4 Session4 GU

download 4 Session4 GU

of 14

Transcript of 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