Exam 4 Flashcards
Causes of gynecomastia
increased estrogen, decreased testosterone and medication side effects.
Medications associated with breast pain
psychotropic drugs, e.g. SSRIs, haloperidol, spironolactone and digoxin.
*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.
Radiologic breast tissue density
Studies show that when percentage of breast area reaches 60 to 75%, the RR of breast CA increases 4-6x in part related to the masking effect of breast density on smaller cancers, which have the same x-ray attenuation as fibroglandular breast tissue.
*Screening for breast CA recommendations
Evaluate risk as early as age 20s, ask about family history especially regarding breast and ovarian CA in maternal or paternal family members (autosomal dominant genetic mutations).
Mammography combined with CBE are most common screening modalities, however, recommendations vary by professional groups on when to start, how often, how to screen.
USPSTF -
- <= 50 years, individual screening based on specific factors
- ages 50-74, biennial mammography
- >= 75 years, insufficient evidence for testing
- Recommends against BSE
ACS
- Ages 40-45, optional annual screening
- 45-54 years, annual screening
- >=55 years, biennial screening with option to continue annual screens
ACOG
- >= 40 years, annual screening
- CBE: 20-39 years, every 3 years
- CBE: >=40 years, annually
- Recommends breast self-awareness
Digital mammography
Performs better in younger women and women with higher breast density.
*Changes seen in breast CA
I: Thickening of skin with unusually prominent pores (peau d’orange), asymmetry due to change in nipple direction, nipple retraction, breast dimpling or retraction seen with arms overhead, asymmetry or retraction may be seen better with leaning forward position. Abnormal contouring.
P: hard, irregular poorly circumscribed nodules, fixed to the skin or underlying tissues. Thickening of the nipple and loss of elasticity. Nodes that are large (>=1 to 2 cm) and firm or hard, matted together, or fixed to the skin or underlying tissues suggest malignancy.
Breast palpation
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 warrants further evaluation for intraductal papilloma, ductal carcinoma in situ or Paget disease of the breast.
BSE
best timed 5-7 days after menses, when hormonal stimulation of breast tissue is low.
Direct vs. indirect inguinal hernias
- Direct - arise more medially due to weakness in the floor of the inguinal canal and are associated with straining and heavy lifting. A bulge near the external inguinal ring. Less common, usually in men 40+, rare in women.
- Indirect - develop at the internal inguinal ring, where the spermatic cord exits the abdomen. May form a scrotal hernia. A bulge near the internal inguinal ring. Chance of incarceration is 10 x more common in this type. More common, in all ages, often in children.
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 - 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
Peak incidence between ages 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
With patient standing, palpate the spermatic cord about 2 cm above the testis. Have patient 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.
Hydroceles
Swellings containing serous fluid that light up with a red glow, or transilluminate. Those containing blood or tissue, such as normal testis, a tumor, or most hernias, do not.
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.
*TSE
- USPSTF- concluded inadequate evidence for the benefit of screening, either by clinical examination or self-examination, and advised against screening for testicular cancer in asymptomatic adolescent or adult males.
- American Cancer Society- recommends a testicular exam should be part of a general physical exam, they do not have a recommendation for regular testicular self-examinations (TSE’s) but advise men to seek clinical attention for: painless lump, swelling, enlargement of either testicle, pain or discomfort in testicle or scrotum, feeling of heaviness or a sudden fluid collection in the scrotum, or a dull ache in the lower abdomen or groin.
- Testicular Self-Exam best performed after a warm bath or shower.
- Testicular cancer strikes men ages 15 to 34, especially those with a positive family history of cryptorchidism
Causes of secondary dysmenorrhea
endometriosis, adenomyosis, PID, and endometrial polyps.
Causes of secondary amenorrhea
low body weight from malnutrition and anorexia nervosa, stress, chronic illness, and hypothalamic-pituitary-ovarian dysfunction.
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
Diagnosed between ages 48-55 years. Cessation of menses x 12 months, progressing through several stages of erratic cyclical bleeding. Stages of variable cycle length, often with vasomotor symptoms: hot flashes, flushing and sweating, represent perimenopause.
- Estrogen and progesterone drop
- Testosterone production persists
- LH and FSH are markedly elevated
Studies suggest that only vasomotor symptoms, vaginal symptoms, and trouble sleeping are consistently linked to menopause. 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 may include 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
STIs and recent IUD insertion are red flags for PID. 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 warrants immediate attention. The DDx is broad but includes life-threatening conditions such as ectopic pregnancy, ovarian torsion, and appendicitis.
Also consider mittelschmerz, ruptured ovarian cyst and tubo-ovarian abscess.
Endometriosis affects 50-60% of women and girls with pelvic pain. Other causes include PID and adenosis, and fibroids, which are tumors in the uterine wall or submucosal or subserosal surfaces arising from the smooth muscle cells of the myometrium.
However, the most common cause is PID, followed by ruptured ovarian cyst, and appendicitis. STIs and recent IUD insertion are red flags for PID.
Cervical motion tenderness and/or adnexal tenderness are hallmarks of PID, ectopic pregnancy, and appendicitis.
*Chronic pelvic pain
Red flag for history of sexual abuse. Also consider 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: at age 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
the CDC and AAP recommend a 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 at age 11 or 12, before their first sexual encounter; the series can begin as early as age 9 years.
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: family history and presence of the BRCA1 or BRCA2 gene mutation. Risk is tripled if there is a 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.
Currently, there are no effective screening tests. CA-125 is neither sensitive nor specific and may be elevated in many other conditions and cancers including pregnancy.
*Most common STI
Chlamydia trachomatis infection which is a cause of urethritis, cervicitis, PID, ectopic pregnancy, infertility, and chronic pelvic pain.
Chlamydia infection rates are highest in women ages 20 -24 years, closely followed by women ages 15 to 19 years. AA 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
Some clinicians carefully 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.
CBE
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 - by quadrant or clock, with cm from nipple
- Size in cm
- Shape - round or cystic, disclike, or irregular in contour
- Consistency - soft, firm, or hard
- Delimitation - well circumscribed or not
- Tenderness
- Mobility - in relation to the skin, pectoral fascia and chest wall.
*Nonpuerperal galactorrhea
Milky discharge unrelated to a prior pregnancy and lactation. Causes include hyperthyroidism, pituitary prolactinoma, and dopamine antagonists, including psychotropics and phenothiazines.
*Trichomonal vaginitis
- Often but always sexually acquired
- Discharge is yellowish green or gray, possibly frothy; often profuse and pooled in the vaginal fornix; may be malodorous
- Pruritis, pain on urination, dyspareunia
- Vestibule and labia minora may be erythematous, vaginal mucosa diffusely reddened, small red granular spots or petechiae in the posterior fornix, in mild cases, the mucosa looks normal
- Scan saline wet mount for trichomonads
*Candidal vaginitis
- Many factors predispose esp. antibiotics
- Discharge is white and curdy; may be thin but typically thick; not as profuse as in trichomonal infection; not malodorous
- Pruritis; vaginal sorenes; pain on urination (from skin inflammation); dyspareunia
- Vulva and surrounding skin are often inflamed and sometimes swollen, vaginal mucosa is often reddened, with white tenacious patches of discharge
- Scan KOH prep for the branching hyphae of Candida
*Bacterial vaginosis
- Often transmitted sexually
- Gray or white, thin, homogeneous, malodorous; coats the vaginal walls, usually not profuse, may be minimal
- Unpleaseant fishy or musty genital odor, reported to occur after intercourse
- The vulva and vaginal mucosa usually appear 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
*Parkinson disease s/s
- T = Tremor
- R = Rigidity
- A = Akinesia
- P = Postural instability
- Bradykinesia (most characteristic clinical sign)
- Micrographia
- Shuffling “freezing” gait
- Difficulty rising from chair
*Fibroadenoma
- noncancerous breast tumor common in young women (and up to age 55).
- smooth, round, well defined, usually solitary, 1-2 cm
- “slippery tumor”
- very mobile
- painless, non-tender
- does not change with cycles
-no retraction signs
*Breast Cysts
- Usually found in age 30-50, regress after menopause unless on estrogen therapy
- Single or multiple
- Round
- Soft to firm, usually elastic
- Mobile
- Often tender
- Absent retraction signs
*Breast Cancer
- Usual in age 30-90 years, most common over age 50
- Usually single, although may coexist with other nodules
- Firm or hard
- Irregular or stellate
- Firm or hard
- Not clearly delineated from surrounding tissues
- May be fixed to skin or underlying tissues
- Usually nontender
- Retraction signs may be present
