Health Assessment #6

areola

surrounds the nipple, small elevated sebaceous glands called Montgomery glands which secretes a protective lipid material during lactation -smooth muscle fibers that cause nipple erection when stimulated, more darkly pigmented than the rest of the breast surface

urine color and discolorations for male GU

tea color: liver disease especially with pale stools, jaundice red color: blood in urine orange color: jaundice (bilirubinemia) cloudy color: UTI, kidney stones

abscess

-infection arising in the anal canal and tracking out to the surface of skin near anal verge, occurs in deep tissue localized cavity of pus infected anorectal glans, characterized by persistent throbbing rectal pain, and appears red, hot, swollen, indurated, and tender -internal abscess: palpated as boggy area on rectal exam, must be incised and drained to prevent spread, recurrence, and formation of fistula

health promotion and patient teaching for breasts, axillae, and regional lymphatics

-some factors increase breast cancer significantly such as having a BRCA1 gene mutation, breast cancer awareness calculates risk of developing breast cancer within next 5 years, age at first period, age at time of birth of first child, family history of breast cancer, number of past present biopsies, number of breast biopsies showing atypical hyperplasia, and race ethnicity

objective data: the aging woman

-increasing age is primary risk factor for developing breast cancer -on inspection: breasts looks pendulous, flattened, and sagging, nipples retracted but can be pulled outward -on palpation: breasts feel more granular, terminal ducts around nipple feel more prominent and stringy, thickening of the inframammary ridge at lower breast is normal -woman older than 50 years have increased risk for breast cancer, problems with arthritis, limited ROM, or decreased vision that may inhibit self-care -talcum powder helps fingers glide over skin: aid to self-examination

hydrocele

-accumulation of fluid around testicle S: painless swelling, although person may complain of weight and bulk in scrotum O: inspection: enlarged mass does transilluminate with pink or red glow -palpation: nontender mass, able to get fingers above mass A: nontender swelling of testis -cystic, circumscribed collection of serous fluid in tunica vaginalis surrounding testis, occur following epipididymitis, trauma, hernia, tumor of testis

developmental competence of anus, rectum, and prostate

-adults: produce no more than one or two stools per day -prostate gland undergoes a rapid increase to more than twice its prepubertal size -benign prostatic hyperplasia (BPH): present in 80% of men over 60 years, imbalance between cell proliferation and programmed cell death (apoptosis) and growth creates bladder outlet obstruction because it constricts the urethra which impedes urine output

aging woman for breasts, axillae, and regional lymphatics

-after menopause ovarian secretion of estrogen and progesterone decreases which causes the breast grandular tissue to atrophy which is replaced with fibrous connective tissue -fat envelope atrophies marked in the woman's 70s and 80s -decreased breast size and elasticity so breasts droop and sag, looking flattened and flabby and inner structures more prominent (drooping: accentuated by kyphosis in some older women) -breast lump may been present for years but suddenly palpable -around nipple, lactiferous ducts are more palpable and feel firm and stringy because of fibrosis and calcification -axillary hair decreases

objective data aging adult for anus, rectum, and prostate

-as an aging person performs Valsalva manuever, note relaxation of perianal musculature and decreased sphincter color

risk factor profile for breast cancer

-breast cancer is second major cause of death from cancer in women -greater than 4: age 65+, biopsy confirmed atypical hyperplasia, two or more first degree relatives with breast cancer diagnosed at an early age -2..1-4.0: personal history of early onset less than 40 years old breast cancer -1.1-2.0: alcohol consumption, height, early menarche, obesity, high socieconomic status

prostate cancer testing

-detected by testing blood for prostate-specific antigen (PSA) and/or on digital rectal examination (DRE) -prostate gland: PSA made by normal prostate gland -when prosate cancer develps, PSA levels increase but benign or noncancerous enlargement of prostate, age, and prostatitis can cause PSA to increase -DRE: gloved lubricated finger being inserted into rectum

adults and aging adults for male genitourinary system

-does not experience a definite end to fertility -production of sperm begins to decrease around 40 years but continues into 80s and 90s -testosterone production decline after age 30 but very gradually -amount of pubic hair decreases and turns gray, penis size decreases due to decreased tone of the dartos muscle, scrotal contents hang lower, rugae decrease, and scrotum looks pendulous -testes decrease in size less firm to palpation -increased CT present in tubules so become thickened and produce less sperm -scrotal skin become excoriated if man continually sits on it -prostate undergoes an expected tissue hyperplasia in about 80% of men over 60 years, a benign prostatic hyperplasia causes an obstructed urine stream and risk for urinary tract infection -lower and less intense sexual response and an erection takes longer to develop and is less full or firm -ejaculation is shorter and less forceful, volume of seminal fluid is less than when the man was younger -withdrawal from sexual acitvity: loss of spouse, preoccupation with work, marital or family conflict, side effects of meds such as antihypertensives, psychotropics, antidepresants, antispasmodics, sedatives, tranquilizers, or narcotics, and estrogens, heavy use of alcohol, lack of privacy, economic or emotional stress, poor nutrition, or fatigue

anorectal fistula

-false passageway between anal canal and perianal skin which persists after perianal abscess drains anorectal abscess starts from an infected anorectal gland -occurs with Crohn disease or radiation therapy -persistent pain and swelling: abscess and sometimes painful and itch, feels like an indurated cord n bidigital palpation; may drain purulent or serosanguineous matter

aging woman for female genitourinary system

-female's hormonal milieu decreases rapidly, menopause is cessation of menses occurs around 48 to 51 years and wide variation of age from 35-60 years -preceding 1-2 years of decline in ovarian function shows irregular menses gradually become farther apart and produce a lighter flow -ovaries stop producing progesterone and estrogen, cells in the reproductive tract are estrogen dependent, decreased estrogen levels during menopause bring dramatic physical changes -uterus shrinks in size because of decreased myometrium -ovaries atrophy to 1-2cm and not palpable after menopause and ovulation may occur sporadically after menopause -sacral ligaments relax and the pelvic musculature weakens, uterus droops -cervix shrinks and looks paler with a thick, glistening epithelium -vagina: becomes shorter, narrower, and less elastic, without sexual activity with vagina atrophies to 1/2 its former length and width and its vaginal epithelium atrophies become thinnier, drier, and itchy resulting in fragile mucousal surface that is at risk for bleeding and vaginitis -decreased vaginal secretions leave vagina dry and risk for irritation and pain with intercourse (dyspareunia) -vaginal pH: becomes more alkaline and glycogen content decreases from decreased estrogen and increase risk for vaginitis because create a suitable medium for pathogens

health promotion and patient teacher for male genitourinary system

-gradual enlargement of prostate gland: normal part of aging -risk factors of testicular self- examination: 1) an undescended testicle, one that fails to move from belly into scrotum before birth, 2) family history of testicular cancer in a father or brother, 3) HIV infection, especially AIDS, 4) cancer in other testicle, 5) race and ethnicity: white men 4-5x more likely to develop testicular cancer than blacks or asians

objective data: male breast

-inspect the chest wall, noting skin surface and any lumps or swelling, palpate nipple area for any lump or tissue enlargement, should feel even with no nodules and palpate the axillary lymph nodes -normal male breast: flat disk of undeveloped tissue beneath tissue -gynecomastia: benign growth of this breast tissue, making it distinguishable from other tissues in the chest wall, feels smooth, firm, movable subareolar fibrous mass (occurs with use of anabolic steroids, meds, and cirrhosis) -male breast cancer: painless, firm, retroareolar lump, nipple discharge, ulceration, retraction, axillary lymphadenopathy

objective data for aging adult in female genitourinary system

-natural lubrication is decreased, use Pedersen speculum because its narrower, flatter blades more comfortable in women with vaginal stenosis or dryness -menopause: result decrease in estrogen production cause numerous physical changes, pubic hair gradually decreases becoming thin and sparse, skin is thinner and fat deposits decrease leaving mons pubis smaller and labia flatter with hanging appearance -clitoris size also decreases after age 60 years and rugae of vaginal walls decrease and walls look pale pink because of thinned epithelium -cervix shrinks and looks pale and glistening may retract appearing to flush with vaginal wall and may protrude into vagina if uterus prolapses -bimanual examination: insert only one gloved finger if vaginal stenosis exists, uterus feels smaller and firmer and ovaries are not palpable normally -for those with arthritis, taking mild analgesic or antiinflammatory before appointment: easy joint pain in positioning, schedule appointment times when joint pain or stiffeness, allow extra time for positioning and unpositioning -women ages 65+ years may choose to stop cervical cancer cancer if they have more than 3 consecutive negative Pap tests or more than 2 consecutive negative HPV within last 10 years, women with a total hysterectomy for benign may stop cervical cancer screening

rectal polyp

-occur anywhere in intestinal tract may e malignant or benign, protruding growth from the rectal mucous membrane that is fairly common, polyp may be pedunculated (on a stalk) or sessile (mound on surface, close to the mucosal wall, soft nodule is difficult to palpate -colonoscopy, removal, and biopsy screen for a malignant growth, removal of adenomatous polyps shown to prevent deaths from colorectal cancer and larger sizes of polyps increase risk of cancer

objective data for male genitourinary system

-patient: may fear erection during examination, laugh occasionally and make jokes to cover embarassment, refuse examination by female -nurse: use firm deliberate touch, demeanor: confident and relaxed, if erection occurs continue examination 1) inspect and palpate penis: skin normally looks wrinkled, hairless, and without lesions, dorsal vein apparent, glans smooth and without lesions -phimosis: narrowed opening of prepuce so cannot retract the foreskin -paraphimosis: painful constriction of glans by retracted foreskin -hypospadias: ventral location of meatus -epispadias: dorsal location of meatus 2) inspect and palpate hernia: inspect inguinal region for bulge as person stands and strains down 3) self-care testicular self examination (TSE): teach every male, 13-14 years old through adulthood how to examine his own testicles, occurs in young men age 15-35 (best time during shower or bath when your hands are warm and soapy and scrotum is warm -hold scrotum in palm of hand and feel testicle gently using thumb and first two fingers (testicle: egg shaped, movable, rubbery with smooth surface, abnormal lumps rare, feel firm, painless lump, hard area, overall enlarged testicle contact physician T: timing, once a month S: shower, warm water relaxes scrotal sac E: examine, check for changes, report changes immediately 4) assess urinary function: urinalysis shows color of pale yellow to amber caused by presence of urochrome pigments -normal urine: clear and slightly acidic with a pH range of 4.5 to 8.0 -specific gravity: measures concentration of urine, dilute at 1.003 to concentrated at 1.030, no little or no protein, no glucose, and fewer than 5 RBCs or WBCs

male genitalia

-penis and scrotum externally -testis, epididymis, and vas deferens internally -glandular structures to the genital organs: prostate, seminal vesicles, and bulbourethral glands

health promotion and patient teaching for anus, rectum, and prostate

-prostate specific antigen (PSA): a small protein made only by prostate gland when it is metabolically active and check to see a rise in PSA level -colorectal cancer: most common diagnosed cancer in the US but can be detected at a curable stage in people who having no warning symptoms (colonoscopy: precancerous polyps which is removed during test decreasing the risk -HPV: most common sexually transmitted infection causing genital or anal cancers

objective data for anus, rectum, and prostate

-rectal pain: local disease, irritation, rock hard constipation, rectal fissures or thrombosed hemorrhoids -rectal positions: left lateral, lithotomy or standing 1) inspect perianal area: instruct person to hold breath and bear down by performing a Valslva maneuver, no break in skin integrity or protrusion through anal opening should be present 2) prostate gland: surface should feel smooth and muscular, check for nodule and diffuse firmness 1) size: 2.5cm long by 4cm wide, should not protrude more than 1cm into rectum 2) shape: heart shape, with palpable central groove 3) surface: smooth 4) consistency: elastic, rubbery 5) mobility: slightly movable 6) sensitivity: nontender to palpation -in females: palpate cervix through anterior rectal wall, feels small with a round mass 3) examination of stool: test stool on glove for occult blood, negative response normal, if stool is Hematest positive indicates occult blood

male breast

-rudimentary structure consisting of a thin disk of undeveloped tissue underlying nipple, areola is well developed -gynecomastia: during adolescence, it is common for breast tissue to temporarily enlarge, condition usually unilateral and temporary, may reappear in aging male and may be due to testosterone deficiency. -reassurance is necessary for adolescent male, whose attention is riveted on his body image.

prostate

-secretes a thin, milky, alkaline fluid that supports sperm -prostate gland: lies in front of anterior wall of rectum and 2cm behind the symphysis pubis which surroundes the bladder neck and urethra has 15-30 ducts that opens into urethra -two seminal vesicles project that secrete a rich fluid in fructose which nourishes sperm and contains prostaglandins -two bulbourethral Cowper's glands located inferior to prostate on either side of urethra secretes a clear, viscid mucus

cancer

-solitary, unilateral, 3 dimensional, usually nontender mass, solid, hard, dense and fixed to underlying tissues or skin as cancer becomes invasive, borders irregular poorly delineated and grows constantly -required diagnostic mammogram for those over age 30 years of age, most common in upper outer quadrant, signs: skin dimpling, nipple retraction, elevation, and discharge

fissure

-split in skin at anal verge causing severe pain and bleedimg with bowel movements an exquisitely painful longitundinal tear in the superficial mucosa at the anal margin, most greater than 90% occur in the posterior midline area, pain with passing stool described as passing "shards of glass" may have bright red blood in the stool -inspection shows as acute: having sharp enlarge edges and a chronic fissure as indurated and accompanied by a papule of skin, sentinel tag, on the anal margin below or polyp above -caused by trauma, ischemia, and elevated anal pressure, constipation, obesity, and hypothyroidism, medical treatments: stool softeners, nitroglycerin ointmetn, topical nifedipine or dilitiazem cream, but injection of botulinum toxic into internal and sphincter

aging adult objective data for male genitourinary system

-thinner, graying pubic hair and decreased size of penis -size of testes may be decreased and may feel less firm -scrotal sac pendulous with less rugae, scrotal skin may become excoriated if man continually sits on it

culture and genetics for breasts, axillae, and regional lymphatics

-women who inherit a mutations of BRCA1 and BRCA2 on one or both have a higher risk of developing breast or ovarian cancer -different risks linked to breast cancer related to age and ethnicity variable -black women higher rates of aggressive triple negative breast cancer and lowest survival rate due to poverty, lower education levels, and a lack of health insurance, geographic, cultural and language barriers, and racial bias -Women's Health Initative study looked at increased risk linkage xth use of combined hormone replacement therapy and development of breast cancer -"alcohol/Western" dietary pattern: linked to increased risk of breast cancer, especially with estrogen or progesterone + tumors -"Mediterranean" dietary pattern: linked to a modest protective effect against breast cancer -mammography: annual screening for those ages 40-44

additional history for aging adult for female genitourinary system

1) after menopause, noted any vaginal bleeding 2) any vaginal itching, discharge, pain with intercourse, tried any products, lubricants, estrogen cream or vaginal tablet 3) any pressure in genital area, loss of urine with cough or sneeze, back pain, or constipation -occurs with weakened pelvic musculature and uterine prolapse 4) are you in relationship involving sex now, aspects of sex satisfactory to you and your partner, adequate privacy for sexual relationship -postmenopausal bleeding: warrants pelvic exan, transvaginal, ultrasonography, and referral -vaginal dryness, decreased lubrication: common with decreased estrogen

regional structures

1) anal canal and rectum is 16cm in adult 2) sigmoid colon named from its S shaped course in the pelvic cavity, accessible to examination through colonoscope

additional history for aging adult for male genitourinary system

1) any difficulty urinating? hesitancy and straining? weakned force of stream, any dribbling, incomplete emptying? 2) do you ever leak waterurine when you don't want to? use pads tissue to catch urine in underwear? -incontinence: involuntary leaking of urine 3) do you need to get up at night to urinate? meds taking? fluids drink in the evening? -nocturia: diuretic meds, habit, or fluid ingestion 3 hrs before bedtime, coffee and alcohol -fluid retention: mild heart failure or varicose veins produces nocturia because recumbency at night mobilizes fluid 4) is it all right to ask you about your sexual function? change in ability to have an erection

culture and genetics for female genitourinary system

1) cervical cancer: most common cancer among women globally, 2nd most common cancer in less developed countries and 3rd leading cause of death in women -in the united states: rates decreased substantially since the introduction of Pap test screening in the 1950s and HPV testing - higher among black women and lower relative survival rates than whites due to 1) presenting with cancer at later stages and being less likely to receive the best treatment due to patient refusal, 2) inappropriate physician recommendation, 3) poorer health, and 4) comborid conditions -decrease cervical cancer rates in older southern black women 2) HPV vaccine: steep declines in teenage girls and young women causes all cervical cancers, vulvar, vaginal, anal, and oropharyngeal cancers in females and penile cancers in males

culture and genetics for male genitourinary system

1) circumcision: made early in pregnancy and is an elective surgical procedure to remove all part of the foreskin (prepuce) from the penis (medical benefits: reduced risk of acquiring HIV infection through heterosexual contact, reduced risk of UTI in infancy and adults a reduced risk of STIs, decreased risk of bacterial vaginosis and trichomoniasis in female partners) -religious and cultural indications for circumcision, prevention of phimosis and inflammation of glans penis and foreskin, decreasing incidence of cancer of penis 2) kidney disease: chronic kidney disease (CKD): determined by blood tests, urinalysis, and imaging studies that show decreased kidney function or kidney damage lasting 3 months or longer, lead to end stage renal disease when person survives only by kidney transplant or dialysis (more common with blacks, american indians, asians, and hispanics) -2 main causes of end stage renal disease (ESRD): diabetes and hypertension due to smoking, high alcohol intake, high sedentary time, unhealthy diet, higher proportion of comorbid conditions such as obesity and hypercholesterolemia, no health insurance, and no routine health care visits 3) bladder cancer: 4th most common cause of cancer in men from smoking, occupational exposure to aniline dyes and other chemicals used in the textile, paint, plastic, printing, and rubber industries (common in whites and initial sign is painless hematuria

subjective data for male genitourinary system

1) frequency, urgency, and nocturia: urinating more than usual, feel as if you cannot wait to urinate, awaken during night because need to urinate? -frequency: average adult voids 3-6 times a day varying with fluid intake and individual habits -polyuria: excessive quantity -oliguria: diminished, greater than 400mL/24 hrs -nocturia: occurs together with frequency and urgency in urinary tract disorders (cardiovascular, habitual, diuretic medication) 2) dysuria: any pain or burning with urinating? -dysuria: burning common with acute cystitis, prostatitis, urethritis 3) hesitancy and straining: trouble starting urine stream, need to strain to start or maintain stream, change in force of stream: narrowing, becoming weaker? dribbling, afterward still feel like need to urinate, ever had an UTI? 4) urine color: is it clear, or discolored, cloudy, foul-smelling, bloody? -cloudy urine: UTI -hematuria may signal glomerulonephritis or cancers of prostate or bladder 5) past GU history: any difficulty controlling urine, accidentally urine when sneeze, laugh, cough, or bear down? history of kidney disease, kidney stones, flank pain, UTI, prostate trouble -urge incontinence: involuntary urine loss from overactive detrusor muscle in bladder -stress incontinence: involuntary urine loss with physical strain, sneezing, or coughing caused by weakness of pelvic floor 6) penis: problems with penis: pain or lesion? any discharge, how much, color, odor, discharge associated with pain or urination> -urethral discharge: infection 7) scrotum, self-care behaviors: any problem with the scrotum or testicles, lump or swelling on testes, change in size of scrotum, any bulge or swelling in scrotum, how long, ever told had a hernia, heavy feeling in scrotum 8) sexual activity and contraceptive use: are you in a relationship involving sexual intercourse now? sex satisfactory, any changes in erection when aroused? use condoms or contraceptives? how many sexual partners had in past 6 months? what is sexual preference? 9) STI contact: any sexual contact with partner having STI such as gonorrhea, herpes, HIV, chlamydia, HPV, venereal warts, syphilis? when? how was it treated, do you use condoms to help prevent STIs

inguinal/femoral hernia

1) indirect inguinal: sac herniates through internal inguinal ring; can remain in canal or pass into scrotum, pain with straining soft swelling that increases with intra-abdominal pressure may decrease when lying down (congenital or acquired) 2) direct inguinal: directly behind and through external inguinal ring above inguinal ligament rarey enters scrotum, usually painless round swelling close to the pubis in area of internal inguinal ring, reduced when supine (acquired weakness, brought on by heavy liftingl muscle atrophy, obesity, chronic cough, or ascites 3) femoral: through femoral ring and canal below inguinal ligament, pain may be severe may become strangulated (acquired due to increased abdominal pressure, muscle weakness, or frequent stooping)

teach Breast Self-Examination (BSE)

1) lie down, press the 3 middle fingers in a circular motion and use 3 levels of pressure, following an up and down pattern 2) sit up examine underarm with arms slightly raised 3) note surface changes with hands pushed on hips, shoulders hunched -best time to perform BSE is right after menstrual period (day 4 to 7 of the cycle) when the breasts are smaller and less congested, person who does not have her period should choose a familiar date such as the first of the month and give pamphlet, palpate while in shower where soap and water assist palpation or lie supine watch her palpate her own breasts while you monitor her technique

subjective data for female genitourinary system

1) menstrual history: tell me about your menstrual periods, date of last menstrual periods, age of first period, how often, how many days does period last, usual amount of flow: light, medium, heavy? pads or tampons do you use each day, clotting, pain or cramps before or during period, how do you treat it, interfere with daily activities, associated symptoms: bloating, breast tenderness, moodiness, spotting between periods -menarche: mean age at onset at 12-13 years, delayed onset suggests endocrine or underweight problems -cycle: normally every 28 days varies from 18-45 days -amenorrhea: absent menses -menorrhagia: heavy menses -clotting indicates heavy flow or vaginal pooling -dysmenorrhea: responds to ibuprofen because it works on uterine smooth muscle 2) obstetric history: have you ever been pregnant? how many times, how many babies have you had, any miscarriage or abortion, describe pregnancy, pregnant now, any symptoms? -gravida: number of pregnancies -para: number of births -abortions: interrupted pregnancies, including elective abortions and spontaneous miscarriages 3) menopause: cessation of menstruation -perimenopausal period: age 40 to 55 years has hormone shifts resulting in vasomotor instability -side effects of hormonal therapy include fluid retention, breast pain, vaginal bleeding, and cardiovascular and breast cancer risk 4) patient-centered care: how often do you have a gynecologic checkup? recommended screening for cervical cancer prevention by age: 1) no Pap tests if under 21 years, regardless of sexual activity, 2) Pap test once every 3 years for women ages 21-30 years, 3) HPV and Pap co-testing every 3 years for women ages 30-65 years, last Pap test results? chlamydial infection screening in all sexually active women under 25 years and in older women with new sex partner, more than one sex partner, or sex partner with other partners with first catch urine -chlamydia: most frequent STI in US and has serious sequelae from lack of treatment: PID, ectopic pregnancy, infertility 5) acute pelvic pain: any pain in lower abdomen or pelvis, when did it start, constant or come and go, associated with periods, on scale 1-10 how would rate pain -acute pain: greater than 3 months occurs with pelvic inflammatory disease (PID), appendicitis, ruptured ovarian cysts, ovarian torsion which need transvaginal ultrasound imaging 6) urinary symptoms: problems with urinating, frequently and small amounts, sudden urge; cannot wait to urinate, burning or pain on urinating, awaken during night to urinate, blood in urine, urine dark, cloudy, foul smelling, difficulty controlling urine or wetting yourself, urinate with sneeze, laugh, cough, bearing down -urinary incontinence: decrease quality of life, limit activities, and increase falls and fracture risk -hematuria: occurs with UTI, bile in urine or UTI and kidney disease -urge incontinence: overactive detrusor muscle in bladder -stress incontinence: involuntary urine loss with physical strain, sneezing, or coughing 7) vaginal discharge: unusual vaginal discharge, increased amount, character or color: white, yellow-green, gray, curdlike, foul smelling, when did it begin, discharge associated with vaginal itching, rash, pain with intercourse, any meds, family history of diabetes, use a vaginal douche, how often, use feminine hygiene spray? -frequent douching: alters pH and spray: risk for contact dermatitis 8) past history: other problems in genital area, sores or lesions, how were treated, abdominal pain, past surgery? 9) sexual activity: sexual relationship and how it affects their health, are in relationship involving sex, aspects of sex satisfactory or communication to you and partner 10) contraceptive use: currently planning a pregnancy or avoiding pregnancy, do you use contraceptive, any problems? 11) STI contact: any sexual contact with partner having an STI such as gonorrhea, herpes, HIV/ AIDS, chlamydia, venereal warts, syphilis

subjective data for breasts, axilla, and regional lymphatics

1) pain: any pain or tenserness in the breasts, when where, localized or all over? painful spot sore to touch, pain cylic ? brought on by strenuous activity , change in activity, part of underwire, exercise -mastalgia: trauma, inflammation, infection, and benign breast disease -cyclic pain: common with normal breasts, oral contraceptives, and benign breast (fibrocystic) disease 2) lump: ever noticed a lump or thickening in the breast, where? when notice it, changed it all since then, any relation with menstrual period, noticed any change in overlying skin: redness, warmth, dimpling, and swelling 3) discharge: any discharge from nipple? when first notice it, what color, consistency, bloody and odor? -galactorrhea: milky nipple discharge, medication cause clear nipple discharge: oral contraceptives, phenothiazines, diuretics, digitalis, steroids, methyldopa, calcium channel blockers 4) rash: any rash on breast? when first notice it, when did it start, on nipple, areola, or surrounding skin? -Paget disease: starts with a small curst on the nipple apex and spreads to areola -eczema or other dermatitis rarely starts at the nipple unless caused by breast feeding 5) swelling: any swelling in breasts, one spot or all over, related to menstrual period, pregnancy or breast feeding, change in brest feeding? 6) trauma: any trauma or injury to the breasts? did it result in any swelling, lump, or break in skin? -lump from an injury (seat belt injury, direct blow) caused by local hematoma or edema and resolves shortly 7) history of breast disease: any history of breast disease yourself, what type, how was it diagnosed, when did it occur, how is it being treated, any breast cancer in family? -past breast cancer increases risk for recurrent cancer -presence of benign brease disease makes breasts harder to examine -breast cancer occuring before menopause in certain family members increases risk 8) surgery or radiation: ever had surgery on the breasts, was it a biopsy, what were results? mastectomy, mammoplasty, radiation to chest, age? -biopsy-confirmed atypical hyperplasia increases breast cancer risk -female lymphoma survivors: treated with chest or axillary radiation between 10 and 30 years of age are high risk of breast cancer 9) medications: have you taken any oral contraceptives, how long? hormone replacement therapy, estrogen and progestin, how long, do you drink alcohol, days per week? 10) patient centered care: have you ever been taught breast self-examination, how often do you perform it, ever had mammography, a screening x-ray image of breasts, screening mammography begins at ages 40-44 years, annual mammography over age 55 years axilla: 1) tenderness, lump, or swelling: tenderness or lump in underarm area, when did first notice it? -breast tissue extends up into axilla, axilla contains many lymph nodes 2) rash: axillary rash, describe it, seem to be a reaction to deodarant?

objective data for female genitourinary system

1) position: place woman in lithotomy position with examiner sitting on stool, help woman into supine position with feet in stirrups and knees apart and buttocks at edge of examining table elevate head to 45 degrees and arms on side or across chest -help woman relax, decrease anxiety, retain a sense of control by: 1. have her empty bladder before examination 2. position examination table so perineum is not exposed 3. ask if she would like a friend, family member but position person by woman's head to maintain privacy 4. elevate her head and shoulders to a semisitting position to maintain eye contact 5. place stirrups so legs are not abducted too far 6. explain each step before doing it 7. assure woman she can say stop 8. use gentle, firm touch and gradual movements 9. communicate through examination 10. use technique of educational or mirror pelvic 2) inspect and cervix and its os: 1) color: pink and even, 2nd month of pregnancy it looks blue (Chadwick sign), and after menopause is pale 2) position: midline, either anterior or posterior, projects 1-3cm into the vagina 3) size: diameter in 2.5cm (1 inch) 4) os: small and round in nulliparous woman, parous woman: horizontal, irregular slit and show healed lacerations on sides 5) surface: smooth, but cervical eversion or ectropion may occur normally after vaginal deliveries, endocervical canal is everted or rolled out looks red, beefy halo inside pink cervix surrounding the os -nabothian cysts: benign growths that commonly appear on the cervix after childbirth which are small, smooth, yellow nodules, may be single or multiple 6) note cervical secretions: depending on day of menstrual cycle, secretions may clear and thin or thick, opaque, stringy, odorless and nonirritating 3) obtain cervical tests and cultures: Pap test screens for cervical cancer do not obtain during the woman's menses or if heavy infectious discharge is present, instruct woman not to douche, have intercourse, or put anything into vagina with 24hrs before collecting specimens use liquid based 4) testing for STIs: note any abnormal vaginal discharge: obtain gonorrhea/chlamydia culture: insert cotton applicator into os, rotate 360 degrees, leave in place 10-20 seconds 5) bimanual examination: rise to stand and have woman remain in lithotomy position, drop lubricant onto the first two fingers of regloved intravaginal hand, first two fingers extended last two reflexed onto palm and thumb abducted and insert fingers into vagina and wait for relax then insert fingers fully -cervix: midline, consistency: smooth and firm and velvety at 5-6 weeks of pregnancy, contour evenly round, mobility: with a finger on either side, move cervix gently from side to side producing no pain 6) rectovaginal examination: use this technique to assess rectovaginal septum, posterior uterine wall, cul-de-sac, and rectum, lubricate first two fingers and instruct woman which may feel uncomfortable and will mimic feeling of moving her bowels and ask to bear down as insert your index finger into vagina and middle finger gently into rectum -should feel thin, firm, pliable, and smooth, uterine wall and fundus feel firm and smooth

culture and genetics of anus, rectum, and prostate

1) prostate cancer (PC): most frequently diagnosed cancer in men, heterogenous, common in north america and NW europle many are indolent, nonlethal, and slow growing and aggressive, known risk factors: age, African ancestry, obesity, family history, and inherited mutations of BRCA1 and BRCA2 genes, heavy in red meat or high fat dairy products -not smoking, keeping healthy body weight, and maintaining regular vigorous exercise seem to delay prostate cancer progression, tomatoes rich in antioxidant lycopene, broccoli, cauliflower, healthy sources of vegetable fats, and may reduce risk of cancer progression -high risk screening age 45 2) colorectal cancer (CRC): higher in black women and men and Alaska Natives, bleeding most common, those under 50 years, begin screening at age 50 for those at average risk but earlier with family history -hereditary factors includes family history, inherited genetic Lynch syndrome (hereditary nonpolyposis colorecta cancer), familial polyposis, personal history of chronic inflammatory bowel disease (ulcerative colitis or Crohn disease) type 2 diabeters

objective data for breasts, axillae, and regional lymphatics

1) symmetry of the breast: assymmetry in size is normal (left slightly larger) 2) skin: normally looks smooth and even color, localized areas of redness, bulging or dimpling, skin lesions or focal vascular pattern (fine blue vascular and pale linear striae or stretch marks follow pregnancy), no edema present, edema exaggarates hair follicles giving a pigsin or orange peel also called peau d'orange 3) lymphatic drainage areas: axillary and supraclavicular regions, note any bulging, discoloration, or edema 4) nipple: symmetric, usually protrude, normal nipple inversion may be unilateral or bilateral and can be pulled out, note dry scaling, fissure or ulceration and bleeding or other discharge -supernumerary nipple: normal and common variations, extra nipple along the embryonic milk line on thorax or abdomen is a congenital finding, usually 5-6cm below breast near midline and no associated grandular tissue, looks like a mole 5) inspect and palpate the axillae: axillae while woman sitting, note any rash or infection, palpate the left axilla and high into axilla, move them firmly down in four directions: 1) down chest wall in line from middle of the axilla, 2) along the anterior border of the axilla, 3) along the posterior border, 4) along the inner aspect of the upper arm, nodes are not palpable but may feel small, soft, nontender, expect some tenderness high in axilla 6) palpate breasts: supine position (on the back), small pad under side to be palpated and raise her arm over her head which flattens the breast tissue and displace it medially, -for pendulous breasts: use bimanual technique, sitting position leaning forward, support inferior part of breast with one hand and palpate breast tissue against supporting hand rotate her hips opposite to side you are palpating and use pads of first 3 fingers making a gentle rotary motion on the breast (vertical strip pattern best way to detect a mass to start high in axilla and palpate down the midaxillary line just lateral to breast down to the bra line *if breast lump discovered, examined unnaffected breast first to learn a baseline of normal consistency 1) location: describe distance in cms from nipple 2) size: judge in cms in 3 dimensions w x length x thickness 3)shape: oval, lobulated, round, or indistinct 4) consistency: lump firm, soft, or hard 5) movable: freely movable or fixed 6) distinctness: lump solitary or multiple 7) nipple: displaced or retracted 8) skin over lump: erythematous, dimpled, or retracted 9) tenderness: tender to palpation 10) lymphadenopathy: regional lymph nodes palpable -premenstrual engorgement normal from increasing progesterone which consists of slight enlargement, tenderness to palpation, and generalized nodularity, lobes feel prominent, and margins more distinct -normally feel firm, transverse ridge of compressed tissue in the lower quadrants called inframammary ridge -premenstrual women normal also has tissue edema and mastalgia makes it hard to detect lesion, if findings questionable do follow up examination the first week after her menses when hormone levels are lower and edema not present -women with mastectomy: gentle around scar area, no inflammation or infection, lymphedema of upper arms is common because of interruption of lymphatic drainage and removal of nodes

subjective data for anus, rectum, and prostate

1) urine bowel routine: bowels move regularly, how often, usual color, hard or soft? straining at sole, imcomplete, urge to have bowel movement but noting comes, pain? -constipation: less than 3 stools per week, straining, lumpy or hard stools, incomplete, sensation of blockage, risks: older age, women, inactivity, decreased GI mobility, not enough fiber and water -dyschezia: pain due to local condition (hemorrhoid, fissure) or constipation 2) change in bowel habits: any loose stools or diarrhea, when did it start, how long has it lasted, how severe, number of stools per day, character: watery, bloody, mucus-filled, purulent? nausea, vominting, abdominal pain -diarrhea: gastroenteritis, colitis, irritable colon syndrome, risks include: childcare center, eating raw shellfish, undercooked meat or eggs, contaminated water -noninflammatory diarrhea: milder and viral and noninflammatory diarrhea: more severe and bacterial: associated with travel, foodborne illness, fever, abdominal pain, dehydration -E. coli: most frequent cause of traveler's diarrhea, Clostridium difficule: explosive diarrhea 3) rectal bleeding, blood in the stool: every had black or bloody stools, when did you first notice blood in stools, what is the color: bright red or dark red-black, how much blood, do bloody stools have particular smell? mucus or pus in stool, need to pass gas frequently? -black stools: tarry due to occult blood (melena) from GI bleeding or nontarry from indigestion of iron medications -red blood: GI bleeding, local bleeding around anus, with colon, and rectal cancer -clay color: absent bile pigment, biliary cirrhosis, gallstones, alcoholic or viral hepatitis -steatorrhea: excessibe fat in stool, malabsorption as in celiac disease, cystic fibrosis, chronic pancreatitis, Crohn disease 4) medications: which medcations do you take, prescription and over-the-counter, laxatives or stool softeners, how often, iron pills, do you ever use enemas to move bowels? 5) rectal conditions: any problems in rectal area: ithcing, pain, or burning, hemorrhoids? how do treat these, had a fissure or fistula, how was it treated? -symptomatic hemorrhoids: pruritus, painless, rectal bleeding, red blood on tissue or in bowl -fissure: painful bowel movements like shards of glass -fecal incontinence: leaking of solid or liquid stool involuntarily -mucoid discharge and soiled underwear: prolapsed hemorrhoids 6) family history: any family history: polyps or cancer in colon or rectum, inflammatory bowel disease, bowel disease, prostate cancer? 7) patient-centered care: usual amount of high fiber foods in daily diet: cereals, apples or other fruits, vegetables, whole-grain breads, glasses of water do you drink each day? date of last: digital rectal examination, stool blood test, colonoscopy, prostate-specific antigen blood test -high fiber foods of soluble type: beans, prunes, barley, carrots, broccoli, cabbage and lower cholesterol levels and insoluble fiber foods: cereals, wheat germ reduce risk for colon cancer (fight obesity, stabilize blood sugar, and help some GI disorders) -colonoscopy: after age 50 years then every 10 years, fecal occult blood: annually after age 50 years, 45 for blacks and PSA blood test

internal genitalia of female

1) vagina: flattened, tubular canal extending from orifice up and backward into the pelvis , 9cm long and sits between rectum posteriorly and bladder and urethra anteriorly 2) rugae: thick transverse folds which enables the vagina to dilate widely during childbirth 3) cervix: at end of canal, projects into the vagina, -nupillarous female: cervix appears as a smooth doughnut shape with a small circular hole or os which is slightly enlarged, irregular, endocervical canal lined with columnar epithelium that looks red and tough after childbirth -covered with smooth, pink, stratified squamous epithelium -anterior and posterior fornix: continuous recess present around the cervix, and in front and back, posterior: deep recess formed by peritoneum 4) rectouterine pouch or cul-de-sac of Douglas: anterior and posterior fornix dips down between the rectum and cervix 5) uterus: pear-shaped, thick-walled, muscular organ and is flattened anteroposteriorly and freely movable, not fixed, and usually tilts forward and superior to the bladder called anteverted and anteflexed 6) fallopian tubes: two pliable, trumpet-shaped tubes, extending from the uterine fundus laterally to the brim of the pelvis 7) ovaries: curve posteriorly where their fimbriated ends, located on each side of the uterus at the level of the anterior superior iliac spine, oval shaped and serves to develop ova (eggs) and female hormones

external genitalia of female

1) vulva: also called the pudendum 2) mons pubis: round, firm pad of adipose tissue covering the symphysis pubis after puberty covered with hair in pattern of an inverted triangle 3) labia majora: two rounded folds of adipose tissue extending from the mons pubis down and around to the perineum and after puberty hair covers the outer surfaces of the labia, whereas the inner folds are smooth and moist and contain sebaceous follicles 4) labia minora: labia majora are two smaller, darker folds of skin, joined anteriorly at the clitoris where form hood or prepuce which is joined posteriorly by a transverse fold called the frenulum 5) clitoris: small, pea-shaped erectile body, homologous with male penis and highly sensitive to tactile stimulation 6) vestibule: labial structures encircle a boat-shaped or cleft 7) urethral meatus: appears as dimple 2.5cm posterior to the clitoris 8) paraurethral (Skene) glands: surrounding the urethral meatus and is tiny, multiple, open posterior to the urethra at the 5 and 7 o'clock positions 9) vaginal orifice: posterior to the urethral meatus, appears either as a thin median slit or large opening with irregular edges 10) hymen membranous, thin, circular or crescent shaped fold may cover part of vaginal orifice or may be absent completely 11) vestibular (Bartholin) glands: on either side and posterior to the vaginal orifice which secrete a clear lubricating mucus during intercourse, ducts not visible but open in groove between the labia minora and hymen

additional history for menopausal women for breasts, axillae, and regional lymphatics

1. have you noticed any change in breast contour, size, or firmness -decreased estrogen level causes decreased firmness, rapid decrease in estrogen level causes actual shrinkage

rectum

12 cm long, distal portion of the large intestine, extends from the sigmoid colon at the level of the 3rd sacral vertebra and ends at the anal canal -dilates and turns posteriorly forming the rectal ampulla, rectal interior has 3 semilunar transverse folds called the valves of Houston to hold feces as flatus passes -these cross one-half circumference of rectal lumen and lowest within reach of palpation and must not be mistaken for an intrarectal mass

Chapter 26

Anus, Rectum, and Prostate

Chapter 18

Breasts, Axillae, and Regional Lymphatics

Chapter 27

Female Genitourinary system

Chapter 25

Male Genitourinary System

human papillomavirus (HPV)

O: virus can appear in various forms when affecting cervical epithelium, warty growth appears as abnormal thickened white epithelium -visibility of lesion is enhanced by acetic acid (vinegar) wash which dissolves mucus and temporarily causes intracellular dehydration and coagulation of protein and will progress to cervical cancer if not treated

uterine prolapse

O: with straining or standing, uterus protrudes into vagina, nontender, nonfluctant, smooth hemisphere, may cause a broad based gait, -prolapse is graded: 1st degree: cervix appears at introitus with straining; 2nd degree: cervix bulges outside introitus with straining; 3rd degree: cervix enlarged, edematous, protrudes markedly and without straining

carcinoma of endometrium

S: abnormal and intermenstrual bleeding before menopause; postmenopausal bleeding or mucosanguineous discharge, pain and weight loss occur late in the disease. O: uterus may be enlarged -Pap test rarely effective in detecting endometrial cancer, women with abnormal vaginal bleeding or at high risk should have an endometrial tissue sample, risk factors: early menarche, late menopause, history of infertility, failure to ovulate, tamoxifen, unopposed estrogen therapy, and obesity

cervical cancer

S: bleeding menstrual periods, after sex, after menopause, unusual vaginal discharge O: chronic ulcer and induration are early signs of carcinoma, although lesion may or may not show on the exocervix -diagnosed by Pap test and biopsy, caused by persistent HPV infection, risk factors are early age at first intercourse, multiple sex partners, cigarette smoking, undetected HPV

endometriosis

S: cyclic or chronic pelvic pain, occuring as dysmenorrhea or dyspareunia, low backache, may have irregular uterine bleeding, hypermenorrhea, or be asymptomatic O: uterine fixed, tender to movement, small firm nodular masses tender to palpation on posterior aspect of fundus, uterosacral ligaments, ovaries, sigmoid colon, and ovaries enlarged -masses are aberrant growths of endometrial tissue scattered throughout pelvis, probably transplanted tissue by retrograde menstruation, ectopic tissue responds to hormone stimulation; builds up between periods, sloughs during menstruation and may cause infertility from pelvic adhesions, tubal obstruction, decreased ovarian function

testicular torsion

S: excruciating unilateral pain in testicle of sudden onset often during sleep or following trauma may also have lower abdominal pain, nausea and vomiting O: inspection: red, swollen scrotum, one testis (usually left) higher owing to rotation and shortening -palpation: cord feels thick, swollen, tender; epididymis may be anterior, cremasteric reflex absent on side of torsion -sudden twisting of spermatic cord, blood supply cut off resulting in ischemia and engorgement -doppler ultrasound decreases blood flow

rectocele

S: feeling of pressure in vagina, possibly constipation O: with straining, note introitus widening and presence of soft, round bulge from posterior, rectum covered by vaginal mucosa which prolapses into the vagina

cystocele

S: feeling of pressure in vagina, stress incontinence O: with straining, note introitus widening and presence of soft, round anterior bulge, bladder covered by vaginal mucosa which prolapses into the vagina

urethritis and UTI

S: inflamed urethra and UTI present with dysuria, frequency, urgency, flank of suprapubic pain, older adults may only have communication problems, confusion, and lethargy O: anterior vaginal wall shows erythema, pain along urethra, maybe purulent discharge, E. coli is most common frequent cause and should receive antibiotics where there is a growing emergence of resistant organisms -urine culture is use to diagnose UTI because asymptomatic bacteria common in older people

Solid Ovarian Mass - Ovarian Cancer

S: may have abdominal pain, increased abdominal size, bloating, GI symptoms, may be asymptomatic O: may or may not palpate solid tumor on ovary, heavy solid fixed poorly defined, benign mass may feel mobile and solid -biopsy needed to distinguish the two types of masses. Pap smear doesn't detect

atrophic vaginitis

S: postmenopausal vaginal itching, dryness, burning sensation, dyspareunia, mucoid discharge (may be flecked with blood), postcoital bleeding, symptoms occur gradually due to thinning of epithelial layers O: pale mucosa with abraded areas that bleed easily; decreased rugae, may have bloody discharge, decrease in usual shiny vaginal secretions, vagina may be shortened and narrowed, cervix may be less protuberant, estrogen normally keeps thick, moist, rugated, glycogen rich so loss of estrogen creates sign and increases risk for trauma and infection

benign prostatic hyperplasia (BPH)

S: urinary frequency, urgency, hesitancy, straining to urinate, weak stream, intermittent stream, sensation of incomplete emptying, nocturia O: symmetric nontender enlargement; commonly occur in males beginning in middle years, prostate surface feels smooth, rubbery, or firm (like the consistency of nose), with the median sulcus obliterated

fluctant ovarian mass: ovarian cyst

S: usually asymptomatic when cyst is large can be painful may have dyspareunia O: bimanual palpation shows smooth, round, fluctant, mobile, nontender mass on ovary, ultrasound image shows location of cyst, follicular cyst most common: follicle around ovum does not burst as usual to release egg but grows into cyst

myomas (leiomyomas, uterine fibroids)

S: varies depending on size and location, symtoms include vague discomfort, bloating, heaviness, pelvic pressure, dyspareunia, urinary frequency, backache, headache, or excessive uterine bleeding resulting anemia O: uterus irregularly enlarged, firm, mobile, nodular with hard, painless nodules in uterine wall, heavy bleeding produces anemia -estrogen dependent after menopause

dimpling

The shallow dimple (also called a skin tether) sign of skin retraction, cancer causes fibrosis, which contracts the suspensory ligaments, may be apparent at rest, with compression, or with lifting of the arms. *note the distortion of the areola here as the fibrosis pulls the nipple toward it*

pilonidal cyst

a hair-containing cyst or sinus located in the midline over the coccyx or lower sacrum often opens as a dimple with visible tuft of hair and possible an erythematous halo or may appear as a palpable cyst, when advanced, has a palpable sinus tract although a congenital disorder diagnosed between 15 and 30 years

nipple

below center of the breast, rough, round, and usually protuberant; its surface looks wrinkled and indented with tiny milk duct openings

gynecomastia

bengin enlargement of male breast occurs when estrogen concentration exceeds testosterone levels, mobile disk of tissue located centrally under nipple areola, bilateral tender, firm -occurs with Cushing syndrome, liver cirrhosis, adrenal disease, hyperthyroidism, alchohol and marijuana, estrogen treatment for prostate cancer, and anitbiotics

fibroadenoma

benign mass, most commonly self- detected in late adolescence and early adulthood, solitary nontender mass that is solid, firm, rubbery, elastic, round, oval, or lobulated, 1-5cm, freely movable, slippery, fingers slide easily throughout tissue, painful

fecal impaction (FI)

complete colon blockage by hard, desiccated immovable stool which presents as constipation or overflow incontinence and is common, potentially serious -incapacitated pts (spinal cord injuries, stroke), aging adults, and those in institutions, -causes of constipation and FI: immobility, low fiber, dehydration, hypothyroidism, neurologic diseases, opioids, and other medications (exams of some aging adult: confusion, agitation) -inspect abdominal distention: tympany, palpable cord in left lower quadrant, may not palpate stool on rectal exam if higher impaction -complications: bowel obstruction, perforation, peritonitis -treatment: disimpaction with endoscopy (manual can cause perforation, rectal bleeding, and vaginal stimulation), distal colon cleansing with enemas, bowel regimen to precent recurrence (outpatient setting)

penis

composed of 3 cylindric columns of erectile tissue: 2 corpora cavernosa on dorsal side and corpus spongiosum ventrally -glans: distal end of shaft, corpus spongiosum expands into a cone of erectile tissue -corona: shoulder where the glans joins -urethra: conduit for both genital and urinary system. transverse the corpus spongiosum and its meatus forms a slit at the glans tip -foreskin or prepuce: forms a hood or flap over glans (often surgically removed) -frenulum: fold of foreskin extending from urethral meatus ventrally

grandular tissue

contains 15-20 lobes radiating from the nipple composed of lobules, within each lobule are clusters of alveoli that produce milk -each lobe empties into a lactiferous duct: 15-20 lactiferous duct form a collecting duct system converging toward the nipple -ducts form ampullae, or lactiferous sinuses, behind the nipple, which are reservoirs for storing milk

peritoneum

covers only the upper two-thirds of the rectum, male: anterior part reflects down to within 7.5cm of anal opening forming the rectovesical pouch and then covers the bladder female: recto-uterine pouch and extends down within 5.5cm of anal opening

lymphatics of the penis

drain into inguinal lymph nodes whereas those of testes drain into the abdomen

lymphatics of breast

extensive lymhatic drainage, more tha 75% drains into the ipsilateral (same side) axillary nodes 1) central axillary nodes: high up in the middle of the axilla, over the ribs and serratus anterior muscle, receive lymph from other three groups of nodes 2) pectoral (anterior): along the lateral edge of the pectoralis major, just include the anterior axillary fold 3) subscapular (posterior): along the lateral edge of the scapula, deep in the posterior axillary fold 4) lateral: along the humerus, inside the upper arm from the central axillary nodes, drainage flows up to the infraclavicular and supraclavicular nodes

suspensory ligaments (Cooper ligaments)

fibrous connective tissue extend vertically from skin surface to attach on chest wall muscles and support the breast tissue -become contracted in cancer of breast producing dimples in underlying skin

hemorrhoids

flabby papules are a varicosed vein -extrernal hemorrhoid: painful blood clot just under skin at anal verge, varicose veins that originate below the anorectal line and covered by anal skin -thrombosed: contains clotted blood and becomes a painful, swollen, shiny blue mass that itches and bleeds with defecation -when resolved: painless, flabby skin sac around the anal orifice -internal hemorrhoid: hemorrhoidal tissue protruding through the anus causing bleeding, pressure, and mild discomfort, varicose veins that originate above the anorectal junction covered by rectal mucosa - results from increased pressure with straining at stool, chronic constipation, pregnancy, obesity, or low-fiber diet and accompanied by painless rectal bleeding, red blood on tissue or toilet bowl, pruritus, anal swelling, and pain, fecal soilage, mucus discharge -treat with fiber supplement laxative, decreased time on toilet, rubber band ligitation

anal column

folds of mucosa in the anal canal which contains an artery and vein and under chronic increased venuous pressure, vein may enlarge forming a hemorrhoid

paraphimosis

foreskin retracted and fixed, once retracted behind glans which is tight or inflamed foreskin cannot return to its original position -constriction impedes circulation so glans swells, constricting band prevents venous and lymphatic return from the glans and compromises arterial circulation

acute urinary retention and UTI

inability to pass urine with bladder distention and lower abdominal pain, common in older men due to bladder outlet obstruction of BPH, can cause UTI owing to stasis and turbulent flow -UTI incidence: increases among men ages 60 years and older and presents with dysuria, frequency, urgency, nocturia, suprapubic pain, gross hematuria, and possibly fever

female breasts or mammary glands

lie anterior to the pectoralis major and serratus anterior muscles which is located between the 2nd and 6th ribs extending from the side of the sternum to the midaxillary line

scrotum

loose protective sac which is continuation of abdominal wall, after adolescence scrotal skin is deeply pigmented and has large sebaceous follicles -ruage: scrotal wall consists of thin skin lying in folds and underlying cremaster muscle -cremaster muscle: control the size of the scrotum by responding to ambient temperature which is to keep the testes at 3 degrees celsius below abdominal temperature (best temperature for producing sperm) -when it is cold: muscle contracts, raising the sac, and bringing testes closer to the body to absorb heat necessary for sperm viability -when it is warmer: muscle relaxes, scrotum lowers and skin looks smoother

carcinoma

malignant neoplasm in colon or rectum is asymptomatic which importance of routine imaging by colonosopy and digital rectal examination (DRE) -early lesion may be single firm nodule, may have an ulcerated center with rolled edges, as lesion grows it has an irregular cauliflower shape and is fixed and stone-hard -suggest screening guidelines: family history, fecal occult blood tests annually, and colonoscopy every 10 yrs, starting at age 50 years for those at average risk, earlier for those at high risk S: frequency, nocturia, hematuria, weak stream, hesitancy, pain or burning on urination; continuation pain in lower back, pelvis, thighs O: malignant neoplasm often starts as single hard nodule on posterior surface, producing asymmetry and a change in consistency -invades normal tissue, multiple hard nodules appear, or entire glands feels stone-hard and fixed, medican sulcus is obliterated

epispadias

meatus opens on the dorsal (upper) side of glans or shaft above a broad, spadelike penis, rare; less common than hypospadias but more disabling because of associated urinary incontinence and separation of pubic bones.

tail of Spence

superior lateral corner of breast tissue, projects up and laterally into axilla, close to the pectoral group of axillary lymph, upper outer quadrant is site of most breast tumors

benign (fibrocystic) breast disease

multiple tender masses that occur with numerous symptoms and physical findings: 1) swelling and tenderness (cyclic discomfort), 2) nodularity (lumpiness both cyclic and noncyclic, 3) dominant lumps (including cysts and fibroadenomas), 4) nipple discharge (including intraductal papilloma and duct ectasia), and 5) infections and inflammations (including subareolar abscess, lactational mastitis, breast abscess, and Mondor disease) -nodularity occurs bilaterally, regular firm nodules are mobile, well demarcated, and feel rubbery like small water balloons -pain may be dull, heavy, and cyclic as nodules enlarge, no pain, cysts are discrete, fluid-filled sacs

phimosis

nonretractable foreskin forming a pointy tip with a tiny orifice, foreskin advanced and tight that is impossible to retract over glans -may be congenital or acquired from adhesions secondary to infection -poor hygiene leads to retained dirt and smegma, increases risk for inflammation, calculus formation, obstructive uropathy

inguinal area

or groin, is the juncture of the lower abdominal wall and the thigh -inguinal canal: narrow tunnel passing obliquely between layers of abdominal muscle, 4-6 cm long in an adult -femoral canal: potential space located 3cm medial to and parallel with the femoral artery -these anatomic areas are potential sites for a hernia: loop of bowel protruding through a weak spot in the musculature

anal canal

outlet of GI tract, 3.8cm long in the aduly, function is continence -internal sphincter: under involuntary control by the autonomic nervous system -external sphincter: surround internal sphincter but has a small section overriding the tip of the internal sphincter at the opening, under voluntary control except for passing of feces and gas while sphincters keep the anal canal tightly closed -dentate line: mucocutaneous junction, sensory transition, anal glands

testis

produces sperm, solid oval shape and is suspended vertically by spermatic cord -left is lower than right because left spermatic cord is longer -tunica vaginalis: each testis covered by a double layer membrane which separates it from the scrotal wall and lubricated by fluid so it can slide a little within the scrotum helping prevent injury

edema (Peau d'Orange)

results from skin infiltration of cancer and skin edema, lymphatic obstruction produces edema, thickens the skin and exaggerates the hair follicles, giving a pigskin or orange-peel look, edema usually begins in the skin around and beneath the areola, the most dependent area of the breast.

sperm

transported along a series of ducts 1) testis is capped by epididymis which its main storage site of sperm, comma shaped structure curved over the top and posterior surface of the testis 2) vas deferens: lower part of epididymis continuous with this muscular duct and with other vessels (arteries and veins, lymphatics, and nerves to forms spermatic cord 3) spermatic cord: ascends along the posterior border of the testis and runs through the tunnel of the inguinal canal into the abdomen 4) ejaculatory duct: vas deferens continues back and down behind the bladder where it joins the duct of seminal vesicle and empties into the urethra

HPV

vaccine will protect against major types of HPV that cause cervical cancer but not all types -Pap tests detect cell changes in cervix before turn into cancer -recommended for girls or boys starting at age 11 or 12

adipose tissue

where the lobes are embedded -layers of subcutaneous and retromammary fat provides most of the bulk of the breast -varies depending on age, cycle, pregnancy, lactation, and general nutritional state