Module 6

Question 1

supernumerary nipples

Answer 1

one or more extra or are located along the “milk line” (Fig.18-4). Usually, only a small nipple and areola are present, often mistaken for a common mole. They may be familial, and, in the absence of associated glandular tissue, there is little evidence of association with other congenital anomalies

Question 2

These are the most common breast-related complaints.

Answer 2

Ask if the patient has had any lumps, pain, or nipple discharge of her breasts.

Question 3

(mastodynia or mastalgia)

Answer 3

Breast pain alone, is not typically a sign of breast cancer.

Question 4

diffuse breast pain

Answer 4

(defined as involving >25% of the breast)

Question 5

focal breast pain

Answer 5

(involving <25% of the breast),

Question 6

cyclic breast pain

Answer 6

(pain that occurs prior to menses and generally resolved at the completion of the menstrual period)

Question 7

physiologic discharge

Answer 7

physiologic hypersecretion is seen in pregnancy, lactation, chest wall stimulation, sleep, and stress

Question 8

pathologic discharge

Answer 8

Nipple discharge is more likely to be pathologic when it is bloody or serous, unilateral, spontaneous, associated with a mass, and occurring in women age ≥40 years.

Question 9

galactorrhea

Answer 9

, or the discharge of milk-containing fluid unrelated to pregnancy or lactation, is most commonly caused by hyperprolactinemia

Question 10

The best time for breast examination in a patient who is still menstruating

Answer 10

is 5 to 7 days after the onset of menstruation because breasts tend to swell and become more nodular before menses from increasing estrogen stimulation. For postmenopausal women and for men, any time is appropriate.

Question 11

Inspect the breasts in four views:

Answer 11

arms at sides, arms over head, arms pressed against hips, and leaning forward (skin appearance, size, symmetry, contour, nipple characteristics).

Question 12

(peau d’orange)

Answer 12

Thickening and prominent pores suggest breast cancer.

Question 13

acanthosis nigricans

Answer 13

Deeply pigmented velvety axillary skin suggests —associated with diabetes; obesity; polycystic ovary syndrome; and, rarely, malignant paraneoplastic disorders.

Question 14

Fibroadenoma

Answer 14

15–25 yrs, usually puberty and young adulthood, but up to age 55 yrs

Usually single, may be multiple

Round, disc-like, or lobular; typically small (1–2 cm)

May be soft, usually firm

Question 15

Cysts

Answer 15

30–50 yrs, regress after menopause except with estrogen therapy

Single or multiple
Round
Often tender

Question 16

Cancer- breast

Answer 16

30–90 yrs, most common over age 50 yrs

Usually single, although may coexist with other nodules

Irregular or stellate

Firm or hard
Usually nontender

Question 17

Retraction Signs

Answer 17

As breast cancer advances, it causes fibrosis (scar tissue). Shortening of this tissue produces dimpling, changes in contour, and retraction or deviation of the nipple. Other causes of retraction include fat necrosis and mammary duct ectasia.

Question 18

Skin Dimpling

Answer 18

Look for this sign with the patient’s arm at rest, during special positioning, and on moving or compressing the breast

Question 19

Breast enlargement in men

Answer 19

History of hyperthyroidism, testicular tumor, Klinefelter’s syndrome; medications; prostate cancer treatment; substance abuse

Question 20

Monilial dermatitis

Answer 20

Skin irritation under pendulous breasts from tissue-to-tissue contact or from rubbing of brassiere; treatment

Question 21

Infants- breast changes

Answer 21

Breasts enlarge after birth in boys and girls.
Result of passively transferred maternal estrogen
May persist with breastfeeding

Question 22

Pregnant patients- breast changes

Answer 22

Increase in size; tenderness and tingling; enlarged erect nipples; vascular spiders and striae
Colostrum
Coarse nodularity of breast tissue
Dilated subcutaneous veins

Question 23

Fibrocystic changes

Answer 23

Benign fluid-filled cyst formation caused by ductal enlargement

Question 24

Fibroadenoma

Answer 24

Benign tumors composed of stromal and epithelial elements that represent a hyperplastic or proliferative process in a single terminal ductal unit

Question 25

Fat necrosis

Answer 25

Benign breast lump occurs as inflammatory response to local injury.

Question 26

Intraductal papillomas/papillomatosis

Answer 26

Benign tumors of the subareolar ducts that produce nipple discharge

Question 27

Duct ectasia

Answer 27

Benign condition of the subareolar ducts that produce nipple discharge

Question 28

Paget disease

Answer 28

Surface manifestation of underlying ductal carcinoma

Question 29

Premature thelarche

Answer 29

Breast enlargement in girls younger than 8 years of age Benign in the absence of pubic and axillary hair

Question 30

Heartburn

Answer 30

: a burning sensation in the epigastric area radiating into the throat; often associated with regurgitation

Question 31

retching

Answer 31

(spasmodic movement of the chest and diaphragm like vomiting, but no stomach contents are passed)

Question 32

hematemesis

Answer 32

Blood or coffee ground emesis is known as

Question 33

Visceral pain

Answer 33

: when hollow organs (stomach, colon) forcefully contract or become distended. Solid organs (liver, spleen) can also generate this type of pain when they swell against their capsules. Visceral pain is usually gnawing, cramping, or aching and is often difficult to localize (hepatitis)

Question 34

Parietal pain

Answer 34

: when there is inflammation from the hollow or solid organs that affect the parietal peritoneum. Parietal pain is more severe and is usually easily localized (appendicitis)

Question 35

Referred pain

Answer 35

: originates at different sites but shares innervation from the same spinal level (gallbladder pain in the shoulder)

Question 36

melena

Answer 36

black, tarry stool

Question 37

hematochezia

Answer 37

blood in stool

Question 38

white or gray stools can indicate

Answer 38

liver or gallbladder disease

Question 39

borborygmi

Answer 39

bowel sounds

Question 40

normal frequency of bowel sounds

Answer 40

The normal frequency of sound is 5-34 sounds per minute

Question 41

dullness with bowel sounds

Answer 41

(which could be a large stool or a mass)

Question 42

Percuss over the liver in which two spots

Answer 42

both the midclavicular line and at the midsternal line – Midclavicular percussion should be 6–12 cm; longer than this indicates an enlarged liver – Midsternal line percussion should be 4–8 cm; shorter than this can indicate a small, hard cirrhotic liver

Question 43

voluntary guarding

Answer 43

(patient consciously flinches when you touch him)

Question 44

involuntary guarding

Answer 44

(muscles spasm when you touch the patient, but he cannot control the reaction)

Question 45

Rovsing’s sign

Answer 45

(rebound tenderness in the left lower quadrant)

Question 46

Psoas sign

Answer 46

(the patient flexes his thigh against the examiner’s hand; pain indicates a positive sign)

Question 47

Obturator sign

Answer 47

(flex the patient’s thigh and rotate the leg internally at the hip; pain indicates a positive sign)

Question 48

Right upper quadrant (RUQ) contains

Answer 48

Liver, gallbladder, pylorus, duodenum, hepatic flexure of colon, and head of pancreas

Question 49

Left upper quadrant (LUQ)

Answer 49

Spleen, splenic flexure of colon, stomach, and body and tail of pancreas

Question 50

Left lower quadrant (LLQ)

Answer 50

Sigmoid colon, descending colon, and left ovary

Question 51

Right lower quadrant (RLQ)

Answer 51

Cecum, appendix, ascending colon, terminal ileum, and right ovary

Question 52

Bladder capacity

Answer 52

accommodates roughly 400 to 500 mL of urine

Question 53

(nocturia)

Answer 53

frequent urination at night

Question 54

Dyspepsia

Answer 54

is defined as chronic or recurrent discomfort or pain centered in the upper abdomen, characterized by epigastric pain or burning (or both) and postprandial fullness or early satiety (or both

Question 55

functional, or non-ulcer, dyspepsia

Answer 55

, defined as a 3-month history of nonspecific upper abdominal discomfort or nausea not attributable to structural abnormalities or peptic ulcer disease (PUD

Question 56

Heartburn

Answer 56

is a rising retrosternal burning pain or discomfort occurring weekly or more often. It is typically aggravated by foods such as alcohol; chocolate; citrus fruits; coffee; onions; and peppermint; or positions like bending over, exercising, lifting, or lying supine.

Question 57

odynophagia

Answer 57

Pain with swallowing ()

Question 58

RLQ pain or pain that migrates from the periumbilical region, combined with nausea, vomiting, and loss of appetite is suspicious for

Answer 58

appendicitis

Question 59

Peritonitis

Answer 59

is marked by severe diffuse abdominal pain with guarding and rigidity on examination

Question 60

obstipation

Answer 60

(severe constipation with inability to pass both stool and gas

Question 61

pointing below the sternoclavicular notch suggests

Answer 61

esophageal dysphagia

Question 62

Carotenemia

Answer 62

, the presence of the orange pigment carotene in the blood due to ingestion of carrots, presents as a yellow discoloration of the skin, especially palms and soles, but not the sclera or mucous membranes

Question 63

stress incontinence

Answer 63

, increased abdominal pressure causes bladder pressure to exceed urethral resistance—there is poor urethral sphincter tone or poor support of bladder neck

Question 64

urge incontinence

Answer 64

, urgency is followed by involuntary leakage due to uncontrolled detrusor contractions that overcome urethral resistance.

Question 65

overflow incontinence

Answer 65

, neurologic disorders or anatomic obstruction from pelvic organs or the prostate limit bladder emptying until the bladder becomes overdistended

Question 66

Functional incontinence

Answer 66

e arises from impaired cognition, musculoskeletal problems, or immobility

Question 67

Flank pain, fever, and chills signal

Answer 67

acute pyelonephritis

Question 68

Pink–purple striae are a hallmark of

Answer 68

Cushing syndrome

Question 69

A protuberant abdomen that is tympanitic throughout suggests

Answer 69

intestinal obstruction or paralytic ileus

Question 70

Risk factors for AAA are

Answer 70

age ≥65 years, history of smoking, male gender, and a first-degree relative with a history of AAA repair.

Question 71

positive Murphy sign

Answer 71

A sharp halting in inspiratory effort due to pain from palpation of the gallbladder on examination is a

Question 72

Umbilical Hernia

Answer 72

A protrusion through a defective umbilical ring. When present in infants, it usually closes spontaneously within 1–2 yrs.

Question 73

Incisional Hernia

Answer 73

This is a protrusion through an operative scar. Palpate to detect the length and width of the defect in the abdominal wall. A small defect, through which a large hernia has passed, has a greater risk for complications than a large defect.

Question 74

Epigastric Hernia

Answer 74

A small midline protrusion through a defect in the linea alba occurs between the xiphoid process and the umbilicus. With the patient coughing or performing a Valsalva maneuver, palpate by running your fingerpad down the linea alba.

Question 75

Diastasis Recti

Answer 75

Separation of the two rectus abdominis muscles, through which abdominal contents form a midline ridge typically extending from the xiphoid to the umbilicus and seen only when the patient raises the head and shoulders. Often present in patients with repeated pregnancies, obesity, and chronic lung disease. It is clinically benign.

Question 76

Lipoma

Answer 76

Common, benign, fatty tumors usually in the subcutaneous tissues almost anywhere in the body, including the abdominal wall. Small or large, they are usually soft and often lobulated. Press your finger down on the edge of a lipoma. The tumor typically slips out from under your finger and is well demarcated, nonreducible, and usually nontender.

Question 77

Bruits in bowel

Answer 77

A hepatic bruit suggests carcinoma of the liver or cirrhosis. Arterial bruits with both systolic and diastolic components suggest partial occlusion of the aorta or large arteries. Such bruits in the epigastrium are suspicious for renal artery stenosis or renovascular hypertension.

Question 78

Friction Rubs in bowel

Answer 78

Friction rubs are grating sounds with respiratory variation. They indicate inflammation of the peritoneal surface of an organ, as in liver cancer, chlamydial or gonococcal perihepatitis, recent liver biopsy, or splenic infarct. When a systolic bruit accompanies a hepatic friction rub, suspect carcinoma of the liver.

Question 79

Acute Salpingitis

Answer 79

Frequently bilateral, the tenderness of acute salpingitis (inflammation of the fallopian tubes) is usually maximal just above the inguinal ligaments. Rebound tenderness and rigidity may be present. On pelvic examination, motion of the cervix and uterus causes pain.

Question 80

Acute Pancreatitis

Answer 80

In acute pancreatitis, epigastric tenderness and rebound tenderness and localized guarding are usually present, but the abdominal wall may be soft.

Question 81

Acute Diverticulitis

Answer 81

Acute diverticulitis is a confined inflammatory process, usually in the left lower quadrant, that involves the sigmoid colon. If the sigmoid colon is redundant there may be suprapubic or right-sided pain. Look for localized peritoneal signs and a tender underlying mass. Microperforation, abscess, and obstruction may ensue.