Exam 1 Spring Flashcards
Quadrants and Regions of abdomen
Visceral Pain of abdomen
hollow organs: distention/forceful contraction
solid organs: stretching capsule
desc: gnawing, burning, cramping or aching
assoc: sweating pallor, nausea, vomit, restlessness
Parietal Pain of abdomen
orig: parietal pertoneum –> inflam
steady aching pain, more severe & precise localized than visc
worse with mvmt, cough
assoc with rebound tenderness
Rebound Tenderness
Blumberg’s Sign
Pain introduced or increased by quick withdrawal of pressure
Suggests peritoneal inflammation
“Which hurts more when I press or let go?
Referred Pain of abdomen
usually well localized
refer to chest, spine, pelvis
Vomitus
ask for:
- quant
- odor
- color
- bile: yellow-green
- blood: hematemesis:
- COFFEE GROUND : blood altered by gastric acids
- bright red
diarrhea
Increased water content of stool , stool volume >200 grams in 24 hours
Melena
Presence of black or tarry stool
upper GI bleed or from small bowel/right colon
Hematochezia
bright blood in stool
lower GI tract bleed or brisk upper GI bleed
Jaundice
Yellowish discoloration of the skin and sclera
From increased levels of bilirubin (a bile pigment derived mainly from the breakdown of hemoglobin)
Increased bilirubin is most suggestive of a hemoglobin problem (hemolysis) or a problem within the hepatobiliary system
Can range from benign (neonatal physiologic jaundice) to suggestive of life threatening disease (pancreatic cancer)
•Supra Pubic pain
–Can be caused by bladder or pelvic
–Bladder infection
–Urinary Retention
Order of the Physical Examination : abdomen
ØInspection
ØAuscultation
–Must precede percussion and palpation
ØPercussion
ØPalpation
ØSpecial tests
abdominal profiles
Abdominal Striae in Cushing’s Syndrome
Caput Medusae seen in Portal Hypertension
Sister Mary Joseph Nodule seen in Metastatic Disease
CULLEN’S SIGN
– Periumbilical ecchymosis
– Typically occurs in the presence of hemoperitoneum, hemorrhagic pancreatitis, or uterine tube rupture in ectopic pregnancy.
–Physical findings: Bluish discoloration or ecchymosis around the umbilicus; abdominal tenderness may also be present
GREY TURNER’S SIGN
–Flank ecchymosis
–Typically occurs in the presence of retro-peritoneal bleeding
–Hemorrhagic Pancreatitis
Auscultation of Bowel Sounds
Perform before palpation and percussion.. Why?
- Provides information about bowel motility
Use the diaphragm of your stethoscope
Note the frequency and the character of the bowel sounds
Types of Bowel Sounds: normal
- sounds occur 5 to 34 per minute in frequency and consist of gurgling and clicks in character
Types of Bowel Sounds: borborygmi
•are loud, easily audible sounds. Prolonged gurgles of hyperperistalsis. They are normal, too.
Types of Bowel Sounds: High pitched
•tinkling (raindrops in a barrel) sounds are a sign of early intestinal obstruction.
Types of Bowel Sounds: Increased
•diarrhea or early intestinal obstruction
Types of Bowel Sounds: Decreased
•(none for a minute) are a sign of decreased gut activity. Gut sounds may be markedly decreased after abdominal surgery; abdominal infection (peritonitis) or injury.
ØTypes of Bowel Sounds: absent
(no sounds for 2 minutes)
caused by
- longer-lasting intestinal obstruction
- intestinal perforation
- intestinal (mesenteric) ischemia/infarction
Auscultation of Vascular Sounds
pathology
bruit: abdominal aorta, renal arteries , femoral arteries
friction rub: Over the spleen and liver
venous hum: between xiphisternum and the umbilicus
Auscultation- Bruits
ØTechnique: Use the bell* of your stethoscope to listen for bruits in each of the areas shown in the picture:
ØListen for:
- Aortic bruits – in the epigastrium. They may be a sign of abdominal aortic aneurysm
- Renal artery bruits in each upper quadrant. They may be a sign of renal artery stenosis, which is a potentially treatable cause of hypertension
- Iliac/femoral bruits in the lower quadrants. They may be a sign of peripheral atherosclerosis.
oPercussionf abdomen
Assess the distribution of tympany and dullness
- tympany: normal over gastric air bubble/gas filled portions of intestines
- excess: gas during obstruction
- dullness: normal over solid organs
- unexpected: enlarged organs, mass
technique:
- Epigastric area
- Gastric air bubble
- Liver borders to estimate span
- Spleen size
Palpation: what if pt complains of pain?
palp that area last
Palpation Technique- Light Palpation
Use one hand, fingers together and flat on the abdominal wall, pads of fingers
palp during exhale = facil M relax
- mouth breathe
- voluntary guarding usu dec with these maneuvers
Deep Palpation of abdomen
use both hands: palmar surf
You ask your patient to tell you “ which hurts more when I press or let go” and then you proceed to firmly press your fingers down into her abdomen and then withdraw your hand quickly. By doing this technique you have assessed for the presence of:
a) voluntary guarding
b) Blumberg’s sign
c) rigidity
d) Cullen’s sign
Blumberg’s sign
Percussion- Liver Span
Measure the vertical span of the liver in the right midclavicular line
- lower border: Start at a level below the umbilicus in the right lower quadrant and percuss upward toward the liver
- upper border: nipple line down from lung resonance (have pt displace breast)
normal:
- greater in men & tall people
- midsternal: 4-8cm
- midclav: 6-12 cm
Liver Palpation
Use your left (posterior hand) to bring the liver anteriorly to facilitate palpation by your right hand
Ask the patient to take a deep breath
During inhalation the liver will move inferiorly (about 3cm below the costal margin in midclavicular line)and become easier to palpate
cannot feel it move your palpating hand closer to the costal margin and try again
Hooking Technique
alternative method to palpation of the liver
Splenic Percussion
ØTwo Techniques:
- 6th rib:
- left lower anterior chest wall roughly from the border of cardiac dullness –> anterior axillary line and down to the costal margin, Traube’s space.
- If tympany is prominent, especially laterally, splenomegaly is not likely.
- Test for the Splenic Percussion Sign:
lowest interspace in the left anterior axillary line: usually tympanitic.
- ask the patient to take a deep breath, and percuss again.
- spleen size is normal, the percussion note usually remains tympanitic
Spleen Palpation
pt supine:
Use your left (posterior hand) to bring the spleen anteriorly
Ask the patient to take a deep breath
- During inhalation the spleen will move inferiorly and become easier to palpate
Repeat with the patient lying on their right side with their hips and knees partially flexed
§~In 5% of adults a spleen tip is palpable
Kidney Palpation
With patient supine- Palpate the right kidney
Use your left (posterior hand) to bring the kidney anteriorly
Ask the patient to take a deep breath
- During inhalation the kidney will move inferiorly
- normal right kidney may be palpable
- normal left kid = rarely palp
Costovertebral Angle Tenderness
location: lower border of 12th rib and TP of upper lumbar vert
•Palpation first
–Use fingertips
–May not be enough to elicit tenderness
•Fist Percussion
–Place ball of one hand in the CVA and strike it with the ulnar surface of your fist (of the other hand) Use enough force to cause a perceptible but painless jar or thud
common in UTIs (ascending), kidney stones
- 11/12th rib
Bladder Palpation
- Cannot normally be palpated
- Check for tenderness
- Suprapubic tenderness is present in a bladder infections
•Bladder can be palpable if it is distended above the pubic symphysis
- dome feels smooth and round
•Use percussion to determine how high the bladder rises above the public symphysis
–If filled with urine, will be dull to percussion
–If empty will be tympanic to percussion
Palpation of the Aorta
Press firmly and deeply in the upper abdomen, Slightly to the left of midline
One hand on each side of the aorta
Feel for the aortic pulsations
Assess the width
–>3cm is suggestive of an AAA
Ascites
percussion gives dull note (fluid sinks with gravity and gas
ØTest for shifting dullness: ascites
- turn onto one side
- In a person without ascites, the border between tympany and dullness usually stay relatively constant.
Test for a fluid wave: ascites
ØTest for a fluid wave.
•Ask an assistant to press the edges of both hands firmly down the midline of the abdomen.
- stop the transmission of a wave through fat.
•While you tap one flank sharply with your fingertips, feel on the opposite flank for an impulse transmitted through the fluid. An easily palpable impulse suggests ascites.
The presence of these three
make the diagnosis of ascites highly likely:
§A positive fluid wave
§ shifting dullness
§ Peripheral edema
Appendicitis
§Inflammation of the appendix
§Acute appendicitis often presents as “acute abdomen”
§Early diagnosis is critical
§Most often, the inflamed appendix will be surgically removed so it does not rupture
disease progress progresses, the parietal peritoneum becomes affected by inflammation and the pain migrates and localizes to RLQ
Assessing for Signs of Appendicitis
- Ask patient to show you where pain began and where it is now
- Ask patient to cough to see where pain occurs
- Search for the area of local tenderness … Classically at Mc Burney’s Point
- Assess the Abdomen for Peritoneal signs (guarding rigidity and rebound tenderness)
- Asses for a Rovsing’s Sign
- Assess for a Psoas Sign
- Assess for an Obturator Sign
- Perform Rectal and Gynecologic exam
McBurney’s Point-
§lies two inches from from the Anterior superior iliac spine to navel
ROVSING SIGN-
§pressure (via palpation) on LEFT lower quadrant moves the parietal peritoneum, (including the RLQ, over inflamed appendix) resulting in the RLQ pain
Referred rebound tenderness-
Appendicitis- Psoas Sign
•Pain with resisted flexion on the right side suggests inflammation of the right psoas muscle by the overlying inflamed appendix
Appendicitis-
Obturator Sign
pain with passive internal rotation of flexed thigh
lower leg lat while applying resistance to lat side of knee
You are concerned that your patient has acute appendicitis. You press on her left lower quadrant and she states she feels pain in her right lower quadrant. You have just determined that the patient has a positive:
a) Obturator sign
b) Rovsing’s sign
c) Turner’s sign
d) Murphy’s Point Tenderness
e) Psoas Sign
Rovsing’s sign
Cholecystitis
Murphy’s Sign
Cholecystitis
§elicited by firmly placing a hand at the costal margin in the right upper abdominal quadrant and asking the patient to inhale deeply
§If the gallbladder is inflamed, the patient will experience pain and catch their breath as the gallbladder descends
Ventral Hernia
Are hernias in the abdominal wall exclusive of groin hernias.
Protrusions of the intestines through the abdominal wall
- may be observed as a budge or felt as a mass
Special Technique:
- ask the patient to raise both head and shoulders off the table. The bulge of a hernia will usually appear with this action.
- intra-ab mass will bve obscured by overlying ab M
Assessing for Peritonitis
Ask patient to cough and identify where pain is reproduced
Palpate gently first with one finger then with your hand
Check for rigidity, rebound and percussion tenderness
If positive— suggests peritonitis
Peritonitis Signals an Acute Abdomen
risk factors for AAA
over 65 years old
smoking hx
male
1st degree relative with hx
A 60 year old male presents with passing bright red blood in his stool for the past month. Your patient is having:
a) melena
b) hematochezia
c) hematemesis
d) hemoptysis
hematochezia
A 30 year old female with no past medical history presents with stomach pain and vomiting. When asked to describe the vomit she states that is looks like coffee grounds. You suspect she has:
a) hemorrhoids
b) peptic ulcer disease
c) small bowel obstruction
d) pregnancy
●
b)peptic ulcer disease
A 45 year old male presents with frequent heartburn associated with nausea and vomiting. He is not a new patient to the office. In addition to a thorough examination of his abdomen which other parts of the physical exam will you perform at this visit?
The CORE Physical Exam
The basics-the fundamentals that are always* done:
- General Survey
- HEENNT
- Cardiac
- Respiratory
- Abdomen/GI
- Musculoskeletal
The proper sequence of the abdomen examination is:
●
a) Inspection, percussion, palpation, auscultation, special testing
b) Inspection, palpation, percussion, auscultation, special testing
c) Inspection, auscultation, percussion, palpation, special testing
d) Auscultation, inspection, percussion, palpation, special testing
The proper sequence of the abdomen examination is:
●
a) Inspection, percussion, palpation, auscultation, special testing
b) Inspection, palpation, percussion, auscultation, special testing
c) Inspection, auscultation, percussion, palpation, special testing
d) Auscultation, inspection, percussion, palpation, special testing
Cullen’s Sign
A 25 year old male presents with diarrhea for the past 12 hours. On auscultation of his abdomen you hear:
a) decreased (hypoactive) bowel sounds
b) normal bowel sounds
c) increased (hyperactive) bowel sounds
d) absent bowel sounds
increased (hyperactive) bowel sounds
Diverticulitis
A 35 year old female presents with pain in her “stomach ”. She describes the pain as a steady aching pain which is exacerbated when she moves. To further assess her pain you ask her “ what hurts more when I press in or when I let go” The patient tells you that the pain is worse when you withdraw or let go. She most likely has:
a) Visceral pain
b) Parietal pain
c) Referred pain
a)Parietal pain
Abdominal pain worse as you withdraw your hand on palpation is known as:
Rebound Tenderness
A 40 year old female presents with “pain in my right side” as she points to the right upper quadrant and epigastric region. The patient admits to nausea and her pain worsens after a meal. This patient most likely will have referred pain to the right:
a) Sternal region
b) Subscapular region
c) Iliac region
d) Groin region
•
a)Subscapular region
To further assess the cause of her pain you firmly place your hand at the costal margin in the right upper abdominal quadrant and ask the patient to inhale deeply. Upon palpation of this area the patient experiences pain and catches her breath. This is a positive:
a) Murphy’s sign
b) Rovsing’s sign
c) Obturator sign
d) Psoas sign
Murphy’s sign
A sudden increased in tenderness with a sudden stop of inspiratory effort
indicates: cholescystitis
During the abdominal exam, you palpate deep to the left costal margin during inspiration. At this site you most likely will palpate the:
a) Liver edge
b) Spleen edge
c) Appendix
d) Gallbladder
e) Kidney
●
a)Spleen edge
The normal liver span is approximately :
a) 4-12 cm in the midsternal line
b) 6-8 cm in the midclavicular line
c) 4-8 cm in the midclavicular line
d) 6-12 cm in the midclavicular line
6-12 cm in the midclavicular line
Which part of the abdominal exam is important in a relatively healthy 68 year old male with a 50 year pack history of tobacco?
a) Assessing for a ventral hernia
b) Assessing size of the abdominal aorta
c) Assessing for hepatomegaly
d) Assessing for splenic enlargement
a)Assessing size of the abdominal aorta
Risk factors for AAA - Abdominal Aortic Aneurysm
- > 65 years old
- Smoking history
- Male
- First degree relative with history
•
During your 3rd year rotation you are assigned to follow up on a patient admitted with abdominal pain. You review the chart and note that the resident documented in the abdomen portion of the physical exam that the patient has a positive fluid wave and shifting dullness. This finding indicates that the patient has:
Ascites
A 25 year old female presents with urinary frequency and burning. On physical examination her vital signs are: Temp 101F, BP 110/80mm Hg , HR 80 bpm and RR 16 bpm. There is tenderness on suprapubic palpation but no distention of the urinary bladder. You should further assess her for:
a) Splenomegaly
b) CVA tenderness
c) Ascites
d) Periumbilical tenderness
CVA tenderness: costovert angle
breast health hx concerning symptoms
lump
pain/discomfot
nipple discharge
skin changes
breast ca risks: modifiable
post-menopause obesity
HRT
alcohol
physical inactivity
breast feeding
contraceptives
breast ca risks: NON-Modifiable (5)
age:
- > 50
- 1st full-term preg: late or none
- menarche: early < 12y/o
- menopause: late > 55
prev hx:
- fam breast/ovarian - 1st degree relative
- breast ca
- chest wall rad
atyp hyperplasia
breast density
probably: hx not breastfeeding
ORDER of Breast exam
1.INSPECTION (axilla and breast) with patient’s:
- arms at sides
- arms over head
- hands on hips
- then leaning forward
- PALPATION:
- Axilla (seated)
- Breast (supine)
- Nipple
- If you palpate a mass, go back & recheck for nodes.
AXILLAE EXAM
pt seated: rash, infection, color
- L ax: pt relaxes with arm down
- supp with L hand
- cup R hand –> reach towards apex –> try feel nodes
If central axillary nodes enlarged, feel for
–Pectoral nodes: grasp anterior axillary fold & palpate inner border of pectoralis
–Subscapular nodes: from behind patient feel inside posterior axillary fold
–Lateral nodes: feel along upper humerus from high in axilla
–Remember Infraclavicular and Supraclavicular nodes
Lymphatic flow –female breast
central = deep in ax
- PECTORAL NODES=ANTERIOR: along lower border of Pectoralis Major inside AAF
Drain: anterior chest wall & much of breast
- SUBSCAPULAR NODES = POSTERIOR: along lateral border of scapula; palpated deep in PAF
Drain posterior chest wall and part of arm.
- LATERAL –along upper humerus.
Drain most of arm
Fibroadenoma
- Ages 15-25
- Single, occasionally multiple
- Round, disc-like, or lobular
- Firm and rubbery
- Well delineated, mobile
- Nontender
- No retraction signs
Patient education: teach Breast Self Examination
5-7 days after onset of menses
- supine: pillow under R shoulder, R arm behind head
- palp with 3 middle fingers of L hand in vert strip pattern
- exam L
- soapy shower: ! arm behind head –> palp
- mirror: arms @ sides, hands on hips
PALPATION CBE: clinical breast exam
front opening gown:
- full exposure for inspection
- drape 1 while palp other: 3 min each
vert strip pattern
- circ motion with pads of 3 fing: vary light –> med –> deep
- may need lub to dec noise/skin friction
supine: clav –> inframmam fold, mid stern –> midax: started at tail of breast
lateral: pt on opp hip with hand on forehead: ax –> bra line –> clav –> end at nip
medial: pt shoulders flat with hand @ neck and elbow even with shoulder: nip –> bra line –> clav –> midsternum
Nodules: look for…
- Location, size (cm), shape
- Consistency
- Delimitation-well circumscribed
- Tenderness
- Mobility
Assessment of Nipple Discharge
- Compress circumferentially on areola to determine origin.
- Note # of ducts nipple discharge is from
- NOTE: color, consistency, quantity, location
FEMALE GENITALIA exam, Lithotomy position
Obtain urine specimen ______ GYN exam
before
GYN exam order
1.External inspection & palpation
- external genitalia
- pubic area
- Bartholins glands
2.Speculum exam:
- cervix
- Obtain specimens (Pap smear then cultures)
- Internal inspection: vaginal walls, check for muscle tone
- Bimanual exam: palpation of cervix, uterus, adnexa
- Rectovaginal exam
- Rectal exam- guaiac/hemoccult (if applicable)
Anatomy
ectocerv: visible
- red columnar epith around os
- ext os = vis opening of cervix: round/slit
- pink shiny sq contin with vag opening
endocerv:
- columnar: thick, red
- sq-columnar jx
•@ Puberty- columnar encircling Os= (ectropion )is replaced by squamous epithelium. Later risk dysplasia! PAP smear.
Lymphatics
•Inguinal nodes receive drainage from vulva and lower vagina
•
•Pelvic and abdominal nodes drain upper vagina and internal organs
•
•Only Inguinal Nodes are accessible to examination
Health Promotion and Counseling
- Cervical cancer screening: Pap smear & HPV
- Family planning
- STIs and HIV
- Menopause
•For best results with cervical cancer screening
not on period
avoid sex, douches, tampons, contraceptive forms/creams, vag suppositories for 48hrs prior to exam
Risks for cervical cancer
viral: HPV 16, 18
behavioral: early sex, mult partners, STIs, no PAP, age, nutrition, smoking, immune status
Maximize Comfort for cerv exam
empty bladdar first: urine specimen
supine: head/shoulders elev, arms on side/chest
drape mid-ab to knees, depress in center for eye-contact
assist into lithotomy pos
- side to edge of exam table with butt just past tbl edge
- stirrups: thighs flex, abducted, hips ext rotated
no sudden moves –> may touch inner thigh first
warm speculum if not plastic
•Examiner _____ for speculum exam & ____ for bimanual exam
sits
stands
lubricant
water only
gel may interfere with cultures and cytological studies
gloves while inspecting external genitalia
both hands: double on dom hand
palp of external genitalia
bartholin’s (only if hx or inspection suspects a problem)
- index into introitus post/lat with thumb outside post labia maj
palp for lump
inpect for discharge
culture
Speculum insertion
- water lub
- hold 45 deg: entry angle
- intro closed speculum oveer finger –> vag
- direct post/downward: slide down post vag wall
- remove finger
- rotate to horiz pos
- open blades: warn of clicking noise
- look into vag: rotate until vis cervix
- pos ends until they cup cervix
- “lock” blades into place
pap smear
plastic scraper
- longer end into os –> press/turn/scrape in full clockwise circle
- include txformation/sq-colum jx
- smear –> glass slide
endocerv brush
- cone shapred brush –> cerv ox
- roll in circle b’w thumb/index
- smear onto glass in paint/rolling motion
liquid base test
- less false neg, no slides/ fixative
- use broom –> obtain specimen –> detach tip of broom into container
preg = cotton-tip applicator & saline
CMT
pain with cerv mvmt: cerv motion tenderness
Chandelier’s sign
- adenexal tenderness –> PID
blueish hue to the cervix or vaginal walls
–Chadwick’s Sign of early pregnancy
palp uterus
ext hand b/w pubic symp & umb –> press down and in
int hand: elev cervix –> slide to anterior fornix & palp body of uterus b’w 2 hands
internal pelvic fingers feels anterior uterus
ab hand feels part of posterior uterus
if unable: pt’s uterus may be tipped post –> slide fingers to posterior fornix
palp ovaries
standing
ab hand on RLQ: press in/down –> push adnexa to pelvic hand
pelvic hand in R lat fornex
Assess Pelvic Muscle Strength
Rectovaginal Examination
re-glove by removing glove of dom hand (remember it was dbl gloved)
most useful= feel post of retroverted uterus
- explain
- index = vag, middle = anus
* ask pt to strain down to relax anal sphincter as you insert finger
URETHRAL EXAM
perform for:
- urethritis
- inflam paraurethral glands
- index finger –> vag –> milk outwards
urethral culture for GC, chlamydia
Breast masses: characteristics : benign
- +/- skin changes
- Smooth, soft ,firm and mobile
- Well defined
- But, May still be cancer
Breast masses: characteristics : malignant
- Hard
- Immobile
- Fixed to skin or soft tissue
- Irregular margins
- Skin changes
anorectal jxn
pectinate/dentate line
- serrated line
boundary b/w
- somatic/visc N supp
- vasc
- lymph
- embryo
- histology
anal columns (Morgagni)
- each = A + V
- from retum –> anorectal jxn
- incr venous P –> vein = hemorrhoid
prostate
secr thin, milky alka fl = spern viability
peritoneal reflection
covers only upper 2/3
males = rectovesical pouch
females: rectouterine pouch
valves of Houston
3 semilunar txverse folds
cross 1/2 circum of rectal lumen
lowest can be palp: do not mistake for intrarectal mass
technique for rectal exam
drape
pos: L lat
Pilonidal Cyst or Sinus
- Common
- Congenital
- Sinus tract opening
- Generally asymptomatic
- Slight drainage
anal fistula
- Inflammatory tract or tube
- Openings at skin and anus or rectum
Hemorrhoids
- Chronic increased venous pressure, forming a hemorrhoid
- Internal Hemorrhoids:
–Occurs above dentate line
–Painless rectal bleeding
•External Hemorrhoids:
- –Occurs below dentate line
- –Painful swelling of that area
Pruritus Ani
causes = 7
- May be due to pinworms, especially in younger patients
- Other causes:
–Hemorrhoids
–Excessive skin tags
–Fecal soilage or incontinence
–Anal fistulae (abnormal passageways between the bowel and an organ or skin surface)
–Anal warts
–Irritation
–Fungal infection
Enterobius vermicularis
pinworm: egg deposit on perianal folds
itching = most comm symptom
reinfection common –> can infected entire household
anal fissure
- Painful
- Oval ulceration
- Sentinel tag
- Associated with prior abscess, proctitis, Crohn’s disease
- Anal intercourse places men and women at risk for perianal and rectal abrasions/ lesions and transmission of HIV and other STI’s
Condyloma Acuminata
- Ano-genital warts
- Human Papillomavirus
- Symptoms range from asymptomatic to pruritus, bleeding, burning, tenderness
- Distinguish from condyloma lata
Condyloma lata
- Secondary syphillis
- Flat and velvety
- Distinguish from condyloma acuminata
Rectal prolapse
projection of pink mucosa
Rectal Polyps
- Common
- Variable size and number
- May be pedunculated (on a stalk) or sessile (flat)
- May be difficult to palpate
Rectal Cancer
- Irregular border
- Firm, nodular, rolled edge
- Central Ulceration
Rectal Shelf
- Peritoneal metastasis to peritoneal reflection anterior to rectum
- Source can vary
- Firm or hard
- Felt with tip of examining finger
Fecal Occult Blood Testing
hidden blood
may indicate bleeding in GIT, colon ca, polyps
- but don’t always bleed
one neg stool sample does not rule out ca
- false-pos if person ate red meat w/in 3 days of test
United States Preventive Services Task Force (USPSTF) Colorectal Cancer Screening Guidelines
Screening Test Intervals:
- Annual screening with high-sensitivity fecal occult blood testing
- Sigmoidoscopy every 5 years, with high-sensitivity fecal occult blood testing every 3 years
- Screening colonoscopy every 10 years
DRE: digital rectal exam
- no recomm as stand-alone for colorectal ca
- reach = lim
- stool sample during: can miss>90% colon abnorm, inclu most ca
Normal Anal / Rectal Exam (5)
male and female
No sacrococcygeal, anorectal lesions or fissures.
External sphincter tone intact.
Rectal vault without masses.
Stool brown
Fecal Occult Blood Test negative.
Male: Prostate smooth and non-tender with palpable median sulcus.
Female: Uterine cervix non-tender.
A 24 year old female with a history of hypothyroidism presents with pain with defecation and occasional blood on the toilet paper. She was well until last week when she had food poisoning associated with nausea, vomiting and diarrhea. She had runny stools but no black or bloody stools. Ever since her illness, she has severe pain with bowel movements. She now tries to put off defecation as long as possible and is having constipation. She denies any further diarrhea or leakage of stool. There is no family history of colon cancer. She has had no weight changes or night sweats. On examination, Vital Signs: T 98.6 F, BP 115/70 mm Hg, pulse 80 bpm, RR 16bpm. Abdominal examination: +active bowel sounds, non-tender in all quadrants, and has no masses or hepatosplenomegaly. Inspection of the anus reveals inflammation with erythema. You are unable to insert your finger in the anal canal due to pain.
At this point you want to assess her for an:
a) Anorectal fistula
b) External hemorrhoid
c) Anal fissure
d) Anorectal cancer
a)Anal fissure
A 65-year-old male presents to clinic for a routine examination. The following is the documentation of his prostate examination. Which finding would be of concern?
a. Firm
b. Heart-shaped
c. 2.5 cm long
d. Median sulcus palpable
Firm
DIPSS
male genitalia concerns:
Discharge from penis
Infection (Previous)
Pain in scrotum
Swelling in scrotum
Sores or growths on penis
Phimosis-
•inability to retract the foreskin over the glans.
-Can lead to infection, iatrogenic trauma, and SCC.
Tx: circ or dorsal slit
Smegma-
cheesy & whitish secretion under foreskin
Paraphimosis
•Retracted foreskin cannot be returned to anatomical position.
–Usually caused by healthcare personal.
–If not addressed in timely manner can lead to impairment of circulation and result in gangrenous changes of the glans.
–If reduction is not successful may need surgical dorsal slit.
Hypospadias
–displacement of urethral meatus to the underside
Balanitis
–inflammation of the glans
Balanosposthitis
–inflammation of glans and foreskin
how to palp penis
shaft b/w 1st and 2nd fingers
Anogenital warts
- Most common viral STI in the United States (HPV)
- Asymptomatic or pruritus, bleeding, burning, tenderness, or pain
- Can occasionally form large exophytic masses that can interfere with defecation & intercourse
lesions: colored/pink, flattten papules to verrucous papilliform
location: shaft in circumcised, glans in uncircumcised
tx: chem/phys destruction, immunologic therapy, sx excision
Genital Herpes
HSV1 and HSV2
•Presents with painful ulcers, dysuria, fever, tender local lymphadenopathy, headache
- maybe mild, subclinical, or entirely asymptomatic
- small vesicles followed by painful ulcers on red base
has latent state followed by reactivation and recurrent local disease.
•Average incubation period after exposure is four days (2-12 days)
Syphilis
txmitted via direct contact: early lesions (primary/secondary) = very infectious
incub period = 2-3 weeks
papule (usu painless) @ inoc site –> ulcer –> 1-2 ulcer with raised, indurated margin (classic)
chancres heal spont w/in 3-6 wks even without tx
tx: long-acting pcn
Hypospadias
congenital displac urethral meatus to inferior surf of penis
one of most comm congen anomalies
can have addn congen of genital organs: undesc testes, intersex
- no circumcision
•Peyronie’s disease:
acquired, localized fibrotic d/o of the tunica albuginea resulting in penile deformity, pain, and in some men, erectile dysfunction .
–Pt c/o crooked painful erections
–Palpable nontender hard plaques beneath skin, dorsum of penis
–can resolve spontaneously minority of cases
–Tx: observation, medical, or surgical therapy, depending
Penile Fracture
–Rupture of the tunical albunginea of the corpus cavernosum due to external trauma of the erect penis.
–On examination must rule out associated urethral injury.
Carcinoma of the Penis
–rare in developed countries (up to 20 % of cancers in men in some parts of Africa, Asia, and South America)
indurated, nontender nod/ulcer: biopsy mandatory if no response to conserv therapy
may be masked by foreskin
seen in uncircum
inc risk with HPV, HIV, smoking, PUVA exposure, AA
95% sq cell carcinoma
- The pt is sexually active with only 1 female partner in the last yr. He has had 1 other female partner prior. He became sex active at the age of 15.
- He denies any penile discharge, but is concerned about lesions on his penis. He is anxious and embarrassed. The pts states that these lesions appeared about 7 years earlier.
- He was previously dx with condyloma accuminatum. The lesions did not respond to tx with various topical wart preparations.
- What do you think this patients diagnosis is?
Pearly Penile Papules
- This normal variant is seen more commonly in AA and circ men.
- Asymp acral angiofibromas, typically dist circumferentially on the corona & sulcus of the glans
- More frequently after puberty
- Important:
–Be Familiar with normal anatomical variants which may resemble various dermatologic conditions.
–This helps to relieve anxiety in pts & prevent unnecessary treatments.
Epididymis
sup/post surf of testicle: feels cordlike/nodular
Transillumination of the Scrotum
scrotal swell = red glow = serous, hydrocele
no glow = blood, testis, tumor, most hernias
Hydrocele
- Nontender
- fluid-filled mass in the tunica vaginalis
- fingers can get above mass within the scrotum
•
Scrotal Edema
- Pitting, taut skin
- May be seen in:
–CHF
–Nephrotic syndrome
Epidermoid Cysts
•Firm, yellowish, nontender skin nodules on scrotum
Cryptorchidism
testi = absent/undescended
- inguinal canal, abdomen = undev scrotum
- most common = just outside ext ring (suprascrotal)
inc rist for tes ca if not corrected
- infertility
- tes torsion
- inguinal hernia
most descend spont by 6 mo: if not = sx asap
Acute Orchitis
- Inflamed, painful, tender & swollen testicle
- May be difficult to distinguish from epididymis
- Possibly red scrotum
- Usually Unilateral
- Mumps, viral
Small Testis
tes length: = 3.5 cm
can be due to
- –Atrophy in cirrhosis
–Myotonic dystrophy
–Estrogen use
–Hypopituitarism
–or may follow orchitis: klinefelters (= 2 cm. small firm testes)
Testicular Tumors
risk fac (7)
MOST COMMON neoplasm in men Age 15- 35
- early painless nod –> tumor replacing testicle
- tes feels heavier than usual
Risk factors:
- Cryptorchidism
- Carcinoma of contralateral testicle
- Mumps orchitis
- Childhood hydrocele
- Tumor markers-AFP, bHC
- Lymphatic spread to chest & brain
Dx-ultrasound & bx
Testicular Self Examination TSE age range
15-35
Epididymitis
- Acute and subacute forms
- May have red scrotum
- May have inflamed vas deferens
- Mainly adults
- Commonly seen in conjunction with acute prostatitis
Acute Epididymitis
- Severe swelling and exquisite pain in the involved side
- Often accompanied by high fever, rigors, and irritative voiding symptoms (frequency, urgency, dysuria) secondary to UTI
- May be difficult to distinguish from testis
Varicocele
- “Bag of worms”
- Varicose veins of spermatic cord
- Usually left side
- Possible infertility
- Collapses when scrotum elevated
- Patient Standing for varicocele exam best position
Tuberculosis of the Epididymis
–Chronic inflammation of Tb produces firm enlargement of epididymis
–Sometimes tender
–Thickening or beading of vas deferens
spermatocele/ epididymal cyst
s = >2cm
ec = < cm
painless, movable cyst above testis: txillumin
Testicular Torsion
or
Torsion of the Spermatic Cord
Twisting of the testicle on its spermatic cord
- affect bv –> necrosis
- painful
- tender
- swollon
- retracted up
- red/edema scrtum
pain = constant, severe
no reflex
Inguinal Hernia - Palpation
pt standing: invag scrotal skin with index –> follow spermatic cord, above inguinal lig –> ext inguinal fing –> enter ring –> ask pt to strain/cough –> hernia will touch finger
Indirect Inguinal Hernia
*Most common groin hernia in men and women
- defective obliteration of the fetal processus vaginalis
•Origin: lateral to the inferior epigastric artery
- Comes down inguinal Canal & touches fingertip, often into scrotum
- Often felt as a bulge near the internal inguinal ring
most =
- congenital
- on the right, the side that descends last
Direct Inguinal Hernia
Less common; usually men > 40 y/o
Hesselbach’s triangle
- inguinal ligament inferiorly, the inferior epigastric vessels laterally, and the rectus abdominus muscle medially
weakness in the floor of the canal
Origin: above Inguinal Ligament near pubic tubercle (near EIR)
Bulges anteriorly & pushes finger forward
Can be palpated as a bulge near the external inguinal ring
Rarely enters scrotum
Femoral Hernia
palp anterior thigh over fem canal: ask pt to strain/cough
never enters canal/scrotum
women > men: least comon hernia
most common methods for prostate ca screening
PSA: glycoprotein from prostate
DRE
- many false positives
Anatomy of the Prostate
- 2 LATERAL LOBES against anterior rectal wall.
- It is palpable as a rounded or heart-shaped structure 2.5 cm long
- Lobes separated by MEDIAN SULCUS (groove)
- 3rd (median) lobe anterior to urethra, that is not palpable
- Seminal vesicles lie above prostate, NOT normally palpable
- Prostate increases in size fivefold from puberty to age 20
- 5th decade: prostatic hyperplasia causes further increase in size
•
Examination Findings Prostate
normal:
- round/heart shaped
- 2.5 cm
- palp median sulcus & 2 lat lobes
BPH:
- enlg symm
- smooth, firm, elastic
- protrues into rectal lumen
- medial sulcus may be obliterated
prostate ca
hard area: feels like nodule –> enlg –> irreg & ext beyond gland
median sulcus may be obscured
symp: urin urgency, nocturia, freq/hesitancy with pee
gen cmpt: higher with increased age and fam hx
- usu 50-90 –> lymph spread to bone
new onset ED = suspicion for prostate gland path
Prostatitis
Acute bacterial: tender, swollen, firm, warm prostate, fever
- mostly gram (–) infections
elev PSA
Benign Prostatic Hyperplasia
BPH
Chronic enlargement of prostate
Seen in 1/3 of all men by age 65
Irritative s/s: urgency, frequency, nocturia
obstructive s/s: decreased stream, incomplete emptying straining or both
Can cause urinary obstruction and chronic UTI
