Physical Assessment Modules 5 – 8

Identify appropriate history questions to ask for breast health exam.
1. Any breast pain, is it cyclic, brought on by exercise, sore to touch?
2. Lump or thickening? Change in overlying skin, when did you notice it? Change?
3. Any discharge, when, what color, consistency, odor? What medications?
4. Rash, when did is start, where did it start?
5. Swelling, one spot or all over?
6. Trauma, did it result in a lump?
7. Hx of breast disease?
8. Surgery
9. Self exam behaviors, how often, mammograms?
Describe the anatomy of the breast
Located between the second and 6th rib. Tail of Spence in the axillary. Areola surrounds nipple with sebaceous glands (montgomery glands- secretes protective lipid material)
Glandular Tissue
Fibrous Tissue (suspensory ligaments)
Adipose tissue
Broken up into four quadrants. The upper outer quadrant is the site of most breast tumors.
Describe the components of the breast examination and expected age variations.
-Inspect breasts as the women sits, raises arms overhead (retraction), pushes hands on hips (dimple) and leans forward.(fixation to chest wall)
– General appearance (symmetry)
– Skin (buldging, edema, dilated blood vessels)
– Lymphatic drainage (buldging, edema, discoloration)
– Nipple (deviation, retraction, discharge)
– Inspect the supraclavicular and infraclavicular areas
-Palpate the axillae and regional lymph nodes.
-With woman supine palpate the breast tissue, including tail of Spence the nipples and areola.
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List points to include in teaching the breast self-examination.
1. Affirm she is healthy
2. Regular schedule right after menstural period or 4 -7 days after the 1st day of mensturation.
3. Emphasize the absence of lumps
4. The majority of women will never get cancer
5. Most lumps are benign
6. Early detection is important.
7. Keep teaching simple.
8. Teach to do in front of a mirror, while disrobed. Or in shower. Then move to supine position.
9. Assess technique
10. give out pamphlets.
Benign breast disease
30 -55 years
Round lobular
firm to soft, rubbery
well demarcated
usually multiple, may be single
mobile
Tender
No retraction
size may increase or decrease rapidly
benign
Nodularity occurs bilaterally
List and describe the characteristics to consider when a mass is noted in the breast.
1. Location
2. Size ( 2 x 2)
3. Shape
4. Consistency (soft, firm, hard)
5. Movable
6. Distinctness (solitary, multiple)
7. Note skin over the lump
8. Nipple (displaced or retracted)
9. Tenderness
10. Lympadenopathy (regional lymph nodes palpable)
Abscess breast tissue
Generalized infection. Pocket of pus accumulates in one local area. temp discontinue breast feeding, pump discard milk, antibiotics.
Acute Mastitis
Inflamatory mass before abscess. single quadrant, red tender swollen, hot and hard. H/A malaise, fever chills, flu like symptoms. Treat with frequent nursing, heat to area, antibiotics.
Fibro adenoma
age 15 – 30
Round, lobular
Firm, rubbery
Well demarcated
single
No tenderness
grows quickly
benign
Cancer (Risk factors and Incidence)
African american before the age of 45. White women higher after 45 . Usually after 50
Personal HX of first degree relative with breast cancer.
High breast tissue density
Early menarche or late menopause.<12 or >55
First child after 30
oral contraceptives
never breast fed
Estrogen
obesity
Supernumerary nipples
Normal and common. extra nipple along the breast line. usually 5 to 6 cm below the breast
Paget’s disease
Unilateral clear nipple discharge and dry scaling crust, friable at nipple apex. Spreads outward. retracted nipple. Nipple redened, flattened ulcerated with bloody discharge and plaque surrounding nipple. Tingling , itching, burning. Refer immediately.
Breast history Axilla
Any tenderness of lumps in the armpits. Where, when, rash? Contains many lymph nodes.
Breast history Preadolescent
Have you noticed your breasts changing? For how long? Assess perception of her development.
Breast history Pregnant
Enlargement or fullness of the breast? Hx of inverted nipples? Are you planning to breast feed? Breast feeding for 6 months provides the perfect food. decreases risk of ear infections.
Breast History Menopausal woman
have you noticed change in contour, size, or firmness? Decreased estrogen decreases firmness.
Pregnant breast tissue
Changes during the second month. Enlarge and feel more nodular. Nipples la and supporting fatty tissue and real secretory aveoli, larger, darker and more erect. Expansion of ductal systemVenous pattern prominent over skin surface. After 4th month colostrum may be expressed. Milk begins 1 to 3 days postpartum (emulsified fat and calcium)
Glandular Breast Tissue
15 to 20 lobes radiating from nipple. Lobules are clusters of alveoli that produced milk. The ducts form lactiferous sinuses behind the nipple which are reservoirs for storing milk.
Breast Adipose tissue
Lobes are embedded here. subcutaneous and retromammary fact actually provide most of the bulk. The relative proportion of glandular and fatty tissues depend on age, cycle, pregnancy, lactation and nutritional state.
Lymphatics Breasts
75% drains into the same side.
1. Central (high up in axilla)
2. pectoral (anterior)
3. Subscapular (posterior)
4. Lateral (along humerus, inside upper arm)

From central nodes, drainage flows up to the infraclavicular and supraclavicular then deep into the chest, abdomen or to other breast.

Adolescent Breast Tissue
At puberty estrogen stimulates breast changes, they enlarge mostly because of fat deposits. Duct system grows and branches. Onset between 8 and 10 yrs. Tenderness common. Full development can take 3 years but can range from 1.5 to 6 years. Breast development precedes menarche by 2 yrs, at stage 3 or 4 of breast development.
Nodularity increases from mid-cycle up to menstruation. 3-4 days before menstruation breasts are full, tight and heavy. smallest 4 -7 days after the start of menstruation.
Aging breast tissue
Decrease of estrogen causes breast glandular tissue to atrophy. replaced with fibrous connective tissue. Fat atrophies. decreased breast size and elasticity with droop and sag looking flat and flabby. makes inner structures more prominent. Around nipples lactiferous ducts are more palpable and feel firm and stringy because of fibrosis and calcification. Thickening of the inframmamary ridge at the lower breast.
Suspensory Ligaments
Coopers ligaments, fibrous band from surface to chest wall muscles. Support breast tissue. Become contracted in cancer. (dimples)
Identify appropriate history questions to ask regarding the abdominal examination.
Appetite? (change, weight change)
Dysphagia?
Food intolerance? (Pyrosis-heartburn, Eructation-bleching)
Abdominal pain? (Describe, relieved by food-duodenal ulcer, w/mensturation)
Nausea/vomitting?
Bowel movement? (color, consistency, laxatives)
Past abdominal history? (Sx)
Medications? NSAIDS-peptic ulcers
Nutritional assessment?
Describe the anatomy of the abdomen.
Gallbladder – rests under posterior surface of liver.
Liver – fills RUQ and extends over to left midclavicular line.
Spleen – Posteriorlateral wall of abdomen under diaphram
Aorta – left of midline in upper part of abdomen.
Pancreas – located behind stomach
Kidneys – retroperitoneal Left kidney lies at the 11th and 12th ribs.
Components of abdominal examination
Inspect – Contour, symmetry, Umbilicus, Skin, Pulsations or movement, Hair distribution, Demeanor
Auscultation – Bowel sounds, Vascular sounds
Percussion – all four quadrants, borders of liver and spleen
Palp – Light all four quads, Deeper all four quads, Palp for liver, spleen and kidneys.
Abdominal changes Infant
abdomen protuberant, skin venous pattern, Cord has two arteries and one vein falls off in 10 – 14 days,
Umbilical hernia – appears at 2 to 3 wks max at 1 month.
Diastasis Recti – separation of abdominal muscles, usually black infants disappears by childhood.
Show resp. motion, occ peristalsis,peritonitis absence of resp movement
Auscultation – bowel sounds
Percussion – tympany over stomach, dull over liver.
Palpation – Liver fills RUQ, can palpate spleen tip kidneys, and bladder
Black meconium clears within 24 hrs
Abdominal changes child
Younger than 4 protuberant, lumbar lordosis, resp movement until 7 yrs.
Palpate liver 1 – 2 cm below costal margin. Spleen palpable soft sharp and moveable. can feel right kidney and tip of left kidney.
Percussion – liver size 3.5 cm at 2 yrs, 5 cm at 6 yrs and 6-7 cm in adolescence
Abdominal changes aging adult
Increased sub Q fat on abd. and hips. musculature is thinner and less tone. Organs easier to palpate. Can feel liver edge below costal margin. with inspiration easier to palpate liver, Kidneys are easy to palpate.
Obesity Abdomen
Uniform roundness, umbilicus sunken
Normal bowel tones, Tympany, with scattered dullness over adipose tissue. Palpatation normal.
Aortic Aneurysm
Located below the renal arteries and extend to the umbilicus. feels like a pulsating mass in upper abdomen, just left of midline. Murmur is harsh, systolic or continuous.
Gaseous distention
Single round curve
Auscultation – decreased with ileus, hyperactive with intestinal obstruction. Tympany over large area. palpation – might have muscle spasm of abd wall.
Hyperresonance with gaseous distention
Abdominal Tumor
Localized distention
Normal bowel sounds
Dull over mass
Define borders with palpitation, distinguish from enlarged organs.
Pregnancy Abdomen
Single curve, umbilicus protruding. Breasts engorged.
Fetal heart tones, bowel sounds diminished.
tympany over intestines, dull over uterus
Palpitation – fetal parts.
Ascities
Single curve, everted umbilicus, bulging flanks when supine. glistening skin, recent weight gain, increased abd girth.
Normal bowel sounds, diminished over fluid.
Tympany at top where intestines float. Dull over fluid. produces waves and shifting dullness.
Limit palpitation.
Enlarged liver
The liver fills most of the RUQ and extends to left midclavicular line.
Normal liver span is 6 to 12 cm taller people have longer livers. Chronic emphysema displaces the liver down.
Liver more than 1 – 2 cm below costal margin in enlarged.
Tender on palp – heart failure, acute hepatitis, and hepatic abscess
nontender on palp – fatty infiltration, portal obstruction, cirrhosis, high obstruction of inferior vena cava, or lymphocytic leukemia
Enlarged Spleen
Enlarges down and to the midline, can extend down into pelvix. Splenomegaly (mononucleosis) – moderately enlarged and soft with rounded edges. Chronic – firm or hard with sharp edges. Usually not tender.
Enlarged Gallbladder
Enlarged tender = cholecystitis, feel behind the liver border as smooth and firm mass. Area very painful to fist percussion and inspiratory arrest is present. (murphy sign)
Enlarged non-tender gallbladder is with stones.
enlarged kidney
With hydronephrosis, cyst or neoplasm. extends forward and down. Kidney never has a sharp edge. No palpable notch like the spleen. Percussion is tympanic.
Distended bladder
Dullness over distended bladder
Appendicitis
Starts as dull, diffuse pain in periumbilical region later shifts to severe, sharp persistent pain and tendersness in RLQ. aggrevated by coughing, deep breathing, anorexia, N/V. Use Iliopsoas muscle test when appendicitis expected. Lying supine lift straight leg up and then push down on upper thigh as pt tries to resist. Pain will be present.
inflammation of the kidney.
Thump your hand with the ulnar edge of your fist. With the thud there is sharp pain.
History questions for Musculoskeletal system
1. Any problems with joints, pain, Stiffness, Swelling, limited motion?
2. Any problem with muscles, pain, fever chills, weakness?
3. Any problems with bones, pain, deformity, accidents.
4. Any limitations on usual activities
5. Self care behaviors?
Bones
specialized forms of connective tissue.
Hard, rigid and very dense. Its cells are continually turning over and remodeling.
Muscles
account for 40 -50% of body’s weight. When they contract they produce movement. Skeletal muscles are under conscious control. Muscle attached to bones by tendons.
Joints
is a place of union of two or more bones.
Are functional units of the musculoskeletal system.
SYNOVIAL – are freely moveable because bones that are separated from each other and are enclosed in a joint cavity.
NONSYNOVIAL – are immovable or slightly moveable (skull, vertebrae)
Ligaments
Fibrous bands running directly from one bone to another that strengthen the joint and help prevent movement.
Cartilage
covers the surface of opposing bones.
Avascular it receives nourishment from synovial fluid that circulated during joint movement. Cushions the bones and gives a smooth surface to facilitate movement.
Order of examination of Musculoskeletal
Inspection- size, contour or joint, skin for color, swelling masses or deformity.
Palpation- palpate each joint, skin for temp, tenderness, swelling or masses.
ROM- ask for active ROM, check for limitation, should not cause tenderness.
Muscle Testing- Check primer mover muscle groups for each joint. Should be equal bilaterally and should resist opposing force.
Grading Scale of Musculoskeletal exam
Muscle Testing:
5 – Full ROM against gravity, full resistance 100% (normal)
4 – Full ROM against gravity, some resistance 75% (good)
3 – Full ROM with gravity 50% (Fair)
2 – Full ROM with gravity eliminated (passive motion) 25% poor
1 – Slight contraction 10% (Trace)
0 – No contraction 0% (zero)
Musculoskeletal variations Infants
Examine undressed lying on back. Start with feet. Newborns feet are not held straight but apart (varus) or together (valgus). Scratch outside of bottom of foot to see if foot moves to normal position. Metatrus adductus (forefoot adduction) usually present at birth and resolves by age 3. Check of tibial torsion (twisting tibia) place feet flat on table. increased by sitting reverse tailor position later in life. Use the ortolani maneuver until 1 y/o. flex knees and adduct and abduct hips, should be smooth and no sound. Allis test flex knees place feet on table check to see levelness of knees determine hip dislocation. Unequal gluteal folds may indicate hip dislocation after 2 to 3 months. Normal c curve to back by 2 months head can be lifted builds spinal curve.
Musculoskeletal variations children
Lorodosis common. Genu varum (bow of legs) normal until 1 year. Knocked knees (genu valgum) appears between 2 and 3 years. no treatment indicated. Pronation common between 12 and 30 months old. Pigeon toes corrects by 3 years. Start with feet and hands. Have child stand on one foot to observe hip levelness (trendeleburg sign) subluxation of spine. Check ROM and presence of pain 2 – 4 yrs from forceful removal of clothes.
Musculoskeletal variations Preadolescence / Adolescence
Pay attention to spinal posture. Kyphosis common due to poor posture. Sports related injuries. Forward bend test for scoliosis. (preadolescence)
Musculoskeletal variations aging adult
Decreased height due to shortening of vertebral column. Lengthening of arms. Kyphosis. Slight flexion of hips and knees. Bones become more prominent.
Rheumatoid Arthritis
Chronic systemic inflammatory disease of joints and surrounding connective tissue. Inflammation of synovial membrane lead to thickening, then fibrosis which limits motion and finally bony ankylosis.
Heat, redness, swelling and painful motion of affected joints. Fatigue, weakness, anorexia, weight loss, low grade fever and lymphadenopathey
Osteroarthritis
(Degenerative Joint) Noninflammatory, localized, progressive disorder of deterioration of articular cartilages and subchondral bone and formation of new bone. mostly adults over 60 y/o. Asymmetrical joint involvement, hands, knees, hips and lumbar and cervical segments. Stiffness, swelling with hard bony protuberances. Pain with motion and limitation of motion.
Ankylosing Spondylitis
Form of RA, chronic, progressive inflammation of spine, sacroiliac, and larger joints leading to bony ankylosis and deformity. Late adolescence or early adulthood, men. Spasm of paraspinal muscles pulls spine forward into forward flexion, obliteration cervical and lumbar curves.
Osteoporosis
Decrease in skeletal bones mass occurring when rate of bone resorption is greater than that of bone formation. Postmenopausal white women. Low estrogen, lack of physical activity, an young when start menopause.
Olecranon Bursitis
Large, soft knob or goose egg. Redness from inflammation of olecranon bursa of elbow. Easy to see.
Gouty Arthritis
Joint effusion or synovial thickening, seen first as as bulge or fullness in grooves on either side of olecranon process. Redness and heat. Soft boggy fluctuant fullness to palp. limited extension of elbow.
Subutaneous Nodules
Raised firm, nontender nodules that occur with RA. common in the olecranon bursa and along extensor surface of arm.
Ganglion cyst
Round, cystic nontender nodule overlying the tendon sheath. usually on dorsum of wrist. A common benign tumor.
Carpal Tunnel
Compression of the median nerve inside the carpal tunnel, caused by repetitive motion. Occurs between 30 and 60 y/o. More common in women. Pain, burning sensation and numbness, positive phalen and tinel test and atrophy of thenar muscles.
History questions for Musculoskeletal system Infants and Children
Any trauma when born?
Need for resuscitation?
Baby’s milestones achieved?
Any broken bones?
Any deformity?
History questions for Musculoskeletal system Adolescents
Involved with sports at school?
Need any special equipment?
Daily warm-up?
What do you do if you get hurt?
How do sports fit in with other daily activities?
History questions for Musculoskeletal system Aging Adult
Any change in weakness?
Any increase in falls or stumbling?
Any mobility devices?
Functional assessment Aging
Walk – shuffle pattern
Climb stairs – holds onto rail
Pick up object – bends at waist instead of at knees.
Rise up from chair – uses arms to push off
Rise up from bed – rolls to one side.
TMJ
articulation of mandible and temporal bone.
Ask person to open and shut mouth, protrude lower jaw and move side to side.
Spine
Vertebrae 33 connective bones
7 cervical, 12 thoracic, 5 lumbar, 5 sacral, 3 coccygeal.
Cervical and lumbar concave, Thoracic and sacrococcygeal are convex.
Intervertebral disks constitute one fourth of the length. Each disk has a nucleus pulposis made of semifluid mucoid material that cushions the spine.
Shoulder
glenohumeral joint – humerus with glenoid fossa of the scapula. Rotator cuff. Large subacromial bursa helps during abduction of arm. Acromiom process at top of shoulder.
elbow
articulation of humerus, radius and ulna of forearm. allows flexion and extension. Medial and lateral epicondyles or humerus and olecranon process between them.
Function of MS system
1)Support
2)Movement
3)Protect
4)Produce red blood cells in bone marrow
5) Storage of essential minerals
H/H questions MS System
Any pain, deformity, redness, swelling, limitation of movement? Accidents, ADL?
H/H questions of neuro system
-Any headaches?
-Any Head injuries?
-Seizures? (motor activity, associated signs, postical phase, precipitating factors)
-Any Tremors?
-Any weakness in a body part?
-Incoordination?
-Numbness or tingling?
-Difficulty swallowing?
-Difficulty speaking?
-PMH of CVA, alcoholism, congenital defect?
-Occupational hazards?
Anatomy of Neuro system
Cerebral Cortex – humans highest functions(reasoning, memory, voluntary movement)
Frontal lobe – Personality.
Basal Ganglia – Coordinate movements.
Hypothalamus – temp, appetite, HR, BP, sleep
Cerebellum – Postural balance, equilibrium.
Posterior columns – Sensation of position, vibration, localized touch.
Cranial Nerve I
Olfactory – test on people who report loss of smell, with head trauma, abnormal mental status and presence of intracranial lesion. Occlude one nostril, eyes closed smell. (Anosmia) decreased smell. Bilateral tobacco, allergic, cocaine. Unilateral neurogenic.
Cranial Nerve II
Optic Nerve – Visual acuity by confrontation test, visual fields, shine light in eye, direct inspection
Papilledema with ICP
Cranial Nerve III, IV, VI
Oculomotor, Trochlear, abducens
Check pupil for size, regularity, equality, light reaction and accommodation. Cardinals position of gaze
Nystagmus with vestibular, cerebellum or brainstem disease.
Cranial Nerve V
Trigeminal – Assess muscles of mastication by palpating masseter.Sensory – eyes closed light touch on forehead, cheeks and chin.
Corneal reflex with unilateral sensorineural hearing loss. Touch cornea with cotton.
Cranial Nerve VII
Facial nerve – mobility facial symmetry as person smiles, frown, close eyes,lift eyebrow, show teeth, and puff cheeks.
Sensory – Sense of taste only if you suspect facial nerve injury.
Cranial Nerve VIII
Acoustic (vestibulocochlear) Test hearing ability by whisper voice test
Cranial Nerve IX and X
Glossopharyngeal and vagus nerve – (Motor) Note pharynx movement as person says AHHH. uvula and soft palette should rise in midline. Note gag reflex
Cranial Nerve XI
Spinal accessory – sternomastoid and trapezius muscle for equal size. check strength by turning head against opposing force. Shrug shoulders with resistance.
Cranial Nerve XII
Hypoglossal – Inspect tongue no tremors present.
say “light, tight, dynamite” and note lingual speech.
Cerebellar Function
complex motor system coordinates movement, maintains equilibrium, and helps maintain posture. receives info about the position of muscles and joints. . Uses feedback pathways to exert its control back on the cortex or down to the lower motor neurons in the spinal cord. On the subconscious level.
Cerebellum Function
Located under occipital lobe, concerned with motor coordination of voluntary movements, equilibrium, posture of the body. Doesn’t initiate movement.
Bicep Reflex
Support forearm on yours, place thumb on the biceps tendon and strike a blow to your thumb
Tricep Reflex
Hold up upper arm and let forearm fall down, strike triceps tendon directly above the elbow. Normal response is extension of forearm.
Brachioradialis Reflex
Hold persons thumb to suspend forearm, strike the forearm directly above 2-3 cm above the radial styloid process.
Quadriceps Reflex
Let low leg dangle of the side of table. strike the tendon directly just below the patella. Extension is expected.
Achilles Reflex
Position pt with knee flexed and the hip externally rotated. Hold the foot in dorsiflexion, and strike the Achilles tendon directly. The foot will plantar flex against had.
Deep tendon Reflex grading Scale
4+ very brisk, hyperactive with clonus,, indicative of disease.
3+ Brisker than average, may be disease may be normal
2+ Average, normal
1+Diminished, low normal,only with reinforcement
0 No response
Reinforcement
Ask the person to perform an isometric exercise in a muscle group away from the one being tested. Used to relax the muscles and enhance the response.
Glascow Coma Scale
Accurate quantitative tool to describe level of consciousnes.
Eye opening- 4 to 1, Spontaneous to no Response
Motor response- 6 to 1 Obeys verbal commands – No response
Verbal response- Oriented to No response 5 – 1
Spastic hemiparesis
Arm immobile against body, with flexion of the shoulder, elbow wrist and finger. Leg is stiff and extended and circumducts.
Upper motor neuron lesion (CVA, truama)
Cerebellar ataxia
Staggering, wide based gait, difficult with turns, uncoordinated movement. Positive Romberg sign. Alcohol on cerebellum, cerebral tumor, MS
Parkinsonian
Posture is stooped, trunk is pitched forward, elbow, hips and knees are flexed. Steps short and shuffling. Hesitation to begin walking. Difficulty with change in direction.
Scissors
Knees cross or are in contact, like holding an orange between their legs. short steps walking requires effort. MS, Paraparesis of legs
Steppage
Slapping quality – looks like walking up the stair and finds no stair. weakness of peroneal and anterior tibial muscles.
Lower motor neuron lesion at spinal cord. (poliomyelitis)
Waddling
Weak hip muscles. when person takes a step, the opposite hip drops. marked lumbar lordosis and protruding abdomen. Muscular dystrophy, dislocation of hips
Reflex response Upper motor lesion
CVA, hyperflexia, ankle clonus, diminished or absent superficial abdominal reflexes, positive babisnski
Located in CNS
Reflex response lower motor lesion
Poliomyelitis, herniated intervertebral disk.
Hyporeflexia or areflexia, no babinski sign, no pathologic reflexes. Located in Peripheral Nervous system.
H/H question Kids
-Any problems with pregnancy?
-Tell about babies birth? Reflexes, what have you noticed about babies behavior?
-Any problem with balance?
-Any Seizures?
-Hit developemental milestones?
-Environmental exposure to lead?
-Attention Span?
-FM Hx of problems?
H/H question Aging Adults
-Any problems with dizziness?
-Get up at night and feel faint, any safety modifications?
-Decreased memory or change in mental function?
-Noticed tremors?
-Sudden vision change?
Neuro variations children
Neuro variations aging adults
Change in cranial nerve and taste. decrease in muscle bulk in hands
Senile tremors, Dyskinesias – repetitive movement in jaw, lips or tongue. Loss of vibration sensation at ankle malleolus. Tactile sensation impaired. Abdominal reflex absent.
Female history questions
Mentrual history- menarche, LPM, cycle, duration, menorrhagia
Obstetric HX – Gravida, para, abortion
Menopause – period slowed down
Self care behaviors – annual pap until 30 yrs after 3 normal pap then q 2 – 3 yrs.
Urinary system –
Vaginal discharge –
Past HX-
Sexual activity
Contraceptives?
STDs?
STD reductions? condoms?
External genitalia female
Vulva – external genitalia
Mons Pubis – fat pad covering symphysis pubis (location of pubic hair)
Labia majora – adipose tissue extends from mons pubis to perineum.
Labia minora – joined at clitoris and posteriorly at frenulum.
Clitoris – erectile body sensitive to stimulation.
Vestibule- encircled by the labia
Urethral meatus –
Paraurethral (skines’s) glands -open to urethra
Vaginal orifice- vaginal opening
Hymen – thin skin that covers vaginal orifice/
Bartholins gland – secrete lubricant during intercourse.
Internal genitalia female
Vagina
Rugae
Cervix- covered with smooth stratified squamous epithelium
Os – columnar epithelium red and rough
Squamocolumnar junction- where the two tissues meet
Uterus – muscular organ
Fallopian tubes- trumpet shaped tubes
Ovaries – located on each side of the uterus at level of superior iliac spine. 3 cm long by 2 cm wide by 1 cm thick.
Physical findings puberty
Examine along. Increased vaginal fluid (leukorrhea) normal because of estrogen.
During bimanual examination adnexa are not palpable.
Physical findings Pregnancy
Week 16 fundus palpable between symphysis and umbilicus
at 20 lower edge of umbilicus, 28 wks between umbilicus and xiphoid and 36 wks almost to xiphoid.
External genitalia – hyperemia of perineum and vulva, varicose veins labia or legs, Hemorrhoids.
Vaginal wall appear blue (chadwick sign) deeply rugated mucosa thickens. Cervix softer, velvety.
Uterus feels soft and easily compressed between two hands (hegar sign) Adnexal structures not palpable during pregnancy.
Physical findings perimenopause/Menopause
between 40 to 55 years
Vasomotor instability
Irregular menses. Uterus shrinks, ovaries atrophy, uterus droops, cervix shrinks and looks pale.
vagina becomes shorter, less elastic, epithelium atrophies, becoming thinner drier itchy, fragile mucosal risk for bleeding. Ph becomes alkaline. increase risk for vaginitis.
, pubic hair decreases. Used pedersen speculum because it is narrower. Clitoris size decreases. Uterus feels small and firm. Cervical exam up to 70, with hysterectomy no more unless neoplasm then 10 yrs after tx.
Candidiasis
Intense puritis thick whitish discharge
vulva and vagina erythematous and edematous.
Cause or contraceptives, antibiotics, vaginal pH, pregnancy
Trichomoniasis
Puritis, watery malodorous vaginal discharge.
Urinary frequency. worse during menstruation,
vulva erythematous, vagina diffusely red raised papules and petechiae. Frothy yellow green foul smelling discharge.
Bacterial vaginosis
Profuse discharge “constant wetness” foul fishy rotten odor.
Thin creamy gray-white discharge.
No inflammation. Clue cells. fishy odor after adding KOH.
Chlamydia
Minimal to no symptoms, postcoital bleeding.
NAAT test for pregnancy and chlamydia. urinary frequency dysuria. cervial motion tenderness. causes PID. Most common STD.
Gonorrhea
Abcess in bartholins or skene glands, asymptomatic. may have purulent vaginal discharge may progress to acute salpingitis PID.
cervical erosion
Cervical lips inflamed and eroded. Reddened granular surface is superficial inflammation with no ulceration. secondary to purulent cervical discharge.
cervical polyp
May have mucoid discharge or bleeding. bright red growth from os, benign, determined by bx
Nabothian cysts
Normal, appear on cervix after childbirth. obstruction of cervical glands.
Cervical carcinoma
Bleeding between menstration, ulcer and induration, diagnosed by BX Factors are early age intercourse, multiple partners, smoking, STDs
adnexal enlargement
Fallopian tube mass- sudden fever, suprapubic pain, boardlike lower abd. movement of cervix causes pain. PID, ectopic preg.,
ectopic pregnancy
Amenorrhea or irregular vaginal bleeding. pelvic pain, softening of fundus and cervix, movement of cervix or uterus causes pain. may cause peritonitis.
ovarian cyst
Asymptomatic, non-tender mass, may resolve in 60 days.
History questions for male
Frequency, urgency, nocturia?
Dysuria?
Hesitation, straining?
Urine color?
Past Hx?
Penis, pain or lesions?
Scrotum – lumps or swelling?
Sexual activity?
History questions for adolescent male
Often boys your age……..!
12 -13 y/o growth of penis and scrotum, wet dreams. Teach to examine testes. Sexual abuse?
History questions for aging male
Problems urinating?
Leak urine?
Nocturia?
Sexual function?
Internal male genitalia
Cremaster muscle – controls size of scrotum respondent to ambient temp.
Testes- produce sperm, suspended by spermatic cord.
Epididymis – main storage sight of sperm/
Vas deferens – joins to form ejaculatory duct.
Inguinal area – (groin)
External male genitalia
Penis – 2 corpora cavernosa and 1 corpus spongiosum ventrally.
Glans – cone of erectile tissue
Corona – where glans join the shaft.
Physical exam male infants
perform after abd exam. Foreskin tight for first 3 months and should not be retracted. Cryptorchidism (undescended testes common in premature infants)
Physical exam male adolescents
Puberty starts between 9 1/2 to 13 1/2 first sign is enlargement of testes. next pubic hair then penis size.
Physical exam male aging
Inspect and palpate Penis – wrinkled, hairless without lesion. Dorsal vein apparent. Compress the glans, should be pink, smooth without discharge.
Inspect and Palpate Scrotum- Asymmetry normal with left scrotal half lower than right. No lesions other than cysts firm nontender sebaceous cysts. Smooth nontender cord.
Scrotal lump
Mass – Tenderness?
distal or proximal to testes?
Can you place your fingers over it?
Does it reduce with lying down?
Auscultate bowl sounds?
epididymitis
Severe pain, sudden onset. Rapid swelling fever. Acute infection. Enlarged scrotum, reddend.
varicocele
a dilated tortuous varicose vein in spermatic cord due to incompetent valves in the vein. Most often left side. Dull pain constant pulling or dragging feeling. Soft irregular mass post and above testes. Bag of worms.
spermatocele
Painless, retention cyst in epididymis. poss obstruction of tubules. round freely moveable mass may feel like a third testes.
testicular tumor
Painless, occur between 18 and 35. All are malignant. Whites. Must Bx to confirm. Risk factor undescended testis.. Palpable node.
hydrocele
Painless swelling.Circumscribed collection of seous fluid in tunicA VAGINALIS surrounding testes. weight and bulk in scrotum. enlarged mass does tranilluminate.
indirect inguinal hernia
Sac herniated through internal inguinal ring, can remain in canal or pass into scrotum. Pain with straining. most common. infants< 1 yrs and age 16 to 20.
direct inguinal hernia
Directly behind and through external inguinal ring. rarely enters scrotum. painless, round swelling close to pubis. reduced with supine. acquired weakness. Heavy lifting, obesity, chronic cough.
femoral hernia
Through femoral ring. More often right side. Pain may be severe . May become strangulated. Less common. frequent stooping.
Herpes infection male
Clusters of small vesicles with surrounding erythema which is often painful.initial infection lasts 7 to 10 days.
syphilis males
A small solitary silvery papule that erodes to a red round superficial ulcer with yellowish drainage. lymph nodes enlarge. can be treated with PCN. untreated leads to cardiac and neurologic problems. and blindness.
genital warts males
Soft, pointed, moist fleshyu painless papules may be single or multiple. shaft and anus. HPV most common STD.
carcinoma males
Red raised warty growth or ulcer with watery discharge. may necrose and slough. on Glans or inner foreskin.l and following chronic inflammation. enlarged lymph nodes.
orchitis males
Acute inflammation of testes. cause mumps. sudden onset, swollen testis, fever. Enlarged edematous, reddened testes.
urethritis males
Painful burning on urination. Meatus edges are reddened. purulent discharge. 50% caused by chlamydia infection.
Adolescent female history
When did you……..?
Age 9 – 10 breast developement/pubic hair.
Have you started your period?
Who do you talk to about body changes?
Intercourse?
Have you talked about STD?
HPV vaccine? ages 9 – 26
Length of anal canal and rectum in adult and location
12 cm long the distal portion of large intetines. extends from sigmoid colon at level of third sacral vertebrae and ends at anal canal.
Constipation
Reduced stool frequency, less than 3 BM per week. straining lumping or hard stool
Hemorrhoids,
Thrombosed becomes painful and swollen, shiny blue mass that itches and bleeds.
Melena
Black tarry stool due to occult blood from GI bleeding or non tarry from iron intake.
Soluble high fiber foods.
Beans, prunes, barley, carrots, broccoli,cabbage
(lower cholesterol)
insoluble high fiber foods.
Cereal, wheat germ
(reduce risk of colon cancer, fight obesity, blood sugar)
Bowel elimination influenced by growth and developemtn
Starts as a gastrocolic reflex, voluntary control cannot occur until the nerves have become fully mylinated. usually around 1 1/2 to 2 y/o.
Anal relaxation for examination
Instruct to point toes together, theis relaxed the regional muscles, making it easier to spread the buttock. Male left lateral or standing, female lithotomy or left lateral. Place index finger gently against the anal verge. insert toward umbilicus.
Risk factors for colon and prostate cancer.
Over 50 y/o
has colorectal polyps or inflammatory bowel disease. I(ncreased in african americans,. colonscopy every 10 years.
Protrate cancer – First degree relative. BRCA2
Mutations. Diet, in red meat, saturated fats and dairy.
Prostate gland
on anterior wall. Smooth and muscular. 2.5 cm long by 4 cm wide. heart shaped with palpable groove.elastic, rubbery, slightly moveable. nontender on palpation.
Pilonidal cyst
Hair containing cyst. or sinus located in the midline over the coccys. Opens as a dimple. congenital usually diagnoses between 15 and 30 y/o
Anorectoal fistula
Chronically inflammed gastrointestinal tract creates and abnormal passage from inner anus out to skin surrounding anus. May drain when pressure applied.
Benign hypertorphy
Urinary frequency, urgency hesitancy, straining,
symmetric nontender enlargement, common in middle years. smooth rubbery or firm. caused by hormonal imbalance

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