PD E3- Study Guide

What is hegar’s sign?

Softening of isthmus of uterus

What is Chadwick’s sign?

Increased vascularity throughout pelvic region → bluish discoloration of vagina and cervix

What does melanocyte stimulating hormone cause during pregnancy?

Linea nigra, darkening of nipple & areola, facial chloasma, melasma, longlasting suntan

What skin changes does estrogen cause during pregnancy?

Spider nevi, palmar erythema

What skin changes does corticosteroid effects cause during pregnancy?

Striae on abdomen & breasts

What is brownish-black pigment along the midline of the abdomen?

*d/t melanocyte stimulating hormone

Linea nigra

What is diastasis recti?

Rectus abdominis muscles separate at midline (noticeable in later trimesters)

How does the abdomen enlarge throughout pregnancy?

Uterus rises out of pelvis into abdomen by 12th week → inc in abdominal girth apparent by 15th week

*enlargement may appear earlier if multiparous female

What is the first trimester?

0-14 wks

What is the second trimester?

14-28 wks

What is the third trimester?

28 wks - birth

What characterizes the level of descent of the presenting part of the fetus?

• 0 = fetal occiput (vertex presentation) has reached level of maternal ischial spines (engagement)

• -1 = 1 cm above

• +1 = 1 cm below

Station

What is the degree to which the cervix has thinned, expressed as a number of cm in which cervix has changed?

• also expressed as percentage

• determined by digital exam

• 4 cm = is unchanged

Effacement

What is the number of cm of the opening of the internal os, determined on exam with 1-2 fingers?

Dilation

What rule is used to calculate estimated date of confinement (EDC)?

Naegele’s rule → first day of LMP - 3 months + 1 year & 7 days

What can compression of the descending aorta and IVC during the OB exam cause (patient should sit briefly before proceeding to pelvic exam to avoid- semi-sitting position with knees bent)?

Supine hypotensive syndrome

What is mammary soufflé?

Increased blood flow through dilated internal mammary artery → easily heard in 2nd & 3rd interspace in parasternal areas

Which murmurs, if heard in pregnancy, may accompany anemia & should be investigated?

Diastolic murmurs & dyspnea

What is the fundal height at 12 weeks?

Barely palpable above pubic symphysis

What is the fundal height at 15 weeks?

Midpoint between pubic symphysis and umbilicus

What is the fundal height at 20 weeks?

At the umbilicus

What is the fundal height at 28 weeks?

6 cm above umbilicus

What is the fundal height at 32 weeks?

6 cm below xyphoid process

What is the fundal height at 36 weeks?

2 cm below the xyphoid process

What is the fundal height at 40 weeks?

*d/t engagement & descent, fundal height at 40 weeks is less than at 36 weeks

4 cm below xyphyoid process

What is maneuvers provide useful information to assess the lie and presentation of the fetus from the 28th week & on?

Leopold’s maneuvers

What are the 4 parts of Leopold’s maneuvers?

Determine what fetal part occupies fundus: buttocks feels firm but irregular, head feels hard & moveable

Determine what side is fetal back: one side rounded but firm, other is irregular, lumpy, & moves

Identify descent of presenting part: if lower pole not engage, moveable part will be felt

Identify cephalic prominence: confirm presentation part & locate side of cephalic prominence

What exercise is appropriate during pregnancy?

Moderate exercise for 30 min/day most days of week

*active before pregnancy → continue mild-moderate; non-active before pregnancy → join program

What exercise should patient avoid after first trimester?

Contact sports, anything in supine position → compresses IVC and decreases blood flow to placenta

What vaccines should be avoided in pregnancy?

Live vaccines (VZV, MMR)

What vaccines can be given in pregnancy?

Tetanus, influenza, pneumococcal, meningococcal, HBV

What is polythelia?

Extra nipples

What is polymastia?

Accessory breasts

In what positions should the breasts be inspected?

Sitting w/ arms over head or pressed on hips: dimpling & retraction

Sitting leaning forward: asymmetry, retraction of nipple / areola

Lying w/ arm behind head: allow breast tissue to spread over chest

What does retraction of the nipple or areola suggest?

Cancer

What are possible causes of peau d’orange?

Breast cancer, mastitis, & lymphedema

What would nipple inversion (if previously everted) along with signs of itching & pain be a sign of?

Inflammatory breast cancer

How should breast normally appear to palpation?

*use pads of middle 3 fingers held together w/ metacarpal-phalangeal joint slightly flexed

Firm w/o masses, tenderness or warmth, no nipple dc, & smooth axillae w/ non palpable nodes

What imaging do you do for a suspicious breast mass in an adolescent female?

US

How are geriatric breasts anatomically different?

Flatter, elongated, loosely suspended, granular feel, smaller flatter nipples, breasts cysts if on HRT

When should self breast exams be performed?

Monthly at the end of menses in all menstruating women

What is the most sensitive screening tool for breast cancer?

Mammogram

What is roentgenography of breasts without injection of contrast medium?

Mammogram

Screening or diagnostic mammogram?

• look for breast disease in women who appear to have no breast problems

Screening

Screening or diagnostic mammogram?

• Find breast disease in women who have sx or found a lump or abnormal radiological changes

Diagnostic

What should you do if an area of concern is found on mammogram?

Biopsy

What is the presence of a painless, firm, solitary, mobile, slowly growing lump in the breast of a woman of childbearing years?

*MC young women, 1-3 cm, no menstrual cycling; 2nd MCC of benign breast problems

FIbroadenoma

What breast condition?

• long follicular or luteal phase of cycle

• fluid filled cysts, BL, multiple, tender

• MC 30-55 y/o

Fibrocystic disease

What condition?

• benign breast condition → NOT a disease

• exaggerated response to hormones (cyclic BL pain & engorgement)

  • diffuse, may radiate to shoulders or upper arms

• changes most prominent just prior to menses

Fibrocystic changes

When are fibrocystic changes to the breast MC?

Premenstrual time frame, nulliparous women, non uses of hormonal contraceptives, mid 20s - early 30s, high caffeine or nicotine intake

What is the treatment for fibrocystic changes?

OCs, DMPA, NSAIDs, dietary changes- low fat, caffeine free, vits E & B, & stop smoking

What is the workup for fibroadenoma?

PE, mammo/ US, tissue sample w FNA or excision, cystic aspiration (therapeutic and diagnostic)

What does straw colored fluid on a breast cyst aspiration indicate?

Fibrocystic

Can a mammogram alone prove that an area of concern is breast cancer?

No

What does persistent redness, scaling, crusting on nipple or areola that is unilateral usually indicate?

Paget’s disease

What is the shape of the external os in nulliparous patients?

Round or oval

What is the shape of the external os after childbirth?

Slit like or stellate

What are periurethral glands that lie on either side of urethral meatus?

Skene’s glands

What is the extension of the peritoneum off the superior surface of the uterus and on the anterior face of the rectum that is reachable on rectal exam?

Pouch of Douglas / retrouterine pouch / cul-de-sac

What has in utero DES exposure been linked to?

Mother: breast CA

Females: vaginal adenosine, cervical hood, clear cell carcinoma

Males: cryptorchidism, hypospadias, testicular cancer

How should the patient be positioned for GU exam?

Drape mid abdomen to knees & depress drape between knees so patient can see you, dont place arms overhead bc can tense abdominal muscles

What glands are responsible for vaginal lubrication, located at 5 & 7 o’clock at introitus?

*obstruction will lead to pain, enlargement, and discharge

Bartholin’s glands

What types of hernias are more common in women?

*palpate in labia majora, go upward just lateral of pubic tubercles

Indirect inguinal / femoral

What are endocervical glands on the cervix that become filled with secretions that accumulate as pimple-like elevations (benign)?

Nabothian cysts

PAP smear guidelines

start at age 21 x every 3 years, start HPV testing at 25 ? (idk what he wants since he put 3 different guidelines)

What checks for abnormal cells (dysplasia) and cancerous cells on the cervix & checks the endocervical canal?

*checks for cervical cancer only, not uterine

Pap smear (Papanicolaou)

What area of the cervix should you obtain the specimen when performing a Pap smear?

Transformation zone

What does cervical ectropion (eversion) indicate in menstruating women?

Normal

What do cultures taken from the cervix test for?

Gonorrhea & chlamydia

What do cultures taken from the vagina test for?

*pH, wet mount, KOH on vaginal discharge

Trich, BV, candidiasis

What does cervical ectropion (eversion) in postmenopausal women indicate?

Ominous finding, requires consideration of cervical CA

What will you feel on a bimanual exam if an infection is deposited along the vaginal wall or a tubo-ovarian abscess is present?

*d/t fallopian tubes opening into abdominal cavity

Enlarged tender mass on lateral vaginal wall

What defects are you inspecting for with internal pelvic exam?

Anterior wall defect → cystocele

Posterior wall defect → rectocele

apical → prolapse

*present if protruding mass seen

What exam would you perform for to palpate a retroverted uterus?

Rectovaginal exam

When is a rectovaginal exam performed?

Colon cancer, incontinence, rectocele, cul-de-sac tumors, infx suspected

Which cancer does the Pap smear rule out?

Cervical cancer

What does an ovary > 1-3 cm suggest?

Cysts or cancer

What are the borders of Hesselbach’s triangle?

Lateral (upper L to center): inferior epigastric vessels

Inferior (upper R to bottom L): Inguinal ligament

Medial (upper L to bottom L): rectus abdominis muscle

What is the region of potential weakness where a direct inguinal hernia can occur?

Hesselbach’s triangle

Direct or indirect inguinal hernia?

• protrudes through both deep inguinal ring & superficial inguinal ring

  • can protrude into scrotum

• due to incomplete closure of deep inguinal ring

  • possibly congenital

• MC in males - infancy or old age

Indirect inguinal hernia

Direct or indirect inguinal hernia?

• protrude through hesselbach triangle into inguinal canal

  • exit inguinal canal through superficial inguinal ring

• lump in groin

• caused by weakness in abdominal wall due to age

Direct inguinal herna

What diagnosis?

• Transillumination: no

• Tenderness: none

• Location: testes > 4cm inferior to pubic tubercle

• Association: smooth with epididymis

Normal testes

What diagnosis?

• Transillumination: no

• Tenderness: none

• Association: risk of testicular cancer

Cryptorchidism

What diagnosis?

• Transillumination: yes

• Tenderness: none

• Location: anterior to testes

• Association: fluid in tunica vaginalis

Hydrocele

What diagnosis?

• Transillumination: yes

• Tenderness: none

• Location: head of epididymis posterior to testes

• Association: benign

Spermatocele

What diagnosis?

• Transillumination: no

• Tenderness: none, unless infarction or torsion

• Location: contiguous with testes anterior & posterior

• Association: irregular nodule or mass

Neoplasm

What diagnosis?

• Transillumination: no

• Tenderness: none to mild

• Location: posterior to tests - left side

• Association: increase with valsalva, decrease with scrotal elevation; “bag of worms”

Varicocele

What diagnosis?

• Transillumination: no

• Tenderness: yes

• Location: posterior to testes

• Association: swelling or discrete nodule or mass

Epididymitis

What diagnosis?

• Transillumination: no

• Tenderness: yes

• Location: swelling and mass tender around testes

• Association: exquisite pain and tenderness, associated with testicular cancer

Torsion

What diagnosis?

• Transillumination: no

• Tenderness: no

• Location: epididymitis anterior to testes

• Association: normal variant

Anteverted epididymitis

What are hydroceles commonly associated with?

Indirect inguinal hernia

Where is an indirect inguinal hernia?

Out of hesselbachs triangle → enters inguinal canal lateral to inferior epigastric vessels & exits inferior to inguinal ligament

Where is a direct inguinal hernia?

Within hesselbach’s triangle → breaches posterior inguinal wall & passes medial to inferior epigastric vessels

What kind of hernia?

• Transillumination: no

• Tenderness: none, unless incarcerated or strangulated

• Location: base of mass from hesselbach’s triangle floor → may extend into scrotum

• Etiology: reducible or incarcerated or strangulated

Direct inguinal hernia

What kind of hernia?

• Transillumination: no

• Tenderness: none, unless incarcerated or strangulated

• Location:scrotal hernia; congenital; through the internal and external rings

• Etiology: reducible or incarcerated or strangulated

Indirect inguinal hernia

What kind of hernia?

• Transillumination: no

• Tenderness: none, unless incarcerated or strangulated

• Location: thigh hernia under the medial inguinal ligament

• Etiology: reducible or incarcerated or strangulated

Femoral hernia

What is edematous foreskin that becomes trapped behind the head of the penis?

Paraphimosis

What is foreskin that is unable to be retracted from the head of the penis?

Phimosis

What condition?

• inflammation of glans → redness, pain & swelling

• urinary discharge, dysuria, dribbling of urine

Balantitis

What are causes of balantitis?

Candida albicans, reiter’s syndrome, AI disorder