Clin Assess Lectures Flashcards
common and concerning symptoms in the breast and axillae exam (3)
- Breast lump/mass 2. Breast pain or discomfort 3. Nipple discharge
Palpable mass – what could it be? 15-25 y.o
fibroadenoma
Palpable mass – what could it be? 25-50 y.o.
breast cyst, fibrocystic changes, cancer
Palpable mass – what could it be? over 50 y.o.
cancer until proven otherwise
what is the lifetime risk for breast cancer
1 in 8
what is a risk assessment tool available for breast cancer
Gail model
what is a fibroadenoma
non tender/solid mass in breast/mobile
Palpable mass/ fixed/ non tender
breast cancer
older you live the _____ likely you are to get breast cancer
more
what exam do you usually always do when possbile breast cancer
ultrasound
_______ can change during menstrual cycle
lobules **** fibrocystic breast changes can happen from one exam to the next over a period of time
most common risk factor for breast cancer
AGE
breast cancer risk factors (7)
- 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
what do ovaries produce
estrogen
what are you at a higher risk of with increased production of estrogen?
breast cancer
who is screening for breast cancer indicated in
ALLL WOMEN
how do we screen for breast cancer other then a self breast screening
mammography
4 things to remember with screening (Mammographies) 1. what do you discuss? 2. recommendations? 3. when to start mammos? 4. how frequent?
- Discuss risks and benefits; individualize screening 2. Recommendations controversial 3. Start sometime between 40-50 y.o. 4. Frequency – annual, biennial, discontinue?
what are some mammo risks
– false positives, overdiagnosis; benefits – early diagnosis
what does USPSTF (2009) suggest for screening age and frequency and duration
screening mammo every 2 years for women ages 50-74
what is the breast cancer screening test of choice
mammo
what if you are highly concerned someone has a risk of breast cacner… what age do we get a mammo
Highly concerned: age 40 is the soonest you would screen (then every other year) but you can do it every year
at what life expectancy can we stop screening for breast caner
If life expectancy is less then 10 years: can stop screening
what test do we accompany with the mammo if pt has a high risk of breast cancer
MRI then mammo
what type of breast have diffculty with a mammo screening.. so what do we use instead
dense breast so then use breast MRI instead
what if patient is less then 30 y.o and dense breast tissue
ultrasound
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
mammo or MRI
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)
- 1st degree relative w/ breast CA BEFORE age 50
- ≥2 individuals in same lineage w/ breast CA
- 1st degree relative w/ ovarian CA
what is the purpose of a clinical breast examination (CBE)?
•Purpose:
–Identify breast masses
–Teach self-breast examination (SBE)? (kinda)
what ages are you getting a CBE and how often
ages 20-40, every 2-3 years and annually if >40 years old
what is the debate about self breast exams currrently
debate right now. They say there has been no benefit to this. Has not changed morbidity and mortality rates.
female breast and lymphatics
what are some lymph nodes/chains we are feeling for? (3)
central deep axillary chain, infraclavicular, and supraclavicular nodes
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!)
- 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
Where are most breast cancers:
upper outer quadrant
what are the 6 characteristics you describe if you find a breast mass/lump?
–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
what are 4 abnormal findings of the breast
–Fibroadenoma
–Breast cyst
–Breast cancer
–Gynecomastia: enlarged breast from possible endocrine issues
what are 4 abnormal findings of the nipple
–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
what are 4 abnormal findings of the axillae
–Hidradenitis suppurativa, acanthosis nigrans
male pt breast cancer
- where is it usually
- what percent of males
- what consists in a male breast exam
- usually behind nipple
- 1% of all breast cancer is in males………Rare/but there
- NO DIFFERENT THAN FEMALE BREAST EXAM
what are you thinking of if the Skin changing on nipple… what diagnostic testing will you get.
Skin changing on nipple: Pagents Disease: diagnostic mammogram and then biopsy
Microcalcifications… what is the significance of these
itll be 2 years before you actually palpate a lump on breast exam: this is why mammo are so important!
5 different breast cancer diagnostic testing options
- Breast biopsy – FNA cytology or core biopsy
- Breast ultrasound
- Mammography – √microcalcifications
- Breast MRI (contrast-enhanced)
- Cytology of nipple discharge?
when do you refer (3)
- Suspect BRCA1 or BRCA2 mutations
- Breast lump/mass – general surgery
- Abnormal nipple discharge
common or concerning symptoms to then get a male genitalia and hernia exam
- Sexual response
- Penile discharge or lesions
- Scrotal pain, swelling or lesions
–Testicular self-examination (TSE)
•STIs
form age 15-35 what is the most common cancer in men
testicular cancer
what is key about STIs and HIV (3 types)
•Prevention is key!
–Condoms
–HPV vaccine
–Universal testing
when does the HPV vaccine start (age)
when do you complete the series (age)
how many shots/ at what times
HPV vaccine – start series at age 11 or 12, complete series anytime through age 26, 3 shots – 0, 1-2 months and 6 months
6 tips for Techniques of Examination: M/F
- 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
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
- 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)
- Inspect: bulging, asymmetry
Near internal inguinal ring, often in scrotum
•Indirect hernia
–Near external inguinal ring, rarely in scrotum
–Associated w/ lifting/straining
•Direct hernia
–Below inguinal ligament
–More associated w/ bowel incarceration/strangulation
•Femoral hernia
hernias are an ________ referral
emergent
leaves the abdomen through the internal inguinal ring, exiting through the external inguinal ring and descending into the scrotum
Indirect inguinal hernia
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)
direct inguinal hernia
HASSELBACH’S TRANGLE
how do we examine a RIGHT inguinal hernia
•To examine right inguinal hernia, use right index finger
Indirect hernia: internal inguinal canal
if someone has acute scrotal pain what are two options for what could be going on
testicular torsion
or
epididymitits
testicular torsion
- what is absent
- what does it look like and what type of deformity is present
- is there swelling
- Cremasteric reflex absent
- High riding testis, w/ bell clapper deformity
- Profound testicular swelling
what is the cremasteric reflex
stroke upper inner thigh, scrotom on that one side with elevate
Epididymitis
- what is present
- what 2 things do we notice about the epididymis
- Cremasteric reflex present
- Epididymis tenderness & induration
what is Cryptorchidism
when you balls dont drop….
soooo undescended testes
abnormal STI findings (4)
–Genital warts
–Genital herpes simplex
–Syphilis (chancre)
–Chancroid: ulcer, Hemophilus ducreyi
abnormal penile discharge or lesion findings (3)
–Peyronie’s disease
–Hypospadias: urethral opening ventral side of penis
–Carcinoma of the penis
abnormal scrotal swelling, pain or lesion findings (shit ton… just read them to be familiar)
–Scrotal edema
–Hydrocele
–Scrotal hernia
–Acute orchitis
–Spermatocele
–Acute epididymitis
–Varicocele: varicose veins of venous vasculature in spermatic cord
–Testicular torsion
–Cryptorchidism
–Testicular cancer
possible dignostic testing for abnormal findings (7)
- 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)
when do we refer a male pt (3) and where
- Testicular torsion – emergency!
- Testicular mass – urology
- Hernia – general surgery
- Incarcerated/strangulated – emergency!
common or concerning signs on female genitalia
- Menstruation, menopause, postmenopausal bleeding
- Pregnancy
- Vulvovaginal symptoms
- Sexual response
- Pelvic pain – acute & chronic
- STIs
what is a normal mentrual cycle
Normal menstrual cycle – every 21-35 days
what is part of a pts menstrual history (7)
- 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
term for frequent periods
Polymenorrhea
term for light infrequent periods
oligomenorrhea
term for abnormally heavy bleeding at menstruation.
menorrhagia
term for abnormal bleeding from the uterus.
metrorrhagia
term for non-menstrual bleeding that occurs immediately after sexual intercourse
postcoital bleeding
Gravida Para Notation
normal
and
even more detailed
- 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
- Cervical cancer
- Ovarian cancer: risk factors
- STIs and HIV
- Family planning options
- Menopause
- Ask parent(s) to leave, if present
all topics of discussion with your patient
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.
- 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
- 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
JUST SOME TIPS FOR SUCCESS
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
- 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
what is visible with the speculum… aka what are we looking for
external os of the cervix
what is common in asolescense when looking at the cervix
ectropion is common (columnar eptithelium will be replaced with squamous epithelium
what is adnexa
ovaries, tubes and supporting tissues
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 :)
- 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
odor after applying KOH to specimen (aka “whiff” test)
Amine test
what are some diagnostic test that can be done on women….
again just read over.
- 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
True or False
Swabs are common
TRUE
WHAT ARE THE DIAGNOSTIC TESTS YOU WOULD GET FOR SOMEONE WITH MENSTRUAL PROBLEMS (4)
TSH,
CBC,
pregnancy,
± coag studies (eg, check for vWD)
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
- 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
how are ultrasounds usually done if there is a vaginal complaint
transvagually
what is Polycystic Ovarian Syndrome (PCOS)
•Ovulatory dysfunction & hyperandrogenism
what are you at risk for with PCOS (4)
- •Risk for metabolic syndrome,
- T2DM,
- CVD
- endometrial cancer
what do you find on PE with someone with PCOS (4)
–Acne
–Hirsutism
–Menstrual irregularities
–Obesity
what lab and imaging do you want with someone with PCOS
–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
what do you do once you diagnose PCOS
–Fasting glucose & lipid panel
what is the diagnostic procedures for PCOS (8)
- Colposcopy w/ cervical, vaginal or vulvar biopsy
- Dilation & curettage (D&C)
- Endometrial biopsy
- Endocervical curettage
- Hysteroscopy
- Saline infusion sonohysterography
- Hysterosalpingography (HSG)
- Laparoscopy
what are the different types of PAP results (8)
- 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
what are the 2 subtypes of cervical cancer nd there percentage
Cervical cancer = 2 subtypes 90% squamous cell carcinoma, 10% adenocarcinoma (in glandular cells)
when am i going to refer a women with a pelvic/vaginal issue (4)
- OB/GYN emergencies!
- Ectopic pregnancy
- Ovarian torsion
- Chronic pelvic pain
- Surgical conditions (eg, pelvic organ prolapse)
- Abnormal Pap
what are common / concerning symptoms that then require an anus, rectum and prostate exam
- Pain with defection; rectal bleeding or tenderness
- Anal warts or fissures
- Weak stream of urine
- Burning with urination
perineal, sacral or suprapubic pain, fever and irritative voiding symptoms w/ possible urinary retention. Exquisite DRE
usually from e.coli
Acute bacterial prostatitis
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)
- 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
STEP BY STEP rectal/prostate exam!
- 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
What are some abnormal findings you can see on rectal exam
again there are a ton… do what you want with the list :)
- 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)
what are some common diagnostic tests for males with an abnomral finding on rectal exam (5)
- 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
when are we going to refer a male with a rectal exam abnormality (3)
- Surgical condition
- Rectal or prostate mass, suspicious for malginancy
- Chronic bacterial prostatitis
when can a take home test turn positive
could do it all the way to the week before you start your next period!
when should you tell your pts to check with a take home pregnancy test
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
