Breast, Genitalia, Abdomen, Rectal, urinary, and Renal Exam Flashcards
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
· Breast/axillary mass or lump
identify precise location, how long it has been present, and any change in size or variation w/in menstrual cycle, changes in breast contour, dimpling, swelling, or puckering of skin over breast. when describing: Location (quadrant/clock) and cm from nipple, Size-feel and guestimate size, Shape, Consistency- spongy, hard, Delimitation- well circumscribed or not, Tenderness, Mobility things that don’t move irregular, hard, irregular all malignancy. Common breast masses: Fibroadenoma- spony oblong tootsie roll like, Cyst- fluctuant, round, well-circumscribed, Abscess- pain and tenderness, Fibrocystic disease- tend to have more cyclic changes and nodular feeling breasts, Tumor- dimpled skin, irregular, hard, not tender
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
· Mastalgia or breast discomfort
breast pain most common symptom causing visits, pain w/out mass not considered breast cancer risk factor if diffuse, focal, cyclic or noncyclic, could be related to medications. Unilaterally tenderness is bad compared to bilaterally. Clinical breast examination (CBE) is warranted. Focal breast pain is more likely to merit diagnostic imaging. Medications associated with breast pain include hormonal therapy; psychotropic drugs such as selective serotonin reuptake inhibitors and haloperiodol; spironolactone, and digoxin.
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
· Galactorrhea or nipple discharge
Physiologic hypersecretion discharge is seen in pregnancy, lactation, chest wall stimulation, sleep, and stress and is usually bilateral, multiductal, prompted by stimulation, and ranges in color from white to yellowish or green. nonpuerperal Galactorrhea, or the discharge of milk- containing fluid unrelated to pregnancy or lactation or greater than 6 month of weaning, is more likely to be pathologic when it is bloody or serous, unilateral, spontaneous, associated with a mass, and occurring in women aged ≥40 years. Questions to ask: Does the discharge appear only after compression of the nipple, or is it spontaneous? If spontaneous, what is the color, consistency, and quantity? Is the color milky, brown or greenish, or bloody? Ask if the discharge is unilateral or bilateral. Causes of nipple discharge include hyperthyroidism, pituitary prolactinoma, and dopamine antagonists, including psychotropics and phenothiazines. Spontaneous unilateral bloody discharge from one or two ducts warrants further evaluation for intra- ductal papilloma ductal carcinoma in situ, or Paget dis- ease of the breast. Clear, serous, green, black, or nonbloody discharges that are multiductal are usually benign
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
· Cyclic hormonal and age related changes
breasts usually feel fuller around menses, birth control and type/age related changes of becoming less dense and more fat-filled. Occur over time best time to examine is 5-7 days after menses. Older women more likely to have cancer than younger. Hormonal changes may cause benign masses or painful and may need to check out for birth control to help ease patients symptoms.
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
· Skin or nipple changes
Breast/axillary mass or lump
Discuss the significance of additional relevant history questions including:
Previous breast biopsies/surgery
where? Why? Mastectomy patient- very thorough someone w/ scar tissue cant find nodule differentiating
Discuss the significance of additional relevant history questions including:
Family history of breast cancer
who? What age? Related? Ovarian cancer? Make it more likely that you will develop breast cancer particularly if there are a large number in a single family line or if the other’s with breast cancer are in your primary family. Should get BRCA and other testing to know your risk and monitor this patient frequently and in greater depth.
Discuss the significance of additional relevant history questions including:
BSE habits
did you compare? What did you notice? Does not reduce mortality leading to higher rate of benign breast biopsies, but women should be familiar w/ how their breasts normally look and feel.
Discuss the significance of additional relevant history questions including:
Personal history of breast cancer
What age diagnoses? Radiation? Surgery? Chemo? If have before higher risk of developing it than anyone else should be screened regularly and more frequently than most
Given a diagram of the breast and axilla, identify the following structures, and discuss function and physiologic variations.
adipose tissue
majority of the breast (glandular and sebaceous tissue) surrounding breast in superficial and peripheral areas. vary with such factors as age, state of nutrition, exogenous hormones and pregnancy (stretched out because of lactation
Given a diagram of the breast and axilla, identify the following structures, and discuss function and physiologic variations.
Areola
darker pigmented area (papilla), part babies latch onto, areola has small rounded elevations formed by sebaceous glands, sweat glands, and accessory areolar glands w/ a few hairs. While pregnant sebaceous glands produce oily secretion serve as protective lubricant for areola and nipple during lactation. Supplied w/ smooth muscle contracts to express milk from ductal system during breastfeeding rich sensory innervation, in nipple triggers milk letdown following neurohormonal stimulation
Given a diagram of the breast and axilla, identify the following structures, and discuss function and physiologic variations.
Central nodes
most likely to be palpable lie along chest wall, high in axilla and midway between anterior and posterior axillary folds
Given a diagram of the breast and axilla, identify the following structures, and discuss function and physiologic variations.
Lateral nodes
drain into central nodes and are seldom palpable. located along the upper humerus. They drain most of the arm.
Given a diagram of the breast and axilla, identify the following structures, and discuss function and physiologic variations.
Subscapular nodes
drain into central nodes and are seldom palpable. posterior, located along the lateral border of the scapula; palpated deep in the posterior axillary fold. They drain the posterior chest wall and a portion of the arm.
Given a diagram of the breast and axilla, identify the following structures, and discuss function and physiologic variations.
pectoral nodes
drain into central nodes and are seldom palpable. located along the lower border of the pectoralis major inside the anterior axillary fold. These nodes drain the anterior chest wall and much of the breast.
Given a diagram of the breast and axilla, identify the following structures, and discuss function and physiologic variations.
Breast
breast is a modified sebaceous (exocrine) gland- sensitive to hormonal fluctuation (tenderness increased fullness). Grapes w/ ducts stem and glands are grapes. All breasts feel lumpy/glandular/nodular lie against anterior thoracic wall second rib up till inframammary cleft sternum to midaxillary line.
Given a diagram of the breast and axilla, identify the following structures, and discuss function and physiologic variations.
Cooper’s ligaments or suspensory ligaments
fibrous connective tissue bands structural support in form of fibrous bands or suspensory ligaments extend from under the skin and attach to the underlying muscle, supporting glandular tissue - because of them can indicate something bad going on
Given a diagram of the breast and axilla, identify the following structures, and discuss function and physiologic variations.
glandular tissue
produces milk which is excreted to the nipple surface via lactiferous ducts and sinuses - baby latches on whole areola not just the nipple. composed of ~15-20 septated lobes in each breast radiating around nipple w/ smaller lobules draining into larger collecting ducts and sinuses onto porous openings on surface of areola and nipple. feeling breast tissue or physiologic nodularity can compare between them especially during menses. vary with such factors as age, state of nutrition, and pregnancy (stretched out because of lactation) atrophy after menopause
Given a diagram of the breast and axilla, identify the following structures, and discuss function and physiologic variations.
infraclavicular nodes
Malignant cells from a breast cancer may spread directly to the infraclavicular nodes or into the internal mammary chain of lymph nodes within the chest.
Given a diagram of the breast and axilla, identify the following structures, and discuss function and physiologic variations.
Montgomery glands
glands around edge of nipple or areolar gland can get degree blocked and inflamed
Given a diagram of the breast and axilla, identify the following structures, and discuss function and physiologic variations.
Nipple
both nipples should be same color, direction, and around same size. Nipples can chafe bilaterally when running with patients complaining of tissue irritation. if it is seen on one nipple is concerning. Occasionally, the nipple is inverted, or points inward, depressed below the areolar surface. It may be enveloped by folds of areolar skin, but can be moved out from its sulcus normal variant, except for possible difficulty when breastfeeding. Thickening of the nipple and loss of elasticity suggest an underlying cancer.
Given a diagram of the breast and axilla, identify the following structures, and discuss function and physiologic variations.
supraclavicular nodes
nodes above clavicle
Given a diagram of the breast and axilla, identify the following structures, and discuss function and physiologic variations.
tail of Spence
small portion of mammary tissue extends into the axillary region ( aka axillary tail)
Define, describe and discuss the following terms, and associate history and physical examination findings with underlying conditions:
breast cancer found in, presentation, and screening tools.
is commonly a hereditary cancer that is most commonly found in women and sometimes men.
Presentation: Single irregular/stellate mass, erythema (inflammatory cancer not warm)/other color changes, assymetrical/flattening, firm/hard, dimpling(fibrous strands attached to skin and fascia over pectoral muscles w/ cancer pull on them during muscle contraction) /peau d’orange appearance (prominent pores lymphatic obstruction), retractions(with position changes you can see the breast displaced and that there is something pulling on the cooper ligaments), skin thickening, not clearly delineated, abnormal contour, nipple deviation, areolar inversion, immobile, nontender, rapid enlargement, abnormal lymph nodes upon palpation.. When did you first notice?
Screening tools => Right upper quadrant has cancer the most so any mass in that area is more concerning being sure to feel lymph node and the tail of spence. Breast: Self-Examination (BSE) Clinical Breast Examination (CBE) Mammography Whole breast ultrasound BRCA1/BRCA2 testing
Define, describe and discuss the following terms, and associate history and physical examination findings with underlying conditions:
breast cyst
Usual age: 30 - 50 Number: single Shape: Round Consistency: Soft to firm Delimitation: Well delineated Mobility: Mobile Tenderness: Often tender Retraction signs:Absent. Cyst-nice and round, darkness in ultrasound is fluid young patient w/ palpable finding or mammogram. Screening images w/ ultrasound diagnostically is a great tool. Palpation round guestimate size, margins smooth, mobile, well circumscribed very well margins. fluctuant, round, well-circumscribed
Define, describe and discuss the following terms, and associate history and physical examination findings with underlying conditions:
Fibroadenoma
Usual age: 15- 25 Number: Usually single Shape: Round, disc-like, lobular Consistency: Usually firm, rubber bandy Delimitation:Well delineated Mobility: Very mobile Tenderness: Absent Retraction signs: Absent . Less common than cysts. spony oblong totsie roll like. Fibrous tissue mass, young women. African american get more commonly. Not commonly develop into cancer
Define, describe and discuss the following terms, and associate history and physical examination findings with underlying conditions:
fibrocystic changes
symptoms include breast pain, slight swelling both breasts, ropelike, and tenderness. Pendulous with diffuse fibrocystic changes-diagnosis not physiologically (physiologic nodularity). Single firm 1 x 1 cm mass. Tend to have more cyclic changes and nodular, glandular, lumpy breasts feeling breasts. Birth control pills help relieve. diffusely nodular ultrasound. Commonly caused by coffee. Don’t do breast exams because of benign workups.
Define, describe and discuss the following terms, and associate history and physical examination findings with underlying conditions:
gynecomastia
benign enlargement in male breast tissue 1/3 males 2 cm button of tissue under areola. adolescents become self conscious with hormonal changes occur and eventually will go away. Proliferation of palpable glandular tissue or accumulation of subareolar fat. Causes: puberty, Liver disease, Hormonal abnormalities, Opiate abuse, Anabolic steroids Estrogen-secreting tumors, decreased testosterone Heavy marijuana use Certain endocrine disorders problem if you find it in older individual
Define, describe and discuss the following terms, and associate history and physical examination findings with underlying conditions:
inverted nipple
Ask them if this is their norm. usually is both. Kooper ligament and lactiferous ducts a little more pulling on nipple area.
Define, describe and discuss the following terms, and associate history and physical examination findings with underlying conditions:
lactating adenoma
Benign,Rare, but are the most common mass that occurs during pregnancy and lactation,Mass is usually well circumscribed and non-tender
Define, describe and discuss the following terms, and associate history and physical examination findings with underlying conditions:
Mastitis
Mainly affects breast-feeding women. Erythema, edema and pain. Pain, sore tender breast, achey, low grade temperature, fatigue, nauseous. Well demarcated, tender, bacteria in babies mouth getting in and causing infection. Hot compress, antibiotics
Define, describe and discuss the following terms, and associate history and physical examination findings with underlying conditions:
Paget’s disease
An uncommon breast cancer, Symptoms affect the nipple and areola. Appears as a scaly, eczematous, unilateral lesion or rash that can progress to a weepy, crusty erosion. Persistent dermatitis of the nipple and/or areola should raise a high index of suspicion for Paget’s Disease. Paget chronic disease or complaint not going away even when they try to. Scaly,weepy or crusty or one sided.
Define, describe and discuss the following terms, and associate history and physical examination findings with underlying conditions:
peau d’orange
characteristic “orange peel” appearance ,Thickened skin with enlarged pores, Lymphatic blockage results in edema of the skin,Often appears 1st in lower portion of breast or areola. Skin of orange because of blockage of lymphatics and edema and swelling of tissue. Towards bottom of lower portion of breast or areola concerning to see that if previously had breast cancer and lymph node dissection could be normal. Dependent edema need to find out why.
Define, describe and discuss the following terms, and associate history and physical examination findings with underlying conditions:
Polymastia
the presence of supernumerary breasts commonly grows when lactating (>1 pair)
Define, describe and discuss the following terms, and associate history and physical examination findings with underlying conditions:
Polythelia
the presence of supernumerary nipples(>1 pair). Up in axilla extra nipple along milk line with halo effect determining if mole or extra nipple along milk line and never regressed not discovered till adolescence and when puberty begins, variation of normal.
Define, describe and discuss the following terms, and associate history and physical examination findings with underlying conditions:
skin retraction
Skin dimpling-size, shape, symmetry, Abnormal breast contours-hanging differently, Nipple retraction.inversion or deviation not facing same direction caused by cancer normally if one sided
Define, describe and discuss the following terms, and associate history and physical examination findings with underlying conditions:
supernumerary nipple
Embryologically- growing and developing have milk line along that line is extra nipple, breast tissue and will regress as you develop. Can show increased pigmentation, swelling, tenderness, or even lactation during puberty, menstruation, or pregnancy
Describe changes during adolescent breast development, and identify the Tanner stages (I-V) depicted in a picture or diagram. See slide 59
Tanner I
Tanner I: no glandular tissue; areola follows the skin contours of the chest (prepubertal) [typically age 10 and younger]
Describe changes during adolescent breast development, and identify the Tanner stages (I-V) depicted in a picture or diagram. See slide 59
Tanner II
Tanner II: breast bud forms, with small area of surrounding glandular tissue; areola begins to widen [10-11.5]
Describe changes during adolescent breast development, and identify the Tanner stages (I-V) depicted in a picture or diagram. See slide 59
Tanner III
Tanner III: breast begins to become more elevated, and extends beyond the borders of the areola, which continues to widen but remains in contour with surrounding breast [11.5-13]
Describe changes during adolescent breast development, and identify the Tanner stages (I-V) depicted in a picture or diagram. See slide 59
Tanner IV
Tanner IV: increased breast size and elevation; areola and papilla form a secondary mound projecting from the contour of the surrounding breast [13-15]
Describe changes during adolescent breast development, and identify the Tanner stages (I-V) depicted in a picture or diagram. See slide 59
Tanner V
Tanner V: breast reaches final adult size; areola returns to contour of the surrounding breast, with a projecting central papilla. [15+]
Discuss indications for and interpretation of findings for breast cancer screening and diagnostic tools.
Mammography
biennial screening for women aged 50 to 74 years highest risk for developing cancer early diagnosis for early treatment. Insurance covers one every year.. Breast density, young women breast imaging is not as good because of it and younger women less at risk of cancer. Not routine for under 40-49 yr old, should only start before 50 on individual basis, weigh specific benefits and risks. For breast tissue noted to be >50% dense on mammogram Heterogeneously dense (category C) Extremely dense (category D)
Discuss indications for and interpretation of findings for breast cancer screening and diagnostic tools.
Magnetic Resonance Imaging (MRI)
often used for women with breast implants sensitivity is double that of mamograms, best given to women with high risk yearly above age 30
Discuss indications for and interpretation of findings for breast cancer screening and diagnostic tools.
Breast Self-Examination (BSE)
Inspection: In front of a mirror with 3 different positions. Palpation: In shower using soapy finger pads with ipsilateral arm raised behind head, Supine with rolled towel or pillow beneath shoulder on same side as breast to be palpated with same arm raised over head. Not reccommended by many governing boards because of the frequency of false problems
Discuss indications for and interpretation of findings for breast cancer screening and diagnostic tools.
Breast cancer screening (BRCA1, BRCA2)
BCRA1 for women, BCRA2 for men, blood test anyone w/ family history of breast cancer two relatives on same side increasing risk for breast or ovarian cancer. Predicts predisposition. IF HAVE Mutated tumor suppressor gene screen more regularly using adjunct screening tools or mri. Begin asking women as young as 20 about family history of breast or ovarian cancer on maternal or paternal sides. If family history is suspect, the next steps for clinicians include using the BRCAPRO calculator, genetic testing, referral for genetic counseling, consideration of mammography as well as magnetic resonance imaging (MRI) for screening, and appropriate specialty referrals.
Discuss indications for and interpretation of findings for breast cancer screening and diagnostic tools.
Fine needle aspiration (FNA)
fine needle aspiration. Small needle with suction from syringe (suction) used to obtain cells or fluid looking under microscope. More likely they think is benign, less invasive
Discuss indications for and interpretation of findings for breast cancer screening and diagnostic tools.
Needle core biopsy
A small tubular portion of tissue is removed. if malignant they will get core of it to look at core localization w/ imaging machine.
Discuss indications for and interpretation of findings for breast cancer screening and diagnostic tools.
Lumpectomy
Before go in and take out breast cancer inject die can trace lymphatics and can see first lymph node that lights up in color and radioactivity to get sentinel node biopsy is there cancer that is trracked out. Performed in an operating room, surgical excision biopsy or “lumpectomy”. Remove lump.
Discuss indications for and interpretation of findings for breast cancer screening and diagnostic tools.
Clinical Breast Examination
Hand on hips superhero pose, reach for the sky (changing and lifting see under breast, yeast infections) arms down by side
Discuss indications for and interpretation of findings for breast cancer screening and diagnostic tools.
Ultrasound
Supplemental/adjunct screening For breast tissue noted to be >50% dense on mammography. Heterogeneously dense (category C) Extremely dense (category D), If you have dense breast go back for bilateral screening ultrasound combination screening finding smaller abnormalities more sensitive for woman that are younger, Cyst-nice and round, darkness in ultrasound is fluid young patient w/ palpable finding or mammogram. Screening imagins w/ ultrasound diagnostically ultrasound is great tool. Palpation round guestimate size, margins smooth, moble, well circumscribed very well margins.
List positive and negative, both modifiable and non-modifiable, risk factors for breast cancer.
Non-modifiable- being women, 70% of cancer have no risk. 1/7 women have breast cancer, Gender – ↑ risk if female - ↑ risk with increasing age Family history – 1st degree relative genetic factor involved Personal history of breast disease-fibroadenoma, more surgical procedures High breast tissue density- denser breasts, or screening tools are less effective with those type of women and have a higher association w/ cancer. Age of first full-term pregnancy- younger you are less risk you have Early menarche- starts period <11 timeframe exposed to estrogen. Late Menopause- extending out those years longer duration of time exposed to estrogen Genetic Predisposition,Environment. Never had a baby, had baby at 35 risk later in life because it shuts off estrogen during pregnancy and lactation. Breast tissue sensitive so risk factor of developing.
Modifiable: Postmenopausal Obesity- estrogen increased when overwiehgt increase risk factors Use of hormone replacement therapy- risk vs. benefit Alcohol intake- increases not getting proper food intake increase liver disease and increase estrogen production Physical inactivity- obesity factor
Negative risk factors: ↑ Parity- more children.Early childbirth.Breast feeding-supressing ovaries and estrogen,Late menarche-periods later,Early menopause,Women who reside in Asia-low BMI, healthy diet, Conversely, the opposite (↓ parity, late childbirth, not breast feeding, etc) will increase the risk of breast CA = positive risk factor
Positive Risk factors: Conversely, the opposite (↓ parity, late childbirth, not breast feeding, etc) will increase the risk of breast CA = positive risk factor
Risks for men: Risk factors include radiation exposure, BRCA1 and BRCA2 mutations, Klinefelter syndrome, testicular disorders, family history of male or female breast cancer, alcohol use, cirrhosis, African American, and obesity
Describe and demonstrate appropriate techniques for the breast and axillae examination to include: see slide 49
Positioning
With patient seated on the exam table, perform in 3 positions: Arms at side Arms over head Hands pressed against hips-flexing muscles flattening out breast tissue might exacerbate tissue
Appearance of the skin Note the color Any thickening Any enlarged pores Size and symmetry Contours-bilaterally look symmetrical should hang same way Retraction or dimpling-nipples pointing in same direction
Areola and Nipples Size Shape-fairly round Direction Rashes-problem if unilateral Ulcers- particularly on areola Discharge Inversion- depends on the person if both or not versus new
Palpation: Patient should be supine, best when flattened, with ipsilateral arm up and shoulder supported Use the pads of the 2nd,3rd & 4th fingers Palpate in small, concentric circles. Pie shaped and circular don’t use on larger breasted woman have to be aware of aware you are working out depending upon where you are might be skipping. Large breasted women and women in general go up and down. Past inframammary cleft go further than where you think there is to sternum and laterally to midclavicular line.
Palpate the breast for: Consistency of the tissue-small curd cottage cheese consistent lumpiness bilaterally compare same side to other breast if find something weird Normal consistency varies widely, depending on the proportions of firmer glandular tissue and soft fat. Physiologic nodularity may be present, increasing before menses. Note the firm inframammary ridge, which is the transverse ridge of compressed tissue along the lower margin of the breast, especially in large breasts. This ridge is sometimes mistaken for a tumor. Tenderness-area tender Nodules Tender cords suggest mammary duct ectasia, a benign but sometimes painful condition of dilated ducts with surrounding inflammation and, at times, with associated masses. A mobile mass that becomes fixed when the arm relaxes is attached to the ribs and intercostal muscles; if fixed when the hand is pressed against the hip, it is attached to the pectoral fascia.Examine the Nipple for: Elasticity- not hard, spongy rubber bandy. If large pendulous chest, have lean forward to best see This position may reveal asymmetry or retraction of the breast, areola, or nipple that is not otherwise visible, suggesting an underlying cancer.
Male => Inspect for nodules, swelling, ulcers or gynecomastia,Palpate the areola and breast tissue for nodules,If the breast is enlarged: Palpate to distinguish between soft, fatty enlargement of obesity and the firm disc of glandular enlargement. Determining if gynecomastia, or adipose. Able to palpate glandular tissue depending upon age. A hard, irregular, eccentric, or ulcerating pain- less dominant mass suggests breast cancer.4
For both men and woman: Inspection axillary for rash, lesions, masses, or unusual pigmentation. Sweat gland infection from follicular occlusion (hidradenitis suppurativa) may be present. Deeply pigmented velvety axillary skin suggests acanthosis nigricans—associated with diabetes; obesity; polycystic ovary syndrome; and, rarely, malignant paraneoplastic disorders. If lymphadenopathy is present, note: Location and number, Size, Shape, Consistency, Mobility, Tenderness- less worried about it because of immune reaction. Palpate the lymph nodes: Central axillary lymph nodes, Pectoral (anterior) LN, Lateral axillary LN, Subscapular (posterior) LN, Infraclavicular LN, Supraclavicular LN- do while upright. Box of axilla shaking patients hand supporting it crossing over axilla to palpate w/ the other arm. Grip around pectoral upper humerus lateral. Drains breast anything abnormal would be finding abnormal lymph node first. Nodes that are large (≥1 to 2 cm) and firm or hard, matted together, or fixed to the skin or underlying tissues sug- gest malignancy.
Describe and demonstrate appropriate techniques for the breast and axillae examination to include: see slide 49
Assessment of nipple discharge
ask patient to describe when it occurs, color, how the breast feels, when did it start and ask them to express it. Can be associated w/ lactation or cancer
Instruct a patient on the proper technique for breast self-examination and observe their technique while offering appropriate feedback. See slide number 27
Inspection and palpation
In front of a mirror with 3 different positions, Palpation: In shower using soapy finger pads with ipsilateral arm raised behind head Supine with rolled towel or pillow beneath shoulder on same side as breast to be palpated with same arm raised over head, Hand on hips superhero pose, reach for the sky (changing and lifting see under breast, yeast infections) arms down by side
Describe special techniques to examine the mastectomy or breast augmentation patient.
Mastectomy patient- very thorough someone w/ scar tissue cant find nodule differentiating Inspection. Inspect the mastectomy scar and axilla carefully for any masses, unusual nodularity, or signs of inflammation or infection. Lymphedema may be present in the axilla and upper arm from lymph drainage interrupted by surgery. Palpation. Palpate gently along the scar—these tissues may be unusually sensitive. Palpate the breast tissue and incision lines bordering breast augmenta- tion or reconstruction. Use a circular motion with two or three fingers. Pay special attention to the upper outer quadrant and axilla. Note any enlarged lymph nodes. Masses, nodularity, and change in color or inflammation, especially in the incision line, suggest recurrence of breast cancer.
Breast augmentation patient- part of medical history, can notice scars from surgery look a little closer at scars when doing palpation Tanner staging.
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Dysuria
pain w/ urination. Women feel internal urethral discomfort or pressure or external burning over inflamed labia when having UTI. Men feel burning proximal to glans penis. Ex. bladder infection (cystitis), urethritis, UTI, bladder stones, tumors, Women- urethritis/herpes and vulvovaginitis.
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Flank Pain
pain in sides of body located at or below psoterior costal margin near CVA may radiate anteriorly toward umbilicus. Kidney is visceral and flank caused by distention of renal capsule, dull, aching, and steady. Caused by pyelonephritis, kidney stone, stones lodged in ureters- if have colicky pain radiating around trunk into lower abdomen and groin from distenation. Right flank pain appendicitis.
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Frequency
abnormally frequent voiding can be high (polyuria)- diabetes or low volume (infection) ex. UTI, bladder neck obstruction.
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Hematuria
blood in urine, visible to naked eye is gross or if microscopic hematuria. Smaller amounts tinge pinkish or brown. Medications may cause or bladder cancer or stone. myoglobin from rhabdomyolysis-disease of degradation of skeletal muscle excreted in urine tinge urine pink in absence of rbcs.
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Hesitancy, decreased stream in males
difficulty initiating or maintaining flow of urine w/ hesitancy commonly associated w/ BPH, straining to void, reduced caliber and force of urinary stream, dribbling.
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Incontinence - Stress Incontinence
involuntary voiding or lack of awareness suggests cognitive or neurosensory deficits socially restricting and problems w/ hygiene. Controlled by S2-S4 cauased by stress incontinence, urge incontinence (neurosensory problem from tumor dementia), overflow (weakness of resistance from BPH or tumor), functional (shyness), medications.
stress incontinence having had a lot of children, obesity etc decreased intraurethral pressure Leaky small amounts of urine due to increased intra-abdominal pressure from coughing, sneezing, laughing, or lifting bladder pressure exceeds urethral resistance poor urethral sphincter tone poor support of bladder neck.
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Urge Incontinence
followed by involuntary leakage due to uncontrolled detrusor contractions overcome urethral resistance. Men w/ weak streams partial bladder outlet obstruction BPH or urethral stricture. due to brain tumor, dementia, or spinal lesions, bladder infection and fecal imapct
IntonDiscuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Overflow Incontinence
neurologic disorders or anatomy obstruction from pelvic organs or prostate limit bladder emptying until bladder overdistended. BPH, peripheral nerve disease, diabetic neuropathy
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Functional Incontinence
impaired cognition, musculoskeletal problems, or immobility. Combined stress and urge incontinence mixed shy bladder
NoDiscuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Nocturia
Stronlg associated w/ polyuria because of edema (ascities, CHF, CVI), chronic renal insufficiency, and coffee.
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Polyuria
significant increase in 24-hour urine volume, exceeding 3L caused by high fluid intake of psychogenic polydipsia, poorly controlled diabetes, decreased ADH of diabetes insipidus, decreased renal sensitivity
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Urgency
unusually intense and immediate desire to void, leading to involuntary voidign or urge incontinence ex. UTI or irritation from urinary calculi.
Compare and contrast suprapubic pain, flank pain and ureteral colic.
Supra pubicPain and flank pain
suprapubic rectal or bladder disorders can cause such as overdistention or infection
Flank pain in back (kidney) below costal margin near CVA. Stays in flank region radiating and refferring anteriorly. Ex. pyelonephritis
Compare and contrast suprapubic pain, flank pain and ureteral colic
Uretal Colic
(severe pain coming in waves associated w/ nausea and vomiting spasm like pain blockage by stone, clot, or tumor as tissues attempt to expand and distend radiating pain into groin). Ureteral pain can radiate and refer into scrotum or testicle, upper thigh, or labium from distention of ureter and renal pelvis can also have fever, chills, or hematuria.
Compare and contrast suprapubic pain, flank pain and ureteral colic
Acute Waves
of sharp constricting pain that “take the breath away”- colic pain renal or biliary
Compare and contrast suprapubic pain, flank pain and ureteral colic
Waves of dull pain with vomiting
with vomiting-obstruction
Compare and contrast suprapubic pain, flank pain and ureteral colic
worsened by movement
–Sharp, constant pain, worsened by movement- peritoneal irritation peritonitis appendicitis
Compare and contrast suprapubic pain, flank pain and ureteral colic
Cramping
Obstruction
Compare and contrast suprapubic pain, flank pain and ureteral colic
Tearing
AAA thoracic disection
Compare and contrast suprapubic pain, flank pain and ureteral colic
Dull Ache
diverticulitis
Compare and contrast suprapubic pain, flank pain and ureteral colic
Burning
hingles herpes zoster, UTI
Given a diagram or picture of the urinary system, identify the following anatomic structures:
Costovertebral Angle
Behind visceral and parietal peritoneum.Angle between rib and spine. If having flank pain will start tapping there to see if there is discomfort showing if some kind of renal issue. Pain at this angle is usually involved w/ kidneys an infection or stone
Given a diagram or picture of the urinary system, identify the following anatomic structures:
Kidney
Bladder, Ureter, Urethra
Regulation of the water and electrolyte balance in the body, Filtration and excretion of waste products, Maintenance of acid/base balance
Define, describe and discuss the following terms, and associate history and PE findings with underlying conditions
Cystitis
bladder infection with increased urinary frequency, urgency, dysuria (painful urination), pain above pubic region, WBCs and bacteria in urine, more common in women. dull and pressure-like. Overdistention of bladder agonizing acute urinary retention
Define, describe and discuss the following terms, and associate history and PE findings with underlying conditions
Prostatic Pain
men- caused by acute prostatis felt in perinum and rectum
Define, describe and discuss the following terms, and associate history and PE findings with underlying conditions
Pyelenophritis
UTI where both kidneys are also inected with flank pain, high fever, malaise, chills, WBCs and bacteria in urine, urinary symptoms similar to cystitis. Pain w/ pressure or fist percussion.
Define, describe and discuss the following terms, and associate history and PE findings with underlying conditions
Urethral Structure
narrowing of the urethral passageway because of stone or infection.
Define, describe and discuss the following terms, and associate history and PE findings with underlying conditions
Urethritis
symptoms include dysuria,w/out frequency or urgency just pain STD or inflammation from urethra. Milk urethra outward from inside vagina usually from trachomatis or gonorrhoeae
Describe and demonstrate appropriate techniques to examine the bladder and kidneys.
CVA tenderness- associated w/ renal disease Right sided pain underneath costal margin tap lightly on left side first might cause pain on left side then use heel of hand to First start with light tapping. Then, use the heel of your closed fist to strike the patient firmly over the costovertebral angles. Clinical Tips: Start on the unaffected side! Use a light tapping motion to start.
Document a CC and HPI for a patient with:
Renal calculi
Increased incidence in males, nausea and vomiting, hematuria, dysuria, and urinary frequency. agonizing sharp, sudden severe flank pain may radiate to groin, testicles, abdominal area cramping intermittently radiating to right or LLQ or groin renal stone depending upon stone movement. Diagnosed via ultrasound, IVP, renal stones, KUB (X-ray), serum (calcium oxalate and uric acid). Risk factors or etiology include: infection, urinary stasis and retention, immobility, dehydration, increased uric acid and urinary oxalate.
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Abdominal pain (further classify into upper or lower and acute or chronic pain)
Upper pain can be from thorax or GI. lower can be lower GI, reporductive, or excretory organs. Acute is usually things like appendicitis, obstruction, cholecystitis, stones, pancreatiis, angina, cholangitis etc. Chronic: dyspepsia, peptic ulcer, GERD, IBS, cancer. abdominal pain ask for the location- point to it, Onset- exacerbation of chronic issue what were you doing, (apetite, changes in bowel habits) Timing, Quality, Radiation/Referred, Severity- what is your 10/10, Alleviating/AggravatingFactors- lying (peritoneal), food aggravation Associated Symptoms (n/v/d, dysphasia, constipation, blood in stools change in bowel). Prior surgeries, foreign travel, work issues, family history.
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Bloating
occur w/ lactose intolerance, inflammatory bowel disease, or ovarian cancer, belching results from aerophagia, or swallowing air
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Constipation
lumpy hard feces passed, 25% or more straining or incomplete evacuation fewer than 3 bowel movements a week. Split into: primary/functional (normal transit, slow, impaired expulsion [pelvic floor disorder], constipation predominant IBS) or secondary causes of constipation (meds-iron, opiates, anticholinergic, conditions: amyloidosis, hypothyroidism, hypercalcemia, diabetes, and CNS (MS, parkinson). Thin pencil like stool in obstructing lesion of sigmoid colon.
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Diarrhea
painless loos or watery stools > 75% of defection for 3 months. up to 14 days acute-foodbrone infection, chronic 30 days or more- Crohn disease and ulcerative collitis. •What does it look like? –Toothpaste/peanut butter? Watery? Color? Amount? (volume, size), bubbly? Greasy, oily, frothy?floating? (steatorrhea- from malabsorption in celiac sprue, pnacreatic insufficiency small bowel bacterial overgrowth). Foulsmelling? (Recent hospitalization- clostridium difficile infection). Any mucus, pus or blood? (intusception) Frequency?, Recent travel?, Diet?, Baseline habits?, Immunocompromised? Coomonlny from immune or glucose medicatioin. Nocturnal diarrhea- pathological. Common w/ penicillins, laxatives and other meds
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Dyspepsia
chronic or recurrent discomfort or pain centered in the upper abdomen/epigastric, characterized by postprandial fullness, early satiety, and epigastric pain or burning. If chronic: peptic ulcer disease, IBS, GERD
5Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Dysphagia
(oropharyngeal dysphagia) difficulty swallowing solids and liquids?food seems to stick or not go down right suggesting motility disorder or structural anomalies Ex. Esophageal stricture, neuromuscular problem MS. Also associated with drooling, nasopharyngeal regurgitation, cough from aspiration. mechanical/obstructive in younger adults and neurologic/muscular in older adults (stroke, parkinson). Located at sternum- esophageal. If solid foods is strctural like esophageal stricture, weebing or schatzki ring (structural), and neoplasm; if both motility disorder like achalasia.
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Acute gastrointestinal bleeding
upper or lower GI differentiating serious can be fatal changes color of stool to melena or hematochezia, or found with lab noting anemia. Lower GI- bright red blood in stools or large upper GI bleed caused by cancer, polyp, irritation from colitis or inflammation, recurrent diarrhea, medication specifically that cause bleeding like (aspirin, NSAIDS, alcohol (liver cirrhosis issue w/ pressure in portal venous system backing up pressure in veins becoming varicose and varicese or esophageal varices causing fatal bleeding)) ulcer- mild to fatal bleeding w/ blood transfusion.
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Jaundice
yellow/brown/tea-colored discoloration of skin and sclera due to a lack of breakdown of bilirubin suggesting liver issues. Dumped into bile duct through pancreas (makes conjugated or water soluble excreted in urine and feces). Intrahepatic jaundice- hepatocellular damage, cholestatic impaired excretion from damaged hepatocytes or intrahepatic ducts, extrahepatic jaundice from obstruction of extrahepatic bile ducts from cancer of liver, cholestasis, or cirrhosis
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Nausea and Vomiting
unpleasant sensation leading to vomit can be migraine, with severe visceral pain, prengnacy, diabetic ketoacisosi, adrenal insufficiency, hypercalcemia, uremia, liver disease, adverse drug, GI bleeds, estrangulation of instestine through hernia
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Anorexia
Early satiety- eating very small amounts feeling very full. Asking how is your apetite. Unexplained weight loss- without diet and exercise how much over what time period. Along w/ nausea and vomiting found w/ GI disorders such as pregnancy, diabetic ketoacidosis, adrenal insufficiency, hypercalcemia, uremia, liver disease, emotional states, and adverse drug reactions. Induced vomiting w/out nausea is anorexia/bulimia.
Identify conditions in other systems (not GI) which may present with abdominal complaints
Cardiovascular
inferior wall myocardial infarction, aaa. Agina from inferior wall coronary artery disease may present as indigestion, but is precipated by exertion and relieved by rest.
Identify conditions in other systems (not GI) which may present with abdominal complaints
Neuromuscoluskeletal
trauma, nerve root compression
Identify conditions in other systems (not GI) which may present with abdominal complaints
Pulmonary
pneumonia, pulmonary tumor
Identify conditions in other systems (not GI) which may present with abdominal complaints
Endocrine
pancreatitis
Identify conditions in other systems (not GI) which may present with abdominal complaints
Geonitourinary
ovarian cysts, renal calculi, ectopic pregnancy
Identify conditions in other systems (not GI) which may present with abdominal complaints
Lymphatic/Hematologic-sickle cell anemia
painful vascoinclusiveepisodes, lymphadenopathy (enlarged lymph odes in chest)
Identify the abdominal contents corresponding to each of the four major quadrants, the epigastric, umbilical, and suprapubic areas
RUQ
liver, galbladder, duodenum, common bile duct, head of pancreas
Identify the abdominal contents corresponding to each of the four major quadrants, the epigastric, umbilical, and suprapubic areas
LUQ
stomach, spleen, body and tail of pancreas and pancreatic duct
Identify the abdominal contents corresponding to each of the four major quadrants, the epigastric, umbilical, and suprapubic areas
RLQ
appendix, cecum, ½ small instetines, ascending colon, ½ transverse colon, sigmoid colon, left ovary, half of rectum and anus, cecum
Identify the abdominal contents corresponding to each of the four major quadrants, the epigastric, umbilical, and suprapubic areas
LLQ
½ of transverse colon, descending colon, ½ of rectum and anus
Given a diagram of the abdomen (Bates, p. 416), identify the following structures:
Aorta
Ascending colon
Bladder- distended bladder can be palpable above pubic symphysis. Parasympathetic innervation at low pressures. Rising pressure triggers concious urge to void, can be overcome by increased intraurethral pressure preventing incontinence. Sphincter wraps around to prevent voidance.
Cecum
Descending colon
Duodenum
Gallbladder
Iliac artery
Kidneys
Liver
Pancreas
Sigmoid colon
Spleen
Stomach
Transverse colon
Xiphoid process
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Acute Abdomen
severe symptoms resulting in severe intervention ex. Appendicitis, intestinal obstruction, or cholecystitis are common causes
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Biliary Colic
sudden obstruction of bile duct by galstone resulting in cholecystitis epigastric or right upper quadrant pain radiate to scapula and shoulder steady, achy, not colicky
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Borborygmi
bowel sounds if more intense or louder than usual could be indicative of some kind of digestive issue diarrhea, peritonitis. if quiet obstruction
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Collicky
pain from a renal or bile stone patients move around frequently trying to find a comfortable position
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Dysentry
inflammation of intestines leading to diarrhea and abdominal pain can lead to fever and feeling of incomplete defecation ex. Stomach bug
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Gastroparesis
condition in which your stomach cannot empty itself of food in a normal fashion. It can be caused by damage to the vagus nerve, which regulates the digestive system. causes early satiety
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
GERD
prolonged exposure of esophagus to gastric acid due to impaired esophageal motility or excess relaxations of lower esophageal sphincter can cause esophagitis. Epigastric pain. Chronic upper abdominal discomfort or pain complain of heartburn, dysphagia, or regurgitation. If together more than one time in week, diagnose by mucosal damage. Can have atypical respiratory symptoms aka chest pain, cough, wheezing, and aspiration pneumonia hoarseness soar throat and laryngitis. Increased risk factors are reduced salivary flow, prolongs add clearance by dampening bicarb, obesity; delayed gastric emptying; selected medications; and hiatal hernia. Can have esophagitis, peptic strictures, barret esophagus, or esophageal cancer gurguling and regurgitation- diverticulum.
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Globus
feels like something stuck in throat problem swallow (globus)- foreign body in throat unrelated to swallowing
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Heartburn/Indigestion
pain behind sternum (peptic ulcer, heartburn) Epigastric pain. Rising retrosternal burning pain or discomfort occuring weekly or more often. Aggravated by foods such as alcohol, chocoalte, citrus fruits, coffee, onions, and peppermint, or positions. Can also have barrett esophagus, change in esophageal lining from normal squamous to columnar epithelium. Angina rpesents as this also.
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Hematemsis
vomiting blood red flag caused by esophageal or gastric varices, mallory-weiss tears, or peptic ulcer disease
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Icterus
yellow discoloration of skin and sclerae from increase bilirubin, breakdown of hemoglobin, Unconjugated billirubin from increased production in hemolytic (sickle) anemia, gilbert syndrome, decreased uptake of it by liver, decreased ability to conjugate or excrete (viral hepatitis, cirrhosis, primary biliary cirrhosis, drug-induced cholestasis from OC, test). If feces pale gray or light colored no bile so some type of blockage or obstruction in the tube lack of brown in poop- acholic stools also in viral hepatisis. Liver and pancreatic cancer, cirrhosis. Dark yellow brown, tea color urine imparied from Gi tract. Painless is malignant, painful is hepatitis or cholangitis. Itching cholestatic or obstructive.
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Obstipation
no passage of stool or signifies intestinal obstruction.
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Odynophagia
painful swallowing (strep throat), esopahgeal ulceration from ingestion of aspirin or NSAIDS, caustic ingestion, radiaiton, or infection Candida, cytomegalovirus, herpes, HIV
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Parietal Pain
Inflammation of parietal peritoneum (peritonitis), Intense, steady aching, more severe than visceral (won’t wanna move and guarding), precisely Localized over the involved structure, Aggravated by movement or coughing. If start periumbilical move to right lower quadrant in appendix.
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Referred Pain
Felt in remote areas that share innervation with the involved structure. Develops as initial pain becomes more intense radiation or traveling from initial site palpable but usually localized. Pain from duodenum or pancreas referred to back, biliary tree to right scapular region or posterior thorax. Pain from inferior MI to epigastric/ aka referred pain
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Regurgitation
acid type regurgitation in throat may or may not have pain. Not actual vomit but involuntary spasms of the stomach, diaphragm, and esophagus precedes and culminates in vomitings. raises esophageal or gastric contents w/out nausea or retching occurs in GERD, esophageal stricture, and esophageal cancer.
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Somatic Pain
pain that is pinpoint and can be distinguished because of the sensory fibers. pain in ectoderm area Nociceptive (somatic) pain is linked to tissue damage to the skin, musculoskeletal system, or viscera (vis- ceral pain), but the sensory nervous system is intact, as in arthritis or spinal stenosis. It can be acute or chronic. It is mediated by the afferent A-delta and C-fibers of the sensory system. The involved afferent nociceptors can be sensitized by inflammatory medi- ators and modulated by both psychological processes and neurotransmitters like endorphins, histamines, acetylcholine, serotonin, norepinephrine, and dopamine. parietal pain
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Visceral Pain
Fairly diffuse, midline. When hollow organs contract unusually forcefully or are distended and stretched, ischemia. Described as gnawing, burning, cramping, or aching. When severe: sweating, pallor, nausea, vomiting, and restlessness. RUQ- liver distention from hepatitis. Epigastric- stomach, duodenum or pancreas. Periumbilical pain- small intestine (pain disproportionate to findings intestinal mesenteric ischemia food fear distended soft nontender abdomen), appendix (start middle go to right lower gastric acute appendicitis), proximal colon. Suprappubicpain- rectum. Hypogastric pain- colon, bladder, uterus, colonic pain more diffuse
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Vomiting
forceful expulsion of gastric contents out of mouth, note color (gastric juice clear and mucoid, small amounts of yellow or green is common and normal, brown or black-digested blood), odor, and quantity and amount. w/ pain indicate small bowel obstruction. Fecal odor occurs w/ small bowel obstruction and gastrocolic fistula. If vomit contains blood common in esophageal or gastric varices, mallory-weiss tears, or peptic ulcer disease. recurrent vomiting is a red flag and can also lead to aspiratioin, dehydration, electrolyte imbalance
Describe, discuss, and demonstrate appropriate techniques that will enhance the examination of the abdomen.
Setting up the abdominal exam: Empty bladder, Relaxed – arms to side or chest, knees bent. Pillow. Warm hands and stethoscope, Trimmed nails; Slow, methodical, tell them what you are gonna do, do painful region(s) last; Use patient’s hand under yours or distract the patient if necessary if ticklish or talking to them, Observe patient’s face. Provider stands on patient’s right unless palpating left kidney do palpation last can change bowel sounds.
Describe, discuss, and demonstrate appropriate techniques that will enhance the examination of the abdomen.
Symmetry, umbilicus, signs of peristalsis
check for symmetry, which can be altered in hepato/splenomegaly, enlarged organ or mass
umbilicus: observe contour and any signs of an umbilical hernia invagination w/ the intestine can cause strangulation.
signs of peristalsis (rhythmic movement of the intestine that can be seen in thin people) and pulsations (aorta)
Describe, discuss, and demonstrate appropriate techniques that will enhance the examination of the abdomen.
contour of the abdomen: flat, rounded, protuberant(fluid ascites marking w/ liver disease and portal venous hypertension, suprapubic bulde of distended bladder or pregnant uterus, ventral, femoral, or inguinal hernia),or scaphoid (concavity, acute or chronic mesenteric issues difficulty eating because of severe pain)? Any flank or local bulges?
Skin: scars, striae (stretch marks- pink/purple striae halmark of cushing syndrome), rashes (burrow marks parasitic mite scabies, ecchymosis of abdominal wall in intraperiotneal or retroperitoneal hemmorhage), lesions, dilated veins (caput medusae backup portal venous system hypertension from cirrhosis or inferior vena cava obstruction)
Describe, discuss, and demonstrate appropriate techniques that will enhance the examination of the abdomen.
Auscultation:
Listen first and throughout for bowel sounds with diaphragm
Borborygmi–sound stomach makes (rumbling, gurgling-moving of materials w/ gas through intestines), Go clockwise starting right move to left when listening going the direction of the intestines and dont go the opposite way. when hungry hyperperistalsis if loud and fast could be obstruction. (ex. 5-34 per minute) if don’t hear it listen for full 5 min.
Listen over the aorta (umbilicus), renal (lateral), iliac, and femoral arteries for bruits staying in midcavicularline with bell
Place the diaphragm over the liver and the spleen to listen for venous hum (could mean portal hypertension) or friction rubs (grating type of sound peritoneal inflammation) having patient breathe in
Describe, discuss, and demonstrate appropriate techniques that will enhance the examination of the abdomen.
Percussion:
helps you assess amount and distribution of gas in abdomen, viscera and masses that are solid, fluid-filled, and size of liver and spleen. Tympany (gas) dullness (fluid and feces) over all four quadrants Determine tympany and dullness over clockwise pattern hearing tympany if dullness could be fluid or consolidation or stool, bladder (hear dullness w/ full bladder).
Describe, discuss, and demonstrate appropriate techniques that will enhance the examination of the abdomen.
Percuss vertical span of liver
along midclavicular line- Start below the level of the umbilicus, & percuss upward until you hear dullness. Mark this area. Start above the liver just below the breast (having patient hold breast up) and percuss downward along the midclavicular line until you hear dullness. Mark this area. Measure the distance between the marks. Normal liver span is 4-6 cm midsternal and 6 – 12 cm right midclavicular. Span of liver decreased when small, free air below diaphragm from perforated bowel or hollow viscus, decrease w/ resolution of hepatitis or heart failure. Liver dullness displaced downward by COPD w/ normal span. Dullness from right pleural effusion or consolidated lung may falsely increase size. Gas in colon may produce tympany in RUQ obscure dullness falsely decrease estimated liver size.
Describe, discuss, and demonstrate appropriate techniques that will enhance the examination of the abdomen.
Splenic percussion-
All organs pushed down during inspiration. Find last intercostal space or 11th and 12th rib then above in the 10th rib intercostal space or anterior axillary line percuss along here spleen shouldn’t be near this percussing there for tympany then have the patient breath in and if splenomegaly going to hear dullness when comes over anterior axillary (don’t do deep palpation for splenic rupture). This is a positive splenic percussion sign. Fluids or solids in stomach or colon may also cause dullness.
Describe, discuss, and demonstrate appropriate techniques that will enhance the examination of the abdomen.
Palpation:
gentle aids detection of abdominal tenderness, muscular resistance, and superifical organs and masses. Deeper for liver edge, kidneys, and abdominal masses
Deep- about 2 inches or more checking for tenderness or masses
Describe, discuss, and demonstrate appropriate techniques that will enhance the examination of the abdomen.
Light-
in all four quadrants, in a clockwise pattern, Identify any superficial lesions or masses, tenderness, and resistance/voluntary guarding(flinching) versus involuntary guarding (muscles become rigid breathing in and out or through mouth), Use relaxation techniques to assess voluntary guarding: Instruct to breathe out deeply, Instructto breathe through the mouth. If have appendicits there will be peritoneal irritation w/ guarding and tightening.
Describe, discuss, and demonstrate appropriate techniques that will enhance the examination of the abdomen.
Liver-
Palpate with your hands below the level of liver dullness along the R midclavicular line. Place both hands side by side on right abdomen below border of liver dullness costal margin. Press down and upward using the hooking technique (especially if they are obese) ask the patient to take a deep breath; as they exhale begin to palpate. Ask the patient to take another deep breath in and feel for the liver edge to come down and meet your fingertips with inhalation. Note any tenderness (may be normal), enlargement. When palpable the liver edge should be soft, sharp, regular with a smooth surface.
Describe, discuss, and demonstrate appropriate techniques that will enhance the examination of the abdomen.
Spleen-
With your left hand lift up the left lower rib cage. Palpate with your right hand below the left costal margin, press in towards the spleen. Ask the patient to take a deep breath. Begin palpation with exhalation. Ask the patient to take another deep breath. Note any tenderness or enlargement. Spleen is usually not palpable. If palpable describe size, contour. May suggest organomegaly.
Describe, discuss, and demonstrate appropriate techniques that will enhance the examination of the abdomen.
Kidney:
Retroperitoneal location and usually not palpable. A normal right kidney may be palpable, especially in thin, well-relaxed individuals. If palpable describe size, contour. Left kidney (move to the patient’s left side) : Place your left hand in the left upper quadrant below the costal margin. Place your right hand behind the patient, just below the 12thrib. Lift anteriorly. Ask the patient to take a deep breath. At the peak of inspiration push deeply from anterior to posterior, trying to capture the kidney. Ask the patient to breathe out and stop breathing for a moment. Slowly release the pressure and feel for the kidney sliding back into its expiratory position. A normal left kidney is rarely palpable. Right kidney: Place your right hand in the right upper quadrant and left hand behind. Repeat same technique noted above.
Describe, discuss, and demonstrate appropriate techniques that will enhance the examination of the abdomen.
Aortic:
Press firmly deep in the upper abdomen (epigastrium), slightly to left of midline and identify aortic pulsations. Place your fingers on the edges of the aorta and try to detect aortic pulsations and estimate it width. 2-3 cm is normal. Assess for tenderness.
Discuss the significance of the following findings during the abdominal examination
Bruits
suggest vascular occlusive disease. hepatic bruit suggests carcinoma of liver or cirrhosis. Arterial bruits w/ both systolic and diastolic components suggest parital occlusion of aorta or large arteries atherosclerotic arterial disease. Bruits in epigastrium suspicious for renal artery stenosis or renovascular hypertension.
Discuss the significance of the following findings during the abdominal examination
Masses
physiologic (pregnant uterus), vascular (AAA), neoplastic (colon cancer), obstructive (distended bladder or dilated loop of bowel). Raise head and shoulders or strain down tightening abdominal muscle feeling for it intra-abdominal mass obscured by muscular contraction
Discuss the significance of the following findings during the abdominal examination
Tenderness
pain upon touching usually found in irriated and inflamed structures
Discuss the significance of the following findings during the abdominal examination
Borborygmi
increased in diarrhea or early intestinal obstruction. Changes in bowel sounds for diarrhea, intestinal obstruction, paralytic ileus, and peritonitis. Decreased then absent as in adynmaic ileus and peritonitis listen for longer. High-pitched intestinal sounds suggest fluid and air under tension in dilated bowel. Rushes of high pitched sounds coinciding w/ abdominal cramp signal intestinal obstruction
Discuss the significance of the following findings during the abdominal examination
Hepatomegaly
enlargement of liver (hepatoblastoma, ascites, or from mononucleosis) caput medusae backup of portal venous system
Discuss the significance of the following findings during the abdominal examination
Speomegaly
enlargement of spleen from mononucleosis caused by portal hypertension, hematologic malignancies, HIV, infiltrative diseases amyloidosis, splenic infarct or hematoma detected by change in percussion note from tympany to dullness on inspiration positive splenic percusion sign. Left flank mass palpable nothc on medial border, edge extends beyond midline, percussion is dull, fingers can probe deep to medial and lateral borders but not between mass and costal margin.
Discuss the significance of the following findings during the abdominal examination
Protuberant Abdoment
fat is most common cause (umbillicus sunken, pannus apron of fatty tissue below inguinal ligmane), gas- localized or generalized tympanic percussion caused by intestinal obstruction and paralytic ileus more marked in colon than bowel. Prengnancy, tumor (rising out of pelvis dull air-filled to periphery ovarian tumors, uteirne fibroids, distended bladder. Ascites fluid- lowest point in abdomen
Discuss the significance of the following findings during the abdominal examination
Rebound Tenderness
pain expressed by patient after examiner presses down on an area of tenderness and suddenly removes hand. Present for: acute salpingitis, peritoneal inflammation (acute pancreatitis, appendicitis). diverticulitis
Identify history or PE findings associated with the following abdominal conditions:
Appendicitis
peak incidence 10-12 years, begins as dull, steady pain in periumbilical area. Progresses over 4-6 hours and localizes to right lower quadrant: low grade fever, nausea, anorexia. Sudden pain relief may indicate rupture of appendix leading to peritonitis. Rebound pain or tenderness (RLQ) at McBurney’s point. Visceral and move to parietal give antibiotics and appendectomy. Positive cough test, guarding, rigidity, rebound tenderness, Rovsing (left sided pain right sided pressure), obturator and psoas signand percussion tenderness early voluntary guarding replaced by involuntary muscular rigidity and signs of peritoneal inflammation w/ RLQ pain on quick withdrawl or deferred rebound tenderness.
Identify history or PE findings associated with the following abdominal conditions:
Aortic Aneurysm
increased pulsations w/ increased pulse pressure pain may signal rupture more liekly if larger than 4 cm deadly
Identify history or PE findings associated with the following abdominal conditions:
Ascites
protein containing fluid in the abdomen increased hydrostatic pressure in cirrhosis (most common cause), heart failure, constrictive pericarditis, or inferior vena cava or hepatic vein obstruction. Decreased osmotic pressure in nephrotic syndrome, malnutrition or ovarian cancer. Dullness shift to more dependent side, tympany shift to top, shifting fluid wake, and peripheral edema all common
Identify history or PE findings associated with the following abdominal conditions:
Cholectystits
inflammation of galbladder due to obstruction of cystic duct by gallston. fever and leukocytosis, jaundice, nausea and vomiting, anorexia, pain (right upper quadrant or right shoulder may radiate to back steady aching, increase w/ deep breathing), fat intolerance, feeling of fullness, abdominal distention. Positive cough test, guarding, rigidity, rebound and percussion tenderness RUQ pain, murphy’s sign
Identify history or PE findings associated with the following abdominal conditions:
Cholestasis
as a decrease in bile flow due to impaired secretion by hepatocytes or to obstruction of bile flow through intra-or extrahepatic bile ducts impaired secretion of conjugated billirubin caused by drugs
Identify history or PE findings associated with the following abdominal conditions:
Cushing’s Syndrome
increased adrenal cortisol production produces round moon face w/ red cheeks. Excessive hair growth in mustache, sideburns, chin, chest, abdomen, and thighs purple striae halmark of cushing syndrome. Striae, atrophy, purpura, ecchymoses, telangiectasias, acne, moon facies, buffalo hump, hypertrichosis
Identify history or PE findings associated with the following abdominal conditions:
Diverticulitis
Stool or fecal matter can get stuck in diverticulosis nuts and things difficult to digest get stuck and can cause inflammation. Because of constipation straining of pressure in colon. LLQ pain w/ a palpable mass characterized by diffuse abdominal pain w/ abdominal distention, hyperactive high-pitched bowel sounds, tenderness on palpation marks small or large bowel obstruction; pain w/ absent bowel sounds, rigidity, percussion tenderness, and guarding points to peritonitis.
Identify history or PE findings associated with the following abdominal conditions:
Hepatic Cirrhosis
can have unpleasant abdominal fullness after light or moderate meals or early satiety. Enlarged palpable liver edge. Firmness or hardness of liver, bluntness or rounding of its edge, surface irregularity suspicious for liver disease.
Identify history or PE findings associated with the following abdominal conditions:
Hepatitis
fecal oral route of A poor hand washing contaminating water and food, rarely fatal. Hep B- chronic infection, immature immune system easier to infect up to age 5 die from cirrhosis or liver cancer. Hep C- percutaneous exposure most prevlanet chronic bloodbrone pathogen. Rare sexual transmission creates cirrhosis, hepatocellular carcinoma, and end-stage liver disease
Identify history or PE findings associated with the following abdominal conditions:
Intestinal Obstruction
caused by adhesions or hernias or cancers cramping pain in periumbilical or upper abdominal increased peristaltic waves found, protuberant abdomen tympanitic throughout signified by obstipation
Identify history or PE findings associated with the following abdominal conditions:
Irritable Bowel Syndrome
will have functional, nonucler, dyspepsia w/ 3 month hisotry of nonspecfici upper abdominal discomfort or nausea not attributable to structural abnomralities or peptic ulcer disease recurring and present for more than four months. Also include delayed gastric emptying, gastritis, peptic ulcer disease, change in form of stool (lose, watery, pellet-like), linked to luminal and mucosal irritants that alter motility, secretion, and pain sensitivity.
Identify history or PE findings associated with the following abdominal conditions:
Pancreatitis
acute or chronic pancreatitis, nasty w/ stones clotting pancreatic duct and you can see pancreatic cancer jaundice only in sclera. Sudden knife-like epigastric pain radiating to the back. Epigastric pain
Identify history or PE findings associated with the following abdominal conditions:
Peptic Ulcer
mucosal ulcer in stomach or duodenum covered w/ fibrin extending through muscularis mucosa H. pylori infection epigastric radiate to back
Identify history or PE findings associated with the following abdominal conditions:
Peritonitis
signs of peritonitis include positive cough test, guarding (voluntary contraction of abdominal wall), rigidity (involuntary reflex contraction of abdominal wall from peritoneal inflammation persists over examination), rebound tenderness, and percussion tenderness.
Identify history or PE findings associated with the following abdominal conditions:
Polycystic Kidney Disease
genetic disorder that causes many fluid-filled cysts to grow in your kidneys. Unlike the usually harmless simple kidney cysts that can form in the kidneys later in life, PKD cysts can change the shape of your kidneys, including making them much larger.bilateral enlargement of the kidney
Identify history or PE findings associated with the following abdominal conditions:
Pregnant Uterus
suprapubic bulge of distended protuberant pelvis tympany everywhere else dull where belly button and fetus is
Describe and correctly demonstrate on a model patient the special techniques for assessing ascites, appendicitis, and acute cholecystitis.
Appendicitis
Ask patient to cough (increase intra-abdominal pressure Rigid abdomen.
Palpate McBurney point checking for peritoneal irritation rebound tenderness/Rovsing’s sign (Press your fingers in deeply, evenly, and slowly. Then QUICKLY withdraw them. Positive finding is pain in right lower quadrant because of peritoneal irritation. Indications of acute abdomen. Pressure from your fingertips may be sufficient to elicit tenderness. Tap on right side and may elicit left sided pain, heel strike or jump
Describe and correctly demonstrate on a model patient the special techniques for assessing ascites, appendicitis, and acute cholecystitis.
Psoas Sign
patient raise right knee against resistance, lay on left side passively extend right hip to stretch muscle positive sign is increased pain in RLQ.
Describe and correctly demonstrate on a model patient the special techniques for assessing ascites, appendicitis, and acute cholecystitis.
Obturator
flex right hip, knee bent, rotate leg internally at hip positive if increase pain in RLQ.
Describe and correctly demonstrate on a model patient the special techniques for assessing ascites, appendicitis, and acute cholecystitis.
Kidney Tenderness
Fist percussion: Place ball of one hand over each costovertebral angle and strike it with the ulnar aspect of your fist. Use need enough force to cause a perceptible, but painless jar of the patient, Document as positive or negative for CVA tenderness
Ascites- an abnormal fluid collection in the peritoneal cavity. A protuberant abdomen with bulging flanks is suspicious for ascites. (fluid in abdomen, fluid on sides). Percuss the abdomen for areas of tympany and dullness. Think of gravity. Test for shifting dullness: have the patient roll to one side. In stellate pattern percuss on either side for the areas of tympany and dullness as you get more lateral. Fluid wave- ask patient or assistant to press edges of both hands down firmly in midline of abdomen. Pressure helps to stop transmission of wave through fat and tap one flank sharply feeling on opposite side for impulse transmission through fluid.
Describe and correctly demonstrate on a model patient the special techniques for assessing ascites, appendicitis, and acute cholecystitis.
Ascites
Place your hands for liver palpation; under the right costal margin. Ask the patient to take a deep breath and observe. Watch the patient’s breathing and note the degree of tenderness. Positive Murphy’s sign is a sudden stop in inspiratory effort due to severe tenderness.
vomiting blood red flag caused by esophageal or gastric varices, mallory-weiss tears, or peptic ulcer diseaseDescribe and correctly demonstrate on a model patient the special techniques for assessing ascites, appendicitis, and acute cholecystitis.
cholecystitis
Place your hands for liver palpation; under the right costal margin. Ask the patient to take a deep breath and observe. Watch the patient’s breathing and note the degree of tenderness. Positive Murphy’s sign is a sudden stop in inspiratory effort due to severe tenderness.
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Change in bowel habits
red flag for cancer Any change in the pattern of bowel function? Any change in the size or caliber of the stool? Any diarrhea or constipation? What color is the stool? Any blood or mucus in the stool? Passing gas (flatus)? Any family history of colonic polyps or colon cancer? w/ a mass lesion warns of colon cancer around 12 weeks of preceding 12 months w/ relief from defecation, change in frequency of bowel movements. Excessive flatulus- aerophagia, ingestion of legumes or foods, intestinal lactase deficiency, & IBS.
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Blood in stool
bright red fresh blood (maroon colored) in the stools from lower GI blood or very serious upper GI bleed. •Black or dark red blood (oxidized, broken down takes several days): Epigastric pain, heartburn? (peptic ulcer), Recent alcohol, aspirin, or non-steroidal anti-inflammatories? (gastritis), Alcohol abuse? (cirrhosis), Retching, vomiting? (reflux esophagitis) illness for week or two. Change in bowel habits?(colon cancer). Diarrhea, urgency, tenesmus? (UC, Crohn’s, infectious diarrhea). Blood on toilet paper? (hemorrhoids, anal fissure)
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Pain with defecation, rectal bleeding or tenderness
red flag for cancer hemmorhoids. Anorectal pain, itching, tenesmus, or discharge or bleeding from infection or rectal abscess suggest proctitis. Causes include gonorrhea, chlamydia, lymphogranuloma venereum, recep- tive anal intercourse, ulcerations ofherpes simplex, or chancres of primary syphilis. Commonly caused by hemmorhoids. External hemorrhoids are dilated hemorrhoidal veins that originate seldom produce symptoms unless thrombosis occurs. Thrombosis causes acute local pain that increases with defecation and sitting. A tender, swollen, bluish, ovoid mass is visible at the anal margin
Discuss the following common or concerning symptoms, the etiology, presentation, as well as appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Anal warts or fissures
red flag for cancer. Ask the patient their sexual history, History of STIs anal warts or fissures? Analwarts- anywhere in genital region caused by HPV leading to dysplasia cancer. Fistula is an extranal communication from rectoanal juncture out to skin pus and feces can come from this location due to chronic inflammation, surgical procedure done to repair. Associated pain, especially with bowel movements?
Given a diagram of the anus, rectum and prostate (Bates, pp. 555-556), identify the following structures:
Anal sphincters- External-voluntary and internal-involuntary anal sphincters. Do rectal on patient that has spinal cord injury or nerve damage checking their tone. Shouldn’t be painful, is uncomfortable
Anorectal junction
Bladder
Levator ani muscle- enormous pelvic floor muscle covering entire pelvic basin
Rectum
Urethra
Valve of Houston- folds help keep tone of rectum accommodate for expansion of fecl material. Rectum up till this point w/ junction.
Given a diagram of the anus, rectum and prostate (Bates, pp. 555-556), identify the following structures:
Prostate
Prostate – lateral lobe lie against anterior rectal wall. Round, heart-shaped, 2.5 cm long, n a male patient you can palpate right and lateral lobes of prostate through rectum. Palpate shouldn’t be tender, may feel like they have to urinate w/ pressure and
Prostate - median sulcus can palpate on a male patient through rectum if enlarged won’t be able to feel sulcus or groove.
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Hematochezia
bright red fresh blood (maroon colored) in the stools from lower GI blood or very serious upper GI bleed.
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Hemorrhoid
Very common with chronic constipation straining, intra abdominal pressure problems, straining during childbirth. The veins become inflamed are varicose veins. Internal hemorrhoid can pop out (when you ask patient to bear down and is not as painful) external pops out when bearing down (outside of skin more painful). Can hold a lot of blood. Red blood on toilet tissue from hemorrhoid or anal fissure. May not feel any pain just bleeding, itching, leakage of feces. Removed with Hemorrhoidectomy
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Melena
black tar like stool (sticky and shiny), due to digested blood in stool from upper GI issue. Or if Black, Non stickystools- recent iron ingestion, medications, (pepto bismol). Can take vitamin C and help with digestion of iron or can be tums.
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Proctitis
inflammation of the rectum & anus, acute or chronic, characterized by rectal pain, tenesmus, discharge or bleeding
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Pruritus ani
anal itching, may be due to poor hygiene, physical trauma, infection, contact irritants, foods, hemorrhoids with bile salts in skin accompanies jaundice.
Define, describe, and discuss the following terms, and associate history and PE findings with underlying conditions:
Tenesmus
a constant urge to defecate with associated pain, cramping and involuntary straining, cannot completely evacuate bowel. String or ribbon shape feces- sign of obstruction or partial obstruction
Describe, discuss, and demonstrate appropriate techniques for the rectal examination, and describe both normal and abnormal findings.
Inspect the sacrococcygeal and perianal areas- Assess for lumps, ulcers, inflammation, rashes, or excoriations. Palpate any abnormal areas, noting lumps or tenderness. The patient may stand, leaning forward with their upper body resting across the examination table and hips flexed. The patient may lie on their side with the buttocks close to the edge of the exam table near you; flex the patients hips and knees, especially the top leg. Examine the anus, explain what you are going to do.
Insertion: Lubricate a gloved index finger, Ask the patient to bear down, Place finger pad over the anus and gently insert your fingertip into the anal canal; proceed with insertion upon relaxation of the sphincter especially as patient is bearing down, Aim towards umbilicus. Note sphincter tone, tenderness, induration, nodules, or irregularities. Pressing finger into rectum as far as possible. Rotate hand clockwise and palpate as much of rectal surface as possible, then counterclockwise. Palpate for nodules, irregularities, or induration.
For females: rectal examination in lithotomy position, if rectum only requires examination, side-lying position afford a much better view to the perianal and sacrococcygeal areas.
Before removing gloves, note character of fecal matter, test for occult blood (hemooccult)
Prostate may prompt an urge to urinate – inform patient, Sweep finger carefully over the prostate gland, Identify lateral lobes and median sulcus, Note size, shape, and consistency, Identify any nodules or tenderness a normal prostate is rubbery and nontender.
Identify history or PE findings associated with the following rectal conditions:
Rectal Polyps
Rectal polyps- Very common for patients to have polyps growing slowly, not usually symptomatic, can bleed when they get larger over time having dysplasia or pre-cancer from benign to malignant and can spread rapidly and become fatal spreading into rest of colon as well as throughout body. Screen for blood ins tool.
Identify history or PE findings associated with the following rectal conditions:
Cancer of the rectum
fecal occult blood tests, screening starting at 50, colonoscopy every 10 years more likely if long-standing IBD, family history. Anal intercourse also increases risk due to perianal and rectal abrasions and HIV transmission. Rectal exam yearly for middle-aged to older men not done for younger men unless complaint.
Identify history or PE findings associated with the following rectal conditions:
Prostate Cancer
actors include age (<50), ethnicity (African advanced-stage and before 50), and family history, diets, obesity, smoking. BPH not a risk factor palpable nodule, area of induration, or asymmetry can screen for DRE or PSA.
Discuss the following common or concerning symptoms, the etiology, presentation, and appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses
Pelvic Pain
RLQ pain pain that migrates from periumbilical region with abdominal wall rigidity on palpation can be pelvic inflammatory disease, ruptured ovarian follicle, and ectopic pregnancy.
Discuss the following common or concerning symptoms, the etiology, presentation, and appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses
if amenorrhea suggests it, ask about last date of intercourse. Common early symptoms: tenderness, tingling, or increased size of breasts, urinary frequency, nausea and vomiting, easy fatigability, and sensation baby is moving 20 weeks.
Discuss the following common or concerning symptoms, the etiology, presentation, and appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses
Vaginitis
postcoital bleeding, external burning, superficial pain, can be caused by trichomonal, candidal, or bacterial. Vaginal discharge in children
Discuss the following common or concerning symptoms, the etiology, presentation, and appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses
Abnormal Vaginal Bleeding
bleeding between menses; includes frequent, excessive, prolonged, or postmenopausal bleeding can be caused by pregnancy, cervical or vaginal infection or cancer, cervical or endometrial polyps or hyperplasia, fibroids, bleeding disorders, and hormonal contraception or replacement therapy.
Define the following terms related to the menstrual history and discuss their significance
Amenorrhea
no period could be not developing periods, missed periods, having a period then it stopping. most common pregnancy, are you sexually active, birth control, have regular period, weight changes, chronic illness, increase in stress? Primary- never initiating period 16 y/o w/out period (chromosomal abnormalities, anatomic, malnutrition, Endocrine reasoning: HHA- adipose tissue estrogenic HPO (hypothalamus pituitary Ovarian access). Secondary-menstruating then stop, ex. pregnancy, menopause, OC, polycystic ovarian syndrome, idiopathic, lactation. Amenorrhea followed by heavy bleeding suggests threatened abortion or dysfunctional uterine bleeding due to lack of ovulation.
Define the following terms related to the menstrual history and discuss their significance
Dysmenorrhea
painful menses, can include back achy cramping before or during menses. menstrual cramps ask sacred seven what day before menstruation and heaviest bleeding any other associated symptoms? Can be primary w/out cause (increased prostaglandin production in luteal phase) or secondary w/ cause (endometriosis, adenomyosis, PID, and endometrial polyps)
Define the following terms related to the menstrual history and discuss their significance
Menarche
first onset of period between the ages of 9-16 average age 11 based on genetic endowment, socioeconomic status, and nutrition. Imperforate hymen occasionally delays menarche. When doing exam virgin vagina only admit one finger and a small pederson.
Define the following terms related to the menstrual history and discuss their significance
Menopause
cessation of menses 48-55 normally 50-51 for 12 consecutive months
menstrual period with abnormal heavy or long periods. what products are you using, your definition of heavy, duration of flow, how many products going through, when did you start, length of cyclesDefine the following terms related to the menstrual history and discuss their significance
Menorrhagia
menstrual period with abnormal heavy or long periods. what products are you using, your definition of heavy, duration of flow, how many products going through, when did you start, length of cycles
Define the following terms related to the menstrual history and discuss their significance
Menstruation
shedding of endometrial layer of the uterus monthly (LMP-last menstrual period was the first day of last menstrual period and flow). First ½ of cycle- estrogen increase. Progesterone- 2nd half more predominant hormone crave carbs, hard, breast tenderness. For someone that is actively menstruating Ask frequency, duration (3-7 days), flow (how often are you changing tampon or pad excessive flow include clots), and your methods of contraception (extended cycle of birth control ex. IUD women dont get period. Average length between 24-32
Define the following terms related to the menstrual history and discuss their significance
Metrorrhagia
Uterine bleeding at irregular intervals, particularly between the expected menstrual periods. Metrorrhagia may be a sign of an underlying disorder, such as hormone imbalance, endometriosis, uterine fibroids or, less commonly, cancer of the uterus.
Define the following terms related to the menstrual history and discuss their significance
Oligomenorrhea
condition in which you have infrequent menstrual periods. It occurs in women of childbearing age. PCOS, skip perios, Some variation in menstruation is normal, but a woman who regularly goes more than 35 days without menstruating may be diagnosed with oligomenorrhea. Periods usually occur every 21 to 35 days.
Define the following terms related to the menstrual history and discuss their significance
Perimenopause
(transition time having a lot of signs and symptoms ex. Hot flashes, night sweats, mood swings, skipping or shorter periods, accelerated bone loss, increase in total and LDL, cholesterol, and urethral and vulvovaginal atrophy w/ dryness, dysuria, and dyspareunia. insomnia around 45). erratic cyclical bleeding, flushing. Ovaries stop producing estradiol, progesterone, estrogen drop testosterone persists w/ LH and FSH elevated highly. Estradiol remains.
Define the following terms related to the menstrual history and discuss their significance
Polymenorrhea
term used to describe a menstrual cycle that is shorter than 21 days.
Define the following terms related to the menstrual history and discuss their significance
Postmenopausal
12 months w/out a period otherwise perimenopausal. 6 months w/out period then bleeding should check can lead to endometrial pathologic. For someone that is post-menopausal as the age of menarche but not as importnant only for breast cancer, menstruation history, age at menopause, and if there is any postmenopausal vaginal bleeding (nex. Endometrial cancer unless proven otherwise doing pelvic ultrasound and biopsy when does it occur, after voiding, intercourse)
Define the following terms related to the menstrual history and discuss their significance
Postmenopausal Bleeding
bleeding commonly occurring 6 months or more after cessation of menses; any vaginal bleeding post menopausal after a year out of menopause, need to do a workup could be dryness, sex, endometrial cancer, hormone replacement therapy (HRT), uterine and cervical polyps
Define the following terms related to the menstrual history and discuss their significance
Premenstrual Syndrome
cluster of physical and emotional symptoms (social withdrawal) that occur in the one to two weeks before a women’s period for three consecutive cycle, resolving around the start of bleeding may change over time interference w/ daily activities
Define the following terms related to the menstrual history and discuss their significance
Vulvovaginal Symptoms
irritation of genital area, itching, inflammation, increased strong smelling discharge (color, consistency, odor), discomfort while urinating. other associated symptoms any abnormalities where it started and other associated symptoms
Define the following terms related to sexual function and discuss their significance:
Dispareunia
painful intercourse localizing where it occurs (superficial pain is local inflammation, atrophic vaginitis, or inadequate lubricatoin) (deeper pain- pelvic disorders or pressure on normal ovary_, perimenopausal, vaginal dryness, how often having sex, timing w/ ovulation, every time?, external or deep?, post-coital bleeding usually related to situational and psychosocial factors.
Define the following terms related to sexual function and discuss their significance:
Pelvic Pain
LMP, point to it, quantify, qualify, associated symptoms, vaginal discharge, dysuria, bowel habits, constant or cyclic, visceral? Pelvic pain is acute and chronic-greater than 6 months nonresponsive to treatment red flag for sexual abuse, pelvic floor spasm myofascial pain; most commonly caused by endometriosis (retrograde mammary flow outside uterus, PID, adenosis, and fibroids). Acute in menstruating girls and women warrants immediate attention broad differential including life-threatening ectopic pregnancy, ovarian torsion, and appendicitis. Can be GI, infectious or urinary, STIs commonly caused by PID, ruptured ovarian cyst.
Define the following terms related to sexual function and discuss their significance:
Postcoital Bleeding
bleeding after sex, might be because of a cervical polyp, papsmear for cervical cancer, atrophic vaginitis, or due to vaginal dryness
Define the following terms related to sexual function and discuss their significance:
Gender Identity
one’s innermost concept of themselves one, both, or neither same or different from what they were born as
Define the following terms related to sexual function and discuss their significance:
Gravida-Para Notation
gravida= total # of pregnancies, P=outcome of pregnancies F (full term) P(preterm>37 weeks) A (Abortion elective or spontaneous<24weeks/miscarriage >24) L (living children). F,P, and A always add up to g unless pregnant
NSVD- natural spontaneous vaginal delivery: C/S-cesarean section not if remarkable postpartum hemorrhage or laceration
Define the following terms related to sexual function and discuss their significance:
Sexual Preference
n-inherent or immutable sexual attraction to or other people who are you attracted to ex. LGBTQ higher risk for abuse, alcohol abuse, AIDS, suicidal ideations and attempts
Define the following terms related to sexual function and discuss their significance:
Sexual Response
issues or concerns things in the relationship are healthy or not. Libido, problems, satisfaction, desire, arousal (lubrication), orgasm (impaired by stress). High risk sex- Unprotected sex, multiple partners (male, female, or both)-non-judgemental. Sexual dysfunction: women may lack desire, fail to arousal and attain adequate lubrication, despite arousal unable to reach orgasm. Can be due to estrogen, clinical illness, trauma or abuse, surgery, pelvic anatomy, and psychological and psychiatric condition.
Define the following terms related to sexual function and discuss their significance:
Vaginismus
involuntary contraction of muscles around the opening of the vagina in women with no abnormalities in the genital organs. The tight muscle contraction makes sexual intercourse or any sexual activity that involves penetration painful or impossible. perimenopausal, vaginal dryness, how often having sex, timing w/ ovulation, every time?, external or deep?, post-coital bleeding. involuntary spasms of muscles following introitusdue to physiologic and psychological issue, can insert tampons cant have sex underlying history of abuse can do physical therapy as well as psychiatric support, underlying issue of anxiety
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
External: Bartholin’s Gland
inferior to introitus can palpate pea sized glands openings on either side located posteriorly of opening
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
External: Clitoris
structure for sexual satisfaction for a female
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
External: Hymen
thin mucous membrane covering introitus can see some of the findings remnant of hymen can cause problem. Imperforate hymen- if closed might be accumulating blood hematocolpos need to pass menstrual blood
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
External: Introitus
Between labia minora opening for vagina may be hidden by hymen
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
External: Labia Majoris
rounded folds of adipose tissue overlying symphysis pubis
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
External: Labia Minora
thinner pinkish red folds or inner lips that extend anteriorly to form prepuce and clitoris
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
External: Mons Pubis
fat filled hair pad
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
External: Perineum
midline between vagina and anus can be asymmetric if had a tear during delivery
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
External: Prepuce
covering of clitoris
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
External: Skene’s Paraurethral glands
lateral to vagina. Pale and atrophic indicator of menopause
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
External: Urethral Meatus
hole for urethra opens into vestibule between clitoris vagina
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
External: Uterus
hick-walled fibromuscular structured shaped like an inverted pair. Containing fundus, body/corpus, and cervix at isthmus. Perimetrium (serosa perineum), myometrium, endometrium
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
External: Vagina
musculomembranous tube extending upward and posteriorly between bladder, urethra, and rectum lies at horizontal plane and terminates at fornix mucosa in transverse folds or ruga
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
External: Vestibule
between labia minora boat shaped fossa
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
External: Vulva
whole outside of vagina
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
Internal: Adnexa
appendages of uterus ovariy(size of almond),fallopian tubes, along w/ ligament and supportive structure .
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
Internal: Anterior Fornix
space between the uterine cervix anterior to the body of the uterus near the bladder
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
Internal: Bladder
muscular structure holding urine, anterior to the uterus uterus lays anterolateral over it
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
Internal: Cervical OS
part of the female reproductive located in the pelvis. It is the opening in the lower part of the cervix between the uterus and vagina.
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
Internal: Cervix
lower part of uterus. Outer area of cervix squamous (shiny and pink), epithelium metaplastic cells, inner is squamocolumarjunction. Screen for abnormalities when doing pap smear, squamous, columnar and in between metaplasticcells. Endocervix=plushy and red endothelial cells produce mucus
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
Internal: Cul-de-sac/rectouterine pouch
rectouterine pouch
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
Internal: Fallopian Tube
tubes connecting the ovary to the uterus, ectopic pregnancy commonly occur here. Fimbria extend from ovary to each side of uterus conduct oocyte to cavity.
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
Internal: Isthmus of the Uterus
part closest to the fundus on the uterine tube
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
Internal:
Ovary
produce estrogen, progesterone, and testosterone
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
Internal: Posterior Fornix
space between the uterus posterior to body of the uterus near the rectum
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
Internal: Serosa
outer layer
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
Internal: Transformation Zone
transition from squamous to columnar epithelium from vagina to uterus
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
Internal: Urethra
pee hole
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
Internal: Uterus
uterus is about size of fist and pear-shaped, continuous w/ vagina. On exam able to palpate fundus (convex, smooth, nodular, tender, enlarged)
Vagina - entrance to the uterus
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
Vagina-
musculomembranous tube extending upward and posteriorly between bladder, urethra, and rectum lies at horizontal plane and terminates at fornix mucosa in transverse folds or ruga
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
vestibule
vagina
between labia minora boat shaped fossa
whole outside of vagina
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
Internal:
Adnexa-
Anterior fornix-
Bladder-
adnexa- appendages of uterus ovariy(size of almond),fallopian tubes, along w/ ligament and supportive structure .
Anterior fornix- space between the uterine cervix anterior to the body of the uterus near the bladder
Bladder- muscular structure holding urine, anterior to the uterus uterus lays anterolateral over it
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
\Cervical os-
Cervix-
Cul-de-sac
Cervical os- part of the female reproductive located in the pelvis. It is the opening in the lower part of the cervix between the uterus and vagina.
Cervix- lower part of uterus. Outer area of cervix squamous (shiny and pink), epithelium metaplastic cells, inner is squamocolumarjunction. Screen for abnormalities when doing pap smear, squamous, columnar and in between metaplasticcells. Endocervix=plushy and red endothelial cells produce mucus
Cul-de-sac/rectouterine pouch
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
Fallopian Tube
Isthmus
Fallopian tube- tubes connecting the ovary to the uterus, ectopic pregnancy commonly occur here. Fimbria extend from ovary to each side of uterus conduct oocyte to cavity.
Isthmus of the uterus- part closest to the fundus on the uterine tube
Given a diagram of the female reproductive system, identify the major anatomic structures, their function, and physiologic variations.
ovary, posterior fornix, serosa, transformation zone, urethra, and uterus
Ovary- produce estrogen, progesterone, and testosterone
Posterior fornix- space between the uterus posterior to body of the uterus near the rectum
Serosa- outer layer
Transformation zone- transition from squamous to columnar epithelium from vagina to uterus
Urethra- pee hole
Uterus- uterus is about size of fist and pear-shaped, continuous w/ vagina. On exam able to palpate fundus (convex, smooth, nodular, tender, enlarged)
Vagina- entrance to uterus
Special circumstances to decrease pain of patient: 1st pelvic exam- calm patient down building rapport; MO- make sure thorough exam but limiting, elderly- extra lubricant, electronic table or DD-developmental disability patient, Postmenopausal patient, Victims of sexual assault- awkward and uncomfortable more bearable. Ask patient to abstain from intercourse24-48 hours at most. Male provider w/ female patient should have chaperone.
Have ALL your equipment ready. Position your patient & drape appropriately. ALWAYS let the patient know BEFORE you touch her…she can’t see what your doing! ALWAYS describe what you are or will be doing. Patients head elevated, tell them what you are doing
List and describe the equipment and supplies used during the pelvic examination.
Equipment needed for exam: Exam table with stirrups; Sink, cleansing agent; A stool, Lamp, Gloves, Specula (Graves- more rounded duck bill if have had children or morbidly obese because it provides more support for visualization , Pederson-parallel edges no duckbill Young women never had children, elderly or for dryness), Lubricant, Pap smear media, Culture collection media; Slides, saline, KOH, Tissues
Describe and demonstrate appropriate positioning and draping for the pelvic exam.
Start with the patient lying supine on the exam table with the head elevated 30-45 degrees. Assist the patient placing her heels in the stirrups. Adjust the angle & length of the stirrups to “fit” the patient. Have the patient slide her hips down until she contacts the edge of the table. Have the patient relax her knees outward. Uncover the vulva by moving the center of the drape away from you. Try to avoid creating a “screen” with the drape pulled tight between the patient’s knees. Announce what you are going to do and then touch the patient on the thigh with the back of your hand before proceeding
Describe, discuss, and demonstrate (on a model patient) appropriate techniques for performing an examination of the female genitalia to include:
External Examination
Inspection: Infection or concerns w/ piercing, monsfor rashes vulva. Excoriations or itchy, small, red maculopapules suggest pediculosis pubis (lice) found at base of pubic hairs. Enlarged clitoris in masculinizing endocrine disorders. Bartholin gland for infection. Palpation bartholin gland 4-o-clock and 8-o-clock position outside labium majus w/ discharge or exudate.
Describe, discuss, and demonstrate (on a model patient) appropriate techniques for performing an examination of the female genitalia to include:
Insert Speculum
(Warm and/or lubricate the speculum- enlarge intriotus by inserting finger pointing down and palpating. Varies based on type of spec/purpose of exam), Announce what you are going to do, then touch the patient on the inner thigh before proceeding, Expose the introitus by spreading the labia minora from below using the index and middle fingers of the NON-DOMINANT HAND (peace sign), Insert the speculum at a 45 degree angle with slight downward motion, Avoid contact with the anterior structures. Once past the introitus, rotate the speculum to a horizontal position and continue insertion until the handle is almost flush with the perineum, Open the “bills” of the speculum 2 or 3 cm using the thumb lever, Position the bills so that the cervix “falls” in between, Secure the speculum, Do not move the speculum while it is locked open. When cervix retroverted, cervix points anteriorly.
Describe, discuss, and demonstrate (on a model patient) appropriate techniques for performing an examination of the female genitalia to include:
Internal Genitalia Inspection
(Pap sampling, cultures, wet prep sample)-see slide 58 cells are removed from cervix by cervix brush for the outer squamous and transformation zone then collected cervix cells w/ cytobrush. Goal of pap is to sample area. Normal cervical mucous around ovulation can see junction of squqmaousred plush like endocervicalcells, passed a baby. Irregular, warty HPV sample whole outside and inside of cervix. Getit when there is dysplasia
Describe, discuss, and demonstrate (on a model patient) appropriate techniques for performing an examination of the female genitalia to include:
Remove Speculum
Slowly remove the speculum same way inserted at 45 degree angle, clear cervix before letting blades go down visualizing as you go out and close w/ introitus exit.
Bimanual examination- Apply lubricant to 2nd & 3rd finger. Inform patient you are going to insert your fingers, de-glove non dominant hand on bimanual exam. Insert fingers at an oblique angle. Place your other hand on the patient’s lower abdomen. Ask patient to bear down to feel the muscle tone squeezing your fingers (weakness form aging, deliveries, neurologic conditions, contributing to stress incontinence) (over recruitment tightening, vaginal wall tenderness, and referred pain signal pelvic pain from spasm, cystitis, vulvodynia), Palpate and feel vagina checking for nodularity, tenderness. Palpate cervix w/ your index finger noting size, shape, and consistency, assess for masses as well as the cervical os and ectocervix and fornix where it hangs down feel all four of area. Gently move cervix side to side between your fingers trapping it, noting mobility and tenderness, lifting it forward and noting mobility and tenderness. Press downward with the abdominal hand and palpate the uterus (if possible) Note uterine position, consistency, tenderness and estimate uterine size also on uterus palpate fundus to feel for nodules, size (if enlarged due to pregnancy, uterine myomas, fibroids, or malignancy), masses, tenderness. If obese or not relaxed may not be able to feel. Go to right exam adnexus trapping to feel ovary on one side rotating hand up and over to other side to palpate other ovary note size, shape, any other palpable adnexal structures. Menopausal women: ovaries atrophy if palpable could be ovarian cyst or cancer. Document: No tenderness, uterus was mobile, limited by body habitus. Firm, spongy, not enlarged or quantify number of weeks for pregnant uterus everything is 6 weeks usually, umbillicusis 20 weeks. Halfway between pubic bone and umbillicus 10 weeks.
Describe, discuss, and demonstrate (on a model patient) appropriate techniques for performing an examination of the female genitalia to include:
Rectovaginal Examination
, +/-Rectovaginalexamination: Change gloves (or double glove initially), Apply lubricant to 2nd& 3rdfingers, Insert 2nddigit into vagina & 3rdinto rectum, Palpate the RU pouch, uterus and rectum: Consistency, Masses, Tenderness, Fecal occult blood testing. Can feel retroverted uterus best this way. For palpate retroverted uterus, uterosacral ligaments, cul-de-sac, and adnexa downward pressure (nodularity and thickening of uterosacral ligaments from endometriosis w/ pain movement)
Describe the indications and techniques for obtaining specimens for cervical cytology and/or culture.
Every two years when young, and every year as you get older. If doing a pap smear make sure patient doesnt have period. No sex 24-48 hours before. 72-120 hours timeline for evidence collection. Not usually done on young adults unless amenorrhea, excessive bleeding, unexplained abdominal pain, vaginal discharge, or dysmennorhea. Dont lubricate speculum when taking sample will interfere with sampling. Rotate tip of brush in cervical os clockwise can also test for chlamydia and gonorrhea. Done for (age 21 and under 65- every 3 years under 30, 5 years between 30-65 and one partner). Speculum exam once sexuallyactive, no matter the age. Wouldn’t do manual unless having problems. If sexually active have a full exam. When pregnant women use cotton tipped applicator instead of endocervical brush
Describe the significance of the following physical examination findings:
Bartholin Cyst
Lesions of the vulva
bartholin gland cyst or infection commonly there is a duct blockage that forms an abscess that is tender and sore not allowing patient to sit can be causes by trauma, gonocooci, anaerobes (bacteroids) gland appears as tense, hot, very tender. Pus emerging from duct or eryhtmea around duct opening
Describe the significance of the following physical examination findings:
Genital Herpes
Exquisitely tender, patients will come in with burning w/ urination (UTI) when because when these soars come in contact w/ urine. Ulcer w/ exudate, shallow, small painful ulcers take 2-4 weeks to heal flat or depressed areas, inflamed, multiple or diffuse, mirroring both sides of labia start out as fluid filled vescile rupturing to ulceration 4-7 days after exposure. Flu-like symptoms, blah. Lymphadenopathy
Type 1 and type 2 cross border between upstairs and downstairs, Type 1- few number of lesions type 1 genitally, Type 2 more severe outbreak lesions soar
Describe the significance of the following physical examination findings:
Primary Syphilis
T. palenium. Single lesion that is painless chancre. Different stages of syphilis if test positive never have a lesion could have been on cervix and never knew about it. How it looks, size, location, descriptors. Small lesion 1cm lateral to introitus at 9 painless
Describe the significance of the following physical examination findings:
Secondary Syphilis
large raised, round or oval, flat-topped gray or white lesions point to condylomata lata. Contagious and w/ rash sores in mouth, vagina, or anus.
Describe the significance of the following physical examination findings:
Vulvar Candiasis
Well demarcated border, itchy, jock itch for female patient, red, adematous, itchy, recent antibioticuse, areas where skin folds and moisture. Contact dermatitiis detergent soaps, or yeast infection (classic example saddle-like lesions)
Describe the significance of the following physical examination findings:
Melanoma
occurs where sun doenstshine, dermatologist or watch.Irregular border, pigmentation, spread, prepuce
Describe the significance of the following physical examination findings:Vaginal Discharges - Normal
1-4 ml in 24 hour period, White/transparent, thick or mucoid, Odorless or minimal “musky” odor, Increases with pregnancy, OCP use and around the time of ovulation, Lactobacillus is normal flora, Acidic pH because of lactobacillus. Self cleaning organ, squamous epithelium, sheds squamous cells women on daily is squamous, mucous white/yellowish thick have minimal odor irritated or itchy. Deuche- gets rid of good bacteria and alters pH
Describe the significance of the following physical examination findings:
Vaginal Discharges
bacterial vaginosis
Incredibly common, imbalance of natural fleura offset by diet, stress, poor hydration, more at risk,not sexually transmitted. Complaining of discharge fishy odor bacteria don’t want in vagina fishy odor, milky and white homogenous and a little bit fishy selling. Can be very subacute, polymicrobial facultative anaerobes can cause mild irritation.
Describe the significance of the following physical examination findings:
Vaginal Discharges
Trichomonas(STI)
parasite WBCs- look same. Largerthan WBC find one can focus and flagella moved get dizzy going in circle, strawberry cervix similar to candida infection punctate erythema, discharge like EV, green from heme break down punctate areas of bleeding greenish discharge old blood frothy making foam. Profuse discharge and pooling in posterior area, comlainingof painful intercourse or urination
Describe the significance of the following physical examination findings:
Vaginal Discharges
Candida
yeast infection. Wet prep, normal saline swab of vagina w/ saline on microscope yeast hyphae spores. Discharge for yeast, if external discharge looks stuck on white, clumpy cottage cheese like discharge yeasty smell, red erythema swelling, itchy on outside may or may not have vulvitis symptoms w/ it. Antibiotic wipes out normal flora, yeast normal once antibiotics formed.
Describe the significance of the following physical examination findings:
Vaginal Discharges
bacterial vaginosis
Pooling w/ more discharge milky white, mild,fishy odor. pH elevation not as acidic as it should be, clue cells furry squamous cells bacteria adhering to it. KOH and if you put it w/ wet mount get intense fishy odor. No inflammation. Yeast and tricinflammation
Describe the significance of the following physical examination findings:
Bulges, Swelling of the vulva, vagina and urethra
Genital Warts
HPV, stuck on warts,exophitic, cauliflower like 1 or 2 versus 20. can look like skin tag and classic appearance can diagnose
Describe the significance of the following physical examination findings:
Bulges, Swelling of the vulva, vagina and urethra
Vulvar Carcinoma
Hard, irregular,nontender, itchy, bleeding from clothing rub
Describe the significance of the following physical examination findings:
Bulges, Swelling of the vulva, vagina and urethra
Rectocele
prolapse of the rectum, posterior wall prolapse, herniation of rectum into posterior wall of vagina, resulting from weakness or defect in endopelvic fascia. Calm steady pressure to reinsert into body for 5-8 minutes relaxing and pops it back in
Describe the significance of the following physical examination findings:
Bulges, Swelling of the vulva, vagina and urethra
Cystocele
prolapse of the bladder, anterior wall prolapse. Damaging fascia, pelvic floor symptoms, stress incontinence, incomplete void, need for further bowel movement, heaviness in pelvic area. Ask them to bear down to see if they have prolapse
Describe the significance of the following physical examination findings:
Variations in the shape and surface of the cervix
Normal nulliparous cervix
nulliparous cervical os is smaller and either round or oval. Cervix is covered by smooth pink epithelium
Describe the significance of the following physical examination findings:
Variations in the shape and surface of the cervix
Normal parous cervix
after childbirth, cervical os presents a slit-like appearance. Not always slit like can return depending upon dilation
Describe the significance of the following physical examination findings:
Variations in the shape and surface of the cervix
Endometriosis
lateral displacement of cervix, involving uterosacral ligaments.
Describe the significance of the following physical examination findings:
Variations in the shape and surface of the cervix
Unilateral transverse, bilateral transverse and stellate
trauma of difficult childbirth deliveries tear cervix, producing permanent transverse or stellate lacerations
Describe the significance of the following physical examination findings:
Variations in the shape and surface of the cervix
Premlaginant changes or dysplasia
whitening on cervix is bad and is indicator for cervical cancer unless proven otherwise
Describe the significance of the following physical examination findings:
Variations in the shape and surface of the cervix
Cervicitis
Inflammation of cervix-red angry looking. Yellow pustule inflammation white blood cells. Testing for STDs giving antibiotics
Describe the significance of the following physical examination findings:
Variations in the shape and surface of the cervix
Mucoprurulent cervicitis
Inflammation of cervix-red angry looking. Yellow pustule inflammation white blood cells. Testing for STDs giving antibiotics
Describe the significance of the following physical examination findings:
Variations in the shape and surface of the cervix
Intrauterine exposure to DES (diethylstilbestrol)
40s-80s estrogen replacement therapy w/ premature ovarian failureto prevent miscarriages and causes cancer or vaginal adenosis developing into clear cell carcinoma screening regularly more sampling. Cockcombarea of extra tissue above the top ask about exposure of themslevesor someone else to DES see slide 62. daughters of women who took DES are at higher risk for several abnormalities columnar epithelium covering cervix, vaginal adenosis extension of epithlium to wall, circular collor ridge of tissue rare carcinoma of upper vagina
Common glandular tissue of cervix, nontender, little round elevationsDescribe the significance of the following physical examination findings:
Variations in the shape and surface of the cervix
Nabothian Cyst
Common glandular tissue of cervix, nontender, little round elevations
everytime we have sex I bleed intercourse rubbing on it, forceps and grasp onto it twist and pull out for pathology, don’t know how deep stalk is doesn’t inhibit mensesDescribe the significance of the following physical examination findings:
Variations in the shape and surface of the cervix
Endocervical polyps
everytime we have sex I bleed intercourse rubbing on it, forceps and grasp onto it twist and pull out for pathology, don’t know how deep stalk is doesn’t inhibit menses
Describe the significance of the following physical examination findings:
Variations in the shape and surface of the cervix
Weakness of pelvic floor
weakness of pelvic floor muscles may cause pain; urinary incontinence, fecal incontinence, and prolapse of pelvic organs can produce cystocele, rectocele, or enterocele. Risk of surgery, age, childbirth, obesity, diabetes (neuropathy), parkins and multiple sclerosis, medications, intrabdominal pressure COPD constipation.
Describe the significance of the following physical examination findings:
Variations in the shape and surface of the cervix
Cervical Cancer
HPV is major risk factor for cervical cancer due to persistent infection with it after 10 years. Biggest risk factors failure to undergo screening and multiple sex partners, smoking, immunosuprression HIV, long-term use of OC, chlamydia, parity. Raised, friable, or lobed wart-like lesiosn seen.
Describe the significance of the following physical examination findings:
Variations in the shape and surface of the cervix
Vaginal Cancer
rare only found found w/ DES exposure, HPV infections
Anteverted leaning toward bladder. Cervix at intriotus
Describe the significance of the following physical examination findings:
Positions and abnormalities of the uterus
Normal position of the uterus
Anteverted leaning toward bladder. Cervix at intriotus
Describe the significance of the following physical examination findings:
Positions and abnormalities of the uterus
Prolapse
Having babies damaging to structure, postmenopausal- loss of estrogen, more prone. Uterus based on severity grade 1-3 prolapse w/ grade 3 being completely out of the uterus
Uterus= cervix very anterior cervixuterus goes back 20-25% variation of normal. More of backaches than pelvic aches during menses.
Can also be anteflexed antivereted and anteflexed both pressing on bladder,
retroverted and retroflexed pressing on bowel when inserting specule have to press toward bellybutton
Describe the significance of the following physical examination findings:
Adnexal masses
Uterine fibroid
Fibroids in wall of uterus, pedunculated- outside, subserosal- in surface,submucosal- cause irregular bleeding. Nodularity of uterus fundus dome shaped might feel irregularity. Almost always benign
tenderness mild moderate severe on palpation and deeper when theycomplain can feel round mass smooth fluctuant. Diagnosed w/ pelvic ultrasound fullness and tenderness on side, moveaorundDescribe the significance of the following physical examination findings:
Adnexal masses
ovarian cyst
tenderness mild moderate severe on palpation and deeper when theycomplain can feel round mass smooth fluctuant. Diagnosed w/ pelvic ultrasound fullness and tenderness on side, moveaorund
Describe the significance of the following physical examination findings:
Adnexal masses
ovarian carcinoma
older than 55 years, three symptoms merit special attention: abdominal distention, abdominal bloating, and urinary frequency; however, these are usually reported w/in 3 months of diagnosis and frequently occur in other conditions. Began in area of metapalsia, cannot be distinguished. Forms extensive, irregular, cauliflower-like growth, caused by smoking, early frequent intercourse, multiple partners and HPV. Family history, presence of BRCA1 or 2. Risk decreased by oral contracpetives, multiple pregnancies, breastfeeding, and tubal ligation.
Describe the significance of the following physical examination findings:
Adnexal masses
Pevlic Inflammatory Disease
Most commonly caused by gonorrhea chlamydia discharge inflammation and infection in a tube. Don’t want to move anything in pelvis from so much inflammation long term untreated blockage, because of of ectopic pregnancy, feverish, looking toxic. Differential appendicitis. Chandelier sign positive cervical motion tenderness barely tolerate speculum or recent IUD insertion, or appendicitis
Describe the significance of the following physical examination findings:
Adnexal masses
Ectopic Pregnancy
Pregnancy where it should not be growing fetus embryo, life threatening in fallopian tube (slow bleed, rupture pain resolves 5-6 weeks ectopic) w/ only so much give rupturing. Pelvic pain, sexually active, similar to PID not as severe gnawing unilateral pain, shoulder pain. Varying tenderness and pain may cause cervical motion tenderness.
Assess the sexual maturity stage of an adolescent patient, then assign and document appropriate Tanner stages (I-V)
Tanner I
Delayed puberty is often familial or related to chronic illness. Reflect disorders of hypothalamus, anterior pituitary, or ovaries.
Pubic hair (both male and female)
no pubic hair at all (prepubertal) [typically age 10 and younger]
Assess the sexual maturity stage of an adolescent patient, then assign and document appropriate Tanner stages (I-V)
Tanner II
Tanner II- small amount of long, downy hair with slight pigmentation at the base of the penisand scrotumor on the labia majora[10–11.5]
Assess the sexual maturity stage of an adolescent patient, then assign and document appropriate Tanner stages (I-V)
Tanner III
hair becomes more coarse and curly, and begins to extend laterally [11.5–13]
Assess the sexual maturity stage of an adolescent patient, then assign and document appropriate Tanner stages (I-V)
Tanner IV
adult-like hair quality, extending across pubisbut sparing medial thighs [13–15]
Assess the sexual maturity stage of an adolescent patient, then assign and document appropriate Tanner stages (I-V)
Tanner V
adult-like hair quality, extending across pubisbut sparing medial thighs [13–15]
Discuss the following common or concerning symptoms, the etiology, presentation, and appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Penile discharge or lesions
ask patient if it is staining underwear, and if there are other symptoms like: fever, chills, rash. Gonorrhea- Yellow penile discharge, chlamydia- white discharge (non-gonococcal urethritis).
Discuss the following common or concerning symptoms, the etiology, presentation, and appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Scrotal pain swelling or lesions
Ulcers- Syphilitic chancre and herpes. HPV- warts. Swelling- mumps, scrotal edema, and cancer. Pain- testicular torsion, epididymitis, and orchitis
Discuss the following common or concerning symptoms, the etiology, presentation, and appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Erectile Dysfunction
can affect: libido, orgasm (not orgasming w/ ejaculation suggests psychogenic), ejaculation; can cause: premature ejaculation, reduced or absent ejaculation (affecting middle-aged or older men caused by medications, surgery, neurologic deficits, or lack of androgen), and impotence. From psychogenic causes if early morning erection is preserved. Otherwise can be caused by decreased test., decreased blood flow in hypogastric arterial system, impaired neural innervation, and diabetes.
Discuss the following common or concerning symptoms, the etiology, presentation, and appropriate history questions to aid in the evaluation of patients presenting with such complaints. Discuss the significance of responses.
Urinary Symptoms
dysuria, frequency, urgency, hesitancy; nocturia, weak stream, incontinence- difficulty w/ stream, blood in urine, and urinating at night suggest BPH or cancer. Frequency, urgency, and pain acute prostatitis.
Define the following terms and discuss their significance:
Balanitis
is inflammation of the glans penis. Etiology of bacterial, fungal secondary to poorly retractile foreskin and poor hygiene caused by candida, strep. Have patient be in bright, cool, and dry room, can be washed off
Define the following terms and discuss their significance:
Balanoposthitis
inflammation of both glans penis and prepuce. Etiology of bacterial, fungal secondary to poorly retractile foreskin and poor hygiene caused by candida, strep. Have patient be in bright, cool, and dry room , can be washed off
Define the following terms and discuss their significance:
Chlamydia
intracellular pathogen. Most commonly reported, silent most are asymptomatic can cause PID in women. Can affect and become pneumonia in newborn.
Define the following terms and discuss their significance:
Cryptorchidsm
Absence of one or both testes from scrotum. Testis is atrophied and lies outside scrotum in inguinal canal, abdomen, or near pubic tubercle or absent increases risk of cancer. Common birth defect for males will descend within first year surgery not needed. Cryptorchidism is distinct from monorchism, condition of having only one testicle
Define the following terms and discuss their significance:
Ejaculation
relies on testosterone, arterial blood flow from internal iliac>pudendal, neural innervation adrenergic. Venous engorgement of corpora cavernosa from sympathetic triggers T11-L2, stimulation from genitalia 2-S4. Parasympathetic pathways pudendal.
Define the following terms and discuss their significance:
Epidermoid Cyst
Epidermoid cysts or epidermal inclusion cysts are symptomatic, semi-solid cysts are filled and lined with keratin. responsible for the soft, “cheesy” keratin contents. Common on the scrotum, (rarely found on the penis). Cysts can be located almost anywhere, including the face, neck, scalp, or trunk. Unknown pathogenesis. Misnomer to call these sebaceous cysts. Hypothesized that some epidermoid cysts may originate from median raphe cysts
Define the following terms and discuss their significance:
Epididymitis
infection causing Inflammation of the epididymis usually accompanies Orchitis (inflammation of testicles). Caused by chlamydia, gonorrheae, E. colli, and Pseudomonas. Highest prevalence 19-35 y/o. Painful swelling in scrotum, reddened, vas deferens inflamed. develops rapidly 24-48 hrs. Starts in epididymis may progress to one large inflammatory mass encompassing both epididymis and testicle. Prehn’sSign: alleviation of pain with scrotal elevation. May have dysuria or discharge if concomitant urethritis. May have reactive hydrocele. May have fever or elevated WBC. Differential diagnoses: Testicular torsion, Testicular tumor, Torsion of appendix testes, Scrotal hernia or hydrocele, Trauma, Henoch-Schonleinpurpura.
Define the following terms and discuss their significance:
Gonorrhea
causes urethritis the mucosal susceptible to infection are oral-pharyngeal, genitals, eyes, rectum. In genitals wil develop into painful urination and pus discharge and can block urethra, cause strictures, or sterilitly can become complicated when untreated leading to endocarditis, meningitis, and arthritis. No vaccinations. Rash, tenosynovitis, monoarticular arthritis, menigngits, diessminated gonorrhea.
Define the following terms and discuss their significance:
Hernia
Abnormal protrusion/saccular outpouching of viscera through peritoneal walls, develop at points of weakness in abdominal wall, Hernia in the early stages can be harmless, Calm steady pressure to reinsert into body for 5-8 minutes relaxing and pops it back in if someone relaxes ask about vacations. Use trendelenburg and reducing patient, hernia repair most overall fail. Progression may result in an irreducible hernia, with: Ischemia, injury & infarction. Resulting in tissue death.
Define the following terms and discuss their significance:
Inguinal Hernia
Clinical exam in not accurate in determining whether a hernia is direct or indirect. Can be described as pain in groin while performing exercise, pain with Valsalva, i.e.: coughing, lifting or sneezing. A bulge in the groin that disappears on lying down. Pressure, ‘heaviness’ or “weakness” in groin. Pain & swelling into scrotum or around the testicles.
Inguinal hernia: Most common, Most adult indirect hernias are acquired. Indirect hernias have a peritoneal sac, can contain bowel (incarcerate, strangulate). congenital. developing form the peritoneal sac
Direct hernias medially due to weakness in floor of inguinal canal commonly found in people who strain and heavily lift. contain preperitoneal fat, BUT large direct hernias can: Have a peritoneal sac, Descend into the scrotum, incarcerate, strangulate just like an indirect and are always acquired.
Define the following terms and discuss their significance:
Hydrocele
part of peritoneum lined w/ fluid allowing intestines to slide and if open gravity will push fluid into scrotum. Peritoneal fluid surrounds Testicle, sliding between: Visceral tunica vaginalis and Parietal tunica vaginalis. Processus vaginalis- extra bit of defect: A diverticulum of the peritoneal cavity into the scrotum. Commonly found in infants goes away, defect or irritation in tunica vaginalis inflammatory. If found in adult can be due to local injury, infection, radiotherapy, chronic accumulation from peritoneum is a painless scrotal swelling, increases w/ progression of day. Signs: non-tender, trans-illuminent because translucent fluid may be bluish if on right-side suspicious for testicular tumor and can be obscured by hydrocele otherwise benign. Commonly found in ascites, washcloth below it from elevation.
Define the following terms and discuss their significance:
Hypospadias
congenital ventral displacement of meatus on penis to inferior surface of penis. Meastus may be subcoronal, midshaft, or at junction of penis and scrotum.
Impotence- inability to achieve an erection or orgasm
Define the following terms and discuss their significance:
Impotence
inability to achieve an erection or orgasm
Define the following terms and discuss their significance:
Incarcerated Hernia
when its contents cannot be returned to the abdominal cavity. develop at internal inguinal ring, spermatic cord exits characterized by pain, abdominal distention, absolute constipation. Surgical emergency, acute bowel obstruction w/ ischemic bowel, with high risk of incarceration/strangulation if small internal ring small and hernia is large. Reduce it in supine position, analgesia/sedation, ice can reduce swelling. Slow-steady manual pressure (3-10 minutes) trendelenburg helpful Ex. morphine, fentanyl,
Define the following terms and discuss their significance:
Libido
desire for sex low libido may arise from depression, endocrine dysfunction, or side effects of medications.
Define the following terms and discuss their significance:
Orchitis
inflammation of the testis painful, tender, and swollen. Difficult to distinguish from and usually accompanies epidiymitis. Reddened scrotum in mumps or viral infections and is usually unilateral.
Define the following terms and discuss their significance:
Orgasm
climax of sexual excitement, characterized by feelings of pleasure centered in genitals experiences as an accompaniment to ejaculation (males)
Define the following terms and discuss their significance:
Phimosis
tight prepuce that cannot be retracted over glans (foreskin or prepuce) covering the head (glans) of the uncircumcised penis. Phimosis may appear as a tight ring or “rubber band” of foreskin around the tip of the penis, preventing full retraction. Uncircumcised may not retract and become hung up.
Paraphimosis- tight prepuce that once retracted foreskin trapped behind the glans of the peniscannot be returned w/ ensuing edema. Paraphimosis is a urologic emergency that requires immediate treatment to prevent necrosis/gangrene, with amputation of the glans penis. Most common in nursing home.
(common in young men)
Define the following terms and discuss their significance:
Premature Ejaculation
(common in young men)
Define the following terms and discuss their significance:
Prosatitis
caused by: Acute and chronic Bacterial Prostatitis, Chronic Nonbacterial Prostatitis (Inflammatory), Granulomatous Prostatitis; Nonbacterial, Non Inflammatory Prostatitis (Prostatodynia/ Chronic pelvic pain). Can present as several syndromes. Signs and symptoms: acute onset of: low back pain, perineal pain, fever/chills, hematuria, and general malaise. Sepsis presentation: fever, tachycardia, and hypotension range from normal to nodular, tender, boggy, and firm. Pain: perineal, groin, suprapubic, penile, scrotal, rectal; Voiding dysfunction: dysuria, poor stream, frequency, urgency, nocturia; Sexual: pain with ejaculation.
Define the following terms and discuss their significance:
STI / STD
any orifice where you have sex. Infections from oral-penile transmission include gonorrhea, chlamydia, syphilis, and herpes. Symptomatic or asymptomatic proctitis follow anal intercourse.
Define the following terms and discuss their significance:
Smegma
An oily, cheese-like substance that builds up on uncircumcised male penises due to poor hygiene. Left unattended it may eventually form a cheese beanie. Smegma can be washed out with plain water. Carefully retract your foreskin. Smegma usually builds up behind the inner end of the glans (just behind the bell-shaped tissue known as the corona). Soap isn’t advised.
Define the following terms and discuss their significance:
Strangulated
blood supply to entrapped contents in hernia is compromised. Suspect if tender, nausea, vomiting, need surgery.
Define the following terms and discuss their significance:
Torsion of the spermatic cord
torsion or twisitng of testicle on its spermatic cord, producing Abrupt onset of pain, tender, and swollen usually testicular, can be lower abdominal, inguinal. May follow exercise or minor trauma (teenagers up to 40). Need to fix otherwise can lose testicle, May awaken from sleep. Cremasteric contraction with nocturnal stimulation in REM. Up to 8% report testicular pain in past. Symptoms: Edematous, tender, swollen scrotum if delayed, Elevated from shortened spermatic cord. Horizontal lie common, Reactive hydrocele may be present. Cremasteric reflex absent in nearly all(unreliable in <30mo old). Prehn’s sign unreliable (elevation relieves pain in epididymitis and not torsion). Surgical emergency prompt clinical. Detort w/in 6 hours best but still need surgery rotate outward. If presents before swelling, Need appropriate sedation, In 2/3rds of cases testes torsemedially, 1/3rd lateral. Success if pain relief, & testes lowers in scrotum, Still need surgical fixation
Torsion of appendix testis- Appendix testis- Small vestigial structure, remnant of Mullerian duct. - Pedunculated, ~ 0.3cm long (note other appendix structures). Prepubertal estrogen may enlarge appendix and cause torsion seen as a blue dot of gangrenous appendix testis little bit of appendage dying off. Analgesics, scrotal support to relieve swelling surgery for persistent pain no need for contralateral exploration.
Define the following terms and discuss their significance:
urethral stricture
auses bladder distension induration along ventral surface of penis or carcinoma causing. Tenderness in indurated area suggests periurethral inflammation.
Define the following terms and discuss their significance:
Urethritis
male urethra normally sterile. Most is caused by STDs. Most commonly caused by: gonorrhea (yellow) and chlamydia (scanty white or clear) . Gonorrhea: Painful urination w/ pus discharge, can cause blockage later on
Define the following terms and discuss their significance:
Varicocele
Scrotal vein dilation & tortuosity (bag of worms distort contours of scrotal skin), thickened venous plexus (backing up pressure larger health problem causes change in temperature Often asymptomatic. Associated with infertility?: Elevated testicular temperature, Interference with mitochondrial function, Decreased spermatogenesis and motility. Red flag if there is a sudden onset in older man can be a renal tumor, or spermatic vein occlusion. If treated doesn’t help fertility.
Identify the major anatomic structures, their function, and physiologic variations of the following components of the male reproductive system:
Corona
base of glans
Identify the major anatomic structures, their function, and physiologic variations of the following components of the male reproductive system:
Epididymis
posterolateral of each testis, softer, tightly coiled tubules becoming vs derens seperated by sulcus.
Identify the major anatomic structures, their function, and physiologic variations of the following components of the male reproductive system:
external inguinal ring
external opening of tunnel triangular slit-like structure palpable just above and lateral to pubic tubercle. When forced through produce inguinal hernia.
Identify the major anatomic structures, their function, and physiologic variations of the following components of the male reproductive system:
femoral canal
route for herniating mass below inguinal ligament. Near artery w/ bowel incarceration or strangulation.
Identify the major anatomic structures, their function, and physiologic variations of the following components of the male reproductive system:
glans
internal head of penis made up of spongiosum
Identify the major anatomic structures, their function, and physiologic variations of the following components of the male reproductive system:
inguinal canal
lies medially to and parallel to inguinal ligament, forms tunnel for vas deferns passing through abdominal muscles.
Identify the major anatomic structures, their function, and physiologic variations of the following components of the male reproductive system:
internal inguinal ring
1cm above midpoint of inguinal ligament. Neither palpable through wall.
Identify the major anatomic structures, their function, and physiologic variations of the following components of the male reproductive system:
penis
shaft made up of corpus spongiousm (from bulb to glans making up all of glans), urethra, corpora cavernosa. Lymph goes to deep and external inguinal lymph nodes.
Identify the major anatomic structures, their function, and physiologic variations of the following components of the male reproductive system:
prepuce
foreskin of penis covers entrance in uncircumcised men where smegma, secretions of glans, collect.
Identify the major anatomic structures, their function, and physiologic variations of the following components of the male reproductive system:
Scrotum
Pubic Tubercle
Sac outside of abdominal cavity, part of abdomen Dual chambered pouch of skin & muscle, Contains testes, epididymis & lower spermatic cords, Divided by septum (scrotal raphe). Cremaster muscle and tunica dartos make involuntary adjustments to regulate temperature for spermatogenesis (seminiferous tubules) optimal is 94o > 98 hot. Contain: spermatic cord, cremasteric muscle, tunica vaginalis, epididymis (very easily palpated and extremely sensitive most sensitive when hit), fascia (dartos). Has a scrotal raphe separating left from right. Lymph from scrotum into superficial inguinal lymph nodes.
Identify the major anatomic structures, their function, and physiologic variations of the following components of the male reproductive system:
Seminal Vesicle
sits atop bladder connected to vas deferens stores sperm for delivers
Identify the major anatomic structures, their function, and physiologic variations of the following components of the male reproductive system:
Spermatic Cord
vas, blood vessels, nerves, and muscle
Identify the major anatomic structures, their function, and physiologic variations of the following components of the male reproductive system:
Testis
paired ovoid glands of seminiferous tubules and interstitial covered by tunica albuginea. Tunica vaginalis covers testis if lining remains open creates indirect inguinal hernia w/ parietal (anterior ⅔ of testis) and visceral layers (lines adjacent scrotum)) form potential space for abdominal fluid or hydrocele. Cancer common if have HIV or cryptorchidism
Identify the major anatomic structures, their function, and physiologic variations of the following components of the male reproductive system:
Urethral Meatus
Urethra
entrance of penis
Identify the major anatomic structures, their function, and physiologic variations of the following components of the male reproductive system:
Vas Deferens
firm muscular cord-like structure transports sperm from tail of epididymis along circular route to uretha from scrotal sac into pelvic through inguinal merge to seminal vesicle becoming ejaculatory duct emptying into urethra
Discuss strategies for the prevention of STDs and human immunodeficiency virus (HIV). Describe the types of patients for whom the United States Prevention Services Task Force (USPSTF) recommends screening and counseling for HIV and STDs.
Women 24 and younger for gonorrhea and chlamyida. HPV vaccination in males 11-21. Lower risk to female partners of orophargyneal cancers. Early HIV infection ART decreases risk of progressing to AAIDS, reducing risk of transmitting to uninfected heterosexual partners and mother to child. 15-65 testing and pregnant woman. Annuualy for high-risk groups younger than 15 years old, men w/ male sex partners, multipel sex partners, injection drug use, prostitutes, sex partners who are HIV infected, bisexual, or any other STI.
Discuss strategies for the prevention of STDs and human immunodeficiency virus (HIV). Describe the types of patients for whom the United States Prevention Services Task Force (USPSTF) recommends screening and counseling for HIV and STDs.
Factors affecting spread of STDs
sexuality and secrecy, racial and ethnic disparities, poverty and marginilization, limited access to health care, substance abuse, and sexual networks.
Prevent STI- seek attention for genital lesions, penile discharge. Use condoms with each act, apply before it occurs, water-based lubricants, immediately withdraw if breaks and holding it, limiting number of partneers, regular healthcare treatment for STIs and HIV.
Describe the techniques for testicular self-exam (TSE), the recommendations for performing TSE, and the PE findings that should prompt evaluation.
Used for screening for testicular cancer. Every month, perform this test during or after a shower. This way, the scrotal skin is warm and relaxed. Best while standing. Gently feel your scrotal sac to locate a testicle. (Don’t expect symmetry!) Firmly but gently roll the testicle between the thumb and fingers of both hands to examine the entire surface. Epididymis is lumpy at the top
Feel for change! Feel any hard lumps or nodules (smooth rounded masses). Be aware of any change in the size, shape, or consistency of your testicles. Repeat the procedure with the other testicle. Come in if painless lump, swelling, or enlargement in either testicle, pain or discomfort in testicle or scrotum, heaviness or sudden fluid collection, or dull ache in lower abdomen and grown.
Describe, discuss, and demonstrate (on a model patient) appropriate techniques for performing an examination of the male genitalia to include:
Inspection and palpation of the penis
Have patient stand, especially for varicoeles. Palpate shaft noting induration, abnormality, noting tenderness.
Skin: on ventral and dorsal surface and base of penis for excoriations or inflammation (lice, crabs, scabies). Prepuce: foreskin if present, retract prepuce or ask patient to retract to detect chancres and carcinoma, smegma (cheesy, whitish material accumulate under foreskin). Retract and replace.
Glans: ulcers, scars, nodules, or signs of inflammation. Compress glans between fingers open meatus allow to detect disrachge. If unable to see and patient has noted it has him to milk shaft from base to glans expelling.
Urethral meatus: location
Describe, discuss, and demonstrate (on a model patient) appropriate techniques for performing an examination of the male genitalia to include:
Inspection and palpation of the scrotum and its contents
Skin: lift scrotum to inspect posterior surface noting lesions or scars and inspect pubic hair distribution. Epidermal cysts- Dome-shaped white or yellow papules or nodules from occluded follicles filled with keratin debirs of desquamated follicular epithelium, common, multiple, and benign. May reveal nevi, hemangiomas, or telangiectasis (dilated veins), STIs (condyloma), ulcers- herpes and chancroid (painful), (painless) sympthilis and lymphogranuloma venereum (inguina lymphadenopathy)
Contours: swelling, lumps, veins, bulging masses, or asymmetry of left and right hemiscrotum. Poorly developed scrotum on one or both sides suggest cyrptorchidism (undescended testicle). Indirect inguinal hernia, hydrocele, scrotal edema, and carcnoma.
Inguinal areas: erythema, excoriation, or visible adenopathy. Erythema and mild excoriation fungal infection, not uncommon in moist areas.
Palpate: each testis and epiddiymis fradle palpate contents slide them back and forth one one hand to other. Firm not hard, descended, symmetric, nontender, and without masses. Tender painful scrotal swelling in acute epidiymitis, orchitis, torsion of spermatic cord, or strangulated inguinal hernia. Painless nodule on testis (testicular cancer 15-34 year old).
Spermatic cord: palpate including vas deferens (stiff and tubular distinct- if chronically infected feel thickened or beaded w/ a cyst suggest hydrocele), epididymis to external inguinal ring. Varicocele- palpate cord 2cm above testis hold breath and bear down valsalva. (temporary increase in diameter of spermatic cord indicates filling of dilated veins) Nodules or swellings (transillumination behind scrotum)- will light up w/ red glow if hydrocele. Blood or tissue in normal, tumor or hernia dont.
Describe, discuss, and demonstrate (on a model patient) appropriate techniques for performing an examination of the male genitalia to include:
Inspection and palpation for hernias
Inspect: bulging area and assymmetry for hernia.
Palpate: While standing place tip of dominant index finger at anterior inferior margin of scrotum, superficial to testicle move finger and hand upward toward external inguinal ring, invaginating scrotal skin beneath peripubic fat pad next to base of penis. Follow spermatic cord upward to inguinal ligmanet finding external inguinal ring (triangular slit-like would be direct inguinal hernia) and its floor above and lateral to tubercle trying to get up into internal (would be indirect hernia) if possible. Ask to cough in both regions feeling for bulge or mass that touches against finger. Palpate for femoral hernia fingers on anterior thigh in region of femaoral canal, asking them to strain dwon again or cough noting swelling or tenderness.
Scrotal mass or hernia: have patient lie down, mass return to abdomen, fingers above mass in scrotum-hydrocele- transilluminate. Listen to mass w/ stethoscope, or may be hydrocele transmitting from abdomen- hernia. Try to reduce it by sustained pressure w/ fingers dont do if tender or if patient is nauseas and vomiting.
Describe the following PE findings:
Abnormalities of the penis and scrotum
abnormalities of the testis, epididymis, and spermatic cord
- Swelling of spermatic cord- Hydrocele (fingers above mass), Varicocele (bag of worms) , Hernia (listen to mass with stethoscope w/ bowel sound)
- Swelling of testis- Testicular Torsion, Orchitis, Testicular Carcinoma
- Swelling of epididymis- Epididymitis, Spermatocele
- Swelling of skin- Epidermoid cyst, squamous cell CA
Document the results of the examination of the male genitalia for the standardized patient in your comprehensive PE assignment.
Tanner I Testicular Volume
Tanner I testicular volume < 1.5 ml; small penis (prepubertal; typically age 9 & younger)
Document the results of the examination of the male genitalia for the standardized patient in your comprehensive PE assignment.
Tanner II testicular volume
Tanner II testicular volume ~ 1.6 and 6 ml; skin on scrotum thins, reddens and enlarges
Document the results of the examination of the male genitalia for the standardized patient in your comprehensive PE assignment.
Tanner III testicular volume
Tanner III testicular volume ~ 6 and 12 ml; scrotum enlarges further; penis lengthens (11–12.5)
Document the results of the examination of the male genitalia for the standardized patient in your comprehensive PE assignment.
Tanner IV testicular volume
Tanner IV testicular volume ~ 12 and 20 ml; scrotum enlarges further and darkens;
Document the results of the examination of the male genitalia for the standardized patient in your comprehensive PE assignment.
Tanner V testicular volume
Tanner V testicular volume > 20 ml; adult scrotum and penis (14+)
