, plantar flexion; teeth clenched; hyperextended back •More ominous than decorticate rigidity; indicates lesion in brainstem at midbrain or upper pons

Osteoporosis

Decrease in skeletal bone mass leading to low bone mineral density and impaired bone quality.

2+

Deep Tendon Reflex Test Grades (1-4) Average, normal

3+

Deep Tendon Reflex Test Grades (1-4) Brisker than average, may indicate disease, *PROBABLY* normal (lmao wtf kind of standard grading system is this)

1+

Deep Tendon Reflex Test Grades (1-4) Diminished, low normal, or occurs only with reinforcement

0+

Deep Tendon Reflex Test Grades (1-4) No response

4+

Deep Tendon Reflex Test Grades (1-4) Very brisk, hyperactive with clonus, indicative of disease

Orthopnea

Difficulty breathing when supine

Tinel Sign

Direct percussion of the location of the median nerve at the wrist produces no symptoms in the normal hand. If symptoms *are* present, this is a positive _______ sign.

b

During a neurologic examination, the tendon reflex fails to appear. Before striking the tendon again, you will use the technique of: a. Two-point discrimination b. Reinforcement c. Vibration d. Graphesthesia

c

During examination of the scrotum, a normal finding would be that: a. The left testicle is firmer to palpation than the right b. The left testicle is larger than the right c. The left testicle hangs lower than the right d. The left testicle is more tender to palpation than the right

Guarding

During palpation of the abdomen, voluntary _________ can occur, which happens when the person is cold, tense, or ticklish. It is bilateral and the muscles relax slightly during exhalation

d

During palpation of the testes, the normal finding would be: a. Firm to hard and rough b. Nodular c. 2 to 3 cm long by 2 cm wide and firm d. Firm, rubbery, and smooth

d

During the assessment of the spine, the patient would be asked to: a. Adduct and extend d. Supinate, evert, and retract c. Extend, adduct, invert, and rotate d. Flex, extend, abduct, and rotate

a

During the examination of a full term male newborn, a finding requiring investigation would be: a. An absent testes b. A meatus centered at the tip of the penis c. A wrinkled scrotum d. A penis 2 to 3cm in length

c

During the examination of an infant, use a cotton-tipped applicator to stimulate the anal sphincter. The absence of a response suggests a lesion of: a. L2 b. T12 c. S2 d. C5

c

During the examination of the genitalia of a 70 year old woman, a normal finding would be: a. Hypertrophy of the mons pubic b. Increase in vaginal secretions c. Thin and sparse pubic hair d. Bladder prolapse

d

During transillumination of the scrotum, you note a nontender mass that transilluminates with a red glow. This finding is suggestive of: a. Scrotal hernia b. Scrotal edema c. Orchitis d. Hydrocele

Developmental Competence: The Aging Adult

Elasticity ØLoses elasticity; skinfolds/sags Sweat and sebaceous glands ØDecrease in number/function, skin dry Senile purpura ØDiscoloration due to increasing capillary fragility Skin breakdown due to multiple factors ØCell replacement is slower/wound healing is delayed. Hair matrix ØFunctioning melanocytes decrease, leading to gray fine hair

Inspection and Palpation of the Axillae

Examine axillae while woman is sitting. •Inspect skin, noting any rash or infection; lift woman's arm and support it so that her muscles are loose and relaxed; use right hand to palpate left axilla. •Reach fingers high into axilla; move them firmly down in four directions. •Move woman's arm through range-of-motion to increase surface area you can reach. •Usually nodes are not palpable, although you may feel a small, soft, nontender node in central group. •Note any enlarged and tender lymph nodes.

Papules

Felt and caused by superficial thickening of the epidermis

mouth overview cont.

Floor of mouth consists of the horseshoe-shaped mandible bone, tongue, and underlying muscles. Tongue: striated muscle arranged in a crosswise pattern so that it can change shape and position •Papillae: rough, bumpy elevations on its dorsal surface •Ventral surface: smooth, shiny and has prominent veins •Frenulum: midline fold of tissue connecting tongue to floor of mouth

a

Foods that may be beneficial to reduce the risk for colon cancer include: a. Foods high in fiber b. Foods low in fat c. Foods high in protein c. Foods high in carbohydrate

T: Timing, Once a month S: Shower, warm water relaxes scrotum E: Examine, check for changes, report immediately

For a male, performing a testicular self examination is important. What does the acronym, TSE, stand for?

c

For a woman, history of her mother's health during pregnancy is important. A medication that requires frequent follow up is: a. Corticosteroid b. Theophylline c. Diethylstilbestrol d. Aminoglycoside

Pectus Carinatum

Forward protrusion of the spine

Common Causes of Constipation

Found in the older adult •Decreased physical activity •Inadequate intake of water •Low-fiber diet •Side effects of medications •Irritable bowel syndrome •Bowel obstruction •Hypothyroidism •Inadequate toilet facilities, that is, difficulty ambulating to toilet may cause a person to deliberately retain stool until it becomes hard and difficult to pass

Abnormal Findings Abnormalities of the Wrist and Hand

Ganglion cyst ØFluid filled cyst Colles' fracture ØComplete radial break Carpal tunnel syndrome ØCompression of nerve Ankylosis Dupuytren's contracture ØThickening of tissue beneath skin Swan-neck and boutonniere deformities Ulnar deviation or drift Degenerative joint disease or osteoarthritis Acute rheumatoid arthritis Syndactyly ØWebbed fingers Polydactyly ØMore than five fingers

Inspection of the Breast

General appearance: •Note symmetry of size and shape. •Common to have a slight asymmetry in size Skin: •Normally smooth and of even color •Note any localized areas of redness, bulging, or dimpling; and any skin lesions or focal vascular pattern. •Fine blue vascular network visible during pregnancy; pale linear striae, or stretch marks, follow pregnancy. Normally no edema is present.

d

Hematopoiesis takes place in which of the following? a. Liver b. Spleen c. Kidneys d. Bone marrow

Splinter Hemorrhage

Hemorrhage caused by trauma or injury to the nail bed that damages the capillaries and allow small amounts of blood flow.

d

Hyperactive bowel sounds are: a. High pitched b. Rushing c. Tinkling d. All of the above

Accessory (Spinal) (11)

Identify the cranial nerve associated with this test: Ask person to rotate head forcibly against resistance applied to side of the chin. Then ask person to shrug shoulders against resistance.

Facial (7)

Identify the cranial nerve associated with this test: Have patient smile, frown, close eyes tightly, lift eyebrows, show teeth, and puff cheecks

Hypoglossal (12)

Identify the cranial nerve associated with this test: Inspect tongue, and note forward thrust in the midline as this happens. Next, ask person to say "light, tight, dynamite" and note speech being clear and distinct

Trigeminal (5)

Identify the cranial nerve associated with this test: Motor: Palpate temporal and masseter muscles for mastication. Try to separate jaws by pushing down on the chin. (normally, you cannot do this). Sensory: Use cotton wisp to test light touch sensation on forehead, cheeks, and chin

Olfactory (1)

Identify the cranial nerve associated with this test: Occlude one nostril at a time, asking person to sniff. Then, occlude one nostril and present an aromatic substance

Vestibulocochlear (Acoustic) (8)

Identify the cranial nerve associated with this test: Test hearing acuity by using the whisper voice test

Optic (2)

Identify the cranial nerve associated with this test: Use visual acuity test, and confrontation test. Use the opthalmoscope to examine the ocular fundus to determine color, size, and shape of optic disc

Glossopharyngeal (9) Vagus (10)

Identify the cranial nerves associated with this test: Depress tongue and note pharyngeal movement when person says "ahhhh" or yawns. Uvula and soft palate should rise in the midline, and tonsillar pillars should move medially. Next, test for gag reflex.

Oculomotor (3) Trochlear (4) Abducens (6)

Identify the cranial nerves associated with this test: PERRLA, extraocular eye movements by cardinal positions of gaze, nystagmus

Identification of a Mass

If you identify a mass, then note the following: •Location •Size •Shape •Consistency: soft, firm, hard •Surface: smooth, nodular •Mobility, including movement with respirations •Pulsatility Tenderness

b

In placing a finger on either side of the cervix and moving it side to side, you are assessing: a. The diameter of the fallopian tube b. Cervical motion tenderness c. The ovaries d. The uterus

Tenderness

Normally, there is mild _________ when palpating the signmoid colon

Developmental Competence: Infants and Adolescents MALE GU

Infants •Prenatally, testes develop in abdominal cavity near kidneys. •At birth, testis measure 1.5 to 2 cm long and 1 cm wide. •Only a slight increase in size occurs during prepubertal years. Adolescents •Signs of puberty are appearing earlier in boys according to research studies both in the United States and other countries. •First sign is enlargement of testes. •Next, pubic hair appears, then penis size increases. •Stages of development are documented in Tanner's sexual maturity ratings.

Acute rhinitis

Inflammation of the nasal mucosa with sneezing, tearing, and profuse secretion of watery mucus, as seen in the common cold

Abnormal Findings Abnormalities Affecting Multiple Joints

Inflammatory conditions: ØRheumatoid arthritis ØAnkylosing spondylitis-type of arthritis Degenerative conditions: ØOsteoarthritis (degenerative joint disease) ØOsteoporosis

Abnormal Findings Abdomen

Inspection •Umbilical hernia •Epigastric hernia •Incisional hernia •Diastasis recti Abnormal bowel sounds •Succussion splash •Marked peristalsis •Hypoactive bowel sounds •Hyperactive bowel sounds Friction rubs and vascular sounds •Peritoneal friction rub •Arterial bruit •Venous hum On palpation of enlarged organs •Enlarged liver •Enlarged nodular liver •Enlarged gallbladder •Enlarged spleen •Enlarged kidney •Aortic aneurysm

Culture and Genetics Lactose intolerance

Lactase is a digestive enzyme necessary for absorption of carbohydrate lactose (milk sugar). - These people are lactose intolerant and have abdominal pain, bloating, and flatulence when milk products are consumed. •Ethnic variation seen •Estimated incidence of lactose intolerance is - 20% to 30% of whites, 70% of Mexican Americans, and 80% of blacks and 100% American Indians.

Tumors

Larger in diameter, firm or soft, deeper into dermis, may be benign or malignant,

Bullas

Larger than 1 cm diameter, usually single chamber, superficial in dermis and ruptures easily

Anatomic Locations of Left Upper Quadrants

Left upper quadrant (LUQ) •Stomach •Spleen •Left lobe of liver •Body of pancreas •Left kidney and adrenal gland •Splenic flexure of colon •Part of transverse and descending colon

Auscultation

Listening to sounds produced by body generally with stethoscope

Inspection of the Breast (con't)

Lymphatic drainage areas ØObserve axillary and supraclavicular regions; note any bulging, discoloration, or edema Nipple ØShould be symmetric on same plane on both breasts ØNipples usually protrude, although some are flat and some are inverted ØNormal nipple inversion may be unilateral or bilateral and usually can be pulled out ØNote any dry scaling, any fissure or ulceration, and bleeding or other discharge ØSupernumerary nipple is normal variation Check the breast for skin retraction ØPerform sequence of maneuvers to assess for this abnormality

Cranial nerves 3, 4, 6

MOVE EYES **

The Clinical Setting: Hands On

Measurement and vital signs Have patient change into examination gown. ØMaintain privacy and respect. Perform hand hygiene. Provide explanations. ØBegin with person's hands as point of initial contact. ØConcentrate on one step at a time—avoid distractions. ØExamination sequence—offer health teaching ØProvide explanations. Summarize findings for person.

Thoracic Cavity

Mediastinum: middle section of thoracic cavity containing esophagus, trachea, heart, and great vessels Lungs - Right and left pleural cavities contain lungs. - Note lung borders at apex, base, lateral and posterior positions. Lobes of lungs - Lungs are paired but not precisely symmetric structures. - Right lung shorter than left because of underlying liver - Left lung narrower than right because heart bulges to left - Right lung has three lobes, and left lung has two lobes.****

Abnormalities of the Knee

Mild synovitis Prepatellar bursitis Swelling of menisci Osgood-Schlatter disease - Knee pain in adolescents Chondromalacia patellae -runner's knee - Deterioration of cartilage

Epistaxis **

Most common in anterior septum (Kiesselbach Plexus)

5

Muscle Testing Grade (0-5) -Full ROM against gravity, full resistance -100% Normal -Normal Assessment

4

Muscle Testing Grade (0-5) -Full ROM against gravity, some resistance -75% Normal -Good Assessment

3

Muscle Testing Grade (0-5) -Full ROM with gravity -50% Normal -Fair Assessment

2

Muscle Testing Grade (0-5) -Full ROM with gravity eliminated (passive motion) -25% Normal -Poor Assessment

0

Muscle Testing Grade (0-5) -No Contraction -0% Normal -Zero Assessment

1

Muscle Testing Grade (0-5) -Slight Contraction -10% Normal -Trace Assessment

Osteoarthritis

Noninflammatory, localized, progressive disorder involving deterioration of articular cartilages and subchondral bone and formation of new bone at joint surfaces.

Liver

Normal _______ span in the adult ranges from 6-12 cm, with it being located at the 5th intercostal space

b

Normal stool is described as: a. Black in color and tarry in consistency b. Brown in color and soft in consistency c. Clay-colored and dry in consistency d. Varies depending on the individuals diet

Direct inguinal hernia

Older men, weakness of transversals fascia, travels medial to vessels, remains superficial

Abnormal Findings Abnormalities of the Elbow

Olecranon bursitis Gouty arthritis- sudden; uric acid in joint Subcutaneous nodules Epicondylitis—tennis elbow

Pneumonic Cranial Nerves

Ooh, ooh, ooh to touch and feel very good velvet. Such heaven

Developmental Competence

Order of the developmental stage is more meaningful than the chronologic age.

Scars

Permanent fibrotic change after healing

Glossopharyngeal

Phonation, swallowing, tasting posterior third of tongue

Structure and Function: Thorax and Lungs

Position and surface landmarks •Thoracic cage is a bony structure with a conical shape, which is narrower at top. •Defined by sternum, 12 pairs of ribs, and 12 thoracic vertebrae •First seven ribs attach to sternum by costal cartilages. •Ribs 8, 9, and 10 attach to costal cartilage above. •Ribs 11 and 12 are "floating," with free palpable tips. •Costochondral junctions are points at which ribs join their cartilages; they are not palpable.

Objective eye data

Preparation: - Position person standing for vision screening; then sitting up with head at your eye level Equipment needed: - Snellen eye chart - Handheld visual screener - Opaque card or occluder - Penlight

Objective Data Abdomen

Preparation: •Adequate lighting •Expose abdomen so that it is fully visible; drape genitalia and female breasts. •Position for comfort to enhance abdominal wall relaxation. •Empty bladder prior to examination with specimen saved if needed. •Warm stethoscope and examine areas identified as painful last so as to prevent guarding. •Auscultate prior to palpation and percussion. •Use distraction to keep patient relaxed/facilitate muscle relaxation. Equipment •Stethoscope, small centimeter ruler, and skin-marking pen •Alcohol wipe to clean endpiece

Objective Data: Preparation and Equipment Lungs

Preparation: •Provide respect and comfort while allowing for access of examination techniques. •Perform inspection, palpation, percussion, and auscultation on posterior and lateral thorax. Equipment: •Stethoscope •Small ruler, marked in centimeters •Marking pen •Alcohol wipe

Objective data of Breasts

Preparation: •Woman sitting up facing examiner •An alternative draping method is to use a short gown, open at back, and lift it up to woman's shoulders during inspection. •During palpation when woman is supine, cover one breast with gown while examining other. Be aware that many women are embarrassed to have their breasts examined; use a sensitive but matter-of-fact approach. •After examination, be prepared to teach woman breast self-examination. Equipment: •Small pillow •Ruler marked in centimeters Pamphlet or teaching aid for breast self-examination (BSE)

Subjective Data Questions: Rash and Swelling Breasts

Rash ØAppearance: Any rash on breast? ØOnset: When did you first notice this? ØLocation: Where did it start? On the nipple, areola, or surrounding skin? Swelling ØLocation: Any swelling in breasts? In one spot or all over? ØAppearance: r/t your menstrual period, pregnancy, or breastfeeding? ØAny change in bra size?

Rooting Reflex

Reflex: Brush the infants cheek near the mouth. He or she normally turns the head toward that side and opens the mouth.

Moro Reflex

Reflex: Startle the infant by jarring the crib, making a loud noise, or supporting the head and back in a semi-sitting position and quickly lowering the infant to 30 degrees. The baby looks like the are hugging a tree; with symmetric abduction and extension of the arms and legs, fanning fingers, and curling the index finger and thumb to C position.

Tonic Neck Reflex

Reflex: With the baby supine, relaxed, or sleeping, turn the head to one side with the chin over the shoulder. Note ipsilateral extension of the arm and leg and flexion of the opposite arm and leg. This is the "fencing" position. If you turn the baby's head to the opposite side, the positions reverse.

Palmar Grasp

Reflex: Offer your finger and note tight grasp of all the baby's fingers. Sucking enhances grasp. You can often pull baby to a sitting position from grasp

Atrophic scars

Resulting skin level is depressed with loss of tissue and thinning

Anatomic Locations of Lower Quadrants

Right lower quadrant (RLQ) •Cecum •Appendix •Right ovary and tube •Right ureter •Right spermatic cord Left lower quadrant (LLQ) •Part of descending colon •Sigmoid colon •Left ovary and tube •Left ureter •Left spermatic cord

Anatomic Locations of Right Upper Quadrants

Right upper quadrant (RUQ) •Liver •Gallbladder •Duodenum •Head of pancreas •Right kidney and adrenal gland •Hepatic flexure of colon •Part of ascending and transverse colon

a

Right upper quadrant tenderness may indicate pathology in the: a. Liver, pancreas, or ascending colon b. Liver and stomach c. Sigmoid colon, spleen, or rectum d. Appendix or ileocecal valve

a

Shifting dullness is a test for: a. Ascites b. Splenic enlargement c. Inflammation of the kidneys d. Hepatomegaly

Palpation Preformation

Should be performed slow and systematic ØStart with light and proceed to deep. ØBimanual palpation is used for certain body parts or organs.

Skin function

Skin is waterproof, protective, and adaptive ØProtection from environment ØPrevents penetration ØPerception ØTemperature regulation ØIdentification ØCommunication ØWound repair ØAbsorption and excretion Production of vitamin D

Olfactory

Smell

Test Central Visual Acuity

Snellen alphabet chart

Nodules

Solid, elevated, hard or soft, greater than 1 cm that may extend deeper into dermis than papule

Rebound Tenderness

Special Procedure: Choose a site away from the painful area. Hold hand 90 degrees or perpendicular to the abdomen. Push down slowly and deeply, then lift up quickly. A normal response is the absence of pain on release of pressure

Wheals

Superficial, raised, transient and erythematous, irregular in shape due to edema

Anterior Thoracic

Suprasternal notch: U shaped depression just above sternum between clavicles. Sternum: "breastbone" -Manubrium, body, and xiphoid process Manubriosternal angle: "Angle of Louis," at articulation of manubrium and sternum, and continuous with second rib - Identify Angle of Louis, palpate lightly to second rib, and slide down to second intercostal space. - Angle of Louis also marks site of tracheal bifurcation into right and left main bronchi - Corresponds with upper border of atria of the heart, and it lies above fourth thoracic vertebra on back. Costal angle: the right and left costal margins form an angle where they meet at xiphoid process.

Subjective Data Questions: Treatment and Medications Breasts

Surgery or radiation ØSurgical intervention: Biopsy with results ØMastectomy? Mammoplasty, augmentation, or reduction? ØRadiation as part of therapy? ØImaging studies: Mammography, a screening x-ray examination of breasts? When was last x-ray? Medications ØHave you taken oral contraceptives? How long? ØHave you been on HRT? How long? ØTypes of medications: Rx and OTC

Flexion and Extension

The metacarpophalangeal and interphalangeal joints permit finger ____________ and ___________.

Eye Examination

Test visual acuity - Snellen eye chart Test visual fields - Confrontation test Inspect EOM function - Corneal light reflex, cover test, diagnostic positions test Inspect external eye structures Inspect anterior eyeball structures Inspect ocular fundus: what you should see** - Optic disc, retinal vessels, general background, and macula

Vibration

Test: Strike a low-pitched tuning fork on the heel of your hand and hold the base on a bony surface of the fingers and great toe. Ask the person to indicate when the vibration starts and stops Normal Findings: A buzzing sensation felt

b

The Glasgow Coma Scale (GCS) is divided into three areas. They include: a. Pupillary response, a reflex test, and assessing pain b. Eye opening, motor response to stimuli, and verbal response c. Response to fine touch, stereognosis, and sense of position d. Orientation, rapid altering movements, and the Romberg test

d

The Landau reflex in the infant is seen when: a. The head is held and then flops forward as the baby is pulled to a sitting position by holding her or his wrist b. The infant's toes curl down tightly in response to touch on the ball of his or her foot c. The infant attempts to place his or her foot on the table while being held with the top of the foot touching the underside of the table d. The baby raises his or her head and arches the back, as in a swan dive

McMurray

The _________ test is used with people with a history of trauma followed by locking, giving way, or pain in the knee. Extending the leg during this normally occurs smoothly with no pain

Ortolani

The ___________ maneuver is done in infants. Abducting the legs with the knees flexed produces normal findings which are smooth feeling and no sound

c

The absence of bowel sounds is established after listening for: a. 1 full minute b. 3 full minutes c. 5 full minutes d. None of the above

a

The bulge sign is a test for: a. Swelling in the suprapatellar pouch b. Carpal tunnel syndrome c. Heberden's nodes d. Olecranon bursa inflammation

a

The congenital displacement of the urethral meatus to the inferior surface of the penis is: a. Hypospadias b. Epispadias c. Hypoesthesia d. Hypophysis

d

The control of body temperature is located in: a. Wernicke's area b. Thalamus c. Cerebellum d. Hypothalamus

b

The cremasteric response: a. Is positive when disease of the pyramidal tract is present b. Is positive when the ipsilaterl testicle elevates on stroking of the inner aspect of the thigh c. Is a reflex of the receptors in the muscles of the abdomen d. Is not a valid neurologic examination

c

The examiner is going to inspect and palpate for a hernia. During this examination, the man is instructed to: a. Hold his breath during palpation b. Cough after the examiner has gently inserted the examination finger into the rectum c. Bear down when the examiner's finger is at the inguinal canal d. Relax in a supine position while the examination finger is inserted into the canal

c

The examiner measures a patient's legs for length discrepancy. Which is a normal finding? a. No difference in measurements b. .5 cm difference c. Within 1 cm of eachother d. 2 cm difference

a

The gastrocolic reflex is: a. A peristaltic wave b. Passage of meconium in the newborn c. Another term for borborygmi d. Reverse peristalsis

Rotator Cuff

The glenohumeral joint is enclosed by a group of four powerful muscles and tendons that support and stabilize it. This is commonly called the what?

d

The left upper quadrant (LUQ) contains the: a. Liver b. Appendix c. Left ovary d. Spleen

a

The medical record indicates that a person has an injury to Broca's area. When meeting this person, you expect: a. Difficulty speaking b. Receptive aphasia c. Visual disturbances d. Emotional lability

Gyrus

The precentral ________of the frontal lobe initiates voluntary movement

List

The spine tilts to one side, away from the affected side, usually associated with pressure on the local spinal nerve root from a herniated disk

Pons

This brain structure has two respiratory centers (Pneumotaxic and apneustic) that coordinate with the main respiratory center in the medulla

Medulla

This brain structure has vital autonomic centers (respiration, heart, GI function) and nuclei for cranial nerves 8-12.

Midbrain

This brain structure merges into the thalamus and hypothalamus. It contains many motor neurons and tracts

Dermatome

This is a circumscribed skin area that is supplied mainly from one spinal cord segment through a particular spinal nerve

Reinforcement

This is a technique done when reflex response fails to appear. You ask the patient to perform an isometric exercise away from the one being tested. Example for enhancing patellar reflex: Ask person to lock fingers together and "pull as hard as you can" Strike the tendon during these exercises

Glenohumeral Joint

This joint is the articulation of the humerus with the glenoid fossa of the scapula. Its ball and socket action allows great mobility of the arm on many axes

Temporomandibular Joint (TMJ)

This joint is the articulation of the mandible and temporal bone. It is felt in the depression anterior to the tragus of the ear.

Temporal Lobe

This lobe is the primary auditory reception center, with functions of hearing, taste, and smell

Occipital Lobe

This lobe is the primary visual receptor center

Parietal Lobe

This lobes precentral gyrus is associated with sensation

Phalen Test

This test consists of asking the person to hold both hands back to back while flexing the wrists 90 degrees. Normally, doing this for 60 seconds produces no symptoms

b

To elicit the Babinski reflex: a. Gently tap the Achilles tendon b. Stroke the lateral aspect of the sole of the food from heel to across the ball c. Present a noxious odor to the person d. Observe the person walking heel to toe

b

To insert the speculum as comfortably as possible, the examiner: a. Opens the speculum slightly and inserts it in an upward direction b. Presses the introitus down with one hand and inserts the blades obliquely with the other c. Spreads the labia with one hand and inserts the closed speculum horizontally with the other d. Pushes down on the introitus and inserts the speculum in an upward direction

Bimanual Technique

To overcome the resistance of an obese abdomen, use this technique. You place your hands on top of one another. The top hand pushes, while the bottom hand is relaxed and concentrates on the sense of palpation

c

To test for stereognosis, you would: a. Have the person close their eyes, and then raise the person's arm and ask the person to describe its location b. Touch the person with a tuning fork c. Place a coin in the person's hand and ask him or her to identify it d. Touch the person with a cold object

Subjective Data Questions: Trauma and History of Breast Disease

Trauma ØAny trauma or injury to the breasts? ØPresentation: Did it result in any swelling, lump, or break in skin? History of breast disease ØAny history of breast disease yourself? ØDiagnosis: What type? How was this diagnosed? ØMedical management: When did this occur? How is it being treated? ØFamily history: Any breast cancer in your family? Who? Sister, mother, maternal grandmother, maternal aunts, daughter? •At what age did this relative have breast cancer?

Decorticate Rigidity

Upper Extremities: Flexion of arm, wrist, and figures; adduction of arm Lower Extremities: extension, internal rotation, plantar flexion. This indicates hemispheric lesion of cerebral cortex

Decerebate Rigidity

Upper Extremities: Stiffly extended, adducted; internal rotation, palms pronated Lower Extremities: Stiffly extended, plantar flexion; teeth clenched; hyperextended back. More ominous. Indicates lesion in brainstem at midbrain or upper pons

Abnormal Findings: Urinary Problems and Male Genital Lesions

Urinary problems •Urethritis (urethral discharge and dysuria) •Renal calculi •Acute urinary retention and urinary tract infection •Urethral stricture Male genital lesions •Tinea cruris •Genital herpes—HSV-2 infection •Genital warts •Syphilitic chancre Carcinoma

d

Vaginal lubrication is provided during intercourse by: a. Labia minora b. Sebaceous follicles c. Skene glands d. Bartholin glands

Palpation of the Breasts

Vertical strip pattern is recommended to detect for breast masses. - Two other patterns are in common use: - From the nipple palpating out to periphery as if following spokes on a wheel - Palpating in concentric circles out to periphery In nulliparous women, normal breast tissue feels firm, smooth, and elastic. ØAfter pregnancy, tissue feels softer and looser. Premenstrual engorgement is normal from increasing progesterone. After palpating over four breast quadrants, palpate nipple; note any induration or subareolar mass. ØWith your thumb and forefinger, gently depress nipple tissue into well behind areola; tissue should move inward easily. If woman reports spontaneous nipple discharge Øpress areola inward with your index finger. Ørepeat from a few different directions; note color and consistency of any discharge. If woman mentions a breast lump that she has discovered herself, examine unaffected breast first to learn a baseline of normal consistency for this woman.

Optic

Vision

The nurse is preparing to do a physical assessment on a patient who is end-stage HIV positive. What should the nurse do for self-protection?

Wash hands, don gloves, and wash hands after examination; no other protective equipment is necessary.

Aorta

What are you locating? Using your opposing thumb and fingers, palpate the pulsation in the upper abdomen slightly to the left of the midline. It is normally 2.5-4cm wide in adults and pulsates in an anterior direction

Acites

What are you testing for? Place ulnar edge of patient's hand firmly on abdomen midline. Place YOUR left hand on their right flank. With your right hand, reach across the abdomen and give the left flank a firm strike. If this is present, the blow will generate a fluid wave through the abdomen

b

What does the notation in a health record indicating the patient is a "G2 P3 Ab0" mean? a. The woman has delivered 3 children, 2 of whom are living; her blood type is Ab0 b. The woman has been pregnant twice with 3 children (twins and another child), and all her children are living c. The woman has been pregnant 3 times, has delivered 2 children, and has had no abortions d. The woman has been pregnant 3 times, has 2 living children, and has had no spontaneous abortions

Spleen

What organ are you locating? Normally, is it not palpable and must be enlarged 3 times its normal size to be felt. It will be felt at the left upper quadrant

Liver

What organ are you locating? Place left hand under person's back, parallel to the 11th and 12th ribs, and lift up to support the abdominal contents. Place right hand on the right upper quadrant, with fingers parallel to the midline. Push deeply down and ask the person to take a deep breath. It is normal to feel the edge of this organ bump your fingertips

Kidney

What organ are you locating? You can search for the right one by placing your hands together in a duckbill position at the person's right flank. Press two hands firmly and ask the person to take a deep breath. With most people, you will feel no change

b

What problems are associated with smoking and the use of oral contraceptives? a. Increased risk for alcoholism and cirrhosis of the liver b. Thrombophlebitis and pulmonary emboli c. Infertility and weight gain d. Urinary tract infections and skin cancer

e

You are assessing an adolescent boy. The first physical sign of puberty is: a. Height spurt b. Penis lengthening c. Sperm production d. Pubic hair development e. Testes enlargement

Spleen

You can locate the ________ by percussing a dull note from the 9th to the 11th intercostal spaces just behind the midaxillary line. The area of dullness is not normally wider than 7cm in adults

Light

_______ palpation of the abdomen is done with the four fingers close together, depressing the skin about 1 cm

Deep

_______ palpation of the abdomen is done with the four fingers close together, depressing the skin about 5 to 8 cm, moving clockwise, exploring the entire abdomen

Synovial

__________ joints are freely movable because they have bones that are separated from one another and enclosed in a cavity filled with fluid

Nonsynovial

_____________ joints consist of bones united by fibrous tissue or cartilage. These joints are either immovable (such as sutures in skull), or slightly movable (such as vertebrae)

Ballottement

_____________ of the patella is a reliable test when larger amounts of fluid are present in the knee. Use your left hand to compress the suprapatellar pouch to push any fluid into the knee joint. Then, push the patella sharply against the femur. If no fluid is present, the patella is already against the femur

Subluxation

________________ indicates the forearm is dislocated posteriorly

cherry angioma

a small, smooth, round, bright red blood vessel tumor on the skin, often on the trunk of the elderly

If a patient is comatose, you can check all eye function except..

accommodation

Allergic rhinitis

an allergic reaction to airborne allergens that causes an increased flow of mucus

Fissure

an opening; a groove; a split

Polyscyclic

annular lesions grow together

Puritis

intense itching

Mongolian spot

irregular pigmented area in lumbar-sacral region in infants with more melanin

Café-au-lait spot

large round or oval patch of light brown pigmentation usually present at birth

Abducens

lateral movement of eyes

Tattoos are considered...

lesions

Confluent

lesions run together

Zosteriform

linear shape of skin lesion along a nerve route

Vitiligo

localized loss of skin pigmentation characterized by milk-white patches

Depression

lowering a body part

Pitting

marking with tiny indentations

Trigeminal

mastication and sensation of face, scalp, cornea

uvula should always be at the

midline

Hypoglossal

movement of tongue

Spinal (Accessory)

movement of trapezius and sternomastoid muscles

Retraction

moving a body part backward and parallel to the ground

Protraction

moving a body part forward and parallel to the ground

Abduction

moving a limb away from the midline of the body

Adduction

moving a limb toward the midline of the body

Circumduction

moving the arm in a circle around the shoulder

Rotation

moving the head around a central axis

Inversion

moving the sole of the foot inward at the ankle

Eversion

moving the sole of the foot outward at the ankle

PERRLA

pupils equal, round, reactive to light and accommodation

Elevation

raising a body part

Ocular Fundus Examination

red reflex

Wheal

small, round, raised area on the skin that may be accompanied by itching; usually seen in allergic reactions

Papule

small, solid skin elevation

Hip structure / function

ØAcetabulum and head of femur (hip joint) ØAnterior superior iliac spine ( iliac crest-palpable landmarks) ØIschial tuberosity ( iliac crest-palpable landmarks) ØGreater trochanter of femur (width of a persons palm below the iliac crest, felt best when person is standing)

Characteristics of sounds

ØAmplitude (intensity)—loud or soft sound ØPitch (frequency)—number of vibrations per second ØQuality (timbre)—subjective difference Duration—length of time sound lingers

Pregnant woman breast questions

ØAppearance: Have you noticed any enlargement or fullness in the breasts? ØPresentation: Is there any tenderness or tingling? ØMedical history: Do you have inverted nipples? ØAnticipatory planning: Are you planning to breastfeed your baby?

Preadolescent girl breasts questions

ØAppearance: Have you noticed your breasts changing? ØOnset: How long has this been happening? ØDescription: What have you noticed? ØFeelings: What do you think about all this?

Lesions: if any are present, note the following:

ØColor ØElevation ØPattern or shape ØSize ØLocation and distribution on body ØAny exudate: note color and odor ØUse a Wood's light (ultraviolet light filtered through special glass) to detect fluorescing lesions.

Knee structure and function

ØFemur, tibia, and patella ØSuprapatellar pouch ØMedial and lateral menisci (cushion the tibia and femur) ØCruciate ligaments ØPrepatellar bursa (prevent friction) Quadriceps muscle (start the landmarks of the knee

Structure and Function shoulder

ØGlenohumeral joint (ball-and-socket action) ØRotator cuff (four muscles) ØSubacromial bursa ØAcromion process (felt at the very top of the shoulder) ØGreater tubercle of the humerus ØCoracoid process

Menopausal woman breast questions

ØHave you noticed any change in breast contour, size, or firmness?

Stationary Hand (Percussion Method)

ØHyperextend the middle finger (the pleximeter). ØPlace distal joint and tip firmly against the person's skin. ØOnly distal joint and tip of middle finger should be touching the person's skin.

Elbow structure / function

ØMedial and lateral epicondyles ØOlecranon process of ulna

Joint types

ØNonsynovial (immovable joints) ØSynovial joints (moveable joints) ØCartilage (avascular connective tissue) ØLigament (fibrous bands) ØBursa (sac filled with synovial fluid, area of friction)

Wrist and carpals structure / function

ØRadiocarpal joint ØMidcarpal joint ØMetacarpophalangeal joints (finger flexion and extension) ØInterphalangeal joints (finger flexion and extension)

Muscle structure / function

ØTendon (Strong fibrous cord) ØSkeletal muscle movements ØSkeletal = Voluntary muscles

Ankle and Foot structure and function

ØTibiotalar joint (articulation of the tibia, fibula, and talus) ØMedial and lateral malleolus (two bony prominences) ØMetatarsals

Striking Hand (Percussion Method)

ØUse the middle finger of your dominant hand (the plexor). ØHold forearm to skin surface making muscles steady but not rigid. ØFlex striking finger so tip makes contact.

Spine

ØVertebrae ØLandmarks of the spine ØIntervertebral disks

Cranial nerve I: olfactory nerve (not tested routinely) TESTING

•Test sense of smell in those who report loss of smell, head trauma, and abnormal mental status, and when presence of intracranial lesion suspected.

Spinal nerves

•31 pairs of spinal nerves arise from length of spinal cord and supply rest of body. •Named for region of spine from which they exit - 8 cervical 12 thoracic, 5 lumbar, 5 sacral, and 1 coccygeal •"Mixed" nerves - Contain both sensory and motor fibers •Each innervates particular segment of body. •Dermal segmentation - Cutaneous distribution of various spinal nerves

Teeth

•32 teeth •Crown •Neck •root

Reflex response graded on 4-point scale

•4 = very brisk, hyperactive with clonus, indicative of disease •3 = brisker than average, may indicate disease •2 = Average, normal •1 = diminished, low normal, or occurs with reinforcement •0 = no response

ABCDEF Skin Assessment

•A: asymmetry •B: border irregularity •C: color variations •D: diameter greater than 6 mm •E: elevation or evolution •F: funny looking—"ugly duckling" —different from others

Scrotum Abnormalities

•Absent testis, cryptorchidism •Small testis •Testicular torsion •Epididymitis •Varicocele •Spermatocele •Early testicular tumor •Diffuse tumor •Hydrocele •Scrotal hernia •Orchitis •Scrotal edema

Developmental Competence: Adolescent

•Adolescents show wide variation in normal development of genitals •Using SMR charts, note •enlargement of testes and scrotum •pubic hair growth •darkening of scrotal color •roughening of scrotal skin •increase in penis length and width •axillary hair growth Be familiar with normal sequence of growth

Developmental Competence as related to thorax/lungs

•Aging adult •Increasing AP diameter, kyphosis, or an outward curvature of thoracic spine •Chest expansion may be somewhat decreased, although still symmetric. •Tend to tire easily during auscultation when deep mouth breathing is required •Acutely ill patient •Use of second examiner to assist with positional changes •Use of rolling technique if solo examiner but can interfere with bilateral comparison •Mechanical ventilation

Mechanics of Respiration: Changing chest size

•Air rushes into the lungs as chest size increases (inspiration) and is expelled from lungs as chest recoils (expiration). •Mechanical expansion and contraction of chest cavity alters size of thoracic container in two dimensions. •Vertical diameter and anteroposterior diameter

Lobes of the Lung

•Anterior chest •On anterior chest, oblique fissure crosses fifth rib in midaxillary line and terminates at sixth rib in midclavicular line. •Posterior chest •Most remarkable point about posterior chest is that it is almost all lower lobes. •Lateral chest •Lung tissue extends from apex of axilla down to seventh or eighth rib. •Left lung •Has no middle lobe •Anterior chest contains mostly upper and middle lobe with very little lower lobe. •Posterior chest contains almost all lower lobes.

Central nervous system components

•Basal ganglia: Gray matter in two cerebral hemispheres that form subcortical associated motor system (extrapyramidal system) •Thalamus: Main relay station where sensory pathways of spinal cord, cerebellum, and brainstem form synapses •Hypothalamus: Major respiratory center with basic function control and coordination •Cerebellum: Concerned with motor coordination and muscle tone of voluntary movements •Brainstem: Central core of the brain—contains midbrain, pons and medulla •Spinal cord: Main pathway for ascending and descending fiber tracts that connect brain to spinal nerves

Reflexes

•Basic defense mechanisms of nervous system •Involuntary; below level of conscious control permitting quick reaction to potentially painful or damaging situations

Percussion of Anterior Chest

•Begin percussing apices in supraclavicular areas. - Perform bilateral comparison. - Do not percuss directly over female breast tissue because this would produce a dull note; shift breast tissue over slightly using edge of your stationary hand. •Note borders of cardiac dullness normally found on anterior chest. - Do not confuse these with suspected lung pathology. - In right hemithorax, upper border of liver dullness is located in fifth intercostal space in right midclavicular line. - On left, tympany is evident over gastric space

Annular or circular

•Begins in center and spreads to periphery

Abnormal Findings: Breast Lumps

•Benign (Fibrocystic) breast disease •Cancer •Fibroadenoma •Differentiating breast lumps: •Age •Shape, consistency, and demarcation •Number, mobility, and tenderness •Skin retraction, pattern of growth, and risk to health

Developmental Competence Breasts: Pregnant Woman

•Breast changes start during the second month of pregnancy and are an early sign for most women •Colostrum may be expressed after fourth month ØThick yellow fluid is precursor for milk, containing same amount of protein and lactose, but practically no fat ØBreasts produce colostrum for first few days after delivery ØRich in antibodies that protect newborn against infection, so breastfeeding is important •Lactation: Milk production ØBegins 1 to 3 days postpartum ØWhitish color is from emulsified fat and calcium caseinate

Adolescents girl developmental competency

•Breast development usually begins on an average between 8 and 10 years. •Tanner staging •Teach BSE

Internal Anatomy of Breast

•Breast is composed of •glandular tissue •fibrous tissue, including suspensory ligaments •adipose tissue •Glandular tissue contains 15 to 20 lobes radiating from nipple, and these are composed of lobules •Cooper's Ligaments: Fibrous bands extending vertically from surface to attach on chest wall muscles •Lobes are embedded in adipose tissue •Breast may be divided into four quadrants by imaginary horizontal and vertical lines intersecting at nipple. •Upper outer quadrant is the site of most breast tumors

Breast Surface Anatomy

•Breasts lie anterior to pectoralis major and serratus anterior muscles. •Located between second and sixth ribs, extending from side of sternum to midaxillary line •Tail of Spence: Superior lateral corner projects up and laterally into axilla •Areola surrounds nipples. •Montgomery's Glands: Small elevated sebaceous glands •Secrete protective lipid material during lactation

Cerebral cortex

•Cerebral cortex is cerebrum's outer layer of nerve cells. •Cerebral cortex is center of functions governing thought, memory, reasoning, sensation, and voluntary movement. - Each half of cerebrum is hemisphere. - Each hemisphere divided into four lobes: frontal, parietal, temporal, and occipital

Cranial nerves III, IV, and VI: oculomotor, trochlear, and abducens nerves TESTING

•Check pupils for size, regularity, equality, direct and consensual light reaction, and accommodation. •Assess extraocular movements by cardinal positions of gaze. •Assess for nystagmus.

Objective assessment: tongue

•Check tongue for color, surface characteristics, and moisture. •Ask the person to touch tongue to roof of mouth. •Ventral surface looks smooth, glistening, and shows veins. •With a glove, hold tongue with a cotton gauze pad for traction and swing tongue out and to each side; inspect for any white patches or lesions; normally none are present. •If any occur, palpate these lesions for induration. •Inspect carefully entire U-shaped area under tongue behind teeth. •Oral malignancies are most likely here. •Note any white patches, nodules, or ulcerations. •If lesions are present, or with any person over 50 years old or with a positive history of smoking or alcohol use, use your gloved hand to palpate area. •Place your other hand under jaw to stabilize tissue and to "capture" any abnormality; note any induration.

Sexual Expression in Later Life MALE

•Chronologic age by itself should not mean a halt in sexual activity; physical changes need not interfere with libido and sexual pleasure. •Older male is capable of sexual function as long as he is in reasonably good health and has an interested, willing partner. •Danger is in male misinterpreting normal age changes as a sexual failure; once this idea occurs, it may demoralize man and place undue emphasis on performance rather than on pleasure. •In the absence of disease, withdrawal from sexual activity may be due to (any combination of) - loss of spouse, depression, preoccupation with work. - marital or family conflicts. - side effects of medication, heavy alcohol use. - lack of privacy, living with children or in a nursing home. - economic or emotional stress. poor nutrition or fatigue.

Inspection

•Close, careful scrutiny, first of individual as a whole and then of each body system •Begins when you first meet person with a general survey •Start assessment of each body system with inspection. Inspection always comes first.

Culture and genetics: colorectal cancer

•Colorectal cancer also has racial variation. •Screening and treatment differences that occur along racial/ethnic lines and to insurance status •Age paradox seen with increased incidence in younger population and increased death rate in older population •Hereditary factors that lead to increased CRC: - Family history, inherited genetic syndromes, personal history of inflammatory bowel disease, or type 2 diabetes

Upper motor neurons

•Complex of descending motor fibers that can influence or modify lower motor neurons •Located completely within CNS; convey impulses from motor areas of cerebral cortex to lower motor neurons •Examples of upper motor neuron diseases are cerebrovascular accident, cerebral palsy, and multiple sclerosis.

Penis

•Composed of three cylindric columns of erectile tissue: •Two corpora cavernosa on dorsal side - Corpus spongiosum ventrally •Glans: at distal end of shaft corpus spongiosum expands into cone of erectile tissue •Corona: shoulder where glans joins shaft •Urethra conduit for both genital and urinary systems. - Foreskin or prepuce forms hood or flap over glans. - Often removed shortly after birth by circumcision •Frenulum: fold of foreskin extending from urethral meatus ventrally

Inspection of the Abdomen

•Contour - Determine profile from rib margin to pubic bone; contour describes nutritional state and normally ranges from flat to rounded. •Symmetry - Abdomen should be symmetric bilaterally. •Umbilicus - Normally it is midline and inverted, with no sign of discoloration, inflammation, or hernia. •Skin - Surface smooth and even, with homogeneous color; assess skin turgor - Inspect for pigment change/presence of lesions or scars. •Pulsation or movement - Normally you may see pulsations from aorta beneath skin in epigastric area, particularly in thin persons with good muscle wall relaxation. •Hair distribution - Pattern of pubic hair growth normally has diamond shape in adult males and an inverted triangle shape in adult females. •Demeanor - A comfortable person is relaxed quietly on examining table and has a benign facial expression and slow, even respirations.

Motor pathways

•Corticospinal or pyramidal tract - Fibers mediate voluntary movement, particularly very skilled, discrete, purposeful movements. - Motor nerve fibers travel to brainstem crossing to opposite, contralateral side, (pyramidal decussation) and then pass down in lateral column of spinal cord. •Extrapyramidal tracts include - Motor nerve fibers originating in motor cortex, basal ganglia, brainstem, and spinal cord outside pyramidal tract. - Subcortical motor fibers that maintain muscle tone and control body movements, especially gross automatic movements, such as walking. •Cerebellar system - Coordinates movement, maintains equilibrium and posture - Receives information on position of muscles and joints, body's equilibrium, and kind of motor messages sent from cortex to muscles - Integrates information using feedback pathway to exert control

Subjective Data Cough

•Cough •Shortness of breath •Chest pain with breathing •History of respiratory infections •Smoking history •Environmental exposure •Patient-centered care •Do you have a cough? When did it start? Gradual or sudden? Ask about •duration, frequency, timing, and presence of cough as an irritating factor. •Productive vs. nonproductive •quality of cough •precipitating and/or alleviating factors. •treatments tried as well as both Rx and over the counter. •any associated symptoms. •impact of cough on ADLs and quality of life.

Nerves: tongue

•Cranial nerve XII - hypoglossal nerve •Cranial nerve IX and X - glossopharyngeal and vagus nerves

Superficial reflexes overview

•Cremasteric reflex, L1 to L2 (not routinely done) - On male, lightly stroke inner aspect of thigh with reflex hammer or tongue blade. - Note elevation of ipsilateral testicle. •Plantar reflex, L4 to S2 - Position thigh with slight external rotation. - With reflex hammer, draw a light stroke up lateral side of sole of foot and inward across ball of foot, like an upside-down "J." - Normal response is plantar flexion of toes and inversion and flexion of forefoot

Pathways of the CNS

•Crossed representation is notable feature of nerve tracts. - Left cerebral cortex receives sensory information from and controls motor function to right side of the body. - Right cerebral cortex likewise interacts with left side of body. •Knowledge of where fibers cross midline will help interpret clinical findings.

Scolosis

•Curvature of thoracic and lumbar spine •May reduce lung volume •Risk for impa

The aging adult

•DTRs less brisk; those in upper extremities usually present, but ankle jerk commonly lost; knee jerks may be lost; because aging people find it difficult to relax limbs, always use reinforcement when eliciting DTRs - Plantar reflex may be absent or difficult to interpret; often, you will not see a definite normal flexor response; still should consider definite extensor response abnormal. - Superficial abdominal reflexes may be absent, probably because of stretching of musculature through pregnancy or obesity.

Developmental Competence: Aging Adults Lungs / Thoracic

•Decreased vital capacity and increased residual volume based on structural changes •Histologic changes lead to decreased gas exchange. •Respiratory muscle strength declines •More rigid in structure

Average Respiratory Patterns

•Depth: 500-800 mL •Pattern: even •Rate: 12-20 breaths per minute

Voice Sounds

•Determine quality of voice sounds or vocal resonance as noted in tactile fremitus. - Normal voice transmission is soft, muffled, and indistinct; you can hear sound through stethoscope but cannot distinguish exactly what is being said. •Pathology that increases lung density enhances transmission of voice sounds. •Perform supplemental maneuvers if you suspect lung pathology on basis of earlier data. - Testing for possible presence of bronchophony, egophony, and whispered pectoriloquy

Dyspnea

•Difficult or labored breathing •Common, burdensome, predictor of negative outcomes

Abnormal Findings: Signs of Retraction and Inflammation Breasts

•Dimpling •Nipple retraction •Edema (peau d'orange) •Fixation •Deviation in nipple pointing

Abnormal Findings: Adventitious Lung Sounds

•Discontinuous sounds •Crackles—fine •Crackles—course •Atelectatic crackles •Pleural friction rub •Continuous sounds •Wheeze—sibilant •Wheeze—sonorous rhonchi •Stridor - medical emergency! •Discontinuous sounds •Crackles—fine •Crackles—course •Atelectatic crackles •Pleural friction rub •Continuous sounds •Wheeze—sibilant •Wheeze—sonorous rhonchi •Stridor - medical emergency!

Rectum

•Distal portion of large intestine •Rectal interior has three semilunar transverse folds, called valves of Houston.

Developmental Competence as related to breasts

•During embryonic life, ventral epidermal ridges, or "milk lines," are present and curve down from axilla to groin bilaterally. •Develops along ridge over thorax, and rest of the ridge usually atrophies •Supernumerary nipple occasionally persists and is visible along track of mammary ridge •At birth, the only breast structures present are lactiferous ducts within nipple

Culture and Genetics: Circumcision

•During pregnancy or immediate neonatal period, parents may ask whether or not to circumcise male infant. •Religious and cultural as well as medical indications - American Academy of Pediatrics (AAP) health benefits outweigh risks •Circumcision: - Lowers risk for certain STIs such as HPV, herpes simplex virus, genital ulcer disease in men and decreased risk for bacterial vaginosis and trichomoniasis in females •Reduced risk for contracting HIV infection through heterosexual contact

Sweat Glands

•Eccrine produce sweat. •Apocrine produce milky secretion and open into hair follicles.

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 •Early detection of cancer enhanced if male is familiar with his normal consistency •Points to include during health teaching are: •T—timing, once a month •S—shower, warm water relaxes scrotal sac •E—examine, check for, and report changes immediately

Sperm

•Epididymis: markedly coiled duct system and main storage site of sperm; comma-shaped structure, curved over top, and posterior surface of testis •Vas deferens: a muscular duct continuous with lower part of epididymis and with other vessels (arteries and veins, lymphatics, nerves) that forms spermatic cord

Subjective Data: Shortness of Breath (SOB)

•Ever had any shortness of breath or hard-breathing spells? •Precipitating factor, severity, and duration. •Any impact of change of position and specific timing pattern. •association with any other clinical symptoms. •Any triggering mechanisms r/t: food, environment, or emotion. •Treatments •Impact of SOB on ADLs. •Progression of SOB

Kyphosis

•Exaggerated posterior curvature of the thoracic spine

Cranial nerve XI: spinal accessory nerve TESTING

•Examine sternomastoid and trapezius muscles for equal size. •Check equal strength by asking the person to rotate head against resistance applied to side of chin. •Ask the person to shrug shoulders against resistance.

Abnormal Findings:Ear Canal Abnormalities

•Excessive cerumen - excessive wax •Otitis externa- severe swelling of canal, inflammation, tenderness •Osteoma- single, stony hard, rounded nodule that obscures eardrum •Exostosis - small, bony hard, rounded nodules of hyptertrophic bone. Don't obstruct the ear drum •Furuncle- painful, reddened, infected hair follicle •Polyp- indicates chronic ear disease. Arises from mucosal tissue, red, bleeds, purulent discharge •Foreign body - lego

Objective assessment: nose

•External nose •Symmetry •Midline •proportion •Test patency of nostrils •Sniff test

Lower motor neurons

•Final common pathway, providing final contact with muscle •Located in anterior gray column of spinal cord, but nerve fibers extend to muscle •Movement must be translated into action by lower motor neuron fibers. - Examples of lower motor neurons are cranial nerves and spinal nerves of peripheral nervous system. - Examples of lower motor neuron diseases are spinal cord lesions, poliomyelitis, and amyotrophic lateral sclerosis.

Palpation Techniques

•Fingertips: best for fine tactile discrimination of skin texture, swelling, pulsation, determining presence of lumps •Fingers and thumb: detection of position, shape, and consistency of an organ or mass •Dorsa of hands and fingers: best for determining temperature because skin is thinner than on palms •Base of fingers or ulnar surface of hand: best for vibration

External nose

•First segment of the respiratory system •Made of bone and cartilage •2 nasal bones form the upper portion •The external nose contains 2 external openings called nares (nostrils)

Break in continuity of skin surface

•Fissures—Linear crack with abrupt edges extending into dermis •Erosions—Scooped out but shallow depression •Ulcers—Deeper depression extending into dermis with irregular shape, may bleed, leaves scar

Abnormal postures

•Flaccid quadriplegia - Complete loss of muscle tone and paralysis of all four extremities, indicating nonfunctional brainstem •Opisthotonos - Prolonged arching of back, with head and heels bent backward; indicates meningeal irritation

Abnormalities in muscle tone

•Flaccidity •Spasticity •Rigidity •Cogwheel rigidity

Measurement of Pulmonary Function Status: Spirometer

•Forced expiratory time is number of seconds it takes to exhale from total lung capacity to residual volume. •It is a screening measure of airflow obstruction. •Can screen for pulmonary function •Spirometer is used in ambulatory care settings to measure lung health.

Subjective Data

•Frequency, urgency, and nocturia •Dysuria •Hesitancy and straining •Past genitourinary history •Penis—pain, lesion, discharge •Scrotum—self-care behaviors, lump •Sexual activity and contraceptive use •Sexually transmitted infection (STI) contact

Paranasal sinuses

•Frontal - Accessible to examination •Maxillary - Accessible to examination •Ethmoid •Sphenoid •Maxillary and ethmoid sinuses present at birth

Palpate the sinuses areas

•Frontal and maxillary sinuses •Transillumination •Not a supported practice if you suspect sinus inflamation

Lobes have areas that mediate specific functions:

•Frontal lobe: personality, behavior, emotions, and intellectual function\ - Broca's area in frontal lobe mediates motor speech •Parietal lobe: sensation •Occipital lobe: visual receptor center •Temporal lobe: auditory reception center, taste, and smell - Wernicke's area in temporal lobe associated with language comprehension

Abnormal Findings:Abnormalities of External Ear

•Frostbite - reddish blue discoloration and swelling after exposure to extreme cold •Branchial remnant and ear deformity - leftover skin tag from birth •Otitis externa (Swimmer's ear) - infection of the outer ear •Cellulitis - inflammation of the loose, subcutaneous connective tissue

mouth

•Function in the digestive and respiratory systems •Hard and soft palates •Uvula •Tongue

Aging Adult

•Gradual loss of subcutaneous fat starts during later middle adult years, making the nose appear more prominent in some people. •Atrophic tissues ulcerate easily - increasing risk for older people for infections, such as oral moniliasis and malignant lesions. •Natural tooth loss exacerbated by inadequate dental care, poor oral hygiene, and tobacco use - can lead to malocclusion leading to further tooth loss and pain. •Diminished sense of taste and smell decreases an aging person's interest in food and may contribute to malnutrition. •Trouble with mastication can lead to dietary pattern changes which may place the older adult at risk for nutritional deficits (protein, vitamins, and minerals).

Testes

•Have a solid oval shape, suspended vertically by spermatic cord •Left testis is lower because left spermatic cord is longer. •Tunica vaginalis: double-layered membrane covers each testis and separates it from scrotal wall

nasal cavity objective data

•Holding the otoscope •Nasal septum Turbinates

Abnormal bowel sounds:

•Hypoactive—decreased, can follow abdominal surgery or with inflammation •Hyperactive—loud, high-pitched signal increased motility

Abnormal Findings: Penis Abnormalities

•Hypospadias •Priapism •Phimosis •Paraphimosis •Epispadias Peyronie's disease

Assess sensory system

•Identify various stimuli to test intactness of peripheral nerve fibers/sensory nerve tracts - Routine screening procedures include testing superficial pain, light touch, and vibration in few distal locations, and testing stereognosis. - Complete testing of sensory system warranted in those with neurologic symptoms (e.g., localized pain, numbness, and tingling) or if you discover abnormalities. •Compare sensations on symmetric parts of body. •When you find definite decrease in sensation, map it by systematic testing in that area. •Proceed from point of decreased sensation toward sensitive area; ask the person to tell you where sensation changes; you can map exact borders of deficient area; draw results on diagram. •The person's eyes should be closed during tests. •Take time to explain what will be happening and exactly how you expect the person to respond.

Breast Cancer: Culture and Women

•In many cultures, female breasts signify more than their primary purpose of lactation - Affects body image - Influenced by society and media response - Integrated with women's self-concept •A woman who has found a breast lump may come to you with fear, anxiety, and panic - Although many breast lumps are benign, women initially assume worst possible outcome, including cancer, disfigurement, and death - Be sensitive to individual's perception of female body image

Abnormal Findings: Tactile Fremitus

•Increased tactile fremitus •Decreased tactile fremitus •Rhonchial fremitus •Pleural friction fremitus

Developmental Competence Newborns Breasts

•Infants and children •In neonate, breasts may be enlarged and visible due to maternal estrogen crossing placenta. •May secrete "witch's milk"—not significant will resolve •Note position of nipples on prepubertal child. •Symmetric, just lateral to midclavicular line, between fourth and fifth ribs Nipple is flat, and areola is darker pigmented.

Abdomen Internal Anatomy

•Inside abdominal cavity, all internal organs are called viscera. •Peritoneum lines abdominal wall (parietal) and covers surface(visceral) of most organs. •Solid viscera maintain characteristic shape. •Liver, pancreas, spleen, adrenal glands, kidneys, ovaries, and uterus •Shape of hollow viscera depends on content. •Stomach, gallbladder, small intestine, colon, and bladder Divided into 4 quadrants •Right and left and upper and lower •Midline organs—aorta, uterus if enlarged and bladder if distended

Summary Checklist: Male Genitourinary System

•Inspect and palpate the penis. •Inspect and palpate the scrotum. •If a mass exists, try to transilluminate it •Palpate for an inguinal hernia. •Palpate the inguinal lymph nodes

Examination of stool

•Inspect any feces remaining on glove. •Normally color is brown, and consistency is soft. •Test any stool on glove for occult blood - If stool Hematest is positive, it indicates occult blood. •Enhance self-care by providing the average risk patient an at-home collection kit to screen for asymptomatic colorectal cancer and precancerous lesions.

Inspection and Palpation: Hernia

•Inspect inguinal region for bulge as a person stands and strains down; normally none is present. •Palpate inguinal canal. - For right side, ask male to shift his weight onto left leg. - Use technique: NAVEL (Nerve, Artery, Vein, Empty space, Lymphatics) •Palpate femoral area for a bulge. - Normally you feel none.

Inspection and Palpation: Scrotum

•Inspect scrotum as male holds penis out of the way; alternatively, you hold penis out of the way with back of your hand. •Palpate gently each scrotal half between your thumb and first two fingers. •Palpate each spermatic cord between your thumb and forefinger, along its length from epididymis up to external inguinal ring. •If you find a mass, then provide additional specific information relative to location, size, shape, and ability to reduce. •Perform transillumination if mass or swelling is detected

Cranial nerve XII: hypoglossal nerve TESTING

•Inspect tongue; no wasting or tremors should be present. •Note forward thrust in midline as the person protrudes tongue. •Ask the person to say "light, tight, dynamite," and note that lingual speech (sounds of letters l, t, d, n) is clear and distinct.

Requisite skills performed one at a time typically in this order

•Inspection •Palpation •Percussion Auscultation

Posterior Chest

•Inspection: Thoracic cage •Note shape and configuration of chest wall. •Note the position the person takes to breath. •Assess skin color and condition. •Note any lesions; inquire about changes.

Palpate anus and rectum

•Instruct the person that palpation is not painful but may feel like needing to move bowels. •Drop lubricating jelly onto gloved index finger; place pad of index finger gently against anal verge. •Rotate examination finger to palpate entire muscular ring. •Above anal canal, rectum turns posteriorly, following curve of coccyx and sacrum. •Promptly report any mass you discover for further examination.

Internal nose

•Internal nose extends from the anterior to the posterior nares •2 nasal cavities separated by the nasal septum •Inside each nares is a vestibule for each nasal cavity •Each cavity has 3 projections from the lateral wall called conchae or turbinates - superior, middle, and inferior turbinates. •Cilia line the turbinates •The turbinates are highly vascular and covered with mucous membrane •The vascular supply warms the incoming air •Turbinates use secreted mucus and ciliary action to filter the air by trapping dust and foreign particles •The collection of debris is then moved via ciliary action to the throat, where it is swallowed •Olfactory receptors are found on the mucosa and stimulated by breathing=this is how we smell

Inguinal Area or Groin

•Juncture of lower abdominal wall and thigh - Potential site for hernia development •Borders are the anterior superior iliac spine and symphysis pubis. •Between these landmarks lies inguinal ligament. •Inguinal canal is 4 to 6 cm long in adult. Openings are: •Internal ring: 1 to 2 cm above midpoint of inguinal ligament •External ring: above and lateral to pubis

Abbreviation of neurological exam for head trauma or neurological deficit caused by systemic disease

•Level of consciousness—change in LOC—perform relative assessments •Motor function—check voluntary movement of each extremity by giving specific commands •Pupillary response—check for PERLA noting size in millimeters •Vital signs—measure and monitor - Glasgow coma scale—eye opening, motor and verbal response—quantitative measurement tool to assess LOC - Diabetic neuropathy screening—monofilament test—standardized measurement tool to detect peripheral neuropathy

Structure: prostate gland

•Lies in front of anterior wall of rectum and 2 cm behind symphysis pubis •Surrounds bladder neck and urethra and has 15 to 30 ducts that open into urethra •Two seminal vesicles project above prostate. - Secrete a fluid rich in fructose, which nourishes sperm, and contains prostaglandins •Two bulbourethral Cowper's glands located inferior to prostate on either side of urethra secrete a clear, viscid mucus.

Objective assessment just mouth

•Lips •Teeth and gums •Tongue •U-shaped area under the tongue •Buccal mucosa •Palate •Hard and soft palate •Torus palatinus •Uvula

Common Sites of Referred Abdominal Pain

•Liver—RUQ •Esophagus—behind lower sternum •Ulcer—shoulder •Gallbladder—RUQ •Appendix—RLQ •Pancreas—Midscapular •Kidney—flank pain •Small intestine—diffuse •Colon—colicky pain and bloating

Characteristics of Lump or Mass on Breast

•Location •As with clock face, describe distance in centimeters from nipple; or diagram breast in woman's record and mark in location of lump. •Size •Judge in centimeters in three dimensions: width, length, and thickness. •Shape •State whether lump is oval, round, lobulated, or indistinct. •Consistency •State whether lump is soft, firm, or hard. •Movable •Is lump freely movable or fixed when you try to slide it over chest wall? Distinctness ØIs lump solitary or multiple? Nipple ØIs it displaced or retracted? Note skin over lump ØIs it erythematous, dimpled, or retracted? Tenderness ØIs lump tender to palpation? Lymphadenopathy ØAre any regional lymph nodes palpable?

Scrotum

•Loose protective sac; continuation of abdominal wall •Scrotal wall consists of thin skin lying in folds, or rugae, and underlying cremaster muscle. •Cremaster muscle controls size of scrotum by responding to ambient temperature. •Septum inside separates sac into halves; in each is a testis, which produces sperm.

Culture and Genetics as related to Lungs

•Lung cancer •Second most diagnosed cancer—smoking leading to mutational burden •Tuberculosis •Affected more than 1/3 of the world's population—social and migratory disease •Need to identify and actively treat •Asthma •Most common chronic disease in childhood •Highest burden seen in those living at or below the federal poverty level •Ethnic and environmental factors play significant role.

Lymphatics

•Lymphatics of penis and scrotal surface drain into inguinal lymph nodes •Lymphatics of testes drain into abdomen. •Abdominal lymph nodes are not accessible to clinical examination.

•Patches

•Macules that are larger than 1 cm

Control of respirations

•Major feedback loop is humoral regulation or change in carbon dioxide and oxygen levels in blood, and, less important, hydrogen ion level. - Normal stimulus to breathe for most of us is an increase of carbon dioxide in blood, or hypercapnia. - Decrease of oxygen in blood (hypoxemia) also increases respirations but is less effective than hypercapnia.

Developmental Competence: Adults and Aging Adults MALE GU

•Male does not experience a definite end to fertility as female does. •Around age 40 years, production of sperm begins to decrease, although it continues into 80s and 90s. •Testosterone production declines after age 30 but continues very gradually so resulting physical changes are not evident until later in life. •Pubic hair decreases and penis size decreases. •Due to decreased tone of dartos muscle, scrotal contents hang lower, rugae decrease, and scrotum becomes pendulous. •Testes decrease in size and are less firm to palpation. •Increased connective tissue is present in tubules, so these become thickened and produce less sperm.

Male Genitourinary System

•Male genital structures include: •External - Penis and scrotum •Internal - Testis, epididymis, and vas deferens •Glandular structures accessory to genital organs: - Prostate, seminal vesicles, and bulbourethral glands

Abnormal Findings: Abnormal Nipple Discharge

•Mammary duct ectasia •Intraductal papilloma •Carcinoma •Paget disease (intraductal carcinoma)

Percussion has following uses:

•Mapping location and size of organs •Signaling density of a structure by a characteristic note •Detecting a superficial abnormal mass

Disorders occurring during lactation:

•Mastitis •Breast abscess •Plugged duct

Developmental Competence: Aging Adult MALE GU

•May note thinner, graying pubic hair and decreased size of penis •Size of testes may be decreased and may feel less firm •Scrotal sac pendulous with less rugae (wrinkle, fold, ridges) •Scrotal skin may become excoriated if man continually sits on it

Cranial nerves IX and X: glossopharyngeal and vagus nerves TESTING

•Motor function •Depress tongue with tongue blade, and note pharyngeal movement as the person says "ahhh" or yawns; uvula and soft palate should rise in midline, and tonsillar pillars should move medially. •Touch posterior pharyngeal wall with tongue blade, and note gag reflex; voice should sound smooth, not strained. •Sensory function •Cranial nerve IX does mediate taste on posterior one third of tongue, but technically too difficult to test.

Cranial nerve VII: facial nerve TESTING

•Motor function: •Note mobility and facial symmetry as a person responds to selected movements. •Have the person puff cheeks, then press puffed cheeks in, to see that air escapes equally from both sides

Cranial nerve V: trigeminal nerve TESTING

•Motor function: assess muscles of mastication by palpating temporal and masseter muscles as a person clenches his or her teeth •Sensory function: with a person's eyes closed, test light touch sensation by touching a cotton wisp to designated areas on a person's face: forehead, cheeks, and chin •Assess corneal reflex if the person has abnormal facial sensations or abnormalities of facial movement. •Tests all three divisions of CN V: ophthalmic, maxillary, and mandibular.

Throat

•Nasopharynx •Oropharynx •Tonsils

Structure and function of Nervous System

•Nervous system divided into two parts: - Central nervous system (CNS), which includes brain and spinal cord - Peripheral nervous system (PNS), which includes all nerve fibers outside brain and spinal cord •Includes 12 pairs of cranial nerves, 31 pairs of spinal nerves, and all their branches •Carries sensory (afferent) messages to CNS from sensory receptors •Motor (efferent) messages from CNS to muscles and glands, as well as autonomic messages that govern internal organs and blood vessels

Palpation of Spleen

•Normally spleen is not palpable and must be enlarged three times its normal size to be felt. •To search for it, reach your left hand over abdomen and behind left side at the 11th and 12th ribs. •Lift up for support; place your right hand obliquely on LUQ with fingers pointing toward left axilla and just inferior to rib margin. •Push your hand deeply down and under left costal margin, ask the person to take deep breath. You should feel nothing firm Enlargement seen with: •Mononucleosis, leukemia and lymphomas, portal HTN and HIV infection •Normally spleen is not palpable and must be enlarged three times its normal size to be felt. •An alternative position is to roll a person onto his or her right side to displace spleen more forward and downward. •If palpable, do not continue to palpate as it is friable and can rupture.

Bowel Sounds Overview

•Note character and frequency of bowel sounds. •Bowel sounds originate from movement of air and fluid through small intestine. •Bowel sounds are high pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5 to 30 times per minute •Borborygmus is the sound of hyper peristalsis . •Perfectly "silent abdomen" is uncommon; you must listen for 5 minutes by your watch before deciding bowel sounds are completely absent.

Inspection of Anterior Chest

•Note shape and configuration of chest wall. •Note patient's facial expression. •Assess level of consciousness. •Note skin color and condition. •Assess quality of respirations. •Note respiratory effort. •Observe for symmetry. •Determine if accessory muscles are being used.

Subjective data: mouth and throat

•Notice any Sores or lesions in mouth, tongue, or gums? •How about Sore throats? •Any Bleeding gums? •Any Toothache? •Any Hoarseness or voice changes? •Dysphagia---Any difficulty swallowing? •Altered taste---Any change In sense of taste? •Do you smoke or drink alcohol? •Self-care behaviors •Dental care pattern—How often do you brush and floss your teeth? •Dentures or appliances—Do you have any dental appliances?

Abnormal Findings: Abdominal Distention

•Obesity •Air or gas •Ascites •Ovarian cyst •Pregnancy •Feces Tumor

Assessment of Urinary Function

•Observe urine color •Note pH and specific gravity •Serum analysis of kidney function correlates with creatinine level which is relatively stable (end-product of muscle metabolism) BUN measures urea which can vary based on several factors (end- product of protein metabolism)

Prostate gland palpation

•On anterior wall in male, note elastic, bulging prostate gland. •Palpate entire prostate in a systematic manner; note that only superior and part of lateral surfaces is accessible to examination Note the following characteristics: •Size •Shape •Surface •Consistency •Mobility •Sensitivity

mouth overview

•Oral cavity: short passage bordered by lips, palate, cheeks, and tongue Lips: anterior border of oral cavity, transition zone from outer skin to inner mucous membrane lining the oral cavity Palate: arching roof of mouth divided into two parts Hard palate: anterior part made up of bone Soft palate: posterior part, an arch of muscle that is mobile Uvula: free projection hanging down from middle of soft palate Cheeks are the side walls of oral cavity.

Structure and function: throat

•Oropharynx: separated from mouth by a fold of tissue on each side, the anterior tonsillar pillar •Tonsils: behind folds, each is a mass of lymphoid tissue look more granular, and surface shows deep crypts •Tonsillar tissue enlarges during childhood until puberty. •Posterior pharyngeal wall is seen behind these structures. •Nasopharynx: continuous with oropharynx above oropharynx and behind nasal cavity •Pharyngeal tonsils (adenoids) and eustachian tube openings are located here.

Anal canal

•Outlet of gastrointestinal tract; lined with modified skin; no hair or sebaceous glands •Surrounded by two concentric layers of muscle, the sphincters •Under voluntary control; except for passing feces and gas, sphincters keep anal canal tightly closed

Anterolateral tract

•Pain - Tested by the person's ability to perceive pinprick •Temperature - Test temperature sensation only when pain sensation is abnormal; otherwise, you may omit it because the fiber tracts are much the same. •Light touch - Apply wisp of cotton to skin in random order of sites and at irregular intervals; include arms, forearms, hands, chest, thighs, and legs; ask the person to say "now" or "yes" when touch is felt. Compare symmetric points.

Cranial nerve II: optic nerve TESTING

•Test visual acuity and visual fields by confrontation. •Using ophthalmoscope, examine ocular fundus to determine color, size, and shape of optic disc.

Patterns of sensory loss

•Peripheral neuropathy - Loss of sensation involves all modalities; loss most severe distally at feet and hands. •Individual nerves or roots - Decrease or loss of all sensory modalities; corresponds to distribution of involved nerve •Spinal cord hemisection (Brown-Séquard syndrome) - Loss of pain and temperature, contralateral side, loss of vibration and position discrimination on ipsilateral side •Acute compression of spinal cord - Symmetric loss of sensation under a circumferential boundary •Thalamus - Loss of all sensory modalities on face, arm, and leg; contralateral to lesion •Cortex - Loss of discrimination on contralateral side; loss of graphesthesia, stereognosis, recognition of shapes and weights, finger finding

Purpuric lesions

•Petechiae •Ecchymosis •Purpura

Anal region abnormalities

•Pilonidal cyst or sinus •Fissure •Hemorrhoids •Pruritus ani •Fecal impaction (FI) •Anorectal fistula

Palpation of Liver

•Place your left hand under a person's back parallel to 11th and 12th ribs and lift-up to support abdominal contents. •Place your right hand on RUQ, with fingers parallel to midline. - Push deeply down and under right costal margin. - Ask the person to take a deep breath; it is normal to feel edge of liver bump your fingertips as diaphragm pushes it down during inhalation. - It feels like a firm regular ridge; often liver is not palpable. •Hooking technique - Alternative method used to palpate liver.

Hemangiomas

•Port-wine stain (nevus flammeus) •Strawberry mark (immature hemangioma) •Cavernous hemangioma (mature)

Costovertebral Angle Tenderness

•Positive finding indicates inflammation of the kidney. •Indirect fist percussion causes tissues to vibrate instead of producing a sound. •To assess kidney, place one hand over 12th rib at costovertebral angle on back. - Thump that hand with ulnar edge of your other fist. •A person normally feels thud but no pain. - Its usual sequence in complete examination is with thoracic assessment, when the person is sitting up and you are standing behind.

Objective assessment mouth / throat

•Preparation •Positioning •Equipment needed •Otoscope with short, wide-tipped nasal speculum attachment •Pen light •Two tongue blades •Cotton gauze pad (4 x 4 inches) •Gloves •Long-stem light attachment for otoscope (occasionally)

Common Skin lesions

•Primary contact dermatitis •Allergic drug reaction •Tinea corporis (ringworm of the body) •Tinea pedis (ringworm of the foot)—Athlete's foot •Labial herpes simplex (cold sores) •Tinea versicolor •Herpes zoster (shingles) •Erythema migrans of lyme disease •Psoriasis

Health promotion teaching anus, rectum, etc.

•Prostate cancer, colorectal cancer (CRC) and HPV •PSA—effective earl screening test •Screening for CRC starts at age 50 with recommended colonoscopy •FIT—Fecal Immunochemical test—start at age 40 •HPV vaccine—Men under 26 years of age

Diagnostic Clues to Chronic Dyspnea and Associated Symptoms

•Pulmonary - Alveolar, interstitial, obstruction of airflow, restrictive, or vascular •Cardiac - Dysrhythmia, heart failure, restrictive or constrictive pericardial disease, or valvular •Gastrointestinal - Aspiration •Neuromuscular - Respiratory muscle weakness •Psychological - Anxiety

Measurement of Pulmonary Function Status: Pulse OX/6 MWT

•Pulse oximeter is noninvasive method to assess SpO2. - A healthy person with no lung disease and no anemia normally has an SpO2 of 97% to 98%. - Every SpO2 result must be evaluated in context of a person's Hb level, acid-base balance, and ventilatory status. •The 6-minute walk test (6 MWT) is a safer, simple, inexpensive, clinical measure of functional status in aging adults.

Coordinated and skilled movements

•Rapid alternating movements (RAM) •Ask the person to pat knees with both hands, lift up, turn hands over, and pat knees with backs of hands; then ask the person to do this faster. •Normally done with equal turning and quick rhythmic pace •Alternatively, ask the person to touch thumb to each finger on same hand, starting with the index finger, then reverse direction. •Finger-to-finger test •Finger-to-nose test •Heel-to-shin test

Abnormalities: anus and rectum

•Rectum - Abscess - Rectal polyp - Anorectal fistula - Carcinoma •Prostate - Benign prostatic hypertrophy (BPH) - Prostatitis - Carcinoma

Abnormal Findings: Abnormalities of Tympanic Membrane

•Retracted drum- light reflex absent, drum is dull and lusterluss •Acute otitis media - redness and bulging •Perforation- ruptured drum •Insertion of tympanostomy tubes- relieve middle ear pressure and promote drainage •Cholesteatoma- overgrowth of epidermal tissue in middle ear. Pearly white appearance •Scarred drum- dense white patches •Blue drum (hemotympanum)- blood in the middle ear •Fungal infection (otomycosis)- colony of black or white dots on drum •Bullous myringitis- small vessels containing blood on eardrum

Culture and Genetics: Breast Cancer

•Review statistics of breast cancer morbidity, mortality, and prognosis. •BRCA1 and BRACA2 mutation •Cumulative risk •Survival varies by stage when diagnosed. •Consider family history, ethnicity, and other environmental variables •Racial disparity in survival •Socioeconomic conditions affecting access to health care •Screening mammography recommendations •Review lifestyle risk factors: •Alcohol dose-dependent effect •Postmenopausal weight gain •Decreased physical activity

Barrel Chest

•Ribs are horizontal •Result of hyperinflation of the lungs

Cerebellar function tests

•Romberg sign •Ask the person to stand up with feet together and arms at sides; when in stable position, ask the person to close eyes and to hold position for about 20 seconds. - Normally the person can maintain posture and balance even with visual orienting information blocked. •Ask the person to perform shallow knee bend or hop in place, first on one leg, then other. •Demonstrates normal position sense, muscle strength, and cerebellar function Some individuals cannot hop because of aging or obesity.

Patient Centered Care Lungs

•Screening and follow-up testing When was the last time you had the following? • TB skin test • Chest x-ray study • Pneumonia or influenza immunization

Gums/Gingivae

•Thick fibrous tissues covered with mucous membrane •Different from rest of oral mucosa because of their pale pink color and stippled surface

Abnormal Findings: Respiration Patterns

•Sigh: purposeful to expand alveoli - Can lead to hyperventilation and dizziness •Hyperventilation: increase in rate and depth - Caused by exertion, fear, anxiety - Blows off Co2, causing decreased level in blood •Hypoventilation: irregular shallow pattern - Caused by overdose of narcotics or anesthetics - Purposeful to avoid respiratory pain •Tachypnea: rapid, shallow breathing - Rate > 24 - Normal response to fever, fear, exercise •Bradypnea: slow breathing - Rate < 10 - Can be drug induced or related to neurological defecits •Cheyne-Stokes: respirations wax and wean - increase in rate and depth then decrease - Regular pattern - Associated with periods of apnea •Biot Respiration: like Cheyne-Stokes, but irregular pattern •Chronic Obstructive Breathing: normal inspiration and prolonged expiration to overcome increased airway resistance - Can lead to dyspnea

Inspect and palpate motor system

•Size - Inspect all muscle groups for size noting bilateral comparison. •Strength - Test muscle groups of extremities, neck, and trunk. •Tone: normal tension in relaxed muscles - Persuade the person to relax completely, and move each extremity smoothly through a full range of motion; normally note mild, even resistance to movement. •Involuntary movements - Normally none occur; if present, note location, frequency, rate, and amplitude; note if movements can be controlled at will.

Inspection and Palpation: Penis

•Skin normally looks wrinkled, hairless, and without lesions; dorsal vein may be apparent. •Glans looks smooth and without lesions; ask uncircumcised male to retract foreskin, or you retract it; it should move easily. - Some cheesy smegma may have collected under foreskin; after inspection, slide foreskin back to original position. •Urethral meatus positioned just about centrally •Compress glans anteroposterior between your thumb and forefinger; meatus edge should appear pink, smooth, and without discharge.

Pleurae

•Slippery pleurae form an envelope between lungs and chest wall •Visceral pleura lines outside of lungs •Pleural cavity normally has a vacuum, or negative pressure, which holds lungs tightly against chest wall. •Pleural cavity is potential space filled only with few milliliters of lubricating fluid.

Macules

•Solely a color change, flat and circumscribed, less than 1 cm

Adventitious Sounds

•Sources differ as to the classification and nomenclature of these sounds: - Crackles (or rales) and wheeze (or rhonchi) are terms commonly used by most examiners -Atelectatic crackles: a type of adventitious sound that is not pathologic •Short, popping, crackling sounds that sound like fine crackles but do not last beyond a few breaths

Abnormal gaits

•Spastic hemiparesis •Cerebellar ataxia •Parkinsonian (festinating) •Scissors •Steppage or footdrop •Waddling •Short leg

Telangiectases

•Spider or star angioma •Venous lake

Inspection of Perineal Area

•Spread buttocks wide apart and inspect perianal region. - Anus normally looks moist and hairless, with coarse folded skin more pigmented than perianal skin. - Anal opening tightly closed; no lesions present •Inspect sacrococcygeal area; normally appears smooth and even. - Instruct a person to hold breath and bear down by performing a Valsalva maneuver. - No break in skin integrity or protrusion through anal opening should be present. - Describe any abnormality in clock-face terms, with 12:00 as the anterior point toward symphysis pubis and 6:00 toward coccyx.

Pressure Injuries (PI)Pressure Ulcer, Decubitus Ulcer Stages

•Stage I: Non-blanchable erythema •Stage II: Partial-thickness skin loss •Stage III: Full-thickness skin loss •Stage IV: Full-thickness skin/tissue loss

Tactile discrimination (fine touch): tests also measure discrimination ability of sensory cortex

•Stereognosis: test the person's ability to recognize objects by feeling their forms, sizes, and weights •Graphesthesia: ability to "read" a number by having it traced on skin •Two-point discrimination: test ability to distinguish separation of two simultaneous pin points on skin •Extinction: simultaneously touch both sides of body at same point; normally both sensations are felt •Point location: touch skin and withdraw stimulus promptly; ask the person to put finger where you touched

Three types of reflexes:

•Stretch on/deep tendon (myotatic), e.g., knee jerk - DTR has 5 components: intact sensory (afferent) nerve, functional synapse in the cord, intact motor (efferent) nerve, neuromuscular junction and competent muscle •Superficial (cutaneous), e.g., plantar reflex •Visceral (organ), e.g., pupillary response to light and accommodation

Pregnancy skin conditions

•Striae •Linea nigra •Chloasma •Vascular spiders

Pectus Excavatum

•Sunken sternum and adjacent cartilages •Most noticeable on inspiration

Superficial reflexes

•Superficial (cutaneous) reflexes •Sensory receptors in skin rather than in muscles; motor response is localized muscle contraction. •Abdominal reflexes: upper: T8 to T10;lower: T10 to T12 - Person in supine position, knees slightly bent; use handle end of reflex hammer to stroke skin - Move from each corner toward midline at both upper and lower abdominal levels. - Normal response is ipsilateral contraction of abdominal muscle with observed deviation of umbilicus toward stroke.

Turbinates (three boney projections)

•Superior •Middle •Inferior

Mechanisms of Respiration: Function

•Supplying oxygen to the blood •Eliminates carbon dioxide (CO2) •Hypoventilation: causes carbon dioxide to build up in the blood •Slow, shallow breathing •Hyperventilation: causes carbon dioxide to be blown off •Rapid, deep breathing

Clonus: test when reflexes hyperactive

•Support lower leg in one hand and with other hand, move foot up and down to relax muscle; then stretch muscle by briskly dorsiflexing foot; hold the stretch. •Normal response: you feel no further movement •When clonus present, you will note rapid rhythmic contractions of calf muscle and movement of foot. •Sustained clonus is associated with UMN disease

Percussion

•Tapping person's skin with short, sharp strokes to assess underlying structures

Cranial nerve VIII: acoustic nerve (vestibulocochlear) TESTING

•Test hearing acuity by ability to hear normal conversation and by whispered voice test.

Light and Deep Palpation

•With either technique, note location, size, consistency, and mobility of any palpable organs and presence of any abnormal enlargement, tenderness, or masses - Making sense of what you are feeling is more difficult than it looks. •Inexperienced examiners complain that abdomen "all feels same," as if they are pushing their hand into a soft sofa cushion. - Helps to memorize anatomy and visualize what is under each quadrant as you palpate •Also remember that some structures are normally palpable. •Mild tenderness normally present when palpating sigmoid colon •Any other tenderness should be investigated. •If you identify a mass, first distinguish it from a normally palpable structure or an enlarged organ.

Palpation of Kidney

•You can elect to palpate either the right or the left kidney. •Patient must take a deep breath prior to examination. •Right kidney - Feel no change or feel smooth muscle mass - Either is normal •Left kidney - Feel no change with inhalation - Not normally palpable - 1 cm higher than right kidney

Inspection requires

•good lighting. •adequate exposure. •occasional use of instruments, including otoscope, ophthalmoscope, penlight, or nasal and vaginal specula, to enlarge your view.

Nasal cavity structure / function

•larger than nose would indicate •Filter dust and Bacteria •Nasal hairs •Mucous membranes

glands

•secrete saliva, the clear fluid that moistens and lubricates the food bolus, starts digestion, and cleans and protects the mucosa

Number of facial bones

■14 facial bones also articulate at sutures -With exception of mandible

Abnormal Facial Appearances Associated with Chronic Illness

■Acromegaly -Elongated head, massive face, overgrowth of nose, lower jaw, heavy eyebrow ridge, and coarse facial features ■Cushing syndrome -Classic "moonlike" face, red cheeks, and hirsutism -Hirsutism: excessive growth of dark hair in women due to hormone imbalance ■Bell palsy -Paralysis on one side of the face as a result of LMN lesion ■Stroke or brain attack -UMN lesion leading to paralysis of lower facial muscles ■Parkinson syndrome -Classic "maskline" appearance, elevated eyebrows, staring gaze, oily skin and drooling due to dopamine deficiency ■Cachectic appearance -Sunken eyes, hollow cheeks, and defeated expression that accompanies chronic wasting diseases

Sutures

■Adjacent cranial bones mesh at sutures -Coronal -Sagittal Lambdoid

Physical Examination: Infants and Children - Neck

■An infant's neck looks short; it lengthens during the first 3 to 4 years. ■Assess muscle development with gentle passive ROM. -Cradle infant's head with your hands and turn it side to side and test forward flexion, extension, and rotation. -Note resistance to movement, especially flexion. ■During infancy, cervical lymph nodes are not palpable normally, but child's lymph nodes are palpable. -Palpable nodes less than 3 mm are normal. ■Children have a higher incidence of infection, so you will expect a greater incidence of inflammatory adenopathy; no other mass should occur in neck.

Two common variations in newborn cause shape of skull to look markedly asymmetric due to birth trauma:

■Caput succedaneum: edematous swelling that is self-limiting and extends across suture lines ■Cephalohematoma: subperiosteal hemorrhage, well defined over one cranial bone over periosteum, reabsorbed during first few weeks of life

Physical Examination: Infants and Children - Face

■Check facial features for symmetry, appearance, and swelling. -Note symmetry of wrinkling when infant cries or smiles (e.g., both sides of lips rise and both sides of forehead wrinkle). -Normally, no swelling is evident. ■Parotid gland enlargement best seen when child looks up; swelling appears below angle of jaw

Abnormal Findings: Swelling of Head and Neck

■Congenital torticollis -Hematoma in one sternomastoid muscle, probably injured by intrauterine malposition, results in head tilt to one side and limited neck ROM to opposite side ■Simple diffuse goiter (SDG) -Endemic goiter due to iodine deficiency that results in chronic enlargement of the thyroid gland ■Thyroid—multinodular goiter (MNG) -Multiple nodules usually indicate inflammation or multinodular goiter rather than a neoplasm; however, suspect any rapidly enlarging or firm nodule ■Pilar cyst (Wen) -Benign growth that presents as smooth, fluctuant swelling on scalp ■Parotid gland enlargement -Rapid painful enlargement seen in response to mumps, blockage of duct, abscess, or tumor

Physical Examination: Pregnant Female

■During second trimester -chloasma may show on face. ■A blotchy, hyperpigmented area over cheeks and forehead that fades after delivery ■Thyroid gland may be palpable normally during pregnancy.

Inspection of Face

■Facial structures -Always should be symmetric. ■Note facial expression and appropriateness to behavior or reported mood. ■Note any abnormal facial structures -Coarse facial features, exophthalmos, changes in skin color or pigmentation, or abnormal swellings ■Note any involuntary movements (tics) in facial muscles; normally none occur.

Inspection and Palpation of the Neck

■Head and neck symmetry -Head position is centered in midline, and accessory neck muscles should be symmetric. -Head should be held erect and still. ■Range of motion -Note any limitations. -Test muscle strength. -Observe for enlargement of glands and/or pulsations. ■Trachea -Should be midline - Palpate for any tracheal shift -Note any deviation from midline ■Thyroid gland -Difficult to palpate; check for enlargement, consistency, symmetry, and presence of nodules -Position patient for best approach ■Posterior approach ■Anterior approach -Auscultate thyroid for bruit, if enlarged.

Subjective Data: Health History

■Headache ■Head injury ■Dizziness ■Neck pain, limitation of motion ■Lumps or swelling ■History of head or neck surgery

Abnormal Findings: Pediatrics

■Hydrocephalus -Obstruction of drainage of cerebrospinal fluid results in excessive accumulation, increasing intracranial pressure, and enlargement of the head ■Plagiocephaly -Positional or deformational due to sleeping position ■Craniosynostosis -Premature closing of one or more cranial sutures that leads to head malformation ■Atopic (allergic) facies -A variety of presentations seen in children who have chronic allergies -Include exhausted face, allergic shiners, Morgan lines, central facial pallor and allergic gaping ■Fetal alcohol spectrum disorders (FASD) -Narrow palpebral fissures, epicanthal folds, thin upper lip, and midfacial hypoplasia ■Allergic salute and crease -Appearance of transverse line on the nose in response to chronically repeated use of hand to push the nose up and back ■Down syndrome

Physical Examination: Aging Adult

■Neck may show an increased concave curve -to compensate for kyphosis. ■Maintain patient safety by indicating patient perform ROM and position changes slowly -minimize potential for dizziness.

Structure and Function: Lymphatic System

■Part of immune system - Detects and eliminates foreign substances from body ■Rich supply of lymph nodes -Accessible to examination only in the head and neck, arms, axillae, and inguinal region -Greatest supply is in head and neck. ■Small, oval clusters of lymphatic tissue ■Lymphatic drainage -Helps to prevent potentially harmful substances from entering the circulation -You should be familiar with direction of drainage patterns of lymph nodes. -All head and neck structures eventually drain into the deep cervical chain ■Lymph: clear, watery fluid

Infants and Children: Special Procedures

■Percussion -With an infant, you may directly percuss with your plexor finger against head surface. - This yields a resonant or "cracked pot" sound, which is normal before closure of fontanels. ■Auscultation -Bruits are common in skull of children under 4 or 5 years of age or children with anemia. ■Systolic or continuous; heard over temporal area

Thyroid Disorders: Graves Disease

■Physical presentation neck and face -Goiter -Eyelid retraction -Exophthalmos

Thyroid Disorders: Hypothyroidism

■Physical presentation neck and face -Puffy edematous face -Periorbital edema -Coarse facial features -Coarse hair and eyebrows

Structure and Function: Lymph Nodes

■Preauricular -In front of ear ■Posterior auricular (mastoid) -Superficial to mastoid process ■Occipital -At base of skull ■Submental -Midline, behind tip of mandible ■Submandibular -Halfway between angle and tip of mandible ■Jugulodigastric -Under angle of mandible ■Superficial cervical -Overlying sternomastoid muscle ■Deep cervical -Deep under sternomastoid muscle ■Posterior cervical -In posterior triangle along edge of trapezius muscle ■Supraclavicular -Just above and behind clavicle, at sternomastoid muscle

Skull

■Rigid box that protects brain. -Includes bones of cranium and face -Supported by cervical vertebra

Inspection and Palpation of Skull

■Size and shape -Normocephalic: round and symmetric -Assess shape: place fingers in person's hair and palpate scalp -Cranial bones that have normal protrusions: - Forehead, lateral edge of parietal bones, occipital bone, and mastoid process behind each ear ■Temporal area -Palpate temporal artery above zygomatic (cheek) bone between eye and top of ear

Physical Examination Skull: Infants and Children

■Skull -Measure infant's head at each visit up to age 2 years and yearly up to age 6 years. ■Note infant's head posture and head control; infant can turn head side to side by 2 weeks.

Physical Examination: Aging Adult

■Temporal arteries -may look twisted and prominent. ■In some aging adults, a mild rhythmic tremor of head may be normal. -senile tremors are benign and include head nodding and tongue protrusion. ■If some teeth have been lost

Structure of thyroid gland

■The gland has two lobes -Connected in middle by a thin isthmus and above that by the cricoid cartilage or upper tracheal ring ■Thyroid cartilage -Small palpable notch in upper edge ("Adam's apple" in males) -Cricoid cartilage or upper tracheal ring -Isthmus of the thyroid gland