NR 509 Final Exam questions with answers, Exams of Nursing

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NR 509 Final Exam questions with

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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. 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
5. Appendicitis is three times more likely if there is McBurney point tenderness. 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. 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-gesting irritation of the psoas muscle by an inflamed appendix. 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. Acute Cholecystits ✔RUQ pain Murphy Sign

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. Acute Pancreatitis Process ✔Intrapancreatic trypsinogen activation to trypsin and other enzymes, result-ing in autodigestion and inflammation of the pancreas Acute Pancreatitis Location ✔Epigastric, may radiate straight to the back or other areas of the abdomen; 20% with severe sequelae of organ failure Acute Pancreatitis Quality ✔Usually steady Acute PancreatitisTiming ✔Acute onset, persistent pain Acute Pancreatitis Aggrevating Factors ✔Lying supine; dyspnea if pleural effusions from capillary leak syn-drome; selected medications, high triglycerides may exacerbate Acute Pancreatitis Relieving factors ✔Leaning forward with trunk flexed Acute Pancreatitis Associated Symptoms and Setting ✔Nausea, vomiting, abdominal dis-tention, fever; often recurrent; 80% with history of alcohol abuse or gallstones 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

Peptic Ulcer Disease Location ✔Epigastric, may radiate straight to the back Peptic Ulcer Disease Quality ✔Variable: epigastric gnawing or burning (dyspepsia); may also be boring, aching, or hungerlike No symptoms in up to 20% 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 Peptic Ulcer Disease aggravating factors ✔Variable Peptic Ulcer Disease relieving factors ✔Food and antacids may bring re-lief (less likely in gastric ulcers) 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 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 GERD Location ✔Chest or epigastric GERD Quality ✔Heartburn, regurgitation GERD timing ✔After meals, especially spicy foods GERD aggravating factors

✔Lying down, bending over; physical activity; diseases such as scleroderma, gastroparesis; drugs like nicotine that relax the lower esophageal sphincter GERD : relieving factors ✔Antacids, proton pump inhibi-tors; avoiding alcohol, smoking, fatty meals, chocolate, selected drugs such as theophylline, cal-cium channel blockers 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 Diverticulitis process ✔Acute inflammation of colonic diver-ticula, outpouchings 5-10 mm in di-ameter, usually in sigmoid or descend-ing colon Diverticulitis location ✔Left lower quadrant Diverticulitis quality ✔May be cramping at first, then steady Diverticulitis timing ✔Often gradual onset Diverticulitis aggravating factors ✔-- Diverticulitis relieving factors ✔Analgesia, bowel rest, antibiotics Diverticulitis associated symptoms and setting ✔Fever, constipation. Also nausea, vomiting, abdominal mass with rebound tenderness 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. 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, correctional facilities, programs for gay men, chronic hemodialysis facilities, facilities for people with Developmental Delays. IBS patterns ✔1. diarrhea—predominant

2. constipation—predominant
3. mixed. --Symptoms present ≥6 mo and abdominal pain for ≥3 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) 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-endocrine signaling, and changes in microbiomes IBS characteristics of stool ✔Loose; ∼50% with mucus; small to mod-erate volume. Small, hard stools with constipation. May be mixed pattern. IBS timing ✔Worse in the morning; rarely at night. IBS associated symptoms ✔Crampy lower ab-dominal pain, ab-dominal disten-tion, flatulence, nausea; urgency, pain relieved with defecation IBS setting, persons at risk ✔Young and middle-aged adults, especially women

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. 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. 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. Stress Incontinence Physical signs ✔Stress incontinence may be demonstrable, especially if the patient is examined before voiding and in a standing position. Atrophic vaginitis may be evident. Bladder distention is absent. Urge incontinence problem ✔Detrusor contractions are stronger than normal and overcome the normal urethral resistance. The bladder is typically small. 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. 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 inflammation 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.

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. 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. Overflow incontinence mechanisms ✔Obstruction of the bladder outlet, as in benign prostatic hyperplasia or tumor. Weakness of the detrusor muscle associated with peripheral nerve disease at S2- level. Impaired bladder sensation that interrupts the reflex arc, as in diabetic neuropathy. Overflow incontinence symptoms ✔When intravesicular pressure overcomes urethral resistance, continuous dripping or dribbling incontinence ensues. Decreased force of the urinary stream. Prior symptoms of partial urinary obstruction or other symptoms of peripheral nerve disease may be present. Overflow incontinence physical signs ✔Examination often reveals an enlarged, sometimes tender, bladder. Other signs include prostatic enlargement, motor signs of peripheral nerve disease, a decrease in sensation (including perineal sensation), and diminished to absent reflexes. Functional incontinence problem ✔The patient is functionally unable to reach the toilet in time because of impaired health or environmental conditions. 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. Functional incontinence symptoms ✔Incontinence on the way to the toilet or only in the early morning. Functional incontinence physical signs

✔The bladder is not detectable on examination. Look for physical or environmental clues as the likely cause. Incontinence secondary to medications problem ✔Drugs may contribute to any type of incontinence listed. Incontinence secondary to medications mechanisms ✔Sedatives, tranquilizers, anticholinergics, sympathetic blockers, and potent diuretics. Incontinence secondary to medications symptoms ✔Variable. A careful history and chart review are important. Incontinence secondary to medications physical signs ✔Variable. Colorectal cancer screening ✔Adults ages 50 to 75 years—options (grade A recommendation)

1. Hi-sens fecal occult blood testing annually
2. Sigmoidoscopy every 5 years w/ high-sensitivity FOBT every 3 years
3. Screening colonoscopy every 10 years B: Adults 76-
4. Screening not advised because the benefits are small in comparison to the risks
5. 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)
6. Screening not advised because "competing causes of mortality preclude a mortality benefit that outweighs harms" 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.
7. 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. 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, 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%. Colorectal cancer risk factors ✔1. Increasing age

2. personal history of colorectal cancer
3. adenomatous polyps, or long-standing inflammatory bowel disease
4. 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:
5. male sex
6. African American race
7. tobacco use
8. excessive alcohol use
9. red meat consumption
10. obesity. Colorectal cancer prevention ✔Primary prevention:
11. screen for and
12. remove pre-cancerous adenomatous polyps Also associated with decreased risk
13. Physical activity
14. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs)
15. Postmenopausal combined hormone replacement therapy (estrogen and progestin) 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,
16. Lipoma, 4. Fat, 5. Gas, 6. Tumor, 7. Pregnancy, 8. Ascites Abdominal Auscultation ✔1. Bowel sounds
17. Bruits: hepatic (Cirrhosis), Arterial with systolic and diastolic component (occlusion of aorta or large artery (ex. epigastric--renal artery stenosis/renovascular hypertension)
18. Venous Hum: rare soft humming w/ sys/dias.= increase collateral circ btwn portal and systemic systems (hepatic cirrhosis)
19. Friction Rub over liver or spleen: Rare grating sounds w/ respiratory variation=inflammation (liver cancer, chlamydial/gonococcal perihepatitis, liver bx, splenic infarct)

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. Abdomen palpation ✔gently palpate over 4 quadrants: abnormal: involuntary rigidity=peritoneal inflammation Deep palpation to feel for masses: physiologic (pregnancy), inflammatory (diverticulitis), vascular (AAA), neoplastic (colon cancer), or obstructive (distended bladder or dilated loop of bowel) Liver assessment ✔Percussion: liver span should be about 4-8cm in midsternal 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). Spleen assessment ✔Enlargement: expands anteriorly, downward, and medially, replacing tympany of stomach and colon with dullness of solid organ. Percussion:
4. 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)
5. If tympany is prominent, splenomegaly is unlikely.
6. 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. 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 beyond 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. Kidney assessment: RIGHT ✔A normal right kidney may be palpable, especially 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. 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. 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. 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). Aorta abnormalities ✔A periumbilical or upper abdominal mass with expansile pulsations that is ≥3 cm in diameter suggests an AAA. Sensitivity of palpation increases as AAAs enlarge. Risk factors for AAA ✔1. Age ≥65 years

2. history of smoking
3. male gender
4. first-degree relative with a history of AAA repair Ascites assessment ✔A protuberant abdomen with bulging flanks is suspicious 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 Breast Exam Males ✔Enlargement: gynecomastia proliferation of palpable glandular tissue pseudogynecomastia accumulation of subareolar fat 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. Breast masses ✔May be physiologic or pathologic.

1. Fibroadenoma: 15-25 yrs up to 55 yrs, single, round, disclike, or lobular, small, soft, firm, well delineated, mobile, nontender, no retraction signs.
2. Cyst: 30-50 yrs, regress after menopause, single or multiple, round, soft to firm, elastic, well delineated, mobile, tender, without retraction signs.
3. 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. Visible signs of breast cancer ✔1. Retraction signs (dimpling, changes in contour, retraction/deviation of nipple)
4. Abnormal contours: variations in normal convexity
5. Skin dimpling: best seen with arm at rest, during special positioning, or on moving/compressing breast
6. Nipple retraction and deviation: nipple flattened or pulled inward, OR broadened and thickened, when asymmetric, nipple may deviate.
7. 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.
8. 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. 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. 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 ≥ years. Thickening of the nipple and loss of elasticity suggest an underlying cancer. 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.

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). 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. Breast exam positions ✔Arms Over Head; Hands Pressed Against Hips; Leaning 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 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 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 (≥1 to 2 cm) and firm or hard, matted together, or fixed to the skin or underlying tissues sug-gest malignancy. 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 fingers--

Make overlapping, dime-sized circular motions to feel the breast tissue-->Apply three levels of pressure in each spot-->up-and-down or "strip" pat-tern Standing:

1. 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.
2. Examine each underarm while sitting up or standing and with your arm only slightly raised Erectile Dysfunction ✔1. Psychogenic causes, especially if early morning erection is preserved
3. Decreased testosterone
4. decreased blood flow in the hypogastric arterial system
5. impaired neural innervation
6. diabetes Penile Discharge/rash ✔yellow penile discharge in gonorrhea white discharge in non-gonococcal urethritis from Chlamydia. Rash, tenosynovitis, monoarticular arthritis, even meningitis, not always with urogenital symptoms, occur in disseminated gonorrhea. Look for an ulcer in syphilitic chancre and herpes; warts from human papillomavirus (HPV); swelling in mumps orchitis, scrotal edema, and testicular cancer; pain in testicular torsion, epididymitis, and orchitis. Testicular Cancer ✔Cryptorchidism, present in 7% to 10% of men with testicular cancer, con-fers a 3-to 17-fold increased risk for testicular cancer. Seek clinical attention if: a painless lump, swelling, or enlargement in either testicle; pain or discomfort in a testicle or the scrotum; a feeling of heaviness or a sud-den fluid collection in the scrotum; or a dull ache in the lower abdomen or the groin. Urethral Stricture ✔1. Inspect for induration along the ventral surface of the penis
7. May have tenderness in the indurated area d/t periurethral inflammation Prepuce and glans abnormalities ✔1. Phimosis is a tight prepuce that cannot be retracted over the glans.
8. Paraphimosis is a tight prepuce that, once retracted, cannot be returned. Edema ensues.
9. Balanitis is inflammation of the glans

3. balanoposthitis is inflammation of the glans and prepuce. Check for varicocele ✔Patient standing
4. palpate the spermatic cord about 2 cm above the testis.
5. Have the patient hold his breath and "bear down" against a closed glottis for about 4 seconds (the Valsalva maneuver).
6. During this maneuver, a temporary increase in the diameter of the spermatic cord indicates filling of abnormally dilated spermatic veins draining the testis. Swellings containing serous fluid, such as hydroceles, light up with a red glow, or transilluminate. Those containing blood or tissue, such as a normal testis, a tumor, or most hernias, do not. 4. feels like soft bag of worms. 5. appears to distort contours of scrotal skin. Vas Deferens abnormalities ✔The vas deferens, if chronically infected, may feel thickened or beaded. A cystic structure in the spermatic cord suggests a hydrocele of the cord. Penis abnormalities ✔1. Hypospadis (congenital ventral displacement of the meatus on the penis)
7. Peyronie Disease
8. Carcinoma of the penis (induration of ventral surface)
9. Pubic/genital excoriations: lice (crabs) or scabies in pubic hair. Scrotal abnormalities ✔1. Scrotal edema
10. Hydrocele
11. Scrotal Hernia
12. Cryptorchidism (poorly developed scrotum)
13. Small Testes
14. Acute Orchitits (Tender painful scrotal swelling)
15. Tumor of the testes
16. Acute Epididymitis (Tender painful scrotal swelling)
17. Torsion of the spermatic cord (Tender painful scrotal swelling)
18. Strangulated inguinal hernia (Tender painful scrotal swelling)
19. scrotal nevi, hemangiomas, or telangiectasias
20. STIs condyloma or ulcers from herpes and chancroid (painful) and syphilis and lymphogranuloma venereum (painless), with associated inguinal lymphadenopathy.
21. Erythema and mild excoriation point to fungal infection, not uncommon in this moist area. Prostate cancer ✔A distinct hard nodule that alters the contour of the gland may or may not be palpable.

As the cancer enlarges, it feels irregular and may extend beyond the confines of the gland. The median sulcus may be obscured. Hard areas in the prostate are not always malignant. They may also result from prostatic stones, chronic inflammation, and other conditions. benign prostatic hyperplasia (BPH) ✔1. Nonmalignant enlargement of prostate gland

2. increases with age, present in more than 50% of men by age 50 yrs.
3. Symptoms d/t smooth-muscle contraction in the prostate and bladder neck and from compression of the urethra.
4. Symptoms are: urgency, frequency, nocturia, obstructive (decreased stream, incomplete emptying, straining), or both, and are seen in more than one third of men by age 65 yrs.
5. May be normal in size, or may feel symmetrically enlarged, smooth, and firm, though slightly elastic; there may be obliteration of the median sulcus and more notable protrusion into the rectal lumen. Prostatitis ✔1. presents with fever and urinary tract symptoms such as frequency, urgency, dysuria, incomplete voiding, and sometimes low back pain.
6. Palpation: tender, swollen, "boggy," and warm.
7. Examine it gently.
8. More than 80%: gram-negative aerobes such as Escherichia coli, Enterococcus, and Proteus.
9. In men < 35 yrs, consider sexual transmission of Neisseria gonorrhea and Chlamydia trachomatis.
10. Chronic bacterial prostatitis is associated with recurrent urinary tract infections.
11. Men may be asymptomatic or have symptoms of dysuria or mild pelvic pain. The prostate gland may feel normal, without tenderness or swelling. Cultures of prostatic fluid usually show infection with E. coli.
12. Hard to distinguish from the more common chronic pelvic pain syndrome (80% of symptomatic men who report obstructive or irritative symptoms on voiding but show no evidence of prostate or urinary tract infection). Normal Prostate ✔1. Palpated through the anterior rectal wall
13. Rounded, heart-shaped structure approximately 2.5 cm long.
14. The median sulcus can be palpated between the two lateral lobes.
15. Only the posterior surface of the prostate is palpable.
16. Anterior and central lesions, including those that obstruct the urethra, are not detectable by physical examination. primary dysmenorrhea

✔1. increased prostaglandin production during the luteal phase of the menstrual cycle, when estrogen and progesterone levels decline. secondary dysmenorrhea causes ✔1. endometriosis

2. adenomyosis (endometriosis in the muscular layers of the uterus)
3. pelvic inflammatory disease (PID)
4. endometrial polyps. Primary amenorrhea ✔Never having started period secondary amenorrhea ✔Pregnancy, lactation, and menopause are physiologic causes of secondary amenorrhea. low body weight from any condition, including malnutrition and anorexia nervosa, stress, chronic illness, and hypothalamic-pituitary-ovarian dysfunction. Heart rates under 1 year ✔Birth-1 mo: 140 (90-190) 1-6mo: 130 (80-180) 6-12 mo: 115 (75-155) Cutis marmorata ✔Premature infants or infants with congenital hypothyroidism and Down syndrome -Lattice-like, bluish mottled appearance (trunk, legs, arms) Acrocyanosis ✔Blue cast to hands and feet when exposed to cold. Common for first few days into early infancy. --should disappear within 8 hrs of birth or warming. Harlequin dyschromia ✔--Found occasionally in newborns --Transient cyanosis of one half of body or extremity from temporary vascular instability. Slate Blue Patches ✔Dark bluish pigmentation over buttocks and lower lumbar regions in newborns of African, Asian, and Mediterranean descent. --Disappear during childhood.

Lanugo ✔Fine, downy growth of hair over entire body especiallly shoulders and back. --Shed within first few weeks. --Prominent in premature infants Cafe au lait spots ✔Pigmented light brown lesions <1-2cm. Isolated= no significance. Multiple lesions with sharp borders may mean Neurofibromatosis Miliaria rubra ✔Scattered vesicles on erythematous base (face or trunk) result from obstruction of sweat gland ducts. Disappears within weeks. Pustular melanosis: ✔Common in black infants, presents at birth as small vesiculopustules over brown macular base; can last several months. Erythema toxicum ✔Appears day 2 or 3 of life; erythematous macules with central pinpoint vesicles scattered diffusely over body. Similar to flea bites. Disappear within 1 week. Milia ✔pinhead-sized smooth white raised areas without surrounding erythema on nose, chin, forehead, from retention of sebum in openings of sebaceous glands. Usually appear within first few weeks and disappear over several weeks. Midline Hair tuft over lumbosacral spine region ✔--Possible spinal cord defect Jaundice in newborn ✔--within 24 hours: hemolytic disease of newborn --2-3 weeks beyond birth: biliary obstruction or liver disease --Normally seen especially in breast feeding, should resolve within 10-14 days. Newborn vascular markings ✔1. Salmon patch: nevus simplex, "flame nevi", telangiectatic nevus, capillary hemangioma -flat, pink, disappear by 1 year

2. Port wine stain: unliateral dark, purplish lesion. --Sturge-Weber syndrome: over ophthalmic branch of trigeminal nerve--associated with seizures, hemiparesis, glaucoma, mental retardation.

Eyelid patch ✔Birthmark fades within first year of life Developmental milestones: Birth ✔Physical: Focuses; fixes/follows Cognitive/language: Responds to sounds Social/Emotional: Regards face Developmental milestones: 1-2mos ✔Physical: Head control Cognitive/language: Coos Social/Emotional: Smiles Developmental milestones: 3-4 mos ✔Physical: Rolls over; grasps rattle; works for toy Cognitive/language: Babbles Social/Emotional: Developmental milestones: 4-5mos ✔Physical: Cognitive/language: Squeals Social/Emotional: Laughs Developmental milestones: 5- 6 mos ✔Physical: Sits Cognitive/language: Social/Emotional: Developmental milestones: 7-8 mos ✔Physical: Cognitive/language: Dada/mama Social/Emotional: Feeds self; indicates wants Developmental milestones: 9-10 mos ✔Physical: Pulls to stand; crawls Cognitive/language: Social/Emotional: Waves and plays peek-a-boo Developmental milestones: 11-12 mos ✔Physical: Walks

Cognitive/language: 2-3 words Social/Emotional: Uses spoon Tanner stages: Women development ✔Stage 1. Preadolescent- small slightly elevated nipple; no pubic hair Stage 2. Breast Bud- small mound, areola enlarges; initial growth of pubic hair (straight, not curly) Stage 3. Breast and areola elevation enlarge w/no separation of contours; more widespread pubic hair, some curls noted Stage 4.Nipple and areola project to form secondary mound over breast; more dense hair growth, with curls and dark hair Stage 5. Mature stage: nipple projection, areola recedes into general breast contour; adult women hair growth extending to thighs Developmental Milestones 1 year ✔Physical: Walk; run Cognitive/language: 2-3 single words Social/Emotional: Peek-a-boo; separation anxiety Developmental Milestones: 2 years ✔Physical: Throws a ball overhand Cognitive/language: 2-3 word phrases; draws circle Social/Emotional: Imitates activities; prefers to do tasks by self Developmental Milestones: 3 years ✔Physical: Pedals tricycle; jumps in place; feeds self Cognitive/language: knows colors; sentences; asks, "why?" Social/Emotional: Sings songs; knows self; knows gender Developmental Milestones: 4 years ✔Physical: Cuts with scissors; hops; balances on 1 foot Cognitive/language: 100% understandable speech; paragraphs Social/Emotional: imaginative; sings; imaginary play; takes turns; puts on clothes Developmental Milestones: 5 years ✔Physical: Copies; skips; balances well on 1 ft; walks on tiptoes Cognitive/language: Says ABCs; copies figures; defines words Social/Emotional: Dresses self, buttons, zips; plays games; knows whole name and telephone number Immunizations in pregnancy ✔1. Tdap (27-36 wks gestation) (and caretakers of infant)

2. Inactivated influenza during influenza season

Safe during pregnancy: Hep A and B. meningococcal polysaccharide and conjugate, pneumococcal polysaccharide. NOT SAFE: MMR, polio, varicella Laboratory testing in pregnancy ✔1. Rh(D) and antibody typing at first visit, 28wks, and delivery.

2. CBC
3. Rubella titer
4. Syphilis test
5. Hep B surface antigen
6. HIV
7. STI for gonorrhea and chlamydia
8. Urinalysis w/ culture
9. Oral glucose test (24-28 wks)
10. Rectovaginal swab for group B streptococcus at 35-37 weeks. Naegele's Rule ✔Due date calc tool: -40 weeks from first date of LMP
11. add 7 days to LMP, subtract 3 months, add 1 year preeclampsia ✔abnormal condition associated with pregnancy,
12. high blood pressure (SBP >140 or DBP >90) after 20 weeks on 2 occasions at lease 4 hours apart in women w/ previously normal BP or BP >160/110
13. Proteinuria >300mg/24 hrs, proteine: creatinine >0.3, or dipstick 1+ OR
14. new onset HTN without proteinuria AND: thrombocytopenia (platelets <100,000), impaired liver fx, new renal insufficiency, pulmonary edema, or new onset cerebral or visual symptoms. Pregnancy problems ✔1. hemorrhoids: often become engorged late in pregnancy, may be painful, bleed, or thrombose
15. Varicose veins may begin or worsen Elder abuse ✔Prevelance ranges from 5-10% higher among depression and dementia elderly. 90% of abusers are family No screening tool recommended, careful history required. Functional assessment ✔Assess independence and optimal level of function.

-ability to perform tasks and fulfill social roles associated with daily living across wide range of complexity. -identifies geriatric syndromes like:

1. cognitive impairment
2. Falls
3. Incontinence
4. Low BMI
5. Dizziness
6. Impaired vision/hearing 10 minute geriatric screener ✔1.vision a. difficulty driving/watching TV/reading -->snellen chart with corrective lenses (normal: <20/40)
7. hearing: audioscope at 40dB (1,000 and 2,000) (+= inability to hear one in both or one ear)
8. leg mobility: Get up and Go test: rise, walk 10 ft, turn, walk back, sit down (+= greater than 10 seconds)
9. urinary incontinence: Ask: a. lose urine and gotten wet in last year? b. 6 times? (+= yes to both)
10. nutrition/weight loss: a. lost 10 lbs in 6 mos? b. check weight (+= <100lbs)
11. memory: three-item recall (+= unable to remember all 3 after 1 min)
12. depression: Ask: do you feel sad/depressed (+= yes)
13. physical disability (6 questions: 1. strenious activity? 2. Heavy work? 3. Shopping?
14. Go to places out of walking distance? 5. Bath/shower? 6. Dress?) (+= no to any) Adult immunizations ✔Influenza: >50 yrs, disorders present, immunosuppressed, nursing homes residents, household contacts of children <5 yrs. Pneumococcal: >65 yrs, adults 19-64 with immunosuppression or other problems. Tdap: All adults no previously immunized and every 10 years. Zoster: >60 years (except with history of immunodeficiency) Mental status examination ✔1. Attention: ability to focus or concentrate
15. Memory: registering or recording info
16. Orientation: awareness of personal identity, place, and time
17. Perceptions: sensory awareness of object in environment (external stimuli and internal stimuli)
18. Thought processes: Logic, coherence, relevance
19. Thought content: what pt thinks about
20. Insight: awareness of normal and abnormal behavior
21. Judgment: process of comparing and evaluating alternatives
22. Affect: observable behaviors that express feelings or emotions (tone of voice, facial expression, demeanor)
23. Mood: sustained emotion that colors the person's perceptions.
24. Language:

12. High cognitive functions: vocabulary, fund of info, abstract thinking, calculations, dimensions. Aphonia ✔loss of the voice as a result of disease or injury to the larynx or nerve supply Dysphonia ✔impariment in volume, quality, or pitch of voice Dysarthria ✔defect in muscular control of speech apparatus (defective articulation) Aphasia ✔Disorder in producing or understanding language. Wernicke Aphasia ✔Receptive aphasia (impaired comprehension with fluent speech). The linguistic opposite of Broca aphasia. The person can hear sounds and words but cannot relate them to previous experiences. Speech is fluent, effortless, and well articulated but has many paraphasias (word substitutions that are malformed or wrong) and neologisms (made-up words) and often lacks substantive words. Speech can be totally incomprehensible. Often there is a great urge to speak. Repetition, reading, and writing also are impaired. Lesion is in posterior language area called the association auditory cortex or Wernicke area. Broca aphasia ✔Expressive aphasia (preserved comprehension and slow nonfluent speech). The person can understand language but cannot express himself or herself using language. This is characterized by nonfluent, dysarthric, and effortful speech. The speech is mostly nouns and verbs (high-content words) with few grammatic fillers, termed agrammatic or telegraphic speech. Repetition and reading aloud are severely impaired. Auditory and reading comprehensions are surprisingly intact. Lesion is in anterior language area called the motor speech cortex or Broca area. Depression screening ✔USPSTF recommendation: B in primary care setting two questions
13. Over past 2 weeks, have you felt down, depressed, or hopeless?
14. Over past 2 weeks, have you felt little interest or pleasure in doing things (anhedonia)? --Yes to either of these warrants full diagnostic interview Suicide risk and prevention

✔-Suicide is the 10th leading cause of death in the U.S. --Second among 15-24 year olds. --Highest rate: 45-54 year olds --Men 4 times more likely than women -There exist a variety of motives for suicide. -May be biological and/or "contagious" (the Werther effect) -Prediction and prevention is difficult, however warning signs are abundant. Anxiety disorders ✔excessive worry persisting over a 6 month period suggests anxiety disorder. --3 % prevalence

1. Panic disorder
2. OCD
3. PTSD
4. Social anxiety disorder
5. Phobias Schizophrenia ✔1. Grooming and personal hygiene may deteriorate
6. flat affect and remoteness
7. Hallucinations and illusions
8. Derailment
9. Neologisms: invented or distorted words
10. Incoherence: speech that is incomprehensible and illogical
11. Blocking: sudden interruption of speech in midsentence or before idea is complete.
12. Perseveration: persistent repetition of words or ideas
13. Echolalia: repetition of words and phrases of others
14. Clanging: speech with choice of words based on sounds rather than meaning (rhyming and punning). Male Tanner staging ✔1. preadolescent, no pubic hair + pre-pubertal testes
15. Initial growth of scrotum and testes, skin reddened, thin, wrinkled; few thin hairs around root of penis
16. Penis longer, testes and scrotum growth, skin of scrotum darker; coarser curlier hair, still sparse
17. glans develops, penis growth in length and width, scrotum and testes have grown; darker more coarse curly hair extending to thighs
18. adult size/shape; pubic hair spreads to medial surface of thigh and up towards umbilicus bacterial vaginosis ✔1. Bacterial overgrowth: often transmitted sexually
19. Gray or white, thin, homogeneous, malodorous discharge