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Advanced Physical Assessment

Breast mass exclude malignancy
Age 15 breast mass Usually smooth, rubbery, round, mobile, nontender
Age 25-50 breast mass cysts, fibrocystic changes, cancer
Cysts Usually soft to firm, round, mobile, often tender (25-50)
Fibrocystic changes nodular and rope-like (25-50)
Cancer Irregular, firm, may be mobile or commonly, fixed to surrounding tissue (25-50)
Pregnancy and lactation breast masses lactating adenomas, cysts, mastitis and cancer
Lactating adenomas in prego Usually smooth, rubbery, round, mobile, nontender
Mastitis in prego Fever, tender, hard, area of fluctuation, erythema, and heat (± pus discharge)
Greatest risk factor for breast CA Two or more first degree relatives with breast cancer (diagnosed at an early age)
Mammograms Most effective mortality-reducing cancer screening method
Clinical breast exam its value is controversial (Sensitivity 40%, Specificity 88—99%)- use mammogram with it
Chemoprevention tamoxifen- at the age of 40 for 5 years- whenever ≥ 2 first degree relatives (mother, sister) have breast cancer- ↓ the risk by 30-50%
Anatomy of breast divided into 6 quadrants- upper outer quadrant has most malignancies- most glandular tissue- tail of spencer can have it too
Male breast has ducts instead of lobules
Pay attention to the upper outer quadrant for lymphatic drainage axillary and supraclavicular- also called pectoral
Cyclic vs non-cyclic pain in breasts Cyclic: r/t menstrual cycle; usually worse in the premenstrual and mid- cycle days, and improves toward the end and w/ oral contraceptive therapy, dopamine agonists or weak androgens. ↓Caffeine
Non-cyclic pain in breasts may indicate serious disease such as malignancy.
Nipple discharge meds steroids, Contraceptives, hormones, diuretics, phenothiazines, digitalis.
Gynecomastia from non-breast conditions- Hyperthyroidism, Testicular cancer, Klinefelter syndrome
Meds that may cause gynecomastia antiandrogens (finasteride) or gonadotropin-releasing hormone analogs, steroids, MJ, Cimetidine, PPIs (Omeprazole), Spironolactone, antiretroviral drugs (Efavirenz), chemotherapy agents (Bleomycin), CCB, Risperdal
Family hx in breast CA ask about 1st degree relatives, Known BRCA1 or BRCA2 mutation
Caffeine and the breast impact on breast tissue- (does not increase risk of breast CA, but can increase discomfort of fibrocystic breast lumps).
Inspect of breasts do BOTH breasts and compare: with patient seated and arms hanging loosely at the sides, veins in breast- both sides=IVC, one side is metastasis, Supernumerary breasts/ nipples
A venous pattern that is prominent on one side over the other could be a sign of a cancerous tumor of the breast, one side only=IVC
Inspect nipple & areola for the 5 Ds 1) Discharge 2) Depression- inversion, or retraction 3)Discoloration 4) Dermatologic changes- Pagets=eczema and is malignant 5) Deviation
Palpation of the breast Chest wall sweep, Bimanual digital palpation, Lymph nodes (Including axillary & infra-clavicular- Normally should NOT be palpable)
Discharge of the nipple unilateral or bilateral- single or multiple duct- unilateral is concerning
Breast tissue in gynecomastia is often TENDER, and in obesity (>2cm), psuedogyncoomastia, it is not
Full breasts (firm, dense, and slightly enlarged) may become engorged.
Engorged breasts feel hard and warm and are enlarged, shiny, and painful- not unusual in the 1st 24-48 Hrs after the breasts fill with milk; later development may signal the onset of mastitis.
Benign breast masses Size changes with the cycle: ↑early & ↓later in cycle-Tender, Mobile, Regular, well-delineated borders, Soft/cystic quality (Benign cyst is the MOST COMMON breast mass)
Best diagnostic for Cyst US
Malignant masses Rapid enlargement over a period of weeks to months, Lack of tenderness, Non-mobile, Irregular, poorly-defined borders, Retraction, inversion or flattening, Dimpling, Altered contour, discharge, rock-hard, edema (Peau d’orange), superficial venous pattern
The common breast masses fibroadenoma, cysts and cancer
Fibroadenoma age 15-25 (up to 50), single, round or lobular, small, soft to firm, well-defined, very mobile, nontender
Cysts age 30-50, multiple, round, soft to firm, well defined, mobile, tender
Cancer age >50, single, irregular, hard, not well defined, non-mobile, non-tender, retracts
*Fibrocystic disease Fibrocystic changes are also commonly palpable as nodular, rope-like densities in women aged 25-30. They may be tender or painful. They are considered benign and not a risk factor for breast cancer
Pagets disease of the nipple Starts as a scaly, eczema-like lesion on the nipple that may sweep, crust, or erode. A mass may be present
Edema of skin Peau d’orange
The most common types of nipple discharge are serous (thin and watery) or bloody.
Approximately 5% of women with nipple discharge have cancer; while 25% with a bloody discharge have cancer
Galactorrhea Abnormal-caused by normal pregnancy or many other causes of an elevated level of prolactin, including; stress, Hypothyroidism, Nipple stimulation (piercing), SSRIs, phenothiazines, H2 blockers, benzodiazepines, oral contraceptives, and alpha methyldopa
Galactorrhea should be evaluated with the following tests Pregnancy test, Prolactin level, MRI of the brain
Why does hypothyroidism result in galactorrhea hypothalamus senses that the thyroid hormones are low and yells at the pituitary TRH- thyrotropin releasing hormone- also inhibits release of dopamine (which inhibits prolactin)- so now it’s released= milk!
Pts with hypothyroidism, when they stop taking their levothyroxine, get galactorrhea? not enough dopamine to inhibit prolactin
Male adult gynecomastia Hyperprolactinemia, Liver disease such as cirrhosis, ↑estrogen levels, Castration, Testicular cancers that overproduce estrogen, medications, ↑ body fat which in turn produces more estrogen
Paget- malignant- have to remove surgically- radiation- axillary dissection
Firm irregular mass, often appearing as an area of discoloration, History of trauma to the breast (including surgery), Painless lump fat necrosis
Duct Ectasia of the Breast (aka: Mammary Duct Ectasia/Plasma Cell Mastitis) self limiting- Menopausal w:Nipple Discharge: Spontaneous, Uni or bilateral, May be sticky, greenish/brown/ bloody, pain/retraction, Mass behind nipple, may have Tenderness, Nipple retraction/inversion
Intraductal papilloma (Papillomatosis) concerning for malignancy- may or may not have mass- benign unilateral nipple discharge
Cervical CA screening age 21-65 cytology q3years, Ages 30-65- cytology plus HPV testing (for high-risk or oncogenic HPV types) every 5 yrs
When to end cervical screening > 65 yrs (3 consecutive negative cytology) or 2 consecutive negative results on cytology + HPV within 10 yrs before cessation of screening, (most recent test performed within 5 yrs)
Hysterectomy no need for cervical screening
Bad Strains of HPV 16, 18, 6, 11
most commonly reported STI in the U.S. and the most common STI in women chlamydia
chlamydia causes urethritis, cervicitis, PID (inflammation distorts fallopian tube- fibrotic), ectopic pregnancy, infertility, and chronic pelvic pain.
Ovarian CA There are no effective screening tests to date- BRCA1 and 2 are risk factors
Estrogen therapy alone increase the risk of endometrial CA
s/s ovarian CA abdominal bloating, urinary frequency
dysmenorrhea Pain with menses, often with bearing down, aching, or cramping sensation in the lower abdomen or pelvis
PMS cluster of emotional, behavioral, and physical symptoms occurring 5 days before menses for 3 consecutive cycles
Menopause Absence of menses for 12 consecutive months, usually occurring between ages 48 and 55 years
Post-menopausal bleeding Bleeding occurring 6 months or more after cessation of menses
Period questions Ask about the 1st day of LMP, as well as the one prior (PMP)- exclude pregnancy!
Primary vs secondary amenorrhea failure to begin periods is primary amenorrhea; cessation of established periods is secondary amenorrhea
Polymenorrhea less than 21-day intervals between menses
Oligomenorrhea or infrequent bleeding
Menorrhagia excessive flow
Metorrhagia intermenstrual bleeding
Other causes of secondary amenorrhea include low body weight from any condition→ malnutrition, anorexia nervosa, stress, chronic illness, and hypothalamic-pituitary ovarian dysfunction
Causes of abnormal bleeding vary by age-pregnancy, cervical/ vaginal infection or cancer, cervical/endometrial polyps or hyperplasia, fibroids, bleeding d/o, and hormonal contraception or replacement
Postcoital bleeding suggests cervical polyps or cancer-in an older woman, atrophic vaginitis
Primary dysmenorrhea (without an organic cause) results from ↑ PG production during luteal phase of the menstrual cycle, when estrogen and progesterone levels decline→NSAIDS
Secondary dysmenorrhea (with an organic cause) causes include endometriosis, pelvic inflammatory disease (PID) & endometrial polyps
Acute pelvic pain: The most common cause is (ectopic pregnancy) PID, ruptured ovarian cyst, appendicitis, STIs and recent IUD insertion are red flags for PID
mittelschmerz pain mild ovulation pain, unilateral pain arising at mid-cycle from ovulation, ruptured ovarian cyst and tubo-ovarian abscess
gonorrhea d/c mucopurulent d/c, thick, yellow/green
chlamydia d/c mucopurulent d/c
Trichomonas vaginalis d/c offensive, yellowish, profuse, frothy + Itching
bacterial vaginosis watery, profuse, gray, fishy smelling
TestDischarge with itching Trichomonas vaginalis (sexual). Candidiasis (non-sexual)
Discharge with NO itching Chlamydia, Gonorrhea, Bacterial vaginosis
Sexual vs non-sexual d/c candidiasis and bacterial vasginosis are non and gonorrhea, chlamydia and trichomonas are sexually transmitted
For desire or libido ask “Do you have an interest in (appetite for) sex?”
For arousal ask “Do you get sexually aroused? Do you get wet or slippery? Do you stay too dry?”
For orgasm ask “Are you able to reach climax (have an orgasm or ‘come’)?” “Do you enjoy sex without that?”
Vaginismus is involuntary spasm of the vaginal orifice making penetration painful or even impossible
Superficial pain (intercourse) suggests local inflammation, atrophic vaginitis or inadequate lubrication
Deeper pain (intercourse) may arise from pelvic disorders or pressure on a normal ovary
GTPAL Gravidity (total number of pregnancies),T: number of Term pregnancies, P: Preterm pregnancies, A: Abortions (spontaneous or induced), L: Living children
Milk the urethra for STD/d/c- STDs give you chlamydia/ gonorrhea/ trichomonas- discharge cervicitis/urethritis (frequency, urgency, burning, dysuria) but with d/c
Examine for Bartholin gland labial swelling- palpate each side- vulvar glands
Test Cervical motion tenderness sign for PID-seen in ectopic pregnancy (this with secondary amenorrhea)- sometimes, it’s appendicitis
Positions of the uterus anteverted, retroverted, retroflexed
Uterine enlargement suggests pregnancy, uterine myomas (fibroid), or malignancy
Nodules on the uterine surface suggests myomas (fibroids)
Weeks 10 to 12 of prego Uterus within pelvis; fetal heartbeat can be detected with Doppler.
Week 12 of prego Uterus palpable just above symphysis pubis.
Week 16 of prego Uterus palpable halfway between symphysis and umbilicus; ballottement of fetus is possible by abdominal and vaginal
Week 20 of prego Uterine fundus at lower border of umbilicus; fetal heartbeat can be auscultated with a fetoscope.
Weeks 24 to 26 of prego Uterus changes from globular to ovoid shape; fetus palpable.
Week 28 of prego Uterus approximately halfway between umbilicus and xiphoid; fetus easily palpable.
Week 34 of prego Uterine fundus just below xiphoid.
Week 40 of prego : Fundal height drops as fetus begins to engage in pelvis.
Epidermoid Cyst A small, firm, round cystic nodule in the labia suggests an epidermoid cyst-yellowish in color, with a dark punctum marking the blocked opening of the gland
Venereal Wart (Condyloma Acuminatum) Warty lesions on the labia and within the vestibule suggest condyloma acuminata from infection with human papillomavirus
Genital Herpes shallow, small, painful ulcers on red bases suggest a herpes infection-Initial infection may be extensive. Recurrent infections are usually confined to a small local patch
Syphilitic chancre firm, painless ulcer suggests the chancre of primary syphilis-most chancres in women develop internally, they often go undetected
Secondary Syphilis (Condyloma Latum) Slightly raised, round or oval flat-topped papules covered by a gray exudate suggest condyloma lata, a manifestation of secondary syphilis-contagious
Carcinoma of the Vulva An ulcerated or raised red vulvar lesion in an elderly woman may indicate vulvar carcinoma
Cystocele bulge of the upper two-thirds of the anterior vaginal wall, together with the bladder above it-results from weakened anterior supporting tissues-from urinary bladder
Cystourethrocele the entire anterior vaginal wall together with the bladder and urethra, produces the bulge, a cystourethrocele is present. A groove sometimes defines the border
Rectocele a herniation of the rectum into the posterior wall of the Urethral Caruncle:
A urethral caruncle small red benign tumor visible at the posterior urethral meatus- postmenopausal women-no symptoms
Prolapse of the Urethral Mucosa swollen red ring around the urethral meatus- before menarche or after menopau se.
Bartholin Gland Infection trauma, gonococci, anaerobes like bacteroids and peptostreptococci, and C.trachomatis- appears as a tense, hot, very tender abscess.
Trichomonas vaginitis A protozoan, often sexually acquired,Yellowish- green, profuse, malodorous, red vulva, normal/red vagina, lab: Saline wet mount, Metronidazole tx
Candidal vaginitis yeast r/t antibiotic use, white, curdy, itchy, no smell, vaginal soreness, dysuria, dyspareunia- red and white patches, vulva red/swollen, KOH for hyphae, Vaginal nystatin or clotrimazole
Bacterial vaginosis Anaerobic bacteria, Gray/white, thin, scant, malodorous, fishy, Saline wet mount, whiff test, metronidazole, vagina/vulva normal
Gonorrhea Neisseria gonorrheae, Gr – bacteria, mucopurulent, thick, yellow/green, s,s of urethritis/ cervicitis, dyspareunia, May be red/ swollen, burning, gram stain and culture, newer PCR, Ceftriaxone + Azithromycin
Chlamydia Intracellular patho-genic bacteria, mucopurulent, s/s of urethritis/ cervicitis, dyspareunia, looks normal, only d/c, Nucleic acid amplification test, Azithromycin or doxycycline
Cervical Polyp usually arises from endocervical canal, becoming visible only when it protrudes through cervical os-bright, red, soft, and rather fragile-benign but may bleed
Mucopurulent Cervical Discharge/cervicitis Purulent yellow discharge emerging from the cervical os by Chlamydia trachomatis or Neisseria gonorrheae- may occur w/o s/s
An anteverted uterus Lies in a forward position at roughly a right angle to the vagina.This is the most common position
An anteflexed uterus A forward flexion of the uterine body in relation to the cervix.Often coexists with anteversion
A retroverted uterus Is tilted posteriorly with its cervix facing anteriorly
A retroflexed uterus* Has a posterior tilt that involves the uterine body but not the cervix
A uterus that is retroflexed or retroverted may be felt only through the rectal wall; some cannot be felt at all
Myomas of the Uterus (Fibroids) very common benign uterine tumors- single or multiple and vary greatly in size-is confused with an ovarian mass or retroflexed uterus.
Prolapse of the uterus results from weakness of the supporting structures of the pelvic floor and is often associated with a cystocele and rectocele-uterus becomes retroverted and descends down the vagina
In first-degree prolapse, the cervix is still well within the vagina
In second-degree prolapse cervix it is at the introitus
In third-degree prolapse (procidentia) the cervix and vagina are outside the introitus:
Ectopic pregnancy Abnormal bleeding, Low back pain, Mild cramping on one side, Pain in lower abdomen/pelvis, lightheaded or syncope, Pain felt in shoulder area, Severe, sharp, and sudden pain in the lower abdomen, Cervical motion tenderness, surgical emergency
PID Symptoms may be mild or absent, Unusual vaginal discharge-foul odor-painful intercourse, painful urination, irregular menstrual bleeding, pain in the right upper abdomen
Acute PID produces very tender, bilateral adnexal areas; the pt guards and usually cannot tolerate bimanual examination
S/s of chronic PID are bilateral, tender, irregular, and fairly fixed adnexal areas
PID Infection of the uterus, fallopian tubes, and other reproductive organs; a common and serious complication of some sexually transmitted infections-Often caused by Neisseria gonorrheae and Chlamydia trachomatismay be acute or chronic
Polycystic Ovarian Syndrome (PCOS) Abnormal metabolism of androgens/estrogens; results in ovarian cysts- Most common cause of infertility-one of the most common endocrine disorders of reproductive-age women
Polycystic Ovarian Syndrome (PCOS) Menstrual irregularity, infertility, hirsutism, acne. Obesity and metabolic syndrome- associated with Heart and blood vessel complications, diabetes, uterine CA, sleep apnea, metabolic syndrome
Created by: arsho453