NUR3065 Comprehensive Nursing Exam Study Guide 2025 – Abdomen, Reproductive, Musculoskeletal & Neurological Systems

NUR3065 Exam #3 – Study Guide I. Abdomen and Gastrointestinal System Assessment Sequence- Inspection → Auscultation → Percussion → Palpation (avoid altering bowel sounds) Organs Found in Each Quadrant (figure 16-3): RUQ- Liver, gallbladder, right kidney, duodenum, ascending/transverse colon. Pain: Gallstones (Murphy’s sign positive—pain with inspiration during RUQ palpation). LUQ- Stomach, spleen, pancreas tail, left kidney. Pain: Pancreatitis—radiates to back, worse after fatty meals. RLQ- Appendix, cecum, right ovary/tube. Pain: Appendicitis (starts periumbilical → localizes to RLQ). LLQ- Sigmoid & descending colon left ovary/tube Pain: Diverticulitis—crampy LLQ pain, fever, leukocytosis. Abdominal Pain Types (pg. 504-506) Type Description Examples Visceral Dull, crampy, poorly localized. From organ distention or w abdominal organs such as the intestine or biliary tree contract unusually forcefully or are distended or stretched. Early appendicitis, cholecystitis, bowel obstruction.May be difficult to localize. It is typically palpable near the midline at levels that vary according to the structure involved, as illustrated in Figure 16-5. Visceral pain varies in quality and may be gnawing, burning, cramping, or aching. When it becomes severe, it may be associated with sweating, pallor, nausea, vomiting, and restlessnes Parietal Sharp, localized, aggravated by movement.It is a steady, aching pain that is usually more severe than visceral pain and more precisely localized over the involved structure. It is typically aggravated by movement or coughing Late appendicitis, peritonitis. riginates from inflammation in the parietal peritoneum Referred Felt in area distant from origin due to shared felt in more distant sites, which are innervated at approximately the same spinal levels as the inflamed structures. Referred pain often develops as the initial pain becomes more intense and thus seems to radiate or travel from the initial site. It may be palpated superficially or deeply but is usually well localized. Pain may also be referred to the abdomen from the chest, spine, or pelvis, and complicate the assessment of abdominal pain. Gallbladder → right shoulder (Kehr’s sign); Pancreas → back; MI → epigastrium. Common GI Disorders Disorder Key Findings Diagnostic Signs Appendicitis ( about 6 questions) The pain of appendicitis classically begins near the umbilicus, then migrates to the RLQ. Older adults are less likely to report this pattern. McBurney’s Point-lies 2 in from the anterior superior spinous process of ilium on a line drawn from that process to the umbilicus Psoas sign- Place your hand just above the patient’s right knee and ask the patient to raise that thigh against your hand. Alternatively, ask the patient to turn onto the left side. Then extend the patient’s right leg at the hip. Flexion of the leg at the hip makes the psoas muscle contract; extension stretches it. Increased abdominal pain on either maneuver is a positive psoas sign, suggesting irritation of the psoas muscle by an inflamed appendix. Rosving’s sign- Press deeply and evenly in the left lower quadrant. Then quickly withdraw your fingers. Pain in the RLQ during left-sided pressure is a positive Rovsing sign. Pain in the RLQ when pressure is released from the LLQ is referred rebound tenderness. Obturator sign-(though this sign has very low sensitivity). Flex the patient’s right thigh at the hip with the knee bent and rotate the leg internally at the hip. This maneuver stretches the internal obturator muscle. Right hypogastric pain is a positive obturator sign, suggesting irritation of the obturator muscle by an inflamed appendix. Diverticulitis LLQ pain, especially with a palpable mass, signals iffuse abdominal pain with abdominal distention, hyperactive high-pitched bowel sounds, and tenderness on palpation may indicate small or large bowel obstruction. Pain with absent bowel sounds, rigidity, percussion tenderness, and guarding points to peritonitis. Triggers: often a change in bowel habits, weight loss Often no other symptoms Often no other symptoms unless inflammation causes Pancreatitis Epigastyric pain Doubling over with cramping, colicky pain may signal a renal stone. Sudden knife-like epigastric pain Cholecystitis RUQ pain inflammation of the gallbladder, assess Murphy sign Murphey’s sign-A sharp increase in tenderness with inspiratory effort is a positive Murphy sign. When ook your left thumb or the fingers of your right hand under the costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin. Alternatively, palpate the RUQ with the fingers of your right hand near the costal margin. If the liver is enlarged, hook your thumb or fingers under the liver edge at a comparable point below. Ask the patient to take a deep breath, which forces the liver and gall bladder down toward the examining fingers. Watch the patient’s breathing and note the degree of tenderness. positive, Murphy sign triples the likelihood of acute cholecystitis Irritable Bowel Syndrome termittent pain for 12 weeks of the preceding 12 months with relief from defecation, change in frequency of bowel movements, or change in form of stool (loose, watery, pellet-like) without structural or biochemical abnormalities are symptoms Some patients may complain of passing excessive gas, or flatus, normally about 600 mL per day Functional change in frequency or form of bowel movement without known pathology; possibly from change in intestinal bacteria Three patterns: diarrhea-predominant, constipation-predominant, or mixed. Symptoms present 6 mo or longer and abdominal pain for 3 mo or longer plus at least two of three features (improvement with defecation; onset with change in stool frequency; onset with change in stool form and appearance) Ascites Shifting dullness,-Percuss the border of tympany and dullness with the patient supine, then ask the patient to roll onto one side . Percuss and mark the borders again. In a person without ascites, the borders between tympany and dullness usually stay relatively constant. positive fluid wave-Ask the patient or an assistant to press the edges of both hands firmly down the midline of the abdomen. This pressure helps stop the transmission of a wave through fat. While you tap one flank sharply with your fingertips, feel on the opposite flank for an impulse transmitted through the fluid, as shown in Figure 16-28. Unfortunately, this sign is often negative until ascites is obvious, and it is sometimes positive in people without ascites. In ascites, dullness shifts to the more dependent side, whereas tympany shifts to the top. is the accumulation of fluid in the peritoneal cavity, causing abdominal be due to protein deficiency liver disease and low albumin. fluid characteristically sinks with gravity, whereas gas-filled loops of bowel rise, dullness appears in the dependent areas of the abdomen. Percuss for dullness outward in several directions from the central area of tympany. Map the border between tympany and dullness Ascites can be a clue to increased hydrostatic pressure in cirrhosis (most common), heart failure, constrictive pericarditis, or inferior vena cava or hepatic vein obstruction. This may be from decreased osmotic pressure in nephrotic syndrome, malnutrition, or ovarian cancer. Hepatitis (pg.558-560) Type Method of transmission A ingestion of contaminated water or food B parenteral or mucous membrane exposure to infectious body fluids such as blood, serum, semen, and vaginal fluid, especially through sexual contact with an infected partner or use of shared needles for injection drug use C sharing of needles of infected persons or tainted blood transfusions ● Palpation of the liver (pg.540-544) ● Palpation and percussion of the spleen (pg.545-548) Sound Description Normal Location Abnormal / Clinical Meaning Tympany High-pitched, drumlike; from air-filled areas Over stomach & intestines ↑ Tympany = gas, distention; hyperresonance may indicate bowel obstruction. Dullness Thud-like; from solid or fluid-filled organs Over liver, spleen, distended bladder Widespread dullness → ascites or enlarged organs. Flatness Very short, soft tone Over bone or muscle Normal over ribs. Shift in Dullness Dullness moves when patient turns — Indicates free fluid in peritoneum (ascites). Costoverbral angle Formed by the lower border of the 12th rib and the transverse processes of the upper lumbar vertebrae II. Breast Assessment Examination and Findings ● Positions for inspection AND CLINCAL DEATURES ELICTED:nspect the breasts and nipples with the patient in the sitting position, disrobed to the waist. A thorough examination of the breast includes careful inspection for skin changes, symmetry, contours, and retraction in four views —arms at the sides, arms over the head, arms pressed against the hips, and leaning forward. ○ Arms at the Sides ○ Redness in a light complexion or deeper pigmentation in a dark skin woman may be from local infection or inflammatory carcinoma. ○ The appearance of the skin, including: • Color • Thickening of the skin and unusually prominent pores, which may accompany lymphatic obstruction ○ Thickening and prominent pores suggest breast cancer. ○ The size and symmetry of the breasts. Some difference in the size of the breasts, including the areolae, is common and is usually normal, as shown in Figure 17-6. ○ FIGURE 17-6 Some asymmetry between the sizes of the breasts and areolae is common. ○ The contour of the breasts. Look for changes such as masses, dimpling, or flattening. Compare one side with the other. ○ Flattening of the normally convex breast suggests cancer. See Table 17-2, “Visible Signs of Breast Cancer.” ○ The characteristics of the nipples, including: • Size and shape • Direction in which they point • Any rashes or ulceration • Any discharge ○ Asymmetry of directions in which nipples point suggests an underlying cancer. Rashes or ulceration may indicate Paget disease of the breast (Lakhera et al., 2020) (see Table 17-2). ○ Occasionally, the shape of the nipple is inverted, or depressed below the areolar surface (Fig. 17-7). It may be enveloped by folds of areolar skin, as illustrated. Longstanding inversion is usually a normal variant of no clinical consequence, except for possible difficulty when breast-feeding. ○ FIGURE 17-7 An inverted nipple. ○ Recent or fixed flattening or depression of the nipple suggests nipple retraction. A retracted nipple may also be broadened and thickened, suggesting an underlying cancer. ○ Arms Over the Head; Hands Pressed against the Hips; Leaning Forward ○ To bring out dimpling or retraction that may otherwise be invisible, ask the patient to raise the arms over the head (Fig. 17-8), and then press the hands against the hips to contract the pectoral muscles (Fig. 17-9). ○ Inspect the breast contours carefully in each position. If the breasts are large or pendulous, it may be useful to have the patient stand and lean forward, supported by the back of the chair. ○ FIGURE 17-8 The arms over the head for breast inspection. FIGURE 17-9 Hands pressed against the hips for breast inspection. FIGURE 17-10 Leaning forward for breast inspection. ○ ● Palpation pattern:Palpation is best performed when the breast tissue is flattened. The patient should be supine. Plan to palpate a rectangular area extending from the clavicle to the inframammary fold or lower bra line, and from the midsternal line to the posterior axillary line and well into the axilla for the tail of the breast. ● While lying supine, have the patient reach behind their head with their right hand when the right breast is examined. Placing the hand behind the head will displace the breast tissue for easier palpation. ● Use the finger pads of the second, third, and fourth fingers, keeping the fingers slightly flexed. ● The vertical stripe pattern is currently the best validated technique for detecting breast masses. It is important to be systematic. ● Palpate in small, dime-size, concentric circles at each examining point; if possible, apply light, medium, and deep pressure. You will need to press more firmly to reach the deeper tissues of a large breast. ● Continue in vertical overlapping strips until your examination covers the entire breast, including the periphery, tail, and axilla ● ● Lymph nodes to palpate and location: ● Mass characteristics: ○ Benign:Smooth, Soft or rubbery, Mobile, Well circumscribed, Tender with menses, Multiple sometimes ○ Malignant:Hard, Irregular borders, Fixed or less mobile, Nontender, Single, dominant, Associated findings: retraction, nipple changes, lymphadenopathy ● Red Flags for Malignancy:Dimpling, Retraction of nipple, Peau d’orange, Non-lactational discharge (bloody), Hard, fixed mass, Axillary lymphadenopathy, New inversion of nipple ● What are risk factors for breast cancer? · When to do (time) a self-breast examination? III. Male Reproductive System Common Scrotal and Testicular Disorders (Table 21-7, Table 21- 9) Condition Key Findings Diagnostic Clues Note s Hydrocele Non-tender, fluid filled mass within the tunica vaginalis, it transilliuminates The examining fingers can palpatae above the mass within the sctotum Varicocele Usually on the left , soft bag of worm above the testis it will collapses in the supine position so you must do this in supine and stadnign position if there is no collapse in supine suspect left spermatic vein obstruction within the abdomen Scrotal Hernia Inderirct inguina hernia that comes through the external iguninal ring Examining fingers cant get above it within the scrotum Torsion of Spermatic Cord Torsion or twisting of the testicle on its spermatic cord produces an acutley painful tender, and swollen organ that is often retracted upward in the scrotum. If the presentaion ide delayed the scrotum becoms red and edematious. NO ASSIACATED URINARY INFECTION, most common in nennates and adoleces SURGCIAL Epididymitis Inflamed, indudarte, swollen, and notably tender, making it difficult to distinguish form the testies. The scrotum may be rededned and the vas defences infamed causing infections like ginerha and clahamidhya Prostate Disorders Condition Symptoms Physical Exam Not es Benign Prostatic Hyperplasia (BPH) Urinary incontinenceOther signs include prostate enlargement, motor signs of peripheral nerve disease, a decrease in sensation Prostatitis Weak flow, difficulty starting or holding back urine, urination amount, aly blood in the urine or semes,ejuagtion pain Prostate Cancer age(65 and older rare before 40 and normal at 66) Ethnicity: african american men(2 times as likely to die) and african caribbean men Fmaly histort- fathers and brothers with prostate cancer doubles chances incomplete emptying of the bladder, urinary frequency or urgency, weak or intermittent stream or straining to initiate flow, hematuria, nocturia, or bony pains in the pelvi Prostate screening may be done with a prostate-specific antigen (PSA) blood test or a digital rectal examination (DRE) by an advanced practice health care provider. Both the PSA and DRE may yield false negatives or positives, potentially exposing the man to unnecessary further testing, surgery, or missed cancer diagnoses IV. Female Reproductive System Menstrual Definitions Box 21-2 (pgs. 784-786) Term Definition Menarche Onset of menses( monthly flow of bloody fluid from uterus) Menopause Absence of menses for 12 consecutive months, usually occurring between 48-55 years Perimenopause Periods of years marking the transition to menopause( hot flashes, flusisng, sweating , sleep disturbances) Postmenopausal bleeding Bleeding occurring 6 months or more after cessation Amenorrhea Absences of menses Dysmenorrhea Pain with menses Dyspareunia - After menopause pain with sex due to love levels of estrogens (mild hirititsum, hair loss) Menorrhagia Excessive flow Abnormal Uterine Bleeding Bleeding between menses or infrequent, excessive, prolonged, or postmenopausal bleeding Oligomenorrhea Infrequent bleeding Metrorrhagia Intermenstrula bleeding - Frequency: measured form the first day of one menses to the first day of the next menses. The interval between periods ranges roughly 3-7 Vaginal and Vulvar Disorders (Table 21-1 and Table 21-2) Condition Key Features Diagnostic Findings Candida Vaginitis Yeast infection, white and curdy,thick, itchy, fungal infection,(hyphaea), vulva is inflamed Bacterial Vaginosis Gray or white thin discharge, fishy smell, (clue cells) Trichomonas Vaginitis Yellow green or gray discharge, frothy appearance , (tricomonades) Genital Herpes Shallow, small, painful ulcers on red bases points Epidermoid Cyst A small, firm , round cystic nodule in the labia, yellowish in color, blocked openeing of the gland Venereal Wart (condyloma acuminatum) Warty lesions on the labia and withitn the vestibule are often condyloma acuminata from infection with human papillornavirus Syphilitic chancre Firm painless ulvcer form primary syphilis forms 21 days after exposure to reponerna pallidum( can go unected in vagina and heals 3-6 with/ wo treatment) Uterine Prolapse Utrues protrudes into the vagina Sexually Transmitted Infections of Male Genitalia (Table 21-6) Disorder Key Findings Diagnostic Clues Primary Syphilis Primary Syphilis ○ Appearance: Small red papule that becomes a chancre, or painless erosion up to 2 cm in diameter. Base of chancre is clean, red, smooth, and glistening: borders are raised and indurated. Chancre heals within 3-8 wk ○ Causative organism: Treponema pallidum, a spirochete ○ Incubation: 9-90 days after exposure ○ May develop inguinal lymphadenopathy within 7 days; lymph nodes are rubbery, nontender, mobile ○ 20-30% of patients develop secondary syphilis while chance still present (suggests confection with HIV) ○ Distinguish from genital herpes simplex; chancroid; granuloma inguinale from Klebsiella granulomatis (rare in the United States: four variants, so difficult to identify) Genital Herpes (HSV-2) ○ Appearance: Small scattered or grouped vesicles, 1-3 mm in size, on glans or shaft of penis. Appear as erosions if vesicular membrane breaks ○ Causative organism: Usually herpes simplex virus 2 (90%), a double-stranded DNA virus ○ Incubation: 2-7 days after exposure ○ Primary episode may be asymptomatic; recurrence usually less painful, of shorter duration ○ Associated with fever, malaise, headache, arthralgias; local pain and edema. lymphadenopathy ○ Need to distinguish from genital herpes zoster (usually in older patients with dermatomal distribution) and candidiasis Syphilitic Chancre- female This firm painless ulcer form primary syphilis form-21 days after exposure to trponerna pallidum- heals regardless of treatment in 3-6 wk Genital Warts Condylomata Acuminata (HPV) ○ Appearance: Single or multiple papules or plaques of variable shapes, may be round, acuminate (or pointed), or thin and slender. May be raised, fat, or cauliflower-like (verrucous) ○ Causative organism: Human papillomavirus (HPV), usually from subtypes 6, 11; carcinogenic subtypes rare, approximately 5-10% of all anogenital warts ○ Incubation: weeks to months; infected contact may have no visible warts ○ Can arise on penis, scrotum, groin, thighs, anus; usually asymptomatic, occasionally cause itching and pain ○ May disappear without treatment Chancroid ○ Appearance: Red papule or pustule initially, then forms a painful deep ulcer with ragged nonindurated margins, contains necrotic exudate, has a friable base ○ Causative organism: Haemophilus ducreyi, an anaerobic bacillus ○ Incubation: 3-7 days after exposure ○ Painful inguinal adenopathy, suppurative buboes in 25% of patients ○ Need to distinguish from primary syphilis; genital herpes simplex; lymphogranuloma venereum, granuloma inguinale from Klebsiella granulomatis (both rare in the United States) Cant maiantne and urine stream benign prtoatic hyperpasslaaia men hydrocele- ● Recommendations for the HPV Vaccine (pgs. 798-800) Variable Recommendation Age at which 21 y to begin screening Screening method and interval Age 21–65 y: cytology every 3 y OR Age 21–29 y: cytology every 3 y Age 30–65 y: cytology every 3 y alone, every 5 y with high- risk human papillomavirus (hrHPV) testing alone, or every 5 y with hrHPV testing alone, or every 5 y with cotesting Age at which to end screening >65 y, assuming 3 consecutive negative results on cytology or 2 consecutive negative results on cytology plus HPV testing within 10 y before cessation of screening, with the most recent test performed within 5 y Screening Not recommended with removal of the cervix after hysterectomy ● Risk factors for prostate cancer (pg.818-819) V. Musculoskeletal System Joints and Structure (Table 18-1 and pg. 596) Type of Definition and Example Joint/Structure Synovial Joint Freely movable, keee, shoulder Cartilaginous Joint Slightly movable, vertebral bodies of the spine Fibrous Joint Immovable, skull sutures Ligaments rope-like bundles of collagen fibrils that connect bone to bone. Tendon collagen fibers connecting muscle to bone. Cartilage collagen, overlies the articular surfaces of the bone ends and facilitates smooth painless movement of the joint bursae pouches of synovial fluid that cushion the movement of tendons and muscles over bone or other joint structures. Range of Motion Terms Motion Description Flexion a movement that decreases the angle between two body parts Extension a movement that increases the angle between two body parts Abduction movement away from the trunk Adduction movement toward the trunk Supination/Pronation Palms up/down Inversion/eversion inward/outwardx Dorsiflexion/Plantarflexion Ceiling/ floor Musculoskeletal Disorders Disorder Key Findings Rheumatoid Arthritis AUTOIMMUNE DISAESe/ Local redness from nodular episcleriti and smking/ joint pain/subcutaneous nodules symmetric deformity in the PIP, MCP, and wrist joints with ulnar deviation is present. Acute Rheumatoid Arthritis Tender, painful, stiff joints in rheuratoid arthritis, usually with symmetric involvement on both sides of the body. The proximal interphalangeal, metacarpophalangeal, and wrist joints are the most frequently affected. Note the fusiform or spindle-shaped swelling of the proximal interphalangeal joints in acute disease. Chronic Rheumatoid Arthritis In chronic disease, note the swelling and thickening of the metacarpophalangeal and proximal interphalangeal joints. Range of motion becomes limited, and fingers ma deviate toward the ulnar side. The interosseous muscles atrophy. The fingers may show "swan neck" deformities (hyperextension of the proximal interphalangeal joints with fixed flexion of the distal interphalangeal joints). Les: common is a boutonnière deformity (persistent flexion of the proximal interphalangeal joint with hyperextension of the distal interphalangeal joint). Rheumatoid nodules are seen in the acute or the chronic stage. Osteoarthritis Herbeden’s nodes-are seen at the DIP joints Bouchard’s nodes-IP joints. Heberden nodes on the dorsolateral aspects of the distal interphalangeal joints from bony overgrowth of osteoar-thritis. Usually hard and painless, they affect middle-aged or older adults; often associated with arthritic changes in other joints. Flexion and deviation deformities may develop. Bouchard nodes on the proximal interphalangea joints are less common. The metacarpophalangeal joints are spared. Carpal Tunnel tinel’s sign-for median nerve compression by tapping lightly over the course of the median nerve in the carpal tunnel(Aching and numbness in the median nerve distribution is a positive test.) Phalen’s sign-median nerve compression by asking the patient to hold the wrists in flexion for 60 seconds. Alternatively, ask the patient to press the backs of both hands together to form right angle(Numbness and tingling in the median nerve distribution within 60 seconds is a positive test result.) t is a channel beneath the palmar surface of the wrist and proximal hand. The channel contains the sheath and flexor tendons of the forearm muscles and the median nerve. ften related to repetitive motion with wrists flexed (as in keyboard use, mail sorting), pregnancy, rheumatoid arthritis, diabetes, and hypothyroidism. Thenar atrophy may also be present. Decreased sensation in the median nerve distribution is common Osteoporosis a disease marked by reduced bone strength leading to an increased risk of fractures ( ypically arises from bone loss during aging, but reduced bone mass from suboptimal bone growth in childhood and adolescence Osteopenia—Bone density T score between −2.5 and −1.0 (1.0–2.5 standard deviations below the young adult mean)1104 • Osteoporosis—T score less than −2.5 (bone density 2.5 or more standard deviations below the young adult mean) Painful Shoulders (Table 18-5) Disorder Key Findings Rotator Cuff Tendinitis Repeated shoulder motion, as in throwing or swimming, can cause edema and hemorrhage followed by inflammation, most commonly involving the supraspinatus tendon. Acute, recurrent, or chronic pain may result, often aggravated by activity. Patients report sharp catches of pain, grating. and weakness when lifting the arm overhead. When the supraspinatus tendon is involved, tenderness is maximal just below the tip of the acromion. In older adults, bone spurs on the undersurface of the acromion may contribute to symptoms. Patients are typically athletically active. Rotator Cuff Tears The rotator cuff muscles and tendons keep the head of the humerus in place against the concave glenoid fossa and strengthen arm move-ment—the subscapularis is used with internal rotation, the supraspina-tus with elevation, and the infraspinatus and teres minor with external rotation. Injury from a fall or repeated impingement of muscle or tendon against a bone may weaken the rotator cuff, causing a partial or complete tear, usually after age 40. Weakness, atrophy of the supra-spinatus and infraspinatus muscles, pain, crepitus and tenderness may ensue. In a complete tear of the supraspinatus tendon (illustrated). active abduction and forward flexion at the glenohumeral joint are severely impaired, producing a characteristic shrugging of the shoulder and a positive "drop arm" sign. drop -arm sign Empty cans test Anterior Dislocation of the Humerus Shoulder instability from anterior dislocation of the humerus usually results from a fall or forceful throwing motion, then becomes recur-rent. The shoulder seems to "slip out of the joint" when the arm is abducted and externally rotated, causing a positive apprehension sign for anterior instability when the examiner places the arm in this post-tion. Any shoulder movement may cause pain, and patients hold the arm in a neutral position. The rounded lateral aspect of the shoulder appears flattened. Dislocations may also be inferior, posterior (relatively rare), and multidirectional. Grading Muscle strength (Box 18-3) ● What are risk factors for osteoporosis? VI. Neurological System Reflexes & Motor Signs Reflex Tested Site Normal Response Patellar Achilles Biceps triceps brachioradalis Scale for Grading Reflexes 4+ Very brisk, hyperactive, with clonus (rhythmic oscillations between flexion and extension) 3+ Brisker than average; possibly but not necessarily indicative of disease 2+ Average; normal 1+ Somewhat diminished; low normal Consciousness & Posturing Discriminative Sensations (pg. 746-747 Sign Meaning Associated Condition Graphesthesia Identityfy number If arthritis or other conditions prevent the patient from manipulating an object well enough to identify it, test the ability to identify numbers. With the blunt end of a pen or pencil, draw a large number in the patient’s palm (Fig. 20-25). A person can generally identify most numbers. Stereognosis refers to the ability to identify an object by feeling it. Place a familiar object such as a coin, paper clip, key, pencil, or cotton ball, in the patient’s hand, and ask the patient to tell you what it is. Normally a patient will manipulate it skillfully and identify it correctly within 5 seconds. Asking the patient to distinguish “heads” from “tails” on a coin is a sensitive test of stereognosis. Kernig’s / Brudzinski’s Signs Brudzinski Sign As you flex the neck, watch the hips and knees in reaction to your maneuver. Normally they should remain relaxed and motionless. Flexion of the hips and knees is a positive Brudzinski sign and suggests meningeal inflammation Kernig- flex the patient’s leg at both the hip and the knee, and then straighten the knee (Fig. 20-47). Discomfort behind the knee during full extension occurs in many healthy people, but this maneuver should not produce pain.Pain and increased resistance to extending the knee are positive Kernig sign Romberg Test test of position sense. The patient should first stand with feet together and eyes open and then close both eyes for 30 to 60 seconds without suppor Tremors and Involuntary Movements (Table 20-5) Tremor Signs Associated Condition Resting (static) Tremor seen when limb is at rest, supported, and not moving/ Decreases with voluntary movement Key Clinical Signs ● “Pill-rolling” motion in hands ● Tremor disappears with action Causes ● Parkinson disease (MOST important) ● Parkinsonian syndromes ● Drug-induced parkinsonism (antipsychotics, metoclopramide) Why it happens ● Damage to basal ganglia dopamine pathways Postural (action) ● Tremor present when actively maintaining a posture (holding arms outstretched, standing, writing) Key Clinical Signs ● Tremor occurs with action or resisting gravity ● Hands shake when arms are extended Causes ● Essential tremor (most common cause) ● Hyperthyroidism ● Anxiety ● Fatigue ● Drug withdrawal (alcohol, benzos) ● Certain medications (β-agonists like albuterol) Intention ● Tremor that worsens as a limb approaches a target (finger-to-nose test, heel-to-shin test) Key Clinical Signs ● Dysmetria (overshoot/undershoot) ● Tremor increases at end of movement ● Very prominent in finger–nose testing Causes ● Cerebellar lesions ● Multiple sclerosis ● Stroke affecting cerebellum ● Tumors ● Chronic alcohol use → cerebellar degeneration ● Seizure Types (Table 20-4): ○ Generalized seizures ○ The person loses consciousness suddenly, sometimes with a cry, and the body stiffens into tonic extensor rigidity. Breathing stops, and the person becomes cyanotic. A clonic phase of rhythmic muscular contraction follows. Breathing resumes and is often noisy, with excessive salivation. Injury, tongue biting, and urinary incontinence may occurA sudden brief lapse of consciousness, with momentary blinking, staring, or movements of the lips and hands but no falling. Two subtypes are recognized. Typical absences last less than 10 s and stop abruptly. Atypical absences may last more than 10 s ○ Unresponsive, confusion, frightened, very tired, and sore - Tonic–clonic (previously known as grand mal seizures) - Sudden brief, rapid jerks involving the trunk or limbs Associated with a variety of disorders - Confusion, drowsiness, fatigue, headache, muscular aching, and sometimes the temporary persistence of bilateral neurologic deficits such as hyperactive reflexes and Babinski responses. The person has amnesia for the seizure and recalls no aura - Absence - Sudden loss of consciousness, staring into space. Subtle body movement (e.g., eye blinks, lip smacking) - No aura recalled. Previously known as petit mal seizures. In absences, a prompt return to normal; in atypical absences, some postictal confusion ● Cauda Equina Syndrome Symptoms: Red-flag symptoms (medical emergency): ● Severe low back pain ● Saddle anesthesia – Numbness/tingling in the inner thighs, buttocks, perineum ● Bowel dysfunction – New onset constipation OR loss of bowel control ● Bladder dysfunction – Urinary retention (MOST common early sign) – Overflow incontinence ● Sexual dysfunction ● Lower extremity weakness – Foot drop – Trouble walking, stumbling ● Decreased reflexes in legs ● Severe, bilateral sciatica ● Loss of anal sphincter tone ● Reduced perineal reflexes Extra things good to study: ● Common causes: large lumbar disc herniation (L5–S1), trauma, tumor, abscess ● CES requires emergent MRI and surgical decompression within hours. Stroke Signs (General Stroke Symptoms) Think FAST: ● F – Face droop (uneven smile, numbness) ● A – Arm weakness (drift, numbness) ● S – Speech difficulty (slurred, unable to understand/speak) ● T – Time to call 911 Other common stroke signs: ● Sudden numbness or weakness (especially one-sided) ● Sudden confusion ● Sudden vision problems (one or both eyes; double vision) ● Sudden difficulty walking ● Dizziness, imbalance, loss of coordination ● Sudden severe headache – “Worst headache of your life” → indicates possible hemorrhagic stroke ● Trouble swallowing (dysphagia) ● Loss of consciousness (severe cases) Extra things good to study: ● Ischemic stroke = clot ● Hemorrhagic stroke = bleeding ● Importance of CT scan to differentiate before treatment ● tPA window = 4.5 hours (ischemic only) Risk Factors for Stroke Non-modifiable: ● Age (↑ risk with age) ● Sex (men higher risk; women higher mortality) ● Race/ethnicity (African American, Hispanic ↑ risk) ● Family history of stroke ● Prior stroke or TIA Modifiable risk factors (KEY to study): ● Hypertension (BIGGEST risk factor) ● Diabetes mellitus ● Hyperlipidemia ● Smoking ● Atrial fibrillation (major cause of embolic strokes) ● Carotid artery disease ● Obesity ● Sedentary lifestyle ● Poor diet (high salt, high saturated fat) ● Excessive alcohol ● Cocaine or illicit drug use ● Sleep apnea