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Physical Assessment Exam Five - Coggle Diagram
Physical Assessment Exam Five
CH 21 - Abdomen
A&P Review
diaphragm separates the thoracic cavity and the abdominal cavity
peritoneum - serous membrane lining abdominal cavity
viscera
Hollow viscera change shapes
small intestine
colon
rectum
stomach
Solid viscera maintain shape
spleen
liver
pancreas - behind stomach with spleen
adrenal glands
kidneys - retroperitoneal, R is lower than L because liver
ovaries
uterus
ventral abdominal wall = 4 layers of large, flat muscles
rectus abdominis extends across entire midline
Linea alba - tendon down the middle
Regions
Quadrants
RUQ
LLQ
RLQ
LUQ
Older system
Epigastric (center)
R and L hypochondriac regions
Umbilical (center)
R and L lumbar regions
Hypogastric (center)
R and L iliac regions
Aorta - L of midline, bifurcates into L and R common iliac arteries at L4
Subjective
appetite
dysphagia
food intolerance
pain (remember PQRST)
quality
radiation
palliative/provocative
site
timing
nausea and vomiting
bowel habits
history
smoking
medications
Objective
Preparation
empty bladder
supine position
arms relaxed by side
Inspect
skin - color, scars, veins, hair, rash, or lesions
umbilicus - contour, location, and hernias
contour
flat
rounded
protuberant
scaphoid
gravid - pregnant
symmetry
peristalsis
Auscultate (BEFORE Palpating)
use diaphragm
begin in RLQ at ileocecal valve
note character and frequency of sounds
normal
hyperactive
hypoactive
absent - indicates ileus or obstruction (torsion, strangulated hernia, sometimes objects)
borborygmus - bowel sounds, 5-10 sounds per minute; if none, auscultate for 5 WHOLE minutes
Palpate
light
use all fingers
begin in RLQ
tender areas last
assess for guarding - voluntary or involuntary
deep
push down 5-8 cm
may require two hands
Percuss
Abnormal
hematemesis - vomiting blood
hematochezia - bright blood in stool
melena - black stool
jaundice -> icteric sclera (yellowed sclera)
grey/white stool - liver/gallbladder problems
Ascites - abnormal fluid collection in abdomen due to failing liver
pernicious anemia - malabsorption of vitamin B12, calcium, and iron due to decreased gastric secretions
rebound tenderness - no pain with press, pain with release
psoa's sign - extending hip and knee leads to pain, indicates peritonitis or psoas muscle inflammation
causes
appendicitis
pelvic inflammatory disease
Murphy's sign - acute cholecystitis, patient exhales and you push then patient inhales; positive if patient winces upon inspiration
McBurney's point - normal location of appendix base, 1/3 distance from right anterior superior iliac spine and umbilicus; migrates in pregnancy; can be used to test for appendicitis
Rovsing's sign - pushing on LLQ causes pain in RLQ
diastasis recti
peritoneal friction rub
pyrosis - heartburn
Developmental Considerations
Elderly
fat redistribution to abdomen and hips
decreased salivation, and gastric acid secretion
delayed esophageal emptying
decreased liver function
constipation is common but not part of aging
Infants and Children
big liver
Pregnancy
diminished bowel sounds
hemorrhoids are very common
CH 22 - Musculoskeletal
A&P Review
Functions
support
movement
flexion/extension
abduction/adduction
pronation/supination
circumduction
inversion/eversion
rotation
protraction/retraction
elevation/depression
protection
production - RBC's, WBC's, and platelets
storage
Subjective
problems with joints, muscles or bones
Functional ADLs
self-care + occupational hazards
Objective Assessment by Joint
Muscle testing
grades 1-5 (5 = normal, 1 = no resistance)
should be equal bilaterally
Temporomandibular Joint (TMJ) - Tests CN V Integrity
1) sit person down
2) tips of two fingers on joint and ask person to open and close mouth
smooth movement, no clicks
3) person should clench jaw = muscle testing - temporalis and masseter
Spine = 33 vertebrae
Regions
Lumbar
Sacral
Thoracic
Coccygeal
Cervical
Landmarks
C7/T1 are prominent at base of neck
T7/T8 - inferior angle of scapula
L4 - level with iliac crest, innervates back
Dimples over superior iliac spine
Cervical
inspect alignment
torticolis = tilted head
ROM
strength of sternomastoid (CN XI)
ROM should be smooth and symmetrical for spine
Thoracolumbar
straightness
equal horizontal position between shoulders
knees, feet, and trunk should be in a line
Shoulder
ROM
external/internal rotation
abduction
adduction
strength (CN XI)
shrug
abduct
Elbow
size and contour
ROM = flexion and exstention
strength
Wrist/Hand
position
contour
shape
palpate joints
Carpal Tunnel Tests
Palen's Test - numbness/burning upon flexion of 90 degrees
Tinel's sign - burning/tingling upon percussion of median nerve
Tactile Discrimination
Stereognosis - recognition of objects by touch
Graphesthesia - recognize characters written into skin
Hip
symmetry in...
iliac crests
gluteal folds
buttocks
gait
leg length
ROM
Knee
ROM
flexion
extension
hyperextension
strength
Ankle and Foot
Inspect both while seated and while walking
weight should be centered
ROM = inversion/eversion
Order of Examination
Palpate
ROM
Inspect
Developmental Considerations
Infants and Children
epiphyseal plate closure = end of growth
nutrtion and exercise plays huge role
obesity and osteoporosis begin here
Pregnancy
relaxin - increases joint mobility
Elderly
bony prominences stick out more
sedentary = faster onset of problems
Kyphosis
osteoporosis -> decreased height
Abnormal
The 5 P's
Pain
Pulse
Pallor
Paresthesia - numbness
Paralysis
Acute Ischemia
The 5 P's + cold to touch
Rheumatoid arthritis (inflammatory)
Osteoarthritis (degenerative)
Osteoporosis
Carpal Tunnel
Scoliosis
CH 23 - Neurological
A&P Review
PNS = nerves outside of the CNS = 12 CNs + 31 spinal nerves
Cranial Nerves
Mixed
V - trigeminal nerve, facial sensation, chewing
VII - the facial nerve, facial expressions
IX - glossopharyngeal, swallowing, taste, gag reflex
X - vagus nerve, digestion, HR, speech, breathing, gag reflex
III - oculomotor, eye movement
Motor
VI - abducens, outward eye movement, motor ONLY
XI - the accessory nerve, trapezius + sternomastoid
XII - hypoglossal, tongue movement
IV - trochlear nerve, down and inward movement
Sensory
I - the olfactory nerve, smell
VIII - vestibulocochlear, hearing and balance
II - the optic nerve, vision
Travel of Messages
Afferent = to CNS
Efferent = from CNS
Reflexes
deep tendon - knee jerk
superficial - corneal reflex
visceral - pupillary light
pathologic - Babinski
Spinal nerves are connected to dermatomes which are connected to skin
CNS = Brain + Spinal Cord
Brain
Cerebral Cortex - thought, memory, reasoning, sensation, and voluntary movement
Lobes
Frontal
Parietal - sensation
Temporal - hearing, taste, smell
Wernick's area - language comprehension
Broca's area - motor speech, expressive aphasia
Occipital - vision
Damage = occluded artery = Cerebral vascular accident/Stroke
disability correlates to area that got damaged
CNs I and II
Basal Ganglia - movement coordination and automatic movements
Hypothalamus = Respiration
appetite
sex drive
vital signs
sleep
pituitary gland regulation
ANS coordination
bodily functions
unconcious
fight or flight
stress + emotions
Cerebellum
voluntary movement
equilibrium
muscle tone
motor skills
Brain Stem
CNs III to XII live here
midbrain merges into thalamus and hypothalamus
pons = respiration in medulla
medulla - cardiac, respiratory, vomiting, and vasomotor control center = ANS functions
Spinal Cord - highway for ascending and descending fiber tracts, reflexes for posture, urination, and pain
Objective
Sequence
mental status
Glasgow Coma Scale, scores 1-15 = measures LOC = most important indicator of change
motor system
Romberg Test - tests cerebellum
gait - walk straight line in heel to toe fashion
sensory system
superficial pain
light touch
vibration
sterognosis - recognition of objects by touch
graphesthesia - reading what is written on the skin
cranial nerves
I - smells
II - visual acuity, peripheral vision
III, IV, and VI - eye movement, PERRLA
V - mastication, typically for musculoskeletal assessment
VII - facial movement
VIII - whispered voice test
IX and X - ahhh, gag reflex
XI - shrug test, head tilt test
XII - tongue out, light tight dynamite
reflexes
biceps
brachioradialis
quadriceps/knee jerk
plantar/Babinski
Grading = 1-4, 2 is normal
Subjective
headache
head injury
vertigo/dizziness
seizures
tremors
weakness
coordination problems
numbness/tingling
difficulty swallowing or speaking
Developmental Considerations
elderly
atrophy of neurons
decrease in weight of cerebral cortex
loss of muscle tone
impaired coordination
pupillary changes
slow reaction time
decreased cerebral blood flow
Abnormal
Muscle tone
flaccidity - hypotonia
spasticity - hypertonia
rigidity
cogwheel rigidity - small jerks of rigidity
Muscle movement
paralysis
fasciculation - fascia twitching, around eye in particular
myoclonus - rapid sudden jerk at regular intervals, hiccups for example
Tic
Tremor
Rest tremor - muscles keep moving slowly at rest
Intention tremor - muscle tremors when trying to do something
Postures
decortigate rigidity - flexion of arms, extension and inward rotation of legs
decerebrate rigidity - extension of arms and legs, back hyperextension
flaccid quidriplegia
opisthotonos - arching of back, head and heels arch back too
dysphagic
diplopia
ptosis - drooping eyelid
parethesia
anosmia - loss of taste
CH 25 - Anus, Rectum, and Prostate
A&P Review
Anal Canal
outlet of the GI system
Nerves = ANS + Somatic Sensory Nerves
Muscles = Smooth + Skeletal
Sphincters
Internal - controlled by ANS
External - controlled by somatic sensory system, surrounds internal sphincter, voluntary
4cm long
Rectum - connector between sigmoid colon and anus
contains anal columns which connect rectum and anorectal junction
12cm long
Prostate
in front of anterior wall of rectum
surrounds bladder neck and urethra
fluid contains prostaglandins (alkaline, sperm viability and motility, stimulates smooth muscle contractions in female reproductive system)
2.5cm x 4cm
seminal vesicles sit above prostate and make fluid (fructose rich)
Cowper's glands on either side of urethra make mucus and 70% of seminal fluids
Objective
Males
positions
left lateral
standing
flex finger tip, point to umbilicus
palpation of prostate should feel smooth, elastic, nontender, and slightly moveable
Females
positions
left lateral
standing
lithotomy
palpation of uterus should be small, round mass
exam is often bimanual (rectal and vaginal exam are simultaneous)
Anal Canal + Rectum = 16 cm
ALWAYS point towards umbilicus
rectal thermometer goes in a little bit but suppository is shoved in there as far as you can get it
Subjective
usual bowel routine
changes in bowel habits
rectal bleed/black stools/red stools
medications
pruitus - itching
hemorrhoids
fissure
fistula
family and personal history
diet and exercise
Prostate-specific antigen blood test
Developmental Considerations
puberty = prostate doubles in size
middle adulthood = begin benign prostatic hypertrophy
caused by hormone changes
10% of men have it
common in those older than 60
urine dribbling and slow flow
passing stool is involuntary until 1-2 years old due to myelination
Abnormal
Prostate Cancer
Causes
red meat
high-fat dairy
obesity
BRCA2 = aggressive prostate cancer
Screening begins annually at 50 years of age
prostate-specific antigen blood test, results altered by
UTI
prostate stimulation (sex)
vigorous exercise
medications
digital rectal exam
Colorectal Cancer - 2nd leading cancer killer
Risk factors
diet
smoking
alcohol
family history
age
Screening begins annually at 50 years of age, or 45 with family history
identifies precancerous polyps for removal
colonoscopy (every 10 years)
fecal occult blood test
sigmoidoscopy
double contrast barium enema
Stool Changes
melena = upper GI bleed or iron supplements
Pale yellow/greasy stool = malabsorption
fatty stool = steatorrhea
Constipation
can cause toxic reabsorption
causes
diet
voluntary holding it back
Dyschezia - painful bowel movement