Your Hesi exam is scheduled for Tuesday, August 6 at 07:45-09:55 am (exam length is 130 minutes). There is no blueprint as it is a national exam. You need to study all the content from the syllabus to prepare for the HESI NGN EXAM (the hesi exam contributes 10% of your grades to pass the course). No backtracking on this exam. I will share more information on HESI NGN questions during our lecture on 7/30. · Your Final Exam is scheduled for Tuesday, August 13, from 07:45 to 08:50 (the final exam contributes 20% to your grade to pass the course). No questions related to the pediatric population and pregnant women. Backtracking is allowed in exams. · Also, please make sure to take your Elsevier HESI practice test before the due date 08/04/2024 at 11:59 pm (https://hesi-preparation-suite.elsevier.com/#/assignment). Please note that the first attempt grade is considered as final grade Exam Blueprint Final Exam-Summer 2024 In each chapter, you need to focus on the assessment procedure, normal findings, and abnormal findings for each system). (Study contents from book chapters, PPT, lectures and review EAQ questions from Sherpath) Musculoskeletal System Assessment (Approx. 10 questions) Fibrous joints: do not move (sutures in skull) Cartilaginous joints: slightly moveable (vertebrae) Synovial joints: freely moveable Bursae is cushion; facilitate movement of muscles and tendons Tendon - attach muscle to bone Ligament - two bones together (attach bone to one another) Joint (articulation): place of union of two or more bones · Normal palpation and range of motion (ROM) for all joints Flexion Bending limb at joint Extension Straightening limb at joint Abduction Moving limb away from midline of body Adduction Moving limb towards midline of body Pronation Turning forearm so palm down Supination Turning forearms so palm up Circumduction Moving arm in circle around shoulder Inversion Moving sole of foot inward at ankle Eversion Moving sole of foot outward at ankle Rotation Moving head around central axis Protraction Moving body part forward, parallel to ground Retraction Moving body part backward, parallel to ground Elevation Raising a body part Depression Lowering a body part Cervical Spine Normal Assessment Inspection of head/neck Spine is straight & head is erect Nontender, firm and smooth, with no muscle spasm Palpate spinous processes, sternomastoid, trapezius, and paravertebral muscles Test ROM Ask pt to touch chin to chest (flexion) & to look at the ceiling (hyperextension) Test lateral bending Ask pt to touch ear to shoulder on both sides Evaluate rotation Ask pt to turn head to right and left Shoulders Inspect shoulders Compare both shoulders posteriorly & anteriorly Palpate shoulders Stand in front of person, note muscular spasm or atrophy, swelling, heat, or tenderness Flexion & extension → 45° Can maintain flexion against full resistance (tests cranial nerve XI spinal nerve) L & R side → 40° Abnormal Assessment Pain & tenderness compression fractures or lumbosacral muscle strain Cervical strain most common Limited ROM can indicated neck injuries, osteoarthritis, spondylosis, or disk degeneration Rotation → 70° Clinical Tips & OAC Impaired ROM, neck pain, fever, chills, headache meningitis Impaired ROM and/or pain refer for further evaluation Humerus, scapula, clavicle (3 large bones) Symmetrically round No redness, swelling, deformity, or heat. No tenderness. Atrophy Dislocated shoulder Joint effusion Tear of rotator cuff limited abduction Frozen shoulder-adhesive capsulitis If pt reports shoulder pain, ask pt to point to spot with hand of unaffected side shoulder pain may be local or referred (local pain is reproducible Test ROM Flexion, extension, adduction, abduction, motion against resistance Shrug shoulders Bring hands together behind the head with elbows flexed (external rotation) & behind the back (internal rotation) Knees Inspection: size, shape, symmetry, swelling, deformities, and alignment Palpate: tenderness, warmth, consistency, and nodules during exam by palpation or motion) Flexion → 180° Hyperextension → 50° Adduction → 50° Abduction → 180° Internal rotation → 90° External rotation →90° Shoulder shrug tests cranial nerve XI (spinal accessory) Largest joint in body; hinge joint Symmetric, hollow, no swelling or deformities, lower leg in alignment with upper leg Nontender, cool, firm, no nodules Swelling, not symmetric, tender, warm nodules Shiny and atrophic skin. Swelling or inflammation If swelling is present perform bulge test to determine if fluid is d/t accumulation of fluid or soft-tissue swelling Lesions (psoriasis) Angulation deformity: - Genu varum (bowlegs) - Genu valgum (knock-knees) - Flexion contracture Test knees ROM: flexion, extension/hyperextension TMJ (mandible and temporal bone) Flexion → 120-130° Extension to hyperextension → 15° Pt should have full ROM against resistance Osteoarthritis decreased ROM with synovial thickening & crepitation Ballottement test detects large amounts of fluid in knee Older adults: pt may be bow-legged because of decreased muscle control Inspection: Check for symmetry Palpate: contracted temporalis and masseter muscles as person clenches teeth; Compare right and left sides for size, firmness, and strength; Ask person to move jaw forward and laterally against your resistance, and to open mouth against your resistance (tests CN V). ROM: - Hinge action to open and close jaws - Gliding action for protrusion and retraction - Gliding for side-to-side movement of lower jaw Symmetric shape/size on each side; Audible and palpable snap or click occurs in many healthy people as mouth opens Swelling, limitation of motion and/or reported pain. Articulation of mandible and temporal bone Limited ROM: inability to open/close fully, unable to retract or protrude, or sliding Can feel it in depression anterior to tragus of ear Speaking and chewing: Crepitus and pain occur with TMJ dysfunction during movement or chewing (CN V) permits jaw function of speaking and chewing. Elbow Inspect size and contour of elbow in both flexed and extended positions. Check olecranon bursa and the normally present hollows on either side of the olecranon process - Deformity, redness, or swelling - Subluxation of the elbow shows the forearm dislocated posteriorly - Swelling in olecranon bursa; effusion or synovial thickness on either side of olecranon process occurs w/ gouty arthritis and bursitis “Tennis elbow” – Inflammation of the lateral epicondylitis es Palpate Use your left hand to support the person’s left forearm and palpate the extensor surface of the elbow—the olecranon process and the medial and lateral epicondyles of the humerus—with your right thumb and fingers Landmarks: medial and lateral epicondyles and large olecranon process ROM – bend and straighten @ elbow – Place forearm on table and move palm up and palm down Flexion → 150 to 160° Extension → 0° Pronation & Supination → 90° epicondyles, head of radius, and tendons are common sites of inflammation and local “Tennis elbow” – Inflammation of the lateral epicondyles Contains 3 bony articulations: humerus, radius and ulna of forearm Some healthy people lack 5-10° of full extension, and others have 5-10° of hyperextensi on. After a fall or trauma, full extension of the elbow can usually rule out fracture. Wrist & Hand (Radiocarpal joint) Inspect - inspect hands and wrists on dorsal and palmar sides. - Note position, contour, and shape; Normally no swelling or redness, deformity, or nodules are present. kin looks smooth with knuckle wrinkles present and no swelling or lesions. Muscles are full, with the palm showing a rounded mound proximal to the thumb (the thenar eminence) and a smaller rounded Subluxation (partial dislocation) of wrist. Ulnar deviation; fingers list to ulnar side. Ankylosis; wrist in extreme flexion. Dupuytren contracture; flexion contracture of finger(s). Subluxation (partial dislocation) of wrist. Ulnar deviation; fingers list to ulnar side. Ankylosis; wrist in extreme flexion. Dupuytren contracture; mound proximal to the little finger. Palpate - each joint in the wrist and hands. Facing the person, support the hand with your fingers under it and palpate the wrist firmly with both of your thumbs on its dorsum Use your thumb and index finger in a pinching motion to palpate the sides of the interphalangeal joints ROM Hip Normal depressed areas that overlie joint space Joint surfaces feel smooth, w/ no swelling, bogginess, nodules, or tenderness Normally no synovial thickening, tenderness, warmth or nodules present Pronation →° Supination →° Flexion → 90° wrist and hands (@ fingers) Extension → 70° (@ wrist), 30° (@ fingers) Radial flexion → 20° Ulnar flexion →55° (50-60) Making a fist, Abduction of fingers → 20° Touch thumb to fingers Swan-neck or boutonnière deformity in fingers. Atrophy of the thenar eminence with carpal tunnel syndrome Ganglion cyst is a localized swelling in wrist Synovial swelling on dorsum. flexion contracture of finger(s). Rheumatoid arthritis (RA) shows bilateral swelling and tenderness. Generalized swelling with arthritis and infection. Tenderness after a fall—check for fracture. Articulation of distal radius on thumb side and row of 8 carpal bones Metacarpoph alangeal (MCP) and the interphalange al joints (DIP and PIP) permit finger flexion and extension Inspect inspect the hip joint together with the spine a bit later in the examination as the person stands Symmetric levels of iliac crests, gluteal folds, and equally sized buttocks. Palpate In supine position, palpate the hip joints. Joints should feel stable and symmetric, with no tenderness or crepitus. Pain with palpation ROM Flexion w/ knee extended → 90° Flexion w/ knee bent and other leg straight on table →120° Fleas knee and hip to 90: - internal rotation →40° - external rotation →45° Abduction → 40-45° Adduction → 20-30° Hyperextension (swinging leg back when standing ) → 15° - Limited motion. - Pain with motion. - Flexion flattens the lumbar spine; if this reveals a flexion deformity in the opposite hip, it is a + Thomas test. Weight-bearing should fall on middle of foot; most feet have a longitudinal arch, but this can vary normally from “flat feet” to high instep. Note locations of calluses or bursal reactions as they reveal areas of abnormal friction. Ankle & Foot (tibiotalar joint) Inspect Compare both feet, noting contour of joints; foot should align with long axis of lower leg. Articulation between acetabulum and head of femur A smooth, even gait reflects equal leg lengths and functional hip motion. Toes point straight forward and lie flat Ball and suction action permits wide ROM Crepitation - Limited internal rotation of hip is an early and reliable sign of hip disease. - Limitation of abduction of the hip while supine is the most common motion dysfunction found in hip disease. hallux valgus the distal part of the great toe is directed Landmarks and 2 bony prominences: medial malleolus and lateral malleolus away from the body midline Palpate Palpate metatarsophalangeal joints between your thumb on dorsum and fingers on plantar surface The ankles (malleoli) are smooth bony prominences. Normally the skin is smooth, with even coloring and no lesions Joint spaces should feel smooth and depressed, with no fullness, swelling, or tenderness. ROM assess for any limitation or presence of pain Plantar flexion → 45° Dorsiflexion → 20° Eversion → 20° Inversion → 30° Hammertoes. Calluses. Ulcers. -Swelling or inflammation. -Tenderness, occurs with arthritis, trauma to ligaments. -Plantar fasciitis shows localized tenderness under heel where fascia is torn -Swelling or inflammation, tenderness, occur with arthritis or trauma. Limited ROM. Pain with motion. · Carpal Tunnel Syndrome and related examinations ❖ Caused by pressure because of compression on the median nerve in the carpal tunnel of the wrist ➢ carpal tunnel – narrow passageway surrounded by bones and ligaments on the palm side of the hand. ❖ S/S ➢ pain, nighttime pain, burning and numbness, positive findings on Phalen test, positive Tinel sign, and often atrophy of thenar muscles (bulges on palm by thumb). ➢ Pain along thumb, index finger, and middle finger and atrophy (from interference with motor function) ➢ Caused by chronic repetitive motion; occurs between 40 and 60 years and is more common in women ❖ Test ➢ Phalen test – Ask the person to hold both hands back to back while flexing the wrists 90 degrees. Acute flexion of the wrist for 60 seconds produces no symptoms in the normal hand ■ produces numbness and burning in a person with carpal tunnel syndrome ➢ Tinel sign test – Direct percussion of the location of the median nerve at the wrist produces no symptoms normally ■ In carpal tunnel syndrome percussion of the median nerve produces burning and tingling along its distribution → + Tinel sign. ➢ · Musculoskeletal examinations for knee-related abnormalities ❖ Knee abnormalities ➢ Angulation deformity: ■ Genu varum (bowlegs) (see p. 608) ■ Genu valgum (knock-knees) ■ Flexion contracture ➢ Hollows disappear; then they may bulge with synovial thickening or effusion. ➢ Atrophy of quadriceps muscle (prime mover of knee) occurs with disuse or chronic disorders ■ 1st appears in the medial part of the muscle, although it is difficult to note because the vastus medialis is relatively small. ➢ Feels fluctuant or boggy with synovitis of suprapatellar pouch ➢ Limited ROM. ➢ Contracture. ➢ Pain with motion. ➢ Limp. ➢ Sudden locking—The person is unable to extend the knee fully. This usually occurs with a painful and audible “pop” or “click.” ■ Sudden buckling, or “giving way,” occurs with ligament injury, which causes weakness and instability. ➢ + McMurray’s Test ➢ At tibiofemoral joint ■ Irregular bony margins occur with osteoarthritis. ■ Pain at joint line. ■ Pronounced crepitus is significant, and it occurs with degenerative diseases of the knee · Spine deformities; special testes and abnormal findings related to the range of motion of back, knee, and spine (bulge sign and ballottement of the patella, McMurray’s test, Straight Leg Raising etc) ❖ Spine deformities ➢ Kyphosis: Enhanced thoracic curve typically seen in aging people ➢ Lordosis: Pronounced lumbar curve seen in obese people ➢ ROM – flexion 75-90 degrees and smoothness and symmetry of movement ■ Concave lumbar curve should disappear with this motion; back should have single convex C-shaped curve. ■ If you suspect spinal curvature during inspection, this may be more clearly seen when person touches toes. ■ While person is bending over, mark a dot on each spinous process; when person resumes standing, dots should form a straight vertical line. ■ ❖ Back ❖ Knee Deformities ➢ Bulge sign → confirms the presence of small amounts of fluid as you try to move the fluid from one side of the joint to the other ■ For swelling in the suprapatellar pouch ■ Firmly stroke up on the medial aspect of the knee 2 or 3 times to displace any fluid ■ Tap the lateral aspect ■ Abnormal ● Watch medial side in hallow for a distinct bulge from fluid wave ■ occurs with very small amounts of effusion, 4 to 8 mL, from fluid flowing across the joint ■ IDs pt @ risk for knee pain and progressive osteoarthritis of the knee ➢ Ballottement of Patella – reliable when larger amounts of fluid are present ■ Use your left hand to compress the suprapatellar pouch to move any fluid into the knee joint. ■ With your right hand push the patella sharply against the femur. ■ Normal – no fluid is present ● the patella is already snug against the femur ■ Abnormal – fluid has collected ● your tap on the patella moves it through the fluid, and you will hear a tap as the patella bumps up on the femoral condyles ➢ McMurray’s test – to test for meniscal tears w/ ROM ■ Perform this test when the person has reported hx of trauma followed by locking, giving way, or local pain in the knee ■ Steps: ● 1. Position the person supine as you stand on the affected side ● 2. Hold the heel and flex the knee and hip ● 3. Place your other hand on the knee with fingers on the medial side. ● 4. Rotate the leg in and out to loosen the joint. ● 5.Externally rotate the leg, and push a valgus (inward) stress on the knee. ● 6. Slowly extend the knee. Normally the leg extends smoothly with no pain ■ Abnormal finding – hearing a “click” → + McMurry Test → torn meniscus; should be referred to ortho for imaging and possible surgery ➢ Straight Leg Raising aka Lasègue’s Test ■ If test produces back and leg pain and may confirm presence of herniated nucleus pulposus. ■ Straight leg raising while keeping the knee extended normally produces no pain. ■ Test positive if it reproduces sciatic pain; if lifting affected leg reproduces sciatic pain, it confirms presence of herniated nucleus pulposus. ■ This stretches the nerve route over the disc protrusion and gives a painful response of muscle contraction. ■ Raise unaffected leg leaving other leg flat; inquire about involved side to check for a crossed straight leg raise test · Health promotion and patient teaching specifically for older age ❖ Focus on the following areas: ➢ Diet to protect and maintain healthy bones ➢ Smoking cessation ➢ Alcohol intake pattern ➢ Exercise promotion ➢ Osteoporosis ■ Screening ● Recommendation for DEXA (low dose xray) screening for females: Women ages 65 and older postmenopausal women younger than 65 years who are at increased risk for osteoporosis with a low-dose x-ray called DXA ■ To reduce the risk, all adults should engage in regular physical activity, including strength training, balance training, and fast walking ■ Maintain a healthy body weight and get the recommended amount of calcium and vitamin D ➢ Fall prevention risk ❖ · Abnormalities Affecting Multiple Joints: Shoulder, Elbow and Spine, Wrist, Hand Knee, Ankle and Foot Abnormalities (focus lecture, PPT, and footnotes in the PPT) ❖ Inflammatory conditions ➢ Rheumatoid arthritis – autoimmune disease characterized by chronic inflammation and pain. ■ Patients are treated with anti-inflammatory agents but may still experience chronic pain despite inflammatory suppression ■ Rheumatoid Nodules: ● raised firm nodules are granulomatous lesions that grow along small blood vessels in people with RA. ● Can be tender or nontender, movable or fixed; skin slides freely over nodules. ● Develop over pressure points such as extensor surface of arm (ulna) and olecranon. ■ Chronic RA conditions ● Swan-neck and boutonniere deformities ● Ulnar deviation or drift ● Degenerative joint disease or osteoarthritis ● Acute rheumatoid arthritis – Painful swelling and stiffness of joints, with fusiform or spindle-shaped swelling of the soft tissue of PIP joints. ◆ Fusiform swelling is usually symmetric, the hands are warm, and the veins are engorged. ◆ inflamed joints have a limited range of motion ● Syndactyly ● Polydactyly ➢ Ankylosing spondylitis – chronic inflamed vertebrae (spondylitis) that in extreme form leads to bony fusion of vertebral joints (ankyloses). ■ affects the spine, pelvis, and thoracic cage ■ characterized by inflammatory back pain that is dull and deep in lower back or buttocks ■ morning back stiffness that lasts ≥30 minutes and decreases with activity, nighttime awakening with pain, age at onset ≤45 years. ■ It affects males more often than females. ■ Although the pathogenesis is not known, there does appear to be a genetic risk. ❖ Degenerative conditions ➢ Osteoarthritis (degenerative joint disease) – Noninflammatory, localized, progressive disorder ■ involving deterioration of articular cartilages (cushion between the ends of bones) and subchondral bone remodeling, synovial inflammation, and formation of new bone (osteophytes) at joint surfaces. ■ Increased risk occurs with older age, female sex, obesity, genetics, and major joint injury. ■ Asymmetric joint involvement commonly affects hands, knees, hips, and lumbar and cervical segments of the spine. ■ Affected joints have stiffness; swelling with hard, bony protuberances; pain with motion; and limitation of motion. ■ Diff from RA: OA is characterized by hard, nontender, noninflammatory nodules, 2 to 3 mm or more. ● osteophytes (bony overgrowths) of the DIP (distal interphalangeal) joints =Heberden nodes ● Osteophytes of PIP (proximal interphalangeal) joints = Bouchard nodes and are less common. ➢ Osteoporosis ❖ Shoulder ➢ Atrophy ➢ Dislocated shoulder ➢ Joint effusion ➢ Tear of rotator cuff ➢ Frozen shoulder—adhesive capsulitis ❖ Elbow ➢ Olecranon bursitis ➢ Arthritis ➢ Rheumatoid nodules ➢ Epicondylitis—tennis elbow ■ Chronic disabling pain at lateral epicondyle (LE) of humerus ■ Radiates down extensor surface of forearm ■ Pain can be located with one finger ■ Resisting extension of the hand increases the pain ■ Inflammation along flexor and extensor tendons of elbow joint with overuse ■ Occurs with excessive pronation and supination of forearm with an extended wrist (e.g., racquet sports or using a screwdriver). ❖ Spine ➢ Scoliosis ➢ Herniated intervertebral disc ❖ Wrist & Hand ➢ Ganglion cyst ➢ Colles’ fracture ➢ Carpal tunnel syndrome with atrophy of thenar eminence ➢ Ankylosis ➢ Dupuytren’s contracture ❖ Knee ➢ Osgood-Schlatter disease ➢ Post-polio muscle atrophy ➢ Mild synovitis ➢ Prepatellar bursitis ➢ Swelling of menisci ❖ Ankle and foot ➢ Achilles tenosynovitipalpates ➢ Tophi with chronic gout/acute gout ■ can be treated effectively with medication ■ Tophi formation occurs in severe, chronic gout ■ Hard nodules (tophi) occur most often in the metatarsophalangeal joint of first toe (hallux). ● Tophi are collections of sodium urate crystals caused by chronic gout in and around the joint. ■ Uric Acid Crystals are strong inflammation triggers that cause extremely painful swelling and joint deformity. ■ Acute gout – triggered by surgery, trauma, diuretics, alcohol intake ● Episodes are characterized by redness, swelling, warmth, and extreme pain such as a continuous throbbing. ● Increased prevalence in obesity, metabolic syndrome, hypertension, hyperlipidemia ➢ Hallux vagus with bunion and hammer toes ➢ Plantar fasciitis ■ plantar fascia is a band of connective tissue that extends lengthwise from the medial tubercle of the heel to the metatarsal heads and the five proximal phalanges of the toes ■ An inflammatory response to repetitive microtrauma to this fascia is the most frequent cause of heel pain ■ Risk factors include obesity, high-arched foot, running, standing long periods on hard flooring, or recent activity changes. ■ Pain is unilateral, “throbbing, searing, or piercing,” and is localized to the plantar medial part of the heel; it is worse in the morning or after periods of long rest. ■ Ultrasound imaging often aids in diagnosis. ■ Self-limiting but may take 6 to 12 months to resolve. Treatments include rest and oral pain medications or steroids, stretching exercises, orthotics for shoes, and night splints. ➢ Ingrown toenail ➢ Plantar wart ■ Vascular papillomatous growth is caused by HPV and occurs on the sole of the foot, commonly at the ball and has small dark spots. ■ Although it looks like a callus, it is extremely painful. ■ The wart is tender if you pinch it side to side, whereas a callus is tender to direct pressure Female Genitourinary System, Breasts, Axillae, & Regional Lymphatics and sexually transmitted diseases in females (approx. 10 questions) · Normal anatomy of external and internal Genitalia ❖ Normal: ➢ Darker pink labia minora ➢ Inverted triangle hair pattern ➢ Symmetric, plump, & well-formed labia minora ■ Nulliparous → midline ■ Parous → gaping & slightly shriveled ➢ Some clear discharge is normal ➢ Bartholin gland located b/w vaginal opening & labia minora ➢ Pink & even cervical mucosa ➢ Older postmenopausal women → pale pink cervix is normal ➢ Fibrous tissue at the introitus → hymen ■ Cervical os (os– opening): ● Nulliparous (before child birth) → small & round ● Parous (after childbirth) → horizontal, irregular slit-like ● Nabothian cysts → little yellow benign cysts ➢ Scar tissue on perineum → d/t tearing in childbirth · Examination and Normal and abnormal findings of female external and internal genitalia, including cervical exam (textbook chapter 27; pp:744-750) ❖ Preparation for examination: ➢ Environment → comfortable temp, blanket/sheet & gown, correct speculum ➢ Pt → Empty bladder first, lithotomy position w/ feet in stirrups; ask pt not to douche for 48 hrs before examination; tell pt that during a rectovaginal exam may cause the pt to feel uncomfortable, like they have to move their bowels ➢ Other → privacy is key; ask pt if they want a chaperone; position the bed where the perineum is NOT facing the door; use pt own vaginal secretions for lubrication of speculum ❖ Abnormalities ➢ Bluish cervix in nonpregnant woman (normal in pregnant pt) → indicated cyanosis ➢ Abscess in Bartholin Glands → could be d/t gonorrhea ➢ Inflamed cervix ➢ Abnormal discharge: ■ Thin, grayish-white vaginal discharge with fishy odor → bacterial vaginosis ■ Thick, white vaginal discharge → yeast infection ■ Purulent discharge when palpating Bartholin’s glands → obtain a culture ■ Malodorous, yellow discharge → obtain wet mount slide ➢ Immobile ovaries during palpation ➢ Fixed or tender uterus → indicated fibroids, infection, or presence of a mass ➢ Cystocele → protrusion of bladder through the anterior vaginal wall ➢ Rectocele → protrusion of the rectum through the posterior vaginal wall ➢ Vulvovaginal Candidiasis → yeast infection: ■ Pruritus, thick, whitish curdy discharge, no odor, vulvar & vaginal erythema and edema, dyspareunia ■ Causes – antibiotics, diabetes, douching, immune system issues ■ Rx – fungal vaginal creams; Fluconazole ➢ Endometriosis ■ Benign, common, estrogen dependent disorder ■ s/s: pelvic pain, severe dysmenorrhea, infertility, dyspareunia; may be asymptomatic ➢ Bacterial Vaginosis → thin, grayish-white vaginal discharge with a fishy odor · Complications related to STDs ❖ Chlamydia: ➢ Risk factors - in persons < 25 yrs. of age & prior infection with chlamydia ➢ May be asymptomatic in females initially BUT – causes chronic complications – pelvic inflammatory disease (PID) ➢ Vaginal discharge – none; clear, mucoid to mucopurulent. ➢ Spotting & post-coital bleeding common d/t inflammation ❖ Gonorrhea: ➢ 2nd most common → teens & young adults ➢ Most common bacterial vaginal infection ■ Can occur in any portion of genital tract, oropharynx or become disseminated ➢ Often asymptomatic in females ➢ May result in: Pelvic Inflammatory Disease; Pelvic Abscess; Infertility ➢ Reported to state for being a communicable disease ➢ Gonorrhea culture → Z pattern spread on culture plate ❖ Genital Herpes (HSV Type 2) ➢ Episodes of local pain, dysuria, fever; inguinal lymphadenopathy ➢ clusters of small, shallow vesicles with surrounding erythema; erupts on genital areas, inner thigh, gluteal cleft, usually bilaterally ➢ Rx available to treat acute symptoms. ➢ Virus remains dormant in the body ➢ Spreads with direct contact even when no symptoms ❖ HPV ➢ S/S ■ Fleshy lesions on labia and within perineum ■ painless warty growths may be pink or flesh-colored, soft, pointed, moist, warty papules ■ Single or multiple (cauliflower-like patch) ■ and believed to be sexually transmitted ➢ Cervical cancer now #1 preventable cancer ➢ HPV vaccine now available to prevent infection with certain genotypes ➢ Screening & follow-up essential for those with positive HPV testing ❖ Syphilis ➢ Small superficial ulcer w/ yellowish serous discharge ➢ Resolves spontaneously but secondary syphilis follows: ■ Fever, lymphadenopathy, mucocutaneous red rash, and sore throat · gynecologic examination: HPV testing, Papanicolaou cytology cotesting and Pap smear test (textbook chapter 27 pp: 746; 734) · Breast: Anatomy of breast, breast examination, abnormal conditions of the breast ❖ Prep for exam ➢ Items ■ Gloves ■ drape for privacy ➢ Procedure ■ explain procedure to client ■ position supine or sitting upright ■ have client elevate the hand to under/back of the head when examining breast ■ inspect prior to palpating ❖ Anatomy of breast ➢ External ■ Tail of Spence – superior lateral corner of breast tissue that projects up and laterally into the axilla (should not feel lumps) ■ Nipple – center of breast ● round with tiny milk duct openings ■ Areola – •surrounds nipple 1-2 cm in radius ➢ Internal ■ Glandular tissue – 15-20 lobes radiating from nipple; lobes consist of lobules that have clusters of alveoli that produce milk ■ Fibrous tissue – these are the ligaments (Cooper ligaments) are fibrous connective tissue that support the breast tissue ■ Adipose tissue – fatty tissue that constitutes the bulk of the breast ➢ 4 Quadrants: either upper or lower and inner or outer (Upper outer quadrant typical issues; common for infection) ➢ Male breast ■ Consists of a thin disk with undeveloped tissue underlying the nipple ■ Areola – well developed ■ Gynecomastia – breast enlargement; can be noted during adolescence ❖ Objective data ➢ Inspect – look at breasts preferably in a sitting position ➢ Palpate – feel breasts and axillae by using pads of fingers (lying position with arm flexed under head) ➢ Technique – circular motion (clockwise direction), from nipple outward or vertical motion, can be applied · Breast examinations (abnormal and normal findings) (textbook chapter18; pp: 394-399) ❖ Normal findings ➢ Symmetry of breasts ➢ Location of breasts ➢ Intact skin ➢ Location of nipples ❖ Abnormal findings (more related to breast cancer) ➢ Asymmetry of breasts ➢ Dimpling ➢ Edema (peau d’orange) — more advanced cancer ➢ Fixation (does not move) ➢ Nipple deviation (shifted to a side) ➢ Abnormal nipple discharge ➢ Breast abscess & mastitis ➢ Bleeding/spontaneous discharge → refer for cytologic study ➢ Paget disease → red, scaly areolas ➢ Fibroadenomas → lobular, ovoid, or round lesions ➢ Infection → tenderness & redness · Breast self-examination (BSE) (textbook chapter18; pp: 401) · Age-related changes in breast and breast structure. ❖ Fetal life – dev of breasts begins during fetal development ❖ Supernumerary nipple – extra nipple visible along mammary ridge ❖ At birth – breast structures are present ❖ The adolescent – during puberty, the hormone estrogen stimulates breast development ❖ Pregnancy – ductal system & fatty tissue expand; breast enlarge, more nodular; nipples & areola larger, darker in color, nipples more erectile, tubercles more prominent, colostrum present, vein network visible ❖ Aging - ↓ in breast size due to menopause · Preparing clients for Breast examinations and Breast cancer-related signs and symptoms. ❖ Breast cancer: ➢ Pronounced & asymmetric vein patterns on breasts ➢ Retractions & dimpling ➢ Peau d’ orange → orange, thick skin w/ exaggerated hair follicles ➢ Irregular, firm lumps/masses ➢ Ask pt what age they began menstruation ➢ Skin and tissue – firmer; thicker ❖ · Sexually Transmitted disease: Signs and symptoms of Gonorrhea, Genital Warts, Human Papilloma Virus, Primary & secondary syphilis, Chlamydia See above · HPV virus, HPV genital warts (textbook chapter 27; pp:760; 762), HPV Vaccine Teaching · Female Gu: Abnormal findings (pages 759- 767), Pelvic inflammatory disease/Acute salpingitis (page 750; 766). ❖ External ➢ Labia – ■ genital warts ■ nits/lice (Pediculosis Pubis or crab lice) ● Excoriations and erythematous areas ● Brown hemorrhagic crusts localized in pubic hair ● Transmitted through sexual contact and through contaminated clothing and bedding ■ lesions, rashes ➢ Discharge – sign of infection ➢ Swelling, pain, tender ➢ Bleeding – lesions, infection ➢ Thin Perineum – occurs in older adults ❖ Internal ➢ Uterus – enlarged, bulging, prolapsed, mass ➢ Adnexal (ovaries + fallopian tubes)– mass ➢ Cervix – lesions, inflammation ➢ Pain on examination ❖ Cystocele – bladder prolapses into the vagina from weakened anterior pelvic muscles. S/S pressure in vagina, stress incontinence ❖ Rectocele – part of the rectum prolapses into the vagina from posterior tissue weakness. S/S feeling of pressure in vagina, possibly constipation ❖ Uterine prolapse – uterus protrudes in the vagina; feeling of pelvic pressure ❖ Cervical cancer – ulcer on the cervix; risk factors: infection, first intercourse at an early age, multiple sex partners, cigarette smoking, undetected HPV. Diagnosis – Pap test and biopsy ❖ Endometrial cancer – abnormal and intermenstrual bleeding before menopause; postmenopausal bleed ❖ Ovarian cancer – vague symptoms: abdominal pain, pelvic or back pain, increased abdominal size, bloating ❖ Pelvic Inflammatory disease (PID)/Acute Salpingitis – ➢ PID: Inflammatory process of microorganisms in the cervix and vagina ascending to the endometrium and fallopian tubes ■ complications : ectopic pregnancy, infertility, and reinfection – usually caused by untreated Chlamydia, Gonorrhea, and BV ➢ S/S ■ Mild symptoms: Vaginal leukorrhea, organ tenderness on bimanual exam ■ Severe symptoms: sudden fever (>38 or 100.4), suprapubic pain and tenderness ■ Acute – rigid boardlike lower abdominal musculature ■ May have purulent discharge from cervix Male Genitalia & Rectum, Anus, Rectum, Prostate, & Male Genitalia assessment and sexually transmitted diseases in males (approx. 10 questions) (textbook, focus PPT & lecture) · Male GU: Anatomy (PPT), All the abnormal conditions of Testes, Scrotum, Penis, Abnormal conditions of prostrate and diagnostic tests, All the definitions and related terminologies, Hernia, older age considerations. ❖ Testes/Scrotum: ➢ Epididymitis: acute infection w/ severe, and sudden onset of pain, fever, tenderness, & swelling ■ Positive Prehn sign → passive elevation of testes relieves pain ■ Causes: Iatrogenic; infection; prostatitis or bacterial infection ➢ Enlarged scrotal sac results from fluid collection → hydrocele → easily transilluminates (transillumination is not normal) ■ Hematocele / tumors: No transillumination ➢ When assessing scrotum of adult pt → thin & rugate scrotal skin with little hair dispersion → normal findings ➢ Testicular torsion → sudden twisting of spermatic cord, very painful, immediate referral for surgery bc circulation is obstructed ➢ Orchitis → inflammation of the testes, associated with mumps (measles); pain, heaviness & fever; enlarged & red, hard to differentiate bw testes & epididymis ➢ Cryptorchidism → newborn male infant; neither testicle is distended ➢ Sparse pubic hair can be d/t chemotherapy ❖ Penis: ➢ To palpate for urethral discharge → nurse would gently squeeze the glans between the thumb & index finger obtain a sample of yellow/white discharge for culture ➢ Phimosis → foreskin-unretractable over the penis tip (fixed via circumcision) ➢ Paraphimosis → inability to replace foreskin; penile pain & swelling; if untreated then gangrene of the glans penis ➢ Hypospadias → displacement of urinary meatus in the ventral surface of the penis ➢ Pt unable to obtain & maintain erection ask about meds ❖ Prostate & Diagnostic Test ➢ Prostate ■ Prostate gland: Two round lobes separated by median sulcus ■ Prostatic hypertrophy: ● Enlarged → difficulty urinating (such as hesitancy) ● An enlarged smooth, firm, slightly elastic prostate that may not have a median sulcus suggests benign prostatic hypertrophy (BPH) ● Nocturia, dribbling, slow start, incomplete emptying hesitancy could signal a blockage, including prostatic enlargement ➢ Diagnostic Tests ■ Digital rectal exam (DRE) ● Palpate prostate through rectum ● Classified as to the amount of protrusion into the rectum ● Benign prostatic hypertrophy occurs in almost all males as they age ● After age 40 it is part of usual exam ■ Prostate-specific antigen (PSA) ● Glycoprotein specific to prostate but not to prostate cancer ● Testing controversial – not recommended for most pt’s ● Men aged 50 or more should talk to a health care provider about the pros and cons of PSA testing so that they can make an informed decision regarding testing ● PSA 4 ng/mL – normal ● PSA level may be elevated in benign prostate hypertrophy or with infection or inflammation of the prostate. If a prostate biopsy is done and is negative, then an additional test (this one of urine) may be done for the PCA3 gene for prostate cancer ❖ Definitions ➢ Dysuria – painful urination ➢ Urgency – have to go right away ➢ Hesitancy – difficulty getting the urine stream going ➢ Nocturia – needing to void 2-3 x night ➢ Nocturnal enuresis – “bedwetting” ➢ Cryptorchidism – Failure of one or both testicles to descend into scrotum. ➢ Spermatocele – benign accumulation of sperm occurring on the epididymitis/ Sperm-filled cystic mass located on epididymis. ➢ Hydrocele: enlarged scrotal sac may result from fluid and easily transilluminates. ➢ Hematocele- If there is blood in the scrotum, it will not transilluminate. ➢ Varicocele- enlargement of the veins within the scrotum, which may cause low sperm production and decreased sperm quality, which can cause infertility. ➢ Hypospadias - displacement of the urinary meatus to the ventral surface of the penis. ➢ Epispadias - displacement of the urinary meatus to the dorsal surface of the penis ➢ Melena – black, tarry stool from bleeding higher up in GI tract ➢ Occult blood – hidden blood in the stool – stool guaiac tests positive ➢ Dyschezia – chronic constipation with defect reflex for defecation ➢ Encopresis -fecal incontinence or soiling, is the repeated passing of stool (usually involuntarily) into clothing. (Chronic constipation – long periods of constipation with fecal incontinence & liquid stool) ➢ Flatulence – flatus (gas) expelled. ➢ Steatorrhea – excess fat in the stool ➢ Stress incontinence- It is the involuntary loss of urine during coughing, sneezing, laughing, or other physical activities that increase abdominal pressure. ❖ Hernias ➢ Femoral hernia: a portion of intestine bulging through the femoral canal, which houses the femoral artery as it runs from the abdomen to the groin and upper thigh ➢ Inguinal hernia: a portion of intestine bulging into or through the inguinal canal ■ When inspecting the inguinal area for bulging have pt bear down as if having a bowel movement ➢ Incarcerated scrotal hernia: ■ Mass cannot be pushed into the abdomen ■ Auscultate mass for bowel sounds (?) ❖ Old Age Considerations ➢ Older age considerations ➢ Testes hang lower in the scrotum ➢ Testes do not decrease in size with aging ➢ Bulging in the inguinal area would be considered an abnormal finding associated with a hernia ➢ Penis size may decrease with aging & hair becomes gray & sparse · Sexually Transmitted disease: Signs and symptoms of Gonorrhea, Genital Warts, Human Papilloma Virus, Primary & secondary syphilis, Chlamydia, ❖ Gonorrhea: ➢ If symptomatic – most common is painful purulent penile discharge with urethritis ➢ Mucopurulent discharge (or drip) from the penis (white, yellow, beige, or greenish) ➢ Swelling or redness at the opening of the penis ➢ Greater frequency or urgency of urination ➢ May have: epididymitis, proctitis, pharyngitis ➢ Epididymitis, which can present as unilateral testicular pain without discharge or dysuria ➢ Often seen with Chlamydia infection ❖ Genital Warts (Human Papilloma Virus): ➢ HPV associated with genital cancers can lead to cancer of the anus or penis in men; major risk for cervical cancer ➢ Vaccine available to prevent infection ➢ Genital warts are the first symptom: single or multiple, moist, fleshy papules; painless. ➢ They do not contain fluid, and they do not typically bleed. Genital warts may be firm, but they are never shiny. ❖ Primary syphilis: ➢ Presence of chancre – average days - may go undetected ➢ After the initial infection, the syphilis bacteria can lie dormant in body for decades before becoming active again. ➢ SYPHILITIC CHANCRE: Firm, red and painless superficial genital ulcers. Initially a small, silvery-white papule that develops a red, oval ulceration and it is Painless. A sign of primary syphilis that spontaneously regresses ❖ Secondary syphilis: ❖ Within a few weeks of the original chancre healing, rash that begins on trunk, but eventually covers entire body, palm and feet with systemic symptoms – several weeks to months ❖ Chlamydia: ➢ Most common bacterial STD ➢ Risks: adolescent & young adults; new sex partner; # or sex partners. ➢ Mostly asymptomatic in males ➢ May have watery penile discharge ➢ Often seen with gonorrhea; re-infection is common ❖ Herpes progenitalis recurrence can happen w/ varying frequency & s/s is clear vesicles that erupt · Anus & Rectum: Examinations of perianal area, rectum and anus, Bowel pattern and abnormalities of stool, Abnormal conditions of anus and rectum (both PPT and text book), All the definitions and related terminologies. ❖ Position the pt in the left side-lying position ❖ Rectum: ➢ Valve of Houston - 3 semilunar transverse folds that protrude into the rectum, not the anal canal as that lies below the rectum. ■ Support the weight of fecal matter, and prevent its urging toward the anus, which would produce a strong urge to defecate ■ Lowest part can be palpated ❖ Anus: ➢ Inspect – moist & hairless; skin more pigmented than perianal skin; tightly closed. ➢ Abnormalities – hemorrhoids, fissure, pilonidal cyst (with tuft of hair). ➢ Pilonidal cysts: An abnormal skin growth located at the tailbone that contains hair and skin. If a pilonidal cyst becomes infected, the resulting abscess is often extremely painful. Assessing Mental Status: (focus on PPT, lecture) (approx. 5-7 questions) · · · · · · · Mental status examination (each component) Abnormal findings of each component of the mental status examination Mental health exam focusing on cognitive assessment Levels of consciousness Cognition: Delirium, dementia, Alzheimer’s dementia Depression, suicide, speech disorders Mental health of older adults Also, Focus on exam 2& 3 blueprints related to the below modules Module V: Thorax & Lungs Assessment (Approx. 5 questions) Module VI: Heart and Neck Vessels, Peripheral Vascular System, and Lymphatic System Assessment (Approx. 5 questions) Module VII: Assessing the Abdomen (Approx. 5 questions) Module VIII: Assessment of Head, Neck, Mouth, Throat, Nose, Sinuses, Eyes & Ears and Neurological Assessment (Approx. 5 questions) Read: Chapter 28: Putting it all together: The complete health assessment All the Very Best Wishes on your exam!!!!
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