Exam 4 Flashcards
*Pathologic galactorrhea
Not affiliated with pregnancy or lactation and if bloody or serous, unilateral, spontaneous, associated with a mass and occurring women aged 40+ years.
*Breast CA masses
Irregular, firm, may be mobile, or fixed to surrounding tissue.
Risk factors for breast CA
- Most important RF: age.
- Other non-modifiable RFs: family history of breast and ovarian cancers, inherited genetic mutations, personal history of breast CA or lobular carcinoma in situ, high levels of endogenous hormones, breast tissue density, proliferative lesions with atypia on breast bx, and duration of unopposed estrogen exposure related to early menarche, age of first full-term pregnancy, and late menopause.
- Modifiable RFs: breastfeeding for less than 1 yr, postmenopausal obesity, use of HRT, cigarette smoking, alcohol ingestion, physical inactivity, and type of contraception.
BRCA1 and BRCA2 gene
occur in <1% of the population but account for roughly 5-10% of female breast cancers. They also confer increased risk for ovarian CA.
*Screening for breast CA recommendations
USPSTF and ACOG
USPSTF
- Mammography: ages 50-74, biennial(every other year)
- > 75 years: NO
- no BSE, no CBE
ACOG
- CBE: ages 25-39 q 1-3 and annually 40+
- mammography: 40, q 1-2 yrs until 75
- no BSE but self awareness
visible signs of breast cancer
retracted/deviation nipple (from shortening of tissues)
skin dimpling
edema of skin/orange peel (lympathic blockage; thickened skin with enlarged pores)
abnormal contours (flattened area of breast)
paget disease of nipple (scaly, eczema like lesion on nipple that weep, crust, or erode)
Breast palpation best performed in what position
is best performed when the breast tissue is flattened and patient is supine.
*Intraductal papilloma s/s
*Spontaneous unilateral bloody discharge from one or two ducts further evaluation for:
- intraductal papilloma, ductal carcinoma in situ or Paget disease of the breast.
BSE best done when
best timed 5-7 days after menses, when hormonal stimulation of breast tissue is low.
post menopausal: anytime is ok
Direct vs. indirect inguinal hernias
-
Indirect -
- all ages, often children
- internal inguinal ring, where the spermatic cord exits the abdomen.
- May form a scrotal hernia.
- Chance of incarceration is 10x
- Direct
- external inguinal ring
- bulge d/t weakness in the floor of the inguinal canal
- straining and heavy lifting
- Less common, usually in men 40+, rare in women
Femoral hernias
more likely to present as emergencies with bowel incarceration or strangulation. More common in women than in men.
Penile discharge
- Gonorrhea - yellow
- non-gonococcal urethritis from chlamydia - white
Disseminated gonorrhea
rash, tenosynovitis, monoarticular arthritis, even meningitis, not always with urogenital symptoms.
Penile/scrotal sores
- Syphilitic chancre and herpes - ulcer
- HPV - warts
- mumps orchitis, scrotal edema, and testicular CA - swelling
- testicular torsion, epididymitis and orchitis - pain
Phimosis and paraphimosis
- Phimosis - tight prepuce that cannot be retracted over the glans.
- Paraphimosis - tight prepuce, that once retracted, cannot be returned. Edema ensues.
Tender painful scrotal swelling
present in acute epididymitis, acute orchitis, torsion of the spermatic cord, or a strangulated inguinal hernia.
Testicular cancer
Painless nodule on the testis a potentially curable cancer
15-34 years
Cryptorchidism, present in 7-10% of men with testicular cancer, confers a 3-17 fold increased risk for testicular CA.
Other risk factors: history of carcinoma in the contralateral testicle, mumps orchitis, and inguinal hernia, a hydrocele in childhood and a postive family history.
Varicocele of spermatic cord
supine it’s collapsed so need to be standing, palpate 2 cm above the testis. hold his breath and beard down against a closed glottis for about 4 seconds (Valsalva maneuver)
A temporary increase in diameter of the cord indicates filling of abnormally dilated spermatic veins draining the testis.
“bag of worms”
Hydroceles
Swellings containing serous fluid that light up with a red glow, or transilluminate.
if blood or tissue, such as normal testis, a tumor, or most hernias, do not glow
Palpating the epididymis
Feels nodular and cord-like and should not be confused with an abnormal lump and should NOT be tender.
Suspect intestinal strangulation
in the presence of tenderness, nausea, and vomiting, and consider surgical intervention.
Causes of primary vs secondary dysmenorrhea
primary: inc prostaglandin production during luteal phase of menstrual cycle, when estrogen and proge lvls decline
secondary: endometriosis, adenomyosis, PID, and endometrial polyps.
Causes of secondary amenorrhea
low body weight (malnutrition) and anorexia nervosa, stress, chronic illness, and hypothalamic-pituitary-ovarian dysfunction, excessive exercise
Causes of abnormal vaginal bleeding
Vary by age group and include pregnancy, cervical or vaginal infection or CA, cervical or endometrial polyps or hyperplasia, fibroids, bleeding disorders, and hormonal contraception or replacement therapy.
*Menopause symptoms
48-55 years. Cessation of menses x 12 months, progressing through several stages of erratic cyclical bleeding.
- Estrogen and progesterone drop
- Testosterone production persists
- LH and FSH are markedly elevated
perimenopause = vasomotor symptoms, vaginal symptoms, and trouble sleeping
Vaginal symptoms are due to vulvovaginal atrophy with vaginal drying, dysuria, or dyspareunia.
*Post-menopausal bleeding
Always ask about any bleeding or spotting after menopause as this may be an early sign of CA.
causes: endometrial CA, HRT and uterine/cervical polyps.
Amenorrhea followed by heaving bleeding…
suggests a threatened abortion or dysfunctional uterine bleeding related to lack of ovulation.
*PID red flags and hallmark signs
STIs and recent IUD insertion
Always rule out ectopic pregnancy first with serum or urine testing and possible ultrasound.
Cervical motion tenderness and/or adnexal tenderness are hallmark signs.
*Acute pelvic pain
in menstruating girls and women, immediate attention!!
emergency: ectopic pregnancy, ovarian torsion, and appendicitis, PID
*Chronic pelvic pain
lasts more than 6 months, doesn’t respond to tx
endometriosis (retrograde menstrual flow/extension of uterine lining outside uterus), PID, adenomyosis, fibroids (tumors in uterine wall)
Red flag for history of sexual abuse
pelvic floor spasm from myofascial pain with trigger points on examination.
Cervical cancer
Most important risk factor for cervical CA is persistent infection with high-risk HPV subtypes, especially HPV-16 or HPV-18.
Other two notable risk factors including failure to undergo screening, which accounts for roughly half of women diagnosed with cervical CA, and multiple sexual partners.
*Cervical cancer screening for average-risk women
(USPSTF, ACS/ASCCP/ASCP, and ACOG)
- Initiate: 21 years
- Interval
- Ages 21-65 cytology q 3 years
- OR
- Ages 21-29: cytology every 3 years
- Ages 30-65 yrs, cytology plus HPV testing every 5 years
- Ages 21-65 cytology q 3 years
- Age at which to end screening: age > 65 yrs after 3 consecutive negative results on cytology or two on cytology plus HPV testing within 10 years
- Screening after hysterectomy with removal of cervix (TAH): not recommended.
HPV vaccine
9 or age 11 or 12:
3-dose series over 6 months with either the quadrivalent (HPV 16,18,6,11) or bivalent (HPV 16,18) vaccine for girls and boys before their first sexual encounter
Catch-up: recommended for females ages 13-26 years who have not had prior vaccination or completed the 3-dose series. Through age 21 in males not vaccinated previously (age 26 years if immunocompromised or having sex with other men).
Ovarian CA s/s, risk factors, screening
abdominal distention, abdominal bloating, and urinary frequency; however, these are usually reported within 3 months of diagnosis and frequently occur in other conditions.
Risk factors: BRCA1 or BRCA2 gene. Risk is 3x first-degree relative with breast or ovarian CA.
Other risk factors: obesity, nulliparity, growing evidence of increased risk from postmenopausal HRT.
Risk decreased by: use of oral contraceptives, multiple pregnancies, breastfeeding, and tubal ligation.
no screening tests
*Most common STI
Chlamydia trachomatis infection = urethritis, cervicitis, PID, ectopic pregnancy, infertility, and chronic pelvic pain.
Rates are highest in 20 -24 years, closely followed by women ages 15 to 19 years. Black women and American Indian/Alaskan natives are at highest risk for infection.
As with other STIs, risk factors are:
- Younger than 24 years and sexually active
- Prior infection with chlamydia or other STIs
- New or multiple partners
- Inconsistent condom use, and
- Occupational sex work
*STI and HIV screening per CDC 2014
- Chlamydia and gonorrhea screening annually for all sexually active women ages < 25 years and older with risk factors of new or multiple sex partners, or a sex partner infected with an STI.
- Chlamydia, syphilis, hep B and HIV screening for all pregnant women and gonorrhea screening for at-risk pregnant women starting early in pregnancy.
- Chlamydia, gonorrhea, and syphilis screening at least annually for all sexually-active gay, bisexual, and other MSM. MSM who have multiple or anonymous partners should be screened more frequently for STIs (3-6 month intervals).
- HIV testing at least once for all adults and adolescents from ages 13-64 years.
- HIV testing at least annually for anyone having unsafe sex or using injection drug equipment. Sexually active gay and bisexual men may benefit from testing q3-6 months.
Inserting speculum
enlarge the vaginal introitus by lubricating one finger with water and applying downward pressure at its lower margin, then palpate the location of the cervix in order to angle the speculum more accurately.
clinical breast exam
The vertical strip pattern shown is currently the best validated technique for detecting breast masses. Using the pads of the 2nd, 3rd and 4th fingers, keeping the fingers light flexed, spend about 3 minutes for each breast. Palpate in small, concentric circles applying light, medium and deep pressure at each examining point.
*Descriptors of breast nodule
- Location - which breast, by quadrant, clock, with cm from nipple
- Size in cm
- Shape - round or cystic, disclike, or irregular in contour
- Consistency - soft, firm, or hard, boggy
- Delimitation - well circumscribed or not
- Tenderness
- Mobility - in relation to the skin, pectoral fascia and chest wall.
PMS (pre-menstrual syndrome)
emotional/behaviorial sx’s (depression, angry outbursts, irritability, anxiety, cry, sleeping distubrance,s anxiety, poor concentration, social w/drawal)
5 days before menses for at least 3 consecutive cycles
sx’s stop 4 days after onset of menses
interference with daily activities
*Primary amenorrhea
Absence of ever initating periods by age 16.
Causes: anatomic or genetic cause
Issues with pituitary gland or hypothalamus from gonadal dysgenesis including Turner syndrome (43%), Mullerian agenesis (lack of vagina – 15%), constitutional delay (less common in females, 14%), PCOS (7%), isolated GnRH deficiency (5%), anorexia nervosa (2%), hypopituitarism (2%), and others.
Postcoital bleeding
bleeding after sex
suggests cervical polyps or cancer, or in an older woman = atrophic vaginitis
Suspect HIV infection in women with…
recurrent vulvocandidasis, concurrent STIs, abnormal Pap smears (occurring in 40% of HIV-positive women), and HPV infection: HIV testing is indicated
Failure rates of family planning methods
- Lowest - subdermal implant, IUD, female sterilization, vasectomy
- Intermediate - injectables, oral contraceptives, the patch, vaginal ring, and diaphragm
- Highest - male and female condoms, withdrawal, sponge in parous women, fertility awareness methods and spermicides
Bimanual examination of the vagina
Palpate the cervix - cervical motion tenderness and/or adnexal tenderness are hallmarks of PID, ectopic pregnancy, and appendicitis.
Palpate the uterus - with your other hand on the abdomen about midway between the umbilicus and the symphysis pubis. Uterine enlargement suggests pregnancy, uterine myomas (fibroids), or malignancy.
Palpate each ovary - Normal ovaries are somewhat tender. Within 3-5 years after menopause, the ovaries become atrophic and usually nonpalpable. If palpable, may investigate further for ovarian cyst or ovarian CA.
*Trichomonal vaginitis
cause
discharge color
sx’s
vulva/vaginal mucosa
lab eval
- Often but always sexually acquired
- Discharge:
- yellowish green or gray, possibly frothy; often profuse and pooled in the vaginal fornix; may be malodorous
- sx’s:
- Pruritis, pain on urination (inflamed), dyspareunia
- Vestibule and labia minora may be erythematous, vaginal mucosa diffusely reddened, small red granular spots or petechiae in the posterior fornix
- mild cases, the mucosa looks normal
- Scan saline wet mount for trichomonads
*Candidal vaginitis
cause
discharge
sx’s
vulva/vaginal mucosa
lab eval
- normal overgrowth; many factors predispose esp. antibiotics
- Discharge
- White and curdy; may be thin but typically thick
- not as profuse as in trichomonal infection
- not malodorous
- Sx’s:
- Pruritis; vaginal sorenes; pain on urination (inflamed skin); dyspareunia
- Vulva and surrounding skin are often inflamed and sometimes swollen, vaginal mucosa is often reddened, with white tenacious patches of discharge
- mucosa bleed if scraped off
- Scan KOH prep for the branching hyphae of Candida
*Bacterial vaginosis
cause
discharge
sx’s
vulva/vaginal mucosa
lab eval
- transmitted sexually
- discharge
- Gray or white, thin, homogeneous
- malodorous
- coats the vaginal walls, usually not profuse, may be minimal
- sx’s:
- Unpleaseant fishy or musty genital odor after sex
- vulva and vaginal mucosa: normal
- Scan saline wet mount for clue cells (epithelial cells with stippled borders), sniff for fishy odor after applying KOH (“whiff test”); test vaginal secretions for pH >4.5
Risk factors for Prostate Cancer
- Age - rates increase rapidly after age 50
- Ethnicity - AA have highest incidence and mortality rates
- Family hx - Risk increases 2x for one affected first-degree relative, increase 5-11x with 2-3 first-degree relatives
- Other: exposure to Agent Orange by Vietnam vets, diets high in animal fat, obesity, and cigarette smoking. BPH is not a risk factor for prostate CA!
*Prostate cancer screening
begin early, at 40-45 years to men at high risk for CA, African Americans and those with a family hx of prostate CA. Otherwise, may begin at age 50.
1) If agreeable, PSA testing recommended q1-2 years
2) DRE optional
3) Stop offering screening at age 70 or whenever life expectancy is less than 10 years
Male genitalia in newborns
2 common scrotal masses:
reducible or not?
Two common scrotal masses: hydroceles and inguinal hernias.
Both may coexist on the right side.
Hydroceles are not reducible, and can be transilluminated and most resolve by age 18 months.
Hernias are usually reducible, often do not transilluminate and do not resolve.
*Cremasteric reflex
Stroke/scratch the medial aspect of the thigh.
The testis on the side being scratched will move upward
*Female puberty
*Physical changes in girl’s breast are of the first signs of puberty. Menarche usually occurs when a girl is in breast stage 3 or 4.
General order of pubertal changes: height spurt, breast changes, pubic hair, menarche.
Normal range of onset of breast development is 7 years for white girls and 6 for AA and Hispanic girls.
Delayed puberty (no breasts or pubic hair development by age 12 years) is usually caused by inadequate gonadotropin secretion from the anterior pituitary due to defective hypothalamic GnRH production. A common cause is anorexia nervosa.
*Male puberty
First reliable sign between ages 9 and 13.5 years is increase in testes size, then appearance of pubic hair, with progressive enlargement of the penis, and finally a growth spurt.
Delayed puberty is suspected in boys who have no signs of pubertal development by 14 years of age.
High-yield screening questions for DEPRESSION
- Over the past 2 weeks, have you felt down, depressed, or hopeless?
- Over the past 2 weeks, have you felt little interest or pleasure in doing things (anhedonia)?
[(sensitivity: 83%, specificity 92%) for detecting major depression]
All positive screening tests warrant full diagnostic interviews.
High-yield screening questions for ANXIETY
- Over the past 2 weeks, have you been feeling nervous, anxious, or on edge?
- Over the past 2 weeks, have you been unable to stop or control worrying?
- Over the past 4 weeks, have you had an anxiety attack–suddenly feeling fear or panic?
*Components of Mental Status Examination
(always see my task completion)
- appearance and behavior (LOC, posture, dress/grooming, facial, manner)
- Speech and language (quanity, quality, rate, aphasia)
- mood and affect
- thoughts and perception (logic, compulsions, obsessions, delusions, insight, judgment)
- cognitive function (orientation: time, place, person, attention: spelling backwards or series of 7)
- memory (remove, recent, new learning ability)
( higher cognitive function (vocab, calculating, abstract thinking, clock)
*Causes of near-syncope and syncope
seizures, neurocardiogenic conditions such as vasovagal syncope, postural tachycardia syndrome, carotid sinus syncope, and orthostatic hypotension, and cardiac disease causing arrhythmias, especially V. tach and bradyarrhythmias.
Documented and modifiable risk factors for stroke
- Hypertension
- Smoking
- Dyslipidemia
- Diabetes
- Weight
- Diet and nutrition
- Physical inactivity
- Alcohol use
Stroke: Disease-specific risk factors
- Atrial fibrillation
- CAD
- OSA
*Neurologic exam
- Mental status, speech and language
- Cranial nerves
- The motor system
- the sensory system
- Muscle stretch reflexes
Brudzinski Sign
Flex neck, watch hips and knees.
If they flex, it is positive and you may consider meningitis or subarachnoid hemorrhage.
Kernig Sign
Flex the patient’s leg at both the hip and knee, then slowly extend and straighten the knee.
Pain and increased resistance to knee extension = positive
concern for meningitis or subarachnoid hemorrhage
Straight-leg Raise
In supine position, raise the patient’s relaxed and straightened leg, flexing the thigh at the hip.
Pain radiating into the ipisilateral leg = positive straight leg test for lumbosacral radiculopathy.
Foot dorsiflexion can further increase leg pain in lumbosacral radiculopathy, sciatic neuropathy, or both.
Increased pain when the contralateral healthy leg is raised is a positive crossed straight-leg raise sign.
*Ankle reflex in infant
Grasp infant’s malleolus with one hand and abruptly dorsiflex the ankle.
note rapid, rhythmic plantar flexion of the newborn’s foot (ankle clonus) in response to this maneuver.
Up to 10 beats are normal in newborns and young infants (unsustained ankle clonus).
With sustained ankle clonus, CNS disease should be suspected.
palmar grasp reflex
present birth to 3-4 months
place fingers into the infants hands and press against palmar surfaces. infant will flex all fingers to grasp your fingers
persists beyond 4-6 months: pyramidal tract dysfunction
*Parkinson disease s/s
- T = Tremor
- R = Rigidity
- A = Akinesia
- P = Postural instability
- Bradykinesia (most characteristic clinical sign)
- Micrographia (writing gets smaller)
- Shuffling “freezing” gait
- Difficulty rising from chair
*Fibroadenoma
- noncancerous breast tumor common in young women (15-25, and up to 55 yrs old).
- round, disc-like or lobular; 1-2 cm
- “slippery tumor”
- very mobile
- no pain, non-tender
- does not change with cycles
-no retraction signs
*Breast Cysts
- age 30-50, regress after menopause unless on estrogen therapy
- Single or multiple
- Round
- Soft to firm, usually elastic
- Mobile
- Often tender
- NO retraction signs
*Breast Cancer
- age 30-90 years, most common over age 50
- Usually single, although may coexist with other nodules
- Irregular or stellate
- Firm or hard
- Not clearly delineated from surrounding tissues
- May be fixed to skin or underlying tissues
- Usually nontender
- maybe retraction signs
testicular torsion
torsion or twisting of the testicle on spermatic cord
acutely painful, swollen organ that is restracted upward in the scrotum
NO/absent cremasteric reflex
common in neonates and adolescents but any age
surgical emergency / blocked circulation, need surgery
cresent-shaped hymen
border lower part of vaginal orifice & extend to posterior and lateral margins of hymenal ring
don’t encircle vaginal orifice
annular hymen
visible with labial traction
annular = hymen surrounds the orifice circumferentially
cerebellar function tests
rapid alternating movements (RAMs), point to point movements, finger-to-nose, heel to shin, gait
plantar grasp reflex
present birth to 6-8 months
touch soles at base of toes = curl
persists: pryamidal tract dysfunction
rooting reflex
presnt birth to 3-4 months
stroke perioral skin at corners of mouth = open & infant will turn head toward stimulated side and suck
abnormal: severe generalized or CNS disease
moro reflex (startle)
present birth to 4 months
hold supine supporting head, back, legs. abruptly lower entire body 1 foot. arms should abduct/extend, hands will open, legs flex, infant may cry
neurologic dz (Cerebral palsy) esp if beyond 6 months
Asymmetric tonic neck reflex
present birth to 2-3 months
infant supine, turn head to 1 side, holding jaw over shoulder. arms/legs on side to which head is turned will extend while opposite arm/leg will flex
persists: asymmetric CNS development, CP
trunk incurvation (Galant) reflex
present birth to 3-4 months
support infant prone 1 hand and stroke 1 side of the back 1cm from midline, form shoulder to buttock. spine will curve toward stimulated side
transverse spinal cord lesion or injury
Parachute reflex
present 8 months and does not disappear
suspend infant prone, slowly lower head toward surface; arms and legs will extend in protective fashion
Delay in appearance my predict future delays in voluntary motor development
CN XI
spinal accessory
atrophy or fasciculations (small irreg twitching of muscle fibers) in trap muscles, compare
shrug both shoulders against hands (strength & contraction)
turn head against side of hand and note force against hand
