NR 509 Final Exam 6 Questions with answers, Exams of Nursing

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NR 509 Final Exam 6 Questions with

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Childhood immunizations ✔Birth- Hep B, Flu 1-2 mos- DTap, Hep B(2), HIB, Polio, Pneumococcal, Rotavirus 3-4 mos- DTap (2), HIB (2), Polio (2), Pneumo (2), Rotavirus (2) 5-6 mos- Dtap (3), HIB (3), polio (3), pneumo (3), Rotavirus (3), Flu 7-11 mos- flu 12-23 mos- Varicella, DTap (4), HIB (4), MMR (1), Polio (3), Pnuemo (4), Hep A, Hep B (3), Flu 2-3 years- Flu 4-6 years- DTap (5), Polio (4), MMR (2), Varicella (2), Flu 7-10 years- Flu, HPV 11-12 years- Mening, HPV (2), Tdap (1) 13-18 years- Mening (2), Serogroup B Mening (2) Apgar scale ✔a standard measurement system that looks for a variety of indications of good health in newborns. Score at 1 min and again at 5 min 3 pt scale (0,1,2) score ranges 0- HR: absent- <100- > Resp: Absent- slow- good Color: Blue/pale- Pink body/blue arms- pink Muscle tone: Flaccid- Some flexion- Active Reflexes: None- Grimaces- Vigorous Cry Gestational Age Assessment ✔Performed within 2 to 12 hr of birth Newborn Measurements and New Ballard Scale Gestational age estimation and baseline to assess growth and development. *Neonatal morbidity and mortality are related to gestational age and birth weight. Large gestational age ✔above 90th percentile risk for hypoglycemia- s/s include jitteriness, irritability, cyanosis small gestational age ✔<10th percentile

babies who weigh substantially less than is normal for whatever their gestational age May be caused by fetal, placental, maternal factors, maternal smoking Preterm appropriate gestational age at risk for ✔respiratory distress, apnea, patent ductus arteriosis (PDA) with left to right shunt and infection Preterm small gestation age at risk for ✔asphyxia, hypoglycemia, hypocalcemia tremors after 4 days old suggest ✔CNS disease, asphyxia, drug withdrawal, central or peripheral neurologic defect, or birth injuries s/s include asymmetric movements of arms or legs failure to thrive ✔1) growth <5th percentile

2. drop >2 quartiles in 6 months
3. weight for length <5th percentile Causes include environmental, psychosocial, GI, neurologic, cardiac, renal, and endocrine diseases Macrocephaly ✔>95th percentile or 2 standard deviations above mean Hydrocephalus, subdural hematoma, brain tumor, inherited familial, megaloencephaly Causes of HTN in newborns ✔renal artery disease (stenosis, thrombosis), congenital renal malformations, coarctation of aorta Polycythemia ✔A disorder characterized by an abnormal increase in the number of red blood cells in the blood Ruddy complexion- reddish/purple Cutis marmorata

✔Lattice-like, bluish mottled skin seen in premature infants, hypothyroidism, down syndrome Acrocyanosis ✔Temporary cyanotic condition, usually in newborns resulting in a bluish color around the lips, hands and fingernails, feet and toenails. May last for a few hours and disappear with warming. If color doesn't return to normal in 8 hours consider congenital heart disease harlequin dyschromia ✔Occasionally in newborns there is a transient cyanosis over one half of the body or one extremity, presumably from vascular instability African American newborns skin tone ✔light except for nailbeds, genitals, and ear folds which are dark Dark/Bluish pigment over buttocks lower lumbar (slate blue patches) Neonatal acne ✔red pustule/papules over cheeks and nose of newborns seborrhea ✔salmon red, scaly eruption on face, neck axilla, diaper area, and ears atopic dermatitis ✔erythema, scaly, dry intense itching Candidal diaper dermatitis ✔bright red rash involves the intertriginous folds with small "satellite lesions" along the edges Contact Diaper Dermatitis ✔irritant rash is secondary to diarrhea or irritation & is noted along contact areas Cafe au lait spots ✔Smooth edged tan-to-brown pigmentations on the skin measuring <1-2cm at birth if

5 spots seen in neurofibromatosis erythema toxicum

✔pink rash that appears suddenly anywhere on the body of a term newborn during the first 3 weeks may be mistaken for herpes or staph infection presents with a pinpoint vesicle (looks like flea bite) Midline hair tufts over the lumbosacral spine region suggest a possible ___________. ✔spinal cord defect Jaundice ✔<24hrs hemolytic disease of the newborn 2-3wks old suggest biliary obstruction or liver disease breast feeding jaundice resolves 10-14 days salmon patch ✔common vascular marking disappears by 1 year port-wine stain ✔a flat vascular birthmark made up of dilated blood capillaries, creating a large, reddish-purple discoloration on the face or neck (opthalmic branch) sign of sturge-weber syndrome- associated with seizures, hemiparesis, glaucoma, mental retardation impetigo ✔bacterial skin infection characterized by isolated pustules that become crusted and rupture bullous or crusty yellow from pus Millaria rubra ✔scattered vesicles on an erythamatus base of face and trunk due to obstructed sweat gland Pustular melanosis ✔transient benign rash -- small dry superficial vesicles over a dark macular base, leave a hyperpigmented region when they rupture -- more common in african american infants Milia

✔small raised white spots on nose, chin, and forehead due to retention of sebum in sebaceous glands. disappear in weeks Pityriasis Rosea ✔Presents with a herald patch, Christmas-tree pattern. Tineas corporis ✔annular lesion central clearing and papules along border Brushfield spots ✔salt and pepper speckling on the iris associated with Down Syndrome Dark light reflex ✔cataracts or retinopathy white reflex ✔leukocoria- cataract, retinal detatchment, chorioretinitis, retinoblastoma Choanal atresia ✔closure of nasal cavity due to congenital septum between nasal cavity and pharynx test by passing a #8 feeding tube through each nostril Infant cries ✔shrill/high pitched- increased ICP, narcotic addiction Hoarse- hypocalcemia, tetany, or congenital hypothyroidism Stridor- obstruction (polyp) small larynx, tracheomalacia stridor after birth- croup, foreign object, GERD Absent- severe illness, vocal cord paralysis, brain damage palmar grasp reflex ✔Birth to 3-4 mos infant can flex all fingers to grasp your fingers. if present >4 mos suggest pyramidal tract dysfunction Plantar Grasp Reflex ✔Birth to 6-8 mos touch base of toes making the toes curl. if >8 mos suggest pyramidal tract dysfunction rooting reflex

✔Birth to 3-4 mos stroke corners of mouth, infant will turn head to that side and suck. if absent severe generalized CNS disease Moro (startle) reflex ✔birth to 4mos support infant and abruptly drop 2 feet- arms will abduct and extend hands open with legs flexed, and infant will cry. If motion is asymmetric indicates fracture of clavicle, humerus, brachial plexus Asymmetric Tonic Neck Reflex ✔birth-2 mos Stimulus: Fully rotate infant's head and hold for 5 seconds. Response: Extension of extremities on the face side, flexion of extremities on the skull side. if seen >2mos suggest CNS asymmetry or Cerebral Palsy Trunk incurvation (Galant reflex) ✔Place infant prone on flat surface; run finger down back about 1.5 to 2 inches lateral to the spine, first on one side and then on the other. In response, infant flexes the trunk and swings his or her pelvis toward the stimulated side. Absent indicates- transverse spinal cord lesion or injury persistence- delayed development Landau reflex ✔Infant birth to 6 mos should attempt to raise the head and arch the back when placed in a prone position Persistence= delayed development parachute reflex ✔appears by 7 to 9 months for life: a protective arm extension that occurs when an infant is suddenly thrust downward when prone delay= delay in motor development Positive Support Reflex ✔2-6 months, weight placed on balls of feet = stiffening of legs into extension. Infant will stand briefly before sagging after 20-30 sec Lack of reflex= hypotonia, flaccidity Fixed extension with adduction of legs (scissoring)= suggest spacisity from neurological disorder or CP

• Interferes with standing/walking, can lead to PF contractures

Placing and stepping reflex ✔birth (4 days) pretend walking reflex. variable age to disappear. absence may mean paralysis, also babies born breech may not have placing reflex. Milestones 1 year ✔walks runs 2-3 words plays peek a boo separation anxiety Milstones 2 year ✔throws ball overhand 2-3 word sentences draws circles imitates activities prefers to do task themself Milestones 3 year ✔pedals tricycle jumps in place feeds self with utensils knows colors speaks in sentences asks questions "why" sings Knows self in the mirror knows gender Milestones 4 years ✔cuts with scissors hops balances on one foot 100% speech understood talks in paragraphs imaginative sings takes turns puts on clothes Milestones 5 years ✔copies skips

balances well walks on tip toes says ABC copies figures defines words dresses self- buttons, zippers plays games knows name and phone number Middle childhood milestones ✔5-10 years goal directed exploration increased physical and cognitive abilities achievements by trial and error strength and coordination improve- more aware of disabilities and limitation concrete operational-rooted in present with little ability to understand consequences more independent establish fit in groups self esteem develops evolving self identity hypertension in children ✔transient HTN- d/t ritalin, prednisone sustained HTN- primary or secondary d/t renal, endocrine, neurological disease, vascular, drugs/meds, psychological, obesity Causes of short stature ✔<5th percentile growth hormone deficiency, endocrine disorder, GI disease, renal/metabolic disease, genetic syndrome coarctation of the aorta ✔if BP is the same or lower in the thigh as it is in the upper arm (thigh BP is normally 10mmHg higher) Acute Mastoiditis ✔presents with auricle protruded forward and outward with area over the mastoid bone red, swollen, and tender Acute Otitis Media ✔presents with red, bulging, tympanic membrane with dull or absent light reflex and diminished movement on otoscopy purulent drainage may present ruptured- leads to pus in auditory canal cant see tympanic membrane

Effusion- movement of tympanic membrane is present with hearing loss present at times Otitis Externa ✔the pinna is painful with movement but no signs of otitis media conductive hearing loss ✔congenital, trauma, recurrent OM and tympanic perforation Sensourineural Hearing Loss ✔hereditary, congenital, ototopic drugs, trauma, infections (meningitis) Allergic rhinitis ✔boggy, pale nasal mucosa sinusitis ✔purulent rhinitis >10 days, HA, sore throat, fever, tenderness to sinuses foreign nasal body ✔foul-smelling, purulent, unilateral discharge, often preschool aged kids staining of teeth ✔Intrinsic- d/t tetracycline <8 years yellow, gray, brown stain that can't be polished off Extrinsic- iron (black) fluoride (white) can be polished off thumb sucking can cause ✔malocclusion and misalignment or premature loss of primary teeth strawberry tongue ✔scarlet fever, strep pharyngitis geographic tongue ✔tongue appearance with creases, bends, and unusual appearance; tends to occur in people with allergic disease but has no significant pathology Steptococcal Pharyngitis

✔strawberry tongue, white/yellow exudate on tonsels or posterior pharynx, beefy red uvula, palatal petechial peritonsillar abscess ✔erythema, asymmetric enlargement of one tonsil, pain, lateral displacement of uvula Acute Epiglottitis ✔Inflammation of the epiglottis; H influenzae type b is the most common cause, especially in nonimmunized children s/s sore throat, difficulty swallowing, sitting up stiffly, tripod DON'T OPEN MOUTH Tonsillits ✔caused by streptococcus rocks in the mouth voice and enlarged tonsils with exudate nuchal rigidity ✔marked resistance to movement of the head any direction suggest Meningitis, bleeding, tumor, extremely irritable paradoxical irritability- increase with being held May position in tripod position unable to assume full upright position asthma ✔expiratory wheeze, increased expiratory phase with inspiratory rhonchi exaggerated pot belly ✔celiacs, cystic fibrosis, constipation, or aerophagia (air swallowing) Constipation tympanitic with stool palpable functional disorders causing abdominal pain ✔IBS,, functional dyspepsia, childhood functional abdominal pain syndrome Organic causes of abdominal pain ✔gastritis, ulcer, GERD, constipation, IBD Acute gastroenteritis

✔most common cause of abdominal pain s/s- increased bowel sounds and mild tenderness with palpation Liver span in children ✔range 3.5-6.1 in ages 2- hepatomegaly- cystic fibrosis, protein malabsorption, parasites, fatty liver, tumor accompanied by splenomegaly, portal HTN, storage disease, chronic infections, malignancy Causes of splenomegaly in children ✔caused by infection, hematologic disorder, hemolytic anemia, infiltrative disorder, inflammation or autoimmune, congestion from portal HTN Precoucious puberty ✔early puberty Male- penis/testes enlarged with signs of pubertal changes due to excess androgen- adrenal or pituitary tumor Female- pubic hair before age 7 Vulvovaginal pruritis and erythema ✔d/t external irritants including bubble baths, masturbation, pin worm, candida, STI s/s of Sexual Abuse (in a child) ✔lacerations ecchymosis newly healed sores of the hymen lack of hymenal tissue from 3-9 o'clock healed hymenal transections purulent discharge herpatic lesions nurse maid's elbow ✔subluxation of the radial head from tugging injury holds arm slightly flexed at elbows acute limp in obese child ✔consider slipped capital femoral epiphysis

Normal leg appearance ✔bow-legged until 18 mos knock-knee by age 3-4 years corrects by age 9 severe bowing (genuvarum)- resolves spontaneous unilateral severe bowing- rickets or tibia vara (blount disease) chronic limp ✔caused by blount disease, avascular disorder of the hip, leg length discrepency, spinal disorder, systemic disease (leukemia) Spastic diplegia (scissoring) ✔hypotonia as infant with increased tone and spacisity scissoring and clenched fists seen in toddler and child Gower's sign ✔when asked to get up from sitting on floor, child will move hands on legs as though crawling up to the thighs and then assume a standing position Suggest muscular dystrophy mononucleosis ✔persistent fever, tonsillar pharyngitis, cervical lymphadenopathy Pulmonary flow murmur ✔begins after the 1st sound and ends before the 2nd no crescendo-decrescendo quality benign normal intensity and split IF SPLIT HEARD AT 2ND HEART SOUND= ATRIAL SEPTAL DEFECT Delayed puberty in males ✔no testicular growth has occurred by age 14 or no skeletal growth spurt has occurred by age 18 constitutional- most common. familial trait. normal hormones primary/secondary hypogonadism (less common) or congenital GnRH deficiency Premature adrenarche ✔may be associated with PCOS, insulin resistance, metabolic syndrome, obesity, may cause early onset puberty

delayed puberty in females ✔no breast/pubic growth by age 12 caused by inadequate gonadotropin secretion in the anterior pituitary d/t defective hypothalmic GnRH- caused by anorexia, Below 3rd percentile- turner syndrome or chronic disease sudden cardia death during sports ✔dizziness palpitations prior syncope family history cardiac murmurs wheezing previous history of concussion focused neuro exam immunizations and pregnancy ✔1) Tdap at 27-36wks gestation for every pregnancy

2. inactivated influenza- give in flu season
3. safe to give during pregnancy- pneumococcal, meningoccal, hepatitis A and B
4. Not safe- MMR, polio, varicella Lab work for pregnant women ✔must have rubella titer Rh(D) and antibody typing at 1st prenatal visit, 28 weeks and delivery- give anti-d to all Rh-negative women at 28 weeks and 3 days after delivery blood type, antibody, CBC, hematocrit, platelet, rubella titer, syphilis, hep B antigen, HIV test, STI test for gonorrhea, chlamydia, UA with culture oral glucose test at 24-28 weeks and rectovaginal swab for group B strep at 35- weeks test glucose in 1st trimester if obese Naegele's Rule ✔add 7 days to LMP, subtract 3 months, add 1 year Leopold maneuver sequence ✔1st maneuver- upper fetal pole- fetal buttocks firm and irregular

2nd maneuver- sides of abdomen- 32 weeks back is smooth, firm surface, as long as your hand fetal arms/legs feel like irregular bumps 3rd maneuver- lower fetal pole and descent into pelvis head feels firm and globular (vertex or cephalic with head presenting part) 4th maneuver- flexion of fetal head extended if cephalic prominence juts out along fetal back flexed if cephalic prominence juts out along anterior side Peripartum cardiomyopathy ✔Occurs during the last trimester of pregnancy or the first 6 months after delivery s/s include dyspnea, increased RR, cough, rale, resp distress. These s/s may also be caused by infection, PE, asthma anemia in pregnancy ✔may present with diastolic murmur, pale conjunctiva mastitis ✔focal tenderness with erythema, bloody/purulent drainage. Abnormal When should fetal movement be felt? ✔18-20 weeks if not felt after 24 weeks consider miscalculation, fetal death, or morbidity, or false pregnancy uterine contractions with or without pain >37 weeks ✔suggest preterm labor fundal height >4cm than expected ✔consider multiple gestation, large fetus, extra fluid, uterine leiomyoma fundal height <4cm than expected ✔low fluid, missed abortion, intrauterine growth retardation, fetal anomaly gestational hypertension ✔SBP >140 DBP >90 after 20 weeks without proteinuria or pre-eclampsia, resolves 12 weeks postpartum

Pre-eclampsia/eclampsia ✔.140/90 after 20wks x 2 occasions at least 4 hours apart in women with previous BP normal or BP 160/110 and proteinuria >300mg/24 protein/cret >0.3 or dispstick 1+ new onset HTN w/o proteinuria and thrombocytopenia impaired liver function , renal insufficiency, pulmonary edema, new onset cerebral or visual symptoms may present with facial edema GERD ✔prolonged exposure of esophagus to gastric acid d/t impaired esophageal motility or excess relaxations of lower esophageal sphincter H.pylori Located in chest, epigastric, heartburn, regurgitation after meals, especially spicy aggravated by lying down, bending over, physical activity or disease like scleroderma, gastroparesis, drugs such as nicotine or that relax the lower sphincter relieved by antacids, PPI, avoid alcohol, smoking, fatty meat, chocolate, Ca+ channel blocker, theophylline associated sx- wheezing cough, SOB, hoarse, choking sensation, dysphagia, regurg, halitosis, sore throat increase risk for Barrett and esophageal CA PUD ✔mucosal ulcer in stomach/duodenum >5mm covered in fibrin H. Pylor in 90% of PUD Located in epigastric region: radiate straight to back Quality is gnawing, burning, boring, aching, hunger-like Duodenal- pain that wakes you at noc and occurs intermittently over a few wks disappear for months and recurs aggravating factors are variable relieved by food and antacid (less likely with gastric ulcer) Sx- N/V, belching, bloat, heartburn (duod) wt loss (gastric) dyspepsia (20-29yrs) gastric >50 years duod 30-60 years

Acute appendicitis ✔acute inflammation of the appendix with distention or obstruction poorly localized periumbilical pain that migrates to the right lower quadrant Quality mild but increasing, cramping, steady and severe Lasts 4-6 hours depending on Tx aggravated with cough or movement Relief from pain= suspect perforation Sx- anorexia, nausea, vomiting, fever Acute Pancreatitis ✔Intrapancreatic trypsinogen activation to trypsin and enzymes causing autodigestion and inflammation of pancreas epigastric and radiates to back and abdomen Quality is steady Acute onset, persistent pain aggravated by lying supine, dyspnea if pleural effusion from capillary leak, medications, increase triglycerides Relieved by leaning forward with trunk flexed sx- N/V, abd distention, fever, recurrent, Hx of alcohol abuse or gallstones Chronic Pancreatitis ✔irreversible destruction of the pancreatic parenchyma from recurrent inflammation of ducts location is epigastric radiating to the back quality is severe, persistent, deep chronic or recurrent course alcohol, heavy or fatty meats relieved by leaning forward with trunk flexed often intractable sx- pancreatic enzyme insufficient, diarrhea (steatorrhea) DM

McBurney's point ✔A point on the right side of the abdomen, about two-thirds of the distance between the umbilicus and the anterior bony prominence of the hip. indicative of appendicitis Rovsing's sign ✔Pain in RLQ with palpation of LLQ indicative of appendicitis Psoas sign ✔RLQ pain with extension of right thigh indicative of appendicitis Obturator sign ✔pain in the lower abdomen or inside of thigh when the hip is flexed and internally rotated; a sign of appendicitis Acute diverticulitis ✔acute inflammation of clonic diverticula outpouching 5-10mm in diameter usually sigmoid or descending colon located in LLQ quality is cramping at first then steady gradual onset, no aggravating factors relieved with analgesics, bowel rest, abx sx- fever, constipation, n/v, abd mass with rebound tenderness Ulcerative colitis ✔mucosal inflammation extending from the rectum (proctitis) to colon (colitis, pancolitis) with microulcerations and polyps (chronic) stool is frequent watery, often containing blood Diarrhea onset abrupt, recurrent, persisting and may awaken at night Sx include cramping with urgency, tenesmus, fever, fatigue, weak, abd pain (toxic megacolon) episcleritis, uvetiti, arthritis, erythema nodosum Risk factors include young adults, ashkenazi jewish decent, altered CD4+ t cell Th response, increases risk for colon CA Irritable bowel syndrome

✔Functional change in frequency/form of stool without known pathology, possibly from a change in intestinal bacteria Sx- three patterns- diarrhea- predominant constipation predominant or mixed

6m and abd pain >3 months plus 2-3 features of improvement with defecation onset with change in stool frequency onset with change in stool from and appearance Visceral pain RUQ ✔liver distention against its capsule in alcoholic hepatitis Visceral periumbilical pain d/t distention/inflammation of organ suggests ✔appendicitis pain disproportionate to physical findings with "food fear" suggest ✔intestinal mesenteric ischemia parietal pain ✔peritonitis- colicky px from renal stone patient moves frequently to get comfortable referred pain ✔felt in distant sites seen with pain in the duodenal or pancreatic origin to back pain from biliary tree- referred to right scapula or right posterior thorax pleurisy or inferior MI referred to epigastric knife like epigastric pain radiating to back= pancreatitis GERD alarm symptoms ✔dysphagia, odynophagia, weight loss, bleeding, early satiety, vomiting, anemia, risk factors for gastric CA, palpable mass, painless jaundice order endoscopy for possible esophagitis, peptic stricture, esophageal CA Barrett esophagus- metaplastic change in esophageal lining from squamous to columnar epithelium RLQ pain that migrates from periumbilical in women consider ✔PID, ruptured ovarian follicle, ectopic pregnancy

LLQ cramping or groin pain consider ✔renal stone LLQ pain with palpable mass consider ✔diverticulitis Diffuse pain and distention with hyperactive sounds and tenderness ✔small/large bowel obstruction Pain with absent bowel sounds, rigidity, percussion tenderness, and guarding ✔perotinitis change in bowel habits with mass ✔colon cancer vomiting and pain ✔small bowel obstruction and gastrocolic fistula hematemesis ✔esophageal/gastric varices Mallory-weiss tears PUD Early satiety ✔hepatitis Pink-purple striae ✔Cushing's syndrome dilated veins ✔-portal hypertension -cirrhosis -ascites -vena cava obstruction -malnutrition ecchymosis ✔intraperotineal or retroperotineal hemorrhage

bulging flanks ✔acites suprapubic bulge- distended bladder or pregnant uterus, ventral, femoral, inguinal hernia asymmetry of abdomen ✔hernia, enlarged organ, mass lower abdominal mass suggest ovarion/uterine CA Increased peristalsis ✔intestinal obstruction Increased pulsations ✔AAA increased pulse pressure protuberant or tympanitic abdominal percussion ✔intestinal obstruction, ileus dull abdominal percussion ✔occurs over a distended bladder, pregnant uterus, ovarion tumor, large liver or spleen situs inversus ✔complete reversal of all abdominal organs air bubble on right liver dullness on left peritonitis ✔caused by appendicitis, cholecystitis, perforation s/s positive cough test, guarding, rigid, rebound tenderness, percussion tenderness rigidity makes peritonitis 4x more likely palpation of aorta ✔periumbilical or upper abd mass with expansial pulsation >3 cm diameter= AAA sensitivity to palpation increases as AAA enlarge

pain signals rupture- increase if >4cm ultrasound screen men >65 year of age who smoke ascites ✔increased hydrostatic pressure d/t cirrhosis, HF, pericarditis, inferior vena cava or hepatic vein obstruction decreased osmotic pressure in nephrotic syndrome, malnutrition, ovarian CA dullness shifts to dependent side tympany shifts to top fluid wave tap one flank feel wave on other side Hepatits A ✔transmission is fecal/oral route prevent with handwashing and cleaning with diluted bleach does not cause chronic hepatitis vaccine at 1 year, chronic liver disease, increase treavel to endemic areas, MSM, drug use IV, vets, clot dx post exposure- hep A immune globulin <2 weeks after exposure Hepatitis B ✔may become chronic- increase risk with immature immune system chronic leads to cirrhosis or liver CA screening- born in endemic country, HIV, drug use, MSM, household contact, sexual partners with HBV, pregnant in 1st trimester Hepatitis C ✔no vaccination transmitted percutaneously most prevalent blood borne pathogen

IV drug use, blood transfusions, organ transplant before 1992, transfusion with clotting factor >1987, hemodyalisis, health care needle stick, HIV, birth from positive mother Chronic illness in 70% people with cirrhosis, hepatocellular carcinoma, and liver transplant Colorectal cancer ✔3rd most common cancer, 3rd leading cause of death risk factors include age, polyps, inflammatory bowel disease, family hx secondary risk factors- male sex, african, tobacco, excessive alcohol use, red meat consumption, obesity prevention with screening and remove pre-cancerous polyps, physical activity, aspirin, NSAID, hormone replacement (caution with aspirin and NSAID) stool test, endoscopic exam, barium enema and CT- if test abnormal colonoscopy indicated Screening grade A- age 50-75 FOBT annual sigmoidoscopy every 5 years with increased sensitivity FOBT every 3 years BEST SCREENING TEST IS THE ONE THAT GETS DONE Systolic and Diastolic abdominal bruits ✔renal artery stenosis d/t HTN atherosclerotic arterial disease friction rubs in abdomen could be caused by ✔heptoma infection of the liver splenic infarction pancreatic carcinoma A protuberant and tympanic abdomen ✔intestinal obstruction, ileus Dull abdomen ✔pregnant uterus, ovarian tumor, distended bladder, large liver or spleen dullness in both flanks-ascites abdominal masses

✔physiologic- preg uterus, inflammatory- diverticulitis, vascular AAA, neoplastic (colon CA) obstructive- distended bladder and dilated loop of bowel causes of decreased liver dullness ✔small liver free air below diaphragm from perf bowel hollow viscus resolution of hepatitis HF progression of fulminant hepatitis Gas in colon may cause tympan in RUQ and falsely decrease dullness of liver displaced liver dullness downward by diaphragm is due to ✔COPD Firm oval mass below liver edge ✔obstructed distended gallbladder positive splenic sign means ✔change in percussion from tympany to dullness on INSPIRATION spleen is enlarged d/t portal HTN, hematologic malignancy, HIV infection, amyloidosis, splenic infarction, hematoma kidney enlargement ✔Left side- splenomegaly, enlarged lt kidney right side- hydronephrosis, cyst, tumor bilateral- polycystic kidney disease pain= pyelonephritis if fever and dysuria present Depression and Bipolar ✔depression frequently accompanies chronic illness anhedonia- loss of pleasure in daily activities sleep disorders, difficulty concentrating or making decisions vulnerable patients- young, female, single, divorced, serious/chronic illness, bereaved, psychiatric disorder, substance abuse

Ask 2 questions regarding mood and anhedonia Suicide risk ✔age 45-54 and >85 years 4x higher in men- firearms Women use poison non-hispanic whites lethargic ✔drowsy but open eyes and look at you, respond, then fall asleep obtunded ✔open eyes, look at you, response slow, confused agitated depression ✔tense posture, restless, anxious depression ✔hopeless, slumped posture, slowed movement manic episode ✔agitated and exspansive movements, elation and euphoria, excellerated low speech, flight of idea OCD- excessive fastidiousness paranoia ✔anger, hostility, suspiciousness, evasiveness circumstantiality ✔mild thought disorder, speech detail indirection, delay in reaching the point derailment ✔loosening associations- tangential speech with shifting topics loosely connected or unrelated unaware of lack of association SEEN IN SCHIZOPHRENIA, MANIC, PSYCHOTIC Schizoprenia ✔Neologism (invented/distorted words)

incoherence- speech incomprehensible blocking- sudden interruption of speech midsentence perservation- persistent repetition of words and phrases echolalia- repetition of words and phrases of others clanging- speech based on sounds, rhyming, punny illusions, hallucinations PTSD ✔illusions- misinterpretation of real external stimuli Hallucinations- perception-like experience that seems real External genitalia in pregnancy ✔relaxation of introitus, enlargement of labia and clitoris, scars from tears/episiotomy Abnormal- labial varicosities, cyctocele, rectocele, lesions (herpes simplex) Internal genitalia of pregnancy ✔nulliparous- dot parous- arc (smile) ectropion-inner portion of cervix darker pink/red os vagina-bluish, deep rugae, increased milky discharge Abnormal- pink= nonpregnant state irritation- cervicitis abnormal vagina- candida, bacterial vaginosis lateral surface of cervical tip to lateral fornix at >34 weeks should measure ✔>3cm OS ✔external os open in multiparous internal os closed until late pregnancy may become shortened or opened <37 weeks preterm irregular shaped uterus ✔uterine leiomyomata fibroids bicomuate uterus eclampsia ✔hand/facial edema >20 weeks hyperreflexia- corticol irritability uterus changes with pregnancy