Week 6

ASSESSING THE ABDOMEN

Visceral pain

 Hollow organs forcefully contract or become distended- most common

o Examples: stomach, pancreas, intestine, colon
 Solid organs (liver, spleen)—if swollen against their capsules
 Characteristics: gnawing, burning, cramping, or aching
 Often difficult to localize
o Examples:
 Hepatitis
 Cholecystitis (gallbladder)
 Irritable bowel syndrome (IBS)

Parietal pain- more severe than visceral

 Inflammation on the peritoneum or organs attached to the parietal peritoneum

 Characteristics: steady, aching pain; more severe and easily localized
o Example:
 Appendicitis
 Peritonitis

Referred pain

 Originates at different sites but shares innervation from the same spinal level
o Example: gallbladder pain (cholecystitis) referred to the right scapula or shoulder

Anatomical landmarks

 Quadrants
o Right Upper Quadrant (RUQ)
o Right Lower Quadrant (RLQ)
o Left Upper Quadrant (LUQ)
o Left Lower Quadrant (LLQ)
 Nines: Central 3 areas
o Epigastric
 o Umbilical
o Suprapubic (hypogastric)

Structures

 Stomach
 Pancreas
 Spleen
 Small and large intestines
 Liver
 Gallbladder
 Kidneys—lower poles
 Muscles
 Costal margins
 Arteries: aorta, renal, iliac, femoral
Physical exam technique order

1. Inspection
o Ensure good lighting.
2. Auscultation
o Relaxed patient with an empty bladder.
3. Percussion
o Full exposure of the abdomen; warm room.
4. Palpation
o Patient with arms at sides or across chest.
o Flex knees if the abdomen is tense or the patient is ticklish.

Abdominal exam details

Inspection

 Size, contour, symmetry

 Skin condition:
o Color, lesions, veins, hair distribution, hernias
 Movements:
o Respirations, pulsations (arteries), peristalsis
o Note what organs the pulsations are over.

Auscultation

 Listen to bowel sounds in all four quadrants.

o Duration: at least 2 minutes.
o Frequency: 5–34 gurgles/minute.
 Check vascular sounds for bruits over arteries.

Percussion
  Indirect: Tympany or dullness over all four quadrants.
o Liver size at right midclavicular line (6–12 cm).
 Start by doing down and go up from the abdomen.
o Splenic dullness.
 Start by going down anterior axillary line at the lowest possible margin
and should be tympanic, and when patient takes deep breath, should
remain tympanic
 Direct= Fist/Blunt: Assess organ tenderness or costovertebral angle (CVA) tenderness.

Palpation

 Light Palpation
o Assess surface characteristics, tenderness, guarding.
 Deep Palpation
o Detect masses and organs:
 Liver
 Kidneys
 Spleen
 Aorta

Liver palpation techniques

1. Bimanual palpation
2. Hook technique- Stand above the patient and tuck fingers under the costal margin

Spleen and aorta palpation

 Evaluate size and tenderness of the spleen.

 Assess aortic pulsation and size.
o Always auscultate the aorta but in adults over 50, good idea to always palpate the
aorta in adults over 50
 Careful not to confuse thumb pulse for aortic pulse when measuring aorta
with index finger and thumb
 Anytime you hear a bruit, palpate!!!

Changes with aging

 Increased fat in lower abdomen/hip area.

 Relaxation of abdominal muscles.
 Symptoms of abdominal conditions experienced less severely:
o Less pain, fever, and rebound tenderness.
 Fever is less pronounced in the elderly as is abdominal pain

Week 7
ASSESSING THE MUSCULOSKELETAL SYSTEM

Anatomical Terminology

 Articular structures (moveable): include joint capsule and articular cartilage, synovium
and synovial fluid, intra-articular ligaments, and juxta-articular bone.
 Extra-articular structures: include periarticular ligaments, tendons, bursae, muscle,
fascia, bone, nerve, and overlying skin.
 Ligaments: ropelike bundles of collagen fibrils that connect bone to bone.
 Tendons: collagen fibers connecting muscle to bone.
 Cartilage: collagen matrix overlying bony surfaces.
 Bursae: pouches of synovial fluid that cushion the movement of tendons and muscles
over bone or other joint structures.

3 Types of Joints

1. Synovial—freely movable
2. Cartilaginous—slightly movable
3. Fibrous—immovable (e.g., skull)

Synovial Joints

 Synovial joint
o Joint is freely movable.
o Bones are covered by articular cartilage.
o Bones are separated by a synovial cavity (bones do not touch).
o Synovial membrane secretes synovial fluid that lubricates joint movement.
o Examples: shoulder, knee.
 

Types of Synovial Joints

  Spheroidal (ball and socket): shoulder, hip.
 Hinge (one plane): elbow, digits (interphalangeal joints). Don’t go around in a circle
 Condylar: knee, temporomandibular joint (TMJ)—articulating surfaces are convex or
concave.
o Condylar Joints:
 TMJ and knee • The knee and the TMJ are condylar joints because of their
structure--both have "condyles" or convex surfaces
 The motion of the knee is a hinge joint because of the ligaments that hold
it together. The condylar surfaces allow for rotation in multiple
directions--which unfortunately it does when there is an ACL, MCL tear
etc.
 So in structure it is a condylar joint but in function it is a hinge joint
(because of the ligaments holding it stable). Condylar joint: TMJ
 TMJ is also a condylar joint because of it's structure. It has a rounded
condyle. So in function it usually only opens and closes (hinge joint) but it
can go side to side because the structure is condylar.

Cartilaginous Joints

 Joint is slightly movable.

 Bones separated by fibrocartilaginous discs.
o Discs contain nucleus pulposus that cushions bony movement.
 Example: vertebral bodies of the spine.

Fibrous Joints

 Joints have no appreciable movement.

 Bones separated by fibrous tissue or cartilage.
 Example: sutures of the skull.

Range of Motion (ROM): Movements

 Flexion
 Extension (Hyperextension)
 Abduction
 Adduction (Circumduction)
 Internal rotation
 External rotation
 Pronation
 Supination
 Inversion
 Eversion
 Ulnar deviation- Toward pinky side, only applies to wrist
  Radial deviation- Toward thumb, only applies to wrist

Shoulder ROM

 Flexion and Extension.

 Abduction and Adduction.
 Internal rotation.
 External rotation.

Spine and Neck ROM

 Neck:
o Flexion and extension: chin to chest, look up at ceiling.
o Rotation: chin to shoulder.
o Lateral bending: bring ear to shoulder.
Elbow (Hinge joint)

 Movements: flexion and extension.

Wrists and Hands ROM

 Interphalangeal Joints:
o DIP: Distal InterPhalangeal.
o PIP: Proximal InterPhalangeal.
o MCP: MetaCarpoPhalangeal.
 Finger ROM:
o Flexion, extension, hyperextension.
o Abduction, adduction.
 Need to know the bones on the hand, meta are bones on the hand
Hip ROM

 Movements:
o Flexion and Extension.
o Abduction and Adduction.
o Internal and External rotation.

Knee ROM

 Flexion and Extension.

 Patella:
o Floating.
o Quadriceps tendon: attaches to thigh.
o Patellar tendon: attaches to tibia.
 Need to know the joints

Patella

• Floating
• Quadriceps tendon

• To thigh

• Patellar tendon

• To tibia

Ankle ROM

 Movements:
o Dorsiflexion and Plantar flexion.
 “Plant your feet on the floor”
 Dorsiflex is pointing up
o Inversion and Eversion.

Musculoskeletal Assessment

Physical Assessment

 Techniques: inspection, palpation, percussion.

 Tools:
o Tape measure.
o Goniometer. Used by sports medicine to measure angle of joint movement
o Stadiometer. Used to measure height
o Scoliometer. Used to measure scoliosis

Inspection

 Check for swelling, erythema, symmetry, deformity.

 Assess Range of Motion (ROM).
  Posture: head position, alignment.
 Spinal curves: cervical, thoracic, lumbar, sacral.
 Spinal deformities: kyphosis, scoliosis, lordosis.

Inspection (Standing)

 Leg shape:
o Genu varum (bowlegs—air between knees).
o Genu valgum (knock knees—gum sticks together).
 Toeing
o width of stance- base of support
o gait (cadence- smooth or jerky?, stride length, arm swing, speed).

Palpation

 Muscle tone and strength: upper and lower extremities.

o Grade strength 0–5. Expect a 5
 Check for joint crepitus, swelling, effusion, bogginess, warmth, tenderness, and stability.

 Hockey stick crease seen in FASD or FAS

 Single transverse palmer crease
 Can be normal
 Seen in Down Syndrome
  Fetal Alcohol syndrome

 Distribution of carpal tunnel is the thumb, index, middle, and half of ring finger d/t
innervation of nerve
 Test by tapping on flexor reticulum (Tinel’s tap) or Phelens

Signs of Inflammation
  Swelling.
 Warmth.
 Erythema.
 Pain or tenderness.

Common Musculoskeletal Abnormalities

Carpal Tunnel Syndrome

 Tests:
o Tinel’s (tap).
o Phalen’s test.

Osteoarthritis

 Heberden’s nodes: Distal Interphalangeal (DIP).

o “hob nob”
 Bouchard’s nodes: Proximal phalanges.
o

Rheumatoid Arthritis

 Boutonniere deformity (not nodule): flexion of PIP, hyperextension of DIP.

o Deformities are with rheumatoid and nobs are with osteoarthritis
 
 Swan neck deformity: hyperextension of PIP, flexion of DIP.

Developmental Dysplasia of the Hip (DDH)

 Barlow Test: Thumb and index and middle finger on greater trochanter, bring legs
together and shouldn’t hear a clunk.
o If you do, refer for US, not Xray until after 4 mo because there’s too much
cartilage
 Ortolani Test: separate legs and abduct one leg
 Allis sign: flex the knees, plant feet on the table and knees should be the same level
  Signs: Allis sign, asymmetric thigh folds.
o Asymmetric thigh folds can indicate hips aren’t in their sockets the way they
should be

Hallux Valgus

 Bunion deformity.

Lifespan Changes

 Older adults:
o Decreasing height due to thinning intervertebral discs.
o Muscle bulk loss.
o Decreased ROM, often from osteoarthritis.

ASSESSING THE NEUROLOGICAL SYSTEM

Anatomical Terms- will need to know

 Cervical nerves: C1–C8

 Thoracic nerves: T1–T12

 Lumbar nerves: L1–L5

 Sacral nerves: S1–S4

 Coccygeal nerve

 Sacral plexus

 Frontal lobe

 Parietal lobe

 Temporal lobe

 Occipital lobe

 Cerebellum

 Motor cortex

 Sensory cortex

 Dorsal and ventral root

 Afferent and efferent neurons

  Corpus callosum

 Cerebral cortex

Nervous System Basics

 Neurons: nerve cells.

 Axons: long fibers that transmit nerve impulses.

 Gray matter: forms the cerebral cortex.

 White matter: neuronal axons coated with myelin.

o Myelin sheath: improves nerve conduction.

 Motor cortex: located in the frontal lobe; controls voluntary movement.

 Sensory cortex: located in the parietal lobe; processes tactile sensory information.

Lobe Functions

 Frontal lobe:

o Motor function.

o “Executive function,” problem-solving, memory, language, initiation, organization

o Judgment, impulse control, social/sexual behavior.

 Parietal lobe:

o Somatic sensation (touch and limb position).

o Spatial and visual attentional processes.

 Temporal lobe:

o Memory (contains hippocampus and amygdala).

o Functions: language, social cues, emotions, facial recognition.

 Semantic processing is the words we use and what they mean

 Occipital lobe:

o Vision, distance, and depth perception.

o Object/face recognition, memory formation.

 Cerebellum:

o Balance, proprioception, and voluntary movement coordination.

Peripheral Nervous System

 Includes cranial nerves, spinal nerves, peripheral nerves, neuromuscular junctions.

 Somatic nervous system: voluntary control through skeletal muscles.

o During patient exams, we are focusing on somatic NS

 Autonomic nervous system: involuntary control of inner organs.

o Subdivided into:

 Parasympathetic nervous system.

 Sympathetic nervous system.

 Components:

o Dorsal (posterior) or sensory root

o Ventral (anterior) or motor root

  Sensation from the periphery → afferent nerve fiber → dorsal root → spinal cord
→ sensory cortex (parietal lobe).

o Motor cortex → ventral root → efferent fibers → muscle movement.

o Mnemonic: “DMV—Motor Ventral.”

5- IS THE DORSAL ROOT

6- VENTRAL ROOT – TAKING MUSCLE STIMULS TO THE PART OF THE BODY THAT NEEDS TO MOVE
Somatic Reflex Arc

 Afferent neurons: carry sensory information away from the periphery to the spinal cord.

o Mnemonic: “Afferent AWAY.” Away from the muscle

o Via the dorsal root up to the brain

 Efferent neurons: carry motor impulses to the neuromuscular junction.

o Mnemonic: “Efferent TO.” ET go home to muscle

o Via the ventral root.

 Deep tendon reflex (DTR).

The nerves don’t cross, you if the pt feels pain it is likely to cover this area.

Neurological Assessment

Sensory Functions

 Superficial sensation: pain, temperature, light touch.

 Deep sensation: vibration, proprioception.

o Vibration decreased in peripheral neuropathy, spinal lesions.

o Proprioception decreased in B12 deficiency, MS.

 Special sensory tests: stereognosis, two-point discrimination.

Cerebellar Function

 Balance tests:

o Gait.

o Tandem walk (heel-to-toe).

o Toe and heel walking.

o Deep knee bend, hop on one foot.

o Romberg test.

 Proprioception tests:

o Finger-to-nose, alternating hand movements.

 o Fingers-to-thumb, heel-down-shin.

o Stereognosis, number identification, two-point discrimination (<5 mm normal).

Deep Tendon Reflexes (DTRs)

 Reflex sites:

o Biceps, triceps, brachioradialis, patellar, Achilles.

 You must hold the patient’s arm while they are relaxing otherwise the tendon is
already stretched and won’t elicit a reflex.

 Grading:

o 4+: Very brisk.

o 3+: Brisker than average.

o 2+: Normal.

o 1+: Somewhat diminished.

o 0: Absent.

Age-Dependent Reflexes

Babinski Reflex

 Ages 0–2 years:

o Positive Babinski: big toe curls upward.

 Ages >2 years:

o Negative Babinski: big toe curls downward.

o POSITIVE INDICATES UPPER MOTOR NEURON LEISON IN SPINAL CORD AND BRAIN
Clonus

 Test for central nervous system lesions, upper motor neuron involvement.

o May occur with drugs: SSRIs, SNRIs, MAOIs, cocaine, amphetamines.

o Also seen in serotonin syndrome – DO A TEST OF CLONUS

 CLONUS HAPPENS WITH HYPERREFLEXIA, COUNT THE NUMBER OF BEATS

 Often accompanied by hyperreflexia.

 Technique:

o Rapidly dorsiflex the foot, maintain dorsiflexion.

o Positive clonus: rhythmic beats felt.

Neurology Documentation

 Example documentation:

o "Alert and oriented x3. CN II–XII intact. Alternating hand movements intact.
Finger-to-nose and finger-to-thumb intact. Gait normal. Tandem walk intact.
Romberg negative. DTRs 2+ in all extremities."

AHA WEEK 9

Male Genitourinary System

Male genitourinary system anatomy:

**Scrotum the equivalent to the ovaries***

Seminal vesicles have a duct that joins with the prostate and goes thru
urethra
Testes hold sperm and transport to Vas Deferens for ejaculation
In males, reproductive system is combined with urinary system

Groin anatomy:
 Inguinal ligament- lies lateral inferior of groin
 Inguinal canal
 Lies above and parallel to the inguinal ligament
 Forms a tunnel for the vas deferens
 External inguinal ring
 The exterior opening of the inguinal canal
 Internal inguinal ring (proximal (closest to heart)
 The internal opening of the inguinal canal
 

Hernia Locations:
Hernia means wall of that organ has become weak and it allows that
organ to protrude thru
 Epigastric
 Umbilical
 Inguinal- inguinal canal
 Femoral- inner upper thigh

Penis anatomy:
  Shaft
 Glans
 Prepuce or foreskin (in uncircumcised men)
 Smegma: secretions of the glans
 Urethral meatus
Anus and rectum anatomy: *** only place where you can feel the
prostate**
 Anal canal
 Anal sphincter
 Prostate- Heart shaped walnut sized organ
 Median sulcus
 Lateral lobe
 Seminal vesicles

Rectal Exam Techniques:

 Least popular segment of the physical examination
 Requires calm demeanor, explanation of procedure, and possible
sensations
 A skillfully performed examination should not be painful
  In asymptomatic adolescents, it is appropriate to defer the
rectal exam
 Check exterior structures like scrotum but not rectum
unless it’s a CC like hemorrhoids.
Anus, rectum, and prostate examination:
 Position patient: 2 CHOICES BASED ON PREFERNCE
 Left lateral decubitus: Lie on left side with buttocks close to
the edge of the exam table near you, flex the patient's hips and
knees, especially the top leg
 Leaning over the exam table: Patient stands, leaning forward
with upper body resting across the examining table and hips
flexed
 External exam:
 Inspect the sacrococcygeal and perianal areas
 The "sacrococcygeal area" refers to the region at the base
of the spine, specifically where the sacrum (triangular
bone) meets the coccyx (tailbone), while the "perianal
area" is the skin directly surrounding the anus
 Assess for lumps, ulcers, fissures, hemorrhoids, inflammation,
rashes, or excoriations
 Palpate any abnormal areas, noting lumps or tenderness, texture,
indurated?
Digital Rectal Exam:
1. Lubricate gloved index finger
2. Explain procedure and tell pt you won’t do anything without telling
them first.
3. Ask the patient to strain down before you insert your finger and that
pushes muscles towards you.
4. Place finger pad over anus, gently insert fingertip into anal canal
 Tell pt to take a deep breath
5. Proceed with insertion upon relaxation of the sphincter (in the direction
of the umbilicus)
6. Assess for sphincter tone of the anus, tenderness, induration,
irregularities, or nodules
 Tenderness, hardness/induration – could indicate cancer
Prostate examination:
 Palpate the posterior surface of the prostate gland
 Identify lateral lobes and median sulcus
 Note size, shape, and consistency
 Walnut and heart shaped.
 Normal prostate is rubbery and nontender
 Should not be boggy, tender or have nodules
 Identify any nodules or tenderness
 If tender, stop palpating b/c it can release a lot of bacteria
into the system
 If possible, extend your finger above the prostate to the region of the
seminal vesicles and the peritoneal cavity
 Note any nodules or tenderness
 Note the color of fecal matter on the glove; test for occult blood
(hidden blood in stool not visible to naked eye)
Tanner Stages:
 Tanner’s Staging for males

Normal for there to be enlarged testes and smaller penis during

stage 2
 Pay attention to the
Female Anatomy and Exam-

order of the exam!!1

Anatomical terms
 Vaginal structures
 Introitus
 Hymen
 Mons pubis
 Posterior forchette
 Bartholin glands
 Labia majora
 Labia minora
 Cervix
 Columnar epithelium
 Clitoris
 Squamocolumnar junction
 Urethral meatus
 Squamous epithelium
 Skene’s glands
 Transformation zone
 Fornix
 Perineum
 Uterus
 Ovaries
 Fallopian tubes
Uterus, ovaries, fallopian tubes
 Cervix- Feels like the end of your nose
 Circle with dimple in the middle, OZ= opening.
 Endocervical canal
 Ectocervix

When doing a PAP need to get all 3 kids of epithelium.

 Columnar epithelium is at the Os
o Os goes into endocervical canal
 Squamocolumnar where they are joining and that’s the transformation
zone
 Squamous is at the periphery
In females. reproductive system is separate from the urinary system.

History
 Private room with the woman fully clothed
 Introduction
 Reason for the visit (chief complaint - CC)
 HPI – History of present illness
“Why did you come to the clinic today?”
Menstrual History
 Age
 LNMP (record the first day of flow. Use 1st day to 1st day to
determine how long the cycle is )
 Menstrual history:
 Menses regular?
 Cycle length (21‐35 days between menstrual cycles)
 Duration and amount of flow
 How many pads or tampons pt uses
 Associated symptoms (PMS)
 Menarche (age at onset of menses)—average age 9‐16
  Menopause: No menses for 12 months (average age 45‐52)
 Abnormal bleeding

Menstrual History — Terms

 Dysmenorrhea: Painful periods with cramping or aching in the lower
pelvis and lower back
 PMS/PMDD: Psychological and physical symptoms before menses
 Symptoms occurring 4 to 10 days before the onset of menses
 Psychological symptoms include tension, irritability, depression,
and mood swings
 Physical symptoms include weight gain
 Polymenorrhea: Too frequent periods
 Oligomenorrhea: Minimal or infrequent periods
 Metrorrhagia: Bleeding between periods
 Menorrhagia: Increased bleeding or duration
 Amenorrhea: Absence of menses
 Primary: Failure to initiate menses
 Secondary: Cessation after periods have begun

Obstetric History
 Gravidity: Number of pregnancies regardless of outcome
 Parity: Number of pregnancies resulting in delivery of a term-size
fetus
 Abortions: Spontaneous or induced
 Contraceptive History:
 Current method • Methods used in past • Problems with methods
• Pregnancy planning

Pelvic Examination
 Communicate each step of the exam
 Explain sensations
  Use the exam as a teaching opportunity
 Encourage the patient to voice concerns
1. Assemble supplies
2. Wash hands.
3. Glove both hands
4. Drape patient
5. Do not impede eye contact
6. Position patient
7. Stirrups placed at a comfortable length
8. Hands at side or folded over abdomen
9. Avoid startling patient
 Verbally instruct patient she will be touched & tell her
where (inner thigh)

SEQUENCE OF THE FEMALE GENITAL EXAMINATION

1. Examine external genitalia
2. Perform speculum examination
3. Perform bimanual examination
4. Perform rectovaginal examination
5. Perform rectal examination

1. Examine External Genitalia

 Structures: Mons pubis, labia majora, labia minora, prepuce, clitoris,
urethra, perineum, anal area
 Helps to spread the l. majora to help visualize the structures
 Insert index finger • Bartholin’s glands • Introitus 5 & 7 o’clock •
Milk urethral meatus • Skene’s glands • 4 & 8 o’clock below
urethral meatus • To assess pelvic floor tone: • Insert index &
middle finger into vagina & ask the woman to “bear down” &
“squeeze”
2. Speculum Exam
• Select speculum
• Width & depth vary depending on age
• Lubricate speculum with warm tap water
• Ensure blades of speculum are closed for insertion
• Separate labia & introduce speculum at a slightly oblique (diagonal) and
downward angle toward coccyx
 When speculum is half way inserted, rotate speculum to the horizontal
position
 Insertion should be slow & ensure the speculum points down towards
the patient’s coccyx
 Insert speculum into the vagina until flush with the perineum
 Check the woman’s comfort – visual or verbal contact
 Open the blades until the cervix is visualized
 Cervix should fall in between the tip of the blades and be seen easily
 If no cervix or only a portion of the cervix is visible, then readjust
speculum for better visualization
 With speculum open, slightly withdraw speculum
 Close speculum and reinsert posteriorly in the axis of the vagina
toward the tip of the coccyx
Cervix Inspection
• Once the cervix is visualized, inspect the cervix and the os
Note: • Color • Erythema • Nodularity/Lesions/Ulcerations • Bleeding •
Discharge (color, amount) • Squamocolumnar junction (margin between the
pink squamous epithelium & the red columnar epithelium near the os •
Vaginal walls (color, rugation, discharge)
• Obtain Pap smear if indicated
• Obtain one specimen from the endocervix and one from the ectocervix, or
a combination specimen using the cervical brush “broom”
• If indicated, obtain cultures for chlamydia, gonorrhea, or herpes; wet prep
(saline slide of the vaginal and cervical secretions) for vaginitis (trichmonas
or bacterial vaginosis)
Inspecting the Vagina
• While withdrawing the speculum, assess the walls of the vagina
• When removing the speculum, make sure the blades are closed
• Removing an open speculum can cause lacerations to the vaginal
walls and to the urethral meatus
• If indicated, place two fingers inside the labia and ask the patient to
bear down in order to see if the vaginal walls bulge or if any part of the
rectum protrudes from the anus

3. Bimanual Examination
 Insert fingers along the posterior vaginal wall
 Palpate vaginal walls, cervix, uterus, and adnexa
 Stand at end of table between patient’s legs • Apply lubricant on index
& middle finger of non-dominant hand • Insert fingers vertically along
the posterior wall • Rotate fingers into palm-up position • Fingers are
aimed at cervix
 Palpate the vaginal walls • Feel for any irregularities (note that the
vaginal walls have rugae and will feel “bumpy”)
 Palpate the cervix • Note its position (anterior, posterior, deviated to
the left or right), shape, consistency (firm or soft), mobility, and
tenderness
 Palpate the uterus in the midline • Use your dominant hand and place
it over the suprapubic area just superior to the pubic bone • Press your
hand over the bladder, catching the uterus between your hands; feel
its size, shape, consistency, mobility, and tenderness • If you cannot
 feel the uterus, slide the fingers in the pelvis into the posterior fornix; if
you can feel the uterus butting against the fingers, the uterus is tipped
posterior (retroflexed)
 Note uterine:
 Size • 3-6 cm • Contour • smooth • Consistency • Soft &

mobile • Posi
Adnexae
• Note : • Size & consistency of ovaries • Normally, these structures
are small (ovaries 2-4 cm) & may NOT be palpable • Ovaries are sensitive &
some discomfort may be experienced • Fallopian tubes (not normally
palpable) • Any masses/tenderness
To assess right adnexal (fallopian tube & ovary) region, place fingers in
the right lateral fornix • Move abdominal hand to the lower abd quadrant on
the same side as the internal hand • Apply upward pressure with the vaginal
fingers • Apply downward pressure with the abdominal hand • Moving hands
together, sweep the fingers toward the symphysis pubis • Evaluate entire
region with 3-4 sweeps • Repeat on the left side
4. Rectovaginal Exam
• Rectovaginal exams has three primary purposes
• Palpate a retroverted uterus, the uterosacral ligaments, cul-de-sac,
and adnexa
 • Screen for colorectal cancer
• Assess pelvic pathology
 Vaginal hand is removed & clean glove applied • Apply lubricant to
middle (rectal) finger • Place middle finger against anal sphincter in
a palm up position • Ask patient to bear down • Gently insert
lubricated finger

 Insert index finger into vagina & locate cervix • Apply downward
pressure with the abdominal hand & outline the uterus • Check
adnexal areas using both rectal & vaginal fingers • With rectal &
vaginal fingers, also palpate:

o Rectal walls (masses, lesions, fistulas) • Anal sphincter (tone

5. Rectal Exam
• Insert gloved, lubricated finger into rectal vault • Palpate for hemorrhoids,
masses, tone • Remove finger • Fecal occult blood test (FOBT)
Use tissues to remove any excess lubricant • Pull drape over patient’s legs •
Assist patient to sitting position • Inform patient when to expect test results
• Give patient opportunity to ask any remaining questions

Completion of Examination
 Remove lubricant, assist the patient to a sitting position
 Discuss test results and answer any questions

Documentation
Documentation • External genitalia without lesions on the labia majora and
minora. No discharge. (Tanner stage if adolescent) • Vaginal mucosa pink
and moist without lesions. • Cervix nulliparous, pink and smooth with no
polyps, cysts, ulcerations or friability. Os without friability or discharge. •
Uterus midline (anteverted, anteflexed, retroverted, retroflexed), normal
height, non-tender to palpation. • Adnexa non-tender to palpation, negative
Chandeliers. • Ovaries normal size (describe size if possible). Ovaries not
palpable (or ovaries smooth, rubbery soft, slightly tender, & approximately 2
cm in size bilaterally). No cervical or adnexal tenderness noted. • Post-
menopausal—ovaries shrink 3-5 yrs after • Rectal vault without masses;
good sphincter tone.

Variations and Abnormal Findings

  Bartholin cyst, Nabothian cyst

BREAST ASSESSMENT
Key Terms
 Axillary nodes
 Central
 Lateral
 Subscapular (posterior)
 Pectoral (anterior)
 Areola
 Nipple
 Montgomery’s glands
 Ligaments of Cooper
 Lactiferous duct
 Pectoralis major
Know where the breast and nipple lie in the ribs!!
Manubrium hooks into 1st rib, 2nd rib is Angle of Louis
 Nipple is at the 5th intercostals space
Tail of Spence goes all the way to axilla and where most cancers
occur first.

Know Lateral, Central, Subscapular, & Anterior!!

Flow of drainage to Lymph Nodes- If you feel a supra or
infraclavicular node, your alarms should be sounding because it
means that something below it is happening and you shouldn’t be
able to palpate it.
Anatomy
 Ribs: 1st, 2nd, 3rd, 4th, and 5th ribs
 Nipple, Areola, Montgomery glands (little bumps on areola)
 Breast lymphatics

Physical Exam: Inspection

 Four positions for inspection:
1. Arms at side
2. Arms overhead
3. Hands on hips (press pectorals forward)
4. Leaning forward
 Assess for:
 Size, shape, symmetry
 Color, lesions
 Venous pattern, dimpling, or retraction
 Vascularity can indicate blockage
 Nipple and areola: Position and direction, any discharge
 Axillae: Color, lesions, rashes

Inspection Abnormalities
  Unilateral vascularity
 Unilateral nipple inversion
 Inversion for entire life is normal, looking for new changes

 Peau d'orange skin (associated with inflammatory breast cancer)

 Dimpling, retraction
 Supernumerary nipples (normal variant)
 Inverted nipple: Abnormal if it is a recent change

Palpation
 Breasts and lymph nodes
 Lymph nodes: Axillary, epitrochlear, supra- and infraclavicular
 Assess: Consistency, masses, tenderness
 Breasts: Elasticity, tenderness, discharge

Mass Characteristics (if present)

 Location
 Size
 Shape
 Consistency (Hard/ firm)
 Mobility
 Nipple/skin changes
  Tenderness
 Lymphadenopathy

Special Breast Examinations

 Male breast: Check for abnormalities, sitting, axillary notes, lie supine
 Post-mastectomy: Examine the scar area (most common site for
recurrence), check scar area as that is most common site for
reoccurrence
 Check axillary nodes

Lifespan Changes
 Older adults:
 Breast atrophy, decreased glandular tissue
 Breasts become smaller, pendulous, and flatter
 Ductal tissue becomes more palpable (stringy)
 Pregnancy changes:
 Breasts increase 2-3 times in size
 Nipples enlarge, areola darkens
 Superficial veins become prominent
 Colostrum may be expressed

Tanner's Staging (Breast Development)

 Stage 1: Preadolescent
 Stage 2: Breast budding
 Stage 3: Coning without contours
 Stage 4: Secondary mound formation
 Stage 5: Mature stage, nipple projection
 Typically begins at ages 10-11 due to estrogen release during
puberty
Mammogram: USPSTF Guidelines
 Category B (ages 50-74): Biennial screening recommended
 Category C (ages 40-49): Individualized decision based on potential
benefits and harms. There’s a lot of false positives for woman in their
40’s. But if the benefit outweighs the risk, such as family hx, then it’s
individual preference

Health Promotion: Breast Self-Examination (BSE)

 American Cancer Society: Research does not show a clear benefit of
regular physical breast exams by health professionals or self-exams.
Women should be familiar with their breast appearance and feel, and
report any changes.
 USPSTF: BSE or clinical breast exams are Category D (not
recommended)
 BSE:
 Learn breast familiarity
 Perform after menses (before ovulation)
 For post-menopause: Perform on the 1st day or 1st Sunday of the
month
 American Cancer Society— “Research has not shown a clear
benefit of regular physical breast exams done by either a
health professional (clinical breast exams) or by women
themselves (breast self‐exams). Women should be
familiar with how their breasts normally look and feel and
should report any changes to a health care provider right
away.” • USPSTF—BSE or clinical breast exam—Category D •
BSE—Benefit‐‐gain familiarity with breast • After menses before
ovulation • Menopause‐ 1st day of month or first Sunday of
month

AHA WEEK 10
Mental Status Examination

 Includes:
o Appearance and behavior
o Speech and language
o Mood and affect
 o Thoughts and perceptions
o Cognition:
 Memory
 Attention
 Information and vocabulary
 Calculations
 Abstract thinking
 Constructional ability

Appearance and Behavior

 Level of consciousness:
o Alert: the patient is awake and aware.
 Orientation to time, place, person, situation
 Lethargic: you must speak to the patient in a loud forceful
manner to get a response.
 Obtunded: you must shake a patient to get a response.
 Stuporous: the patient is unarousable except by painful
stimuli.
 Coma: the patient is completely unarousable.
 Posture
o Erect, slumped?
 Motor behavior
 Personal hygiene, dress, grooming
 Affect
o Facial expression
o Is it appropriate to the stated mood or the situation?
o Examples of disturbed affect:
 Flat- depression
 Labile- Ex. From tears then smiley
 Inappropriate
 Stony- (Parkinsonism)

Further Details on Appearance and Behavior

 Posture and motor behavior:

o Does the patient sit in chair or exam table or prefer to walk
around?
 Pacing, rill rolling, etc
o Is the patient agitated with repetitive movements?
 Assess the patient’s dress, grooming, and personal hygiene:
o Generally, grooming and hygiene deteriorate in depression or
schizophrenia.
 Assess the patient’s facial expressions:
 o A flat affect (lack of facial movement) can be seen due to a
physical reason such as Parkinson’s disease or a psychological
reason such as profound depression.
 Assess the patient’s manner, affect, and relationship to people
and things:
o Does the affect reflect the mood?
o Is the affect stable or labile (mood changing from happiness to
tears and back quickly)?
o Does the patient seem to see or hear things you do not?

Speech and Language

 Quantity: Is the patient talkative or silent?

 Rate: Is the speech fast or slow?
 Volume: Is speech loud or soft?
 Articulation of words: Does the patient speak clearly and distinctly?
 Fluency: Involves the rate, flow, and melody of speech.
o Hesitancies in speech (as seen in patients with aphasia from
strokes).
o Monotone inflections (schizophrenia or severe depression).
o Circumlocutions: words or phrases are substituted for the
word a person cannot remember; e.g., “the thing you block out
your writing with” for an eraser.
o Paraphasias: words are malformed (“I write with a den”),
wrong (“I write with a branch”), or invented (“I write with a
dar”).
 Make sure pt understands what they are saying or hearing
 Fetal alcohol syndrome, many time pt doesn’t
understand so they end up in correctional system a
lot and don’t understand their Miranda rights etc.
 Look for discrepancies between fluency and comprehension:
o FASD (fetal alcohol syndrome): Speech clear but not
understand concepts.
o Wernicke disorder (Vit B1 deficiency): Speech is fluent, rapid,
effortless but words and sentences lack meaning. May have
paraphasias.

Language Terminology

 Language: Symbolic system for expressing written and verbal

thoughts, emotion, attention, and memory.
 Need language to assess other mental functions.
 Cultural differences, particularly with language:
o Cultural humility
  Self-awareness
 Respectful communication
 Collaborative partnerships

Assessing Mood

 Use open-ended questions (OARS):

o “How do you feel about that?”
o “How are you feeling?”
o “How long have you felt this way?”
o “How good or bad has the patient felt?”
 Do not be afraid to ask the patient about thoughts of self-harm
or suicide. Always ask.

Affect and Mood

 Affect: The observable mood of a person expressed through facial

expression, body movements, and voice.
 Mood: The sustained emotion of the patient.
o Euthymic: normal
o Dysthymic: depressed
o Manic: elated

Thought and Perceptions

 Thought processes:
o The logic, coherence, organization, and relevance of a patient’s
thoughts as they lead to thoughts and goals; HOW people think.
 Examples of disorders of thought processes: flight of ideas
or derailment.
 Insight:
o Awareness that thought, symptoms, or behaviors are normal or
abnormal; e.g., distinguishing that a daydream or hallucination is
not real.
o Ask the patient about the reasons behind his clinic visit.
o Patients with psychological disorders often lack insight into their
disease.
 Judgment:
o Process of comparing and evaluating different possible courses
of action.
o May be able to assess judgment by noting the patient’s
responses to stressors, e.g., relationships, job, and finances.
Thought and Perceptions: Perceptions

 Perceptions:
o External stimuli: sensory awareness of the objects in the
environment to the five senses and their interrelationships.
 Eg. Burning on stove
o Internal stimuli: dreams or hallucinations.
 Abnormalities of perception:
o Illusions: Misinterpretations of real stimuli; e.g., the postman
leaves mail, therefore there is a plot to poison the patient.
o Hallucinations: A stimuli the patient hears or sees that others
do not hear or see and that the patient may not recognize as
false; these can be auditory, visual, olfactory, gustatory, or
tactile.
 e.g., Abe Lincoln speaks to the patient from the back of a
penny.
 Do not include false perceptions associated with
dreaming/falling asleep.

Cognitive Function

 Attention: The ability to focus or concentrate over time on one task or

activity.
 Memory: The process of recording and retrieving information.
o Short-term memory: minutes to days before.
o Long-term memory: months to years before.
 Higher cognitive functions:
o Level of intelligence assessed by vocabulary, knowledge base,
calculations, and abstract thinking.

Higher Cognitive Functions

 Information and vocabulary

 Complexity of ideas
 Calculating ability:
o Ask the patient to perform more difficult calculations such as
making change (e.g., if you had a dollar’s worth of nickels and
someone needed 65 cents how many nickels would you have
left?).
 Abstract thinking:
o Interpreting proverbs: “A stitch in time saves nine”, “Squeaky
wheel gets the grease”.
 o Similarity exercises: What do a ball and an orange have in
common?
o Eg FASD – Fetal Alcohol Syndrome

Cognitive Functions—How to Assess

 Assess orientation to person, place, and time.

 Assess attention:
o Three Digit recall: Give the patient 3 numbers to recite back to
you in a few minutes.
o Serial 7s: Ask the patient to subtract serial “7s” from 100.
o Spelling backward: Ask the patient to spell W-O-R-L-D
backwards.
 Assess remote memory: By asking about past historical events.
 Assess recent memory: By asking about something recent (weather,
national event, last night’s dinner, etc.).

Higher Cognitive Functions: Constructional Ability – Dementia

 Ask a patient to copy a geometric figure onto a sheet of paper such as

a triangle, circle, pentagon, diamond, or a cube.
 Ask a patient to draw a clock face indicating 5:00.

Standardized Mental Status Examinations

 Mini-Mental State Examination™ (MMSE):

o Cognition dysfunction or dementia.
o Standardized score, highest possible 30.
o Must be purchased thru the Psychological Assessment Resources
 Psychological Assessment Resources:
o Anxiety:
 Mobility Inventory for Agoraphobia (MIA)
 Agoraphobia Cognitions Questionnaire (ACA)
 Body Sensations Questionnaire (BSQ)
o Depression:
 Primary Care Evaluation of Mental Disorders (PRIME-MD)
 Beck Depression Inventory
 Hamilton Depression Rating Scale
 Edinburgh Postnatal Depression Scale

Mental Health Interview Process

Chief Complaints: FNP vs PMHNP

 FNP:
o Not sleeping well
o Feel tired all the time
o Can’t concentrate
o Kids failing school
o Loss of family member
o E.g. My head hurts, stomach hurts, etc.
 PMHNP:
o My wife/husband etc. told me to come in. I don’t know why I’m
here.
o My kids won’t listen. They are driving me nuts!
o I feel scared all the time.
o Referred by PCP. They can’t figure out what’s wrong with me.

Diagnostic Reasoning Process

 HPI -- OLDCARTS
 ROS: Include MH diagnoses
 PMH: Especially MH diagnoses
 FH: Especially MH
 SH: Where and how they live

OBJECTIVE

 Observe everything:
o Skin, hair, nails
o Oxygenation
o Eye contact
o Posture
o Clothing

For All Interviews: OARS

 O: Open-ended questions
 A: Affirmations
o Patient is doing the best they can do
o Affirm their strengths
 R: Reflective listening
o Let patient know you heard them
o Clarify
 Use their own words

 S: Summarize

Principles of Interviewing

 Find out what is important to the patient

o Goals and motivation
 Remember we do not have the answer for the patient’s situation
 Mostly listen while the person tells their story and understand their life
situation and their internal motivation
 Allow the patient to come up with their own answers—MUCH more
likely to change

Screen for Depression

 USPSTF Category B
 Screen for depression in:
o Adolescents, general adult population including pregnant and
postpartum women.
o Especially in rural areas
 Screening should be implemented with adequate systems in place to
ensure accurate diagnosis, effective treatment, and appropriate follow-
up.
o USPSTF, 2016

Screen with PHQ-2

1. Little interest or pleasure in doing things 0-3

2. Feeling down, depressed, or hopeless 0-3

 Score of 3:
o 90% specificity for Major Depressive Disorder (MDD)
o 95% specificity for any depressive disorder
 Score of 6:
o 99.8% specificity for MDD
 If 3 or higher then have patient fill out the PHQ-9

PHQ-9 Scoring
Valid means we are checking what we want to be checking (depression),
reliable is it can be used across populations.

Suicide

 People who committed suicide are more likely to have seen their
primary care provider than a mental health provider in the four weeks
prior to their death.
 ALWAYS ASK about suicidality
o Asking does not increase risk of suicide

Columbia Suicide Severity Rating Scale

1. Wish to be Dead:
o Have you wished you were dead or wished you could go to sleep
and not wake up?
2. Suicidal Thoughts:
o Have you actuallyhad any thoughts of killing yourself?
3. Suicidal Thoughts with Method (without Specific Plan or Intent
to Act):
o Have you been thinking about how you might kill yourself?
4. Suicidal Intent (without Specific Plan):
o Have you had these thoughts and had some intention of acting
on them?
5. Suicide Intent with Specific Plan:
o Have you started to work out or worked out the details of how to
kill yourself and do you intend to carry out this plan?
6. Suicide Behavior:
o Have you done anything, started to do anything, or prepared to
do anything to end your life?

WEEK 11
Slide 1: Children and Adolescents
 Cognitive Stages of Development
o Preoperational—without sustained logical thought processes
 Early childhood (1 to 4 years)
o Concrete operational—capable of logic and more complex
learning
 Limited in abstract reasoning
 Short-term focus
 Middle childhood (5 to 10 years)
 Early Adolescence (10 to 14 years)
o Transition period—problem-solving, decision-making
 Middle Adolescence (15-16 years)
o Formal operational—long term focus, abstract reasoning,
planning, organization
 Late Adolescence (17-20 years and into adulthood)

Slide 2: Early Childhood

 Ages 1-4 Years
o Tips for Examining the Young Child
 Use a reassuring voice throughout the examination
 Let the child see and touch the examination tools you will
be using
 Avoid asking permission to examine a body part; instead,
ask the child which body part he or she would like to have
examined first
 Give a choice
 Examine the child in the parent’s lap; allow the parent to
undress the child
 If unable to console the child, allow a short break while
maintaining respect for the parent’s parenting
 Make a game out of the examination
Slide 3: Early Childhood (1 to 4 years)
 Rate of Growth
o Slows to 50% of that of infancy
 Tips for Examination Sequence
o Start with the child seated – examine the eyes, palpate neck,
percuss/auscultate
o Move child to supine position – examine abdomen,
musculoskeletal, nervous system; examine genitalia last
o End the examination with the patient upright; look at the
throat and ears
o Stand to observe gait, balance, squatting, stand or hop on one
foot
 Early Childhood (1 to 4 years): VS, HEENT
o Vital Signs
 Measure blood pressure starting at age 3 and then
screen annually****
o Neck
 Palpate for lymph nodes; adenopathy is common on
posterior cervical chain- EXPECTED
o Eyes
 Cover and uncover test for position and alignment of eyes
 Hirschberg’s
 Funduscopic: red reflex, cataracts
o Ears
 Visualization of tympanic membrane is the greatest
challenge
 Pull back and down under 1, up and back over 1
o Nose/Sinuses
 Maxillary sinuses present by age 4
 AAP Guidelines on BP Screening
o Flynn JT, Kaelber DC, Baker-Smith CM, et al., and AAP
Subcommittee on Screening and Management of High Blood
 Pressure in Children. Clinical practice guideline for screening and
management of high blood pressure in children and adolescents.
Pediatrics. 2017;140(3)

Slide 4: Early Childhood (1 to 4 years)

 Heart
o Brachial pulses still easier to feel than radial
 Abdomen
o Protuberant abdomen still normal
o Liver span 1-2 cm below costal margin is still normal
o Spleen edge 1-2 cm below costal margin is normal
 Male Genitalia
o Testes undescended in scrotal sac by age 1 is abnormal and need
to refer unless retractile
 Musculoskeletal System
o Knock-knees from 18 months to 4 years of age
 Genu valgum
o Inspect spine for scoliosis in any child who can stand

Slide 5: Question
 You enter the room of a 2-year-old female who is visibly upset and
afraid of being at the clinic. To facilitate the examination, which of the
following actions would be most appropriate?
o a. Tell parent to calm the child and that you’ll return when the
child is calm
o b. Have the parent leave the room since his or her presence is
making the “acting out” worse
o c. Ask the child’s permission to examine a body part
o d. Examine the child in the parent’s lap

Slide 6: Middle Childhood

 Ages 5-10 Years
  Middle Childhood (5 to 10 years)
o Sequence that is used in adults can be used
o Nose and Paranasal Sinuses
 Frontal and sphenoid sinuses by age 8
o Tonsils
 Large
o Breasts: Thelarche
 Development in girls is the first sign; may start as early as
age 6 or 7 depending on ethnicity
o Musculoskeletal System
 Peak growth is 8-16 years
o Inspect legs and feet
o Inspect spine scoliosis
 Adolescence: Breast
o Puberty: Thelarche (Breast development)
o Tanner stages to determine stage of puberty
 Stage 1: Preadolescent. Elevation of nipple only
 Stage 2: Breast bud stage
 Stage 3: Further enlargement of elevation of breast and
areola with no separation to their contours
 Stage 4: Projection of areola and nipple to form a
secondary mound above the level of breast
 State 5: Mature stage, projection of nipple

Slide 7: Adolescence
 Female Tanner Stages
o Female puberty
o Tanner stages to determine stage of puberty
 Male Puberty
o Male puberty
 Sometimes testes grow while penis is still prepubital.
Normal
o Tanner stages to determine stage of puberty
 o

Infant Physical Assessment

 Infants, Children, and Adolescents Well Visits
o Areas assessed at every visit
 Physical development
 Cognitive and language development
 Social and emotional development

Tips for Examining an Infant

 Sequence of Examination
o If asleep, stay asleep
o Perform non-disturbing maneuvers early
 Anterior and posterior fontanelle first, cardiac/lungs
next w/ warm stethescope
o Perform potentially distressing maneuvers near the end;
e.g., ears, mouth, and musculoskeletal system
Infancy: Growth in First 12 Months
 Newborn
o Lose average of 5-10% of birth weight
o Regain by 7 to 10 days
 0-12 months is the most rapid rate of growth
o Double birth weight by 4-6 months
o Birth weight triples by 12 months
o Height increases by 50% by the end of year one

Infancy: Physical Examination Features

 Head
o Inspect for symmetry, size, shape
o Palpate:
 Anterior fontanelle:
 90% close between 7 and 19 months
 13 months median
 About an 1” in diameter
 Posterior fontanelle:
 Usually closes by 2 months of age

Critical Thinking Question

 An 8-month-old child presents with a posterior fontanelle that closed 6
months ago, but the anterior fontanelle is still open and soft. Which of
the following is true about this infant?
o a. The anterior fontanelle should be closed by now.
o b. Both fontanelles should close within 2 to 4 months of each
other.
o c. The posterior fontanelle has closed early.
o d. The anterior fontanelle is appropriate to still be open.
Infancy: Eyes, Ears, Nose
 Eyes
o Inspect sclerae, pupils, irides, extraocular movements
 We hold baby with head supported. Turn your body
o Funduscopic: presence of red reflex
o By one month—fixes on objects
o Must maintain eye contact by 4 months—if not, refer
 Can indicate autism or another deficit.
 With autism, can have eye contact initially as baby
and then it goes away
 Ears
o Check the newborn screening hearing test results
 BAER—Brainstem Auditory-Evoked Response—pass
o Skin tags—check for renal disease or FH hearing loss
 Could indicate kidney disease or FH hearing loss.
 Skin tags and kidneys are formed at very similar
times in the wound.
 Skin tags can be common – can be normal. Most of
time, baby has already had renal ultra sound in the
hospital.
o Acoustic blink reflex
 If we snap our fingers by baby’s ear, eyes should blink
o TMs are dull, gray, immobile in first 1 to 4 weeks
o DOWN and BACK until ~3 years old

Critical Thinking Question

 What would the NP anticipate when doing the eye exam on this infant?
 o A. Red reflex is present in both eyes.- no because cataract on
one eye
o B. Cover test will be positive.
o C. Fundoscopic exam will show sharp disc margins.- No because
cataract
o D. Red reflex will be present in left eye only.

Mouth and Neck

 Nose
o Infants prefer nose breathing but are not obligate nasal breathers
for the first 2 months of life
 Saline and humidifier come in handy
 Mouth/Pharynx
o Inspect mucosa, tongue, gums, palate, tonsils, and posterior
pharynx
o Palpate gums and teeth
 Teeth: 6 to 26 months of age, 1 tooth per month
 Central and lateral incisors erupt first, molars last
 Neck
o Assess mobility of neck
o Torticollis— “twisted neck”- common finding
 The SCM is tight on one side and baby will rest head on
one side b/c it hurts them> leading to flattening of head on
one side, plagiocephaly
 Flattening of head—plagiocephaly
 Check head regularly
 Tummy time keeps head off flat side
  Stimulate on other side: bottle, breast

Infancy: Thorax and Lungs

 Inspect for color, respiratory rate, and work of breathing
o Thorax is more rounded in infants than in older children and
adults
 Must auscultate for respiratory rate d/t irregular
and rapid breathing
 Take onesie off!!
 Work of Breathing
o Nasal Flaring
o Chest wall, mid-epigastrium, and suprasternal notch for
retractions
o Retractions:
 Suprasternal
 Intercostal
 Substernal
 Subcostal
 Auscultate
o Generally, sounds are louder and harsher
o Distinguish between upper and lower airway sounds
 Upper: loud, symmetric transmission throughout the chest
and are coarse during inspiration
o Newborn 0-2 months: RR 30-60- NORMAL
o Infant 2-12 months: RR <50/min
o Percussion is not helpful in infants
 Intercostal: Take a lot of energy. Need immediate intervention.
Leads to severe respiratory distress.

Infancy: Cardiovascular
 Heart
o Inspect for cyanosis:
 Buccal mucosa, tongue, conjunctivae, nailbeds
o Palpate:
 PMI is not always palpable; 1 interspace higher than in
adults
 In babies, it’s in the 4th intercostal space
 Thrills
 Feel with finger pads all 5 cardiac landmarks-
always!!!!
 Peripheral pulses, especially brachial- Easiest one to find
 Check BUE AND BLE- femoral
o Auscultate:
 S1, S2 (Split S2 is normal)
 S3 is frequently heard and is normal in infants
 Likely to hear d/t thin chest wall
 Murmurs – functional murmurs vs. pathologic
 Don’t need to know which one is which in this course
Infancy: Breasts, Abdomen, Male/Female GU
 Breasts
o Breast buds common in newborns (secondary to maternal
estrogen)
 Resolves within year, normal
 Abdomen
o Inspect – umbilical cord remnant is gone on average by 2 weeks
of age
o Palpable liver edge 1-3 cm below costal margin is normal;
palpable spleen tip is normal
 Peds= palpable (3 finger widths)
 Adult- Absent/ Not palpable – normal
o Rectal – generally not done
 But make sure testes have descended into the sac, if not,
they can bake and become cancerous
 Male Genitalia
o Inspect
o Palpate for descent of testes into scrotal sac
 If testes are not in the sac, the testes will bake.. need to
stay cool
 Female Genitalia
o Inspect using labial traction
o May be milky discharge from maternal estrogen in newborns

Infancy: Musculoskeletal
 Inspect the Spine (skin or hair on spine—abnormal)
 Palpate the Clavicle (check for fractures)
 Legs
o Bowlegged (Genu varum) to age 18 months is normal
o By 2, Abnormal
 Feet
o Club foot—rigid
 Immediate referral while foot is still growing.

o Metatarsus adductus—flexible
 6-9 months bones start to calsify so need to address before
that with special shoes
 Put shoes on opposite foot to help with alignment
 Hips- don’t have to know how to do each maneuver
o Inspect skin folds on thighs
o Ortolani- externally rotating and abducting the hip- know!!!
o Barlow- externally rotating and abducting the hip- know!!!
 Index and 3rd finger over greater trochanter b/c that’s
where you feel the click
o Allis sign
 One knee lower than the other, and thigh unsymmetric
folds
 Spine: tufts, dimples, discoloration
o Hair and discoloration or fistulas, always need to be referred to
specialist
 o

Neurological System
 Inspect/Palpate Motor Tone (passive ROM). Lay prone and supine
o Make sure baby using bilateral strength, example both
arms to push themselves up
 Normal Newborn Reflexes- KNOW!!!
o Grasp reflex—put object into palm, infant flexes fingers
o Moro reflex—let head fall into examiner’s hand, startles infant,
arms abduct and then flex. Legs flex.
o Rooting reflex—stroke the perioral skin. Infant will turn head to
that side and suck.
o Tonic neck reflex—place supine turn head to the side, leg and
arm on the same side (ipsilateral) extends. Opposite side
(contralateral) flexes
o Babinski Positive—toes curl up (until walking)
 By 6 months the triceps, brachioradialis, abd. reflexes are present

Critical Thinking Question

 Which of the following indicates that an infant can hear? Select all that
apply
o A. Acoustic blink reflex intact
o B. Moro reflex intact
o C. Babbling at 6 months- good sign learning how to speak
o D. BAER test pass- Has to be both ears.
 o E. No skin tags
Don’t need to know what ages reflexes disappear. KNOW THE
REFLEXES IN THE PPT

Week 12
Statistics
 Population Growth:
o Older Americans currently at 46 million, projected to reach 98
million by 2060.
o Older adults constitute 24% of the population.
o Fastest-growing age group: individuals over 85.
o Current U.S. lifespan: 81 years for women, 76 for men.
The Older Adult
 Focus on Healthy Aging:
o Emphasis on cognition, mental health, physical activity, and
social networks.
o Functional assessment and family, social, and community
support are essential.
o Promote long-term health and safety.
Primary Aging
 Physiologic Reserve Decline:
o Independent of disease, affecting function, morbidity, and
mortality.
o Impactful during stress.
Vital Signs
  Key Changes:
o Blood Pressure: Arteries stiffen, leading to atherosclerosis.
o Heart Rate & Rhythm: Increased atrial and ventricular ectopy.
o Respiratory Rate: Typically unchanged.
o Temperature Regulation: Reduced adaptability, less likely to
develop a fever.
Anatomy and Physiology
 Skin, Nails, and Hair:
o Skin becomes fragile, purple patches appear.
o Nails thicken, hair loses pigment.
 Eyes:
o Common conditions: Arcus senilis, presbyopia.
 Ears and Mouth:
o Ears: Presbycusis (hearing loss).
o Mouth: Decreased saliva, taste changes.
Cardiovascular System
 Thorax and Lungs:
o Reduced exercise capacity, stiffness, decreased gas exchange.
o Kyphosis and barrel chest may develop.
 Heart:
o S3 may suggest heart failure; S4 indicates decreased vascular
compliance.
o Murmurs common from conditions like aortic stenosis and mitral
regurgitation.
 Peripheral Vascular System:
o Atherosclerosis risk, potential for AAA, temporal arteritis.
Breast and Abdomen
 Breast Changes:
o Size diminishes, ducts become more palpable.
 Abdomen:
 o Fat accumulates in lower abdomen and hips.
o Blunted pain response to acute abdominal disease.
Male and Female Genitourinary (GU)
 Female:
o Menopause typically occurs between ages 48-55; symptoms may
include hot flashes.
o Post-menopausal changes: vaginal dryness, urge incontinence.
 Male:
o Sexual interest remains, but erectile function may decrease.
o Benign prostatic hyperplasia begins in the third decade.
Musculoskeletal
 Changes:
o Trunk shortens, kyphosis, and osteoporosis.
o Muscle mass decreases; range of motion may decline due to
osteoarthritis.
Nervous System
 Mental and Physical Function:
o Decline in brain volume and intrinsic networks.
o Common cognitive changes: slower data retrieval, benign
forgetfulness.
o Risk for delirium and diminished reflexes.
Geriatric Syndromes and Health History
 Health History:
o Importance of respectful communication, proper lighting, and
allowing time.
o Older adults often underreport symptoms.
 Cultural Considerations:
o Knowledge of cultural impacts on work, retirement, health,
medications, and end-of-life decisions.
Functional Impairments
 Assessment Tools:
 o Activities of Daily Living (ADLs): Bathing, dressing, toileting,
etc.
o Instrumental Activities of Daily Living (IADLs): Shopping,
managing money, etc.
Areas of Concern for Older Adults
 Medication Management:
o Use Beers criteria, reconcile medications.
 Nutrition:
o Assess for malnutrition.
 Social and Psychological Support:
o Consider isolation, advance directives, and palliative care.
 Depression and Cognitive Decline:
o Screening tools: Geriatric Depression Scale (GDS), Mini-Mental
State Examination (MMSE).
Physical Examination
 General Survey:
o Focus on functional status, risk of falls.
 Vital Signs:
o Blood pressure, weight, pulse pressure, and arrhythmias.
 Skin and HEENT:
o Assess for signs of aging like skin thinning, actinic purpura.
 Cardiovascular and Peripheral Vascular:
o Check for bruits, diminished pulses indicating occlusions.
 Abdomen:
o Inspect for masses or bruits.
 Breast and Axilla:
o Investigate any lumps or masses.
 Genital Exams:
o Check for masses and other abnormalities.
 Musculoskeletal:
 o Examine for joint deformity, gait, and balance.
 Nervous System:
o Assess for deficits, memory issues, signs of Parkinson’s.
Health Promotion and Counseling
 Encouragement of Preventative Care:
o Regular screenings, exercise, safety measures, immunizations,
cancer, vision, and hearing checks.
 Screen for:
o Depression, cognitive impairment, elder abuse.

WEEK 12
Lot of info on this, listen to it again to catch
what was missed

Outline: Older Adult

Statistics
 Older Americans now number more than 46 million; expected to reach
98 million by 2060.
 Older adults make up 24% of the population.
 Fastest-growing age group is over 85.
 In the United States, lifespan is currently 81 for women and 76 for
men.

The Older Adult

 Focus on healthy or “successful” aging:
o Positive cognition, mental health, physical activity, and social
networks.
o Consider functional assessment and limitations.
o Understand and utilize family, social, and community support.
o Opportunities for promoting long-term health and safety.
Primary Aging
 Changes in physiologic reserve over time, independent of disease.
 Can lead to impairments, decline in functional capacity, morbidity, and
mortality.
o As you age, there is a decline in thirst leading to dehydration,
leading to drop in BP, leading to risk for falls
 Most impacted during times of stress.

Vital Signs
 Blood Pressure: Aorta and large arteries stiffen and become
atherosclerotic.
o As aorta is less able to expand, causes stroke volume > greater
rise in SBP.
 DBP usually stops rising in 6th decade.
 Heart rate and rhythm: Atrial and ventricular ectopy.
 Respiratory rate: Unchanged.
 Temperature regulation: Not as adaptable, less likely to have a fever
due to decreased inflammatory response.
o Susceptible for hypothermia d/t loss of fat cells
 Less like to have a fever- decreased inflammatory response
o Sometimes they have a UTI and only symptoms is confusion, or
sepsis with no fever.

Anatomy and Physiology – Skin

 Skin, nails, and hair changes:
o Skin becomes fragile, loose, and transparent (hands/forearms).
o Purple patches (actinic purpura).
o Nails lose luster, yellow, and thicken.
o Hair loses pigment, hairline recedes, hair loss occurs on trunk,
axilla, pubic area, and limbs.
 Aging causes thinning of scalp hair as they age
 o Women over 55 may develop coarse facial hair.

Eyes
 Eyeballs recede into orbit, dry eyes.
o Dry eyes d/t fewer lacramal secretions
 Corneas lose luster; Arcus senilis is common (fatty deposit common in
older eyes, unrelated to cholesterol) = Opaque ring around eye
o In younger adults, it can be due to hypercholesterinemia but not
in older aldults
 Pupils become smaller.
o Making it harder to see at night
 Presbyopia is common.
o Farsightedness, light rays behind the retina instead of on the
retina making it harder to see things up close
 Requires bifocal or reading glasses

Ears and Mouth

 Ears:
o Presbycusis: Acuity of hearing diminishes with age.
o Decreased hearing with higher tones.
 Lower tones when speaking
 Mouth:
o Diminished salivary secretions and decreased sense of taste.
o Medications may also cause these symptoms.

Heart and Lungs

 Thorax and lungs:
o Capacity for exercise decreases, chest wall stiffens, cough less
effective, gas exchange declines.
 At risk for atelectasis- when alveoli collapse making it
difficulties to have O2 and CO2 exchange
 o Skeletal changes cause kyphosis, barrel chest.
 Curvature of thoracic spine
 Cardiovascular system:
o Carotid systolic bruits in middle/upper portions of artery suggest
partial obstruction.
 Increases risk of stroke.
 Have them hold breath when listening. If you hear bruit,
need to refer to doppler and on to cardiovascular
cardiologist.
o S3 suggestive of congestive heart failure.
 Extra heart sounds are more likely to be heard after 40
o S4 suggests decreased vascular compliance and impaired
ventricular filling.
 Can be heard in healthy adults but much more likely to be
^^^

Cardiovascular
 Cardiac output: Myocardial contraction is less responsive to B-
adrenergic catecholamines.
o Drop in resting and maximum heart rate.
o Increased myocardial stiffness, leading to hypertrophy.
 Cardiac murmurs:
o Aortic stenosis from thickening of the aortic valve leaflets. Stiff
and unable to close properly
 1/3 of ppl over 60 will develop aortic stenosis and more
than half over 85 will have it. – Leads to murmur
o Mitral regurgitation from left ventricular compromise.
 Usually develops 10 years after aortic stenosis
o Aortic sclerosis: Outflow obstruction.
 Peripheral vascular:
o Atherosclerosis more likely in older adults.
o Increased risk for AAA and temporal arteritis.
Breast and Abdomen
 Breast and axillae:
o Breasts diminish in size as glandular tissue atrophies and is
replaced by fat.
o Ducts surrounding nipple become more palpable, firm, and
stringy.
o Axillary hair diminishes; males may develop increased breast
fullness.
 Abdomen:
o In later years, abd muscles weaken
o Fat tends to accumulate in the lower abdomen and hips.
o Pain from acute abdominal disease is blunted: pain less
severe, fever less pronounced. (Consequences of aging)
 Guarding and rebound tenderness may be diminished or
absent

Male and Female GU

 Female:
o Menstrual periods cease between ages 48-55.
o Women may experience hot flashes for up to five years, as
estrogen decreases> vaginal dryness, urge incontinence, or
dyspareunia.
o Ovaries are no longer palpable within 3-5 years post-menopause.
If you feel them, you should be concerned for a mass.
 Male:
o Sexual interest remains intact, but frequency declines.
o Erection is more dependent on tactile stimulation.
o Erectile dysfunction affects half of older men.
 Usually caused by peripheral vascular disease
 Prostate:
 o Benign prostatic hyperplasia begins in third decade, continues
into seventh decade, then plateaus.
 Only about half of all men with BPH will have
symptoms that include urinary hesitancy, urgency,
frequency and nocturia

Muscular
 Musculoskeletal:
o Height loss: Shortening of the trunk as intervertebral discs
become thinner, leading to kyphosis and increased AP diameter
of the chest
 M slower than W, and W faster after menopause
 Ca+ reabsorption from bone rather than diet increases with
aging as parathyroid hormones level rise
 This leads to bone density and may lead to osteoporosis
o Vertebral bodies may shorten or collapse due to osteoporosis.
o Skeletal muscles decrease in bulk and strength.
 30-50% decline in body mass in M & W
 Muscle mass due to inflammatory and interkin changes
and sedentary life style
o Range of motion may decrease from osteoarthritis or
inflammation of joints

Nervous System
 Aging affects mental status, motor and sensory function, and reflexes
affected by aging.
o Brain volume, brain cells, and intrinsic connecting networks
decrease.
o Most older adults perform well on mental status exams but may
display selected impairments
 Memory problems: Benign senescent forgetfulness:
forget names, objects.
o Older adults have slower data retrieval and processing, longer
learning times.
 o Increased susceptibility to delirium.
 Maybe the 1st clue to infection, medication complication, or
underlying impairment
o Motor –
 Older adults move and react with less speed and agility
 Muscle wasting occurs hands and extremities
 May develop a benign essential tremor
 Often confused with parkinsonism
o Position and vibratory sense
 Position sense may diminish or disappear
 This is knowing where their limbs are without seeing
them
 Loss of vibration in feet and ankles
o Reflexes
 Gag reflex, abdominal and ankle reflexes diminish or
absent

Geriatric Syndromes- Strongly linked to functional decline

 Found in over half of older adults aged 65, multifactorial,
linked to functional decline
Health History
 Elicit preferred way of being addressed.
 Ensure proper lighting in the exam room.
o Older adults need about 30% more light to ensure good vision
 Speak so the patient can hear.- 50% will develop hearing problems
o Most will develop prebycupous making it difficult to high-pitched
sounds
 Provide time for patient to talk.
 Older adults often underreport concerns and symptoms.
 Atypical presentation of illness.
o Older adults are less likely to have a fever
o MI atypical symptoms: SOB, syncope, palpitation, and confusion
o Hyperthyroidism atypical symptoms: 1/3 present with fatigue,
tachycardia, and weight loss instead of normal signs
 In lieu of classic symptoms like sweating, heat intolerance,
hyperreflexia
o Ask direct questions and use geriatric screening tool
 Assess fatigue, loss of appetite and pain

Cultural Dimensions of Aging

 Providers must acquire knowledge of health beliefs and culture.
o Culture affects all aspects of aging: work and retirement, health
and illness, medications, death and dying.

Assessing Functional Impairments

 Activities of daily living: Bathing, dressing, toileting, transferring,
continence, and feeding.
o First ask how well the older adult performs the basic ADLs
o Then move on to more complex functions: See below
  Instrumental activities of daily living: Telephone use, shopping,
preparing food, housekeeping, laundry, transportation, taking
medicine, managing money.
o Can pt perform independently, do they need help, or completely
dependent on others.

Areas of Concern for Older Adults

 Medications:
o Beers criteria, reconcile meds at each visit.
 Medications are the single most common modifiable reason
that increases risk for falls.
 Nutrition:
o Assess for poor nutrition.
 Many live alone, skip meals, or snack all day
 Smoking and alcohol:
o More than 40% drink alcohol, 4-5% binge drinkers, 2% alcohol
dependent
 No more than 2 drinks on any one day and no more than 7
drinks a week
o CAGE, AUDIT.
 Social support, isolation.
 Advance directives.
 Palliative care.
o Advance or terminal illness

Depression and Cognitive Decline

 Depression:
o 10% older men, 18% older women.
 Undiagnosed, untreated, or undertreated often
o Geriatric Depression Scale (GDS)
o Patient Health Questionnaire (PHQ) screening.
  Cognitive decline:
o Mini-mental State Examination (MMSE)
o Mini-Cog.

Physical Exam
 Functional status
 General survey: Risk for falls, hygiene, dress.
o Notice how they walk or posture
 Vital Signs:
o BP < 140/80 (ACC)
 As ppl age their Systole increases and Diastolic decreases
 widened pulse pressure
o listen for arrhythmias
 important to listen to an apical pulse instead of feeling for
radial pulse
o Height 1x yr & check weight at every visit.
 Weight can give you insight to diet and HF
 Skin: Physiologic changes of aging—thinning, wrinkling, loss of
elasticity, turgor.
o Actinic purpura- well demarcated purple macules
o Skin breakdown and pressure injuries
 HEENT: Examine for entropion, extopion, arcus senilis (Whitish around
the iris), hearing, dentition.
o Entropian: Inverted eyelashes, Extropian is when eyelashes turn
out causing excessive crusting of the eye
 Thorax and lungs: Perform usual exam, look for changes in pulmonary
function, increased AP diameter.
 Cardiovascular system
o Auscultate for carotid bruits
o Auscultate at the PMI and all cardiac sites
 S3, S4
  S3 suggests dilation of L ventricle from CHF
 S4 accompanies HTN
 Systolic murmur in R 2nd ICS suggest aortic sclerosis or
stenosis
 Harsh holist murmur at the apex radiating to axilla suggest
mitral regurgitation – the most common murmur in older
adults
 Peripheral vascular
o Diminished or absent pulse may indicate arterial occlusion
 If severely diminished, will need further work up for
peripheral arterial disease
 Abdomen
o Inspect for masses or visible pulsations
o Auscultate for bruits over aorta, renal and femoral arteries
o Palpate to the right and left of aorta for any pulsations
 Try to assess the width by pressing more deeply on each
lateral margin
 Breast and axilla
o Lumps and masses mandate further investigation
 Especially in tail of spence that extends into axilla
 Female genitalia and pelvic exam
o Allow time for careful positioning
o Explain pelvic exam
o For women who cannot flex the knees, ask assistant raise the
knees
 Male genitalia/prostate
o Pay attention to any masses in the rectum and nodularity or
masses of the prostate
 Inspect penis retracting foreskin if present as well as
testes, scrotum, and epididymis
 Proceed to rectal exam:
 Note rectal tone, nodularity, and masses of prostate
  ONLY the posterior portion of prostate is palpable on
digital rectal exam
 The anterior portions and central lobes are
inaccessible to palpation
 Musculoskeletal
o Joint deformity, deficits in mobility, or pain with movement
requires more thorough examination
o Abnormalities of gait and balance correlate with risk of falls -
Timed Up and Go Test
 Excellent screen for fall risk
 Stand from seated position, walk 10 feet and turn around
and walk back to chair and sit down all while timing it
 Normal if done within 10 seconds
 If joint deformities exist, pain with movement,
perform more thorough and comprehensive exam
 Pay attention to stride
 Nervous system
o Pursue further examination if any deficits are noted
o Focus on memory and cognition
o Look for signs of Parkinsons
 One of most characterizes signs I bradykinesia or slow
movement, shuffling gait and difficulty rising from chair

Health Promotion and Counseling

 Encourage:
o Regular health screening exams
 If they have medi-care, should be coming in once a year to
get them up to date with screening
 If no medi-care, should be coming in once a year for
wellness exam
o Exercise
o Immunizations
  Shingles, flu, covid, pneumonia etc.
o household safety
 Proper lighting, handles and railing, non-stick rugs
o cancer screening
 mammograms, cervical screenings, prostate cancer etc
o vision and hearing screenings
 Assess for:
o Depression @ least yearly
 Check PHQ-9 frequently and suicidal ideation, especially if
hx of MH
o dementia, mild cognitive impairment
o elder abuse

Pregnancy
Hormonal Changes

 Metabolic rate increases 15-20%

o Daily demands increased by 85, 285, 475 kilo calories in 1st-3rd trimesters
 Estrogen – increases prolactin and thromboembolic risk by 4-5 x that lead to
thromboembolic events
o Promotes endometrial growth to support embryo, marks enlargement of the
pituitary gland
 Progesterone – affects lungs, GI, GU
o Can lead to respiratory alkalosis and subjective SOB
 Human chorionic gonadotropin (HCG)
o Supports pregnancy and prevents loss of early embryo
 Thyroid hormones – physiologic hyperthyroidism (transient)
o Monitor frequently when thyroid issues are pre-existing
 Relaxin – relaxes SI joint and pelvis
o Sacral iliac joints
 Erythropoietin – increased blood volume

Anatomic Changes

 Abdomen – diastasis recti

o As muscle pulls away in twins or triplets, the uterus is only protected by skin,
fascia, and peritoneal lining
 Breasts – enlarge moderately & tender d/t hormonal changes and increased vascularity
o Hyperplasia of glandular tissue, more nodular- 3rd trimester
o Areolae darken- 3rd trimester colostrum begins to be expressed
 o Montgomery’s glands are more pronounced- sebaceous glands that support the
excretion of breast milk
o Venous pattern increasingly visible
 Uterus – palpable at 12 weeks, rotates to right
o Changes in shape and direction as baby grows. Rotates to right to accommodate
the colon
 Vagina – secretions are thick, white, profuse
 Cervix
o Chadwick’s sign – cervix bluish tint. Present 6-8 weeks after conception and
remains until delivery
o Hegar’s sign – softening of cervix on palpation; mucus plug protects the uterus
and fetus from outside pathogens, expelled a few weeks prior to delivery

Prenatal Visit

 Initial visit
o Confirm pregnancy with lab test
 Blood or urine
 Qualitative serum HCG or quantitive to determine how far along fetus is
in gestation
o Assess health status of mother
o Counsel mother – nutrition, fluids, stress
o ATOD – ask at every visit-matter of fact and open ended.
 How much alcohol did you drink before you got pregnant and how much
do you drink now?
 Tobacco cessation
 2nd worst drug to baby
 Alcohol cessation
 Alcohol is the most teratogenic to the fetus, no safe amount
 Cocaine, Mj, etc affect the brain, but effects don’t appear to be permanent

Subsequent visits

o Assess health status of mother

o Assess fetus

Prenatal Visit

 Assess for intimate partner violence

o Screen at prenatal visit and every trimester
o 1 in 5 women suffer some sort of abuse during pregnancy
 Ask pt how involved she would like you to be. It is her choice to decide
your involvement. Unless children are affected in which case you are
responsible to report to authorities
 Perinatal depression
o PHQ-9, Edinburgh Postnatal Depression Scale
 10% of women report prenatal depression at 1st visit
 Immunization status
 o Tdap regardless of status, Influenza (inactivated) any trimester
o Hep B, meningococcal, and pneumococcal are also safe during pregnancy
 Live vaccines: MMR, varicella, polio, Herpes zoster, Flu mist (live)
should be avoided and are not safe
 Caution: if mother is pregnant and one of her kids is due for live
vaccine, usually held until after baby is born
 Prenatal screenings
o Syphilis, urine culture, HepB, HIV, CBC, glucose tolerance test
 Any woman who gives birth to still born fetus should be tested for syphilis
 Recommended to send urine culture at 1st prenantal visit to screen
for asymptomatic bacteremia, IF +, tx with abx.
o All pregnant women are at increased risk of iron deficiency anemia
o If mom already has Hep B infection, medications can be given to decrease viral
load.
 If mother contracts HEP B during pregnancy, transmission to fetus is as
high as 90%.
 Baby can also be given Hep B vaccine at birth or immunoglobulin
to prevent transmission of the virus
o Oral glucose tolerance test should be administered between 24-28 weeks to screen
for gestational diabetes.

Rh Factor

 ABO type is important for hemorrhage & subsequent need of blood

 85% of the population is Rh Positive. Rh factor is inherited from parents
 Risk to fetus and newborn if blood of Rh-negative mother is mixed with Rh-positive fetus
 Anti-Rh antibodies can cross placenta and attack fetal blood cells
 Risk is increased with subsequent pregnancies
o Tx must be given during 1st pregnancy before mom’s body starts to make
antibodies
 Blood can cross during amniocentesis, baby’s position is turned and
trauma results, etc.
o Important***********RH- mom can also develop antibodies during ectopic
pregnancy, miscarriage, or during induced abortion so they still need to be treated
even if not carrying baby to term

Prenatal Visit – Continued

 Symptoms of pregnancy
o Absence of menses; breast tenderness
o Nausea and vomiting, fatigue, indigestion later in pregnancy
o Increased frequency of urination as baby pressing on bladder
 Assess maternal concerns and attitudes about pregnancy
o Was it planned? Is it desired? Does she plan to carry to term?
 Assess current state of health
o Exercise habits
o Occupational history, ask about workplace hazards
 Inhalants they are exposed to that can affect the fetus
  Are they on their feet all day? Do they sit all day?
o Assess current socioeconomic status
 Is father supportive and is he going to be involved?
 Does she have family support? Health insurance?

OB/GYN Documentation

 Gravida: Number of pregnancies

 Para: Number of completed pregnancies beyond 20 weeks (not number of children per
delivery)
 Preterm birth: 20 0/7 to 36 6/7
 Term births: 37 0/7 to 41 6/7
 Post-term births: 42+
 Abortions: # of spontaneous or induced abortions prior to 20 0/7 weeks gestation
 Living children: number of

Prenatal Visit: History

 Assess past obstetrical history

o Past pregnancies, prenatal or delivery problems
o Previous birth weights, miscarriages
 Assess past medical history
o Review systemic diseases that would affect a pregnancy (hypertension, diabetes,
seizures)
 Assess family history of congenital disease
o Sickle cell, cystic fibrosis, bleeding disorders
 If mom has bleeding disorder, she can be at higher risk for clot or
hemorrhage

Establish the Estimated Date of Delivery (EDD)

 Naegele’s Rule: take the first day of LMP (last menstrual period), add one week, subtract
three months, and add one year
 OR: Add 9 months plus one week
o Example: LMP 5/20/14 – add one week >> 5/27/14; subtract three months >>
2/27/14; add one year >> EDD 2/27/15
 The EDD can be verified in several ways:
o Doppler (positive at 10-12 weeks)
o Fetoscope (heard at 18 weeks)
o Fetal movement (quickening) 18-24 weeks
o Ultrasound

Practice Question

A pregnant patient reports the first day of her last menstrual period was July 11th of 2008. Based
on this information, determine her EDD using Naegele’s rule.
  Which of the following is the correct EDD?
a. 5/11/09
b. 4/18/09
c. 4/11/09
d. Information given is not sufficient to determine EDD

Pregnancy Physical Exam

 General inspection
o Overall health status, emotional state, nutritional state
o Baseline blood pressure is very important in establishing if a patient becomes
hypertensive during pregnancy
 Chronic HTN: BP >140/>90 before 20 weeks gestation
 Gestational HTN: BP becomes >140/>90 after 20 weeks gestation
 Preeclampsia: BP >140/>90 after 20 weeks’ gestation with protein in the urine

 Head: mask of pregnancy (chloasma), edema (puffy eyelids)

o Dark down discoloration
 Hair: often dry, thinning
 Eyes: examine conjunctiva; pallor could be anemia
 Nose: edema causing congestion is normal
 Mouth: periodontal disease is common in pregnancy
 Thorax and lungs: may have shortness of air
 Heart: listen for venous hums
o Common b/c of increased flow
 Breasts: symmetry and color; veins may be prominent

 Abdominal exam
o Inspect for scars (previous C-section), striae, Linea nigra
o Palpate for masses
o Palpate the uterus
o Fetal movement felt by examiner at 24 weeks
o Contractions palpated by examiner

 Fundal height
o Measure the fundal height from the superior portion of the pubis symphysis to the
top of the fundus
o From 20 weeks to 32 weeks, the fundal height in centimeters should approximate
the number of weeks of gestation
 After 20 weeks cm should match weeks of gestation
 Auscultation
o Auscultate the fetal heart rate with the doppler (from 10 weeks) or the fetoscope
(from 18 weeks)
o Fetal heart rate will be 150’s to 160’s during the first weeks of pregnancy, 120’s
to 140’s at term
 Should never be below 100 at any time in gestation
Practice Question

A pregnant patient at 8 weeks gestation presents for a routine prenatal check. She is excited and
wants to hear the fetus’ heartbeat. Using the doppler to listen midline just below the umbilicus, a
student shadowing you finds a heartbeat of 88 bpm. You suspect this is a maternal heartbeat.
Which of the following facts leads you to this conclusion?

 A. Normal fetal heart rate at this gestation is 150-160 bpm- HR should never be under
100!
 B. The pregnancy is too early to auscultate a fetal heartbeat
 C. The student is listening too high on the abdomen for this early gestation
 D. All of the above

 Genitalia: episiotomy scars and perineal lacerations from prior pregnancies

 Anus: hemorrhoids, fissures, genital warts d/t changes in immune system, anal fissures
are common
 Have patient bear down to look for rectocele or cystoceles
o Where the bladder or rectum are prolapsing
 Speculum exam
o Note the cervix color (Chadwick’s sign – cervix appears bluish in color),
consistency (Hegar’s sign – softness of cervix)
o Obtain PAP smear and STI cultures

Leopold’s Maneuvers (Can help determine the baby’s position)

 10-18 Wks fetal heart sounds are heard midline

 After that, best heard back or chest of infant and position of that
depends on the fetus position.

 First maneuver – upper pole

o Stand at the patient’s side facing her head. Keep the fingers of the hands together
and gently palpate with the fingertips the upper pole of the uterine fundus to
determine what part of the fetus is there (e.g., buttocks in the vertex position or
head in the breach position).
 If early in pregnancy, ok, but if not late in pregnancy, will be more
concerned.
 o

 Second maneuver – sides of maternal abdomen

o Place one hand on each side of the patient’s abdomen, capturing the fetus between
the hands. Use one hand to steady the fetus while the other feels for parts (back,
elbows, knees, arms, legs, hands, feet).
o Once the back is determined, the doppler should be placed there to assess heart
sounds.

 Third maneuver – lower pole

o Use the flat surface of the fingers of both hands to palpate the area above the
pubic symphysis. Note whether the hands diverge with downward pressure or stay
together.
o If the hands diverge, the presenting part is descended into the pelvis. If the hands
stay together, the presenting part is above the pelvis.
  Fourth maneuver – flexion of fetal head
o Facing the women’s feet, place hands on either side of the uterus, identify the
front and back of sides of the fetus.

WEEK 14
Genetics
 Key Terms
o DNA
o RNA
o Nuclear genome
 o X, Y chromosomes
 Autosomal inheritance
 Autosomal dominant
 Autosomal recessive
 X-linked inheritance
 X-linked dominant
 X-linked recessive
o Allele
o Dominant
o Recessive
DNA
 Deoxyribonucleic acid
o Primary molecular constituent of chromosomes
 Stores genetic information of humans
 Genetic information encoded by the sequence of the four bases: CGAT
o Cytosine, Guanine, Adenine, Thymine

RNA
 Ribonucleic acid
 Polymer consisting of phosphoribose and 4 bases
o Cytosine, Guanine, Adenine, and Uracil—CGAU
 Types of RNA
o Messenger RNA (mRNA)—Transmits the genetic information of the DNA
to the ribosomes (protein synthesis machinery)
o Ribosomal RNA (rRNA) is an integral component of ribosomes, the
organelles responsible for protein synthesis.
o Transfer RNAs (tRNAs) carry specific amino acids
Nuclear Genome
 Blueprint for the human genome
 Comprised of 3 billion (3x10⁹) base pairs of DNA
 Organized into 23 chromosomes
 o 22 autosomes and 1 sex chromosome (X or Y)
 Female (X, X)
 Male (X, Y)
 Gene—section of DNA that determines traits or characteristics
 Allele—gene variants that codes for a particular gene
o Eg. Hair or eye color

Chromosomes

 Most cells: 2 pairs of chromosomes (46 total, diploid)

 Germ cells: 23 chromosomes (22 autosomes + X or Y chromosome)
 Heredity:
o Autosomal conditions
o X-linked conditions- if inherited through x chromosome

Genotype and Phenotype

 Genotype: Gene expression (What’s in that gene)

o Homozygous—two same alleles
o Heterozygous—two different alleles
 Phenotype (what does it present as): Physical traits of alleles (e.g., blue eyes, black
hair)

Trait Inheritance

 Allele—occurs in pairs at a specific region or locus on a chromosome

o One from each parent
 Only one allele per trait
o Dominant: Only need one allele needed to cause the condition
o Recessive: Both parents must have the recessive gene
o Punnett Square

Autosomal Dominant Inheritance

 Example:
o Blood type A: Dominant
o Blood type O: Recessive
o Genotype: AA, AO
o Phenotype: Blood type A
 All offspring’s get Type A blood
 

Autosomal Recessive Inheritance

 Both parents must carry the recessive gene

 Example: Brown eyes (dominant, B), Blue eyes (recessive, b)
o Genotype: BB, Bb, bb
o Phenotype: 75% Brown, 25% Blue
 Examples: Sickle cell anemia, cystic fibrosis
o Both parents have to have the gene
X‐linked Dominant Pattern of Inheritance
 Dominant—so only one X chromosome mutation required for condition to be
inherited
 Everyone born with an X‐linked dominant disorder will have the disease
 A woman will transmit the disorder to 50% of offspring (male or female)
 A man will transmit the disorder to 100% of his daughters (they receive his X‐
chromosome)
 Rare
 Examples: Incontinentia pigmenti
X‐linked Recessive Pattern of Inheritance
 Recessive—so both parents need to have the recessive gene
 Mother—X chromosome carries the disorder
 Father—X chromosome carries the disorder
o No male‐to‐male transmission because mutation on the X chromosome
 Occurs usually in males
 Rare for females to get it.
 Examples:
o Hemophilia
 o Fragile X
o Duchenne muscular dystrophy
TELEHEALTH
NSC 832
1. Synchronous Telemedicine
 Real-time, audio-video communication that connects providers [physicians] and
patients in different locations.
o Note: This definition is used for telehealth for CMS* coverage and
payment.
o *CMS—Centers for Medicare & Medicaid Services
 Real-time audio and telephone communications.
o AMA (2021): Telehealth Framework for Practices
2. Remote Patient Monitoring (RPM)
 Patient data being collected and transmitted outside the office, mostly
asynchronous, resulting in clinical decision-making and care management follow-up
that may be provided in-person or virtually.
 Tools and wearable devices (may involve the use of mHealth apps) that measure
weight, blood pressure, pulse oximetry, respiratory flow rate, musculoskeletal
system status, therapy adherence, therapy response, and other patient-generated
data for review and treatment management.
o Telehealth Definitions Resource
3. Telehealth Visit Overview
 Establish the patient’s identity.
 Confirm that telehealth/telemedicine services are appropriate for the patient’s
individual situation and medical needs.
 Collect the patient’s medical history.
 Evaluate the indication, appropriateness, and safety of any prescription.
 Document the clinical evaluation and prescription; provide a visit summary to
the patient.
4. AMA Telemedicine Overview
 Deliver care in a transparent manner by:
 o Identification of the patient and physician/provider in advance of the
service delivery.
o Patient cost-sharing responsibilities.
o Any limitations on drugs that can be prescribed via telemedicine.
5. Set-Up Telehealth
 Determine protocols for if/when a telehealth visit is appropriate.
 Survey or set of questions for patients to answer electronically or over the phone
for triage.
 Obtain advanced consent from patients for telemedicine interactions.
o Document consent in the patient’s record.
 Establish protocols for referrals for emergency services.
 Abide by state Scope of Practice laws.
6. Set-Up Telehealth (Continued)
 Determine when telehealth visits will be available on the schedule.
 Set up space in your practice to accommodate telehealth visits.
 Reach out to the payer with the highest percentage of your patient population to
discuss telehealth payment coverage.
o Telehealth Modernization Act of 2020
o Telehealth Practice Implementation
7. Telehealth Challenges
 One in three U.S. households headed by seniors do not have computer access.
 Uneven access to broadband in rural areas.

TELEHEALTH VISIT PROTOCOL

8. Telehealth Checklist: Environment
 Desktop computer vs. tablet
 High-speed internet
 Web camera
 Microphone
 Dual screens for EHR documentation and note-taking
 RPM dashboard (if using)
  Headphones
 Provider alone in a private location
9. Telehealth Checklist: Environment (Continued)
 Ensure privacy (HIPAA).
 Provider alone.
 Clinically appropriate exam room location, size, and layout.
 Avoid background noise.
 Adequate lighting for clinical assessment.
10. Telehealth Checklist: Provider Behavior
 Dress professionally.
 No eating or drinking.
 Ensure adequate lighting.
o Avoid being backlit (dark face).
 Adjust the webcam to eye level to ensure contact.
o Ensure the camera is pointing to your face.
 Position yourself in front of the camera with a full head view.
 Avoid distracting background or jewelry/clothing.
11. Telehealth Checklist: Communication
 Turn off web applications and notifications.
 Turn off your cell phone.
 Review patient complaints and records before beginning the call.
 Introduce yourself and the facility.
 Confirm the patient’s name and date of birth.
 Speak clearly and deliberately.
 Use empathetic language.
 Use non-verbal language to signal that you are listening.
12. Telehealth Checklist: Communication (Continued)
 Pause to allow for transmission delay.
 Do not multitask—focus entirely on the patient.
 Narrate actions with the patient (e.g., turning away or taking notes).
 Conduct a virtual physical exam as appropriate.
  Verbalize and clarify next steps, such as follow-up appointments, care plans, or
prescription orders.

DOCUMENTING A TELEHEALTH VISIT

13. Telehealth Documentation
 HIPAA compliant.
o Include a statement of the telehealth visit and encrypted technology.
 Include patient identifiers.
 Include patient location/site.
 List others present with the patient.
 Include provider identifiers.
 Include provider location.