Repro LOs Flashcards

Question 1

Q

1. Document clinical findings of the breast using appropriate anatomical landmarks (eg, upper outer quadrant) and/or face of a clock (eg, 3 o’clock) with the distance from the nipple in centimeters (p 406)

Answer

A

4 Quadrants
Fifth Area: Axillary Tail of Breast Tissue (“tail of Spence”
“Breast pendulous w/ diffuse fibrocystic changes. Single, firm 1x1cm mass, mobile and non-tender noted in right breast upper outer quadrants at 11 o’clock, ~2cm from nipple”

Question 2

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning breast symptoms:

a. Breast lump or mass (p 430)
- Breast Cyst

Answer

A

Age: 30-50
- Regress post-menopause
  - (expect w/estrogen rx)
Number: 1 or more
Shape: Round
Consisitency: Soft to Firm; elastic
Delimitation: Well-Delinated
Mobility: Mobile
Tenderness: often Tender
Retraction: Absent

Question 3

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning breast symptoms:

a. Breast lump or mass (p 430)
- Fibroadenoma

Answer

A

Age: 15-25
- Usually puberty/young adult
- Up to age 55
Number: 1 or more
Shape: Round, disc-like, lobular
Consisitency: May be soft, usually firm
Delimitation: Well-Delinated
Mobility: Very Mobile
Tenderness: Usually Non-Tender
Retraction: Absent

Question 4

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning breast symptoms:

a. Breast lump or mass (p 430)
- Breast Cancer

Answer

A

Age: 30-90
- More common >50
Number:Usualy single
- May have other nodules
Shape: Irregular or Stellate
Consisitency: Firm or Hard
Delimitation: Not clearly Delineated
Mobility: May be fixed to skin/underlying tissues
Tenderness: Usually Non-tender
Retraction: May be Present

Question 5

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning breast symptoms:

Breast Cancer
- Retraction Signs (p 431)

Answer

A

Advancing Breast CA causes:

Fibrosis (Scar Tissue)
- Tissue shortens =’s
  - dimpling
  - changes in contour
  - retration/nipple deviation

Other causes of retraction:

Fat Necrosis
Mammary Duct Ectasia

Question 6

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning breast symptoms:

Breast Cancer
- Abnormal Contours (p 431)

Answer

A

Look for:

Variation in normal convexity of each breast
Compare both breasts

Use Special Positioning

Question 7

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning breast symptoms:

Breast Cancer
- Skin Dimpling (p 431)

Answer

A

Look for when:

Arm is at Rest
Special Positioning
Moving & Compressing Breast

Question 8

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning breast symptoms:

Breast Cancer
- Nipple Retraction & Deviation

Answer

A

Retracted Nipple:

Pulled inward
Flattened
May be:
- Broadened
- Feel Thickened

If Asymmetric Involvement:

May deviate or point in different direction
- Typically toward the CA

Question 9

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning breast symptoms:

Breast Cancer
- Edema of the Skin (p 431)

Answer

A

Produced by lymphatic blockage

Appears as:

Thickened skin
Enlarged Pores
- “peau d’orange sign”

(Often) first seen in lower breast or areolar region

Question 10

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning breast symptoms:

Breast Cancer
- Paget’s Disease of the Nipple (p431)

Answer

A

Uncommon form of Breast CA

Starts:

Scaly
Eczema-like lesion
May: Weep, crust, erode
May have: Breast Mass

Suspect if: Dermatitis of nipple or areola

Can present with: Invasive Breast CA, or DCIS

Question 11

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning breast symptoms:

b. Breast Pain or Discomfort (p408)

Answer

A

Ask about breasts during hx or during PE

Ask: Any discomfort, pain, or lumps in breasts?

~50% of women have palpable lumps or nodularity; pre-menstrual enlargement & tenderness are common

Wide ranges of changes in Breast Tissue & Sensation:

Cyclic Swelling & Nodularity
Distinct Lumps/Masses

Question 12

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning breast symptoms:

c. Nipple Discharge
- i. Galactorrhea (p 409)
  - Pt. 1

Answer

A

Ask about: Discharge from Nipples
1. When does it occur?
  1. Compression? Spontaneous?

Physiologic Hypersecretion seen in:

Pregnancy
Lactation
Chest Wall Stimulation
Sleep
Stress

Question 13

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning breast symptoms:

c. Nipple Discharge
- i. Galactorrhea (p 409)
  - Pt. 2

Answer

A

If spontaneous discharge:
1. Color?
  1. Milky? Brown? Green? Blood?!
2. Consistency?
3. Quantitiy?
Unilateral or Bilateral Discharge?

Question 14

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning breast symptoms:

c. Nipple Discharge
- i. Galactorrhea (p 409)
  - Pt. 3

Answer

A

Glactorrhea:

Inappropriate discharge of milk-containing fluid
Abnormal if:
- occurs 6 or more months post-childbirth or cessation of breast feeding

Question 15

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

a. Lifetime risk of developing invasive breast cancer (p 410)

Answer

A

Most common cause of CA in women Worldwide!*
>10% of CA in women*
2^nd leading cause of CA death in women*

In US:

12% or 1 in 8 lifetime risk

95% of new cases occur in women 40+

Probability increases by decade

Question 16

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

b. Factors that increase relative risk of breast cancer (p 411-412)

***MOST IMPORTANT RISK FACTOR!!***

Answer

A

Most Important Risk Factor

AGE

Question 17

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

b. Factors that increase relative risk of breast cancer (p 411-412)

*Modifiable Risk Factors*

Answer

A

Modifiable Risk Factors

Post-menopausal obesity
Use of HRT
Alcohol use
Physcial Inactivity
Breast-Feeding choice
Contraceptive choice
Radiation Exposure

Question 18

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

b. Factors that increase relative risk of breast cancer (p 411-412)

*Non-Modifiable Risk Factors*

Answer

A

Non-Modifiable Risk Factors:

Family History
Breast Tissue Density
Proliferative Lesions w/ Atypia on Breast Bx
Duration of Unopposed Estrogen Exposure (earlly menarche/late menopause)
Age of First Full-Term Pregnancy

Question 19

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

b. Factors that increase relative risk of breast cancer (p 411-412)

*Nonetheless….. Basically Anyone can get Breast CA***

Answer

A

“Over 50% of Women w/ Breast CA have no Familial or Reproductive Risk Factors”….

Question 20

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

b. Factors that increase relative risk of breast cancer (p 411-412)

Male Breast Cancer

Answer

A

Male Breast CA:
- 1% of all Breast CA
- Peaks ~71yo
Risk Factors:
- BRCA2 Mutations
- Obesity
- Family Hx of M/F Breast CA
- Testicular D/Os
- Work Exposures!

Question 21

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

C. Breast cancer risk assessment tools (eg, Gail model; p 412-413)

Answer

A

Risk Assessment Tools
Gail & Claus:
- Estimate Absolute Lifetime Risk of Breast CA
- Most commonly used
- Assess based on large population data
- DO NOT: Predict dz in Indivdual
BRCAPRO Model:
- Predicts Risk of BRCA 1 or BRCA2

NO Single Model Addresses ALL known RFs or Includes all of Genetic Details of Personal/Family Hx

Question 22

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

C. Breast cancer risk assessment tools (eg, Gail model; p 412-413)

- Gail Model -

Answer

A

Gail Model:
- 5-year Lifetime Estimates of
  - Risk for Invasive Breast CA
- Incorporates:
  - Age
  - Race
  - 1st Degree Relatives w/ BreastCA
  - Previous Breast Bx
  - Hyperplasia presence
  - First Menarche
  - First Delivery
- Best For:
  - Ages 50+
  - w/ no Family Hx, or 1 first degree relative
  - Annual Screening Mammograms
- DONT Use for:
  - Hx of Breast CA or Radiation Exposure
  - <35yo
- DOES NOT:
  - Determine Risk for Non-Invasive Breast CA
  - No Paternal Hx, or 2nd Degree Relatives
Includes Breast Density….but is getting more Difficult to Use!

Question 23

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

C. Breast cancer risk assessment tools (eg, Gail model; p 412-413)

- Claus Model -

Answer

A

Claus Model:
- Assess risk for High-Risk Women
- Incorporates:
  - Family Hx
    - M/F 1st & 2nd degree relatives
    - Includes Age @ Onset
  - Women’s Current Age
- Best for:
  - Individuals w/no more than
    - 2 1st/2nd degree relatives w/Breast CA
- Expanded Version:
  - Family Members w/ Ovarian CA
- DOES NOT Include:
  - Person
  - Lifestyle
  - Reproductive Risk Factors

Downside: Has been discrepancies btwn published tables & computerized versions

Question 24

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

C. Breast cancer risk assessment tools (eg, Gail model; p 412-413)

- BRCAPRO Model -

Answer

A

BRCAPRO Model:
- High Risk Women
- Assess risk of:
  - BRCA 1 & BRCA 2 mutations
- Incorporates:
  - Published BRCA 1 & 2 mutation freq.
  - Cancer penetration in affected carriers
  - Age of Onset in 1/2nd degree M/F relatives
- DOES NOT Include:
  - Non-Hereditary RFs

Question 25

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

D. Family history – BRCA1 and BRCA2 mutations (p 413-414)

Answer

A

Ask about Family Hx starting ~age 20
Pattern of Breast/Ovarian CA = suspicious
Autosomal Dominant Genetic Mutations
Look for:
- - family hx
    - Age <50yo @ dx
    - Breast CA in 2+ ppl of same lineage (paternal or maternal)
    - Multiple primary or ovarian tumors in 1 person
    - Breast CA in male relative
    - Ashkenazi Jewish Ancestry
    - Family Member w/ predisposing gene

Question 26

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

D. Family history – BRCA1 and BRCA2 mutations (p 413-414)

Answer

A

BRCA 1 & 2 gene mutations =
- 1/2 of Familial Breast CAs
- & Increased Risk for Ovarian CA
Mutations in <1% of population
- but 5% of Breast CA!!
BRCA 1 = risk of Breast CA = 57%
BRCA 2 = risk of Breast CA = 49 %
- (by age of 70)

Question 27

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

D. Family history – BRCA1 and BRCA2 mutations (p 413-414)

Answer

A

If suspect Familial History:

BRCAPRO Calculator
Coduct Genetic Testing
Consider MRI screen (in addition to Mammogram)
Make appropriate Specialty Referrals

Question 28

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

E. Screening mammography recommendations including frequency (p 415)

Answer

A

Step 1: Screen all women for Risk Factors!
- (via tables & models)
- Ask about Ovarian CA
Controversy amoung groups on when to start screening….
- Risk vs. Benefit Reviews

Question 29

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

E. Screening mammography recommendations including frequency (p 415)

*Ages 40 - 50*

Answer

A

Mammography (Women ages 40-50)
- Controversial
- Lower Sensitivity & Specificity
  - related to: Heterogenous Estrogen pre-menopausal exposure
- High ### of False Positives (~10%)
  - Resulting in unneccasry invasive procedures

Question 30

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

E. Screening mammography recommendations including frequency (p 415)

* Ages 40-50 *

Answer

A

Mammography (Women ages 40-50)
- USPSTF Recommends:
  - Under age 50:
    - “Individual Decision Making” versus Routine Biennial Screening
    - Take patient context into account
- American College of Physicians agree
- v. AMA & ACS Recommend:
  - Annual Mammorgraphy beginning at Age 40!

Question 31

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

E. Screening mammography recommendations including frequency (p 415)

* Ages 50-74 *

Answer

A

Mammography (Women ages 50-74 years)
- Performs best in this age group!
  - Sensitive (77-95%)
  - Specific (94-97%)
- USPSTF Recommends (2009):
  - Ages 50-74
    - Biennial Screening for women
      - Reduces harms of mammography screening by 1/2
      - Preserves 80% of benefits of annual screening
      - Averts 40% of False +’s
      - Similar diagnostic & 10yr survival rates as annual
v. AMA & ACS Recommend:
- Annual Mammorgraphy
WHO recommends:
- every 1-2 years

Question 32

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

E. Screening mammography recommendations including frequency (p 415)

Answer

A

“Digital Mammography performs better in Younger Women & Women w/ Higher Breast Density”

Question 33

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

E. Screening mammography recommendations including frequency (p 415)

*Ages 75+*

Answer

A

Mammography in Women ages 75+
- USPSTF, ACS, AGS:
  - Support “Individualized Decisions” re: continued screening
    - Depending on co-exisiting conditions/5-yr survivial
USPSTF concludes:
- 3 Factors that alter benefits of screening for this age group:
  - Benefits occur several years later
  - CA more likely to be Estrogen-Receptor + =’s easily treatable
  - More likely to die of other conditions
- No women aged 75+ have been included in trials
- “Data insuffient to make firm recommendation”

Question 34

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

F. Clinical breast examination including frequency (CBE; p 416)

Answer

A

2009 - USPSTF
- “CBE is Insufficient for Establishing Balance of Benefit v. Harms”
  - WHO agrees
vs. ACS recommends:
- CBE q 3 years for 20-39yo
- Annual (before mammo) @ 40+yo
- “CBE = education for patient, even if time consuming (10+minutes)
ACOG = Recommends CBE
- Wants Standardization
  *

Question 35

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

F. Clinical breast examination including frequency (CBE; p 416)

Answer

A

Sensitivity of CBE: 40%
Specificity of CBE: 88-99%
Very influenced by Technique of Examiner!*

Question 36

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

G. Breast self-examination including frequency (BSE; p 416, 426-427)

Answer

A

USPSTF (2009)
- Recommended teaching AGAINST teaching BSE
- Evidence:
  - Does NOT reduce Mortality
  - May lead to more bengign biopsies (bx)
ACS
- Advocates BSEs w/ Mammography & CBE
  - Promote Health Awareness
  - Advises Clinicians to Teach & Review Technique
Some studies:
- “Women performing BSE = more likely to pursue mammography”
- May benefit high risk women

Question 37

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

G. Breast self-examination including frequency (BSE; p 416, 426-427)

Answer

A

Sensitivity: 12-41%
Some say: Duration & Frequency = inadequate

Question 38

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

G. Breast self-examination including frequency (BSE; p 416, 426-427)

Answer

A

Monthly BSE 5 to 7 days after menses onset
- can be taught to women starting at age 20

Question 39

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

G. Breast self-examination including frequency (BSE; p 416, 426-427)

**Instructions for BSE**

Answer

A

Inexpensive
High proportion of breast masses are detected by individual examining own breasts
Promotes Stronger Health Awareness
More active self-care
Use w/CBE & Mammographies
Best timed 5-7 days after Menses

Question 40

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

G. Breast self-examination including frequency (BSE; p 416, 426-427)

**Instructions for BSE - Lying Supine**

Answer

A

See page 427 of Bates

Lying Supine
1. Pillow & Arm behind head of breast you’re examining
2. Use finger pads
3. Press w/ variations of pressure
4. Press in Strip, Circle, or Wedge pattern (cover all tissue)
5. Don’t forget the axilla region
6. Do both breasts
Contact Clinician if any abnormalities

Question 41

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

G. Breast self-examination including frequency (BSE; p 416, 426-427)

**Instructions for BSE - Standing**

Answer

A

See page 427 of Bates

Standing:
1. Hands press firmly on hips
  1. Inspect
2. Examine each underarm while sitting up or standing & arm slightly raised

Question 42

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

H. Role of diagnostic imaging for further evaluation of a breast mass/symptom including:

i. Breast ultrasound

Answer

A

Minimally Invasive& Inexpensive

Solid mass? Fluid-filled cyst?
Can use w/ dense breast tissue
Evaluation and characterization of palpable masses and other breast related signs and/or symptoms
Initial imaging evaluation of palpable masses in women under 30 years of age who are not at high risk for development of breast cancer, and in lactating and pregnant women.

Question 43

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

H. Role of diagnostic imaging for further evaluation of a breast mass/symptom including:

ii. Mammography

Answer

A

Shown to reduce mortality
Microcalcifications
Not as accurate when assessing dense breast tissue
Screening tool to detect early breast cancer in women experiencing no symptoms, or symptomatic women
Diagnostic mammography: Done after an abnormal screening mammogram; evaluates area of concern on the screening exam
See previous LOs for Indications

Question 44

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

H. Role of diagnostic imaging for further evaluation of a breast mass/symptom including:

iii. Breast MRI (p417)

Answer

A

Focused on high-risk populations
Sensitivity: 77% (double mammograms)
- 2x amount of False Positives
ACS Recommends:
- If above 20% = High Risk
  - ANNUAL screening w/ MRI & Mammogram
- If 15-20% = Moderate Risk
  - Discuss option w/ Provider

Question 45

Q

3.Analyze and assess female patients’ risk of breast cancer by gaining a general understanding of each of the following:

H. Role of diagnostic imaging for further evaluation of a breast mass/symptom including:

iii. Breast MRI (p417)

Answer

A

USPSTF, 2009:
- Evidence is Insufficient to determine utility of MRI for screening
- Expertise varies across locations, so consider this

Question 46

Q

4. Understand and practice the techniques for examination of the breasts and axillae (p 419-426)

Refer to Clin Assess Class & Pett Center Skills

Answer

A

ID Breast Masses
Educate Patient
- Teach techniques
- Standardized Approach
Inspect - Appearnce, size, symmetry…
Palpate - Supine; fingerpads, systematic
- Consistency, tenderness, nodules

Question 47

Q

4. Understand and practice the techniques for examination of the breasts and axillae (p 419-426)

Refer to Clin Assess Class & Pett Center Skills

Answer

A

Male Breast:
- Brief, but Important
- Nipple & Areola for nodules, edema, ulcers
- Palpate
- Gynecomastia present?
  - Due to imbalance of estrogen & androgren
  - Can be drug-related

Question 48

Q

4. Understand and practice the techniques for examination of the breasts and axillae (p 419-426)

Refer to Clin Assess Class & Pett Center Skills

Answer

A

The Axilla
- Don’t forget to check out the Nodes around here
- Sitting up = Preferable!!

Question 49

Q

5. Understand common indications and advantages/disadvantages of each of the following diagnostic laboratory and/or imaging tests used to further evaluate breast and/or nipple concerns;

Breast biopsy – FNA cytology or core biopsy
Information NOT from Bates*

Answer

A

Gold Standard for Dx of Breast CA:
- FNA
- Core-Needle*
- Open Excision*
  - * = 2 best dx pathologically
  - Core Needle: More reliable than Cytology!
Use in Correlation with:
- Exam
- Imaging
Evaluates Microcalcifications

Triple Test for Dx: PE, Mammo, FNA!

Question 50

Q

5. Understand common indications and advantages/disadvantages of each of the following diagnostic laboratory and/or imaging tests used to further evaluate breast and/or nipple concerns;

Breast ultrasound

Answer

A

See LO 3h

Pros: Easy to get, inexpensive, not invasive

Cons: Does not decrease Mortality

Question 51

Q

5. Understand common indications and advantages/disadvantages of each of the following diagnostic laboratory and/or imaging tests used to further evaluate breast and/or nipple concerns;

Mammography

Answer

A

See LO 3h

Pros: Early Diagnosis

Cons: Lots of False Positives, Over-Diagnosis

Question 52

Q

5. Understand common indications and advantages/disadvantages of each of the following diagnostic laboratory and/or imaging tests used to further evaluate breast and/or nipple concerns;

Breast MRI (contrast-enhanced)

Answer

A

See LO 3h

Great in High-Risk Populations

Question 53

Q

5. Understand common indications and advantages/disadvantages of each of the following diagnostic laboratory and/or imaging tests used to further evaluate breast and/or nipple concerns;

Cytology of nipple discharge
Information NOT from Bates*

Answer

A

Helpful when no palpable or mammographic abnormality is identified;
- otherwise, a galactography, a fine needle aspiration (FNA) or excisional biopsy is usually performed.
The sensitivity ranges from 40 to 60%.
- It can not be used as a screening test for breast cancer because a discharge can be obtained only in few asymptomatic women.
Bloody or unilateral discharge = usually no bueno!
Poor Accuracy
- May adversely impact patient care.
A benign nipple discharge cytologic diagnosis does not exclude malignancy
False–positive/suspicious rate requires confirmation of a malignant nipple discharge prior to definitive patient management.

Question 54

Q

1. Understand the course, presentation, physical examination techniques to differentiate hernias in the groin including each of the following (p 521, 538);

a. Indirect inguinal hernia

Answer

A

Frequency: Most Common
Age: All Ages
Gender: M/F
Point of Origin:Develop @ Internal Inguinal Ring
- Above Inguinal Ligament (near midpoint)
Course: Into Scrotum
- Comes down canal & “taps” fingertip

Question 55

Q

1. Understand the course, presentation, physical examination techniques to differentiate hernias in the groin including each of the following (p 521, 538);

b. Direct inguinal hernia

Answer

A

Frequency: Less Common
Age/Gender: Men >40yo; rare in women
Point of Origin: Near External Inguinal Ring
- Above Inguinal Ligament (pubic tubercle)
Course: Rarely into Scrotum
- Bulges Anteriorly & Pushes Side of Finger Forward

Often due to weakness in Floor & Assc. w/ strain/heavy lifting.

Question 56

Q

1. Understand the course, presentation, physical examination techniques to differentiate hernias in the groin including each of the following (p 521, 538);

c. Femoral Hernia

Answer

A

Frequency: Least Common
Age/Gender: Women > Men
Point of Origin: More lateral than Inguinal
- Below Inguinal Ligament
Course: Never into Scrotum
- Inguinal canal = empty

More likely Emergent: Bowel Incarceration/Strangulation

Question 57

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning symptoms regarding male genitalia and hernias:

a. Erectile Dysfunction

Answer

A

May be Psychogenic
- Esp. if early morning Erection present
Decreased testosterone
Decreased blood flow in hypogastric arterial system
Impaired neural innervation
DM

Ask: Can you achieve and maintain an erection?

Explore: Are there times when erection normal? Outside contributing factors.

Question 58

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning symptoms regarding male genitalia and hernias:

b. Premature Ejaculation

Answer

A

Common
- Esp. in Young Men
Less Common:
- Reduced, absent ejaculation (middle age/older men)
Possible Causes:
- Meds
- Surgery
- Neuro
- Lack of Androgen
Lack of Orgasm w/ ejaculation = usually psychogenic
Review: Frequency & setting of problem

Question 59

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning symptoms regarding male genitalia and hernias:

c. Penile Discharge or Lesions

i. Peyronie’s Dz

Answer

A

Palpable
Non-Tender
Hard Plaques
- Just Beneath the Skin
- Usually along Dorsum of penis
C/O:
- Crooked & Painful Erections

Question 60

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning symptoms regarding male genitalia and hernias:

c. Penile Discharge or Lesions

i. Hypospadias

Answer

A

Congenital Displacement of Urethral Meatus to Inferior Surface of Penis
Groove present from actual location to normal on tip of glans

Question 61

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning symptoms regarding male genitalia and hernias:

c. Penile Discharge or Lesions

i. Carcinoma of the Penis

Answer

A

Indurated Nodule or Ulder
- Non-tender (usually)
Almost completely Limited to:
- Uncircumsized men
  - Masked by Prepuce
Suspicious of:
- Persistent Penile Sore!

Question 62

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning symptoms regarding male genitalia and hernias:

d. Scrotal Pain, Swelling, or Lesions

i. Scrotal Edema

Answer

A

Pitting edema may may scrotal skin taut
Seen in:
- HF or Nephrotic Syn

Question 63

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning symptoms regarding male genitalia and hernias:

d. Scrotal Pain, Swelling, or Lesions

ii. Hydrocele

Answer

A

Non-tender, Fluid-filled Mass
- W/in Tunica Vaginalis
Transilluminates
Examine – Fingers CAN get above the mass w/in Scrotum

Question 64

Q

2. Identify and discriminate the clinical significance, presenting signs, differential diagnosis, and further evaluation including laboratory and/or diagnostic imaging tests for the following common and concerning symptoms regarding male genitalia and hernias:

d. Scrotal Pain, Swelling, or Lesions

iii. Scrotal Hernia

Answer

A

Usually an: Indirect Inguinal Hernia
Comes through External Inguinal Ring
Examine - Fingers CANNOT get above it w/in scrotum

Answer 65

A

Testis = atrophied
May lie in:
- Inguinal Canal
- Abdomen
Results In: Un-filled Scrotum
Examine:
- No palpable testis or epididymis
Raises risk for Testicular CA

Answer 66

A

Usually <3.5cm
Klinefelter’s Syn:
- Small (<2cm), firm testes

versus

Atrophy due to Cirrhosis, Mytonic Dystropy, Estrogen Use, Hypopituatrism, post-orchitis:
- Small, soft testses

Answer 67

A

Acutely Inflammed Testis (usually, unilateral)
Painful, Swollen
Hard to distinguish from: Epididymis
Reddened Scrotum
Seen in:
- Mumps
- Other Viral Infxn

Answer 68

A

Early:
- Painless Nodule
- ANY Nodule = Investigation for Malignancy
Late:
- May seem to replace entire Testis!
- Feels Heavier!

Answer 69

A

Painless, movable cyst
- Just about testis
Both Transilluminate
Spermatocele: Contains Sperm
Cyst: Doesn’t contain Sperm

Clinically Indistinguiable!!!

Answer 70

A

Acutely inflamed
Tender, Swollen
Hard to differentiate form Testis
Scrotum & Vas Deferens = may be inflammed
MC with: Chlamydia infxn
Support Dx:
- Co-exisiting UTI
- Prostatitis

Answer 71

A

Varicose veins of the Spermatic Cord
- usually on the LEFT Side!!!
“Bag of Worms”
Collapses when Scrotum is Elevated in supine pt
Assc w/ Infertility

Answer 72

A

Acutely painful, tender, swollen organ
Retracted upward in Scrotum
Scrotum = red & edematous
No assc. UTI
Common in: Adolescents
SURGICAL EMERGENCY!!!!
- Obstructs Circulation
  - Can cause Testis Necrosis!

Answer 73

A

TB Chronic Inflammation
- Firm Enlargement of Epididymis
  - Tender
  - Thickened or Beading Vas Deferens

Answer 74

A

Appearance: Single or multiple papules or plaques; variable shapes (round or acuminate; thin, slender; raised, flat, cauliflowerlike)
Causative Organism: HPV (6, 11); carcinogenic subtypes rare (~5-10%)
Incubation: Weeks - Months
Infected Contact may have NONE visible!
Arise on: Penis, Scrotum, Groin, Thighs, Anus
- Asymptomatic
  - sometimes: Itching & Pain
May: Disappear w/o Treatment!

Answer 75

A

Appearance: Small, scattered or grouped vesicles; 1-3mm on glans or shaft. Erosions if membrane breaks.
Causative Organism: HSV 2 (90%)
Incubation: 2-7 days after exposure
Primary Episode: May be asymptomatic
- Recurrance: Less painful, shorter duration
Assc. w/: Fever, malaise, HA, arthralgias; local pain, edema, lymphadenopathy
Differentials: Genital Herpes Zoster, candidiasis

Answer 76

A

Appearance: Chancre- Smallred papule, painless erosion (2cm). Base is clear, red, smooth, glistens; raised, indurated borders
- Heals w/in 3-8 weeks
Causative Organism: T. pallidum (spirochete)
Incubation: 9-90 days post-exposure
W/in 7 days: may = inguinal lyphadenopathy
- Lymphs = rubbery, non-tender, mobile
Suggests Co-Infxn w/ HIV: 20-30% develop 2nd Syphilis w/ chancre present
Differentials: Genital Herpes Simplex, chancroid, K.granulomatis

Answer 77

A

Appearance: Red papule or pustule initally then painful deep ulcer w/ ragged non-indurated margins; necrotic exudate & friable base
Causative Organism: H. ducreyi
Incubation: 3-7 days post-exposre
Painful Inguinal Adenopathy
- 25% of patients = Suppurative Buboes
Suggests Co-Infxn w/ HIV: 20-30% develop 2nd Syphilis w/ chancre present
Differentials: Genital Herpes Simplex, syphilis

Answer 78

A

Yellow Penile Discharge
Disseminated:
- Rash
- Tenosynovitis
- Monoarticular Arthritis
- Meningitis

Answer 79

A

White discharge in non-gonococcal urethritis from Chlamydia

Answer 80

A

Testicular CA incidence = low

Most common CA in young men

(highest in white men)

Testicular Self-Exam = NOT formally Endorsed as a Screening Tool

(Teach your patient anyways)

Detect early = FANTASTIC Prognosis

Answer 81

A

Evidence to guide screening rec. = scant

2010 - USPSTF: Unable to find studies on benefit v. harm
ACS Recommends: Enourage men (esp. 15-34yo) to perform monthly testicular self-exams & seek clinician assessment if painless lump, swelling, testicular englargement; heaviness, fluid in scrotum; dull ache in abd./groin

Answer 82

A

Risk Factors:
- Cryptorchidism
  - High-risk in undescended testicle
- Hx or Carcinoma in Contralateral Testis
- Mumps Orchitis
- Inguinal Hernia
- Hydrocele in Childhood

Cryptorchidism & Family Hx = Increase risk 2 to 8-fold!

Answer 83

A

After warm bath/shower
Stand in front of mirror & check for swelling on scrotum
(Penis out of way) - Examine each testicle
Cup testicle btwn thumb & fingers w/ both hands & roll gently btwn fingers
1. 1 testicle might be larger , but thats normal
2. Concern: Lump or pain
Find Epididymitis: Not abnormal lump, part of anatomy!
If you find a lump: DONT WAIT! See your doctor!!

Answer 84

A

Agressive Clinician Education!
Early Detection during Hx Taking
Physical Exam
Treatment

Growing burden, affecting health of ALL populations!

Esp. Adolescents and Young Adults!

USA = Rates higher than any other industrialized country (19M new STIs yearly!)

Answer 85

A

CDC: “Universal Testing from ages 18-64, regardless of Risk”

Population growing
- >1.1M Americans infected
- 56K new infxn annually

Highest Risk: MSM & African American Males

Test High Risk Groups Annually

If have other STI, test for HIV!

Answer 86

A

Be Frank, but Tactful! Be INTERACTIVE!
- w/ skill, can lower high-risk behavoir
Gather Key Info:
- Sexual Orientation
- # of Partners (in past month)
- Hx of past STIs
Screen ETOH/Drug use
Talk about general risk & personalized info

Answer 87

A

Advise:
- Seek Prompt Attention for any Lesions or Penile Discharge
- Use of Condoms
Address:
- Preventative Behavoirs: condoms, lower sexual partners, est. regular health care
Recommend:
- HPV Vaccine (Gardasil)
  - Ages 9-26yo
  - Prevent Genital Warts!

Answer 88

A

May feel uneasy
Explain process step-by-step
Erection during exam = explain to patient this is normal
Patient refuses? That’s A-Okay!

Answer 89

A

Patient Stand or Supine (gown)
Stand for:
- Hernias
- Varicocles
Provider - sit comfortably in stool
WEAR GLOVES!!

Answer 90

A

Inspect - Skin, prepuce, glans
- Excoriations? Inflammation?
- Nits? Lice?
Compress Glans - Inspect urethral meatus
If patient reports discharge:
- Visualize it, or
- Have him or self try to expel some discharge
- Glass Slide & Culture Materials!

Answer 91

A

Phimosis - Tight prepuce cannot be retracted over glans
Paraphimosis - Tight prepuce that (once retracted) cannot be return = Edema!
Balantis - Inflammation of the Glans
Balanoposthitis - Inflammation of Glans & Prepuce
Hypospadias - Congenital, Ventral Displacement of meatus on penis
Gram Stain and Culture abnormal discharge (yellow, scanty white, etc..)

Answer 92

A

Palpate any abormality
- Tender? Induration?
- Induration may suggest:
  - Urethral Stricture
  - possible Carcinoma
Omit palpation on young, asymptomatic pt.
Retract foreskin? Put it back in place.

Answer 93

A

Skin -Life up scrotum & look posteriorly
Scrotal Contours
- Swelling?
- Lumps?
- Veins?
Epidermoid Cysts: Occluded Follicles filled w/ Keratin Debris…
- Common, multiple, benign
- Dome-shaped, white or yellow
- papules or nodules

Answer 94

A

Epidermoid Cysts
Cryptorchidism
Scrotal Swellings:
- Inguinal Hernias
- Hydroceles
- Scrotal Edema
- Rare: Testicular CA

Answer 95

A

Palpate: Each Testis & Each Epididymis
- btwn thumb & 1st 2 fingers
- Epididymis: Superior, posterior; nordular & cord-like!
Note: Size, shape, consistency, tenderness; nodules?
Palpate: Each Spermatic Cord (+vas deferens)
- Swelling? Nodules?
- Infected Vas may feel “thickened or beaded”

Answer 96

A

Transilluminate: Swelling in scrotum
- Serous Fluid = Lights up!
- Tissue, blood = Don’t light up

Answer 97

A

Inspect: Bulging areas & Asymmetry
- Strain & Bear Down
  - Increases intra-abd pressure
    - Eaiser to see Hernias

Answer 98

A

Palpate: Face patient
- Right inguinal region, right index finger
- Inferior Margin of Scrotal Sac
  - Move finger upward along canal
- Follow Spermatic Cord up to inguinal ligament
- Find: External inguinal ring
  - Ask patient to bear down
    - Bulges? Masses?
- Try to palpate towards internal inguinal ring
  - Bear down… any bulges?

Answer 99

A

Bulge near External Inguinal Ring =
- Direct Inguinal Hernia
Bulge near Internal Inguinal Ring =
- Indirect Inguinal Hernia

Sensitivity 75%

Specificity 95%

Surgical Eval = best way to detect either type of mass

Answer 100

A

Place fingers on anterior thigh in region of femoral canal
- Ask patient to Strain Down or Cough
- Swelling? Tenderness?

Answer 101

A

If find a large Scrotal Mass…
- Ask patient to lie down
- If returns to abdomen by itself =’s Hernia!!

Consider:

Can you get your fingers above the mass in the scrotum? If so, Hydrocele!
Listen for bowel sounds in mass: If bowel sounds, Hernia!

If a Hernia… try to reduce it w/ sustained pressure

Do NOT do this if tender mass, or Nausea/Vomiting

History can be helpful in these situations…

Answer 102

A

Incarcerated: Contents cannot be returned to abdominal cavity
Strangulated: When blood supply to entrapped contects is compromised
- Suspect if: Tenderness, N/V
- Surgical Intervention

Answer 103

A

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