Health Assessment and Diagnostic Tests

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR2 DISTRIBUTION NOT FOR SALE OR DISTRIBUTION © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC HealthNOT FOR Assessment SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

©and Jones & Bartlett Diagnostic Learning, LLC Tests© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Beth M. Kelsey

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR2. Presenting SALE problem/illness—chronologicalOR DISTRIBUTION account of problem(s) Health History for which client is seeking care a. Description of principal symptoms should include OLD-CARTS • Purpose and correlation to physical examination mnemonic: (1) Onset 1. Begins the client–clinician relationship © Jones & Bartlett Learning, LLC (2) Location © Jones & Bartlett Learning, LLC 2. Identifies the client’s main concerns NOT FOR SALE OR DISTRIBUTION (3) Duration NOT FOR SALE OR DISTRIBUTION 3. Provides information concerning client’s social determinants of health (4) Characteristics 4. Provides information for risk assessment and health promotion (5) Aggravating/Associated factors 5. Provides focus for physical examination and diagnostic/screening (6) Relieving factors tests © Jones & Bartlett Learning, LLC (7)© T emporalJones factors & Bartlett Learning, LLC 6. Provides information about cultural variations in health beliefs NOT FOR SALE OR DISTRIBUTION (8)NOT Severity FOR SALE OR DISTRIBUTION and practices b. Include pertinent negatives in symptom descriptions; when a • Health history communication principles symptom suggests that an abnormality may exist or develop in 1. Use inclusive language—“partner” or “spouse” instead of “boy- that area, include documentation of the absence of symptoms friend” or “husband”; client-preferred pronouns if transgender, that may help eliminate some of the possibilities © Jones & Bartlettgender nonconforming, Learning, or genderLLC queer; options on forms regard© -Jones &c. BartlettDescribe impact Learning, of illness/problem LLC on client’s usual lifestyle d. Summarize current health status and health promotion/disease NOT FOR SALEing gender OR to DISTRIBUTION include transgender and “other,” with option to writeNOT FOR SALE OR DISTRIBUTION in gender identity prevention needs if client has no presenting problem 2. Assess health literacy—the degree to which an individual is able to 3. Past health history obtain, process, and understand basic health information and ser- a. General state of health as client perceives it vices needed to make health decisions; use appropriate written and b. Childhood illnesses graphic materials, patient© Jones navigators, & trained Bartlett medical Learning, interpreters LLC c. Major adult illnesses © Jones & Bartlett Learning, LLC 3. Use active listening—startNOT with FOR open-ended SALE questions, OR DISTRIBUTION focus on d. Psychiatric illnesses NOT FOR SALE OR DISTRIBUTION what is being said, reflect back on what is heard to confirm mutual e. Accidents/injuries understanding, allow silence for client to have time to express f. Surgeries/other hospitalizations thoughts and feelings g. Blood transfusions—dates and number of units 4. Address sensitive issues in a nonjudgmental, respectful manner; 4. Current health status ensure© Jones confidentiality & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION a. CurrentNOT medications—prescription, FOR SALE OR DISTRIBUTION over-the-counter, herbal, 5. Adopt cultural humility—be humble about recognizing limits of review medications prescribed by all health providers the client own knowledge of a client’s situation, avoid generalizing assump- sees for care (medication reconciliation) tions, be aware of own biases, use patient-centered communication b. Allergies—name of allergen, type of reaction • Components of the health history c. Tobacco, vaping, marijuana, alcohol, substances (e.g., paint © Jones &1. Bartlett Reason for Learning,visit/chief concern—brief LLC statement in client’s own © Jones & Bartlettfumes), prescription Learning, drugs taken LLC as other than intended use, NOT FOR SALEwords ofOR reason DISTRIBUTION for seeking health care NOT FOR SALEillicit drugs—type, OR DISTRIBUTION amount, frequency

7 © Jones & Bartlett Learning LLC, an Ascend Learning Company. NOT FOR SALE OR DISTRIBUTION. 8 CHAPTER 2 Health Assessment and Diagnostic Tests

d. Nutrition—24-hour diet recall, recent weight changes, eating b. Parity—total number of pregnancies reaching 20 weeks or © Jones & disorders,Bartlett special Learning, diet LLC © Jonesgreater & Bartlett gestation Learning, LLC NOT FORe. SALEScreening OR tests—dates DISTRIBUTION and results NOT FOR(1) SALEInclude term, OR preterm, DISTRIBUTION and stillbirth deliveries f. Immunizations—dates (2) Include length of each pregnancy; type of delivery; weight g. Sleep patterns and sex of infant; length of labor; complications during h. Exercise/leisure activities prenatal, intrapartum, or postpartum periods; infant complications; cause of stillbirth if known i. Environmental/occupational© Jones hazards & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC c. Ectopic pregnancies—treatment provided j. Use of safety measures—safetyNOT belts,FOR smoke SALE detectors OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION d. Abortions—spontaneous and induced k. Disabilities—functional assessment if indicated e. GTPAL—Gravida, Term, Preterm, Abortion, Living children is 5. Family health history—provides information about possible gen- a commonly used method of obstetric history notation etic, familial, and environmental associations with client’s health f. Any infertility evaluation and treatment a. Age and health or age and cause of death of immediate family members—parents,© Jones & Bartlettsiblings, children, Learning, spouse/significant LLC 8. Menstrual history—may© Jones include& Bartlett in separate Learning, section or in reviewLLC otherNOT FOR SALE OR DISTRIBUTION of systems NOT FOR SALE OR DISTRIBUTION a. Age at menarche, regularity, frequency, duration, and amount b. Specific conditions to ask about—heart disease, hyperten- of bleeding sion, stroke, diabetes, cancer, epilepsy, kidney disease, thyroid disease, asthma, arthritis, blood diseases, tuberculosis, alcohol- b. Date of last normal menstrual period ism, allergies, congenital anomalies, mental illness, genetic c. Use of pads, tampons, douching © Jones & Bartlettdisorders Learning, LLC © Jonesd. Abnormal & Bartlett uterine Learning, bleeding LLC NOT FORc. SALEInclude targetedOR DISTRIBUTION genetic/familial risk assessment for hereditary NOT FORe. Premenstrual SALE ORsymptoms DISTRIBUTION breast and ovarian cancer syndrome as well as other hereditary f. Dysmenorrhea cancer syndromes g. Perimenopausal symptoms d. Indicate if client is adopted and/or does not know family health h. Age at menopause, use of hormone therapy, postmenopausal history © Jones & Bartlett Learning, LLCbleeding © Jones & Bartlett Learning, LLC 6. Psychosocial history 9. Sexual history/contraceptive use—may include in separate section, a. Living situation NOT FOR SALE OR DISTRIBUTIONunder current health status, or inNOT review FOR of systems SALE OR DISTRIBUTION b. Access to care a. Age at first sexual intercourse—consensual/nonconsensual c. Support system b. History of sexual abuse or sexual assault d. Intimate-partner violence/domestic violence c. Sexual orientation e. Stressors© Jones and coping & Bartlett mechanisms Learning, LLC d. Gender ©identity Jones & Bartlett Learning, LLC f. Religious/spiritual/culturalNOT FOR SALE practices OR DISTRIBUTION and preferences e. CurrentNOT sexual relationship(s)FOR SALE OR DISTRIBUTION g. Outlook on present and future (1) Frequency of sexual intercourse h. Special issues to address with adolescent clients include (2) Satisfaction or concerns with sexual relationship(s) HEADSS: Home, Education, Activities, Drugs, Sex, Suicide (3) Dyspareunia, orgasmic or libido problems i. Cultural assessment considerations f. Sexually transmitted infection (STI)/human immunodeficiency © Jones & (1)Bartlett Cultural/ethnic Learning, identification—place LLC of birth, length of © Jonesvirus & Bartlett (HIV) infection Learning, risk assessment LLC NOT FOR SALEtime ORin country DISTRIBUTION NOT FOR(1) SALETotal number OR of DISTRIBUTIONsexual partners and number in past 3 months (2) Communication—language spoken, use of nonverbal com- (2) Types of sexual contact—vaginal, oral, and/or anal munication, use of silence (3) Use of condoms or other barrier methods (3) Space—degree of comfort with distance between self and (4) Previous history of STIs others, degree of comfort with touching by others (5) Use of injection drugs or sex with partner who has used (4) Social organization—family© Jones structure & Bartlett and roles, influence Learning, LLC injection drugs © Jones & Bartlett Learning, LLC of religion/spiritualityNOT FOR SALE OR DISTRIBUTION(6) Sex while under the influenceNOT of FORalcohol and/orSALE drugs OR DISTRIBUTION (5) Time—past-, present-, or future-oriented; view of time— (7) Previous testing for HIV clock-oriented or social-oriented g. Current and future desire for pregnancy (6) Environmental control—internal or external locus of h. Contraceptive use ©control, Jones belief & in Bartlett supernatural Learning, forces LLC (1) Establish© Jones if pregnancy & Bartlett is not a concern—hysterectomy, Learning, LLC (7) Use of culturally based healing practices or remedies NOT FOR SALE OR DISTRIBUTION sterilization,NOT FOR not sexually SALE active, OR only DISTRIBUTION sexually active with 7. Obstetric history—may include in separate section, past health females, menopausal history, or review of systems—includes all pregnancies regardless (2) Current method, length of time used, satisfaction, problems of outcome or concerns a. Gravidity—total number of pregnancies including a current (3) Previous methods used, when, length of time used, satisfac- © Jones & Bartlettpregnancy Learning, LLC © Jones & tion,Bartlett problems Learning, or concerns, reason LLC for discontinuation NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

10. Review of systems—used to assess common symptoms for each ma- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC jor body system to avoid missing any potential or existing problems; Physical Examination NOT FOR SALEspecial ORfocus forDISTRIBUTION gynecologic and reproductive health includes: NOT FOR SALE OR DISTRIBUTION a. Endocrine • Purpose and correlation to health history (1) Amenorrhea or infrequent menses 1. Findings may indicate need for further health history information (2) Heavy or prolonged menstrual bleeding 2. Takes into account normal physical variations of different age and (3) Premenstrual ©symptoms Jones & Bartlett Learning, LLC racial/ethnic groups © Jones & Bartlett Learning, LLC (4) Difficulty becomingNOT pregnant FOR SALE OR DISTRIBUTION• Techniques of examination NOT FOR SALE OR DISTRIBUTION (5) Heat/cold intolerance 1. Inspection—observation using sight and smell (6) Excessive hair growth or hair loss a. Takes place throughout the history and physical (7) Recent weight change examination (8) Hot flashes b. Includes general survey and body system–specific observations b.© Genitourinary Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION 2. Auscultation—useNOT FOR of hearing,SALE usually OR withDISTRIBUTION a stethoscope, to listen (1) Painful periods to sounds produced by the body (2) Abnormal vaginal discharge a. Diaphragm best for high-pitched sounds (e.g., S1, S2 heart (3) Pain with sex sounds) (4) Pain with urination, blood in urine, frequent urination b. Bell best for low-pitched sounds (e.g., large blood vessels) © Jones & Bartlett(5) Unintended Learning, urine leaking, LLC leaking urine with cough or © Jones3. &Percussion—use Bartlett Learning, of light, brisk tapping LLC on body surfaces to pro- lifting, urgency to urinate NOT FOR SALE OR DISTRIBUTION NOT FORduce SALE vibrations OR in DISTRIBUTION relation to density of underlying tissue and/or to (6) Postmenopausal bleeding elicit tenderness c. Breasts—pain, lumps/masses, nipple discharge a. Provides information about size, shape, location, and density of 11. Concluding question—Is there anything else I need to know about underlying organs or tissue your health to provide you with the best health care? b. Percussion sounds are distinguished by intensity (soft–loud), • Risk factor identification© Jones & Bartlett Learning, LLC pitch (high–low), and quality© Jones & Bartlett Learning, LLC 1. Consider prevalence (existingNOT FOR level of disease)SALE and OR incidence DISTRIBUTION (rate c. Tympany—loud, high-pitched,NOT FORdrum-like SALE sound (e.g.,OR gastric DISTRIBUTION of new disease) in general population and in your client population bubble, gas-filled bowel) d. Hyperresonance—very loud, low-pitched, boom-like sound 2. Determine risks specific to the client related to the following: (e.g., lungs with emphysema) a. Gender e. Resonance—loud, low-pitched, hollow sound (e.g., healthy b.© AgeJones & Bartlett Learning, LLC lungs)© Jones & Bartlett Learning, LLC c.NOT Ethnic FOR or racial SALE background OR DISTRIBUTION f. Dull—softNOT FOR to moderate, SALE moderate-pitched, OR DISTRIBUTION thud-like sound d. Family history (e.g., liver, heart) e. Environmental exposures g. Flat—soft, high-pitched sound, very dull (e.g., muscle, f. Military service—currently serving or veteran, deployment bone) locations, role, related physical/mental health issues 4. Palpation—use of hands and fingers to gather information about © Jones & Bartlettg. Lifestyle Learning, LLC © Jones &body Bartlett tissues and Learning, organs through LLC touch NOT FOR SALEh. Geographic OR DISTRIBUTION area NOT FORa. SALE Finger pads, OR palmar DISTRIBUTION surface of fingers, ulnar surface of fingers/ i. Inadequate preventive health care hands, and dorsal surface of hands are used • Problem-oriented medical record—organized sequence of recording b. Light palpation—about 1 cm in depth, used to identify muscu- information using SOAP format lar resistance, areas of tenderness, and large masses or areas of distention 1. SOAP format © Jones & Bartlett Learning, LLC c. Deep palpation—about© 4 cm Jones in depth, & used Bartlett to delineate Learning, organs LLC a. S—subjective information obtained during history. When NOT FOR SALE OR DISTRIBUTION and to identify less obviousNOT masses FOR SALE OR DISTRIBUTION writing the history, use terms such as “reports,” “endorses,” or “describes,” rather than “complains of.” • Physical examination b. O—objective information obtained through physical examina- 1. General appearance—posture, dress, grooming, personal hygiene, tion and laboratory/diagnostic test results body or breath odors, facial expression c.© AJones—assessment & Bartlett of objective andLearning, subjective data LLC to determine a 2. Anthropometric© Jones measurements & Bartlett Learning, LLC NOTdiagnosis FOR with SALE rationale OR or a prioritizedDISTRIBUTION differential diagnosis a. HeightNOT and FOR weight SALE OR DISTRIBUTION d. P—plan to include diagnostic tests, therapeutic treatment regi- b. Body mass index (BMI) provides measurement of total body men, client education, referrals, and date for reevaluation fat; weight (kg)/height (m2); tables available to calculate BMI 2. Problem list—list each identified existing or potential problem and based on the individual’s height and weight indicate both onset and a resolution date (1) Underweight—BMI less than 18.5 © Jones &3. Bartlett Progress notes—use Learning, SOAP formatLLC for information documented© at Jones & (2)Bartlett Normal weight—BMILearning, 18.5 LLC to 24.9 NOT FOR SALEfollow-up OR visits DISTRIBUTION NOT FOR SALE(3) Overweight—BMI OR DISTRIBUTION 25 to 29.9

(4) Obesity—BMI 30 to 39.9 (3) External eye structures—eyebrows equal; lids without lag © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC (5) Extreme obesity—BMI 40 or greater or ptosis; lacrimal apparatus without exudate, swelling, or NOT FORc. SALEWaist circumference OR DISTRIBUTION NOT FOR SALEexcess tearing; OR conjunctivaDISTRIBUTION clear with small blood vessels (1) Provides measurement of abdominal fat as an independent and no exudate; sclera white or buff colored prediction of risk for type 2 diabetes, dyslipidemia, hyper- (4) Eyeball structures tension, and cardiovascular disease in individuals with BMI (a) Cornea and lenses—no opacities or lesions between 25 and 39.9 (overweight and obesity) (b) Pupils—Pupils Equal, Round, React to Light, and © Jones & Bartlett Learning, LLC Accommodate (PERRLA)© Jones & Bartlett Learning, LLC (2) Has little added valueNOT in disease FOR risk SALE prediction OR in DISTRIBUTION NOT FOR SALE OR DISTRIBUTION individuals with BMI 40 or greater (extreme obesity) (5) Extraocular muscle (EOM) function—symmetrical (3) Measure with a horizontal mark at uppermost lateral border movement through the six cardinal fields of gaze without of right iliac crest and cross with a vertical mark at midaxil- lid lag or nystagmus lary line; place tape measure at the cross and measure in (6) Ophthalmoscopic examination—red reflex present with no horizontal plane around abdomen while client is standing clouding or opacities; optic disc yellow to pink color with © Jones & Bartlett Learning, LLC distinct© Jones margins; arterioles& Bartlett light red Learning, and two-thirds LLC of the (4) NOTIn adult FOR female, SALE increased OR relative DISTRIBUTION risk is indicated at NOT FOR SALE OR DISTRIBUTION greater than 35 in. (88 cm) diameter of veins with bright light reflex; veins dark red and larger than arterioles with no light reflex; no venous 3. Skin, hair, and nails tapering at the arteriole–venous (AV) crossings a. Skin—color, texture, temperature, turgor, moisture, lesions, (7) Sample deviations from normal tattoos, piercings (a) Opacity of lens—cataracts © Jones &b. BartlettHair—color, Learning,distribution, quantity, LLC texture © Jones & (b)Bartlett Dysconjugate Learning, gaze—diseases, LLC injuries, or lesions af- NOT FORc. SALENails—color, OR shape, DISTRIBUTION thickness NOT FOR SALEfecting OR cranial DISTRIBUTION nerves III, IV, VI d. Skin lesion characteristics—size, shape, color, texture, (c) Nystagmus—cerebellar system disorders, vestibular elevation, exudate, location, and distribution disorders, drug toxicity (1) Primary lesions—occur as an initial, spontaneous reaction (d) Lid lag—exophthalmos, hyperthyroidism to an internal or external stimulus (macule, papule, pustule, (e) Papilledema—increased intracranial pressure vesicle, wheal) © Jones & Bartlett Learning, LLC (f) AV nicking—hypertension© Jones & Bartlett Learning, LLC (2) Secondary lesions—resultNOT fromFOR later SALE evolution OR or trauma DISTRIBUTION to (g) Retinal hemorrhagesNOT and exudates—diabetes, FOR SALE OR DISTRIBUTION a primary lesion (ulcer, fissure, crust, scar) hypertension e. ABCDEs of malignant melanoma—Asymmetry, Borders ir- c. Ears regular, Color blue/black or variegated, Diameter greater than (1) Hearing evaluation 6 mm, Elevation (a) Whispered voice—able to hear softly whispered words 4. Head,© eyes, Jones ears, nose, & andBartlett throat Learning, LLC ©in eachJones ear at &1 to Bartlett 2 ft Learning, LLC a. HeadNOT and neckFOR SALE OR DISTRIBUTION (b) NOTWeber test—testsFOR SALE for lateralization OR DISTRIBUTION of sound through bone conduction; normally hear sound equally in both ears (1) Skull and scalp—no masses or tenderness (c) Rinne test—compares bone and air conduction of (2) Facial features—symmetrical, without swelling, without sound; normally air-conducted (AC) sound is heard involuntary movements (tics) for twice as long as bone-conducted (BC) sound (3) Trachea—midline © Jones & Bartlett Learning, LLC © Jones & Bartlett(AC:BC = Learning, 2:1) LLC (4) Thyroid—no masses or tenderness, rises symmetrically (d) Weber and Rinne tests may help in differentiating NOT FOR SALEwith ORswallowing DISTRIBUTION NOT FOR SALEconductive OR DISTRIBUTIONand sensorineural hearing loss (5) Neck—full range of motion (ROM) without pain (e) Precision, test–retest reproducibility, and accuracy of (6) Lymph nodes Weber and Rinne tests have been questioned (a) Preauricular, postauricular, occipital, tonsillar, (2) External ears—symmetrical; no inflammation, lesions, submandibular,© submental, Jones superficial & Bartlett cervical, Learning, LLC nodules, or drainage © Jones & Bartlett Learning, LLC posterior and deep cervical chains, supraclavicular (3) Tragus tenderness may indicate otitis externa; mastoid pro- (b) Normal findings—lessNOT thanFOR 1 cm SALE in size, nontender,OR DISTRIBUTION cess tenderness may indicateNOT otitis FOR media SALE OR DISTRIBUTION mobile, soft, and discrete (4) Otoscopic examination (7) Sample deviations from normal (a) External canal—no discharge, inflammation, lesions, (a) Enlarged, smooth, soft, nontender thyroid—goiter or foreign bodies; varied amount, color, and consist- ©(b) Jones Single thyroid & Bartlett nodule—cyst, Learning, benign tumor, LLC malignant ©ency Jones of cerumen & Bartlett Learning, LLC tumor (b) Tympanic membrane—intact, pearly gray, translucent, b. EyesNOT FOR SALE OR DISTRIBUTION NOTwith cone FOR of light SALE at 5:00 toOR 7:00; DISTRIBUTION umbo and handle of (1) Visual acuity malleus visible; no bulging or retraction (a) Snellen chart for central vision; normal 20/20 (5) Sample deviations from normal (b) Rosenbaum card or newspaper for near vision (a) Conductive hearing loss—sound transmission (c) Impaired near vision—presbyopia © Jones & Bartlett Learning, LLC © Jones & Bartlettimpaired Learning,through external LLC or middle ear; exudate/ (d) Impaired far vision—myopia swelling, perforated eardrum NOT FOR SALE(2) Peripheral OR DISTRIBUTIONvision—estimated with visual fields by NOT FOR SALE(b) Sensorineural OR DISTRIBUTION hearing loss—defect in inner ear distort- confrontation test ing sound; loud noise exposure, aging, acoustic neuroma

d. Nose and sinuses (2) Transmitted voice sounds/vocal resonance—normally voice © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC (1) Nasal mucosa pinkish red; septum midline sounds are muffled or indistinct; bronchophony, egophony, NOT FOR SALE(2) ORFrontal DISTRIBUTION and maxillary sinuses nontender NOT FOR SALEwhispered OR DISTRIBUTIONpectoriloquy indicate fluid or a solid mass in e. Mouth and oropharynx lungs (1) Mouth—lips, gums, tongue, mucous membranes all pink, 6. Cardiovascular system moist, without lesions or inflammation; teeth—none miss- a. Blood pressure (BP)—less than 120/80 mm Hg; pulse—60 to ing, free from ©caries Jones or breakage & Bartlett Learning, LLC 90 beats per minute (bpm),© Jones regular, not & bounding Bartlett or thready Learning, LLC (2) Oropharynx—tonsils,NOT FORposterior SALE wall of pharynx OR DISTRIBUTION without le- b. Heart NOT FOR SALE OR DISTRIBUTION sions or inflammation (1) Apical impulse—fourth to fifth left intercostal space (ICS) (3) Sample deviations from normal medial to the midclavicular line (MCL), no lifts or thrills (a) White patch (leukoplakia) on side or underside of (2) Auscultation at second right ICS; second, third, fourth, fifth tongue—possible squamous cell carcinoma left ICS at the sternal border; and fifth left ICS at the MCL © Jones(b) Pharynx & Bartlett erythematous, Learning, tonsils 3+, whiteLLC exudate, ©(a) Jones Assess rate & andBartlett rhythm Learning, LLC NOT FORenlarged SALE and tender OR anterior DISTRIBUTION cervical nodes—probable NOT(b) Identify FOR S1 SALEand S2 at eachOR site DISTRIBUTION using diaphragm end- streptococcal pharyngitis piece of stethoscope—S1 occurs at start of systole, 5. Respiratory system heard best at apex; S2 occurs at start of diastole, heard best at base a. Chest symmetrical, anterior–posterior diameter less than trans- (c) Identify extra heart sounds at each site—see Table 2-2 verse diameter; respiratory rate 16 to 20 breaths/min, rhythm (d) Murmurs—note timing, duration, pitch, intensity, regular; no rib retraction or use of accessory muscles; no cya- © Jones & Bartlett Learning, LLC © Jones & Bartlettpattern, Learning, quality, location, LLC radiation, respiratory phase nosis or clubbing of fingers NOT FOR SALE OR DISTRIBUTION NOT FOR SALE variationsOR DISTRIBUTION b. Anterior and posterior respiratory expansion—symmetrical c. Neck vessels movement when client inhales deeply (1) No jugular venous distention c. Tactile fremitus—decreased with emphysema, asthma, pleural effusion; increased with lobar pneumonia, pulmonary edema (2) Carotid arteries—strong, symmetrical, no bruits d. Percussion—resonant© Jones throughout & lung Bartlett fields Learning, LLC d. Extremities (peripheral© arteries) Jones & Bartlett Learning, LLC e. Auscultation—vesicularNOT over FOR most SALEof lung fields; OR bronchovesic DISTRIBUTION- (1) No erythema, pallor,NOT or cyanosis; FOR no SALE edema or OR varicosities; DISTRIBUTION ular near main bronchus and bronchial over trachea skin warm; capillary refill time less than 2 seconds; normal hair distribution; no muscle atrophy (1) Adventitious sounds—see Table 2-1 (2) Pulses strong and symmetrical—brachial, radial, femoral, dorsalis pedis, posterior tibial © Jones & Bartlett Learning, LLC (3)© Lymph Jones nodes & less Bartlett than 1 cm, Learning,nontender, mobile, LLC soft, and TableNOT 2-1 FORAdventitious SALE BrOReath DISTRIBUTION Sounds NOTdiscrete—axillary, FOR SALE epitrochlear, OR DISTRIBUTION inguinal 7. Abdomen Breath Sound Characteristics Cause a. Symmetrical, no lesions or masses; no visible pulsations or Crackles Fine crackles—heard during Air flowing by fluid— peristalsis inspiration; high pitch, crackling pneumonia, bronchitis, b. Auscultation—active bowel sounds; no vascular bruits or fric- or popping, short duration early heart failure © Jones & Bartlett Learning, LLC © Jones & Bartletttion rubs Learning, LLC Course crackles—heard during c. No guarding, tenderness, or masses on palpation NOT FOR SALE ORinspiration, DISTRIBUTION may be present NOT FOR SALE OR DISTRIBUTION during expiration; low pitch, d. Liver border—edge smooth, sharp, nontender; no more than 2 loud, bubbling or gurgling, cm below right costal margin longer duration e. Spleen and kidneys—usually not palpable Crackles usually don’t disappear f. Aorta—slightly left of midline in upper abdomen; less than 3 with coughing© Jones & Bartlett Learning, LLC cm width © Jones & Bartlett Learning, LLC Rhonchi Heard duringNOT inspiration FOR and SALE Air passing OR DISTRIBUTION over solid g. Percussion—tympany isNOT predominant FOR tone; SALE dullness OR over DISTRIBUTION or- expiration or thick secretions gans or any masses h. Liver span—normally 6 to 12 cm at the right MCL Low pitch, loud, sounds like a in large airways— snore, tend to disappear after bronchitis, pneumonia i. Splenic dullness—sixth to 10th ICS just posterior to midaxil- coughing lary line on left side © Jones & Bartlett Learning, LLC j. No© tenderness Jones on & fist Bartlett percussion Learning,over the costovertebral LLC angle; WheezesNOT FORHeard SALE during inspiration OR DISTRIBUTION and/or Air flowing through NOT FOR SALE OR DISTRIBUTION expiration constricted costovertebral angle tenderness (CVAT) may indicate kidney problem High pitch, continuous, louder passageways— during expiration, sounds like asthma, chronic k. Special maneuvers/signs used to evaluate abdominal pain a squeak emphysema (1) Possible peritonitis—guarding, rigidity, rebound tenderness © Jones &Pleural Bartlett friction Learning,Heard during inspiration LLC or Inflammation of © Jones & Bartlett Learning, LLC rub expiration pleural tissue— (2) Possible appendicitis NOT FOR SALE OR DISTRIBUTION NOT FOR SALE(a) McBurney’sOR DISTRIBUTION point—localized tenderness right lower Dry, rubbing, grating pleuritis, pericarditis quadrant

Table 2-2 Examples of Extra Heart Sounds © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORHeart Sound SALE ORLocation DISTRIBUTION Characteristics NOT FOR SALE ORCauses DISTRIBUTION

Physiologic Base; heard best with diaphragm Heard during inspiration Normal finding, 2S actually two sounds that merge split S2 during expiration

Fixed split S2 Base; heard best with diaphragm Heard during inspiration and expiration Delayed closure of pulmonic valve caused by atrial septal defect, right ventricular failure © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Increased S3 Apex; heard best with bell Early diastole, low pitched, increased on May be normal finding in young adults and in late (ventricular NOT FOR SALE inspirationOR DISTRIBUTION pregnancy NOT FOR SALE OR DISTRIBUTION gallop) Rapid ventricular filling caused by decreased myocardial contractility, heart failure, volume overload

Increased S4 Apex; heard best with bell Late diastole, low pitched, increased on May be normal finding in well-trained athletes and (atrial gallop)© Jones & Bartlett Learning, inspirationLLC © Jonesolder adults & Bartlett Learning, LLC Forceful atrial ejection into distended ventricle NOT FOR SALE OR DISTRIBUTION NOTcaused FOR by SALEaortic stenosis, OR hypertensive DISTRIBUTION heart disease, cardiomyopathy Physiologic Second to fourth left ICS between left Mid-systole, little radiation, grades 1–3, Normal finding, common in pregnancy murmur sternal border and apex soft to medium pitched, usually disappears © Jones & Bartlett Learning, LLC or decreases on ©sitting Jones & Bartlett Learning, LLC NOT FORMurmur SALE of mitral ORApex; DISTRIBUTION heard best with bell Early to late diastole,NOT FOR SALE ORNarrowed DISTRIBUTION mitral valve restricts forward flow, stenosis no radiation, grades 1–4, low pitched forceful ejection into ventricle Systolic click Apex; heard best with diaphragm Mid- to late systole, high pitched, increased Mitral valve prolapse with inspiration Pericardial Variable, usually best in third ICS to left Grating sound heard throughout cardiac Pericarditis friction rub of sternum; heard© Jones best with diaphragm& Bartlettcycle, Learning, high pitched, little LLC radiation © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

(b) Rovsing’s sign—referred rebound tenderness, pain in (5) CN VII (facial)—observe for any weakness, asymmetry, or © Jonesright lower & quadrantBartlett when Learning, left-sided pressure LLC is ap- abnormal© Jones movements & Bartlett of face Learning, LLC plied and then quickly withdrawn NOT FOR SALE OR DISTRIBUTION (6) CN NOTVIII (acoustic)—assess FOR SALE auditory OR DISTRIBUTIONacuity (c) Psoas and obturator signs—irritation of right psoas or (7) CN IX and X (glossopharyngeal and vagus)—observe abil- obturator muscles by inflamed appendix, maneuvers ity to swallow; symmetry of movement of soft palate and cause increased abdominal pain uvula when client says, “Ah”; gag reflex; any abnormal voice (3) Possible cholecystitis—Murphy sign: sharp increase in ten- quality derness and sudden stop in inspiratory effort with upward © Jones & Bartlett Learning, LLC © Jones(8) & CNBartlett XI (spinal Learning,accessory)—observe LLC and palpate strength and pressure under right costal margin while client takes deep symmetry of trapezius and sternocleidomastoid muscles NOT FOR SALEbreath OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION (9) CN XII (hypoglossal)—observe tongue for any deviation, 8. Musculoskeletal system asymmetry, or abnormal movement a. No gross deformities; body aligned, extremities symmetrical, b. Cerebellar function—smooth coordinated gait, able to walk normal spinal curvature, no involuntary movements heel to toe, balance maintained with eyes closed (Romberg b. Muscle mass and strength© equalJones bilaterally; & Bartlett full ROM withoutLearning, LLCtest), rapid rhythmic alternating© Jones movements & smooth Bartlett and Learning, LLC pain coordinated NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION c. No inflammation, nodules, swelling, crepitus, or tenderness of c. Sensory function—able to identify superficial pain and touch, joints able to identify vibration on bony prominences and passive po- 9. Neurologic system sition change of fingers and toes, normal response to discrimi- a. Cranial nerves (CN)—CN II through XII routinely tested, CN I natory sensation tests, all findings symmetrical tested© Jones if abnormality & Bartlett is suspected Learning, LLC d. Deep tendon© Jones reflexes—brisk & Bartlett and symmetrical Learning, (biceps, LLCbrachio- (1)NOT CN I (olfactory)—test FOR SALE ability OR to DISTRIBUTION identify familiar odors radialis,NOT triceps, FOR patellar, SALE Achilles) OR DISTRIBUTION (2) CN II (optic)—test visual acuity, peripheral vision; inspect 10. Mental status optic discs a. Physical appearance and behavior—well groomed, emotional (3) CN III, IV, VI (oculomotor, trochlear, abducens)—observe status appropriate to situation, makes eye contact, posture erect for PERRLA, EOM function, and ptosis b. Cognitive abilities—alert and oriented, able to reason, recent © Jones & (4)Bartlett CN V (trigeminal)—palpate Learning, LLC strength of temporal and mas- © Jonesand & remoteBartlett memory Learning, intact, able to LLC follow directions NOT FOR SALEseter OR muscles; DISTRIBUTION test for sharp/dull and light touch sensation NOT FORc. Emotional SALE stability—no OR DISTRIBUTION signs of depression or anxiety, logical on forehead, cheeks, and chin thought processes, no perceptual disturbances

d. Speech and language skills—normal voice quality and articula- (4) Follow same procedures for client with implants because © Jones & Bartletttion, coherent, Learning, able to follow LLC simple instructions © Jones & Bartlettcorrectly Learning, placed implants LLC are located behind breast tissue NOT FOR SALEe. Mini OR Mental DISTRIBUTION Status Examination (MMSE)—standardized NOT FOR SALE(5) Include OR palpation DISTRIBUTION of chest wall, skin, and incision area in screening tool used for mental status assessment client with mastectomy f. Depression screening tools—Patient Health Questionnaire (6) Breast tissue—consistency varies from soft fat to firmer (PHQ), Geriatric Depression Scale, Edinburgh Postnatal glandular tissue; physiologic nodularity may be present; Depression Scale (EPDS)© Jones & Bartlett Learning, LLC there may be a firm© ridge Jones of compressed & Bartlett tissue under Learning, lower LLC • Detailed female reproductive examination edge of breasts NOT FOR SALE OR DISTRIBUTION (7) Describe any palpableNOT mass FORor lymph SALE nodes in OR terms DISTRIBUTION of lo- 1. Breasts cation according to clock face as examiner faces client—size, a. The female breast extends from the second to the sixth ribs and shape, mobility, consistency, delimitation, and tenderness from the sternal border to the midaxillary line (8) Describe any nipple discharge in terms of whether spon- b. Inspect breasts with client in sitting position and hands above © Jones & Bartlett Learning, LLC ©taneous/not Jones spontaneous,& Bartlett bilateral/unilateral, Learning, LLCsingle or the head, pushing against hips, and leaning forward; view multiple ducts, color, and consistency NOTbreasts FOR from all SALE sides to assessOR DISTRIBUTIONfor symmetry and skin changes NOT FOR SALE OR DISTRIBUTION 2. Pelvic examination (1) Tanner sexual maturity rating in adolescent a. Pelvic examination can trigger anxiety, fear, or post-traumatic (2) Skin—smooth, color uniform, no erythema, masses, retrac- stress disorder symptoms in individuals with history of sexual tion, dimpling, or thickening abuse or prior experience with painful or insensitive care (3) Symmetry—breast shape or contour is symmetrical; some b. Trauma-informed care during the pelvic examination uses © Jones & Bartlettdifference Learning, in size of breastsLLC and areola is common and usu© -Jones & Bartlett Learning, LLC strategies to allow clients to maintain control (e.g., obtain per- NOT FOR SALE ORally normal DISTRIBUTION NOT FOR SALE OR DISTRIBUTION mission; adapt positioning, use of stirrups, use of speculum, (4) Nipples—pointing in same direction, no retraction or dis- specimen collection techniques for comfort; explain steps of charge, no scaling; long-standing nipple inversion is usually exam in advance; touch thigh gently before touching genitals; normal variation use gentle technique; monitor comfort throughout exam) c. Palpate axillary, supraclavicular, infraclavicular lymph nodes c. Prepare equipment/supplies prior to examination with client in sitting© position Jones and & arms Bartlett relaxed at Learning,sides LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONd. Conduct pelvic examinationNOT with FOR attention SALE to preventing OR DISTRIBUTION d. Palpate breasts with client lying down, arm above head, small contamination of equipment such as examination lights and pillow under shoulder/lower back on side being examined if lubricant containers needed to provide even breast tissue distribution (1) Include entire area from midaxillary line, across inframam- mary ridge and fifth/sixth rib, up lateral edge of sternum, © Jonesacross clavicle, & Bartlett back to midaxillary Learning, line LLC © Jones & Bartlett Learning, LLC Superficial level NOT(2) Palpate FOR using SALE finger ORpads ofDISTRIBUTION middle three fingers with over- NOT FOR SALE OR DISTRIBUTION lapping dime-shaped circular motions in a vertical strip pattern over entire area including nipples; do not squeeze nipples unless client indicates having spontaneous nipple discharge (Figure 2-1) Right Midline lateral © Jones & Bartlett(3) Palpate Learning, each area of LLCbreast tissue using three levels of pres©- Jones & Bartlett Learning, LLC NOT FOR SALE ORsure—light, DISTRIBUTION medium, and deep (Figure 2-2) NOT FOR SALE OR DISTRIBUTION Intermediate level

Deep level

Apply pressure in a circular motion with the pads of your fingers to increasing levels, making three circles: superficial, intermediate, and deep pressure. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALEFigure 2-1 OR PalpationDISTRIBUTION technique for clinical breast NOT FOR Figure SALE 2-2 ORPalpation DISTRIBUTION of breast tissue to three different examination. levels of pressure.

e. Positioning—client lying supine with head and shoulders el- i. Palpation of internal structures—bimanual examination © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC evated, lithotomy position, arms relaxed at side or across abdo- (1) Vaginal walls—smooth, nontender NOT FOR SALEmen, buttocks OR extendingDISTRIBUTION slightly beyond edge of table, draped NOT FOR(2) SALECervix—smooth, OR DISTRIBUTION firm, mobile, nontender, about 2.5 cm in from mid-abdomen to knees, drape depressed between knees diameter; protrudes 1–3 cm into vagina to allow eye contact (3) Uterus—smooth, rounded contour, firm, mobile, nontender; f. Inspection and palpation of external structures—mons pubis, 5.5 to 8 cm long and pear shaped in nulliparous female; may labia majora and minora, clitoris, urethral meatus, vaginal © Jones & Bartlett Learning, LLC be 2 to 3 cm larger in parous© Jones female; position & Bartlett anteverted, Learning, an- LLC introitus, paraurethral (Skene’s) glands, Bartholin’s glands, teflexed, midplane, retroverted, or retroflexed (Figure 2-3) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION perineum (4) Adnexa—fallopian tubes nonpalpable; ovaries ovoid, (1) Tanner sexual maturity rating in adolescent smooth, firm, mobile, slightly tender; size during reproduc- (2) Mons pubis—pubic hair inverted triangular pattern, skin tive years 3 cm × 2 cm × 1 cm smooth with uniform color (5) Note presence of enlargements, masses, irregular surfaces, (3)© Labia Jones majora—may & Bartlett be gaping Learning, or closed and dry LLC or moist, consistency© Jones other than& Bartlett firm, deviation Learning, of positions, LLC tissue soft and homogenous, covered with hair after puberty immobility, tenderness NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION (4) Labia minora—moist and dark pink, tissue soft and j. Rectovaginal examination homogenous (1) Purpose—palpate retroverted/retroflexed uterus; assess (5) Clitoris—approximately 2 cm or less in length and 0.5 cm pelvic pathology; not recommended for colorectal cancer in diameter screening © Jones & Bartlett(6) Urethral Learning, meatus—irregular LLC opening or slit © Jones(2) & RepeatBartlett the maneuvers Learning, of the bimanual LLC examination with NOT FOR SALE(7) Vaginal OR introitus—thin DISTRIBUTION vertical slit or large orifice, irregu- NOT FOR SALEindex finger OR in vaginaDISTRIBUTION and middle finger in rectum lar edges from hymenal remnants, moist (3) Rectum—smooth, nontender without masses; firm anal (8) Skene’s and Bartholin’s glands—opening of Skene’s glands sphincter tone just posterior to and on each side of urethral meatus; (4) Rectovaginal septum—smooth, intact, nontender, without opening of Bartholin’s glands located posteriorly on each masses side of vaginal orifice© Jonesand not usually & Bartlett visible Learning, LLCk. See Chapter 5, Gynecologic, Reproductive,© Jones and & SexualBartlett Disorders Learning,, LLC (9) Perineum—consistsNOT of tissue FOR between SALE introitus OR and DISTRIBUTION anus; for descriptions of deviationsNOT from normal FOR pelvic SALE exam ORfindings DISTRIBUTION smooth; may have episiotomy scar • Male-focused reproductive health assessment (10) Note presence of any abnormal hair distribution, discoloration, erythema, swelling, atrophy, lesions, masses, 1. Health history discharge, malodor, fistulas, tenderness a. Reason for visit and any presenting problems/illness g. Pelvic© Jonesfloor muscles—form & Bartlett supportive Learning, sling for pelvic LLC contents b. Review ©of pastJones health history,& Bartlett current healthLearning, status, family LLC health history, psychosocial/cultural health history as appropri- andNOT functional FOR sphincters SALE for ORvagina, DISTRIBUTION urethra, and rectum; able NOT FOR SALE OR DISTRIBUTION to constrict introitus around examining fingers, snug compres- ate for reason for visit sion of examining fingers for 3 or more seconds is full strength; c. Review of systems—endocrine, genitourinary assess for anterior or posterior bulging of vaginal walls, inconti- d. Sexual health history nence, or protrusion of cervix or uterus when client bears down (1) Age at first intercourse—consensual/nonconsensual © Jones &h. BartlettInspection of Learning, internal structures—speculum LLC examination © Jones(2) & HistoryBartlett of sexual Learning, abuse or sexual LLC assault (1) Choose speculum type and size that facilitate visualization NOT FOR SALE OR DISTRIBUTION NOT FOR(3) SALESexual orientation OR DISTRIBUTION while minimizing discomfort (4) Gender identity (a) Pederson speculum—straight sided; pediatric, narrow, (5) Current sexual relationship(s)—frequency of sexual inter- and regular sizes course; satisfaction or concerns with sexual relationship(s); (b) Graves speculum—duck-billed shape; may be used libido; ability to achieve and sustain erection; ability to when lax vaginal musculature or submucosal fat im- achieve orgasm; dyspareunia pedes visualization;© Jones small, average, & Bartlett and large sizesLearning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION(6) STI/HIV risk assessment—totalNOT numberFOR ofSALE sexual partnersOR DISTRIBUTION (2) Vaginal walls—pink, rugated, homogenous; may have thin, and number in past 3 months; types of sexual contact clear/cloudy, odorless discharge (vaginal, oral, anal); use of condoms; previous history of (3) Cervix—midline, smooth, round, pink, about 2.5 cm in STIs; use of injection drugs or sex with partner who uses diameter; protrudes 1–3 cm into vagina; points posteriorly injection drugs; sex while under the influence or of drugs with anteverted uterus, anteriorly with retroverted uterus, and/or alcohol; previous testing for HIV ©horizontally Jones with& Bartlett midposition Learning, uterus; nabothian LLC cysts may © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION (7) ContraceptiveNOT FOR use by SALE female partner(s) OR DISTRIBUTION or self if not be present; os small and round (nulliparous); may be oval, desiring pregnancy slit-like, or stellate if parous; may have area of darker red (8) Fertility/infertility concerns epithelial tissue around os if squamocolumnar junction is on ectocervix (9) Any current penile discharge, lesions, scrotal swelling, or pain (4) Note presence of discoloration; erythema; swelling; atro- 2. Physical examination © Jones & Bartlettphy; friable Learning, tissue; lesions; LLC masses; discharge that is pro- © Jonesa. Tanner & Bartlett sexual maturity Learning, rating in adolescent LLC NOT FOR SALEfuse, OR malodorous, DISTRIBUTION thick, curdy, frothy, gray, green, yellow, NOT FORb. Pubic SALE hair—skin OR smooth DISTRIBUTION with uniform color, hair course in or adherent to vaginal walls triangular pattern pointing toward umbilicus

A Anteverted. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

B Anteflexed.

E Midposition of the uterus.

c. Penis—skin smooth without hair, no lesions, no tenderness; of teeth, decrease in olfactory neurons: decreased appetite, dry © Jones & prepuceBartlett (foreskin), Learning, if present, LLCretracts easily; may have some © Jonesmouth, & Bartlett loss of teeth, Learning, difficulty chewing LLC NOT FOR SALEsmegma ORunder DISTRIBUTIONprepuce; glans penis without lesions or ery- NOT FORe. Thorax SALE and lungs—rib OR DISTRIBUTION cage less mobile, decreased strength thema; urethral meatus on ventral surface at tip of glans penis, of expiratory muscles, alveoli less elastic: decreased ability to without lesions or erythema clear lungs with less efficient cough; decreased ventilation at d. Scrotum—loose, wrinkled skin darker pigment than rest of lung bases; decreased reserve for response to exercise, stress, or body; no lesions; may appear asymmetrical with one testis, disease © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC usually the left testis, lower than the other f. Heart—left ventricular wall thickens, myocardium becomes e. Testes—oval, smooth, rubbery,NOT FORmove freely SALE when palpated,OR DISTRIBUTION less elastic, fibrosis and sclerosisNOT of heart FOR valves SALE and within OR con DISTRIBUTION- sensitive to pressure but not tender duction system (SA node), stroke volume decreases, heart rate f. Epididymis—posterolateral surface of testes, comma shaped, slows but resting heart rate not significantly influenced: cardiac smooth, softer than testes, nontender output during exercise declines with less efficient response to increased oxygen demand and longer recovery time to baseline, g. Spermatic© Jones cords—starts & Bartlett at lower endLearning, of epididymis LLC and ex- © Jones & Bartlett Learning, LLC tends to external inguinal ring; smooth; nontender irregular heart rhythms, mild ECG changes h. ProstateNOT gland—surrounds FOR SALE urethra OR DISTRIBUTIONat bladder neck; heart g. PeripheralNOT vascular FOR system—aorta SALE OR and large DISTRIBUTION arteries stiffen: shaped, approximately 4 × 3 × 2 cm, smooth, rubbery, rise in systolic blood pressure, tendency toward orthostatic nontender hypotension i. Perianal area—skin smooth with no lesions or inflammation, h. Gastrointestinal (GI) system—decreased motility of intestines, decreased secretion of digestive enzymes and protective mu- © Jones & Bartlettanus moist, sphincterLearning, closed LLC © Jones & Bartlett Learning, LLC j. Examples of deviations from normal cus in intestinal tract, decrease in liver size and hepatic blood NOT FOR SALE OR DISTRIBUTION NOT FORflow: SALE constipation, OR indigestion,DISTRIBUTION decreased ability to metabolize (1) Hypospadias—congenital displacement of urethral me- some drugs and alcohol, increased risk of stomach ulcers and atus to inferior surface of penis GI bleeding with long-acting nonsteroidal anti-inflammatory (2) Peyronie’s disease—palpable nontender, hard plaques just drugs (NSAIDs) beneath skin, usually along dorsum of penis; may have i. Musculoskeletal system—bone demineralization, decreased crooked, painful erections © Jones & Bartlett Learning, LLCmuscle mass and strength, decreased© Jones ROM, & joint Bartlett and cartilage Learning, LLC (3) Varicocele—varicoseNOT veins FOR of spermatic SALE cord, OR usually DISTRIBUTION on erosion: decreased bone density,NOT decreased FOR agility SALE and endurOR -DISTRIBUTION left, feels like “bag of worms” separate from testes; may be ance, gait disturbances, increased risk for falls associated with infertility j. Neurologic system—general decrease in brain volume and ce- (4) Acute epididymitis—acutely inflamed, tender, swollen rebral blood flow, decrease in velocity of nerve impulse conduc- epididymis; scrotum may be reddened; most common tion, diminished sensory perceptions of touch and pain stimuli, © causeJones is chlamydia & Bartlett infection Learning, LLC motor responses© Jones slow: & slower Bartlett reaction Learning,time, possible decreased LLC (5)NOT Torsion FOR of spermatic SALE cord—twisting OR DISTRIBUTION of testicle on its responseNOT to pain, FOR decrease SALE in coordination OR DISTRIBUTION and balance spermatic cord; acutely painful, tender, swollen organ k. Genitourinary—vulvovaginal atrophy, ovarian atrophy, retracted upward in scrotum; scrotum red and edematous; decreased bladder capacity and tone: urethral carbuncles most common in adolescents; surgical emergency common, dyspareunia; ovaries usually not palpable; urinary • Older adults frequency, urgency, incontinence; pelvic prolapse © Jones1. &Aging—process Bartlett Learning,of becoming older; LLC genetically determined and © Jones3. Cognitive & Bartlett changes Learning, LLC NOT FORenvironmentally SALE OR modulatedDISTRIBUTION NOT FORa. Definitions/characteristics SALE OR DISTRIBUTION (Institute of Medicine, 2015) 2. Anatomic and physiologic changes with aging/potential clinical (1) Cognition is multidimensional, including mental functions implications (not all inclusive) involved in attention, thinking, understanding, learning, a. Skin remembering, solving problems, and making decisions (1) Thinner, decreased elasticity, cell regeneration slower; seba- (2) Cognitive aging is inherent in all humans as they age; ceous and sweat gland© activityJones decreases: & Bartlett dry skin, Learning,pruritus, LLC highly dynamic process with© Jones variability & within Bartlett and be- Learning, LLC increased risk of skinNOT infection, FOR decreased SALE wound OR healing DISTRIBUTION tween individuals NOT FOR SALE OR DISTRIBUTION (2) Cutaneous sun exposure damage contributes to increase (3) Some cognitive domains may not change, some decline, in skin changes—wrinkles; irregular pigmentation; solar and some may actually improve lentigines (brown/age spots); telangiectasia; cherry angio- (4) Factors that may influence cognitive aging include genetics, mas; seborrheic keratosis; and actinic keratosis, which are education, environment, culture, chronic medical condi- ©premalignant Jones & sun-induced Bartlett growths Learning, LLC tions,© physicalJones activity, & Bartlett and other healthLearning, behaviors LLC b. Eyes—decreasedNOT FOR tear SALE production, OR pupilsDISTRIBUTION smaller, lens stiff- (5) CognitiveNOT aging FOR is not SALE a neurologic OR orDISTRIBUTION psychiatric disease ens: dry eyes, decreased near vision, decreased adaptation to b. Abnormal (pathologic) causes of cognitive changes darkness (1) Dementia (most common form is Alzheimer’s disease)— c. Ears—atrophy of auditory neurons; increased cerumen; scle- insidious onset; slowly progressive; persistent; recent rosis of tympanic membrane: sensorineural hearing loss (high memory and new learning especially impaired; changes in © Jones & Bartlettfrequency first), Learning, conductive hearing LLC loss © Jones & speech,Bartlett mood, Learning, thought processes, LLC judgment; behavior may NOT FORd. SALE Mouth, nose,OR and DISTRIBUTION teeth—decreased number of taste buds, NOT FOR SALEbecome inappropriate; OR DISTRIBUTION may have delusions and/or halluci- atrophy of salivary glands, gingival tissue less elastic, softening nations; may have fragmented sleep

(2) Delirium (may be caused by infection, toxins, medications, a. Mean corpuscular volume (MCV)—average volume or size of a © Jones & Bartlettwithdrawal Learning, from alcohol LLC or other substances, trauma, neu©- Jones & Bartlettsingle RBC Learning, LLC NOT FOR SALE ORrologic DISTRIBUTION or neoplastic disorders)—sudden onset; fluctuatingNOT FOR SALE(1) Normal OR finding—80 DISTRIBUTION to 95 mm3, normocytic with lucid intervals, worse at night; lasts hours to weeks; (2) Microcytic/abnormally small—seen with iron-deficiency immediate and recent memory impaired; changes in alert- anemia and thalassemia ness, attention, speech, mood, thought processes, judg- (3) Macrocytic/abnormally large—seen with megaloblastic ment; may be agitated or somnolent; may have delusions © Jones & Bartlett Learning, LLC anemias such as vitamin© Jones B deficiency & Bartlett and folic acid Learning, LLC and/or hallucinations; disrupted sleep deficiency NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION (3) Depression—may have some cognitive symptoms along b. Mean corpuscular hemoglobin (MCH)—average amount or with depressed mood, such as inability to think or concen- weight of Hgb within an RBC trate, indecisiveness, psychomotor agitation or retardation; (1) Normal finding—27 to 31 pg/cell individuals with diagnosis of dementia may also have clinical depression (2) Causes for abnormalities same as for MCV ©(4) Jones MMSE—screens & Bartlett for dementia, Learning, although notLLC definitive; may c. Mean© Jonescorpuscular & hemoglobin Bartlett concentration Learning, (MCHC)— LLC NOTbe FOR used to SALE detect progression OR DISTRIBUTION of dementia averageNOT concentration FOR SALE or percentage OR DISTRIBUTION of Hgb within a single RBC (1) Normal finding—32 to 36 g/dL, normochromic (2) Decreased concentration or hypochromic—seen with Diagnostic Studies/Laboratory Tests iron-deficiency anemia and thalassemia 4. White blood cell (WBC) count with differential—provides infor- © Jones & Bartlett Learning, LLC © Jones &mation Bartlett useful in Learning, evaluating individual LLC with infection, neoplasm, • Complete blood count (CBC) with differential NOT FOR SALE OR DISTRIBUTION NOT FORallergy, SALE or immunosuppression OR DISTRIBUTION (Table 2-3) 1. Red blood cell (RBC) count—measurement of RBCs per cubic mil- 5. Peripheral blood smear—microscopic examination of smear of limeter of blood peripheral blood to examine RBCs, platelets, and leukocytes a. Normal findings (adult female)—4.2 to 5.4 million/mm3 b. Potential causes of low values include hemorrhage, hemolysis, • Blood clotting studies dietary deficiencies,© hemoglobinopathies, Jones & Bartlett bone marrow Learning, failure, LLC1. Used as part of investigation© of Jones possible bleeding& Bartlett disorder Learning, or LLC chronic illness, medicationsNOT FOR SALE OR DISTRIBUTIONthrombotic episode NOT FOR SALE OR DISTRIBUTION c. Potential causes of high values include dehydration, diseases 2. Includes platelet count, prothrombin time (PT), partial thrombo- causing chronic hypoxia such as congenital heart disease, poly- plastin time (PTT), coagulation factors cythemia vera, medications 3. Platelet count 2. Hematocrit (Hct)/hemoglobin (Hgb)—rapid indirect measure- a. Normal finding (adult)—150,000 to 400,000/mm3 ment© Jones of RBC count & Bartlett Learning, LLC b. Potential© Jones causes of& low Bartlett count (thrombocytopenia) Learning, LLC include a.NOT Hct—percentage FOR SALE of total OR blood DISTRIBUTION volume that is made up autoimmuneNOT FOR disorders, SALE cirrhosis, OR sepsis, DISTRIBUTION hypersplenism, hem- of RBCs orrhage, leukemia, cancer chemotherapy, viral infection, some (1) Normal findings (nonpregnant adult female)—37% to 47% medications (2) Normal findings (pregnant adult female)—33% or greater c. Potential causes of high count (thrombocytosis) include some in first and third trimesters, 32% or greater in second malignant disorders, polycythemia vera, rheumatoid arthritis, © Jones & Bartletttrimester; Learning, adjustment LLC in values for Black women—31% © Jones & Bartlettmyeloproliferative Learning, disease LLC NOT FOR SALE ORor greater DISTRIBUTION in first and third trimesters, 30% or greater inNOT FOR4. PT SALE and PTT OR DISTRIBUTION second trimester a. Used to evaluate how well coagulation factors in coagulation b. Hgb—measurement of total Hgb (which carries oxygen) in the cascade work together blood b. Measures number of seconds it takes for clot to form in a blood (1) Normal findings (nonpregnant adult female)—12 to 16 g/dL sample after reagents are added; prolonged results indicate that (2) Normal findings© (pregnantJones adult & Bartlett female)—11 Learning, g/dL or LLC blood clotting is taking ©longer Jones than normal & Bartlett Learning, LLC greater in first NOTand third FOR trimesters, SALE 10.5 g/dLOR or DISTRIBUTION greater c. Conditions that may causeNOT a prolonged FOR PTSALE with normal OR PTTDISTRIBUTION in second trimester; adjustment in values for Black include, but are not limited to, liver disease, vitamin K defi- women—10.2 g/dL in first and third trimesters, 9.7 g/dL in ciency, chronic low-grade disseminated intravascular coagula- second trimester tion (DIC), defective factor VII, anticoagulation drug (warfarin) c. Potential causes of low values include anemia, hemoglobinopa- therapy © thies,Jones cirrhosis, & Bartlett hemorrhage, Learning, dietary deficiency, LLC bone marrow d. Conditions© Jones that may& Bartlett cause a normal Learning, PT with prolonged LLC PTT NOTfailure, FOR renal disease,SALE chronic OR illness,DISTRIBUTION some cancers include,NOT but FOR are not SALE limited to, OR decreased/defective DISTRIBUTION factor VIII, d. Potential causes of high values include erythrocytosis, poly- IX, XI, XII; von Willebrand disease; presence of systemic lupus cythemia vera, severe dehydration, severe chronic obstructive erythematosus (SLE) anticoagulant pulmonary disease e. Conditions that may cause both prolonged PT and PTT include, e. Heavy smokers and individuals living at higher elevations may but are not limited to, decreased or defective factor I, II, V, X; © Jones & Bartlettalso have Learning, higher Hgb levels LLC © Jones & Bartlettsevere liver disease;Learning, acute DIC, LLC warfarin overdose NOT FOR SALE3. RBC indices—provide OR DISTRIBUTION information about size, weight, and HgbNOT FORf. SALEPT and PTTOR do DISTRIBUTION not provide specific information on cause concentration of RBCs; useful in classifying anemias of blood clotting abnormality; further testing for specific

Table 2-3 White Blood Cell (WBC) Count with Differential © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORNormal SALE Values (Adult) OR DISTRIBUTIONLow Values: Potential Causes NOTHigh Values: FOR Potential SALE Causes OR DISTRIBUTION Total WBC count 5000 to Bone marrow suppression Dehydration 3 10,000/mm Autoimmune disorders Infection Immunosuppressive disorders Inflammatory conditions Overwhelming© Jones infection & Bartlett Learning,Some LLC malignancies © Jones & Bartlett Learning, LLC CancerNOT that spreadsFOR to SALE bone marrow OR DISTRIBUTIONMay be elevated in late pregnancy and duringNOT labor FOR SALE OR DISTRIBUTION Traumatic injury Neutrophils 30–70% Bone marrow suppression Acute bacterial infection Autoimmune disorders Inflammation or tissue necrosis © Jones &Immunosuppressive Bartlett Learning, disorders LLC Some malignancies © Jones & Bartlett Learning, LLC NOT FOR SALEOverwhelming OR infection DISTRIBUTION Cushing syndrome NOT FOR SALE OR DISTRIBUTION Cancer that spreads to bone marrow Increased immature forms (band and stabs) sometimes called shift to left with ongoing acute bacterial infection Basophils 0–3% Occasional low number is usually not Hypersensitivity reaction medically significant Chronic inflammatory disorders © Jones & Bartlett Learning, LLC ©Some Jones leukemias & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOTUremia FOR SALE OR DISTRIBUTION Eosinophils 0–5% Occasional low number is usually not Allergic reaction medically significant Parasitic infections Chronic inflammatory disorders © Jones & Bartlett Learning,Some LLCmalignancies © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONAddison disease NOT FOR SALE OR DISTRIBUTION Lymphocytes 15–40% Autoimmune disorders Acute viral infections Debilitating illness Chronic bacterial infections Immunodeficiency syndromes Chronic inflammatory disorders © Jones & SomeBartlett malignancies Learning, LLC Some malignancies © Jones & Bartlett Learning, LLC NOT FOR SALECorticosteroids OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Monocytes 2–8% Chronic diseases—rare Chronic infections Recovery phase of infections Some malignancies © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION coagulation factor deficiency or defect may be indicated as well 2. Two-hour postload glucose during oral glucose tolerance test (OGTT) as tests for other underlying conditions a. Sample obtained 2 hours after a glucose load containing the 5. Comprehensive metabolic panel (CMP) equivalent of 75 g of glucose dissolved in water a. Provides information on status of metabolism; monitors status b. Normal finding—less than 140 mg/dL of known conditions and© kidney- Jones or liver-related & Bartlett side effectsLearning, of LLCc. Impaired glucose tolerance—140© Jones mg/dL to &199 Bartlett mg/dL Learning, LLC medication NOT FOR SALE OR DISTRIBUTIONd. Diagnostic for diabetes—200NOT mg/dL FORor greater SALE OR DISTRIBUTION b. Fasting for 10–12 hours may be needed depending on reason 3. American Diabetes Association (ADA) criteria for the diagnosis of for ordering CMP diabetes mellitus with blood glucose tests c. CMP includes glucose, calcium, albumin, total protein, electro- a. Classic symptoms of hyperglycemia plus random nonfasting lytes (sodium, potassium, CO2, chloride), kidney tests (blood urea glucose concentration of 200 mg/dL or greater nitrogen© Jones [BUN], creatinine),& Bartlett liver testsLearning, (ALP, ALT, AST,LLC bilirubin) b. Fasting© glucose Jones of 126 & mg/dL Bartlett or greater Learning, LLC d. AbnormalNOT FORtest results SALE are usually OR followed DISTRIBUTION up with specific tests c. Two-hourNOT post-glucose FOR ofSALE 200 mg/dL OR or DISTRIBUTIONgreater to confirm or rule out a suspected diagnosis d. Repeat testing on a subsequent day to confirm diagnosis • Blood glucose—used for diagnosis and evaluation of diabetes mellitus 4. HbA1c or A1c 1. Fasting glucose a. May be used for the diagnosis of diabetes © Jones &a. BartlettNo caloric intake Learning, for at least 8LLC hours © Jonesb. Threshold & Bartlett for diagnosis Learning, of diabetes LLC is 6.5% or greater; predia- NOT FORb. SALE Normal findingOR DISTRIBUTION (adult)—less than 100 mg/dL NOT FORbetes SALE is 5.7% toOR 6.4% DISTRIBUTION c. Impaired fasting glucose—100 to 125 mg/dL c. Gold standard for measurement of long-term (previous d. Diagnostic for diabetes—126 mg/dL or greater 60–90 days) glycemic control in individuals with diabetes

d. Reliable tool for evaluating need for drug therapy and monitor- • Thyroid function studies © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ing effectiveness of therapy 1. Thyroid-stimulating hormone (TSH)—used to diagnose hyperthy- NOT FOR SALEe. Good OR diabetic DISTRIBUTION control—less than 7% NOT FORroidism SALE and OR primary DISTRIBUTION hypothyroidism, differentiate primary from • Lipid profile secondary hypothyroidism, and monitor thyroid replacement or suppression therapy 1. Determines risk for coronary heart disease and evaluation of hyperlipidemia a. Normal finding (adult)—0.4 to 4.12 mU/mL b. Increased levels—seen with primary hypothyroidism and 2. Includes total cholesterol,© Jones triglycerides, & Bartlett high-density Learning, lipoproteins LLC © Jones & Bartlett Learning, LLC thyroiditis (HDLs), and low-densityNOT lipoproteins FOR SALE(LDLs) OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION c. Decreased levels—seen with secondary hypothyroidism, 3. Fast for 12–14 hours prior to obtaining sample hyperthyroidism, suppressive doses of thyroid 4. Total cholesterol normal level (adult)—less than 200 mg/dL; medication may be elevated in pregnancy d. Upper limit of normal may be higher in older adults 5. Triglycerides© Jones normal & Bartlett finding (adult Learning, female)—35 LLC to 135 mg/dL; e. Upper© Jones limits during & Bartlettpregnancy are Learning, lower and based LLC on trimes- mayNOT be elevated FOR inSALE pregnancy OR DISTRIBUTION ter—2.5NOT to FOR3.5 mU/mL SALE OR DISTRIBUTION 6. HDL—removes cholesterol from peripheral tissues and transports 2. Free thyroxine (FT4)—used in diagnosis of thyroid disease to liver for excretion a. Normal finding (adult female)—0.58 to 1.64 ng/dL a. Normal level (adult)—40 mg/dL or greater b. Increased levels—hyperthyroidism and acute thyroiditis b. Low levels associated with increased risk for heart and c. Decreased levels—hypothyroidism © Jones & Bartlettperipheral Learning, vascular disease LLC © Jones & Bartlett Learning, LLC 3. Total thyroxine (T4) NOT FOR SALE7. LDL—cholesterol OR DISTRIBUTION carried by LDL can be deposited into peripheralNOT FOR SALE OR DISTRIBUTION a. Normal finding (adult female)—4.5 to 12.0 µg/dL tissues b. Measurement affected by increases in thyroxine-binding a. Normal finding (adult)—less than 130 mg/dL globulin (TBG) b. High levels associated with increased risk for heart and c. Causes of increased TBG include pregnancy, oral contraceptive peripheral vascular disease © Jones & Bartlett Learning, LLC use, and estrogen therapy© Jones & Bartlett Learning, LLC • Renal function tests NOT FOR SALE OR DISTRIBUTION4. Antithyroid peroxidase antibodiesNOT FOR(anti-TPO)—used SALE OR in differen DISTRIBUTION- 1. BUN—indirect measure of renal and liver function tial diagnosis of thyroid disorders associated with autoimmune a. Normal finding (adult)—10 to 20 mg/dL disease b. Increased levels—hypovolemia, dehydration, reduced cardiac a. Normal finding—negative antithyroid antibodies function, GI bleeding, starvation, sepsis, renal disease b. Positive antithyroid antibodies—Graves’ disease; Hashimoto’s c.© DecreasedJones levels—liver& Bartlett failure, Learning, malnutrition, LLC nephrotic thyroiditis© Jones & Bartlett Learning, LLC syndrome NOT FOR SALE OR DISTRIBUTION • Liver functionNOT studies FOR SALE OR DISTRIBUTION 2. Serum creatinine—indirect measure of renal function 1. Bilirubin a. Normal finding (adult female)—0.5 to 1.1 mg/dL a. Normal findings (adult)—total bilirubin 0.3 to 1.0 mg/dL; dir- b. Increased levels—renal disorders, dehydration ect (conjugated) bilirubin 0.1 to 0.3 mg/dL; indirect (unconju- c. Decreased levels—debilitation and decreased muscle mass © Jones & Bartlett Learning, LLC © Jones & Bartlettgated) bilirubin Learning, 0.2 to 0.8 mg/dL LLC 3. Creatinine clearance—calculated from serum and 24-hour b. Elevated direct bilirubin level—occurs with gallstones and ob- NOT FOR SALEurine creatinineOR DISTRIBUTION levels to determine rate at which kidneys are NOT FOR SALEstruction OR of extrahepatic DISTRIBUTION duct clearing creatinine from the blood, reflecting glomerular c. Elevated indirect bilirubin level—seen with hepatocellular filtration rate (GFR) dysfunction (hepatitis, cirrhosis) and hemolytic anemias a. Normal finding—serum creatinine (adult female), 0.5 to 1.1 mg/ 2. Albumin dL; 24-hour urine creatinine, 500–2000 mg; GFR deter mined with equation that ©takes Jones into account & Bartlettage, gender, andLearning, race LLC a. Normal finding (adult)—3.5© Jones to 5.0 g/dL & Bartlett Learning, LLC b. Increased levels—increasedNOT FOR muscle SALE mass, exercise, OR DISTRIBUTIONpregnancy, b. Increased levels—dehydrationNOT FOR SALE OR DISTRIBUTION high dietary meat intake, some medications c. Decreased levels—seen with liver disease, malabsorption c. Decreased levels—impaired renal function, reduced renal syndromes, nephropathies, severe burns, malnutrition, and blood flow, heart failure, shock, some medications inflammatory disease 4. Urine protein/creatinine (PC) ratio 3. Liver enzymes © Jones & Bartlett Learning, LLC a. Alkaline© Jones phosphatase & Bartlett (ALP) Learning, LLC a.NOT Helps FOR evaluate SALE kidney function OR DISTRIBUTION when significant and persistent NOT FOR SALE OR DISTRIBUTION protein is found on urinalysis (1) Normal finding—30 to 120 U/L b. Random urine sample (2) Elevated levels—liver disease, bone disease, and c. Approaches accuracy of a 24-hour urine sample when both myocardial infarction protein and creatinine are measured b. Aspartate aminotransferase (AST), alanine aminotransferase © Jones & Bartlettd. Persistent Learning, and/or increased LLC amount of protein in urine may © Jones & Bartlett(ALT), lactic Learning,dehydrogenase (LDH)LLC NOT FOR SALEindicate OR kidney DISTRIBUTION damage or disease; also associated with other disNOT- FOR SALE(1) Normal OR findings—AST DISTRIBUTION 0–35 U/L, ALT 4–36 U/L, LDH eases/conditions (e.g., preeclampsia, diabetes, multiple myeloma, 100–190 U/L other) (2) Useful in differentiating cause for ALP elevation

c. Gamma-glutamyl transpeptidase (GGT) b. May detect pregnancy as early as 28 days from last menstrual © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC (1) Normal finding—8–38 U/L period NOT FOR SALE(2) Elevated OR levels DISTRIBUTION with liver disease, myocardial infarction, NOT FORc. First SALE morning OR urine DISTRIBUTION is best, as will be most concentrated pancreatic disease, and heavy or chronic alcohol use d. Cross-reactions with other hormones not a problem with • Stool for occult blood highly sensitive urine tests 1. Evaluation of GI conditions that may cause GI bleeding 3. Serum hCG radioimmunoassay (RIA) or immunometric assay a. Provides level of hCG (quantitative); not any advantage for use 2. Positive test—may indicate© GI Jones cancer or polyps,& Bartlett peptic ulcer Learning, dis- LLC © Jones & Bartlett Learning, LLC as qualitative (positive/negative) test over highly sensitive urine ease, inflammatory or ischemicNOT bowel FOR disease, SALE GI trauma, OR bleedingDISTRIBUTION NOT FOR SALE OR DISTRIBUTION tests in most situations caused by medications b. Single level useful in conjunction with ultrasound if concern 3. Several interfering factors can cause false positives or negatives about ectopic pregnancy—should be able to visualize intrauter- a. Red meat and some raw fruits and vegetables, if consumed ine pregnancy when level is 1500–2000 mIU/mL within 3 days prior to or during the test period, can result in c. Serial testing of serum hCG allows for following the rise or fall false© positive Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION of levels—assistsNOT FOR in diagnosis SALE of ectopic OR pregnancy,DISTRIBUTION evolving b. Large amounts of vitamin C consumed within 3 days prior to or spontaneous abortion, possible retained products of concep- during the test period can result in false negative tion, surveillance for persistent trophoblastic proliferation after 4. Positive test requires further evaluation with sigmoidoscopy, colo- uterine evacuation of hydatidiform mole noscopy, or barium enema • Reproductive hormone studies © Jones• Blood & Bartletttype and Rh Learning,factor LLC © Jones1. Used & to Bartlettevaluate and Learning,monitor treatment LLC of infertility; assist in dif- NOT FOR1. Used SALE to determine OR DISTRIBUTION blood type prior to donating or receiving blood NOT FORferential SALE diagnosis OR of gonadal DISTRIBUTION dysfunction; assist in diagnosis of and to determine blood type in pregnant individual certain neoplasms 2. Blood types are grouped according to presence or absence of anti- 2. Levels fluctuate throughout menstrual cycle in reproductive-age gens A, B, and Rh on RBCs individual and may be affected by use of hormonal contraception 3. Individual without a particular© Jones antigen may & developBartlett antibodies Learning, to LLC3. Results should be correlated with© individual’s Jones age& Bartlettand clinical Learning, LLC that antigen if exposed through blood transfusion or fetal–mater- presentation nal blood mixing NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 4. Estradiol (E2) 4. Blood type O negative is universal donor because no antigens on a. Increased—adrenal tumor, estrogen-producing tumor, hepatic RBCs; AB positive is universal recipient because no antibodies will cirrhosis, hyperthyroidism be present to react to transfused blood b. Decreased—postmenopause, ovarian failure, primary or • Sickle cell© screening Jones (Sickle & Bartlett Cell Prep, Sickledex) Learning, LLC secondary© hypogonadism,Jones & Bartlett Turner’s syndrome, Learning, anorexia LLC 1. Used toNOT screen FOR for sickle SALE cell disease OR and DISTRIBUTION trait nervosaNOT FOR SALE OR DISTRIBUTION 2. Positive test—presence of Hgb S indicates sickle cell disease or trait 5. Progesterone a. Increased—pregnancy, ovulation, progesterone-secreting ovar- 3. Hgb electrophoresis is definitive test to be performed if screening ian tumor or cyst, congenital adrenal hyperplasia, hydatidiform test is positive; identifies Hgb type and quantity mole © Jones• Autoantibodies/antinuclear & Bartlett Learning, antibodies LLC (ANA) © Jonesb. Decreased—primary & Bartlett Learning, or secondary LLC hypogonadism, threat- NOT FOR1. Test SALE used as OR part ofDISTRIBUTION diagnostic workup for SLE and other connec- NOT FORened SALE abortion, OR fetal DISTRIBUTIONdemise, preeclampsia, short luteal phase tive tissue autoimmune disorders such as scleroderma, rheumatoid syndrome arthritis, Sjögren’s syndrome 6. Follicle-stimulating hormone (FSH) 2. Positive ANA found in 95% of individuals with SLE; titer may be a. Increased—postmenopause, gonadotropin-secreting pitu- negative early in disease itary tumor, ovarian failure, primary hypogonadism, Turner’s 3. Test results must be correlated© Jones with other & criteria Bartlett for the particularLearning, LLCsyndrome © Jones & Bartlett Learning, LLC autoimmune disease NOT FOR SALE OR DISTRIBUTIONb. Decreased—pregnancy, pituitaryNOT or hypothalamicFOR SALE dysfunction, OR DISTRIBUTION 4. Antinuclear antibody subtypes may be used to aid in diagnosis— hyperprolactinemia, anorexia nervosa anti-dsDNA and anti-Sm are highly specific to SLE but have vari- 7. Luteinizing hormone able sensitivity a. Increased—postmenopause, primary hypogonadism, gonadal 5. Higher titers indicate more active disease; lower titers associated failure with effective© Jones treatment & Bartlett Learning, LLC b. Decreased—pituitary© Jones &or hypothalamicBartlett Learning, dysfunction, anorexia LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Pregnancy test nervosa 1. Used to detect human chorionic gonadotropin (hCG) in blood/ • Urinalysis—dipstick and/or microscopic evaluation of urine urine 1. Includes evaluation of appearance, color, odor, pH, protein, spe- 2. Urine hCG tests cific gravity, leukocyte esterase, nitrites, ketones, crystals, casts, © Jones &a. BartlettHighly sensitive Learning, urine tests provide LLC accurate qualitative © Jonesglucose, & Bartlett WBCs, and RBCsLearning, LLC NOT FOR SALE(positive/negative) OR DISTRIBUTION results with hCG levels as low as 5 to NOT2. FOR Obtain SALE midstream OR clean-catch DISTRIBUTION specimen so culture can be per- 50 mIU/mL formed if urinalysis indicates infection

3. Normal findings Table 2-4 In-Office Diagnostic Test Findings: © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC a. No nitrites, ketones, crystals, casts, or glucose Normal, Bacterial Vaginosis, Trichomonas vaginalis, and Vulvovaginal Candidiasis NOT FOR SALEb. Clear, OR amber DISTRIBUTION yellow, aromatic NOT FOR SALE OR DISTRIBUTION c. pH 4.6 to 8.0 Condition In-Office Diagnostic Test Findings d. Protein 0 to 8 mg/dL Normal • Vaginal pH 3.8–4.5 e. Specific gravity (adult)—1.005 to 1.030 • Whiff test negative f. Leukocyte esterase© negative Jones & Bartlett Learning, LLC • Wet mount:© epithelial Jones cells, & few Bartlett or no WBCs, Learning, LLC g. WBCs 0 to 4 per high-powerNOT FOR field (HPF)SALE OR DISTRIBUTION lactobacilliNOT present FOR SALE OR DISTRIBUTION h. RBCs at 2 or less Bacterial • Vaginal pH > 4.5 vaginosis • Whiff test positive • Urine culture • Wet mount: >20% of epithelial cells are clue cells, 1. Used for diagnosis of urinary tract infection (UTI) and antimicro- 0–1 WBCs per epithelial cell, lactobacilli reduced or bial© susceptibilityJones & testingBartlett of causative Learning, organisms LLC © Jonesabsent & Bartlett Learning, LLC • Point-of-care vaginal fluid sialidase test positive 2. SpecimenNOT FOR obtained SALE from mid-stream OR DISTRIBUTION clean catch urine, sometimes NOT FOR SALE OR DISTRIBUTION obtained via sterile catheter Trichomonas • Vaginal pH > 4.5 vaginalis • Whiff test negative or positive 3. Positive culture indicates UTI • Wet mount: motile trichomonads, >1 WBC per a. Typically consider positive with presence of a single type of epithelial cell, lactobacilli reduced or absent bacteria at 100,000 colony-forming units (CFU)/mL • Point-of-care rapid antigen test positive © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC b. Lower CFU/mL of 1000 or greater may be used to indicate Vulvovaginal • Vaginal pH ≤ 4.5* NOT FOR SALEinfection OR whenDISTRIBUTION UTI symptoms are present NOT FORcandidiasis SALE (VVC) OR• Whiff DISTRIBUTION test negative c. Growth of several different types of bacteria is likely due to • Wet mount: hyphae/spores (best seen after KOH contamination of the specimen applied), > 1 WBC per epithelial cell, lactobacilli 4. Susceptibility testing identifies antimicrobials that are likely to be present effective for the identified© Jones bacteria & Bartlett Learning, LLC* When VVC and a concomitant BV or T. vaginalis© Jones infection occur,& Bartlett the vaginal pH mayLearning, be LLC greater than 4.5. 5. See Chapter 3, PrimaryNOT Care, forFOR more SALE information OR on DISTRIBUTIONUTIs NOT FOR SALE OR DISTRIBUTION • Vaginal microscopy/wet mount/pH/amine test 1. Used to aid in detection of organisms responsible for symptoms of 12. Additional tests for vaginal infection diagnosis vaginal infections through evaluation of vaginal discharge a. Nucleic acid amplification tests (NAAT)—CDC-recommended test for Trichomonas vaginalis 2. Obtain© Jones specimen & (vaginalBartlett discharge/secretions) Learning, LLCfrom lateral vagi- © Jones & Bartlett Learning, LLC nal walls—avoid contamination with cervical secretions b. Culture NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 3. pH test—place a strip of pH litmus paper directly on the wall (1) Yeast culture may be useful when wet mount is negative but of the vagina or place discharge from a collection swab on symptoms, discharge, or other signs suggestive of VVC are the strip present; can help confirm the diagnosis and identify species of yeast when recurrent or persistent signs/symptoms are 4. Prepare initial slide with drop of saline and drop of discharge present © Jones &5. Bartlett Alternative Learning, procedure—place LLC the swab used to collect the speci©- Jones & (2)Bartlett Culture forLearning, Trichomonas vaginalisLLC is available; less sensitive NOT FOR SALEmen into OR a test DISTRIBUTION tube containing less than 1 mL of saline and stirNOT FOR SALEand moreOR expensiveDISTRIBUTION than NAAT gently; place drop of the mixture onto a slide (3) Culture for BV is not recommended; no bacteria are spe- 6. Place a cover slip over the solution on the slide, followed by im- cific for BV mediate examination under a microscope at both low (10×) and 13. See Chapter 5, Gynecologic, Reproductive, and Sexual Disorders, for high (40×) power; scan thoroughly for clue cells, motile tricho- detailed information on assessment and management of vaginal monads, WBCs; delays© of Jones more than & 10 Bartlettminutes reduce Learning, the chance LLC © Jones & Bartlett Learning, LLC infections of visualizing motile trichomonadsNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Tests for STIs 7. Prepare second slide with vaginal discharge specimen and 10% potassium hydroxide (KOH) to facilitate visualization of yeast buds 1. Health history and pelvic examination findings are essential to and pseudohyphae correlate with test findings for diagnosis 2. Tests for screening and diagnosis of STIs—see Table 2-5 8. Addition© Jones of KOH & mayBartlett be used toLearning, detect presence LLC of amines (whiff © Jones & Bartlett Learning, LLC test) 3. See Chapter 5, Gynecologic, Reproductive, and Sexual Disorders, for NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 9. Health history and pelvic examination findings are essential to detailed information on assessment and management of STIs correlate with wet mount, pH, whiff test findings for diagnosis • HIV 10. Other in-office point of care tests used for vaginal infection diag- 1. Enzyme immunoassay (EIA) conducted in laboratory or as rapid nosis—vaginal fluid sialidase test positive with bacterial vaginosis screening at testing site using blood or oral mucosal transudate © Jones & Bartlett(BV), rapid Learning, antigen test positive LLC with Trichomonas vaginalis © Jones &sample Bartlett Learning, LLC NOT FOR 11.SALE In-office OR diagnostic DISTRIBUTION test findings—normal, BV, Trichomonas vagiNOT- FOR2. Western SALE blot OR or immunofluorescence DISTRIBUTION assay (IFA) used to confirm nalis, vulvovaginal candidiasis (VVC) (Table 2-4) reactive EIA test

Table 2-5 Tests for Diagnosis of Sexually Transmitted Infections © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORSTI/Causative SALE Organism OR DISTRIBUTIONScreening/Diagnostic Tests NOT FOR SALE OR DISTRIBUTION Chlamydia/Chlamydia • Nucleic acid amplification test (NAAT)—test recommended by Centers for Disease Control and Prevention (CDC) trachomatis • NAAT provides option of testing with urine, vaginal (provider or patient obtained), or endocervical sample; some approved for liquid-based cytology specimens; few approved for rectal or oropharyngeal specimens Gonorrhea/Neisseria • NAAT provides same testing ability as with Chlamydia gonorrhoeae • Culture© Jones with antimicrobial & Bartlett sensitivity Learning, testing should LLC be used with suspected or documented© treatmentJones failure & Bartlett Learning, LLC Syphilis/Treponema • DarkNOT field FOR microscopy SALE examination OR DISTRIBUTIONand direct fluorescent antibody tests of lesion exudateNOT or tissue FOR are definitive SALE methodsOR DISTRIBUTION of pallidum diagnosing early syphilis • Serology—provides for presumptive diagnosis 1. Nontreponemal tests (nonspecific)—Venereal Disease Research Laboratories (VDRL), rapid plasma reagin (RPR) a. Become positive 1–2 weeks past chancre © Jones & Bartlettb. Reported Learning, as nonreactive LLC or reactive © Jones & Bartlett Learning, LLC NOT FOR SALEc. Reactive OR DISTRIBUTION test also reported quantitatively as titer NOT FOR SALE OR DISTRIBUTION d. False positives associated with mononucleosis, collagen vascular disease, and some other medical conditions; usually see low titer 1:8 e. Reactive nontreponemal tests must be confirmed with a treponemal test f. Titers also used for follow-up after treatment g. Usually become nonreactive with time after successful treatment © Jones & Bartlett Learning,2. Treponemal LLC tests (specific)—fluorescent ©treponemal Jones antibody & Bartlett absorption Learning, test (FTA-ABS), Treponema LLC pallidum NOT FOR SALE OR DISTRIBUTIONimmobilization test (TPI) NOT FOR SALE OR DISTRIBUTION a. Reported as positive or negative; not quantitative b. Usually remain positive indefinitely after treatment Genital herpes/herpes • Tissue culture and polymerase chain reaction (PCR) are the CDC-recommended tests for patients presenting with genital simplex virus (HSV) lesions 1.© PCR Jones assays are & more Bartlett sensitive than Learning, tissue culture LLC © Jones & Bartlett Learning, LLC 2.NOT Sensitivity FOR varies SALE with stage OR of infection—highest DISTRIBUTION if sample comes from vesicular lesionNOT FOR SALE OR DISTRIBUTION • Type-specific serologic tests—serum; detect presence of HSV-1 and HSV-2 antibodies; may take 4–12 weeks for seroconversion; useful if history is suggestive of HSV but no current lesions, negative culture of lesions but suspect HSV infection, partner with known HSV infection, or patient with HIV infection Chancroid/Haemophilus • Culture—specimen obtained from lesion or bubo, difficult to isolate ducreyi © Jones & •Bartlett Gram stain—gram Learning, negative orLLC chains © Jones & Bartlett Learning, LLC Trichomoniasis/NOT FOR SALE• NAAT—test OR recommended DISTRIBUTION by CDC NOT FOR SALE OR DISTRIBUTION Trichomonas vaginalis • NAAT provides option of testing with urine, vaginal (provider or patient obtained); some approved for liquid-based cytology specimens • Several NAAT assays test for N. gonorrhoeae, C. trachomatis, and T. vaginalis on the same sample • See Table 2-4 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 3. HIV antibody detectable in 95% of individuals within 6 months of 2. Hepatitis B (HBV) tests infection a. Hepatitis B surface antigen (HBsAg)—rises before onset of 4. HIV-1 p24 antigen test detects HIV-1 antigen as early as 2 to clinical symptoms, peaks during first week of symptoms, and 6 weeks after infection and declines once HIV antibodies develop returns to normal by the time jaundice subsides 5. Combined HIV antibody and© p24Jones antigen & test Bartlett is available Learning, LLC(1) Indicates active HBV infection—individual© Jones & Bartlett is Learning, LLC infectious 6. See Chapter 3, Primary CareNOT, for detailed FOR information SALE OR on diagnosis DISTRIBUTION NOT FOR SALE OR DISTRIBUTION (2) Individual is considered a carrier if HBsAg persists and management of HIV b. Hepatitis B surface antibody (HBsAb)—appears 4 weeks after • Other infectious disease tests disappearance of surface antigen 1. Rubella (German measles) (1) Indicates end of acute infectious phase and signifies immu- a. Hemagglutination© Jones & inhibition Bartlett (HAI) Learning, test—used to LLCdetect immunity© to Jonessubsequent & infection Bartlett Learning, LLC nityNOT to rubella FOR and SALEto diagnose OR rubella DISTRIBUTION infection (2) AlsoNOT used to FOR denote SALEimmunity OR after DISTRIBUTIONadministration of HBV (1) Titer of 1:10 or greater indicates immunity to rubella vaccine (2) High titers (1:64 or greater) may indicate current rubella c. Hepatitis B core antibody (HBcAb)—indicates past infection; infection chronic hepatitis b. Rubella IgM antibody titer—used if pregnant woman has a rash d. Hepatitis B e-antigen (HBeAg)—seen with acute infection; © Jones & Bartlettsuspected to Learning,be from rubella; LLCif titer is positive, recent infection © Jonesindicates & Bartlett infectivity Learning, LLC NOT FOR SALEhas occurred; OR IgMDISTRIBUTION antibodies appear 1 to 2 days after onset of NOT FORe. Hepatitis SALE B e-antibody OR DISTRIBUTION (HBeAb)—seen with convalescence; rash and disappear 5 to 6 weeks after infection indicates decreased infectivity

3. Hepatitis C (HCV) tests 3. Specimen obtained with sterile swab rubbed against back of throat © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC a. HCV antibody assay (rapid fingerstick/venipuncture blood test and tonsils NOT FOR SALEor laboratory OR DISTRIBUTION test) NOT FOR4. Rapid SALE streptococcal OR DISTRIBUTION antigen test—positive test indicates presence b. Follow reactive antibody test with HCV RNA test; positive HCV of GABHS, negative test indicates individual probably does not RNA test indicates current HCV infection; negative HCV RNA have GABHS infection but more likely has a viral infection; 5–15% test indicates either past resolved HCV infection or false HCV of adult pharyngitis cases are caused by GABHS antibody positivity© Jones & Bartlett Learning, LLC5. Throat culture not recommended© Jones for routine & Bartlett evaluation ofLearning, adult LLC 4. Tuberculosis (TB) testsNOT FOR SALE OR DISTRIBUTIONpharyngitis or for confirmationNOT of FORnegative SALE rapid antigen OR test DISTRIBUTION a. Usually positive within 6 to 8 weeks after infection 6. Throat culture useful if other pathogens (e.g., gonococcus) are be- b. Does not indicate whether infection is active or dormant ing considered c. Interpretation of purified protein derivative (PPD) skin test re- 7. See Chapter 3, Primary Care, for more information on sults—measure area of induration, not erythema pharyngitis (1) High-risk population: 5 mm induration or greater © Jones & Bartlett Learning, LLC • Skin/wound© Jonesculture & Bartlett Learning, LLC (2) Moderate-risk population: 10 mm induration or greater NOT FOR SALE OR DISTRIBUTION 1. IdentifiesNOT organism FOR causing SALE infection OR throughDISTRIBUTION superficial breaks in (3) General population: 15 mm induration or greater skin or involving deeper tissues d. Once positive reaction, usually persists for life 2. Indicated if skin/wound is tender, red, swollen, draining fluid or e. False-negative PPD test may result from incorrect administra- pus, or slow to heal or is accompanied by fever tion (must be intradermal), administration after recent live © Jones & Bartlettvirus vaccination, Learning, or immunosuppression LLC © Jones3. &Specimen Bartlett obtained Learning, with sterile swabLLC from cells or pus from the NOT FOR SALEf. False-positive OR DISTRIBUTION PPD test may result if individual had prior imNOT- FORsite SALE of suspected OR infection;DISTRIBUTION may include aspiration of fluid with munization with bacillus Calmette–Guérin (BCG) vaccine syringe g. PPD test is contraindicated if history of BCG vaccination or 4. Specimen placed on appropriate nutrient media; if fungal infection active TB because severe local reaction can occur is suspected, may require separate type of media h. TB blood test (interferon-gamma release assay [IRGA]) meas- 5. Identifies type of pathogenic organism; includes susceptibility ures how immune ©system Jones reacts &to bacteriaBartlett causing Learning, TB; result LLC testing to identify antimicrobials© Jones that are & likely Bartlett to be effective Learning, LLC reported as positiveNOT or negative; FOR preferred SALE method OR forDISTRIBUTION person against identified organismNOT FOR SALE OR DISTRIBUTION who has had BCG vaccination or will have trouble returning in 6. A Gram stain is often also performed to provide a more rapid pre- 48–72 hours to read PPD skin test liminary result while culture is pending 5. Cytomegalovirus (CMV) antibody test • Cervical cytology and human papillomavirus (HPV) test a. Used to diagnose current, past, or reactivated CMV infection © Jones & Bartlett Learning, LLC 1. Screening© Jones technique & for Bartlett detection of Learning,precancerous and LLC early can- b. Indicated for pregnant or immunocompromised person if exposure cerous lesions of the uterine cervix NOTis suspected FOR or SALE has flu-like OR symptoms DISTRIBUTION that suggest a CMV infection NOT FOR SALE OR DISTRIBUTION 2. Instruct client to avoid douching, intercourse, and use of vaginal c. IgM antibodies can be detected within a week or two after an creams for 48 hours prior to test initial exposure, usually decline and fall below detectable levels after a few months, levels rise again if latent CMV is reactivated 3. Avoid scheduling when on menses d. IgG antibodies are produced several weeks after initial CMV 4. Speculum may be lubricated with water prior to insertion © Jones & Bartlettinfection Learning, and provide protection LLC from getting another primary© Jones5. &Entire Bartlett squamocolumnar Learning, junction LLC (transformation zone) must be NOT FOR SALEinfection; OR DISTRIBUTIONlevels stabilize as infection resolves, but remain NOT FORsampled SALE with OR spatula/broom DISTRIBUTION device to avoid false negative related detectable for rest of life to sampling technique 6. Toxoplasmosis antibody test 6. Endocervical sampling must be obtained with broom device/ a. Used to diagnose current or past infection with Toxoplasma endocervical brush gondii © Jones & Bartlett Learning, LLC7. Spatula—insert longer end© into Jones cervical os,& pressBartlett and rotate Learning, LLC b. Indicated for pregnant or immune-compromised individual if spatula 360 degrees exposure is suspectedNOT or has FOR flu-like SALE symptoms OR DISTRIBUTION8. Endocervical brush—insertNOT so bristles FOR are fullySALE in cervical OR os,DISTRIBUTION ro- c. IgM antibodies can be detected within a week or two after an tate brush 180 degrees initial exposure; usually decline and fall below detectable levels 9. Broom device—insert central bristles in endocervical canal so that after a few months shorter bristles fully contact the ectocervix, push gently and rotate d.© IgGJones antibodies & Bartlettare produced Learning, several weeks after LLC the initial in clockwise© Jones direction & 5Bartlett times Learning, LLC infection and provide long-term protection; levels stabilize as NOT FOR SALE OR DISTRIBUTION 10. If slideNOT preparation FOR of SALEspecimen ORis used, DISTRIBUTION rapid cytologic fixative ap- infection resolves but remain detectable for rest of life plication is essential to avoid air-drying artifact • Strep throat test 11. HPV DNA testing can be performed on specimens transferred in 1. Determines if pharyngitis is caused by group A beta-hemolytic aqueous solution streptococci (GABHS) 12. See Chapter 3, Primary Care, for cervical cancer screening © Jones &2. Bartlett Indicated inLearning, adults with pharyngitis LLC who meet two or more of the© Jones &recommendations Bartlett Learning, and Chapter 5,LLC Gynecologic, Reproductive, and NOT FOR SALEfollowing OR criteria: DISTRIBUTION fever, lack of cough, tonsillar exudates, tenderNOT FORSexual SALE Disorders OR, forDISTRIBUTION information on management of abnormal anterior cervical adenopathy results

• Colposcopy 11. Transfer contents of pipelle into histologic solution for transport © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 1. Used to inspect vagina, cervix, and/or vulva using a binocular to lab NOT FORmicroscope; SALE OR detects DISTRIBUTION lesions/abnormalities that may be biopsied NOT12. FOR Have client SALE remain OR supine DISTRIBUTION for a few minutes until any pain or diz- for histologic examination; also used in anogenital examination to ziness passes, observe for vasovagal response identify injuries from sexual assault 13. Provide perineal pad, may use NSAIDs for cramping; advise to 2. Vagina and/or cervix—position speculum and colposcope for return if severe cramping, heavy bleeding, bleeding lasting longer adequate visualization © Jones & Bartlett Learning, LLCthan 2 days, foul-smelling discharge© Jones & Bartlett Learning, LLC 3. Swab cervix/vagina to removeNOT secretions; FOR wash SALE cervix/vagina OR DISTRIBUTION with • Breast biopsy NOT FOR SALE OR DISTRIBUTION 2% acetic acid to allow for easier identification of abnormalities 1. Used to determine whether breast mass found on examination or 4. Look for areas of abnormalities—aceto-white areas, abnormal through imaging contains benign or malignant cells vascular patterns (e.g., punctation, mosaic pattern, “corkscrew 2. Fine-needle aspiration—obtains fluid/cells from breast mass vessels), leukoplakia visible before application of acetic acid a. Cleanse area with antiseptic; local anesthesia usually not 5. Biopsy© any Jones abnormal & areas Bartlett Learning, LLC © Jones & Bartlett Learning, LLC required 6. Apply NOTpressure FOR to biopsy SALE site(s) withOR large DISTRIBUTION swab to stop bleeding b. Secure breastNOT mass FOR with SALEone hand; OR introduce DISTRIBUTION 20- or 22-gauge 7. Apply silver nitrate or Monsel’s solution if bleeding continues needle attached to 10- to 20-mL syringe • Vulvar biopsy c. Withdraw all fluid from cyst and prepare slide of specimen if 1. Used to sample areas of vulva that appear abnormal for diagnostic fluid is not clear © Jones &purposes; Bartlett use on Learning, lesions smaller LLCthan 0.5 cm © Jonesd. If & no Bartlettfluid obtained, Learning, mass is likely solid;LLC pass needle through mass several times with suction to obtain cellular specimen, 2. Use good lighting, magnifying lens or colposcope; application of NOT FOR SALE OR DISTRIBUTION NOT FORthen SALE prepare slideOR DISTRIBUTION 5% acetic acid can enhance identification of abnormal areas e. Apply firm pressure over site for 5–10 minutes to prevent 3. Identify vulvar lesion(s) to biopsy and inject local anesthetic hematoma 4. Cleanse area with antiseptic solution or iodine-soaked swabs 3. Tissue biopsy—leads to definitive diagnosis, with histologic find- 5. Place punch biopsy instrument© Jones over site and& Bartlettrotate several Learning, times LLCings providing foundation for treatment© Jones plan & Bartlett Learning, LLC with downward pressure toNOT obtain specimenFOR SALE OR DISTRIBUTIONa. Wire-guided excisional biopsy—wireNOT FOR placed percutaneouslySALE OR DISTRIBUTION 6. Elevate specimen from skin with forceps and incise at base with in vicinity of abnormality by radiologist; needle may be placed scissors over wire for better localization; surgeon uses wire to guide 7. Place specimen in histologic solution for transport to lab removal of abnormal tissue 8. Control bleeding—pressure, silver nitrate, Monsel’s solution b. Stereotactic core needle biopsy—client placed prone on table with breast in dependent position; breast imaged to localize 9. Instruct© clientJones to call & if anyBartlett redness, increasingLearning, discomfort, LLC © Jones & Bartlett Learning, LLC lesion; core biopsy needle advanced into lesion; cores of tissue malodorousNOT or FOR bloody SALE drainage, ORfever DISTRIBUTION NOT FOR SALE OR DISTRIBUTION obtained for evaluation • Endometrial biopsy • Genetic testing 1. Used to evaluate abnormal bleeding (perimenopause, postmeno- 1. Identifies changes in chromosomes, genes, or proteins pause); rule out/confirm endometritis; determine endometrial a. Confirm or rule out suspected genetic conditions—commonly © Jones &response Bartlett to progesterone Learning, in infertile LLC individual suspected to have © Jones & Bartlett Learning, LLC luteal-phase defect done as newborn screening, may be done during pregnancy NOT FOR SALE OR DISTRIBUTION NOT FORb. Predictive SALE gene OR testing—determine DISTRIBUTION individual’s chance of de- 2. If pregnancy is a possibility, time to avoid potential disruption of veloping a genetic disorder or passing on a genetic disorder implantation 3. Inform client that she may experience cramping while biopsy 2. Genes—basic unit of heredity passed from parents to offspring; instrument is in uterus; may take NSAID 30 to 60 minutes before consist of segment of DNA arranged along a chromosome; humans procedure and/or use topical© anesthesiaJones on& cervix Bartlett Learning, LLChave about 23,000 genes © Jones & Bartlett Learning, LLC 4. Perform bimanual examination—determineNOT FOR SALE uterine positionOR DISTRIBUTION 3. Chromosomes—found in nucleusNOT of cell; FOR contains SALE genes; normal OR DISTRIBUTION and size human cell contains 46 chromosomes in pairs; 22 pairs are auto- somes, and one pair is the sex chromosomes 5. Insert appropriate-size speculum; evaluate cervix and vagina for any signs of infection—do not proceed if suspect infection 4. Karyotype—individual’s collection of chromosomes; also lab technique used to produce an image of an individual’s chromosomes 6. Cleanse ectocervix and vagina with antiseptic © Jones & Bartlett Learning, LLC and look for© abnormal Jones numbers & Bartlett or structures—for Learning, example, LLC tri- 7. May manually curve tip of endometrial pipelle while in sterile NOT FOR SALE OR DISTRIBUTION somy 21, orNOT Down FORsyndrome, SALE in which OR individual DISTRIBUTION has three copies package to accommodate uterine curvature of chromosome 21 instead of two copies 8. Apply tenaculum to stabilize cervix/straighten uterus as needed if 5. Gene mutation—change in DNA sequence anteflexed or retroflexed, remove tenaculum after pipelle is inserted a. Somatic mutation—acquired; occurs after conception; DNA 9. Gently pass endometrial pipelle through cervix up to fundus copying mistake during cell division or exposure to ionizing ra- © Jones10. &Pull Bartlett back rapidly Learning, on piston as far LLC as it will go to create suction; ro- © Jonesdiation, & Bartlett chemicals, Learning, or viruses during LLC gestation or later in life NOT FORtate SALE the pipelle OR 360 DISTRIBUTION degrees, moving from fundus down to internal NOT FORb. Germ SALE cell mutation—inherited; OR DISTRIBUTION occurs during conception; cervical os and repeating 3 or 4 times present in egg or sperm cells of parent

Table 2-6 Inheritance Patterns © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORInheritance SALE PatternOR DISTRIBUTIONDescription NOT FOR SALE OR DISTRIBUTIONExamples Autosomal • Only one mutated copy of gene in each cell needed Huntington disease, dominant • Usually have one affected parent BRCA1/BRCA2 mutations, • Each offspring has 50% chance of inheriting abnormal gene and having condition and 50% chance of Lynch syndrome not being affected Autosomal • Two© mutated Jones copies & ofBartlett gene present Learning, needed to have LLCdisease © JonesCystic & Bartlettfibrosis, sickle Learning, cell LLC recessive • UsuallyNOT have FOR unaffected SALE parents OR (carriers—each DISTRIBUTION has single copy of mutated gene) NOT FORanemia SALE OR DISTRIBUTION • If both parents are carriers, offspring has 50% chance of being a carrier, 25% chance of having disease, 25% chance of being unaffected X-linked dominant • Mutation in genes on X chromosome Fragile X syndrome • Females more frequently affected than males © Jones &• BartlettFathers cannot Learning, pass trait to sons LLC © Jones & Bartlett Learning, LLC NOT FOR• SALEIf mother OR is affected, DISTRIBUTION both male and female offspring have 50% chanceNOT of inheriting FOR theSALE disorder OR DISTRIBUTION X-linked recessive • Mutation in genes on X chromosome Hemophilia • Males more frequently affected than females • Fathers cannot pass trait to sons • Female offspring (XX) need to inherit affected X chromosome from both parents as carriers to have © Jones & Bartlett Learning,the condition LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Males (XY) need to inherit only the affected X NOTchromosome FOR from SALE mother to OR have DISTRIBUTIONthe condition

6. Genetic marker—DNA sequence with known physical location on 2. Digital mammography—detectors convert X-rays into electric a chromosome; can help© Joneslink inherited & diseaseBartlett with theLearning, respon- LLC signals, produce images that© canJones be seen &on computerBartlett screen; Learning, most LLC sible genes; several genetic markers are associated with increased centers now use digital mammography NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION risk of breast cancer 3. Digital mammography and conventional film mammography are 7. Pattern of inheritance of genetic conditions caused by mutations in similar overall in ability to detect breast cancer a single gene depends on the gene involved (Table 2-6) 4. Digital mammography may offer better detection in women who 8. Other disorders may be caused by combination of effects of multi- are premenopausal, are perimenopausal, and/or have dense breast ple© genesJones or by &interactions Bartlett between Learning, genes and theLLC environment— tissue© Jones & Bartlett Learning, LLC heartNOT disease, FOR diabetes, SALE schizophrenia, OR DISTRIBUTION certain types of cancer 5. Tomosynthesis/three-dimensionalNOT FOR SALE OR (3D) DISTRIBUTION mammography— modification of digital mammography providing images as thin slices; FDA approved for screening Imaging Studies 6. Mammographic findings standardized terminology—Breast Imaging Reporting and Data System (BI-RADS): six assessment • Pelvic ultrasonography © Jones & Bartlett Learning, LLC © Jones &categories Bartlett (0–5) Learning, provide overall assessmentLLC of likelihood that find- NOT FOR SALE1. Use of ORhigh-frequency DISTRIBUTION sound waves to evaluate internal pelvic orNOT- FORings SALE represent OR a malignancy DISTRIBUTION gans/structure for diagnostic purposes 7. Instruct client to avoid use of any underarm deodorant spray or a. Distinguish between solid and cystic pelvic masses powder prior to procedure b. Confirm viability and location of gestation/products of conception 8. Typically two views taken of each breast for screening c. Determine endometrial thickness mammogram d. Evaluate size/location© Jonesof uterine myomas& Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 9. Target specific area with multiple views and magnifications if sus- e. Evaluate adnexal masses/fullnessNOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION picious lesion found on clinical breast examination or screening f. Evaluate fetal growth mammogram—diagnostic mammogram g. Detect fetal anomalies/abnormalities 10. Referral and/or biopsy recommended on any clinically suspicious 2. Transabdominal pelvic ultrasound—use if pelvic structures to be lesion regardless of mammography results examined© Jones extend & intoBartlett abdomen; Learning, instruct client toLLC have full blad- © Jones & Bartlett Learning, LLC der; pass transducer over tissue/organs to be examined 11. See Chapter 3, Primary Care, for mammography screening NOT FOR SALE OR DISTRIBUTION recommendationsNOT FOR SALE OR DISTRIBUTION 3. Transvaginal ultrasound—better resolution than transabdominal ultrasound; instruct client to empty bladder, use vaginal probe • Breast ultrasound placed in sterile sheath (glove, condom) 1. Use of high-frequency sound waves as adjunct to mammography • Mammography to assist in diagnosis of breast disease; not a screening tool © Jones &1. Bartlett Radiographic Learning, examination ofLLC the breast to determine presence ©of Jones2. &Helpful Bartlett in differentiating Learning, cystic fromLLC solid masses NOT FOR SALEsmall cancerous,OR DISTRIBUTION precancerous, and benign lesions; screening andNOT FOR3. May SALE be used OR as a guideDISTRIBUTION for needle aspiration, for needle core bi- diagnostic use opsy, and in localization procedures

4. Handheld, real-time, high-frequency probe passed over tissue to 3. Z-score used to compare bone density in premenopausal woman © Jones &be examinedBartlett Learning, LLC © Jonesto age-, & gender-,Bartlett and Learning,ethnicity-matched LLC reference population; may NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Bone densitometry/bone density testing be used in evaluation for secondary causes of osteoporosis 1. Used for screening, diagnosis and monitoring treatment of osteo- 4. Procedure for dual-energy X-ray absorptiometry (DEXA) scan— penia and osteoporosis most-used technique, low radiation exposure a. Client lies supine while imager passes over body 2. T-score used to compare bone density in postmenopausal woman to young adult female reference© Jones population & Bartlett Learning, LLCb. Process takes 10 to 15 minutes© Jones & Bartlett Learning, LLC a. Normal—bone mineralNOT density FOR(BMD) withinSALE 1 standard OR DISTRIBUTION de- c. Computer calculates densityNOT of client’s FOR bones SALE OR DISTRIBUTION viation (SD) of young normal adult; T-score greater than –1 d. Image/regions scanned for osteoporosis diagnosis—hip, spine, b. Osteopenia—BMD between 1 and 2.5 SD below that of young radius; use of other sites such as heel or finger may predict frac- normal adult; T-score between –1 and –2.5 ture risk but cannot be used for diagnosis c. Osteoporosis—BMD 2.5 SD or more below that of young nor- e. See Chapter 3, Primary Care, for bone density screening guide- mal© adult; Jones T-score & at Bartlettor less than –2.5Learning, LLC lines and© for Jones more information & Bartlett on osteoporosis Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Questions Select the best answer. 7. Evaluation of EOM movement includes: © Jones1. A& 17-year-old Bartlett client Learning, presents at the LLC clinic with the following reason © Jonesa. ophthalmoscopic & Bartlett examination. Learning, LLC NOT FORfor SALE seeking care: OR “I DISTRIBUTIONhave been sick for three days. I feel sick to my NOT FORb. PERRLA SALE evaluation. OR DISTRIBUTION stomach and have diarrhea.” Which of the following would be most c. the six cardinal fields of gaze. appropriate to document as her reason for her visit/chief complaint? d. visual fields by confrontation. a. Flulike symptoms 8. The adventitious lung sound most commonly associated with b. GI distress asthma is: c. “I feel sick to my stomach© and Jones have diarrhea” & Bartlett Learning, LLCa. crackles. © Jones & Bartlett Learning, LLC d. Possible pregnancy, needsNOT further FOR evaluation SALE OR DISTRIBUTIONb. pleural rub. NOT FOR SALE OR DISTRIBUTION 2. Which of the following would be considered a subjective assessment c. rhonchi. finding to be placed in the S section of SOAP format charting? d. wheezes. a. Motile trichomonads 9. When auscultating lung sounds, the normal finding over most of b. Mucopurulent discharge the lung fields is: c. Trichomoniasis© Jones vaginitis & Bartlett Learning, LLC a. bronchial.© Jones & Bartlett Learning, LLC d. VaginalNOT itching FOR SALE OR DISTRIBUTION b. resonant.NOT FOR SALE OR DISTRIBUTION 3. Which of the following includes a pertinent negative that needs to c. tympanic. be documented? d. vesicular. a. 16-year-old female who has never been sexually active; no hist- 10. Increased tactile fremitus would be an expected finding in a client ory of STIs with: © Jones b.& 25-year-old Bartlett female Learning, with abdominal LLC pain; no nausea, vomiting, © Jonesa. asthma. & Bartlett Learning, LLC NOT FOR SALEor diarrhea OR DISTRIBUTION NOT FORb. emphysema. SALE OR DISTRIBUTION c. 40-year-old female with depression; past history of suicidal attempt c. lobar pneumonia. d. 60-year-old female with stress incontinence; no breast mass or d. pleural effusion. nipple discharge 11. The sound heard over the cardiac area if the client has pericarditis is 4. Appropriate information in the review of systems section of the mostly likely to be a(n): health history would include:© Jones & Bartlett Learning, LLCa. diastolic murmur. © Jones & Bartlett Learning, LLC a. alert, cooperative, well groomed.NOT FOR SALE OR DISTRIBUTIONb. fixed split S2. NOT FOR SALE OR DISTRIBUTION b. had measles and chickenpox as a child. c. friction rub. c. occasional loss of urine with coughing. d. increased S4. d. walks 2 miles a day for exercise. 12. Which of the following is an abnormal abdominal examination 5. Which of the following would most appropriately be documented in finding in an adult? the A section© Jones of SOAP & charting Bartlett format? Learning, LLC a. Abdominal© aortaJones 2.5 cm & in Bartlett width Learning, LLC a. CBCNOT ordered FOR SALE OR DISTRIBUTION b. Liver borderNOT nonpalpable FOR SALE OR DISTRIBUTION b. Client states that she would like to quit smoking c. Liver span 8 cm at the right MCL c. Medication instructions provided d. Splenic dullness at the left anterior axillary line d. Mucopurulent cervicitis 13. One of the cranial nerves for which you would test both motor and 6. The bell of the stethoscope should be used when listening for: sensory function is: © Jones a.& bowel Bartlett sounds. Learning, LLC © Jonesa. CN & II—optic Bartlett nerve. Learning, LLC NOT FORb. SALEcarotid bruits. OR DISTRIBUTION NOT FORb. CN V—trigeminalSALE OR nerve. DISTRIBUTION c. lung sounds. c. CN VI—abducens nerve. d. S1 and S2 heart sounds. d. CN XI—spinal accessory nerve.

14. A client with an Hgb of 10.2 g/dL and RBC indices indicating both 24. Appropriate management for a 45-year-old client who has no diabe- © Jones & Bartlettmicrocytosis Learning, and hypochromia LLC most likely has: © Jones tes& riskBartlett factors and Learning, no symptoms ofLLC diabetes with a fasting glucose NOT FOR SALEa. folic acidOR deficiency. DISTRIBUTION NOT FORof 130SALE mg/dL OR would DISTRIBUTION include which of the following? b. iron deficiency. a. Inform client she has impaired glucose tolerance c. severe dehydration. b. Order HbA1c level d. vitamin B12 deficiency. c. Repeat glucose testing on another day d. Repeat glucose screening in 3 years 15. A client with an increased© Jones WBC count & related Bartlett to infectious Learning, hepatitis LLC © Jones & Bartlett Learning, LLC would most likely have an elevated level of: 25. A client who either has acute active HBV infection or who is a car- a. basophils. NOT FOR SALE OR DISTRIBUTIONrier (chronic active state) wouldNOT have FOR a positive SALE test for: OR DISTRIBUTION b. eosinophils. a. HBsAg. c. lymphocytes. b. HBsAb. d. neutrophils. c. HBeAg. d. HBeAb. 16. Expected© Jones thyroid & function Bartlett test findings Learning, with primary LLC hypothyroid- © Jones & Bartlett Learning, LLC ism include: 26. Tests for cerebellar function include: a. NOTdecreased FOR TSH SALEand decreased OR FT DISTRIBUTION4. a. deepNOT tendon FOR reflex evaluation. SALE OR DISTRIBUTION b. decreased TSH and increased FT4. b. short-term memory evaluation. c. increased TSH and decreased FT4. c. discriminatory sensation tests. d. increased TSH and increased FT4. d. Romberg test for balance. © Jones &17. BartlettA pregnant clientLearning, presents with LLC a recent-onset rash. Which of the© Jones27. Which& Bartlett of the following Learning, statements LLC is correct regarding autosomal following laboratory results would be reassuring that this is not recessive inheritance of a genetic disorder? NOT FOR SALElikely rubella? OR DISTRIBUTION NOT FORa. SALEBoth parents OR are DISTRIBUTION unaffected but are carriers of the mutated gene. a. HAI titer of 1:10 at her initial visit 1 month earlier b. Disorder tends to occur in every generation of the affected b. HAI titer of 1:128 at the current visit family. c. Increased IgG antibody levels at the current visit c. Male offspring are more likely to be affected than females. d. Increased IgM antibody levels at the current visit d. One parent has the genetic disorder with the mutated gene. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 18. A client who had HBV 6 months ago currently has no symptoms but 28. Obtaining a Z-score on a bone mineral density test might be appro- has a positive test for HbsAg.NOT This FOR most likelySALE indicates OR that DISTRIBUTION she: priate for evaluating: NOT FOR SALE OR DISTRIBUTION a. has immunity to future infection. a. a 40-year-old female with a nontraumatic hip fracture. b. has persistent active infection. b. a 46-year-old female with a strong family history of osteoporosis. c. is a chronic carrier of HBV. c. a 60-year-old female who smokes cigarettes and has low body d. is in the early stage of reinfection. weight. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 19. A false-negative TB PPD test may be the result of: d. a 70-year-old female with osteoporosis being treated with a a.NOT dormant FOR infection. SALE OR DISTRIBUTION bisphosphonate.NOT FOR SALE OR DISTRIBUTION b. immunosuppression. 29. A client who was treated for primary syphilis one year ago now has c. intradermal injection. the following test results: VDRL nonreactive and FTA-ABS positive. d. prior BCG vaccination. These findings indicate that the client most likely: 20. A client with cholecystitis would most likely have a(n): a. was not adequately treated for primary syphilis one year ago. © Jones & Bartletta. decreased Learning, alkaline phosphatase. LLC © Jones b.& hasBartlett become reinfected Learning, since completion LLC of treatment one year NOT FOR SALEb. decreased OR indirectDISTRIBUTION bilirubin. NOT FOR SALEago. OR DISTRIBUTION c. increased albumin level. c. has some other condition that is causing a false-positive d. increased direct bilirubin. FTA-ABS. d. was treated adequately for syphilis and has not become 21. Measuring waist circumference is most appropriate when the client’s reinfected. BMI places her in which of the following categories? a. Underweight © Jones & Bartlett Learning, LLC30. Which of the following heart© sounds Jones may be& a Bartlett normal finding Learning, in the LLC b. Normal weight NOT FOR SALE OR DISTRIBUTIONthird trimester of pregnancy?NOT FOR SALE OR DISTRIBUTION c. Overweight a. Diastolic murmur d. Extreme obesity b. Fixed split S2 c. S 22. Which of the following lab values is not normally affected by pregnancy? 3 d. S a. Cholesterol 4 b.© MCV Jones & Bartlett Learning, LLC 31. Pelvic ©findings Jones on examination & Bartlett of a 22-year-old Learning, nulliparous LLC client are uterus 7 cm in length and ovaries 3 cm × 2 cm × 1 cm. These c.NOT T4 FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION d. Triglycerides findings are consistent with: a. an enlarged uterus and enlarged ovaries. 23. A 65-year-old female has a bone densitometry test, with the results b. a normal-size uterus and enlarged ovaries. of T-score being –2.0. This indicates she has: c. an enlarged uterus and normal-size ovaries. a. bone density that is greater than that of most women her age. d. a normal-size uterus and normal-size ovaries. © Jones & Bartlettb. bone density Learning, that is equal LLC to that of a young normal adult. © Jones & Bartlett Learning, LLC NOT FOR SALEc. bone OR loss thatDISTRIBUTION is at the level for a diagnosis of osteopenia. NOT FOR SALE OR DISTRIBUTION d. bone loss that is at the level for a diagnosis of osteoporosis.

32. A laboratory test finding of increased immature neutrophils (shift to 41. The best position for palpating the axilla is with the woman: © Jonesthe & left)Bartlett is consistent Learning, with a(n): LLC © Jonesa. lying & downBartlett with her Learning, arm above the headLLC on the side you are NOT FORa. SALEacute bacterial OR infection. DISTRIBUTION NOT FORexamining. SALE OR DISTRIBUTION b. acute viral infection. b. lying down with her arm at her side on the side you are c. allergic reaction. examining. d. chronic bacterial infection. c. sitting up with her arm raised above her head on the side you are examining. 33. An elderly woman has had gastroenteritis© Jones &with Bartlett vomiting and Learning, diar- LLC © Jones & Bartlett Learning, LLC rhea for the past 3 days. Her mucous membranes appear dry, and d. sitting up with her arm down on the side you are examining. she says she has not urinatedNOT yet today. FOR Expected SALE laboratory OR testDISTRIBUTION 42. Which of the following would be NOTconsidered FOR a positive SALE PPD ORresult? DISTRIBUTION findings related directly to her current condition might include: a. General population: 5 mm induration a. decreased urine specific gravity. b. General population: 10 mm induration b. decreased hematocrit. c. Moderate-risk population: 5 mm induration c. increased blood glucose. d. High-risk population: 5 mm induration © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC d. increased blood urea nitrogen. 43. Abnormal findings on a urinalysis would include: 34. The bloodNOT type FORin which SALE an individual OR has DISTRIBUTION no antigens on his or her a. pH 5.0. NOT FOR SALE OR DISTRIBUTION RBCs is: b. specific gravity 1.5. a. AB+. c. WBCs 3 per HPF. b. AB–. d. protein 4 mg/dL. c. O+. © Jones & Bartlett Learning, LLC © Jones44. Adding & KOH Bartlett to a wet mountLearning, slide before LLC viewing it under the mi- d. O–. croscope is useful in the detection of: NOT FOR35. The SALE heart sound OR heard DISTRIBUTION best at the base of the heart is: NOT FORa. clue SALEcells. OR DISTRIBUTION a. S1. b. pseudohyphae. b. S2. c. trichomonads. c. S3. d. WBCs. d. S . 4 © Jones & Bartlett Learning,45. LLC A 42-year-old female is concerned© she Jones may be pregnant& Bartlett because Learning, LLC 36. A client who was sexually assaulted 3 weeks ago by an individual she is 12 days late for her period. The best initial pregnancy test to known to be HIV positive hasNOT a nonreactive FOR rapidSALE EIA testOR result DISTRIBUTION obtain is a: NOT FOR SALE OR DISTRIBUTION using an oral mucosal transudate specimen. The most appropriate a. qualitative sensitive urine hCG test. next step would be to: b. qualitative serum hCG test. a. advise the client to return for repeat testing in 3 months. c. quantitative sensitive urine hCG test. b. repeat the rapid EIA test now using a blood sample. d. quantitative serum hCG test. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC c. order an HIV-1 p24 antigen test. 46. A client presents with no symptoms but is concerned because she d. orderNOT a Western FOR blot SALE test to confirm OR theDISTRIBUTION nonreactive EIA test had sexual intercourseNOT FOR 3 weeks SALE ago with OR a new DISTRIBUTION partner who has re- result. cently disclosed having a history of genital herpes. The client wants 37. An abnormal finding on ophthalmoscopic examination would be: to know if there is a test that can be performed at this visit to see a. arterioles smaller than veins. if she has been infected. Which of the following would be the best b. a yellow optic disc. response? © Jones c.& presence Bartlett of a redLearning, reflex. LLC © Jonesa. A Pap& Bartletttest can be done Learning, at this visit that LLC will show if she has been NOT FORd. SALEtapering ofOR the veins.DISTRIBUTION NOT FORinfected. SALE OR DISTRIBUTION 38. When examining the cervix of a 20-year-old client, you note that b. A blood test can be done at this visit to see if she has recently most of the cervix is pink, but there is a small ring of dark-red tissue been infected. surrounding the os. This is most likely: c. If she does not develop lesions in the next 4 to 8 weeks, she is not a. an endocervical polyp. infected. b. due to cervical dysplasia.© Jones & Bartlett Learning, LLCd. She can have a blood test in 1 ©to 2Jones months to & determine Bartlett whether Learning, LLC c. due to cervical infection.NOT FOR SALE OR DISTRIBUTIONshe has herpes antibodies. NOT FOR SALE OR DISTRIBUTION d. the squamocolumnar junction. 47. The glands located posteriorly on each side of the vaginal orifice are 39. The laboratory test that is done for definitive diagnosis of sickle cell the: disease is: a. Bartholin’s glands. a. Hgb electrophoresis. b. Bulbar glands. b. peripheral© Jones blood smear.& Bartlett Learning, LLC c. Nabothian© glands.Jones & Bartlett Learning, LLC c. RBCNOT indices. FOR SALE OR DISTRIBUTION d. Skene’s glands.NOT FOR SALE OR DISTRIBUTION d. sickle cell preparation. 48. Which of the following statements regarding gene mutations is 40. A woman who is currently pregnant, has had two full-term deliver- correct? ies, and has had one first-trimester abortion would be considered: a. All gene mutations occur at the time of conception. a. gravida 2 para 2. b. Germ cell mutations occur after conception. © Jones b.& gravida Bartlett 3 para Learning, 2. LLC © Jonesc. Germ & Bartlettcell mutations Learning, may occur as aLLC result of exposure to NOT FORc. SALEgravida 3 ORpara 3. DISTRIBUTION NOT FORradiation. SALE OR DISTRIBUTION d. gravida 4 para 2. d. Somatic mutations may occur at any time in a person’s life.

49. The CDC-recommended diagnostic test for Trichomonas is: 51. A premenopausal women with which of the following conditions © Jones & Bartletta. culture. Learning, LLC © Jones would& Bartlett be most likely Learning, to have a low LLC FSH and low estradiol level? NOT FOR SALEb. NAAT. OR DISTRIBUTION NOT FORa. SALEAdrenal tumor OR DISTRIBUTION c. vaginal fluid sialidase test. b. Anorexia nervosa d. wet mount evaluation for motile trichomonads. c. Premature ovarian failure 50. Which of the following statements concerning testing for strep throat d. Turner’s syndrome in an adult client with sore© throat,Jones fever, & and Bartlett tonsillar exudate Learning, is correct? LLC © Jones & Bartlett Learning, LLC a. A positive rapid streptococcal antigen test indicates the need for antibiotic treatment.NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION b. No testing is indicated, as these findings are indicative of a viral infection. c. Throat culture is recommended rather than a rapid streptococcal antigen test. d. ©Throat Jones culture & is Bartlett indicated if aLearning, rapid streptococcal LLC antigen test is © Jones & Bartlett Learning, LLC NOTnegative. FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Answers with Rationales © Jones &1. Bartlett c. “I feel sick Learning, to my stomach LLC and have diarrhea” © Jones11. &c. Bartlettfriction rub. Learning, LLC NOT FOR SALEIn the healthOR DISTRIBUTIONhistory, the reason for a client’s visit/chief concern NOT FORA SALE pericardial OR friction DISTRIBUTION rub may be heard over the cardiac area as a should be documented as a brief statement in the client’s own grating sound throughout the cardiac cycle when inflammation of words. the pericardium is present. 2. d. Vaginal itching 12. d. Splenic dullness at the left anterior axillary line Subjective information is obtained as part of the health history and Splenic dullness may be percussed at the sixth to tenth ICS just is what the client or caregiver© Jones tells you. & Bartlett Learning, LLC posterior to the midaxillary© line Jones on the left & side, Bartlett with the clientLearning, in LLC 3. b. 25-year-old femaleNOT with abdominal FOR SALE pain; no nausea,OR DISTRIBUTION vomiting, the supine position. SplenicNOT dullness FOR at the anteriorSALE axillary OR lineDISTRIBUTION is or diarrhea indicative of an enlarged spleen. The description of presenting symptoms should include pertinent 13. b. CN V—trigeminal nerve. negatives. When a symptom suggests that an abnormality may exist The cranial nerves with both motor and sensory functions are or may develop in that area, include documentation of absence of CN V (trigeminal nerve), CN VII (facial nerve), CN IX (glosso- symptoms© Jones that &may Bartlett help eliminate Learning, some of the possibilities. LLC pharyngeal© Jones nerve), and& Bartlett CN X (vagus Learning, nerve). Routinely, LLC the only 4. c.NOT occasional FOR loss SALE of urine withOR coughing. DISTRIBUTION cranialNOT nerve FORin which SALE you test bothOR motor DISTRIBUTION and sensory function The review of systems is used to assess common symptoms for each is CN V. major body system to avoid missing any potential or existing problems. 14. b. iron deficiency. 5. d. Mucopurulent cervicitis RBC indices provide information about size, weight, and Hgb con- The A section of SOAP charting format includes your diagnosis or centration of RBCs and are useful in classifying anemia when the © Jones & Bartlettprioritized Learning,list of problems determinedLLC from your assessment of© Jones &individual Bartlett has a Learning,low Hgb level. Iron-deficiency LLC anemia is charac- NOT FOR SALEsubjective OR and DISTRIBUTION objective data. NOT FORterized SALE by abnormally OR DISTRIBUTION small (microcytic) and pale (hypochromic) RBCs. 6. b. carotid bruits. The bell of the stethoscope is best for listening to low-pitched 15. c. lymphocytes. sounds such as those heard over large blood vessels. The WBC count with differential provides information useful in evaluating an individual with infection, neoplasm, allergy, or im- 7. c. the six cardinal fields of gaze. munosuppression. Lymphocytes and monocytes are increased with EOM function is evaluated© Jones by assessing & symmetry,Bartlett lid Learning, lag, and LLC © Jones & Bartlett Learning, LLC acute viral infections and chronic bacterial infections. nystagmus as the clientNOT holds herFOR head SALEstill and follows OR DISTRIBUTIONyour finger NOT FOR SALE OR DISTRIBUTION through the six cardinal fields of gaze. 16. c. increased TSH and decreased FT4. An increased TSH level is seen with primary hypothyroidism and 8. d. wheezes. thyroiditis. A decreased FT level is seen with hypothyroidism. Wheezes are high-pitched (sound like a squeak), continuous ad- 4 17. a. HAI titer of 1:10 at her initial visit 1 month earlier ventitious© Jones lung & sounds Bartlett that may Learning, be heard when airLLC flows through © Jones & Bartlett Learning, LLC constricted passageways that occur in conditions such as asthma. The HAI test is used to detect immunity to rubella and to diagnose NOT FOR SALE OR DISTRIBUTION rubellaNOT infection. FOR Titers SALE of 1:10 orOR greater DISTRIBUTION indicate immunity to 9. d. vesicular. rubella. High titers (1:64 or greater) may indicate current rubella The lung sound over most of the lung fields is vesicular, with inspi- infection. ratory sounds lasting longer than expiratory sounds. 18. c. is a chronic carrier of HBV. 10. c. lobar pneumonia. HBsAg rises before onset of clinical symptoms, peaks during the Tactile fremitus refers to the palpable transmission of vibrations © Jones & Bartlett Learning, LLC © Jones &first Bartlett week of symptoms, Learning, and returns LLC to normal by the time jaundice through the bronchus to the chest wall when the client is speaking. subsides. An individual is considered to be a carrier (remains infec- NOT FOR SALEThere isOR increased DISTRIBUTION transmission through consolidated tissue, as NOTis FOR SALE OR DISTRIBUTION tious) if HBsAg persists. found with lobar pneumonia.

19. b. immunosuppression. 32. a. acute bacterial infection. © Jones &False-negative Bartlett TB Learning, PPD tests may resultLLC from incorrect administra- © JonesNeutrophils & Bartlett are increased Learning, with acute bacterialLLC infections and NOT FORtion SALE (must be OR intradermal) DISTRIBUTION or immunosuppression. NOT FORtrauma. SALE Increased OR immature DISTRIBUTION neutrophil forms (band or stab cells), 20. d. increased direct bilirubin. referred to as a “shift to the left,” are seen with ongoing acute bacte- An elevated direct (conjugated) bilirubin level occurs with gall- rial infection. stones and obstruction of the extrahepatic duct. 33. d. increased blood urea nitrogen. 21. c. Overweight © Jones & Bartlett Learning, LLCBUN is an indirect measure of renal© Jones and liver function.& Bartlett Increased Learning, LLC levels may be seen with hypovolemia, dehydration, reduced cardiac Waist circumference providesNOT measurement FOR SALE of abdominal OR fat DISTRIBUTION as an NOT FOR SALE OR DISTRIBUTION independent prediction of risk for type 2 diabetes, dyslipidemia, function, GI bleeding, starvation, sepsis, and renal disease. hypertension, and cardiovascular disease in individuals with BMI 34. d. O–. between 25 and 39.9 (overweight and obesity). Waist circumference Blood types are grouped according to presence or absence of anti- has little added value in disease risk prediction in individuals with gens A, B, and Rh on RBCs. Blood type O negative has no antigens BMI of© 40 Jones or greater &(extreme Bartlett obesity). Learning, LLC on RBCs. © Jones & Bartlett Learning, LLC 22. b. MCVNOT FOR SALE OR DISTRIBUTION 35. b. S2. NOT FOR SALE OR DISTRIBUTION Cholesterol and triglyceride levels may be elevated during pregnancy. The S2 heart sound is heard best at the base of the heart using the T4 levels are affected by the amount of TBG, which is increased dur- diaphragm of the stethoscope. ing pregnancy. The MCV is the average volume or size of a single 36. c. order an HIV-1 p24 antigen test. RBC. Although the Hgb/Hct levels may be lower during pregnancy, The HIV-1 p24 antigen test detects HIV-1 antigen as early as 2 to 6 © Jones &the Bartlett size of the RBCs Learning, should not change LLC unless the woman has iron- © Jonesweeks & after Bartlett infection; Learning, levels of this antigen LLC decline once HIV anti- deficiency anemia, thalassemia, vitamin B deficiency, or folic acid NOT FOR SALE OR DISTRIBUTION12 NOT FORbodies SALEdevelop. HIV OR antibodies DISTRIBUTION are detectable in 95% of individuals deficiency. within 6 months of infection. A combined HIV antibody and p24 23. c. bone loss that is at the level for a diagnosis of osteopenia. antigen test is available. Osteopenia is defined as BMD between 1 and 2 SD below that of a 37. d. tapering of the veins. young normal adult. This is a T-score of between –1 and –2.5. The normal retinal artery wall is transparent except for the column 24. c. Repeat glucose testing on© another Jones day & Bartlett Learning, LLCof blood going down the middle,© so Jonesa vein crossing & Bartlett beneath the Learning, LLC A fasting glucose of 126 mg/dLNOT or greater FOR is SALEdiagnostic OR for diabetes. DISTRIBUTION artery can be seen up to the columnNOT of blood FOR on eitherSALE side OR(arte- DISTRIBUTION Repeat testing should be done on a subsequent day to confirm the riovenous crossing). When narrowing of the retinal artery occurs diagnosis. (as with hypertension), the arterial wall thickens and becomes less 25. a. HBsAg. transparent. The vein crossing under the narrowed artery appears HBsAg is present with both acute active infection and a chronic to taper down on either side of the artery. active© (carrier) Jones state. & Bartlett Learning, LLC 38. d. the squamocolumnar© Jones &junction. Bartlett Learning, LLC 26. d. RombergNOT testFOR for balance. SALE OR DISTRIBUTION The squamocolumnarNOT FOR junction SALE is the areaOR where DISTRIBUTION squamous epithe- The cerebellum coordinates motor activity, maintains equilibrium, lium (pink) and columnar epithelium (dark red) of the cervix meet. and helps to control posture. The junction may be inside the cervical os so that only squamous epithelium is visible, or a ring of columnar tissue may be visible to a 27. a. Both parents are unaffected but are carriers of the mutated gene. varying extent around the os. In autosomal recessive inheritance of a genetic disorder, the af- © Jones &fected Bartlett individual Learning, has two mutated LLC copies of the responsible gene © Jones39. a. Hgb & electrophoresis.Bartlett Learning, LLC The sickle cell preparation is used to screen for sickle cell disease NOT FORin SALE each cell. OR The affectedDISTRIBUTION individual usually has unaffected par- NOT FOR SALE OR DISTRIBUTION ents (carriers), each of whom carries a single copy of the mutated and trait. A positive test indicates the presence of Hgb S, indicating gene. either sickle cell disease or trait. Hgb electrophoresis is the definitive test performed if the screening test is positive, as it identifies 28. a. a 40-year-old female with a nontraumatic hip fracture. Hgb type and quantity. A Z-score may be used to compare bone density in a premenopausal woman to an age-, gender-,© Jones and ethnicity-matched & Bartlett referenceLearning, 40.LLC d. gravida 4 para 2. © Jones & Bartlett Learning, LLC population to evaluate for secondary causes of osteoporosis. Gravida denotes the total number of pregnancies, including a cur- NOT FOR SALE OR DISTRIBUTIONrent pregnancy. Para denotes totalNOT number FOR of pregnancies SALE reachingOR DISTRIBUTION 29. d. was treated adequately for syphilis and has not become 20 weeks or longer gestation. reinfected. Nontreponemal tests (VDRL, RPR) usually become nonreactive 41. d. sitting up with her arm down on the side you are examining. with time after treatment. Treponemal tests (FAT-ABS, TPI) usually The examiner palpates the axillary lymph nodes and the breast remain© positive Jones indefinitely & Bartlett after treatment. Learning, LLC tissue that ©extends Jones into the & axillary Bartlett area (tail Learning, of Spence) with LLC the woman sitting with arms relaxed at her side. The examiner sup- 30. c. S 3 NOT FOR SALE OR DISTRIBUTION ports the lowerNOT arm FOR and uses SALE the palmar OR surface DISTRIBUTION of fingers to pal- An increased S may be audible in late pregnancy. This heart sound 3 pate the entire area. is heard early in diastole during rapid ventricular filling. 42. d. High-risk population: 5 mm induration 31. d. a normal-size uterus and normal-size ovaries. In the individual considered to be high risk for tuberculosis, a PPD The uterus is 5.5 to 8 cm long and pear shaped in the nulliparous skin test resulting in a 5-mm or greater area of induration is a posi- © Jones &woman. Bartlett During Learning,the reproductive LLCyears, the ovaries are approxi- © Jones & Bartlett Learning, LLC tive reaction. NOT FORmately SALE 3 cm OR × 2 cmDISTRIBUTION × 1 cm. NOT FOR SALE OR DISTRIBUTION

43. b. specific gravity 1.5. 48. d. Somatic mutations may occur at any time in a person’s life. © Jones & BartlettNormal values Learning, are as follows: LLC specific gravity 1.005 to 1.030, pH© 4.6 Jones &Somatic Bartlett mutations Learning, are acquired andLLC occur after conception. A DNA NOT FOR SALEto 8.0, WBCsOR DISTRIBUTION0 to 4 per HPF, and protein 0 to 8 mg/dL. NOT FORcopying SALE mistake OR may DISTRIBUTION occur during cell division or from exposure 44. pseudohyphae. to ionizing radiation, chemicals, or viruses during gestation or later The addition of KOH to the vaginal wet mount slide facilitates visual- in life. ization of Candida pseudohyphae and buds. 49. b. NAAT. 45. a. qualitative sensitive© urine Jones hCG test. & Bartlett Learning, LLC The CDC-recommended test© forJones Trichomonas & Bartlett is the NAAT. Learning, It is LLC more sensitive than a wet mount or culture. Sensitive urine hCG testsNOT may FORdetect pregnancy SALE asOR early DISTRIBUTION as 28 days NOT FOR SALE OR DISTRIBUTION from the last menstrual period. Cross-reactions with other hor- 50. a. A positive rapid streptococcal antigen test indicates the need for mones are not a problem. A qualitative (positive/negative) test is antibiotic treatment. the appropriate pregnancy test choice. A positive rapid streptococcal antigen test indicates the presence 46. d. She can have a blood test in 1 to 2 months to determine of GABHS requiring antibiotic treatment. A negative test indicates whether© Jones she has & herpes Bartlett antibodies. Learning, LLC that the© infection Jones is more& Bartlett likely viral. Learning,A culture is not neededLLC to confirm a negative test. Type-specificNOT FOR serologic SALE tests OR detect DISTRIBUTION HSV-1 and HSV-2 antibodies. It NOT FOR SALE OR DISTRIBUTION may take 4 to 12 weeks for seroconversion to occur. 51. b. Anorexia nervosa 47. a. Bartholin’s glands. The premenopausal woman with anorexia nervosa may have both a The glands located posteriorly on each side of the vaginal orifice are low FSH and low estradiol level. the Bartholin’s glands. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FORBibliography SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

American College of Obstetricians and Gynecologists. (2018). Committee Opinion Kramer, D. (2016). Special considerations in the gerontological patient. In S. Miller No. 729: Importance of social determinants of health and cultural awareness in the (Ed.), Adult-gerontology nurse practitioner certification review guide (6th ed., delivery of reproductive health care. Obstetrics and Gynecology, 131(1), e43–e48. pp. 31–45). Burlington, MA: Jones & Bartlett Learning. American Diabetes Association.© (2019). Jones Classification & Bartlett and diagnosis Learning,of diabetes mel- LLCLab Tests Online. (n.d.). Home page. Retrieved© Jones from https://labtestsonline.org/ & Bartlett Learning, LLC litus. Diabetes Care, 42(supplNOT 1), S13–S28. FOR SALE OR DISTRIBUTIONLewinsohn, D., Leonard, M., LeBue, P.,NOT Cohn, D., FOR Daley, C., SALE Desmond, OR E., & Woods, DISTRIBUTION Ball, J., Dains, J., Flynn, J., Solomon, B., & Stewart, R. (2019). Seidel’s guide to physical G. (2017). Official American Thoracic Society/Infectious Diseases Society of examination (9th ed.). St. Louis, MO: Mosby. America/Centers for Disease Control and Prevention clinical practice guidelines: Carcio, H., & Secor, M. (2018). Advanced health assessment of women: Clinical skills Diagnosis of tuberculosis in adults and children. Clinical Infectious Diseases, 64(2), and procedures (4th ed.). New York, NY: Springer. e1–e33. Centers for Disease Control and Prevention. (2006). Revised recommendations for Lister Hill National Center for Biomedical Communications. (2013). Handbook: Help HIV© testing Jones of adults, & adolescents, Bartlett and pregnant Learning, women in healthcareLLC settings. me understand© Jones genetics. Washington, & Bartlett DC: National Learning, Institutes of Health. LLC MorbidityNOT and FOR Mortality SALE Weekly Report, OR 55 (RR14),DISTRIBUTION 1–17. National InstituteNOT of Child FOR Health SALE and Human OR Development. DISTRIBUTION (2016). How are obesity Centers for Disease Control and Prevention. (2012). Recommendations for the and overweight diagnosed. Retrieved from https://www.nichd.nih.gov/health identification of chronic hepatitis C virus infection among persons born during /topics/obesity/conditioninfo/diagnosed 1945–1965. Morbidity and Mortality Weekly Report, 61(RR04), 1–18. National Osteoporosis Foundation. (2013). Clinician’s guide to prevention and treat- Centers for Disease Control and Prevention. (2013). Testing for HCV infection: An ment of osteoporosis. Washington, DC: Author. update of guidance for clinicians and laboratorians. Morbidity and Mortality Pagana, K., & Pagana, T. (2018). Mosby’s manual of diagnostic and laboratory tests © Jones & WeeklyBartlett Report, 62Learning, (Early Release), 1–4. LLC © Jones(6th & ed.). Bartlett St. Louis, MO: Learning, Mosby. LLC Centers for Disease Control and Prevention. (2016). Guide to infection prevention in Rhoads, J., & Petersen, S. (2021). Advanced health assessment and diagnostic reasoning NOT FOR SALEoutpatient settings:OR DISTRIBUTION Minimum expectations for safe care. Retrieved from https://NOT FOR(4th ed.).SALE Burlington, OR MA: DISTRIBUTION Jones & Bartlett Learning. www.cdc.gov/infectioncontrol/pdf/outpatient/guide.pdf Schuiling, K., & Likis, F. (2017). Women’s gynecologic health (3rd ed.). Burlington, Gourlay, M., Fine, J., Preisser, J., May, R., Li, C., Lui, L., . . . Ensrud, K. (2012). Bone- MA: Jones & Bartlett Learning. density testing interval and transition to osteoporosis in older women. New Eng- Touhy, T., & Jett, K. (2016). Ebersole and Hess’ toward healthy aging: Human needs and land Journal of Medicine, 366, 225–233. nursing response (9th ed.). St. Louis, MO: Mosby Elsevier. Institute of Medicine. (2015). Cognitive© Jones aging: Progress & Bartlett in understanding Learning, and oppor- LLCUniversity of Washington STD Prevention© JonesTraining Center. & Bartlett(2019). National Learning, STD LLC tunities for action. Washington, DC: National Academies Press. curriculum. Retrieved from https://www.std.uw.edu/ Jarvis, C. (2016). Physical examinationNOT and FOR health assessment SALE (7th OR ed.). DISTRIBUTIONSt. Louis, MO: Workowski, K. A., & Bolan, G. A.; CentersNOT for Disease FOR Control SALE and Prevention. OR DISTRIBUTION (2015). Elsevier. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recommenda- King, T. K., Brucker, M., Osborne, K., & Jevitt, C. (Eds.). (2019). Varney’s midwifery tions and Reports, 64(RR-03), 1–137. (6th ed.). Burlington, MA: Jones & Bartlett Learning.

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