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Sasha: Module 8 Repro/GU > Clin Assess Lectures > Flashcards

Clin Assess Lectures Flashcards

1
Q

common and concerning symptoms in the breast and axillae exam (3)

A
  1. Breast lump/mass 2. Breast pain or discomfort 3. Nipple discharge
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2
Q

Palpable mass – what could it be? 15-25 y.o

A

fibroadenoma

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3
Q

Palpable mass – what could it be? 25-50 y.o.

A

breast cyst, fibrocystic changes, cancer

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4
Q

Palpable mass – what could it be? over 50 y.o.

A

cancer until proven otherwise

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5
Q

what is the lifetime risk for breast cancer

A

1 in 8

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6
Q

what is a risk assessment tool available for breast cancer

A

Gail model

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7
Q

what is a fibroadenoma

A

non tender/solid mass in breast/mobile

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8
Q

Palpable mass/ fixed/ non tender

A

breast cancer

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9
Q

older you live the _____ likely you are to get breast cancer

A

more

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10
Q

what exam do you usually always do when possbile breast cancer

A

ultrasound

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11
Q

_______ can change during menstrual cycle

A

lobules **** fibrocystic breast changes can happen from one exam to the next over a period of time

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12
Q

most common risk factor for breast cancer

A

AGE

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13
Q

breast cancer risk factors (7)

A
  1. Age (most important risk factor) 2. Family history: do you have a family member with breast cancer and what age was the diagnosis… [was it before the age of 50] 3. Breast tissue density 4. Biopsy showing atypical hyperplasia 5. Unopposed estrogen exposure (eg, early menarche, late menopause, no pregnancies) 6. Radiation to chest wall 7. >50% of women w/ breast CA have NO family/reproductive RF
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14
Q

what do ovaries produce

A

estrogen

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15
Q

what are you at a higher risk of with increased production of estrogen?

A

breast cancer

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16
Q

who is screening for breast cancer indicated in

A

ALLL WOMEN

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17
Q

how do we screen for breast cancer other then a self breast screening

A

mammography

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18
Q

4 things to remember with screening (Mammographies) 1. what do you discuss? 2. recommendations? 3. when to start mammos? 4. how frequent?

A
  1. Discuss risks and benefits; individualize screening 2. Recommendations controversial 3. Start sometime between 40-50 y.o. 4. Frequency – annual, biennial, discontinue?
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19
Q

what are some mammo risks

A

– false positives, overdiagnosis; benefits – early diagnosis

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20
Q

what does USPSTF (2009) suggest for screening age and frequency and duration

A

screening mammo every 2 years for women ages 50-74

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21
Q

what is the breast cancer screening test of choice

A

mammo

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22
Q

what if you are highly concerned someone has a risk of breast cacner… what age do we get a mammo

A

Highly concerned: age 40 is the soonest you would screen (then every other year) but you can do it every year

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23
Q

at what life expectancy can we stop screening for breast caner

A

If life expectancy is less then 10 years: can stop screening

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24
Q

what test do we accompany with the mammo if pt has a high risk of breast cancer

A

MRI then mammo

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25
Q

what type of breast have diffculty with a mammo screening.. so what do we use instead

A

dense breast so then use breast MRI instead

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26
Q

what if patient is less then 30 y.o and dense breast tissue

A

ultrasound

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27
Q

but if the same patient that is less then 30 years old and has dense breasts says, “ohh hey, I have the BRACA 1 and 2” then what can you do

A

mammo or MRI

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28
Q

what re the three different criteria that someone can have a spotive family hisroty and Suspect BRCA1 and/or BRCA2 mutations (based on family history)

A
  1. 1st degree relative w/ breast CA BEFORE age 50
  2. ≥2 individuals in same lineage w/ breast CA
  3. 1st degree relative w/ ovarian CA
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29
Q

what is the purpose of a clinical breast examination (CBE)?

A

•Purpose:

–Identify breast masses

–Teach self-breast examination (SBE)? (kinda)

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30
Q

what ages are you getting a CBE and how often

A

ages 20-40, every 2-3 years and annually if >40 years old

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31
Q

what is the debate about self breast exams currrently

A

debate right now. They say there has been no benefit to this. Has not changed morbidity and mortality rates.

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32
Q

female breast and lymphatics

what are some lymph nodes/chains we are feeling for? (3)

A

central deep axillary chain, infraclavicular, and supraclavicular nodes

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33
Q

step by step of a breast exam

  • while seated what do we ask first
  • inspection/ arm positions (4)
  • palpation (tecnique/ what part do we not forget!)
A
  • While patient seated, in gown
    • Ask if she’s noticed any lumps
  • Inspection, while patient seated
    • Ask her to lower gown to fully expose chest for inspection
    • Inspect breasts and nipples w/ patient’s:
      • Arms at sides
      • Arms over head
      • Hands pressed against hips
      • Leaning forward
  • Palpation, while patient supine
    • Expose 1 breast at a time (keep other in gown)
    • Palpate breast tissue using fingerpads
    • Be systematic!
      • Vertical strip pattern
      • Small, concentric circles
      • Apply light, medium & deep pressure
    • Don’t forget the nipple & lymph nodes
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34
Q

Where are most breast cancers:

A

upper outer quadrant

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35
Q

what are the 6 characteristics you describe if you find a breast mass/lump?

A

–Location (by quadrant or clock, w/ centimeters from nipple)

–Size

–Shape

–Consistency

–Tenderness

–Mobility

****how far away form the nipple and which part of the clock!

example: fixed non tender lump 2 cm from the nipple at 1030 about 2cm in size

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36
Q

what are 4 abnormal findings of the breast

A

–Fibroadenoma

–Breast cyst

–Breast cancer

–Gynecomastia: enlarged breast from possible endocrine issues

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37
Q

what are 4 abnormal findings of the nipple

A

–Paget’s disease

–Galactorrhea: nipple discharge; medication SE (psych meds); pituitary gland issue; no really necessary to collect nipple discharge

Concerning nipple d/c – unilateral, spontaneous, bloody

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38
Q

what are 4 abnormal findings of the axillae

A

–Hidradenitis suppurativa, acanthosis nigrans

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39
Q

male pt breast cancer

  1. where is it usually
  2. what percent of males
  3. what consists in a male breast exam
A
  1. usually behind nipple
  2. 1% of all breast cancer is in males………Rare/but there
  3. NO DIFFERENT THAN FEMALE BREAST EXAM
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40
Q

what are you thinking of if the Skin changing on nipple… what diagnostic testing will you get.

A

Skin changing on nipple: Pagents Disease: diagnostic mammogram and then biopsy

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41
Q

Microcalcifications… what is the significance of these

A

itll be 2 years before you actually palpate a lump on breast exam: this is why mammo are so important!

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42
Q

5 different breast cancer diagnostic testing options

A
  • Breast biopsy – FNA cytology or core biopsy
  • Breast ultrasound
  • Mammography – √microcalcifications
  • Breast MRI (contrast-enhanced)
  • Cytology of nipple discharge?
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43
Q

when do you refer (3)

A
  • Suspect BRCA1 or BRCA2 mutations
  • Breast lump/mass – general surgery
  • Abnormal nipple discharge
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44
Q

common or concerning symptoms to then get a male genitalia and hernia exam

A
  • Sexual response
  • Penile discharge or lesions
  • Scrotal pain, swelling or lesions

–Testicular self-examination (TSE)

•STIs

45
Q

form age 15-35 what is the most common cancer in men

A

testicular cancer

46
Q

what is key about STIs and HIV (3 types)

A

•Prevention is key!

–Condoms

–HPV vaccine

–Universal testing

47
Q

when does the HPV vaccine start (age)

when do you complete the series (age)

how many shots/ at what times

A

HPV vaccine – start series at age 11 or 12, complete series anytime through age 26, 3 shots – 0, 1-2 months and 6 months

48
Q

6 tips for Techniques of Examination: M/F

A
  • Explain each step to patient before exam
  • Ask permission!
  • Have chaperone present
  • Wear gloves throughout exam
  • Keep patient adequately covered w/ gown/drapes
  • If patient refuses exam, respect wishes
49
Q

step by step male exam

  • how are they positioned
  • what if an erection occurs
  • what are you inspecting and palpating on the penis
  • what are we inspecting and palpating on the scrotum
  • what position is pt in for hernia check
  • what are we inspecting and palpaing for in a hernia check
A
  • Patient supine or standing
  • If erection occurs, explain that this is a normal response
  • Penis
    • Inspect: skin, foreskin, glans, urethral meatus
    • Palpate: ± shaft of penis
  • Scrotum and its contents
    • Inspect: skin, scrotal contours
    • Palpate: each testis, epididymic & spermatic cord between thumb and first 2 fingers
  • Hernias, with patient standing
    • Inspect: bulging, asymmetry
      • Ask patient to strain/bear down
    • Palpate: external & internal inguinal rings, femoral canal, scrotum (if mass present, √BS)
50
Q

Near internal inguinal ring, often in scrotum

A

•Indirect hernia

51
Q

–Near external inguinal ring, rarely in scrotum

–Associated w/ lifting/straining

A

•Direct hernia

52
Q

–Below inguinal ligament

–More associated w/ bowel incarceration/strangulation

A

•Femoral hernia

53
Q

hernias are an ________ referral

A

emergent

54
Q

leaves the abdomen through the internal inguinal ring, exiting through the external inguinal ring and descending into the scrotum

A

Indirect inguinal hernia

55
Q

leaves the abdomen through a weakness in the transversalis fascia (the posterior wall of the inguinal canal) and bulges above inguinal ligament (pushing through external inguinal ring)

A

direct inguinal hernia

56
Q
A

HASSELBACH’S TRANGLE

57
Q

how do we examine a RIGHT inguinal hernia

A

•To examine right inguinal hernia, use right index finger

Indirect hernia: internal inguinal canal

58
Q

if someone has acute scrotal pain what are two options for what could be going on

A

testicular torsion

or

epididymitits

59
Q

testicular torsion

  1. what is absent
  2. what does it look like and what type of deformity is present
  3. is there swelling
A
  • Cremasteric reflex absent
  • High riding testis, w/ bell clapper deformity
  • Profound testicular swelling
60
Q

what is the cremasteric reflex

A

stroke upper inner thigh, scrotom on that one side with elevate

61
Q

Epididymitis

  1. what is present
  2. what 2 things do we notice about the epididymis
A
  • Cremasteric reflex present
  • Epididymis tenderness & induration
62
Q

what is Cryptorchidism

A

when you balls dont drop….

soooo undescended testes

63
Q

abnormal STI findings (4)

A

–Genital warts

–Genital herpes simplex

–Syphilis (chancre)

–Chancroid: ulcer, Hemophilus ducreyi

64
Q

abnormal penile discharge or lesion findings (3)

A

–Peyronie’s disease

–Hypospadias: urethral opening ventral side of penis

–Carcinoma of the penis

65
Q

abnormal scrotal swelling, pain or lesion findings (shit ton… just read them to be familiar)

A

–Scrotal edema

–Hydrocele

–Scrotal hernia

–Acute orchitis

–Spermatocele

–Acute epididymitis

–Varicocele: varicose veins of venous vasculature in spermatic cord

–Testicular torsion

–Cryptorchidism

–Testicular cancer

66
Q

possible dignostic testing for abnormal findings (7)

A
  • Scrotal ultrasound
  • UA/UC
  • Gram stain of urethral discharge
  • STI testing (urine gonorrhea/chlamydia)
  • Semen analysis
  • Aspiration
  • Tumor markers – alpha fetoprotein (AFP) & human chorionic gonadotropin (beta-hCG)
67
Q

when do we refer a male pt (3) and where

A
  1. Testicular torsion – emergency!
  2. Testicular mass – urology
  3. Hernia – general surgery
    • Incarcerated/strangulated – emergency!
68
Q

common or concerning signs on female genitalia

A
  • Menstruation, menopause, postmenopausal bleeding
  • Pregnancy
  • Vulvovaginal symptoms
  • Sexual response
  • Pelvic pain – acute & chronic
  • STIs
69
Q

what is a normal mentrual cycle

A

Normal menstrual cycle – every 21-35 days

70
Q

what is part of a pts menstrual history (7)

A
  • Menarche
  • Menopause
  • Postmenopausal bleeding (PMB)
  • Amenorrhea – primary or secondary: pregnancy is the #1 reason for this
  • Dysmenorrhea: painful cramping menses
  • Premenstrual syndrome (PMS)
  • Abnormal uterine bleeding – excessive, prolonged, intermenstrual, infrequent, PMB
71
Q

term for frequent periods

A

Polymenorrhea

72
Q

term for light infrequent periods

A

oligomenorrhea

73
Q

term for abnormally heavy bleeding at menstruation.

A

menorrhagia

74
Q

term for abnormal bleeding from the uterus.

A

metrorrhagia

75
Q

term for non-menstrual bleeding that occurs immediately after sexual intercourse

A

postcoital bleeding

76
Q

Gravida Para Notation

normal

and

even more detailed

A
  • G = gravida or total # of pregnancies
  • P = para or outcomes of pregnancies

Example: G1P0

  • Even more detailed…
  • G = gravida or total # of pregnancies
  • TPAL = term, preterm, abortion, living children

Example: G4P2113

77
Q
  • Cervical cancer
  • Ovarian cancer: risk factors
  • STIs and HIV
  • Family planning options
  • Menopause
  • Ask parent(s) to leave, if present
A

all topics of discussion with your patient

78
Q

what is the cervical cancer screening recommendations

  • what age and stop at what age
  • how often for what ages with what
  • what is the new test
  • when do you stop screeening
  • what dont we want to forget about.. vaccination wise.
A
  • Start at age 21, discontinue at age 65
  • Screen every 3 yrs for ages 21-29 w/ Pap
  • Screen every 5 yrs for ages 30-65 w/ Pap + HPV “co-test”
  • (New test: HPV every 3 yrs for ages ≥25)
  • Stop screening if post-hysterectomy
  • Don’t forget about HPV vaccine!

other random facts:

Cervical cancer is slow growing: probably die from something else before cervical cancer by the age of 65

Gardacil: 11-12 years old

79
Q
  • Depress drape between knees to provide eye contact w/ patient
  • Have supplies ready and good lighting!
  • Avoid unexpected or sudden movements
  • Speculum – choose correct size/shape, warm w/ tap water
A

JUST SOME TIPS FOR SUCCESS

80
Q

STEP BY STEP WOMEN EXAM

  • What position
  • what do we as her to do when in this position
  • what do we examine first
  • what do we select and with what kind of pressure
  • what do we then do to examine internal genitlaia
  • what do we find next
  • then which exam do we perform
  • how do we perfrom the bimanual exam
    • what are we palpating (3)
  • what do we assess for muscles
  • which exam do we do last if indicated
A
  • Patient in lithotomy position
  • Ask her to slide down to end of table
  • Examine external genitalia
  • Select speculum then insert into vagina, applying downward pressure
  • Open speculum to examine internal genitalia
  • Find cervix then collect specimen(s)
  • Perform bimanual exam (use lubricants)
  • Insert index & middle finger of gloved hand into vagina, while other hand is pressing downward on abdominal wall, then…
  • –Palpate cervix
  • –Palpate uterus
  • –Palpate each ovary
  • Assess pelvic floor muscles
  • Rectovaginal exam, if indicated
81
Q

what is visible with the speculum… aka what are we looking for

A

external os of the cervix

82
Q

what is common in asolescense when looking at the cervix

A

ectropion is common (columnar eptithelium will be replaced with squamous epithelium

83
Q

what is adnexa

A

ovaries, tubes and supporting tissues

84
Q

what are some abnormal findings that can be found on female exam

guys there are a MILLION… dont memorize this list just be familiar with what they are :)

A
  • Epidermoid cyst
  • Genital warts
  • Genital herpes
  • Syphilis - chancre
  • Vulvar cancer
  • Trichomoniasis
  • Vulvovaginal candidiasis
  • Bacterial vaginosis
  • Pelvic organ prolapse
    • Cystocele
    • Rectocele
    • Uterine prolapse
  • Bartholin’s gland infection
  • Cervical lesions
    • Nabothian cyst
    • Cervical polyp
    • Dysplasia
    • Cervical cancer
    • Cervicitis
  • Uterine fibroids
  • Ovarian cysts
  • Ovarian cancer
  • Polycystic ovarian syndrome
  • Ectopic (tubal) pregnancy
  • Pelvic Inflammatory Disease
85
Q

odor after applying KOH to specimen (aka “whiff” test)

A

Amine test

86
Q

what are some diagnostic test that can be done on women….

again just read over.

A
  • Ultrasound
    • Transvaginal (TVUS)
    • Pelvic
  • CA-125
  • FSH (>25 IU/L = menopause)
  • TSH, CBC
  • Prolactin
  • Pregnancy
    • Urine hCG
    • Serum hCG (quant or qual)
  • Pap smear & HPV testing
  • STI & HIV testing
  • Herpes – serology or probe
  • Wet prep
    • Clue cells
    • Yeast
    • Trich
87
Q

True or False

Swabs are common

A

TRUE

88
Q

WHAT ARE THE DIAGNOSTIC TESTS YOU WOULD GET FOR SOMEONE WITH MENSTRUAL PROBLEMS (4)

A

TSH,

CBC,

pregnancy,

± coag studies (eg, check for vWD)

89
Q

HOW TO Interpret Serum hCG Results

  • has to risk by atleast what percent in how many hours in a normal preganacy
  • what if it rises to fast?
  • what about too slow?
  • what is condisdered the discriminatory zone to see IUP on TVUS
A
  • Rises by at least 50% every 48 hrs in normal pregnancy (usually 2x)
  • Rises too fast? Multiple gestation, GTN (gestational trophoblastic neoplasia)
  • Rises too slow? Nonviable IUP, ectopic pregnancy
  • hCG 1,500-2,000 “discriminatory zone” to see IUP on TVUS
90
Q

how are ultrasounds usually done if there is a vaginal complaint

A

transvagually

91
Q

what is Polycystic Ovarian Syndrome (PCOS)

A

•Ovulatory dysfunction & hyperandrogenism

92
Q

what are you at risk for with PCOS (4)

A
  • •Risk for metabolic syndrome,
  • T2DM,
  • CVD
  • endometrial cancer
93
Q

what do you find on PE with someone with PCOS (4)

A

–Acne

–Hirsutism

–Menstrual irregularities

–Obesity

94
Q

what lab and imaging do you want with someone with PCOS

A

–TVUS w/ polycystic ovaries

–Urine hCG

–TSH, prolactin, FSH

–Serum testosterone

–17-hydroxyprogesterone (17-OHP) to r/o CAH

– DHEA-S to r/o adrenal hyperanfrogenism

95
Q

what do you do once you diagnose PCOS

A

–Fasting glucose & lipid panel

96
Q

what is the diagnostic procedures for PCOS (8)

A
  • Colposcopy w/ cervical, vaginal or vulvar biopsy
  • Dilation & curettage (D&C)
  • Endometrial biopsy
  • Endocervical curettage
  • Hysteroscopy
  • Saline infusion sonohysterography
  • Hysterosalpingography (HSG)
  • Laparoscopy
97
Q

what are the different types of PAP results (8)

A
  • NIL = negative for intraepithelial lesion or malignancy
  • ASC-US = atypical squamous cells of undetermined significance
  • LSIL = low-grade squamous intraepithelial lesion
  • HSIL = high-grade squamous intraepithelial lesion
  • Invasive squamous carcinoma
  • Atypical endometrial cells
  • Atypical glandular cells
  • Adenocarcinoma
98
Q

what are the 2 subtypes of cervical cancer nd there percentage

A

Cervical cancer = 2 subtypes 90% squamous cell carcinoma, 10% adenocarcinoma (in glandular cells)

99
Q

when am i going to refer a women with a pelvic/vaginal issue (4)

A
  • OB/GYN emergencies!
    • Ectopic pregnancy
    • Ovarian torsion
  • Chronic pelvic pain
  • Surgical conditions (eg, pelvic organ prolapse)
  • Abnormal Pap
100
Q

what are common / concerning symptoms that then require an anus, rectum and prostate exam

A
  • Pain with defection; rectal bleeding or tenderness
  • Anal warts or fissures
  • Weak stream of urine
  • Burning with urination
101
Q

perineal, sacral or suprapubic pain, fever and irritative voiding symptoms w/ possible urinary retention. Exquisite DRE

usually from e.coli

A

Acute bacterial prostatitis

102
Q

what are the criteria for needing a prostate cancer screening (5)

  • 3 risk factors
  • if it begins at what age?
  • secreen if your life expectancy is greater then?
  • what is optional
  • what should you “maybe” get every 2-4 years (up in the air)
A
  • RF: age, African American, family history
  • Begin at age 50; individualized
  • Screen if >10 yr life expectancy
  • Digital rectal exam (DRE) optional
  • Prostate specific antigen (PSA) every 2-4 yrs?
    • Not ideal (false positives and false negatives)
    • Cutoff point? If ≥4.0 ng/mL, proceed to biopsy
    • Early dx has NOT been shown to reduce mortality and may overdiagnosis and lead to overtreatment
      • Overdiagnosis – diagnosis men whom would NOT have clinical symptoms w/n lifetime
103
Q

STEP BY STEP rectal/prostate exam!

A
  • Least popular segment of physical exam
  • Explain to patient – exam uncomfortable but not painful
  • Have patient stand & lean forward w/ upper body resting on table or side-lying position
  • Wear gloves, spread buttocks apart
  • Inspect sacrococcygeal & perianal areas
  • Examine anus & rectum (via DRE):
    • Lubricate gloved index finger, ask patient to bear down
    • As sphincter relaxes, gently insert into anal canal
    • Then insert finger into rectum as far as possible, rotate clockwise & counterclockwise
  • Palpate prostate (lateral lobes & median sulcus)
    • Note size, shape, consistency √ nodules/tenderness
104
Q

What are some abnormal findings you can see on rectal exam

again there are a ton… do what you want with the list :)

A
  • Pilonidal cyst
  • Hemorrhoids (external & internal)
  • Anal fissure
  • Anorectal fistula
  • Rectal polyp
  • Rectal cancer: hard lesions
  • Bacterial prostatitis (acute & chronic): hurts a ton
  • Benign prostatic hyperplasia (BPH): 80% of men by the time of age 90 have BPH
  • Prostate cancer: hard lesion with assymetry; PSA and further diagnostic imaging (transrectal ultrasound)
105
Q

what are some common diagnostic tests for males with an abnomral finding on rectal exam (5)

A
  • PSA
  • Guaiac-based fecal occult blood test (FOBT)
  • Transrectal ultrasound guided prostate biopsy
  • Post-prostatic massage urine culture: (Massage then pee and then put stuff in urine to help say what the causative agent it)
  • Colonoscopy
106
Q

when are we going to refer a male with a rectal exam abnormality (3)

A
  • Surgical condition
  • Rectal or prostate mass, suspicious for malginancy
  • Chronic bacterial prostatitis
107
Q

when can a take home test turn positive

A

could do it all the way to the week before you start your next period!

108
Q

when should you tell your pts to check with a take home pregnancy test

A

tell her a week after her missing period.. because depending on the take home test depends how much HCG needs to be present to turn the test positive

Sasha: Module 8 Repro/GU (2 decks)

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