NR 509 Final Exam 2023, Exams of Nursing

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NR 509 Final Exam 2023

1. Appendicitis: 1. McBurney point tenderness
2. Rovsing sign
3. the psoas sign
4. the obturator sign --Appendicitis is twice as likely in the presence of RLQ tenderness, Rovsing sign, and the psoas sign --The pain of appendicitis classically begins near the umbilicus, then migrates to the RLQ. Older adults are less likely to report this pattern. --Localized tenderness anywhere in the RLQ, even in the right flank, suggests appendicitis.
5. McBurney Point: 1. McBurney point lies 2 inches from the anterior superior spinous process of ilium on a line drawn from that process to the umbilicus
6. Appendicitis is three times more likely if there is McBurney point tenderness.
7. Rovsing sign: Press deeply and evenly in the LLQ. Then quickly withdraw your fingers. Pain in the RLQ during left-sided pressure is a positive Rovsing sign.
8. Psoas Sign: --Place your hand just above the patient's right knee and ask the patient to raise that thigh against your hand. Alternatively, ask the patient

to turn onto the left side. Then extend the patient's right leg at the hip. Flexion of the leg at the hip makes the psoas muscle contract; extension stretches it. --Increased abdominal pain on either maneuver is a positive psoas sign, sug- gest- ing irritation of the psoas muscle by an inflamed appendix.

5. Obturator Sign: --Less helpful --Flex the patient's right thigh at the hip, with the knee bent, and rotate the leg internally at the hip. This maneuver stretches the internal obturator muscle. --Right hypogastric pain is a positive obturator sign, from irritation of the obturator muscle by an inflamed appendix. This sign has very low sensitivity.
6. Acute Cholecystits: RUQ pain Murphy Sign
7. Murphy Sign: Hook your left thumb or the fingers of your right hand under the costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin. Alternatively, palpate the RUQ with the fingers of your right hand near the costal margin. If the liver is enlarged, hook your thumb or fingers under the liver edge at a comparable point. Ask the patient to take a deep breath, which forces the liver and gallbladder down toward the examining fingers. Watch the patient's breathing and note the degree of tenderness.

--A sharp increase in tenderness with inspiratory effort is a positive Murphy sign. When positive, Murphy sign triples the likelihood of acute cholecystitis.

8. Acute Pancreatitis Process: Intrapancreatic trypsinogen activation to trypsin and other enzymes, result-ing in autodigestion and inflammation of the pancreas
9. Acute Pancreatitis Location: Epigastric, may radiate straight to the back or other areas of the abdomen; 20% with severe sequelae of organ failure
10. Acute Pancreatitis Quality: Usually steady
11. Acute PancreatitisTiming: Acute onset, persistent pain
12. Acute Pancreatitis Aggrevating Factors: Lying supine; dyspnea if pleural effusions from capillary leak syn-drome; selected medications, high triglycerides may exacerbate
13. Acute Pancreatitis Relieving factors: Leaning forward with trunk flexed
14. Acute Pancreatitis Associated Symptoms and Setting: Nausea, vomiting, abdominal dis-tention, fever; often recurrent; 80% with history of alcohol abuse or gallstones
15. Peptic Ulcer Disease Process: Mucosal ulcer in stomach or duode- num >5 mm, covered with fibrin, ex-tending through the muscularis mu- cosa; H. pylori infection present in 90% of peptic ulcers
16. Peptic Ulcer Disease Location: Epigastric, may radiate straight to the back
17. Peptic Ulcer Disease Quality: Variable: epigastric gnawing or burning (dys- pepsia); may also be boring, aching, or hungerlike No symptoms in up to 20%

18. Peptic Ulcer Disease Timing: Intermittent; duodenal ulcer is more likely than gastric ulcer or dyspepsia to cause pain that (1) wakes the patient at night, and (2) occurs intermittently over a few wks, disappears for months, then recurs
19. Peptic Ulcer Disease aggravating factors: Variable
20. Peptic Ulcer Disease relieving factors: Food and antacids may bring re-lief (less likely in gastric ulcers)
21. Peptic Ulcer Disease associated symptoms and setting: Nausea, vomiting, belching, bloating; heartburn (more common in duodenal ulcer); weight loss (more common in gastric ulcer); dyspepsia is more com-mon in the young (20-29 yrs), gastric ulcer in those over 50 yrs, and duodenal ulcer in those 30-60 yrs
22. GERD Process: Prolonged exposure of esophagus to gastric acid due to impaired esopha-geal motility or excess relaxations of the lower esophageal sphincter; Helico-bacter pylori may be present
23. GERD Location: Chest or epigastric
24. GERD Quality: Heartburn, regurgitation
25. GERD timing: After meals, especially spicy foods
26. GERD aggravating factors: Lying down, bending over; physical activity; dis- eases such as scleroderma, gastroparesis; drugs like nicotine that relax the lower esophageal sphincter

27. GERD : relieving factors: Antacids, proton pump inhibi-tors; avoiding alcohol, smoking, fatty meals, chocolate, selected drugs such as theophylline, cal-cium channel blockers
28. GERD associated symptoms and setting: Wheezing, chronic cough, short-ness of breath, hoarseness, choking sensation, dysphagia, regurgitation, halitosis, sore throat; increases risk of Barrett esophagus and esopha-geal cancer
29. Diverticulitis process: Acute inflammation of colonic diver-ticula, outpouch- ings 5-10 mm in di-ameter, usually in sigmoid or descend-ing colon
30. Diverticulitis location: Left lower quadrant
31. Diverticulitis quality: May be cramping at first, then steady
32. Diverticulitis timing: Often gradual onset
33. Diverticulitis aggravating factors: --
34. Diverticulitis relieving factors: Analgesia, bowel rest, antibiotics
35. Diverticulitis associated symptoms and setting: Fever, constipation. Also nausea, vomiting, abdominal mass with rebound tenderness
36. Hepatitis: -Tenderness over liver (liver inflammation) --Hep A and B prevention: Vaccination Hep A: spread through fecal matter and asymptomatic children Hep B: 1% fatality, 15-25% of chronic infection die from cirrhosis or liver cancer

(usually asymptomatic until onset of advanced liver disease). Hep C: Mainly percutaneous exposure.

37. Hepatitis B high risk: -Sexual contact: w/ partners infected, more than one parter in prior 6 mos, people seeing eval of treatment for STD, men with men -Perc and Mucosal exposure to blod: drugs, household contacts, residents and staff of facilties of DD, Health care, dialysis

-Others: Travel to endemic areas, chronic liver disease and HIV, people seeking protection from Hep B. --All adults in high risk-settings: STD clinics, HIV programs, Drug programs, cor- rectional facilities, programs for gay men, chronic hemodialysis facilities, facilities for people with Developmental Delays.

38. IBS patterns: 1. diarrhea—predominant
39. constipation—predominant
40. mixed. --Symptoms present e6 mo and abdominal pain for e3 mo plus at least 2 of 3 features (improvement with defecation; onset with change in stool frequency; onset with change in stool form and appearance)
41. IBS: process: Altered motility or secretion from luminal and mucosal irritants that change mucosal permeability, immune activation, and colonic transit, including maldigested carbohydrates, fats, excess bile acids, gluten intolerance, entero-en- docrine signaling, and changes in microbiomes
42. IBS characteristics of stool: Loose; <50% with mucus; small to mod- erate volume. Small, hard stools with constipation. May be mixed pattern.
43. IBS timing: Worse in the morning; rarely at night.
44. IBS associated symptoms: Crampy lower ab-dominal pain, ab-dominal dis- ten-tion, flatulence, nausea; urgency, pain relieved with defecation
45. IBS setting, persons at risk: Young and middle-aged adults, especially women

44. Stress Incontinence problem: The urethral sphincter is weakened so that transient increases in intra-abdominal pressure raise the bladder pressure to levels that exceed urethral resistance.
45. Stress Incontinence mechanisms: In women, pelvic floor weakness and inadequate muscular and ligamentous support of the bladder neck and proximal urethra change the angle between the bladder and the urethra (see Chapter 14, pp. 592-593). Causes include childbirth and surgery. Local conditions affecting the internal urethral sphincter, such as postmenopausal atrophy of the mucosa and urethral infection, may also contribute. In men, stress incontinence may follow prostate surgery.
46. Stress Incontinence symptoms: Momentary leakage of small amounts of urine with coughing, laughing, and sneezing while the person is in an upright position. Urine loss is unrelated to a conscious urge to urinate.

47. Stress Incontinence Physical signs: Stress incontinence may be demon- strable, especially if the patient is examined before voiding and in a standing position. Atrophic vaginitis may be evident. Bladder distention is absent.
48. Urge incontinence problem: Detrusor contractions are stronger than normal and overcome the normal urethral resistance. The bladder is typically small.
49. Urge incontinence mechanism: Decreased cortical inhibition of detrusor contractions from stroke, brain tumor, dementia, and lesions of the spinal cord above the sacral level. Hyperexcitability of sensory pathways, as in bladder infections, tumors, and fecal impaction. Deconditioning of voiding reflexes, as in frequent voluntary voiding at low bladder volumes.
50. Urge incontinence symptoms: Involuntary urine loss preceded by an urge to void. The volume tends to be moderate. Urgency, frequency, and nocturia with small to moderate volumes. If acute inflam- mation is present, pain on urination. Possibly "pseudo-stress incontinence"—voiding 10-20 sec after stresses such as a change of position, going up-or downstairs, and possibly coughing, laughing, or sneezing.
51. Urge incontinence physical signs: The small bladder is not detectable on abdominal examination.

When cortical inhibition is decreased, mental deficits or motor signs of central nervous system disease are often present. When sensory pathways are hyperexcitable, signs of local pelvic problems or a fecal impaction may be present.

52. Overflow incontinence problem: Detrusor contractions are insufficient to overcome urethral resistance, causing urinary retention. The bladder is typically flaccid and large, even after an effort to void.
53. Overflow incontinence mechanisms: Obstruction of the bladder outlet, as in benign prostatic hyperplasia or tumor. Weakness of the detrusor muscle associat- ed with peripheral nerve disease at S2-4 level. Impaired bladder sensation that interrupts the reflex arc, as in diabetic neuropathy.
54. Overflow incontinence symptoms: When intravesicular pressure overcomes urethral resistance, continuous dripping or dribbling incontinence ensues. De- creased force of the urinary stream. Prior symptoms of partial urinary obstruction or other symptoms of peripheral nerve disease may be present.

55. Overflow incontinence physical signs: Examination often reveals an en- larged, sometimes tender, bladder. Other signs include prostatic enlargement, mo- tor signs of peripheral nerve disease, a decrease in sensation (including perineal sensation), and diminished to absent reflexes.
56. Functional incontinence problem: The patient is functionally unable to reach the toilet in time because of impaired health or environmental conditions.
57. Functional incontinence mechanisms: Problems in mobility resulting from weakness, arthritis, poor vision, or other conditions. Environmental factors such as an unfamiliar setting, distant bathroom facilities, bed rails, or physical restraints.
58. Functional incontinence symptoms: Incontinence on the way to the toilet or only in the early morning.
59. Functional incontinence physical signs: The bladder is not detectable on examination. Look for physical or environmental clues as the likely cause.
60. Incontinence secondary to medications problem: Drugs may contribute to any type of incontinence listed.
61. Incontinence secondary to medications mechanisms: Sedatives, tranquil- izers, anticholinergics, sympathetic blockers, and potent diuretics.
62. Incontinence secondary to medications symptoms: Variable. A careful his- tory and chart review are important.

63. Incontinence secondary to medications physical signs: Variable.
64. Colorectal cancer screening: Adults ages 50 to 75 years—options (grade A recommendation)
65. Hi-sens fecal occult blood testing annually
66. Sigmoidoscopy every 5 years w/ high-sensitivity FOBT every 3 years
67. Screening colonoscopy every 10 years B: Adults 76-
68. Screening not advised because the benefits are small in comparison to the risks
69. Use individual decision making if screening an adult for the first time C. Adults older than age 85 years—do not screen (grade D recommendation)
70. Screening not advised because "competing causes of mortality preclude a mortality benefit that outweighs harms"
71. Colorectal cancer screening tests: 1. Stool tests that detect occult fecal blood: a. fecal immunochemical tests, b. high-sensitivity guaiac-based tests, c. tests that detect abnormal DNA.

2. Endoscopic tests: a. colonoscopy, which visualizes the entire colon and can remove polyps, b. flexible sigmoidoscopy, which visualizes the distal 60 cm of the bowel. --Colonoscopy is the most commonly used and gold standard, though people may prefer other tests like FOBTs because they are safer and easier to perform.
3. Colorectal cancer epidemiology: --Third most frequently diagnosed cancer among both men and women (over 140,000 new cases) and the third leading cause of cancer death (nearly 50,000 deaths) each year in the United States. --The lifetime risk of diagnosis with colorectal cancer is about 5%, while the lifetime risk for dying from colorectal cancer is about 2%.
4. Colorectal cancer risk factors: 1. Increasing age
5. personal history of colorectal cancer
6. adenomatous polyps, or long-standing inflammatory bowel disease
7. family history of colorectal neoplasia—particularly multiple first-degree relatives, a single first-degree relative diagnosed before age 60 years, or a hereditary colorectal cancer syndrome. Weaker risk factors:
8. male sex
9. African American race
10. tobacco use
11. excessive alcohol use
12. red meat consumption
13. obesity.

68. Colorectal cancer prevention: Primary prevention:
69. screen for and
70. remove pre-cancerous adenomatous polyps Also associated with decreased risk
71. Physical activity
72. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs)
73. Postmenopausal combined hormone replacement therapy (estrogen and prog- estin)
74. Abdominal insepction: Abnormal: purple striae: cushing syndrome Dilated veins: portal HTN from cirrhosis or ICV obstruction Ecchymosis: intraperitoneal or retroperitoneal hemorrhage Protuberant abdomen: 1. Hernia (umbilica, incisional, epigastric, 2. Diastasis Recti,
75. Lipoma, 4. Fat, 5. Gas, 6. Tumor, 7. Pregnancy, 8. Ascites

70. Abdominal Auscultation: 1. Bowel sounds
71. Bruits: hepatic (Cirrhosis), Arterial with systolic and diastolic component (oc- clusion of aorta or large artery (ex. epigastric--renal artery stenosis/renovascular hypertension)
72. Venous Hum: rare soft humming w/ sys/dias.= increase collateral circ btwn portal and systemic systems (hepatic cirrhosis)
73. Friction Rub over liver or spleen: Rare grating sounds w/ respiratory variation=in- flammation (liver cancer, chlamydial/gonococcal perihepatitis, liver bx, splenic infarct)
74. Abdomen percussion: --Tympany dominates d/t gas --Dull areas: fluid, feces, mass, enlarged organ --Protuberant abdomen: note where tympany changes to dullness (solid posterior structures) --Percuss lower anterior chest above costal margins: normal= right dullness over liver, left tympany over gastric air bubble and spelnic flexure of colon.
75. Abdomen palpation: gently palpate over 4 quadrants: abnormal: involuntary rigidity=peritoneal inflammation Deep palpation to feel for masses: physiologic (pregnancy), inflammatory (divertic- ulitis), vascular (AAA), neoplastic (colon cancer), or obstructive (distended bladder or dilated loop of bowel)
76. Liver assessment: Percussion: liver span should be about 4-8cm in midster- nal line and 6-12cm in right midclavicular line. Palpation ("hooking technique" may be helpful):

1. start below line of dullness of lower liver border and press gently in and up.
2. Have pt take deep breath in and feel liver edge (soft, sharp, and regular with smooth surface, non-tender).
3. Inspiration: liver is palpable 3cm below right costal margin in midclavicular line. (gallbladder may merge with liver causing firm oval mass below liver edge) Percussion tenderness in nonpalpable liver: strike right side with ulnar surface of hand and compare to sensation felt on left side: tenderness suggests inflammation (hepatitis or congestion from heart failure).
4. Spleen assessment: Enlargement: expands anteriorly, downward, and medi- ally, replacing tympany of stomach and colon with dullness of solid organ. Percussion:
5. Percuss the left lower anterior chest wall roughly from the border of cardiac dullness at the 6th rib to the anterior axillary line and down to the costal margin, an area termed Traube space. As you percuss along the route, note the lateral extent of tympany. Percussion is moderately accurate in detecting splenomegaly (80% of

the time)

2. If tympany is prominent, splenomegaly is unlikely.
3. Check for a splenic percussion sign. Percuss the lowest interspace in the left anterior axillary line (usually tympanic). Have patient to take a deep breath, and percuss again. When spleen size is normal, the percussion note usually remains tympanitic. Palpation (supine and on right side): Splenomegaly is eight times more likely when the spleen is palpable (portal hypertension, hematologic malignancies, HIV infection, infiltrative diseases like amyloidosis, and splenic infarct or hematoma). In 5% of normal adults: Spleen tip, is just palpable deep to the left costal margin.
4. Kidney assessment LEFT: Retroperitoneal and nonpalpable. Palpation: lay on left side. Place R hand behind the pt, just below and parallel to the 12th rib, with fingertips just reaching the CVA. Lift, trying to displace the kidney anteriorly. Place your left hand gently in the LUQ, lateral and parallel to the rectus muscle. Ask the patient to take a deep breath. At the peak of inspiration, press your left hand firmly and deeply into the LUQ, just below the costal margin. Try to "capture" the kidney between your two hands. Ask the patient to breathe out and then to stop breathing briefly. Slowly release the pressure of your left hand, feel-ing at the same time for the kidney to slide back into its expiratory position. If the kidney is palpable, describe its size, contour, and any tenderness.

OR Deep palpation: Stand on pt right side, use left hand, reach over and around pt to lift up beneath the left kidney, and with right hand, feel deep in the LUQ. Have pt to take deep breath, feel for a mass. Abnormal: Splenomegaly (if palpable notch on medial border, edge extends be- yond midline, percussion is dull, and fingers can prode deep to the medial and lateral borders but NOT btwn mass and costal margin) Large kidney if: normal tympany in LUQ and can probe with fingers between mass and costal margin but not deep to its medial and lower borders.

76. Kidney assessment: RIGHT: A normal right kidney may be palpable, espe- cially when the patient is thin and the abdominal muscles are relaxed. To capture the right kidney, return to the patient's right side. Use your left hand to lift up from the back, and your right hand to feel deep in the RUQ. Proceed as before. The kidney may be slightly tender. The patient is usually aware of a capture and release. Causes of kidney enlargement include hydronephrosis, cysts, and tumors. Bilateral enlargement suggests poly- cystic kidney disease.

77. Kidney Percussion: assess percussion tenderness over the CVAs. Pressure from your fingertips may be enough to elicit tenderness; if not, use fist percussion. Place the ball of one hand in the CVA and strike it with the ulnar surface of your fist (Fig. 11-29). Use enough force to cause a perceptible but painless jar or thud. Pain with pressure or fist percussion supports pyelonephritis if associated with fever and dysuria, but may also be musculoskeletal.
78. Bladder assessment: Percussion dullness: bladder must be 400-600ml full for dullness to appear. Palpation: dome of distended bladder feels smooth, round, nontender. Causes of bladder distention: outlet obstruction from a urethral stricture or prostatic hyperplasia, medication side effects, and neurologic disorders such as stroke or multiple sclerosis. Suprapubic tenderness is common in bladder infection.
79. Aorta assessment: Press firmly deep in the epigastrium, slightly to the left of the midline, and identify the aortic pulsations Adults over age 50 years, assess the width of the aorta by pressing deeply in the upper abdomen with one hand on each side of the aorta (normally no more than 3cm wide).
80. Aorta abnormalities: A periumbilical or upper abdominal mass with expansile pulsations that is e3 cm in diameter suggests an AAA. Sensitivity of palpation increases as AAAs enlarge.
81. Risk factors for AAA: 1. Age e65 years

2. history of smoking
3. male gender
4. first-degree relative with a history of AAA repair
5. Ascites assessment: A protuberant abdomen with bulging flanks is suspi- cious for ascites dullness appears in the dependent areas of the abdomen. Test for shifting dullness: site of dullness shifts when pt turns to one side. Test for fluid wave: have someone hold both sides of abdomen and sharply tap top part of abdomen and feel for fluid to shift to lower part. A positive fluid wave, shifting dullness, and peripheral edema makes the presence of ascites to three to six times more likely
6. Breast Exam Males: Enlargement: gynecomastia proliferation of palpable glandular tissue pseudogynecomastia accumulation of subareolar fat

84. Breast lymphatics: Pectoral- anterior: located along lower border of pectoralis major inside ant. axillary fold. Drain anterior chest wall and breast. Subscapular-posterior: lateral border of scapula, palpated deep in the posterior axillary fold. Drain post chest and portion of arm. Lateral nodes: located along upper humerus: drain arm. --some breast lymp drains into infraclavicular or internal mammary chain of lymph within chest.
85. Breast masses: May be physiologic or pathologic.
86. Fibroadenoma: 15-25 yrs up to 55 yrs, single, round, disclike, or lobular, small, soft, firm, well delineated, mobile, nontender, no retraction signs.
87. Cyst: 30-50 yrs, regress after menopause, single or multiple, round, soft to firm, elastic, well delineated, mobile, tender, without retraction signs.
88. Cancer: 30-90 years, single, may exist with other nodules, irregular or stellate, firm or hard, not clearly delineated from surrounding tissues, nontender, may have retraction sign.
89. Visible signs of breast cancer: 1. Retraction signs (dimpling, changes in contour, retraction/deviation of nipple)
90. Abnormal contours: variations in normal convexity
91. Skin dimpling: best seen with arm at rest, during special positioning, or on moving/compressing breast
92. Nipple retraction and deviation: nipple flattened or pulled inward, OR broadened and thickened, when asymmetric, nipple may deviate.
93. Edema of skin: produced by lymphatic blockage, appears as thickened skin with enlarged pores (orange peel), seen first in lower portion of breast or areola.

6. Paget disease of nipple: scaly, eczema-like lesion on nipple that may weep, crust, or erode. Mass may be present. Often (>60%) presents with underlying ductal or lobular carcinoma.
7. Breast pain: mastalgia. Pain without mass is not a breast cancer risk factor Medications can cause breast pain: hormonal therapy, psychotropic drugs, spironolactone, and digoxin.
8. Nipple exam: Discharge: Galactorrhea, or the discharge of milk- containing fluid unrelated to preg-nancy or lactation, is more likely to be pathologic when it is bloody or serous, unilateral, spontaneous, associated with a mass, and occurring in women aged e40 years. Thickening of the nipple and loss of elasticity suggest an underlying cancer.
9. Breast cancer risk factors: The most significant risk factors for breast cancer are age, BRCA status, and breast density on mammogram. Personal history

of breast cancer, fam-ily history, and reproductive factors affecting duration of uninterrupted estrogen exposure are also important.

90. Breast exam Inspection: Redness suggests local infection or inflammatory carcinoma. Thickening and prominent pores suggest breast cancer. Flattening of the normally convex breast suggests cancer. Asymmetry due to change in nipple direction suggests an underlying can- cer. Eczematous changes with rash, scaling, or ulceration on the nipple extending to the areola occurs in Paget disease of the breast, associated with underlying ductal or lobular car-cinoma (see p. 445).60 A nipple pulled inward, tethered by underlying ducts signals nipple retrac-tion from a possible underlying cancer. The retracted nipple may be depressed, flat, broad, or thickened.
91. Breast exam positions: Arms Over Head; Hands Pressed Against Hips; Lean- ing Forward. Breast dimpling or retraction in these positions suggests an underlying cancer. Cancers with fibrous strands attached to the skin and fascia over the pectoral muscles may cause inward dimpling of the skin during muscle contraction. Occasionally, these signs accompany benign conditions such as posttrau-matic fat necrosis or mammary duct ectasia, but should always be further evaluated. Leaning forward: may reveal asymmetry or retraction of the breast, areola, or nipple that is not otherwise visible, suggesting an underlying cancer
92. Breast exam palpation: Supine:

1. at least 3 minutes for each breast.
2. Use pads of the 2nd, 3rd, and 4th fingers, keeping the fingers slightly flexed.
3. Use vertical strip pattern
4. Palpate in small, concentric circles applying light, medium, and deep pressure at each examining point. Press more firmly to reach the deeper tissues of a large breast.
5. Examine the entire breast, including the periphery, tail, and axilla. Examining the lateral portion of the breast. To examine the lateral portion of the breast, ask the patient to roll onto the opposite hip, placing her hand on her forehead but keeping the shoulders pressed against the bed the medial portion of the breast, ask the patient to lie with her shoulders flat against the bed or exam-ining table, placing her hand at her neck and lifting up her elbow until it is even with her shoulder
6. Axilla Exam: Enlarged axillary nodes may result from infection of the hand or arm, recent immunizations or skin tests, or generalized lymphadenopathy. Check

the epitrochlear nodes medial to the elbow and other groups of lymph nodes. Nodes that are large (e1 to 2 cm) and firm or hard, matted together, or fixed to the skin or underlying tissues sug-gest malignancy.

94. Breast Self-Exam: best timed 5 to 7 days after menses, when hormonal stimulation of breast tissue is low. Supine with pillow under one shoulder-->finger pads of the three middle fin- gers-->Make overlapping, dime-sized circular motions to feel the breast tis- sue-->Apply three levels of pressure in each spot-->up-and-down or "strip" pat-tern Standing:
95. hands pressing firmly down on your hips, look at your breasts for any changes of size, shape, contour, or dimpling, or redness or scaliness of the nipple or breast skin.
96. Examine each underarm while sitting up or standing and with your arm only slightly raised
97. Erectile Dysfunction: 1. Psychogenic causes, especially if early morning erection is preserved
98. Decreased testosterone
99. decreased blood flow in the hypogastric arterial system
100. impaired neural innervation
101. diabetes
102. Penile Discharge/rash: yellow penile discharge in gonorrhea white discharge in non-gonococcal urethritis from Chlamydia.