Test bank for NURS 6512 Week 6 Midterm Exam-with 100% verified solutions.docx, Exams of Nursing

Download Test bank for NURS 6512 Week 6 Midterm Exam-with 100% verified solutions.docx and more Exams Nursing in PDF only on Docsity! Test bank for NURS 6512 Week 6 Midterm Exam-with 100% verified solutions QUESTIONS 1. Before performing an abdominal examination, the examiner should: Have the patient empty their bladder 2. During an interview, tears appear in the patient’s eyes and his voice becomes shaky. Initially, you should: Keep the interview moving to distract the patient 3. Which of the following is the most accurate reflection of an individual’s food intake? Food Diary 4. Percussing at the right midclavicular line, below the umbilicus, and continuing upward is the correct technique for locating the: Lower liver border 5. A fixed image of any group that rejects its potential for originality or individuality is known as a: Stereotype 6. Peritonitis produces bowel sounds that are Decreased/Hypoactive 7. Brittle nails are typical findings in: Older adults 8. Which of the following is an expected change in the assessment of the thyroid during pregnancy? A Bruit is auscultated d/t increased vascularity 9. You are planning to palpate the abdomen of your patient. Which part of the examiner's hand is best for palpating vibration? Ulnar Surface 10. A 5-year-old child presents with nasal congestion and a headache to assess for sinus tenderness you should palpate over the: Maxillary sinuses only 11. During physical examination of a 30-year-old Chinese man you notice a slight asymmetry of his face. the cranial nerve examination is normal. Your best action is to Ask the patient if this characteristic runs in his family 12. Unusual white areas on the skin may be due to Vitiligo 13. You are using an ophthalmoscope to examine a patient’s inner eye. You rotate the lens selector clockwise, then counterclockwise to compensate for: Myopia 14. Mrs. Webb is a 38-year old patient who has been changing her lifestyle to eat in a healthy way and lose weight: during your health promotion education regarding her nutritional status, you explain the function of dietary protein as: Building and maintaining tissues 15. Mr. Akins is a 78-y/o patient who presents to the clinic with complaints of hearing loss. Which of the following are changes in hearing that occur in the elderly? Select all that apply. c. Loss of high frequency e. Sounds may be garbled, difficult to localize f. Unable to hear in a crowded room 16. The most superior part of the stomach is the Fundus 17. Mrs. Grace is a 58-year-old patient who has a diagnosis of pernicious anemia. Which B vitamin is deficient in patients with pernicious anemia? B12 18. A 51-y/o woman calls with complaints of weight loss and constipation. She reports enlarged hemorrhoids and rectal bleeding. You advise her to: Come to the laboratory for a stool guaiac test. 19. Placing the base of a vibrating tuning fork on the midline vertex of the patient’s head is a test for: Lateralization of Sound 20. Which technique is most likely to result in the patients understanding of questions? Use the patient's own terms if possible. 21. Mr. Williams, age 25, has recovered recently from an upper and lower respiratory infection. He describes a long-standing nasal dripping. He is seeking treatment for a mild hearing loss that has not gone away. Information concerning his chronic postnasal drip should be documented within which section of the history? Past medical data 22. Nasal symptoms that imply an allergic response include: Bluish gray turbinates. ("Turbinates that appear bluish gray or pale pink with a swollen, boggy consistency may indicate allergies"-Seidel p.243) 23. Mr. Franklin is speaking with you the health care provider, about his respiratory problem. Mr. Franklin says, “I’ve had this cough for 3 days and it’s getting worse.” You reply, “Tell me more about your cough.” Mr. Franklin states, “I wish I could tell you more, that’s why I am here! You tell me what’s wrong.” Which caregiver response would be the most appropriate for enhancing communication? After 3 days, you're tired of coughing. Have you had a fever?" 24. When taking a history, you should: Use a chronologic and sequential framework. 25. Which of the following formats would be used for visits that address problems not yet identified in the problem-oriented medical record (POMR)? Brief SOAP note 53. Mrs. Hartzell is a 34-year-old patient who has presented for nutritional counseling because she is a vegetarian. Deficiency of which of the following is a concern in the vegetarian diet? Proteins, calcium, iron, B12, and vitamin D 54. Underestimation of blood pressure will occur if the blood pressure cuff’s width covers? Cuff that are too wide will underestimate blood pressure, which would happen with a cuff that is more than one third of the upper arm 55. Mrs. Britton is a 34-year-old patient who presents to the office with complaints of skin rashes. You have noted a 4’3cm, rough, elevated area of psoriasis. This is an example of a? Plaque 56. Penicillin is considered a? Miracle drug for all the reasons except. It was not the first antibiotic. 57. Small, minute bruises are called? Petechiae 58. After thorough inspection of the abdomen, the next assessment step is? Auscultation 59. When you are questioning a patient regarding alcohol intake, she tells you that she is only a social drinker. Which initial response is appropriate? What amount and what kind of alcohol do you drink in a week? 60. Regardless of the origin, discharge is described by noting? Color and consistency 61. Recommended carbohydrate content of total dietary intake (% total calories) is? 50% 62. Tuning forks with a frequency of 500 to 1000 Hz are most commonly used to measure? Hearing range of normal speech 63. Auscultation should be carried out last, except when examining the? The abdomen 64. Mr. Kevin Marks is a new health care provider. What is the best method to develop cultural competence? Realize the cultural values are difficult to change and must be respected 65. Which of the following is an “ABCD” characteristic of malignant melanoma? Asymmetric borders 66. Tracheal tug suggests the presence of a(n)? Aortic aneurysm 67. Your patient presents with symptoms that lead you to suspect acute appendicitis. Which assessment finding is least likely to be associated with this condition early in its course? Consistent right lower quadrant pain 68. The review of systems is a component of the: Personal and social history 69. Cherry angiomas are a common finding in: Adults older than 30 years 70. Mr. Donalds is a 45-year-old roofer. Your inspection to determine color variations of the skin is best conducted: with illumination provided by daylight. 71. To correctly document absent bowel sounds, one must listen continuously for: 5 minutes 72. The adult recommended dietary fat intake should be g/day. 20 to 35 73. Mr. Jones is a 45-year-old patient who presents for a physical examination. On examination, you note costochondral beading, enlarged skull, and bowed legs and diagnose him with rickets. A deficiency of which fat-soluble micronutrient can result in rickets? Vitamin D 74. A flat, non-palpable lesion is described as a macule if the diameter is: Less than 1 cm 75. Mrs. Raymonds is a 24-year-old patient who has presented for a routine concern over her current weight. In your patient teaching with her, you explain the importance of macronutrients. Which of the following is a macronutrient? Fat 76. Which of the following organs is part of the alimentary tract? continuous tract from the mouth to the esophagus, stomach, small intestine, large intestine, and anus 77. Mr. Sanchez is a 45-year-old gentleman who has presented to the office for a physical examination to establish a new primary care health care provider. Which of the following describes a physical, not a cultural, differentiator? Race 78. To approximate vocal frequencies, which tuning fork should be used to assess hearing? 500 to 1000 Hz 79. During percussion, a dull tone is expected to be heard over: The liver 80. The attitudes of the health care professional: Culturally derived/are largely irrelevant to the success of relationships with the patient 81. When recording physical findings, which data are recorded first for all systems? Inspection 82. Spasmodic muscular contractions of the head, face, or neck are called: tics 83. Which of the following occurs when firm pressure is used to apply the stethoscope’s bell end-piece to the skin? It functionally converts to a diaphragm end-piece. 84. Differential diagnoses belong in the: Assessment 85. Pigmented, raised, warty lesions over the face and trunk should be assessed by an experienced practitioner who can distinguish: seborrheic keratoses from actinic keratoses. 86. Mr. Walter’s, a 32-year-old patient, tells you that his ears are “stopped up.” An objective assessment of this complaint is achieved by using the: tympanometer 87. Mrs. Leonard brings her newborn infant into the pediatrician’s office for a first well-baby visit. As the health care provider, you teach her that newborns are more vulnerable to hypothermia due to: a poorly developed subcutaneous fat layer. 88. Tympanic thermometers measure body temperature when a probe is placed: Eardrum (in the ear) 89. A serous membrane that lines the abdominal cavity and forms a protective cover for many abdominal structures is the: peritoneum 90. White, rounded, or oval ulcerations surrounded by a red halo and found on the oral mucosa are: aphthous ulcers (canker sores) 91. When assessing abdominal pain in a college-age woman, one must include: the first day of the last menstrual period. 92. Your patient is complaining of acute, intense sharp epigastric pain that radiates to the back and left scapula with nausea and vomiting. Based on this history, your prioritized physical examination should be to: inspect for ecchymosis of the flank. 93. The infant should be placed in which position to have his or her height or length measured? Supine on a measuring board 94. Mr. Marks is a 66-year-old patient who presents for a physical examination to the clinic. Which question has the most potential for exploring a patient’s cultural beliefs related to a health problem? "Why do you think you are having these symptoms?" 95. Which of the following is the most vital nutrient? water 96. What finding is unique to the documentation of a physical examination of an infant? skin is best conducted: Peritonitis produces bowel sounds that are: Macronutrients are so named because they: In examining the neck of a 34-year-old female patient, you note that the uppermost ridge of the tracheal cartilage is at the: Which of the following occurs when firm pressure is used to apply the stethoscope's bell end-piece to the skin? You have just completed a skin assessment on Mr. Baker. During your assessment, you have transilluminated a skin lesion. During the physical examination, you know that skin lesions are transilluminated to distinguish: The position on a clock, topographic notations, and anatomic landmarks: Mrs. Kinder is a 39-year-old patient who presents to the office with complaints of an earache. In explaining to the patient about the function of her ears, which ear structure would you tell her is responsible for equalizing atmospheric pressure when swallowing, sneezing, or yawning? • Question 15 1 out of 1 points • Question 16 1 out of 1 points • Question 17 1 out of 1 points • Question 18 1 out of 1 points • Question 19 1 out of 1 points • Question 20 1 out of 1 points • Question 21 1 out of 1 points • Question 22 1 out of 1 points Ms. Jones is a 31-year-old female patient who presents for a routine physical examination. Which examination technique will be used first? When recording physical findings, which data are recorded first for all systems? Percussing at the right midclavicular line, below the umbilicus, and continuing upward is the correct technique for locating the: Ms. G. is being seen for her routine physical examination. She is a college graduate and president of a research firm. Although her exact salary is unknown, she has adequate health insurance. Most of the above information is part of Ms. G.'s history. You are planning to palpate the abdomen of your patient. Which part of the examiner's hand is best for palpating vibration? Which of the following is an "ABCD" characteristic of malignant melanoma? Mrs. Webb is a 38-year-old patient who has been changing her lifestyle to eat in a healthy way and lose weight. During your health promotion education regarding her nutritional status, you explain the function of dietary protein as: George Michaels, a 22-year-old patient, tells the nurse that he is here today to "check his allergies." He has been having "green nasal discharge" for the last 72 hours. How would the nurse document his reason for seeking care? • Question 23 1 out of 1 points • Question 24 1 out of 1 points • Question 25 1 out of 1 points • Question 26 1 out of 1 points • Question 27 1 out of 1 points • Question 28 1 out of 1 points • Question 29 0 out of 1 points Sweat glands, hair, and nails are all formed from: Your patient returns for a blood pressure check 2 weeks after a visit during which you performed a complete history and physical. This visit would be documented by creating a(n): Your patient is complaining of acute, intense sharp epigastric pain that radiates to the back and left scapula with nausea and vomiting. Based on this history, your prioritized physical examination should be to: Expected normal percussion tones include: Recommended carbohydrate content of total dietary intake (% total calories) is %. Underestimation of blood pressure will occur if the blood pressure cuff's width covers: Which technique is most likely to result in the patient's understanding of questions? Which question would be considered a leading question? • Question 30 1 out of 1 points • Question 31 0 out of 1 points • Question 32 1 out of 1 points • Question 33 1 out of 1 points • Question 34 0 out of 1 points • Question 35 1 out of 1 points • Question 36 1 out of 1 points • Question 37 1 out of 1 points • Question 38 a: Which cranial nerves innervate the face? Which technique is most likely to result in the patient's understanding of questions? Which of the following is the most accurate reflection of an individual's food intake? When assessing abdominal pain in a college-age woman, one must include: The infant should be placed in which position to have his or her height or length measured? A 17-year-old girl presents to the clinic for a sports physical. Physical examination findings reveal bradycardia, multiple erosions of tooth enamel, and scars on her knuckles. She appears healthy otherwise. You should ask her if she: A 5-year-old child presents with nasal congestion and a headache. To assess for sinus tenderness you should palpate over the: Coarse, dry, and brittle hair is associated with which metabolic disorder? • Question 55 1 out of 1 points • Question 56 1 out of 1 points • Question 57 1 out of 1 points • Question 58 1 out of 1 points • Question 59 1 out of 1 points • Question 60 1 out of 1 points • Question 61 1 out of 1 points • Question 62 1 out of 1 points A detailed description of the symptoms related to the chief complaint is presented in the: Mr. Sanchez is a 45-year-old gentleman who has presented to the office for a physical examination to establish a new primary care health care provider. Which of the following describes a physical, not a cultural, differentiator? You are using an ophthalmoscope to examine a patient's inner eye. You rotate the lens selector clockwise, then counterclockwise to compensate for: Tracheal tug suggests the presence of a(n): Auscultation should be carried out last, except when examining the: Unusual white areas on the skin may be due to: A serous membrane that lines the abdominal cavity and forms a protective cover for many abdominal structures is the: A blood pressure cuff bladder should be long enough to: • Question 63 1 out of 1 points • Question 64 1 out of 1 points • Question 65 1 out of 1 points • Question 66 1 out of 1 points • Question 67 1 out of 1 points • Question 68 1 out of 1 points • Question 69 1 out of 1 points • Question 70 1 out of 1 points Mr. Walters, a 32-year-old patient, tells you that his ears are "stopped up." An objective assessment of this complaint is achieved by using the: Mrs. Raymonds is a 24-year-old patient who has presented for a routine concern over her current weight. In your patient teaching with her, you explain the importance of macronutrients. Which of the following is a macronutrient? Knowledge of the culture or cultures represented by the patient should be used to: During percussion, a dull tone is expected to be heard over: You are palpating a patient's thyroid and find that its broadest dimension measures 4 cm. The right lobe is 25% larger than the left. These data would indicate: The adult recommended dietary fat intake should be g/day. Before performing an abdominal examination, the examiner should: A college student comes to the student health center complaining of difficulty in concentrating during class and while studying. The diet that would contribute to this • Question 71 1 out of 1 points • Question 72 1 out of 1 points • Question 73 1 out of 1 points • Question 74 1 out of 1 points • Question 75 1 out of 1 points • Question 76 1 out of 1 points • Question 77 1 out of 1 points • Question 78 0 out of 1 points Mr. Kevin Marks is a new health care provider. What is the best method to develop cultural competence? Mrs. Grace is a 58-year-old patient who has a diagnosis of pernicious anemia. Which B vitamin is deficient in patients with pernicious anemia? The term denoting the caregiver's need to do no harm to the patient is: Penicillin is considered a Mrs. Leonard brings her newborn infant into the pediatrician's office for a first well- baby visit. As the health care provider, you teach her that newborns are more vulnerable to hypothermia due to: Mr. Mills is a 55-year-old patient who presents to the office for an initial visit for health promotion. A survey of mobility and activities of daily living (ADLs) is part of a(an): Mrs. Berger is a 39-year-old woman who presents with a complaint of epigastric abdominal pain. You have completed the inspection of the abdomen. What is your next step in the assessment process? ANOTHER When completing this exam, did you comply with Walden University’s Code of Conduct including the expectations for academic integrity? •Question 2 1 out of 1 points When hearing is evaluated, which cranial nerve is being tested? • Question 95 1 out of 1 points • Question 96 1 out of 1 points • Question 97 1 out of 1 points • Question 98 1 out of 1 points • Question 99 1 out of 1 points • Question 100 1 out of 1 points •Question 3 1 out of 1 points Bulging of an amber tympanic membrane without mobility is most often associated with: •Question 4 1 out of 1 points The examiner's evaluation of a patient's mental status belongs in the: •Question 5 1 out of 1 points Mrs. Grace is a 58-year-old patient who has a diagnosis of pernicious anemia. Which B vitamin is deficient in patients with pernicious anemia? •Question 6 1 out of 1 points Which of the following organs is part of the alimentary tract? •Question 7 1 out of 1 points Mrs. Berger is a 39-year-old woman who presents with a complaint of epigastric abdominal pain. You have completed the inspection of the abdomen. What is your next step in the assessment process? •Question 8 1 out of 1 points Mrs. Tuber is a 36-year-old patient who comes into the health center with complaints that her fingernails are not growing. Which structure is the site of new nail growth? •Question 9 1 out of 1 points Mr. L. presents to the clinic with severe groin pain and a history of kidney stones. Mr. L.'s son tells you that, for religious reasons, his father wishes to keep any stone that is passed into the urine filter that he has been using. What is your most appropriate response? •Question 10 1 out of 1 points The most superior part of the stomach is the: •Question 11 1 out of 1 points Before performing an abdominal examination, the examiner should: •Question 12 1 out of 1 points You are collecting a history from an 11-year-old girl. Her mother is sitting next to her in the examination room. When collecting history from older children or adolescents, they should be: •Question 13 1 out of 1 points Mr. Donalds is a 45-year-old roofer. Your inspection to determine color variations of the skin is best conducted: •Question 14 0 out of 1 points The review of systems is a component of the: •Question 15 1 out of 1 points Expected hair distribution changes in older adults include: •Question 16 1 out of 1 points During percussion, a dull tone is expected to be heard over: •Question 17 1 out of 1 points Mr. Akins is a 78-year-old patient who presents to the clinic with complaints of hearing loss. Which of the following are changes in hearing that occur in the elderly? Select all that apply. • Question 18 1 out of 1 points You are using an ophthalmoscope to examine a patient's inner eye. You rotate the lens selector clockwise, then counterclockwise to compensate for: •Question 19 1 out of 1 points Nuchal rigidity is most commonly associated with: •Question 20 1 out of 1 points Tympanic thermometers measure body temperature when a probe is placed: •Question 21 1 out of 1 points During an interview, you have the impression that a patient may be considering suicide. ANOTHER Question 56 0 out of 1 points A tool used to screen adolescents for alcoholism is the: •Question 57 1 out of 1 points You are examining a pregnant patient and have noted a vascular lesion. When you blanche over the vascular lesion, the site blanches and refills evenly from the center outward. The nurse documents this lesion as a: •Question 58 1 out of 1 points Which question would be considered a leading question? •Question 59 1 out of 1 points Your patient presents with symptoms that lead you to suspect acute appendicitis. Which assessment finding is least likely to be associated with this condition early in its course? •Question 60 1 out of 1 points Before performing an abdominal examination, the examiner should: •Question 61 1 out of 1 points Which of the following formats would be used for visits that address problems not yet identified in the problem-oriented medical record (POMR)? •Question 62 1 out of 1 points Which statement is true regarding the relationship of physical characteristics and culture? •Question 18 2 out of 2 points During auscultation, you can limit your perceptual field best by: Response Feedback: By closing your eyes, your sense of hearing becomes more acute and it increases your ability to isolate sounds. •Question 19 2 out of 2 points Standard Precautions apply to all patients: Response Feedback: Although all of the statements are true, the best answer is 4. Want ANOTHER Question 84 1 out of 1 points Fluorescing lesions are best distinguished using a(n): •Question 85 1 out of 1 points Mr. D. complains of a headache. During the history, he mentions his use of alcohol and illicit drugs. This information would most likely belong in the: •Question 86 1 out of 1 points You are using an ophthalmoscope to examine a patient's inner eye. You rotate the lens selector clockwise, then counterclockwise to compensate for: •Question 87 1 out of 1 points Expected hair distribution changes in older adults include: •Question 88 1 out of 1 points Mr. Mathews is a 47-year-old patient who presents for a routine physical examination. On examination, you have noted a bruit heard over the thyroid. This is suggestive of: •Question 89 1 out of 1 points George Michaels, a 22-year-old patient, tells the nurse that he is here today to "check his allergies." He has been having "green nasal discharge" for the last 72 hours. How would the nurse document his reason for seeking care? •Question 90 1 out of 1 points Under normal circumstances, how much water is lost daily by the body? •Question 91 1 out of 1 points Mrs. Britton brings her 16-year-old son in with a complaint that he is not developing correctly into adolescence. Which structures disproportionately enlarge in the male during adolescence? •Question 92 1 out of 1 points When assessing abdominal pain in a college-age woman, one must include: •Question 93 1 out of 1 points During an interview, you have the impression that a patient may be considering suicide. Which action is essential? •Question 94 1 out of 1 points Nuchal rigidity is most commonly associated with: •Question 95 1 out of 1 points Placing the base of a vibrating tuning fork on the midline vertex of the patient's head is a test for: •Question 96 1 out of 1 points In counseling a client regarding nutrition education, you explain that linoleic acid, a major fatty acid, is thought to be essential for: •Question 97 1 out of 1 points Periods of silence during the interview can serve important purposes, such as: •Question 98 1 out of 1 points A 51-year-old woman calls with complaints of weight loss and constipation. She reports enlarged hemorrhoids and rectal bleeding. You advise her to: •Question 99 1 out of 1 points Mrs. Kinder is a 39-year-old patient who presents to the office with complaints of an earache. In explaining to the patient about the function of her ears, which ear structure would you tell her is responsible for equalizing atmospheric pressure when swallowing, sneezing, or yawning? •Question 100 1 out of 1 points Which of the following is the most accurate reflection of an individual's food intake? •Question 101 1 out of 1 points You are examining a pregnant patient and have noted a vascular lesion. When you blanche over the vascular lesion, the site blanches and refills evenly from the center outward. The nurse documents this lesion as a: NURS 6512 Midterm Exam Review (Weeks 1-6) Building A Complete Health History 1. Communication techniques used to obtain a patient’s health history o Courtesy ▪ Knock before entering a room ▪ Address (first time) the patient formerly, such as Miss, Ms., Mrs. Mr. – can shake their hand(s) ▪ Meet and acknowledge others in the room. Establish their role and degree of participation ▪ Learn their names ▪ Ensure confidentiality ▪ Give them your undivided attention – take some time – don’t rush out ▪ Take minimal notes – use keywords. Observe and listen ▪ Respect the need for modesty ▪ Allow the patient time to change back into street clothes before resuming conversation o Comfort ▪ Ensure everyone is comfortable (including yourself) ▪ Maintain close, but comfortable proximity with patient o Culture – reflects the whole of human behavior, including ideas and attitudes; ways of relating to one another; manners of speaking; and the material products of physical effort, ingenuity, and imagination o Physical characteristics – gender, race, phenotypic traits o Minimize stereotyping and prejudice to achieve cultural competence o Cultural competence – Knowledge of cultural encounters, desire, awareness, knowledge, and skill o For ethnic minorities, assess social context through inquiry of stressors, support networks, sense of life control, and literacy o Be sensitive to a patient’s heritage, sexual orientation, socioeconomic status, ethnicity, and cultural background 7. Socioeconomic, spiritual, and lifestyle factors affecting diverse populations o Disease is shaped by illness and illness is shaped by the totality of the patient’s experience o Definition of ill or sick is based on the patient’s belief system and is determined by their enculturation 8. Functional assessments o Beliefs and behaviors that will have an impact on patient assessment include: ▪ Mode of communication – speech, body language, space • In the US, people talk more loudly while the English worry about being overheard and are more modulated • In US – people are direct in conversation and prefer to avoid the subject and to come to the point quickly while the Japanese do the opposite, using indirection and talking around points, and emphasizing attitudes and feelings • Silence allows those who are Native American to think and a response should not be forced; allow for quiet time • Firm eye contact is evident in the Spanish and French while Asian and Middle Eastern cultures believe it is a sign of disrespect. ▪ Health beliefs and practices that may vary from your own • Naturalistic or holistic approach believes that external factors must be kept in balance to remain well • Balance of hot and cold is a belief of Asians, Middle Eastern, Hispanics, and Native Americans • Treat condition with the opposite to restore balance ▪ Diet and nutritional practices • Orthodox Jewish will not take some medicines, particularly during holiday period like Passover • Muslims must respect Halal • Chinese patient with HTN and salt-restricted diet may need to limit MSG and soy sauce • Dietary supplements containing ephedra alkaloids mat increase risk of stroke, whereas other herbal preparations interact with prescribed medicines ▪ The nature of relationships within a family • Be aware of the sequence of related behaviors because it may be unrelated to the integrity of the family structure, gender, or background • Parenting style of child-rearing practices like setting boundaries and expectations may be culturally driven Assessment Tools and Diagnostic Tests in Adults and Children 9. Growth, Development, and Measurements in children and adults General o Growth Hormone: stimulates the pituitary to release the growth hormone. o Somatostatin inhibits the secretions of the growth hormone and thyroid stimulating hormone. o Growth hormone promotes growth, increase in organ size, regulates car, protein and lipid metabolism. o Thyroid hormone stimulates growth hormone secretion and production of insulin like growth factor-plays an important role in bone formation and resorption. o 70% of growth occurs during sleep. o At 34 weeks gestation, 65% of the weight of the newborns brain is present. o By 3 years old, most brain growth is complete. o Lymphatic tissues: reach adult size at age 6, double at 10-12 years of age, then decrease back to adult size during adolescence. Infants and Children o Legs are the fastest growing body part during childhood. o Fat tissue increases slowly until 7 years old, then pre-pubertal fat spurt occurs before the true growth spurt. o In adolescence, 50% of the individual weight is gain, and skeletal mass and organ sytm double in size. o Sexual Maturation in girls: early 7, late 12 o Sexual Maturation in boys: early 9, late 14 Older adults o Physical stature declines beginning at age 50. o Age 60 and over will have a decrease in weight for height and BMI, and approximately 5% body weight loss over several years. o Older adults will see an increase in body fat, and skeletal muscle loss due to decrease in exercise. o May see a decrease in size and weight of organs such as liver, kidney, lung. o In the last 15 years, there has been an increase in obese older adults. Pregnant Adults o Fetus accounts for 6-8 pounds of total weight gained, the other is due to an increase in maternal tissues. ▪ Fluid volume: 2-3 pounds ▪ Blood volume: 3-4 pounds ▪ Breast enlargement: 1-2 pounds ▪ Uterine enlargement: 2 pounds ▪ Amniotic fluid: 2 pounds ▪ Maternal fat and protein stores: 4-6 pounds o Weight gain slow during first trimester, rapid during second and third, fetal growth accounts for most weight gained during third trimester o Inadequate weight gain=increased risk for low birth weight infant BMI o Most common method used to assess nutritional status and total body fat. ▪ Undernutrition: less than 18.5 ▪ Appropriate: 18.5-24.9 ▪ Overweight: 25-29.9 ▪ Obese: 30-39.9 ▪ Extreme obesity: 40 and higher Infant Measurements o Health baby length: 18-22 inches o Weigh the baby to the nearest 10 g o Average variations in birth weight (5lbs 8oz to 8lbs 13oz) =2500-4000g o Infants double their birth weight by 4-5months and triple by 12 months o Head circumference: measure nearest 0.5cm or ¼ inch; wrap tape around occipital protuberance and the supraorbital prominence o Normal newborn head circumference: 32.5-37.5 cm o Chest circumference: used when problem is suspected; measure midway between inspiration and expiration to the nearest 0.5cm or ¼ inch; wrap at nipple line; at 5mths-2 years the chest and head are close to same size, and after 2 years, the chest exceeds the head circumference. 10. Nutritional assessment to include recommended water intake and energy requirements o Assess the patient’s nutritional status including: ▪ Recent growth, weight loss, weight gain ▪ Chronic illnesses ▪ Medication and supplement ▪ Nutrition screen ▪ Assessment of nutrition intake o Water: most vital nutrient, body is approximately 55-65% water o Pulse oximeter – measures the percentage of hemoglobin saturated with oxygen (oxyhemoglobin); adult/pediatric sites are finger, toes, pinna (top) or lobe of the ear; infant sites are the foot, palm of the hand, big toe, or thumb o Doppler – should be used when there is difficulty auscultating with regular stethoscope; they are ultrasonic stethoscopes that detect blood flow; used to detect systolic BPs, auscultate fetal heart activity, locate vessels, take weak pulses, assess vessel patency, localize acute and chronic arterial occlusions, assess DVTs and valvular incompetency, and assess testicular torsion and varicocele o Portable ultrasound – ultrasound waves pass through fluids and soft tissue; helpful in assessing fluid-filled organs (bladder) and soft organs (gallbladder and liver); shows the structure and movement of organs, blood flow through vessels, and abnormalities (cysts, tumors, and infections); aids in clinical procedures (pleural effusions, abscesses, and biopsies) o Fetal monitoring equipment – fetal heart rate determined by using fetoscope and Leff scope, a stethoscope, or an electronic instrument that uses doppler o Ophthalmoscope – enables visualization of the interior structures of the eye; numbers on the instrument correspond to the magnification power o PanOptic Ophthalmoscope – uses and optical design that allows a large field of view o StrabismoScope – used for detecting strabismus (eye misalignment) and can be used as part of eye testing in children o Photoscreening – used to detect amblyopia (lazy eye) and strabismus in children through the use of camera or video to obtain images of pupillary reflexes and red reflexes o Visual acuity charts – Snellen Alphabet (screening exam of far vision for literate, verbal, and English-speaking adults and school-aged children), Tumbling E (nonalphabet version of Snellen chart; has the letter “E” facing in different directions), HOTV (wall chart composed only of H’s, O’s, T’s, and V’s; child must match the letter on the wall chart to the testing board), LEA Symbols (consists of four optotypes – circle, square, apple, house – that blur equally and child must match), and lastly Broken Wheel Cards (picture cards where child must identify the cards with broken wheels on the car) o Near vision charts – can use a designed chart (Rosenbaum or Jaeger) or simply newsprint o Amsler grid – used to test those at risk for macular degeneration o Otoscope – provides illumination for examining the external auditory canal and tympanic membrane; can also be used for nasal examination o Tympanometer – simple and reliable way of assessing the functions of the ossiscular chain, eustachian tube, and tympanic membrane o Nasal speculum – used with a penlight to visualize the lower and middle turbinates of the nose o Tuning fork – used in screening tests for auditory function and for vibratory sensation as part of the neuro exam o Percussion (reflex hammer) – used to test deep tendon reflexes o Neurologic hammer – variant of the reflex hammer; also used for testing deep tendon reflexes o Tape measure – used for determining circumference, length, and diameter o Transilluminator – consists of a strong light source with a narrow beam; beam is directed to a body cavity to determine media present in the cavity (fluid in the sinuses or blood in the scrotum) o Vaginal speculum – two blades and a handle; three types (Graves, Pederson, and Pediatric/Virginal) o Goniometer – used to determine the degree of joint flexion and extensions o Wood’s Lamp – contains a light source that aids in determining the presence of fungi on skin lesions o Dermatoscope – a skin surface microscope that uses epiluminescence microscopy (ELM) to illuminate and magnify a skin lesion to allow for a more detailed inspection o Calipers for Skinfold Thickness – measure the thickness of subcutaneous tissue at certain points of the body o Monofilament – designed to test for loss of protective sensation, particularly on the plantar surface of the foot o Scoliometer – measures the degree of rotation of the spine to screen for scoliosis Assessment of the Skin, Hair, and Nails 17. Skin lesion characteristics o Skin lesion – general term that collectively describes any pathologic skin change or occurrence ▪ May be primary or secondary o Lesions should be described according to characteristics, exudates, configuration, and location and distribution ▪ Macule – flat, circumscribed area that is a change in the color of the skin; <1 cm in diameter (freckles, measles, petechiae, flat moles) ▪ Papule – elevated, firm, circumscribed area; <1 cm in diameter (wart, elevate mole) ▪ Patch – flat, nonpalpable, irregularly-shaped macule >1 cm in diameter (vitiligo, Mongolian spots, port-wine stains) ▪ Plaque – elevated, firm, and rough lesion with flat top surface >1 cm in diameter (psoriasis, actinic keratoses) ▪ Wheat – elevated, irregular-shaped area of cutaneous edema; solid, transient, variable diameter (insect bites, urticaria, allergic reaction) ▪ Nodule – elevated, firm, circumscribed lesion; deeper in dermis than a papule; 1-2 cm in diameter (erythema nodosum, lipoma) ▪ Tumor – elevated and solid lesion; may or may not be clearly demarcated; deeper in dermis; >2 cm in diameter (neoplasms, benign tumor, lipoma) ▪ Vesicle – elevated, circumscribed, superficial, not into dermis; filled with serous fluid; <1 cm in diameter (varicella, herpes zoster) ▪ Bulla – vesicle >1 cm in diameter (blister) ▪ Pustule – elevated, superficial lesion; similar to a vesicle but filled with purulent fluid (impetigo, acne) ▪ Cyst – elevated, circumscribed, encapsulated lesion; in dermis or subcutaneous layer; filled with liquid or semisolid material (sebaceous cyst, cystic acne) ▪ Telangiectasia – fine, irregular, red line produced by capillary dilation (rosacea) ▪ Scale – heaped-up, keratinized cells; flaky skin; irregular; thick or thin; dry or oily; variation in size (flaking of skin from dermatitis or drug reaction; dry skin) ▪ Lichenification – rough, thicken epidermis secondary to persistent rubbing, itching, or skin irritation; often involves flexor surfaces of extremity (chronic dermatitis) ▪ Keloid – irregularly shaped, elevated, progressively enlarging scar; grows beyond the boundaries of the wound; caused by excessive collagen formation during healing (keloid formation following surgery) ▪ Scar – thin to thick fibrous tissue that replaces normal skin following injury or laceration to the dermis (heated wound or surgical incision) ▪ Excoriation – loss of the epidermis; linear hollowed-out, crusted area (abrasion or scratch, scabies) ▪ Fissure – linear crack or break from the epidermis to the dermis; may be moist or dry (athlete’s foot, cracks at the corner of mouth) ▪ Erosion – loss of part of the epidermis; depressed, moist, glistening; follows rupture of a vesicle or bulla (varicella, variola after rupture) ▪ Ulcer – loss of epidermis and dermis; concave; varies in size (decubiti, stasis ulcers) ▪ Crust – dried serum, blood, or purulent exudates; slightly elevated; size varies; brown, red, black, tan, or straw-colored (scab on abrasion, eczema) ▪ Atrophy – thinning of skin surface and los of skin markings; skin translucent and paper-like (striae, aged skin) 18. Documenting skin lesions using “ABCD” rule o To document changes in moles o A – asymmetry o Chest and Abdomen ▪ Vellus hair grows on the chest and abdomen of both sexes at all stages of development ▪ Puberty to adulthood – males grow increasing amounts of terminal hair over the chest and abdomen areas • Women can grow terminal hairs around areola o Arms ▪ Grows on forearms ▪ Terminal arm hair – concentrated on the wrist end of the forearm, extending over the hand • Males – much more intense than in females (especially with dark hair) ▪ Vellus arm hair – seen on elbow end of the forearm and ends on the lower part of the upper arm • Women – looks hairy but it is softer and different compared to men’s arm hair o Feet ▪ Visible hair on the top surfaces of feet and toes that begins with the onset of puberty ▪ More intense in adult and adolescent males than in females o Legs ▪ Appears at the onset of adulthood, with legs of men more often hairier than those of women o Pubic ▪ Collection of coarse hair found in the pubic region, thighs, and abdomen ▪ Thick pubic hair acts as a cushion during intercourse ▪ The gential area of males and females are first inhabited by shorter, lighter vellus hairs that are next to invisible and only begin to develop into darker, thicker pubic hair at puberty o Armpits ▪ Underarm hair starts at the beginning of puberty and ends during the teenage years ▪ Thin fine hairs o Facial ▪ Grows around one’s face ▪ Non-vellus facial hair will begin to grow around puberty • Men – facial hair begins to grow around the age of puberty, although some men may not grow a moustache until they reach late teens or not at all • Women – develop a few facial hairs under or around the chin, along the sides of the face (in the area of sideburns), or on the upper lip. Assessment of Head, Neck, Eyes, Ears, Nose, and Throat 25. Cranial Nerves associated with the HEENT system N e r v e Test A bn or m al Fi nd in gs Po ssi bl e Ca us es I : O l f a c t o r y Iden tify fami liar odor s A no sm ia U pp er res pir at or y inf ect io n (te m po rar y); to ba cc o or co cai ne us e; fra ct ur e of cri bri for m N e r v e Test A bn or m al Fi nd in gs Po ssi bl e Ca us es pl ate or et h m oi d ar ea; fro nt al lo be les io n; tu m or in olf act or y bu lb or tra ct I I : O p t Visu al acuit y De fe ct in or ab Co ng en ita l bli N e r v e Test A bn or m al Fi nd in gs Po ssi bl e Ca us es al les io ns gl au co m a; di ab ete s I I I : O c u l o m o t o r Insp ectio n Di lat ed pu pil , pt osi s, ey e tur ns ou t an d sli gh tly do w n Pa ral ysi s in C N III fro m int er na l ca rot id an eu ry sm ; tu m or; inf la m N e r v e Test A bn or m al Fi nd in gs Po ssi bl e Ca us es m at or y les io ns; un cal he rni ati on wi th in cr ea se d int ra cr an ial pr es su re Extr Fa Pt aocu ilu osi lar re s mus to fro cle m m mov ov m eme e ya nt ey sth N e r v e Test A bn or m al Fi nd in gs Po ssi bl e Ca us es e en up ia , gr in, av do is; w oc n ul o m ot or ne rv e pa lsy ; H or ne r sy nd ro m e Shin A Bl e bs in light en dn in t es eye lig s; ht dr ref ug le inf x lu en ce; N e r v e Test A bn or m al Fi nd in gs Po ssi bl e Ca us es on ; se qu ela e of alc oh ol inj ect Clen W U ch ea nil teeth kn ate es ral s we of ak m ne as ss set wi er th or C te N N e r v e Test A bn or m al Fi nd in gs Po ssi bl e Ca us es m V po les ral io is n; m bil us ate cle ral s we ak ne ss wi th U M N or L M N dis or de r V Extr Fa Br I aocu ilu ai : lar re nst A mus to e b cle m m d mov ov tu u eme e m c nt to lat or e right er or n and all tra s left y, u sides di m pl a; N e r v e Test A bn or m al Fi nd in gs Po ssi bl e Ca us es op ia on lat er al ga ze fra ct ur e of or bit V I I : F a c i a l Wrin kle fore head , clos e eyes tight ly A bs en t or as y m m etr ic fa cia l m ov e m en t Be ll pa lsy (L M N les io n) ca us es pa ral ysi s of en tir e ha lf of fa ce Smil e, puff Lo ss of U M N N e r v e Test A bn or m al Fi nd in gs Po ssi bl e Ca us es V I I I : A c o u s t i c Hear ing acuit y De cr ea se or los s of he ari ng Inf la m m ati on ; oc cl ud ed ea r ca na l; ot os cle ro sis ; pr es by cu sis ; dr ug to xi cit y; tu m or N e r v e Test A bn or m al Fi nd in gs Po ssi bl e Ca us es I X : G l o s s o p h a r y n g e a l Gag refle x Se e C N X X : V a g u s Pho nate s “ahh ” U vu la de vi ate s to sid e Br ai nst e m tu m or; ne ck inj ur y; C N X les io N e r v e Test A bn or m al Fi nd in gs Po ssi bl e Ca us es n Gag refle x N o ga g ref le x Vo cal co rd we ak ne ss Note voic e quali ty H oa rse or br as sy Na sal tw an g H us ky So ft pa lat e we ak ne ss U nil ate ral C N X les io n Note swal lowi ng D ys ph ag ia, flu ids re gu Bi lat er al C N X les io N e r v e Test A bn or m al Fi nd in gs Po ssi bl e Ca us es s a l e of m ov e m en t N les io n 26. Normal assessment findings of an adolescent’s nose and throat (Same as Adult) o Nasal mucosa should glisten and appear deep pink o A film of clear discharge is often apparent on the nasal septum ▪ Purulent drainage may indicate: respiratory infection, sinusitis, or foreign body o Hairs may be present in the vestibule. o Turbinates are parallel curbed bony structures covered by vascular mucous membrane that form the lateral walls of the nose and protrude into the nasal cavity. They increase the nasal surface area to warm, humidify, and filter the air. ▪ Inferior meatus drains the nasolacrimal duct, the medial meatus drains the paranasal sinus, and the superior meatus drains the posterior ethmoid sinus. ▪ They are firm and the same color as the surrounding area. ▪ Turbinates with bluish-gray or pale pink with a swollen, boggy consistency may indicate allergies ▪ Rounded, elongated masses projecting into the nasal cavity from the boggy mucosa may be a polyp o Nasal septum close to midline and fairly straight with the anterior septum thicker than the posterior septum ▪ Deviation may be indicated by the asymmetric size of the posterior nasal cavities o Sense of smell (CN1) tested with different odors. o Sinuses: Only the maxillary and frontal sinuses are accessible for physical examination ▪ Frontal sinuses: use thumbs to press up under the bony brown on each side of the nose. Press up under the zygomatic processes, use either thumbs or index and middle fingers to palpate the maxillary sinuses: Expect no tenderness or swelling over the soft tissue: if present there may indicate infection or obstruction. ▪ Use transillumination if swelling or tenderness present: Glow is expected, opaque (no transillumination): secretions or never developed, dull (reduced transillumination). o Throat: ▪ Tonsils are usually the same pink color of the pharynx and are expected to fit in within the tonsillar pillars. ▪ May have crypts where cellular debris and food particles collect ▪ Reddened, hypertrophied, and covered with exudate, an infection may be present. ▪ Pharnyx posterior wall should be smooth, glistening, pink mucosa with some small, irregular spots of lymphatic tissue and small blood vessels. ▪ A red bulge adjacent to the tonsil and extending beyond the midline may indicate a peritonsillar abscess. ▪ A yellowish mucoid film in the pharynx is typical of postnasal drip ▪ Gag response: touch the posterior wall of the pharynx- tests glossopharyngeal and vagus nerve (CN IX and X) 27. Normal examination findings of an infant’s fontanelles o The seven cranial bones are soft and separated by the sagittal, coronal, and lambdoid sutures. o The anterior and posterior fontanels are formed where the four cranial bones meet and intersect. o Ossification of the sutures begins after completion of brain growth at about 6 years of age and finished by adulthood. o Posterior fontanel usually closes by 2 months, and the anterior fontanel closes by 12-15 months. o Suture lines feel ridgelike until about 6 months of age, after which they are no longer palpable. o Anterior fontanel less than 6 months should not exceed 4-5 cm and should get progressively smaller beyond that age until closing at 12-15 months. o Palpate anterior fontanel for bulging or depressions: it should feel slightly depressed, and some pulsation is expected. If the child is tense or crying the fontanel may protrude above the bone level. o A bulging fontanel with marked pulsations may indicate increased intracranial pressure from a space-occupying mass or meningitis 28. Examination findings of a patient with hypothyroid and hyperthyroid o To assess the thyroid gland: ▪ Neck swelling, pain, difficulty or pain with swallowing, redness ▪ Temperature intolerance, mood and energy changes ▪ Changes in hair texture, skin or nails ▪ Thyroid gland should move with swallowing o Hypothyroid ▪ Cold intolerance, puffiness and weight gain and swelling, coarse dry pale skin, fatigue, decreased appetite, hair loss or brittle dry hair, decreased sweating, hoarseness, goiter, bradycardia and hypotension (decrease SBP, and increased DBP), myxedema, hyporeflexia, constipation ▪ EVERYTHING IS SLOWED o Hyperthyroid ▪ Bulging eyes as if staring with eyelid lag, increased sweating, heat intolerance, skin moist hot and smooth, hand tremors, weight loss with increased appetite, increased heart rate or A fib, HTN (SBP with wide pulse pressure, oligomenorrhea, diarrhea ▪ Graves disease ▪ EVERYTHING IS EXCELERATED 29. Techniques for examining the HEENT systems o Palpate and inspect skull; note hair color, texture, and mount; look for lesions, bumps, and trauma o Palpate sinuses (frontal and maxillary) for tenderness o Note symmetry of head, eyes, nose, and mouth o Lymph node assessment – palpate and note pain o Palpate thyroid gland, note size o Listen to carotid arteries for bruits o Note any drainage from the eyes or nose o Note eye color and sclera color 30. Examination findings for a patient with sinus symptoms o Frontal and maxillary sinus tenderness o Headache o Nasal mucosal erythema and edema ▪ BEHIND: 2 fingers on each sides of the trachea- swallow (feeling for movement of the isthmus) displace trachea to left (with fingers from right hand) with fingers from left hand palpate left lobe as patient swallows. Assessment of the Abdomen and Gastrointestinal System 35. Organs involved in the alimentary tract o The alimentary tract is 27 feet long and runs from the mouth to the anus including: ▪ Esophagus • Collapsible 10 inches long connecting the pharynx to the stomach ▪ Stomach • Three sections: fundus, body, and pylorus • Secretes hydrochloric acid and digestive enzymes that break down fats and proteins • Pepsin digests proteins • Gastric lipase emulsifies fat • Little absorption takes place here ▪ Small intestines • 21 feet long • Coiled in the abdominal cavity • First 12 inches’ duodenum forms a C shaped curve around the head of the pancreas • Next 8 feet is the jejunum that gradually becomes larger and thicker • Last 12 feet are the ileum • Ileocecal valve lies between the ileum and the large intestines to prevent backflow • Nutrients are absorbed through the mucosa of the small intestines ▪ Large intestines • Begins with the cecum, a blind pouch about 2-3 inches long that hold ileal contents • Vermiform appendix extends from the cecum • Ascending colon extends from the cecum along the right posterior abdominal wall- under surface of the liver • Transverse colon crosses the abdominal cavity toward the spleen and down toward the splenic flexure • Descending colon runs along the left abdominal wall to the rim of the pelvis turning medially and inferiorly • Sigmoid colon is the S-shaped that connects to the rectum extending from the sigmoid to the pelvic floor through the anal canal and terminates at the anus o The alimentary tract functions to digest food; absorb nutrients, electrolytes, and water; and excrete waste products 36. Correct assessment order for examining the abdomen o Patient remains supine. Cover chest with the patient’s gown. Arrange draping to expose the abdomen from the pubis to the epigastrium. ▪ Inspect skin characteristics, contour, pulsations, and movement ▪ Auscultate all quadrants for bowel sounds ▪ Auscultate the aorta and renal, iliac, and femoral arteries for bruits or venous hums ▪ Percuss all quadrants for tones ▪ Percuss liver borders and estimate span ▪ Percuss left midaxillary line for splenic dullness ▪ Lightly palpate all quadrants ▪ Deeply palpate all quadrants ▪ Palpate right costal margin for liver borders ▪ Palpate left costal margin for spleen ▪ Palpate laterally at the flanks or right and left kidneys ▪ Palpate midline for aortic pulsation ▪ Test abdominal reflexes ▪ Have your patient raise their head as you inspect the abdominal muscles 37. Examination technique and findings of the liver o General Info: ▪ Located in the right upper quadrant, below the diaphragm and above the gallbladder and right kidney ▪ Heaviest organ of the body, weighs 3 lbs. ▪ Made of 4 lobes, which contain lobules. Lobules are made of liver cells which radiate around a central vein ▪ Branches of the portal vein, hepatic artery, and bile duct penetrate deep into the periphery of the lobules ▪ The hepatic artery transports blood directly from the aorta to the liver. The portal vein carries blood from the digestive tract and spleen to the liver. ▪ Metabolizes carbs, fats, and proteins. Concerts glucose into glucagon and stores for use. ▪ The liver uses cholesterol to form bile salts ▪ The liver also detoxifies o Examination Technique: ▪ Percuss for liver span by starting at the right midclavicular line over an area of tympany. Always begin in an area of tympany and move to an area of dullness. Percuss upward along the midclavicular line to determine lower border of liver. Dullness is usually heard at the costal margin. Mark the border with a pen. ▪ A lower liver border that is more than 2-3 cm below the costal margin may indicate organ enlargement or downward displacement of the diaphragm due to emphysema or pulmonary disease. ▪ For the upper border: begin percussion to the right of the midclavicular line at an area of lung resonance around the third intercostal space. Continue down until the percussion tone changes to dullness. This marks the upper border, mark it with a pen. It is usually at the 5th intercostal space, an upper border lower than this may indicate organ displacement or liver atrophy. Dullness above the 5th intercostal space may indicate upward displacement of the liver from abd fluid or mass. ▪ Measure the distance between the marks to estimate the vertical span of the liver, normal span is 6-12 cm. Greater span = liver enlargement; lesser span = atrophy ▪ Errors in percussion for liver span can be caused by dullness from a pleural effusion. Gas in the colon can cause tympany and obscure the dullness of the liver. ▪ If enlargement is suspected additional percussion is needed. Percuss upward and downward on the right midaxillary line, liver dullness is detected at the 7th intercostal space. ▪ To assess the descent of the liver, ask the pt. to take a deep breath and hold it while you percuss upward from the abd at the right midclavicular line. The area of the lower border should move 2-3 cm down. These maneuvers assess later palpation of the liver. ▪ Palpating the liver: place your left hand under the pt. at the 11th and 12th ribs. Pressing upwards to elevate the liver toward the abdominal wall. Place your right hand on the abd, fingers pointing towards the head and extended so the tips of the fingers rest on the right midclavicular line below the level of liver dullness. Have the pt. breathe regularly a few times then take a deep breath. Feeling for the liver edge as the diaphragm pushes it downwards towards your fingertips. Normally the liver is not palpable but can sometimes be felt in thin persons. The liver edge should feel firm, smooth, even, and nontender. Feel for nodules, tenderness and irregularity. If the liver is palpable, repeat the assessment medially and laterally to assess the entire border. ▪ Alternate palpation: hook fingers over the right costal margin below the margin of dullness and press in and up toward the costal margin, feeling for the liver edge as they breathe. ▪ Scratch Test: Useful if the abd is distended to assess liver border. Place the diaphragm of the stethoscope over the liver and with the finger of the other hand scratch the abd surface lightly, moving towards the liver border, when you are over liver, the sound intensifies. ▪ Direct percussion can also check for liver tenderness. o Findings: 39. Examining McBurney’s sign o Rebound Tenderness felt over McBurney’s Point in the lower right quadrant suggests appendicitis and is a positive McBurney’s sign. 40. Assessment of abdominal pain in women o Potential threats to life in women: ▪ Ectopic pregnancy – typically presents with lower abdominal pain and vaginal bleeding, late missed period, peritoneal irritation • Associated internal bleeding may show shoulder tip pain • Female abdominal pain must be investigated – ask for sexual & menstrual history, conduct pelvic exam, & perform urine pregnancy test. Anticipate the emergency of a RUPTURE. ▪ Incomplete Miscarriage ▪ Genital Tract Trauma ▪ Pulmonary Embolism ▪ Toxic Shock Syndrome o Causes of abdominal pain in women: ▪ Common: UTI, PID, Dysmenorrhea, Labor ▪ Uncommon: Ectopic pregnancy, Appendicitis, Biliary Colic, Ovarian Syndromes, Miscarriage ▪ Rare: Ovarian Hyperstimulation Syndrome, Curtis Fitzhugh Syndrome, Toxic Shock Syndrome ▪ The menstrual history must be taken and pregnancy or its complications o Cystitis – frequency and dysuria ▪ R/o pelvic appendicitis (abdominal pain, dysuria, frequency, and protein, blood, and WBC in UA) o Pyelonephritis – urinary symptoms & groin pain, fever, and nausea, and vomiting 41. Landmarks for abdominal examination o RUQ – Liver and Gallbladder, Pylorus, Duodenum. Head of Pancreas (HOP), Right Adrenal Gland (RAG), Portion of Right Kidney (PORK), Hepatic Flexure of Colon (HFC), Portions of Ascending and Transverse Colon (PAT-C) o LUQ- Left Lobe of Liver (3L), Spleen, Stomach, Body of Pancreas (BOP), Left Adrenal Gland (LAG), Portion of Left Kidney (POLK), Splenic flexure of Colon (SFC), Portions of Ascending and Transverse Colon (PAT-C) o RLQ – Lower Pole of Right Kidney (L-PoRK), Cecum and Appendix, Portion of Ascending Colon (PAC), Bladder (if distended), Ovary and Salpinx, Uterus, Rt. Spermatic Cord, Right ureter o LLQ- Lower pole of Left Kidney (L-Polk), Sigmoid Colon, Portion of Descending Colon, Bladder (if Distended), Ovary and Salpinx, Uterus (if enlarged), Left Spermatic Cord, Left ureter o Right Hypochondriac – Right Lobe of Liver, Gallbladder, Portion of Duodenum, Hepatic Flexure of Colon, Portion of Rt. Kidney, Right Adrenal Gland o Epigastric – Pylorus, Duodenum, Pancreas, Portion of Liver o Left Hypochondriac- Stomach, Spleen, Tail of pancreas, Splenic flexure of Colon, Upper Pole of Left Kidney, Left Adrenal Gland o Right Lumbar – Ascending Colon, Lower Half of Right Kidney, Portion of Duodenum and Jejunum o Umbilical – Omentum, Mesentery, Lower Part of Duodenum, Jejunum, and Ileum o Right Iliac – Cecum, Appendix, Lower end of Ileum, Right ureter, Right Spermatic Cord, Right Ovary o Hypogastric (Pubic) – Ileum, Bladder, Uterus o Left Inguinal – Sigmoid Colon, Left Ureter, Left Spermatic Cord, Left Ovary 42. Characteristics of bowel sounds heard during auscultation o Normal – Clicks and gurgle sounds heard irregularly from 5-35 minutes. o Borborygmi -growling, loud prolonged gurgles. ▪ Heard in gastroenteritis, early intestinal obstructions, or hunger o High-Pitched tinkling sound – heard in early obstruction o Decreased Bowel Sounds – heard in peritonitis and paralytic ileus o Absent Bowel Sounds – no bowel sounds after 5 minutes of auscultation. o Friction Rub – high-pitched, heard in auscultation with respiration ▪ Indicates inflammation of the peritoneal surface of the organ from tumor, infection, or infarct. o Bruit- Harsh or musical intermittent auscultatory sound ▪ Indicates blood flow turbulence and indicate vascular disease o Use bell of the stethoscope in listening for the aortic, renal, iliac, and femoral artery bruits. Also in epigastric region and umbilical region for “venous hum” – soft, low pitched, and continuous which indicates increased collateral circulation between portal and systemic venous systems.