Module 6 Flashcards
supernumerary nipples
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
These are the most common breast-related complaints.
Ask if the patient has had any lumps, pain, or nipple discharge of her breasts.
(mastodynia or mastalgia)
Breast pain alone, is not typically a sign of breast cancer.
diffuse breast pain
(defined as involving >25% of the breast)
focal breast pain
(involving <25% of the breast),
cyclic breast pain
(pain that occurs prior to menses and generally resolved at the completion of the menstrual period)
physiologic discharge
physiologic hypersecretion is seen in pregnancy, lactation, chest wall stimulation, sleep, and stress
pathologic discharge
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.
galactorrhea
, or the discharge of milk-containing fluid unrelated to pregnancy or lactation, is most commonly caused by hyperprolactinemia
The best time for breast examination in a patient who is still menstruating
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.
Inspect the breasts in four views:
arms at sides, arms over head, arms pressed against hips, and leaning forward (skin appearance, size, symmetry, contour, nipple characteristics).
(peau d’orange)
Thickening and prominent pores suggest breast cancer.
acanthosis nigricans
Deeply pigmented velvety axillary skin suggests —associated with diabetes; obesity; polycystic ovary syndrome; and, rarely, malignant paraneoplastic disorders.
Fibroadenoma
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
Cysts
30–50 yrs, regress after menopause except with estrogen therapy
Single or multiple
Round
Often tender
Cancer- breast
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
Retraction Signs
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.
Skin Dimpling
Look for this sign with the patient’s arm at rest, during special positioning, and on moving or compressing the breast
Breast enlargement in men
History of hyperthyroidism, testicular tumor, Klinefelter’s syndrome; medications; prostate cancer treatment; substance abuse
Monilial dermatitis
Skin irritation under pendulous breasts from tissue-to-tissue contact or from rubbing of brassiere; treatment
Infants- breast changes
Breasts enlarge after birth in boys and girls.
Result of passively transferred maternal estrogen
May persist with breastfeeding
Pregnant patients- breast changes
Increase in size; tenderness and tingling; enlarged erect nipples; vascular spiders and striae
Colostrum
Coarse nodularity of breast tissue
Dilated subcutaneous veins
Fibrocystic changes
Benign fluid-filled cyst formation caused by ductal enlargement
Fibroadenoma
Benign tumors composed of stromal and epithelial elements that represent a hyperplastic or proliferative process in a single terminal ductal unit
Fat necrosis
Benign breast lump occurs as inflammatory response to local injury.
Intraductal papillomas/papillomatosis
Benign tumors of the subareolar ducts that produce nipple discharge
Duct ectasia
Benign condition of the subareolar ducts that produce nipple discharge
Paget disease
Surface manifestation of underlying ductal carcinoma
Premature thelarche
Breast enlargement in girls younger than 8 years of age
Benign in the absence of pubic and axillary hair
Heartburn
: a burning sensation in the epigastric
area radiating into the throat; often associated
with regurgitation
retching
(spasmodic movement of the
chest and diaphragm like vomiting, but no stomach
contents are passed)
hematemesis
Blood or coffee ground emesis is known as
Visceral pain
: 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)
Parietal pain
: 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)
Referred pain
: originates at different sites but shares
innervation from the same spinal level (gallbladder pain in the
shoulder)
melena
black, tarry stool
hematochezia
blood in stool
white or gray stools
can indicate
liver or gallbladder disease
borborygmi
bowel
sounds
normal frequency of bowel sounds
The normal
frequency of sound is 5-34 sounds per minute
dullness with bowel sounds
(which
could be a large stool or a mass)
Percuss over the liver in which two spots
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
voluntary guarding
(patient consciously
flinches when you touch him)
involuntary
guarding
(muscles spasm when you touch the patient,
but he cannot control the reaction)
Rovsing’s sign
(rebound tenderness in the left
lower quadrant)
Psoas sign
(the patient flexes his thigh against
the examiner’s hand; pain indicates a positive sign)
Obturator sign
(flex the patient’s thigh
and rotate the leg internally at the hip; pain indicates
a positive sign)
Right upper quadrant (RUQ) contains
Liver, gallbladder, pylorus, duodenum, hepatic flexure of colon, and head of pancreas
Left upper quadrant (LUQ)
Spleen, splenic flexure of colon, stomach, and body and tail of pancreas
Left lower quadrant (LLQ)
Sigmoid colon, descending colon, and left ovary
Right lower quadrant (RLQ)
Cecum, appendix, ascending colon, terminal ileum, and right ovary
Bladder capacity
accommodates roughly 400 to 500 mL of urine
(nocturia)
frequent urination at night
Dyspepsia
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
functional, or non-ulcer, dyspepsia
, defined as a 3-month history of nonspecific upper abdominal discomfort or nausea not attributable to structural abnormalities or peptic ulcer disease (PUD
Heartburn
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.
odynophagia
Pain with swallowing ()
RLQ pain or pain that migrates from the periumbilical region, combined with nausea, vomiting, and loss of appetite is suspicious for
appendicitis
Peritonitis
is marked by severe diffuse abdominal pain with guarding and rigidity on examination
obstipation
(severe constipation with inability to pass both stool and gas
pointing below the sternoclavicular notch suggests
esophageal dysphagia
Carotenemia
, 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
stress incontinence
, increased abdominal pressure causes bladder pressure to exceed urethral resistance—there is poor urethral sphincter tone or poor support of bladder neck
urge incontinence
, urgency is followed by involuntary leakage due to uncontrolled detrusor contractions that overcome urethral resistance.
overflow incontinence
, neurologic disorders or anatomic obstruction from pelvic organs or the prostate limit bladder emptying until the bladder becomes overdistended
Functional incontinence
e arises from impaired cognition, musculoskeletal problems, or immobility
Flank pain, fever, and chills signal
acute pyelonephritis
Pink–purple striae are a hallmark of
Cushing syndrome
A protuberant abdomen that is tympanitic throughout suggests
intestinal obstruction or paralytic ileus
Risk factors for AAA are
age ≥65 years, history of smoking, male gender, and a first-degree relative with a history of AAA repair.
positive Murphy sign
A sharp halting in inspiratory effort due to pain from palpation of the gallbladder on examination is a
Umbilical Hernia
A protrusion through a defective umbilical ring. When present in infants, it usually closes spontaneously within 1–2 yrs.
Incisional Hernia
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.
Epigastric Hernia
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.
Diastasis Recti
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.
Lipoma
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.
Bruits in bowel
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.
Friction Rubs in bowel
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.
Acute Salpingitis
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.
Acute Pancreatitis
In acute pancreatitis, epigastric tenderness and rebound tenderness and localized guarding are usually present, but the abdominal wall may be soft.
Acute Diverticulitis
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.
