NSG500 / NSG 500 Exam 2 V1 | Latest 2026/2027 Update | Advanced Health Assessment | Wilkes | Practice Questions & Accurate Solutions

GRADED A++++++++++ NSG500 / NSG 500 Exam 2 V1 | Latest 2026/2027 Update | Advanced Health Assessment | Wilkes | Practice Questions & Accurate Solutions Q: What is the normal RR to HR ratio? Answer 1:4 Q: How much should the lower border of the liver drop with deep breath? Answer 2-3 cm Q: Distance person is from chart is what a normal person can see at 20 feet Answer 20/20 vision Q: Abnormal breath sounds Answer Crackles Rhonchi Wheezes Friction Rub Mediastinal crunch GRADED A++++++++++ Q: What sound indicates COPD/Emphysema or restrictive lung disease? Answer Decreased diaphragmatic excursion Q: What are some abnormal findings of aging ears, nose and throat? Answer Presbycusis Conductive hearing loss Q: Abnormal findings of aging eyes Answer Macular degeneration Decreased accommodation Cataracts d/t compressed fibers Q: What is macular degeneration? Answer Decreased central vision GRADED A++++++++++ Q: How do you detect macular degeneration? Answer Use Amsler grid Q: What is decreased accommodation called? Answer Presbyopia, focusing power Q: What are abnormal findings of aging in HEENT? Answer Neck pain Crepitus Dizziness Jerkiness Limitation of movement Q: What are abnormal respirations? Answer Tachypnea Bradypnea Hyperpnea Kussmaul Hypopnea Cheyne-Stokes GRADED A++++++++++ Q: What are absent bowel sounds? Answer No sounds after 5 minutes of continuous listening Q: What does absent bowel sounds mean? Answer If it's associated with abdominal pain and rigidity, it's a surgical emergency. Q: What does a normal ear look like? Answer Uniform pink Hair on the outer 2/3 Some cerumen No lesions No discharge No foreign bodies TM is translucent and pearly gray Landmarks visible GRADED A++++++++++ Q: Adult Otoscopic Exam Answer Pull auricle upward and back Q: What are the landmarks of the ear? Answer Umbo Handle of Malleus Light Reflex Concavity at umbo Q: What is the relationship between AC and BC sound? Answer Air-conducted should be 2x as long as bone-conducted. Q: Altered resonance Answer bronchophony whispered pectoriloquy egophony GRADED A++++++++++ Q: What does an anterior pointed cervix indicate? Answer Retroverted uterus Q: What does a prominent lateral pulsation suggest? Answer Aortic aneurysm Q: How do you identify an aortic regurgitation murmur? Answer Heard with diaphragm with pt sitting and leaning forward. Q: How can you hear an Austin-Flint murmur? Answer Heard w/ bell at apex What is an Austin-Flint murmur? Answer Severe aortic regurge murmur GRADED A++++++++++ Where is an ejection click heard? Answer In the second intercostal space What is an aortic stenosis murmur? Ejection sound at second right intercostal border. Where can an aortic stenosis murmur be heard? Over the aortic area How to you identify the aortic valve area? In the second right intercostal space at the right sternal border. What special tests can help identify appendicitis? Rebound tenderness Rovsing's sign Iliopsoas sign Obturator's sign Cutaneous hyperesthesia Markle test What do you inspect when examining nipples? Shape Color GRADED A++++++++++ Texture Eversion Retraction/Deviation What should be the normal texture of areolas? Smooth except for nontender Montgomery turbercles How do you identify arterial embolic disease? Pain Paresthesia Nail bed hemorrhages What tests diagnose ascites? Fluid wave Shifting Dullness How to assess for tactile fremitus? Pt Repeats 99. Provider systematically palpates chest front, back, and sides. Touch should be light, but firm to feel for vibrations What is a normal finding for tactile fremitus? Vibration should be symmetrical GRADED A++++++++++ How do you auscultate chest/lungs? Move systematically from apex to base. Compare sides. Listen through inspiration/expiration What tool do you use to auscultate chest/lungs? Stethoscope diaphragm How should the patient breath during auscultation? Slowly and deeply through mouth What should the patient's position be for auscultation of posterior chest? head bent forward Arms crossed What should the patient's position be for auscultation of lateral chest? Raise arms What should the patient's position be for auscultation of anterior chest? Erect w/ shoulders back Cardiac Auscultation Mnemonic GRADED A++++++++++ All Patient Easily Take Medicine What does the Cardiac Auscultation Mnemonic stand for? A= Aortic P= Pulmonic E= Erb's Point T= Tricuspid M= Mitral What position do you put a baby for a otoscopic examination? Supine or prone How to perform an otoscopic examination for babies? Turn head to side Pull auricle down What are normal findings of otoscope exam for babies? Tympanic membrane extremely oblique. Light reflex may appear diffuse. What sounds are best heard with the bell of the stethoscope? Low-pitched sounds GRADED A++++++++++ How do you perform a bimanual digital palpation? One palm under the right breast Walk fingers of other hand across tissue Feeling for lumps while compressing tissue For which individuals is bimanual liver palpation used? Obese individuals Biot respiration Irregular breathing Varies in depth Interrupted irregularly w/ apneic intervals What are the findings of Blumberg sign? Rebound tenderness Perioneal irritation Appendicitis Borborygmi sounds loud, prolonged gurgles. (Stomach growling). What is bradycardia? Heart rate under 60bpm. GRADED A++++++++++ What can bradycardia indicate? problems with the electrical system. What does breath sounds sound like if a mass or lesion was present in the chest? Absent or diminished sounds In what conditions would you see an abnormal diaphragmatic excursion? Pneumothorax Pleural effusion In pneumothorax, what would shown in abnormal excursion? Asymmetrical Chest Pleural effusion Not enough thoracic pressure to push the fluid to perform excursion over the chest When would abnormal diaphragmatic excursion be decreased? Emphysema Massive Ascites Tumor Superficial pain GRADED A++++++++++ What is tactile fremitus? Palpable vibration of the chest wall that results from speech How do you perform tactile fremitus? Conducted with palmar surface or both hands and ulnar aspect. Pt says 99 or Mickey Mouse What can decreased or absent fremitus indicate? Emphysema Pleural effusion Bronchial obstruction Excess air COPD = related to alveoli collapse. What can increased fremitus indicate? Consolidation Heavy bronchial secretions Compressed lung Fluid in lungs Mass in lungs Where is fremitus most prominent? Posteriorly and Laterally at the level of the bifurcation of the bronchi. GRADED A++++++++++ Between the scapulae and around the sternum, sites where the major bronchi are closest to the chest wall. Which population shouldn't you percuss during a respiratory exam? Pediatrics How do you differentiate between crackles and rhonchi? Auscultate lungs before and after the patient coughs. Rhonchi clears with coughing. Why does rhonchi clear with coughing? Represents secretions in larger airways. Bronchophony Clarity and loudness of spoken sounds. When is bronchophony extreme? When there is consolidation of the lungs. Egophony nasal quality spoken voice increased resonance of voice sounds when auscultating the lungs Air-filled lung tissue in an insulator of sound GRADED A++++++++++ Pectoriloquy Whisper heard quality Stridor High-pitched sound with inspiration What causes stridor? Laryngeal obstruction or narrowing from foreign body or swelling What cardiac sound is heard with left ventricular hypertrophy? Feel a thrill over the left sternal border Systolic murmurs: Where do they commonly occur? Between S1 and S2 Are systolic murmurs usually serious? No. What does a systolic murmur indicate? Regurgitation and/or ejection GRADED A++++++++++ When is a mitral valve prolapse murmur best heard? While the patient is changing positions. What can magnify the sounds of a mitral murmur? Listening while the patient goes from sitting to standing position. Explain murmur grade scale The higher you go, the worse and more severe the murmur. How can the murmurs of higher grades be heard? Can be heard with stethoscope off the chest Murmur, Grade I barely audible Murmur, Grade II quiet, but audible Murmur, Grade III moderately loud GRADED A++++++++++ Murmur, Grade IV loud, associated with thrill Murmur, Grade V very loud, thrill easily palpable Murmur, Grade VI very loud, thrill palpable and visible Jugular vein distention can indicate what? Left sided heart failure What can JVD pulsation indicate? Back up of venous system seen with right heart failure. What does back up of venous system in heart indicate? Edema Venous congestion Enlarged liver portal vein How does S1 and S2 differ? S2 is shorter and higher pitch. GRADED A++++++++++ What is a S3 heart sound. An adventitious sound What does an S3 heart sound indicate? Early sign of heart failure What is the point of maximal impulse (PMI) Where the apical pulse is most readily seen or felt What does is it mean if the apical PMI is palpated beyond the 5th intercostal space? It may indicate left ventricular hypertrophy Where is the PMI in dextroccardia It would be displaced to the right What is normal Jugular Venous Pressure (JVP)? Less than 9cm H2O. What does a JVP of over 9cm H2O indicate? increased pressure. GRADED A++++++++++ What causes a carotid bruit? a partially occluded blood vessel What does a carotid bruit indicate? Blood flow turbulence and/or vascular disease What is a bruit? The sound of turbulent blood flow auscultated over arteries What tool is a bruit best heard with? The bell of a stethoscope What can causes a carotid bruit? Age High cholesterol What risk increases with the carotid bruit? Stroke MI What should provider do when they hear a carotid bruit? Get an ultrasound to see how blocked the carotids are GRADED A++++++++++ Is venous hum normal in children? No, but it is usually benign. Does a venous hum have any pathologic significance? No. What position can a venous hum in children be heard the best? Sitting position What does a venous hum in children indicate? Turbulence of blood flow in the internal jugular veins What does venous disease look like? Warm, thick skin Ulcers found on the medial or lateral aspects of the lower limbs What are symptoms of venous disease? Induration Dependent edema Prolonged capillary refill hyperpigmentation GRADED A++++++++++ What does arterial disease look like? Cool, thin skin Necrotic feet/toes What causes arterial disease? Damage to arteries due to lack of blood flow to tissue. What are symptoms of arterial disease? Pain with activity, relieved at rest What are some symptoms of arterial disease? Intermittent claudication angina What temp does raynaud's disease occur? cold What temp does arterial disease occur? Any temperature How does blood volume change in pregnancy? Blood volume increases GRADED A++++++++++ What is the purpose of the bell end of the stethoscope? Best to hear low pitched sounds (S3 and S4) What are signs and symptoms of Tetralogy of Fallot? dyspnea with feeding poor growth exercise intolerance cyanosis with crying/agitation paroxysmal dyspnea with loss of consciousness What symptoms present in older children that have Tetralogy of Fallot? Clubbing in fingers and toes Tetralogy of Fallot: Parasternal heave and precordial prominence Systolic ejection murmur over the 3rd intercostal space; single S2 is heard. What could happen is=f Tetralogy of Fallot is not treated? Heart Failure if not surgically corrected What caution should you take on pulsating aortas? Never push on them GRADED A++++++++++ Why should you never push on a pulsating aorta? It may rupture What should you evaluate on the breast lumps? Location Size Shape Consistency Tenderness Mobility Delineation of borders and retraction What is important to ask a woman complaining of a breast lump? Ask the lump's relationship to menses Which lumps should be investigated further? New solitary or dominant masses What are fibrocystic changes? Benign fluid filled cysts What are the characteristics of fibrocystic changes? Tender GRADED A++++++++++ Usually bilateral soft to firm tense round mobile well-delineated borders Why should you ask a woman c/o breast lumps about their menses? Fibrocystic changes fluctuate with menses What are fibroadenomas? benign, painless tumors. Fibroadenomas: Do they fluctuate with the menstrual cycle? No. Fibrocystic changes: Do they fluctuate with the menstrual cycle? Yes. What are the characteristics of fibroadenoma? Round or discoid Firm Rubbery mobile GRADED A++++++++++ well-delineated borders, usually bilateral What should be done with a fibroadenoma? Biopsy to rule out cancer What are malignant breast tumors? Painless lump that change in size, shape, and/or contour of breast. Malignant breast tumors: what happens if lymph nodes are involved? Axilla may be tender What are the characteristics of a malignant breast tumor? Palpable Usually single Unilateral Irregular or stellate in shape Poorly delineated borders fixed hard/stonelike nontender What are characteristics of the breast if there is a malignant breast tumor? dimpling retraction GRADED A++++++++++ prominent vasculature Skin has orange or thickened Nipple newly inverted or deviate in position How to perform a breast exam? Inspect both simultaneously. Perform chest wall sweep. Bimanual digital palpation What are normal breast changes during pregnancy? Increased venous mapping What are breast cancer risk factors? Nulliparity First child after 30 Obese BRCA gene Late Menopause Early Menarche Drinking 1+ alcoholic beverages daily When should breast cancer screening start? 45 years old GRADED A++++++++++ What is most likely diagnosis for unilateral arm swelling after a mastectomy? Lymphedema Why is there unilateral arm swelling after mastectomy? When the lymph nodes are removed, they don't drain which leads to arm swelling. What care should be on the arm that swells after mastectomy? Limb alert on this arm What is a related cause for gynecomastia? Low testosterone What can you do about gynecomastia? Check testosterone levels and replace, as necessary or refer to endocrinologist. How to assess for eye accomodation Ask pt to look at distant object, then at a test object that is held 10cm from bridge of nose. What do you expect to see from accomodation? Expect the pupils to constrict when eyes focus on the near object. How can you test eye accommodation with pts with darker pupils? GRADED A++++++++++ Observe pupil dilation when the patient looks from near to far When do you test eye accommodation for diagnostic purposes? When there is a defect in the pupillary response to light. In what conditions can you expect a failure response to light, but retaining constriction during accommodation. Diabetes Syphilis What are the visual acuity charts? Snellen Rosenbaum Snellen chart alphabet chart containing letters of graduated sizes, used for screening far vision for literate, verbal, and English-speaking adults and school age children. Rosenbaum chart Used for screening near vision. Contains a series of numbers E, X, O in graduated sizes. What does cobblestoning of the conjunctiva indicate? Allergic reaction, or infectious (conjunctivitis) GRADED A++++++++++ What should you expect for bilateral pink eyes? Allergic reaction What should you expect for unilateral pink eyes? Infection, injury, foreign body How to conduct the Weber test? Placement of tuning fork = midline top of head Ask patient if sound is heard equally or if its better in one ear. What does the Weber test assess? Unilateral hearing loss What are normal findings of the Weber test? Sound heard equally in both ears. Weber test: Conductive hearing loss sound heard better in affected ear Weber test: Sensorineural hearing loss Sound lateralizes to better ear GRADED A++++++++++ How to conduct the Rinne test. Placement of tuning fork= mastoid bone Ask pt to tell you when the sound is no longer heard. Time the interval in seconds Position the still vibrating tines 1cm from ear and ask pt to tell when sound is no longer heard. Compare number of seconds. What does the Rinne test assess for? Helps to distinguish whether the patient hears better by air or by bone conduction What is a normal finding of the Rinne test? Air conducted sounds should be heard twice as long as bone. Rinne test: Conductive hearing loss Bone conduction heard longer than air. Rinne test: Sensorineural hearing loss Air conduction heard longer than bone Tonsil grading: visible 1+ GRADED A++++++++++ Tonsil grading: Halfway between tonsillar pillars and the uvula 2+ Tonsil grading: Nearly touching the uvula 3+ Tonsil grading: Touching each other 4+ Tympanic membrane rupture s/sx Sharp pain Foul smelling, yellow, purulent, bloody discharge Pain resolves Decreased hearing What is the treatment for tympanic membrane rupture? Ear drops are needed Why should you take caution when prescribing ear drop for a tympanic membrane rupture? Many are ototoxic to the ear drum What characterizes an allergic response to the nasal passage? GRADED A++++++++++ Bluish gray turbinates or pale pink nasal turbinates that are swollen and boggy What characterizes cocaine use in nasal passages? Rhinorrhea, congestion, nose bleeds/hyperemia, nasal mucosa edema, perforation/hole, scabs. What characterizes infection in the nasal passages? Reddened mucosa How to examine a pediatric ear? Pull auricle down and back What are some risk factors for cataracts? Diabetes Older age Family Hx Steroids UV light cigarette smoking What changes does hypertensive retinopathy in the eyes occur? Rentinal arteriolar narrowing Ateriovenous nicking GRADED A++++++++++ How do you evaluate hearing in a 0-3 month old? Startles at loud noise How do you evaluate hearing in a 4-6 month old? Turns head toward sound How do you evaluate hearing in a 7-12 month old? Responds to name/listens What age is recommended for colon cancer screening? 50 years old and continue to 75. What should you consider regarding colon cancer screening? Pt's overall health and prior screening history. What are s/sx of colon cancer? Change in bowel habits Weight loss Feeling full quicker than usual when eating What body system is peristalsis regulated by? The autonomic nervous system GRADED A++++++++++ How to percuss for liver size Begin at the right midclavicular line over an area of tympany and proceed to an area of dullness Where do you percuss to determine the lower border of the liver? Percuss toward the midclavicular line from the right midclavicular line. Where do you percuss to determine the upper border of the liver? Around 3rd intercostal space. It is typically in the 5th intercostal space. What is normal size of the liver? 6-12 cm or 2.5-4.5 inches. What does it mean if a liver is greater than 6-12 cm? Liver enlargement What does it mean if a liver is small than 6-12 cm? Liver atrophy How do you test for liver size in an obese pt? Scratch test GRADED A++++++++++ Ascities: Appearance Glistening, taut Shifting dullness to dependent side Fluid wave in ascites: Where to assess supine, feel for impulse of a fluid wave What are the most sensitive techniques for assessing ascities? Flank dullness Presence of bulging flanks What is the most specific test for ascites? Presence of a fluid wave How can you identify ascites in an obese pt? Scratch test What are absent bowel sounds suggestive of? Peritonitis Appendicitis s/sx Anorexia, N/V, Waxing and waning pain that is becoming more intense, Psoas/ Iliopsoas sign, + obturator signs. GRADED A++++++++++ Psoas/Iliopsoas sign Pain on passive extension of the right thigh Obturator sign Pain felt with the slow internal movement of the hip joint, while the knee is flexed. Other s/sx of Appendictis Periumbilical/ Epigastric pain that later becomes localized to RLQ. Often at McBurney point. Guarding RLQ skin hyperesthesia Low grade fever +Aaron sign Rovsing sign McBurney sign Markle sign Aaron sign pain in the abdominal region over the McBurney point that is elicited when pressure is applied and indicates appendicitis McBurney sign (acute appendicitis) Severe RLQ pain with deep tenderness GRADED A++++++++++ Rovsing's sign Pain in RLQ with palpation of LLQ indicative of appendicitis Markle sign pain elicited in a certain area of the abdomen when the standing patient drops from standing on toes to the heels with a jarring landing Gallbladder Disease Risk Factors Female Fertile Fat Fair Skin Forty Murphy's sign Pain during RUQ deep palpation with inspiration, similar to rebound tenderness Most common congenital anomaly of the GI tract Meckel diverticulum Meckel Diverticulum Outpouching of the ileum GRADED A++++++++++ Meckel Diverticulum signs and symptoms Most pts are Asymptomatic. Painless rectal bleeding is most common Some have intense abd pain intestinal obstruction diverticulitis bilious emesis Meckel Diverticulum signs and symptoms in children. Bright or dark red rectal bleeding with little abdominal pain. CVA tenderness indicates? nephrolithiasis, ureteropelvic junction obstruction, pyelonephritis. renal abcess renal calculi How do you distinguish pyelonephritis from UTIs? Pyelonephritis has flank pain and CVA tenderness Where do you assess for CVA? At 12th rib and between spine, put hand over and hit it. Adnexa of uterus GRADED A++++++++++ fallopian tubes and ovaries What does it mean if adnexa of uterus is tender? Suggestive of PID Define Menopause 1 year without menses Gynecologic exam technique Choose correct size speculum Lubricate the speculum Press the introitus downward Insert the closed speculum obliquely Gently insert finger to push the introitus down to relax the pubococcygeal muscle Hold the closed speculum with the other hand and insert speculum past finger obliquely. Order of speculum collection Pap smear Vaginal cultures Gonorrhea Chlamydia What are clue cell indicative of? Bacterial vaginosis GRADED A++++++++++ When is the first pelvic exam recommended for women? 21 years old for sexually inactive female Cervix changes with early pregnancy Softens (Goodell sign) Bluish color (Chadwick sign) Assessing for inguinal hernias Patient to bear down and inspect the area of the inguinal canal. Insert finger into part of the scrotum and carry it upward along the vas deferens into the inguinal canal. What is the #1 risk factor for testicular cancer? Cryptorchidism (Undescended Testicles) What are other risk factors for testicular cancer? Family/Personal history of cancer HIV 20-34 years old White Androgen suppression GRADED A++++++++++ What should a patient be evaluated for if they present with sudden onset of severe testicular pain? Torsion Why would you use transillumination of testes? To determine if a mass is solid or fluid filled How do you know if a mass on the testes is a fluid filled cyst? Fluid filled cyst with illuminate How do you know if a mass on the testes is solid? Solid mass will block out the light. it is noncardiac chest pain if: constant achiness, does not radiate, worsens with pressing on chest wall, fleeting/needle like jab that lasts a few seconds, situated in shoulders or between shoulder blades in the back dullness on percussion present in pleural effusion or lobar pneumonia tactile fremitus decreased or absent if excess air in lungs (emphysema), pelural thickening or effusion, bronchial obstruction increased if presence of fluids, solid mass, consolidation GRADED A++++++++++ trachea exam eviation: volume loss from fibrosis or atelactasis will pull the trachea that direction. mau also be anterior mediastinal tumor, inlammation lung percussion dull=cardiac, luver tympany--stomach resonant--lungs flat--muscles and bones lung percussion order back (10 areas), right lateral--4 areas, left lateral 4 areas, front8 areas classification of breath sounds vesicular--low pitched, low intesity (normal healthy tissue) bronchovesicular--over major bronchi, moderate in pitch and intensity bronchial breath soudns--highest in pitch and intensity--over trachea bronchovesicular and bronchial breath sounds over peripheral lung tissue ABNORMAL breath sounds like blowing across the mouth of a bottle amphoric=stiff pulmonary caivty or tension pneumothorax GRADED A++++++++++ rub sound--lungs cratchy and high pitched types of crackles fine: high pitched discrete with end of inspiration, doesn't clear with cough medium: lower more in middle stage of inspiration coarse: bubbly with inspiration, loud rhonchi deeper rumbling more pronounced during expiration. d/t thick secretions vocal resonance with lung ausculatation bronchophony--consolidation in lungs--even a whisper can be heard clearly egophony--consolidation of lung tissue--ee turns into "a" bronchial breath sounds harsh, hollow sound - best heard over trachea and larynx bronchovesicular breath s over bronchi, med pitch and loudness GRADED A++++++++++ vesicular sounds heard every where else, softest and lowest pitch fine crackles are more often in bases of lungs coarse crackles more often in trachea and large bronchi rhonchi are due to airway obstruction from mass, secretions, muscular constriction wheezes are due to constriction, mass, secretions stridor strained, high-pitched sound heard on inspiration caused by obstruction in the pharynx or larynx S1 heart sound mitral and tricuspid valve closure with ventricular contraction GRADED A++++++++++ s2 initiation of diastole aortic and pulmonic valves closing after ventricles have emptied s3 sometimes occurs when ventricular filling is almost complete. due to RAPID ventricular filling. low pitch, use bell s4 occurs with atria contraction to ensure ejection of any remaining blood. Due to forceful atrial ejection into distended ventricle. low pitch, use bell chest pain: cardiac substernal provoked by effort, emotion, eating and relieved by rest, nitro, often accompanied by diaphoresis and sometimes nausea chest pain: pleural with breathing or coughing: sharp, present with respiration, absend when holding breath chest pain: esophageal burning, substernal, radiation to shoulder, nocturnal/lying flat, releived with food, antacids and sometimes nitro chest pain: peptic: almost always infradiaphragmatic and epigastric. PM and AM attacks relieved by food GRADED A++++++++++ chest pain: biliary under right scapula, prolonged, after eating, will trigger angina chest pain: arthritis/bursitis local tender/pain with movement chest pain: cervical pain with movement, associated with injury chest pain musculoskeletal with movement, twisting, bending, focal tenderness sequence of chest assessment inspection, palpation, percussion, auscultation what is a thrill? palpable vibration it feels like the throat of a purring cat. the thrill signifies turbulent blood flow and directs you to locate the origin of loud murmurs -use your palm aspect of your four fingers with grade 4 murmur or higher GRADED A++++++++++ order of cardiac auscultation Aortic (2nd space right sternal border) pulmonic (2nd space left sternal border) second pulmonic area (erb's point) 3rd intercostal space at left sternal border Tricuspid (4th intercostal space left border) mitral (5th left interspace, midddle chest) causes of lounder s1 sound increased blood velocity (anemia, fever, high thyroid, etc), stenoic mitral valve heart block decreased s1 sounds increased fat or fluid, systemic or pulmonary HTN (more forceful atrial contraction) fibrosis and calcification of diseased mitral valve splitting when mitral and tricuspid or pulmonic and aortic valves don't close simultaneously. split s1 RARELY heard. S2 common: A2 and P2--this is an expected event because depolarization earlier on left side how to hear s3 and s4 often are quiet, can ask pt to raise a leg (increased venous return) or squeeze hand over and over (increased arterial pressure). When s3 is easy te hear and intense sounds like a gallop. GRADED A++++++++++ Best position for s3 left lateral decubitus position, s4 common in elderly because increased ventricular resistance to filling d/t loss of compliance. Use bell @ apex in supine or left lateral recumbent- pericardial friction rub sounds like cardiac-generated sounds like a machine. d/t roughened parietal and visceral surfaces SAFER Approach Syndromic features age (murmurs in infants likely pathologic) family history eval of feeding and growth rheumatic fever FRAIL SCALE fatigue resistance ambulation illnesses loss of weight use to identify risk of frailty GRADED A++++++++++ bacterial endocarditis people with congential or acquired valve defects, prior endocarditis or use of IV drugs or susceptible subjective: fever, fatigue, sudden CHF objective: murmur, deuro dysfunction, janeway lesions (palms and soles red spots) osler nodes (tips of fingers or toes caused by septic emboli) left sided HF results in pulmonary congestion many causes can by syystolic (impaired LV contraction)or diastolic (stiff, inaility to fill) systolic HF narrow pulse pressure Diastolic HF wide pulse pressure right sided HF inability to propel blood forward so results in systemic congestion many causes GRADED A++++++++++ subjective: peripheral edema weight gain objective: pitting edema, JVD, ascites, hepatomegaly pericarditis often after viral infection or ca, HIV, hypothyroid, meds. may cause pericardial effusion and tamponade subjective: sharp/stabbing chest pain, worse with cough, swallow, deep breath or laying fltat mor severe pain with laying flat, relieved by sitting up and forward objective: friction rub, esp left of sternum in erd and 4th intercostal spaces cardiac tamponade excessive accumulation of effused fluids between pericardium and heart. can be d/t aortic dissection, trauma, pericarditis, malignancy. causes inability for cardiac relaxation soe blood can't return to right heart subjective: anxiety, restless, c/p, dyspnea, snycope, pale/gray/blue skin, palpitations, swelling of abdomen or arms objective: beck triad (JVD, hypotension, muffled heart sounds) Beck triad hypotension, distended neck veins, distant heart sounds cardiac tamponade cor pulmonale enlargement of right ventricle d/t lung disease. usually chronic. but can be caused by ARDS or massive PE GRADED A++++++++++ in COPD or chronic cor pulmonale: gradual hypertrophy of right ventricle until HF d/t COPD and PAH subjective: fatigue, tachypnea, exertional dyspnea, cough, hemoptysisi, lightheadedness, syncope objective: pulm. disease, wheezes/crackles, increased chest diameter, cyanosis, L2 louder in pulmonic region, BLE edema, disteded neck veins, s/s rt HF and hypertrophy MI usually in left ventricle. d/t atherosclerosis of coronary vessels that rupture or clot. subjective: deep or visceral pain, may be mild esp in old or dbtc pts, nausea, fatigue, dyspnea objective: s4 present, dysrhythmias common, distand heart sounds, apical murmur, thready pulse, pulse pressure varying, new ST elevation in 2 leads myocarditis focal or diffuse inflammation of the myocardium vague symptoms but common after 1-2 weeks of flu-like syndrome sick sinus syndrome due to malfunction of sinus node. d/t HTN, idiopathic, arteriosclerotic heart disease. causes fainting, transient dizzy or light-headedness, szr, palpitations, angine objective: dysrhythmias, s/s CHF atherosclerotic heart disease d/t deposition of cholesterol, leads to thick heart walls and narrowing lumen. GRADED A++++++++++ Senile cardiac amyloidosis amyloid, fibrillary protein produced by chronic inflammation or neoplastic disease, deposition in the heart pulmonary system routes through lungs: venous blood-- right superior and inferior vena cava--right atrium--tricuspid valve--right ventricle--pulmonic valve--pulmonary artery, arterioles and calpilaries til alveoli--O2 O2 O2!--pulmonary vein- left atrium--mitral valve--left ventricle--aortic valve--aorta- system--LOSS OF O2 IN TISSUES-- back up to inf/sup vena cave Jugular veins empty directly into superior vena cava and reflects the right side of heart activity. pulse amplitude scale 0= absent 1+= weak 2+= normal 3+= Increased 4+= bounding giant cell arteritis (temporal arteritis) inflammatory disease, often unknown etiology. causes arterial wall thickening and thrombosis- dec. blood supply of structures like masseter muscle, tonue or optic nerve. s/s: age 50, flu like s/s, HA in temporal region, ocular symptoms, tongue pain GRADED A++++++++++ objective: area of temporal artery red, swollen, tender, temporal pulse weak, strong or absent arterial aneurysm d/t weak arterial wall usually asymptomatic dil ruptur, dissect, etc. objective: thrill or bruit AV fistula congenital or acquired communication between an artery and a vein. often LE edema, varicose veins and claudication objective: edema, bruit or thrill PAD stenosis of blood supply d/t atherosclerosis risk factors: dbts, htn, dyslipidemia, tobacco, trauma, radiation subj: pain after exercise that disappears with rest objective: claudication: limb appears healthy but weak or absent pulse may have severe ischemia--pain at rest, cold, numb, skin changes Ulceration is common Raynaud's phenomenon spasm of digital arterioles d/t cold GRADED A++++++++++ arterial embolic disease emboli in arterial system d/t thrombus, tathero. plaques, atrial myxomas most common s/s is pain and numbnesj migraine headache headache which is usually (but not always) on one side of the head. It is a headache that lasts from two to seventy-two hours, typically, and it is often associated with nausea and/or vomiting, sensitivity to light and/or sound. The character of the pain is typically a throbbing pain. tension headache "hatband" headaches because they typically painful around the back of the head, the temples and forehead, as if a tight hat were in place. They tend to be pressure-like at onset and can last from hours to days. hypnic headache occurs exclusively at night, typically lasting between 15 and 60 minute cluster headache excruciating stabbing or burning sensations located in the eye or cheek lasting usually between 20 minutes and two hours. It is always one-sided and is associated with symptoms such as a stuffy nose on one side, tearing, an enlarged pupil, or a droopy lid. PERRLA stands for pupils equal, round, reactive to light and accomodation GRADED A++++++++++ near vision test patient holds card 14 inches from the eye and reads the chart - with glasses on. This test is for patients with poor eye sight. Test results should read "14/14" (Jaeger card is used) far vision test 20 feet with Snellen chart Opthalmascope use keep light to brightest and Whitest (ignore colors) and circular (not the slits) look for red reflex, optic disc and macula strabismus crossed eyes (stroke, head injury, graves disease) Psuedostrabismus Appearance of strabismus caused by epicanthal folds normal in babies cobblestoning a lumpy appearance of the pharynx typically self-limiting if due to a viral cause GRADED A++++++++++ Weber test hearing test using a tuning fork; distinguishes between conductive and sensorineural hearing loss Normal hearing will produce equal sound in both ears. Conductive loss will cause the sound to be heard best in the abnormal ear. Sensorineural loss will cause the sound to be heard best in the normal ear. Rhine test Normal hearing will show an air conduction time that is twice as long as the bone conduction time. In other words, you will hear the sound next to your ear twice as long as you will hear the sound behind your ear. If you have conductive hearing loss, the bone conduction is heard longer than the air conduction sound. If you have sensorineural hearing loss, air conduction is heard longer than bone conduction, but may not be twice as long. tonsil grading 1+ visible 2+ halfway between tonsillar pillars and uvula 3+ touching the uvula 4+ touching each other TM rupture symp: hearing loss, tinnitus, pain, dizziness, otorhea GRADED A++++++++++ tx: most heal on own. 5% require aids symptoms of obstruction below glottis a cough, stridor or noisy breathing, difficulty breathing, and respiratory distress. symptoms of obstruction above glottis noisy breathing, recurrent croup, polyps ear exam 3+ adult auricle UP/back peds auricle DOWN/back Tympanic membrane: translucent, shiny, light gray, taut, say "ah"=intact/vibrates Hearing: whisper, Weber (bone conduction=top of head), Rinne (sound conduction=mastoid bone) Geriatrics: ear lobes pendulous, presbycusis at 50, slowly progressive Cataract: Risk factors/Causes Age: 50% of those over 65 have one, nearly 100% over 70 Trauma Heredity UV Light Long-term use of corticosteroids (Crohn's Disease - prednisone) Diabetes---get them at younger age Smoking GRADED A++++++++++ hypertensive retinopathy with macular star Punctate exudates are readily visible: some are scattered; others radiate from the fovea to form a macular star. Find the flame-shaped hemorrhages nasal findings in allergic rhinitis pale, boggy, blue-gray mucosa is typical for allergic rhinitis, Thin watery secretions nasal findings drug use deviation or septal perforation nasal findings infection erythematous with purulent secretions diaphragmatic excursion 3-5 cm, but can be increased in well-conditioned persons to 7-8 cm. This measures the contraction of the diaphragm. It is performed by asking the patient to exhale and hold it. diaphragmatic excursion--abnormal Is 4-6 centimeters between full inspiration and full expiration. May be abnormal with hyperinflation, atelectasis, the presence of a pleural effusion, diaphragmatic paralysis, or at times with intra-abdominal pathology. GRADED A++++++++++ respiratory to heart rate ratio 1:4 thorax percussion sites sequence of examination Head-to-toe sequence for assessing adult clients IPPA Sequence for pediatric assessments generally altered to accommodate child's developmental needs Use chronological age as the main criteria tactile fremitus a tremulous vibration of the chest wall during speaking that is palpable on physical examination tactile fremitus findings An increase in tactile fremitus indicates denser or inflamed lung tissue, which can be caused by diseases such as pneumonia. A decrease suggests air or fluid in the pleural spaces or a decrease in lung tissue density, which can be caused by diseases such as chronic obstructive pulmonary disease or asthma. Bronchophony Ask the patient to say "99" in a normal voice. Listen to the chest with a stethoscope. The expected finding is that the words will be indistinct. Bronchophony is present if sounds can be heard clearly. GRADED A++++++++++ pectoriloquy a striking transmission of voice sounds through the pulmonary structures, so that they are clearly audible through the stethoscope; commonly occurs from lung consolidation egophony While listening to the chest with a stethoscope, ask the patient to say the vowel "e". Over normal lung tissues, the same "e" (as in "beet") will be heard. If the lung tissue is consolidated, the "e" sound will change to a nasal "a" (as in "say"). whispered voice test Test one ear at a time while masking hearing in the other ear. Head should be 30-60cm from the person's ear, exhale and whisper slowly a set of 3 random numbers and letters, such as "5, B, 6". Normally person repeats correctly after you say it. -nonquantitative; this test documents the presence of hearing loss but does not measure the degree of loss. Use of stethoscope *Always directly place on skin* Bell best for low pitched sounds (vascular & some heart sounds) Diaphragm best for high pitched sounds (bowel and some abnormal lung sounds) Point of maximal impulse (PMI) the point where the apex of the heart touches the anterior chest wall and heart movements are most easily observed and palpated PMI lateral to the midclavicular line or below the sixth intercostal space suggests GRADED A++++++++++ left ventricular enlargement. If the PMI is greater than 2 cm in size there is likely left ventricular hypertrophy or dilation PMI downward and to the right COPD. usually in gastric area. if COPD pt has a PMI where it should be then often d/t cardiomegaly heave indicates right ventricular hypertrophy thrill indicates murmur jugular vein distention A visual bulging of the jugular veins in the neck that can be caused by fluid overload, pressure in the chest, cardiac tamponade, or tension pneumothorax. aortic stenosis murmur second right intercostal, crescendo-decrescendo Aortic regurgitation murmur High-pitched "blowing" early diastolic decrescendo murmur GRADED A++++++++++ Pulmonic stenosis murmur loud, harsh systolic murmur +/- thrill at ULSB which radiates to L shoulder Mitral stenosis murmur Diastolic RUMBLE with opening snap. LOW frequency= Rumble Grading murmurs -Grade 1: barely audible -Grade 2: clearly audible, but faint -Grade 3: moderately loud, easy to hear -Grade 4: loud, associated with palpable thrill -Grade 5: very loud, associated thrill -Grade 6: loudest, associated thrill mitral valve murmurs Heard best at apex; Accentuated in left lateral decubitus position. Normal JVP measurement determined as the vertical distance above the midpoint of the right atrium, is 6 to 8 cm H2O bruit blowing, swooshing sound heard through a stethoscope when an artery is partially occluded GRADED A++++++++++ PVD vs PAD There are subtle differences between the terms, PAD and PVD. Peripheral Arterial Disease (PAD) afflicts the arteries alone while Peripheral Vascular Disease (PVD) is a broader term which includes any blood vessel including, veins and lymphatic vessels Tetrology of Fallot DROP (Defect, septal, Right ventricular hypertrophy, Overriding aortas, Pulmonary stenosis) Venous hum in children -benign murmur in children -soft, hollow, continuous sound -louder in diastole -location: just below the right clavicle -murmur is eliminated by maneuvers that lower venous return (e.g. lying supine) -may be mistaken for breath sounds breast lump - Young = USG; mammogram less sensitive in younger than 35 year old - Core Needle biopsy - OCPs reduce breast cysts Risk factors for breast cancer -Related to estrogen exposure 1. Female gender 2. Age- cancer usually arises in postemenopausal women, with exception of hereditary breast cancer GRADED A++++++++++ 3. Early menarche/late menopause 4. Obesity (androgen -- estrone) 5. Atypical hyperplasia (5x increased risk factor) 6. First degree relative with breast cancer fibrocystic changes 20-49, bilateral, 1+, round, soft to firm, mobile, no retraction,+tenderness, +variation with menses breast examination visual inspection and manual examination of the breast for changes in contour, symmetry, dimpling of skin, retraction of the nipple, and the presence of lumps. If substantial breast tissue reinspeact with arms extended overhead anor flexed behind neck, hands pressed on hips with shoulderts forward, seated and leaning forward, recumbent. Perform a chest wall sweep and bimanual digital palpation sequence of breast exam -inspection (both sitting and supine) -palpation (while supine) Breast cancer screening 1. Age 20 -- self breast exams 2. Age 20 - 39 -- breast exam every 3 years 3. Age 40 -- breast exam annually GRADED A++++++++++ 4. Age 50-79 -- mammogram every other year Gynecomastia causes hyerthyroidism, test. ca, hyperestrogenism (cirrhosis, testicular tumor, puberty, old age) Klinefelter syndrome drugs (spinonolactone, digoxin, cimetidine, alcohol, ketoconazole, omeprazole) prostate ca treatmetn breast changes during pregnancy lactiferous ducts increase, alveoli increase in size and number so breasts enlarge. montgomery tuburcles develope. vertical strip pattern best way to detect a breast mass fibroadenoma 15-55, usually bilateral, usually single round or discoid, firm or rubbery, mobile, no retration, nontender, no variation with menses breast cancer age 30-80, usually unilateral, usually single. usually hard, ierregular, stelate or stonelike, fixed, often retraction, often nontender, borders poorly delineated and irregular GRADED A++++++++++ sequence of GI physical exam Inspect, auscultate, percuss, palpate Colon Cancer risk factors family, age over 50, IBS, af am., jews, diet, obesity, high red meat and processed meat diet, smoke, alcohol, t2DM paralytic ileus complete absence of peristaltic movement that may follow abdominal surgery or complete bowel obstruction. Often also due to narcotics, hypothyroidism, hypokalemia 9 regions of the abdomen right hypochondriac, epigastric, left hypochondriac, right lumbar, umbilical, left lumbar, right iliac, hypogastric, left iliac Peristalsis Involuntary waves of muscle contraction that keep food moving along in one direction through the digestive system. bowel sounds ususally 5-35/minute increased bowel sounds gastroenteritis, early GI obstruction, hunger high pitched tinkling sounds GRADED A++++++++++ suggest fluid and air under tension in a dilated bowel. Rushes of high pitched sounds coinciding with abdominal cramps suggest intestinal obstruction. decreased bowel sounds peritonitis and paralytic ileus absent bowel sounds occur if no sounds after 5 minutes of listending. SURGICAL EMERGENCY Friction Rubs over the Liver and Spleen DIAPHRAGM PT TAKES 3 DEEP BREATHS Liver: midclavicular bw 6th and 10th ICS on right Spleen: midaxillary bw 6th and 10th ICS on left State: If present, it will produce a sandpaper rubbing sound. Indicates inflammation of peritoneal surface of an organ from infection or tumors listening for bruits in abdomen listen over epigastric, aortic, renal and iliac arteries. use the bell. also listen for venous hum (in kids, collateral circ between portal and systemic venous systems) Percussion of abdomen - percuss lightly on all 4 quadrants - tympany should dominate b/c air rises to GI surface when pt is supine *dullness occurs over a distended bladder, adipose tissue, fluid, or a mass GRADED A++++++++++ *hyperresonance is present with gaseous distention Liver: bottom edge dull, around costal margin. then go up to where tympany is noted in intercostal space and work way down until percussion tone changes to dullness Typical liver span is 6-12 cm moderate abdominal palpation used to assess liver/spleen they move during respiration. push down and when patient breaths in they bump against hand deep palpation changes for obese patients bimanual. one hand on top of the other gallbladder palpation Positive increased pain and reflex apnea (place hand during deep palpation below liver margin, have patient take a deep breath, as inflammed gallblader comes into contact with fingers that patient will experience pain and halt breathing (Murphy's sign) Indicates cholecystitis If nontender but enlarged--bile duct obstruction fluid wave test this test for ascites GRADED A++++++++++ by standing on the right side of the person-place the ulnar edge of another person's hand or patient's hand firmly in the middle of the abdomen-place your hands on the patient's right and left flank-give left flank a firm strike if ascites is present= a wave will generate through abdomen & you will feel a distant tap on your left hand a positive test occurs with large amounts of ascitic fluid if distention is due to gas or adipose tissue=no change Apley rule The further the localization of pain from the umbilicus, the more likely it is that there is an underlying organic disorder. Appendicitis S/S starts as periumbilical/epigastric and collicky, later becomes RLQ pain, low grade fever, nausea, rebound tenderness at McBurney's point. Peritonitis s/s: onset sudden/gradual; pain general or local, dull or severe, unrelenting; guarding; pain on deep instpiration +blumberg, markle and ballance. n/v, obturator + iliopsoas signs Blumberg's sign The experience of sharp, stabbing pain as the compressed area returns to a noncompressed state Markle sign GRADED A++++++++++ pain elicited in a certain area of the abdomen when the standing patient drops from standing on toes to the heels with a jarring landing Ballance's sign constant dullness to percussion in the left flank/LUQ and resonance to percussion in the right flank seen with splenic rupture/hematoma Obturator sign RLQ on internal rotation of right thigh indicative of appendicitis Iliopsoas sign Hyperextension of the right hip causes abdominal pain due to appendicitis. appendicitis s/s guarding, tender, +ilipsoas, obturator, markle, mcburney cholecystitis pain Abrupt severe abdominal pain. RUQ or epigastric may refer to rt subscapular area cholecystitis s/s -RUQ pain & referred to right shoulder -Murphy's sign -low-grade fever & chills -N/V GRADED A++++++++++ -anorexia -poss. jaundice pancreatitis pain dramaitc sudden excruciating LQU, epigastric or umbilical pain. may refer to shoulder and back pancreatitis s/s epigastric tenderness, vomiting, fever, shock + grey turner sign, +cullen, both occur 2-3 days post-onset Grey turner sign and Cullen sign -Presence of bluish discoloration of the lower abdominal flanks -Or around the umbilical area -Indicates hemorrhagic pancreatitis and an accumulation of blood in these areas -Rare and don't appear till 48 hours after onset of symptoms salpingitis Lower quadrant pain, worse on left s/s salpingitis n/v/fever/suprapubic tenderness, rigid abdomen, pain on pelvic exam PID GRADED A++++++++++ lower quadrant pain inc. with activity PID s/s tender adnexa and cervix, cervical d/c, dyspareunia diverticulitis epigastric, radiating down left side after eating diverticulitis s/s fars, borborgymus, diarrhea, dysuria, tenderness on palp. perforated ulcer ABRUPT RUQ pain radiating to shoulders perforated ulcer s/s abd. free air, distension, resonance over liver, tender epigastric and RUQ, rigid abd. wall and rebound tenderness intestinal obstruction pain abrupt, severe, colicky spasmodic, referred to epigastrium, umbilicus intestinal obstruction s/s GRADED A++++++++++ high pitched bowel sounds before obstruction and absent sounds after, pain and distention, N/V, minimal rebound tenderness, vomiting, visible peristalsis, bowel sounds absent or hyperactive leaking abdominal aneurysm: usual pain characteristics, possible assoc signs and symptoms steady, throbbing midline pain penetrating to back and flank. n/v/abd. mass and bruit biliary stones pain episodic, severe RUQ or epigastric 15min+. biliary stones s/s RUQ tenderness, jaundice, soft abd. wall, anorexia, vomiting renal calculi pain In the flank and radiates to the groin, intense renal calculi s/s fevar, +kehr sign, hematuria ectopic pregnancy pain lower quadrant, ruptur is agonizing. s/s pregnancy, +kehr and cullen ruptured ovarian cyst GRADED A++++++++++ low quad. steady, worse with cough or motion. tender pelvic exam splenic rupture intense, LUQ, radiating to left shoulder, may worsen with foot of bed elevated cushing disease GI symptoms GI findings liver cirrhosis most commonly caused by alcohol and hep C. jaundice, anorexia, abdominal pain, clay colored stools, tea colored urine, fatigue. prominent abdominal vasculature, cutaneous spider angiomas, hematemesis and abdominal fullness. GI findings diastasis recti seperation 1-4 cm wide in midline. usually no repair needed. needs surgery if peristalsis is noted. Tests for appendicitis McBurney's point tenderness, Psoa's sign Obturators, Rovsing's Rovsing's sign Pain in RLQ with palpation of LLQ indicative of appendicitis CVA tenderness GRADED A++++++++++ Costo-vertebral Angle tenderness; tenderness over the kidney's pyelonephritis Meckel's diverticulum Abdominal pain, Mucus, bloody stools OB history (GTPAL) G - gravity (# of pregnancies) T - term (born 37 weeks) P - Preterm (born 37 weeks) AB - abortions/miscarriages L - # of children living what is menopause? during 40s menstrual periods cease. definition is 1 year without menses. estrogen decreases- labia and clitoris smaller, adrenal androgens and ovarian testosterone decrease--?dec libido and muscle mass and strength menstrual cycle days 1-4 estrogen begins rising preparing next follicle, progesterone causes vasoconstriction and upper endometrium shedding. FSH and LH decrease. menstrual bleeding. menstural cycle days 5-12 (preovulatory) ovary and maturing follicle produce estrogen (follicular phase) in uterus lining thickens (proliferative phase). FSH --ovarian follicular growth GRADED A++++++++++ ovulation day 13-14 egg expelled and drawn into fallopian tube. follicle closes and forms corpus letum. uterus--progesterone thickens the wall LH and estrogen rise rapidly, LH causes egg release Secretory phase (15-20) egg moved into uterus by cilia. follicle--corpus luteum--secretes progesterone which dominates premenstrual luteal phase days 21-28 if no implantation corpus letum degenerates, prog. dec., est. dec and then rises again as new follicle develops. uterus--menstruation around day 28 GnRH increased due to inc. FSH. specimen collections for pap test, vaginal discharge specimen collection risk factors for cervical cancer HPV, high parity, young parity, cigarette, chlamydia, diet, DES oral contraceptives risk factors for ovarian cancer GRADED A++++++++++ BRCA1 or BRCA2, family hx, obesity, nulliparity or parity after age 35, fertility drugs, HRT, testosterone or birth controll, high fat diets Pelvic Exam Labs Wet Prep - Vaginal Wet Mount GC - Gonococcus CT - Chlamydia Trachomatis Genital Cx - Genital Culture pelvic examp tips empty bladder first, patient privacy. lithotomy position, drop open knees. exam, hair distribution, mons, labi majora (gaping or closed, dry or moist, shriveled or full), labia minora, clitoris, urethral orifice, vaginal introitus, perineum. assess for discoloration, tenderness, ulcers or vsicles, irritation, excoriation and discharge The Skene and Bartholin glands: A) produce the hormones that trigger menstruation. B) are responsible for proper adhesion of a fertilized egg to the uterine wall. C) regulate the vascular structures of the endometrium. D) provide lubrication during sexual stimulation. urethral caruncle fleshy red lesion @ urethral meatus internal pelvic exam GRADED A++++++++++ - index & 3rd finger into vag, press down gently visualizing vag orifice -- have Pt cough or bear down to assess for prolapsed pelvic organ Speculum Examination of internal genitalia select the appropriate size speculum. hold with index finger over top of proximal end of anterior blade and other fingers around the handle. insert at downward or oblique angle (path of least resistance), sweep slowly up until cervix comes into view. reposition if needed to locate cervix, adjust light source. manipulate to fully expose the cervix between top and bottom blades and lock blades into place what to look for in pelvic exam -inspect cervix and its Os -obtain cervical smears and cultures -inspect vaginal wall -bimanual examination while still open with speculum cervix assess color, position, size, surface characteristics, discharge, size and shape of os. should be pink. if blue means pregnancy. pale anemia, redness around os is abnormal (for new practitioner) position: should be midline smooth Nabothian cysts benign cysts located within the cervix GRADED A++++++++++ cervical polyps benign lesions attached to the cervix withdrawal of speculum unlock and remove it slowly and carefully so vaginal walls can be inspected Bimanual Examination: Uterus Assess with intravaginal fingers in anterior fornix -Determine position, or version, of uterus -In many women, uterus is anteverted; you palpate it at level of pubis with cervix pointing posteriorly -Two other positions occur normally: midposition and retroverted Palpate uterine wall with your fingers in fornices -Bounce uterus gently between your abdominal and intravaginal hands -Normally, it feels firm and smooth, with contour of fundus rounded; it softens during pregnancy; it should be freely movable and nontender When to get vaginal smear? after cervix and surrounding tissues have been inspected. collect sample from ectocervix with a spatula. longer projection into os, rotate 360 degrees keeping it flush agains the cervical tissue. withdraw and spread specimen on glass slide. spray with cytologic fixative and label as ectocervical. then use brush devce to insert into os until bristles closest to handle are exposed. rotate 1/2 turn, remove and prepare smear by rolling/testing with mod pressure. fix with spray and label endocervical specimen. OR can us broom device for both. GRADED A++++++++++ Liquid based pap test use broom and insert genral bristles into os til lateral bristles bend against ectocervix. rotate brush 3-5 times left and right, withdraw brush (can use this for pap smear too). For liquid based rinse brush in the solution by swirling, deposit broom end directly into collection vial. gonococcal culture specimen AFTER pap use sterile cotton swab into os, hold in place 10-30 seconds, withdraw and draw Z into culture medium. DNA testing for wome matches DNA or RNA of target tissue. swab, rotate 30 seconds, avoid vaginal mucous membranes, place in tube with specimen reagent. (can use fo gonorrhea and chlamydia wet mount and KOH procedures used for vaginal discharge. presence of trich or bact. vaginosis or candidiasis. smear a sample on glas slide, add a drop of normal saline and view under microscope. If t. vaginalis- trichomonads. If clue cells (bacteria filled epithelial cells)--vaginosis. on speerate glass slide place specimen of discharge, apply a drop of 10%KOH and place cover. if fishy odor--BV. KOH dissolves ep. cells, debris and if mycelia presents or yeast cells--candidiasis KOH of candidiasis budding yeast and pseudohyphae Trichomonads characteristics Clue cells GRADED A++++++++++ bacterial vaginosis recommendations for first pelvic exam sexually active or 21 whichever comes first position of fetus leupod maneuver--hands over fundus to identify a part. palm on back other hand to feel for hands and feet, use hands to feel what is presenting part over symphysis pubis, hands to ouline head Trichomonas symptoms in women vaginal discharge, which can be white, gray, yellow, or green, and usually frothy with an unpleasant smell. vaginal spotting or bleeding. genital burning or itching. genital redness or swelling. frequent urge to urinate. pain during urination or sexual intercourse. gonorrhea symptoms women-greenish-yellow discharge from the cervix of the uterus or discomfort wile urinating, fever, lower abdominal cramping, pain, vaginal bleeding men- inflammation of the urethra and the sides around the opening of the urethra, yellowish white or yellowish-green discharge from the penis, burning while urination risk factors for testicular cancer GRADED A++++++++++ family history of testicular cancer, undescended testicle and cancer of the other testicle 20-34 years, which more gommon than black and asians and natives, androgen suppression (decreases risk in trans women) inguinal hernia exam with patient standing ask to bear down as if having a BM, inspect area of inguinal canal and fossa ovalis. have patient relax, insert exam finger into lower part of scrutum and cary it upwards alon the vas deferens into the inguinal canal. if uncomplicated reducible hernias can auscultate for bowel sounds. will feel bulge against finger. Indirect if it lies within the inguinal canale. usually appens bilaterally. if medial to external canal is direct inguinal hern