Chapter 17-20 outline Flashcards
Breast tissue extends from the (blank) ribs to the (blank) ribs.
2 to 6
The breast tissue begins at what margin to what line?
sternal margin to the midaxillary line
What is the breast composed of?
glandular and fibrous tissue, subcutatneous and retromammary fat
Breasts are divided into how many segments?
5 segments, 4 quadrants and a tail of Spence.
What lymphatics drain skin? what drain mammary lobules?
superficialdeep
(blank) nodes are more superficial and accessible to palpation when enlarged.
axillary
What is the start of breast development called?
thelarche
What is an early sign of puberty?
thelarche
(blank) is a scale of physical development in children, adolescents and adults. The scale defines physical measurements of development based on external primary and secondary sex characteristics, such as the size of the breasts, genitalia, testicular volume and development of pubic and axillary hair.
Tanner’s 5 stages
In pregnant women. what proliferates and increase extensively in size and number causing breasts of enlarged size?
lactiferous ducts and alveoli
mammary tissue is in direct contact with the (blank) lymph node
axillary
When will areolae become more deeply pigemented and diameter increase. Nipples are more prominent, darker and erectile.
pregnancy
When will mammary vascularization increase?
pregnant women
Small amounts of (blank) are secreted after delivery.
colostrums (first milk)
When does milk production begin?
2-4 days after delivery
Breasts become full and dense as (blank) fills.
lactiferous ducts
Breast engorgement can result from what?
milk production, tissue edema, and delay in effective ejection
When does glandular tissue atrophy gradually and get replaced by fat?
after menopause
When does relaxation of suspensory ligaments occur and tissue changes cause breasts to hang more loosely?
In older adults after menopause
Where does scapular, brachial, intermediate nodes toward axiallary nodes drain from?
superficial upper outer quadrant
Where does internal mammary chain toward opposite breast and abdomen drain from?
superficial medial portion
The deep upper arm of the breast drain to which nodes?
lateral axillary nodes (brachial)
The retroareolar are of the breast drains to which nodes?
interpectoral nodes into the axillary chain (rotter)
The areola and nipple drain to which nodes?
midaxillary, infraclavicular, and supraclavicular nodes
What is this important for?o OLDCARTS o Relationship to menses – timing and severity o unilateral or bilateral, associated lumps or masses, discharge from nipple, recent injury to breasts, medications (hormones
Breast discomfort/pain
What is this important for?o Length of time since it was first noticed. Changes in lump with size, character and relationship to menses. Is it always present or does it come and go. o Association with tenderness or pain, dimpling, change in contour, nipple discharge, retraction, tender lymph nodes, medications (hormones)
Breast mass or lump
What is this for?o Spontaneous or provoked, unilateral or bilateral, gradual or sudden onset, duration, color, odor, consistency, and amount o Association with nipple retraction, lump/mass, pain/tenderness, relationship to menses, recent injury to breasts, medications
nipple discharge
What is this for?o Hx of hyperthyroidism, testicular tumor, Kleinfelter syndromeo Medications, antiandogens or gonadotropin-releasing hormone analogs, illicit/recreational drugs (anabolic steroids, marijuana)
Breast enlargement in men
What is the most common cancer among women in the US?
breast cancer
When do you start mammograms?
at 40 years of age
If women are at high risk for cancer, what do you do?
give MRI
What are the 5 D’s related to nipple
Discharge, depression, discoloration, dermatologic changes, deviations
What are these important for:• Previous breast disease, family hx of genetic mutations such as BRCA1 and BRCA2, hx of other cancers (ovarian, endometrial, colorectal), hx of hereditary cancer syndromes, surgeries, risk factors for breast cancer, any changes in breast characteristics, previous mammograms and results. • Menstrual hx, pregnancy hx, lactation, breast feeding, menopause, use of hormonal medications (ex: BCP, hormone therapy in post menopausal women)
Past medical history
What are these factors for?• Age, amount of caffeine intake, use of alcohol, use of anabolic steroids or marijuana • Breast self examination• Use of breast support with exercise
Personal and social history for breast exams
What are the 2 parts of the physical breast exam?
inspect and palpate
When inspecting the breast for the physical exam, how will you do it?
patient sitting, arms resting at sides, reinspect w/ patient seated w/ arms over head, reinspect seated with hands on hips and shoulders rolled forward, reinspect seated with leaning forward.
When looking at the breasts what are you looking for?
size, symmetry, contour, retractions, dimpling, skin color, texture, venous patterns and lesions • Retraction and dimpling – carcinoma • Peau d’orange – advanced or inflammatory carcinoma • Unilateral venous dilation – possible malignancy
When looking at the nipples and areolae what are you looking for?
Compare for size, shape, color, smoothness, inversion, eversion or retraction Supernumary nipples – usually present along the embryonic mammary ridge (milk line)
What are the steps of palpation?
chest wall sweepbimanual digital palpationpalpate for lymph nodespalpate breast tissuedepress nipple inward in to the well behind areolaNipple compression if patient complains of nipple discharge.
How should the patient lay for a palpation?
supine
Who does this happen in? Breasts are enlarged temporarily due to passively transferred maternal estrogen. Rarely more than 1-1.5 cm in diameter and usually disappears within 2 weeks
Infants
Who does this happen in? Normal for breasts to develop asymmetrically in females Many males may have transient unilateral or bilateral subareolar masses at puberty. This is normal and usually disappears within a year. Gynecomastia is also common in males at puberty. Usually temporary, benign and resolves spontaneously.
adolescents
Who does this happen in? Experience sensation of fullness with tingling, tenderness, and enlargement. Important to have adequate breast support. Breasts feel lobular because of hypertrophy of mammary alveoli and dilated subcutaneous veins may be more prominent
Pregnant women
Who does this happen in? Engorged breasts may be hard, warm, shiny, and painful. Clogged milk ducts are common which may result in mastitis. Examine nipples for signs of irritation or crackling
lactating women
Who does this happen in? May appear flattened, elongated and suspended more loosely. Feel more granular rather than lobular. Nipples are smaller and flatter.
Older adults
Is nipple discharge always bad?
no
What are the components of the external genitalia?
mons pubis, labia majora, labia minora, clitoris, vestibular glands, vaginal vestibule, vaginal orifice, and uerthral opening
Vestibule has 6 openings, what are they?
urethra, vagina, two ducts of Bartholin glands, and two ducts of Skene glands
What are the parts of?o Anterior wall of vagina is separated from bladder and urethra by vesicovaginal septum. Posterior wall of vagina is separated from the rectum by the rectovaginal septum. o Pocket around cervix is divided into the anterior, posterior and lateral fornices. Internal pelvic organs can be palpated through these fornices. o Uterus is flattened anteroposteriorly and usually inclines forward at a 45 degree angle. It may also be anteverted, anteflexed, retroverted, or retroflexed. Uterus opens into vagina via the external cervical os o Adnexa of uterus comprise of the fallopian tubes and ovaries
internal genitalia
What is this?o Formed from 4 bones: two innominate (consisting of ilium, ischium, and pubis), the sacrum, and the coccyx o Has 4 pelvic joints: symphasis pubis, the sacrococcygeal, and two sacroiliac joints
bony pelvis
When is the uterus enlarged due to high hormone levels and pressure from the fetus. Hormonal activity softens the pelvic cartilage and strengthens the pelvic ligaments.
Pregnant women
Who does this happen in: During menopause, estrogen levels decrease causing the labia and clitoris to become smaller. Adrenal androgens and ovarian testosterone levels decrease which may account for decreases in libido and in muscle mass and strength. Vaginal mucosa becomes thin, pale and dry which may result in dyspareunia (painful sex). Ligaments and connective tissue of the pelvis sometimes lose their elasticity and tone, thus weakening the support sling for pelvic contents.
oLDER ADULTS
What are these important for:o interval between periods, amenorrhea, prolonged menses, bleeding between periods, post menopausal bleeding o Change in flow, number of pads/tampons used, presence of clots, onset, duration, precipitating factors, associated symptoms and medications
Genital abnormal bleeding
What are these important for:o Associated vaginal discharge or bleeding, GI symptoms, abdominal distension or tenderness, association with menstrual cycle, voiding, eating, defecation, exercise, body positions, and sexual activity
Genital Pain
What are these important for:o Amount, color, odor, consistency, acute vs chronic, douching habits, clothing, sexual history, and associated symptoms including itching, dyspareunia, dysuria, burning with urination, abdominal pain or cramping, pelvic fullness, inflamed or bleeding external tissues, and medications (oral contraceptives and antibiotics)
Vaginal dischare
What are these important for:o Headacches, weight gain, edema, breast tenderness, mood changes, frequency of symptoms, alleviating and aggravating factors
Premenstrual symptoms
What are these important for:o Age of menopause, menstrual changes, mood changes, tension, hot flashes, bleeding, mother’s experience with menopause, mediations (hormone therapy, SERM)
menopausal symptoms
What are these important for:o Length of time attempting pregnancy, sexual activity pattern, anatomical abnormalities of female reproductive organs, stress, nutrition, chemical substances, partner factors, diagnostic tests
Infertility
What are these important for:o Acute vs chronic, frequency of symptoms, characteristics of urine, presence of blood, associated symptoms such as vaginal discharge, bleeding, abdominal pain or cramping, abdominal distension, pelvic fullness, or flank pain
• Urinary symptoms – dysuria, burning, frequency, and urgency
What is a common problem of females that can present as cyclic or noncyclic pelvic pain?
endometriosis
What is thiso Age of menarche, LMP (first day of last cycle), # of days in cycle, character of flow (amount, duration, clots)o Dysmenorrhea, intermenstrual bleeding or spotting, intermenstrual pain, premenstrual symptoms
menstrual history
What is thiso G: Gravity – total # of pregnancies o T: # of term pregnancieso P: # of preterm pregnancieso A: # of abortions, spontaneous or inducedo L: # of living children o Ask about complications of pregnancy, delivery, abortion, or with fetus/neonate
Obstetric history
What is thiso Prior Pap smears, HPV testing and results. If abnormal ask about date, treatment and follow upo Past gynecologic procedures and surgeries, STI, PID, vaginal infections, DM and cancers (breast, colorectal, endometrial, ovarian, cervical)
gynecologic history
What is this• Diabetes, cancers, multiple pregnancies, congenital anomalies, mother’s use of diethylstilbestrol (DES)
Family history questions about female genitalia
What are these?• Contraceptive history (methods, duration of use, effectiveness) and douching history • Sexual history – number of parteners, gender, methods of contraception, use of protection, prior STIs
personal and social history questions
Who is this for:ask about suspicion of insertion of foreign objects of possible sexual abuse with bleeding, pain and discharge (mucoid discharge is normal in newborns)
Infants and children
Who is this for:ask about suspicion of insertion of foreign objects of possible sexual abuse with bleeding, pain and discharge (mucoid discharge is normal in newborns)
Infants and Children
Whos is this for:ask about EDC, previous birth hx, previous OB and menstrual hx, prior uterine surgery, bleeding, discharge, passage of fluid, pain, GI symptoms
Pregnant Women
Who is this for:symptoms associated with age related changes – itching, urinary symptoms, dyspareunia; changes in sexual desire or behavior
Older Adults
What exam is this:o Inspect the pubic hair characteristics and distribution o Inspect and palpate labia majora and minora for symmetry in color, caking of discharge, inflammation, irritation or excoriation, swelling, tenderness, rashes, and lesions. o Inspect clitoris for size, atrophy, inflammation and adhesions o Inspect urethral meatus and vaginal opening for discharge, inflammation, irritation, lesions, polyps, and fistulaso Milk the Skene glands and palpate the Bartholin glands. Look for discharge, swelling, tenderness and masseso Test muscle tone at the vaginal opening. Inspect bulging and urinary incontinence as the patient bears downo Inspect and palpate perineum for smoothness, tenderness, inflammation, fistulas, and lesionso Inspect the perineal area and anus for skin tags, lumps, lesions, fissures, excoriation, and inflammation
External genitalia exam
What exam is this:o Insert speculum along the path of least resistance o Inspect the cervix for color, position, size, surface characteristics, discharge, size and shape of os Cervical os is small and round in nulliparous women, and slit-like in women who have had previous pregnancies.o Collect specimens if necessary o Inspect vaginal walls for color, surface characteristics, lesions, bleeding, and secretions. Look for cystocele (hernia protrudes through wall of vagina) or rectrocele (a prolapse of the wall between the rectum and the vagina.).
Internal Genitalia Speculum Exam
What exam is this:o Insert the index and middle fingers of one hand into the vagina and place the other hand on the abdominal midlineo Palpate the vaginal walls for smoothness, tenderness, and lesions o Palpate the cervix for size, shape, length, position, mobility, and tenderness o Palpate the uterus for location, position, size, shape, contour, mobility, and tendernesso Palpate the ovaries for size, shape, consistency, and tenderness o Palpate adnexal areas for masses and tenderness
Bimanual Exam
What exam is this:o Insert the index finger into the vagina and the middle finger into the anus o Assess sphincter tone o Palate the rectovaginal septum for thickness, tone and noduleso Palpate the posterior aspect of the uterus confirming findings from vaginal examination o Palpate the anterior and posterior rectal wall for masses, polyps, modules, strictures, and tendernesso Note characteristics of the feces on gloved finger
Rectovaginal Exam
What position is the patient in during a female genitalia exam?
lithotomy
What is mittelschmerz and andexal tenderness?
lower abdominal pain associated with ovulation.
is vaginal bleeding ever normal in children?
NO
What is the sign called at 4-6 weeks of pregnancy and it is the softening of the cervix?
goodell
What is the sign called at 6-8 weeks and is the softening of the uternie isthmus?
hegar
What is the sign called when the fundus flexes easily on the cervix?
McDonald
What is the sign called when the fullness and the softening of the fundus near the site of implantation.
Braun von Fernwald
What is the sign called when palpable lateral bulge or soft prominence of one uterine cornu
piskacek
What is the sign of blusih color of the cervix, vagina and vulva called?
chadwick
What are leopald maneuvers?
in third trimester, used to detect fetal position
What do you do to assess fetal well being?
Fetal heart rate and fetal movement
What are braxton hicks contraction?
uterine contractions in 3rd month of pregnancy
What is the male genitalia comprised of?
penis, testicles, epididymides, scrotum, prostate gland, seminal vesicles
What does the penis consist of?
corpora cavernosa, and corpus spongiosum. Glans penis is covered by foreskin (prepuce)
Scrotum contains what?
testis, epididymis, spermatic cord, and cremasteric muscle
What allows scrotum to relax or contract, important for cooling temperature by altering distance of testes from body.
cremasteric muscle
Spermatogenesis requires temperatures below (blanK) degrees?
37
(blank) are responsible for spermatozoa and testosterone production.
testcless
What provides storage, maturation and transmit of sperm?
epididymis
What form the ejactulatory duct?
vas deferens and seminal vesicle
What surrounds urethra at the bladder neck and forms most of ejaculatory fluid?
Prostate gland
Which testicle is lower and why?
left testicle due to longer length of spermatic cord
During the (blank) , the testes descend from the retroperitoneal space through the inguinal canal to the scrotum. At full term, one or both tests may still lie within the inguinal canal and descend into the scrotum in the early postnatal period. Descent may be arrested at any point or may follow an abnormal path.
3rd trimester
With onset of (blank) testicles grow, penis enlarges in length and breadth, scrotal skin reddens and thins, and prostate gland enlarges.
puberty,
Scrotum becomes more pendulous with (blank). Erection may develop more slowly and orgasms are less intense.
Aging/old people
What are these for:o Pain with erection, constant or intermittent, association with alcohol or medications (diuretics, sedatives, antihypertensives, antidepressants, ect)
difficulty achieving or maintaining erection
What are these for:o Hx of sickle cell anemia, leukemia, MS, DM, spinal cord injury o Trauma, association with alcohol or medications
Persistant erections unrelated to sexual stimulation
What are these for:o Painful or premature, characteristic of ejaculate (color, odor, consistency, amount), association with medications (alpha blockers, antidepressants, antipsychotics, clonidine, methyldopa)
Difficulty with ejaculation
What are these for:o Presence of lumps, sores, or rash, does it itch, burn or stingo characteristic of discharge (color, consistency, odor)o exposure to STI
Discharge or lesion on penis
What are these for:o OLDCARTSo Change in testicular size, irregular lumps, soreness, or heaviness, related to trauma, association with medications
Testicular pain or mass
What are these for:o Intermittent or constant, associated with straining or lifting, duration, presence of pain, changes in size or character of mass, ability to reduce the mass
Enlargement in inguinal area
What are these for:o Ask about factors that may increase temperature of scrotum (tight clothing, hot baths, ect)o History of undescended testes, length of time attempting pregnancy, diagnostic evaluation (seman analysis), medications
Infertility
What are important PMH for male genitalia?
• GU tract surgeries (undescended testes, hypospadia, epispadias, hydrocele, varicocele, hernia, prostate, vasectomy)• STI and treatment• Chronic illness such as testicular or prostate cancer, neurologic or vascular diseases, and DM
What are these important for:• Occupational risk of trauma, exposure to toxins or radiation, use of protective device with sports, use of alcohol and recreational drugs, sexual practices• Testicular self examination practices
Personal and social history
What should you ask when assessing infants and genitalia?
: ask about maternal use of sex hormones or BCP during pregnancy, circumcision, scrotal swelling with crying or bowel movements, and congenital anomalies
What should you ask about adolescents with genitalia issues?
Ask about presence of nocturnal emissions, pubic hair, enlargement of genitalia
What should you ask about older adults with genitalia issues?
Ask changes in frequency of sexual activity, desire or response
What are these for?• Inspect pubic hair characteristics and distribution • Inspect penis and urethral meatus with foreskin retracted (if patient is uncircumcised). Smegma may be present over glans penis. • Palpate penile shaft • Strip urethra for discharge • Inspect scrotum for color, texture, asymmetry, lesions, thickening and presence of hernia • Transilluminate masses in scrotum
Summary of physical exam for male genitalia
What is transluminate and no change in size with reduction?
hydrocele
What does not translminate and is reducable?
hernia
What does not transluminate and no change in size with reduction?
incarcinated hernia
what position is a patient in when palpating for a hernia?
standing and bearing down
What should the opening of the urethra look like?
glistening an dpink
What vein should be apparents on the penis?
dorsal vein
What is the most common type of hernia?
indirect inguinal
What is the cremasteric reflex?
stroke the inner thigh with a blunt instrument -> normal response should have testicle and scrotum rise on stroked side
What should you not do with the foreskin?
retract it (dont want binding adhesion)
What is viscus and usually felt medial to inguinal ring?
direct hernia
What is viscus coming through inguinal ring?
indirect hernia
What should you palpate for consistency, size,tenderness, bleeding, masses, lumps and nodules
testes, epididymides, vas deferens
How long is the anal canal?
2.5-4cm long
The lower half of the anal canal is supplied with what kind of nerves? upper half?
somatic sensory nerves (sensory)autonomic control (insensitive)
Is the rectum inferior or superior to the anus and how long is it?
rectum is superior, about 12 cm long
Where is the prostate gland located?
base of the bladder and surrounds the urethra.
What is 4X3X2 cm and composed of muscular and glandular tissue?
prostate gland
The posterior surface of the prostate is palpable by digital exam through the (blank).
anterior rectal wall
The prostate is divided into how many lobes and is it palpable by exam?
3 lobes ( right, left and median) The right and left are palpable but not the median
Prostate remains undeveloped until (blank)
puberty
(blank) are predisposed to developing hemorrhoids due to pressure in the veins below the uterus.
pregnant women
Who does this happen in:degeneration of neurons in the rectal wall inability to relax internal sphincter constipation. However, as internal sphincter loses tone, fecal incontinence may occur.
old people
In males, (blank) hyperplasia of prostatic glandular tissue is may occur.
benign
What are these questions for:o Number, frequency, consistency of stools, presence of mucus or blood, color, and odor o Onset, duration, and relation to diet or stresso Accompanying symptoms such as incontinence, flatus, pain, N/V, cramping, abdominal distension
changes in bowel function
What are these questions for:o Relation to body position and defecation, straining with defecation, presence of mucus or blood
Anal discomfort: itching, pain, stinging, burning
What are these questions for:o Color (bright or dark red, black), relation to defecation, amount (spotting vs active bleeding), changes in stool, associated symptoms such as incontinence, flatus, pain, abdominal distension, weight loss
Rectal bleeding
What are these questions for:o Hx of enlarged prostate or prostatitiso Hesitancy, urgency, nocturia, dysuria, caliber of stream, dribbling, discharge, medications
Changes in urinary function
What is this for:• Hemorrhoids, spinal cord injury, bowel habits and characteristincs, prostate cancer or hypertrophy, colorectal cancer or related cancers (breast, ovarian, endometrial), inflammatory bowel disease
Past medical history
What is this for:• prostatic cancer, rectal polyps, colon cancer or familial cancer syndromes (FAP, HNPCC, Gardner syndrome)
Family history
What is this for:• recent travels, diet (fiber foods, amount of animal fat, changes), risk factors for colorectal, prostate or anal cancer, sexual practices (males with males), alcohol use
Personal and social history
What is this the summary of the physical exam for the UG?
inspect-sacrococcygeal and perianal-anus-assess sphincter tonePalpate-muscular ring-lateral and posterior rectal walls-anterior rectal wall (prostate or cul-de-sac)-posterior surface of prostate gland
What should the prostate gland feel like?
like a pencil erase (firm and smooth and slightly mobile)
What are problems with prostate gland?
a. Rubbery or boggy consistency – indicative of BPHb. Stony hard nodules – indicative of carcinoma, prostatic calculi or chronic fibrosisc. Tender, fluctuate and soft – indicative of prostatic abscess
In females, palpate (blank) through anterior rectal wall for size, shape, position, smoothness, and mobility
palpate cervix and uterus
Withdraw finger and examine any (blank). Note any blood or pus, stool color, consistency, and test for occult blood if necessary.
fecal material
What is a clue that a patient is having acute pain?
patient will shift uncomfortably from side to side when sitting
What should you use to detect perianal abscess?
Bidigital palpation
Prostate enlargement is classified by the amount of protrusion into the rectum, What are the cm corresponding to each grade?
Grade I; 1-2 cmGrade II; 2-3 cmGrade III; 3-4 cmGrade IV; more than 4 cm
Stool:intermittent, pencil like stools suggest?persisitant, pencil like stools suggest?decreased caliber (pencil thin stools) indicate?A large amount of mucus in fecal matter suggest?Small flecks of blood stained mucus in fecal matter suggest?fatty stools?Stools the color of aluminum?
-spasmodic contraction in rectal area-permanent stenosis from scarring or from pressure -lower rectal stricture-intestinal inflammation and mucous colitis-amebiasis-pancreatic disorders and malabsorption syn.-tropical sprue, carcinoma of hepatopancreatic ampulla, and children treated with sulfonamides for diarrea
WHen attempting a digitial rectal exam on a newborn what finger do you use
pinky
Color of infant stool
newborn greenish black3-6 days is thin slimy brown to greenbreast fed-mushy yellow non irritating to skinformula fed-yellow irritating to skin
An unexplained fever means utilize what?
rectal exam
