NR 509 Final Exam Study Guide Review 2024 PDF

NR 509 Final Exam Sudy Guide Review 2024 New Updaes Perec Revision Chapter 18 Breasts and Axillae Techniques o examinaon o Arms over head ▪ Can bring ou dimpling or reracon ha may b...

NR 509 Final Exam Sudy Guide Review 2024 New Updaes Perec Revision Chapter 18 Breasts and Axillae Techniques o examinaon o Arms over head ▪ Can bring ou dimpling or reracon ha may be invisible Palpae he breass ▪ Bes wih p. supine ▪ A horough examinaon akes a leas hree minues ▪ Use he vercal srip paern o deec breas mass ▪ Palpae in small, concenric circles applying ligh, medium, and deep pressure a each examining poin ▪ When pressing deeply on he breas a normal rib can be misaken or a hard breas mass ▪ To palpae laeral breas, ask paen o roll ono he opposie hip, placing her hand on her orehead bu keeping he shoulder pressed agains he bed or examining able as his aens he laeral breas ssue. ▪ To palpae he medial poron o he breas, have p. lie a wih shoulders agains he examining able ▪ Inspec he axillae ▪ Palpae he axillary nodes ▪ By moving in a sraigh line down he bra line, hen move ngers medially and palpae in a vercal rip up he ches o he clavicle. Anaomy o Female breas/axillae assessmen o Breas lump or mass ▪ Can be physiologic or pahologic ranging rom cyss and broadenomas o breas cancer o Breas cys ▪ Usually rm, round, mobile, and oen ender, mosly common beween ages o 25-50 years old o Breas discomor or pain ▪ SSRI, Haldol, Aldacone, and dig can cause breas pain Nipple discharge o Lymph nodes o The lymphac drainage o he breas is o grea imporance in he spread o carcinoma, and abou hree-quarers o i is o he axillary nodes. ▪ Cenral nodes (axillary) o The male breas o Gynecomasa: males who develop benign breas enlargemen. Causes include increased esrogen, decreased esoserone, and medicaon side eecs o Inspec he nipple and areola (nodules, swelling, ulceraon) o Palpae he areola and breas ssue (nodules) Breas cancer (including screening and risk acors)  o Redness suggess local inecon or inammaory carcinoma Thickening and prominen pores suggess breas cancer o Flang o he normally convex breass sugges cancer Asymmery in nipple direcon suggess cancer o Eczemaous changes wih rash scaling or ulceraon on he nipple exending o areola suggess Page disease o Invered nipple sugges cancer o Breas dimpling or reracon sugges cancer o Milky discharge unrelaed o pregnancy is nonpuerperal galacorrhea ▪ Caused by hypohyroidism, piuiary prolacnoma, and dopamine anagoniss o Risk acors ▪ Increasing age 65+ unl age 80 ▪ Biopsy: conrmed aypical hyperplasia ▪ Firs-degree amily members diagnosed wih breas cancer a an early age ▪ Inheried genec muaons- BRCA 1 and BRCA2 ▪ Personal hisory o breas cancer or ducal or lobular carcinoma ▪ Relavely denser breass on mammography ▪ High-dose radiaon o he ches a a young age ▪ High levels o endogenous hormones ▪ Age a rs ull erm pregnancy ▪ Lae menopause o Modiable risk acors ▪ Breasteeding or less han 1 year, posmenopausal obesiy, use o HRT, smoking, alcohol consumpon, physical inacviy, and ype o conracepon. Clinical breas examinaon (CBE) and sel-breas examinaon (SBE) echniques o The bes me is in a paen who is sll mensruang 5-7 days aer he onse o mensruaon because breass end o swell and become more nodular beore menses o Inspec breass in our views: arms a sides, arms over head, arms pressed agains hips, and leaning orward. o Breas sel-examinaon ▪ A high proporon o breas masses are deeced by women examining heir own breass. For screening, he BSE has no been shown o reduce breas cancer moraliy bu may promoe healh awareness and earlier reporng o breas changes or masses, which may reduce unnecessary esng and biopsies compared o monhly sel-examinaon. The BSE is bes med 5 o 7 days aer menses, when hormonal smulaon o breas ssue is low. Physiologic changes associaed wih he normal aging process o Fibroadenoma ▪ very mobile, round dislike, ypically small (1-2cm), rm, usually single bu very well delineaed. 15-25 years, pubery. o Cys ▪ mobile, round, well delineaed, so o rm, single, 30-50 years. o Cancer ▪ may be xed o he skin or underlying ssues, usually single, irregular or sellae in shape, rm or hard, mos common over age o 50 Lacaon o Chapter 19 Abdomen Techniques o examinaon o Dierenals or epigasric pain ▪ GERD ▪ Pancreas ▪ Peroraed ulcers ▪ MI o Abdomen ▪ Noe he general appearance ▪ Inspec he surace, conours, and movemens o he abdomen including skin emp, color, and scares or sriae ▪ Ecchymosis is seen in inraperioneal or reroperioneal hemorrhage. ▪ Asymmery suggess a hernia, enlarged organ or a mass. ▪ Bulging anks o ascies, suprapubic bulge, large liver or spleen, umors. ▪ Perisalsis waves ▪ Increased in GI obsrucon ▪ Lisen or bowel sounds ▪ Less han 5 per minue is considered hypoacve >34 a minue is considered hyperacve ▪ Fricon rubs ▪ Liver umor or splenic inarc ▪ Percuss in all our quadrans ▪ A ympanic abdomen hroughou suggess inesnal obsrucon or paralyc ileus. ▪ Palpae lighly hen deeply ▪ Palpang an abdominal mass ▪ Occasionally here are masses in he abdominal wall raher han inside he abdominal caviy. ▪ Ask he paen o eiher raise he head and shoulders or o srain down, his ghens he abdominal muscles, hen eel or he mass again. ▪ Check or signs o perionis o Liver ▪ Esmae he size along he righ midclavicular line by percussion ▪ Palpae and characerize he liver edge ▪ In chronic liver disease an enlarged palpable liver edge below he ribs is suggesve o an enlarged liver and cirrhosis ▪ Firmness or hardness o he liver, blunness or rounding o is edge, and surace irregulariy are suspicious or liver disease ▪ An obsruced disended gallbladder may merge wih he liver, orming a rm oval mass below he liver edge and an area ha is dull o percussion ▪ There is increased dullness wih percussion in hepaomegaly rom acue hepas, hear ailure, decreased dullness in cirrhosis ▪ Hepac brui in carcinoma o he liver and alcoholic hepas. o Spleen  ▪ Percuss or splenic enlargemen along he raube space ▪ Palpae he splenic edge wih he paen supine and in he righ laeral decubius posion (lying on he righ side wih legs exed a hips and knees) ▪ A change in percussion noe rom ympany o dullness on inspiraon is a posive splenic percussion sign, bu his sign is only moderaely useul or deecng splenomegaly ▪ Splenomegaly is 8 mes more likely when he spleen is palpable ▪ Caused by poral hyperension, hemaologic malignancies, HIV inecon, inlrave diseases like amyloidosis and splenic inarc or hemaoma o Kidneys ▪ Check or cosoverebral angle (CVA) enderness (Flank pain) ▪ Tenderness in pyelonephris ▪ Pain wih pressure or s percussion suppors pyelonephris i associaed wih ever and dysuria bu may also be MSK o Urinary bladder ▪ Blood in urine can be caused by BPH, urolihiasis, UTI, or prosae, bladder, and kidney cancer. ▪ Percuss or disenon and enderness ▪ Suprapubic enderness is common in bladder inecon ▪ Pink-purple sriae are a hallmark o Cushing syndrome ▪ Forms on inconnence ▪ Sress inconnence ▪ he urehral sphincer is weakened so ha ransien increases in inra-abdominal pressure raise he bladder pressure o levels ha exceed urehral resisance. ▪ Causes ▪ childbirh, surgery, posmenopausal arophy o he mucosa, and urehral inecon. May ollow prosae surgery in men. ▪ Urge inconnence ▪ derusor conracons are sronger han normal and overcome he normal urehral resisance. The bladder is usually small. ▪ Mechanisms ▪ decreased corcal inhibion o derusor conracons rom sroke, brain umor, demena, and lesions o he spinal cord above he sacral level. Also, hyperexciabiliy o sensory pahways ie: bladder inecons umors, and ecal impacon. Decondioning o voiding reexes, such as requen volunary voiding a low bladder volumes. ▪ Overow inconnence ▪ derusor conracons are insucien o overcome urehral resisance, causing urinary reenon. The bladder is ypically accid and large, even aer eor o void. ▪ Mechanisms  ▪ obsrucon o he bladder oule ie BPH or umor. Weakness o he derusor muscle associaed wih peripheral nerve disease a S2-4 level. Impaired bladder sensaon ha inerrups he reex DIABETIC NEUROPATHY. ▪ Funconal inconnence ▪ he paen unconally able o reach he oile in me because o impaired healh or environmenal condions. ▪ Mechanism ▪ he problems in mobiliy resulng rom weakness, arhris, poor vision, and oher condions. Also- environmenal acors such as an unamiliar seng, disan bahroom acilies, bedrails, or physical resrains. ▪ Inconnence secondary o medicaons ▪ drugs may conribue o any ype o inconnence lised: sedaves, ranquilizers, ancholinergics, sympahec blockers, and poen diurecs. Aora o Increased abdominal pulsaons indicae AAA ▪ Risk acors or AAA are age >65, hisory o smoking, male gender, and a rs degree relave wih a hisory o AAA repair ▪ Severe and ripping pain may signal rupure ▪ Periumbilical mass wih expansile pulsaons >3 cm in diameer in AAA, his needs o be assessed urher or risk o rupure. Anaomy o RUQ: ▪ liver, gallbladder, pylorus, duodenum, hepac exure o colon, and head o pancreas o LUQ ▪ spleen, splenic exure o colon, somach, and body and ail o pancreas o LLQ ▪ sigmoid colon, descending colon, and le ovary  o RLQ ▪ cecum, appendix, ascending colon, erminal ileum and righ ovary Abdominal pain (including acue and chronic sympomaology) o Abdominal pain, acue and chronic ▪ Onse ▪ he ming as o when he sympoms occurred, and is progression can help deermine i i is emergen ▪ Locaon ▪ he knowledge o where he viscera are posioned in he abdominal caviy is a key par in narrowing he diagnosis ▪ Characer ▪ deermining he underlying pahophysiologic process may help elucidae he cause ▪ Radiaon ▪ presence or absence o pain migraon can help deermine he cause, especially in disease processes involving he liver, biliary rac, and appendix ▪ Palliave, provoking, or associaed acors ▪ may provide insigh o diagnosis ▪ PMH ▪ help provide clues o possible causes ▪ Visceral pain ▪ Occurs when hollow abdominal organs such as he inesnes or biliary ree conrac unusually orceully or are disended or sreched. ▪ Maybe dicul o localize ▪ Varies in qualiy, may be gnawing, burning, cramping, or aching. ▪ When severe, may be associaed wih sweang, pallor, nausea, voming, reslessness ▪ Visceral pain in he RUQ suggess liver disenon ▪ Causes ▪ Hepas, including alcoholic hepas ▪ Somac or parieal pain ▪ From inammaon o he parieal perioneum ▪ Seady aching ▪ Usually more severe ▪ Usually more precisely localized over he involved srucure and visceral pain ▪ Visceral periumbilical pain can be suggesve o early acue appendicis rom disenon o inamed appendix, hen gradually changes o parieal pain in he RLQ ▪ Reerred pain ▪ Occurs in more disan sies innervaed a approximaely he same spinal levels as he disordered srucure. ▪ Pain rom he ches, spine, or pelvis may be reerred o he abdomen. ▪ Palpaon a he sie o reerred pain oen does no resul in enderness.  ▪ P wih colicky pain rom a renal sone will move around requenly rying o nd a comorable posion ▪ Pain o pancreac origin may be reerred o he back, righ shoulder or righ poserior rom he biliary ree. ▪ Pain rom he pleurisy or acue myocardial inarcon may be reerred o he epigasric area. ▪ Pain o he duodenal or pancreac origin may be reerred o he back ▪ Pain in LLQ accompanied by diarrhea in a paen wih a hisory o conspaon is suggesve o diverculis ▪ Nonspecic diuse abdominal pain wih abdominal disenon, nausea, emesis, and lack o gas and BM may have a bowel obsrucon ▪ Perionis is marked by severe abdominal pain wih guarding and rigidiy on examinaon ▪ Paens wih sympoms o abdominal pain and enderness may have ischemia which requires urgen surgical consulaon ▪ Hemaemesis may accompany esophageal or gasric varices, Mallory-weiss ears or pepc ulcer disease. ▪ Diculy swallowing ▪ Liquid and solid oods consider hings like esophageal neuromuscular disorders (achalasia), sricure, webbing or narrowing (Schazki ring) ▪ Associaed GI sympoms including indigeson, nausea, voming, hemaemesis, loss o appee, early saey ▪ Painul swallowing ▪ Radiaon, causc ingeson, inecon rom cyomegalovirus, herpes simplex, HIV, esophageal ulceraon rom ASA or NSAIDs. ▪ Change in bowel uncon ▪ Pancreas Pain ▪ Acue pancreas ▪ inrapancreac rypsinogen acvaon o rypsin and oher enzymes, resulng in auodigeson and inammaon o he pancreas. ▪ Locaon: epigasric, may radiae sraigh o he back, or oher areas o he abdomen, 20% w/ severe sequelae o organ ailure. ▪ Chronic pancreas ▪ irreversible desrucon o he pancreac parenchyma rom recurren inammaon o heir large ducs or small ducs. ▪ Locaon: epigasric, radiang o he back. o Diarrhea ▪ Acue diarrhea is usually caused by inecon ▪ Chronic diarrhea is usually IBS ▪ High-volume requen waery sools are usually rom he small inesne ▪ Small volume sools wih mucus, pus, or blood occur in recal inammaory condions ▪ Oily residue somemes rohy or oang occurs wih seaorrhea ▪ Conspaon o Jaundice  ▪ Plasma bilirubin >3 mg/dL ▪ Impaired excreon o conjugaed bilirubin in viral hepas, cirrhosis, primary biliary cirrhosis, drug induced cholesasis. ▪ Common bile duc obsrucon rom gallsones or pancreac, cholangio- or duodenal carcinoma ▪ Dark urine rom increased conjugaed bilirubin excreed in he urine (hepas). ▪ Acholic clay colored sool when bilirubin excreon ino inesne is obsruced. ▪ Iching or puris occurs in cholesac or obsrucve jaundice when bilirubin levels are markedly elevaed. Pepc ulcer disease o Pain aer meals o Many paens wih upper abdominal discomor or pain will have unconal or non- ulcer, dyspepsia, dened as a 3-monh hisory o nonspecic upper abdominal discomor or nausea. Gasroesophageal reux disease (GERD) o I paens repor hearburn and eorless regurgiaon ogeher more han once a week he accuracy o diagnosing GERD is over 90% ▪ Epigasric pain ▪ Bloang can occur wih GERD o Some paens wih GERD have aypical respiraory sympoms such as ches pain, cough, wheezing, and aspiraon pneumonia o Ashma Appendicis (including special assessmen echniques) o When a ender area is palpaed or guarding, early volunary guarding may be replaced by involunary muscular rigidiy and signs o perioneal inammaon. There are also RLQ pain on quick wihdrawal aer palpiaon suggesng rebound enderness. o Visceral periumbilical pain can be suggesve o early acue appendicis which can hen gradually change o parieal pain he RLQ. o Preorm a recal exam and in women preorm a pelvic exam ▪ Local enderness appears i appendix is rerocecal. o Loss o appee combined wih RLQ is suggesve o appendicis o Assess wih ▪ McBurney poin enderness ▪ Have he paen lay on heir back and apply slow pressure o heir RLQ and quickly release. I here is presence o severe pain i is indicave o a posive es. ▪ Rovsing sign (indirec enderness) ▪ Press deeply and evenly in he LLQ hen quickly wihdraw your ngers. I pain is presen in he RLQ when pressing on he LLQ i is a posive sign. ▪ Psoas sign ▪ Place your hand jus above he paen’s righ knee. Ask he paen o raise ha high agains your hand or ask he paen o urn ono he le side. Then exend he paens righ leg a he hip o srech he psoas muscle. ▪ Pain rom irriaon o he psoas muscle suggess an inamed appendix. ▪ Oburaor sign  ▪ Flex he paen’s righ high a he hip, wih he knee ben, and roae he leg inernally a he hip, which sreches he inernal oburaor muscle. ▪ Appendicis is wice as likely in he presence o RLQ enderness, Rovsing sign, and he psoas sign; i is hree mes more likely wih McBurney poin enderness. Diverculis o LLQ pain ▪ Diuse abdominal pain wih abdominal disenon, hyperacve bowel sounds and enderness on palpiaon ▪More common aer age 40 Biliary colic o Cause by cholelihiasis (gallsone blocking a duc) o Cholecyss ▪ Murphy’s sign ▪ When assessing or possible acue cholecyss- here migh be RUQ pain and enderness. ▪ To es ▪ Hook your le hump or ngers o your righ hand under he cosal margin a he poin where he laeral boarder o he recus muscle inersecs. Ask he paen o ake a big beep breah and wih your ngers push down, noe he paens breahing and noe he degree o enderness. ▪ A sharp increase in enderness wih inspiraory eor is a posive murphy’s sign Hepas o Risk acors ▪ Travel or meals in areas o poor saniaon, ingeson o conaminaed waer or oods (Hep A) ▪ Pareneral or mucus membrane exposure o inecous body uids such as blood, scrum, semen, saliva, especially hrough sexual conac wih an ineced individual or shared needles or injecon drug use (Hep B) ▪ Illici injecon drug use or blood ransusion (Hep C) ▪ Alcoholic hepas or alcoholic cirrhosis ▪ Toxic liver damage ▪ Medicaons, indusrial solvens, environmenal oxins, or some aneshec agens ▪ Gallbladder disease or surgery ha may resul in exrahepac biliary obsrucon ▪ Herediary disorders in amily hisory o Hep A ransmission ▪ Transmission hrough ecal-oral roue. Fecal shedding ollowed by poor handwashing conaminaes waer and oods leading o inecon o household and sexual conacs. ▪ Illness occurs 30 days aer exposure. ▪ Dilued bleach can be used o clean environmenal suraces. ▪ Vaccinaon ▪ All children under he age o 1 ▪ Individuals wih chronic liver disease.  ▪ Groups a risk or acquiring hep A ▪ Travelers, men who have sex wih men, injecon and illici drug users, individuals working wih nonhuman primaes, and persons who have clong disorder. ▪ The vaccine alone may be adminisered a any me beore ravel o endemic areas. o Hep B ▪ Transmission occurs hrough conac p ineced body uids such as blood, semen, saliva, and vaginal secreons. ▪ Inecon increases risk o ulminan hepas, chronic inecon, and subsequen cirrhosis and hepaocellular carcinoma. ▪ Vaccinaon ▪ Aduls in high-risk sengs ▪ STI clinics, HIV esng and reamen programs, drug abuse reamen programs and programs or persons who injec drugs, correconal acilies, programs wih men having sex wih men, chronic hemodialysis acilies and end sage renal disease programs, and acilies or people wih developmenal disabilies. ▪ People wih exposure o blood ▪ Injecon drug users, household conacs o angen posive persons, residens, and sa o acilies or he developmenally delayed, healh care workers, and people on dialysis. ▪ Ohers ▪ Travelers o endemic areas, people wih chronic liver disease and HIV inecon, and people seeking proecon rom Hep B. o Hep C ▪ Is he mos common orm o hepas, i is spread by blood exposure and injecon drug use. ▪ There is no vaccine or Hep C so prevenon arges counseling o avoid risk acors and serologic screening should be recommended or high-risk groups. Ulcerave colis (UC) o Inammaon and ulceraon o he mucosa and submucosa o he recum and colon o Sools are so waery oen conaining blood. Inammaory bowel disease (IBS) o A disorder o bowel moliy wih alernang diarrhea and conspaon o Bloang may occur wih IBS o Loose sools may show mucus bu no blood, also small hard sools wih conspaon. Hepaomegaly o Normal liver spans ▪ 4-8 cm in midsernal line ▪ 6-12 cm in righ midclavicular line o Increased dullness is ound o Hepaomegaly may be missed i palpang oo high in he RUQ so you need o sar well below he cosal margin Ascies o Palpae by having he paen lay supine and hen on heir side.  o Ascic uid normally shis o dependen side, changing he margin o dullness. o Resuls o uid wave ess are no specic. o To palpae an organ or mass in an ascic abdomen place your sened and sraighened ngers on he abdomen and briey jab hem oward he srucure and ry o ouch is surace. Your hand will quicky displace he uid and sops abruply as i ouches a solid surace. Colon cancer and screening recommendaons o Screening ▪ Aduls aged 50-75 years - opons ▪ Sool based ess ▪ Fecal immunochemical es (FIT) annually ▪ High sensiviy guaiac based ecal occul blood esng annually ▪ FIT-DNA esng every 1-3 years ▪ Direc visualizaon ess ▪ Colonoscopy every 10 years ▪ Sigmoidoscopy every 5 years ▪ Flexible sigmoidoscopy every 10 years wih FIT every 3 years ▪ CT colonography every 5 years ▪ Aduls aged 76-85 ▪ individualized decision making, decisions should ake ino consideraon lie expecancy and pervious screening. Previously unscreened aduls migh bene rom screening. ▪ Aduls over 85 ▪ do no screen because risks do no ouweigh benes. o Screening and removing precancerous adenomaous polyps are he mos eecve way o screen or colon cancer o Physical acviy, aspirin, and oher NSAIDs and posmenopausal hormone replacemen herapy proec agains colorecal cancer o Sool ess and colonoscopy can screen or colon cancer Chapter 20 Male Genitalia Techniques o examinaon o Look or scroal swelling in mumps, orchis, scroal edema, and escular cancer ▪ Fever and dysuria in a man suggess acue prosas, acue pyelonephris, disseminaed gonococcal inecon, syphilis, or pos obsrucve UTI o The paen may be sanding or sing o Inspec he skin, prepuce, and glans ▪ Phimosis is a gh prepuce ha canno be reraced over he glans ▪ Paraphimosis is a gh prepuce ha once reraced canno be reurned ▪ Hypospadias is venral displacemen o he meaus on he penis while epispadias is dorsal displacemen o Inspec he urehral meaus and i indicaed, srip or “milk” he penile sha ▪ Urehral sricures mos commonly occur in he proximal urehra, bu induraon or rmness along he venral surace o he penis suggess a urehral sricure or possibly a carcinoma o Palpae he sha o he penis  o Inspec he scroum including skin, hair, and conour ▪ A poorly developed scroum on one or boh sides sugges cryporchidism (an undescended escle) o Palpae each ess including he epididymis and spermac cord ▪ Tender painul scroal swelling is presen in acue epididymis, acue orchis, escular orsion, and srangulaed inguinal hernia ▪ Any painless nodule on he ess raises he possibiliy o escular cancer ▪ The vas deerens, i chronically ineced, may eel hickened or beaded, a cysc srucure in he srucure in he spermac cord suggess a hydrocele o he cord Anaomy o Screening or sexually ransmied inecons (STIs) o Penile discharge or lesions and scroal or escular pain, swelling, or lesions STIs o Look or yellow penile discharge in gonorrhea Whie discharge is rom chlamydia o Suspec scabies or lice in a paen complaining o inense pruris wih evidence o penile or pubic excoriaons. o Epididymis ▪ Acue ▪ Inamed epididymis is induraed, swollen, and noably ender, making i dicul o disnguish rom he ess. The scroum may be reddened and he vas deerens inamed. o Syphilis ▪ Secondary (Condyloma lanum) ▪ Large raised, round or oval, a opped grey or whie lesions poin o condylomaa laa. These are conagious and, along wih rash and mucus membrane sores in mouh, Vagina, or anus are maniesaons. ▪ Female ▪ Syphilic chancre (genial ulcer)- rm painless ulcer orm primary syphilis, orms approximaely 21 days aer exposure o reponema pallidum. I may remain hidden and undeeced in he vagina and heals regardless o reamen in 3-6 weeks. ▪ Male ▪ Primary syphilis, small red papule ha becomes a chancre, a painless erosion up o 2 cm in diameer. Base o chancre is clean, red, smooh, and glisening, boarders are raised and induraed. Chancre heals wihin 3-8 weeks. o Genial Wars (condylamaa acuminaa) ▪ Papules or plaques o variable shapes Caused by HPV, usually srains 6 and 11 ▪ Takes weeks o monhs or i o visible ▪ Can arise on penis, scroum, groin, highs, and anus ▪ Can cause iching and pain ▪ May disappear wihou reamen ▪ Ineced conacs may have no visible wars ▪ Small red papule ha becomes a chancre May develop inguinal lymphadenopahy ▪ 20-30% develop secondary syphilis which suggess coinecon wih HIV o Genial Herpes  ▪ Small scaered or grouped vesicles ▪ Primary episode may be asympomac ▪ Associaed wih ever, malaise, headache, arhralgias, local pain, edema, and lymphadenopahy ▪ Red papule or pusule inially hen orms a painul deep ulcer wih ragged noninduraed margins ▪ Conain necroc exudae Tescular disorders and cancer o Abnormalies o he eses ▪ Cryporchidism ▪ Teses are arophy and may lie in inguinal canal or he abdomen, resulng in an unlled scroum. There is no palpable le ese or epididymis. This raises he risk or escular cancer. ▪ Small eses ▪ in aduls, escular lengh is usually greaer han 3.5 cenmeers. Small, rm eses are seen in Kleineler syndrome, usually less han wo cenmeers. Small, so eses suggesng arophy seen in cirrhosis, myoonic dysrophy, use o esrogens, and hypopiuiarism; May also ollow or orchis. ▪ Acue orchis ▪ he eses is acuely inamed, painul, ender, and swollen. I may be dicul o disnguish rom ha epididymis. The scroum maybe red end. Seen in mumps and oher viral inecon; Usually unilaeral. ▪ umor o he eses (early)-mos commonly diagnosed cancer in whie men ages o 20 o 34 years. ▪ usually appears as a painless nodule. Any nodule wihin he eses warrans invesgaon or malignancy. ▪ Risk acors o escular cancer. ▪ Whie ehniciy, amily hisory, HIV, and hisory o cryporchidism. ▪ Tumor o he eses (lae) ▪ as a escular neoplasm grows and spreads, i may seem o replace he enre organ. The escle characeriscally eels heavier han normal. ▪ Acue epididymis ▪ An acuely inamed epididymis is Tinder and swollen and may be dicul o disnguish rom he eses. The scroum maybe red and in he vas deerence inamed. I occurs chiey in aduls. Coexisng urinary rac inecon or prosas suppors he diagnosis. ▪ spermaocele and cys o he epididymis ▪ a painless, movable cys mass jus above he eses sugges a spermaocele or epididymal cys. Boh ransilluminae. The ormer conains sperm, and laer does no, bu hey are clinically indisnguishable. ▪ Variceal o he spermac cord ▪ heir seal reers o varicose veins o he spermac cord, usually ound on he le. I eels like a so” bag o worms” separae rom he eses, and slowly collapses when he scroum is elevaed in he supine paen. ▪ orsion o he spermac cord  ▪ wisng o he escle on is spermac cord produces an acuely painul and swollen organ ha is reraced upwards in he scroum, which becomes red and edema. There is no associaed urinary inecon. I is a surgical emergency because o he obsruced circulaon. Hernias o I he perioneal lining remains an open channel o he scroum, i can give rise o an indirec inguinal hernia o The parieal and visceral layers orm a poenal space or he abnormal uid accumulaon o a hydrocele o Femoral hernias prorude in he groin and can presen as an emergency wih bowel incarceraon or srangulaon o When loops o bowel orce heir way hrough he inguinal canal, hey produce inguinal hernias o Srangulaed hernia requires promp surgical evaluaon Human papillomavirus (HPV) (including vaccinaon recommendaons) o Chapter 21 Female Genitalia Techniques o examinaon o Inspec he mons pubis, labia, perineum ▪ Excoriaons or ichy, small red maculopapular sugges pediculosis pubis ▪ An enlarged clioris is seen in masculinizing endocrine disorders ▪ The Barholin glands are no visible ▪ A Barholin gland may become acuely or chronically ineced resulng in swelling. ▪ Acue ▪ The gland appears ense, ho, very ender abscess. Possible labial swelling. ▪ Look or pus emerging orm he duc or eryhema around he duc opening. ▪ Chronic ▪ A nonender cys is el ha may be large or small. o Inspec cervix ▪ A yellowish discharge on he endocervical swab commonly represens mucopurulen cervicis rom chlamydia, gonorrhea, or herpes simplex ▪ Raised, riable, or lobed war-like lesions are seen wih condylomaa or cervical cancer o Inspec vagina ▪ Vaginal discharge oen accompanies inecon rom candida, richomonas vaginalis, and BV ▪ Use he lower blade as a reracor during bearing down helps expose anerior vaginal wall deecs such as cysoceles o Palpae he cervix  ▪Cervical moon enderness and adnexal enderness are hallmarks o PID, ecopic pregnancy, and appendicis ▪ Nodulariy, immobiliy, and enderness in he ornices may resul rom endomeriosis ▪ Nodules on he uerine suraces sugges myomas Palpae he uerus o Palpae he ovaries ▪ Wihin 3-5 years aer menopause, he ovaries become arophic and usually nonpalpable ▪ In posmenopausal women, invesgae a palpable ovary or possible ovarian cys or ovarian cancer ▪ Pelvic pain, bloang, increased abdominal size and UTI sympoms are more common in women wih ovarian cancer o Assess he pelvic oor muscles ▪ Weakness o he pelvic oor muscles may cause pain, urinary inconnence, ecal inconnence, and prolapse o he pelvic organs o Perorm a recovaginal examinaon i indicaed ▪ Sool in he recum may smulae a recovaginal mass bu unlike a malignan mass i can be dened by digial Anaomy o Screening or sexually ransmied inecons (STIs) o Bacerial vaginosis o Trichomonal vaginis: a proozoan, oen bu no always acquired sexually. ▪ Discharge: yellowish, green, gray, possibly rohy, may be malodorous o Oher s/s: prurius, pain on urinaon, dyspareunia ▪ Vulva and vaginal mucosa: vesbule and labia minora may be eryhemaous, he vaginal mucosa may be diusely reddened, wih small red granular spos or peechiae in he poserior ornix. Mild cases he mucosa looks normal. o Lab eval: scan saline wen moun or richomonads sni or shy odor aer applying whi es. Candidiasis o candida albicans, a yeas, normal overgrowh o vaginal ora, many acors may predispose, including anbioc herapy. ▪ Discharge: whie and curdy, may be hin bu ypically hick, no as prouse as in richomonal inecon, no malodorous o Oher s/s: pruris, vaginal soreness, pain on urinaon, dyspareunia ▪ Vulva and vaginal mucosa: he vulva and surrounding skin are oen inamed and swollen o a variable exen. Paches o discharge, mucosa may bleed when hese paches are scraped o, in mild cases he mucosa looks normal. o Lab eval: scan poassium hydroxide preparaon or he branching hyphae o candida. GYN/pelvic examinaon (including Pap smear esng) o Esrogen is recommended or paens who have had a hyserecomy or combined use o esrogen and progesn or prevenng chronic condions in posmenopausal women Pelvic inammaory disease (PID) o Cervical disorders  o Uerine umors o Cervical cancer (including screening and risk acors) o Human papillomavirus (HPV) (including vaccinaon recommendaons) o HPV oers he opporuniy o preven cervical cancer and pre-cancers o Pap-smears can also ideny high-risk precancerous changes or early cancers o Prevens inecon rom HPV subypes 16,18, 6, and 11, which cause 90% o genial wars. o The bivalen vaccine prevens inecon rom subypes 16 and 18 o Recommended or prevenon o cervical, vulvar, and vaginal cancers and precancers emales as well as anal cancer, and genial wars in boh emale and males. o Vaccinaed women should sll ge cervical screening because vaccines do no preven all HPV subypes. o Condoms does no eliminae he risk o cervical HPC inecon o Recommended or hose wih compromised immune sysems including HIV Chapter 22 Anus, Rectum, and Prostate Techniques o examinaon o Pu p. in a side lying posion ▪ Inspec he sacrococcygeal and perianal areas Inspec he anus ▪ A ender purulen reddened mass wih ever or chills suggess an anal abscess. Abscesses unneling o he skin surace rom he anus or recum may orm a clogged or draining ano-recal sula. Fisulas may ooze blood, pus, or eculen mucus. Consider anoscope or sigmoidoscopy or beer visualizaon. ▪ Sphincer ghness may occur wih anxiey, inammaon or scaring ▪ Sphincer laxiy occurs in neurologic disease such as S2-S4 cord lesions and signals possible changes in he urinary sphincer and derusor muscle o Perorm a digial recal examinaon ▪ Assess he anal sphincer one ▪ Palpae he anal canal and recal surace ▪ I a mass is noed wih irregular borders, suspicious o recal cancer ▪ In persons wih prosaes palpae he prosae gland Common concerns o Change in bowel habis ▪ Pencil hin sools may warn o colon cancer o Blood in sool ▪ Dark arry sools i polyps, carcinoma, GI bleeding, mucus in villas adenomas, IBD, or IBS o Pain wih deicaon, recal enderness ▪ Hemorrhoids, procs rom STIs o Anal wars or ssures  ▪ HPV, condylomaa laa in secondary syphilis, ssures in Crohn’s disease, procs rom recepve anal inercourse, ulceraons o herpes simplex, or chancers o primary syphilis. o Weak urinary sream ▪ These sympoms sugges urehral obsrucon rom BPH or prosae cancer, especially men >70 years. The AUA sympoms index helps quany BPH sympom score index ▪ Higher sores (max 35) indicae more severe sympoms, scores