Nur 307 Exam 3

Musculoskeletal, Neuro, Male/Female Reproductive, Domestic Violence, Older Adults

Muscle Movement Terms

Abduction = away from midline

Adduction = toward midline

…

Extension = increase angle between body parts by straightening a joint

Flexion = decrease angle between body parts by bending a joint

…

Inversion = foot rolls inward toward the body at ankle

Eversion = foot rolls outward from the body at ankle

…

Pronation = turning forearm so palm is down

Supination = turning forearm so palm is up

…

Protraction = moving body part forward and parallel to ground

Retraction = moving body part backward and parallel to ground

….

Circumduction = circular movement of a limb with distal making circle while proximal is fixed

-rotating the wrist

Musculoskeletal Conditions

Ankylosis = stiff or fixated joint

Ataxia = lack of voluntary muscle coordination

Crepitation = grating/crackling sound/sensation in joint

….

Kyphosis = hunchback, outward curve of spine

Lordosis = swayback, inward curve of neck/lower back

Musculoskeletal Terms

Tendon = muscle to bone

Ligament = bone to bone

…

Nucleus pulposus = gel-like center of intervertebral disc cushioning vertebrae

Bursa = small, fluid-filled sac cushioning bones

….

Plantar = sole of foot

Olecranon process = point elbow formed by ulna

Types of Joints

Cartilaginous Joint = limited movement

—Vertebrae, Rib cage, Pubic bone

-Bones connected entirely by cartilage

-Two types: synchondroses and symphyses

…………………………

Fibrous Joint = fixed/immovable

—Skull, Fibula/Tibia Connector

-Bones connected by dense, fibrous connective tissue, mainly collagen

………………………….

Synovial Joint = free movement

—Shoulder, Elbow, Knee, Wrist, Thumb

-Bones connected by fluid-filled cavity and fibrous capsule

-Types: ball and socket, plane, saddle/gliding, hinge, condyloid, pivot

Subjective Assessment: Joint Pain/Stiffness/Etc.

Location:

-Unilateral or bilateral?

-Which joint?

…

Aggravating:

-Affected by weather?

…

ROS:

-Any recent tick/insect bites?

-Chills, fever, recent sore throat?

-Repetitive motions?

Subjective Assessment: Knee Injury

Onset:

-What happened?

…

Characteristics:

-Did you hear/feel a pop?

…

ROS:

-Chills, fever, numbness, weakness, skin changes?

-Repetitive motions? Work or bended knees?

-Can you bend/straighten leg/knee?

Subjective Assessment: Myalgia/Muscle Weakness

Characteristics:

-Describe weakness

-Sharp, dull, throbbing, aching?

…

ROS:

-chills, fever, numbness, weakness, skin changes, weight loss, night sweats

Subjective Assessment: Bone Pain/Deformity/Trauma

Onset:

-what happened?

…

Characteristics:

-any change in ROM?

-what looks different?

…

ROS:

-cancer history?

-chills, fever, numbness, weakness, skin changes, weight loss, night sweats

MSK Assessment

5 Ps: Pain, Pallor, Pulse, Paresthesia, Paralysis

…

Order: Inspect, Palpate, ROM, Muscle Strength

MSK Inspection

Check dorsi/plantar flexion bilaterally for ANY back pain patient

…………………………………………………………………………………………………………………………

Joint size & contour

Skin color, swelling, masses, deformities

………………………………………………

Gait

-Spastic = stiff/jerky movement, leges close, feet inward

-Scissor = legs crossing

-Propulsive = stiff posture, head & neck bent forward

-Steppage = toes drag on ground, lift leg higher

—foot drop

-Waddle = side-to-side swaying, hip weakness

…

Ataxia = unsteady gait that may be used to compensate for an injury/pain in extremities

……………………………………………….

Foot Drop

-Weakness/paralysis of muscles in lower leg or inability to control plantar flexion of ankle

-Can lead to steppage gait

-Could be MSK or neurologic issue

MSK Palpation

Always palpate distal pulse when assessing joint

…

Temperature

Bony Articulations

Tenderness

Swelling

Masses

Muscle Strength Grading

Ask person to move as you apply opposing force

Should be equal bilaterally

…………….

5, Normal = Full ROM against gravity, full resistance

4, Good = Full ROM against gravity, some resistance

3, Fair = Full ROM with gravity

2, Poor = Full ROM without gravity

1, Trace = Slight contraction

0, Zero = No contraction

…

Against gravity = active

Without gravity = passive

Temporomandibular Joint TMJ

Inspect

-Anterior to outer ear

-Ability to open/close mouth when talking

…

Palpate

-two fingers, front of each ear, opening/closing mouth

-Compare clenched jaw bilaterally: size, firmness, strength

-Normal:

—No swelling, crepitus

—Smooth motion of mandible

—No audible click or palpable snap

…

ROM

-Laterally move jaw side to side

-Depression = open mouth

-Elevation = closed mouth

-Protrusion = protraction of chin to neck

-Retrusion = retraction of chin to neck

Cervical Spine

Inspect

-Alignment of head & neck

—Should be straight with head erect

…

Palpate

-Spinous process & surrounding muscles

-Note any spasm or tenderness

…

ROM

-Flexion = chin to chest

-Hyperextension = chin toward ceiling

-Lateral bending = ear to each shoulder

-Rotation = chin to shoulder

Shoulder

Inspect

-Posteriorly & Anteriorly

-Size, contour, body landmarks

-No redness, atrophy, deformity, swelling

…

Palpate

-Both shoulders for spasm, atrophy, heat, tenderness

-Start with clavicle, work outwards

…

ROM

-Flexion = move arms outward, forward, up

-Extension = move arms outward, backward

-Abduction = move arm straight outward from body

-Adduction = move arm toward body

-Protraction = bent elbow, inward toward body

-Retraction = bent elbow, outward toward body

Elbow

Inspect

-No deformity, redness, swelling

…

Palpate

-Elbow flexed at 70deg, relaxed

-Note any synovial thickening, swelling, nodules, tenderness, heat

…

ROM

-Supination = move palm up

-Pronation = move palm down

-Flexion = bend elbow

-Extension = straight elbow, palm up

Wrist & Hand

Inspect

-Note contour, position, shape

-No swelling, redness, deformity, or nodules

-Thenar Eminence = fleshy mound on base of thumb on palm

…

Palpate

-Each joint of wrist/hand

-No swelling, bogginess, nodules, tenderness

-Snuffbox tenderness = pain/sensitivity in thumb connecting to wrist

…

ROM

-Flexion = hand down at wrist

-Extension = hand up at wrist

-Radial Deviation = hand wave thumb side

-Ulnar Deviation = hand wave pinky side

-Pronation = rotate in/down

-Supination = rotate out/up

Carpal Tunnel

Irritation/extra pressure on median nerve in wrist

..

Clinical Manifestations

-Numbness, pain, tingling in wrist, hands, or fingers

-Trouble using hands to hold or control objects

……………………………

Phalen Test

-Hold both hands back to back while flexing the wrist at 90deg

-Acute flexion at wrist for 60sec

—Normal/Negative: no symptoms

—Positive: pain, tingling

…

Tinel Sign

-Direct percussion on median nerve at the wrist

—Positive: causes burning/tingling along median distribution

Hip

Inspect:

-Symmetric levels of iliac crests

-Smooth, even gait

-Equal leg lengths

…

Palpate

-while supine

-Joints should feel stable, symmetric

-No tenderness or crepitus

…

ROM

-Flexion: on back, bent knee up

-Extension: on front, slightly bent knee up

-Abduction: on side, top leg straight up

-Adduction: on side, lower leg straight up

-External Rotation: sitting, knees bent, leg in

-Internal Rotation, sitting, knees, bent, leg out

Knee

Inspect:

-Skin should look smooth, equal coloring, and no lesions

-Genu varum = bow legs, legs curve outwards at knee while feet and ankles touch

-Genu valgum = knock knees, legs curve inward at knee, knees touch

…

Palpate

-muscles should feel solid

-joints should feel smooth with no warmth, tenderness, thickening, or nodularity

-Palpate infrapatellar fat pad

…

ROM

-Flexion: bend knee back

-Extension: straight leg, outward up to hip

-Duck walk = squat, knee on floor, other bent

Ankle & Foot

Inspect

-Non-weight-bearing position, standing, & walking

-Compare bilaterally

-Malleoli = smooth, bony prominences

-Note any areas of callus/bursal retraction

…

Palpate

-support ankle by grasping heel

-Ensure no swelling or tenderness

…

ROM

-Dorsiflexion: toes/foot up

-Plantar flexion: toes/foot down

-Inversion: foot inward

-Eversion: foot outward

Back Pain Red Flags

Chills, Fever

Bladder/Bowel Incontinence

Progressive Movement Loss and Weakness

New Paresthesia/Numbness

Unexplained Weight Loss

History of Cancer, IV Drug Use

Spine

Inspect

-Spine is straight

-Note equal horizontal positions

…

Palpate

-Spinous process should be straight, nontender

-Paravertebral muscles should feel firm, no tenderness or spasm

…

ROM

-Flexion: back forward

-Extension: back backward

-Lateral Flexion: Back side to side

-Rotation

MSK in Older Adults

Height starts decreasing in 70s/80s

-Long bones don’t shorten

-Kyphosis is common

…

Decrease in periphery body fat

More abdomen and hip fat

…

Bony prominences more pronounced, bony hollows deeper

…

Osteoporosis

-Loss of mineralized bone density

-Women over 65yo need DEXA bone mineral density scan

……………………………………………

Get Up & Go Test

-Identify older adults at risk for falling

-Record time it takes to rise from armchair, walk 10ft, turn around, wall back & sit down

—Normal: under 12sec

—Over 12ec = increased fall risk

….

….

Brain Lobe Functions

Frontal

-Movement

-Reasoning, Personality, Decision-Making

……….

Temporal

-Hearing

-Memory

……….

Parietal

-Sensory Perception

—Pressure, Pain, Touch, Taste

………..

Occipital

-Vision/Sight

………..

Cerebellum

-Coordination, Balance

…………

Brainstem

-Breathing, Blood Pressure, Temperature

Cranial Nerves

1, Olfactory

2, Optic

3, Oculomotor

4, Trochlear

5, Trigeminal

6, Abducens

7, Facial

8, Vestibulocochlear

9, Glossopharyngeal

10, Vagus

11, Accessory

12, Hypoglossal

Spinal Innervation

8 Cervical

-Head, Neck, Upper Chest/Back where arms attach, Arms

…

12 Thoracic

-Chest, Back

…

5 Lumbar

-Lower Back, Lower Abdomen, Legs

…

5 Sacral

-Lower Butt, Back of Legs

Spinal Conditions

Radiculopathies

-Commonly due to disc herniations

—Advanced age, trauma

…

Shingles

-Reactivation of chickenpox virus

Mental Status

Appearance

Behavior

Cognition

Thought Process

When do you perform a dedicated mental status exam?

Abnormal affect or behavior

Aphasia = impaired language ability

Anxiety, Depression

Family concerned about behavior

Neurologic disorder, brain lesion

Bizarre behavior, concentration problems, troubles with simple activities, inappropriate judgement

Appearance

Posture

-Erect, relaxed

…

Body Movements

-Voluntary, deliberate

-Coordinated

-Smooth, even

…

Dress, Grooming, Hygiene

-Unilateral neglect?

-Change in normally well-groomed person

…

Pupils

-PERRLA

Abnormal Appearance

Rest Tremor

-Muscles are quiet, supported

-Disappears with voluntary movement

…..

Intention Tremor

-Worse with voluntary movements

—Reaching towards a visually-guided target

…..

Essential Tremor

-Type of intention tremor

-Benign, common among aging people

……………

Tic

-Involuntary, compulsive, repetitive twitching of a muscle group

-Can be neurologic or psychogenic

….

Fasciculation

-Rapid, continuous twitching of resting muscle or part of muscle without movement of limb

Glasgow Coma Scale GCS

Scale = 3-15

-Eye opening, verbal, motor

-15 is best, 3 is worst, 8 = intubate

……………….

Eye Opening Response

4 = open when walk in

3 = open to speech

2 = open to pain

1 = don’t open eyes

……………….

Verbal

5 = oriented X3

4 = confused

3 = inappropriate verbal

2 = incomprehensible

1 = no response

………………..

Motor

6 = can wiggle fingers & follow command

5 = pinched hand, moving other hand across midline to stop

4 = pinched hand, pulls pinched hand away but cannot stop it directly

3 = abnormal flexion/decorticate

—arms bend towards body, legs straighten

2 = abnormal extension/decerebrate

—arms straighten & rotate outward, legs stiffen & extend

1 = no movement

Posturing

Decorticate

-Arms like Cs

-move toward the spinal Cord

-Problems with cervical spine or cerebrum

……..

Decerebrate

-Arms like Es

-Problems with midbrain or pons

Behavior

Level of Consciousness

Facial Expression

-appropriate to situation?

Speech

Mood/Affect

Level of Consciousness Terms

Lethargic

-Not fully alert, drifts off to sleep

-May seem slow & fuzzy

…….

Obtunded

-Sleeps most of time, difficult to awake

—Confused when awoken

-Speech may be mumbled

-Need constant stimulation to cooperate

……..

Stupor/Semi-Coma

-Responds only to persistent & vigorous shaking/pain

-Can withdraw from pain but only groans

……...

Coma

-Unconscious, no response

Speech

Dysphonia

-Discomfort when talking caused by laryngeal disease

……

Dysarthria

-Weakness, paralysis, or poor coordination of muscles for speech

-Know what they want to say & can understand

—Slurred, slow, or difficult to understand

-Stroke, Parkinson’s Disease

……………………………………………………..

Aphasia

-Caused by brain damage

-Affects ability to understand, speak, read, write

-Difficulty in processing or producing language

…

Expressive = difficulty producing/saying

Receptive = difficulty processing/understanding

Mood/Affect

Flat/Bunted = lack of emotional response

Depressed = sad, gloomy

Euphoria = inappropriately excessive wellbeing/cheer

Anxiety = worried

Histrionic = dramatic

Bizarre

Cognitive Function

Attention Span

Recent Memory

Remote Memory

New Learning

-4 words, then asked to recall 5 min into interview

—Normal: 3 or 4 words

Orientation

Part of Cognitive Function

…

Oriented to time, person, place

-your name, where are you, the date

—AAOX3 = awake, alert, oriented

—AAOX2 = missing 1, usually time

—AAOX1 = missing 2, usually only knows name

Thought Process

Does this person make sense?

Are they aware of reality?

Mini Mental Status Exam

Test of cognitive functions

Must be able to read and write without any vision impairment

…..

11 questions, 5-10min, 1 time or multiple for comparisons

….

Max Score = 30

-24-30 = no cognitive impairment

-18-23 = mild cognitive impairment

-Below 17 = severe cognitive impairment

Subjective Assessment; Headache

Onset

-Gradual or sudden?

……..

ROS

-Recent trauma or illness?

-N/V, cold symptoms, dizziness, beck pain, moodiness, fever?

Subjective Assessment: Head Injury

Onset

-Wearing a helmet?

-How did you feel before getting hurt?

…..

Location

-Where is pain?

…..

Duration

-Headache right away?

…….

Severity

-Pain getting worse or better?

……..

ROS

-N/V, Seizures, Loss of Consciousness, Confusion, Visual Changes, Other Pains

Subjective Assessment: Dizziness

Onset

-what were you doing before?

……..

Duration

-intermittent or constant?

…….

Characteristics

-room spinning, you spinning, unsteady, feeling like you’re going to pass out, weak

—syncope = passing out

—vertigo = room spinning

…….

Aggravating

-Certain part of day?

-Certain movements?

…….

ROS

-Recent trauma or illness?

-N/V, tinnitus, cold symptoms, palpitations, slurred speech, shortness of breath

Subjective Assessment: Seizures

Seizure = involuntary muscle movements, altered/loss of consciousness & sensory disturbances

…

Postictal Phase = recovery period after a seizure, can last minutes to hours

…

Aura = subjective sensation that precedes a seizure

……………………………………………………………………………………………………………………

Onset

-History?

-When did it start? What were you doing? Any symptoms before?

……..

Duration

-how long did it last? how do you know?

-how long was postictal phase?

………

Characteristics

-what did it look like? who saw it?

-cyanosis, injury/tongue biting, incontinence?

………

ROS

-recent trauma or illness?

-Headache, confusion, dizziness, numbness, weakness, incontinence, shortness of breath, N/V?

Subjective Assessment: Tremors

Location

-Where? Unilateral or bilateral?

……..

Characteristics

-Does it affect ADLs?

………

Aggravating

-anxiety, intention, rest?

……...

Relieving

-rest, activity, alcohol?

………

ROS

-recent trauma or illness?

-headache, confusion, dizziness, numbness, weakness, change in gait, change in mood?

Subjective Assessment: Weakness

Paresis = partial or incomplete paralysis

Paralysis = total loss of motor function

Dysmetria = inability to control the distance, power, and speed of a muscle action

……………………………………………………………………………………………………………………

Location

-generalized or localized?

-unilateral or bilateral?

……

Characteristics

-can you still move? certain movements?

-affects ADLs?

……

Aggravating

-anxiety, illness, rest?

……

Relieving

-rest, activity, alcohol, stress?

……

ROS

-recent trauma or illness?

-headache, confusion, dizziness, numbness, weakness, change in gait, change in mood?

Subjective Assessment: Incoordination

Onset

-What were you doing?

-Sudden or gradual?

……

Location

-generalized or local?

-unilateral or bilateral?

…….

Duration

-intermittent or constant?

……..

Characteristics

-can still move? certain movements?

-affects ADLs?

-recent falls?

………

Aggravating

-anxiety, illness, rest?

………

Relieving

-rest, activity, alcohol, stress?

……….

ROS

-recent trauma or illness?

-headache, confusion, dizziness, numbness, weakness, change in gait, change in mood?

Subjective Assessment: Numbness/Tingling

Onset

-sudden or gradual?

……..

Location

-generalized or local?

-unilateral or bilateral?

……..

Duration

-intermittent or constant?

………

Characteristics

-pins/needles, can’t feel anything? can’t feel certain things? can still move? certain movements?

-affects ADLs?

-recent falls?

……….

Aggravating

-certain movements, repetitive movements, pain elsewhere?

……..

ROS

-recent trauma or illness?

-headache, confusion, dizziness, numbness, weakness, change in gait, change in mood?

Subjective Assessment: Dysphagia/Difficulty Swallowing

Onset

-gradual or sudden?

………

Location

-food gets stuck? Where?

………

Duration

-intermittent or constant?

……….

Characteristics

-painful?

-liquids or solids?

………..

Aggravating

-during a certain part of the day?

-certain foods?

……….

ROS

-recent trauma, travel, or illness?

-how often/last dentist visit?

-facial swelling, headache, facial pain, sore throat, bleeding gums, mouth sores, numbness, weakness, drooling, vomiting?

Subjective Assessment: Difficulty Speaking

Onset

-gradual or sudden?

-when did it start? what were you doing? happened before?

……….

Duration

-intermittent or constant?

………..

Characteristics

-difficulty forming words, no able to think of right words, forgetting words, not making sense?

………..

Aggravating

-certain part of the day?

……….

ROS

-recent trauma, travel, or illness?

-confusion, headache, dizziness, facial changes, numbness, weakness, cold symptoms, sore throat, N/V, weight loss, night sweats?

Mental Status Factors

History of:

Stroke, Spinal Cord Injury, Congenital Defect

Alcohol

Meningitis = inflammation of meninges

Encephalitis = inflammation of brain

…………

Environmental Hazards:

Pesticides/Insecticides

Solvents, Lead

Medications, Alcohol, Drugs

CN1: Olfactory

Function: Smell

Test: Close eyes, cover 1 nare, smell alcohol wipe, repeat

Normal: can identify scent correctly on both sides

……

Abnormal:

-Anosmia = decrease/loss of sense of smell

CN2: Optic

Function: Vision

Test: Confrontation Test, Snellen

Normal: 20/20 vision, peripheral vision intact, no field cuts

…...

Abnormal:

-Hemianopia = loss of half of visual field

……………………………………………………….

Confrontation Test

-Sitting across from each other, cover eye, move finger in periphery

-Normal: see finger when you do

-Abnormal: visual field cut, peripheral vision loss

…………………………………………………………

Snellen Test

-20 ft from chart with corrective lenses on, read smallest line with both eyes after covering each eye

-Normal: Snellen 20/20, PVS 14/14

—Note any squinting, leaning, difficulty

-Abnormal: Hyperopia, Myopia

CN3 Oculomotor, CN4 Trochlear, CN6 Abducens

Function: Eye movement, pupil constriction, eyelid elevation

Test: Pupillary response, diagnostic positions test, observe eyelid

Normal: PERRLA, EOMI, no ptosis

………..

Abnormal:

-ptosis = drooping eyelid

-anisocoria = unequal pupil size

………………………………………………………..

Diagnostic Positions Test DPT

-6 positions of gaze with parallel tracking

-Normal: no nystagmus

…………………………………………………………

Pupillary Light Reflex

-darkened room, shine light from side

-Normal: both eyes constrict, round & equal size

…………….

Accommodation

-distant object, shift 3in from face

-Normal: dilate looking in distance, constrict when close

……………………………

Normal: Pupils 3mm ERRLA

Abnormal: Aniscoria, Irregular shaped pupil, sluggish pupil, Mydriasis, Miosis

CN5 Trigeminal

Function: Facial sensation of forehead/cheek/jaw and chewing

Test: close eyes, cotton ball to skin, can feel it? palpate jaw muscles when teeth clenched & try to separate

Normal: symmetric facial sensation, jaw strength strong

……….

Abnormal:

Unequal sensation bilaterally

Able to separate jaw when clenched

CN7 Facial

Function: Facial expression

Test: have patient smile, frown, close eyes tightly while attempting to open, puff out cheeks

Normal: facial movements symmetric

………..

Abnormal:

Bell’s Palsy

Facial Droop

CN8 Acoustic/Vestibulocochlear

Function: Hearing & Balance

Test: Whispered Voice, Weber & Rinne, Rhomberg

Normal: hearing intact bilaterally, negative rhomberg

………..

Abnormal:

Sensorineural hearing loss

Vertigo

…………………………………………………………

Whisper Test

-Stand 1-2ft behind, cover untested ear, whisper 3 random numbers/letters, repeat back

-Fail = perform Rhinne & Weber

—Differentiate between conductive & sensorineural hearing loss

—Conductive = sound cannot get through outer/middle ear

—Sensorineural = damage to inner ear

…………………………………………………………

Romberg

-stand with feet together & arms at sides, close eyes & hold position for 20 sec, be ready to catch them

-Normal: Able to stay still & maintain balance

CN9 Glossopharyngeal, CN10 Vagus

Function: Swallowing, gag reflex, speech

Test: say “ah” and watch uvula rise, assess speech

Normal: uvula midline rises symmetrically, voice clear

………..

Abnormal:

Dysphagia

Absent Gag Reflex

CN11 Accessory

Function: Shoulder & neck movement

Test: shrug shoulders & turn head against resistance

Normal: Strong equal shoulder shrug bilaterally

…………

Abnormal:

Accessory nerve palsy = weakness in shoulder shrugging or head turning

CN12 Hypoglossal

Function: Tongue Movement

Test: Stick out tongue, move it side to side

Normal: Tongue midline without deviation and moves freely

…………

Abnormal:

Hypoglossal nerve palsy = tongue deviates to one side

Cerebellar Function

Rapid Alternating Movements

-Flip palms up and down repeatedly

-Thumb touch each finger then reverse

……..

Finger to Nose

-Hold finger in front of patient, have them touch your finger then their nose

-Repeat while moving finger to different spots

………

Heel to Shin

-Lift leg up off bed, brush heel down shin

………

Rhomberg

………

Gait

-heel toe walk

-walk on tip toes, walk back on heels

Testing Upper Motor Neuron Function

Importance: detect subtle weakness that might not be obvious

-Could indicate stroke, brain tumor, MS

…

Test: close eyes, extend both arms palms up like holding a tray, hold for 20-30sec

….

Normal: No drift

Abnormal: positive pronator drift, 1 arm drifts down and pronates

Motor Function

Requires 4 Nervous Systems to work together

-Cerebellar = posture, rhythmic movement

-Motor = muscle strength

-Sensory = position sense, vibrations

-Vestibular = balance, coordination

…………………………………………………………

Hypotonia = decreases muscle tone

Flaccidity = loss of muscle tone

Hypertonia = increased muscle tone

…

Rigidity = muscles contracted & tense

Spasticity = increased muscle tone causing stiffness & tight muscles

….

Hemiparesis = loss of muscle tone & strength to one side of the body

…

Paraplegic = loss/impairment of motor & sensory function in lower extremities below thoracic

Quadriplegic = loss/impairment of motor & sensory function in upper & lower extremities, typically cervical issue

Sensory Function

Compare bilaterally

Don’t need to do full exam unless there’s a neurologic symptom or abnormal finding

Be aware of dermatomes

—specific areas of skin connected to particular spinal nerves

………………………………

Anterolateral = sharp/dull extinction, eyes closed, patient let you know when they feel cotton ball

Posterior = using tuning fork, when vibration sensation starts & stops, start at toes, if not felt start moving proximally

……………..

Stereognosis = close eyes, put familiar object in patient’s hand

-Astereognosis = cannot properly identify

…..

Kinesthesia = passively move finger/big toe up or down while patient’s eyes are closed, have patient tell you what direction digit was moved, hold digit on both sides

Graphesthesia = trace a number on skin, typically on palm

……

Extinction = tell what side I’m touching

Pole Location = where did I touch you

Deep Tendon Reflex DTR

Reveals an involuntary muscle contraction

Limb needs to be relaxes, muscle partially stretched

Apply short, snappy blow of reflex hammer into tendon insertion

Compare bilaterally

…………………………………………………………

Clonus = rapid, rhythmic contractions of the same muscle

Hyporeflexia = absence of a reflex

Hyperreflexia = exaggerate reflex

DTR Scale

4 = Hyperactive with clonus

3 = Brisker than average

2 = Average

1 = Diminished

0 = Absent

DTR Testing

Biceps: C5-C6

-thumb on biceps tendon, strike below thumb

………

Triceps: C7-C8

-let arm relax while suspending arm, strike directly above elbow

……….

Brachioradialis: C5-C6

-hold thumbs while suspending forearms in relaxation, strike 2-3cm above radial styloid process

……….

Quadricep: L2-L4

-legs dangle freely, strike below the patella

—if supine, use your arm

……….

Achilles: S1-S2

-knee flexed with hip externally rotated, hold in dorsiflexion and strike achilles tendon

—If supine, cross ankle over mid shin & strike

………..

Patella L3-L4

…………………………

Babinski Reflex

-trace on bottom of foot

—Normal = Negative = crunching of toes

—Abnormal = Positive = big toe dorsiflexes while other toes fan out, only normal in infants-age 2

Stroke

Blood flow interrupted to brain

Damage can be permanent or temporary

…………………….

Common Signs

-weakness/numbness in face/arms/legs

—typically unilateral

-confusion, trouble speaking or understanding

-changes in vision

-trouble with walking, dizziness, loss of balance or coordination

-speech changes

-headache

……………………

FAST

-Face drooping, Arm weakness, Speech difficulty, Time to call 911

Herpes Zoster, Shingles

Reactivation of chickenpox

Vaccination recommended 50-60yo

Mental Status in Older Adults

General atrophy with steady neuron loss in brain and spinal cord

Decreased weight/volume in cerebral cortex

…………..

Loss of muscle tone in face, neck, spine

Decreased muscle strength

Impaired fine motor & agility

Loss of vibratory sense in ankle

Decreased/absent Achilles DTR

Loss of position sense of big toe

Pupillary miosis

Irregular pupil shape & decrease pupillary reflex

…………………………………………………………

Progressive decrease in cerebral blood flow and oxygen consumption

……………

Dizziness, loss of balance with position change

Walk more slowly and deliberately

…………………………………………………………

Safety modifications, decreased/changing memory/mental function, Tremors, Sudden vision changes/blindness, Falls

….

….

Anus & Rectum

Rectum = Extends from sigmoid colon to the anal canal

-Peritoneum = covers upper portion of rectum

-Levator ani muscle provides external support

-Rectal ampulla = stores feces

-Valves of Houston = help retain stool

-Nerve supply = autonomic, less sensitive to pain

…………

Anal Canal = Connects to rectum at anorectal junction

-Sphincters

—Internal = involuntary, autonomic control

—External = voluntary control

—Maintain continence except during defecation

—Groove separates the 2 sphincters

-Nerve supply = somatic, very sensitive to pain

-Anal canals = contain arteries & veins

—Increased venous pressure leads to hemorrhoids

Prostate Gland

Located anterior to rectum

Produces alkaline fluid for sperm

Normally smooth, rubbery, heart-shaped

…………

Seminal Vesicles

-Secrete fructose-rich fluid to nourish sperm

…………

Bulbourethral Glands

-Secrete lubricating mucus

Subjective Assessment: Bowl Routine

How often are your bowel movements?

Usual color?

Straining, incomplete evacuation, urge but nothing comes?

Lumpy or hard stool? Fewer than 3 per week?

Do you eat breakfast?

Any pain while passing?

Rectal/Anal Red Flags

Rectal bleeding, blood in stool

-Ever had black or bloody stools?

-When did you first notice blood in stool?

-Bright read or dark red-black?

-How much blood?

-Any particular smell?

Subjective Assessment: Bowel Changes

Clay-colored stools? Absent bile pigment

Mucus or pus in stool? Frothy stool?

Need to pass gas frequently?

Subjective: Anus/Rectum

Medications: Prescriptions & OTC drugs

-Laxatives, stool softeners, iron supplements

-Enema use, frequency & type

…

Family History:

-Colorectal cancer, polyps

-Inflammatory Bowel Disease IBD

-Prostate Cancer

…

Daily Diet: high-fiber foods

-Soluble fiber lowers cholesterol

Hydration

Inspection of Perianal Area

Looking for:

-Redness, inflammation

-Lesions, lumps, wounds, excoriations, hemorrhoids, fissures

……………

Abnormal:

-Patulous anus = open, distended

-Redness, inflammation, lesions, wounds, hemorrhoids

-Rectal prolapse = partially or fully comes through anus

PSA Screening

For Prostate Cancer

-50yo, 45yo for black men, 40yo when multiple relatives with it

-Protein from prostate

—Increases with benign growth, infection, or ejaculation

……..

Benefits: early detection

-5 and 10 year survival rates close to 100 & 98%

Limitations: can’t distinguish slow vs aggressive

Colorectal Cancer Screening

Start 45yo

Colonoscopy detects cancer & removes polyps

If normal: repeat every 10 years

Fecal Immunochemical Test FIT

Home stool test, starting at 45yo

Detects occult blood: possible cancer or polyps

…

Positive result = colonoscopy required

Valsalva Maneuver

Bearing down

…

…

Scrotum

Sac at base of penis

-cutaneous, fibromuscular sac with sebaceous glands, sweat glands, & nerve endings

Skin: loose, wrinkled skin with folds

-Folds = rugae

…

Contents: testis, epididymis, part of spermatic cord

…

Cremaster Muscle: allows for temperature regulation

-raises or lowers testes to maintain an optimal temperature for sperm production

—3C below body temperature

Testes

Oval-shaped glands, olive-sized with soft, rubbery consistency

-Responsible for spermatogenesis & testosterone

…

Left testis normally hangs lower than right

-Left spermatic cord is longer

Epididymis

Located on top & behind each testis

Connects testicle to vas deferens

Collection area for mature sperm

Vas Deferens

Long muscular tube that connects testes with urethra

Stores & transports sperm through epididymis

Muscle contractions propel sperm into ejaculatory duct & out through the urethra

Seminal Vesicles

Behind bladder & prostate

Connect vas deferens to form ejaculatory duct, emptying into urethra

…

Function: Produces thick, alkaline fluid that makes up 60% of semen

Spermatic Cord

Suspends testis in scrotum

Left cord slightly longer than right

Contains vas deferens, testicular artery, & veins

Prostate Gland

Doughnut-shaped gland, walnut-sized

Located between bladder & rectum

Wraps around urethra

-Contains 15-20 branches, tubular glands which form lobules

…

Function: Secretes a viscid, alkaline seminal fluid which aims in sperm motility & in neutralizing acidity of vagina to product the sperm

Male Inguinal Area

Lymphatic Drainage

-Inguinal Lymph Nodes: penis & scrotal surface

-Abdominal Lymph nodes: testes

………………………..

Potential site for hernia development

-junction between lower abdominal wall & thigh

-bordered by anterior superior iliac spine ASIS and the symphysis pubis

—inguinal ligament runs between landmarks

……….

Inguinal Canal

-narrow passage 4-6cm in adults

-2 openings: internal and external rings

…

Femoral Canal

-located below inguinal ligament

-another possible site for hernia formation

Circumcision

Elective removal of foreskin

-exposes glans

-Tissue changes to tougher, drier surface

—may reduce infection risk

…

Benefits

-decreases risk of female-to-male HIV transmission

-decreased infant UTIs

-possible decrease in STIs

….

Risks

-Complications

-Pain, bleeding, swelling

Sexually Transmitted Infections STIs

Highest Risk: 15-24yo make up 50%

May be asymptomatic = may unknowingly spread to partners

…

Common STIs = chlamydia, gonorrhea, syphilis, HPV, HSV, HIV, Hepatitis B

…

Prevention

-Condom use

-Fewer partners

Normal Urinalysis

Clear, pale yellow-amber

pH: 4.5-8.0, slightly acidic

Specific gravity: 1.003-1.030

Minimal protein, no glucose

<5 RBCs and WBCs

Abnormal Urinalysis

Cloudy urine = WBCs, bacteria, casts

Proteinuria = glomerular/kidney disease

Glycosuria = hyperglycemia/diabetes

Increased WBCs = UTI

Increased RBCs = UTI, kidney stones, trauma, cancer

Isolated color changes = meds, supplements, foods

Incontinence

Urge = involuntary urine loss from overactive detrusor muscle in bladder

Stress = involuntary urine loss with physical strain, sneezing, or coughing caused by weakness of pelvic floor

Benign Prostatic Hyperplasia BPH

Enlarged prostate compresses urethra, obstructing flow