Wk 8: Women's health physical exam (11% of final)

Question 1

1) What is the purpose of a women’s general physical exam?
2) What determines the extent of it?
3) What should the pt be wearing?

Answer 1

1) Detect abnormalities (suggested & unsuspected)
2) Chief complaint, managed conditions, & medically indicated by history
3) Gown is open to front

Question 2

3 exams of special importance to OB/GYN care are what?

Answer 2

1) Breast
2) Abdominal
3) Pelvic

Question 3

What objective numbers have women’s health implications for abnormal values?

Answer 3

Vitals (temp., HR, RR, BP), height, weight, BMI

Question 4

What vital is concerning during pregnancy for preeclampsia, gestational HTN, or chronic HTN, depending on timing and other features (e.g., proteinuria)

Answer 4

BP ≥140/90 mmHg

Question 5

1) What should you do first in a breast exam?
2) Is asymmetry of breasts common?
3) What should you further evaluate for?
4) What should you describe about any masses?
5) What is normal for large breasts?

Answer 5

1) Visual inspection first; have pt lean forward for large and/or pendulous breasts
2) Yes, some asymmetry is common
3) Marked differences or recent changes
4) Size, shape, consistency, position, & mobility
5) Normal firm transverse inframammary ridge with large breasts

Question 6

1) When should you palpate the breast?
2) In what 2 positions should you inspect?
3) In what positions should you palpate? How should you palpate?

Answer 6

1) After visual inspection
2) With pt seated with arms at sides, then with pt supine and ipsilateral arm above head*
Palpation with pt supine, ipsilateral arm above head; use pads of fingers for palpation (not tips/no nails)

Question 7

1) What should you thoroughly palpate during a breast exam?
2) What technique is best validated?
3) What should you squeeze?

Answer 7

1) Rectangular area extending from clavicle to inframammary fold and from midsternal line to posterior axillary line and well into axilla (tail of breast)
2) Vertical strip
3) Not nipple, but rather tissue surrounding

Question 8

What 5 groups of lymph nodes need to be palpated during a breast exam?

Answer 8

1) Central
2) Anterior (pectoral)
3) Lateral (humeral)
4) Posterior (subscapular)
5) Infraclavicular and supraclavicular

Question 9

How do you examine the axillary nodes?

Answer 9

1) Use your right hand to examine the left axilla. Ask the patient to relax with the left arm down and warn the patient that the examination may be uncomfortable. Support the patient’s left wrist or hand with your left hand.
2) Cup together the fingers of your right hand and reach as high as you can toward the apex of the axilla

Question 10

1) How do you palpate the central nodes?
2) How do you palpate the anterior (pectoral) nodes?

Answer 10

1) Place your fingers directly behind the pectoral muscles, pointing toward the midclavicle. Now press your fingers in toward the chest wall and slide them downward, trying to palpate the central nodes against the chest wall.
2) Grasp the anterior axillary fold between your thumb and fingers, and, with your fingers, palpate inside the border of the pectoral muscle.

Question 11

1) Where are the lateral (humeral or deep) nodes?
2) How do you examine the posterior (subscapular) nodes?
3) What other nodes should you examine?

Answer 11

1) Lateral (humeral or deep) nodes: from high in the axilla, feel along the upper humerus.
2) Step behind the patient, and, with your fingers, feel inside the muscle of the posterior axillary fold.
3) Infraclavicular (deltopectoral) and supraclavicular
-also reexamine the infraclavicular and supraclavicular nodes.

Question 12

What are 8 symptoms concerning for malignancy?

Answer 12

1) Rapid change in the appearance of one breast
2) Thickness, heaviness or visible enlargement of one breast
3) Discoloration, giving the breast a red, purple, pink or bruised appearance
4) Unusual warmth of the affected breast
5) Dimpling or ridges on the skin of the affected breast, similar to an orange peel
6) Itching
7) Enlarged lymph nodes under the arm, above the collarbone or below the collarbone
8) Flattening or nipple inversion

Question 13

1) What does redness of the breast suggest?
2) What is it often due to?
3) In women who have not recently nursed a baby it is worrisome for what?

Answer 13

1) Infection or inflammation
2) Mastitis in postpartum patient.
3) Inflammatory breast cancer (IBC)

Question 14

What is a “Peau d’orange” quality? What is it concerning for?

Answer 14

An “Orange Peel” like texture caused by an uncommon, aggressive inflammatory cancer

Question 15

1) What is dimpling often a sign of?
2) In what positions should you assess it?

Answer 15

1) A tumor beneath.
2) With pt supine, sitting, and standing

Question 16

1) Is it suspicious if there’s asymmetry of the breast?
2) What is nipple retraction a sign of if new?

Answer 16

1) Yes
2) A tumor beneath. Carefully palpate around and under the nipple

Question 17

List 5 abnormal nipple findings

Answer 17

1) Discoloration or ulceration
2) Clear or milky discharge (galactorrhea)
3) Nipple discharge may be sent for culture & sensitivity and cytopathology
4) Bloody discharge (usually unilateral)
5) Pus/purulent discharge

Question 18

1) What is galactorrhea and what may it be due to? Bilateral or unilateral usually?
2) Is bloody discharge of the nipple usually bilateral or unilateral? What is it associated with?
3) What does pus usually indicate?

Answer 18

1) Clear or milky discharge may be due to stimulation (normal) or elevated prolactin levels (abnormal).
-Bilateral (usually)
2) Usually unilateral, associated w. inflammation (usually intraductal papilloma).
-Evaluation to rule out malignancy is required.
3) Infection but may be due to underlying tumor.

Question 19

1) Is nipple discharge usually cancer? Explain.
2) What can be a sign of ductal ectasia or fibrocystic changes?

Answer 19

1) Usually benign but may be an early sign of endocrine dysfunction or cancer
2) Non-bloody, bilateral discharge with nipple stimulation (“nonspontaneous”)
*spontaneous = occurring without nipple stimulation

Question 20

1) When is milky discharge of the nipple common? What else is it associated with?
2) What is bloody unilateral nipple discharge concerning for?
What does it usually require?

Answer 20

1) Common during childbearing; associated with hyperprolactinemia or hypothyroidism, OCPs, tricyclic antidepressants
2) Invasive ductal carcinoma, intraductal papilloma, or intraductal carcinoma (e.g., be concerned for cancer)
-Ductography and ductal excision

Question 21

1) If you clearly identify a discrete mass, consider it to be _________ until proven otherwise.
2) In general, determination of final diagnosis requires a what?

Answer 21

1) malignant
2) Biopsy

Question 22

1) Should a dominant breast mass that does not have a corresponding abnormality on Mammogram still be considered malignant until proven otherwise?
2) Mammograms miss up to ____% of cancers

Answer 22

1) Yes
2) 30%

Question 23

True or false: While uncommon, breast cancer can occur in men

Answer 23

True
(Thus, discrete masses should be appropriately evaluated).

Question 24

1) Breast cancer can occur in young women (20s and 30s) so what should be appropriately evaluated?
2) What is more difficult about evaluating young patients for breast cancer?

Answer 24

1) Thus worrisome masses in this population should be appropriately evaluated.
2) Mammograms more likely to be false-negative

Question 25

1) True or false: you should pay very careful attention to any mass that the patient brings to your attention.
2) True or false: Women who are very self-aware can often detect subtle/early changes concerning for malignancy that an examiner may have difficulty identifying.

Answer 25

1) True
2) True

Question 26

1) Define mastalgia (breast pain)
2) What percent of women does it affect during lifetime?

Answer 26

1) Breast pain
2) 70% of women

Question 27

1) What is the most common type of mastalgia? What is it associated with? Bilateral or unilateral?
2) What is noncyclical mastalgia not associated with? What is it associated with?
3) What is extramammary (non-breast, pain referred from other locations) mastalgia associated with?

Answer 27

1) Bilateral and benign, begins during luteal phase, resolves with menses
2) Not associated with menstrual cycle; assoc with duct ectasia, mastitis, large breast size, meds, pregnancy, etc.
3) Chest wall trauma, rib fxs, shingles (varicella-zoster virus), heart, gallbladder, etc.

Question 28

1) What is required to determine the cause of mastalgia?
2) What should be done if there’s concerning findings? Why? Give examples

Answer 28

1) Careful physical exam to determine cause.
2) Imaging to rule out malignancy/serious pathology (unilateral, noncyclical, localized pain, breast mass, skin changes, etc.)

Question 29

1) Define fibrocystic breast changes
2) How common is it?
3) What are the symptoms?

Answer 29

1) Benign changes in breast epithelium producing a nodular, sensitive breast
2) Common; ½ of all women experience
3) Lumpiness, swelling, pain/tenderness; nodular, rope-like densities

Question 30

What are the essentials of fibrocystic breast change diagnosis? What is the most common age?

Answer 30

1) Painful, often multiple, usually bilateral mobile masses in the breast.
2) Rapid fluctuation in size of masses is common. *Frequently worsens just before menses (increase in pain and size of cysts).
3) Affected by hormone levels
-Most common age is 30–50 years (premenopausal); occurrence is rare in postmenopausal women.

Question 31

1) How are fibrocystic breast changes diagnosed
2) How are they treated?

Answer 31

1) Diagnosed with CBE and sx history; mammogram, ultrasound may be used. Aspirate palpable cysts
2) Observation (Decrease caffeine intake), vitamin E supplementation

Question 32

1) Define mastitis
2) What are the symptoms?

Answer 32

1) Inflammation of breast tissue that may be accompanied by infection (e.g., bacteria):
2) Erythema, warmth, swelling, tenderness/pain; fatigue, malaise, fever

Question 33

1) When does mastitis generally occur? What is it particularly associated with?
2) How is lactational mastitis treated?

Answer 33

1) I lactating or recently lactating women; incomplete emptying of the breast (engorgement) or plugged duct(s)
2) NSAIDs, cold compresses, ongoing breastfeeding and/or hand expression to help empty breast, antibiotics if associated infection

Question 34

3 most common breast masses are what?

Answer 34

Fibroadenoma (benign tumor), cysts, and breast cancer

Question 35

1) With fibroadenoma (benign tumor) what is the typical age?
2) How many are there usually?
3) Shape and size?
4) Consistency?
5) Delineation?
6) Mobility?
7) Tenderness?
8) Retraction signs?

Answer 35

1) 15-25 years, usually puberty and young adulthood, but up to 55
2) Usually single, may be multiple
3) Round, disc like, or lobular; typically small (1-2cm)
4) Usually firm (but may be soft)
5) Well delineated
6) Very mobile
7) Usually nontender
8) Absent

Question 36

1) In cysts of the breast, what is the typical age?
2) How many are there usually?
3) Shape?
4) Consistency?
5) Delineation?
6) Mobility?
7) Tenderness?
8) Retraction signs?

Answer 36

1) 30-50 yrs, regress after menopause
2) Single or multiple
3) Round
4) Soft to firm, usually elastic
5) Well delineated
6) Mobile
7) Often tender
8) Absent

Question 37

1) In breast cancer, what is the typical age?
2) How many are there usually?
3) Shape?
4) Consistency?
5) Delineation?
6) Mobility?
7) Tenderness?
8) Retraction signs?

Answer 37

1) 30-90, most common >50
2) Usually single, although may coexist w other nodules
3) Irregular or stellate
4) Firm or hard
5) Not clearly delineated
6) May be fixed to skin or underlying tissues
7) Usually nontender
8) May be present

Question 38

1) What should you inspect on the abdomen in the women’s health PE?
2) What should you percuss for?

Answer 38

1) Contour (flat, scaphoid, protuberant)
Presence & distribution of hair
Striae, operative scars, masses
2) Areas of distention (tympany & dullness)

Question 39

What should you palpate for on the abdomen in the women’s health PE?

Answer 39

1) Tenderness (hand flat, start in non-painful area)
Rebound tenderness, muscle guarding, rigidity
2) Masses: size, cystic or solid, smooth or nodular, fixed or mobile, associated with ascites

Question 40

1) What age is a pelvic exam recommended in?
2) Describe how to perform a pelvic exam

Answer 40

1) ACOG recommends annual pelvic exam in women 21 yrs & older
2) -Empty bladder to ensure comfort & assist your exam
-“Clean catch” urine specimen from mid-stream if needed
(A full bladder will push the uterus and cervix higher in the pelvis and make the exam more difficult and uncomfortable.)
-Muscle relaxation needed
-Explain every part of exam before performing (“Talk before you touch”)
-Avoid being abrupt or stern
-Rehearse what you will say and how you will say it.

Question 41

1) Describe the positioning of a pelvic exam
2) What should be available?

Answer 41

1) Draping sheet over patient’s lap & knees, assist patient to assume lithotomy position
-Examiner position: seated at foot of table (exam lamp position/lit speculum)
2) Gloves and lubricant

Question 42

What should you visually inspect on the vulva and perineum during a pelvic exam?

Answer 42

Mons pubis, labia majora, labia minora, clitoris, urethral meatus, introitus, ducts of Skene’s and Bartholin’s glands; perineum; perianal area, anus

Question 43

What does the vulva include?

Answer 43

Labia majora, labia minora, mons pubis, clitoris, vestibule, and ducts of glands that open into the vestibule (Skenes and Bartholins).

Question 44

What should you look for during an external pelvic exam?

Answer 44

1) Hair distribution (Sexual Maturity/Tanner Staging)
2) Degree of development and/or atrophy of external structures
3) Condition of hymen (intact/perforated)
4) Clitoromegaly?
5) Inflammation of Bartholin’s or Skene’s glands?
6) Any lesions? Ulcers? Warty growths?
7) Any scarring?
8) Any enlarged femoral or inguinal lymph nodes?

Question 45

1) What may be difficult these days due to current hair removal practices?
2) What is cliteromegaly concerning for?
3) What are genital warts concerning for?

Answer 45

1) Due to current hair removal practices (also many variances in anatomy from patient to patient).
2) Masculinizing endocrine disorders (androgen excess, congenital adrenal hyperplasia, etc.)
3) HPV

Question 46

Pap smear:
1) What size should the speculum be?
2) What should be completely visualized?
3) How much lubricant? Why?
4) When should it be deferred?

Answer 46

1) Large enough to adequately displace the vaginal side walls and allow visualization
2) Cervix
3) Can interfere with results (particularly with the old slide method)
4) If there’s heavy cervical bleeding or active cervicitis (as these can obscure results)

Question 47

1) What are the available speculum sizes?
2) What about speculums can vary besides size?
3) What should you ensure about the speculum before you use it?

Answer 47

1) Pediatric, small, medium, and large
2) Plastic, metal; lit, unlit
3) Ensure it’s warm and lubricated (unless contraindicated for the procedure)

Question 48

1) Which hand do you use during a bimanual exam?
2) What should you palpate for?
3) What should you assess bilaterally?

Answer 48

1) Dominant hand is the vaginal hand, use your non-dominant hand as the abdominal hand
2) Palpate the cervix: Do you feel any abnormalities? Is it painful for the patient? Use your abdominal hand to locate the fundus of the uterus and estimate uterine size.
3) Adnexa
-Ovaries are small and very soft. Not usually palpable; if you can feel them easily there is a problem

Question 49

What should you evaluate about the cervix?

Answer 49

1) Nulliparous vs multiparous
2) Normal vaginal discharge?
3) Ectropion (when inside of cervical canal everts), retention (Nabothian) cysts, small polyps (benign)
4) Inflammation, masses, dysplasia (further eval)

Question 50

Describe the shape of the cervix pre and post pregnancy

Answer 50

1) Nulliparous: external os = circular dot
2) Parous: more arc or “slit-like”

Question 51

What is ectropion and when does it occur?

Answer 51

Inner portion of cervix everts slightly during pregnancy and appears as “glandular friable darker pink/red” area inside os

Question 52

What changes about the cervix post-menopause?

Answer 52

Becomes smaller and flattened, usually pale, thin epithelium (bleeds easy, may have petechial hemorrhagic spots)

Question 53

There’s an increased risk of uterine perforation in anteflexed or retroflexed positions during procedures such as what?

Answer 53

Dilation and curettage or IUD insertion.

Question 54

True or false: An anteverted uterus is considered normal

Answer 54

True

Question 55

1) Define adnexal space
2) What are the adnexa?

Answer 55

1) The area between the lateral pelvic wall and the cornu/horns of the uterus
2) Ovaries and fallopian tubes

Question 56

What should you do during a female rectal exam?

Answer 56

1) Any obvious deformities/lesions/hemorrhoids
2) Have patient bear down before introducing clean, gloved, lubricated finger(s)
3) Assess sphincter tone
4) Assess for any palpable mucosal lesions
5) Hemoccult testing for occult blood
-Not usually part of annual female exam

Question 57

1) What is an adnexal mass?
2) Where may it originate?
3) Is it often malignant?

Answer 57

1) A growth that develops near the uterus, generally in the ovaries or fallopian tubes
2) In the reproductive system or other nearby system (such as GI-intestines or GU-urinary bladder)
3) Often NOT malignant but can be

Question 58

1) What does an adnexal mass require for evaluation?
2) What is the primary component of evaluation?

Answer 58

1) A thorough pelvic examination
2) Pelvic ultrasound

Question 59

List the 5 early Sx of Adnexal Neoplasm. Specify which is most common

Answer 59

1) Abdominal bloating or distention- most common
2) Abdominal or pelvic pain
3) Decreased energy or lethargy
4) Early satiety
5) Urinary urgency

Question 60

What are some ddx (differential diagnoses) of Adnexal Mass (premenopausal)?

Answer 60

1) Cyst
2) UTI
3) Renal and ureteral calculi
4) Appendicitis
5) Inflammatory Bowel Disease (IBD)
6) Diverticulosis/diverticulitis
7) Hydrosalpinx (blocked fallopian tube fills with fluid)
8) Ectopic pregnancy

Question 61

1) You should not be able to feel the ovaries of who during a pelvic exam?
2) Ovaries shrink with _____

Answer 61

1) Postmenopausal women
2) Age

Question 62

What should you physically examine for Adnexal Neoplasm?

Answer 62

1) Assess for any signs of infection or cancer
2) The breast examination is especially important because the ovary is a common site of metastatic breast carcinoma (abdomen, too)
3) Bimanual exam assessing each side and comparing sides
-keep in mind age-parameters for ovarian size

Question 63

Adnexal cancer risk is increased with what?

Answer 63

1) Cervical (neck), supraclavicular, and/or inguinal lymphadenopathy
and/or
2) Prescence of pleural effusions or ascites (abdomen).

Question 64

Give the vague symptomatology of ovarian cancer

Answer 64

Abdominal bloating or distention
Abdominal or pelvic pain
Decreased energy
Early satiety
Urinary urgency
Abnormal menstrual cycles
Unexplained back pain that worsens over time
Non-specific gastrointestinal symptoms

Question 65

List the main risk factors for ovarian cancer

Answer 65

1) Increasing age
2) Early age at menarche or late menopause
3) Nulliparity
4) Endometriosis
5) Hereditary ovarian cancer syndromes/family history (e.g., BRCA mutations)

Question 66

1) What are functional ovarian cysts?
2) What type of cyst occurs when an ovarian follicle fails to rupture during follicular maturation and ovulation does not occur?

Answer 66

1) Not neoplasms, but anatomic variations that arise due to normal ovarian function
2) Follicular cyst

Question 67

1) When does a follicular cyst become medically significant?
2) How are they diagnosed?

Answer 67

1) If large enough to cause pain or persists beyond one menstrual interval
2) Pelvic ultrasound (adjunct to PEx)

Question 68

1) How do most follicular cysts resolve?
2) What if the presumed functional cyst persists?

Answer 68

1) Most spontaneously resolve within 6 weeks
2) Another type of cyst or neoplasm should be suspected and further evaluated