Health Assessment Unit 6

Muscles

• Over 600 muscles in the human body protect our bones.

• Responsible for body movement

Three types of muscle

• Cardiac

• Smooth

• Skeletal

Types of Muscle and Joint Movements (Photo)

Be able to describe in words

Tendons

Tendons allow for the attachment of muscle to bones.

Tendon Injury Type

Strain

Ligaments

Ligaments attach bone to bone

Ligaments Injury Type

Sprain

Diagnostics (MSK System)

• Blood test

  • Creatine phosphokinase (CPK)

• X-ray

• Magnetic resonance imaging (MRI)

• Computed tomography (CT scan)

• Dual-energy x-ray absorptiometry (DEXA) scan

Health History (MSK System)

• Family history

• Past surgical history

• Past medical history

• Nutrition

• Pain assessment

• Risk factors

• Cultural considerations

Sequence of Assessment (MSK System)

• Inspection

• Palpation

• Assessing range of motion

• Assessing strength

The Five “Ps”

• “Five Ps” will help you to focus on specific musculoskeletal symptoms or injuries.

  • Pain

  • Paralysis

  • Paresthesia

  • Pallor

  • Pulselessness

Inspecting Gait

Technique

• Have the patient walk away from you first and then back toward you.

• Inspect any differences in leg swing and arm swing.

• Assess the patient’s ability or inability to control any joints.

• Assess if the patient uses any assistive devices.

Inspecting Gait

Findings

• Normal Findings

  • Gait length is approximately 1.5 m for adults

  • Equal leg and arm swing

  • Arm swing contralateral

  • Smooth, even pattern

  • No assistive devices

  • Maintains balance easily

  • No limp

  • Expected motion

• Abnormal Findings

  • Unequal leg and/or arm swing

  • Arm swing not contralateral

  • Pattern is not smooth or even

  • Using assistive device

  • Unable to maintain balance

  • Limping

  • Alterations in motion

    • Limited

    • Increased

  • Ataxia

  • Scissors

  • Shuffling

  • Foot drop

Scissoring Gait

Foot Drop

• A weakness or paralysis of the muscles of the lower leg or the inability to control plantar flexion of the ankle; it may indicate peroneal nerve injury or muscle or neurological disorders.

• In this condition, the patient is unable to use the muscles to bring the foot into the neutral position (Fig. 16-10A).

• This is where the foot is at 90 degrees to the lower leg, much like the letter L.

Inspecting Posture

Techniques

• Inspect the patient’s posture while the patient is walking.

• Is the head centered on the axial skeleton?

• Is there an alteration in balance, ability to ambulate or stand?

• Have patient sit in a chair and get up from a chair; note any difficulties in lowering or raising him- or herself.

• Assess position of shoulders and head.

• Ask patient to rotate (turn) the head to the right and then to the left.

• Ask patient to tip the head to the right and then to the left.

• Ask patient to flex and extend the neck.

• Assess patient’s ability to stand and sit.

• Ask the patient to bend forward at the waist; inspect the spinal curvature.

• Ask patient to bend at the waist to the right and left, forwards and backwards.

Inspecting Posture

Findings

• Normal Findings

  • When standing, feet are shoulder width apart

  • When standing and sitting, head centered on axial skeleton

  • When standing, weight is distributed evenly on both lower extremities

  • ROM of the neck and back are symmetrical

• Abnormal Findings

  • Numbness or tingling

  • Head not centered on the axial skeleton

  • Limitations in ROM

  • Shoulders are not level

  • Motion of trunk is not symmetrical

Inspecting and Palpating Vertebral Column

Technique

• Purpose: To assess for abnormalities in the structure of the vertebral column

• Have patient stand.

• Inspect alignment of vertebral column.

• Using two or three finger pads, starting at the top of the vertebral column, palpate the vertebral column for tenderness, deviations, or protrusions.

Inspecting and Palpating Vertebral Column

Findings

• Normal Findings

  • Vertebral column is straight

  • No pain or alteration of sensation

  • No deviations in any plane

  • No deformities found

• Abnormal Findings

  • Presence of pain, tenderness, altered sensation

  • Deformities found

    • Scoliosis

    • Kyphosis

    • Lordosis

  • Protrusions or depressions

Scoliosis

An abnormal curvature of the spine that occurs in a lateral manner; it may look like a C or S on visualization and be palpable

Kyphosis

A curvature of the spine that looks like a slouching, or hunchback, posture; this can lead to problems with the contents of the thorax. This occurs in the thoracic spine

Lordosis

A curvature of the spine that looks like an arched lower back: it is an increased inward curvature of the lumbar spine

Inspecting and Palpating Upper Extremities

Technique

• Always compare the right with the left side

• Assess

  • Shoulder

  • Elbow

  • Wrist

  • Hand/fingers and joints

• Using two or three finger pads, gently palpate the upper extremity on the right side.

• Assess for

  • Tenderness

  • Depressions

  • Bulges

  • Changes in temperature

• Repeat on the left side and compare sides.

Inspecting and Palpating Upper Extremities

Findings

• Normal

  • Symmetry between right and left

  • No pain or alteration of sensation

  • No deformities found

  • Full range of motion

  • Some flexion of the fingers

  • No forward rounding of shoulders

  • Upper arms straight

  • Slight bend at elbow

  • Wrists in alignment with lower arm

• Abnormal

  • Presence of pain, altered sensation

  • Deformities found

  • Limited range of motion

  • No symmetry between right and left

  • Forward rounding of shoulders

  • Upper arms not straight

  • No, or excessive, bend at elbow

  • Wrists not in alignment with lower arm

Bouchard’s Nodes

Bony enlargements on the proximal interphalangeal joints (PIP) joints; commonly seen in osteoarthritis or rheumatoid arthritis

Heberden’s node

Bony enlargements on the distal interphalangeal joints (DIP); commonly seen in osteoarthritis

Assessing ROM and Muscle Strength of Upper Extremities

Technique

• Ask the patient to perform specific motions independently first and then against resistance.

• Assess ROM before strength.

Shoulder Movement

Flexion

Flexion against resistance

Extension

Extension against resistance

Abduction

Abduction against resistance

Adduction

Adduction against resistance

Internal rotation

Internal rotation against resistance

External rotation

External rotation against resistance

See Table 16-1 for expected ROM.

Expected Range of Motion of the Shoulder Table

Expected Range of Motion at the Elbow and Forearm Table

Expected Range of Motion of the Wrist Table

Elbow motion

• Flexion

• Flexion against resistance

• Extension

• Extension against resistance

Hand motion

• Pronation of hand

• Pronation of hand against resistance

• Supination of hand

• Supination of hand against resistance

Wrist Motion

• Flexion

• Flexion against resistance

• Extension

• Extension against resistance

• Radial deviation

• Radial deviation against resistance

• Ulnar deviation

• Ulnar deviation against resistance

Finger Motion

• Flexion

• Flexion against resistance

• Extension

• Extension against resistance

Assessing for Carpal Tunnel Syndrome

Tinel’s Test

Assessing for Carpal Tunnel Syndrome

Phalen’s Test

Grading Muscle Strength

0: Unable to contract muscle in a gravity eliminated position

1: Able to contract muscle slightly

2: Able to move joint in a gravity eliminated position

3: Able to move joint against gravity

4: Able to move joint with some resistance through range of motion.

5: Able to move joint with full resistance through range of motion

Assessing ROM and Muscle Strength of Upper Extremities

Findings

• Normal

  • Symmetric ROM from right to left

  • Absence of pain or altered sensation

  • Strength equal from right to left

  • Strength between 4 and 5

• Abnormal

  • Asymmetric ROM from right to left

  • Presence of pain or altered sensation

  • Unequal strength between right and left

  • Strength < 4

  • +Tinel’s or Phalen's test

Inspecting and Palpating Lower Extremities

Technique

• Purpose: To assess for any abnormalities within the lower extremity

• Ask patient to perform specific motions independently first and then against resistance.

• Ask patient to perform the following ROM activities of the right and left lower extremity.

• Inspect each extremity and compare the right side with the left side.

Palpating Lower Extremities

• Hip

• Knee

• Ankle

• Foot

• Toes

Palpating Lower Extremities

Assess the presence of:

• Tenderness

• Depressions

• Bulges

• Temperature change

Inspecting and Palpating Lower Extremities

Findings

• Normal

  • No pain or alteration of sensation

  • No deformities found

  • Symmetry between right and left

  • Weight placed on both legs evenly

  • Hips in neutral position

  • Slight bend at knee, pointed forward

  • Ankle is perpendicular to lower leg

  • Foot straight forward

• Abnormal

  • Presence of pain, altered sensation, temperature change

  • Deformities found

  • Hallux Valgus

  • Hammertoe

  • No symmetry between right and left

  • Weight unevenly distributed to one side

  • Hips not in neutral position

  • No, or excessive bend at knee

  • Ankle not perpendicular to lower leg

Assessing ROM and Strength of Lower Extremities

Technique

• Tell the patient you will be assessing each lower extremity separately and he or she will have to perform specific motions without assistance.

• Assess any differences in symmetry of motion and the fluid nature of the motion.

• Assess strength: Graded 0–5

Grading Strength of Muscle Chart

Hip Motion

• Flexion

• Flexion against resistance

• Extension

• Extension against resistance

• Abduction

• Abduction against resistance

• Adduction

• Adduction against resistance

Knee Motion

• Flexion

• Flexion against resistance

• Extension

• Extension against resistance

Foot Motion

• Inversion

• Inversion against resistance

• Eversion

• Eversion against resistance

Ankle Motion

• Dorsiflexion

• Dorsiflexion against resistance

• Plantar flexion

• Plantar flexion against resistance

Assessing ROM and Strength of Lower Extremities

Findings

• Normal

  • Symmetric ROM from right to left

  • Motion is fluid and without pain

  • Absence of pain or altered sensation

  • Strength equal from right to left

  • Strength between 4 and 5

• Abnormal

  • Asymmetric ROM from right to left

  • Motion is not fluid

  • ROM limitation

  • Presence of pain or altered sensation

  • Unequal strength between right and left

  • Strength < 4

Healthy People 2030 (MSK System)

• Arthritis Goal:

  • Reduce pain and disability from arthritis (ODPHP, 2020)

• Osteoporosis Goal:

  • Prevent fractures and disabilities related to osteoporosis (ODPHP, 2020)

• Workplace Goal:

  • Promote the health and safety of people at work (ODPHP, 2020)

• Chronic Pain Goal:

  • Reduce chronic pain and misuse of prescription pain relievers (ODPHP, 2020)

Ataxia

An unsteady gait that may be used to compensate for an injury or pain in the extremities. This may also indicate a problem with cerebellar function.

Scissors or Diplegic Gait

Most commonly seen in cerebral palsy. The legs cross the midline in a swinging fashion to compensate for lack of motion.

Female Reproductive System

Diagnostics

Mammogram

Needle biopsy

Sonogram

Papanicolaou test (Pap smear)

Human papillomavirus (HPV) test

Vaginal specimens

Menstrual History

• Age of the start of menstruation

• Date of last menstrual period

• Regular or irregular

• Menstrual cycle is expressed as X/Y

  • X = Duration

  • Y = Cycle

• Number of days of bleeding

• Type of absorbent products used

• Amount of bleeding

• Duration

• Menstrual cramps

  • Primary dysmenorrhea

  • Secondary dysmenorrhea

• Bleeding between cycles

• Premenstrual syndrome

• Bleeding after sexual intercourse

• Menopause

• Perimenopause

• Post menopause

• Amenorrhea

• Metrorrhagia

• Menorrhagia

• Oligomenorrhea

Sexual Health

• Ask questions about the “P’s”

  • New sex partners

  • Practices

  • Protection

  • Past history of STIs

  • Prevention of pregnancy

• Additional questions: “Is there anything else about your sexual practice that I need to know about?”

Contraceptive History

• Ask patient about contraceptive method

  • Birth control pills

  • Transdermal patch

  • NuvaRing

  • Subdermal hormonal methods

  • Diaphragm

  • Intrauterine devices (IUDs)

  • Cervical cap

  • Female/Male condom

  • Spermicide

  • Rhythm method

Breast Health

• Breast surgeries

  • Mastectomy

  • Breast reduction

• Breast examinations

  • Clinical breast exam (CBE)

  • Breast self-examination (BSE)

• Mammogram – date of last test

Family history of breast cancer or breast disease

See Box 18-3 for Warning signs of breast cancer

• Fibrocystic breast disease/cysts

• Warning Signs for Breast Cancer

  • Lump.

  • Thickening or dense tissue felt inside the breast or underarm area.

  • Swelling, warmth, inflammation, or color changes.

  • Change in the size or shape of the breast.

  • Dimpling or puckering of the skin.

  • Itchy, scaly sore or rash on or around the nipple.

  • Retraction of the nipple or other parts of the breast.

  • Nipple discharge.

  • Pain in an area of the breast.

Risk factors for breast cancer

See Box 18-4.

Family history of one or more first-degree relatives.

• Inherited mutations in the BRCA1 and BRCA2 genes.

• Advancing age.

• Obesity in advancing age.

• Moderate levels of alcohol.

• Combined hormonal therapy of estrogen and progesterone.

• Physical inactivity.

• Increased breast tissue density.

• Long menstrual period (periods that start early and/or end later in life).

• Oral contraceptives.

• Never having children.

• Having a child after age 30.

Breast concerns

• Lumps

• Pain in one or both breasts

  • Mastalgia is breast pain that usually is correlated to a woman’s menstrual cycle.

• Tenderness

• Breast nipple discharge

• Skin changes

• Axillary changes

Gynecological History

• Past and present gynecological symptoms

  • Gynecologic cancers

  • Vaginal discharge, bleeding, or itching

  • Genital sores

  • Abdominal or pelvic pain

  • Painful urination

  • Infertility

• Gynecological surgeries or procedures

• Infertility

• Vaginal discharge

  • Onset, duration, frequency, volume, and odor of discharge.

  • Normal vaginal discharge is clear but may turn white or yellow when exposed to the air.

• Abnormal discharge

• Sexually transmitted infections (STIs)

• Pelvic exam and PAP smear

  • Ask date of last exam/test

• Gynecologic cancers

• Gynecological symptoms

• Use of external products such as douches

• Pelvic pain

Gynecological History

Abnormal Discharge

Inspecting Female Breasts

• Purpose: To assess the breasts for size, shape, color and abnormalities

• Inspect the breasts in four different positions:

  • Seated with the arms hanging by each side

  • Seated with the arms placed over the head

  • Seated with the hands on the hips

  • Standing and leaning forward

Inspecting Female Breasts

Inspect the skin

Color

Contour

Edema

Lesions

Ulcerations

Texture of skin

Vascularity

Venous patterns

Inspecting Female Breasts

Inspect the areola

Shape

Color

Hair

Visible lumps

Inspecting Female Breasts

Inspect the nipples

Size

Position

Shape

Discharge

Crusting

Presence of accessory nipples

Inspecting Female Breasts

Inspect the signs of retraction

Dimpling

Puckering

Furrows

Eversion of Nipple

Inversion of Nipple

Paget’s Disease of the Breast

Picture

General Breast Assessment

Picture

Breast Appearances

Picture

Inspecting Female Breasts

Inspect the lower aspect of breasts

Symmetry

Skin changes

Nipple deviations

Inspecting Female Breasts

Inspect the axilla

Hair distribution

Skin texture

Protrusion of lumps or masses

Inspecting Female Breasts

Ask Patient before inspecting

• Ask the patient to press her hands against her hips contracting the pectoral muscles and inspect:

  • Symmetry

  • Skin changes

  • Retraction areas

  • Nipple deviations

• Ask the patient to stand and bend forward and inspect from the front and laterally:

  • Symmetry

  • Skin changes

  • Retraction areas

  • Nipple deviations

Inspecting Female Breasts

Normal Findings

• Breasts are symmetrical

• Color of skin is uniform

• Areola is round or oval, uniform color

• Montgomery tubercles are present

• Nipples are centered, round, without discharge or crusting

• Venous patterns are the same on both breasts

Inspecting Female Breasts

Abnormal Findings

• Asymmetrical breasts

• Erythema or signs of inflammation

• Mastitis

• Breast tissue retraction, lumps, or dimpling

• Unilateral venous pattern

• Peau d’orange

Palpating Female Breasts

• Purpose: To assess for lumps, density of breast tissue, or breast masses

• Equipment: Gloves (if needed)

• Three pattern techniques:

  • Circular

  • Radial spoke

  • Vertical strip

• The vertical strip method is superior for ensuring that all breast tissue is examined.

Palpating Female Breasts

Ask Patient before palpating

• Assist or ask the patient to assume the supine position.

• Ask the patient to take her right arm out of the gown sleeve and raise it above her head.

• Stand on the patient’s right side.

• Following one of the three patterns, using the finger pads of three fingers of your dominant hand, palpate the right breast and corresponding axillary area.

Palpating Female Breasts

While palpating, assess for:

• Tissue density

• Lumps, masses, or increased density

  • Shape

  • Consistency

  • Location (use a clock face to identify location, i.e., 1:00 o’clock)

  • Size

  • Moveable or fixed

  • Tenderness

Palpating Female Breasts

While palpating

• Wear gloves if any history or nipple drainage or reports of nipple drainage.

• Gently palpate the nipple and compress the nipple and areola between your thumb and index finger to assess for any discharge.

• If discharge, note

  • Amount

  • Color

  • Odor

  • Consistency

• Repeat steps on the left side.

Palpating Female Breasts

Normal Findings

No tenderness

No lumps

No increased tissue density

No nipple discharge

Palpating Female Breasts

Abnormal Findings

Tenderness or pain

Lumps or masses

Nipple discharge

Paget’s disease

Breast Self-Examination (BSE)

• Breast cancer mortality can be effectively reduced through screening and awareness (ACOG, 2016).

• Assess the patient’s understanding of

  • Breast self-awareness (BSA)

  • Breast self-exam (BSE)

  • How and when the patient is doing BSE

Male Reproductive System

Diagnostics

• Prostate-specific antigen (PSA) test is a blood test that measures the amount of PSA, a protein secreted by prostate epithelial cells.

• Prostate biopsy procedure removes a sample of body tissue.

• Urethral specimens are obtained in men with penile discharge.

Male Reproductive System

Health History

• See Table 19-1 for risk factors for male cancers.

  • Testicular

  • Penile

  • Prostate

  • Male breast

• Past medical or surgical history of conditions related to kidneys, bladder, rectum, genital area

• Family history of bladder, breast, kidney, penis, prostate, and testicular cancers

Risk Factors for Male Cancers

• Testicular Cancer

  • Family history (brother or father)

  • Undescended testicle (cryptorchidism)

  • Cancer in the other testicle

  • Carcinoma in situ of the testicle

  • Men infected with HIV and AIDs

  • Body size – tall men (ACS, 2020a)

• Penile Cancer

  • Not being circumcised

  • HPV infection

  • AIDS

  • Phimosis

  • Smoking and tobacco use

  • Advancing age

  • Ultraviolet light treatment for psoriasis (ACS, 2018b)

• Prostate Cancer

  • African American men

  • Advancing age

  • BRCA1 and BRCA2 gene changes

  • Family history (ACS, 2020b)

• Male Breast Cancer

  • Advancing age

  • Radiation exposure to chest area

  • High estrogen levels

  • Family history of breast cancer

  • Inherited gene mutation (BRCA1, BRCA2)

  • Klinefelter syndrome

  • Alcohol

  • Testicular conditions

  • Liver disease

  • Obesity

  • (ACS, 2018a)

Common Sexually Transmitted Infections

• Sexually transmitted infection (STI) occurs when either bacteria or viruses enter the body; patient asymptomatic

• STIs disrupt the normal body function or structure, and signs and symptoms appear.

• Common STIs

  • Gonorrhea

  • Chlamydia

  • Genital herpes

  • Human papillomavirus (HPV)

  • Human immunodeficiency virus (HIV)

  • Syphilis

Male Reproductive System

Pain

• Use the OLDCARTS mnemonic

• Dysuria

• Bladder pain

• Costovertebral pain

• Testicular pain

• Inguinal pain

Male Reproductive System

Urinary Symptoms

• Difficulty starting the stream

• Hesitancy or urinary retention

  • Benign prostatic hypertrophy (BPH)

• Frequency

• Penile sores, lesions, or discharge

  • Color

  • Amount

  • Consistency

  • Odor of discharge

Male Reproductive System

Scrotum

Male Reproductive System

Sexual Health

• World Health Organization (WHO) has defined sexual health as a state of physical, mental, and social well-being in relation to sexuality.

• Four P’s of sexual history:

  • Partners – sexual relationship, number and type of sexual partners.

  • Practices – types of sexual practices

  • Protection – precautions and protection

  • Past STIs – time frame, treatment

Male Reproductive System

Erectile Dysfunction

• Erectile dysfunction (ED) occurs when a consistent inability to get or maintain an erection prevents a man from having satisfying sex.

• Linked to several common diseases such as diabetes, heart disease, hypertension

• Ask the patient: “Are you able to achieve or maintain an erection?”

• Symptoms

  • Length of time, occur gradually or suddenly

Male Reproductive System

Preparation for Assessment

• Sequence of Assessment

  • Inspecting and palpating the male breasts

  • Inspecting the male genitalia

• Provide a warm and comfortable room.

• Reassure the patient that confidentiality will be maintained.

• Encourage the patient to empty his bladder.

• Expose only the area being assessed.

Inspecting/Palpating Male Breasts

• Purpose: To assess for lumps, nipple discharge or abnormalities

• Equipment: Gloves, additional PPE (if needed)

• With the patient lying in the supine position, inspect the male breasts.

  • Symmetry

  • Color

  • Contour (dimpling or retraction)

  • Edema

  • Lesions

  • Ulcerations

  • Texture of skin

Inspecting/Palpating Male Breasts

Inspecting Areola

Shape

Color

Inspecting/Palpating Male Breasts

Inspecting Nipples

Size

Position

Shape

Discharge

Scaling or crusting

Inspecting/Palpating Male Breasts

Ask patient while inspecting/palpating

• Ask the patient to raise his arms to over his head.

• Inspect the lateral aspect of the breasts toward the mid-axillary line for skin changes.

• Gently palpate each breast and axillary area using the finger pads of your second, third, and fourth fingers using the vertical strip pattern assessment techniques.

Palpating Male Breasts

• Palpate any lump or mass and note the following:

  • Shape

  • Size

  • Consistency

  • Mobility

  • Location

• Put on gloves and palpate each areola.

• Palpate and press each nipple and note any discharge.

  • Color

  • Consistency

  • Odor