Health Assessment Test 3

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nonsynovial joints

the bones are united by fibrous tissue or cartilage and are immovable (sutures of the skull) or only slightly movable

cartilage

covers the surface of opposing bones

ligament

fibrous bands running from one bone to another that strengthen the joint and help prevent movement in undesirable directions

bursa

an enclosed sac filled with viscous synovial fluid, much like a joint

synovial joints

are freely movable because they have bones that are separated from each other and are enclosed in a joint cavity

flexion

bending a limb at a joint

extension

straightening a limb at a joint

abduction

moving a limb away from the midline of the body

adduction

moving a limb toward the midline of the body

pronation

turning the forearm so the palm is down

supination

turning the forearm so the palm is up

circumduction

moving the arm in a circle around the shoulder

inversion

moving the sole of the foot inward at the ankle

eversion

moving the sole of the foot outward at the ankle

rotation

moving the head around a central axis

protraction

moving a body part forward and parallel to the ground

retraction

moving a body part backward and parallel to the ground

elevation

raising a body part

depression

lowering a body part

Phalen's test

ask person to hold hands back to back while flexing the wrists 90 degrees; pain means there is carpal tunnel

Tinel's sign

direct percussion of the location of the median nerve at the wrist produces no symptoms

McMurray's test

special test for Meniscal Tears - if you hear or feel a 'click,' McMurray's test is positive for a torn meniscus

Rheumatoid arthritis

inflammatory condition of the joints

Ankylosing spondylitis

chronic progressive inflammation of spine, sacroiliac, and larger joints of the extremities leading to deformity

osteoarthritis

degenerative joint disease

osteoporosis

decrease in skeletal bone mass

Order of Examination for Musculoskeletal

1. Inspection: size and contour of joint; skin and tissues over joint.
2. Palpation: skin temperature; muscles, bony articulations, area of joint capsule.
3. Range of Motion
4. Muscle testing: apply opposing force, grading muscle strength

Menopause and the breast

ovarian secretion of estrogen decreases, which causes breast glandular tissue to atrophy

Breast cancer

incidence varies with cultural groups; although 12% higher in black women than in white women, black women had a 36% higher death rate than white women

Breast changes in the older adult

-glandular tissue atrophy; replaced with fibrous connective tissue
-decreased size and elasticity
-axillary hair decreases

What to note if a lump is present

-location: breast as clock wise face; distance in cm or diagram nipple and record lump
-size: in cm, width x length x height
-shape: oval, round, lobulated, or indistinct
-consistency: soft, hard, or firm
-movable
-distinctness: solidarity or multiple
-nipple retraction: displaced or retracted
-overlying skin: erythematous, dimpled, or retracted
-tenderness
-lymphadenopathy:palpable lymph nodes

Visible signs of breast cancer

-Retraction signs: abnormal contours, skin dimpling, nipple retraction and deviation
-Skin edema
-Paget's Disease of the Nipple

Benign breast disease lump (formerly fibrocystic breast disease)

-shape: round, lobular
-consistency: firm to soft, rubbery
-demarcation: well demarcated
-mobility: fixed

Cancer lump

-shape: irregular, star shaped
-consistency: firm to stony hard
-demarcation: poorly defined
-mobility: fixed

fibroadenoma lump

-shape: round, lobular
-consistency: usually firm, rubbery
-demarcation: well demarcated, clear margins
-mobility: very mobile, slippery

preadolescent female breast

only a small elevated nipple

female breast bud stage

1. a small mound of breast and nipple develops, the areola widens
2. the breast and areola enlarge; the nipple is flush with the breast surface
3. the areola and nipple form a secondary mound over the breast

Mature female breast

only the nipple protrudes; the areola is flush with the breast contour--the areola may continue as a secondary mound in some normal women

gynecomastia

benign enlargement of male breast that occurs when peripheral tissue convert androgen hormones to estrogens; it is a mobile disk of tissue located centrally under the nipple-areola

central axillary nodes

high up in the middle of the axilla, over the ribs and serratus anterior muscle

pectoral (anterior) nodes

along the lateral edge of the pectoralis muscle, just inside the anterior axillary fold

subscapular (posterior) nodes

along the lateral edge of the scapula, deep in the posterior axillary fold

lateral nodes

along the humerus, inside the upper arm

glandular tissue

lobes, lobules, and alveoli; lactiferous ducts and sinuses

fibrous tissue

suspensory ligaments or Cooper's ligaments, extend vertically from the surface to attach on chest wall muscles

adipose tissue

layers of subcutaneous and retromammary fat which provide most of the bulk of the breast

four quadrants of the breast

divide the breast into four part by imaginary horizontal and vertical lines intersecting at the nipple; make convenient map to describe clinical findings.

Upper outer quadrant: tail of Spence, and most common site of breast tumors

tail of Spence

the cone shaped breast tissue that projects up into the axilla, close to the pectoral group of axillary lymph nodes; located in the upper outer quadrant of the breast

Inspection of female breast

general appearance, skin, lymphatic drainage areas, nipples should be symmetrical; maneuvers to check for skin retraction

Maneuvers to screen for retraction (female breast)

direct woman to change position while you check the breasts for skin retraction signs; ask her to lift arms slowly over her head; both breasts should move up symmetrically;

next ask her to put hands onto hips and push palms together contracting the pectoralis major--both breast should lift slightly

ask a woman with large pendulous breast to lean forward while you support her forearms and note free-forward movement of both breasts

supernumerary nipple

extra nipple along the the embryonic "milk line" on the thorax or abdomen; a congenital finding

Palpation of axillae

while supporting arm palpate: 1) down the chest wall in a line from the middle of the axilla, 2) along the anterior border of the axilla, 3) along the posterior border, and 4) along the inner aspect of the upper arm

Palpate of female breast

in supine position, arm up over head with pad under side to be palpated to spread breast tissue medially, use patterns to palpate every inch of the breast and examine the tail of Spence high into the axilla

Patterns for palpating female breasts

vertical strip: start high in the axilla and palpate down just lateral to the breast

spokes on a wheel: from the nipple palpate out to the periphery as if following spokes on a wheel

concentric circles: palpate in concentric circles out to the periphery

inframmatory ridge

firm transverse ridge of compressed tissue in the lower quadrants of female breast

bimanual technique of palpation for female breasts

used for women with large pendulous breasts; with woman in sitting position, leaning forward: support the inferior part of the breast with one hand, use your other hand to palpate the breast tissue against your supporting hand

abdomen and the aging adult

fat accumulation in the suprapubic area of females due to the decreased estrogen levels; males also have fat deposits in abdominal level

adipose tissue is redistributed way from the face and extremities and to the abdomen and hips

GI and aging adult

-salivation decreases, causing dry mouth and decreased sense of taste

-esophageal emptying is delayed causing risk of aspiration

-gastric acid secretion is decreased

-greater incidence of gallstones

-liver size decreases; drug metabolism by the liver is impaired

-constipation

solid viscera

those that maintain a characteristic shape: liver, pancreas, spleen, adrenal glands, kidneys, ovaries, and uterus

hollow viscera

stomach, gallbladder, small intestine, colon, and bladder; shape will depend on the contents; usually not palpable unless distended (colon-feces, bladder-urine)

liver

fills most of the right upper quadrant and extends over to the left midclavicular line; lower edge of the liver may be palpable

kidney

bean shaped are retroperitoneal, or posterior to the abdominal contents; left kidney lies at the 11th and 12th ribs, right kidney rests 1-2 cm lower and may be palpable

Abdomen: Right upper quadrant

Liver
Gallbladder
Duodenum
Head of Pancreas
Right kidney and adrenal glands
Hepatic flexure of colon
Part of ascending and transverse colon

Left upper quadrant

Stomach
Spleen
Left lobe of liver
Body of pancreas
Left kidney and adrenal
Splenic flexure of colon
Part of transverse and descending colon

Right Lower Quadrant

Cecum
Appendix
Right ovary and tube
Right ureter
Right spermatic cord

Left lower Quadrant

Part of ascending colon
Sigmoid colon
Left ovary and tube
Left ureter
Left spermatic cord

Midline (abdomen)

Aorta
Uterus (if enlarged)
Bladder (if distended)

Contours of the abdomen

describe the nutritional state and normally range from flat to rounded; stand on the person's right side and look down at abdomen, then stoop down to view across the abdomen: flat, scaphoid, rounded protuberant

Inspection of the abdomen

Performed 1st
Contour
Symmetry
Umbilicus
Skin
Pulsation or movement
Hair distribution
Demeanor

Auscultating the abdomen

Performed 2nd
Bowel sounds: character and frequency, normal, hypoactive, or hyperactive; high pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5-30 times per minute, do not count them

Vascular sounds (bruits): check over the aorta, renal arteries, iliac, and femoral arteries

Percuss the abdomen

Performed 3rd
-General tympany
-Liver span
--Usual technique
--Scratch test
-Splenic dullness
-Costovertebral angle tenderness
-Special procedures
--Fluid wave
--Shifting dullness

borborygmus

stomach growling caused by hyperperastalsis

hyperactive sounds

loud, high pitched, rushing, tinkling sound that signal increased motility

hypoactive or absent sounds

follow abdominal surgery or with inflammation of the peritoneum

Palpate the abdomen

normally palpable structures:
liver, spleen, kidneys, and aorta

light and deep palpation used, for large or obese abdomens use bimanual technique

light palpation

with first 4 fingers close together, depress the skin about 1 cm; make a rotary motion, sliding the fingers and skin together

deep palpation

using the same technique as light palpation, but push down 5-8 cm

bimanual technique for palpating abdomen

place two hands on top of each other; the top hand pushing, the bottom hand is relaxed and can concentrate on the sense of palpation

percussion of costovertebral angle tenderness

indirect fist percussion causes the tissues to vibrate instead of producing a sound, to assess the kidney, place one hand over the 12th rib at the costovertebral angle on the back; thump that hand with the ulnar edge of your other fist; person will feel thud and pain is not normal. Sharp pain occurs with the inflammation of the kidney or paranephric area

PATIENT EDUCATION TO PROVIDE TO MALES PERFORMING A TESTICULAR EXAMINATION

teach testicular self examination to males 13, 14 through adulthood; teach to know the body and not necessarily about cancer since incidence is low, however early detection is key.

TSE
T-Timing, once a month
S-shower, warm water relaxes the scrotal sac
E-examine, check for changes, report changes immediately

palpate in a sweeping side to side motion

cryptorchidism

undescended testes

hydrocele

a cystic collection of serous fluid in the tunica vaginalis, surrounding the testis

Females who are post menopausal

rapid decline of hormones, natural lubrication is decreased; cervical cancer screening should continue into age 70 if cervix is intact and patient is in good health

menopause

cessation of menses, usually occurring between 48-51,

aging and the musculoskeletal system

bone remodeling, osteoporosis; postural changes and decreased height because of shortening of the vertebral column due to loss of water content and thinning of the vertebral discs; contour changes due to loss of fat in the body periphery; bony prominences become more marked

ROM of head and neck

-Chin to chest: flexion
-Lift chin: hyperextension
-Each ear to shoulder: lateral bending
-Turn chin to each shoulder: rotation

ROM of shoulders

-Arms forward and up: forward flexion
-Arms behind back and hands up:
-Arms to sides and up over head: abduction,
-Touch hands behind head: external rotation

ROM of Elbow

-Bend and straighten elbow: flexion, extension
Pronate and supinate hand

ROM of hands and wrist

-Bend hand up, down: extension, flexion
-Bend fingers up, down: hyperextension, flexion
-Turn hands out, in: ulnar deviation, radial deviation
-Spread fingers, make fist: abduction
-Touch thumb to each finger

ROM of hip

-Raise leg: flexion
-Knee to chest: flexion
-Flex knee and hip; swing foot out, in: external rotation, internal rotation
-Swing leg laterally, medially: abduction, adduction
-Stand and swing leg back: hyperextension

ROM of knee

-Bend knee: flexion
-Extend knee: extension, hyperextension
-Check knee during ambulation

ROM of ankle and foot

-Point toes down, up: plantar flexion, dorsiflexion
-Turn soles out, in: eversion, inversion
-Flex and straighten toes

ROM of spine

-Bend sideways, backward: lateral bending, hyperextension
-Twist shoulders to each side: rotation of

kyphosis

enhanced thoracic curve, common in aging people

lordosis

pronounced lumbar curve, common in obese people

scoliosis

a difference in shoulder elevation and in level of scapulae and iliac crests

thought process

the way a person thinks, logical train of thought

language

using the voice to communicate one's thoughts and feelings

attention

the power of concentration

memory

recent: evokes day to day events
remote: brings up years' worth of experiences

the ability to lay down and store experiences and perceptions for later recall

consciousness

aware of one's existence, feelings, and thoughts

thought content

what the person thinks

abstract reasoning

pondering a deeper meaning beyond the concrete and literal

When to perform a full mental status examination

Behavior changes
Brain lesions (trauma, tumor, brain attack)
Aphasia (caused by brain damage)
Symptoms of psychiatric mental illness

Main components of mental status examination: ABCT

A-appearance
B-behavior
C-cognition
T-thought processes

mental status: appearance

posture, body movement, dress, grooming and hygiene

mental status: behavior

level of consciousness, facial expression, speech, mood and affect

mental status: cognition

orientation, attention span, recent and remote memory, new learning, judgement

mental status: thought processes

thought processes, thought content, perceptions, screen for suicidal thoughts

judgment

a person exercises judgment when he or she can compare and evaluate the alternatives to a situation and reach an appropriate course of action

central nervous system

cerebral cortex: frontal lobe, parietal lobe, occipital lobe, Wernicke's area, Broca's area

hypothalamus

cerebellum

basal ganglia

thalamus

brainstem

spinal cord

frontal lobe

part of cerebral cortex; behavior, emotion, intellectual functions, personality

parietal lobe

sensation

occipital lobe

visual reception

Wernicke's area

speech comprehension

Broca's area

motor speech

hypothalamus

major control center for temperature, heart rate, blood pressure, sleep center, etc.

cerebellum

located under the occipital lobe

concerned with motor coordination of voluntary movements, equilibrium, and muscle tone

does not initiate movement, but coordinates, and smoothes it (swimming, playing piano, juggling)

basal ganglia

control automatic associated movements of the body, i.e. arm swinging alternating with the legs during walking

thalamus

main relay station for the nervous system

brainstem

midbrain

pons

medulla: vital autonomic centers (respiration, heart, GI function); nuclei for Cranial Nerves VIII-XII

peripheral nervous system

composed of the cranial nerves and spinal nerves; these nerve fibers are further divided into two functional parts: somatic and autonomic

somatic fibers

innervate the skeletal (voluntary) muscles

autonomic fibers

innervate smooth (involuntary) muscle, cardiac muscle, and glands

reflex arc

Reflexes are basic defense mechanisms of the nervous system.
They are involuntary.
They permit a quick reaction to potentially painful or damaging situations.
Reflexes also help the body maintain balance and appropriate muscle tone.

Reflexes

Deep Tendon Reflexes: Patella or knee jerk

Superficial Reflexes: Corneal reflex; abdominal reflex

Visceral Reflex; Pupillary response to light and accommodation

Pathologic (abnormal) Reflex: Babinski's or extensor plantar reflex

Cranial nerve I

Olfactory: smell

Cranial nerve II

Optic: visual acuity

Cranial nerve III

Oculomotor: extra-ocular movement - 6 cardinal points--whisker test

Cranial nerve IV

Trochlear: down and inward movement of the eye--whisker test

Cranial nerve V

Trigeminal: motor fucntion, person clenches teeth; sensory function, person's eyes close, test light touch sensation

Cranial nerve VI

Abducens: lateral movement of eye

Cranial nerve VII

Facia: motor function, symmetry-person smiles

Cranial nerve VIII

Acoustic: whisper test

Cranial nerve IX

Glossopharyngeal; tested with absence or asymmetry of the soft palate movement is a dysfunction

Cranial nerve X

Vagus: motor function, gag reflex; tested with absence or asymmetry of the soft palate movement is a dysfunction

Cranial nerve XI

Spinal accessory: ask person to shrug shoulders; or testing the sternomastoid and trapezius muscles against resistance

Cranial nerve XII

Hypoglossal: ask person to stick out tongue - tongue should be midline

Romberg's test

ask person to stand up with feet together and arms at side; once in a stable position ask the person to close their eyes and hold that position.

stereognosis

Ability to recognize objects by feeling forms, sizes and weights. Place a familiar object (paper clip; key, coin, pencil) in the person's hand

graphesthesia

ability to "read" a number by having it traced in the hand

two-point discrimination

person's ability to distinguish separation of two simultaneous points on the skin

extinction

simultaneously touch both sides of the body at the same point; ask the person to state how many sensations are felt and where

point location

touch the skin and withdraw quickly; have person point to where they were touched

tandem walking

ask person to walk in a straight line in a heel-to-toe fashion

cranial nerves

enter and exit the brain rather than the spinal cord

lethargic

not fully alert, drifts off to sleep when not stimulated, can be aroused to name when called in normal voice but looks drowsy, responds appropriately to questions or commands but thinking seems slow and fuzzy, inattentive, loses train of thought, spontaneous movements are decreased

obtunded

transitional state between lethargy, and stupor; some sources omit this level; sleeps most of time, difficult to arouse--needs loud shout or vigorous shake, acts confused when is aroused, converses in monosyllables, speech may be mumbled and incoherent, requires constant stimulation for even marginal cooperation

stuporous

spontaneously unconscious, responds only to persistent and vigorous shake or pain; has appropriate motor response, withdraws hand to avoid pain; other wise can only groan, mumble, or move restlessly; reflex activity exists

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