Week 7 - Male/Female Genatalia, Rectum, Prostate, Pregnancy Flashcards
Vaginal discharge may be caused by….
- Candida
- Bacterial vaginosis
- Trichomonas vaginalis
Mucopurulent discharge from the cervix can be caused by….
- Chlamydyia trachomatis
- Neisseria gonorrhoeae
- Herpes simplex
What should you do when a breast lump is reported?
- Identify precise location
- How long has it been present
- History of trauma
- Tender
- Change in size or variation with menstrual cycle
- Change in breast contour, dimpling, swelling, puckering of skin on breastS?
- Changes in nipple –> skin changes, itchiness, redness, flaking
- Family history of breast cancer
Components of a breast exam - Woman
- 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).
- Palpate the breasts (consistency, tenderness, nodules, nipple for color, consistency, and quantity of any discharge).
- Inspect the axillae (rash, irritation, infection, unusual pigmentation).
- Palpate the axillary nodes (size, shape, delimitation, mobility, consistency, and any tenderness).
Components of a breast exam - Man
- Inspect the nipple and areola (nodules, swelling, ulceration).
- Palpate the areola and breast tissue (nodules).
When doing a breast exam what should you look for?
- Consistency of tissues
- Tenderness
- Nodules
- Location (clock or quadrants)
- Size (cm)
- Shape – round/cystic, disc like, irregular
- Consistency – soft, firm, hard
- Delimitation – well circumscribed or not
- Tenderness
- Mobility
- Hard, irregular poorly circumscribed nodules fixed to the skin or underlying tissues strongly suggest cancer
What to look for when palpating the nipples?
- Thickening of nipple and loss of elasticity suggest cancer
- Bloody discharge –> cancer
- Clear, serous, green, black or non-bloody discharge are usually benign
What does assessment of the axillae involve?
Inspection
- Rash, irritation, infection, unusual pigmentation
Palpation
- Left axilla (use right hand and vice versa)
- Large nodes, firm, hard, matted together or fixed to skin suggest malignancy
Gynecomastia
Benign breast enlargement in men. Caused by increased estrogen, decreased testosterone and medication side effects
Anatomy of the breast
Mammary gland lobules
- Lactiferous ducts
- nipple/areola
Divided into four quadrants or use a 12 hour clock + the tail of spence
Axillary lymph nodes
- Anterior group
- Posterior group
- Lateral group
- Central group
- Apical group
- Infraclavicular group
Factors that may indicate breast cancer
- Redness – local infection, inflammatory carcinoma
- Thickening and prominent pores
- Flattening of normally convex breast
- Asymmetry in nipple direction
- Eczematous changes with rash, scaling, ulceration of the nipple extended to areola
- Nipple inversion
- Breast dimpling or retraction
At what age should mammography start?
Age 40
What are three types of breast tumors?
Fibroadenoma (benign tumor)
- Up to age 55
- Single or multiple
- Soft or firm
- Well deliniated
- Mobile
- Nontender
- Round, disclike lobular
Cysts
- 30-50
- Single or multiple
- Round
- Soft to firm, elastic
- Well delineated
- Mobile
- Tender
Cancer
- 30-90 (more common over 50)
- Usually single
- Irregular edge
- Firm or hard
- Not clearly delineated from other tissues
- Fixed to skin or underlying tissues
- Nontender
Self-breast examinations
Should be done 5-7 days after menses.
- Use three fingers
- Lying down
- Circular movements up and down
- Repeat standing with hand behind the head
- Let us know if you find any changes
Concerning symptoms found on breast self-examination.
Mass
- Location
- How long
- Change in size
Dimpling/puckering of skin
Pain
Nipple discharge
What physiologic changes do the breasts go through as the woman ages?
The glandular ducts begin to atrophy and are replaced by adipose tissue.
Male genital exam
- Inspect the skin, prepuce, and glans (ulcers, scars, nodules, inflammation).
- Inspect the urethral meatus (discharge), and, if indicated, strip or “milk” the penile shaft.
- Palpate the shaft of the penis (induration, tenderness).
- Inspect the scrotum including skin, hair, and contour (lesion, swelling, veins, bulging masses, asymmetry).
- Palpate each testis including the epididymis and spermatic cord (presence, size, shape, consistency, symmetry, tenderness, masses, nodules).
- Perform special techniques as indicated:
- Evaluate for groin hernias:
- Inspect for a groin bulge.
- Palpate for an inguinal hernia (direct or indirect).
- Palpate for a femoral hernia.
- Evaluate for scrotal mass.
Questions prior to male genital exam
Penile discharge>
- Yellow –> gonorrhea
- White –> chlamydia
Amount
Fever
Chills
Rash
Associated symptoms
Sores or growths
pruritis or itching
Swelling or pain
Anatomy of the penis
Penis – formed by three columns of vascular erectile tissue
- Corpus spongiosum (contains the urethra)
- Corpora cavernosa x2
Phimosis
Tight foreskin that cannot be retracted
Paraphimosis
tight foreskin that once retracted cannot be returned
Balantitis
Inflammation of the penile glans
Hypospadias
congenital ventral displacement of the urethral meatus (to bottom of penis)
Hydrocele
nontender, fluid filled mass, transilluminates – palpable within the scrotum
Screening for STIs in men
Previous history of herpes, gonorrhea, or syphilis
What kind of sex are you having? –> symptoms at various openings
Concerns for HIV?
Systemic illness or other symptoms
- Sore throat
- Diarrhea
- Rectal bleeding
- Anal itching/pain
Genital warts
- Single or multiple papules or plaques of variable shapes
- Caused by HPV
- Itching and pain
- May disappear without treatment
Primary syphilis
Small red papule and painless erosion up to 2 cm
Genital herpes
- Small scattered or grouped vehicles on glans or shaft of penis
- Associated with headache, fever, malaise, arthralgias, local pain and edema
Cryptorchidism
undescended testicle
Scrotal swelling suggests…
- Acute ependymitis
- Acute orchitis
- Testicular torsion
- Strangulated inguinal hernia
Risk factors for testicular cancer
- Undescended testicle
- White male
- Family history
- Kleinefleter syndrome
- HIV infection
Strangulated hernia
Blood supply is compromised. Usually has these symptoms:
- Nausea and vomiting
- Tenderness
Incarcerated hernia
Cannot be easily returned to the abdominal cavity
HPV vaccination recommendation
Usually age 11 or 12 -26 years old (can start at age 9). Two dose series - second dose 6-12 months after first dose
Female genitalia exam
- Obtains permission; selects chaperone
- Explains each step of the examination in advance
- Drapes the patient from midabdomen to knees; depresses the drape between the knees to provide eye contact with patient
- Avoids unexpected or sudden movements
- Chooses a speculum that is the correct size
- Warms the speculum with tap water
- Monitors the comfort of the examination by watching the patient’s face and obtaining verbal feedback
- Uses excellent but gentle technique, especially when inserting the speculum
Uterus anatomy
- Isthmus – lower portion
- Corpus – body portion
- Fundus – upper portion
Three layers of the uterine wall
- Perimetrium - outer layer
- Myometrium – distensible smooth muscle
- Endometrium – inner layer
Adnexa
Ovaries, fallopian tube and supporting tissues
Functions of the pelvic floor
- Aid in sexual function
- Urinary and fecal continence
- Stabilization of connecting joints
Menarche
Onset of menses
Dysmenorrhea
pain with menses, often with bearing down, aching, or cramping sensation in the lower abdomen or pelvis
Premenstrual syndrome (PMS)
cluster of emotional, behavioral, and physical symptoms occurring 5 d before menses for three consecutive cycles
Abnormal uterine bleeding
bleeding between menses; includes infrequent, excessive, prolonged, or postmenopausal bleeding
Menopause
absence of menses for 12 consecutive months, usually occurring between ages 48 and 55 yrs
Postmenopausal bleeding
bleeding occurring 6 mo or more after cessation of menses
Bacterial vaginosis
- Bacterial overgrowth from anerobic bacteria often sexually transmitted
- Gray, white, thin, homogenous, malodorous discharge often coats vaginal walls
- Fishy smell
Candidiasis
- Overgrowth of vaginal yeast
- White curdy discharge
- Pruritis, vaginal soreness, pain on urination
- Vulva and surrounding skin may be inflamed
Pelvic examination steps
Perform an external examination:
- Assess sexual maturity (if adolescent).
- Inspect the mons pubis, labia, perineum (inflammation, ulceration, discharge, swelling, nodules, any lesions).
Perform an internal examination:
- Inspect the cervix (color, position, surface characteristics, any ulcerations, nodules, masses, bleeding, discharge).
- Inspect the vagina (masses, lesions, or abnormal discharge or bleeding).
Perform a bimanual examination:
- Palpate the cervix (position, shape, consistency, regularity, mobility, tenderness).
- Palpate the uterus (size, shape, consistency, mobility, any tenderness or masses).
- Palpate the ovaries (size, shape, consistency, mobility, any tenderness).
- Assess the pelvic floor muscles (strength and tenderness).
Perform a rectovaginal examination (if indicated).
Pelvic inflammatory disease
Caused by “spontaneous ascension of microbes from the cervix or vagina to the endometrium, fallopian tubes, and adjacent structures.”
- 85% of cases involve STIs or bacterial vaginosis affecting the fallopian tubes (salpingitis) or the tubes and ovaries (salpingo-oophoritis), primarily N. gonorrhoeae and C. trachomatis.
Symptoms
- adnexal, cervical, and uterine compression tenderness.
- If not treated, a tubo-ovarian abscess may ensue; 18% of treated patients report infertility after 3 yrs. Infection of the fallopian tubes and ovaries may also follow childbirth or gynecologic surgery.
Mucopurulent cervicitis
Purulent discharge from the cervical os usually trachomatic, gonorrhea, herpes
Carcinoma of the cervix
Extensive irregular cauliflower like growth
Myoma
Benign uterine tumors. single or multiple and vary greatly in size, occasionally reaching large proportions. They feel like firm irregular nodules that are continuous with the uterine surface.
Cervical cancer screening
- PAP smear yearly
- 21-25 three year cytology screening
- 30-65 Q3 years cytology, Q5 years w/cytology and HPV testing together
- No screening under 21 or over 65
Risk factors for cervical cancer
- Multiple sex partners
- Early age of sexual activity
- Inadequate screening
- Immunosuppression
- Long term use of oral contraceptives
- Coinfection with chlamydia
- Smoking
- More than three full term pregnancies
Technique for anorectal and prostate exam
- Properly position the patient for the exam (left side)
- Inspect sacrococcygeal and perianal areas (lesions, ulcers, inflammation, rash, excoriation)
- Inspect the anus (lesion, mass, skin breakdown)
- Perform a digital rectal examination
- Assess anal sphincter tone
- Palpate the anal canal and rectal surface (mass, tenderness, mucosal breaks, nodules, irregularities, induration)
- In person with prostates, palpate the prostate gland (size, shape, mobility, consistency, nodule tenderness)
Anatomy of the prostate
- Lies around the urethra
- Apex – pointed bottom
- Right and left lateral lobes (palpable)
- Posteromedial (posterior) lobe
- Cannot palpate anterior and median lobes (no contact with rectal wall)
How to identify anorectal cancer?
Firm, nodular with rolled edge on palpation
Screening for prostate cancer
Test for PSA - prostate specific antigen - a blood test
- Testing from age 55-69
- annually (ACS) or biannually (AUA)
Risk factors for prostate cancer
- Age
- Ethnicity
- Family history (having it or early diagnosis – before 55)
- Smoking
- Diets high in animal fat
- Obesity
- Cadmium exposure
Proctitis symptoms and cause
Symptoms
- Fever
- Urinary symptoms
- Frequency
- Urgency
- Dysuria
- Incomplete voiding
- Low back pain
- Gland feels swollen, tender, boggy, warm
- Most caused by E Coli or Enterococcus and Proteus spp (also gonorrhea or claymidia)
Techniques of exam for pregnant woman
- Assess general health, emotional state, nutritional status, and neuromuscular coordination.
- Measure height and weight. Calculate BMI.
- Measure the blood pressure at every visit.
- Inspect the head and neck (facial skin changes or edema, hair condition and distribution, conjunctival pallor, nasal congestion or epistaxis, teeth and gum health, thyroid masses or nodules).
- Inspect, percuss, and auscultate the thorax and lungs.
- Palpate location of the apical impulse.
- Auscultate the heart (S1 splitting, murmurs, venous hum or mammary souffle).
- Inspect the abdomen (striae, scars, size, shape, and contour).
- Palpate the abdomen (masses, fetal movement, uterine contractility and fundal height).
- Auscultate fetal heart tones (location, rate and rhythm).
- Inspect the external genitalia (labial varicosities, cystoceles, rectoceles, lesions, sores, Bartholin and Skene gland tenderness and cysts).
- Inspect the internal genitalia by performing speculum and bimanual examinations.
- Speculum examination: Inspect the cervix (color, shape, os closure) and vaginal walls (color, relaxation, rugae, and discharge). Perform a Pap smear if indicated.
- Bimanual examination: Palpate the cervix (length, os), uterus (shape, consistency, and position), adnexa (masses, tenderness), pelvic floor strength.
- Inspect the anus (masses or hemorrhoids).
- Examine the extremities (varicosities, edema) and elicit reflexes (hyperreflexia).
- Perform Leopold maneuvers (if indicated).
Gravidity
the number of time that a woman has been pregnant
Parity
the number of time that she has given birth to a fetus >=24 weeks (alive or stillborn)
GTPAL
G - Gravidity - number of times she has been pregnant
T - Term - # pregnancies carried to term
P - pre term births - 20-36 weeks
A - abortion - number of pregnancies lost before 20 weeks
L - living children
Miscarriage
Pregnancy loss before 20 weeks
Ectopic pregnancy
Occurs when a fertilized egg grows outside of the uterus. Almost all ectopic pregnancies—more than 90%—occur in a fallopian tube. As the pregnancy grows, it can cause the tube to burst (rupture). A rupture can cause major internal bleeding.
Gestational age calculation
Count the number of weeks and days since the LMP
Estimated date of delivery
- 40 weeks from the first date of the LMP
- Take the LMP add 7 days, subtract 3 months and add 1 year
Screening and lab tests suggested during pregnancy
- Rh(D) compatability screening
- Syphilis
- Bacteriuria
- Hep B
- HIV
- Iron deficiency
- Gestational diabetes
- Perinatal depression
- Domestic violence
Vitamin supplements during pregnancy
- Daily prenatal vitamin with 600IU vit D and 1000mg calcium
- Folic acid
- Iron supplementation
Nutrition recommendations during pregnancy
Avoid
- Unpasteurized milk/foods
- Raw & undercooked seafood, eggs, meat
- Pate, meat spreads, smoked salmon
- Hot dogs, lunch meat, cold cuts (unless served steaming hot)
Take
- 2-3 servings per week of fish/shellfish (low mercury – salmon, shrimp, pollock, tuna, tilapia, cod, catfish)
Exercise recommendation during pregnancy
30+ minutes of moderate exercise most days
Preeclampsia
SBP ≥140 or DBP ≥90 after 20 weeks on two occasions at least 4 hours apart in a woman with previously normal BP or BP ≥160/110 confirmed within minutes and proteinuria ≥300 mg/24 hours, protein to creatinine ratio ≥0.3, or dipstick 1+ OR:
New-onset hypertension without proteinuria and any of the following: thrombocytopenia (platelets <100,000/μL), impaired liver function (liver transaminase levels more than twice normal), new renal insufficiency (creatinine >1.1 mg/dL or doubles in the absence of renal disease), pulmonary edema, or new-onset cerebral or visual symptoms
Gestational hypertension
SPB >140 or DBP >90
Hyperemesis gravidarum-
N/V with weight loss that exceeds 5% of pre-pregnancy weight
Gestational Diabetes
A 50-g oral glucose tolerance test (OGTT) is administered and venous glucose checked 1 hour after the glucose load, with screening thresholds of 130 to 140 mg/dL used at various institutions.
Patients with a positive 50-g screen then undergo a 100-g, 3-hour diagnostic OGTT. Patients are diagnosed with gestational diabetes when two or more values are abnormal on the 3-hour OGTT
Immunizations recommended during/after pregnancy
- Tdap (27-36 weeks gestation)
- Inactivated flu vaccine
- Rubella titer –> vaccine given after delivery if not immune
USPSTF Recommendations for Breast Cancer Screening
- Breast exam annually for women 40+
- Mammography for women 50-74 biannuallly
- no breast self-exam
- breast self-awareness
Testicular cancer
- Painless nodules
- 15-34 year olds - peak
- Palpable inguinal lymph nodes
STI discharge in men
Penile discharge is :
white -chlamydia
yellow - gonorrhea
chancre - syphyllis
STIs in women
Vaginal discharge is:
yellow - chlamydia
yellow - gonorrhea
chancre, large flat top lesions - syphyllis
Safe vaccines during pregnancy
- TDAP
- inactivated flu
- pneumococcal
- meningococcal
- Hep A & B
