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Sasha: Module 8 Repro/GU > CA Bates > Flashcards

Flashcards in CA Bates Deck (309):
1

how many quadrants is the breast broken up into for documentatio

4 horizanl vertical line crossing the nipple
and a 5th area (axillary tail of breast tissue sometimes called tail of spense) and it extends laterally across the anterior axillary fold

2

how are findings locaalized

as the time on the face of a clock
and
distance in cm from nipple

3

what are the three most common kinds of breast masses

fibroadenoma (benign tumor)
cysts
breast cancer

4

commonly palpable as nodular, rope-like densities in women ages 25-50. may be tender or painful. considered benign and are not viewed as a risk factor for breast cancer

" nodular and ropelike"

fibrocystic changes

5

fibroadenoma
age
number
shape
consistency
delimitation
mobility
tenderness
retraction signs

age : 15-25
usually puberty and young adults, but up to age 55

number: usually single, may be multiple

shape: round disclike or lobular
consistency: may be soft usually firm

delimitation: well delineated

mobility: very mobile

tenderness: non tender

retraction signs: absent

"smooth, rubbery, round mobile, nontender"

6

Cysts
age
number
shape
consistency
delimitation
mobility
tenderness
retraction signs

age : 30-50, regress after menopause except with estrogen therapy

number: single or multi

shape: round

consistency: soft to firm, elastic

delimitation: well delineated

mobility: mobile

tenderness: tender

retraction signs: absent

"soft to firm, round, mobile, tender"

7

cancer
age
number
shape
consistency
delimitation
mobility
tenderness
retraction signs

age : 30-90 most common OVER 50

number: single but can coexist with other nodules

shape: irregular or stellate

consistency: firm or hard

delimitation: no clearly delineated from surrounding tissue

mobility: fixed to skin or underlying tissue

tenderness: non tender

retraction signs: maybe

"irregular firm may be mobile or fixed to surrounding tissue

8

breast masses should be carefully evaluated and usually warrants further investigation like..... (4)

ultrasound, aspiration, mammo, or biopsy

9

what are three retraction signs

1. abnormal contours
2. skin dimpling
3. nipple retraction and deviation

10

as breast CA advances it causes fibrosis (scar tissue). shortening of the tissue produces dimpling, changes in contour and retraction of deviation of the nipple. other causes of ____________ are fat necrosis and mammary duct ectasia.... what am i referring to?

retraction signs

11

variation in the normal convexity of each breast, and compare one side to the other. special positioning may again be useful. marked flattening of the lower outer quadrant of the left breast is an example of what you may see in this type of retraction sign

abnormal contours

12

seen when pts arms are at rest, during special positioning and on moving or compressing the breast

skin dimpling

13

nipple is flattened or pulled inward. can be broadened and feels thickened. when involvement is radially asymmetric the nipple may point in a different direction from its normal counterpart, typically toward the underlying cancer

nipple retraction and deviation

14

produced by lymphatic blockade. appears as thickened skin with enlarged pores
also called peau d'orange (orange peel) sign
seen first in the lower portion of the breast or areola

edema of the skin

15

uncommon form of breast cancer usually starts as a scaly eczema like lesions that may weep, crust, or erode.
breast mass may be present.
suspect this is any persisting dermatitis of the nipple and areola occur.
can present with invasive breast cancer or ductal carcinoma in situ

Paget's Disease of the Nipple

16

inappropriate discharge of milk containing fluid, and is abnormal if it occurs 6 or more months after childbirth or cessation of breast feeding

galactorrhea

17

milky discharge unrelated to prior pregnancy and lactation. causes include hypothyroidism, pituitary prolactinoma, and drugs that are dopamine agonists, including many psychotropic agents and phenothiazines

nonpuerperal glactorrhea

18

spontaneous unilateral bloody discharge fro one or two ducts warrants further evaluation for ____________

intraductal papiloma

ductal carcinoma in situ or Pagets disease of the breast

19

clear serous, green, black, non bloody discharge that are multiductal are

usually benign

20

masses nodularity and change in color or inflammation especially in the incision line suggest

recurrence of breast cancer

21

deeply pigmented velvety axillary skin suggests

acanthosis nigricans
associated with internal malignancy

22

thickening of the nipple and loss of elasticity suggests

underlying cancer

23

tender cords
benign but sometimes painful conditon of dilated ducts with surrounding inflammation, sometimes associated masses

mammary duct ectasia

24

hard irregular poorly circumscribed nodules fixed to the skin or underlying tissue

cancer

25

if you are above the age of _____ it is cancer until proven otherwise

50

26

what is the most common type of cancer in women worldwide
and the second leading cause of death in women

breast cancer

27

breast cancer accounts for more than _____% of cancers in women

10%

28

in the US. a women born now has a ___% or ___ in ____ lifetime risk of developing breast cancer

12%
1 in 8

29

95% of new breast cancers occur above the age of ____

40

30

factors which increase relative risk of breast cancer:
(this card is a lot but it is an LO so here I go)

page 412 in bates

>40 Relative Risk: factors are:
female
age
inherited genetic mutations
2 or more first degree relatives with breast cancer diagnoses at an early age
personal history of breast cancer
high breast tissue density
biopsy confirmed atypical hyperplasia

2.1-4.0 RR: factors are:
one 1st degree relative with breast cancer
high dose radiation to chest
high bone density (postmenopausal)

1.1-2.0 RR: factors are:
late age at first full term pregnancy >30
early menarche (55)
no full term pregnancies
never breast fed a child
recent oral contraceptive use
recent and longterm use of hormone replacement therapy
obesity

other factors:
personal history of endometrium ovary or colon cancer
alcohol consumption
height
high socioeconomic status
jewish heritage

31

estimate absolute lifetime risk of breast cancer and are the most commonly used. they assess risk based on large population Data sets, BUT hey do not predict disease in a single individual.

Gail and CLaus models

32

used for predicting BRCA1 or BRCA2

BRCAPRO model

33

there is no single model that addresses all the known risk factors or includes all of the genetic details of personal and daily history, so devising data bases personalized management strategies is an on going focus for reseach

true

34

Breast cancer risk assessment tool often called the _____________ provides 5 year and first degree relatives with breast cancer previous breast biopsies and presence of hyperplasia, age at menarche, and age at first delivery. it is the best used for individuals over the age of 50 who have either no family history of breast cancer or one affected first degree relative and who have annual screening mammos. should not be used for women with a past history of breast cancer or radiation exposure, or those who are 35 or younger. does not determine risk for noninvasive breast cancer and does not take paternal history or disease in second degree relatives into account or age of onset of disease
this model was recently updated to include breast density but depends on the use of digital mammo and special software making it more difficult to use

GAIL MODEL

35

assess risk for high risk women and incorporates family history for both female And male 1st and 2nd degree relatives, including age of onset.
based on the woman's current age
it is best used for individuals with no more than two first or second degree relatives with breast cancer.
expanded version includes family members with ovarian cancer,
model does not include personal, lifestyle or reproductive risk factors
discrepancies in risk assessment between published tables and the computerized program have been reported

CLAUS MODEL

36

used for high risk women to assess risk of BRACA1 and BRACA 2 mutations frequencies, cancer penetration i affected carriers and age of onset in first and second degree female and male relatives.
DOES NOT include on hereditary risk factors

BRCAPRO model

37

when do we begin evaluating a womans breast cancer risk?

early 20s by asking about family history

38

pattern of breast or ovarian in maternal or paternal family member is suspicious for

autosomal dominant genetic mutations

39

what do you loook specifically for in a positive family history

1. age 50 or younger for diagnosis
2. breast cancer in two or more indiv. in the same lineage (paternal or maternal)
3. multiple primary or ovarian tumors in one person
4. breast cancer in a male relative
5. Ashkenazi Jewish ancestry
6. family member with a known predisposing gene

40

what mutation represent roughly half of the familial breast cancers

BRCA1 and 2

account for 5% of breast cancers

41

if family history is suspect the next steps for clinical include

using the BRCAPRO calculator, conducting genetic testing, considering MRI for sceening in addition to mammo and making appropriate specialty referals

42

mammo women 40 to 50

controversial: why?
1. due to lower sensitivity and specificity
2. maybe related to heterogenous estrogen exposure in women still premenopausal
3. high number of false positives (9 out of 100 women)
4. high rate of resulting invasive procedures

having mammo 40-50 is based on individual patient

43

screening mammo age 50-74

biennial screening for women. changed it from annual to biennial.
reduced the harm of ammo screening. decreased false positives

however American cancer society and world health organization recommend annual mammo. world health organization says every 1 to 2 years.

digital mammo appears to perform better in younger women and women with higher breast density

44

screening mammos for over 75 yo

individualized decisions about continuing screening, depending on coexisting conditions and anticipated 5 year survival

45

Clinicial Breast Examination (CBE) guideleines

USPSTF and World Health Organization: determined evidence supporting insufficiency of CBE for establishing balance of benefits and harms
American Cancer Society recommends the CBE every 3 years for women ages 20-39 and annually preferably before mammo, beginning age 40. CBE provides pt education but cautions that a thorough CBE may take up to 10 min.

CBE is heavily influenced by the technique of the examiner.

46

Breast self exam contraversy

evidence that is does not reduce mortality and may lead to higher rate of benign biopsies

but some say it promotes health awareness and advises clinicians to teach and review the patient techniques.

monthly BSE 5 to 7 days after onset of menses (when hormonal stimulation of breast tissue is low) can be taught to women as early as their 20s

47

BSE instructions on how to perform. page 427 in bates

again this is long. but it is an LO so i would read it over :)


you can do it!

lying supine:
1. lie down with a pillow under your right shoulder. lace right arm behind your head.
2. use finger pads of the three middl fingers on your left hand to feel for lumps in the right breast. finger pads are the top third of each finger
3. firmly press enough to know how your breast feels, using firmer pressure for tissue closest to the chest and ribs. firm ridge in the lower curve of each breast is normal. if you're not sure how hard to press talk with provider. or try to cop the at they do it
4. press firm on he breast in an up and down or strip patient. also can us a circular or wedge pattern but be sure to use the same pattern every time. check the entire breast area form the underarm tot he sternum and the collarbone to the ribs below the breast. remember how your breast feels from month to month
5. repeat exam on your left breast
6. if you fin a mass or lump or skin change go see your doctor DUH

Standing:
1. while standing in front of a mirror with your hands pressing firmly down on your hips , look at your breasts and say.... I am beautiful hahaha!.... but for real look at your breasts for changes in size shape contour or dimpling or redness or scaliness of nipple or breast skin.
2. examine each underarm while sitting up or standing and with your arm only slightly raised so you can easily feel in this area. raising arm straight up tightens he tissue in this area and makes it hard to examine.

48

breast MRI screening criteria

annual screening with MRI and mammo for women at high lifetime risk of breast cancer, above 20%. woen at moderate lifetime risk (15% to 20%)urged to discuss MRI screening with their provider.

49

high risk (20% -25%) criteria and factors for breast cancer and therefore indicated to get a breast MRI include

(5)

1. lifetime risk 20-25% using assessment tools
2. BRCA1 or 2 mutation
3. 1st degree relative (father, brother, with BRCA1 or 2 mutation but woman not tested)
4. history of chest radiation between ages of 10-30
5. high risk genetic syndrome in 1st degree relative with high risk syndrome

50

moderate risk (15-20%)

(3)

1. lifetime risk of 15-20% using risk assessment tools
2. history of breast cancer, ductal or lobular carcinoma in situ, atypical ductal or lobular hyperplasia
3. extremely dense breasts or unevenly dense breasts on mammograms

51

tunnel for the vas deferens as if passes through the abdominal mucles

inguinal canal

52

triangular, slitlike structure palpable just above and lateral to the pubic tubercle.

external inguinal ring

53

aprrox 1 cm above the midpoint of the inguinal ligament.

internal inguinal ring

54

what is not palpable through the abdominal wall relating to anatomy of the groin

canal nor internal ring

55

how are inguinal hernias formed

loops of bowel force their way through weak areas of the inguinal canal and produce inguinal hernias.

56

what is another route for a hernia mass

femoral canal

57

develop at the internal inguinal ring, where the spermatic cord exits the abdomen

indirect inguinal herniea

58

arise more medially from weakness in the floor of the inguinal canal and are associated with straining and heavy lifting

direct inguinal hernias

59

more present as emergencies with bowel incarceration or strangulation

femoral hernias

60

INGIRECT HERNIA
frequency, age, sex
point of origin
course
examination during straining

frequency, age, sex: all ages, both sexes. often children, may be adults

point of origin: above inguinal ligament, near its midpoint (internal inguinal ring)

course: often into the scrotum

examination during straining: the hernia comes down the inguinal canal and touches the finertips

61

DIRECT HERNIA
frequency, age, sex
point of origin
course
examination during straining

frequency, age, sex: less common, men older than 40; rare in women

point of origin: above inguinal ligament, close to the pubic tubercule (near the external inguinal ring)

course: rarely into the scrotum

examination during straining: the hernia bulges anteriorly and pushes the side of the finger forward

62

FEMORAL HERNIAS
frequency, age, sex
point of origin
course
examination during straining

frequency, age, sex: least common, more common in women

point of origin: below the inguinal ligament, appears more lateral than an inguinal hernia. can be hard to differentiate from lymph nodes

course: never into scrotum

examination during straining: inguinal canal is empty

63

may be from psychogenic causes, especially if early morning erection is reserved; it may also reflect decreased testosterone, decreased blood flow in the hypogastric arterial system, impaired neural innervation, and diabetes

erectile dysfunction

64

common in young men. possible causes are medications, surgery, neurologic deficits, lack of androgen.

premature ejaculation

65

lack or orgasm with ejaculation is usually

psychogenic

66

reduced or absent ejaculation affects

middle aged or older men

less common

67

yellow penile discharge

gonorrhea

68

white penile discharge

non gonococcal urethritis from chlamydia

69

rash, tenosynovitis, monoarticular arthritis, even meningitis, not always with urogenital symptoms

disseminated gonorrhea

70

what are the 4 infections from oral-penile transmission

1. gonorrhea
2. chlamydia
3. syphilis
4. herpes

71

tight prepuce that cannot be retracted over the glans.

phimosis

72

tight prepuce that once retracted cannot be returned edema ensues

paraphimosis

73

inflammation of the glans

blanitis

74

inflammation of the glans and prepuce

balanoposthitits

75

congenital, ventral displacement of the meatus on the penis

hypospadias

76

profuse yellow discharge

gonococcal urethritis

77

scanty white or clear discharge

nongonococcal urthritis

78

what is the definitive diagnosis required for gonococcal urthiritis and nongonococcal urthrititis

gram stain and culture

79

induration along the ventral surface of penis suggests

and tenderness in the indurated area suggest

urethral stricture or possibly carcinoma

periurethral inflammation secondary to urrthral structure

80

4 things that a tender, painful scrotal swelling could be

1. acute epididymitis
2. acute orchitis
3. torsion of the spermatic cord
4. strangulated inguinal hernia

81

multiple tortuous veins in this area, usually on the left, may be palpable and even visable

varicocele

82

vas deferens if infected may feel thickened or beaded. cystic structure in the spermatic cord suggests

hydrocele of the cord

83

bulge that appears with straining

hernia

84

how does bowel sounds help differentiate between a hernia and a hydrocele

bowel sounds may be heard over a hernia

bowel sounds are NOT heard over a hydrocele

85

when a hernias contents cannot be returned to the abdominal cavity

incarcerated

86

when a hernias blood supply to the entrapped contents is compromised

stangulated

87

hernia with tenderness, nausea, vomiting and consider surgical intervention
a. strangulation OR
b. incarcerated

A. STRAGULATION

88

what is the most common form of cancer for men between ages 15-34

testicular carcinoma

89

what are three conditions that have to do with penile discharge or lesions
p.535

i. Peyronie’s disease
ii. Hypospadias
iii. Carcinoma of the penis

90

palpable, non tender hard plaques are found just beneath the skin, usually along the dorsum of the penis. the pt complains of a rooked, painful erection

Peyronie’s disease

91

an indurated module or ulcer that is usually non tender. limited almost completely to me who re not circumcised, it may be masked by the prepuce. any persistent penile sore is suspicious

Carcinoma of the penis

92

congenital displacement of the urethral meatus to the inferior surface of the penis. a groove extends from the actual urethral meatus to its normal location on the top of the glans

Hypospadias

93

may make the scrotal skin taut, seen in heart failure or nephrotic syndrome

scrotal edema

pitting edema

94

non tender, fluid filed mass within the tunica vaginalis. it transilluminates and the examining fingers can get above the mass within the scrotum

hydrocele

95

usually an indirect inguinal hernia, that comes through the external inguinal ring, so the examining fingers cannot get above it within the scrotum

scrotal hernia

96

testis is atrophied and may lie in the inguinal canal or the abdomen, resulting in an unfilled scrotum. no palpable testis or epididymis on the affected side. raises the risk for testicular cancer

cryptorchidism

97

testicular length usually

small testis

98

testis is acutely inflamed, painful, tender, and swollen
may be difficult to distinguish from epididymis
scrotum may be reddened
seen in mumps an other viral infections usually unilateral

acute orchitis

99

usually appears as a painless nodule
any nodule within the testis warrants investigation for malignancy

EARLY tumor or the testis

100

painless nodule spreads, may seem to replace the entire organ. the testicle characteristically feels heavier than normal

LATE tumor of the testis

101

a painless, movable cystic mass just above the testis suggest a _____________ or _____________. both transilluminate.

which contains sperm
and then which dose not,

are they clinically indistinguishable.

Spermatocele or cysts of the epididymis

which contains sperm: spermatocele

which does not contain sperm: cysts of epididymis

YES they are clinically indistinguishable.

102

an acutely inflamed epididymis is tender and swollen and may be difficult to distinguish from the testis. the scrotum may be reddened and the vas deferens inflamed. it occurs chiefly in adults, most commonly with chlamydia infection. coexisting urinary tract infection or prostatitis supports the diagnosis.

acute epididymitis

103

refers to varicose veins of the spermatic cord, usually found on the left. it feels like a soft :bag of worms" separate from the testis, and slowly collapses when the scrotum is elevated in the supine patient. infertility may be associated.

varicocele of the spermatic cord

104

twisting of the testicle on its spermatic cord produces an acutely painful, tender, and swollen organ that is retracted upward in the scrotum. the scrotum becomes red and edematous. there is no associated urinary infection. most common in adolescents, is a surgical emergency because of obstructed ciruclation

torsion of the spermatic cord

105

the chronic inflammation produces a firm enlargement of the epididymis, which is sometimes tender, with thickening or beading of the vas deferens

tuberculous epididymitits

106

Appearance: single or multiple papules or plaques of variable shapes; may be round, acuminate (or pointed), or thin and slender. may be raised, flat or cauliflower-like
causative organism: human papillomavirus (HPV), usually subtypes 6 and 11, carcinogenic subtypes rare
incubation: weeks to months, infected contact may have no visible warts.
can arise on penis, scrotum, groin, thighs, anus, usually asymptomatic, occasional itching and pain
may disappear without treatment

genital warts (condylomata aciminatata)

107

appearance: small scattered or grouped vesicles, 1 to 3 mm in size, on glans or shaft of penis. appear as erosions if vesicular membrane breaks.
Causative organism: usually herpes simplex virus 2 (Double stranded DNA virus)
incubation: 2 to 7 days after exposure
primary episode may be asymptomatic; recurrence usually less painful of shorter duration.
associated with fever, malaise, HA, arthraligias, local pain and edema, lymphadenopathy


what do you need to distinguish this from (2)

genital herpes simplex


need to distinguish from genital herpes zoster (usually in older patients with dermatomal distribution); candidiasis.

108

appearance: small red papule hat becomes chancre, or painless erosion up to 2 cm in diameter. base of chancre is clean, red, smooth and glistening; borders are raised and indurated. chancre heals within 3 to 8 weeks.
causative organism: Treponema pallidium (spirochete
incubation: 9 to 90dyas after exposure
may develop inguinal lymphendopathy within 7 days; lymph nodes are rubbery, non-tender, mobile
20-30% of pt develop secondary syphilis while chancre still present (suggest co-infection with HIV)


what do you need to distinguish from (3)

primary syphilis

distinguish from:
1. genital herpes simplex
2. chancroid
3. granuloma inguinale from Klebsiiella granulomatis (rare in US; 4 variants, so difficult to identify)

109

Appearance: red papule or pustule initially, then forms a painful deep ulcer with ragged non indurated margins; contains necrotic exudate has a friable base
causative organism: Haemophilus ducreyi, an anaerobic bacillus
Incubation: 3 to 7 days after exposure
painful inguinal adenopathy; suppurative buboes in 25% of pts

what do you need to distinguish from? (4)

chancroid


need to distinguish from:
1. primary sphyilis
2. genital herpes simplex
3. lymphoomogranuloma venereum
4. granuloma inguinale from Kelbsiella granulomatis (both rare in the US).

110

its incidence is low (4 per 100,000 men) BUT it is the most common cancer of young men between ages 15-34

testicular cancer

111

when detected early how is the prognosis of testicular cancer

GREAT!

112

what are risk factors for testicular cancer (5)

1. cryptorchidism (which confers a high risk for testicular carcinoma in the undescended testicle)
2. history of carcinoma in contralateral testicle
3. mumps orchitis
4. inguinal hernia
5. hydrocele in childhood

113

Instructions for testicular self exam...


just read it over
p.531

best performed after a warm bath or shower. the heat relaxes the scrotum and makes it easier to find anything unusual
1. standing in front of a mirror, check for any swelling on the skin of the scrotum
2. with the penis out of the way, examine each testicle separately
3. cup the testicle between your thumb and fingers with both hands and roll it gently between fingers. one testicle may be larger than the other; that is normal, but be concerned about any lump or area of pain.
4. find the epididymis, this is a soft, tubelike structure at the back of the testicle that collects and carries sperm, and is not an abnormal lump.
5. if you find any lump, dont wait. see a doctor. the lump may just be an infection, but if it is cancer, it will spread unless stopped by treatment

114

who is at highest risk of HIV/AIDS

african american men and men having sex with men.

115

testing for HIV (what age)

people at high risk: how often?

universal testing from ages 18-64, regardless of risk

groups at high risk: annually

116

presence of any STI (hep B chancroid etc) warrants testing for

coinfection of HIV

117

what type of approach is beneficial in adopting for take a sexual history

client centered counseling!

118

key instructions for using a condom correctly and therefore reducing the risk of STI and HIV (4)

1. using a new condom with each sex act
2. applying the condom before any sexual contact occur
3. adding only water based lubricants
4. holding the condom during withdrawal to keep it from slipping off.

119

what age is HPV vaccination for boys and men recommended.. and what does it prevent

GARDASIL for boys and men ages 9-26 for prevention of genital warts

120

what are you looking for when you retract the prepuce (foreskin)?

chancres and carcinomas.

can see smegma: cheesy, whitish material may accumulate normally under foreskin

121

dome-shaped white or yellow papules or nodules formed by occluded follicles filed with keratin debris of desquamated follicular epithelium

epidermoid cysts

122

change in bowel pattern, especially stools of thin pencil-like shape, may warn of

colon cancer

123

blood in the stool may be from
(4)

polyps or cancer or from gastrointestinal bleeding or local hemroids

124

mucus may accompany

villous adenoma

125

positive answers to person or family history of colonic polyps or colorectal cancer and history of inflammatory bowel disease indicates

increased risk for colorectal cancer and a need for further testing and surveillance

126

may be indicated by itching, anorectal pain, tenesmus, or discharge or bleeding from infection or rectal abscess
causes include gonorrhea, chlamydia, lymphogranuloma veereum, receptive intercourse, ulcerations of herpes simplex, chancre or primary syphilis.

proctitis

127

itching in younger pts may be from

pinworms

128

genital warts may occur from (2)

HPV
condylomata lata in secondary syphilis

129

anal fissures can be found in (2)

proctitis
crohn's disease

130

difficulty starting or holing back urine stream. flow is weak. frequent urination especially at night. pain and burning when urine is passes. blood in urine or semen or pain with ejaculation. frequent pain or stiffness in the lower back, hips, or upper thighs

symptoms suggest urethral obstruction as in benign prostatic hyperplasia (BPH) or prostate cancer, especially in men older than 70 years

131

AUA symptom index helps quantify

BPH severity and need for referral.

132

men feeling discomfort or heaviness in the prostate area at the base of the penis. malaise fever and chills

prostatitis

133

leading cancer diagnosed in US men and the second leading cause of death in men after lung cancer

prostate cancer

134

what are primary risk factors of prostate cancer

1. age
2. ethnicity
3. family history

135

after age ____, the risk of prostate cancer increases sharply with each advancing decade

50

136

incidence rates for prostate cancer are higher in which ethinicity

african american men.

prostate cancer occurs at an earlier age and more advanced stage in african american men.

137

what is a strong risk factor to remember as you interview the patients.

family history

men with on affecte first degree relative namely a father or brother, are 2 or 3 more likely to have prostate cancer.

138

what is their a correlation between concerning prostate cancer and diet

maybe a higher risk if you have a high intake of saturated fat from diary and animal sources

139

what is the most common methods for screening for prostate cancer

prostate specific antigen (PSA)
and
digital rectal exam (DRE)

140

glycoprotein produced by prostate epithelial cells. it is a biomarker for early detection of prostate cancer, bit it has a number of limitations as a screening test.

PSA

141

PSA can be elevated in a number of benign conditions such as: (4)

1. hyperplasia
2. prostatitis
3. ejaculation
4. urinary retention

causing false positives

142

the common cutpoint for proceeding to biopsy is

4.0 ng.mL

143

PSA does not distinguish small volume indolent cancers from aggressive life-threatening disease

true/false

TRUE

144

low sensitivity of 59% with a specificity of 94%. detects tumors on the posterior and lateral aspects of the gland but misses the 25 to 35% of tumors arising in other areas.

DRE

145

prostate PSA testing should begin at age

50 average risk
45 high risk (single affected first degree relative)
40 at very high risk from two or more affected relatives

146

swollen, thickened, fissured perianal skin with excoriations

pruritus ani

147

tender, purulent, reddened mass with fever or chills accompanies an

anal abcess

148

sphincter tightness may occur with

anxiety
inflammation
scarring

149

sphincter laxity may occur with

neurologic diseases such as S2-4 cord lesions

150

fairly common
congenital
abnormality located in the midline superficial to the coccyx or the lower sacrum.
look for opening of sinus tract
opening may exhibit a small tuft of hair surrounded by a halo of erythema
generally asymptomatic except perhaps for slight drainage, abscess formation and secondary sinus tracts may complicate the picture

pilonidal cyst and sinus

151

dilated hemorrhoidal veins that originate below the pectinate line and are covered with skin. seldom produce symptoms unless thrombosis occurs. causes acute local pain that increases with defecation and sitting. tender swollen bluish ovoid mass is visible at the anal margin

external hemorrhoids (thrombosed)

152

enlargements of the normal vascular cushions located above the pectinate line. they are not usually palpable. sometimes, especially during defecation may cause bright red bleeding. may also prolapse through anal canal and appear as reddish, moist protruding masses

internal hemorrhoids (prolapsed)

153

happens when someone is straining for a bowel movement. this may happen to the rectal mucosa with or without the muscular wall.
it appears as a donut or rosette of red tissue.
involving only mucosa is relatively small and shows radiating folds. when the entire bowel wall is involved, it is larger and covered by concentrically circular folds

prolapse of the rectum

154

painful oval ulceration of the anal canal, found most commonly in the midline posteriorly, less commonly in the midline anteriorly. its long axis lies longitudinally. there may be a swollen sentinel skin tag just below it. gentle seperation of the anal margins may reveal the lower edge of the fissure. the sphincter is spastic; the examination is painful. local anesthesia may be required

anal fissure

155

inflammatory tract or tube that opens at one end into the anus or rectum and at the other end onto the skin surface or into another viscus. usually an abscess before it. look for these at opening or openings anywhere in the skin around anus

anorectal fistula

156

common.
variable in size and number
can develop on a stalk (pedunculated) or lie on the mucosal surface (sessile)
soft and may be difficult or impossible to feel even when in reach of the examining finger.
proctoscopy and biopsy are needed for differentiation of benign form malignant lesions

polyps of the rectum

157

asymptomatic
routine rectal examination is important for this reason!
firm, nodular rolled edges of an ulcerated cancer

cancer of the rectum

158

widespread peritoneal metastases from any sources may develop in the are of peritoneal reflection anterior to the rectum

firm to hard nodular

may be just palpable with the tip of the examining finger.

in women this metastatic tissue develops in the rectouterine pouch, behind the cervix and the uterus

rectal shelf

159

palpated through the anterior rectal wall
rounded
heart shaped structure approx 2.5 cm long
median sulcus can be felt between the two lateral lobes
only the posterior surface is palpable
anterior lesions including those that may obstruct the urthetha are not detectable by PE

normal prostate gland

160

presents with fever and urinary tract symptoms such as frequency, urgency, dysuria, incomplete voiding, and sometimes low back pain. the gland feels tender, swollen "boggy" and warm.
examine gently.
more than 80% infections are causes by E.coli, Enterococcus, and Proteus.
in men younger then 35 consider sexual transmission of Neisseria gonorrhea and chlamydia trachonatis

acute bacterial prostatitis

161

associated with recurrent urinary tract infections, usually from the same organism.
men may be asymptomatic or have symptoms of dysuria or mild pelvic pain.
prostate gland may feel normal, without tenderness or swelling
cultures of prostatic fluid show infection of E.coli usually

Chronic bacterial prostatitis

162

seen in 80% of symptomatic men who report obstructive or irritative symptoms on voiding but show no evidence of prostate or UTI.
PE findings are not predictable, but examination is needed to assess any prostate induration or asymmetry suggestive of carcinoma.

chronic pelvic pain syndrome

163

non-malignant enlargement of the prostate gland that increases with age, present in more tan 50% of men by 50 years.
symptoms arise both from smooth muscle contraction in the prostate and bladder neck and from compression of the urethra.
they may be irritative (urgency, frequency, nocturia), obstructive (decreased stream, incomplete emptying, straining), or both and are seen in more than one third of the men by 65 years.
affected gland may be normal in size, or may feel symmetrically enlarged, smooth, and firm through slightly elastic
there may be obliteration of the median sulcus and more notable protrusion into the rectal lumen

benign prostatic hyperplasia

164

suggested by an area of hardness in the gland.
a distinct hard nodule that alters the contours of the gland may or may not be palpable.
as it enlarges, it feels irregular and may extend beyond the confines of the gland.
the median sulcus may be obscured
hard areas in the prostate are not always malignant
may also result form prostatic stones, chronic inflammation and other conditions

cancer of the prostate

165

age of onset of menses

menarche

166

absence of menses for 12 consecutive months usually occurring between 48 and 55 years

menopause

167

bleeding ocurring 6 months or more after cessation of menses

postmenopausal bleeding

168

absence of menses

amenorrhea

169

pain with menses, often with bearing down, aching or cramping sensation in the lower abdomen or pelvis

dysmenorrhea

170

a cluster of emotional behavior and physical symptoms occurring 5 days before menses for 3 consecutive cycles
cessation of symptoms and signs within 4 days after onset of menses, and interference with daily activity

premenstrual syndrome (PMS)

171

bleeding between menses, includes infrequent, excessive, prolonged, or postmenopausal bleeding

abnormal uterine bleeding

172

when do girls usually begin to menstruate

between ages of 9 and 16

173

how long does it take for periods to get into a regular pattern

up to 1 year

174

how long does a flow usually last

3-7 days

175

vocab work for last menstrual cycle and then the term for the one before that

last menstrual period (LMP)
prior menstrual period (PMP)

176

results from prostaglandins production during the luteal phase of the menstrual cycle, when estrogen an progesterone levels decline

primary dysmenorrhea

177

causes of this are:
endometriosis, adenomyosis, pelvic inflammatory disease, endometrial polyps

causes of secondary dysmenorrhea

178

causes of this are:
low body weight (from malnutrition and anorexia nervosa, stress, chronic illness, hypothalamic-pituitary-ovarian dysfunction)

casues of secondary amenorrhea

179

_________ suggests cervical polyps or cancer, or in an older women, atrophic vaginitis

postcoital bleesing

180

what is the issue with giving estrogen to women in menopasue

helps with symptoms BUT increases other heath hazards

181

absence of EVER initiating periods

primary amenorrhea

182

cessation of periods after they have been established

(pregnancy, lactation, menopause: physiologic forms)

secondary amenorrhea

183

less than 21-day interval between menses

polymenorrhea

184

infrequent bleeding

oligomenorrhea

185

excessive flow

menorrhagia

186

intermenstrual bleeding

metorrhagia

187

occurs between ages of 48-55/
peaks at about 51
cessation of menses for 12 months
ovaries stop producing estriadol or progesterone and estrogen levels drop significantly
pituitary secretion of LH and FSH elevted

menopause

188

causes of postmenopausal bleeding

endometrial cancer
hormone replacement therapy
uterine and cervical polyps

189

The Gravida Para Notation

G stands for?
P stands for?

G: gravida, or total # of pregnancies
P: para, or outcomes of pregnancies. after P, you will often see the notations F (full term, P (premature, A (abortion), and L (living child)

190

pap screening ages

21-65

191

several screening guidelines

first screen: 21 yo

women ages 21-29: every 3 years with cytology

women ages 30-65: screen every 3 years with cytology if three consecutive negative screening tests, no history of invasive carcinoma from CIN 2 or CIN 3, and no risk factors such as HIV infection, immunocompromised, or exposure in utero to diethylstilbestrol or with cytology and HPV testing every 5 years.

women with hysterectomy: discontinue screening if hysterectomy for benign indictions and no prior history of high grade CIN.
if hysterectomy for CIN2, CIN3 or cancer and cervix removed, continue annual screening for 20 years after postsurveillance period.

women greater than 65: discontinue

192

when does the CDC recommend gardicil for routine vaccination in girls?

before their first sexual contact , usually ages 11 or 12 but possibly starting at age 9

193

how many dose series is gardacil

three dose series

194

what HPV does gardicil target

16, 18, 6, 11
and prevents most cervical cancer
vaccine also reduces risk of anogenital warts, invasive anogenital cancers, and vulvar and vaginal cancer

195

this is recommended for girls and women ages 13-26 if they have not had all three doses

catch up vaccination

196

what are the men recommendation for gardicil

boys and men ages 9 through 26, ideally before their first sexual contact, since it prevents genital warts.

197

which vaccine is NOT recommended for boys and men

bivalent vaccine which targets HPV 16 and 18

198

in women three symptoms merit special attention for ovarian cancer what are they?

1. abdominal distension
2. abdominal bloating
3. urinary frequency

199

family history
presence of the BRCA1 and BRCA 2 have a lifetime risk of 39% to 46% and 12 to 20%
over 90% of ovarian cancers appear to be random
risk is decreased by use of oral contraceptives, pregnancy, and history of breast feeding

risk factors for ovarian cancers

200

what about CA-125 testing

this is neither sensitive nor specific

201

mons pubis
labia majora and minora
urethral meatus, clitoris
vaginal introitus
perineum

external examination areas

202

vagina, vaginal walls
cervix
uterus, ovaries
pelvic muscles
rectovaginal walls

internal examination areas

203

avoids intercourse, douching, or use of vaginal suppositories for 24 to 48 hours before exam

empties bladder before exam

lies supine, with head and shoulders elevated, arms at sides or folded across chest to enhance eye contact and reduce tightening of abdominal muscles

tips for successful exam for the patient

204

obtains permission, selects chaperone

explains each step of exam in advance

drapes pt from midabdomen to knees , depresses drape between knees to provide eye contact with pt

avoids unexpected or sudden movements

chooses a speculum of correct size

warm speculum tap water

monitors comfort of examination by watching pt

uses excellent gentle technique, especially when inserting the speculum

tips for successful pelvic exam for examiner

205

which speculum is usually most common for a sexually active women

medium pedersen speculum

206

pt with small introitus should have which speculum

narrow bladed pedersen speculum

207

the graves specula are best suited for which type of women

parous women with vaginal prolapse

208

excoriations or itchy, small, red maculopapules
look for nits or lice at bases of pubic hairs

pediculosis pubis (lice or crabs)

209

check for this when menarche seems unduly late in relation to development of a girls breasts and pubic hair

imperforate hymen

210

plastic brush tipped with a broom-like fringe for collection of single specimen containing both squamous and columnar epithelial cells. rotate the tip of the brush in the cervical os, in a full clockwise direction, then place the sample directly into preservatives so that the laboratory can prepare the slide (liquid based cytology)

used to test for chlamydia and gonorrhea

cervical broom

211

place longer end of the scraper in the cervical os. press turn and scraping in a full circle, making sure to include transformation zone and squamocolumnar junction. smear on glass slide.

cervical scrape

212

roll it between your thumb and index finger, clockwise and counterclockwise. remove the brush and to pick up the slide you have set aside. smear slide with a brush using gentle painting motion to avoid destroying any cells.

ENDOCERVICAL BRUSH

213

cervical motion tenderness and or adnexal tenderness suggest

pelvic inflamm disease
ectopic preg
appendicitis

214

uterine enlargement suggests

pregnancy
uterine myomas (fibroids)
malignancy

215

nodules on uterine surface suggest

myomas

216

most common hernia in women

indirect inguinal hernia

and next being femoral hernia

217

small, firm, round cystic nodule in the labia suggests an epidermoid cyst. these are yellowish in color. look for dark punctum marking that blocked opening of the gland

epidermoid cyst

218

warty lesions on the labia and within the vestibule suggest condyloma acuminatum. these result from infection with human paillomavirus

venereal wart (condyloma acuminatum) genital warts

219

shallow, small, painful ulcers on red bases . initial infection may be extensive, as shown. recurrent infections usually are confined to a small local patch

genital herpes

220

a firm, painless ulcers

because most in women develop internally, they often go undetected

syphilitic chancre (syphilis chancre)

221

ulcerated or raised red vulvar lesion in an elderly women may indicate this

carcinoma of the vulva

222

slightly raised, round or oval, flat topped papules covered by a gray exudate suggest condylomata lata. these constitute one manifestation of secondary syphilis and are contagious

secondary syphilis (condyloma latum)

223

causes of this include trauma, gonococci anaerobes like bacteroides and peptostreptococci, and chlamydia trachomatis.
acutely, it appears as a tense, hot, very tender abscess.
look for pus coming out of the duct or erythema around the duct opening.
chronically a nontender cyst is felt.
it may be large or small

bartholin's gland infection

224

cause: trichomonas vaginalis (protazoan) no always acquired sexually

discharge: yellowish green or gray, possibly frothy, often profuse and pooled in the vaginal fornix, may be malodorous

other symp: pruritius, pain on urination, dyspareunia

vulva and vaginal mucosa: vestibule and labia minora may be reddened. vaginal mucosa may be diffusively reddened, with small red granular spots or petechiae in the posterior fornix. in mild cases the mucosa looks normal

lab eval: scan saline wet mount for tichonmonads

trichomnoal vaginitis

225

cause: Candida albicans (yeast) many factors predispose, including abx

discharge: white curdy, thin but usually thick, not as profuse as in trichomonal infection, no malodorous

other symptoms: pruruitus, vaginal soreness, pain on urination, dyspareunia

vulva and vaginal mucosa: the vulva and even the surrounding skin are inflamed and sometimes swollen. vaginal mucosa red, with white patches of discharge. mucosa may bleed when these patches are scraped off. mild cases: mucosa normal

lab eval: scan potassium hydroxide preparation for branching hyphae of candida

candidal vaginitis

226

cause: bacterial overgrowth prob from anaerobic bacteria, may be transmitted sexually

discharge: white or gray, thin, homogenous, malodorous, coats the vaginal walls, usually not profuse, may be minimal

other sym: unpleasant fishy or musty genital odor

vulva and vaginal mucosa: vulva usually normal. vaginal mucosa usually normal

Lab eval: scan saline wet mount for clue cells, sniff for fishy odor after apply KOH ("whiff test") vaginal secretions with PH>4.5

bacterial vaginosis

227

bulge of the upper two thirds of the anterior vaginal wall, together with the bladder above it. results from weakened supporting tissues

cystocele

228

herniation of the rectum into the posterior wall of the vagina, resulting from a weakness or defect in the endopelvic fascia.

rectocele

229

results from weakness of the supporting structures of the pelvic floor and is often associated with a cystocele and rectocele. in progressive stages the uterus becomes retroverted and descends down that vaginal canal to the outside

what are the 3 stages of this

prolapse of the uterus

first degree prolapse: the cervix is still well within the vagina

second degree: it is at the introitus

third degree: (procidentia) the cervix and vagina are outside the introitus

230

with increasing estrogen stimulation during adolescence all or part of the columnar epithelium is transformed into squamous epithelium by a process termed: metaplasia. this change may block the secretions of columnar epithelium and causes ______.

nabothian cysts

231

usually arises from the endocervical canal, becoming visible when it protrudes through the cervical os. it is bright red, soft, and rather fragile. when only the tip is seen, it cannot be differentiated clinically from a polyp originating in the endometrium. they are benign but may bleed.

cervical polyp

232

precancerous condition in which abnormal cell growth occurs on the surface lining of the cervix or endocervical canal, the opening between the uterus and the vagina. It is also called cervical intraepithelial neoplasia (CIN). Strongly associated with sexually transmitted human papillomavirus (HPV) infection, is most common in women under age 30 but can develop at any age.

usually causes no symptoms, and is most often discovered by a routine Pap test. The prognosis is excellent for women who receive appropriate follow-up and treatment. But women who go undiagnosed or who don't receive appropriate care are at higher risk of developing cervical cancer.

dysplasia

233

begins in an area of metaplasia. earliest stages it cannot be distinguished from a normal cervix. later stages: an extensive, irregular, cauliflowerlike growth may develop. early frequent intercourse, multiple partners, smoking, and infection with HPV increase the risk for this

carcinoma of the cervix

234

produces purulent yellow drainage from the cervical os, usually from chlamydia trachomatis, neisseria gonorrhoeae or herpes infection. these infections are sexually transmitted and may occur without symptoms or signs

mucopurulent cervicitis

235

very common benign uterine tumors. may be single or multiple and vary greatly in size, occasionally reaching massive proportions. they feel firm, irregular nodules in continuity with the uterine surface. occasionally, projecting laterally can be confused with an ovarian mass, a nodule projecting posterioly can be mistaken for a retroflexed uterus. project toward the endometiral cavity and are not palpable, although they may be suspected because of enlarged uterus

myomas of the uterus
FIBROIDS

236

may be detected as adnexal masses on one or both sides. later, they may extend out of the pelvis. tend to be smooth and compressible, tumors more solid and often nodular. uncomplicated ones are not usually tender

ovarian cysts

237

rests on exclusion of several endocrine disorders and 2 of the 3 features listed: absent or irregular menses; hyperandrogenism; and confirmation of polycystic ovaries on ultrasound. obesity and absence of lactation outside pregnancy or childbirth are addiotnal predictors

polycystic ovary syndrome

238

relatively rare and usually presents at an advanced stage/ symptoms include: pelvic pain, bloating, increased abdominal size, and urinary tracy symptoms, often there is a palpable ovarian mass. currently there are no reliable screening tests. a strong family history is an important risk facto but occurs in only 5% of cases

ovarian cancer

239

pregnancy spills blood into the periotoneal cavity, causing severe abdominal pain and tenderness. guarding and rebound tenderness are sometimes associated. a unilateral adnexal mass may be palpable, but tenderness often prevents its detection. faintness, syncope, nausea, vomiting, tachycardia, and shock may be present, reflecting the hemorrhage. there may be prior history of amenorrhea or other symptoms of pregnancy

ruptured tubal pregnancy

240

most often a result of sexually transmitted infection of the fallopian tubes or the tubes and ovaries. it is caused by neisseria gonorrhoeae, chlamydia trachomatis and other organisms. acute disease is associated with very tender, bilateral adnexal masses, although pain and muscle spasm usually make it impossible to delineate them. movement of the cervix produces pain. if not treated, a tubo-overian abscess or infertility may ensue.
infection of the fallopian tubes and ovaries may also follow delivery of a baby or gynecologic surgery

pelvic inflammatory disease

241

daughters of women who took this during pregnancy are at great increased risk for several abnormalities like:
1. columnar epithelium that covers most or all of the cervix
2. vaginal adenosis
3. circular collar or ridge of tissue, varying shapes, between the cervix and vagina. much less common is an otherwise rare carcinoma of the upper vagina

fetal exposure to DIETHYLSTILBESTROL (DES)

242

bilateral transverse cervical os

stellate cervical os

unilateral transverse cervical os

types of lacerations from delivery

p.572 in bates

243

normal shapes to the cervical os

1. oval
2. slitlike

244

when the entire anterior vaginal wall, toegther with the bladder and urethra, is involved in the bulge
a groove sometimes defines the border between urethrocele and cystocele but not always present

cystourethrocele

245

small, red benign tumor visible at the posterior part of the urethral meatus. occurs chiefly in postmenopausal women and usually causes no symptoms. sometimes a carcinoma of the urethra is mistaken for this. to check, palpate the uretha through the vagina for thickening, nodularity, or tenderness, and feel for inguinal lympadenopathy

urethral caruncle

246

forms a swollen red ring around the urethral meatus. usually occurs before menarche or after menopause. identify the urethral meatus at the center of the swelling to make this diagnosis

prolapse of the urethral mucosa

247

important topics for health promotion and counseling (7)

nutrition
weight gain
exercise
substance abuse
domestic violence
prenatal lab screenings
immunizations

248

Nutrition

what types of things should you do?

idk this is a learning objective but so vague

pay attention to inadequate nutrition as well as obesity

take a diet history, review examination and lab findings (BMI, hematorcrit for anemia), recommend a multivitamin (0.4 to 0.8 folic acid, 30 mg of iron, and a variety of other routine vitamins), caution the patient about food to avoid (unpasteruized dairy products, soft cheeses, raw eggs, delicatessen meats due to listeria and salmonella and toxoplasmosis, large about of vit A can be toxic, large sea going fish), make nutritional plan (increase intake by only 300 cal per day)

249

weight gain

again vague... idk just read the card hahaah

closely monitored during pregnancy

underweight: BMI 30

250

how many minutes of exercise shoudl a pregnant women engage in for most days of the week

30 min

251

should you initiate exercise in pregnancy

nahhh not really, do a special program if you do

aka get you buttttt to the gym and get into a routine so that when you do get pregnant you can just keep working out safely

252

after first trimester what should women not due relating to exercise?

exercise in the supine position (compresses the inferior vena cava)

253

substance abuse in pregnancy

again vague

universal screenings for this can help address these topics
try to stay judgement free with your approach

tobacco: low birth weights
alcohol: fetal alcohol syndrome: neurodevelopmental disorder
illicit drugs: dont use em
abuse of prescription drugs: ask about unusual narotics, stimulants, benzo, others

254

domestic abuse

universal screening of all women for domestic violence without regard to socioeconomic status

255

prenatal lab screenings in pregnancy

initial screening: what is part of it?


what about the timed screenings?

initial standard prenatal screening panal includes blood type and Rh, Ab screen, CBC, H and H, platelet count, rubella titer, syphilis test, hepatitis B surface Ag, HIV test, STI screen for gonorrhea and chlamydia, and UA with culture

timed screenings include: oral glucose tolerance test for gestational diabetes around 24 weeks, and a vaginal swab for group B streptococcus between 35 and 37 weeks

all other screening is independent on the patient

256

immunizations in pregnancy

should be up to date on tetanus.

flu vaccine indicated in second or third trimester during flu season

these are safe for pregnancy: pneumococcal, menigococcal, Hep B

NOT safe during pregnancy: MMR, polio, varicella, but women should have rubella titers drawn during pregnancy and be immunized after birth if found to be non immune.

Rho (D) immunoglobulin or RhoGAM should be given to all Rh-negative women at 28 weeks gestation and agin within 3 days of delivery to prevent sensitization to an rH positive infant

257

should take into consideration medical, nutritional, psychosocial, cultural and educational needs of patient and her family

plan of prenatal care

258

secreted in to maternal circulation after implantation, which occurs 6-12 days after ovulation

hCG = human chorionic gonadotropin

259

Best time to take Home pregnancy test?

1 week after missed period

260

what will urine HCG show

Urine hCG 20-50 int units/L verses serum hCG 5-10 int units/L

261

what do you factor in when choosing and at home pregnancy test

factor in duration of missed menses, need for accuracy, convenience and cost

262

what is the schedule for prenatal visits: what gestation week






How many weeks though do they say normal pregnancy is?

1st visit – usually at ~8 weeks gestation

Every 4 weeks until 28 weeks gestation

Every 2 weeks until 36 weeks gestation

Weekly from 36 weeks gestation until delivery


40 weeks normally
38-42 weeks

263

what is frequency of follow up determined by

Frequency of follow-up visits determined by individual needs of woman and her risks (more frequent visits – “high risk” due to medical and/or obstetric history, extremes of reproductive age, multiple gestation)

264

Enable health care provider to:
Assess well-being of the woman and her fetus

Provide ongoing, timely and relevant prenatal education

Complete recommended health screening studies and review results

Detect medical and psychosocial complications and institute indicated interventions

Reassure the woman

all the goals of the prenatal visits

265

if someone thinks they're pregnant you get a hitory: what are the three things that are asked in this history

1. LMP/amenorrhea

2. Contraception/sexual history

3. Symptoms of pregnancy

266

what are some symptoms of pregnancy

morning sickness
breast tenderness/fullness urinary frequency
fatigue

267

Personal & demographic info (i.e., occupation)
Past obstetrical history
Personal and family medical history
Past surgical history
Genetic history
Menstrual and gynecological history
Current pregnancy history
Psychosocial information

more history taking....


i know you could recognize these on multiple choice!

268

Calculating estimated due date

measuring crown to rump length

269

Gravida para

G = gravida (# total pregnancies)
P = para (# delivered pregnancies)

270

what can parity further break down to

T= term deliveries
P = preterm deliveries
A = abortions (spontaneous & therapeutic)
L = living children

“32-year-old G3P1102 at 18 weeks gestation determined by LMP presents…”

271

Physical exam

Vital signs (weight, height, BMI, BP)

General

HEENT (including dentition)

Neck (including thyroid)

Breasts – fuller, tender due to ↑ vascularity & glandular hyperplasia, areola darkens, +/- colostrum

Heart

Lungs

Abdomen

Extremities

Skin

Lymph nodes

Pelvic (including speculum & bimanual exam)

Rectum

physical exam of the first prenatal visit

272

PART OF PELVIC EXAM
chadwicks sign

bluish discoloration of cervix due to increased blood flow

273

uterus soft, globular

plum: at how many weeks

orange: how many weeks

grapefruit: how many weeks

plum: 6-8 weeks gestation

orange: 8-10 weeks

grapefruit: 10-12 weeks

274

pre-pregnancy weight related to what your weight gain should be!

underweight (BMI)

275

where does the weight go?

how much in the:
breasts
baby
placenta
uterus
amniotic fluid

your blood
your protein and fat storage
your body fluids

total weight gain:

breasts: 1-2 lb
baby: 6-8 lbs
placenta: 1-2lbs
uterus: 1-2 lbs
amniotic fluid: 2-3 lbs

your blood: 3-4 lbs
your protein and fat storage: 8-10lbs
your body fluids: 3-4 lbs

total weight gain: 25-35 lbs

276

nutrition counseling from the ppt and not bates like above

2 recommendations....

MVI once daily (w/ 0.4-0.8 mg of FOLIC ACID)

Avoid certain fish, cheese, raw milk & meat

277

exercise counseling from the ppt and not bates like above

2 recommendations....

Avoid supine position in 3rd trimester (Supine position – puts pressure on inferior vena cava-- this can lead to decreased floor to placenta to baby)

Avoid contact sports or risky activities

278

substance abuse counseling from the ppt and not bates like above

what is goal

Abstinence is goal

279

domestic violence
counseling from the ppt and not bates like above

Universal screening (abuse increased in pregnancy)

280

immunizations counseling from the ppt and not bates like above

Flu shot (NOT NASAL), Tdap, RhoGAM

If rubella nonimmune, vaccinate AFTER pregnancy

281

what do you always have to discuss with genetic screening

always dicuss informed consent

282

most commongenetic disorder screened for ( 5)

Down syndrome (trisomy 21)
Hemoglobinopathies
Cystic fibrosis
Fragile X
Ashkenazi Jewish population

283

when is Fetal cfDNA in maternal blood drawn


and what id cfDNA?

drawn at ≥9 weeks of gestation

cfDNA = cell-free DNA, checks for trisomy 21, 18, 13 & sex chromosome aneuploidies

284

when is Chorionic villus sampling (CVS) drawn

10-14 weeks gestation

285

when do you do Amniocentesis

15-17 weeks gestation

286

bp changes during pregnancy

MORE TO COME AFTER LECTURE....okay idk what she wants us to know from this slide...

SLIDE 16

287

what does the urine dipstick find: 3 findings

Protein
Glucose
Ketones

288

Physical exam:

Vital signs (weight, BP)

Urine dipstick, if indicated

Fundal height (cm)

Fetal presentation

FHR and fetal movement

Cervix exam (dilation, effacement, station)

LE edema

subsequent prenatal visits

289

First trimester H&P
history

physical exam

labs/imaging

History:
Vaginal bleeding

Physical exam:
Vital signs
Head-to-toe exam including pelvic
FHR (start @ 10-12 wks)

Labs/Imaging : GET ALL OF THESE LABS AND ULTRASOUNDS AT THE FIRST PRENATAL VISIT!!!!
STI screening – gonorrhea, chlamydia, HIV, syphilis & hepatitis B

Pap, if indicated

Labs: genetic screening, CBC, blood type and Rh, antibody screen, rubella & varicella immunity, UC

At-risk:
TSH (if she has thyroid issue need to get this),
hgbA1c (gesttational diabetes around 26 weeks but if she is obese and she has risk factors for diabetes want to do this right at the first visit),
HCV (hoffman says she has a low threshold for when to get hep C testing) ,
HSV (if they have genital herpes needs to be put on suppressive therapy at 36 weeks so she can deliver vaginally!)

Ultrasound(transvaginal)

-heart beat at 10 week gestation

290

this test checks for asymptomatic bacteriuria and treat if >100,000 CFU

UC

291

Rh-negative mother who delivers a Rh-positive baby are at risk of developing


Rh-positive babies of these mothers are at risk of developing

antibodies (“sensitized”).



hemolytic anemia

292

when do you screen for RH factor

first visit

293

if mother is RH negative

check antibody screen & give RhoGAM (immune globin) at 26-28 weeks gestation & after delivery

294

Second trimester H&P

history:
pE:
labs/imaging:

History:
Fetal movement (“quickening” ~18-22 wks, external palpation ~24 wks+/28 )

Vaginal bleeding

Uterine contractions (PTL)



Physical exam:
Vital signs
Fundal height
FHR


Labs/Imaging:
1-hr GDM screen (24-28 wks)
--> 1 hour glucose test is screening
--> 3 hours glucose test is diagnostic for gestational diabetes

CBC (√ hgb & platelets)

Rhogam if Rh- (28 wks)

Ultrasound – √ anatomy

295

how do you measure the fundal height?
from where to where?

when do you start doing this?

where do the lines start and stop on the belly

Measure length (cm) from pubic symphysis to fundus

Start @ 20 weeks gestation



start down by pubic symphasis at 12-14 weeks then 16 weeks then belly button is 20 weeks then 24 weeks then 28 weeks
then 32 weeks and 36 weeks is right under the breasts

slide 22

296

what is a normal fetal HR?

Normal FHR = 120-160 beats per minute

297

Third trimester H&P
history
PE
labs/imaging

History:
Fetal movement
Vaginal bleeding
Uterine contractions (labor)
*****Leaking*****(could have risk for infection)
*****Preeclampsia s/s******


Physical exam:
Vital signs
Fundal height
FHR
*****Fetal presentation******
******Cervix exam*********


Labs/Imaging:
Group B strep (36 wks)
Hgb (hemoglobin) (36 wks)

298

three types of fetal breech presentation


wheat is the name of the maneuver

NOT RECOMMENDED TO DELIVER BREECH IF WE KNOW THIS!

complete breech: both legs curled up
incomplete breech: one leg up straight other leg curled
frank breech: both legs straight up

DEPENDING ON THE BREECH POSITION DEPENDS ON HOW WELL THE MANEUVER WILL WORK TO MOVE THEM AROUND
external cephalic version (ECV) is the name of the maneuver to move them out of breech position

299

vertex presentation

head first

300

leopold maneuvers
(4)

4 maneuvers used to determine fetal position, beginning in 2nd trimester, accuracy greatest after 36 weeks gestation

1st maneuver = determine what fetal part is located at the fundus or “upper fetal pole”

2nd maneuver = feel for fetal back while placing hands on sides of maternal abdomen

3rd maneuver = palpate presenting fetal part at the “lower fetal pole” distinguishing head from buttock

4th maneuver = check flexion/extension of the fetal head

301

cervix exam: 5 different things you are examining

1. Dilation (0-10cm)
2. Effacement (0-100%)
3. Fetal station (-3 to +2)
4. Consistency (firm, medium, soft)
5. Position (posterior, middle, anterior)

302

What is cervical effacement?

steps of effacement and dilation... how they are related?

cervical effacement: length of the cervix: so when babies head pushes down the length of the cervix shortens... and this occurs at the same time as the dilation.

1. cervix not effaced (long cervix) or dilated

2. cervix is 50% effaced and not dilated

3. cervix is 100% (compltly thinned out cervix) effaced and dilated 3cm

4. cervix is fully dialted to 10 cm

303

Fetal station
what is this?

on either side of cervix you can feel pelvic ring.. when you feel top of babies head and it is right at ring that is 0 station
if it is 3 cm above the ring it is at -3 station
if babies head is pushing through pelvic ring then going into positive cm.

-3 to +3

0 station midway between ischial spines

slide 31 has a good picture

304

Heartburn
Urinary frequency
Vaginal discharge
Constipation
Hemorrhoids
Backache
Nausea and/or vomiting
Breast tenderness/tingling
Fatigue
Lower abdominal pain
Abdominal striae
Uterine contractions
Loss of mucous plug
Edema

Common complaints in pregnancy

305

HEENT:
facial edema in preeclampsia
conjunctival pallor in anemia
nasal congestion & nose bleeds
gingival enlargement with bleeding
dentition

Neck:
modest symmetric thyroid enlargement normal

Heart:
PMI – upward and leftward (4th intercostal space)
venous hum (due to ↑ blood flow thru normal vessels)

Lungs:
elevated diaphragm with percussion

Breasts:
marked venous pattern, darkened areolae, and prominent Montgomery’s glands
nodularity, possible colostrum

Abdomen:
striae and linea nigra
uterine contractility – PTL/labor vs BHC
fundal height, FHR
round ligament pain seen which normally tries to hold uterus in place

GU:
relaxation of introitus and enlargement of labia & clitoris
labial varicosities
cystoceles, rectoceles and uterine prolapse
speculum – cervix friable and leukorrhea may be normal
bimanual – uterus (contour, size)
anus – hemorrhoids

Extremities:
varicose veins
dependent vs non-dependent edema and symmetry

Skin/hair :
acne
hair changes
melasma and hirsutism (mild – on face, abdomen and extremities)

Physical exam findings in pregnancy

306

when is the postnatal visit performed?
what is one of the exams you have done and why?
what do you offer to your patient and what are some examples of that?

Performed at ~6 weeks postpartum

Pelvic exam – confirm uterus is normal size

Offer support/counseling:
Menses resumes
Family planning
Screen for post partum depression
Breastfeeding/return to work
Sexual activity
Weight loss guide
Stress management – relationship, parenting, financial, job, body image

307

if fundal weight is 4 cm more than expected consider

multiple gestations
large fetus
extra amniotic fluid
uterine leiomyoma

308

cervix position is either

posterior, middle or anterior

309

when do you start birth control again after pregnancy

6 weeks