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Exam 2

Patient Assessment 2: Male/Female Genitalia, Breasts, MSK

Articular structures joint capsule, articular cartilage, synovial fluid, etc
Ligaments ropelike bundles of collagen fibrils that connect bone to bone
Tendons collagen fibers connecting muscle to bone
Bursae pouches of synovial fluid; cushion movement (can be very tender when inflamed)
Synovial joints bones do NOT touch (Osteoarthritis)
Cartilaginous joints slightly movable (i.e. vertebra) Sternum
Fibrous joints bones in direct contact ;no appreciable movement (i.e. skull bones)
6 common or concerning Sx of joint pain 1) Neck pain 2) Low back pain 3) Joint pain: monoarticular or polyarticular 4) Inflammatory or infectious joint pain 5) Joint pain with systemic components (RA, SLE) 6) Joint pain with symptoms from other organ systems (gout-uriac acid problem [big toe])
Fraction of men or women that will have osteoporosis-related fracture in their lifetime Men: 1:4; Women: 1:2
Bone Strength/Density: Components? General Pathophysiology? Imaging? Bone Strength reflects bone density AND bone quality. Patho: low Vitamin D/Calcium AND increased osteoclast activity. Imaging: DXA: dual energy x-ray absorptiometry (DEXA)
11 osteoporosis risk factors 1) thin white or asian women 2) prior fracture 3) post-menopausal 4) 50 yo+ 5) less than 154 lbs (70kg) 6) low calcium 7) Vit D deficiency 8) Tobacco/Alcohol 9) FH 10) chronic steroid use 11) some medications and medical conditions
How to interpret DXA results...normal? osteopenia? osteoporosis? Norm: 0 to -1; Penia: -1 to -2.5; Porosis: less than -2.5
Midline back pain conditions (5) 1) musculoligamentous injury 2) disc herniation 3) vertebral collapse 4) spinal cord metastases 5) epidural abscess (rare)
Off-midline back pain conditions (5) 1) muscle strain 2) sacroiliitis 3) trochanteric bursitis 4) sciatica 5) hip arthritis
Back pain with bowel/bladder dysfunction? Cauda Equina Syndrome
Leg pain resolving with rest? Spinal stenosis
Posterior leg pain in S1 distribution increasing with cough or valsalva Sciatica
Lateral hip pain near greater trochanter? Trochanteric bursitis
2 conditions migratory pattern of joint pain? Migratory pattern of joint pain with systemic involvement? Rheumatic fever or gonococcal arthritis; Rheumatoid arthritis.
Severe pain of rapid onset in red swollen joint Acute septic arthritis or gout
Articular joint pain vs nonarticular pain Articular: Loss of active and passive motion; locking. Non-articular: loss of active but not passive ROM.
T/F: Rates of ACL tears are substantially higher in women True
One thing you always have to do when testing warmth TEST BOTH SIDES
TMJ (Temporomandibular Joint) Sx and troubles Facial asymmetry, unilateral chronic pain with chewing, jaw clenching, teeth grinding with stress. Possible HA. Crepitus, clicking is present in poor occlusion, meniscus injury, synovial swelling.
What are the SITS muscles and where do they insert? Supraspinatus, Infraspinatus, Teres Minor, Subscapularis; Insert medial greater tubercle.
Difficulty with Apley Scratch test indicates; also what is it? rotator cuff tear or adhesive capsulitis; touch opposite scapula above shoulder and below
Neer's rotator cuff tear; press on scapula and raise pts arm with other.
Hawkins' rotator cuff tear; like a hawk wing internally rotate
Empty Can Test rotator cuff tear; push down on extended arms
Drop-arm Test rotator cuff tear; pt slowly adducts arm
Golfers elbow? Tennis elbow? Medial epicondylitis; lateral epicondylitis (more common)
What is a tophus? Subcutaneous nodule seen with gout.
Ulnar deviation and subluxation of metacarpophalangeal joints. Swan neck deformities (hyperextension at PIP w/flexion at DIP joints) Rheumatoid arthritis.
What is hypothenar atrophy seen in? Ulnar nerve compression.
Tenderness over snuffbox? Most common injury of which bones? Complications? Scaphoid fracture; carpal bones; avascular necrosis
Hyperextension at PIP w/flexion at DIP joints Swan neck deformities
Contracture of finger at PIP Boutonniere deformity
Wrist pain and grip weakness, especially when a fist is made grasping thumb and hand ulnar deviated (Finkelstein's test) de Quervain's tenosynovitis
Nodes on PIP joints Bouchard nodes
Nodes on DIP joints Heberden nodes
Flexion contracture of finger due to plaque overlying flexor tendon of ring finger Dupuytren's contracture
Cystic swelling along tendon sheaths or joint capsules with a decent chance of recurrence Ganglion
Pain, numbness of 1st 3 fingers of the hand (not palm) esp at night. Loss/decreased sensation in median nerve: palmar surface of thumb, index, middle & medial 4th finger Assess for weak abduction of thumb and Tinel’s and Phalen’s sign. Thenar atrophy? Carpal Tunnel Syndrome
Name of inner part of intervertebral disc? Outer part? I: Nucleus pulposus O: Anulus fibrosis
5 Red Flags of spinal pain 1) MusculoSkeletal pain in older adults w/no previous history 2) Personal history of cancer 3) Pain not responding to treatment (PT) 4) Night-time pain/pain unrelieved by rest 5) Cauda equina syndrome
Forward slippage of one vertebrae or a step-off Spondylolisthesis
Lateral deviation and rotation of the neck (contractions/spasms of sternocleidomastoid muscle Torticollis
3 things that commonly produce sacroiliac tenderness 1) Sacroiliitis 2) ankylosing spondylitis 3) Sciatica
T/F: Most gait problems occur during weight-bearing stance True
4 parts of Gait Analysis 1) Push off 2) Foot flat 3) Midstance 4) Heel strike
When patient stands on one leg, iliac crest drops on the opposite side of weakness because weak abductor cannot support lifted leg (weak ipsilateral abductors on weak side) Positive Tredenlenburg Test
Swelling over the patella from excessive kneeling Prepatellar bursitis
Swelling over tibial tubercle, especially medially from running, fibromyalgias and others Anserine bursitis
Hemarthosis blood in the joint, requires knee aspiration.
Valgus stress bend knee laterally (tests MCL stability; positive is pain and tenderness)
Varus stress bend knee medially (tests LCL stability; positive is pain and tenderness)
Tenderness over 3rd and 4th metatarsal heads more common in women wearing high-heeled shoes w/ narrow toes Morton's neuroma
What does unequal leg length suggest? Scoliosis
Hx of: first step out of bed is a killer" Plantar fasciitis
Lateral deviation of great toe at MP joint; bunion is inflammed bursa; also common in women with narrow toed shoes Hallux valgus w/ bunion
Flexion deformity of PIP w/o deformity of DIP or MP Hammer toe
Flexion of DIP w/ normal alignment of PIP and MP joints Mallet toe
Fixed extension of MP joint w/ flexion of PIP joint Claw toe
Tx for osteoporosis 1) Bisphosphonates (injectable or not) 2) SERMS (tamoxifen) 3) Calcitonin 4) Anabolic drugs
T/F: Right testis usually lower than the left False, Left usually lower than the right
Where does lymph from the penile and scrotal surfaces drain? Testes? Horizontal inguinal nodes; adbomen
Which is more medial: the external or internal inguinal ring? External. Check here using the cough test for hernias.
develop at internal inguinal ring; lateral to inferior epigastric artery. Lies within the inguinal canal; may come through the external canal and pass into scrotal sac Indirect inguinal hernia
defect/weakness in transversalis fascia area of Hesselbach’s triangle; medial to inferior epigastric artery Associated with heavy lifting/straining Direct inguinal hernia
When are femoral hernias more likely to present? W/ bowel incarceration or strangulation
Landmarks of Hesselback triangle 1) inguinal ligament inferior, 2) inferior epigastric artery laterally and 3) rectus abdominus muscle medially
Reducible hernia pushed in, no compromise
Incarcerated hernia can create an obstruction, surgical referral, vascular supply not cut off
Strangulated hernia can quickly lead to bowel ischemia due to cut off of vascular supply
Cryptorchidism testis in inguinal canal, not in scrotum. Often detected early (before adolescence) in males who have regular physical exams. If uncorrected, increased risk for testicular cancer.
Orchitis often resulting from viral infection – mumps commonly. Testis becomes inflamed, tender, painful, swollen. Usually inilateral
Varicocele of spermatic cord varicose veins, usually on left, can be cause of infertility “bag of worms”. Can affect sperm quality even infertility.
Epididymitis occurs typically in adolescents/adults; most often caused by Chlamydia; tender, swollen epididymitis; occasionally scrotum swollen
Small testis Klinefelter syndrome – small, firm testis. If small soft testis, can be related to cirrhosis, estrogen use, hypopituitarism
Testicular tumor painless nodule – think cancer until proven otherwise
Hypospadias congenital condition – ventral displacement of matus on penis
Sexual Maturity Rating (Tanner Scale) 1) Prepubertal w/ no pubic hair. 2) Scrotum and testes have enlarged and have more textured scrotal skin, sparse pubic hair growth. 3) Penis lengthens, hair darker and curlier. 4) Further growth in length and width, glans larger and broader. 5) Maturity
Most common cause of balanitis? Poor personal hygiene especially in uncircumcised.
"Bell clapper" deformity Torsion of testicle...urological/surgical emergency most common in adolescent males.
Most common cancer of young men (15-35)? Other RF? Testicular cancer; RF: age,cryptorchidism, FH of testicular cancer, AIDS
2 other names for anorectal junction and significance Pectinate or dentate line; marks transiontion from skin to mucous membrane and somatic to visceral nerve supplies.
Prostate Cancer: Risk Factors (5) 1) Age (>50) 2) African American (2x higher than white rates) 3) Family History 4) High Fat diet. 5) Genetics: mutations in BRCA 2.
T/F: USPSTF: PSA screenings not recommended. ACA: recommends 50 yo+ w/ 10+ years left to live. Also 45 yo in AA w/ 1st degree relative and 40 yo in anyone w/ 1+ 1st degree relative. True
Where do men usually get colorectal cancer? Women? How common is colorectal cancer? Women: colon; Men: rectum; 3rd most common cancer in US
Risk factors for Colorectal cancer (6) 1) Age, 2) gender, 3) PH, 4) FH (Hx polyposis) 5) Diet 6) Diabetes (insulin dependent diabetes [growth factor for colonic cells])
Colorectal cancer screening recommendations Colonoscopy every 10 years beginning at 50 yo is the best test. High sensitivity Fecal Occult Blood Testing (FOBT) annually. Flexible sigmoidoscopy every 5 years
What is an anal wink? Anus tightens around finger at sphincter. Laxity or looseness indicates neurological disease or a spinal cord injury
What do you do after a DRE/prostate exam? Note color of fecal matter on glove and test for occult blood
Superficial tear in anoderm causing burning, itching, pain often seen in Ulcerative Colitus and Crohns Anal fissure
Sinus tract, hollow tract that develops opening from anal canal to skin. Caused by previous ano-rectal abscesses Anorectal fistula
Female risk factors for breast cancer (8) 1) Age 2) Genetics (BRCA 1, BRCA 2) 3) Early menarche, late menopause 4) PH 5) FH 6) Race/ethnicity 7) Dense breasts 8) Previous chest radiation
Female lifestyle risk factors for breast cancer (8) 1) Nulliparity (never birthing a child) 2) Oral contraceptives 3) hormone therapy post menopause 5) Breastfeeding 6) alcohol use 7) Overweight 8) Physical activity
Male risk factors for breast cancer (4) 1) Radiation exposure to chest 2) high estrogen levels (klinefelters etc) 3) BRCA mutations 4) male relative with breast cancer
USPSTF guidelines 1) no routine mammogram before age 50 2) no self-breast exam requirement 3) Biennial (bi-annual) screening for mammogram age 50-74 4) no screening age 75+
ACOG and ACA guidelines 1) age 40-49: mammogram every 1-2 years. 2) Age 50+: annual mammogram 3) Clinical breast exam every 3 years for 20-39 and annually for 40+. 4) Self-breast exam monthly.
Galactorrhea inappropriate discharge of milk-containing fluid
Where do Lateral, Pectoral and Subscapular lymph nodes drain? Where do central drain? Any exceptions? Central; Infraclavicular; sometimes malignant pectoral cells can drain directly into infraclavicular nodes.
T/F: the Gail model provides 5 year and lifetime estimates of risk for invasive breast cancer in individuals as young as 25. False, only starts at 35.
Benign, sometimes painful condition of dilated ducts w/ surrounding inflammation Mammary duct ectasia
Age 15-25 common breast lesion: Fibroadenoma: round, disc-like, mobile and well defined, soft, nontender
Age 30-50 common breast lesion: Cyst: round, soft-firm and elastic, tender
Age 30-90 common breast lesion: Cancer: irregular, firm, unclear deliniation from surrounding tissue, non tender with retraction
Breast Cancer: % ductal? % lobular? 80% ductal, 15% lobular
Clinical name of a 3rd nipple Superumerary nipple
3 Categories of mastitits and examples 1) Infectious: lactational mastitis in breastfeeding, typically staph. 2) Non-infectious: post irradiation mastitis, duct ectasia 3) malignancy associated: inflammatory breast cancer, ductal carcionma in-situ, advanced BC.
Dermatitis of nipple (scaly, eczema-like, weeping, erosions Paget's Disease of Nipple
Menarche age at which menstrual periods began
Amenorrhea refers to the absence of bleeding (menstruation). Primary is failure to initiate periods. Secondary is cessation of periods after they have been established (pregnancy, lactation, low body weight, ovarian dysfunction)
Dysmenorrhea pain with menstruation (cramping, aching)
Polymenorrhea frequent menses (less than 24 days)
Menorrhagia increase in amount of bleeding or duration of flow (>7 days and/or heavy flow)
Metrorrhagia irregular episodes of uterine bleeding
Oligomenorrhea cycles greater than 35-45 days/infrequent bleeding
PMS complex of symptoms and signs that occur in the 5 days prior to menses and cessation of signs/symptoms within 4 days after onset of menses. Must occur for at least 3 consecutive cycles. S/S
Vaginismus is involuntary contraction of muscles around the opening of the vagina in women with no abnormalities identified during examination. The tight muscle contraction makes sexual intercourse painful or impossible.
Menopause absence of menses for 12 consecutive months. Usually occurs between ages of 45 and 52
Gravida is total number of pregnancies
Para is the outcome of pregnancies.
External female genitalia Vulva: mons pubis, labia majora/minora, clitoris, vestibular glands, vaginal vestibule, urethral opening, vaginal orifice
Internal female genitalia Vagina, uterus, fallopian tubes, ovaries.
Functional maturation of reproductive female organs change in puberty(5) 1) pubic hair 2) vulva/internal genitalia grow and change 3) breast develop 4) endometrial lining thickens 5) physiologic leukorrhea
Tanner scale of maturity in female (stages) 1) Preadolescent, elevation of nipple only. 2) Breast buds, sparse hair. 3) Further elevation/enlargement of breasts, hair becomes darker, coarse, curly. 4) Nipple/areola form 2ndary mound, hair mature but not full. 5) Mature.
4 changes in menopause 1) genitalia decrease in size 2) tissue loses elasticity/tone 3) decrease in libido 4) vagina narrows, loss of lubrication
5 Ps of sexual health 1) partners 2) practices 3) protection 4) past histories 5) prevention of preganancy
Vaginal odor, thin, gray discharge, possible irritation, pH > 4.5 Bacterial vaginosis
No odor, white, curd-like discharge, vulva irritaiton, KOH prep (+), pH <4.5 Candidia
Possible odor, green-yellow discharge, vulvar irritation, dyspareunia (painful intercourse), erythema, strawberry cervix, pH>4.5 Trichomoniasis
Dysmonorrhea painful menses
Most common cause of acute pelvic pain PID (pelvic inflammatory disease)
Mittelschmerz pain from ovulation at midcycle, ruptured ovarian cyst, or tubo-ovarian abscess
T/F: Majority of cervical cancers are adenocarcinomas False, 10-20% are adenocarcinomas...Majority are squamous cell
ACOG PAP Screening Guidelines 21-29 yo: 3 years; 30-65: 5 years Stop screening after 65 w/no history
When examining, where will a cystocele present? Rectocele? Top of vagina; bottom of vagina
Created by: crward88