Final Exam Flashcards
Name the cranial nerves. (there are 12)
- olfactory
- optic
- oculomotor
- trochlear
- trigeminal
- abducens
- facial
- acoustic
- glossopharyngeal
- vagus
- spinal accessory
- hypoglossal
function of the olfactory nerve
smell
function of optic nerve
vision
function of oculomotor nerve
- extraocular motion (EOM)
- eyelid opening
- pupil constriction
- lens shape
function of trochlear nerve
downward and inward extraocular motion
function of trigeminal nerve
- sensations of face, scalp, cornea, mucous membranes of mouth and nose
- muscles of mastication
function of abducens nerve
lateral movement of eye
function of facial nerve
- facial movement
- closing of eyes and mouth
- speech
- taste (anterior 2/3 of tongue)
- saliva and tear produciton
function of acoustic nerve
- hearing
- equilibrium
function of glossopharyngeal nerve
- production of speech and swallowing
- taste (posterior 1/3 of tongue)
- gag & carotid reflex
function of vagus nerve
- talking and swallowing
- sensation from carotid body & sinus, pharynx, and viscera
- carotid reflex
function of spinal accessory nerve
movement of trapezius/sternomastoid muscles
function of hypoglossal nerve
movement of tongue
what to inspect and palpate for muscles in regards to the motor system?
inspect: size and presence of involuntary movements
palpate: strength and tone
what are the coordination tests for the motor system?
- rapid alternating movements
- finger to nose test
- finger to finger test
- heel-to-shin test
spinothalamic tract tests
- pain
- temperature
- light touch
posterior column tract tests
- vibration
- position (kinaesthesia)
- tactile discrimination (fine touch)
spinothalamic tract test - pain
- lightly apply sharpy or dull end at random locations
- ask pt to identify if it is ‘sharp’ or ‘dull’
- sharp = test for pain
- dull = general test for response (control)
- 2 seconds between stimuli
spinothalamic tract tests - light touch
- apply wisp cotton to skin
- brush over random locations
- ask pt to say ‘now’ or ‘yes’ when touch is felt
- use irregular intervals to avoid pt answering from repetition
spinothalamic tract tests - temperature
temperature is omitted unless pain sensation abnormal
posterior column tract tests - vibration
- over distal bony prominences due to (d/t) slower decay of vibrations
- strike tuning fork on heel of your hand and hold at base of bony prominence
- ask pt to tell you when it starts and when it stops
- if they can feel vibration in distal areas, can assume proximal areas are normal
posterior column tract tests - position (kinesthesia)
- with pt’s eyes closed, move their finger or toe up & down
- ask pt to tell you which way it is moved
- vary order of movement
holding digit on side because upward and downward pressure can give pt clue to direction
posterior column tract tests - tactile discrimination (fine touch)
all these tests are done while patient has their eyes closed
- stereognosis
- graphaesthesia
- two point discrimmination
- extinction
- point location
stereognosis
ability to identify object they are touching
graphaesthesia
ability to read number traced on skin
two point discrimination
ability to distinguish separation of 2 simultaneous pinpoints on skin
extinction
ability to feel touch on both sides of body simultaneously
point location
ability to point to spot where they felt touch
deep tendon reflexes
- patient limb relaxed and muscle partially stretched
- short, snappy blow of reflex hammer onto muscle’s insertion tendon
- pointed end on smaller targets
- flat end on wider targets & pain prevention
- compare right and left sides
grading deep tendon reflexes
4+ = very brisk, hyperactive with clonus, indicative of disease
3+ = brisker than average may indicate disease
2+ = average, normal
1+ = diminished, low normal
0 = no response
Deep tendon reflexes - biceps
(C5-C6)
- support forearm
- thumb on bicep tendon
- strike your thumb
- normal = forearm flexion
deep tendon reflexes - triceps
(C7-C8)
- suspend upper arm
- strike triceps tendon directly
- normal = forearm extension
deep tendon reflexes - brachioradialis
(C5-C6)
- suspend forearms by holding pt’s thumbs
- strike forearm directly, 2-3 cm above radial styloid process
- normal = flexion & supination of forearm
deep tendon reflexes - patellar/quadriceps
(L2-L4)
- allow lower leg to dangle
- strike tendon directly just below patella
- normal = extension lower leg
deep tendon reflexes - achilles
(L5-S2)
- knee flexed and hip externally rotated
- hold foot in dorsiflexion
- strike achilles tendon directly
- normal = foot plantar flexes against your hand
superficial reflexes
- abdominal
- plantar or babinski
abdominal reflex
(upper T8-T10; lower T10-T12)
- supine, knees bent
- stroke skin with handle of reflex hammer from side of abdomen to midline (in both upper and lower abdominal levels)
- normal = ipsilateral contraction of abdomen muscles & deviation of umbilicus toward stroke
plantar or babinksi reflex
(L4-S2)
- thigh in slight external rotation
- stroke lateral side of sole of foot and inward across ball of foot (upside down j)
- normal (in children up to 2 years of age) = plantar flexion of toes
- normal (adult) = no reaction
older adult considerations (neurological system)
- taste CN 7, 9, 10) & (CN 1) reduced
- decreased muscle bulk (esp in hands)
- senile tremor (benign)
- dyskinesia with no associated rigidity
- gait slower, deliberate, slightly deviated from midline path
- rapid movements are difficult
- loss sense vibration at ankles ≥ 65 years old
- loss ankle jerk reflex
tactile sensation impaired - deep tendon reflexes less brisk
- absent plantar and superficial abdominal reflexes
flaccidity
decreased muscle tone (hypotonia); muscle feels limp, soft, and flabby; muscle is weak and easily fatigued
spasticity
increased tone (hypertonia); increased resistance to passive lengthening and then suddenly giving away (clasp-knife phenomenon)
rigidity
constant state of resistance (lead-pipe rigidity); resistance to passive movement in any direction; distonia
cogwheel rigidity
type of rigidity in which the increased tone lessens by degrees during passive ROM so that it feels like small regular jerks
Multiple Sclerosis (MS)
- chronic, progressive, immune-mediated disease
- axons become inflamed, demyelinated, degenerated, and undergo sclerosis
- symptoms: blurred vision, diplopia, extreme fatigue, weakness, spasticity, numbness, loss of balance
paraplegia
- lower motor neuron damage by spinal cord injury
- initially produces “spinal shock” = no movement or relfexes below lesion
- gradual return of deep tendon reflexes -> flexor spasms of leg -> extensor spasms of leg
- spasms lead to extensor tone
flexion
bend limb at joint
extension
straighten limb at joint
abduction
move limb away from midline
adduction
move limb towards midline
pronation
turn forearm palm down
supination
turn forearm palm up
circumduction
move arm in circle around shoulder
inversion
move sole inward at ankle
eversion
move sole outward at ankle
rotation
move head around central axis
protraction
move body part forward and parallel to ground
retraction
move body part backward and parallel to ground
elevation
raise body part
depression
lower body part
when should we avoid testing cervical spine ROM and strength?
when there is a suspected neck injury
inspection & palpation - joints
- size
- contour
- skin: colour, swelling, symmetry, masses, deformity
inspection & palpation - ROM
- active: pt replicates movement you show them unassisted
- passive: you support and move pt’s body part for them
inspection & palpation - muscle testing
- strength (against resistance)
- graded 0-5 (0 = no contraction, 5 = full ROM against gravity + resistance)
- symmetry
temporomandibular joint - ROM
- opening & closing mouth
- lateral jaw movement
cervical spine - ROM
extension - 55° backwards
flexion - 45° forwards
lateral bending - 40° left and right
rotation - 70° left and right
elbow - ROM
flexion - 160°
extension - 0°
pronation - 90°
supination - 90°
wrist - ROM
extension - 70°
flexion - 90°
ulnar deviation - 55°
radial deviation - 20°
fingers - ROM
flexion - 90°
hyperextension - 30°
extension - 0°
hips - ROM
hip flexion with knee straight - 90°
extension - 0°
hip flexion with knee flexed - 120°
external rotation - 45°
internal rotation - 40°
abduction - 45°
adduction - 30°
knees - ROM
extension - 0°
flexion - 130°
hyperextension - 15°
ankles - ROM
dorsiflexion - 20°
plantar flexion - 45°
eversion - 20°
inversion - 30°
thoracic and lumbar spine - ROM
flexion - 90°
extension - 30°
lateral bending - 35° (left and right)
rotation - 30°
shoulders - ROM
forward flexion - 180°
extension - 0°
hyperextension - up to 50°
internal rotation - 90°
abduction - 180°
adduction - 50°
external rotation - 90°
older adult changes - MSK
- decrease in height
- kyphosis w/ backward head tilt, flexion hips & knees
- decrease peripheral fat (bony prominences pronounced)
- increased abdominal and hip fat
- ROM and muscular strength same if no MSK illnesses or arthritic changes
rheumatoid arthritic
- chronic systemic inflammation of joint & connective tissue
- limits motion
- symmetrical & bilateral
osteoperosis
- decrease in skeletal bone mass
- weakened state - risk stress fractures
- asymmetrical & unilateral or bilateral
functions of the skin
- protection
- prevents loss of water & electrolytes
- perception
- temperature regulation
- identification
- communication
- wound repair
- absorption and excretion
- production of vitamin D
Hx - integumentary
- history of skin disease
- skin pigmentation
- moles
- texture of skin
- pruritus
- rash or lesions
- medications
- hair loss or growth
- change in nails
- environmental or occupational hazards
- self-care behaviours
inspect & palpate - skin
- colour
- temperature
- moisture
- texture
- thickness
- mobility and turgor
- edema
- hair
- nails
- lesions
4 quadrants of breast
- specify whether left or right
- upper inner quadrant
- upper outer quadrant
- lower inner quadrant
- lower outer quadrant
central axillary node receives lymph from which nodes?
- pectoral
- subscapular
- lateral axillary
where does lymph go from central axillary node?
- infraclavicular area
- supraclavicular
older female breast
- post-menopause, decreased estrogen and progesterone = glandular tissue atrophies
- atrophy of fat = decreased breast size and elasticity
- decrease breast size = more prominent inner structures
- lactiferous ducts more palpable and change in texture
- decreased axillary hair
male breasts
- disc of undeveloped tissue underlying the nipple
- areola developed, nipple small
- gynecomastia: temporary tissue enlargement
palpation of lumps - characteristics
- location (use clock as reference)
- size
- shape (oval =, round)
- consistency
- movability
- distinctness (1 lump or many)
- nipple
- skin over lump (red, dimpled, scaly)
- tenderness (is it sore?)
- lymphadenopathy (any swelling in are on side where lump was found?)
breast cancer
- solitary unilateral non-tender mass
- mass is sold, hard, dense, fixed to underlying tissues or skin
- irregular borders, poorly delineated
- constant growth
- commonly in upper outer quadrant
- advanced changes: firm or hard axillary nodes, dimpling of skin; nipple retraction, elevation and discharge
skin moisture
normally on the face, hands, axilla
- in response to activity, environment, anxiety
skin texture
normal skin feels smooth and firm
skin texture - hyperthyroidism
skin feels smoother and softer, like velvet
skin thickness
- evenly lean over most of body
- thicker on palms of hands and soles of feet
skin mobility and turgor
mobility: skin’s ease in rising
turgor: ability of skin to return to place promptly when released
nails - inspect & palpate
- consistency
- cap refill
- shape/contour
normal: 160°
curved nail: 160°≥
early clubbing: 180°
lesions - characteristics
- colour
- elevation
- pattern or shape
- size
- location
- distribution
lesions - shapes
- annular
- target
- linear
- gyrate
lesions - patterns/distribution
- polycyclic
- grouped
- discrete
- zosteriform
- confluent
ABCDE - skin
A: asymmetrical
B: borders
C: colour
D: diameter
E: evolution - most important
older adult consideration - skin
- slow atrophy of structures
- thinning of skin
- subcutaneous fat & muscle tone are lost
- environmental trauma (sun exposure & cigarette smoking)
- increased risk for shearing & tearing injuries (when skin breakdown occurs, wound healing is delayed
older adult considerations - hair & nails
hair:
- hair loss on the scalp is genetically determined
- grey/white hair feels thin & fine
- males have symmetrical balding in frontal areas
- females may have some bristly facial hair (decr. estrogen)
nails:
- growth rate decreases
toe nails thicken
pressure ulcers - definition
skin defect that extends into dermis or deeper structures
pressure ulcers - pathophysiology
- pressure distorts capillaries
- this occludes blood flow / O2 delivery
pressure ulcers - locations
appear over bony prominences
pressure ulcers - risk factors
- impaired mobility
- decr. sensory perception
- impaired LoC, poor nutrition, shearing injury
- thin, fragile skin of aging, moisture from incontinence
head - inspect & palpate
- general size & shape
- any deformities, lumps, tenderness
- palpate temporal artery and TMJ
face - inspect
- facial structures (eyeballs aligned normally)
- symmetry of movement, noting any abnormal swelling
- look for any involuntary movement (ex. twitching)
- facial expression (CN 7 - facial nerve)
physical exam - neck
symmetry:
- when head is held upright and centered in the midline, the accessory muscles of the neck should be arranged symmetrically
- head should remain straight
- trachea & thyroid should be midline
- note any pulsations
ROM:
- observe any movement limitations
- test CN 11 by resisting pt’s movement with your hands
headaches - primary
- tension
- migraine
- cluster
headaches - secondary
- head trauma
- vascular disorders
- substance or their withdrawal
- systemic infection
- problems of the skull, neck, eyes, ears, nose, teeth, mouth
- neuralgia headaches (or occipital neuralgia)
central visual acuity
- snellen eye chart
- most commonly used and accurate measure of visual acuity
- if they wear glasses or contacts - keep them on
- stand 20 feet from chart
- cover 1 eye and read each line
testing visual fields
- test peripheral vision
- line up ~60 cm from each other and direct pt to cover 1 eye and you cover opposite eye of the pt
- slowly advance your flickering finger inward from the periphery in several directions
- ask pt to saw ‘now’ when they first see the target
what does 20/20 vision mean?
you can read at 20 feet, what the normal eye can read at 20 feet
what does 20/30 vision mean?
you can read at 20 feet what the normal eye can read at 30 feet
corneal light reflex
- assesses parallel alignment of eyes
- shine light toward pt eyes aimed at bridge of nose ~30cm away
- ask pt to stare straight ahead
- note reflection in corneas
- reflection should be in same spot in both eyes
what could asymmetry in corneal light reflex exam signify?
- deviation in alignment d/t eye muscle weakness or paralysis
cover-uncover test
- ask pt to stare straight ahead
- take piece of paper, cover 1 eye, then remove paper
- covered eye should remain straight and focused
- if you notice, reestablishing fixation or jumping; indicates eye muscle weakness
which cranial nerves are you assessing when you assess extraocular muscle function?
CN 3, 4, 6 - oculomotor, trochlear, abducens
six cardinal positions test
- perform this test to assess any eye muscle weakness during movement
- perform 6 cardinal positions by asking pt to hold head straight & steady and follow your finger/pen with their eyes
- hold pen/finger ~30cm away
- move finger out and back in for each position
- should that eyes have normal, parallel tracking
physical exam - eyeballs
aligned normally in their sockets with no protrusion or sunken appearance
physical exam - conjunctiva
- ask pt to look up and inspect the eyeball
- it should be moist and glossy
- note any colour change, swelling, or lesions
physical exam - sclera
white (light-skinned0, grey-blue (dark skinned)
physical exam - anterior eye structures
- using pen light, shine light across cornea from the side
- check for smoothness and clarity
- note pupil size, shape, and if pupils are equal in size & shape
pupillary light reflex
- darken room
- ask pt to stare straight ahead
- shine pen light from side
- note pupil response
- perform on both side
- pupils should constrict with light
accommodation - eye exam
- ask pt to stare at object in the distance and then to shift their gaze to your pen/finger which is in front of their face
- eyes should slightly cross, and pupils should contrict
PERRLA
Pupils
Equal
Round
React to
Light and
Accommodation
older adult considerations - eyes
- skin loses elasticity, causing wrinkling and drooping
- pts may complain of dry eyes d/t fewer lacrimal secretions
- impaired visual acuity impact quality of life
what eye diseases does aging increase the risk of developing?
- macular degeneration
- cataracts
- glaucoma
- diabetic retinopathy
Hx - ears
- earache
- discharge
- hearing loss
- environmental noise
- tinnitus
- vertigo
- self-care behaviours
ear - size & shape
should be equal with no swelling
ear - skin colour
colour should be consistent with skin tone
ear - lumps/lesions
skin should be intact with no lumps/lesions
ear - pain test
- move pinna and push on the tragus
- should not cause any pain
- mastoid process should also produce no pain
ear- opening of the ear
should be no redness, swelling, or drainage
how would you perform a physical ear exam on an adult vs. a young child?
for an adult: pull ear up and out (backwards)
for child under 3: pull pinna straight down
whispered voice test
- ensure room is quiet
- stand arms length behinf pt
- test on ear at a time
- whisper slowly a set of 3 random letters and numbers
- ask pt to repeat what you said
older adult considerations - ear
- hearing acuity usually declines with age
- early losses (strt in young adulthood) involve primarily the high-pitched sounds, but gradually, losses extend to sounds in the middle and lower ranges
what happens to the cilia lining the ear canal with age?
become coarse and stiff impeding sound waves traveling toward eardrum
what happens when a person fails to hear higher tones of words but can still hear lower tones?
words sound distorted and difficult to understand, especially in noisy environments
Hx - nose
- discharge
- frequent colds
- sinus pain
- trauma
- epistaxis
- allergies
- altered smell
what is epistaxis?
nosebleeds
Hx - mouth & throat
- sores or lesions
- sore throat
- bleeding gums
- toothache
- sugar consumption
- bruxism
- hoarseness
- dysphagia
- altered taste
- tobacco/heavy alcohol consumption
- self-care behaviours
what is bruxism?
teeth grinding
inspect & palpate - nose
external structures: symmetrical, midline, proportion to other facial features
patency: gently push one nasal wing shut when asking pt to sniff & repeat
inspection - nasal cavity
- tilt pt’s head back (observe for nasal septum deviation or polyps)
- gently insert otoscope head into nasal vestibule
- inspect nasal mucosa (noting any swelling, discharge, bleeding, or foreign body
physical exam - sinuses
- air-filled pockets within cranium
- only 2 pairs accessible for examination (frontal and maxillary)
- use thumbs to press over frontal sinuses right below eyebrows
- press over maxillary sinuses just below cheek bone
- should not cause any pain
physical exam - lips/tongue
move anterior to posterior
- start with lips (check for any cracking, lesions)
- teeth (absent, lose, abnormally placed teeth)
- gums (pink in colour, remove dentures)
- tongue (pink and even)
- ask pt to touch tongue to roof of mouth (assess bottom part of tongue; check for moisture)
physical exam - oral cavity / pharynx
uvula:
- should be hanging midline
- ask pt to say ah and watch uvula & soft palate (should stay midline)
tonsils:
- should be granular
- crypts should be present
- graded in size
1+: visible
2+: halfway between side of mouth and uvula
3+: tonsils are touching the uvula
4+: tonsils are touching each other
- notice any breath odour
what does ketoacidosis do to a person’s breath?
makes it smell sweet
older adult considerations - nose, mouth, throat
- sense of smell may diminish after age 60 d/t decr. # of olfactory nerve fibers
- decr. salivary secretions and loss of taste
- diminished senses of taste and smell
- decr. in appetite (may contribute to malnutrition)
- d/t absence of some teeth, many eat soft foods, decr. meat and fresh veggie intake, may lead to risk for nutritional deficits
organs with solid viscera
- liver
- spleen
- right & left kidneys
- pancreas
- uterus
- ovaries
organs with hollow viscera
- gallbladder
- stomach
- ascending colon
- cecum
- appendix
- bladder
- small intestine
- descending colon
- sigmoid colon
- duodenum
- rectum
- bladder
organs in RUQ
- liver
- gallbladder
- duodenum
- head of pancreas
- right kidney & adrenal gland
- hepatic flexure of colon
- parts of ascending & transverse colon
organs in LUQ
- stomach
- spleen
- left lobe of liver
- body of pancreas
- left kidney/adrenal gland
- splenic flexure of colon
- parts of transverse & descending colon
organs in RLQ
- cecum
- appendix
- right ureter
- right ovary & fallopian tube
- right spermatic cord
organs in LLQ
- sigmoid colon
- part of descending colon
- left ureter
- left ovary & fallopian tube
- left spermatic cord
older adult considerations - abdomen
- changes in accumulation of adipose tissue
- delayed esophageal emptying = incr. risk of aspiration
- decr.: salivation, gastric acid production, liver size, & renal function
- incr. risk: dehydration, gallstones, constipation, & colorectal cancer
for older adults, what are the change in the accumulation of adipose tissue?
- adipose tissue is redistributed away from extremities and face to the abdomen and hips
- women: incr. in suprapubic area (d/t decr. estrogen)
- men: incr. in abdominal area
what is aspiration?
when food, liquid, or other material enters a person’s airway and eventually the lungs by accident
Hx - abdomen
- appetite
- difficulty swallowing
- food intolerance
- abdominal pain
- nausea/vomiting
- bowel habits
- previous abdominal hx
- medications
- alcohol & tobacco
- nutrition
inspection - abdomen - contour & symmetry
- contour should be flat
- not scaphoid (sucked in), rounded, or protuberant
inspection - umbilicus
colour, position, orientation
abdomen - inspection - skin
- colour
- striae
- presence of veins
- rashes
- lesions
- turgor
abdomen - inspection - other
- pulsation or movement
- hair distribution
- demeanor
- ostomies & percutaneous tubes
auscultation - bowel sounds
- peristalsis of intestines
- diaphragm end
- begin in RLQ
- high-pitched, gurgling, cascading sound that is irregular in rhythm
- normal: 5-30 sounds/min
auscultation - abdomen - vascular sounds
- bell end
- place stethoscope gently against skin
- listen over areas below
- normal: no vascular sound
hyperactive bowel sounds
- increased motility
- normal: stomach growling
- abnormal: loud, high-pitched, rushing, tinkling sounds
- cause: bowel obstruction
hypoactive or absent bowel sounds
- decreased or absent motility
- listen for full 5 minutes
- total absence is rare
- causes: post-abdominal surgery, inflammation or peritoneum
systolic bruit
- pulsing blowing sound
- pitch dependent on cause
- causes: renal artery stenosis, abdominal aortic aneurysm, partial occlusion of femoral arteries
venous hum
- soft, continuous humming noise of medium pitch
- heard between xiphoid process and umbilicus
- causes: portal HTN, liver cirrhosis
percussion - abdomen
- assess density & location of organs
- screen for abnormal fluid or masses
- percuss in clockwise direction
what does the sound ‘tympany’ signify?
hollow organs
what does a dull sound signify?
solid organs
what are some important findings when percussing the abdomen?
hyper-resonance or dullness where there should be tympany
palpation (light) - abdomen
assess: texture, temperature, moisture, swelling, rigidity, pulsation, presence of tenderness/pain
steps:
1. ensure pt is relaxed
2. use first 4 fingers together and depress 1cm
3. move fingers in gentle circular motion
4. lift fingers off before moving to next spot
5. move in clockwise direction
6. examine painful/tender area last
abdomen - palpation - important findings
- involuntary rigidity
- guarding
- tenderness
- masses
- organomegaly
ascites
- fluid collection in the peritoneal cavity d/t portal HTN and low albumin in blood
- causes: liver cirrhosis, congestive heart failure, cancers
bowel obstruction
- history of previour abdominal surgery with adhesions
- vomiting
- absence of stool or gas passage
- distended abdomen (after 2nd day)
- radiograph shows dilated air-filled loops of small bowel with multiple air-fluid levels
- hyperactive bowel sounds in early obstruction; hypoactive or silent in late obstruction
- dehydration and loss of electrolytes
- accumulation of fluid and gas in bowel proximal (above) to obstruction
- colicky pain from strong peristalsis above the obstruction
- fever
- pressure from excess fluid and gas may lead to leaking fluid into peritoneum
- hypovolemic shock
what happens in hypovolemic shock?
- decr BP
- incr pulse
- cool skin if left untreated
older adult considerations - anus, rectum, prostate
- prostate gland enlarge
- hormonal imbalance that causes the production of adenomas
- incr risk of prostate cancer & colorectal cancer
anus, rectum, prostate - Hx (important findings)
- usual bowel routine: constipation, dyschezia
- changes in bowel habits: gastroenteritis, colitis, IBS, parasite
- rectal bleeding, blood in stool: GI bleed, cancer, infection
- medication use: constipation, melena
- rectal conditions: hemorrhoids, fecal incontinence
- family history: colon cancer, rectal cancer, prostate cancer
- self-care behaviours: low fiber diet
what is dyschezia?
difficulty pooping
britol stool chart - type 1
- separate hard lumps, like nuts
- hard to pass
- severe constipation
bristol stool chart - type 2
- sausage shaped but lumpy
- mild constipation
bristol stool chart - type 3
- like sausage but with cracks on the surface
- normal
bristol stool chart - type 4
- like sausage or snake
- smooth and soft
- normal
bristol stool chart - type 5
- soft with blobs with clear-cut edges
- passed easily
- lacking fiber
bristol stool chart - type 6
- fluffy pieces with ragged edges
- a mushy stool
- mild diarrhea
bristol stool chart - type 7
- watery
- no solid pieces
- entirely liquid
- severe diarrhea
inspection - anus, sacrococcygeal area, anal opening
- spread buttocks apart to observe perianal region
anus: moist, hairless, coarse folded skin, increased pigmentation
sacrococcygeal area: smooth, even
anal opening: valsalva manoeuvre produces no break in skin integrity or protrusion
hemorrhoids
- flabby papules that are painless
cause: varicose vein from increased portal venous pressure
- external and internal
hemorrhoids - external
- below anorectal junction and covered by anal skin
- if thromboses contains clotted blood and is painful, swollen, shiny, blue, itchy, bleeding during defacation
what is pruritis?
itchy
hemorrhoids - internal
- above the anorectal junction and covered by mucous membrane
- red mucosal mass seen during valsalva manoeuvre
what is the valsalva manoeuvre?
- pt in supine position
- ask pt to exhale against closed glottis for 10-15 seconds
fecal impaction
- complete colon blockage from hard, immovable stool in rectum
- can produce constipation or overflow incontinence
- community-dwelling older adults at risk
cause: decreased bowel mobility (hospitalized patients and spinal cord injury patients), low-fiber diet
older adult changes - male GU system
- no end to fertility, but sperm production decr ≥ 40 years old
- gradual decr in testosterone production ≥ 55 years old
- decr amount of pubic hair & color change to grey/white
- decr in penis and testes size
- decr in tone of dartos muscle = scrotum hanging lower
- decr rugae = pendulous look to scrotum
- decr testosterone = slower and less intense sexual response
- may become demoralized d/t changes in sexual activity
Hx (important findings) - male GU
- frequency, urgency, nocturia: polyuria, oligura, infection
- dysuria: acute cystitis, prostatitis, urethritis
- hesitancy & straining: prostate enlargement, acute cystitis
- urine colour: dehydration, UTI, hematuria, cancer
- past GU history: incontinence, kidney disease, prostate disease
- penis: infection
- scrotum/testes: hernia, cancer, hydrocele
- sexual activity & contraceptive use: risky sexual activity, STIs, erectile dysfunction
- STI contact: STI
- STI risk reduction: risky sexual activity, no contraceptive use
what is polyuria?
urinate more than usual
what is oliguria?
urinate less than usual
inspection - penis
- penis: wrinkled, hairless, no lesions
- glans: smooth, no lesions, easy retraction and sliding back when uncircumsized
- urethral meatus central
hair distribution consistent with age
palpation - penis
- compress glans anteroposteriorly between thumb and forefinger
- meatus edge pink, smooth, no discharge
- palpate shaft between thumb and 2 first fingers
- penis smooth, semi-firm, nontender
what is hypospadias?
birth defect in boys where the opening of urethra is not located at tip of penis
what is epispadias?
birth defect in boys where urethra does not form fully and urethra typically is found in abnormal location
-typically on bottom side of penis
inspection & palpation - scrotum
- pt to hold penis out of the way (if unable to, use back of gloved hand)
- size dependent on room temp
- left typically lower than right
- lift scrotal soc for posterior view
- palpate each scrotal half gently
- should slide easily, be freely movable, rubbery, smooth, oval, firm
inguinal & femoral hernias
hernia: bulging of internal organs or fatty tissue through on opening in muscle anterior to it
- most common indirect inguinal hernia
- visually see bulge when pt stands
- palpate bump/mass
older adult considerations - female GU
- menopause = cessation of menses
- occurs ~48-51 years old
- preceding 1-2 years irregular menses (lighter flow, further apart)
- ovaries stop producing progesterone and estrogen
- physical changes d/t change in hormone levels
- uterus shrinks and may droop (prolapsed uterus)
- vagina atrophies to 1/3 length and width
- decr vaginal secretions
- decr mons pubis d/t sucr fat pads
- decr labia & clitoris
- decr amount of pubic hair & colour change to grey/white
Hx (important findings) - female GU
- menstrual history: amenorrhea, menorrhagia
- obstetrical history (GTPAL): difficulty conceiving
- menopause: hormone replacement side effects
- self-care behaviours: irregular PAP test
- urinary symptoms: dysuria, nocturia, hematuria, incontinence
- vaginal discharge: vaginal infection
- gynecological history: surgery on uterus, ovaries, vagina
- sexual activity & contraceptive use: risky sexual activity, STIs
- STI contact: STI
- STI risk reduction: risky sexual activity, no contraceptive use
female GU - inspection (preparation)
- lithotomy position
- arms at side or across chest
- drape appropriately
- trauma and violence informed care
- provide mirror for teaching
female GU - inspection (external genetalia
- skin colour & texture
- hair distribution
- labia majora symmetrical, plump, well formed
- gloved hand, separate labia majora
- labia minora dark pink, moist, symmetrical
- urethra opening slit like and midline
- vaginal opening narrow or large
- perinium smooth
- anal skin coarse and dark pigmentation
urethritis
- inflammation of urethra d/t infection
- same bacteria can cause UTI and STI
- subjective: dysuria, pruritis, pain during sex
- objective: purulent discharge from meatus, fever (erythemia, tenderness and induration of urethra in anterior vaginal wall)
what is erythema?
redness of the skin caused by injury or another inflammation-causing condition
urine assessment
- normal urine output: 1200-1500 mL/day
- clear, pale yellow/amber, very slight urine odor
- bladder capacity = 600 - 1000 mL
- moderate distension ≥200mL
- discomfort ≥ 400 mL
- indwelling catheters: anchored, not kinked, placed below bladder level
- meatus pink, smooth, no discharge
urine assessment - important findings
- oliguria
- polyuria
- change in urine colour
- suprapubic tenderness
- costovertebral angle pain/tenderness
- fever
- discharge from meatus
- change in. mental status
