Blueprint for final Exam

Fall 2014

How to access for intracranial pressure

-Check pupils for size, regularity, equality, direct and consensual light
reaction, and accommodation.
-Increasing ICP causes sudden, unilateral, dilated and nonreactive pupil
The control of reflexes
-Reflexes help body maintain balance and appropriate muscle tone
4 types
1. Deep tendon Reflex ex) patellar
2. Superficial ex) corneal reflex, abdominal reflex
3. Visceral ex) pupillary response to light and accomadation
4. Pathologic (abnormal) ex) Babinski
-activation of sensory afferent carries message through from receptor and travel
through dorsal root into spinal cord. Synapse in cord with motor neuron in anterior
horn. Motor fibers leave via the ventral root - stimulate contraction
Dermatones
-circumscribed skin area supplied mainly from one spinal cord segment
through particular spinal nerve.
What is an aura related to a seizure
-what precedes a seizure
-visual changes such as blind spots or flashes of light, tingling in arm or leg,
vertigo

-subjective sensation precedes seizure, could be auditory, visual, or motor

Difference between a Complete Neurologic exam and Neurologic Recheck
Complete Neurologic exam- preform on person who is having neurologic
concerns (headache, weakness, loss of coordination), or who have shown signs of
neurologic dysfunction.
Neurologic recheck- preform on person who have neurologic deficit and
require periodic assessments (hospitalized persons or those in extended care)
Romberg Test
-assesses the ability of the vestibular apparatus in the inner ear to help
maintain standing balance.
-also assesses intactness of the cerebellum and proprioception
-ask person to stand up with feet together and arms at side. Ask person to
close eyes and to hold position. Wait 20 seconds. Person should be able to maintain
posture and balance.
-positive Romberg sign-loss of balance when close eyes.
Signs occur with cerebellar ataxia (multiple sclerosis, being drunk),
-negative Romberg sign- no loss of balance
Glascow Coma Scale
-standard objective assessment. Defines objective assessment that defines
the level of consciousness.
-divided into 3 areas: eye opening, verbal response, motor response. Each
area graded and 3 numbers totaled up. Total score reflects brains functional level.
-fully alert- 15
-7 or less pt in coma
Mini Mental State Examination

-simplified scored form of the cognitive functions of the mental status

examination (memory, orientation to time and place, naming, reading, copying or
visuospatial orientation, writing, and the ability to follow a three-stage command)
- includes a standard set of only 11 questions, and requires only 5 to 10
minutes to administer.
-both initial and serial measurement
-Demonstrate worsening or improvement of cognition over time and with
treatment
- concentrates only on cognitive functioning, not on mood or thought
processes.
-It is a valid detector of organic disease; good screening tool to detect
dementia and delirium and to differentiate these from psychiatric mental
illness.
Blumbergs Sign/McMurrays Sign
Blumberg sign- rebound tenderness
-Assess rebound tenderness when the person reports abdominal pain or when
you elicit tenderness during palpation
-Choose a site away from the painful area.
-Hold your hand 90 degrees, or perpendicular, to the abdomen. Push down
slowly and deeply, then lift up quickly. This makes structures that are
indented by palpation rebound suddenly.
-negative-response is no pain on release of pressure.
-Perform test at the end of the examination, because it can cause severe pain
and muscle rigidity.
-Pain on release of pressure confirms rebound tendernesssign of peritoneal
inflammation. Peritoneal inflammation accompanies appendicitis.
McMurrays sign-

-Perform this test when the person has reported a history of trauma followed
by locking, giving way, or local pain in the knee.
-Position the person supine as you stand on the affected side. Hold the heel,
and flex the knee and hip. Place your other hand on the knee with fingers on
the medial side. Rotate the leg in and out to loosen the joint. Externally
rotate the leg, and push a valgus (inward) stress on the knee. Then slowly
extend the knee.
-Negative- knee extends with no pain
-Positive-if you hear or feel click, pt has torn meniscus.
Bruit
-blowing, swishing sound indicating blood flow turbulence
-auscultate carotid for bruit- listen for bruit in middle aged or older people
who show signs of cardiovascular disease.
-if bruit is present, sign of atherosclerosis
-listen to femoral artery for bruit.
- Listen with the bell.
Occurs with:
Aortic aneurysmmurmur is harsh, systolic, or continuous and accentuated with
systole. Note in person with hypertension.
Renal artery stenosismurmur is midline or toward flank, soft, low to medium
pitch.
Partial occlusion of femoral arteries.
Know the different breath sounds (vesicular, etc)
BRONCHIAL (TRACHEAL)-Inspiration < expiration

-Harsh, hollow tubular

-located in trachea and larynx
BRONCHOVESICULAR
-Inspiration = expiration
-Over major bronchi where fewer alveoli are located: posterior,
between scapulae especially on right; anterior, around upper sternum
in first and second intercostal spaces
VESICULAR
-Inspiration > expiration
-Rustling, like the sound of the wind in the trees
-Over peripheral lung fields where air flows through smaller
bronchioles and alveoli
Anatomy of the lungs, (how many lobes?) Right has 3, left has 2

Signs of chronic pulmonary disease,

Barrel chest

-has horizontal ribs and costal angle >90 degrees.

-seen in emphysema, asthma
-increased anteroposterior to transverse diameter
-result of hyperinflation of lungs.
-ribs are horizontal instead of the normal downward slope.
Clubbing-occurs with congenital cyanotic heart disease and neoplastic and
pulmonary diseases.
-over developed neck muscles
-use of accessory muscles.
-1 to 1 ratio of anterior to transverse diameter
Crepitation
-occurs during limited ROM
-Crepitation is an audible and palpable crunching or grating that
accompanies movement. Occurs when the articular surfaces in the joints are
roughened, as with rheumatoid arthritis
Symptoms of rheumatoid arthritis

-crepitation
-feel for nodules- rheumatoid arthritis
-involves symmetric joints
-pain worse in morning that at night
-produces swelling and tenderness around the whole joint, and it limits all
planes of ROM in both active and passive motion.
-joints roughened
Osteoporosis
-gradual loss of bone density
-the lack of estrogen leads to accelerated bone loss.
-physical exercise helps to prevent osteoporosis
Ortolani maneuver
-should be done at every professional visit until the infant is 1 year old.
- With the infant supine, flex the knees holding your thumbs on the inner
mid-thighs and your fingers outside on the hips touching the greater
trochanters. Adduct the legs until your thumbs touch
-Positive-hear clunk as the head of the femur pops back into place.
-Negative- no sound, smooth
Direction of blood flow through the heart
Liver to RA via IVC; SVC drains venous blood from head & upper
extremities
From RA venous blood TV to RV
RV venous blood pulmonic valve PA
PA delivers unoxygenated blood to lungs

Lungs oxygenate blood & pulmonary veins return blood to LA

From LA arterial blood MV LV
LV ejects blood thru aortic valve into aorta
Aorta delivers oxygenated blood to body
Auscultation of the heart ( 5 landmarks)
Listen in all areas with diaphragm 1st, then bell
-Aortic- 2nd ICS at (R) sternal border
-Pulmonic- 2nd ICS at (L) sternal border- hear S2 more
-Erbs point- 3rd ICS at (L) sternal border
-Tricuspid-5th ICS at (L) lower sternal border
-Mitral- 5th ICS at or medial to MCL- hear S1 more
Pacemaker of the heart

Reason the abdominal assessment differs from other assessments

-You auscultate first because you dont want to disturb the GI sounds
Acites (what is it?)
-free fluid in the peritoneal cavity
- heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and
cancer.
Genu vulgum, genu varum (I will discuss more next week)
Genu Vulgum- knocked knees
-present when there is more than 2.5 cm between the medial malleoli when
the knees are together
-occurs with rickets, poliomyelitis, and syphilis.
-occurs normally between 2 and 3.5 years of age.
Genu Varum- bowlegged stance
-persistent space of more than 2.5 cm between the knees when
the medial malleoli are together
-normal for 1 year after the child begins walking
Hypoactive bowel sounds (How long would you continue to assess)
-5 minutes
-Diminished or absent bowel sounds signal decreased motility as a result of
inflammation as seen with peritonitis
- from paralytic ileus as following abdominal surgery; or from late bowel
obstruction.
-Occurs also with pneumonia.
Bulge Sign
-For swelling in the suprapatellar pouch

- confirms the presence of small amounts of fluid as you try to move the
fluid from one side of the joint to the other
-Firmly stroke up on the medial aspect of the knee two or three times to
displace any fluid
Assessment of muscle strength
-Temporomandibular joint
-Palpate contracted temporalis & masseter muscles as person clenches
teeth
-Compare (R) & (L) sides
-Ask person to perform these movements against resistance
-Move jaw forward & laterally
-Open mouth
-Tests CN V trigeminal
Shoulders
-Ask client to shrug shoulders against resistance
-Tests CN XI spinal accessory
-Flex forward & up against resistance
-Abduct
Elbows
Have client flex elbow & apply resistance just proximal to wrist
Have client extend elbow against resistance
Wrist & hand
Ask client to flex wrist at palm against resistance
Knee

-Ask client to maintain knee flexion while you try to pull leg forward
-Muscle extension shown by rising from low chair or squat without using
hands
Foot and Ankle
-Maintain dorsiflexion & plantar flexion against resistance
Conducting a sexual history of an adolescent male (proper way to ask questions)
- Dont judge
How to teach a testicular self- exam
-Teach every male from age 13 thru adult to perform monthly
-Once a month
-Do in shower-warm water relaxes scrotal sac
-Examine for changes
Report changes immediately
Circumcision based on culture (AAP- Unnecessary surgical procedure)
-Prevention of phimosis & inflammation of glans & foreskin
incidence of cancer of penis
-Slightly incidence of UTI in infants
Possible complications
Sepsis
Distal amputation
Excessive removal of foreskin
Urethrocutaneous fistula
Pain

Normal and abnormal Babinski sign

-extensor plantar reflex.
-Stroke your finger up the lateral edge and across the ball of the infant's foot.
- reflex is present at birth and disappears (changes to the adult response) by
24 months of age (variable).
-Positive Babinski reflex after 2 or years of age occurs with pyramidal tract
disease.
What is a thrill
-A palpable vibration.
- It feels like the throat of a purring cat.
-signifies turbulent blood flow and accompanies loud murmurs.
Risks for breast cancer (who is at great risk?)
Risk Factors that Cant be changed
-Female > 50 y/o
-Personal hx breast cancer
-Mutation of BRCA1 & BRCA2 genes
-1st degree relative with hx breast cancer
-Mother, sister, daughter
-Previous breast biopsy with atypical cell growth
-Previous breast irradiation
-Menstruation < age 12* or menopause > 50
-White race
Lifestyle related Factors:

-Nulliparity or 1st child > 30*

-Current oral contraceptive use*
-Long term use HRT (Hormone Replacement Therapy)
Not breastfeeding
-Alcohol intake 2 to 5 drinks QD
-Obesity (esp. after menopause) & high fat diet
-Physical inactivity
Benefits of breastfeeding (we will discuss next week)
-for 6 months provides the perfect food and antibodies for the baby, decreases risk
for ear infections, promotes bonding, and provides relaxation.

Carrington 2014