NURS 6512 Final Exam Review (Week 7-11)

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1 Heart, Lungs, and Peripheral Vascular (Week 7: Ch. 13, 14, & 15)  Examination techniques of the Heart, Lungs, and PV systems (See Notes)  Examination findings of arterial blood flow in infa... nts (339) (345) o At birth the cutting of the umbilical cord, through which oxygen has been provided in utero, requires the infant to begin breathing. The onset of respiration expands the lungs and carries air to the alveoli. o When pulse is weak, expect cardiac output bay be diminished or peripheral vasoconstriction may be present. A bounding pulse is associated with a large leftright shunt produced by a patent ductus arteriosus. In coarctation of the aorta, a difference is noted in pulse amplitude between the upper extremities or between the femoral and radial pulses or the femoral pules are absent capillary refill times in infants and children younger than 2 years of age are raid, less than 1 second. A prolonged capillary refill time, no longer than 2 seconds, indicates dehydration or hypovolemic shock.  Examination findings of the heart and lungs in a patient with illegal drug use (266) o If an adult- especially young- or an adolescent describes severe, acute chest pain, ask about drug use, particularly cocaine. Cocaine can cause tachycardia, hypertension, coronary arterial spasm (with infarction), and pneumothorax (lung collapse) with severe acute chest pain being the common result.  Description: shortness of breath (orthopnea, platypnea. Tachypnea, bradypnea) (265) o Orthopnea- shortness of breath that begins or increases when the patient lies down; ask whether the patient needs to sleep on more than one pillow and whether that helps. o Platypnea- dyspnea increases in the upright posture. o Tachypnea- increased rate of respirations of breath; abnormally rapid breathing.(COPD or Pneumonia)2 o Bradypnea-breathing more slowly than normal, could mean the body isn’t getting enough oxygen. (sleep apnea, drug overdose, carbon monoxide poisoning) o Paroxysmal nocturnal dyspnea- sudden onset of SOB after a period of sleep; sitting upright is helpful.  Symptoms associated with intrathoracic infection o The patient may have any combination of the nonspecific symptoms, such as fever, dry or productive cough, blood-streaked sputum, shortness of breath, chest pain, weight loss, fatigue, and anorexia. Physical examination may reveal abnormal breath sounds.  Percussion techniques when examining the lungs (273-275) o Percuss the chest directly or indirectly, comparing sides in three areas. On the posterior chest, percuss with the patient’s head bent forward and arms folded in front. On the lateral chest, percuss with the patient’s arms raised. On the anterior chest, percuss with the patient in the same position.  Examination findings when percussing the lungs (274) o You should hear resonance over all lung areas. Hyperresonance associated with hyperinflation may indicate emphysema, pneumothorax, or asthma. Dullness or flatness suggests pneumonia, atelectasis, pleural effusion, pneumothorax, or asthma. Percuss Tones Heard over the Chest (274)  Cardiac examination findings for a patient with rheumatic fever (330-331) o Systemic connective tissue disease occurring after streptococcal pharyngitis or skin infection. Patho- characterized by a variety of major and minor manifestations (major: carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules) (minor: previous rheumatic fever, arthralgia, fever, laboratory, clinical). May result in serious cardiac valvular involvement of mitral or aortic valve; tricuspid and pulmonic are not often affected. Affected valve becomes stenotic and regurgitant. Children between 5 and 15 years of age are most commonly affected. Prevention-adequate treatment for streptococcal pharyngitis or skin infections-is the best therapy. Subjective Data- fever, inflamed swollen joints, flat or slightly raised, painless rash with pink margins with pale centers and a ragged edge (erythema marginatum). Aimless jerky 3 movements (Sydenham chorea or St. Vitus dance). Small, painless nodules beneath the skin. Chest pain, palpations, fatigue, or shortness of breath. Objective Data- characterized by a variety of major and minor manifestations. Murmurs of mitral regurgitation and aortic insufficiency. Cardiomegaly, friction rub of pericarditis, or signs of CHF.  Grading of heart murmurs (311-313) o Diseased valves, a common cause of murmurs, either do not open or close well. When the leaflets are thickened and the passage narrowed, forward blood flow is restricted (stenosis). When valve leaflets, which are intended to fit together snugly, lose competency and leak, blood flows backwards (regurgitation). o Characterization of Heart Murmurs (313)  Evaluation of ECG tracings (298-299) o An electrocardiogram (ECG) is a graphic recoding of electrical activity during the cardiac cycle. The ECG records electrical current generated by the movement of ions in and out of the myocardial cell membranes. The ECG records two basic events: depolarization, which is the spread of a stimulus through the heart muscle, and repolarization, which is the return of the stimulated heart muscle to a resting state. The ECG records electrical activity as specific waves: P-Wave: the spread of a stimulus through the atria (atrial depolarization). PR interval- the time from initial stimulation of the atria to initial stimulation of the ventricles, usually 0.12 to 0.20 seconds. QRS complex- the spread of a stimulus through the ventricles (Ventricular depolarization), less than 0.10 second. ST segment and T wave- the return of stimulated ventricular muscles to a resting state (ventricular repolarization). U wave- a small deflection rarely seen just after the T wave, thought to be related to repolarization of the Purkinje fibers. This is also seen sometimes with electrolyte abnormalities. QT interval- the time elapsed from the onset of ventricular depolarization until the completion of ventricular repolarization. The interval varies with the cardiac rate.  Examination technique for the apical pulse o Feel for the apical impulse and identify its location by the intercostal space and the distance from the midsternal line. The point at which the apical impulse is 4 most readily seen or felt should be described as the point of maximal impulse (PMI). The PMI is typically noted at the left 5th intercostal space, midclavicular line in adults and the 4th intercostal space medial to the nipple in children. If the apical impulse is more vigorous than expected, characterize it as a heave or lift. An apical impulse that is more forceful and widely distributed, fills systole, or is displaced laterally and downward may indicate increased cardiac output or left ventricular hypertrophy. o With warm hands, gently palpate the supine patient’s precordium while moving systematically through five areas. First, palpate at the apex. Second, move to the left sternal border. Third, move to the base. Fourth, go down to the right sternal border. Fifth, move into the epigastrium or axillae, if needed. o Feel for the apical impulse and identify its location, distance from the midsternal line, and width (which is usually no more than 1 centimeter). If the apical impulse is more vigorous than a gentle, brief pulsation, describe it as a heave or lift. Describe the point at which the apical impulse is most readily seen or felt as the point of maximal impulse (or PMI). Feel for a thrill, which is a fine, palpable, rushing vibration that often occurs over the base of the heart at the right or left second intercostal space. You can think of a thrill as a palpable murmur. As you feel the precordium, use your other hand to palpate the carotid artery. The carotid pulse and S1 should occur almost simultaneously.  Examining technique for different cardiac sounds and their names (309-311) o Listen for the four basic heart sounds: S1, S2, S3, and S4. S1 and S2 are the most distinct and should be characterized separately. S3 and S4 normally may or may not be present. o S1 marks at the beginning of systole and is best heard toward the apex, where it is usually louder, lower, and longer than S2. S2 marks at the end of systole and is best heard in the aortic and pulmonic areas. It is louder than S1 at the base of the heart. S3 occurs early in diastole. It normally is quiet, low-pitched, and often difficult to hear. S4 occurs late in diastole. It also normally is quiet and difficult to hear. Splitting of S1 is uncommon, but may be heard in the tricuspid area, particularly on deep inspiration. Splitting of S2 is expected and can be divided into the aortic component (or A2) and the pulmonic component (or P2). o Identify any extra heart sounds because they may indicate pathology. An increased S3 has a galloping rhythm, as in the word Ken-TUCK-y. It is best heard with the bell at the 5 apex and with the patient in the left lateral recumbent position. An increased S4 has the rhythm of the word TEN-nes-see. It is best heard with the bell at the apex and with the patient in the supine or left lateral recumbent position. A gallop is best heard the same way as an increased S4. A mitral valve opening snap is detected with the diaphragm medial to the apex at the second left intercostal space with the patient in any position. An ejection click is auscultated best with the diaphragm in a seated or supine patient. A pericardial friction rub is widely heard, and its grating or rubbing sound is clearest toward the apex.  Varicosity findings in pregnant women (338) (345) o During pregnancy in particular, increased hormonal levels weaken the walls of the vein and result in failure of the valves. o Peripheral edema is a common finding as the pregnancy progresses. Varicose veins can develop during pregnancy and in the postpartum period.  Examination of peripheral arteries(338-339) o The pulses are best palpated over arteries that are close to the surface of the body and lie over bones. These include: carotid, brachial, radial, femoral, popliteal, dorsalis pedis, and posterior tibial arteries. Palpate at least one pulse point in each extremity, usually at the most distal point. When examining the arterial pulses, the thumb may be used, especially if vessels have a tendency to move when probed by fingers. Palpate firmly but not so hard as to occlude the artery. Palpate arterial pulses (radial) to assess the heart rate and rhythm, pulse contour, amplitude, symmetry, and sometimes obstructions to blood flow.  Grading of pulses (340) o The amplitude of the pulse is described on a scale of 0 to 4: 4- bounding, aneurysmal, 3- full, increased, 2- expected, 1- diminished, barely palpable, 0- absent, not palpable.  Examination findings of a child with Kawasaki disease (349) o An acute small vessel vasculitis illness of uncertain cause affecting young males more often than females; the critical concern is cardiac involvement in which coronary artery aneurysms may develop. Patho- the cause of the vasculitis is unknown. Immune-mediated blood vessel damage can result in both vascular stenosis and aneurysm formations. Subjective Data- the symptoms are diffuse and 6 typified by fever lasting 5 days or more. The effects of a systemic vasculitis include weight loss, fatigue, and myalgia, as well as arthritis. Objective Datafindings may include fever, conjunctival injection, strawberry tongue, and edema of the hands and feet. Lymphadenopathy and polymorphous non-vesicular rashes.  Examination findings of a patient with peripheral edema (344) o Inspect the extremities for edema. Press your index finger over the bony prominence of the tibia or medial malleolus for several seconds. A depression that does not rapidly refill and resume its original contour indicates orthostatic pitting edema. The severity of edema may be characterized by grading 1+ through 4+. Any concomitant pitting can be mild or severe, as evidenced by: 1+ slight pitting, no visible distortion, disappears rapidly, 2+ a somewhat deeper pit than in 1+, but again no readily detectable distortion; disappears in 10 to 15 seconds, 3+ noticeably deep pit that may last more than a minute; dependent extremity looks fuller and swollen, 4+ very deep pit that lasts as long as 2-5 minutes; dependent extremity is grossly distorted. o If edema is unilateral, suspect the occlusion of a major vein. If edema is bilateral, consider CHF. If edema occurs without pitting, suspect arterial insufficiency or lymphedema.  Examination of ammonia in breath odor (274) o Bad breath can be a sign of infection, either acute or chronic, somewhere in the nasal or oral cavity or deep in the lung, can be the source. An especially foul or putrid odor of breath and/or sputum suggests anaerobic respiratory infections, emphysema, bronchiectasis, lung abscess, or a particularly insistent bronchitis. Your nose may provide a significant clue. Ammonia-like: uremia (ammonia)  Miscellaneous o Physical Findings Associated with Common Respiratory Conditions (283- 284) o The Sequence of Chest Steps: Inspection, palpation, percussion, and auscultation. o Two common structural findings of the chest: pigeon and funnel chest (267)7 o Do not tell the patient that you are counting the respirations to prevent the patient from varying the rate. Count the respiratory rate after palpating the pulse, just as if you were counting the pulse rate for a longer time. o Chest Pain Causes/Characteristics (301-302) o Cardiac Disease Risk Factors (303) o Heart: inspection, palpation, percussion, and palpation (304-306). o Heart Sounds after Surgical Procedures: if a cardiac surgical procedure involves placement of a prosthetic mitral valve, listen for a distinct click early in diastole, loudest at the apex and transmitted pre-cordially. A prosthetic aortic valve causes a sound in early systole. The intensity of these sounds depends on the type of material used for the prosthesis. Animal tissue is the quietest and may even be silent. Pacemakers do not cause a sound. (311) o CHF (Ride/Left Side Failure) (321) Assessing Musculoskeletal Pain (Week 8: Ch. 21 & Review 4)  Diagnostic tests for patients with carpal tunnel (524) (536) o The likelihood that a patient will have a positive electro-diagnostic study for carpal tunnel syndrome is increased by the following: weakened thumb abduction; a classic or probable distribution of symptoms on the Katz hand diagram; and hypalgesia (decreased pain sensation along the thumb and median nerve distribution when compared to the little finger on the same hand. The Tinel and Phelan tests are less accurate. o Certain patterns of pain, numbness, and tingling are associated with carpal tunnel syndrome. Ask the patient to make the specific locations of pain, numbness, and tingling on the Katz hand diagram. o Have the patient place the hand palm up and raise the thumb perpendicular to it. Apply downward pressure on the thumb to test muscle strength. Full resistance to pressure is expected. Weakness is associated with carpal tunnel syndrome. To perform the Phalen test, ask the patient to hold both wrists in a fully palmarflexed positon with the dorsal surface pressed together for 1 minute. Numbness and paresthesia in the distribution of the median nerve are suggestive of carpal 8 tunnel syndrome. The reverse Phalen test is performed by placing the pals and fingers together with full wrist extension. The Tinel sign is tested by striking the patient’s wrist with your index or middle finger where the median nerve passes under the flexor retinaculum and volar carpal ligament. A tingling sensation radiating from the wrist to the hand in the distribution of the median nerve is a positive Tinel sign and is suggestive of carpal tunnel syndrome. o Compression on the median nerve. Patho- compression of the nerve within its flexor tendon sheath due to micro-trauma, local edema, repetitive motion, or vibration of the hands. Associated with rheumatoid arthritis, gout, acromegaly, hypothyroidism, and the hormonal changes of pregnancy. Subjective Datanumbness, burning, and tingling in the hands often occur at night, can also be elicited by rational movements of the wrist. Pain may radiate to the arms. Objective Data- weakness of the thumb and flattening of the thenar eminence of the palm. Reproduction of symptoms with provocations of the Tinel and Phalen maneuvers.  Examination techniques used for muscle and joint pain  Spinal deformities noted during examination (518-519) o Kyphosis may be observed in aging adults. Lordosis is common in patients who are obese or pregnant. A sharp angular deformity, a gibbus, is associated with a collapsed vertebra from osteoporosis. o Ask the patient to bend forward slowly and touch the toes while you observe from behind. Inspect the spine for unexpected curvature, should remain symmetrical. o Reducing the Risk for Lower Back Pain- use appropriate techniques to lift heavy object to reduce the risk for lower back injury. Rather than bend over to pick up a heavy object, keep the back straight and flex the knees to get closer to the object. Keep the object close to the body and lift with knees. Avoid twisting the back during the lift.  Characteristic examination findings for Rheumatoid Arthritis (513) (538) o A chronic systemic inflammatory disorder of the synovial tissue surrounding the joints. Patho- cause is unknown. Within the inflamed synovial tissue and fluid, 9 poly-morphonuclear leukocytes aggregate. Multiple inflammatory cytokines and enzymes are released that can result in subsequent damage to bone, cartilage, and other tissue. Subjective Data- joint pain and stiffness, especially in the morning or after periods of inactivity. Constitutional symptoms of fatigue, myalgia, weight loss, and low-grade fever are common. Objective Data- involved joints include the hands, wrists, feet, and ankles as well as the hips, knees, and cervical spine. Synovitis with soft tissue swelling and effusions is present on examination. Nodules and characteristic deformities can develop. o Deviation of the fingers to the ulnar side and swan neck or boutonniere deformities of the fingers usually indicates rheumatoid arthritis. o Subcutaneous nodules along pressure points of the ulnar surface may indicate rheumatoid arthritis or gouty tophi.  Orthopedic screening evaluation techniques (538-539) (585) o The 14 step screening orthopedic examination- the athlete should be dressed so that the joints and muscle groups included in the exam are easily visible-usually gym shorts for males and gym shorts and a t-shirt for females. Keep in mind that one of the most important points to look for in the exam is SYMMETRY. o The two conditions that are considered absolute contraindications to sport participation are carditis and fever. Carditis (inflammation of the heart) can result in sudden death with exertion and fever is associated with an increased risk of heart-related illness. A good rule: Do not suggest that an athlete “play through” an injury or a problem.  Characteristic examination findings consistent with Osteoarthritis (538) o The deterioration of the articular cartilage covering the ends of bone in synovial joints. Patho- as a result of cartilage abrasion, pitting, and thinning, the bone surfaces are eventually exposed with bone rubbing against bone. Separately there can be remodeling of the bone surface and formation of bone spurs. Subjective Data- pain in hands, feet, hips, knees, and cervical or lumbar spine (most commonly). Onset usually begins after 40 years of age and develops slowly over many years with nearly 100% of people older than 75 years being affected. 10 Objective Data- the joints may be enlarged due to bone growths (osteophytes). May have crepitus and limited, painful, range of motion. o Risk Factors of Osteoarthritis (509)  Characteristic examination findings consistent with Gout (536) o Gout, a form of arthritis, is a disorder of purine metabolism that results from an elevated serum uric acid level. Patho- monosodium urate crystal deposition in joints and surrounding tissues results in acute inflammatory attacks. Subjective Data- sudden onset of a hot, swollen joint; exquisite pain; limited range of motion. Primarily affects men older than 40 years and women of postmenopausal age. Usually affects the proximal phalanx of the great toe, although the wrists, hands, ankles, and knees may be involved. Objective Data- the skin over the swollen joint may be shiny and red or purple. Uric acid crystals may form as tophi under the skin with chronic gout.  Miscellaneous: o Differential Diagnosis Chart: Comparison of Osteoarthritis with Rheumatoid Arthritis Assessment of Cognition and the Neurologic System (Week 9: Ch. 5 & 22)  Significance of the Denver II tool- (Pg. 72) is useful for determining whether the child is developing fine and gross motor skills, language, and personal-social skills as expected.  Examination of the mental status: (Pg. 66-71) the shorter screening exam is commonly used for health visits when no known neurologic problem is apparent. The following areas include: Appearance and Behavior (grooming, emotional status, & body language) Emotional Stability (mood & feelings and thought process) Cognitive Abilities (state of consciousness, memory, attention span, & judgment), and Speech and Language (voice quality, articulation, comprehension, coherence, and aphasia). o Physical Appearance & Behavior- assess grooming, emotional status, and nonverbal communication (body language)11 o State of Consciousness: patient should be oriented to person, place, time, and make appropriate responses to questions. The Glasgow Coma Scale is used to quantify the level of consciousness after an acute brain injury or medical condition. o Cognitive Abilities- evaluate cognitive functions as the patient responds to questions during the history-taking process (learning, perceiving, decision making, & memory). Analogies- ask the patient to describe simple analogies first and then more complex analogies. Abstract reasoning- ask the patient to tell you the meaning of a fable, proverb, or metaphor (A rolling stone gathers no moss). Arithmetic Calculation- ask the patient to do simple arithmetic, without paper and pencil (50+8). Writing Ability- ask the patient to write his or her name & address or a dictated phrase (letter, syllables, words). Execution of Motor Skills- ask the patient to unbutton a shirt button or to comb their hair. Memory- immediate recall or new learning, recent memory, and remote memory. Attention span- ask the patient to follow a short set of commands. Judgment- determine the judgment and reasoning skills by exploring topics o The Mini-Mental State Examination (MMSE) - is the most studied to date exam to test/assess cognition. It is a standard tool to assess cognitive function changes over time. The 11 items- measuring orientation, registration, attention and calculation, recall, and language take approx. 5-10 min to administer. The maximum score is 30, a score of 20 or less may be associated with dementia, and a score of 26 or higher is not associated with dementia (Pg. 68). o The Mini-Cog- is a brief screening tool for measuring cognitive function that takes up to 5 minutes to administer. Ask the patient to listen carefully to and remember three unrelated words (red, plate, and milk) and then immediately repeat the words. Do not help if a word is not repeated. Next the patient is asked to draw the face of a clock and draw the hands to read a specific time. (Pg. 69). o The importance of validation- if you have concerns about pt. responses/behaviors, it is important to interview a family member, and ask if the patient has had any problems with the following activities remembering important appts. Paying bills, shopping independently for food or clothing, etc.12 o Common Causes of Unresponsiveness (Pg. 67) o Speech and Language Skills- evaluation of communication skills, both receptive and expressive. Voice Quality- determine if there is any difficulty or discomfort in phonation. Articulation- evaluate spontaneous speech for pronunciation and ease of expression. Comprehension- ask the patient to follow simple one-and two step directions during the examination, such as during the attention span assessment. Coherence- the patient’s intentions or perceptions should be clearly conveyed to you. o Emotional stability- evaluated when the patient does not seem to be coping well or does not have resources to meet personal needs. Mood and Feelings- during the history and physical examination, observe the mood and emotional expression evident from the patient’s verbal and nonverbal behaviors. Thought Process & Content- observe the patient’s thought patterns, especially the appropriateness of sequence, logic, coherence, and relevance to the topics discussed. Perceptual Distortions and Hallucinations- determine whether the patient perceives any sensations that are not caused by external stimuli (hears voices, sees vivid images, or shadowy figures, smells offensive odors, tastes offensive flavors, or feels worms crawling on the skin. o Infants & Children- evaluate an infant’s general behavior and level of consciousness by observing the level of activity and responsiveness to environmental stimuli. Note whether the baby is lethargic, drowsy, stupors, alert, active or irritable. o Expressive Language Milestones for Toddlers and Preschoolers- (Pg. 73) o Pregnant Women- the prevalence of depression during pregnancy and postpartum; risk factors include history of depression, prior postpartum depression, and poor social support. o Older adults- mental function as a whole may be evaluated in about 5 minutes with the Isaac Set Test. Ask the patient to name 10 items in each of four groups: fruits, animals, colors, and towns/cities without prompting or rushing. o Prompting Memory and Cognitive Functioning- encourage patients to engage in a variety of cognitive exercises such as using the computer, various games, 13 reading books, and craft activities such as knitting or sewing, d/t significantly reduced risk of developing mild cognitive impairment. o Functional Assessment- activities of daily living, the ability to perform instrumental activities of daily living or ability to live independently is an important assessment (Pg. 74).  Examination findings associated with Attention Deficit Hyperactivity Disorder (ADHD) - (pg. 77) disorder with genetic component potentially affecting dopamine transport and reception; also may be associated with severe traumatic brain injury or function brain abnormalities. Subjective data- short attention span, easily distracted, fails to complete school assignments or follow instruction. Fidgets and squirms, often moving, running, climbing. Disruptive behavior, talks excessively, temper outbursts, labile moods, poor impulse control. Objective- onset before 7 years of age, increased motor activity, difficulty organizing tasks, difficulty sustaining attention, poor school performance, low self-esteem, and has problems in more than one setting.  Behavior patterns of a patient with Schizophrenia, Depression, Anxiety, and Mania (Pg. 76-77). o Schizophrenia- a severe persistent, psychotic syndrome with impaired reality that relapses throughout life; subjective data- hears voices, unpleasant tastes or odors, sees images, paranoid thoughts, unable to experience emotions, blunted affect, apathy, detached from environment, and poor personal hygiene. Objective dataincoherent speech, loose associations, illogical answers to questions, hallucinations, delusions, repetitive or aimless behavior, and inappropriate affect in response to a situation. o Depression- a mood disorder in which feelings of sadness, loss, anger, or frustration interfere with everyday life for an extended period (weeks or longer). Subjective data- feels sad, hopeless, worthless, no interest or pleasure in what was previously of interest or pleasurable, insomnia or excessive sleeping, or increased or decreased appetite. Objective data- poor concentration, slowed thought process and speech, agitation or restlessness. o Anxiety- a group of disorder with such marked anxiety or fear that it causes significant interference with personal, social, and occupational functioning. (Panic14 attacks, generalized anxiety disorder, specific phobias, obsessive compulsive disorder, and posttraumatic stress disorder.  Subjective data: Panic attacks- palpitations, sweating, shaking. Generalized Anxiety Disorder: chronic worry, restless, irritable, tense, fatigue. OCD: preoccupation with contamination, religion, or sexual themes. PTSD: recurrent intrusive flashbacks, dreams, thoughts, avoidance behavior.  Objective Data: Panic attacks- tachycardia, diaphoresis, tremors. Generalized Anxiety Disorders: impaired attention, motor tension, tremors. OCD: Ritualized acts performed compulsively (washing, cleaning, hoarding, counting, organizing). PTSD: anger or rage reactions, impulsive behaviors, hyperarousal, conditions persist more than 4 weeks.  Examination findings of a patient with Diabetic Peripheral Neuropathy- (pg. 578)- a disorder of the peripheral nervous system that results in motor and sensory loss in the distribution of one or more nerves, commonly caused by diabetes mellitus. Subjective data- gradual onset of numbness, tingling, burning, and cramping, most common in the hands and feet, night pain in one or both feet, early signs may be unusual sensations of walking on cotton, floors feeling strange, or inability to distinguish between coins by feel, or sensation of burning accompanied by hyperalgesia (all sensation is painful). Objective data: reduced sensation in the foot with the monofilament; loss of pain or sharp touch sensation to the mid-calf level; distal pulses may be present or diminished; etc.  Examination findings of all Cranial Nerves- cranial nerves are peripheral nerves that arise from the brain rather than the spinal cord. Each nerve has a motor or sensory function, and 4 cranial nerves have parasympathetic functions. o I (Olfactory)- sensory: smell reception and interpretation o II (Optic)- sensory: visual acuity and visual fields o III- (Oculomotor)- motor: raise eyelids, most extraocular movements; parasympathetic: pupillary constriction, change lens shape o IV (Trochlear)- motor: downward, inward eye movement15 o V (Trigeminal)- motor: jaw opening and clenching, chewing, and mastication; sensory: sensation to cornea, iris, lacrimal glands, conjunctiva, eyelids, forehead, nose, nasal, and mouth mucosa, teeth, tongue, ear, facial skin o VI (Abducens)- motor: lateral eye movement o VII (Facial)- motor: movement of facial expression muscles except jaw, close eyelids, labial speech sounds (b, m, w, & rounded vowels); sensory: taste- anterior 2/3 of tongue, sensation to pharynx; parasympathetic: secretion of salvia and tears o VIII (Acoustic)- sensory: hearing and equilibrium o IX (Glossopharyngeal)- motor: voluntary muscles for swallowing and phonation; sensory: sensation of nasopharynx, gag reflex, taste-posterior 1/3 of tongue; parasympathetic: secretion of salivary glands, carotid reflex; motor: voluntary muscles of phonation (guttural speech sounds) and swallowing o X (Vagus)- sensory: sensation behind ear & part of external ear canal; parasympathetic: secretion of digestive enzymes; peristalsis; carotid reflex; involuntary action of heart, lungs, and digestive tract o XI (Spinal accessory)- motor: turn head, shrug shoulders, some actions for phonation o XII (Hypoglossal) - motor: tongue movement for speech sound articulation (l, t, d, and n) and swallowing.  Examination techniques of all Cranial Nerves Evaluate cranial nerves one through twelve (To examine the cranial nerves, perform the following: Keep in mind that taste and smell usually are tested only if a problem is suspected. No matter which nerves you test, their function should be intact. o For cranial nerve one (the olfactory nerve), test the patient’s ability to identify familiar odors, such as coffee and mint extract, one naris at a time with the eyes closed. o For cranial nerve two (the optic nerve), test visual acuity and the visual fields. Also examine the ocular fundus with an ophthalmoscope, as described in the audio review of the Eyes. o For cranial nerves three, four, and six (the oculomotor, trochlear, and abducens nerves), assess the six cardinal points of gaze, inspect the eyelids for drooping, and observe the pupils for equality of size, shape, and reaction to light and accommodation.16 o For cranial nerve five (the trigeminal nerve), perform four assessments. First, inspect the face for muscle atrophy, jaw deviation, and tremors. Second, palpate the clenched jaw muscles for tone and strength. Third, test superficial pain and touch sensations in each branch of the nerve. (If the results are unexpected, also test temperature sensation in these areas.) Fourth, test the corneal reflex. o For cranial nerve seven (the facial nerve), observe for facial symmetry while the patient makes a series of facial expressions. Also test the ability to identify tastes on the sides of the tongue. o For cranial nerve eight (the acoustic nerve), test the sense of hearing and bone and air conduction of sound, and note sound lateralization, as described in the audio review of the Ears, Nose, and Throat. o For cranial nerve nine (the glossopharyngeal nerve), test the patient’s ability to identify tastes on the posterior third of the tongue. o For cranial nerve ten (the vagus nerve), inspect the palate and uvula for symmetry with speech sounds. Also check the gag reflex and the ability to swallow, keeping in mind that this also tests part of cranial nerve nine. Evaluate the patient’s speech sounds to detect any hoarseness, nasal quality, or difficulty with guttural sounds. o For cranial nerve eleven (the spinal accessory nerve), evaluate the size, shape, and strength of the trapezius and sternocleidomastoid muscles, as described in the audio review of the Musculoskeletal System. o For cranial nerve twelve (the hypoglossal nerve), perform four assessments. First, inspect the tongue at rest and while protruded, noting symmetry, tremors, and atrophy. Second, observe tongue movement from side to side and toward the nose and chin. Third, test tongue strength by pressing your index finger against the cheek as the tongue presses against it from the inside. Finally, evaluate the quality of lingual speech sounds, such as l, t, d, and n.  Deep Tendon Reflex evaluation- (pg. 564) With the patient relaxed and seated or lying down, test five deep tendon reflexes. When using a reflex hammer, remember to tap briskly, but not too forcefully. And be sure to score each reflex from zero (for no response) to four-plus (for a hyperactive response with clonus). o For the biceps reflex, hold your thumb over the biceps tendon and strike the thumb with the reflex hammer. This should cause elbow flexion.17 o For the brachioradial reflex, strike the brachioradial tendon (about 1 to 2 inches above the wrist) with the reflex hammer. The expected response is forearm pronation and elbow flexion. o For the triceps reflex, strike the triceps tendon directly, which should produce elbow extension. o For the patellar reflex, strike the patellar tendon just below the patella. Expect to see lower leg extension. o For the Achilles reflex, strike the Achilles tendon at the level of the ankle malleoli. In response, the foot should plantar flex. o Scoring Deep Tendon Reflexes- Grade 0-4+; normal is 2+ active or expected response  Examination technique and findings for nuchal rigidity- (pg. 565-566) a stiff neck or nuchal rigidity, is a sign that may be associated with meningitis and intracranial hemorrhage. Place your patient in a supine position, slip your hand under the head and raise it, flexing the neck. Try to make the patient’s chin touch the sternum, but do not force it. Placing your hand under the shoulder when the patient is supine and raising the shoulders slightly will help relax the neck, making the determination of true stiffness more accurate. Pain and a resistance to neck motion are associated with nuchal rigidity (other causes could be due to painful swollen lymph nodes or superficial trauma can cause neck resistance). o Brudzinski sign- may also be present when neck stiffness is assessed. Involuntary flexion of the hips and knees when flexing the neck is a positive sign and may indicate meningeal irritation. o Kernig sign- evaluated by flexing the leg at the knee and hip when the patient is supine, then attempting to straighten the leg. A positive sign is present when the patient has pain in the lower back and resistance to straightening the leg at the knee, which may indicate meningeal irritation o Vaccines Reduce Meningitis Risk- infants and young children are protected by the Haemophilus influenza type b (Hib) and the pneumococcal vaccine (PCV13) administered as routine immunization, older adolescents and children (MCV4) (pg. 566)18  Miscellaneous o Cerebrum of the brain- primarily responsible for person’s mental status. o Two cerebral hemispheres each divided into lobes, comprise the cerebrum. The gray outer layer-the cerebral cortex-houses the higher mental functions and is responsible for perception and behavior. o Frontal lobe- containing the motor cortex is associated with speech formation (in the Broca area). This lobe is responsible for decision making, problem solving, the ability to concentrate, and short-term memory. Associated areas-related to emotions, affect, drive, and awareness of self and the autonomic responses related to emotional states-also originate in the frontal lobe. o Parietal lobe- primarily responsible for receiving and processing sensory data. o Temporal lobe- responsible for perception and interpretation of sounds as well as localizing their source. It contains the Wernicke speech area, while allows a person to understand spoken and written language. The temporal lobe is also involved in the integration of behavior, emotion, and personality as well as longterm memory. o The limbic system- mediates certain patterns of behavior that determine survival (mating, aggression, fear, and affection). Reactions to emotions such as anger, love, hostility, and envy originate here, but the expression of emotion and behavior is mediated by connections between the limbic system and the frontal lobe. o The reticular activating system (RAS) is the brainstem regulates awareness and arousal. Disruption of the ascending RAS can lead to altered mental status (delirium & confusion). o Brain insults- (infection, trauma, or metabolic imbalance) can damage brain cells, which may result in serious permanent dysfunction in mental status. o Infants- all brain neurons are present at birth in a full-term infant, but brain development continues with myelinization of nerve cells over several years. o Adolescents- abstract thinking (ability to develop theories, logical reasoning, making future plans, use generalizations, and consider risks & possibilities) 19 develops during this period. Judgment begins to develop with education, intelligence, and experience. o Older adults- cognitive function should be intact in the healthy older adult, but declines in cognitive abilities occur in some after 60. Speed of information processing and psychomotor speed begin declining at a modest rate after 30, but verbal skills & general knowledge continue to increase into the 60s. o Medications- anticholinergics, benzodiazepines, opioid analgesics, tricyclic antidepressants, levodopa or amantadine, diuretics, digoxin, antiarrhythmic, sedatives, hypnotics, or alternative and complementary therapies such as gingko biloba and St. John’s Wort. o Proprioception and Cerebellar Functions- (pg. 556-559) coordination and fine motor skills, rapid rhythmic alternating movements, accuracy of movements. Balance of equilibrium and gait. o Sensory function- (pg. 559-562) Characteristics of unexpected gait patterns o Primary Sensory Functions- superficial touch, superficial pain, temperature and deep pressure, vibration, position of joints (pg. 561) o Cortical Sensory Functions- (pg. 561-562) stereognosis, two-point discrimination, extinction phenomenon, graphesthesia, point location. o Advanced Skills (pg. 565-566)) are performed when problems are detected with routine examination. Protective sensation- use the 5.07 monofilament to test for sensation on several sites of the foot in all patients with diabetes mellitus and peripheral neuropathy. Minegial Signs (nuchal rigidity) stiff neck. Jolt Accentuation of Headache- presenting with fever and headache that leads to a suspected diagnosis of meningitis; move head horizontally at a rate of 2 to 3 rotations per second, positive sign indicated by an increased headache over baseline. Posturing- postures that may be found in unresponsive patients are associated with a severe brain injury. Decorticate or flexor posturing is associated with injury to the corticospinal tracts above the brain stem; associated to injury to brainstem. o Indirect cranial nerve evaluation in newborns and infants- (pg. 567-569) o Abnormalities: Disorders of the neurologic system (pg. 573-580)20 Assessing the Genitalia and Rectum Case Study (Week 10: Ch. 16, 18, 19, & 20)  Significance of Montgomery tubercles o Tiny sebaceous glands may be apparent on the areola surface (Montgomery tubercles or follicles). The primary function is lubricating and keeping germs away from the breasts. The glands make oily secretions to keep the areola and the nipple lubricated and protected during pregnancy and location, and it is normal to have small bumps on the flat, brown part of the areola called Montgomery glands.  Examination findings of breast changes during menopausal o The breast in postmenopausal women may appear flattened, elongated, and suspended more loosely from the chest wall as the result of glandular tissue atrophy and relaxation of the suspensory ligaments. A finer granular feel on palpation replaces the lobular feel of glandular tissue. The inframammary ridge thickens and can be felt more easily. The nipples become smaller and flatter.  Examination findings consistent with breast cancer in females o Screening Recommendations & Breast Cancer Risk Factors (354) o Nipple retraction and dimpling of skin, nipple discharge, painless lump, axilla may be tender if lymph nodes involved, palpable mass usually single; unilateral, irregular, or stellate in shape; poorly delineated borders; fixed; hard or stone-like; and non-tender; breast dimpling, retraction, prominent vasculature; skin may have peau d’ orange or thickened appearance; nipple may be inverted or deviated in position.  Proper technique for using a speculum during the vaginal exam (430-431) o Lubricate the speculum with water or a water-soluble lubricant; warm water if speculum is cold. Select the appropriate size speculum and hold it in your hand with the index finger over the top of the proximal end of the anterior blade and the other fingers around the handle. This position controls the blades as the speculum is inserted into the vagina. Apply downward pressure and ask the woman to 21 breathe slowly and relax the muscles. Use the fingers of that hand to separate the labia minora so that the vaginal opening becomes clearly visible. Then slowly insert the speculum along the path of least resistance, often slightly downward, avoid trauma to the urethra and vaginal walls. Insert the speculum the length of the vaginal canal. While maintaining gentle downward pressure with the speculum, open it by pressing on the thumb piece. Sweep the speculum slowly upward until the cervix comes into view. Gently reposition the speculum, if needed until cervix is in view. Once you visualize the cervix, manipulate the speculum to fully expose the cervix between the anterior and posterior blades. Lock the speculum blades into place to stabilize the distal spread of the blades, and adjust the proximal spread as needed.  Proper technique for the bimanual examination o Breast: Place one hand, palmar surface facing up, under the patient’s right breast. Position your hand so that it acts as a flat surface against which to compress the breast tissue. With the fingers of the other hand, walk across the breast tissue, feeling for lumps as you compress the tissue between your fingers and your flat hand. Repeat the procedure for the other breast. o Female Genitalia: Inform of examination internally using the fingers; lubricate index and middle fingers and insert into the vaginal opening and press downward. Gently insert fingers the full length into the vagina. Palpate the vaginal wall as you insert your fingers. It should be smooth, homogeneous, and non-tender. Feel for cysts, nodules, masses, or growths. Be careful where you place your thumb during the bimanual exam. You can tuck it into the palm of your hand, but that will cut down on the distance you can insert your fingers. Be aware of where the thumb is and keep it from touching the clitoris, which can produce discomfort. o Examining the woman who has had a hysterectomy (436)  Proper technique for examining the male genitalia, including the prostate o Inspection and Palpation: 1 st Inspect- Genital Hair Distribution- coarser than scalp hair. 2nd Penis: the dorsal vein should be apparent on inspection if uncircumcised, retract the foreskin, should retract easily and have a bit of smegma (white cheesy sebaceous matter). 3 rd Urethral Meatus- examine the orifice 22 should appear slitlike and be located on the ventral surface from the tip of the glans. Press the glans between the thumb and forefinger to open the urethral orifice, should be glistening and pink, bright erythema or discharge indicates inflammatory disease, and a pinpoint or round opening may result from meatal stenosis. 4 th Penile Shaft- palpate the shaft for tenderness and induration. Strip the urethra for any discharge by firmly compressing the base of the penis with your thumb and forefinger and moving them toward the glans. Discharge may indicate an STI, the texture of the flaccid penis should be soft and free of nodularity. 5 th Scrotum- inspect, it may appear more deeply pigmented than the body skin, and the surface may be coarse. Lumps in the scrotal skin are commonly caused by sebaceous cyst also called epidermoid cysts. They appear as small lumps on the scrotum but they may enlarged and discharge oily material. 6 th Hernia- examine, with the patient standing, ask him to bear down as if having a BM. While he is straining, inspect the area of the inguinal canal and the region of the fossa ovalis. After asking the patient to relax again, insert your examining finger into the lower part of the scrotum and carry it upward along the vas deferens into the inguinal canal. You can auscultate for bowel sounds, which will be present in uncomplicated reducible hernias. It is best to use the middle or index finger in adults, ask the patient to cough. If an inguinal hernia is present, you should feel the sudden presence of a viscus hernia is present, you should feel the sudden presence of a viscus against your finger. The hernia is described as indirect if it lies within the inguinal canal, and suggests the possibility of bilateral herniation, examine both sides thoroughly. If the viscus is felt medial to the external canal, it probably represents a direct inguinal hernia. 7 th Testes- palpate the testes using the thumb and first two fingers, should be sensitive to gentle compression but not tender, should feel smooth and rubbery and be free of nodules. Irregularities in texture may indicate infection, cyst, or a tumor. In some diseases, a testis may be totally insensitive to painful stimuli (syphilis and diabetic neuropathy). 8 th Cremasteric Reflex- stroke the inner thigh with a blunt instrument such as the handle of the reflex hammer, or a finger if a child. The testicle and scrotum should rise on the stroked side. 23 o Genital Self-Examination for Men (470) - the purpose of GSE is to detect any signs or symptoms that might indicate the presence of an STI. Instruct the patient to hold the penis in his hand and examine the head if uncircumcised, gently pull back the foreskin to expose the glans. Inspection and palpation of the entire head should be performed in a clockwise motion while looking for bumps, sores, or blisters on the skin. Bumps and blisters may be red or light colored or may resemble pimples. Have the patient look for genital warts. The urethral meatus should also be examined for discharge. Next the patient will examine the entire shaft and look for the same signs. Instruct him to separate the pubic hair at the base of the penis and carefully examine the skin underneath. Make sure he includes the underside of the shaft in the exam. Instruct the patient to examine the scrotal skin and contents, he should hold each testicle gently and inspect and palpate the skin, including the underneath of the scrotum, looking for lumps, swelling, or soreness. Gently feel each testicle. Suggest to the patient that selfexamination of the scrotum at home be performed while bathing, because the warmth is likely to make the scrotal skin less thick. Lastly, educate the patient regarding symptoms associated with STIs, including, pain, burning on urination, or discharge, including the color, and if any reported, contact health provider.  Proper Technique for examining the prostate (491) o Explain to the patient that the urge to urinate may be felt, but that he will not urinate. In males you can palpate the posterior surface of the prostate gland on the anterior wall. Note the size, contour, consistency, and mobility of the prostate. The gland should feel like a pencil eraser-firm, smooth, and slightly movable-and it should be non-tender. A healthy prostate has a diameter of about 4 cm, with less than 1cm protrusion into the rectum.  Risk factors for testicular and Penile cancer (470) o Testicular Cancer: Undescended testicle (cryptorchidism); risk elevated for both testicles, Personal history of testicular cancer (the opposite testicle is at increased risk), Family history of testicular cancer, abnormal testicle development: Klinefelter syndrome, Age: 20-54 years old, Race: white; 5 times that of black men and more than 3 times that of Asian American and Native American men.24 o Penile Cancer: lack of circumcision with failure to maintain goo hygiene, Phimosis (occasionally the foreskin is tight and cannot be retracted), Infection with high risk types of HPV, Risk increases with age, smoking, HIV Infection, UV light treatment of psoriasis if genitalia exposed.  Normal vs abnormal bowel findings in newborns o Normal bowel findings- the first meconium stool is ordinarily passed within the first 24 to 48 hours after birth and indicates anal patency. Thereafter, it is common for newborns, especially those breastfed, to have a stool after each feeding (the gastrocolic reflex). Both the internal and external sphincters are under involuntary reflexive control because myelination of the spinal cord in incomplete. Control of bowel is often achieved before control of bladder. o If there is no passage of stool in 24 hours in a newborn, suspect rectal atresia. Hirschsprung disease (congenital megacolon), or cystic fibrosis.  Risk factors for colorectal cancer (498) o Cancer of the large intestine or rectum. Patho- adenocarcinomas comprise the large majority of colorectal cancers. Accumulation of genetic and epigenetic alterations that affect essential cellular and tissue-level functions. Begins with cell proliferation with progression to adenoma and invasive carcinoma. The APC tumor suppressor gene is defective in more than 80% of adenomatous polyps and colon cancers. Subjective Data- bleeding most common symptom, often asymptomatic, may report change in bowel habits or stool characteristics. May report abdominal pain or tenderness. May report personal or family history of colon polyps. May report family history of colon cancer. Objective data- rectal cancer may be felt as a sessile polypoid mass with nodular raised edges and areas of ulcerations; the consistency is often stony, and the contour is irregular. Carcinoma higher in the colon not palpable. Polys or lesions visualized on colonoscopy or flexible sigmoidoscopy. o Risk Factors: overweight/obese, physical inactivity, certain diets (red meats/processed meats), smoking, heavy alcohol use, old age after 50, history of colorectal polyps, history of IBS, family history of colorectal cancer or 25 adenomatous polyps, Lynch Syndrome, Familial adenomatous polyposis, Type 2 DM, and ethnic background of black.  Examination findings consistent with Benign Prostate Hypertrophy (498) o Nonmalignant enlargement of the prostate. Patho- common in men older than 50 years. Gland begins to grow at adolescence, continuing to enlarge with advanced age. Growth of the prostate parallels the increased incidence of BPH. Subjective Data- symptoms of urinary obstruction: hesitancy, decreased force and caliber of stream, dribbling, incomplete emptying of the bladder, frequency, urgency, nocturia, and dysuria. Objective Data- Prostate feels smooth, rubbery, symmetric, and enlarged. Median sulcus may or may not be obliterated.  Examination findings consistent with Prostate Cancer o Cancer of the prostate. Patho- Over 99% of prostate cancers are adenocarcinomas, developing from the gland cells in the prostate. In most cases, prostate cancer is a relatively slow-growing cancer; a small percentage is a rapid growing, aggressive form. Incidence increases with age and is less frequent in men younger than 50 years of age. Pathogenesis poorly understood. Following the initial transformation event, further mutations of a multitude of genes lead to tumor progression and metastasis. Subjective Data- early carcinoma asymptomatic, as the malignancy advances, symptoms of urinary obstruction occur. Objective Data- a hard, irregular nodule may be palpable on prostate exam. Prostate feels asymmetric, and the median sulcus may be obliterated. Biopsy required for diagnosis. o Risk Factors of Prostate Cancer (488) o Risk Factors of Anal Cancer (488)  Examination position when assessing anal sphincter tone o Ask pt. to tighten and relax her anal sphincter. Observe sphincter tone. An extremely tight sphincter may be the result of anxiety about the exam; bay be caused by scarring; or indicate spasticity caused by fissures, lesions, or inflammation. A lax sphincter suggests neurologic deficit, whereas an absent sphincter may result from improper repair of a third-degree perineal laceration after childbirth or trauma. Positions: standing position, left lateral decubitus, or knee to chest. 26  Characteristics of menopausal disorder o Menopause is defined as 1 year without menses (amenorrhea). Estrogen levels decrease, causing the labia and clitoris to become smaller. The labia majora becomes flatter as body fat is lost. Pubic hair turns gray and is usually sparser. Both adrenal androgens and ovarian testosterone leaves markedly decrease after menopause, which may account in part for decreases in libido and in muscle mass and strength. The vagina narrows, shortens, and loses its rugae, and the mucosa becomes thin, pale, and dry, which may result in pain with sexual intercourse (dyspareunia). The cervix becomes paler. The uterus decreases in size, and the endometrium thins. The ovaries also decrease, follicles gradually disappear, and the surface of the ovary convolutes. Ovulation usually ceases about 1 to 2 years before menopause. The vaginal walls may lose some of their structural integrity. There may also be an increase in body fat and intraabdominal deposition of body fat, and thermoregulation is altered, which produces the hot flashes associated with menopause.  Characteristics of Pelvic Inflammatory Disease (462) o Infection of the uterus, fallopian tubes, and other reproductive organs; a common and serious complication of some STIs. Often caused by Neisseria gonorrhoeae and chlamydia trachomatis, and may be acute or chronic. Subjective data: symptoms may be mild or absent, unusual vaginal discharge that may have a foul odor, symptoms include painful intercourse, painful urination, irregular menstrual bleeding, and pain in the right upper abdomen. Objective data: acute PID produces very tender, bilateral adnexal areas; the patient guards and usually cannot tolerate bimanual examination; symptoms of chronic PID are bilateral, tender, irregular, and fairly fixed adnexal areas.  Characteristics of Hydrocele, Epididymitis, Epispadias, and Hypospadias o Hydrocele- when any mass other than the testicle or spermatic cord is palpated in the scrotum, determine whether it is filled with fluid, gas, or solid material. It will most likely be a hernia or hydrocele. Attempt to reduce the size of the mass by pushing it back through the external inguinal canal. If a bright penlight transilluminates the mass, and there is no change in size when reduction is 27 attempted, it most likely contains fluid (hydrocele). Fluid accumulation in the scrotum; as a result of a defect in the tunica vaginalis; this condition is common in infancy; if the tunica vaginalis is not patent, the hydrocele will generally disappear spontaneously in the first 6 months of life; painless enlargement or swelling of the scrotum; non-tender, smooth, firm mass superior and anterior to the testes; transilluminates; confined to the scrotum and does not enter the inguinal canal unless it has been present for a long time and is very large and taut. o Epididymitis- acute painful swelling without discoloration and a thickened or nodular epididymis suggest epididymitis. Often seen in association with a urinary tract infection; can occur from STI, chronic epididymitis may occur from tuberculosis. Subjective data- painful scrotum, urethral discharge, fever, pyuria, recent sexual activity. Objective data- epididymis feels firm and lumpy; is tender, vasa deferentia may be beaded, overlying scrotum may be markedly, (482) o Epispadias- is a rare type of malformation of the penis in which the urethra ends in an opening on the upper aspect of the penis. It can also develop in females when the urethra develops too far anteriorly. Usually diagnosed at birth during exam; can go unnoticed until parent note urine leaks after potty training. o Hypospadias- congenital defect in which the urethral meatus is located on the ventral surface of the glans penile shaft or the base of the penis. Congenital defect that is thought to occur embryological during urethral development, from 8 to 20 weeks of gestation. Presence of this disorder places the infant at greater risk of having undescended testicles. Parents may note penile defect or may be found by health care provider. Diagnosis generally made on exam of newborn infant. Urethral meatus located on ventral surface of the glans penile shaft or the base of the penis. Dorsal hood of foreskin and glandular groove are evident, but prepuce is incomplete ventrally. Penis may have ventral shortening and curvature, called chordee, with more proximal urethral defects.  Cancer of the Male Genitalia (Penile/Testicular) (470)  Miscellaneous o Vaginal Discharges and Infections (Female Genitalia) (457)28 o ** Unexplained Fever: the search for an unexplained fever should always include the rectal examination- a rectal condition or prostatitis may be the cause. The Ethics Behind Assessment (Week 11: Ch. 23 24) [Review: Ch. 16 & 18]  Ethical considerations when completing adolescent sports physicals with no injuries vs adolescents with previous injuries  Diagnostics tests used to evaluate sports injuries (583, 585-587, 588-589) o Recommended components of the pre-participation physical evaluation (pg. 583) o Sports-Related Concussion/Sport Concussion Assessment Tool (SCAT3) (pg. 588-592) o The 14 Step screening orthopedic examination (pg. 585-587)  Examination of children with heart murmurs when conducting a sports physical (583) o Heart murmur (auscultation should be performed in both supine and standing positions, or with Valsalva maneuver, to identify murmurs of dynamic left ventricular outflow obstruction).  Ethical considerations to be made as Advanced Practice Registered Nurse  Miscellaneous o Hypertension in the pediatric adult (pg. 582) o Atlantoaxial Instability (pg. 582) o The Female Athlete Triad (pg. 593) a trio of problems- disordered eating, amenorrhea, and osteoporosis-define the female athlete triad due to the sport stressors and the need to be lean (gymnastics, figure skating, diving, ballet, etc.) o Classification of Sports According to Contact (587 [Show More]

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