Exam 4 - Reproductive Flashcards
What are the current recommendations regarding self-breast exams?
- USPSTF* recommends against teaching BSE d/t evidence that it doesn’t reduce mortality and may lead to higher rates of benign breast biopsies
- American Cancer Society* recommends against BSE, but states all women should be familiar with how their breasts normally look and feel
What are the current recommendations regarding breast cancer screening - USPSFT?
Mammography
- 50-74 years - biennially
- <50 years - individualize screening based on patient specific factors
- >75 years - insufficient evidence to recommend
Clinical breast exam
- >40 years - insufficient evidence to assess additional benefits and harms of CBE beyond screening mammography
What are the current recommendations regarding breast cancer screening - American Cancer Society?
Mammography
- 40-45 years - optional annual screening
- 45-54 years - annual screening
- >55 years - biennial screening w/ option to continue annual screens
- Continue screening if good health and life expectancy >10 years
Clinical breast examination
- Not recommended d/t lack of evidence showing clear benefit
What are the current recommendations regarding breast cancer screening - American College of Obstetricians and Gynecologists?
Mammography
- >40 years - annually
Clinical Breast Examination
- 20-39 years - every 1-3 years
- >40 years - annually
What are the seven characteristics of a breast nodule that should be described?
- Location - by quadrant or clock, w/ cm from nipple
- Size - in cm
- Shape - round or cystic, disclike, or irregular in contour
- Consistency - soft, firm, or hard
- Delimination - well circumscribed or not
- Tenderness
- Mobility - in relation to skin, pectoral fascia, chest wall
What history, exam findings, and risk factors are consistent with a fibroadenoma?
Usual age: 15-25 years, usually puberty and young adulthood
Shape: round, disclike, or lobular; typically small (1-2 cm)
Consistency: soft
Delimination: well delineated
Mobility: very mobile
Tenderness: nontender
Retraction signs: absent
What history, exam findings and risk factors are consistent with a cyst?
Usual age: 30-50 years, regress after menopause except w/ estrogen therapy
Shape: round
Consistency: soft to firm, usually elastic
Delimination: well delineated
Mobility: mobile
Tenderness: often tender
Retraction signs: absent
What history, exam findings and risk factors are consistent with cancer?
Usual age: 30-90 years, most common >50 years
Shape: irregular or stellate
Consistency: firm or hard
Delimination: not clearly delineated from surrounding tissues
Mobility: may be fixed to skin or underlying tissues
Tenderness: usually nontender
Retraction signs: may be present
What are some visible signs of breast cancer?
Retraction, dimpling, edema, abnormal contours, nipple retraction and deviation, Paget diease of nipple
What could milky nipple discharge indicate?
Milky discharge unrelated to prior pregnancy and lactation is nonpuerperal galactorrhea
Causes: hyperthyroidism, pituitary prolactinoma, dopamine antagonists (psychotropics and phenothiazines)
What could bloody nipple discharge indicate?
Spontaneous unilateral bloody discharge from one or two ducts indicates:
- Intraductal papilloma
- Ductal papilloma in situ
- Paget disease of the breast
What could clear, serous, green or black nipple discharge indicate?
Usually benign
What are considered normal findings of the breasts of newborns?
Breasts of the newborn in both males and females are often enlarged from maternal estrogen effect (may last several months)
May be engorged w/ white liquid (“witch’s milk”) which lasts 1-2 weeks
What is premature thelarche?
Breast development occurs, most often between 6 months and 2 years
Other signs of puberty or hormonal abnormalities not present
What are the current recommendations regarding testicular self-exams?
USPSTF - inadequate evidence for the benefit of screening, either by clinician or self-examination
- Advised against screening for testicular cancer in asymptomatic adolescent or adult males
American Cancer Society - recommends that testicular examination should be part of general physical exam, but no recommendation for self-examinations
- Advises males to seek medical attention for any of the following: painless lump, swelling, enlargement in either testicle, pain or discomfort, feeling of heaviness or sudden fluid collection in scrotum, dull ache in lower abdomen or groin
What symptoms and exam findings are consistent with a testicular torsion?
- Tender painful scrotal swelling
- Retracted upward in scrotum
- Absent cremasteric reflex on affected side
- No associated urinary infection
Most common in neonates and adolescents; surgical emergency
What is the cremasteric reflex and how is it performed?
Examine the child when he is relaxed b/c anxiety stimulates the cremasteric reflex
Have patient sit cross-legged, give him a balloon to inflate, or an object to lift to increase intra-abdominal pressure
Option 1: Warm hands, palpate lower abdomen, work way down towards scrotum along inguinal canal (minimizes retraction of testes into the canal)
Option 2: Scratch medial aspect of thigh (testes on side being scratched will move up)
What is the difference between a direct and indirect inguinal hernia?
Indirect inguinal hernias develop at the internal inguinal ring, where the spermatic cord exits the abdomen
Direct inguinal hernias arise more medially d/t weakness in the floor of the inguinal canal and are associated w/ straining and heavy lifting
What exam findings are consistent with gonococcal urethritis vs. nongonococcal urethritis?
Gonococcal urethritis
- Profuse yellow penile discharge
Nongonococcal urethritis
- Scanty white or clear penile discharge
What are some benefits of circumcision?
AAP and experts recommend circumcision d/t reduced rates of HIV and other infections among circumcises males
What type of anticipatory guidance would the FNP provide to the child of the uncircumcised male?
- When bathing your child, wash the penis. Then dry it thoroughly.
- Never forcibly pull back (retract) the foreskin when washing your infant or young child
- When the foreskin is able to retract, gently pull it back and bathe the area. Dry the penis thoroughly.
- Return the foreskin to its natural position by pulling it back over the penis. This is important because if the foreskin is left retracted, it could put pressure on the penis. This can cause pain and swelling and may require medical attention.
What are hypospadias?
Congenital ventral displacement of urethral meatus to the inferior surface of penis
Meatus may be subcoronal, midshaft, or at junction of the penis and scrotum (penoscrotal)
What is chordee?
Fixed, downward bowing of the penis (may accompany a hypospadias)
What are considered to be normal scrotal findings of the newborn? The premature newborn?
- Nonretractable at birth, but may retract enough to visualize external urethral meatus
- Foreskin completely covers glans penis; gradually loosens over months to years
- Testes should be 10mm in width and 15mm in length
- Scrotal edema may be present for several days following birth b/c of maternal estrogen
What exam findings are consistent with a hydrocele?
Swelling containing serous fluid lights up with a red glow (transilluminates)
Nontender, fluid-filled mass within tunica vaginalis
Examining fingers can palpate above the mass within the scrotum
What exam findings are consistent with a hernia in the newborn/infant?
More common on the R side, often reducible, DO NOT transluminate or resolve
Sometimes a thickened spermatic cord (“silk sign”) is noted
How would the FNP classify Tanner Stages (Sexual Maturity Rating) in males?
What is the general order of pubertal changes in the male?
- First reliable sign of puberty, between ages 9-13.5 years, is increase in size of testes
- Pubic hair appears along w/ progressive enlargement of penis
What is considered delayed puberty in the male? What are some common causes?
No signs of pubertal development by 14 years
- Most common causes: constitutional delay - familial condition involving delayed bone and physical maturation but normal hormone levels
Can you identify the external female anatomy?
- Mons pubis
- Prepuce
- Clitoris
- Urethral meatus
- Opening of paraurethral (Skene) gland
- Vestibule
- Introitus
- Perineum
- Labia majora/minora
- Hymen
- Vagina
- Opening of Barthlin gland
- Anus
What are the current cervical cancer screening recommendations?
American College of Physicians found no evidence supporting screening w/ routine pelvic exams alone in average-risk, asymptomatic adult women
Screening should begin at 21 years
Ages 21-65 years
- Pap smear every 3 years OR cotesting w/ Pap + HPV testing for high-risk subtypes every 5 years
- Testing for HPV alone or cotesting should only begin after 30 years
Ages >65 years
- Screening can stop if women have had three consecutive negatives on Pap or two consecutive negatives w/ cotesting within 10 years of cessation of screening (w/ most recent test performed within 5 years)
Women w/ hysterectomy
- Do not need screening
What is the difference between perimenopause and menopause?
Menopause: cessation of menses for 12 months, progressing through several stages of erratic cyclical bleeding
- Occurs between 48-55 years (peaking at 51 years)
Perimenopause: stages of variable cycling w/ vasomotor symptoms (e.g. hot flashes, flushing, sweating)
What questions are important to ask when assessing risk for STIs?
- Establish seven attributes of any symptom
- Inquire about sexual contacts
- Establish number of sexual partners in the past 3-6 months
- Ask if patient has concerns about HIV, desires HIV testing, or has current/past partners at risk
- Ask about oral or anal sex (symptoms involving mouth, throat, anus, rectum)
- Review past history of STIs
When considering acute pelvic pain, what are some life threatening conditions that should be on your differential?
Acute pelvic pain in menstruating women warrants immediate action (life threatening)
Differential diagnoses: ectopic pregnancy, ovarian torsion, appendicitis, PID
- Red flags for PID include STIs and recent IUD insertion
- R/o ectopic pregnancy w/ serum or urine testing and ultrasound
What are the differences in symptoms, exam findings and wet mounts finding for: trichomonal vaginitis, candidal vaginitis, and bacterial vaginosis?
Discharge
- Yellowish green/gray, possibly frothy
- Profuse and pooled in vaginal fornix
- Malodorous
Symptoms
- Pruritus (not as severe as candida infection)
- Pain w/ urination
- Dyspareunia
Vulva and vaginal mucosa
- Vestibule and labia minora may be erythematous
- Vaginal mucosa diffusely reddened w/ small red granular spots or petechiae in posterior fornix
Lab evaluation
- Scan saline wet mount for trichomonads
What are the differences in symptoms, exam findings and wet mounts finding for: trichomonal vaginitis, candidal vaginitis, and bacterial vaginosis?
Discharge
- White and curdy; may be thin but typically thick
- Not malodorous
- Not as profuse as in trichomonal infection
Symptoms
- Pruritus, vaginal soreness
- Pain w/ urination
- Dyspareunia
Vulva and vaginal mucosa
- Vulva and surrounding skin often inflammed and swollen
- Vaginal mucosa reddened w/ white tenacious patches of discharge
- Mucosa may bleed when patches are scraped off
Lab evaluation
- Scan KOH preparation for branching of hyphae of candida
What are the differences in symptoms, exam findings and wet mounts finding for: trichomonal vaginitis, candidal vaginitis, and bacterial vaginosis?
Discharge
- Gray or white, thin, homogenous, malodorous
- Coats vaginal wall
- Usually not profuse
Symptoms
- Unpleasant fishy or musty genital odor
- Reported to occur after intercourse
Vulva and vaginal mucosa
- Usually appear normal
Lab evaluation
- Scan saline wet mount for clue cells (epithelial cells w/ stippled borders)
- Sniff for fishy odor after applying KOH (“whiff test”)
- Test vaginal secretions for pH >4.5
What are some tips for a successful pelvic exam?
What are ambiguous genitalia? What are some possible etiologies?
Masculinization of female external genitalia
- Caused by endocrine disorders such as congenital adrenal hyperplasia
What are some normal configurations of the hymen in the prepubertal child?
- Two openings
- Crescent shaped hymen
- Annular hymen
- Redundant labial tissue suggesting estrogen effect (possibility of imperforate hymen)
- Annular hymen and hormonal influence of puberty
How would the FNP classify Tanner Stages (Sexual Maturity Rating) in females?
What is the general order of pubertal changes in the female?
Physical changes in girl’s breasts are one of the first signs of puberty
Breasts progress through five stages (Tanner stages)
- Breast buds in preadolescent stage enlarge, changing contour of the breasts and areola
- Aerola darkens in color
- Development of pubic hair and other secondary sexual characteristics
What is considered delayed puberty in the female? What are some common causes?
No breasts or pubic hair development by age 12 years
- Caused by inadequate gonadotropin secretion from the anterior pituitary d/t defective hypothalamic GnRH production
- Cause: anorexia nervosa, chronic disease
Below 3rd percentile in height
- Cause: Turner syndrome or chronic disease
What is primary vs. secondary amenorrhea? What are some possible causes?
Primary amenorrhea: no menarche by age 16 years
- Cause: anatomic or genetic causes
Secondary amenorrhea: cessation of menses in adolescent who had previously menstruated
- Cause: stress, excessive exercise, eating disorders
What are some physical signs of sexual abuse in the pediatric patient - possible indications?
- Marked and immediate dilatation of anus in knee-chest position, w/ no constipation, stool in vault, or neurologic disorders
- Hymenal notch or cleft that extends >50% of inferior hymenal rim (confirmed w/ knee-chest position)
- Condyloma acuminata in a child >3 years
- Bruising, abrasions, lacerations, bite marks of labia or perihymenal tissue
- Herpes of the anogenital area beyond the neonatal period
- Purulent or malodorous vaginal discharge in a young girl
What are some physical signs of sexual abuse in the pediatric patient - strong indications?
- Lacerations, ecchymoses, newly healed scars of the hymen or the posterior fourchette
- No hymenal tissue from 3 o’clock to 9 o’clock
- Healed hymenal transections especially between 3 o’clock to 9 o’clock (complete cleft)
- Perianal lacerations extending to external sphincter
What are some causes of vaginal discharge in the pediatric patient?
- Perineal irritation (e.g. bubble baths or soaps)
- Foreign body
- Nonspecific vulvovaginitis
- Candida
- Pinworms
- STIs from sexual abuse
What are the current recommendations for prostate cancer screening?
USPSTF - recommends against screening for asymptomatic men regardless of age, race, or family history
American Cancer Society & AUA - encourage screening average risk patients beginning at ages 50-55 years
Providers encouraged to support shared decision making
- If patient agrees, PSA testing recommended every 1-2 years; DRE optional
- Stop offering screening when patients reach 70 years or when life expectancy drops below 10 years
Providers can consider offering screening beginning at ages 40-45 years to men at high risk for cancer (e.g. African Americans, family history of prostate cancer)
What is a normal PSA level?
<4 ng/mL
What history and exam findings are consistent with a normal prostate gland?
- Normal prostate is rounded, heart shaped, approximately 2.5 cm long
- Median sulcus can be palpated between two lateral lobes
- Only posterior surface of prostate palpable
- Anterior and central lesions, including those that obstruct the urethra, are not detectable by physical exam
What history and exam findings are consistent with prostatitis?
Acute bacterial prostatitis (pictured)
- Presents w/ fever and urinary tract symptoms (frequency, urgency, dysuria, incomplete voiding, low back pain)
- Gland feels tender, swollen, “boggy”, warm
Chronic bacterial prostatitis
- Associated w/ recurrent UTI
- Men may be asymptomatic or have symptoms of dysuria or mild pelvic pain
- Gland feels normal w/o tenderness or swelling
- Cultures may show infection w/ e. coli
What history and exam findings are consistent with BPH?
Nonmalignant enlargement of prostate that increases w/ age (>50 years)
Symptoms arise from both smooth muscle contraction in prostate, bladder neck, and compression of urethra
- Irritative (urgency, frequency, nocturia)
- Obstructive (decreased stream, incomplete emptying, straining)
- Gland may be normal in size or feel symmetrically enlarged, smooth, firm
- May have obliteration of medial sulcus
- Notable protrusion into the rectal lumen
What history and exam findings are consistent with prostate cancer?
Suggested by an area of distinct hardness (nodule) in the gland
- Nodule may extend beyond confines of the gland
- Obscured median sulcus
What are the current colorectal screening guidelines?
Offer patients at average risk a range of screening options beginning at 50 years; screening should continue until 75 years
- Annual screening w/ FOBT
- Colonoscopy every 10 years
- Sigmoidoscopy every 5 years (can be combined with FOBT every 3 years)
- Option for double-contrast barium enema or CT colonography every 5 years and periodic fecal DNA testing
Individuals at higher risk will begin screening at a younger age and repeated at shorter intervals
What history and exam findings would be consistent with internal hemorrhoids?
Enlargements of the normal vascular cushions located above the pectinate line, usually not palpable
- Bright-red bleeding (especially during defecation)
- Prolapse through anal canal
- May appear reddish, moist, protruding masses
What history and exam findings would be consistent with external hemorrhoids
Dilated hemorrhoidal veins that originate below the pectinate line that are covered w/ skin
- Seldom produce symptoms unless thrombosis occurs
- Thrombosis causes acute local pain that increases w/ defecation and sitting
- Tender, swollen, bluish, ovoid mass is visible at anal margin
What history and exam findings would be consistent with a prolapsed rectum?
On straining for a bowel movement, the rectal mucosa and musclar wall may prolapse through the anus
- Looks like a doughnut or rosette of red tissue
- Prolapse involving only mucosa is small and shows radiating folds (pictured)
- When entire bowel wall is involved, prolapse is larger and covered by concentrically circular folds
