Patient assess (Tiburzi)-breasts, male/female genitalia

Pelvic Pain—Acute and Chronic. (Women)

-Acute pelvic pain in menstruating girls and women warrants immediate attention. The differential diagnosis is broad but includes life- threatening conditions such as ectopic pregnancy, ovarian torsion, and appendicitis. -identify onset, timing, features of the pain, and associated symptoms, you will need to consider infectious, gastrointestinal (GI), and urinary causes. Be sure to ask about STIs, recent insertion of an intrauterine device (IUD), and any symptoms in the sexual partner. A careful pelvic examination, with attention to vital signs, and testing for pregnancy will help narrow your diagnosis and guide further testing. *The most common cause of acute pel- vic pain is PID, followed by ruptured ovarian cyst, and appendicitis.20 STIs and recent IUD insertion are red flags for PID. Always rule out ectopic preg- nancy first with serum or urine testing and possible ultrasound. Also consider mittelschmerz, which is typically a mild unilateral pain lasting for a few hours to a few days arising at midcycle from ovulation, ruptured ovarian cyst, and tubo-ovarian abscess. -Chronic pelvic pain refers to pain that lasts for more than 6 months and does not respond to treatment. Risk factors are advancing age, prior pelvic surgery or trauma, parity and childbirth, clinical conditions (obesity, diabetes, multiple sclerosis, Parkinson disease), medications (anticholinergics, α-adrenergic blockers), and chronically increased intra-abdominal pressure (COPD, chronic constipation, obesity). -Endometriosis, from retrograde men- strual flow and extension of the uterine lining outside the uterus, affects 50% to 60% of women and girls with pelvic pain. Other causes include PID and adenosis and fibroids, which are tumors in the uterine wall or submucosal or sub- serosal surfaces arising from the smooth muscle cells of the myometrium. -Chronic pelvic pain is a red flag for a history of sexual abuse. Also consider pelvic floor spasm from myofascial pain with trigger points on examination

Male urogenital history taking

-Adapt questions to be age appropriate *younger males: testicular health, STDs, sexual practice *Middle aged/older males: Prostate health, sexual/urinary issues assoc w/dysfunction (pain, changes in urinary/bowel habits, erectile difficulties) -Conduct at end of PE -Explain reason for exam, make sure to say won't hurt, but its important that they say something if there is pain -Common/Concerning symptoms: ● Sexual health: Asking tip: "To provide good care, I need to review your sexual health and see if you are at risk for any sexually transmitted infections. I know this is a sensitive area. Any information you share is confidential and only between us." Explore the patient's sexual response. "How is your current relationship?" "Are you satisfied with your relationship and your sex- ual activity?" "What about your ability to perform sexually?" If the patient expresses relational or sexual concerns, explore both their psychological and physiologic dimensions. To assess libido, or desire, ask "How is your desire for sex?" For the arousal phase, ask "Can you achieve and maintain an erection?" *Low libido may arise from depression, endocrine dysfunction, or side effects of medications. Erectile dysfunction may be from psy- chogenic causes, especially if early morning erection is preserved; it may also reflect decreased testosterone, decreased blood flow in the hypogas- tric arterial system, impaired neural innervation, and diabetes. o learn about the phase of orgasm and ejaculation of semen, if ejaculation is premature, or early and out of control, ask "About how long does intercourse last?" "Do you climax too soon?" "Do you feel you have control over climaxing?" *Premature ejaculation is common, especially in young men. Less common is reduced or absent ejaculation affecting middle-aged or older men. Possible causes are medications, surgery, neurologic deficits, or lack of androgen. Lack of orgasm with ejaculation is usually psychogenic ● Penile discharge or lesions: ● Scrotal pain, swelling, or lesions ● Sexually transmitted infections (STIs)

Breast changes w/age

-Adulthood Normal breast 🡪 physiologic nodularity -Aging Diminish in size Flaccid, Pendulous More easily palpable ducts Diminished axillary hair Phys nodularity: full of bumps, normal Always ask patient if doing own exams, ask patient if any findings are normal for them

STI (women)

-After establishing the seven attributes of any symptoms, elicit the patient's sexual history. -Inquire about sexual contacts and establish the number of sexual partners in the past 3 to 6 months. -Ask if the patient has concerns about human immunodeficiency virus (HIV) infection, desires HIV testing, or has current or past partners at risk. Also ask about oral and anal sex and, if indicated, about symptoms involving the mouth, throat, anus, and rectum. Review the past history of STIs. -U.S. rates of STIs are the highest in the industrialized world. Chlamydia trachomatis is the most commonly reported STI in the United States and the most common STI in women -Often, symptoms are subtle and the infection remains undiagnosed. If untreated, 10% to 15% of women will develop PID, a polymicrobial infection with an 8% to 40% risk of tubal infertility depending on the number of episodes; a third to a half of cases are attributed to coinfection of C. trachomatis with Neisseria gonorrhoeae. -Chlamydial infection is a cause of ure- thritis, cervicitis, PID, ectopic preg- nancy, infertility, and chronic pelvic pain. Risk factors include age younger than 26 years, multiple partners, and prior history of STIs. -Chlamydia infection rates are highest in women ages 20 to 24 years, closely followed by women ages 15 to 19 years. African American women and American Indian/Alaskan natives are at highest risk for infection. As with other STIs, risk factors are age younger than 24 years and sexually active; prior infection with chlamydia or other STIs -Screening recs: ● Chlamydia, syphilis, hepatitis B, and HIV screening for all pregnant women and gonorrhea screening for at-risk pregnant women starting early in pregnancy, with repeat testing as needed to protect the health of mothers and their infants. ● Chlamydia, gonorrhea, and syphilis screening at least once a year for all sexually active gay, bisexual, and other MSM. MSM who have multiple or anonymous part- ners should be screened more frequently for STIs (i.e., at 3- to 6-month intervals). ● HIV testing at least once for all adults and adolescents from ages 13 to 64 years. ● HIV testing at least once a year for anyone having unsafe sex or using injec- tion drug equipment. Sexually active gay and bisexual men may benefit from testing every 3 to 6 months. -HIV: *More than 1.2 million Americans are infected with HIV, and one in seven (14%) is unaware of their infection. At highest risk, are gay, bisexual, and other MSM of all ethnicities. *In the United States, 20% of new infections occur in women, primarily through heterosexual contact (84% in 2010) and injection drug use (14%). Women represent 23% of those living with HIV infection. Among infected women, 64% are African American, 18% are white, and 15% are Hispanic/ Latinos. The CDC reports that women are not accessing health care and are undertreated *CDC recommends universal HIV testing for everyone in the age range of 13 to 64 years due to the prevalence of infections in people without known risk factors and underreporting.

Assessing pelvic floor strength (women)

-After palpating the cervix, uterus, and ovaries, withdraw your examining fingers just clear of the cervix. Then spread them against the vaginal walls. Ask the patient to squeeze around your fingers as long and as hard as she can. Snug compression of your fingers, moving them upward and inward, that lasts 3 or more seconds is full strength. -Check for strength, tenderness during contraction, appropriate relaxation after contraction, and endurance in all four vaginal quadrants. Then, with your fingers still placed against the vaginal walls inferiorly, ask the patient to cough several times or to bear down (Valsalva maneuver). Look for any urinary leakage during increased abdominal pressure. Watch for abdominal muscle overrecruitment or tightening of the adductor or gluteal muscles. -Muscle weakness arises from aging, vaginal deliveries, and neurologic conditions, and contributes to the urine leakage of stress incontinence during increased abdominal pressure. -Overrecruitment with tightening, vaginal wall tenderness, and referred pain signal pelvic pain from pelvic floor spasm, interstitial cystitis, vulvodynia, and urethral spasm. -In patients with pelvic pain or vaginal wall tenderness, palpate the external pel- vic floor muscles in a clockwise rotation to identify trigger points -Trigger point tenderness in these muscles accompanies pelvic floor spasm and pelvic floor dysfunction from trauma, interstitial cystitis, or fibromyalgia. Pelvic floor disorders, present in ∼25% of all women and ≥30% of older women, include urinary and fecal incontinence, pelvic organ prolapse, and other sensory and emp- tying abnormalities of the lower uri- nary and GI tracts.2 Recall that the ischiocavernosus and bulbocavernosus muscles are innervated by the pudendal nerve, so pain may be referred to the perineum and urogenital structures. Trigger-point pain over the levator ani, innervated by the sacral nerve roots S3 to S5, may be referred to the vagina

Ovarian cancer

-Although ovarian cancer is relatively rare, it is the fifth leading cause of cancer-related death for women.46 Two thirds of women affected are older than age 55 years; most are diagnosed when the disease is already metastatic to the peritoneal cavity or other organs. Overall 5-year survival is only 40% -there are no effective screening tests, so clinicians face the challenge of improving identification of symptoms. In women older than age 50 years, three symptoms merit special attention: abdominal distention, abdominal bloating, and urinary frequency; however, these are usually reported within 3 months of diagnosis and frequently occur in other conditions. -Risk factors for ovarian cancer include family history and presence of the BRCA1 or BRCA2 gene mutation. Risk is tripled if there is a first-degree relative with breast or ovarian cancer. Carriers of BRCA1 and BRCA2 have a lifetime risk of 40% to 50% and 20% to 30%, respectively.48 Other risk factors include obesity and nulliparity, with growing evidence of increased risk from use of postmenopausal HRT, especially long-time users and users of sequential estrogen-progesterone schedules.49,50 More than 90% of ovarian cancers appear to be random. Risk is decreased by use of oral contraceptives, multiple pregnancies, breastfeeding, and tubal ligation. Recent investigations show that in high-risk women (BRCA positive; positive family history), some ovarian cancer cells may arise in the fallopian tubes, creating the option of risk-reducing salpingo-oophorectomy -Women frequently ask about CA-125 testing. The CA-125 level is neither sensitive nor specific. Recent studies are investigating additional biomarkers and stratification of CA-125 cutoff points for demographic and clinical subgroups to reduce the high false-positive rate.47,52 Although CA-125 is elevated in more than 80% of women with ovarian cancer and helps predict relapse after treatment, it is also elevated in many other conditions and cancers, including pregnancy; endometriosis; uterine fibroids; PID; benign cysts; and pancreatic, breast, lung, gastric, and colon cancer. Current investigations of combined screening with CA-125, transvaginal ultrasound, and selected tumor markers have not demonstrated benefits that improve survival.

Axilla exam

-Although the axillae may be examined with the patient lying down, a sitting position is preferable. -Inspection: ■ Rash ■ Infection: Sweat gland infection from follicular occlusion (hidradenitis suppurativa) may be present. ■ Unusual pigmentation: Deeply pigmented velvety axillary skin suggests acanthosis nigricans— associated with diabetes; obesity; polycystic ovary syndrome; and, rarely, malignant paraneoplastic disorders. Palpation: -ask the patient to relax with the left arm down and warn the patient that the examination may be uncomfortable. Sup- port the patient's left wrist or hand with your left hand. Cup together the fingers of your right hand and reach as high as you can toward the apex of the axilla. Place your fingers directly behind the pectoral muscles, pointing toward the midclavicle. Now press your fingers in toward the chest wall and slide them downward, trying to palpate the central nodes against the chest wall. Of the axillary nodes, the central nodes are most likely to be palpable. * Enlarged axillary nodes may result from infection of the hand or arm, recent immunizations or skin tests, or generalized lymphadenopathy. Check the epitrochlear nodes medial to the elbow and other groups of lymph nodes -If the central nodes feel large, hard, or tender, or if there is a suspicious lesion in the drainage areas for the axillary nodes, palpate for the other groups of axillary lymph nodes: ■ Pectoral nodes—grasp the anterior axillary fold between your thumb and fingers, and with your fingers, palpate inside the border of the pectoral muscle. ■ Lateral nodes—from high in the axilla, feel along the upper humerus. ■ Subscapular nodes—step behind the patient and,with your fingers, feel inside the muscle of the posterior axillary fold. ■ Infra clavicular and supraclavicular nodes—Also re-examine the infra clavicular and supraclavicular nodes. ****Nodes that are large (≥1 to 2 cm) and firm or hard, matted together, or fixed to the skin or underlying tissues sug- gest malignancy.

Amenorrhea/Abnormal bleeding

-Amenorrhea refers to the absence of periods. Absence of ever initiating periods is primary amenorrhea; cessation of periods after they have been established is secondary amenorrhea. Pregnancy, lactation, and menopause are physiologic causes of secondary amenorrhea. *Other causes of secondary amenor- rhea include low body weight from any condition, including malnutrition and anorexia nervosa, stress, chronic illness, and hypothalamic-pituitary- ovarian dysfunction. -Ask about any abnormal bleeding. The term abnormal uterine bleeding encompasses several patterns. *Causes vary by age group and include pregnancy, cervical or vaginal infec- tion or cancer, cervical or endometrial polyps or hyperplasia, fibroids, bleed- ing disorders, and hormonal contra- ception or replacement therapy. ● Polymenorrhea, or less than 21-day intervals between menses ● Oligomenorrhea, or infrequent bleeding ● Menorrhagia, or excessive flow ● Metrorrhagia, or intermenstrual bleeding ● Postcoital bleeding: suggests cervical polyps or cancer or, in an older woman, atrophic vaginitis.

Penile discharge/lesions

-Ask about any discharge from the penis, dripping, or staining of underwear. If penile discharge is present, clarify the amount, color, and any fever, chills, rash, or associated symptoms. *Look for yellow penile discharge in gonorrhea; white discharge in non- gonococcal urethritis from Chlamydia. *Rash, tenosynovitis, monoarticular arthritis, even meningitis, not always with urogenital symptoms, occur in disseminated gonorrhea. -Inquire about sores or growths on the penis. Ask about swelling or pain in the scrotum. -Because STIs may involve other areas of the body, explain that "Sexually trans- mitted infections can involve any body opening where you have sex. It's impor- tant for you to tell me if you have oral or anal sex." Ask about symptoms such as sore throat, diarrhea, rectal bleeding, and anal itching or pain. *Infections from oral-penile transmis- sion include gonorrhea, chlamydia, syphilis, and herpes. Symptomatic or asymptomatic proctitis may follow anal intercourse.

Approach to pelvic exam (female)

-Asking the patient's permission to perform the examination shows courtesy, respect, and the expectation that the examination is collaborative. Explaining the steps of what you are about to do will also be greatly appreciated. If a Pap smear is to be collected using the glass- slide technique, time the examination so that it does not occur during menses, because blood can interfere with interpretation. *In liquid-based cytology, blood cells can be filtered out. -Exam tips: Obtains permission; selects chaperone Explains each step of the examination in advanceDrapes the patient from midabdomen to knees; depresses the drape between the knees to provide eye contact with patient Avoids unexpected or sudden move- ments Chooses a speculum that is the correct size Warms the speculum with tap water Monitors the comfort of the examina- tion by watching the patient's face Uses excellent but gentle technique, especially when inserting the speculum -Equipment: *A movable source of good light *A vaginal speculum of appropriate size *Water-soluble lubricant *Equipment for taking Papsmears, bacteriologic cultures and DNA probes, or other diagnostic testing materials, such as potassium hydroxide and nor- mal saline -The medium Pedersen specu-lum is usually most comfortable for sexually active women. The narrow- bladed Pedersen speculum is best for the patient with a small introitus, such as a virgin or an elderly woman. The Graves specula are best for parous women with vaginal prolapse. -When using a plastic speculum, warn the patient that it typically makes a loud click and may pinch when locked or released, causing discomfort. -Positioning the Patient: Drapethe patient appropriately and then assisther into the lithotomy position. Placeone heel, then the other into thestirrups. She may be more comfortablein socks or shoes than bare feet. Then ask her to slide all the way down the examining table until her buttocks extend slightly beyond the edge. Her thighs should be flexed, abducted, and externally rotated at the hips. Make sure her head is supported with a pillow.

External exam (female)

-Assess the Sexual Maturity of an Adolescent Patient. You can assess pubic hair during either the abdominal or the pelvic examination *Delayed puberty is often familial or related to chronic illness. It may also reflect disorders of the hypothalamus, anterior pituitary gland, or ovaries. -Seat yourself comfortably and warn the patient that you will be touching her genital area. Inspect the mons pubis, labia, and perineum. Separate the labia and inspect: ■ The labia minora ■ The clitoris ■ Theurethralmeatus ■The vaginal opening, or introitus -Excoriations or itchy, small, red maculo- papules suggest pediculosis pubis (lice or "crabs"), often found at the bases of the pubic hairs. An enlarged clitoris is seen in masculinizing endocrine disorders. Inspect for urethral caruncle, prolapse of the urethral mucosa (p. 597), and tenderness in interstitial cystitis. -Bartholin glands: If the patient reports labial swelling, examine the Bartholin glands. Insert your index fin- ger into the vagina near the posterior introitus (Fig. 14-8). Place your thumb outside the posterior part of the labium majus. Palpate each side in turn, at approximately the "4-o'clock" and "8-o'clock" positions, between your finger and thumb, checking for swell- ing or tenderness. Note any discharge exuding from the duct opening of the gland. If any is present, culture it. *A Bartholin gland may become acutely or chronically infected, resulting in swelling

Lactation

-Both the nipple and the areola are supplied with smooth muscle that contracts to express milk from the ductal system during breast-feeding. Rich sensory innervation, especially in the nipple, triggers "milk letdown" following neurohormonal stimulation from nfant sucking. Tactile stimulation of the area, including the breast examination, makes the nipple smaller, firmer, and more erect, whereas the areola puckers and wrinkles. These smooth muscle reflexes are normal and should not be mistaken for signs of breast disease. -The adult breast may be soft, but it often feels granular, nodular, or lumpy. This uneven texture is normal physiologic nodularity. It is often bilateral and may occur throughout the breast or only in some areas. The nodularity may increase before menses, a time when breasts often enlarge and become tender or even painful.

Breast cancer risk factors

-Breast cancer is most common cancer in women in US -More common in women, only 1% in male -More common in white women -Obesity, fatty diet/alcohol, lack of physical activity/stress, hormone use, radiation exposure, previous cancers -Age, more common in older women -Family History (mother/sister) -Menstrual History & Pregnancy Early menarche Late menopause First live birth after 35 years old Nuliparous -Breast Conditions/Diseases Benign breast disease with biopsy showing atypical hyperplasia or lobular carcinoma in situ -Now looking for breast cancers at 30. Becoming more common, more aggressive when younger Need to examine young patients! Having children late/not at all increases risk because there is no hormonal break, breast feeding also reduces risk Obesity: because fat is a hormonal tissue Hormonal BC: increase in breast cancer, decrease in ovarian cancer

Family Planning

-CDC notes that "Teen pregnancy has declined to the lowest rates in seven decades, yet still ranks highest among the developed countries." -Hispanic black, Hispanic, and American Indian/Alaska Native teen birth rates were still one and a half to two times higher than the rate for non-Hispanic white teens. -Almost half of U.S. pregnancies are unintended -Contraceptive types include: natural, barrier, implantable/pharm, surgery. Failure rates are lowest for the subdermal implant, IUD, female sterilization, and vasectomy at less than 0.8% per year (<1 pregnancy/100 women/yr) and highest for male and female condoms, withdrawal, sponge in parous women, fertility awareness methods, and spermicides at more than 18% per year (or ≥18 preg- nancies/100 women/yr). Failure rates for injectables, oral contraceptives, the patch, vaginal ring, and diaphragm range from 6% to 12% per year (or 6 to 12 pregnancies/100 women/yr).

Common/concerning symptoms of rectum

-Change in bowel habits -Blood in the stool -Pain with defecation; rectal bleeding or tenderness -Anal warts or fissures -Weak stream of urine -Burning upon urination -Questions concerning symptoms related to the anorectal area may be classified into two categories: Lower gastrointestinal (GI) Lower genitourinary (GU)

Implant exams

-Common for thinner breast tissue -Implants can go under breast tissue, under pectoralis, or half and half -Much harder to do exam with implants, also harder for mammo

Pap smear test

-Conventional Pap smears have a sensi- tivity and specificity for detecting cer- vical cancer of 30% to 87% and 86% to 100%, respectively. For liquid-based cytology, these figures are 61% to 95% and 78% to 82%. The sensitivity of Pap smear and HPV DNA testing is 74.6% to 100%. -Classification of Pap Smear Cytology: The Bethesda System (2001): ● Negative for intraepithelial lesion or malignancy: No cellular evidence of neoplasia is present, although other organisms like Trichomonas, Candida, or Actinomyces may be reported in this category. Shifts in flora consistent with bacterial vagino- sis or cellular changes from herpes simplex may also be reported. ● Epithelial cell abnormalities: These include precancerous and cancerous lesions such as: ● Squamous cells, including atypical squamous cells (ASC ), which may be of undetermined significance (ASC-US); low-grade squamous intraepithelial lesions (LSIL), including mild dysplasia; high-grade squamous intraepithelial lesions (HSIL), including moderate and severe dysplasia with features suspi- cious for invasion; and invasive squamous cell carcinoma. ● Glandular cells, including atypical endocervical cells or atypical endometrial cells, specified or not otherwise specified (NOS); atypical endocervical cells or atypical glandular cells, favor neoplasia; endocervical adenocarcinoma in situ; and adenocarcinoma. ● Other malignant neoplasms, such as sarcomas or lymphomas, are rare. -Procedure: *Obtain one specimen from the endocervix and another from the ectocervix, or a combination specimen using the cervical brush ("broom"). For best results the patient should not be menstruating. She should avoid intercourse and use of douches, tampons, contraceptive foams or creams, or vaginal suppositories for 48 hours before the examination. For sexually active women ages 26 years or younger, and for other asymptomatic women at increased risk of infection, plan to culture the cervix routinely for chlamydia *Cervical Broom: Many clinicians use a plastic brush tipped with a broom-like fringe to collect a single speci- men containing both squamous and columnar epithelial cells. Rotate the tip of the brush in the cervical os, in a full clockwise direction, then place the sample directly into preserva- tive so that the laboratory can prepare the slide (liquid-based cytology). Alternatively, stroke each side of the brush on the glass slide. Promptly place the slide in solution or spray with a fixative as described on the next page. Use of the cervical broom and liquid- based cytology is increasingly com- mon and can also be used to test for chlamydia and gonorrhea. *Cervical Scrape: Place the longer end of the scraper in the cer- vical os. Press, turn, and scrape in a full circle, making sure to include the transformation zone and the squamocolumnar junction. Smear the specimen on a glass slide. Set the slide in a safe spot that is easy to reach. Note that doing the cervical scrape first reduces the presence of red blood cells, which sometimes appear after rotating the endocervical brush. *Endocervical Brush: Place the endocervical brush in the cervical os. Roll it between your thumb and index finger, clockwise and counterclockwise. Remove the brush and smear the glass slide using a gentle painting motion to avoid destroying any cells. Place the slide into an ether-alcohol solution at once, or spray it promptly with a special fixative. Note that for pregnant women, a cotton- tipped applicator, moistened with saline, is advised in place of the endocervical brush.

Areola

-Disk of skin encircling base of nipple -Numerous melanocytes -Varies from pink to brown depending on race/parity -Has modified scabs glands -Glands enlarge during pregnancy, called tubercles of montgomery, small little glands on areolar complex, give out almost pheromone scent so that baby can find nipple. Prolactin is released w/suckling, allowing milk to be released. -The surface of the areola has small, rounded eleva- tions formed by sebaceous glands, sweat glands, and accessory areolar glands (Fig. 10-4). A few hairs are often seen on the areola. During pregnancy, the sebaceous glands produce an oily secretion that serves as a protective lubricant for the areola and nipple during lactation. -Pagets disease: cancers found in/under nipple complex, will not see classic tumor but discoloration/discharge of alveolar complex

Describing findings on breast

-Divide breast into 4 quad, horizontal and vertical line, note that axillary tail of breast tissue extends into anterior axillary fold -Can also describe like a clock

Anus/rectum exam

-Examine the anus and rectum *Lubricate a gloved index finger *Explain what you are going to do *Inspect the anus, noting any lesions *Ask the patient to strain down *Place finger pad over the anus and gently insert your fingertip into the anal canal; proceed with insertion upon relaxation of the sphincter *Assess for sphincter tone of the anus, tenderness, induration, irregularities, or nodules -Examine the posterior surface of the prostate gland -Identify lateral lobes and median sulcus -Note size, shape, and consistency of the prostate; identify any nodules or tenderness -Normal prostate is rubbery and nontender -If possible, extend your finger above the prostate to the region of the seminal vesicles and the peritoneal cavity; note any nodules or tenderness -Note the color of any fecal matter on the glove, and test it for occult blood

Cervical cancer/HPV

-HPV infection with high-risk oncogenic subtypes is found in virtually all cervical cancers. -The most important risk factor for cervical cancer is persistent infection with high-risk HPV subtypes, especially HPV 16 or HPV 18. These two subtypes cause roughly 70% of cervical cancers worldwide. Even the 10% of women with persistent infection rarely progress to cervical cancer if they undergo regular screening, insofar as the average estimated time for a high-grade HPV lesion to progress to cervical can- cer is 10 years, allowing a long interval for detection and treatment.28 Genital infection with low-risk subtypes, such as HPV 6 and HPV 11, is associated with genital warts. -Two notable risk factors for cervical cancer include failure to undergo screen- ing, which accounts for roughly half of women diagnosed with cervical cancer, and multiple sexual partners. Other risk factors include smoking, immunosup- pression from any cause including HIV infection, long-term use of oral contraception, coinfection with Chlamydia trachomatis, parity, prior cervical cancer, and genetic polymorphisms affecting the entry of HPV DNA into cervical cells. -Definition of Average Risk: No history of high-grade, precancerous cervical lesion (cervical intraep- ithelial neoplasia grade 2 or a more severe lesion) or cervical cancer; not immunocompromised (including being HIV-infected); and no in utero exposure to diethylstilbestrol. -screening should begin at age 21 years, and that there is no need for annual screening for average-risk women at any age. Pap smear cytology every 3 years or, alternatively, cotesting with cytology plus HPV testing for high-risk sub- types every 5 years, follwing 21. At 65, screening can stop if women have had three consecutive negative results on cytology or two consecutive negative results with cotesting within 10 years of cessation of screening (with the most recent test performed within 5 years), as the risk of cervical cancer is low, and risk factors decrease with age.

Hernias (women)

-Hernias of the groin occur in women as well as men, but they are much less common. The examination techniques are basically the same as for men. A woman should also stand up to be examined. To feel an indirect inguinal hernia, however, palpate in the labia majora and upward to just lateral to the pubic tubercles.

Groin anatomy (male)

-Landmarks *Anterior superior iliac spine, pubic tubercle, inguinal ligament *Inguinal canal - lies above and parallel to the inguinal ligament, forms a tunnel for the vas deferens -Exterior opening of the tunnel is the external inguinal ring, the internal opening of the canal is the internal inguinal ring. When loops of bowel force their way through inguinal canal, inguinal hernias are result *Neither the canal nor the internal ring is palpable through the abdominal wall. The exterior opening of the tunnel, the external inguinal ring, is a triangular slit-like structure palpable just above and lateral to the pubic tubercle.

Concerning signs w/breast

-If breasts are very large, leaning forward can help. Malignancies behind nipple can also be seen easier this way (would be pulling back) -Sometimes malignancies arent necessarily painful, but if keep getting little twang in one spot, look into it, also want to ask if it seems to be related to menses -Malignancy may look like peel of orange. Edema of the skin is produced by lymphatic blockade. It appears as thickened skin with enlarged pores—the so-called peau d'orange (orange peel) sign. It is often seen first in the lower portion of the breast or areola. -In breast findings pics: 3rd pic may also be mastitis from trauma/breastfeeding , but should still be checked for malignancy (dont do mamo tho, too painful), -If see retracted nipple, may be bad, but if bilateral could be normal. As breast cancer advances, it causes fibrosis (scar tissue). Shortening of this tissue produces dimpling, changes in contour, and retraction or deviation of the nipple. Other causes of retraction include fat necrosis and mammary duct ectasia. -Dilation of veins may also be concerning bc tumor compresses surrounding veins, veins should never look dilated on breast -Palpation: Only really do 3 minutes if find something abnormal, this is why we dont want to palpate close to menses bc of tenderness -If benign, should be mobile -Abnormal Contours Look for any variation in the normal convexity of each breast, and compare one side with the other. Special positioning may again be useful. Shown here is marked flattening of the lower outer quadrant of the left breast. -Skin dimpling: Look for this sign with the patient's arm at rest, during special positioning, and on moving or compressing the breast, as illustrated here. -Nipple Retraction and Deviation A retracted nipple is flattened or pulled inward, as illustrated here. It may also be broadened, and feels thickened. When involvement is radially asymmetric, the nipple may deviate or point in a different direction from its normal counterpart, typically toward the underlying cancer. -Paget Disease of the Nipple This uncommon form of breast cancer usually starts as a scaly, eczema-like lesion on the nipple that may weep, crust, or erode. A breast mass may be present. Suspect Paget diseasein any persisting dermatitis of the nipple and areola. Often (>60%) presents with an underlying in situ or invasive ductal or lobular carcinoma .-Always ask about if women are self examining!! Always provide instructions on how to do

Tanner staging in males

-In assigning sexual maturity rating in boys, observe each of the three characteristics separately because they may develop at different rates. Record two separate ratings: pubic hair and genital. If the penis and testes differ in their stages, average the two into a single figure for the genital rating. -Stage 1: *Pubic Hair: Preadolescent—no pubic hair except for the fine body hair (vellus hair) similar to that on the abdomen *Penis: Preadolescent—same size and proportions as in childhood *Testes/Scrotum: Preadolescent—same size and proportions as in childhood -Stage 2: *Pubic hair: Sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, chiefly at the base of the penis *Penis: Slight or no enlargement *Testes larger; scrotum larger, somewhat red- dened, and altered in texture -Stage 3: *Hair: Darker, coarser, curlier hair spreading sparsely over the pubic symphysis *Penis: Larger, especially in length *Testis/scrotum: Further enlarged -Stage 4: *Hair: Coarse and curly hair, as in the adult; area covered greater than in stage 3, but not as great as in the adult and not yet includ- ing the thighs *Penis: Further enlarged in length and breadth, with devel- opment of the glans *Testis/scroum: Further enlarged; scrotal skin darkened -Stage 5: *Hair: Hair adult in quantity and quality, spreads to the medial surfaces of the thighs but not up over the abdomen *Penis: Adult in size and shape *Scrotum/Testis: Adult in size and shape *Delayed puberty may be due to familial (Klinefelter), hypothalamus, anterior pituitary gland, testicular reasons

Hernias in male

-Indirect inguinal hernias develop at the internal inguinal ring, where the spermatic cord exits the abdomen. -Direct inguinal hernias arise more medially due to weakness in the floor of the inguinal canal and are associ- ated with straining and heavy lifting. -Another route for a herniating mass is the femoral canal, below the inguinal liga- ment. Although this canal is not visible, you can estimate its location by placing your right index finger, from below, on the right femoral artery. Your middle finger will then overlie the femoral vein; your ring finger, the femoral canal. Femoral hernias protrude at this location.

Exam of penis

-Inspect: *Inspect the skin on the ventral and dorsal surfaces and the base of the penis for excoriations or inflammation, lifting the penis when necessary. Pubic or genital excoriations suggest lice (crabs) or sometimes scabies in the pubic hair. -If present, retract the prepuce or ask the patient to retract it. This step is essential for the detection of chancres and carcino- mas. Smegma, a cheesy, whitish material, may accumulate normally under the foreskin. Phimosis is a tight prepuce that cannot be retracted over the glans. Paraphimo- sis is a tight prepuce that, once retracted, cannot be returned. Edema ensues. -The glans. Look for any ulcers, scars, nodules, or signs of inflammation. Balanitis is inflammation of the glans; balanoposthitis is inflammation of the glans and prepuce. -The urethral meatus. Inspect the location of the urethral meatus. Hypospadias is a congenital ventral displacement of the meatus on the penis *Compress the glans gently between your index finger above and your thumb belo. This maneuver should open the urethral meatus and allow you to inspect it for dis- charge. Normally, there is none. Palpation: -Palpate the shaft of the penis btw the thumb and first finger fingers, noting any induration. (This may be omitted in a young asymptomatic male patient.) Palpate any abnormality of the penis, noting any induration or tenderness. Induration along the ventral surface of the penis suggests a urethral stricture or possibly a carcinoma. Tender- ness in the indurated area suggests periurethral inflammation from a urethral stricture. -If you retract the foreskin, replace it before proceeding on to examine the scro- tum.

Breast exam

-Inspection -Palpation -Special techniques -Chest fully exposed -5-7 days after onset of menstruation -Clinicians are advised to adopt a more standardized approach, especially for palpation, and to use a systemic up-and- down search pattern, varying palpation pressure, and a circular motion with the fingerpads. -The most significant risk factors for breast cancer are age, BRCA status, and breast density on mammogram. Personal history of breast cancer, fam- ily history, and reproductive factors affecting duration of uninterrupted estrogen exposure are also important. -For screening examinations, the length of time spent on palpa- tion is one of the most important factors in detecting suspicious changes, with highest sensitivity when examiners spend 5 to 10 minutes for the examination of both breasts. -elicit concerns about the breasts during the history or later during the physical examination. Ask if the patient has had any lumps, discomfort, or pain in her breasts. About 50% of women have palpable lumps or nodularity, and premen- strual enlargement and tenderness are common. If your patient reports a lump or mass, identify the precise location, how long it has been present, and any change in size or variation within the menstrual cycle. Ask if there has been any change in breast contour, dimpling, swelling, or puckering of the skin over the breasts. *Lumps may be physiologic or patho- logic, ranging from cysts and fibroadenomas to breast cancer. -Breast pain, or mastalgia, is the most common breast symptom prompting office visits. Breast pain alone (without mass) is not considered a breast cancer risk factor. Determine if the pain is diffuse or focal, cyclic or noncyclic, and related to medications. *Clinical breast examination (CBE) is warranted. Focal breast pain is more likely to merit diagnostic imaging. Medica- tions associated with breast pain include hormonal therapy; psychotro- pic drugs such as selective serotonin reuptake inhibitors and haloperiodol; spironolactone, and digoxin. -Ask about any discharge from the nipples and when it occurs. Does the discharge appear only after compression of the nipple, or is it spontaneous? Physiologic hypersecretion is seen in pregnancy, lactation, chest wall stimulation, sleep, and stress. If spontaneous, what is the color, consistency, and quantity? Is the color milky, brown or greenish, or bloody? Ask if the discharge is unilateral or bilateral. Physiologic discharge is usually bilateral, multiductal, prompted by stimulation, and ranges in color from white to yellowish or green. *Galactorrhea, or the discharge of milk- containing fluid unrelated to preg- nancy or lactation, is more likely tobe pathologic when it is bloody or serous, unilateral, spontaneous, associated with a mass, and occurring in women aged ≥40 years.

Axillae exam

-Inspection Rash Infection Unusual pigmentation -Palpation Patient relaxes with arm down

Lower GI concerns

-Is there any change in the pattern of bowel function? -Any change in the size or caliber of the stool? *Bristol stool chart: goes from 1 to 7 from constipated (pieces, to lumpy), to diarrhea (Mushy, liquid). 3-4 is normal, with stool being sausage shaped w/ cracks or smooth -Any diarrhea or constipation? -What color is the stool? (may be due to diet, or: *Any shade of brown good, little green OK *Green: passing too fast *Black: Bisthmus meds, upper GI bleed *White: Bile duct blockage *Red: bleeding in lower GI/hemorrhoids *Yellow: too much fat, malabsorption, celiac disease -Any obvious blood or mucus in the stool? -Any pain on defecation? Any itching? -Any extreme tenderness in the anus or rectum? -Any purulent discharge or bleeding? Any history of anal warts, ulcerations, or fissures? -Any involvement in anal intercourse?

Lower GU concerns for men

-Is there any difficulty starting or holding back the urine stream? -Is the urine flow weak? -Is there frequent urination, especially at night? -Is there any pain or burning upon urination or ejaculation? -Any blood in the urine or semen? -Any pain or stiffness in the lower back, hips, or upper thighs? -Any discomfort or heaviness at the base of the penis with associated malaise, fever, or chills?

Female breast

-Lies against anterior thoracic wall -Extends from clavicle & 2nd rib to 6th rib -Extends from sternum to midaxillary line -Overlies the pectoralis major and inferiorly over the serratus anterior -Hormonally sensitive tissue -Glandular tissue, consisting of milk-secreting tubuloalveolar glands and ductules, forms 15 to 20 septated lobes radiating around the nipple (Fig. 10-3). Within each lobe are many smaller lobules. The glandular tissue within each lobule drains into larger collecting ducts and lactiferous sinuses leading to 5 to 10 porous openings on the surface of the areola and the nipple. Fibrous connective tissue provides structural support in the form of fibrous bands or suspensory ligaments, also known as Cooper ligaments, connected to both the skin and the underlying fascia. Adipose tissue, or fat, surrounds the breast, predominantly in the super- ficial and peripheral areas. The proportions of these components vary with age, nutritional status, preg- nancy, exogenous hormone use, and other factors. After menopause, there is atrophy of glandular tissue, and a notable decrease in the number of lobules. -breast is often divided into four quadrants based on horizontal and vertical lines crossing at the nipple. A fifth area, an axillary tail of breast tissue, sometimes termed the "tail of Spence," extends laterally across the anterior axillary fold. Alternatively, findings can be localized as the time on the face of a clock (e.g., 3 o'clock) and the distance in centimeters from the nipple. -Its surface area is generally rectangular rather than round

Bimanual exam

-Lubricate the index and middle fingers of one of your gloved hands, and from a standing position, insert your lubricated fingers into the vagina, again exerting pressure primarily posteriorly. *Stool in the rectum may simulate a rectovaginal mass, but unlike a malig- nant mass, it can usually be dented by digital pressure. Rectovaginal examination confirms the distinction. -Note any nodularity or tenderness in the vaginal wall, including the region of the urethra and the bladder anteriorly. -Palpate the cervix, noting its position, shape, consistency, regularity, mobility, and tenderness. Normally, the cervix can be moved somewhat without pain. Feel the fornices around the cervix. *Cervical motion tenderness and/or adnexal tenderness are hallmarks of PID, ectopic pregnancy, and appendicitis. -Palpate the uterus. Place your other hand on the abdomen about midway between the umbilicus and the symphysis pubis. While you elevate the cervix and uterus with your pelvic hand, press your abdom- inal hand in and down, trying to grasp the uterus between your two hands. Note its size, shape, consistency, and mobility, and iden- tify any tenderness or masses. *Uterine enlargement suggests preg- nancy, uterine myomas (fibroids), or malignancy. -Now slide the fingers of your pelvic hand into the anterior fornix and palpate the body of the uterus between your hands. In this position, your pelvic fingers can feel the anterior surface of the uterus, and your abdominal hand can feel part of the posterior surface. If you cannot feel the uterus with either of these maneuvers, it may be tipped posteriorly (retrodisplaced). Slide your pelvic fingers into the posterior for- nix and feel for the uterus butting against your fingertips. An obese or poorly relaxed abdominal wall may also prevent you from feeling the uterus even when it is located anteriorly. *Nodules on the uterine surfaces suggest myomas, or fibroids -Palpate each ovary. Place your abdominal hand on the right lower quadrant, and your pelvic hand in the right lateral fornix. Press your abdominal hand in and down, trying to push the ad- nexal structures toward your pel- vic hand. Try to identify the right ovary or any adjacent adnexal masses. By moving your hands slightly, slide the adnexal structures between your fingers, if possible, and note their size, shape, consistency, mobility, and tenderness. Repeat the procedure on the left side. *Within 3 to 5 years after menopause, the ovaries become atrophic and usually nonpalpable. In postmenopausal women, investigate a palpable ovary for possible ovarian cyst or ovarian cancer. Pelvic pain, bloating, increased abdominal size, and urinary tract symptoms are more common in women with ovarian cancer. -Normal ovaries are somewhat tender. They are usually palpable in slender relaxed women, but are difficult or impossible to feel in women who are obese or tense. *Adnexal masses can also arise from a tubo-ovarian abscess, salpingitis or inflammation of the fallopian tubes from PID, or ectopic pregnancy. Distinguish such a mass from a uterine myoma.

Male lymphatics

-Lymph drainage from the penis passes primarily to the deep inguinal and external inguinal nodes. -Lymph vessels from the scrotum drain into the superficial inguinal lymph nodes. When you find an inflammatory or possibly malignant lesion on these surfaces, assess the inguinal nodes especially carefully for enlargement or tenderness. -Lymphatic drainage from the testes parallels their venous drainage: the left testicular vein empties into the left renal vein, and the right testicular vein empties into the inferior vena cava.

Sexual health (women)

-Maintaining a neutral, nonjudgmental tone helps your patients feel safe and trust you with their concerns. -"Are you currently dating, sexually active, or in a relationship? ""How would you identify your sexual orientation?" The range of responses includes het- erosexual or straight, lesbian, gay, women who have sex with women, men who have sex with men (MSM), bisexual, transsexual, and questioning, among others. "How would you describe your gender identity?" Responses include: male, female, transsexual, transgendered, intersex, female-to-male, male-to- female, unsure or questioning, and even "prefer not to answer." Continue with, "Do you use protection such as birth control or condoms?... Has anyone ever tried to touch or have sex with you without your consent?" -If the patient has concerns about her response to sex, consider direct questions to help you assess each phase of the sexual response: desire, arousal, and orgasm: Sexual dysfunction is classified by the phase of sexual response. A woman may lack desire; she may fail to become aroused and attain adequate vaginal lubrication; or, despite adequate arousal, she may be unable to reach orgasm. Causes include lack of estrogen, clinical illness, trauma or abuse, surgery, pelvic anatomy, and psychological and psychiatric conditions. -Ask also about dyspareunia, or pain with intercourse. If present, try to localize where the pain occurs. Is it near the outside, at the start of intercourse, or does she feel it farther in, when her partner is pushing deeper? Vaginismus refers to an involuntary spasm of the muscles surrounding the vaginal orifice that makes penetration during intercourse painful or impossible. *Superficial pain suggests local inflam- mation, atrophic vaginitis, or inade- quate lubrication; deeper pain may arise from pelvic disorders or pressure on a normal ovary. Causes of vaginis- mus may be physical or psychological. -Commonly, sexual problems are related to situational and psychosocial factors.

Menopause

-Menopause typically occurs between ages 48 and 55 years, peaking at a median age of 51 years. -It is defined retrospectively as cessation of menses for 12 months, progressing through several stages of erratic cyclical bleeding. -Stages of variable cycle length, often with vasomotor symptoms like hot flashes, flushing, and sweating, represent perimenopause. The ovaries stop producing estradiol or progesterone and estrogen levels drop significantly, although some testosterone synthesis persists.4 Pituitary secretion of luteinizing hormone and follicle-stimulating hormone gradually becomes markedly ele- vated. *Women may ask about alternative compounds and botanicals for relief of menopause-related symptoms. Most are poorly studied and not proven to be beneficial. Estrogen replacement relieves symptoms, but poses other health hazards.5 Relatively few medications have been shown to affect symptoms -Ask a middle-aged or older woman if she has stopped menstruating. When? Continue with "How do (did) you feel about not having your periods anymore?" "Has this affected your life in either a positive or negative way?" Did any symptoms accompany her transition to menopause? Always be sure to ask about any bleeding or spotting after menopause as this may be an early sign of cancer. *Causes of postmenopausal bleeding include endometrial cancer, hormone replacement therapy (HRT), and uterine and cervical polyps.

Breast lymph nodes

-Most breast lymph drains toward the axilla -Central nodes are most frequently palpable, lie along chest wall, high in the axilla, midway btw anterior and posterior axillary folds, 3 other groups of LN drain into them -Pectoral nodes Anterior Lower border of pectoralis major, inside anterior axillary fold Drain anterior chest wall & much of breast -Subscapular Nodes Posterior Lateral border of scapula, deep in posterior axillary fold Drain posterior chest wall & portion of arm -Lateral Nodes Upper humerus Drain most of arm -Infraclavicular & Supraclavicular Gets drainage from central nodes May have metastatic spread directly from breast to these nodes Central nodes important, is a bit uncomfy Pectoral, subscap and lateral nodes drain into central

Sphincters of rectum/ Blood supply

-Normally, the anal canal is held in a closed position by two muscles, the voluntary external anal sphincter and involuntary internal anal sphincter -A serrated line demarcates the anal canal from the rectum -The anorectal junction (often called the pectinate or dentate line) is the boundary between somatic and visceral nerve supplies -Arterial: Superior rectal artery Middle rectal artery Inferior rectal artery -Venous: Drainage via corresponding arteries

Menopause/HRT

-North American Menopause Society (NAMS), among others, issued recommendations against using HRT for chronic conditions in postmenopausal women -moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits -estrogen plus progestin and estrogen alone decreased risk for fractures but increased risk for stroke, thromboembolic events, gallbladder disease, and urinary incontinence. Estrogen plus progestin increased risk for breast cancer and probable dementia, whereas estrogen alone decreased risk for breast cancer." The American Heart Association, ACOG, and NAMS recommend against the use of postmenopausal hormone therapy for primary or secondary prevention of cardiovascular disease.69-71 ACOG notes that there is some evidence that transdermal estrogen therapy may have thrombosis- sparing properties and also finds insufficient evidence for recent claims that compounded bioidentical hormones are superior to conventional menopausal HRT.

Female genital anatomy

-Note the mons pubis, a hair-covered fat pad overlying the symphysis pubis; the labia majora, rounded folds of adipose tissue forming the outer lips of the vagina; the labia minora, the thinner pinkish-red folds or inner lips that extend anteriorly to form the prepuce; and the clitoris. The vestibule is the boat-shaped fossa between the labia minora. In its posterior portion lies the vag- inal opening, the introitus, which in virgins may be hidden by the hymen. The term perineum refers to the tissue between the introitus and the anus. -urethral meatus opens into the vestibule between the clitoris and the vagina. Just posterior and adjacent to the meatus on either side lie the openings of the para- urethral (Skene) glands. openings of Bartholin glands are located posteriorly on both sides of the vaginal opening but are not usually visible. The glands themselves are situated more deeply. -upper third of vagina lies at a horizontal plane and terminates in the cup-shaped fornix. The vaginal mucosa lies in transverse folds, or rugae. The vagina lies at almost a right angle to the uterus, a thick-walled fibromuscular structure shaped like an inverted pear (Fig. 14-3). Its convex upper surface is the uterine fundus. The body of the uterus, or corpus, and the cylindrical cervix are joined inferiorly at the isthmus. The uterine walls contain three layers: the peri- metrium, with its serosal coating from the perineum; the myometrium of disten- sible smooth muscle; and the endometrium, the adherent inner coating -The ectocervix is covered by plushy red columnar epithelium that surrounds the os and lines the endocervical canal, and by shiny pink squamous epithelium con- tinuous with the vaginal lining. The squamocolumnar junction forms the boundary between these two types of epithelium. During puberty, the broad band of columnar epithelium encircling the os, called ectropion, is gradually replaced by squamous epithelium. The squamocolumnar junction migrates toward the os, creating the transformation zone. -The ovaries are palpable on pelvic examination in roughly half of women during the reproductive years. Normally, the fallopian tubes are not palpable -The parietal peritoneum extends downward behind the uterus into a cul-de-sac called the rectouterine pouch (pouch of Douglas). You can just reach this area on rectovaginal examination. -pelvic organs are supported by a sling of tissues composed of muscle, ligaments, and endopelvic fascia called the pelvic floor, which helps support the pelvic organs above the outlet of the lesser pelvis. Pelvic floor muscles also aid in sexual function (orgasm), urinary and fecal continence, and stabiliza- tion of connecting joints. *Weakness of the pelvic floor muscles may cause pain; urinary incontinence; fecal incontinence; and prolapse of the pelvic organs that can produce a cystocele, rectocele, or enterocele. Risk factors are advancing age; prior pelvic surgery or trauma; parity and child- birth; clinical conditions (obesity, dia- betes, multiple sclerosis, Parkinson disease); medications (anticholinergics, a-adrenergic blockers); and chronically increased intra-abdominal pressure from chronic obstructive pulmonary disease (COPD), chronic constipation, or obesity. -The pelvic diaphragm is innervated by the sacral nerve roots S3 to S5. The perineal membrane and the urogenital diaphragm are innervated by the pu- dendal nerve. *Loss of urethral support contributes to stress incontinence. Weakness of the perineal body from childbirth predis- poses to rectoceles and enteroceles. -In most women, pubic hair spreads downward in a triangular pattern, pointing toward the vagina. In 10% of women, it may form an inverted triangle, pointing toward the umbilicus. This growth is usually not completed until the middle 20s or later. The growth of pubic hair along with breast development are the main components of sexual maturity assessment in girls. Just before menarche, there is a physiologic increase in vaginal secretions—a normal change that sometimes worries a girl or her mother. As menses become more regular, these increased secretions, or leukorrhea, coincide with ovulation. They also accompany sexual arousal. These normal discharges must be differentiated from the discharges of cervical and vaginal infections.

Inspecting cervix (internal exam)

-Open the speculum carefully. Rotate and adjust the speculum until it cups the cervix and brings it into full view -When the uterus is retroverted, the cervix points more anteriorly than illustrated. If you have difficulty finding the cervix, withdraw the speculum slightly and reposition it on a different slope. If a discharge obscures your view, wipe it away gently with a large cotton swab. -Note the color of the cervix; its position and surface characteristics; and any ulcerations, nodules, masses, bleeding, or discharge. Inspect the cervical os for discharge. -Look for lateral displacement of the cervix in endometriosis involving the uterosacral ligaments. A yellowish discharge on the endocer- vical swab commonly represents mucopurulent cervicitis from C. tra- chomatis, N. gonorrhoeae, or herpes simplex (p. 572). Raised, friable, or lobed wart-like lesions are seen with condylomata or cervical cancer.

Anal fistula

-Originate from the anal glands, which are located between the internal and external anal sphincter and drain into the anal canal. -If the outlet of these glands becomes blocked, an abscess can form which can eventually extend to the skin surface.

Anatomy of testes

-Ovoid, somewhat rubbery structures approximately 4.5 cm long -Produce spermatozoa and testosterone. Gonadotropin-releasing hormone (GRH) from the hypothalamus stimulates pituitary secretion of luteinizing hormone (LH) and follicle-stimulating hormone (FSH). LH acts on the interstitial Leydig cells to promote synthesis of testosterone, which is converted in target tissues to 5α-dihydrotestosterone. It is 5α-dihydrotestosterone that triggers pubertal growth of the male genitalia, pros- tate, seminal vesicles, and secondary sex characteristics such as facial and body hair, musculoskeletal growth, and enlargement of the larynx with its associated low-pitched voice. FSH regulates sperm production by the germ cells and Sertoli cells of the seminiferous tubules. -Covering the testis, except posteriorly, is the serous membrane of the tunica vaginalis, derived from the peritoneum of the abdomen and brought down into the scrotum during testicular descent through the deep internal inguinal ring. *If the peritoneal lining remains an open channel to the scrotum it can give rise to an indirect inguinal hernia. -The parietal layer of the tunica vaginalis cloaks the anterior two thirds of the testis, and the visceral layer lines the adjacent scrotum. *The parietal and visceral layers form a potential space for the abnormal fluid accumulation of a hydrocele. -Contained in the scrotum, a loose, wrinkled pouch divided into 2 compartments -The vas ascends from the scrotal sac into the pelvic cavity through the inguinal canal, then loops anteriorly over the ureter to the prostate behind the bladder. There, it merges with the seminal vesicle to form the ejaculatory duct, which traverses the prostate and empties into the urethra. Secretions from the vasa deferentia, the seminal vesicles, and the prostate all contribute to the seminal fluid. -Covering the testis, except posteriorly is the serous membrane the tunica vaginalis -Posterior surface of each testis is a comma-shaped epididymis -Lymphatic drainage: Parallels vasculature, testicular nodes located in retroperitoneum (most common metastatic site in test cancer). Scrotal and penile lymph drains into inguinal/pelvic nodes -Male sexual function depends on normal levels of testosterone, arterial blood flow from the internal iliac artery to the internal pudendal artery and its penile artery and branches, and intact neural innervation from α-adrenergic and cho- linergic pathways. stimuli appear to increase levels of nitric oxide and cyclic guanosine monophosphate, resulting in local vasodilation.

Premenstrual Syndrome.

-PMS includes emotional and behavioral symptoms such as depression, angry outbursts, irritability, anxiety, confusion, crying spells, sleep disturbance, poor concentration, and social withdrawal. -Ask about signs such as bloating and weight gain, swelling of the hands and feet, and generalized aches and pains. -Criteria for diagnosis are symptoms and signs in the 5 days prior to menses for at least three consecutive cycles; cessa- tion of symptoms and signs within 4 days after onset of menses; and interfer- ence with daily activities.

Self breast exam

-Patient education is a key component in finding early breast cancer

HPV Vax

-Routine vaccination for girls ages 11 and 12. three-dose vaccination series over 6 months with either the quadrivalent or bivalent vaccine for girls and boys at ages 11 or 12, before their first sexual encounter; the series can begin as early as age 9 years. -The quadrivalent vaccine prevents infection from HPV sub- types 16 and 18, as well as 6 and 11, which cause 90% of genital warts. The bivalent vaccine prevents infection from subtypes 16 and 18. Vaccination with the quadrivalent HPV vaccine is also recommended for the prevention of cervi- cal, vulvar, and vaginal cancers and precancers in females, as well as anal can- cers and precancers and genital warts in both females and males. -Catch-upvaccination:isrecommendedforfemalesages13through26years who have not had prior vaccination or completed the three-dose series. If females reach age 27 years before completing the series, the second and/or third vaccine doses can be administered after age 26 years to complete the series. Prevaccination assessments to establish the need for Pap or high-risk HPV DNA testing are not recommended. The HPV vaccine is recommended for persons with compromised immune systems, including infection with HIV, through age 26 years if they have not been fully vaccinated when younger.

Palpation of breast

-Patient supine *Palpate rectangular area *Clavicle to inframammary fold or bra line *Midsternal line to posterior axillary line *Deep into axilla for breast tail *3 minutes per breast *Pads of 2nd, 3rd, 4th fingers, slightly flexed *Systematic *Vertical strip *Small, concentric circles *When pressing deeply on the breast, a normal rib can be mistaken for a hard breast mass. - -Can do palpation in circular, wedge or line manner -Varying levels of pressure used -Where to palpate: *Lateral Breast Patient rolls to opposite hip Places hand on forehead but keeps shoulders pressed against bed or table Nodules in the tail of the breast in the axilla (the tail of Spence) are sometimes mistaken for enlarged axillary lymph nodes. *Medial Breast Patient lies with shoulders flat against bed or table *Hand on neck with elbow lifted to even line with shoulder Nipple -What looking for? Consistency: Normal consistency varies widely, depending on the proportions of firmer glandular tissue and soft fat. Physiologic nodularity may be present, increasing before menses. Note the firm inframammary ridge, which is the transverse ridge of compressed tissue along the lower margin of the breast, especially in large breasts. This ridge is sometimes mistaken for a tumor.* Tender cords suggest mammary duct ectasia, a benign but sometimes pain- ful condition of dilated ducts with sur- rounding inflammation and, at times, with associated masses. Tenderness **Nodules: Assess and describe the characteristics of any nodule. Hard irregular poorly circumscribed nodules, fixed to the skin or underly- ing tissues, strongly suggest cancer. Location Size Shape Consistency Delimitation Tenderness: Check for cysts and inflamed areas; some cancers may be tender. Mobility: try to move the nodule or mass while the patient relaxes her arm and then while she presses her hand against her hip. *Thickening of the nipple and loss of elasticity suggest an underlying cancer. Special techniques: Spontaneous Nipple Discharge Assessment Mastectomy Patient Assessment Self Breast Examination

The female patient may remain in a lateral position for examination of which of the following: Adnexal mass Perianal fissure Integrity of the rectovaginal wall Pelvic mass

-Perianal fissure -The rectum is usually examined while the woman is in the lithotomy position, which is also ideal for conducting the bimanual examination and is suitable for testing the integrity of the rectovaginal wall; it may also help to palpate a cancer high in the rectum -If the rectum only requires examination, the side-lying position affords a much better view to the perianal and sacrococcygeal areas

Zones of prostate

-Peripheral (1), central (2), and transition (3) zones. -Most prostate cancers arise in the peripheral zone, the outer area of the prostate, which is next to the rectum. -Benign prostatic hyperplasia: Most common urologic disease of men; incidence increase with age (50% in 50s and 80-90% in 70s and 80s). Pathophysiology poorly understood; hormone alteration plays a central role Almost exclusively involves the area of transition zone (TZ). Presents with lower urinary tract symptoms (LUTS). Most common non-cancerous cause of serum PSA elevation. Hallmark - nodular enlargement

Examining anus, rectum, prostate

-Positioning: *Leaning/standing: good for simple exams, or when no gowns available *Lateral decubitus: Allows patient to stay on table -Inspect: *anogental "median" raphe, formed in male embryo as line of closure of anogenital folds from anus to tip of penis. There's perineal, scrotal, penile, penosacral raphe. They vary. -Palpate: *Perineum, anus, rectum, prostate *Locate prostate, usually at anterior rectal wall. Palpate in firm circular motion. Patient may feel need to urinate (do to course of urethra through gland). Not size, shape, any nodules, etc. Normal prostate has 2 lobes with sulcus, almost heart shape. Should be symmetrical, firm and rubbery. Softness may be infection, hardness may be malignancy, *Rectal wall -Can test for occult blood, or give patient self 3 day test. *Only the lateral lobes and median sulcus are palpable In the female, the uterine cervix usually is palpable through the anterior wall of the rectum

Order of whys exam for male

-Pubic/groin -Hernias -Scrotum -Penis -rectum/prostate -Breast

Taking health history of breast

-Qs to ask: *Do you do self exams? when/how *Discomfort/pain/lumps? *Discharge? when does it occur? *Do you examine breasts during menstration? (5-7 days after onset is ideal) -Breast lump or mass? When? -Breast pain or discomfort? When? -Nipple discharge? When? -Self breast examination? When? -Risk factors for breast cancer -Breast cancer screening

Menarche/menstruation

-Questions about menarche, menstruation, and menopause provide an opportunity to explore the patient's concerns and her attitude about her body. -often it takes ≥1 year for menstrual cycles to settle into a regular pattern. Age at menarche is variable, depending on genetic endowment, socioeconomic status, and nutrition. The interval between periods ranges roughly from 24 to 32 days; flow lasts from 3 to 7 days. -The dates of previous periods provide clues to possible pregnancy or menstrual irregularities. When did her last menstrual period (LMP) start, and, if possible, the one before that, called the prior menstrual period (PMP). -Unlike the normal dark red menstrual discharge, excessive flow tends to be bright red and may include "clots" (not true fibrin clots)

Testicular self exam

-Risk factors: cryptorchidism, which confers a high risk for testicular carcinoma in the undescended testicle; a history of carcinoma in the contralateral testicle; mumps orchitis; an inguinal hernia; a hydrocele in childhood; and a positive family history. -This examination is best performed after a warm bath or shower. This way, the scrotal skin is warm and relaxed. It is best to do the test while standing. -Standing in front of a mirror, check for any swelling on the skin of the scrotum. -With the penis out of the way, gently feel your scrotal sac to locate a testi- cle. Examine each testicle separately. -Use one hand to stabilize the testicle. Using the fingers and thumb of your other hand, firmly but gently feel or roll the testicle between your fingers. Feel the entire surface. Find the epididymis. This is a soft, tube-like structure at the back of the testicle that collects and carries sperm, and is not an abnormal lump. Check the other testicle and epididymis the same way. - If you find a hard lump, an absent or enlarged testicle, a painful swollen scro- tum, or any other differences that do not seem normal, do not wait. See your health care provider right away. *normal for one testicle to be slightly larger than the other, and for one to hang lower than the other. Normal testicles also have blood vessels, supporting tissues, and tubes that carry sperm. Some men may confuse these with abnormal lumps at first.

Anal health promotion/counseling

-Screen for prostate cancer *Prostate cancer is the leading cancer diagnosed in men in the United States, and the second leading cause of death *The primary risk factors are age, ethnicity, and family history (although a series of studies have suggested an association between intake of dietary fat and risk of prostate cancer) -Screen for polyps and colorectal cancer -Provide counseling about sexually transmitted diseases

Inspection (breast)

-Seated position, disrobed to waist *Four views *Arms at sides *Arms over head *Arms pressed against hips *Leaning forward *Looking for: >Skin changes >Symmetry >Contours >Retraction >Tanner Stages -Arms at side: *Skin color and appearance *Size and symmetry *Contour *Nipple characteristics Size Shape Direction Rashes, ulcerations, discharge *Redness suggests local infection or inflammatory carcinoma. Thickening and prominent pores suggest breast cancer. Flattening of the normally convex breast suggests cancer. *Asymmetry due to change in nipple direction suggests an underlying can- cer. Eczematous changes with rash, scaling, or ulceration on the nipple extending to the areola occurs in Paget disease of the breast, associated with underlying ductal or lobular carcinoma *A nipple pulled inward, tethered by underlying ducts signals nipple retrac- tion from a possible underlying cancer. The retracted nipple may be depressed, flat, broad, or thickened. -Hands Against Hips *Helps to tighten pectoral muscles, helps to see any fixing to muscles/chest wall -Arms overhead: helps to make dimples more noticeable *Breast dimpling or retraction in these positions suggests an underlying cancer. Cancers with fibrous strands attached to the skin and fascia over the pectoral muscles may cause inward dimpling of the skin during muscle contraction. Occasionally, these signs accompany benign conditions such as posttrau- matic fat necrosis or mammary duct ectasia, but should always be further evaluated. -Leaning Forward Accentuates dimpling and retraction (abnormal fibrosis)

Internal exam- Female

-Select a speculum of appropriate size and shape, and moisten it with warm water. (Lubricants or gels may interfere with cytologic studies and bacterial or viral cultures.) -Let the patient know you are about to insert the speculum and apply downward pressure. Some clinicians carefully enlarge the vaginal introitus by lubricating one finger with water and applying downward pressure at its lower margin, then palpate the location of the cervix in order to angle the speculum more accurately. -With your other hand (usually the left), introduce the closed speculum past your fingers at a downward slope -Avoid pulling on the pubic hair or pinching the labia as you open and close the speculum. Separating the labia majora with your right hand helps to avoid this. Be careful of urethra! -After placing the speculum in the vagina, remove your fingers of your other hand from the introitus. Rotate the speculum into a horizontal position, maintaining pressure posteriorly, and insert it to its full length. Do not open the blades of the speculum prematurely. -Next, inspect the cervix, vagina, and do the bimanual exam

Penis anatomy

-Shaft is formed by 3 columns of vascular erectile tissue *Corpus spongiosum (with urethra) *Two corpora cavernosa -Uncircumcised - the glans is covered by loose fold of skin (prepuce) were secretions of the glans may collect -Urethra opens into the vertical, slit like urethral meatus

Male breast

-Small nipple & areola -Overlie a thin disc of undeveloped breast tissue -Firm > 2 cm button of breast tissue 🡪 -Seen in 1 of 3 adults males -Need to look under areolar complex -If feel nontender firm disc of tissue, need to check other side to compare -Some men develop benign breast enlargement from gynecomastia, a proliferation of palpable glandular tis- sue, or pseudogynecomastia, the accu- mulation of subareolar fat. Causes of gynecomastia include increased estro- gen, decreased testosterone, and medication side effects. -Inspect nipple and areola Nodules Swelling Ulceration -Palpate areola and breast tissue Nodules

Techniques of exam

-The anorectal and prostate examinations are usually the least popular segments of the physical examination -A skillfully performed examination should not be truly painful Successful examination requires a calm demeanor, explanation to the patient of what he or she may feel, gentleness, and slow movement of your finger -In asymptomatic adolescents, it is appropriate to defer the rectal exam -The male patient One of several patient positions may be used for examination The patient may stand, leaning forward with his upper body resting across the examining table and hips flexed The patient may lie on his left side with his buttocks close to the edge of the exam table near you; flex the patients hips and knees, especially the top leg *Inspect the sacrococcygeal and perianal areas *Assess for lumps, ulcers, inflammation, rashes, or excoriations *Palpate any abnormal areas, noting lumps or tenderness

Anal exam (female)

-The female patient -The rectum is usually examined after the female genitalia, while the woman is in the lithotomy position; this position is also ideal for conducting the bimanual examination and is suitable for testing the integrity of the rectovaginal wall and may also help to palpate a cancer high in the rectum -If the rectum only requires examination, the side-lying position affords a much better view to the perianal and sacrococcygeal areas Use the same techniques for examination that are used for men

pregnancy

-The health history includes such questions as, "Have you ever been pregnant? How many times?...How many living children do you have?... Have you ever had a miscarriage or an abortion? How many times?" Ask about any difficulties during pregnancy and the timing and circumstances of any abortion, whether spontaneous or induced. How did the woman experience these losses? Obstetricians commonly record the pregnancy history using the "gravida para" system. *G = gravida, or total number of pregnancies ● P = para, or outcomes of pregnancies. After P, you will often see the notations F (full-term), P (premature), A (abortion), and L (living child). -If amenorrhea suggests a current pregnancy, inquire about the date of last inter- course and common early symptoms: tenderness, tingling, or increased size of the breasts; urinary frequency; nausea and vomiting; easy fatigability; and sensations that the baby is moving, usually present at about 20 weeks. Be sensitive to the patient's feelings about these topics; explore them when the patient has special concerns. *Amenorrhea followed by heavy bleeding suggests a threatened abortion or dysfunctional uterine bleeding related to lack of ovulation.

Dysmenorrhea

-pain with menses, is reported by almost half of women patients. Ask if the patient has any discomfort or pain before or during her periods. If so, what is it like, how long does it last, and does it interfere with usual activities? Are there other associated symptoms? Dysmenorrhea may be primary, without an organic cause, or secondary, with an organic cause. -Primary dysmenorrhea results from increased prostaglandin production during the luteal phase of the men- strual cycle, when estrogen and progesterone levels decline. -Causes of secondary dysmenorrhea include endometriosis, adenomyosis (endometriosis in the muscular layers of the uterus), pelvic inflammatory disease (PID), and endometrial polyps.

Different breast masses

-The three most common breast masses are fibroadenoma (a benign tumor), cysts, and breast cancer. -any breast mass should be carefully evaluated and usually warrants further investigation by ultrasound, aspiration, mammography, or biopsy. -Fibrocystic changes are also commonly palpable as nodular, rope-like densities in women aged 25 to 50 years. They may be tender or painful. They are considered benign and not a risk factor for breast cancer. -Fibroadenoma: 15-25 years, usually puberty and young adulthood, but up to age 55 years, Usually single, may be multiple Round, disclike, or lobular; typically small (1-2 cm), May be soft, usually firm Well delineated, Very mobile Usually nontender, retraction Absent -Cysts: 30-50 years, regress after menopause except with estrogen therapy Single or multiple Round, Soft to firm, usually elastic Well delineated, Mobile Often tender, retraction Absent -Cancer: 30-90 years, most common over age 50 years Usually single, although may coexist with other nodules Irregular or stellate Firm or hard Not clearly delineated from surrounding tissues May be fixed to skin or underlying tissues Usually nontender, retraction May be present

Evaluating scrotal hernia

-To assess a scrotal mass and pos- sible hernia, ask the patient to lie down. The mass may return to the abdomen by itself. If so, it is a hernia. If not: -Can you get your fingers above the mass in the scrotum? If you can place your fingers above the mass, suspect a hydrocele. -Listen to the mass with a stethoscope for bowel sounds, but note that bowel sounds may be transmitted from the abdomen through a hydrocele in the scrotum. Transillumination of the scrotal mass may help identify a hydrocele from an intestine-containing hernia. -If your findings suggest a hernia, gently try to reduce it (return it to the abdominal cavity) by sustained pressure with your fingers. Do not attempt this maneu- ver if the mass is tender or the patient reports nausea and vomiting. The history may be helpful. The patient can usually tell you what happens to his swelling when lying down and may be able to demonstrate how he reduces it himself. *A hernia is incarcerated when its contents cannot be returned to the abdominal cavity. A hernia is strangulated when the blood supply to the entrapped contents is compromised. Suspect strangulation in the presence of tenderness, nausea, and vomiting, and consider surgical intervention.

Assessing urethritis

-To evaluate possible urethritis or inflammation of the paraurethral glands, insert your index finger into the vagina and milk the urethra gently outward from the inside. Note any discharge from or about the urethral meatus. If present, culture it. *Causes of urethritis include infection from C. trachomatis and N. gonor- rhoeae.

Screening for testicular cancer/self exam

-While testicular cancer is rare, it is highly treatable when detected early. It is the most commonly diagnosed cancer in white men from ages 20 to 34 years; the risk of diagnosis is five times more common in white men compared to black men -Risk factors are family his- tory, HIV infection, and a history of cryptorchidism (undescended testicle).

Inspecting the vagina

-Withdraw the speculum slowly while observing the vaginal walls. As the speculum clears the cervix, release the thumbscrew and maintain the open position of the speculum with your thumb. During withdrawal, inspect the vaginal mucosa, noting its color and any inflammation, discharge, ulcers, or masses. -Check for bulging in the vaginal wall. Remove either the upper or lower blade of the speculum (or use a single-blade speculum) and ask the woman to bear down so that you can assess the location of vaginal wall relaxation or the degree of uterine prolapse. -Vaginal discharge often accompanies infection from Candida, Trichomonas vaginalis, and bacterial vaginosis. Diagnosis depends on laboratory tests because the sensitivity and specificity of discharge characteristics are low. Vaginal cancer is rare; diethylstilbestrol (DES) exposure in utero and HPV infection are risk factors. Use of the lower blade as a retractor during bearing down helps expose anterior vaginal wall defects such as cystoceles; likewise, use of the upper blade helps expose rectoceles. The standardized Pelvic Organ Quantification (POP-Q) system and diagram is widely used

Spontaneous Nipple Discharge Assessment

-compressing the areola with your index finger placed in radial positions around the nipple (Fig. 10-15). Watch for discharge expressed from any of the duct openings on the nipple surface. Note the color, consistency, and quantity of any discharge and the exact location where it appears. *Milky discharge unrelated to a prior pregnancy and lactation is nonpuer- peral galactorrhea. Causes include hyperthyroidism, pituitary prolactinoma, and dopamine antagonists, including psychotropics and phenothiazines. *Spontaneous unilateral bloody discharge from one or two ducts warrants further evaluation for intra- ductal papilloma, shown in Figure 10-16, ductal carcinoma in situ, or Paget dis- ease of the breast. Clear, serous, green, black, or nonbloody discharges that are multiductal are usually benign.

Assessing Risk of Breast Cancer.

-most common cause of cancer in women worldwide, accounting for more than 10% of cancers in women. -Eighty percent of new breast cancer cases occur after age 50 years, with a median age at diagnosis of age 61 years. The probabil- ity of diagnosis increases with each decade. -Breast cancer is the second leading cause of cancer death in women following lung cancer. Five-year survival rates are 99% for local disease, 84% for regional disease, and 24% for metastatic disease. -Declining death rates overall, but more advanced disease and higher mortality in African American women. -The most important risk factor for breast cancer is age. Other non- modifiable risk factors are family history of breast and ovarian cancers, inherited genetic mutations, personal history of breast cancer or lobular carcinoma in situ, high levels of endogenous hormones, breast tissue density, proliferative lesions with atypia on breast biopsy, and duration of unopposed estrogen exposure related to early menarche, age of first full-term pregnancy, and late menopause. Note that a history of radiation to the chest and diethylstilbestrol (DES) exposure also place women at high risk. Modifiable risk factors include: breastfeeding for less than 1 year, postmenopausal obesity, use of HRT, cigarette smoking, alcohol ingestion, physical inactivity, and type of contraception. Nonetheless, over 50% of women with breast cancer have no familial or reproductive risk factors. -Family History: High-Risk Factors for Familial Breast Cancer: ● Age 50 years or younger at diagnosis of breast cancer ● Breast cancer in two or more individuals in the same lineage (paternal or maternal) ● Multiple primary or ovarian tumors in one person ● Breast cancer in a male relative ● Ashkenazi Jewish ancestry ● Family member with a known predisposing gene (including Li-Fraumeni and Cowden syndromes) -The BRCA1 and BRCA2 gene occur in <1% of the population but account for roughly 5% to 10% of female breast cancers.16 However, these mutations repre- sent only 15% to 20% of the familial breast cancers; they also confer increased risk for ovarian cancer. For BRCA1 mutations, the risk of developing breast cancer by age 70 years is estimated at 44% to 78%, and for BRCA2, the estimated risk is 31% to 51% -Studies show that when radiologic density, expressed as a percentage of breast area, reaches 60% to 75% of breast tissue, the relative risk of breast cancer increases four- to sixfold, in part related to the "masking effect" of breast den- sity on smaller cancers, which have the same x-ray attenuation as fibroglandular breast tissue.

Inguinal/ femoral Hernias

-patient can be either supine or standing. Inguinal: -Inspection: Sitting comfortably in front of the patient, with the patient standing and an assistant present, if indicated, inspect the inguinal regions and genitalia for bulging areas and asymmetry. -Palpation: *place the tip of your dominant index finger at the anterior inferior margin of the scrotum, staying superficial to the testicle, then move your finger and hand upward toward the external inguinal ring, invaginating the scrotal skin beneath the peripubic fat pad next to the base of the penis. *Follow the spermatic cord upward to the inguinal ligament. Find the trian- gular slit-like opening of the external inguinal ring just above and lateral to the pubic tubercle. Palpate the external inguinal ring and its floor. Ask the patient to cough. Palpate for a distinct bulge or mass that moves against your stationary finger during the cough *A bulge near the external inguinal ring suggests a direct inguinal hernia. A bulge near the internal inguinal ring suggests an indirect inguinal hernia. Experts note that distinguishing the type of hernia is difficult, with sensitivity and specificity of 74% to 92%, and 93%. Hernias warrant surgical evaluation, especially when symp- tomatic or incarcerated. Chance of incarceration is low, estimated at 0.3% to 3% per year, and is 10 times more common with indirect hernias *The external ring may be large enough for you to gently palpate obliquely along the inguinal canal toward the internal inguinal ring. Again ask the pa- tient to cough. Check for a bulge that slides down the inguinal canal and taps against the fingertip. Use the same techniques with the same dominant finger to examine both sides -Palpate for a femoral hernia by placing your fingers on the anterior thigh in the region of the femoral canal. Ask the patient to strain down again or cough. Note any swelling or tenderness.

HPV vax men/women

-routine quadrivalent HPV vaccination in males age 11 or 12 years and through age 21 years if not vaccinated previously (age 26 years if immunocompromised or having sex with other men). -vaccine can prevent HPV- related diseases in males (genital warts, anal cancer, and penile cancer) and possibly reduce HPV transmission to female sex partners and lower the risk of oropharyngeal cancers.

Performing rectovaginal exam

-three primary purposes: to palpate a retroverted uterus, the uterosacral ligaments, cul-de-sac, and adnexa; to screen for colorectal cancer in women ages 50 years or older; and to assess pelvic pathology. *Nodularity and thickening of the uterosacral ligaments occur in endometriosis, also pain with uterine movement. -After withdrawing your fingers from the bimanual examination, change your gloves and lubricate your fingers as needed (see note below on lubricants). Slowly reintroduce your index finger into the vagina and your middle finger into the rectum. Ask the patient to strain down as you do this to relax her anal sphincter. Mention that this may stimulate an urge to move her bowels, but this will not occur. Apply pressure against the anterior and lateral walls with the exam- ining fingers, and downward pressure with the hand on the abdomen. -Check the rectal vault for masses. If fecal blood testing is planned, change gloves to avoid contaminating fecal material with any blood provoked by collecting the Pap smear. After the examination, wipe off the external genitalia and rectum, or offer tissues to the patient so that she can do it herself.

Indirect v direct v femoral hernia

Direct: *Less common. Usually in men older than 40 yrs; rare in women. Above inguinal ligament, close to the pubic tubercle (near the external inguinal ring). Rarely into the scrotum. The hernia bulges anteriorly and pushes the side of the finger forward. Indirect: *Most common, all ages, both sexes. Often in children; may occur in adults. Above inguinal ligament, near its midpoint (the internal inguinal ring). Often into the scrotum. The hernia comes down the inguinal canal and touches the fingertip Femoral: *Least common. More common in women than in men. Below the inguinal ligament; appears more lateral than an inguinal hernia. Can be hard to differentiate from lymph nodes. Never into the scrotum. The inguinal canal is empty.

A 65-year-old male presents to clinic for a routine examination. The following is the documentation of his prostate examination. Which statement would be of concern? Firm Heart-shaped 2.5 cm long Median sulcus palpable

Firm The normal prostate is rubbery.

Scrotal exam

Inspection: -The skin. Lift up the scrotum so that you can inspect its posterior surface. Note any lesions or scars. Inspect the pubic hair distribution. *Inspection may reveal scrotal nevi, hemangiomas, or telangiectasias as well as STIs including condyloma or ulcers from herpes and chancroid (painful) and syphilis and lymphogranuloma venereum (painless), with associated inguinal lymphadenopathy. -The scrotal contours. Inspect for swelling, lumps, veins, bulging masses, or asymmetry of the left and right hemiscrotum. *A poorly developed scrotum on one or both sides suggests cryptorchidism (an undescended testicle). Common scro- tal swellings include indirect inguinal hernias, hydroceles, scrotal edema, and, rarely, testicular carcinoma -The inguinal areas. Note any erythema, excoriation, or visible adenopathy. Erythema and mild excoriation point to fungal infection, not uncommon in this moist area. -There may be dome-shaped white or yellow papules or nodules formed by occluded follicles filled with keratin debris of desquamated follicular epithelium. Such epidermoid cysts are common, frequently multiple, and benign Palpation: -If using a one-handed technique, palpate each testis and epididymis between your thumb and first two fingers. The testes should be firm but not hard, descended, symmetric, nontender, and without masses. *Tender painful scrotal swelling is present in acute epididymitis, acute orchitis, torsion of the spermatic cord, or a strangulated inguinal hernia. -Palpate the epididymis on the posterior surface of each testicle without applying excess pressure, which can cause discomfort. The epididymis feels nodular and cord-like and should not be confused with an abnormal lump. Normally, it should not be tender. -Any painless nodule on the testis raises the possibility of testicular cancer, a potentially curable cancer with a peak incidence between the ages 15 to 34 years. Recall that lymph drainage from the testes parallels retroperitoneal venous flow from the renal vein and inferior vena cava, the primary site of lymph node involvement in testicular cancer -Palpate each spermatic cord, including the vas deferens, between your thumb and fingers, from the epi- didymis to the external inguinal ring. The vas feels slightly stiff and tubular and is distinct from the accompanying vessels of the spermatic cord. -To check for a varicocele, with the patient standing, palpate the spermatic cord about 2 cm above the tes- tis. Have the patient hold his breath and "bear down" against a closed glottis for about 4 seconds (the Valsalva maneuver). During this maneuver, a temporary increase in the diameter of the sper- matic cord indicates filling of abnor- mally dilated spermatic veins draining the testis. *The vas deferens, if chronically infected, may feel thickened or beaded. A cystic structure in the spermatic cord suggests a hydrocele of the cord. -Swelling in the scrotum apart from the testicles can be evaluated by transillumination. *Swellings containing serous fluid, such as hydroceles, light up with a red glow, or transilluminate. Those containing blood or tissue, such as a normal testis, a tumor, or most hernias, do not.

Female genital lymphatics

Lymph from the vulva and lower vagina drains into the inguinal nodes. Lymph from the internal genitalia, including the upper vagina, flows into the pelvic and abdominal lymph nodes, which are not palpable.

Tanner staging female hair

Stage 1: Preadolescent—no pubic hair except for the fine body hair (vellus hair) similar to that on the abdomen Stage 2: Sparse growth of long, slightly pigmented, downy hair, straight or only slightly curled, chiefly along the labia Stage 3: Darker, coarser, curlier hair, spreading sparsely over the pubic symphysis Stage 4: Coarse and curly hair as in adults; area covered greater than in stage 3 but not as great as in the adult and not yet including the thighs Stage 5: Hair adult in quantity and quality, spreads on the medial surfaces of the thighs but not up over the abdomen

Tanner staging- Breasts

Stage 1: Preadolescent: elevation of nipple only Stage 2: Breast bud stage: elevation of breast and nipple as a small mound; enlarge- ment of areolar diameter Stage 3: Further enlargement of elevation of breast and areola, with no separation of their contours Stage 4: Projection of areola and nipple to form a secondary mound above the level of breast Stage 5: Mature stage: projection of nipple only; areola has receded to general contour of the breast (although in some normal individuals the areola continues to form a secondary mound) *Masses or nodules in the breasts of adolescent girls should be examined carefully. They are usually benign fibroadenomas or cysts; less likely, etiologies include abscesses or lipomas. Breast carcinoma is extremely rare in adolescence and nearly always occurs in families with a strong history of the disease.

supernumerary nipple

extra nipples located along the "milk line" -Numerary lines from axilla to groin in most animals, in development, should only be left with 2 at normal breast spot, but not uncommon for people to have nipples left over. Look at moles/pimples to see if they fall along supernumerary nipple

Common/concerning symptoms (women's health)

● Menarche, menstruation, menopause, postmenopausal bleeding: ● Pregnancy ● Vulvovaginal symptoms ● Sexual health ● Pelvic pain—acute and chronic ● Sexually transmitted infections (STIs)