Download - 4 Session4 GU
-
8/10/2019 4 Session4 GU
1/14
Session 4Genitourinary Study Guide
SMR = Sexual Maturity Rating PE findingsage not impt just PE findingsKNOW THE FIRST SIGN FOR PUBERTYboys (testicular enlargement); girls (breast and papillae elevated
as small mound; increase in areolae diameter)also be able to identify the image
-
8/10/2019 4 Session4 GU
2/14
-
8/10/2019 4 Session4 GU
3/14
-
8/10/2019 4 Session4 GU
4/14
Breast Exam
Inspection:
o Look for asymmetry, skin abnormalities (eg dimpling, discoloration, obvious masses), nipple
discharge
Palpation:
o 3 techniques below:
Look for TTP (tenderness to palpation) and/or masses
Palpate axilla for enlarged lymph nodes
Information type Examples
What constitutes a normal physical exam
finding
Where (anatomically) structures arenormally located, including helpful
external landmarks
What a normal structure looks like (visualappearance), feels like (palpation), orsounds like (auscultation, percussion)
Most women will NOT have palpable maxillary
lymph nodes
Discharge: most, secondary to benign
conditions
What constitutes an abnormal physical examfinding
Size limitsbeyond which a structure isenlarged
Abnormal locationsof structures
Abnormal appearances, textures, or
sounds associated with examination of astructure
Upper outer quadrant = most common for breastmass
Malignant axillary lymph nodes associatedwith: firmness, increased quantity, adherence
to each other and/or chest wall
NOTE: infection of hand and other dz can causeenlarged LNs; history is very impt
Discharge: - bloody => concerning for cancer; -
milk if not pregnant think prolactin
Dimpling or asymmetry can suggest lesions
such as cancer via adhesion to chest wall
Puckering / Dimpling of nipple => can suggest
mass
Nipple Retraction => concern for mass under
nipple (SEE IMAGE BELOW)
Redness / pain => inflammation and /or
infection (mastitis = diffuse inflammatorycondition from inadequately expressed milk)
Peau dorange = orange peel => aggressive
inflammatory malignancy
Basic physiologic principles that affect how
structures look, feel, or sound like on physical
exam
The greatest amount of breast swelling usually
occurs immediately prior to menses.
-
8/10/2019 4 Session4 GU
5/14
The correct landmarksfor performing a
physical exam maneuver
Physical characteristics of the structure or
appearance of body parts based on normal,expected developmental progression over time
(i.e., age-related changes/features)
Teenage boys often have bilateral breast
hypertrophy during puberty.
With age, the female breast diminishes in size
and become flaccid and more pendulous
Differences in the normal physical examfindings in children compared to adults (if
mentioned in the assigned study materials)
Infants:-Breast of newborns (male and female) often
enlarged due to maternal estrogen (may last
several months)
-Breast of newborns maybe engorged withwithchs milk = white liquid (first 2-3 weeks)
-accessory nipples seen in some pts
Children:-very little breast tissue
-
8/10/2019 4 Session4 GU
6/14
Nipple retraction in right image
-
8/10/2019 4 Session4 GU
7/14
Male & FemaleGenitourinary
Maleblue; femalered ** = see image
See all images (below table) not all mentioned in table
Information type Examples
What constitutes a normal physical exam
finding
Where (anatomically) structures are normallylocated, including helpful external landmarks
What a normal structure looks like (visual
appearance), feels like (palpation), or sounds
like (auscultation, percussion)
-Penis normally straight, not curved
-Left testes lower than the right
-each testes should be same size and consistency
-does NOT transmit light
-vas deferens within spermatic cord => feels firm and
wire-like
-normal prostate: feels like tip of your nose
What constitutes an abnormal physical exam
finding
Size limitsbeyond which a structure isenlarged
Abnormal locationsof structuresAbnormal appearances, textures, or sounds
associated with examination of a structure
-firm nodule => concern for malignancy
-hydrocele = fluid in potential space around tesis
--trans-illuminates light**
--has different texture from testicular tissue
-orchitis = testicular enlargement, due to infectionWITHINbody of testis
--NO TRANSILLUMINATION OF LIGHT**--NOTE: can sometimes cause reactive hydrocele
which WILL transilluminate light
-Varicocele = dilated veins (within spermatic cord) =>
feels like bag of worms
Paraphymosisvenous and arterial obstruction leading
to necrosis of the head of penis **
Phymosis = un-retractable foreskin of head of penis **
Epispadias = urethra opening at top of penis
Hypospadias = urethra opening at bottom-side of penis
Milky discharge => urethritis (seen in Gonorrhea and
Chlamydia)
-testes size discrepancy (ask about surgical removal or
undescended)
-single testes (check inguinal canal)
-Hernias**
--normally NON-tender--tenderness => entrapped contents = surgical
emergency
--auscultation may detect bowel sounds
-Rectal exam: skin abnormalities, bleeding sites, fissuresor hemerrhoids
-Rectal exam: stool moves easily out of the way;
-
8/10/2019 4 Session4 GU
8/14
masses will NOT move
-Prostatefrim => malignancy suspition; enlarged is
abnormal
-prostatepain on palpation => infection
-Older Adult
--Female:--possible findings:
---labial masses, blue swellings = possible varicosities,bulging of anterior vaginal wall below urethra =>
urethrocele or urethral diverticulum; caruncles; clitoralenlargement
--Male:---anterior median lobe inaccessible to palpation
Basic physiologic principles that affect howstructures look, feel, or sound like on physical
exam
-dark tarry stools => upper intestinal-bloodlower intestinal
-stool guaic test for occult blood**
--test for hemoglobin => positive => turns blue--colon = frequent source
The correct landmarksfor performing a physical
exam maneuver
n/a
Physical characteristics of the structure orappearance of body parts based on normal,
expected developmental progression over time
(i.e., age-related changes/features)
See SMR above
Differences in the normal physical exam findingsin children compared to adults (if mentioned in
the assigned study materials)
Older Adults
-Female:
--menopausal changes:
---thinning of skin, loss of pubic hair, decreaseddistensibility of introitus = vaginal orifice
-Male:
Female Infants:-hyperpigmentedlabia majora and minor in some
children
-hymen can be THICKENED in newborns
-genitalia prominent due to maternal estrogen-vaginal discharge sometimes
Female Children
-hymen thin and translucent
Male Infants
-hydroceles = common in newborns-one or both testes can be undescended at birth
-foreskin can NOT usually be retracted
-
8/10/2019 4 Session4 GU
9/14
Male Children-testes may be found in inguinal canal
--if after incr intra-abdmoinal pressure testes detected =
NORMAL, even if much time spent in inguinal canal
-scrota can be hyperpigmented in some children
-testes are EASILY retractile (warm your hands)--cremasteric reflex (may appear undescended)
Infant Rectal exam
only inspection unless suspectpathology
-
8/10/2019 4 Session4 GU
10/14
Images:
1.Paraphymosis: Picture on left demonstrates edematous foreskin which has become trapped behind
the head of the penis. Picture on right demonstrates foreskin in appropriate position covering head of
penis.
Phymosis:Scarred down foreskin which can not be retracted over head of penis.
Penile Condyloma:Growth at edge of glans due
to HPV infection.Syphilitic Ulcer
-
8/10/2019 4 Session4 GU
11/14
HSV Vessicles
Testicular enlargement caused by hydrocele.
Orchitis:Picture on left demonstrates testicular enlargement caused by infection within the body of the testis.
The inflammation has spread from the testis to the skin of the scrotum, with resulting edema causing fewer skinfolds over the right testicle compared with the left. No transillumination is seen (picture on right) as theinflamed testis does not allow the passage of light (as opposed to hydrocele shown above, which readily
conducts light). This is not always the case, as sometimes orchitis will cause a "reactive hydrocele" to form,
which will transilluminate.
Right Inguinal Hernia
-
8/10/2019 4 Session4 GU
12/14
Thrombosed External
HemerrhoidProlapsed Internal Hermerrhoid
Rectal Fissure and Prominent
Skin Tag
Guaiac Positive (Note blue coloration in boxes)
-
8/10/2019 4 Session4 GU
13/14
Additional infoBreast Exam
Anatomy:Rough boundaries of the breast are as follows:
a. Superior aspect of the breast is bounded by the clavicle
b. Inferiorly by the inframamary crease ("bra line")
c. Medially by the sternumd. Laterally by the axilla
Lymphatic Drainage:
~ 90% of which drain into a lymph node group found in the ipsilateral axilla. The remaining 10% drain into the InternalThoracic nodes, which are located beneath the sternum (not accessible by exam).
General information:
Note: neither CBE nor SBE when performed as stand-alone examinations are not shown to improve clinical outcomes.
Mammography (w/ or w/o CBE) has STRONG evidence of support
3 techniques
1.
Vertical line: start at the clavicle, axilla side; vertical line dwn then up covering each region
a. BEST TECHNIQUE CURRENTLYaccording to BATES
2.
Pie or radial spoke pattern: start at the nipple and work your way outward
3.
Circular pattern: start at nipple and work in circular pattern
a. For all make sure you palpate the tail
-
8/10/2019 4 Session4 GU
14/14
Asymptomatic Patient
Examination can be done by the clinician (Clinical Breast Exam - CBE) or patient (Self Breast Exam - SBE). CBE annually,
beginning at the age of 40, which coincides with time of increased risk for development of breast cancer. Other major
breast cancer risk factors include: prior history of breast ca, family history in 1st degree relative (particularly if at a young
age), increasing patient age and features that result in prolonged/uninterrupted exposure to estrogen (e.g. early age at
onset menstruation, never having been pregnant, older age at first pregnancy, older age at menopause).SBE is often
recommended on a monthly-to-every-few-months basis.
Symptomatic Patient
The goal of the examination in the setting of symptoms is to better characterize the abnormality, identifyunderlying etiology, and direct additional evaluation and treatment. Breast related symptoms may include any
of the following:
Discrete massesdetected by the patient, often concerning for malignancy
Pain, which can be associated with a number of processes including: cyclical in a menstruating women
(reflecting transient hormone induced changes in the breast tissue), occasionally malignancies.
Unusual nipple discharge, which may include:
o Blood, concerning for malignancy
o Milk when not pregnant. Suggestive inappropriate Prolactin secretion from the pituitary - may
also be induced by certain medications
o Other
Discoloration or change in the quality of the skin:o Redness suggests infection or inflammation - in the post partum patient, this is often due to
mastitis, a diffuse inflammatory condition caused by congestion from inadequately expressed
milk.
o "Peau d'orange" quality - an "Orange Peel" like texture that's caused by an uncommon,
aggressive inflammatory malignancy