Patient Assessment 2: Male/Female Genitalia, Breasts, MSK
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| Articular structures | joint capsule, articular cartilage, synovial fluid, etc
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| Ligaments | ropelike bundles of collagen fibrils that connect bone to bone
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| Tendons | collagen fibers connecting muscle to bone
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| Bursae | pouches of synovial fluid; cushion movement (can be very tender when inflamed)
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| Synovial joints | bones do NOT touch (Osteoarthritis)
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| Cartilaginous joints | slightly movable (i.e. vertebra) Sternum
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| Fibrous joints | bones in direct contact ;no appreciable movement (i.e. skull bones)
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| 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])
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| Fraction of men or women that will have osteoporosis-related fracture in their lifetime | Men: 1:4; Women: 1:2
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| 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)
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| 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
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| How to interpret DXA results...normal? osteopenia? osteoporosis? | Norm: 0 to -1; Penia: -1 to -2.5; Porosis: less than -2.5
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| Midline back pain conditions (5) | 1) musculoligamentous injury 2) disc herniation 3) vertebral collapse 4) spinal cord metastases 5) epidural abscess (rare)
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| Off-midline back pain conditions (5) | 1) muscle strain 2) sacroiliitis 3) trochanteric bursitis 4) sciatica 5) hip arthritis
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| Back pain with bowel/bladder dysfunction? | Cauda Equina Syndrome
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| Leg pain resolving with rest? | Spinal stenosis
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| Posterior leg pain in S1 distribution increasing with cough or valsalva | Sciatica
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| Lateral hip pain near greater trochanter? | Trochanteric bursitis
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| 2 conditions migratory pattern of joint pain? Migratory pattern of joint pain with systemic involvement? | Rheumatic fever or gonococcal arthritis; Rheumatoid arthritis.
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| Severe pain of rapid onset in red swollen joint | Acute septic arthritis or gout
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| Articular joint pain vs nonarticular pain | Articular: Loss of active and passive motion; locking. Non-articular: loss of active but not passive ROM.
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| T/F: Rates of ACL tears are substantially higher in women | True
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| One thing you always have to do when testing warmth | TEST BOTH SIDES
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| 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.
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| What are the SITS muscles and where do they insert? | Supraspinatus, Infraspinatus, Teres Minor, Subscapularis; Insert medial greater tubercle.
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| Difficulty with Apley Scratch test indicates; also what is it? | rotator cuff tear or adhesive capsulitis; touch opposite scapula above shoulder and below
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| Neer's | rotator cuff tear; press on scapula and raise pts arm with other.
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| Hawkins' | rotator cuff tear; like a hawk wing internally rotate
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| Empty Can Test | rotator cuff tear; push down on extended arms
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| Drop-arm Test | rotator cuff tear; pt slowly adducts arm
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| Golfers elbow? Tennis elbow? | Medial epicondylitis; lateral epicondylitis (more common)
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| What is a tophus? | Subcutaneous nodule seen with gout.
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| Ulnar deviation and subluxation of metacarpophalangeal joints. Swan neck deformities (hyperextension at PIP w/flexion at DIP joints) | Rheumatoid arthritis.
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| What is hypothenar atrophy seen in? | Ulnar nerve compression.
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| Tenderness over snuffbox? Most common injury of which bones? Complications? | Scaphoid fracture; carpal bones; avascular necrosis
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| Hyperextension at PIP w/flexion at DIP joints | Swan neck deformities
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| Contracture of finger at PIP | Boutonniere deformity
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| Wrist pain and grip weakness, especially when a fist is made grasping thumb and hand ulnar deviated (Finkelstein's test) | de Quervain's tenosynovitis
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| Nodes on PIP joints | Bouchard nodes
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| Nodes on DIP joints | Heberden nodes
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| Flexion contracture of finger due to plaque overlying flexor tendon of ring finger | Dupuytren's contracture
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| Cystic swelling along tendon sheaths or joint capsules with a decent chance of recurrence | Ganglion
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| 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
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| Name of inner part of intervertebral disc? Outer part? | I: Nucleus pulposus O: Anulus fibrosis
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| 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
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| Forward slippage of one vertebrae or a step-off | Spondylolisthesis
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| Lateral deviation and rotation of the neck (contractions/spasms of sternocleidomastoid muscle | Torticollis
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| 3 things that commonly produce sacroiliac tenderness | 1) Sacroiliitis 2) ankylosing spondylitis 3) Sciatica
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| T/F: Most gait problems occur during weight-bearing stance | True
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| 4 parts of Gait Analysis | 1) Push off 2) Foot flat 3) Midstance 4) Heel strike
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| 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
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| Swelling over the patella from excessive kneeling | Prepatellar bursitis
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| Swelling over tibial tubercle, especially medially from running, fibromyalgias and others | Anserine bursitis
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| Hemarthosis | blood in the joint, requires knee aspiration.
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| Valgus stress | bend knee laterally (tests MCL stability; positive is pain and tenderness)
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| Varus stress | bend knee medially (tests LCL stability; positive is pain and tenderness)
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| Tenderness over 3rd and 4th metatarsal heads more common in women wearing high-heeled shoes w/ narrow toes | Morton's neuroma
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| What does unequal leg length suggest? | Scoliosis
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| Hx of: first step out of bed is a killer" | Plantar fasciitis
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| Lateral deviation of great toe at MP joint; bunion is inflammed bursa; also common in women with narrow toed shoes | Hallux valgus w/ bunion
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| Flexion deformity of PIP w/o deformity of DIP or MP | Hammer toe
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| Flexion of DIP w/ normal alignment of PIP and MP joints | Mallet toe
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| Fixed extension of MP joint w/ flexion of PIP joint | Claw toe
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| Tx for osteoporosis | 1) Bisphosphonates (injectable or not) 2) SERMS (tamoxifen) 3) Calcitonin 4) Anabolic drugs
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| T/F: Right testis usually lower than the left | False, Left usually lower than the right
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| Where does lymph from the penile and scrotal surfaces drain? Testes? | Horizontal inguinal nodes; adbomen
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| Which is more medial: the external or internal inguinal ring? | External. Check here using the cough test for hernias.
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| 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
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| defect/weakness in transversalis fascia area of Hesselbach’s triangle; medial to inferior epigastric artery Associated with heavy lifting/straining | Direct inguinal hernia
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| When are femoral hernias more likely to present? | W/ bowel incarceration or strangulation
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| Landmarks of Hesselback triangle | 1) inguinal ligament inferior, 2) inferior epigastric artery laterally and 3) rectus abdominus muscle medially
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| Reducible hernia | pushed in, no compromise
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| Incarcerated hernia | can create an obstruction, surgical referral, vascular supply not cut off
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| Strangulated hernia | can quickly lead to bowel ischemia due to cut off of vascular supply
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| 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.
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| Orchitis | often resulting from viral infection – mumps commonly. Testis becomes inflamed, tender, painful, swollen. Usually inilateral
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| Varicocele of spermatic cord | varicose veins, usually on left, can be cause of infertility “bag of worms”. Can affect sperm quality even infertility.
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| Epididymitis | occurs typically in adolescents/adults; most often caused by Chlamydia; tender, swollen epididymitis; occasionally scrotum swollen
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| Small testis | Klinefelter syndrome – small, firm testis. If small soft testis, can be related to cirrhosis, estrogen use, hypopituitarism
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| Testicular tumor | painless nodule – think cancer until proven otherwise
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| Hypospadias | congenital condition – ventral displacement of matus on penis
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| 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
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| Most common cause of balanitis? | Poor personal hygiene especially in uncircumcised.
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| "Bell clapper" deformity | Torsion of testicle...urological/surgical emergency most common in adolescent males.
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| Most common cancer of young men (15-35)? Other RF? | Testicular cancer; RF: age,cryptorchidism, FH of testicular cancer, AIDS
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| 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.
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| 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.
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| 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
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| Where do men usually get colorectal cancer? Women? How common is colorectal cancer? | Women: colon; Men: rectum; 3rd most common cancer in US
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| 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])
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| 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
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| What is an anal wink? | Anus tightens around finger at sphincter. Laxity or looseness indicates neurological disease or a spinal cord injury
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| What do you do after a DRE/prostate exam? | Note color of fecal matter on glove and test for occult blood
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| Superficial tear in anoderm causing burning, itching, pain often seen in Ulcerative Colitus and Crohns | Anal fissure
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| Sinus tract, hollow tract that develops opening from anal canal to skin. Caused by previous ano-rectal abscesses | Anorectal fistula
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| 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
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| 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
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| 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
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| 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+
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| 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.
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| Galactorrhea | inappropriate discharge of milk-containing fluid
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| 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.
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| 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.
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| Benign, sometimes painful condition of dilated ducts w/ surrounding inflammation | Mammary duct ectasia
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| Age 15-25 common breast lesion: | Fibroadenoma: round, disc-like, mobile and well defined, soft, nontender
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| Age 30-50 common breast lesion: | Cyst: round, soft-firm and elastic, tender
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| Age 30-90 common breast lesion: | Cancer: irregular, firm, unclear deliniation from surrounding tissue, non tender with retraction
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| Breast Cancer: % ductal? % lobular? | 80% ductal, 15% lobular
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| Clinical name of a 3rd nipple | Superumerary nipple
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| 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.
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| Dermatitis of nipple (scaly, eczema-like, weeping, erosions | Paget's Disease of Nipple
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| Menarche | age at which menstrual periods began
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| 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)
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| Dysmenorrhea | pain with menstruation (cramping, aching)
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| Polymenorrhea | frequent menses (less than 24 days)
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| Menorrhagia | increase in amount of bleeding or duration of flow (>7 days and/or heavy flow)
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| Metrorrhagia | irregular episodes of uterine bleeding
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| Oligomenorrhea | cycles greater than 35-45 days/infrequent bleeding
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| 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
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| 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.
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| Menopause | absence of menses for 12 consecutive months. Usually occurs between ages of 45 and 52
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| Gravida | is total number of pregnancies
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| Para | is the outcome of pregnancies.
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| External female genitalia | Vulva: mons pubis, labia majora/minora, clitoris, vestibular glands, vaginal vestibule, urethral opening, vaginal orifice
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| Internal female genitalia | Vagina, uterus, fallopian tubes, ovaries.
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| 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
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| 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.
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| 4 changes in menopause | 1) genitalia decrease in size 2) tissue loses elasticity/tone 3) decrease in libido 4) vagina narrows, loss of lubrication
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| 5 Ps of sexual health | 1) partners 2) practices 3) protection 4) past histories 5) prevention of preganancy
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| Vaginal odor, thin, gray discharge, possible irritation, pH > 4.5 | Bacterial vaginosis
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| No odor, white, curd-like discharge, vulva irritaiton, KOH prep (+), pH <4.5 | Candidia
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| Possible odor, green-yellow discharge, vulvar irritation, dyspareunia (painful intercourse), erythema, strawberry cervix, pH>4.5 | Trichomoniasis
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| Dysmonorrhea | painful menses
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| Most common cause of acute pelvic pain | PID (pelvic inflammatory disease)
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| Mittelschmerz | pain from ovulation at midcycle, ruptured ovarian cyst, or tubo-ovarian abscess
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| T/F: Majority of cervical cancers are adenocarcinomas | False, 10-20% are adenocarcinomas...Majority are squamous cell
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| ACOG PAP Screening Guidelines | 21-29 yo: 3 years; 30-65: 5 years Stop screening after 65 w/no history
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| When examining, where will a cystocele present? Rectocele? | Top of vagina; bottom of vagina
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