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PCM 4 midterm > Female GU/Breast (Dr Keeler) > Flashcards

Female GU/Breast (Dr Keeler) Flashcards

1
Q

“Talk before – and as - you touch”

A
  • Explain what to expect at each step

- Touch a neutral area before the sensitive ones

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2
Q

Have patient empty bladder ____ the examination

A

BEFORE

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3
Q

Pelvic Exam Patient Position:

A

dorsal lithotomy position with feet in footrests and HOB raised ~~30-40 deg

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4
Q

During the exam….

A
  • Be gentle, maintain eye contact and be prepared
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5
Q

Use the term ____instead of “stirrups”.

A

“footrests”

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6
Q

A Pt’s First pelvic exam

A
  • sit down w/pt in your office first
  • use a model to show basics
  • use a Pederson Speculum to demonstrate
  • ask if she wants a mother/friend present
  • coach pt about perineal mm and relaxation of that area
  • touch neutral areas first
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7
Q

Confidentiality applies to?

A

any female pt regardless of her age

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8
Q

Confidentiality includes?

A

Anything remotely in the area of “sex”, “reproduction”, “pregnancy”, “STD’s”, “birth control”

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9
Q

To “disclose” information ….

A

get CONSENT and put it prominently in record

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10
Q

______ is NOT a sufficient reason to disclose daughter’s information to her mother !!!!!!!!!

A

“But she is on my insurance!”

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11
Q

A pt may _____consent at anytime

A

withdraw

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12
Q

When do you need a chaperon?

A
  • Every time, no mater your gender
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13
Q

In general, female hair distribution is shaped like ____ – but a slight “diamond” is _____

A

a triangle…..not necessarily “pathological” – ethnic component

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14
Q

Thelarche

A

age at earliest breast development (“bud”)

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15
Q

Adrenarche

A

age at first pubic hair growth (awakening of the adrenal gland)

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16
Q

Menarche

A

= age at first period (11-12 avg)

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17
Q

Thelarche is ____menarche.

A

1-2 years before menarche

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18
Q

Menarche heavily dependent on ….

A

% body fat – threshold ~~~ 20%

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19
Q

Inspection: Labia majora

A

majora-rashes,excoriation,ulcers, trauma

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20
Q

Inspection: Labia minora

A

ulcerations, inflammation – length highly variable

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21
Q

Inspection:Clitoris

A

size, usually 2 cm or less in length

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22
Q

Inspection: Urethral orifice

A

inflammation, discharge

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23
Q

Inspection: Vaginal introitus

A

hymen or remnants

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24
Q

Inspection: Bartholin and Skene’s glands

A

swelling or tenderness, discharge from Skene’s

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25
Q

Clitoral Hypertrophy: Child? Adult?

A

Infant/child = “Intersex” issue

Adult = suggests testosterone issue

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26
Q

How to help prevent Vulvar Carcinoma in older pts?

A

brief, vulvar only exam

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27
Q

DDX for Vulvar squamous carcinoma?

A

Pruritis

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28
Q

Vulvar squamous carcinoma

A
  • red or white lesions (need bx)

- there is an “in-situ” preliminary stage

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29
Q

Vulvar squamous carcinoma Treatment?

A
  • 5-fluoro-uracil (FU) topically
  • CO2 laser
  • LEEP
  • Vulvectomy
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30
Q

Lichen Planus treatment?

A

ts isnt easy - Refer to a dermatologist comfortable with gyn

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31
Q

Lichen sclerosis appearance - gross and bx

A
  • Pruritic white change, widespread, tissue-paper thin

- Biopsy shows thin epithelium w/ underlying inflammatory infiltrate

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32
Q

Lichen sclerosis tx?

A

topical testosterone or steroids

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33
Q

Lichen sclerosis is _____ a “pre-malignant” condition

A

NOT

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34
Q

Candida Infection characteristics

A
  • white cheesy discharge
  • pruritis
  • erythema
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35
Q

Candida Infection test

A

Wet mount (WM) w/KOH or VIP = looking for hyphae

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36
Q

Candida Infection Associations

A

OCP, Preg, antibx, DM, HIV

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37
Q

Trichomonas Infection Characteristics

A
  • Pruritis, odor, OTC yeast Tx fails

- Greenish watery disch occurs w/ froth

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38
Q

Trichomonas Infection test

A
  • WM w/ saline = active trich

- note KOH/VIP will kill it

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39
Q

Bacterial Vaginosis is an ______ and is ______.

A

an environmental issue and is very common

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40
Q

Bacterial Vaginosis Characteristics

A
  • Yellow creamy frothy disch., “fishy” odor, Minimal pruritis
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41
Q

Bacterial Vaginosis causes

A

Obesity, hot tubs, uncercumcised partners, dietary

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42
Q

Bacterial Vaginosis test

A

WM esp w/VIP, saline OK = “clue cells”

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43
Q

Bacterial Vaginosis tx and prevention

A
  • Tx: metronidazole x 7 d

- Prev: dietary (daily yogurt, probiotic)

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44
Q

Wet mount procedure

A
  • On slide (2 or 3) – drop or 2 of KOH, saline, (optional) VIP. Put on slide before the sample.
  • Plain swabs (2) of discharge – obtain from vagina. “Roll” onto microscope slide. Apply cover slip.
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45
Q

VIP = ?

A

crystal violet + alcohol + saline.

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46
Q

What will kill Trichomona on a WM? what to use instead?

A
  • KOH and VIP will kill

- Use saline instead

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47
Q

Pt will often believe their vaginal infection is ____ and will ___?

A

is yeast and will try to treat with OTC methods

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48
Q

If OTC treatment is used ______.

A

WAIT 4-5 days before appointment – Tx will obscure the micro on your WM

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49
Q

Position of Bartholin Glands?

A

5 and 7 o’clock

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50
Q

What to do with Labial swelling or pain?

A

inspect and palpate the Bartholin glands

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51
Q

Bartholin Glands Abscess is usually preceded by what?

A

a cyst

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52
Q

Common causes of Bartholin Glands Abscess?

A

Gonococcus and chlamydia

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53
Q

Bartholin’s Gland Abscess- Tx

A
  • Soaks, analgesics
  • Antibiotics – choose wisely = need 2nd gen cephalosporin
  • Surgical: I&D, I&D w/ “Word” catheter, Marsupialization create a pouch, Full excision
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54
Q

Urethra/Skene’s - exam

A
  • “Stripping” or “milking” of urethra results in cloudy discharge
  • Culture, antibx
  • Urological consult
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55
Q

Skene’s Gland Abscess

A
  • Danger to urethra
  • Don’t I&D yourself
  • Urological referral !
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56
Q

Cyctocele

A

wall between the bladder and vagina is weak

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57
Q

Rectocele

A

wall between rectum and vagina is weak

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58
Q

What is often present with a Cyctocele?

A

“SUI” = stress urinary incontinence - often present

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59
Q

Cyctocele tx?

A

Surgery not required; Pessary may help

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60
Q

What to ask about with a Rectocele?

A

Ask about “digital defecation”

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61
Q

Rectocele tx?

A

Surgery not required;

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62
Q

How to check for severity of a rectocele?

A

“Degree” of rectocele may not be apparent unless ValSalva is done

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63
Q

Uterine Prolapse First degree:

A

The cervix droops into the vagina.

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64
Q

Uterine Prolapse Second degree:

A

The cervix comes down to the opening of the vagina.

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65
Q

Uterine Prolapse Third degree:

A

The cervix is outside the vagina

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66
Q

Uterine Prolapse Fourth degree:

A

The entire uterus is outside the vagina. This condition is also called procidentia. This is caused by weakness in all of the supporting structures.

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67
Q

Pelvic Prolapse - advanced Pt characteristics

A
  • older, multiparous, denial
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68
Q

Advanced Pelvic Prolapse Risks

A

Ulcers and cancer

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69
Q

Advanced Pelvic Prolapse Tx?

A
  • Pessary - minimal help

- Surgery works, but is very complicated – “urogynecologist”

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70
Q

Insertion of the Speculum

A
  • Separate the labia minora with 2 fingers of one hand and insert the speculum with the other.
  • Pressure should be on the perineum and then the posterior wall of the vagina (not the anterior wall which is very sensitive)
  • AVOID catching pubic hair & labia
  • Follow the posterior wall as it angles down towards the sacrum.
  • Do not open the speculum until fully inserted.
  • Adjust set-screws for maximal visualization. –> Release them before removal!!!
71
Q

Speculum angle of insertion: “traditional” and Keeler

A
  • Traditional = 45 deg angle

- Keeler = horizontally ( 0 deg)

72
Q

Speculum Placement – a better way (zero degrees)

A
  • Select appropriate type.
  • Warm and lubricate with warm water or gel.
  • Hold HORIZONTALLY and point downward or posterior.
  • Put gentle downward pressure on the posterior introitus. COACH!!
  • Gently advance, maintaining posterior pressure.
  • Slowly open the speculum to visualize the cervix.
73
Q

Inspection of vagina Epithelium and dischage

A
  • looking for rugae, atrophy, and lesions

- be ready to do a WM if discharge is present

74
Q

inspection of vagina: Gartner’s duct remnants

A
  • = cysts
  • found to the side of the cervix
  • LEAVE ALONE
75
Q

inspection of vagina: Inclusion cyst from episiotomy

A

just inside introitus between 5 & 7 o’clock - leave it alone**

76
Q

CAN’T FIND THE CERVIX??

A
  • OK to stop and do single-finger exam to locate
  • May be very far anterior – behind [pubic] symphysis
    • Vagina may be “deep” – select longer/larger speculum – tell pt to remind you in future
  • Sidewalls may “bulge” inwards and cover – from 3 and 9 o’clock – select wider speculum
77
Q

What to look for on cervical inspection?

A
  • Nabothian Cyst
  • Discharge/pus
  • Mass
  • Tumor
  • Erosion – dangerous word –> cancer until proven otherwise
  • Lesion
  • Color
  • Describe the external os – nullip, parous, lacerated, etc.
78
Q

Nabothian Cysts

A
  • Inclusion cyst of the endocervical glands
  • May resemble cervical pathology
  • Normal variant – do not needle or biopsy
79
Q

Common cause of post coital bleeding?

A

Cervical polyp

80
Q

Cervical polyp is rarely _____.

A

CA

81
Q

Pap Smear

A

The Papanicolaou test (also called Pap smear) is a medical SCREENING technique primarily designed to detect DYSPLASIA (“premalignancy”) of the cervix at the transformation zone = TZ

82
Q

PAP Smear: NOT intended to screen for ____. MAY hint at ____. NOT an ______ – but some labs will add this if you request it separately.

A

NOT intended to screen for ovarian CA. MAY hint at endometrial CA. NOT an STD test – but some labs will add this if you request it separately.

83
Q

If Pap shows an_____, something went wrong!

A

invasive cervical CA

84
Q

Cells should be obtained from the _____.

A

TZ and endocervix

85
Q

Transformation Zone

A

TZ = area between original and current squamocolumnar junction

86
Q

Squamocolumnar junction (SCJ) “moves” dependent _____.

A

on age, parity, and hormonal status

87
Q

Metaplasia is an ____ effect

A

ESTROGEN

88
Q

The transformation zone is an area of metaplasia and it is ____.

A

the location of 90++% of cervical cancers

89
Q

ECTOPY = ?

A
  • a normal finding
  • columnar epithelium is “out” on “portio” of cervix.
  • Reddish or red/orange
  • symmetrical and circumferential
  • may be source of PCB
90
Q

Ectopy tx?

A
  • requires no intervention - just reassurance
91
Q

Infectious cervicitis may be caused by:

A 
Chlamydia trachomatis, 
Neisseria gonorrhoeae,
Trichomonas vaginalis, 
herpes simplex virus (HSV), or
human papillomavirus (HPV).
92
Q

CIN =

A
  • cervical intraepithelial neoplasia

- CIN I, II, III = mild, moderate, severe

93
Q

SIL =

A
  • squamous intraepithelial lesion
94
Q

LGSIL and HGSIL = ?

A

low grade SIL and high grade SIL

95
Q

CIS =

A

carcinoma in-situ – not a “cancer” – but close!

96
Q

Cervical DYSPLASIA =

A
  • CIN/SIL
  • Slow disease until it’s CIS
  • HPV origin – HR types = 16 + 18
  • Not often 360 deg
  • Often in one quadrant only
  • Inspection is good enough to warrant colposcopy/biopsy even if Pap is normal!!!!!
97
Q

Inspection of the vagina is usually done ____.

A

as you withdraw speculum, but do it also w/ insertion of speculum

98
Q

Lesions of the vagina

A
  • Epidermal cysts
  • Venereal warts
  • Genital herpes
  • Chancre (Syphilis)
  • Carcinoma
99
Q

Palpation: Bimanual Exam - Cervix

A

Tenderness, size, position, mobility

100
Q

Palpation: Bimanual Exam - uterus

A
  • Size, shape, consistency, mobility
  • Position
  • Fibroids (nodules)
101
Q

Palpation: Bimanual Exam - Ovaries

A
  • Size, shape, mobility, tenderness

- Remember to palpate bilaterally - may not be palpable

102
Q

Palpation: Bimanual Exam - what to inspect?

A
  • cervix
  • Uterus
  • Ovaries
  • Strength of pelvic floor
103
Q

Version

A

is the relationship between the fundus of the uterus and the vagina

104
Q

Flexion

A

is the relationship between the fundus of the uterus and the cervix – think of this as a “hinge”

105
Q

size of a golf ball, tennis, soft,

A

Golf ball = 3 cm
Tennis ball = 5 cm
Softball = 9-10 cm

106
Q

Adnexae Palpate

A
  • Palpate the “blank space” on either side of uterus. Best done just after period ends.
  • You likely won’t feel anything
107
Q

What do to if you have an adnexal mass

A
  • recheck after one cycle

- Be more suspicious if pt is on BCP - they shouldn’t be ovulating and have functional cysts

108
Q

What do to if you have an adnexal mass >5 ?

A

> 5 cm or bilateral or persistent:

  • Trans-vaginal ultrasound = “TVUS”
  • CA-125 marker
  • Gyn consultation
109
Q

When to do rectal exam?

A
  • Definitely after age +50
  • earlier if high risk
  • at any point if truly will give better insight
110
Q

Rectovaginal exam is useful in assessing:

A
  • Posterior wall of vagina
  • Rectovaginal pouch (Pouch of Douglas AKA the “cul-de-sac”)
  • Retroverted/Retroflexed uterus
111
Q

the most common inguinal hernia in women?

A

Indirect hernia

112
Q

_____is more common in women than in men

A

Femoral hernia

113
Q

_________ = common after pregnancy

A

Umbilical hernia

114
Q

Ways to to find a hernia?

A
  • “Hooking” of your index finger under inguinal zone during bimanual exam
  • Ultrasound with experienced tech
  • Diagnostic laparoscopy
115
Q

A hernia can be present, but it isn’t necessarily______.

A

the cause of the pain

116
Q

The breast is composed of _____ which are each composed of several lobules.

A

15 to 20 lobes

117
Q

________ travel through the breast (suspensory ligaments of Cooper), insert __________, and provide structural support.

A

Fibrous bands of connective tissue…..perpendicularly into the dermis

118
Q

Each lobe of the breast terminates in a _____( 2 to 4 mm in diameter), which opens through a constricted orifice (0.4 to 0.7 mm in diameter) into the________

A

major (lactiferous) duct …..ampulla of the nipple

119
Q

Deep to the nipple-areola complex, each major duct has a_________, which is lined with _________.

A

dilated portion (lactiferous sinus)…….stratified squamous epithelium

120
Q

Major ducts are lined with________, while minor ducts are lined with _______.

A

two layers of cuboidal cells…..a single layer of columnar or cuboidal cells

121
Q

The mature female breast extends from the level of the ______to the inframammary fold at the________

A

second or third rib ….. sixth or seventh rib.

122
Q

The mature female breast extends transversely from the ______.

A

lateral border of the sternum to the anterior axillary line

123
Q

The deep or posterior surface of the breast rests on the fascia of the ______.

A

pectoralis major, serratus anterior, and external oblique abdominal muscles, and the upper extent of the rectus sheath.

124
Q

______quadrant of the breast contains a greater volume of tissue than do the other quadrants.

A

The upper outer

125
Q

The axillary “tail of Spence” extends laterally _____

A

across the anterior axillary fold.

126
Q

The breast receives its principal blood supply from: (3)

A

(1) perforating branches of the internal mammary artery;
(2) lateral branches of the posterior intercostal arteries; and
(3) branches from the axillary artery, including the highest thoracic, lateral thoracic, and pectoral branches of the thoracoacromial artery.

127
Q

______arborize in the breast as the medial mammary arteries

A

The second, third, and fourth anterior intercostal perforators and branches of the internal mammary artery

128
Q

______gives off branches to the serratus anterior, pectoralis major and minor, and subscapularis muscles. It also gives rise to _______.

A

The lateral thoracic artery …… lateral mammary branches

129
Q

The optimal time to examine the breast =?

A

5-7 days following the onset of the LNMP

130
Q

Avoid _____ during a breast exam to respect the pt’s modesty.

A

total uncovering

131
Q

Symptoms of Breast Disease

A
  • Erythema
  • Masses
  • Nipple Discharge
  • Nipple Ulceration
132
Q

DDX for breast erythema?

A

Mastitis, inflammatory carcinoma

133
Q

DDX for Breast masses?

A

Cysts, fibroadenoma, hematoma, carcinoma

134
Q

DDX for Nipple discharge?

A
  • Bloody, esp single duct - Papilloma, cancer

- Non-bloody – green/clear – may be physiologic (normal) or sign of esp prolactin disorder

135
Q

DDX for Nipple Ulceration?

A
  • Paget’s disease

- Mechanical causes

136
Q

_____ is easily incorporated into the “palpation portion” of the exam.

A

Breast inspection

137
Q

_____is unacceptable to most patients during a breast exam and should be avoided.
What to do instead?

A
  • “Total exposure”

- Move the gown around! To expose only what you need.

138
Q

Patient Position for breast Exam?

A

Supine position is usually sufficient – use sitting only if needed

139
Q

During Breast inspection, Observe the breast for? (6)

A
  • Development
  • Size and symmetry
  • Contour
  • Retractions or dimpling of skin
  • Skin color and texture (Peau d’orange)
  • Venous engorgement
140
Q

During breast inspection, Observe the nipple for? (5)

A
  • Retraction unilateral or bilateral
  • Discharge
  • Darkening
  • Rash, crusting or ulcerations
  • Supernumerary nipples
141
Q

Breast Inspection – if you have a question/suspicion?

A

Tell patient that sometimes using additional positions will help with a more complete exam. Then, inspect the breast in four additional (sitting) positions

142
Q

four sitting positions for breast exam:

A
  1. Arm over head (gown covers other side)
  2. Hand against hip (gown covers other side)
  3. (Maybe) - Palms pressed together
  4. (Maybe) - Arms extended and bent forward at the waist
143
Q

Breast Changes in early pregnancy?

A
  • Darkened nipple/areola
  • Tubercles of Montgomery (round bumbs found on the nipple)
  • Size
  • Tenderness (Variable/early)
  • Venous engorgement (variable)
144
Q

Breast changes in late pregnancy?

A
  • BL discharge
  • striae
  • venous engorgement (Variable)
  • Tenderness (Variable/early)
145
Q

Breast mastitis can be ___ or ____.

A

puerperal or non-puerperal

146
Q

Breast Mastitis tx?

A
  • Don’t stop nursing

- ABX directed against staph and strep

147
Q

Inflammatory Breast Cancer requires? Prognosis?

A
  • Immediate consult and imaging

- poor prognosis

148
Q

Methods of palpation

A
  • Use pads of your fingers – not the tips
  • Vertical or horizontal criss-cross
  • Concentric
  • SPIRAL !!!!!!
  • Use two hands – one does exam, the other shifts and retracts
  • Supine, hands over head
149
Q

It is not necessary to ____ the nipples to _____. What if pt tells you she has had discharge?

A
  • Not necessary to “pinch” the nipples to try to elicit discharge.
  • Have her elicit the discharge for you and take sample for micro
150
Q

____ is often the discoverer of breast abnormalities

A

Spouse/partner

151
Q

Breast awareness?

A
  • better term for breast self exam
  • Advise pt to just pay attention, esp in shower w/ soapy water and in front of mirror. Emphasize it’s OK to “report” any question.
152
Q

Breast mass - ddx 6

A
  • Cancer
  • Cyst
  • Fibroadenoma
  • “Clustering” of FCBD
  • Infection
  • Hematoma/trauma
153
Q

What if the pt feels a mass and you dont?

A
  • Believe the pt

- do imaging and follow up

154
Q

A breast mass isn’t resolved until:

A

(a) GONE - have the pt feel and make sure it is gone too

(b) a tissue diagnosis

155
Q

Even if you are sure of a dx through your exam…..

A
  • do a work up to confirm your dx
156
Q

When to do a MRI?

A

only if very high risk profile or proven cancer – this checks the other breast esp. High incidence of false +.

157
Q

Test for bloody discharge?

A

Ductogram

158
Q

(+) mass and (-) mammogream?

A
  • you are not done –> need to do an US
159
Q

A neg FMH for breast cancer is…..

A

not a safe harbor for pts

160
Q

Breast Cancer Risk Factors (11)

A
  • prev or fam hx
  • age >50
  • nulliparous/didnt breast feed
  • 1st child after 30yo
  • early menarche
  • Estrogens and progesterone component of HRT
  • Radiotherapy to chest
  • Smoking
  • ETOH
  • Obesity
  • BRCA1/2
161
Q

90% of breast CA present with a ___

A

positive mammogram

162
Q

_____alone is a very uncommon presentation of breast cancer

A

Breast pain/mastalgia

163
Q

20% of breast CA present with a ___

A

lump which may or may not be painful

164
Q

3% of breast CA present with ___

A

with nipple discharge

165
Q

5% of breast CA present with ___

A

with skin contour changes

166
Q

0-1% of breast CA cases are ___

A

in MALE patients

167
Q

Other signs or breast CA might include:

A
  • Lump or swelling in the armpit
  • Changes in breast size or shape
  • Dimpling or puckering of the skin
  • Redness, swelling and increased warmth in the affected breast
  • Inverted nipple
  • Crusting or scaling on the nipple
168
Q

Stage I breast CA: def and prognosis

A
  • The tumor is
169
Q

Stage 2 breast CA: def and prognosis

A
  • tumor is 2 - 5 cm in diameter. The cancer may or may not have spread to the axillary lymph nodes
  • tumor is more than 5 cm in diameter, but the cancer hasn’t spread to the axillary lymph nodes
  • The tumor is
170
Q

Stage 3 breast CA: def

A
  • known as locally advanced cancer, CA has spread to the lymph nodes near the breast
  • The tumor may be > 5 cm, with spread to the axillary lymph nodes.
  • The tumor is
171
Q

Stage 3 Inflammatory breast CA: def and prognosis

A
  • the cancer has spread to the breast skin, causing swelling and redness, is classified as stage III breast cancer
  • 5 yrr survival rate = 49% - 56%
172
Q

Stage 4 breast CA: def and prognosis

A
  • Distant metastasis (lung, liver, brain, bony, adrenals)
  • Treatment may help shrink or control the cancer for a while, but it usually won’t completely cure the cancer.
  • At this stage, symptom relief becomes a priority.
173
Q

What to record for positive breast exam findings?

A
  • Location (R, L, clock, distance to nipple)
  • Size in cm (use your fingers to estim)
  • Mobility (fixated, mobile)
  • Tenderness
  • Texture (cystic, rubbery, hard)

PCM 4 midterm (6 decks)

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