Test 5 Flashcards
menopause defeinition
without period for 12 months 45-55yrs of age
for females of reproductive age always ask:
the first day of their last period
bigest pelvic acute concern?
ectopic pregnancy
ACOG Guidelines for PAPS
- Begins at age 21 (regardless of behavior, risk factors, and age of first sex
- 21-29 yr olds - cytology every 3 years no HPV testing
- 30-65 yr old- cytology and HPV testing every 5 years; cytology alone every 3 years; HPV alone not recommended
- After 65 yrs - depends on previous resuts; previous negative; 3 consecutive neg or 2 consecutive co-test= no further testing; continue screening if CIN2, CIN3 or adenocarcinoma; hysterectomy = no further testing if cervix removed and no history of CIN2 or higher; screening continues every 3 years for next 20 years
ACOG guidelines do not apply if:
- HIV infection
- Immunosuppression
- Exposure to diethylstilbestrol (DES) in utero
- History of cervical cancer
HPV vaccine guidelines:
- Targets HPV-16 and HPV-18
- 2 most common cancer causing HPV types
- Vaccine does not protect against 30% of cervical cancer caused by HPV types other than 16 and 18
- Nearly 100% protection if women are not exposed to the virus and get the vaccine
- Less level of protection if a woman was already exposed to HPV 16 or 18
- May not see impact of vaccine for 15-20 years, thus still need to screen regularly
- Now given to both sexes
Stage 1 Tanner of Penis
- 9-13yrs
- trace pubic hair
- small amount of lengthening of the penis and testicles
- infrequent erections
Stage 2 Tanner of Penis
- 11-13 yrs
- height 3in per year
- hair thickens and darkens
- testicles lengthen
- sac thins and reddened
- body lean
- more infrequent erections
Stage 3 Tanner of Penis
- 14yrs
- penis continues to grow in length
- testicle sac grows
- hair very prominent
- nipples sensitive
- voice changes/breaks
Stage 4 Tanner of Penis
- 15 yrs
- height of 4in per year
- testicles lengthens
- penis considerably thickens
- armpit hair begins
- pubic hair fully covered
- acne begins
- voice deepens
Stage 5 Tanner of Penis
- 16-18yrs
- adolescence complete
- penis and testicle full size
- body growth slowly stops
- pubic hair to inner thighs
- hair chin and cheeks
- muscle development
direct hernia
- less common
- men>40yr
- rare women
- above inguinal ligament, close to pubic tubercle
- rarely into scrotum
- bulges anteriorly and pushes the side of examiners finger forward
Indirect hernia
- most common
- both sexes
- often children, maybe adults
- above inguinal ligament near midpoint
- often into scrotum
- comes down inguinal canal and touches fingertip
femoral hernia
- least common
- more common in women than men
- below inguinal ligament
- more lateral than inguinal hernia
- hard to differentiate from lymph node
- never scrotum
- inguinal canal is empty
scrotum drains its lymph into the
inguinal nodes
penis drains its lymph into the
inguinal nodes
testes drain its lymph into the
abdomen
melena color of stool
black tarry sticky stool
usually higher GI
GERD, peptic ulcer, gastritis
black color of stool
non-sticky
iron, licorice, bismuth salts
hematochezia color of stool
red blood
usually in colon, rectum, or anus
colon cancer, polyps, diverticula, hemorrhoids, anal fissue, inflammatory conditions of the colon and rectum
reddish, nonbloody cold of stool=
ingestion of certain foods
Prostate cancer screening
- start age 50
- start at 45 if African American , father or brother with prostate cancer before 65
- if tested: PSA with or without rectal; frequency of testing depends on level
PSA Test
Biomarker for early detection Limitations Elevated in benign conditions False positives False negatives Unnecessary testing Biopsy Level interpretation Common cutpoint for biopsy is 4.0 ng/ml Over diagnosis Side effects with treatment
Digital Rectal Exam
Low sensitivity: 59%
Specificity: 94%
Detects tumors on the posterior and lateral aspects
Misses 25-35% of tumors arising in other areas
Abnormal findings need to be investigated
Colorectal Cancer Screening
—-Average risk
Starting at 50 years both male and female
Annual Fecal occult blood
Multiple stool take home kit
Positive result-colonoscopy
Sigmoidoscopy every 5 years with fecal occult blood every 3 years
Screening colonoscopy every 10 years
Another option: double contrast barium enema or computed tomography colonography every 5 years
—-Increased risk
Inflammatory bowel disease or family history of an inherited polyposis syndrome
Colonoscopy every 3-5 years
Prostatitis Acute
Presents fever, UTI and low back pain Gland Tender, swollen, “boggy” & warm E coli Under 35 STI
Prostatitis chronic
Recurrent UTI Asymptomatic of dysuria, mild back pain Gland Normal E coli
Benign Prostatic Hyperplasia
Nonmalignant 50% of 50 year olds Urgency, frequency, nocturia, decrease stream, incomplete emptying Gland Normal or symmetrically enlarged
Prostate Cancer
Gland
Hardness
Irregular
Obscured median sulcus
Anal fissure
Painful
Location
Most are midline posteriorly
Swollen sentinel skin tag
Polyps
Fairly common
Variable size and number
Pedunculated or sessile
Soft and difficult to feel
Anorectal Fistula
Inflammatory tract
Opens into rectum or anus and skin or viscus
Usually caused by abscess
Hemorrhoids internal prolapsed
Enlargement of vascular cushions Above pectinate line Not palpable Bright red bleeding Prolapse Reddish moist
Hemorrhoids external thrombosed
Dilated veins
Below pectinate line
Usually asymptomatic unless thrombosed
Tender, blue, swollen and ovoid
Apendages of the skin
Hair Nails Sebaceous glands Eccrine sweat glands Apocrine sweat glands
hair types:
- Vellus – short, fine, inconspicuous and relatively unpigmented
- Terminal hair - coarser, thicker, more conspicuous, and usually pigmented examples would be scalp hair and eyebrows
nails:
- p33 in lab manual
- Nail plate
- Nail bed
- Cuticle
- Nail root
- Nail plate
- Lunula
- Proximal nail fold
Sebaceous glands
- Secrete sebum – a lipid rich substance that keeps the skin and hair from drying out
- Largest sebaceous glands are found on the face and upper back
- Absent from soles and palms
- Production of sebum is dependent on gland size , which is directly influenced by androgen secretion
Eccrine sweat glands
- Open directly on the surface of the skin
- Help to regulate body temperature through water secretion
- Located mainly in the axillae, forehead, palms and soles
- Absent in the nail beds and some mucosal surfaces i.e. lip margins
Apocrine glands
- Larger and deeper than eccrine glands
- Specialized structures – axillae, nipples, areolae, anogenital area, eyelids, and external ears
- Reach maturity only at puberty
- Secretion can increase in times of stress
- Odorless
- Bacterial decomposition of apocrine sweat produces body odor
‘ABCDEs’ Early recognition of possible Melanoma
A – for Asymmetry of one side compared to the other
B – irregular Borders, ragged, notched, or blurred
C – variation in color – esp. blue and black mixed
D – for Diameter > 6 mm
E – for Evolution or change in size, symptoms, or morphology
‘HARMM’ Melanoma Risk Model
- History of previous melanoma
- Age over 50
- Regular dermatologist absent
- Mole changing
- Male gender
Risk factors for Basal & Squamous Cancer
- Age - > 50
- Chronic exposure to sunlight, UVA & UVB
- Fair, freckled, ruddy complexion
- Light colored hair and eyes
- Sunburn easily
- Childhood blistering burns
- Geographic – equator or high altitudes
- Repeated trauma or irritation
- Exposure to harmful chemicals
Normal mole*
- Uniformly tan or brown
- All look alike
- Round or oval
- Clear defined borders
- Flat or smooth
- Less than 6 mm
- Typical adult 10-40
- Waist, scalp, breast, sun exposed areas
Dysplastic mole*
- Varied appearance
- Irregular borders, notches
- Fades in surrounding skin
- Smooth, scaly, rough, irregular
- Greater than 6 mm
- Anywhere often on back, below waist, scalp, breast, buttocks
Schamroth’s Sign
- clubbing – nail base angle < 180
- Associated with Cardiovascular, respiratory diseases as well as inflammatory bowel disease, cirrhosis
common causes of bounding pulses (with lower extremities?)?
F - Fever A- Aortic insufficiency C - Complete heart block T - Thyrotoxicosis S - Systolic hypertension
bounding pulses caused by and associated with?
associated with wide pulse pressure where the difference bw diastolic and systolic pressure is greater than 60mmHg
delay associated with pulses of capillary refill of toes… 2 potentials?
vasospasm or structural changes to the large vessels
pitting edemas caused by:
heart failure (protein rich edema)press firmly for 5sec and if indent remains for 5sec its piting edema
non-pitting edema caused by
lack of protein in exudate - kidney or liver problem
pitting edema grading:
1+ 2mm
2+ 4mm
3+ 6mm
4+ 8mm
macule definition
primary lesion non palpable skin change <.5cm
patch definition
primary lesion non palpable skin change >.5cm
papule definition
primary lesion palpable solid <.5cm
nodule definition
primary lesion palpable solid .5-1cm
tumor definition
primary lesion palpable solid >1cm
plaque definition
primary lesion palpable solid >.5cm flat, elevated surface formed by coalescence of papules
vesicle definition
primary lesion clear fluid filled <.5cm
bulla definition
primary lesion clear fluid filled >.5cm
pustule definition
primary lesion cloudy pus filled <.5cm
abscess definition
primary lesion cloudy pus filled >.5cm
secondary lesion:
- either the result of progressive changes in the primary lesion or are caused by external causes
- Type: Erosion, crust, scale, fissure, ulcer, lichenification, atrophy, excoriation, scar, keloid
verruca
secondary skin lesion
red and black dots in white lesion
-wipe alchol on it and it will vasodialate
in-grown toe nail
pustule or abcess
thickened nails are not always…
FUNGAL! Sometimes just thick toe nails
distinguish thick toe nails:
(TOE CLYPT) T: trauma O: onychmycosis E: eczema C: circulatory problems L: lichen planus Y: yellow nail syndrome P: psoriasis T: tumor
dry skin due to:
- Insufficient number of sweat glands or autonomic dysfunction (diabetes)
- Tinea pedis
- Psoriasis
- Eczema
ulceration due to
- break down and loss of dermis and epidermis
- due to vascular disease and or anesthetic neuropathy
- poor blood supply or completely numb
- if the ulcer is red itll probably heal as long as you take the pressure up
charcot foot
usually in diabetics where bones in foot loose shape
Spinothalamic tract
- small fibers
- sharp and dull pain (nociceptive)
- temperature
- crude touch - complaint of burning or cramping
posterior colum
- large fibers
- position
- vibration
- fine touch - complaint of pins and needles or electric shock
Touch simuli: testing
- Represents a measure of low threshold mechanoreception
- abnormality indicates small fiber disease
- Using a 5.07 Semmes-Weinstein monofilament (10 gms of pressure), apply pressure to the 1st, 3rd, & 5th, metatarsal heads, the 1st, 3rd, & 5th toes, the plantar arch, the plantar heel, beneath the 5th metabase and the dorsal midfoot
- Normal is detecting filament in at least 7/10 areas. The inability to detect the pressure in more than 3 areas suggests the potential for neurotrophic ulceration
Vibration testing:
- use a 128 cycles/sec tuning fork over the IPJ of the hallux
- ask the patient to tell you when it stops vibrating
- –>if vibration sense decreased, proceed more proximally until vibration felt
- loss of vibration in < 10 seconds is abnormal at any age
- indicates large fiber disease
- done over IP joint just behind nail
Sharp stimuli testing
- Ask the patient to close his eyes. Break a Q-tip in half and use each end to touch the skin
- Ask a three-part question: “Which is sharper, the first touch, the second touch, or are both the same?”
- Inability to detect sharp from dull supports the diagnosis of a small fiber disease
temperature testing
- Omit if pain sensation is normal
- Touch the skin with hot and cold water test tubes
- Lack of temperature sensation suggests small fiber disease
Position sense (proprioception): testing
- Passively move the great toe up and down by grasping along the sides of the interphalangeal joint only a few mms. and ask patient which direction you are moving the toe (PT EYES CLOSED)
- Reduced perception (including falsely perceived motion) indicates large-fiber disease
Small fiber disease list
- Semmes-Weinstein monofilament
- Sharp-dull
- Temperature
Large fiber disease
- Vibration
- Proprioception
tendon reflex tests the
SENSORY REFLEX
stroke patients have what kind of tendow relfex test?
Hpyerreflexive (4/4)
polio patients have what kind of reflex?
hyporeflexive 0/4
Deep reflexes
- Deep reflexes: Often have to use reinforcement (Jendrassie maneuver) to facilitate observation of reflexes in the lower extremity
- Knee reflex: innervated by L 2, 3, 4
- Ankle reflex: innervated by S 1, 2
Knee reflex indicates issue with
L2,3,4
Jendrassie maneuver
having patient pull hands apart so that brain stops thinking about the reflex you are tryin to perform
ANkle reflex indicates issue with
S1 and 2
Superficial reflex or plantar response (L4, L5, S1, S2)
- Elicited by stroking the lateral aspect of the sole from the heel to the ball of the foot, curving medially across the ball
- Toes normally plantarflex
- If there is dorsiflexion of the great toe and fanning of the other toes, it indicates upper motor neuron disease (Babinski response)
All-in-one test
- Hop-in-place with each foot
- Ability to do this indicates:
- intact motor system in the legs
- normal cerebellar function
- good position sense.
peripheral neuropathy is suggested by:
patient is able to stand on tiptoes but not on heels
spinal lesion is suggested by
patient is able to stand on heels but not on tiptoes
how to check for disorders of the autonomous nervous system
- Pulse rate changes with deep breathing: With normal vagal nerve input to the heart, the pulse rate at rest will increase with inspiration and decrease with expiration
- Orthostatic dizziness and changes in blood pressure: A drop of > 30 mm Hg systolic and > 15 mm Hg diastolic recorded 60 to 90 seconds after standing following 5 minutes of supine rest
premature infant range
27-36 weeks
most accurate way to determine gestational age:
use last menstrual period
tool used to estimate gentational age?
Ballard Score - done within first 24 hrs of life based on how the kid looks.
baby head growth after birth?
1cm/mo for first year
fontanel closure ant/post
posterior first at 6-9mo and ant bw 18 and 24 mo
most reliable indicator of infants nutritional status?
weight
Moro reflex
- Abrupt removal of support of infant’s head in a supine position results in extension and abduction of the upper extremities only.
- This reflex is lost at around 5 months
Sucking reflex
-A fingertip introduced into an infant’s mouth will trigger simultaneous movement of the tongue and pharynx to allow for milk to be squeezed out of a nipple and propelled toward the esophagus.
Grasp reflex
- As pressure from a finger is made against the palm of a baby, the fingers curl around the other person’s finger
- Disappearance by 4-6mo of age
Rooting reflex
- When the cheek is lightly touched, the infant turns his head toward the stimulus and purses his lips
- Disappearance by 4-6mo of age
Stepping or Placing reflex
- When the newborn is supported vertically and the plantar surfaces of the feet are placed on a flat surface, the legs extended and partially support the infant.
- If the infant is then lightly propelled, he makes walking movements with good coordination and relatively steady positioning of the feet in a “stepping movement”.
- This reaction persists for about six weeks
Tonic neck reflex
- With the infant supine, turning of the head results in ipsilateral extension of the arm and leg in a “fencing” posture
- Disappearance by 4-6mo of age
Parachute reflex
- With the infant sitting, tilting to either side results in extension of the ipsilateral arm in a protective fashion
- Appears at 6-8 months of age
- Persists throughout life
The AP diameter to lateral diameter ratio during the first three years of life?
DECREASES
-RIB CAGE IS MORE CIRCULAR THAN ADULT
birth RR:
40-60 per min
1-6 mo RR
20-50 per min
60mo to 2 yrs RR
20-40 per min
3 years RR
20-30 per min
6 year RR
16-22 per min
adolescent RR
12-20 per min
physical exam on respiration note
RATE AND EFFORT!
most common palpable mass in an infant=
enlarged kidney
