NR509 /NR 509 Final Exam (Latest 2024/ 2025) Advanced Physical Assessment - Chamberlain

NR 509 Final Exam 10 minute geriatric screener ANSWER: 1.vision a. difficulty driving/watching TV/reading -->snellen chart with corrective lenses (normal: <20/40) 2. hearing: audioscope at 40dB (1,000 and 2,000) (+= inability to hear one in both or one ear) 3. leg mobility: Get up and Go test: rise, walk 10 ft, turn, walk back, sit down (+= greater than 10 seconds) 4. urinary incontinence: Ask: a. lose urine and gotten wet in last year? b. 6 times? (+= yes to both) 5. nutrition/weight loss: a. lost 10 lbs in 6 mos? b. check weight (+= <100lbs) 6. memory: three-item recall (+= unable to remember all 3 after 1 min) 7. depression: Ask: do you feel sad/depressed (+= yes) 8. physical disability (6 questions: 1. strenious activity? 2. Heavy work? 3. Shopping? 4.

Go to places out of walking distance? 5. Bath/shower? 6. Dress?) (+= no to any) Abdomen palpation ANSWER: 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) Abdomen percussion ANSWER: --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.

Abdominal Auscultation ANSWER: 1. Bowel sounds 2. Bruits: hepatic (Cirrhosis), Arterial with systolic and diastolic component (occlusion of aorta or large artery (ex. epigastric--renal artery stenosis/renovascular hypertension) 3. Venous Hum: rare soft humming w/ sys/dias.= increase collateral circ btwn portal and systemic systems (hepatic cirrhosis)

4. Friction Rub over liver or spleen: Rare grating sounds w/ respiratory variation=inflammation (liver cancer, chlamydial/gonococcal perihepatitis, liver bx, splenic infarct) Abdominal insepction ANSWER: 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, 3.

Lipoma, 4. Fat, 5. Gas, 6. Tumor, 7. Pregnancy, 8. Ascites Acrocyanosis ANSWER: 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.

Acute Cholecystits ANSWER: RUQ pain Murphy Sign Acute Pancreatitis Aggrevating Factors ANSWER: Lying supine; dyspnea if pleural effusions from capillary leak syn-drome; selected medications, high triglycerides may exacerbate Acute Pancreatitis Associated Symptoms and Setting ANSWER: Nausea, vomiting, abdominal dis-tention, fever; often recurrent; 80% with history of alcohol abuse or gallstones Acute Pancreatitis Location ANSWER: Epigastric, may radiate straight to the back or other areas of the abdomen; 20% with severe sequelae of organ failure Acute Pancreatitis Process ANSWER: Intrapancreatic trypsinogen activation to trypsin and other enzymes, resulting in autodigestion and inflammation of the pancreas Acute Pancreatitis Quality ANSWER: Usually steady

Acute Pancreatitis Relieving factors ANSWER: Leaning forward with trunk flexed Acute PancreatitisTiming ANSWER: Acute onset, persistent pain Adult immunizations ANSWER: 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) Anxiety disorders ANSWER: 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 Aorta abnormalities ANSWER: 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.

Aorta assessment ANSWER: 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).

Aphasia ANSWER: Disorder in producing or understanding language.

Aphonia ANSWER: loss of the voice as a result of disease or injury to the larynx or nerve supply Appendicitis ANSWER: 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.

Ascites assessment ANSWER: 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 Axilla Exam ANSWER: 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. bacterial vaginosis ANSWER: 1. Bacterial overgrowth: often transmitted sexually 2. Gray or white, thin, homogeneous, malodorous discharge 3. Unpleasant fishy or musty genital odor reported after intercourse 4. Vulva and vaginal mucosa appear normal benign prostatic hyperplasia (BPH) ANSWER: 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.

Bladder assessment ANSWER: 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.

Breast cancer risk factors ANSWER: 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 ANSWER: Redness suggests local infection or inflammatory carcinoma.

Thickening and prominent pores suggest breast cancer.

Flattening of the normally convex breast suggests cancer.

Asymmetry due to change in nipple direction suggests an underlying can-cer. Eczematous changes with rash, scaling, or ulceration on the nipple extending to the areola occurs in Paget disease of the breast, associated with underlying ductal or lobular car-cinoma (see p. 445).60 A nipple pulled inward, tethered by underlying ducts signals nipple retrac-tion from a possible underlying cancer. The retracted nipple may be depressed, flat, broad, or thickened.

Breast Exam Males ANSWER: Enlargement: gynecomastia proliferation of palpable glandular tissue pseudogynecomastia accumulation of subareolar fat Breast exam palpation ANSWER: 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 Breast exam positions ANSWER: 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 lymphatics ANSWER: 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 ANSWER: 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.

Breast pain ANSWER: mastalgia.

Pain without mass is not a breast cancer risk factor Medications can cause breast pain: hormonal therapy, psychotropic drugs, spironolactone, and digoxin.

Breast Self-Exam ANSWER: 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 Broca aphasia ANSWER: 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.

Cafe au lait spots ANSWER: Pigmented light brown lesions <1-2cm. Isolated= no significance. Multiple lesions with sharp borders may mean Neurofibromatosis Check for varicocele ANSWER: Patient standing 1. palpate the spermatic cord about 2 cm above the testis.

2. Have the patient hold his breath and "bear down" against a closed glottis for about 4 seconds (the Valsalva maneuver).

3. 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.

Colorectal cancer epidemiology ANSWER: --Third most frequently diagnosed cancer among both men and women (over 140,000 new cases) and the third leading cause of cancer death (nearly 50,000 deaths) each year in the United States.

--The lifetime risk of diagnosis with colorectal cancer is about 5%, while the lifetime risk for dying from colorectal cancer is about 2%.

Colorectal cancer prevention ANSWER: Primary prevention: 1. screen for and 2. remove pre-cancerous adenomatous polyps Also associated with decreased risk 1. Physical activity 2. Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) 3. Postmenopausal combined hormone replacement therapy (estrogen and progestin) Colorectal cancer risk factors ANSWER: 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: 1. male sex 2. African American race 3. tobacco use 4. excessive alcohol use 5. red meat consumption 6. obesity.

Colorectal cancer screening ANSWER: 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 76-85

1. Screening not advised because the benefits are small in comparison to the risks 2. 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) 1. Screening not advised because "competing causes of mortality preclude a mortality benefit that outweighs harms" Colorectal cancer screening tests ANSWER: 1. Stool tests that detect occult fecal blood: a. fecal immunochemical tests, b. high-sensitivity guaiac-based tests, c. tests that detect abnormal DNA. 2. Endoscopic tests: a. colonoscopy, which visualizes the entire colon and can remove polyps, b. flexible sigmoidoscopy, which visualizes the distal 60 cm of the bowel.

--Colonoscopy is the most commonly used and gold standard, though people may prefer other tests like FOBTs because they are safer and easier to perform.

Cutis marmorata ANSWER: Premature infants or infants with congenital hypothyroidism and Down syndrome -Lattice-like, bluish mottled appearance (trunk, legs, arms) Depression screening ANSWER: USPSTF recommendation: B in primary care setting two questions 1. Over past 2 weeks, have you felt down, depressed, or hopeless?

2. Over past 2 weeks, have you felt little interest or pleasure in doing things (anhedonia)?

--Yes to either of these warrants full diagnostic interview Developmental Milestones 1 year ANSWER: Physical: Walk; run Cognitive/language: 2-3 single words Social/Emotional: Peek-a-boo; separation anxiety Developmental milestones: 1-2mos ANSWER: Physical: Head control Cognitive/language: Coos Social/Emotional: Smiles Developmental Milestones: 2 years ANSWER: 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 ANSWER: 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: 3-4 mos ANSWER: Physical: Rolls over; grasps rattle; works for toy Cognitive/language: Babbles Social/Emotional: Developmental Milestones: 4 years ANSWER: 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: 4-5mos ANSWER: Physical: Cognitive/language: Squeals Social/Emotional: Laughs Developmental Milestones: 5 years ANSWER: 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 Developmental milestones: 5- 6 mos ANSWER: Physical: Sits Cognitive/language: Social/Emotional: Developmental milestones: 7-8 mos ANSWER: Physical: Cognitive/language: Dada/mama Social/Emotional: Feeds self; indicates wants Developmental milestones: 9-10 mos ANSWER: Physical: Pulls to stand; crawls Cognitive/language:

Social/Emotional: Waves and plays peek-a-boo Developmental milestones: 11-12 mos ANSWER: Physical: Walks Cognitive/language: 2-3 words Social/Emotional: Uses spoon Developmental milestones: Birth ANSWER: Physical: Focuses; fixes/follows Cognitive/language: Responds to sounds Social/Emotional: Regards face Diverticulitis aggravating factors ANSWER: -Diverticulitis associated symptoms and setting ANSWER: Fever, constipation. Also nausea, vomiting, abdominal mass with rebound tenderness Diverticulitis location ANSWER: Left lower quadrant Diverticulitis process ANSWER: Acute inflammation of colonic diver-ticula, outpouchings 5-10 mm in diameter, usually in sigmoid or descend-ing colon Diverticulitis quality ANSWER: May be cramping at first, then steady Diverticulitis relieving factors ANSWER: Analgesia, bowel rest, antibiotics Diverticulitis timing ANSWER: Often gradual onset Dysarthria ANSWER: defect in muscular control of speech apparatus (defective articulation) Dysphonia ANSWER: impariment in volume, quality, or pitch of voice

Elder abuse ANSWER: Prevelance ranges from 5-10% higher among depression and dementia elderly.

90% of abusers are family No screening tool recommended, careful history required.

Erectile Dysfunction ANSWER: 1. Psychogenic causes, especially if early morning erection is preserved 2. Decreased testosterone 3. decreased blood flow in the hypogastric arterial system 4. impaired neural innervation 5. diabetes Erythema toxicum ANSWER: 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.

Eyelid patch ANSWER: Birthmark fades within first year of life Functional assessment ANSWER: 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 Functional incontinence mechanisms ANSWER: 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 physical signs ANSWER: The bladder is not detectable on examination. Look for physical or environmental clues as the likely cause.

Functional incontinence problem ANSWER: The patient is functionally unable to reach the toilet in time because of impaired health or environmental conditions.

Functional incontinence symptoms ANSWER: Incontinence on the way to the toilet or only in the early morning.

GERD : relieving factors ANSWER: Antacids, proton pump inhibi-tors; avoiding alcohol, smoking, fatty meals, chocolate, selected drugs such as theophylline, cal-cium channel blockers GERD aggravating factors ANSWER: Lying down, bending over; physical activity; diseases such as scleroderma, gastroparesis; drugs like nicotine that relax the lower esophageal sphincter GERD associated symptoms and setting ANSWER: Wheezing, chronic cough, short-ness of breath, hoarseness, choking sensation, dysphagia, regurgitation, halitosis, sore throat; increases risk of Barrett esophagus and esopha-geal cancer GERD Location ANSWER: Chest or epigastric GERD Process ANSWER: 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 Quality ANSWER: Heartburn, regurgitation GERD timing ANSWER: After meals, especially spicy foods Harlequin dyschromia ANSWER: --Found occasionally in newborns

--Transient cyanosis of one half of body or extremity from temporary vascular instability.

Heart rates under 1 year ANSWER: Birth-1 mo: 140 (90-190) 1-6mo: 130 (80-180) 6-12 mo: 115 (75-155) Hepatitis ANSWER: -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 ANSWER: -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 associated symptoms ANSWER: Crampy lower ab-dominal pain, ab-dominal disten-tion, flatulence, nausea; urgency, pain relieved with defecation IBS characteristics of stool ANSWER: Loose; ∼50% with mucus; small to mod-erate volume. Small, hard stools with constipation. May be mixed pattern.

IBS patterns ANSWER: 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 setting, persons at risk ANSWER: Young and middle-aged adults, especially women IBS timing ANSWER: Worse in the morning; rarely at night.

IBS: process ANSWER: 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 Immunizations in pregnancy ANSWER: 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 Incontinence secondary to medications mechanisms ANSWER: Sedatives, tranquilizers, anticholinergics, sympathetic blockers, and potent diuretics.

Incontinence secondary to medications physical signs ANSWER: Variable.

Incontinence secondary to medications problem ANSWER: Drugs may contribute to any type of incontinence listed.

Incontinence secondary to medications symptoms ANSWER: Variable. A careful history and chart review are important.

Jaundice in newborn ANSWER: --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.

Kidney assessment LEFT ANSWER: 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 ANSWER: 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 ANSWER: 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.

Laboratory testing in pregnancy ANSWER: 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.

Lanugo ANSWER: Fine, downy growth of hair over entire body especiallly shoulders and back.

--Shed within first few weeks.

--Prominent in premature infants Liver assessment ANSWER: 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).

Male Tanner staging ANSWER: 1. preadolescent, no pubic hair + pre-pubertal testes 2. Initial growth of scrotum and testes, skin reddened, thin, wrinkled; few thin hairs around root of penis 3. Penis longer, testes and scrotum growth, skin of scrotum darker; coarser curlier hair, still sparse 4. glans develops, penis growth in length and width, scrotum and testes have grown; darker more coarse curly hair extending to thighs 5. adult size/shape; pubic hair spreads to medial surface of thigh and up towards umbilicus

McBurney Point ANSWER: 1. McBurney point lies 2 inches from the anterior superior spinous process of ilium on a line drawn from that process to the umbilicus 2. Appendicitis is three times more likely if there is McBurney point tenderness.

Mental status examination ANSWER: 1. Attention: ability to focus or concentrate 2. Memory: registering or recording info 3. Orientation: awareness of personal identity, place, and time 4. Perceptions: sensory awareness of object in environment (external stimuli and internal stimuli) 5. Thought processes: Logic, coherence, relevance 6. Thought content: what pt thinks about 7. Insight: awareness of normal and abnormal behavior 8. Judgment: process of comparing and evaluating alternatives 9. Affect: observable behaviors that express feelings or emotions (tone of voice, facial expression, demeanor) 10. Mood: sustained emotion that colors the person's perceptions.

11. Language: 12. High cognitive functions: vocabulary, fund of info, abstract thinking, calculations, dimensions.

Midline Hair tuft over lumbosacral spine region ANSWER: --Possible spinal cord defect Milia ANSWER: 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.

Miliaria rubra ANSWER: Scattered vesicles on erythematous base (face or trunk) result from obstruction of sweat gland ducts. Disappears within weeks.

Murphy Sign ANSWER: 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.

Naegele's Rule ANSWER: Due date calc tool: -40 weeks from first date of LMP 1. add 7 days to LMP, subtract 3 months, add 1 year Newborn vascular markings ANSWER: 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.

Nipple exam ANSWER: 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 ≥40 years.

Thickening of the nipple and loss of elasticity suggest an underlying cancer.

Normal Prostate ANSWER: 1. Palpated through the anterior rectal wall 2. Rounded, heart-shaped structure approximately 2.5 cm long.

3. The median sulcus can be palpated between the two lateral lobes.

4. Only the posterior surface of the prostate is palpable.

5. Anterior and central lesions, including those that obstruct the urethra, are not detectable by physical examination.

Obturator Sign ANSWER: --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.

Overflow incontinence mechanisms ANSWER: Obstruction of the bladder outlet, as in benign prostatic hyperplasia or tumor.

Weakness of the detrusor muscle associated with peripheral nerve disease at S2-4 level.

Impaired bladder sensation that interrupts the reflex arc, as in diabetic neuropathy.

Overflow incontinence physical signs ANSWER: 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.

Overflow incontinence problem ANSWER: 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 symptoms ANSWER: 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.

Penile Discharge/rash ANSWER: 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.

Penis abnormalities ANSWER: 1. Hypospadis (congenital ventral displacement of the meatus on the penis) 2. Peyronie Disease 3. Carcinoma of the penis (induration of ventral surface) 4. Pubic/genital excoriations: lice (crabs) or scabies in pubic hair.

Peptic Ulcer Disease aggravating factors ANSWER: Variable

Peptic Ulcer Disease associated symptoms and setting ANSWER: 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 Peptic Ulcer Disease Location ANSWER: Epigastric, may radiate straight to the back Peptic Ulcer Disease Process ANSWER: Mucosal ulcer in stomach or duode-num >5 mm, covered with fibrin, extending through the muscularis mu-cosa; H. pylori infection present in 90% of peptic ulcers Peptic Ulcer Disease Quality ANSWER: Variable: epigastric gnawing or burning (dyspepsia); may also be boring, aching, or hungerlike No symptoms in up to 20% Peptic Ulcer Disease relieving factors ANSWER: Food and antacids may bring re-lief (less likely in gastric ulcers) Peptic Ulcer Disease Timing ANSWER: 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 preeclampsia ANSWER: abnormal condition associated with pregnancy, 1. 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 2. Proteinuria >300mg/24 hrs, proteine: creatinine >0.3, or dipstick 1+ OR 1. 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 ANSWER: 1. hemorrhoids: often become engorged late in pregnancy, may be painful, bleed, or thrombose

2. Varicose veins may begin or worsen Prepuce and glans abnormalities ANSWER: 1. Phimosis is a tight prepuce that cannot be retracted over the glans.

2. Paraphimosis is a tight prepuce that, once retracted, cannot be returned. Edema ensues.

2. Balanitis is inflammation of the glans 3. balanoposthitis is inflammation of the glans and prepuce.

Primary amenorrhea ANSWER: Never having started period primary dysmenorrhea ANSWER: 1. increased prostaglandin production during the luteal phase of the menstrual cycle, when estrogen and progesterone levels decline.

Prostate cancer ANSWER: 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.

Prostatitis ANSWER: 1. presents with fever and urinary tract symptoms such as frequency, urgency, dysuria, incomplete voiding, and sometimes low back pain.

2. Palpation: tender, swollen, "boggy," and warm.

3. Examine it gently.

4. More than 80%: gram-negative aerobes such as Escherichia coli, Enterococcus, and Proteus.

5. In men < 35 yrs, consider sexual transmission of Neisseria gonorrhea and Chlamydia trachomatis.

6. Chronic bacterial prostatitis is associated with recurrent urinary tract infections.

7. 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.

8. 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).

Psoas Sign ANSWER: --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.

Pustular melanosis: ANSWER: Common in black infants, presents at birth as small vesiculopustules over brown macular base; can last several months.

Risk factors for AAA ANSWER: 1. Age ≥65 years 2. history of smoking 3. male gender 4. first-degree relative with a history of AAA repair Rovsing sign ANSWER: 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.

Schizophrenia ANSWER: 1. Grooming and personal hygiene may deteriorate 2. flat affect and remoteness 3. Hallucinations and illusions 4. Derailment 5. Neologisms: invented or distorted words 6. Incoherence: speech that is incomprehensible and illogical 7. Blocking: sudden interruption of speech in midsentence or before idea is complete.

8. Perseveration: persistent repetition of words or ideas 9. Echolalia: repetition of words and phrases of others 10. Clanging: speech with choice of words based on sounds rather than meaning (rhyming and punning).

Scrotal abnormalities ANSWER: 1. Scrotal edema 2. Hydrocele 3. Scrotal Hernia 4. Cryptorchidism (poorly developed scrotum) 5. Small Testes 6. Acute Orchitits (Tender painful scrotal swelling) 7. Tumor of the testes 8. Acute Epididymitis (Tender painful scrotal swelling) 9. Torsion of the spermatic cord (Tender painful scrotal swelling) 10. Strangulated inguinal hernia (Tender painful scrotal swelling) 11. scrotal nevi, hemangiomas, or telangiectasias 12. STIs condyloma or ulcers from herpes and chancroid (painful) and syphilis and lymphogranuloma venereum (painless), with associated inguinal lymphadenopathy.

13. Erythema and mild excoriation point to fungal infection, not uncommon in this moist area. secondary amenorrhea ANSWER: 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. secondary dysmenorrhea causes ANSWER: 1. endometriosis 2. adenomyosis (endometriosis in the muscular layers of the uterus) 3. pelvic inflammatory disease (PID) 4. endometrial polyps.

Slate Blue Patches ANSWER: Dark bluish pigmentation over buttocks and lower lumbar regions in newborns of African, Asian, and Mediterranean descent.

--Disappear during childhood.

Spleen assessment ANSWER: Enlargement: expands anteriorly, downward, and medially, replacing tympany of stomach and colon with dullness of solid organ.

Percussion: 1. Percuss the left lower anterior chest wall roughly from the border of cardiac dullness at the 6th rib to the anterior axillary line and down to the costal margin, an area termed

Traube space. As you percuss along the route, note the lateral extent of tympany.

Percussion is moderately accurate in detecting splenomegaly (80% of the time) 2. If tympany is prominent, splenomegaly is unlikely.

3. Check for a splenic percussion sign. Percuss the lowest interspace in the left anterior axillary line (usually tympanic). Have patient to take a deep breath, and percuss again.

When spleen size is normal, the percussion note usually remains tympanitic.

Palpation (supine and on right side): Splenomegaly is eight times more likely when the spleen is palpable (portal hypertension, hematologic malignancies, HIV infection, infiltrative diseases like amyloidosis, and splenic infarct or hematoma).

In 5% of normal adults: Spleen tip, is just palpable deep to the left costal margin.

Stress Incontinence mechanisms ANSWER: 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 Physical signs ANSWER: 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.

Stress Incontinence problem ANSWER: The urethral sphincter is weakened so that transient increases in intraabdominal pressure raise the bladder pressure to levels that exceed urethral resistance.

Stress Incontinence symptoms ANSWER: 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.

Suicide risk and prevention ANSWER: -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.

Tanner stages: Women development ANSWER: 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 Testicular Cancer ANSWER: 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 ANSWER: 1. Inspect for induration along the ventral surface of the penis 2. May have tenderness in the indurated area d/t periurethral inflammation Urge incontinence mechanism ANSWER: 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 physical signs ANSWER: 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.

Urge incontinence problem ANSWER: Detrusor contractions are stronger than normal and overcome the normal urethral resistance. The bladder is typically small.

Urge incontinence symptoms ANSWER: 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.

Vas Deferens abnormalities ANSWER: The vas deferens, if chronically infected, may feel thickened or beaded. A cystic structure in the spermatic cord suggests a hydrocele of the cord.

Visible signs of breast cancer ANSWER: 1. Retraction signs (dimpling, changes in contour, retraction/deviation of nipple) 2. Abnormal contours: variations in normal convexity 3. Skin dimpling: best seen with arm at rest, during special positioning, or on moving/compressing breast 4. Nipple retraction and deviation: nipple flattened or pulled inward, OR broadened and thickened, when asymmetric, nipple may deviate.

5. Edema of skin: produced by lymphatic blockage, appears as thickened skin with enlarged pores (orange peel), seen first in lower portion of breast or areola.

6. Paget disease of nipple: scaly, eczema-like lesion on nipple that may weep, crust, or erode. Mass may be present. Often (>60%) presents with underlying ductal or lobular carcinoma.

Wernicke Aphasia ANSWER: 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.