Respiratory system
	Function: exchange of O2 and CO2 between cells of body and external environment. 
	Resp system contains highly branched, hollow tubes forming air passageways. 
•	Small branches are called alveoli (air sacs)
	Anatomy-
	Nose- associated with senses of smell (olfaction, olfactory sense, olfactory region) Inflammation of mucosal membranes: rhinitis vs. allergic rhinitis d/t pollen, dust etc. 
	Pharynx- back of mouth aka the throat. 
	Nasopharynx-Portion immediately behind the nasal cavities and above the soft palate.
	2 auditory tubes
•	Eustachian tubes open from middle ear into the lateral walls of the nasopharynx. 
o	Function to equalize air pressure between the nasopharynx and middle ear. 
Larynx- cartilaginous structure connecting pharynx and trachea at the level of cervical vertebrae. 
Cricoid cartilage- resembles signet ring and connects larynx and trachea. 
Epiglottic cartilage or epiglottis is leave shaped and functions to seal off the respiratory tract when food passes into the esophagus. 
Trachea: aka windpipe. Approx 4-5inches long, midline of neck. Branches into 2 primary bronchi (singular bronchus). Right bronchus is slightly larger and more verticle than left. Bronchi eventually become smaller and smaller and are then known as bronchioles. 
•	Inflammation of the bronchioles is known as bronchitis. 
•	Asthma is one condition that affects the bronchi tree. 
•	S/S wheezing and SOB caused by spasms of the smooth muscles and usually triggered by allergens in environment. 
	Terms of the respiratory system. 
Dyspnea-subjective term used when patients report labored breathing and breathlessness. 
•	Response to exercise or heavy activity is normal if it rapidly disappears upon return to rest. 
•	Patients with lung disease may experience dyspenea with normal activities or even at rest. 
o	Climbing  two stairs
o	Walking one black or walking uphill
•	Anxiety can precipitate dyspnea and hyperventilation. 
•	Described as smothering, tingling around the lips from low carbon dioxide level. 
•	COPD or CHF describe as scary, hard to breathe, shortness of breath cannot get enough air or gasping. 
	Orthopnea-Difficulty breathing when lying flat. 
•	People often sleep on 2 or more pillows or even in a recliners. 
	Paroxysmal Nocturnal Dyspnea- patients who waken at night with sudden shortness of breath. 
•	Causes fluid overload from elevation of legs
•	Shifts fluid there to the body’s core. 
	Platypnea- shortness of breath that is relieved when lying down, and worsens when sitting or standing up. 
	Bradypnea-<10 breaths/min. 
	Tachypnea- >24 breaths/min
	Hyperpnea-increases depth of breathing when required to meet metabolic demand of body tissues, such as during or following exercise or when the body laxs oxygen, for instance in high altitude or as a result of anemia. 
	Hypopnea- disorder which involves episodes of ovely shallow breathing or an abnormally low repiratory rate. 
•	May happen while asleep or while awak
	Kussmaul breathing- deep and labored  often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA). 
•	A form of hyperventilation, breathing which is increased above the required rate. 
•	Rapid deep breathing
	Cheyne-stokes respiration- breathing pattern with period of apnea (10-60seconds) followed by gradually increasing depth and frequency of respiration, gradually decreasing in depth and frequency until period of apnea
•	Poor brain stem perfusion
	Apnea- suspension of external breathing. 
•	no muscle of respiration and volume of the lungs initially remain unchanged. 
•	No gas flow between lungs and the environment. 
	Stridor-loud high pitched crowing or honking sound louder in the upper airway. 
•	Laryngeal or tracheal inflammation or spasm can cause stridor, as can aspiration of a foreign object
o	Epiglottis, croup, partially obstructed airway; can indicate an emergency  requiring immediate attention.
	Vital capacity-the maximum amount of air a person can expel from the lungs after a maximum inspiration. 
•	Equal to the inspiratory reserve volume plus tidal volume plus the expiratory reserve volume. 
	Peak Expiratory Flow Rate-person maximum speed of expiration- measured with a peak flow meter- monitors a person’s ability to breath out air. 
•	Measures the airflow through the bronchi and thus the degree of obstruction in the airways. 
Forced Vital Capacity- the amount of air chich can be forcibly exhaled from the lungs after taking the deepest breath possible. 
Pulse oximetry-monitors oxygen saturation. 
Hyperresonance- occurs with hyper-inflation as in COPD- greather than normal resonance, often of a lower pitch, on percussion of the body. 
Tympanic- common respiratory diagnosis- pulmonary embolism- clear or mild wheezes. No sputum

Musculoskeletal 
Flexion-decreases the angle between bones or brings bones together
•	Dosiflexion-bending the ankle so that the toes move toward the head
•	Plantar flexion-moving the foot so that the toes move away fro the head
	Extension-increases the angle to a straight line or zero degrees
	Hyperextension-extension beyond the neutral position
	Abduction-movement of a part away from the center of the body
	Adduction-movement of a part toward the center of the body
	Rotation- turning of the joint around a longitudinal axis
•	Internal rotation-rotating an extremity medially along its axis
•	External-rotating an extremity laterally along the axis
•	Pronation-turning the forearm so the palm is down
•	Supination-turing the forearm soe the palm is up
	Circumduction-a circular motion that combines flexion, extension, abduction, adduction
	Inversion-turning the sole of the foot inward
	Eversion- turning the sole of the foot outward
	Protraction-moving a body part forward and parallel to the ground
	Retraction-moving a body part backward and parallel to the gound
	Elevation-moving a body part upward
	Depression- moving a body part downward
	Opposition- moving the thumb to touch the little finger. 

Genu valgum-“knock knee”- many children have a temporary period of this condition, but persistant knock knee may be genetic or result of metabolic bone disease. The patient may need to swing each leg outward while walking to prevent striking the planted limb with the moving limb. The strain on the knee frequently causes anterior and medial knee pain. Physical therapy and surgical intervention may be required. 
Genu Varum-bow leggedness- outward bowing of the leg in retention to the thigh, giving the appearance of an archer’s bow. 
Medial and lateral epicondyle- the olcranon process is centered between the medial and lateral epicondyles of the humerous. The sensitive ulnar nerve runs between the olceranon process and the medial epicondyle. 
Olecranon process-a large bursa lies between this and the skin. 
Acomion process- of the scapula, is at the top of the shoulder.  
Medial and lateral malleolus- palpable on either side of the ankle. Strong ligaments extend from each malleolus on the foot to provide lateral stability of the ankle. 
Scoliosis- the lateral curvature of the spine, usually affecting both the thoracic and lumbar spine parts. With a deviation in one direction in the thoracic and in the other direction in the lumbar spine. 
•	Structural
•	Caused by defect in the spine
•	Functional
o	Caused by habits- heavy backpack on one shoulder
•	Often develops early in adolescence, especially in girls. 
	Kyphosis- an exaggerated forward curvature of the spine
•	May occur in older adults. 
Subluxation-partial dislocation of the shoulder from the weight of the arm and the lack of muscle tone to hold joint together. 
Contracture- shortening of tendons, fascia or muscles may result form injury  or prolonged positioning. 
•	Once developed it is difficult to stretch and may require surgery. 
	Crepitation-cracking or popping in a joint. 
	Heberden’s and Bouchards Nodules- hard non tender boney growths on the distal (heberden’s) and proximal (bouchard’s) intraphalangeal joints. Frequently occurs with deviation of the fingers. 
	Fluctuant-
	Bulge test- differentiates soft tissue swelling from accumulation of excess fluid behind the patella. With the patient supine, milk upward along the medial aspect of the knee 4 times. Then press on the lateral side of the knee and check for any bulging on the medial side. A buldge indicates joint effusion or liquid accumulation in the area, which is not a normal finding. 
	Hallux Valgus-(bunion)- the great toe is angled away from the midline, crowning the other toes. 
	
	Muscle strength: 5 point scale:
	5/5-100% normal- complete ROM against gravity and full resistance
	4/5-75%-good- complete ROM against gravity and moderate resistance
	3/5-50%-fair- complete ROM against gravity
	2/5-25%-poor-complete ROM with the joint supported; cannot perform ROM against gravity
	1/5-10%-Trace- muscle contraction detectable, but no movement of the joint
	0/5-0%- Zero- no visable muscle contraction
	
	Phalen’s test- carpel tunnel- patient flexes wrists 90degrees and holds the backs of hands together for 60 secs
	Tinel’s test-carpel tunnel- percuss lightly over the median nerve located on the inner aspect of wrist. 
	Ballottement of patella-evaluates presence of large accumulation of fluid behind the knee. 
	McMurray’s Test-Checks for meniscus injuries. Patient lies supine and flexes the hip and knee. Rotate foot laterally. 
	SLR (Straight Leg Raises)- LeSegue’s- checks herniation of the lumbar disk and nerve irritation or pressure. Patient supine and both legs extended,. 
	Ortolani’s maneuver- check for congenital hip dislocation for newborns- infant is supine with flexed knees and hips so that the heels touch the buttocks. Place hand on greater trochanter of the humerous and adducts the legs moving the knees down laterally. 
•	Should be smooth with no clicking sounds

Male GU and Rectal Outline
Scrotum-the pouch covered with darkly pigmented loose, rugous (wrinkled) skin. The septum divides the scrotum into two sacs, each containingthe testis, epididymis, spermatic cord, and muscle layer. 
Shaft of penis- hairless, thin skin that adheres loosely, allowing for expansionof the erect penis. 
Glans of Penis-lighter in pigmentation than the rest of the organ.
Urethral Orifice-opening is the small slit at the tip of the penis- terminal route for both sperm and urine. 
Dorsum of Penis-the penis contains 3 distensible structures- the two corpora cavernosa, which form the dorsum and the sides of the penis
Vas Deferens-transports sperm from the epididymis to the ejactulatory duct. 
Spermatic cord-vas deferens, arteries, veins, and nerves make this up. 
•	Ascends through the external inguinal ring and into the inguinal canal. 
	Tinae Curis- “jock itch”- fungal infection on the patients groin and upper thighs. Appears with large red scaley patches that are extremely itchy
•	Rarely involves the scrotum
	Hernia- Direct inguinal, indirect inguinal, and femoral. 
	
Hypospadias- urethral meatus on the underside of the penis- the deviation of the meatus makes it difficult to urinate when standing. The physical appearance of the penis is altered, sometimes causing body image disturbances
Epispadias-the urethral meatus opens on the upper side surface of the penis. May be associated with underlying congenital abnormalies in genital urinary development. The lower urinary tract may be exposed in severe cases. 
Priapism-long painful erection. Seen in leukemia or hemoglobinopathies- not sexual excitation- the prolonged erection results from vein thrombosis in the corpora carvernosa
Phimosis-the prepuce cannot be retracted over the glan. It can occur during the first 6 years of life. It may be congenital or follow recurrent infections or balanoposthitis. Occasionally the narrowed foreskin obstructs urinary flow. Resulting in a dribbling stream or ballooning of the foreskin- severe phimosis is treated by circumcision. 
Paraphimosis-the retracted prepuce cannot be place back over the glan. 
•	May be severe enough to restrict circulation to the glan. An uncircumcised male would always have the foreskin pulled toward the urethral opening
	Sctricture- i
	Pilonidal cysts- a cyst or abscess near or on the natal cleft of the buttocks that often contains hair and skin debris.
	Anorectal fissure- a tear in the anal mucosa and can occur midline or posterior or anterior to it. Usually, a fissure is caused by the passage of large, hard stool. On observation a sentinel skin tag may be seen at the lower end of the fissure. Ulcerations may appear at the site. The patient has bleeding, pain, and itching. As the internal sphincter is spastic, anesthesia of the site is necessary for examination. 
	Rectal Prolapse- usually occurs with defecation; the rectal mucosa, with or without the muscular wall, prolapses throught the anal ring. 
•	Present like a doughnut
•	Complete prolapse includes muscular wall and is larger with circular folds. Cystic fibrosis is associated with children who present with rectal prolapse
	Pruitus ani-  is the irritation of the skin at the exit of the rectum, known as the anus, causing the desire to scratch The intensity of anal itching increases from moisture, pressure, and rubbing caused by clothing and sitting. At worst, anal itching causes intolerable discomfort that often is accompanied by burning and soreness.
	Hemorrhoid-classified as external or internal- caused by constant or excessive strainig upon defecation
	
	Diagnostic testing-
	FOBT- Fecal Occult Blood Test-
	PSA-Prostate test- blood test that measures a protein produced by the prostate gland in men. Levels increase with infection, prostitis, hyperplasia and cancer. 
	
	Breast examination
	Terms
	Tail of Spence- extends from the upper outer breast quadrant into the axilla
	Nipple and areola-thin layer of breast tissue with a centrally located nipple and surrounding areola.
	Nipple-center of the breast
•	Darkly pigmented, round, rough, and usually protuberant
•	Composed of smooth muscle fibers
•	Autonamic , sensory or tactile stimulation produces ecection and emptying of lactiferous ducts during breast feeding
	Areola-1-2 cm – darkly pigmented. 
•	Within are small sebaccous glands 
	Montgomery glands-sebaccous glands within the areola- during lactation, these glands secrete protective lubricant. 
	Cooper ligaments- fibrous bands- extends from the connective tissue to the muscle fascia, providing additional support. 
•	Consist of 15 to 20 glandular lobes in each breast that extends from the nipper in the radial fashion. 
	Lactferous ducts- where milk is drained once produced. Milk from each lobe empties into one sinus that terminates at the nipple. 
	Gynecomastia-during midpuberty, one or both male breasts commonly and temporarily enlarge as a result of changing hormone levels. May develop breast buds or tenderness which is usually temporary . 1/3 of adolescent males have these conditions, which resolve in 1 to 2 years..Occurs with use of anabolic steroids, disease, and as a side effect of some medications.
	Mastalgia- severe pain in the breasts- more likely to result from trauma or infection
	Peu d’ orange-orange peel texture- caused by breast edema from blocked lymph drainage and indicates advanced cancer. 
	Supernumerary nipper-accessory nipper- often looks like a mole but when inspected closely, a tiny nipple and areola are evident. 
•	Must evaluate the kidneys,
	Tanner staging
•	Preadolescents-only small elevated nippes
•	Breast bud stage- a small mond of breast and nipple develops- arola widens
•	The breasts and areola enlarge the nipple is flush with the breast surface
•	The areola and nipper form a secondary mound over the breast
•	Mature breasts-only the nipple protrudes the areola is flush with the breast contour
Speculum-
o	Grave’s- wider blades
o	Pederson- narrow blades
	Peritoneum- the uterine walls consist of an outer layer
	Mons pubis-the most anterior structure and comprised of subcutaneous fat tissue covered by the pubic hair. 
	Labia majora-consists of 2 folds that extend from the mons pubis downward to the perineum. 
	Clitoris- embryologic homologue of the penis, responds in an erectile fashion when stimulated. 
	Labia minora-2 small folds that extend from the clitoral hood to the posterior fourchette of the vagina, fuse. 
	Frenulum-the ventral surface of the glans 
	Myometrium-a muscle layer in the peritoneum
	Urethral meatus-outer layer of urethra
	Skene’s gland-within the vestibule, at the 7 and 5o’clock positions- produce clear fluid that aids in lubrication during intercourse. 
	Vaginal introitus-posterior to the urethra
	Bartholin’s glands-base of vestibule, secretes clear mucus into the vaginal introitus during intercourse. 
	Gravida-the number of pregnancies a woman has had including if she is presently pregnant
	Para-the # of births a woman has had after 20 weeks even if the fetus died at birth
	Term-infant born after 37 weeks gestation
	Menarche- median age 12.4 years. First period
	Amenorrhea-absense of menstral period 
	Menopause-the cessation of menstral periods for 12 months of more. 
	Libido- sexual interest
	Nabothian cyst-common among women who have had vaginal births. Small benign nodules resemble yellow pustules. 
Ectopic-most common symptoms are lower quadrant pain, nausea, and referred pain in the neck shoulder from blood beneath the diaphragm. If severe hemorrhage occurs, the patien is at risk for shock. 
Leiomyomas-fibroid tumors-can cause abnormal uterine bleeding and backage, abdominal pressure, constipation, incontinence, and dysmenorrheal if large. 
Ovarian cysts-may be pain, tenderness over the ovary, irregular menses, intraperitoneal bleeding if it ruptures. 
Bimanual exam-to palpate for masses tumors, pain, organs. 
Pediculosis pubic-crab lice-commonly presents with itching in the mons pubis and perineum. The external genitalia are excorciated based on amount of itching. Tiny spots of blood may be seen on the underwear and possible lice. Nits which are the eggs normally adhere to pubic hair and can appear as small dark specks or may be translucent. 
Condyloma acuminatum- warts include vulva or vaginal itching, vaginal secretions, and growths along the vagina or rectum. 
•	Fleshy pink or grey papilloma or wart like projections at the vulva, vagina, or anus. 
	Candidiasis-associated with vulvovaginal and possibly rectal puritus and dyspareunia. Infections cause crusty, multiple red round erosions and pustules. 
•	Immunological deficiencies. 
	HPV vaccine-quadrivalent- types 6, 11, 16, 18. Recombinant vaccine to females aged 9-26 in 3 doses, the second dose 2 months after the first and the 3rd dose 6 months after the first. 
	Dysuria-pain with urination.