Week 8 - Essentials text... Flashcards
What does the acronym NURSE stand for?
Name the emotion Show Understanding Handle the issue with Respect Show Support Ask the patient to Elaborate on the emotion
What does SPIKES stand for?
Setting up the interview (sitting, privacy, etc.)
Perception of the patient (open - ended Q’s)
Invitation to disclose info (what would you like to know)
Knowledge giving (warn patient, avoid medical jargon, avoid being too blunt)
Empathizing with the patient’s emotions (NURSE)
Strategize and Summarize
HEADSS
Home and environment Education and employment Activities Drugs Sexuality Suicide/Depression
What are the 5 P’s of sexual history?
Partners (number and gender, relationship)
Practices (types of sex, sex work, survival sex, genital piercings, etc)
Protection (barriers, PrEP, PEP, HPV immunization)
Past history (Age of sexual activity, past STIs, hx sexual assault/abuse)
Pregnancy (GTPAL, planning, contraception, menstruation)
How do you assess hepatojugular reflux and what does a positive test indicate?
Apply pressure over RUQ/liver for 30 seconds. JVP height should increase transiently. If it remains elevated this indicates heart failure.
What are 1st degree and 2nd degree sensory modalities (Essentials of clinical examination… p. 16)
1st degree: pain, temperature, fine tough, vibration, proprioception
2nd: stereognosis, graphestesia, two point discrimination
Reynold’s pentad (cholangitis)
Charcot’s triad (jaundice, fever, RUQ pain) + hypotension + altered mental status
6 F’s of protuberant abdomen:
Fat Fluid Feces Fetus Flatus Fatal growth
Cullen’s sign
Blueish discolouration around umbilicus
Sister Mary Joseph Node
palpable node bulging into umbilicus indicating pelvic or abdominal malignancy
Grey-Turner’s sign
Bluish discolouration to flanks (retroperitoneal hemorrhage)
What do bulging flanks indicate?
Ascites
Caput medusae
Superficial veins surrounding umbilicus
What is the normal superficial venous flow in the abdomen?
Give an example of abnormal flow and the cause.
Normal flow:
Cephalad (towards to head) above the umbilicus and caudad (towards the feet) below the umbilicus.
Abnormal examples:
Cephalad below umbilicus suggests IVC obstruction
Caudal above the umbilicus suggests SVC obstruction
What is a succession splash?
“Whoosh” heard on auscultation of epigastrium while rolling patient side to side. Caused by gastric outlet obstruction.
How do you landmark for vascular bruits?
Aorta: 1-2 inches above umbilicus
Renal: 1 Inch either side
Bifurcation of common iliac arteries: halfway between iliac and ASIS (ant. sup. iliac spine
Liver + gallbladder exam:
A bruit may be caused by _______ (2)
A venous hum may indicate _________ (1)
Bruit: hepatocellular carcinoma, alcoholic hepatitis
Hum: portal hypertension
Courvoisier sign
palpable gallbladder and painless jaundice –> pancreatic or biliary neoplasm until proven otherwise
What are two tests to assess for ascites?
Shifting Dullness: determine border of tympany in supine then have pt roll onto their side, the border shouldn’t change. If it moves down = dependent fluid = ascites
Fluid wave: Pt hand midline abdomen, tap lateral side and assess for a fluid “thrill” on the contralateral side. (+) = ascites
What is Traube’s space? What is Castell’s sign?
Traube: Left ant axillary line, left costal margin, 6th rib…
normal = tympanic/resonant splenomegaly = dull
Castell’s sign: left ant axillary line, lowest ICS, dull on inspiration = splenomegaly
Must be on empty stomach. Food is dull.
Carnett’s sign
Patient lifts legs with knees extended. Pain = abdominal wall lesion. No pain = abdominal cavity etiology.
Schilling test
Assess for Vit B12 absorption issues. Measurement of urinary Vit B12 after oral ingestion.
MRCP and ERCP
MRCP: MRI for evaluation of biliary obstruction (for pt with jaundice and elevated liver fntn tests)
ERCP: endoscopic procedure to examine common bile duct and pancreatic duct.
AST:ALT ratio for alcoholic liver disease
2:1
Signs portal hypertension (3)
venous hum, splenomegaly, ascites
What is a typical menstrual cycle. Include duration and phases.
Duration:Normal = Q21 to 35 days (average 28d)
Menses: Day 1 (typically 5 days)
Proliferative phase: begins after menses and ends with LH surge (day 7 to 21)
Secretory phase: LH surge to onset of menses (always 14 days)
Kallman’s syndrome
GnRH deficiency –> amenorrhea. Tx w/ hormone replacement. Also known as hypothalamic hypogonadism
Female athlete triad
menstrual dysfunction (amenorrhea)
low energy availability (with or without eating disorder)
decreased mineral density (osteoporosis)
Causes of dyspareunia (introital, mid vaginal, deep)
Introital: inadequate lubricant, vaginismus, vulvovaginitis
Midvaginal: anatomical (short vagina, vaginal septum), UTI
Deep: endometriosis, PID, uterine retroversion
Other: postpartum, pelvic organ prolapse, postoperative, vulvodynia (sometimes idiopathic)
Define: Dysmenorrhea Amenorrhea Polymenorrhea Oligomenorrhea Menorrhagia Metrorrhagia Menometrorrhia Contact bleeding
Dysmenorrhea: painful menses
Amenorrhea: no bleeding (primary or secondary)
Polymenorrhea: increased frequency
Oligomenorrhea: decreased frequency (cycle > 35 days)
Menorrhagia: increased duration OR flow
Metrorrhagia: irregular bleeding
Menometrorrhia: heavy AND irregular bleeding
Contact bleeding: postcoital or other
Location of cervix:
Anterior = _____uterus
Posterior = _____uterus
Anterior cervix = retroverted uterus
Posterior cervix = anteverted uterus (most common)
What types of HPV cause most cervical cancers (70%)?
18 and 16
What types of HPV cause most genital warts?
11 and 6
How can you tell if uterus is ante/retro/midposition with bimanual exam? What is a typical size and shape?
Place intravaginal fingers in posterior fornix and elevate cervix & uterus to abdominal wall.
If best felt by abdominal hand = anteverted (most common)
If best felt by intravaginal fingers = retroverted
If fundus not felt well by either hand = mid position
Size: fist (larger with multiparous or fibroids)
Shape: pear
Normal ovary size and shape?
Size: 3X2X1
Shape: ovoid
Normally smooth, firm, mobile, mildly tender with compression
Uterine fibroids (what are they and what is another name)
fibroids are also called leiyomyomata
Growth of smooth muscle, can be submucosal, intramural, subserosal, or pedunculate.
Bleeding fibroids are usually submucosal.
Hydatidiform mole
Benign form of gestational trophoblastic neoplasm. Ovum fertilized with 2 sperm, or 1 sperm with duplication… abnormal fertilization.
Risk factors: maternal age > 40, low beta carotene diet, Vitamin A deficiency.
Diagnosis: no fetal heart, abnormally rapid progression/growth in pregnancy, high early B-hCG
Tx: D&C. Watch for thyroid storm post-op.
Endometrial cancer (s/s)
Most common gynaecological CA
Post-menopause bleeding (always investigate) or abnormal uterine bleeding.
Ovarian CA Types Risk S/S Investigations
3 types: germ cell, stromal cell, epithelial cell.
Risk factors: white, older age, family history, prolonged intervals of ovulation uninterrupted by pregnancy
Early: usually asymptomatic, vague abdominal symptoms (nausea, bloating, dyspepsia, early satiety), irregular bleeding (rare)
Late: increased abdominal girth, urinary frequency, constipation, ascites
Investigation: bimanual, U/S, lab: CA-125, LFTs, CBC, lytes, Cr.
Cervical CA
Squamous cell CA (95%)
Early: water d/c –> brown or red, postcoital bleeding
Late: bleeding, pelvic/back pain, bowel/bladder symptoms
Vulvular CA
Squamous cell CA (90%)
Asymptomatic or localized pruritus, lump, or ass, raised red, white or pigmented plaque, ulcer, bleeding, discharge, pain, dysuria
Female infertility definition and Ddx
Definition: failure to conceive after 1 year unprotected sex
Ovulatory dysfunction (20-40% cases, PCOS, thyroid disease, hypothalamic pituitary dysfunction, etc)
Tubal factors (20-30% cases, PID, adhesions, tubal ligation, previous gynaecological surgery)
Cervical factors (anti-sperm antibodies, structural abnormalities, acidic mucus)
Uterine factors (polyps, injection, intrauterine adhesions, fibroids, endometriosis)
Hematuria Ddx
Cancer (bladder/urothelial, renal cell) UTI BPH Stone disease Coagulopathy (anti-coagulants) Medical renal disease (proteinuria, urine casts)
Urinary Incontinence Ddx
OAB cauda equina stress incontinence neurogenic bladder weak detrusor muscle (overflow incontinence) pharmacologic (anticholinergics, sedatives, sympathetic blockers) cystitis prostatitis
Peyronie’s disease
angulation of penile shaft on erection
Testicular torsion
adolescent to young adult males preceded by trauma or spontaneous left side more common swollen, tender, high-riding lifting increases pain (whereas epidydimitis decreases pain = phren/friend sign) no cremasteric reflex
Prostate CA and PSA testing
Men > 75 years should not be tested
Males 50-75 years with life expectancy > 10 years should be informed of risks/benefits
Males at higher risk:
- african-american
- 1st gen relative
- high fat diet
- abnormal feeling prostate (discrete change in texture, fullness or symmetry)
