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Physical Diagnosis > Lecture one (Female), EXAM 3 > Flashcards

Lecture one (Female), EXAM 3 Flashcards

1
Q

What are common concerns/chief complaint? (7)

A
  • Issues around onset of menses, menstruation pain and flow, menopause
  • Pregnancy
  • Vulvovaginal symptoms
  • Sexual health
  • Pelvic pain – acute and chronic
  • Sexually Transmitted Infections (STI)
  • Breast pain, nipple discharge, lumps and bumps
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2
Q

What are these terms?
* Menarche
* Dysmenorrhea
* Amenorrhea

A
  • Menarche – age of onset of menstruation
  • Dysmenorrhea – pain with menstruation
  • Amenorrhea – absence of menstruation
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3
Q

What are these terms?
* Abnormal uterine bleeding
* Menopause
* Postmenopausal bleeding

A
  • Abnormal uterine bleeding: between menses, infrequent, excessive, prolonged or postmenopausal
  • Menopause: absence of menses for 12 consecutive months (~ 55 years old)
    * can start early and that can increase gyn cancer
  • Postmenopausal bleeding: occurring 6 or more months after cessation of menses
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4
Q

What are the different scales we need to know (3)

A
  • The Tanner Scale
  • Also known as Sexual Maturity Scale (SMR)
  • Scale of Physical Development based on size of breasts, genitals, testicular volume and development of pubic hair
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5
Q

What are the tanner stages? (5)

A
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6
Q

What is the gravida Para notation?

A

G = gravida, or total number of pregnancies
P = para, or outcomes of pregnancies
* After 24 weeks; Includes stillborn
* Nulliparous: no preg
* multiparous: many

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7
Q

What can you ask after asking para? (4)

A
  • F – full-term
  • P – premature
  • A- abortion
  • L – living child
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8
Q

LY

What are key history questions? (7)

A
  • Have you ever been pregnant?
  • How many living children do you have?
  • Have you ever had an abortion or miscarriage
    * If so, how may times?
  • Ask about difficulties during pregnancies and or giving birth? (ex. c-section)
  • Ask about methods of contraception
  • Ask if the patient has noticed any lumps, bumps, skin changes or nipple discharge in regards to breast
  • Obtain and document any family history of breast cancer
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9
Q

What should you assume about sexual orientation and gender identify?

A

ASSUME NOTHING

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10
Q

Sexual Orientation & Gender Identify:
* Ask what?
* What population frequently recieve inadequate healthcare? Why?
* What is it important to ask and accept these questions?

A
  • Ask re; sexual identity “have you, or do you have sexual encounters with other men/women?”
  • LGBT frequently receive inadequate healthcare – either due to bias or lack of effort of the provider.
  • Important to ask and accept – understand there is an increased risk of suicide, depression, and in some cases, STI.
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11
Q

How would you ask about gender identity?

A
  • ask the patient, early in the visit – ”how would you describe your gender identity”
  • You may also need to ask their gender at birth.
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12
Q
  • How do you need to be when asking about sexual health?
  • What are the questions or information you need to know? (4)
  • What do you need to consider with minors?
A
  • In a neutral, nonjudgmental tone, ask about sexual
    history
  • Current relationship
  • Estimated number of sexual partners
  • Behavior that may indicate increased risk of STI
  • Any concern patient may have
  • Consider asking parents to leave room in order to allow adolescents/teens to speak freely
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13
Q

What is the goal of obtaining a sexual history?

A

Goal – assess the “five P’s” – Partners, Practices, Protection from STI, Past history of STI, Prevention of Pregnancy (CDC)

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14
Q

What do you need to ask about partners in the five Ps?

A
  1. “Do you have sex with men, women, or both?”
  2. “In the past 2 months, how many partners have you had sex with?”
  3. “In the past 12 months, how many partners have you had sex with?”
  4. “Is it possible that any of your sex partners in the past 12 months had sex with someone else while they were still in a sexual relationship with you?”
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15
Q

What do you need to ask about practices in the five Ps?

A
  1. “To understand your risks for STDs, I need to understand the kind of sex you have had recently.”
  2. “Have you had vaginal sex, meaning ‘penis in vagina sex’?” If yes, “Do you use condoms: never, sometimes, or always?”
  3. “Have you had anal sex, meaning ‘penis in rectum/anus sex’?” If yes, “Do you use condoms: never, sometimes, or always?”
  4. “Have you had oral sex, meaning ‘mouth on penis/vagina’?”
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16
Q

What do you need to ask following up with condom answers?

A
  1. If “never”: “Why don’t you use condoms?”
  2. If “sometimes”: “In what situations (or with whom) do you use condoms?”
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17
Q

What do you need to ask about prevention of pregnancy in the five Ps?

A
  1. “What are you doing to prevent pregnancy?”
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18
Q

What do you need to ask about protection from STDs in the five Ps?

A

“What do you do to protect yourself from STDs and HIV?”

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19
Q

What do you need to ask past history of STDs in the five Ps?

A
  1. “Have you ever had an STD?”
  2. “Have any of your partners had an STD?”
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20
Q

Additional questions to identify HIV and viral hepatitis risk include:

A
  1. “Have you or any of your partners ever injected drugs?”
  2. “Have your or any of your partners exchanged money or drugs for sex?”
  3. “Is there anything else about your sexual practices that I need to know about?
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21
Q

What are a list of questions we need for sexual health?

A
  • # of partners (some references recommend # over last twelve months, others life-time)
  • Type of sex – vaginal, anal, oral
  • Gender of partner(s)
  • Performance – desire to have sex (libido), able to achieve orgasm, pain with intercourse (esp women)
  • Known history of Sexually Transmitted Infection
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22
Q

What are some health promotions and counseling for sexual health?

A
  • Cervical cancer screening
  • Ovarian cancer: risk factors and screening
  • Sexually transmitted infections
  • Family planning options
  • Menopause and hormone replacement therapy * Breast pain, masses
  • Breast cancer screening
  • Risk of breast cancer
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23
Q

What does pap test look for?

A

precancerous and cancerous cells

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24
Q

PAP:
* Current recommendations from US Preventive Service Task Force – screening with cytology alone is what?

A

every 3 years for women ages 21 – 65

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25
Q

Women 30-65, cytology alone every 3 years, high risk HPV, test how often?

A

every 5 years; or for those who want to lengthen the screening interval – screen with combo of cytology and HPV testing every 5 years.

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26
Q

What are the PAP cytology results?

A
  • Normal
  • ASCUS: Atypical squamous cells of undermined significance
  • AGUS: Atypical glandular cells of undetermined significance
  • LSIL: Low-grade squamous intraepithelial lesion encompassing: HPV/mild dysplasia/CIN1
  • HSIL: High-grade squamous intraepithelial lesion encompassing: moderate and severe dysplasia, CIN2, CIN3, and carcinoma in sit

LSIL and HSIL to obgyn

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27
Q

What is typically co-tested with PAP test?

A

HPV test

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28
Q

What are current recommendations for PAP and HPV testing

A
  • Not to screen women under age 21 unless there is immune compromise, in utero exposure to diethylstilbestrol
  • Screen more frequently in women with a history of a high grade precancerous cervical lesions or cervical cancer or with immune compromise
  • Screen via PAP every 3 years from age 21-65, HPV testing every 5 years
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29
Q

Mammorgraphy is based on average risk. What is average risk?

A

Not BRCA positive and no chest radiation therapy before the age of 30

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30
Q

What is the mammography guidlines?

A
  • Begin screening at age 40, every other year to age 74
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31
Q

What are factors that greatly increase breast cancer risk (4)?

A
32
Q

Per American Cancer Society:
* Most often when breast cancer is detected because of what?
* Women should be familiar with what?

A
  • Most often when breast cancer is detected because of symptoms (such as a lump), a woman discovers the symptom during usual activities such as bathing or dressing.
  • Women should be familiar with how their breasts normally look and feel and should report any changes to a health care provider right away.
33
Q

What is the screening for those at higher risk of breast cancer?

A
  • Some discrepancy among various guidelines
  • Generally – breast MRI at age 25 if BRCA1 or BRCA2 gene mutation known (yearly)
  • Breast MRI at age 30 if known gene mutation in family member, but individual not tested (yearly)
  • Women in the highrisk categoty should have a clinical breast exam every 6-12 months (hands on exam)
34
Q

Age related changes

  • What is pre-mentstrual syndrome?
  • What happens in menopause? What age?
  • Breast pain expected when?
  • What happens to breast as we age?
A
  • Pre-menstrual syndrome – mood changes, cramping – typically emerges in teen years
  • Menopause, vaginal wall thinning, decrease in vaginal secretions – typically in late ‘40’s – early 50’s
  • Breast pain – expected with menses prior to menopause
  • Loss of tone, pendulous breasts-typical as age progresses
35
Q

Examination of external genitalia:
* Who do you need present?
* What do you need to explain?
* Assist patient into what? ⭐️
* How should you drape the patient?
* Inspect what?
* Palpate what?

A
  • Female chaperone
  • Explain what you are going to do
  • Assist patient into lithotomy position
  • Drape from abdomen over knees, depress between knees so that you may have eye contact and monitor facial expression
  • Inspect the mons pubis, labia major, labia minor and perineum
  • Palpate the inguinal lymph node
36
Q

What do you need to inspect for with female gentaila?

A
  • Inflammation
  • Discharge (some in normal but need to know color and consistency of it in case it is abnormal)
  • Ulceration
  • Swelling
  • nodules
37
Q

What are common findings during female exams?

GO BACK AND ADD LOCATION

A
  • Ingrown hair – erythematous base, typically in area shaved
  • Candidiasis (yeast) rash (esp. in inguninal folds)
  • Bartholin cyst: normal but appearance can be scary. Only worry about it if red, inflammed and non-motile
38
Q

Pelvic examination (speculum)
* What does it follow?
* Select what?
* Warm the speculum with what?
* What should you be doing with the patient?
* Insert what before you enter the speculum?
* How much should you open the speculum?

A
38
Q

What are you looking for during the speculum exam?

A

Normal appearance of the cervis and os
* should be pink and shiny

39
Q

How do you find the cervix? What are you inspecting?

A
40
Q

What does strawberry cervix mean?

A

Strawberry cervix is almost always a sign of trichomoniasis

41
Q

How do you collect the specimen from cervix?

A
  • Pap smears – small brush inserted into os
  • Wet prep/DNA probe (STD testing) – best practice to collect from cervical discharge
  • Specimen collection is done PRIOR to bi-manual exam
  • Stool sample is the exception – may be collected from glove after recto-vaginal exam
42
Q

What do you need to document with the cervix?

A
  • Color, erosions, lesions of the Cervix
  • Shape, bleeding, discharge from the os
43
Q

Pelvic exam:
* How you position your fingers?
* Insert what? What are you checking for?
* You place your non-dominant hand where?
* Move the cervix how and why? ⭐️
* What do you need to palpate?

A
  • Gloves, lubricate first two fingers, third and fourth fingers are flexed, thumb is lifted
  • Insert first two fingers into the vagina and ask the patient to bear down – you are checking for muscle tone, nodularity and tenderness
  • Place non-dominant hand on patient’s lower abdomen
  • Move the Cervix up and down with inserted fingers – you are checking for “cervical motion tenderness” (Chandelier sign for PID)
  • Palpate Fornices (ant/post/lateral)
  • Palpate over adnexa (trying to feel ovaries)
44
Q

What are the three primary purposes of the recto-vaginal exam?

A
  • To palpate a retroverted uterus, the uterosacral ligaments, cul-de-sac, and adnexa
  • To screen for colorectal cancer in women ages 50 years or older
  • To assess pelvic pathology
45
Q

How do you do the rectovaginal exam? What are you checking for?

A
  • Re-glove
  • Lubricate fingers
  • Insert index finger into vagina
  • Insert middle finger into rectum
  • You are checking for smoothness of the septum and you may be able to to feel a portion of the uterus
46
Q

For special exams:
What is the rectocele and cystocele?

A
  • Rectocele: Ask pt to bear down to observe for protrusion from posterior wall of vagina
  • Cystocele: Separate speculum, insert lower portion into vagina and ask patient to bear down.
47
Q
  • What country has the highest rate of STI in the industrialized world?
  • What is the most common STI in women?
  • What is the most common STI among BOTH male and female?
A
  • The US has the highest rate of STI in the industrialized world
  • Chlamydia is the most commonly reported and most common in women
  • HPV is the most common STI among both male and female
48
Q

The Department of Health regulates Communicable Diseases under the authority of Chapter 64D-3 of the Florida Administrative Code. The following diseases are designated as sexually transmitted and need to be reported: (10)

A
  • (AIDS)- Acquired Immune Deficiency Syndrome
  • Chancroid
  • Chlamydia
  • Gonorrhea
  • Granuloma Inguinale
  • Hepatitis A
  • Hepatitis B
  • HIV -Human Immunodeficiency Virus
  • Lymphogranuloma Venereum (Venerial Disease)
  • Syphilis
49
Q

What are the 4 patient positions of the breast exam?

A
  • Sitting with arms at side
  • Sitting with arms over head
  • Sitting with hands on hips
  • Leaning forward.
50
Q

Where are the majority of cancers?

A

Upper outer quad

51
Q

What are visually inspecting of the breasts? (AKA what are some abnormals)

A

check for abnormal fullness, dimpling, abnormal appearance of the nipple

52
Q

What is the technique for breast palpation?

A
53
Q

What pattern should you be using when palpating the breasts?

A

any pattern is fine as long as it allows complete palpation

54
Q

Inspect & Palpate Axilla (Male & Female)

  • Inspect for what?
  • How do you check and palpate the axilla?
A
  • Inspect for rash, lesions, masses, abnormal pigmentation
  • Palpate axilla – with patient’s arm at his/her side, place your hand into the axilla and gently swipe down the lateral chest wall, then grasp the anterior axillary fold and palpate border of pectoral muscle, then palpate high in axilla and bring hand down along upper humerus
55
Q

Finish with palpating with what?

A

Finish with palpating the infraclavicular and supraclavicular lymph nodes.

56
Q

LY

What are some tips she added?

A
57
Q

A 68-year-old former paleontologist presents to clinic with concerns about her breast cancer risk. Her mother developed the disease in her 50s and died from it in her 60s. A younger cousin developed the disease a few years ago before the age of 50 years, but this individual was not tested for the BRCA1 and BRCA2 genes. In addition, the patient suffered from lymphoma in her 20s and had radiation to the chest. She did take hormone replacement therapy for a few years before data emerged that this may contribute to breast cancer risk. She has had several abnormal mammograms in her 50s for persistently dense breasts with subtle findings, but follow-up biopsies never showed any malignant pathology. Which of the following is true regarding magnetic resonance imaging (MRI) screening of this patient?

  1. Regardless of recommendations, the high sensitivity of breast MRI comes at the expense of markedly decreased specificity (i.e., the ability to rule out disease in healthy breasts).
  2. Mammograms are not affected by breast density and thus density is not a factor in choosing MRIs over mammograms in patients such as this individual.
  3. History of chest radiation is not a risk factor for breast cancer and is thus not relevant to deciding whether MRI is appropriate in this patient.
  4. No agency recommends breast MRI for a patient such as this one, who has moderately but not extraordinary risk factors for breast cancer.
  5. The U.S. Preventive Services Task Force (USPSTF) recommends against screening with MRI for patients with such risk factors.
A
  1. Regardless of recommendations, the high sensitivity of breast MRI comes at the expense of markedly decreased specificity (i.e., the ability to rule out disease in healthy breasts).
  • This patient presents with an extraordinary risk profile -
    o Strong family history of breast cancer (suggestive of BRCA linkage to disease but without clear diagnosis)
    o History of chest radiation between the ages of 10-30 convers high risk of breast cancer
    o Dense breasts requiring prior biopsies to rule out malignancy
58
Q

A 22‐year‐old G0P0 undergraduate student presents to clinic after finding a breast mass on breast self‐examination (BSE) at home. The mass is nontender without skin changes, erythema, or overlying swelling. She has heard that most breast cancers are found by patients themselves, and she is very concerned that she may have breast cancer. Which of the following is true about BSE and self‐detection of breast cancer?
a) BSE is universally recommended because of very high sensitivity and specificity for finding cancerous lesions.
b) Because of this patient’s age, breast masses should not be pursued with imaging and diagnosis because the risk of cancer is so low.
c) This patient is more likely to find a fibroadenoma than a cancer on self‐examination.
d) The most likely breast mass this patient is likely to find in herself is an abscess complicating underlying mastitis.
e) Most masses that women find at home and bring to a provider’s attention turn out to be malignant.

A

c) This patient is more likely to find a fibroadenoma than a cancer on self‐examination.

  • Palpable fibroadenomas are more likely to be found in the age range: 15-25
  • 11% BSE masses turn out to be malignant
  • Symptoms of mastitis: localized swelling, erythema, tenderness with generalized fever
  • Risk factors for mastitis: pregnancy and/or breast feeding
  • Definitive diagnosis should be pursued with imaging for all masses
  • BSE: suffers from notoriously low sensitivity and specificity, making it a very controversial recommendation as it tends to overestimate disease in healthy breasts and miss cancer in breasts with subtle disease.
59
Q

A 24‐year‐old graphic designed presents to clinic with a concern for a breast mass. A rubbery, mobile, nontender mass is palpated in the right breast as described by the patient, which is consistent with a fibroadenoma. In describing the location of the mass, the examiner notes that it is 3 cm proximal and 3 cm to the left to the nipple. Which of the following would be the most appropriate way to report this finding?
a) “Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the nipple”
b) “Rubbery, mobile, nontender mass located in right breast, in the 1:30 position from the nipple”
c) “Rubbery, mobile, nontender mass located in right breast, in the lower outer quadrant”
d) “Rubbery, mobile, nontender mass located in right breast, in the upper inner quadrant”
e) “Rubbery, mobile, nontender mass located in the left breast, upper outer quadrant”

A

a) “Rubbery, mobile, nontender mass located in right breast, in the 10:30 position from the nipple”

60
Q

A 44‐year‐old female mathematician presents to clinic with a complaint of a mass in the right breast. Her partner noticed this mass 2 days ago, and the patient feels guilty because she has only had one mammogram and does not engage in breast self‐examination (BSE) on any regular basis. She has no family history of breast cancer, and her prior mammogram was ordered as a routine screening test at age 43 years after a brief discussion with her primary care provider. After a thorough investigation reveals a benign cyst, what advice should be given to this patient about screening for breast cancer in her age group?

a) BSE is well evidenced, and all recommending agencies agree that it should be taught and reinforced.
b) This patient was in compliance with the U.S. Preventive Services Task Force (USPSTF) recommendations for her age group and risk factors prior to her current complaint.
c) Breast cancer screening is extremely well studied, and no controversy exists on the recommended norms for screening and follow‐up.
d) Mammography is most sensitive and specific for women in their 40s, when breast tissue is still dense enough to image accurately.
e) Clinical breast examination (CBE) is superior to BSE and should be a routine part of annual examinations starting at age 30 years.

A

b) This patient was in compliance with the U.S. Preventive Services Task Force (USPSTF) recommendations for her age group and risk factors prior to her current complaint.

61
Q

A 48‐year‐old female psychologist presents to clinic with concerns about her breast cancer risk after an age‐matched cousin was recently diagnosed with this disease. This cousin is the third family member on her father’s side in as many years to be diagnosed with breast cancer, including the patient’s own father, who had surgery and subsequent treatment 3 years ago for breast cancer. The patient has little other knowledge of her family history, only that her grandparents independently arrived from Eastern Europe near the end of World War II and were among very few members of their family that survived the war. The patient has read about testing for the breast cancer genes (BRCA1 and BRCA2) and desires further information about whether this would be appropriate for her. Which of the following is true about this patient’s indications for BRCA testing?

a) The BRCAPRO calculator does not add any further clinical information to this patient’s risk for carrying the BRCA gene.
b) Her familial lineage is irrelevant to her risk of BRCA genes and should be discounted in assessing her risk for these genes.
c) Even if this patient is BRCA positive, no changes in screening or treatment are recommended for patients with this genetic mutation, so the test is not recommended.
d) Breast cancer in a male relative does not add significant weight to the decision to test for the BRCA genes in this patient.
e) This patient carries several risk factors that together justify BRCA testing.

A

e) This patient carries several risk factors that together justify BRCA testing.

62
Q

A 54‐year‐old female dietician presents for a routine annual examination. On review of systems, she reports that she has had many breast findings over several years, including one biopsy with normal pathology. She feels that her breasts have become far less lumpy since she underwent menopause 3 years ago. Which of the following is true regarding changes in the breasts with menopause?
a) Estrogen in hormone replacement therapy (HRT) has no effect on breast density after menopause.
b) Breast density has no genetic component and is entirely due to estrogen dose from endogenous and exogenous sources over the lifetime.
c) Mammography performs most poorly in the menopausal and postmenopausal age group and should be limited for that reason.
d) Transformation of breasts to primarily fatty tissue with menopause decreases the sensitivity and specificity of mammograms.
e) Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the number of lobules

A

e) Glandular tissue of the breast atrophies with menopause, primarily due to decrease in the number of lobules

63
Q

A 66‐year‐old female museum curator presents for a routine annual examination. On examination, a notably enlarged supraclavicular lymph node is appreciated on the right side. The lymph node is nontender and feels firm and rubbery. She denies any localized or systemic symptoms such as breast lumps, fevers, or night sweats. She has been taking conjugated estrogen tablets for 9 years since menopause, though she has not taken progestin compounds since she had a hysterectomy for heavy bleeding at age 45 years. Which of the following is true about this presentation of lymphadenopathy?

a) Supraclavicular nodes are generally considered benign and require no further evaluation or follow‐up.
b) Breast cancer always presents with axillary lymphadenopathy because the lymphatics of the breast uniformly drain into the axilla.
c) Firm, rubbery lymph nodes are generally considered to be benign.
d) Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular nodes without first causing notable changes in the axillary nodes.
e) Supraclavicular nodes are found along the anterior edge of the trapezius muscle in the neck.

A

d) Metastatic breast cancer cells may spread directly into the infraclavicular and then supraclavicular nodes without first causing notable changes in the axillary nodes.

64
Q

A 42‐year‐old female website developer presents for an annual preventive examination with questions about breast cancer screening. She is concerned about the radiation exposure associated with mammography and is interested in magnetic resonance imaging (MRI) as a possible alternative for routine screening. She is otherwise healthy with no family history of breast, ovarian, or colon cancer. Which of the following is true about MRI as a screening modality for breast cancer in the general population?

a) Breast cancer screening by MRI has been well studied in the general population.
b) Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity.
c) Women at low lifetime risk of breast cancer (<20%) are recommended to undergo screening MRI
d) This patient is an ideal candidate for screening via breast MRI based on current evidence
e) Known BRCA1 or BRCA2 mutation is insufficient criteria to justify screening with breast MRI

A

b) Sensitivity of screening for breast cancer increases with breast MRI at the expense of specificity.

65
Q

A 35‐year‐old G0P0 woman presents to clinic with a complaint of bilateral nipple discharge. This discharge started several weeks ago and has occurred at irregular intervals since that time. She does not complain of local tenderness, redness, fever, or any other systemic symptoms aside from slightly irregular periods over the last few months. On examination, she is able to express a small amount of discharge, which is sent to the laboratory and found to be consistent with breast milk but without any signs of blood or pus. Screening laboratories are also sent, which reveal a normal blood count, metabolic panel, thyroid‐stimulating hormone, and human chorionic gonadotropin (HCG) level. Further laboratories are still pending. Which of the following is the most likely diagnosis?

a) Occult pregnancy
b) Prolactinoma
c) Paget disease of the breast
d) Ductal carcinoma in situ
e) Mastitis

A

b) Prolactinoma
Prolactinoma: pituitary tumors that secrete prolactin, which causes the production of breast milk and can suppress menstruation
- Mastitis: breast infection that is typically painful, characterized by a focal area of redness and tenderness in one breast.
- Ductal carcinoma in situ:
o Signs of breast cancer = bloody/pus in nipple discharge + unilateral
o Testing: mammogram and/or ultrasound
- Paget’s disease: usually bloody nipple discharge
- Occult pregnancy: required +HCG test

66
Q

A 24‐year‐old retail clerk presents to the clinic for an annual exam. Her last Pap was 3 years ago and was normal. She is a G0 and is currently not sexually active although she has had two lifetime partners. She is on oral contraceptive pills for cycle control and has no medical problems. Based on guidelines, the clinician proceeds to perform a Pap smear and places the speculum. There are two layers of cells, squamous and columnar. Where is the most important area to obtain cells for a Pap smear?

a) Zona reticularis
b) Squamous zone
c) Columnar zone
d) Linea nigra
e) Transformation zone

A

e) Transformation zone

67
Q

An 18‐year‐old high school senior presents to the clinic complaining of a vaginal discharge. She states that it is thick and yellow and that she has had some recent pelvic pain. She is sexually active and is not using any type of birth control or sexually transmitted infection (STI) prevention. She denies any burning with urination, nausea, vomiting, or diarrhea. She has had some fever and chills with a temperature up to 101.5ºF. Her last menstrual period was last week. After a physical exam, she is diagnosed with pelvic inflammatory disease (PID). Visualization of purulent discharge in which of the following areas would best support a diagnosis of PID?

a) Bartholin gland opening
b) Posterior fornix
c) Cervical os
d) Anterior fornix
e) Skene gland opening

A

c) Cervical os

68
Q

A 23‐year‐old female comes to the clinic to discuss her birth control options. Although she has been sexually active since age 16 years, she has been with one partner for the last year. She has decided to discontinue condoms and would like a different birth control option. She has not had a pelvic exam for 2 years. She had a normal Pap smear that year and negative sexually transmitted infection (STI) testing. Her last menstrual period was 2 days ago. She states that she is still spotting. She also states that she last had sex with her boyfriend 1 week ago, so the clinician elects to postpone her speculum exam. What is the best explanation for the decision to postpone her exam?

a) She is on her menses.
b) She has only one current partner and does not need STI testing.
c) She has been using condoms.
d) She should not be sexually active.
e) She had a normal Pap smear within the last 3 years.

A

a) She is on her menses.

69
Q

A 27‐year‐old G0 bus driver presents to the clinic complaining of an itchy vaginal discharge for the last week. She reached menarche at age 12 years, became sexually active at age 18 years, and has had a total of five sexual partners. She has been with her current partner for 1 month. She is on oral contraceptive pills and does not use condoms as she is allergic to latex. Her last menstrual period was 3 weeks ago. She is not having any pelvic pain, fever, nausea, or vomiting. Her vitals are normal with a body mass index of 22. The clinician places the metal medium Graves speculum in the vagina but cannot find the cervix. What is the best next maneuver to visualize the cervix

a) Replace the speculum with a larger one (large Graves).
b) Withdraw the speculum slightly and reposition it on a different slope.
c) Replace the speculum with a plastic one with a better light source.
d) Discontinue the speculum exam and treat empirically.
e) Withdraw the speculum and do a bimanual exam to find the cervix.

A

b) Withdraw the speculum slightly and reposition it on a different slope.

70
Q

A 21‐year‐old college student presents for her first annual exam. She has been sexually active for 1 year and has had two partners. She is not aware of having had any sexually transmitted diseases (STIs). She is using condoms for birth control and STI prevention but admits to not always using them regularly. Her last menses was 2 weeks ago. On speculum exam, an unusual appearance is noted, which is diagnosed as warts. What is the best description for these lesions?

a) Several shallow ulcers with a red base
b) Bright red, soft lesion arising from the cervical canal
c) Translucent nodules
d) Strawberry cervix (small red granular spots or petechiae)
e) Raised friable or lobed lesions

A

e) Raised friable or lobed lesions

71
Q

A 45‐year‐old driver’s education instructor presents to the clinic for heavy periods and pelvic pain during her menses. She reached menarche at age 13 years and has had regular periods except during her pregnancies. She is a G4P3013 and does not use birth control as her husband has had a vasectomy. She states this has been going on for about a year but seems to be getting worse. Her last period was 1 week ago. On bimanual exam, a large midline mass halfway to the umbilicus is palpated. Each adnexal area is nonpalpable. Her rectal exam is normal. Her body mass index (BMI) is 27. What is the best explanation for her physical finding?

a) Bartholin gland enlargement
b) Ovarian mass
c) 4‐Month pregnancy
d) Large colonic stool
e) Fibroids

A

e) Fibroids

72
Q

A 32‐year‐old G0 woman comes for evaluation on why she and her husband have been unable to get pregnant. Her husband has been married before and has two other children, ages 7 and 4 years. The patient relates she began her periods at age 12 and has been fairly regular ever since. She began oral contraceptive pills from when she got married until last year, when she began to try for a pregnancy. Before this she had regular cycles for 10 years. She has had a history of five prior partners. She relates she was once treated for a severe genital infection when she was in college. Based on this patient’s history, what is the best explanation for her infertility?

a) Prior Bartholin gland infection
b) Prior pelvic inflammatory disease (PID)
c) Metabolic disorder with subsequent hormonal irregularities leading to anovulation
d) Secondary amenorrhea
e) Prior herpes infection

A

b) Prior pelvic inflammatory disease (PID)

73
Q

A 63‐year‐old office worker comes to the clinic for her women’s health exam. Her last Pap smear was 5 years ago and was normal. She is married and has been with the same sexual partner for the last 35 years. After performing the majority of the exam, the clinician decides to do a speculum exam to collect cytology for Pap smear. What is the correct position to have the patient in for her speculum exam?

a) Trendelenburg
b) Prone
c) Sitting
d) Lithotomy
e) Supine

A

d) Lithotomy

74
Q

A 68‐year‐old retired patient presents to the clinic complaining about feeling like something is falling out of her vagina. She is a G6P6007 and had all her children vaginally, even the twins. She went through menopause at age 55 years, and, for the last few months, she has felt this falling sensation. On exam, an anterior bulge in the vaginal wall is apparent when she bears down. Weakness in which muscle would best account for the anterior bulge in the vaginal wall?

a) Levatori ani
b) Pubis symphysis
c) Bulbocavernosus muscle
d) Ischiocavernosus muscle
e) Anal sphincter

A

a) Levatori ani

75
Q

A 35‐year‐old grade school teacher presents for her annual exam. Her last Pap smear was 4 years ago and normal. She is a G1P1 with a 6‐year‐old child. She has had four lifetime partners but only one partner in the last 12 years. Otherwise she has no complaints. A speculum exam is done followed by a bimanual examination during which a rectovaginal mass is palpated. Which of the following exam findings would be most reassuring that this is not a colonic mass?

a) The mass dents with digital pressure
b) Both adnexa are nontender
c) No pus from the os
d) No cervical motion tenderness
e) The perineum has no lesions

A

a) The mass dents with digital pressure

Physical Diagnosis (17 decks)

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