Exam 3 - End of Study Guide Flashcards
Guidelines for pregnancy & nicotine use
Nicotine increases chance of miscarriage and low birth weight; goal is cessation but any decrease is beneficial
Guidelines for pregnancy & alcohol use
No safe amount of alcohol is known due to the risk of fetal alcohol syndrome; women should not drink any alcohol during pregnancy
Guidelines for pregnancy and illicit drug use
Various drugs have various effects, but women should be referred to treatment immediately if addicted to support quitting
Characteristics & presentations of condyloma acuminatum
Genital warts - single or multiple papules or plaques of variable shapes that may be round, acuminate (pointed), or thin and slender. May be raised, flat, or cauliflowerlike (verrucous). Can arise on any part of genitalia , groin, thighs, or anus. Usually asymptomatic but may cause itching or pain. Incubation of HPV for weeks or months before appearance; may disappear w/o treatment, but this is unlikely.
Characteristics & presentations of genital herpes
Small scattered or grouped vesicles 1-3mm in size on glans or shaft; appear as erosion if vesicles break; HSV 2 (double stranded DNA virus) ﾖ 2-7 days after exposure; Primary episode may be asymptomatic; subsequent episodes usually less painful/shorter
Characteristics & presentations of primary syphilis
small red papule that becomes a chancer (painless erosion) up to 2 cm in diameter; base of chancer is smooth, clean, red, & glistening; borders are raised and indurate. Chancer heals in 3-8 wks. Caused by Treponema palliduma spirochete. Incubates 9-90 days before symptoms appear. Inguinal lymphadenopathy may occur within 7 days with rubbery, non-tender, mobile lymph nodes. 20-30% of patients develop secondary syphilis while chancer is still present (suggest coinfection of HIV). Must distinguish from genital herpes, chancroid, granuloma inguinale
Characteristics & presentations of secondary syphilis
A continuation of primary syphilis due to lack of treatment; syphilis infection becomes systemic. Occurs 2-8 wks after developing primary syphilis and usually marked by a non-itchy rash that may be confined to one region, or may present in several regions. A common manifestation is rough, reddish-brown dots on bottoms of feet and palms of hands that may be scaly or smooth.
Steps of a pelvic exam
External exam (inspect & palpate); Internal exam (speculum exam including PAP smear & screenings; bimanual; rectal; bimanual rectal)
Equipment needed for a pelvic exam
Vaginal speculum; water-soluble lubricant; specimen collection materials; large cotton tips swabs and sterile swabs; gloves (2 pair); hemoccult card & reagent; light source
Equipment needed for a PAP smear
Cervical brush and wooden/plastic spatula OR cervical broom; liquid prep media OR glass slide and cytologic fixative; culture plate or media; sterile cotton swabs; DNA probe (for chlamydia and gonorrhea)
Describe how a female patient should be positioned for the pelvic exam.
Lithotomy - elevated head of bed; feet in extended stirrups; buttocks near edge of table; knees “dropped to the side”; patient appropriately draped to cover while maintaining good eye contact
Describe the process of performing an external examination of the female pelvis.
Inspection & palpation of hair (pattern, presence of lice), mons veneris (lesions/swelling); vulva (excoriations, masses, redness, leukoplakia, or pigmentation); labia (lesions, ulcers, discharge, warts, trauma, swelling, atrophic changes, masses); urethral meatus (pus or inflammation); clitoris (size, lesions); Bartholin’s glands (palpate for tenderness, swelling, pus; normal glands not see or felt); perenium (masses, scars, fissures, or fistulae); anus (hemorrhoids, irritation, fissures)
Describe the process of performing an internal examination of the female pelvis.
Position CLOSED speculum as far into the vagina as possible. When completely inserted, rotate speculum so handles point downward. SLOWLY open speculum. With blades open, visualize vaginal walls and cervix. Remove obscuring discharge with large cotton-tipped applicator to allow inspection. Position light to visualize well. May need to reposition the speculum. (Slightly withdraw speculum and reposition.) Cervix should rest within blade of speculum. Inspect cervix. (color, discharge, surface, bleeding, erythema).
Describe how to properly obtain a PAP smear.
Use Endocervical Spatula first. Longer end of spatula into the cervical os. Press, turn, scrape in a full circle clockwise. Make sure to include transformation zone and squamocolumnar junction. Place in cytologic solution. Do it first to minimize obscuring cells with blood. Use endocervical brush 2nd. Place into os. Roll between thumb and index finger. Remove and place in cytologic solution. OR Use an endocervical broom. Allows for collect of single specimen containing all necessary cells (both squamous & columnar epithelials).
Describe the process of performing a bimanual examination on a female.
Lubricate index and middle fingers of dominant hand. From a standing position, insert vertically into the vagina. Apply downward pressure toward perineum. Flex 4th and 5th fingers into palm, extend thumb. Avoid touching the clitoris. Note nodularity or tenderness in vaginal wall. Once fingers inserted, rotate hand 90 degrees so palm facing upward. Place left hand on abdomen, approx 1/3 of the way to the umbilicus from the pubic symphysis. Vaginal hand pushes pelvic organs up and out of pelvis and stabilizes them while they are palpated by the abdominal hand. Push cervix up and back toward the abdominal hand as the abdominal hand pushes downward. This tips an anteverted, anteflexed uterus forward to make palpation easier. Retroverted uterus is not easily felt on bimanual. (remember retro ﾖ toward rectum). Normally can move cervix somewhat without pain, 2 ﾖ 4 cm in any direction. (Extreme cervical motion tenderness ﾓChandelier signﾔ). Palpate fornices. Palpate the body of the uterus between your hands. Pelvic fingers feels anterior surface of the uterus. Abdominal hand feels part of the posterior surface. Palpate adenexa. Abdominal hand on right lower quadrant & pelvic hand in right lateral fornix. Press your abdominal hand in & down, trying to push the adnexal structures toward your pelvic hand. Try to identify the right ovary or any adjacent adnexal masses. Move your hands slightly & slide the adnexal structures between your fingers. Repeat on left side. Move fingers to posterior fornix. Palpate uterosacral ligaments and Pouch of Douglas. Tenderness and nodularity suggest endometriosis.
Explain what is being evaluated in a female bimanual exam.
Evaluate uterus (size, shape, consistency, mobility, and ID any tendernes or masses). Evalute adenexa (size, shape, consistency, mobility, and tenderness). Normal adenexa are slighty tender when palpated and more palpable in slender women. Adnexal tenderness/enlargement is relatively specific for pathology. Tenderness/nodularity of uterosacral ligaments or Pouch of Douglas suggests endometriosis.
Describe the characteristics & expected findings of a retroflexed uterus.
A straighter uterus that is angled toward the rectum.
Describe the characteristics & expected findings of a retroverted uterus.
A uterus that is curved backward toward the rectum. Not easily palpable on a bimanual exam.
Describe the characteristics & expected findings of an anteroflexed uterus.
A straighter uterus that is angled toward the umbilicus. Palpable during bimanual exam, especially when cervix is pushed up and toward abdominal wall.
Describe the characteristics & expected findings of an anteroverted uterus.
Uterus that is curved toward the umbilicus. Palpable during bimanual exam, especially when cervix is pushed up and toward the abdominal wall.
Describe draping techniques for a female pelvic exam.
Sheet over patient’s legs, to the knees. Indent sheet between knees to maintain eye contact with patient while performing pelvic exam.
What are you evaluating during the external examination of the female pelvic exam?
Hair, mons veneris, skin of vulva, urethral meatus, labia, clitoris, Bartholin’s glands; perineum; anus; pelvic relaxation
Describe abnormal findings of the female external pelvic examination.
Presence of lice/nits in HAIR; lesions/swelling of MONS VENERIS; excoriation/masses/redness/leukoplakia/pigment changes of VULVA; pus/inflammation of URETHRAL MEATUS; lesions/ulcers/discharge/warts/trauma/swelling/atrophic changes/masses of LABIA; size changes/lesions of CLITORIS; palpable/tender/swollen/pus of BARTHOLIN’S GLANDS; masses/scars/fissures/fistulae of PERINEUM; hemorrhoids, irritiation, fissues of ANUS;
Describe abnormal findings of the female pelvic relaxation portion of the external pelvic examination.
Process - patient coughs or bears down while labia are spread. Abnormal findings are cystoceles (bulging of anterior wall); retroceles (bulging of posterior wall); uterine prolapse (displacement of cervix toward introitus); stress incontinence
What are you evaluating during the speculum examination of the female pelvic exam?
Color, discharge, surface characteristics, bleeding, and erythema of cervix. Walls of vagina for color of mucosa, presence of inflammation, characteristics of discharge, presence ulcers/lesions
Describe expected and abnormal findings of a speculum examination.
Redness, ulcers, masses, scarring, bleeding, erythema of cervix. Patchy, gray, grayish-yellow, white, or greenish-yellow discharge on cervix; fishy odor; purulent, bubbled, cottage-cheese like, or muco-purulent discharge; red spots on cervix. Abnormal vaginal wall findings include redness, inflammation, discharge (other than normal white/clear); ulcers/lesions, cystoceles, uretocele, rectocele, enterocele, and uterine prolapse
Describe expected findings of a bimanual examination.
Cervix - non-tender with motion; smooth, consistent, regular, mobile Body of uterus - should be palpable unless retroverted; non-tender, mobile, consistent, no masses, symmetrical Ovaries - are normally slightly tender to palpation; may not be palpable in obese or tense women; symmetrical and equal on left/right; smooth; mobile
Describe abnormal findings of a bimanual examination.
Cervix - Chandelier’s sign; redness, masses, tenderness, asymmetry, hardness, or inconsistent texture of cervix, uterus, or ovaries. Tenderness or nodularity when palpating uterosacral ligaments and Pouch of Douglas suggests endometriosis.
What are you evaluating during the rectal examination of the female pelvic exam?
Assessing rectal canal for masses/tenderness, sphincter tone, fecal occult blood, and possibly exam of retroverted uterus
Describe expected findings of a rectal examination.
No masses, tenderness, or blood in stool. Sphincter tone = resistance around phalange
Describe abnormal findings of a rectal examination.
Any masses, tenderness. Positive fecal occult blood test. Lack of resistance around phalange (lack of sphincter tone)
Describe how to properly position and use the speculum in a pelvic exam.
Lubricate speculum. Separate labia majora. Enlarge Posterior or Lateral Introitus with index (posterior) or index and middle fingers (lateral). Insert closed speculum tilted slightly toward coccyx and handle angled about 30 degrees. Slide along posterior wall, slowly rotating to a neutral position where handle is vertical. Remove fingers. Slowly open speculum to expose cervix.
Describe the tools used to collect specimens from the cervix and how to use these.
Cervical spatula - used before brush. Place longer end of spatula into cervical os. Press, turn, and scrape 360 degrees clockwise AND counterclockwise. Place in cytologic solution. Endocervical brush - used after spatula. Placed into os. Roll between thumb and index finger. Remove and place in cytologic solution. Endocervical broom - may be used in place of spatula and brush. Procede with same instructions as brush.
What information should be elicited for related to breast history (HPI)?
Timing/Onset - How long? Does lump come and go? Is it always present? Relationship to menses? Symptoms - Tenderness or pain? Dimpling or change in breast contour? Changes in lump ﾖ Size; Character; Unilateral or bilateral. Associated symptoms - Nipple discharge/retraction; Tender lymph nodes. Medications ﾖ Nonprescription; Prescription
What information should be elicited for related to breast history (PMH)?
Changes in characteristics - Discharge; Lumps; Pain; Size or shape changes; Skin changes; Tenderness. Changes with menses - Lymph nodes enlarged; Pain; Swelling; Tenderness. Surgeries ﾖ Aspiration; Breast biopsies; Implants; Oophorectomy; Reductions. Mammography history ﾖ Frequency; Last mammo; Results. Previous breast disease ﾖ Cancer; Fibroadenoma; Fibrocystic changes. Known hereditary cancer - BRCA1 or BRCA 2; Hereditary, nonpolyposis colorectal cancer. Previous, related cancers ﾖ Colorectal; Endometrial; Ovarian. Breast cancer risk factors
What information should be elicited for related to breast history (FH)?
Breast cancer - Primary relatives; Secondary relatives; Type of cancer; Age at time of occurrence; Treatment and results; Known BRCA1 or BRCA2 mutation Other cancers - Ovarian colorectal; Know hereditary cancer syndromes Other breast disease in female and male family members; Type of disease; Age at time of occurrence
What information should be elicited for related to breast history (SH)?
Breast support used with strenuous exercise or sports activities; Amount of caffeine intake; Breast self-exam (BSE) ﾖ Frequency, When in menstrual cycle; Use of Alcohol - Daily amounts
Describe breast anatomy.
External anatomy has 4 quadrants & Tail of Spence. Internal anatomy Paired mammary glands; Superficial to pectoralis major and serratus anterior muscles; Clavicle and 2nd rib to the 6th rib; Sternal margin to MAL FEMALE BREAST: Glandular, fibrous tissue; Sub Q and retromammary fat; Acini cells; Lactiferous ducts; Sub Q fibrous tissue layer; Suspensory ligaments (Cooperﾒs ligaments). Muscle floor of the breast: Pectoralis major; Pectoralis minor; Serratus anterior; Latissimus dorsi; Subscapularis; External oblique; Rectus abdominus. Internal mammary, lateral thoracic, and branches of intercostal arteries; Sub Q and retromammary fat around glandular tissue; superficial, deep, and areolar and nipple lymph nodes
Describe physiology of breast function.
External anatomy has 4 quadrants & Tail of Spence. Internal anatomy Paired mammary glands; Superficial to pectoralis major and serratus anterior muscles; Clavicle and 2nd rib to the 6th rib; Sternal margin to MAL FEMALE BREAST: Glandular, fibrous tissue; Sub Q and retromammary fat; Acini cells (Small and inconspicuous in non-pregnant, nonlactating women); Lactiferous duct (drains from each lobe onto the surface of the nipple) Sub Q fibrous tissue layer supports breast; Suspensory ligaments (Cooperﾒs ligaments) extend from connective tissue layer through breast and attach to underlying muscle fascia, for further support. Muscle floor of the breast: Pectoralis major; Pectoralis minor; Serratus anterior; Latissimus dorsi; Subscapularis; External oblique; Rectus abdominus Vascular supply for the deeper tissues of the breast and to the nipple from branches of the internal mammary and lateral thoracic arteries; more superficial tissues from intercostal arteries Sub Q and retromammary fat around glandular tissue account for most of bulk of the breast size See additional questions for lymph node drainage.
Which areas of the breast are drained by superficial lymph nodes? Where do these drain?
Upper outer quadrant - drains to scapular, brachial, intermediate nodes toward axillary nodes Medial portion - drains to internal mammary toward opposite breast
Which areas of the breast are drained by deep lymph nodes? Where do these drain?
Posterior chest wall - drains to posterior axillary nodes (subscapular) of arm Anterior chest wall (a portion) - drains to anterior axillary nodes (pectoral) Upper arm - drains to lateral axillary nodes (brachial) Retro-areolar - drains to interpectoral (Rotter) nodes into axillary chain
Which nodes drain the areola and nipple?
Midaxillary, subclavian, and supraclavicular nodes
Describe commonly variable findings of breast A&P.
Size, shape, and asymmetry of breasts; “milk line” nodes; supernumary nipples (extra nipples); Montgomery Tubercles (white bumps on areola near nipple)
Describe abnormal findings of breast A&P.
Bulging, uneven color, contour, dimpling, edema, Peau d’orange, scars, ulcerations of breast; nipple discharge, inversion, plaques, scars, ulcers, change in position; nipples pointing in different directions; erythema
What are some physiological breast tissue changes?
Physiologic nodularity (the breast often has a nodular, granular, lumpy, or uneven texture). During pregnancy - Enlarged, erect alveoli; areolas broadened/darkened; Montgomery tubercles increased in size; breast vein more visible; breast tenderness.
What are some pathological breast tissue changes?
Dimpling, masses, edema, Peau ‘orange
Steps of a breast exam
Consists of: 1. INSPECTION; 2. AXILLARY NODE PALPATION; 3. PALPATION OF BREAST TISSUE Performed in two parts: 1st: Performed with patient sitting up (Inspect breasts; Palpate lymph nodes) 2nd: Performed with patient supine; (Systematically palpate entire breast; wedge, lawnmower, or circular pattern)
What positions should be used in a breast examination?
1) Raised arms and/or hands on hips while leaning forward; 2) Patient’s ipsilateral hand placed on your shoulder; 3) Supine
What aspect(s) of the breast exam are performed while the patient raises her arms or leans forward?
Inspection for dimpling and/or retraction indicative of pathology
What aspect(s) of the breast exam are performed while the patient places an ipsilateral arm on your shoulder?
Palpation of axillary lymph nodes
What aspect(s) of the breast exam are performed while the patient is supine?
Palpation of the breast and Tail of Spence
Is a breast exam necessary after a mastectomy?
Yes, to check for reoccurrences of cancer
How should a breast exam be conducted after a mastectomy?
1) Inspect scar & axilla for masses, nodularity, color changes, inflammation or lymphedema; 2) Palpate gently along scar using circular motion with 2-3 fingers, paying special attention to upper outer quadrant and axilla, noting any lymph node enlargement or signs of inflammation or infection.
What characteristics should be used to describe breast masses?
Size (cm); Position (clock face); Shape; Circumscribed/Delimitation/Borders; Consistency (“hardness” of mass); Mobility (benign tumors are mobile; cancerous are fixed)
What are possible causes of galactorrhea?
Chronic renal failure; Cushing’s disease; Empty sella syndrome; Hypothyroidism; Hyperprolactinemia (idiopathic or drug-induced); Head trauma; Herpes Zoster; Hepatic cirrhosis; prolactin-secreting tumors; sarcoidosis; thoracotomy
What is galactorrhea?
Spontaneous flow of milk from breast, not associated with childbirth or nursing
What is fibroadenoma?
Smooth, rubbery, round, mobile, nontender benign breast mass
What are possible causes of fibroadenoma?
Unknown; possible link to race as they are more prevalent in African American women
Describe cystic/fibrocystic changes.
Benign, nodular, ropelike masses
What are possible causes of cystic/fibrocystic changes?
Breast fibrosis and cysts are associated with mammary epithelial hyperplasia. This is a risk factor for breast cancer.
What is mastitis?
Inflammation of breast tissue
What are possible causes of mastitis?
A blocked milk duct and bacterial infection.
What are possible causes of breast pain (mastalgia)?
abscess; breastfeeding; caffeine; cyst; duct ectasia; alcoholism with liver damage; fibrocystic changes; hormonal changes; mastitis; medications; trauma; stretching of Cooper’s ligaments (esp. in large, pendulous breasts); MOST BREAST CANCERS DO NOT CAUSE PAIN
Describe characteristics of breast cancer.
Breast size or shape change; Lump, thickening, or swelling; Redness/flakiness; Skin irritation; Dimpling; Axillary lymph node thickening or swelling; nipple redness, flakiness, retraction, pain, or discharge
Discuss specific breast cancers.
Most breast cancers are found in the upper outer quadrant and Tail of Spence. 90% of all breast cancers are ductal. 10% are lobular.
Name three breast diseases commonly associated with pregnancy.
mastitis, galactocele, breast cancer
Describe the tx approach for mastitis.
Oral antibiotics; regular emptying of breast with feeding or pumping;
What is a galactocele?
Benign cystic mammary gland containing milk/milky substance as a result of a protein plug blocking outlet
Describe issues of breast cancer during pregnancy.
Breast cancer is often diagnosed at a later stage than if the woman was not pregnant and it is more likely to have spread to the lymph nodes.
What is the most common form of benign breast disease?
Fibroadenoma
Describe the S & SX of fibroadenoma.
Usually a single, easily movable, firm, painless, rubbery lump with a smooth, well-defined border
What is the peak incidence age range for fibroadenomas?
Women < 30
What are risk factors for developing fibroadenoma?
Exact cause unknown; Increased prevalence in African American > Caucasian
Describe the S & SX of fibrocystic breast disease.
Bilateral pain, discomfort (full, swollen, heavy), cyclical w/ menses (may occur throughout month); thick or lumpy breast; pain or discomfort in axilla
What is the peak incidence age range for fibroadenomas?
Most common in 20-45 yr old women; rare after menopause
What are risk factors for developing fibroadenoma?
Exact cause unknown; possible hormonal link
Approproximately how many women develop breast cancer?
1 in 8
Approximately how many men develop breast cancer?
1 in 1000
What are the S & SX of breast cancer?
Breast size or shape change; Lump, thickening, or swelling; Redness/flakiness; Skin irritation; Dimpling; Axillary lymph node thickening or swelling; nipple redness, flakiness, retraction, pain, or discharge
What is the median age of breast cancer occurrence in women?
61 years old
When does breast cancer occur in men?
60-70 yr old
What are risk factors for developing female breast cancer?
BRCA1 & BRCA2 genes (FH breast or ovarian cancer should consider testing); dense breasts; alcohol use; First child after age 35; Nulliparous; older age; menopause onset > 55 yo; Onset of menses < 12 yo; overweight; taking oral contraceptives; Using HRT
What are risk factors for developing male breast cancer
Radiation exposure; FH of CA; High estrogen levels due to chronic liver disease or Kleinfelter’s syndrome; older age; obesity; alcoholism
Which form of cancer KILLS the most women?
Lung cancer
Which form of cancer the second deadliest to women?
Breast cancer
Describe Paget’s Disease
Disease of the nipple with S/Sx that looks similar to eczema with redness, mild scaling, flaking of nipple skin which may include itching, tingling, burning or pain. 50% have a palpable breast lump/mass.
What are the two subtypes of breast cancer?
Ductal carcinomas and lobular carcinoma
Which subtype of breast cancer is most prevalent?
Ductal carcinoma
Which subtype of breast cancer is more difficult to detect? Why?
Lobular carcinomas because they grow in more diffuse patterns with less formation of dense, solid tumors.
