Advanced Physical Assessment
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| Breast mass | exclude malignancy
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| Age 15 breast mass | Usually smooth, rubbery, round, mobile, nontender
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| Age 25-50 breast mass | cysts, fibrocystic changes, cancer
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| Cysts | Usually soft to firm, round, mobile, often tender (25-50)
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| Fibrocystic changes | nodular and rope-like (25-50)
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| Cancer | Irregular, firm, may be mobile or commonly, fixed to surrounding tissue (25-50)
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| Pregnancy and lactation breast masses | lactating adenomas, cysts, mastitis and cancer
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| Lactating adenomas in prego | Usually smooth, rubbery, round, mobile, nontender
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| Mastitis in prego | Fever, tender, hard, area of fluctuation, erythema, and heat (± pus discharge)
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| Greatest risk factor for breast CA | Two or more first degree relatives with breast cancer (diagnosed at an early age)
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| Mammograms | Most effective mortality-reducing cancer screening method
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| Clinical breast exam | its value is controversial (Sensitivity 40%, Specificity 88—99%)- use mammogram with it
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| 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%
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| Anatomy of breast | divided into 6 quadrants- upper outer quadrant has most malignancies- most glandular tissue- tail of spencer can have it too
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| Male breast | has ducts instead of lobules
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| Pay attention to the upper outer quadrant for lymphatic drainage | axillary and supraclavicular- also called pectoral
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| 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
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| Non-cyclic pain in breasts | may indicate serious disease such as malignancy.
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| Nipple discharge meds | steroids, Contraceptives, hormones, diuretics, phenothiazines, digitalis.
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| Gynecomastia | from non-breast conditions- Hyperthyroidism, Testicular cancer, Klinefelter syndrome
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| 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
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| Family hx in breast CA | ask about 1st degree relatives, Known BRCA1 or BRCA2 mutation
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| Caffeine and the breast | impact on breast tissue- (does not increase risk of breast CA, but can increase discomfort of fibrocystic breast lumps).
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| 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
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| 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
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| 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
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| Palpation of the breast | Chest wall sweep, Bimanual digital palpation, Lymph nodes (Including axillary & infra-clavicular- Normally should NOT be palpable)
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| Discharge of the nipple | unilateral or bilateral- single or multiple duct- unilateral is concerning
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| Breast tissue in gynecomastia is often | TENDER, and in obesity (>2cm), psuedogyncoomastia, it is not
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| Full breasts | (firm, dense, and slightly enlarged) may become engorged.
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| 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.
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| 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)
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| Best diagnostic for Cyst | US
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| 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
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| The common breast masses | fibroadenoma, cysts and cancer
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| Fibroadenoma | age 15-25 (up to 50), single, round or lobular, small, soft to firm, well-defined, very mobile, nontender
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| Cysts | age 30-50, multiple, round, soft to firm, well defined, mobile, tender
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| Cancer | age >50, single, irregular, hard, not well defined, non-mobile, non-tender, retracts
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| *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
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| 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
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| Edema of skin | Peau d’orange
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| The most common types of nipple discharge | are serous (thin and watery) or bloody.
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| Approximately 5% of women with nipple discharge have | cancer; while 25% with a bloody discharge have cancer
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| 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
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| Galactorrhea should be evaluated with the following tests | Pregnancy test, Prolactin level, MRI of the brain
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| 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!
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| Pts with hypothyroidism, when they stop taking their levothyroxine, get galactorrhea? | not enough dopamine to inhibit prolactin
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| 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
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| Paget- | malignant- have to remove surgically- radiation- axillary dissection
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| Firm irregular mass, often appearing as an area of discoloration, History of trauma to the breast (including surgery), Painless lump | fat necrosis
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| 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
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| Intraductal papilloma (Papillomatosis) | concerning for malignancy- may or may not have mass- benign unilateral nipple discharge
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| 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
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| 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)
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| Hysterectomy | no need for cervical screening
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| Bad Strains of HPV | 16, 18, 6, 11
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| most commonly reported STI in the U.S. and the most common STI in women | chlamydia
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| chlamydia causes | urethritis, cervicitis, PID (inflammation distorts fallopian tube- fibrotic), ectopic pregnancy, infertility, and chronic pelvic pain.
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| Ovarian CA | There are no effective screening tests to date- BRCA1 and 2 are risk factors
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| Estrogen therapy alone increase the risk of | endometrial CA
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| s/s ovarian CA | abdominal bloating, urinary frequency
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| dysmenorrhea | Pain with menses, often with bearing down, aching, or cramping sensation in the lower abdomen or pelvis
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| PMS | cluster of emotional, behavioral, and physical symptoms occurring 5 days before menses for 3 consecutive cycles
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| Menopause | Absence of menses for 12 consecutive months, usually occurring between ages 48 and 55 years
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| Post-menopausal bleeding | Bleeding occurring 6 months or more after cessation of menses
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| Period questions | Ask about the 1st day of LMP, as well as the one prior (PMP)- exclude pregnancy!
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| Primary vs secondary amenorrhea | failure to begin periods is primary amenorrhea; cessation of established periods is secondary amenorrhea
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| Polymenorrhea | less than 21-day intervals between menses
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| Oligomenorrhea | or infrequent bleeding
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| Menorrhagia | excessive flow
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| Metorrhagia | intermenstrual bleeding
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| Other causes of secondary amenorrhea include | low body weight from any condition→ malnutrition, anorexia nervosa, stress, chronic illness, and hypothalamic-pituitary ovarian dysfunction
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| 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
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| Postcoital bleeding | suggests cervical polyps or cancer-in an older woman, atrophic vaginitis
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| Primary dysmenorrhea (without an organic cause) | results from ↑ PG production during luteal phase of the menstrual cycle, when estrogen and progesterone levels decline→NSAIDS
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| Secondary dysmenorrhea (with an organic cause) | causes include endometriosis, pelvic inflammatory disease (PID) & endometrial polyps
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| 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
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| mittelschmerz pain | mild ovulation pain, unilateral pain arising at mid-cycle from ovulation, ruptured ovarian cyst and tubo-ovarian abscess
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| gonorrhea d/c | mucopurulent d/c, thick, yellow/green
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| chlamydia d/c | mucopurulent d/c
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| Trichomonas vaginalis d/c | offensive, yellowish, profuse, frothy + Itching
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| bacterial vaginosis | watery, profuse, gray, fishy smelling
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| TestDischarge with itching | Trichomonas vaginalis (sexual). Candidiasis (non-sexual)
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| Discharge with NO itching | Chlamydia, Gonorrhea, Bacterial vaginosis
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| Sexual vs non-sexual d/c | candidiasis and bacterial vasginosis are non and gonorrhea, chlamydia and trichomonas are sexually transmitted
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| For desire or libido ask | “Do you have an interest in (appetite for) sex?”
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| For arousal ask | “Do you get sexually aroused? Do you get wet or slippery? Do you stay too dry?”
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| For orgasm ask | “Are you able to reach climax (have an orgasm or ‘come’)?” “Do you enjoy sex without that?”
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| Vaginismus is | involuntary spasm of the vaginal orifice making penetration painful or even impossible
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| Superficial pain (intercourse) suggests | local inflammation, atrophic vaginitis or inadequate lubrication
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| Deeper pain (intercourse) may arise from | pelvic disorders or pressure on a normal ovary
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| GTPAL | Gravidity (total number of pregnancies),T: number of Term pregnancies, P: Preterm pregnancies, A: Abortions (spontaneous or induced), L: Living children
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| Milk the urethra for STD/d/c- STDs give you | chlamydia/ gonorrhea/ trichomonas- discharge cervicitis/urethritis (frequency, urgency, burning, dysuria) but with d/c
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| Examine for Bartholin gland | labial swelling- palpate each side- vulvar glands
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| Test Cervical motion tenderness | sign for PID-seen in ectopic pregnancy (this with secondary amenorrhea)- sometimes, it’s appendicitis
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| Positions of the uterus | anteverted, retroverted, retroflexed
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| Uterine enlargement | suggests pregnancy, uterine myomas (fibroid), or malignancy
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| Nodules on the uterine surface suggests | myomas (fibroids)
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| Weeks 10 to 12 of prego | Uterus within pelvis; fetal heartbeat can be detected with Doppler.
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| Week 12 of prego | Uterus palpable just above symphysis pubis.
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| Week 16 of prego | Uterus palpable halfway between symphysis and umbilicus; ballottement of fetus is possible by abdominal and vaginal
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| Week 20 of prego | Uterine fundus at lower border of umbilicus; fetal heartbeat can be auscultated with a fetoscope.
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| Weeks 24 to 26 of prego | Uterus changes from globular to ovoid shape; fetus palpable.
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| Week 28 of prego | Uterus approximately halfway between umbilicus and xiphoid; fetus easily palpable.
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| Week 34 of prego | Uterine fundus just below xiphoid.
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| Week 40 of prego | : Fundal height drops as fetus begins to engage in pelvis.
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| 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
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| Venereal Wart (Condyloma Acuminatum) | Warty lesions on the labia and within the vestibule suggest condyloma acuminata from infection with human papillomavirus
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| 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
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| Syphilitic chancre | firm, painless ulcer suggests the chancre of primary syphilis-most chancres in women develop internally, they often go undetected
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| 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
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| Carcinoma of the Vulva | An ulcerated or raised red vulvar lesion in an elderly woman may indicate vulvar carcinoma
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| 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
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| 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
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| Rectocele | a herniation of the rectum into the posterior wall of the Urethral Caruncle:
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| A urethral caruncle | small red benign tumor visible at the posterior urethral meatus- postmenopausal women-no symptoms
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| Prolapse of the Urethral Mucosa | swollen red ring around the urethral meatus- before menarche or after menopau se.
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| Bartholin Gland Infection | trauma, gonococci, anaerobes like bacteroids and peptostreptococci, and C.trachomatis- appears as a tense, hot, very tender abscess.
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| Trichomonas vaginitis | A protozoan, often sexually acquired,Yellowish- green, profuse, malodorous, red vulva, normal/red vagina, lab: Saline wet mount, Metronidazole tx
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| 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
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| Bacterial vaginosis | Anaerobic bacteria, Gray/white, thin, scant, malodorous, fishy, Saline wet mount, whiff test, metronidazole, vagina/vulva normal
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| 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
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| Chlamydia | Intracellular patho-genic bacteria, mucopurulent, s/s of urethritis/ cervicitis, dyspareunia, looks normal, only d/c, Nucleic acid amplification test, Azithromycin or doxycycline
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| 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
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| Mucopurulent Cervical Discharge/cervicitis | Purulent yellow discharge emerging from the cervical os by Chlamydia trachomatis or Neisseria gonorrheae- may occur w/o s/s
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| An anteverted uterus | Lies in a forward position at roughly a right angle to the vagina.This is the most common position
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| An anteflexed uterus | A forward flexion of the uterine body in relation to the cervix.Often coexists with anteversion
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| A retroverted uterus | Is tilted posteriorly with its cervix facing anteriorly
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| A retroflexed uterus* | Has a posterior tilt that involves the uterine body but not the cervix
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| A uterus that is retroflexed or retroverted may be felt | only through the rectal wall; some cannot be felt at all
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| 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.
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| 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
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| In first-degree prolapse, the cervix is | still well within the vagina
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| In second-degree prolapse | cervix it is at the introitus
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| In third-degree prolapse (procidentia) | the cervix and vagina are outside the introitus:
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| 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
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| 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
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| Acute PID | produces very tender, bilateral adnexal areas; the pt guards and usually cannot tolerate bimanual examination
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| S/s of chronic PID are | bilateral, tender, irregular, and fairly fixed adnexal areas
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| 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
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| 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
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| 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
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