CA Bates Flashcards
how many quadrants is the breast broken up into for documentatio
4 horizanl vertical line crossing the nipple
and a 5th area (axillary tail of breast tissue sometimes called tail of spense) and it extends laterally across the anterior axillary fold
how are findings locaalized
as the time on the face of a clock
and
distance in cm from nipple
what are the three most common kinds of breast masses
fibroadenoma (benign tumor)
cysts
breast cancer
commonly palpable as nodular, rope-like densities in women ages 25-50. may be tender or painful. considered benign and are not viewed as a risk factor for breast cancer
” nodular and ropelike”
fibrocystic changes
fibroadenoma age number shape consistency delimitation mobility tenderness retraction signs
age : 15-25
usually puberty and young adults, but up to age 55
number: usually single, may be multiple
shape: round disclike or lobular
consistency: may be soft usually firm
delimitation: well delineated
mobility: very mobile
tenderness: non tender
retraction signs: absent
“smooth, rubbery, round mobile, nontender”
Cysts age number shape consistency delimitation mobility tenderness retraction signs
age : 30-50, regress after menopause except with estrogen therapy
number: single or multi
shape: round
consistency: soft to firm, elastic
delimitation: well delineated
mobility: mobile
tenderness: tender
retraction signs: absent
“soft to firm, round, mobile, tender”
cancer age number shape consistency delimitation mobility tenderness retraction signs
age : 30-90 most common OVER 50
number: single but can coexist with other nodules
shape: irregular or stellate
consistency: firm or hard
delimitation: no clearly delineated from surrounding tissue
mobility: fixed to skin or underlying tissue
tenderness: non tender
retraction signs: maybe
“irregular firm may be mobile or fixed to surrounding tissue
breast masses should be carefully evaluated and usually warrants further investigation like….. (4)
ultrasound, aspiration, mammo, or biopsy
what are three retraction signs
- abnormal contours
- skin dimpling
- nipple retraction and deviation
as breast CA advances it causes fibrosis (scar tissue). shortening of the tissue produces dimpling, changes in contour and retraction of deviation of the nipple. other causes of ____________ are fat necrosis and mammary duct ectasia…. what am i referring to?
retraction signs
variation in the normal convexity of each breast, and compare one side to the other. special positioning may again be useful. marked flattening of the lower outer quadrant of the left breast is an example of what you may see in this type of retraction sign
abnormal contours
seen when pts arms are at rest, during special positioning and on moving or compressing the breast
skin dimpling
nipple is flattened or pulled inward. can be broadened and feels thickened. when involvement is radially asymmetric the nipple may point in a different direction from its normal counterpart, typically toward the underlying cancer
nipple retraction and deviation
produced by lymphatic blockade. appears as thickened skin with enlarged pores
also called peau d’orange (orange peel) sign
seen first in the lower portion of the breast or areola
edema of the skin
uncommon form of breast cancer usually starts as a scaly eczema like lesions that may weep, crust, or erode.
breast mass may be present.
suspect this is any persisting dermatitis of the nipple and areola occur.
can present with invasive breast cancer or ductal carcinoma in situ
Paget’s Disease of the Nipple
inappropriate discharge of milk containing fluid, and is abnormal if it occurs 6 or more months after childbirth or cessation of breast feeding
galactorrhea
milky discharge unrelated to prior pregnancy and lactation. causes include hypothyroidism, pituitary prolactinoma, and drugs that are dopamine agonists, including many psychotropic agents and phenothiazines
nonpuerperal glactorrhea
spontaneous unilateral bloody discharge fro one or two ducts warrants further evaluation for ____________
intraductal papiloma
ductal carcinoma in situ or Pagets disease of the breast
clear serous, green, black, non bloody discharge that are multiductal are
usually benign
masses nodularity and change in color or inflammation especially in the incision line suggest
recurrence of breast cancer
deeply pigmented velvety axillary skin suggests
acanthosis nigricans
associated with internal malignancy
thickening of the nipple and loss of elasticity suggests
underlying cancer
tender cords
benign but sometimes painful conditon of dilated ducts with surrounding inflammation, sometimes associated masses
mammary duct ectasia
hard irregular poorly circumscribed nodules fixed to the skin or underlying tissue
cancer
if you are above the age of _____ it is cancer until proven otherwise
50
what is the most common type of cancer in women worldwide
and the second leading cause of death in women
breast cancer
breast cancer accounts for more than _____% of cancers in women
10%
in the US. a women born now has a ___% or ___ in ____ lifetime risk of developing breast cancer
12%
1 in 8
95% of new breast cancers occur above the age of ____
40
factors which increase relative risk of breast cancer:
(this card is a lot but it is an LO so here I go)
page 412 in bates
>40 Relative Risk: factors are: female age inherited genetic mutations 2 or more first degree relatives with breast cancer diagnoses at an early age personal history of breast cancer high breast tissue density biopsy confirmed atypical hyperplasia
2.1-4.0 RR: factors are:
one 1st degree relative with breast cancer
high dose radiation to chest
high bone density (postmenopausal)
1.1-2.0 RR: factors are: late age at first full term pregnancy >30 early menarche (55) no full term pregnancies never breast fed a child recent oral contraceptive use recent and longterm use of hormone replacement therapy obesity
other factors: personal history of endometrium ovary or colon cancer alcohol consumption height high socioeconomic status jewish heritage
estimate absolute lifetime risk of breast cancer and are the most commonly used. they assess risk based on large population Data sets, BUT hey do not predict disease in a single individual.
Gail and CLaus models
used for predicting BRCA1 or BRCA2
BRCAPRO model
there is no single model that addresses all the known risk factors or includes all of the genetic details of personal and daily history, so devising data bases personalized management strategies is an on going focus for reseach
true
Breast cancer risk assessment tool often called the _____________ provides 5 year and first degree relatives with breast cancer previous breast biopsies and presence of hyperplasia, age at menarche, and age at first delivery. it is the best used for individuals over the age of 50 who have either no family history of breast cancer or one affected first degree relative and who have annual screening mammos. should not be used for women with a past history of breast cancer or radiation exposure, or those who are 35 or younger. does not determine risk for noninvasive breast cancer and does not take paternal history or disease in second degree relatives into account or age of onset of disease
this model was recently updated to include breast density but depends on the use of digital mammo and special software making it more difficult to use
GAIL MODEL
assess risk for high risk women and incorporates family history for both female And male 1st and 2nd degree relatives, including age of onset.
based on the woman’s current age
it is best used for individuals with no more than two first or second degree relatives with breast cancer.
expanded version includes family members with ovarian cancer,
model does not include personal, lifestyle or reproductive risk factors
discrepancies in risk assessment between published tables and the computerized program have been reported
CLAUS MODEL
used for high risk women to assess risk of BRACA1 and BRACA 2 mutations frequencies, cancer penetration i affected carriers and age of onset in first and second degree female and male relatives.
DOES NOT include on hereditary risk factors
BRCAPRO model
when do we begin evaluating a womans breast cancer risk?
early 20s by asking about family history
pattern of breast or ovarian in maternal or paternal family member is suspicious for
autosomal dominant genetic mutations
what do you loook specifically for in a positive family history
- age 50 or younger for diagnosis
- breast cancer in two or more indiv. in the same lineage (paternal or maternal)
- multiple primary or ovarian tumors in one person
- breast cancer in a male relative
- Ashkenazi Jewish ancestry
- family member with a known predisposing gene
what mutation represent roughly half of the familial breast cancers
BRCA1 and 2
account for 5% of breast cancers
if family history is suspect the next steps for clinical include
using the BRCAPRO calculator, conducting genetic testing, considering MRI for sceening in addition to mammo and making appropriate specialty referals
mammo women 40 to 50
controversial: why?
1. due to lower sensitivity and specificity
2. maybe related to heterogenous estrogen exposure in women still premenopausal
3. high number of false positives (9 out of 100 women)
4. high rate of resulting invasive procedures
having mammo 40-50 is based on individual patient
screening mammo age 50-74
biennial screening for women. changed it from annual to biennial.
reduced the harm of ammo screening. decreased false positives
however American cancer society and world health organization recommend annual mammo. world health organization says every 1 to 2 years.
digital mammo appears to perform better in younger women and women with higher breast density
screening mammos for over 75 yo
individualized decisions about continuing screening, depending on coexisting conditions and anticipated 5 year survival
Clinicial Breast Examination (CBE) guideleines
USPSTF and World Health Organization: determined evidence supporting insufficiency of CBE for establishing balance of benefits and harms
American Cancer Society recommends the CBE every 3 years for women ages 20-39 and annually preferably before mammo, beginning age 40. CBE provides pt education but cautions that a thorough CBE may take up to 10 min.
CBE is heavily influenced by the technique of the examiner.
Breast self exam contraversy
evidence that is does not reduce mortality and may lead to higher rate of benign biopsies
but some say it promotes health awareness and advises clinicians to teach and review the patient techniques.
monthly BSE 5 to 7 days after onset of menses (when hormonal stimulation of breast tissue is low) can be taught to women as early as their 20s
BSE instructions on how to perform. page 427 in bates
again this is long. but it is an LO so i would read it over :)
you can do it!
lying supine:
- lie down with a pillow under your right shoulder. lace right arm behind your head.
- use finger pads of the three middl fingers on your left hand to feel for lumps in the right breast. finger pads are the top third of each finger
- firmly press enough to know how your breast feels, using firmer pressure for tissue closest to the chest and ribs. firm ridge in the lower curve of each breast is normal. if you’re not sure how hard to press talk with provider. or try to cop the at they do it
- press firm on he breast in an up and down or strip patient. also can us a circular or wedge pattern but be sure to use the same pattern every time. check the entire breast area form the underarm tot he sternum and the collarbone to the ribs below the breast. remember how your breast feels from month to month
- repeat exam on your left breast
- if you fin a mass or lump or skin change go see your doctor DUH
Standing:
- while standing in front of a mirror with your hands pressing firmly down on your hips , look at your breasts and say…. I am beautiful hahaha!…. but for real look at your breasts for changes in size shape contour or dimpling or redness or scaliness of nipple or breast skin.
- examine each underarm while sitting up or standing and with your arm only slightly raised so you can easily feel in this area. raising arm straight up tightens he tissue in this area and makes it hard to examine.
breast MRI screening criteria
annual screening with MRI and mammo for women at high lifetime risk of breast cancer, above 20%. woen at moderate lifetime risk (15% to 20%)urged to discuss MRI screening with their provider.
high risk (20% -25%) criteria and factors for breast cancer and therefore indicated to get a breast MRI include
(5)
- lifetime risk 20-25% using assessment tools
- BRCA1 or 2 mutation
- 1st degree relative (father, brother, with BRCA1 or 2 mutation but woman not tested)
- history of chest radiation between ages of 10-30
- high risk genetic syndrome in 1st degree relative with high risk syndrome
moderate risk (15-20%)
3
- lifetime risk of 15-20% using risk assessment tools
- history of breast cancer, ductal or lobular carcinoma in situ, atypical ductal or lobular hyperplasia
- extremely dense breasts or unevenly dense breasts on mammograms
tunnel for the vas deferens as if passes through the abdominal mucles
inguinal canal
triangular, slitlike structure palpable just above and lateral to the pubic tubercle.
external inguinal ring
aprrox 1 cm above the midpoint of the inguinal ligament.
internal inguinal ring
what is not palpable through the abdominal wall relating to anatomy of the groin
canal nor internal ring
how are inguinal hernias formed
loops of bowel force their way through weak areas of the inguinal canal and produce inguinal hernias.
what is another route for a hernia mass
femoral canal
develop at the internal inguinal ring, where the spermatic cord exits the abdomen
indirect inguinal herniea
arise more medially from weakness in the floor of the inguinal canal and are associated with straining and heavy lifting
direct inguinal hernias
more present as emergencies with bowel incarceration or strangulation
femoral hernias
INGIRECT HERNIA frequency, age, sex point of origin course examination during straining
frequency, age, sex: all ages, both sexes. often children, may be adults
point of origin: above inguinal ligament, near its midpoint (internal inguinal ring)
course: often into the scrotum
examination during straining: the hernia comes down the inguinal canal and touches the finertips
DIRECT HERNIA frequency, age, sex point of origin course examination during straining
frequency, age, sex: less common, men older than 40; rare in women
point of origin: above inguinal ligament, close to the pubic tubercule (near the external inguinal ring)
course: rarely into the scrotum
examination during straining: the hernia bulges anteriorly and pushes the side of the finger forward
FEMORAL HERNIAS frequency, age, sex point of origin course examination during straining
frequency, age, sex: least common, more common in women
point of origin: below the inguinal ligament, appears more lateral than an inguinal hernia. can be hard to differentiate from lymph nodes
course: never into scrotum
examination during straining: inguinal canal is empty
may be from psychogenic causes, especially if early morning erection is reserved; it may also reflect decreased testosterone, decreased blood flow in the hypogastric arterial system, impaired neural innervation, and diabetes
erectile dysfunction
common in young men. possible causes are medications, surgery, neurologic deficits, lack of androgen.
premature ejaculation
lack or orgasm with ejaculation is usually
psychogenic
reduced or absent ejaculation affects
middle aged or older men
less common
yellow penile discharge
gonorrhea
white penile discharge
non gonococcal urethritis from chlamydia
rash, tenosynovitis, monoarticular arthritis, even meningitis, not always with urogenital symptoms
disseminated gonorrhea
what are the 4 infections from oral-penile transmission
- gonorrhea
- chlamydia
- syphilis
- herpes
tight prepuce that cannot be retracted over the glans.
phimosis
tight prepuce that once retracted cannot be returned edema ensues
paraphimosis
inflammation of the glans
blanitis
inflammation of the glans and prepuce
balanoposthitits
congenital, ventral displacement of the meatus on the penis
hypospadias
profuse yellow discharge
gonococcal urethritis
scanty white or clear discharge
nongonococcal urthritis
what is the definitive diagnosis required for gonococcal urthiritis and nongonococcal urthrititis
gram stain and culture
induration along the ventral surface of penis suggests
and tenderness in the indurated area suggest
urethral stricture or possibly carcinoma
periurethral inflammation secondary to urrthral structure
4 things that a tender, painful scrotal swelling could be
- acute epididymitis
- acute orchitis
- torsion of the spermatic cord
- strangulated inguinal hernia
multiple tortuous veins in this area, usually on the left, may be palpable and even visable
varicocele
vas deferens if infected may feel thickened or beaded. cystic structure in the spermatic cord suggests
hydrocele of the cord
bulge that appears with straining
hernia
how does bowel sounds help differentiate between a hernia and a hydrocele
bowel sounds may be heard over a hernia
bowel sounds are NOT heard over a hydrocele
when a hernias contents cannot be returned to the abdominal cavity
incarcerated
when a hernias blood supply to the entrapped contents is compromised
stangulated
hernia with tenderness, nausea, vomiting and consider surgical intervention
a. strangulation OR
b. incarcerated
A. STRAGULATION
what is the most common form of cancer for men between ages 15-34
testicular carcinoma
what are three conditions that have to do with penile discharge or lesions
p.535
i. Peyronie’s disease
ii. Hypospadias
iii. Carcinoma of the penis
palpable, non tender hard plaques are found just beneath the skin, usually along the dorsum of the penis. the pt complains of a rooked, painful erection
Peyronie’s disease
an indurated module or ulcer that is usually non tender. limited almost completely to me who re not circumcised, it may be masked by the prepuce. any persistent penile sore is suspicious
Carcinoma of the penis
congenital displacement of the urethral meatus to the inferior surface of the penis. a groove extends from the actual urethral meatus to its normal location on the top of the glans
Hypospadias
may make the scrotal skin taut, seen in heart failure or nephrotic syndrome
scrotal edema
pitting edema
non tender, fluid filed mass within the tunica vaginalis. it transilluminates and the examining fingers can get above the mass within the scrotum
hydrocele
usually an indirect inguinal hernia, that comes through the external inguinal ring, so the examining fingers cannot get above it within the scrotum
scrotal hernia
testis is atrophied and may lie in the inguinal canal or the abdomen, resulting in an unfilled scrotum. no palpable testis or epididymis on the affected side. raises the risk for testicular cancer
cryptorchidism
testicular length usually
small testis
testis is acutely inflamed, painful, tender, and swollen
may be difficult to distinguish from epididymis
scrotum may be reddened
seen in mumps an other viral infections usually unilateral
acute orchitis
usually appears as a painless nodule
any nodule within the testis warrants investigation for malignancy
EARLY tumor or the testis
painless nodule spreads, may seem to replace the entire organ. the testicle characteristically feels heavier than normal
LATE tumor of the testis
a painless, movable cystic mass just above the testis suggest a _____________ or _____________. both transilluminate.
which contains sperm
and then which dose not,
are they clinically indistinguishable.
Spermatocele or cysts of the epididymis
which contains sperm: spermatocele
which does not contain sperm: cysts of epididymis
YES they are clinically indistinguishable.
an acutely inflamed epididymis is tender and swollen and may be difficult to distinguish from the testis. the scrotum may be reddened and the vas deferens inflamed. it occurs chiefly in adults, most commonly with chlamydia infection. coexisting urinary tract infection or prostatitis supports the diagnosis.
acute epididymitis
refers to varicose veins of the spermatic cord, usually found on the left. it feels like a soft :bag of worms” separate from the testis, and slowly collapses when the scrotum is elevated in the supine patient. infertility may be associated.
varicocele of the spermatic cord
twisting of the testicle on its spermatic cord produces an acutely painful, tender, and swollen organ that is retracted upward in the scrotum. the scrotum becomes red and edematous. there is no associated urinary infection. most common in adolescents, is a surgical emergency because of obstructed ciruclation
torsion of the spermatic cord
the chronic inflammation produces a firm enlargement of the epididymis, which is sometimes tender, with thickening or beading of the vas deferens
tuberculous epididymitits
Appearance: single or multiple papules or plaques of variable shapes; may be round, acuminate (or pointed), or thin and slender. may be raised, flat or cauliflower-like
causative organism: human papillomavirus (HPV), usually subtypes 6 and 11, carcinogenic subtypes rare
incubation: weeks to months, infected contact may have no visible warts.
can arise on penis, scrotum, groin, thighs, anus, usually asymptomatic, occasional itching and pain
may disappear without treatment
genital warts (condylomata aciminatata)
appearance: small scattered or grouped vesicles, 1 to 3 mm in size, on glans or shaft of penis. appear as erosions if vesicular membrane breaks.
Causative organism: usually herpes simplex virus 2 (Double stranded DNA virus)
incubation: 2 to 7 days after exposure
primary episode may be asymptomatic; recurrence usually less painful of shorter duration.
associated with fever, malaise, HA, arthraligias, local pain and edema, lymphadenopathy
what do you need to distinguish this from (2)
genital herpes simplex
need to distinguish from genital herpes zoster (usually in older patients with dermatomal distribution); candidiasis.
appearance: small red papule hat becomes chancre, or painless erosion up to 2 cm in diameter. base of chancre is clean, red, smooth and glistening; borders are raised and indurated. chancre heals within 3 to 8 weeks.
causative organism: Treponema pallidium (spirochete
incubation: 9 to 90dyas after exposure
may develop inguinal lymphendopathy within 7 days; lymph nodes are rubbery, non-tender, mobile
20-30% of pt develop secondary syphilis while chancre still present (suggest co-infection with HIV)
what do you need to distinguish from (3)
primary syphilis
distinguish from:
- genital herpes simplex
- chancroid
- granuloma inguinale from Klebsiiella granulomatis (rare in US; 4 variants, so difficult to identify)
Appearance: red papule or pustule initially, then forms a painful deep ulcer with ragged non indurated margins; contains necrotic exudate has a friable base
causative organism: Haemophilus ducreyi, an anaerobic bacillus
Incubation: 3 to 7 days after exposure
painful inguinal adenopathy; suppurative buboes in 25% of pts
what do you need to distinguish from? (4)
chancroid
need to distinguish from:
- primary sphyilis
- genital herpes simplex
- lymphoomogranuloma venereum
- granuloma inguinale from Kelbsiella granulomatis (both rare in the US).
its incidence is low (4 per 100,000 men) BUT it is the most common cancer of young men between ages 15-34
testicular cancer
when detected early how is the prognosis of testicular cancer
GREAT!
what are risk factors for testicular cancer (5)
- cryptorchidism (which confers a high risk for testicular carcinoma in the undescended testicle)
- history of carcinoma in contralateral testicle
- mumps orchitis
- inguinal hernia
- hydrocele in childhood
Instructions for testicular self exam…
just read it over
p.531
best performed after a warm bath or shower. the heat relaxes the scrotum and makes it easier to find anything unusual
- standing in front of a mirror, check for any swelling on the skin of the scrotum
- with the penis out of the way, examine each testicle separately
- cup the testicle between your thumb and fingers with both hands and roll it gently between fingers. one testicle may be larger than the other; that is normal, but be concerned about any lump or area of pain.
- find the epididymis, this is a soft, tubelike structure at the back of the testicle that collects and carries sperm, and is not an abnormal lump.
- if you find any lump, dont wait. see a doctor. the lump may just be an infection, but if it is cancer, it will spread unless stopped by treatment
who is at highest risk of HIV/AIDS
african american men and men having sex with men.
testing for HIV (what age)
people at high risk: how often?
universal testing from ages 18-64, regardless of risk
groups at high risk: annually
presence of any STI (hep B chancroid etc) warrants testing for
coinfection of HIV
what type of approach is beneficial in adopting for take a sexual history
client centered counseling!
key instructions for using a condom correctly and therefore reducing the risk of STI and HIV (4)
- using a new condom with each sex act
- applying the condom before any sexual contact occur
- adding only water based lubricants
- holding the condom during withdrawal to keep it from slipping off.
what age is HPV vaccination for boys and men recommended.. and what does it prevent
GARDASIL for boys and men ages 9-26 for prevention of genital warts
what are you looking for when you retract the prepuce (foreskin)?
chancres and carcinomas.
can see smegma: cheesy, whitish material may accumulate normally under foreskin
dome-shaped white or yellow papules or nodules formed by occluded follicles filed with keratin debris of desquamated follicular epithelium
epidermoid cysts
change in bowel pattern, especially stools of thin pencil-like shape, may warn of
colon cancer
blood in the stool may be from
4
polyps or cancer or from gastrointestinal bleeding or local hemroids
mucus may accompany
villous adenoma
positive answers to person or family history of colonic polyps or colorectal cancer and history of inflammatory bowel disease indicates
increased risk for colorectal cancer and a need for further testing and surveillance
may be indicated by itching, anorectal pain, tenesmus, or discharge or bleeding from infection or rectal abscess
causes include gonorrhea, chlamydia, lymphogranuloma veereum, receptive intercourse, ulcerations of herpes simplex, chancre or primary syphilis.
proctitis
itching in younger pts may be from
pinworms
genital warts may occur from (2)
HPV
condylomata lata in secondary syphilis
anal fissures can be found in (2)
proctitis
crohn’s disease
difficulty starting or holing back urine stream. flow is weak. frequent urination especially at night. pain and burning when urine is passes. blood in urine or semen or pain with ejaculation. frequent pain or stiffness in the lower back, hips, or upper thighs
symptoms suggest urethral obstruction as in benign prostatic hyperplasia (BPH) or prostate cancer, especially in men older than 70 years
AUA symptom index helps quantify
BPH severity and need for referral.
men feeling discomfort or heaviness in the prostate area at the base of the penis. malaise fever and chills
prostatitis
leading cancer diagnosed in US men and the second leading cause of death in men after lung cancer
prostate cancer
what are primary risk factors of prostate cancer
- age
- ethnicity
- family history
after age ____, the risk of prostate cancer increases sharply with each advancing decade
50
incidence rates for prostate cancer are higher in which ethinicity
african american men.
prostate cancer occurs at an earlier age and more advanced stage in african american men.
what is a strong risk factor to remember as you interview the patients.
family history
men with on affecte first degree relative namely a father or brother, are 2 or 3 more likely to have prostate cancer.
what is their a correlation between concerning prostate cancer and diet
maybe a higher risk if you have a high intake of saturated fat from diary and animal sources
what is the most common methods for screening for prostate cancer
prostate specific antigen (PSA)
and
digital rectal exam (DRE)
glycoprotein produced by prostate epithelial cells. it is a biomarker for early detection of prostate cancer, bit it has a number of limitations as a screening test.
PSA
PSA can be elevated in a number of benign conditions such as: (4)
- hyperplasia
- prostatitis
- ejaculation
- urinary retention
causing false positives
the common cutpoint for proceeding to biopsy is
4.0 ng.mL
PSA does not distinguish small volume indolent cancers from aggressive life-threatening disease
true/false
TRUE
low sensitivity of 59% with a specificity of 94%. detects tumors on the posterior and lateral aspects of the gland but misses the 25 to 35% of tumors arising in other areas.
DRE
prostate PSA testing should begin at age
50 average risk
45 high risk (single affected first degree relative)
40 at very high risk from two or more affected relatives
swollen, thickened, fissured perianal skin with excoriations
pruritus ani
tender, purulent, reddened mass with fever or chills accompanies an
anal abcess
sphincter tightness may occur with
anxiety
inflammation
scarring
sphincter laxity may occur with
neurologic diseases such as S2-4 cord lesions
fairly common
congenital
abnormality located in the midline superficial to the coccyx or the lower sacrum.
look for opening of sinus tract
opening may exhibit a small tuft of hair surrounded by a halo of erythema
generally asymptomatic except perhaps for slight drainage, abscess formation and secondary sinus tracts may complicate the picture
pilonidal cyst and sinus
dilated hemorrhoidal veins that originate below the pectinate line and are covered with skin. seldom produce symptoms unless thrombosis occurs. causes acute local pain that increases with defecation and sitting. tender swollen bluish ovoid mass is visible at the anal margin
external hemorrhoids (thrombosed)
enlargements of the normal vascular cushions located above the pectinate line. they are not usually palpable. sometimes, especially during defecation may cause bright red bleeding. may also prolapse through anal canal and appear as reddish, moist protruding masses
internal hemorrhoids (prolapsed)
happens when someone is straining for a bowel movement. this may happen to the rectal mucosa with or without the muscular wall.
it appears as a donut or rosette of red tissue.
involving only mucosa is relatively small and shows radiating folds. when the entire bowel wall is involved, it is larger and covered by concentrically circular folds
prolapse of the rectum
painful oval ulceration of the anal canal, found most commonly in the midline posteriorly, less commonly in the midline anteriorly. its long axis lies longitudinally. there may be a swollen sentinel skin tag just below it. gentle seperation of the anal margins may reveal the lower edge of the fissure. the sphincter is spastic; the examination is painful. local anesthesia may be required
anal fissure
inflammatory tract or tube that opens at one end into the anus or rectum and at the other end onto the skin surface or into another viscus. usually an abscess before it. look for these at opening or openings anywhere in the skin around anus
anorectal fistula
common.
variable in size and number
can develop on a stalk (pedunculated) or lie on the mucosal surface (sessile)
soft and may be difficult or impossible to feel even when in reach of the examining finger.
proctoscopy and biopsy are needed for differentiation of benign form malignant lesions
polyps of the rectum
asymptomatic
routine rectal examination is important for this reason!
firm, nodular rolled edges of an ulcerated cancer
cancer of the rectum
widespread peritoneal metastases from any sources may develop in the are of peritoneal reflection anterior to the rectum
firm to hard nodular
may be just palpable with the tip of the examining finger.
in women this metastatic tissue develops in the rectouterine pouch, behind the cervix and the uterus
rectal shelf
palpated through the anterior rectal wall
rounded
heart shaped structure approx 2.5 cm long
median sulcus can be felt between the two lateral lobes
only the posterior surface is palpable
anterior lesions including those that may obstruct the urthetha are not detectable by PE
normal prostate gland
presents with fever and urinary tract symptoms such as frequency, urgency, dysuria, incomplete voiding, and sometimes low back pain. the gland feels tender, swollen “boggy” and warm.
examine gently.
more than 80% infections are causes by E.coli, Enterococcus, and Proteus.
in men younger then 35 consider sexual transmission of Neisseria gonorrhea and chlamydia trachonatis
acute bacterial prostatitis
associated with recurrent urinary tract infections, usually from the same organism.
men may be asymptomatic or have symptoms of dysuria or mild pelvic pain.
prostate gland may feel normal, without tenderness or swelling
cultures of prostatic fluid show infection of E.coli usually
Chronic bacterial prostatitis
seen in 80% of symptomatic men who report obstructive or irritative symptoms on voiding but show no evidence of prostate or UTI.
PE findings are not predictable, but examination is needed to assess any prostate induration or asymmetry suggestive of carcinoma.
chronic pelvic pain syndrome
non-malignant enlargement of the prostate gland that increases with age, present in more tan 50% of men by 50 years.
symptoms arise both from smooth muscle contraction in the prostate and bladder neck and from compression of the urethra.
they may be irritative (urgency, frequency, nocturia), obstructive (decreased stream, incomplete emptying, straining), or both and are seen in more than one third of the men by 65 years.
affected gland may be normal in size, or may feel symmetrically enlarged, smooth, and firm through slightly elastic
there may be obliteration of the median sulcus and more notable protrusion into the rectal lumen
benign prostatic hyperplasia
suggested by an area of hardness in the gland.
a distinct hard nodule that alters the contours of the gland may or may not be palpable.
as it enlarges, it feels irregular and may extend beyond the confines of the gland.
the median sulcus may be obscured
hard areas in the prostate are not always malignant
may also result form prostatic stones, chronic inflammation and other conditions
cancer of the prostate
age of onset of menses
menarche
absence of menses for 12 consecutive months usually occurring between 48 and 55 years
menopause
bleeding ocurring 6 months or more after cessation of menses
postmenopausal bleeding
absence of menses
amenorrhea
pain with menses, often with bearing down, aching or cramping sensation in the lower abdomen or pelvis
dysmenorrhea
a cluster of emotional behavior and physical symptoms occurring 5 days before menses for 3 consecutive cycles
cessation of symptoms and signs within 4 days after onset of menses, and interference with daily activity
premenstrual syndrome (PMS)
bleeding between menses, includes infrequent, excessive, prolonged, or postmenopausal bleeding
abnormal uterine bleeding
when do girls usually begin to menstruate
between ages of 9 and 16
how long does it take for periods to get into a regular pattern
up to 1 year
how long does a flow usually last
3-7 days
vocab work for last menstrual cycle and then the term for the one before that
last menstrual period (LMP)
prior menstrual period (PMP)
results from prostaglandins production during the luteal phase of the menstrual cycle, when estrogen an progesterone levels decline
primary dysmenorrhea
causes of this are:
endometriosis, adenomyosis, pelvic inflammatory disease, endometrial polyps
causes of secondary dysmenorrhea
causes of this are:
low body weight (from malnutrition and anorexia nervosa, stress, chronic illness, hypothalamic-pituitary-ovarian dysfunction)
casues of secondary amenorrhea
_________ suggests cervical polyps or cancer, or in an older women, atrophic vaginitis
postcoital bleesing
what is the issue with giving estrogen to women in menopasue
helps with symptoms BUT increases other heath hazards
absence of EVER initiating periods
primary amenorrhea
cessation of periods after they have been established
pregnancy, lactation, menopause: physiologic forms
secondary amenorrhea
less than 21-day interval between menses
polymenorrhea
infrequent bleeding
oligomenorrhea
excessive flow
menorrhagia
intermenstrual bleeding
metorrhagia
occurs between ages of 48-55/
peaks at about 51
cessation of menses for 12 months
ovaries stop producing estriadol or progesterone and estrogen levels drop significantly
pituitary secretion of LH and FSH elevted
menopause
causes of postmenopausal bleeding
endometrial cancer
hormone replacement therapy
uterine and cervical polyps
The Gravida Para Notation
G stands for?
P stands for?
G: gravida, or total # of pregnancies
P: para, or outcomes of pregnancies. after P, you will often see the notations F (full term, P (premature, A (abortion), and L (living child)
pap screening ages
21-65
several screening guidelines
first screen: 21 yo
women ages 21-29: every 3 years with cytology
women ages 30-65: screen every 3 years with cytology if three consecutive negative screening tests, no history of invasive carcinoma from CIN 2 or CIN 3, and no risk factors such as HIV infection, immunocompromised, or exposure in utero to diethylstilbestrol or with cytology and HPV testing every 5 years.
women with hysterectomy: discontinue screening if hysterectomy for benign indictions and no prior history of high grade CIN.
if hysterectomy for CIN2, CIN3 or cancer and cervix removed, continue annual screening for 20 years after postsurveillance period.
women greater than 65: discontinue
when does the CDC recommend gardicil for routine vaccination in girls?
before their first sexual contact , usually ages 11 or 12 but possibly starting at age 9
how many dose series is gardacil
three dose series
what HPV does gardicil target
16, 18, 6, 11
and prevents most cervical cancer
vaccine also reduces risk of anogenital warts, invasive anogenital cancers, and vulvar and vaginal cancer
this is recommended for girls and women ages 13-26 if they have not had all three doses
catch up vaccination
what are the men recommendation for gardicil
boys and men ages 9 through 26, ideally before their first sexual contact, since it prevents genital warts.
which vaccine is NOT recommended for boys and men
bivalent vaccine which targets HPV 16 and 18
in women three symptoms merit special attention for ovarian cancer what are they?
- abdominal distension
- abdominal bloating
- urinary frequency
family history
presence of the BRCA1 and BRCA 2 have a lifetime risk of 39% to 46% and 12 to 20%
over 90% of ovarian cancers appear to be random
risk is decreased by use of oral contraceptives, pregnancy, and history of breast feeding
risk factors for ovarian cancers
what about CA-125 testing
this is neither sensitive nor specific
mons pubis labia majora and minora urethral meatus, clitoris vaginal introitus perineum
external examination areas
vagina, vaginal walls cervix uterus, ovaries pelvic muscles rectovaginal walls
internal examination areas
avoids intercourse, douching, or use of vaginal suppositories for 24 to 48 hours before exam
empties bladder before exam
lies supine, with head and shoulders elevated, arms at sides or folded across chest to enhance eye contact and reduce tightening of abdominal muscles
tips for successful exam for the patient
obtains permission, selects chaperone
explains each step of exam in advance
drapes pt from midabdomen to knees , depresses drape between knees to provide eye contact with pt
avoids unexpected or sudden movements
chooses a speculum of correct size
warm speculum tap water
monitors comfort of examination by watching pt
uses excellent gentle technique, especially when inserting the speculum
tips for successful pelvic exam for examiner
which speculum is usually most common for a sexually active women
medium pedersen speculum
pt with small introitus should have which speculum
narrow bladed pedersen speculum
the graves specula are best suited for which type of women
parous women with vaginal prolapse
excoriations or itchy, small, red maculopapules
look for nits or lice at bases of pubic hairs
pediculosis pubis (lice or crabs)
check for this when menarche seems unduly late in relation to development of a girls breasts and pubic hair
imperforate hymen
plastic brush tipped with a broom-like fringe for collection of single specimen containing both squamous and columnar epithelial cells. rotate the tip of the brush in the cervical os, in a full clockwise direction, then place the sample directly into preservatives so that the laboratory can prepare the slide (liquid based cytology)
used to test for chlamydia and gonorrhea
cervical broom
place longer end of the scraper in the cervical os. press turn and scraping in a full circle, making sure to include transformation zone and squamocolumnar junction. smear on glass slide.
cervical scrape
roll it between your thumb and index finger, clockwise and counterclockwise. remove the brush and to pick up the slide you have set aside. smear slide with a brush using gentle painting motion to avoid destroying any cells.
ENDOCERVICAL BRUSH
cervical motion tenderness and or adnexal tenderness suggest
pelvic inflamm disease
ectopic preg
appendicitis
uterine enlargement suggests
pregnancy
uterine myomas (fibroids)
malignancy
nodules on uterine surface suggest
myomas
most common hernia in women
indirect inguinal hernia
and next being femoral hernia
small, firm, round cystic nodule in the labia suggests an epidermoid cyst. these are yellowish in color. look for dark punctum marking that blocked opening of the gland
epidermoid cyst
warty lesions on the labia and within the vestibule suggest condyloma acuminatum. these result from infection with human paillomavirus
venereal wart (condyloma acuminatum) genital warts
shallow, small, painful ulcers on red bases . initial infection may be extensive, as shown. recurrent infections usually are confined to a small local patch
genital herpes
a firm, painless ulcers
because most in women develop internally, they often go undetected
syphilitic chancre (syphilis chancre)
ulcerated or raised red vulvar lesion in an elderly women may indicate this
carcinoma of the vulva
slightly raised, round or oval, flat topped papules covered by a gray exudate suggest condylomata lata. these constitute one manifestation of secondary syphilis and are contagious
secondary syphilis (condyloma latum)
causes of this include trauma, gonococci anaerobes like bacteroides and peptostreptococci, and chlamydia trachomatis.
acutely, it appears as a tense, hot, very tender abscess.
look for pus coming out of the duct or erythema around the duct opening.
chronically a nontender cyst is felt.
it may be large or small
bartholin’s gland infection
cause: trichomonas vaginalis (protazoan) no always acquired sexually
discharge: yellowish green or gray, possibly frothy, often profuse and pooled in the vaginal fornix, may be malodorous
other symp: pruritius, pain on urination, dyspareunia
vulva and vaginal mucosa: vestibule and labia minora may be reddened. vaginal mucosa may be diffusively reddened, with small red granular spots or petechiae in the posterior fornix. in mild cases the mucosa looks normal
lab eval: scan saline wet mount for tichonmonads
trichomnoal vaginitis
cause: Candida albicans (yeast) many factors predispose, including abx
discharge: white curdy, thin but usually thick, not as profuse as in trichomonal infection, no malodorous
other symptoms: pruruitus, vaginal soreness, pain on urination, dyspareunia
vulva and vaginal mucosa: the vulva and even the surrounding skin are inflamed and sometimes swollen. vaginal mucosa red, with white patches of discharge. mucosa may bleed when these patches are scraped off. mild cases: mucosa normal
lab eval: scan potassium hydroxide preparation for branching hyphae of candida
candidal vaginitis
cause: bacterial overgrowth prob from anaerobic bacteria, may be transmitted sexually
discharge: white or gray, thin, homogenous, malodorous, coats the vaginal walls, usually not profuse, may be minimal
other sym: unpleasant fishy or musty genital odor
vulva and vaginal mucosa: vulva usually normal. vaginal mucosa usually normal
Lab eval: scan saline wet mount for clue cells, sniff for fishy odor after apply KOH (“whiff test”) vaginal secretions with PH>4.5
bacterial vaginosis
bulge of the upper two thirds of the anterior vaginal wall, together with the bladder above it. results from weakened supporting tissues
cystocele
herniation of the rectum into the posterior wall of the vagina, resulting from a weakness or defect in the endopelvic fascia.
rectocele
results from weakness of the supporting structures of the pelvic floor and is often associated with a cystocele and rectocele. in progressive stages the uterus becomes retroverted and descends down that vaginal canal to the outside
what are the 3 stages of this
prolapse of the uterus
first degree prolapse: the cervix is still well within the vagina
second degree: it is at the introitus
third degree: (procidentia) the cervix and vagina are outside the introitus
with increasing estrogen stimulation during adolescence all or part of the columnar epithelium is transformed into squamous epithelium by a process termed: metaplasia. this change may block the secretions of columnar epithelium and causes ______.
nabothian cysts
usually arises from the endocervical canal, becoming visible when it protrudes through the cervical os. it is bright red, soft, and rather fragile. when only the tip is seen, it cannot be differentiated clinically from a polyp originating in the endometrium. they are benign but may bleed.
cervical polyp
precancerous condition in which abnormal cell growth occurs on the surface lining of the cervix or endocervical canal, the opening between the uterus and the vagina. It is also called cervical intraepithelial neoplasia (CIN). Strongly associated with sexually transmitted human papillomavirus (HPV) infection, is most common in women under age 30 but can develop at any age.
usually causes no symptoms, and is most often discovered by a routine Pap test. The prognosis is excellent for women who receive appropriate follow-up and treatment. But women who go undiagnosed or who don’t receive appropriate care are at higher risk of developing cervical cancer.
dysplasia
begins in an area of metaplasia. earliest stages it cannot be distinguished from a normal cervix. later stages: an extensive, irregular, cauliflowerlike growth may develop. early frequent intercourse, multiple partners, smoking, and infection with HPV increase the risk for this
carcinoma of the cervix
produces purulent yellow drainage from the cervical os, usually from chlamydia trachomatis, neisseria gonorrhoeae or herpes infection. these infections are sexually transmitted and may occur without symptoms or signs
mucopurulent cervicitis
very common benign uterine tumors. may be single or multiple and vary greatly in size, occasionally reaching massive proportions. they feel firm, irregular nodules in continuity with the uterine surface. occasionally, projecting laterally can be confused with an ovarian mass, a nodule projecting posterioly can be mistaken for a retroflexed uterus. project toward the endometiral cavity and are not palpable, although they may be suspected because of enlarged uterus
myomas of the uterus
FIBROIDS
may be detected as adnexal masses on one or both sides. later, they may extend out of the pelvis. tend to be smooth and compressible, tumors more solid and often nodular. uncomplicated ones are not usually tender
ovarian cysts
rests on exclusion of several endocrine disorders and 2 of the 3 features listed: absent or irregular menses; hyperandrogenism; and confirmation of polycystic ovaries on ultrasound. obesity and absence of lactation outside pregnancy or childbirth are addiotnal predictors
polycystic ovary syndrome
relatively rare and usually presents at an advanced stage/ symptoms include: pelvic pain, bloating, increased abdominal size, and urinary tracy symptoms, often there is a palpable ovarian mass. currently there are no reliable screening tests. a strong family history is an important risk facto but occurs in only 5% of cases
ovarian cancer
pregnancy spills blood into the periotoneal cavity, causing severe abdominal pain and tenderness. guarding and rebound tenderness are sometimes associated. a unilateral adnexal mass may be palpable, but tenderness often prevents its detection. faintness, syncope, nausea, vomiting, tachycardia, and shock may be present, reflecting the hemorrhage. there may be prior history of amenorrhea or other symptoms of pregnancy
ruptured tubal pregnancy
most often a result of sexually transmitted infection of the fallopian tubes or the tubes and ovaries. it is caused by neisseria gonorrhoeae, chlamydia trachomatis and other organisms. acute disease is associated with very tender, bilateral adnexal masses, although pain and muscle spasm usually make it impossible to delineate them. movement of the cervix produces pain. if not treated, a tubo-overian abscess or infertility may ensue.
infection of the fallopian tubes and ovaries may also follow delivery of a baby or gynecologic surgery
pelvic inflammatory disease
daughters of women who took this during pregnancy are at great increased risk for several abnormalities like:
- columnar epithelium that covers most or all of the cervix
- vaginal adenosis
- circular collar or ridge of tissue, varying shapes, between the cervix and vagina. much less common is an otherwise rare carcinoma of the upper vagina
fetal exposure to DIETHYLSTILBESTROL (DES)
bilateral transverse cervical os
stellate cervical os
unilateral transverse cervical os
types of lacerations from delivery
p.572 in bates
normal shapes to the cervical os
- oval
2. slitlike
when the entire anterior vaginal wall, toegther with the bladder and urethra, is involved in the bulge
a groove sometimes defines the border between urethrocele and cystocele but not always present
cystourethrocele
small, red benign tumor visible at the posterior part of the urethral meatus. occurs chiefly in postmenopausal women and usually causes no symptoms. sometimes a carcinoma of the urethra is mistaken for this. to check, palpate the uretha through the vagina for thickening, nodularity, or tenderness, and feel for inguinal lympadenopathy
urethral caruncle
forms a swollen red ring around the urethral meatus. usually occurs before menarche or after menopause. identify the urethral meatus at the center of the swelling to make this diagnosis
prolapse of the urethral mucosa
important topics for health promotion and counseling (7)
nutrition weight gain exercise substance abuse domestic violence prenatal lab screenings immunizations
Nutrition
what types of things should you do?
idk this is a learning objective but so vague
pay attention to inadequate nutrition as well as obesity
take a diet history, review examination and lab findings (BMI, hematorcrit for anemia), recommend a multivitamin (0.4 to 0.8 folic acid, 30 mg of iron, and a variety of other routine vitamins), caution the patient about food to avoid (unpasteruized dairy products, soft cheeses, raw eggs, delicatessen meats due to listeria and salmonella and toxoplasmosis, large about of vit A can be toxic, large sea going fish), make nutritional plan (increase intake by only 300 cal per day)
weight gain
again vague… idk just read the card hahaah
closely monitored during pregnancy
underweight: BMI 30
how many minutes of exercise shoudl a pregnant women engage in for most days of the week
30 min
should you initiate exercise in pregnancy
nahhh not really, do a special program if you do
aka get you buttttt to the gym and get into a routine so that when you do get pregnant you can just keep working out safely
after first trimester what should women not due relating to exercise?
exercise in the supine position (compresses the inferior vena cava)
substance abuse in pregnancy
again vague
universal screenings for this can help address these topics
try to stay judgement free with your approach
tobacco: low birth weights
alcohol: fetal alcohol syndrome: neurodevelopmental disorder
illicit drugs: dont use em
abuse of prescription drugs: ask about unusual narotics, stimulants, benzo, others
domestic abuse
universal screening of all women for domestic violence without regard to socioeconomic status
prenatal lab screenings in pregnancy
initial screening: what is part of it?
what about the timed screenings?
initial standard prenatal screening panal includes blood type and Rh, Ab screen, CBC, H and H, platelet count, rubella titer, syphilis test, hepatitis B surface Ag, HIV test, STI screen for gonorrhea and chlamydia, and UA with culture
timed screenings include: oral glucose tolerance test for gestational diabetes around 24 weeks, and a vaginal swab for group B streptococcus between 35 and 37 weeks
all other screening is independent on the patient
immunizations in pregnancy
should be up to date on tetanus.
flu vaccine indicated in second or third trimester during flu season
these are safe for pregnancy: pneumococcal, menigococcal, Hep B
NOT safe during pregnancy: MMR, polio, varicella, but women should have rubella titers drawn during pregnancy and be immunized after birth if found to be non immune.
Rho (D) immunoglobulin or RhoGAM should be given to all Rh-negative women at 28 weeks gestation and agin within 3 days of delivery to prevent sensitization to an rH positive infant
should take into consideration medical, nutritional, psychosocial, cultural and educational needs of patient and her family
plan of prenatal care
secreted in to maternal circulation after implantation, which occurs 6-12 days after ovulation
hCG = human chorionic gonadotropin
Best time to take Home pregnancy test?
1 week after missed period
what will urine HCG show
Urine hCG 20-50 int units/L verses serum hCG 5-10 int units/L
what do you factor in when choosing and at home pregnancy test
factor in duration of missed menses, need for accuracy, convenience and cost
what is the schedule for prenatal visits: what gestation week
How many weeks though do they say normal pregnancy is?
1st visit – usually at ~8 weeks gestation
Every 4 weeks until 28 weeks gestation
Every 2 weeks until 36 weeks gestation
Weekly from 36 weeks gestation until delivery
40 weeks normally
38-42 weeks
what is frequency of follow up determined by
Frequency of follow-up visits determined by individual needs of woman and her risks (more frequent visits – “high risk” due to medical and/or obstetric history, extremes of reproductive age, multiple gestation)
Enable health care provider to:
Assess well-being of the woman and her fetus
Provide ongoing, timely and relevant prenatal education
Complete recommended health screening studies and review results
Detect medical and psychosocial complications and institute indicated interventions
Reassure the woman
all the goals of the prenatal visits
if someone thinks they’re pregnant you get a hitory: what are the three things that are asked in this history
- LMP/amenorrhea
- Contraception/sexual history
- Symptoms of pregnancy
what are some symptoms of pregnancy
morning sickness
breast tenderness/fullness urinary frequency
fatigue
Personal & demographic info (i.e., occupation) Past obstetrical history Personal and family medical history Past surgical history Genetic history Menstrual and gynecological history Current pregnancy history Psychosocial information
more history taking….
i know you could recognize these on multiple choice!
Calculating estimated due date
measuring crown to rump length
Gravida para
G = gravida (# total pregnancies) P = para (# delivered pregnancies)
what can parity further break down to
T= term deliveries P = preterm deliveries A = abortions (spontaneous & therapeutic) L = living children
“32-year-old G3P1102 at 18 weeks gestation determined by LMP presents…”
Physical exam
Vital signs (weight, height, BMI, BP)
General
HEENT (including dentition)
Neck (including thyroid)
Breasts – fuller, tender due to ↑ vascularity & glandular hyperplasia, areola darkens, +/- colostrum
Heart
Lungs
Abdomen
Extremities
Skin
Lymph nodes
Pelvic (including speculum & bimanual exam)
Rectum
physical exam of the first prenatal visit
PART OF PELVIC EXAM
chadwicks sign
bluish discoloration of cervix due to increased blood flow
uterus soft, globular
plum: at how many weeks
orange: how many weeks
grapefruit: how many weeks
plum: 6-8 weeks gestation
orange: 8-10 weeks
grapefruit: 10-12 weeks
pre-pregnancy weight related to what your weight gain should be!
underweight (BMI)
where does the weight go?
how much in the: breasts baby placenta uterus amniotic fluid
your blood
your protein and fat storage
your body fluids
total weight gain:
breasts: 1-2 lb
baby: 6-8 lbs
placenta: 1-2lbs
uterus: 1-2 lbs
amniotic fluid: 2-3 lbs
your blood: 3-4 lbs
your protein and fat storage: 8-10lbs
your body fluids: 3-4 lbs
total weight gain: 25-35 lbs
nutrition counseling from the ppt and not bates like above
2 recommendations….
MVI once daily (w/ 0.4-0.8 mg of FOLIC ACID)
Avoid certain fish, cheese, raw milk & meat
exercise counseling from the ppt and not bates like above
2 recommendations….
Avoid supine position in 3rd trimester (Supine position – puts pressure on inferior vena cava– this can lead to decreased floor to placenta to baby)
Avoid contact sports or risky activities
substance abuse counseling from the ppt and not bates like above
what is goal
Abstinence is goal
domestic violence
counseling from the ppt and not bates like above
Universal screening (abuse increased in pregnancy)
immunizations counseling from the ppt and not bates like above
Flu shot (NOT NASAL), Tdap, RhoGAM
If rubella nonimmune, vaccinate AFTER pregnancy
what do you always have to discuss with genetic screening
always dicuss informed consent
most commongenetic disorder screened for ( 5)
Down syndrome (trisomy 21) Hemoglobinopathies Cystic fibrosis Fragile X Ashkenazi Jewish population
when is Fetal cfDNA in maternal blood drawn
and what id cfDNA?
drawn at ≥9 weeks of gestation
cfDNA = cell-free DNA, checks for trisomy 21, 18, 13 & sex chromosome aneuploidies
when is Chorionic villus sampling (CVS) drawn
10-14 weeks gestation
when do you do Amniocentesis
15-17 weeks gestation
bp changes during pregnancy
MORE TO COME AFTER LECTURE….okay idk what she wants us to know from this slide…
SLIDE 16
what does the urine dipstick find: 3 findings
Protein
Glucose
Ketones
Physical exam:
Vital signs (weight, BP)
Urine dipstick, if indicated
Fundal height (cm)
Fetal presentation
FHR and fetal movement
Cervix exam (dilation, effacement, station)
LE edema
subsequent prenatal visits
First trimester H&P
history
physical exam
labs/imaging
History:
Vaginal bleeding
Physical exam:
Vital signs
Head-to-toe exam including pelvic
FHR (start @ 10-12 wks)
Labs/Imaging : GET ALL OF THESE LABS AND ULTRASOUNDS AT THE FIRST PRENATAL VISIT!!!!
STI screening – gonorrhea, chlamydia, HIV, syphilis & hepatitis B
Pap, if indicated
Labs: genetic screening, CBC, blood type and Rh, antibody screen, rubella & varicella immunity, UC
At-risk:
TSH (if she has thyroid issue need to get this),
hgbA1c (gesttational diabetes around 26 weeks but if she is obese and she has risk factors for diabetes want to do this right at the first visit),
HCV (hoffman says she has a low threshold for when to get hep C testing) ,
HSV (if they have genital herpes needs to be put on suppressive therapy at 36 weeks so she can deliver vaginally!)
Ultrasound(transvaginal)
-heart beat at 10 week gestation
this test checks for asymptomatic bacteriuria and treat if >100,000 CFU
UC
Rh-negative mother who delivers a Rh-positive baby are at risk of developing
Rh-positive babies of these mothers are at risk of developing
antibodies (“sensitized”).
hemolytic anemia
when do you screen for RH factor
first visit
if mother is RH negative
check antibody screen & give RhoGAM (immune globin) at 26-28 weeks gestation & after delivery
Second trimester H&P
history:
pE:
labs/imaging:
History: Fetal movement (“quickening” ~18-22 wks, external palpation ~24 wks+/28 )
Vaginal bleeding
Uterine contractions (PTL)
Physical exam:
Vital signs
Fundal height
FHR
Labs/Imaging:
1-hr GDM screen (24-28 wks)
–> 1 hour glucose test is screening
–> 3 hours glucose test is diagnostic for gestational diabetes
CBC (√ hgb & platelets)
Rhogam if Rh- (28 wks)
Ultrasound – √ anatomy
how do you measure the fundal height?
from where to where?
when do you start doing this?
where do the lines start and stop on the belly
Measure length (cm) from pubic symphysis to fundus
Start @ 20 weeks gestation
start down by pubic symphasis at 12-14 weeks then 16 weeks then belly button is 20 weeks then 24 weeks then 28 weeks
then 32 weeks and 36 weeks is right under the breasts
slide 22
what is a normal fetal HR?
Normal FHR = 120-160 beats per minute
Third trimester H&P
history
PE
labs/imaging
History: Fetal movement Vaginal bleeding Uterine contractions (labor) *****Leaking*****(could have risk for infection) *****Preeclampsia s/s******
Physical exam: Vital signs Fundal height FHR *****Fetal presentation****** ******Cervix exam*********
Labs/Imaging:
Group B strep (36 wks)
Hgb (hemoglobin) (36 wks)
three types of fetal breech presentation
wheat is the name of the maneuver
NOT RECOMMENDED TO DELIVER BREECH IF WE KNOW THIS!
complete breech: both legs curled up
incomplete breech: one leg up straight other leg curled
frank breech: both legs straight up
DEPENDING ON THE BREECH POSITION DEPENDS ON HOW WELL THE MANEUVER WILL WORK TO MOVE THEM AROUND
external cephalic version (ECV) is the name of the maneuver to move them out of breech position
vertex presentation
head first
leopold maneuvers
4
4 maneuvers used to determine fetal position, beginning in 2nd trimester, accuracy greatest after 36 weeks gestation
1st maneuver = determine what fetal part is located at the fundus or “upper fetal pole”
2nd maneuver = feel for fetal back while placing hands on sides of maternal abdomen
3rd maneuver = palpate presenting fetal part at the “lower fetal pole” distinguishing head from buttock
4th maneuver = check flexion/extension of the fetal head
cervix exam: 5 different things you are examining
- Dilation (0-10cm)
- Effacement (0-100%)
- Fetal station (-3 to +2)
- Consistency (firm, medium, soft)
- Position (posterior, middle, anterior)
What is cervical effacement?
steps of effacement and dilation… how they are related?
cervical effacement: length of the cervix: so when babies head pushes down the length of the cervix shortens… and this occurs at the same time as the dilation.
- cervix not effaced (long cervix) or dilated
- cervix is 50% effaced and not dilated
- cervix is 100% (compltly thinned out cervix) effaced and dilated 3cm
- cervix is fully dialted to 10 cm
Fetal station
what is this?
on either side of cervix you can feel pelvic ring.. when you feel top of babies head and it is right at ring that is 0 station
if it is 3 cm above the ring it is at -3 station
if babies head is pushing through pelvic ring then going into positive cm.
-3 to +3
0 station midway between ischial spines
slide 31 has a good picture
Heartburn Urinary frequency Vaginal discharge Constipation Hemorrhoids Backache Nausea and/or vomiting Breast tenderness/tingling Fatigue Lower abdominal pain Abdominal striae Uterine contractions Loss of mucous plug Edema
Common complaints in pregnancy
HEENT: facial edema in preeclampsia conjunctival pallor in anemia nasal congestion & nose bleeds gingival enlargement with bleeding dentition
Neck:
modest symmetric thyroid enlargement normal
Heart: PMI – upward and leftward (4th intercostal space) venous hum (due to ↑ blood flow thru normal vessels)
Lungs:
elevated diaphragm with percussion
Breasts:
marked venous pattern, darkened areolae, and prominent Montgomery’s glands
nodularity, possible colostrum
Abdomen:
striae and linea nigra
uterine contractility – PTL/labor vs BHC
fundal height, FHR
round ligament pain seen which normally tries to hold uterus in place
GU:
relaxation of introitus and enlargement of labia & clitoris
labial varicosities
cystoceles, rectoceles and uterine prolapse
speculum – cervix friable and leukorrhea may be normal
bimanual – uterus (contour, size)
anus – hemorrhoids
Extremities:
varicose veins
dependent vs non-dependent edema and symmetry
Skin/hair :
acne
hair changes
melasma and hirsutism (mild – on face, abdomen and extremities)
Physical exam findings in pregnancy
when is the postnatal visit performed?
what is one of the exams you have done and why?
what do you offer to your patient and what are some examples of that?
Performed at ~6 weeks postpartum
Pelvic exam – confirm uterus is normal size
Offer support/counseling: Menses resumes Family planning Screen for post partum depression Breastfeeding/return to work Sexual activity Weight loss guide Stress management – relationship, parenting, financial, job, body image
if fundal weight is 4 cm more than expected consider
multiple gestations
large fetus
extra amniotic fluid
uterine leiomyoma
cervix position is either
posterior, middle or anterior
when do you start birth control again after pregnancy
6 weeks
