NURSING NR 509 Advance health assessment (FINAL STUDY GUIDE) | Download To Score A+

Final Study Guide NOTE: The final exam is cumulative and will include some content from before the midterm exam. Chapter 5 • Behavior/Mental Health Assessment and Modification for Age Change s have also occurred in the classification of somatic syndromes in the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) of 2013. When patients have “distressing somatic symptoms plus abnormal thoughts, feelings, and behaviors in response to these symptoms,” contains 26 questions and takes up to 10 minutes to complete.25 The DSM-5 acknowledges the diagnostic challenges facing primary care providers and has reduced the total number of disorders as well as their subcategories in the reclassification of Somatic Symptoms and Related Disorders. Patient Indications for Mental Health Screening Medically unexplained physical symptoms—more than half have depression or anxiety disorder Multiple physical or somatic symptoms or “high symptom count” High severity of the presenting somatic symptom Chronic pain - Chronic pain may be a spectrum dis-order in patients with anxiety, depression, or somatic symptoms. Symptoms for more than 6 weeks Physician rating as a “difficult encounter” Recent stress Low self-rating of overall health Frequent use of health care services Substance abuse Personality Disorders. Patients with personality disorders can also display problematic office behaviors that escape diagnosis. The DSM-5 characterizes these disorders as “an enduring pattern of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.” These patients have dysfunctional interpersonal coping styles that disrupt and destabilize their relationships, including those with health care providers. High-Yield Screening Questions for Office Practice Depression - Over the past 2 weeks, have you felt down, depressed, or hopeless? - Over the past 2 weeks, have you felt little interest or pleasure in doing things (anhedonia)? Anxiety - Anxiety disorders include generalized anxiety disorder, social phobia, panic disorder, posttraumatic stress disorder, and acute stress disorder. - Over the past 2 weeks, have you been feeling nervous, anxious, or on edge? - Over the past 2 weeks, have you been unable to stop or control worrying? - Over the past 4 weeks, have you had an anxiety attack—suddenly feeling fear or panic? Illness Anxiety Disorder (Replaces Hypochondriasis in DSM-5) - Whiteley Index: 14-item self-rating scale Substance-Related and Addictive Disorders - CAGE questions adapted for alcohol and drug abuse Multidimensional - PRIME-MD (Primary Care Evaluation of Mental Disorders) for the five most common disorders in primary care: depression, anxiety, alcohol, somatoform, and eating disorders; 26-item patient questionnaire followed by clinician evaluation; takes approximately 10 minutes. - PRIME-MD Patient Health Questionnaire, available as patient health questionnaire for self-rating; takes approximately 3 minutes. A: Odd or Eccentric Disorders ● Paranoid - Distrust and suspiciousness ● Schizoid - Detachment from social relations with a restricted emotional range ● Schizotypal - Eccentricities in behavior and cognitive distortions; acute discomfort in close relationships B: Dramatic, Emotional or Erratic Disorders ● Antisocial - Disregard for, and violation of, the rights of others ● Borderline - Instability in interpersonal relationships, self-image and affective regulation; impulsivity ● Histrionic - Excessive emotionality and attention seeking ● Narcissistic - Persisting grandiosity, need for admi-ration and lack of empathy C: Anxious or Fearful Disorders ● Avoidant - Social inhibition, feelings of inadequacy and hypersensitivity to negative evaluation ● Dependent - Submissive and clinging behavior related to an excessive need to be taken care of ● Obsessive–compulsive - Preoccupation with orderliness, perfectionism, and control Borderline Personality Disorder. Patients with borderline personality disorders are especially challenging. These patients show “a pervasive pattern of instability of interpersonal relationships, self-image, and affects, and marked impulsivity.” They make “frantic efforts to avoid real or imagined abandonment” and show recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior. Recognition of borderline features is essential for patient understanding, reduction of patient self-harm, and referral for expert evaluation. In the DSM-5, delirium and dementia fall under the new category of neurocognitive disorders, based on consultation with expert groups. Dementia is classified as a major cognitive disorder; a less severe level of cognitive impairment is now mild neurocognitive disorder, which applies to younger individuals with impairment from traumatic brain injury or HIV infection. • Normal VS. Abnormal Findings and Interpretation • Speech Patterns • Mental Status Examination The Mental Status Examination: Appearance and behavior Speech and language Mood Thoughts and perceptions Cognition, including memory, attention, information and vocabulary, calculations, abstract thinking, and constructional ability The Mental Status Examination consists of five components: appearance and behavior; speech and language; mood; thoughts and perceptions; and cognitive function. Cognitive function includes orientation, attention, memory, and higher cognitive functions such as information and vocabulary, calculations, abstract thinking, and constructional ability. Prepare the patient for formal testing and explain your rationale. Appearance and behavior: Level of Consciousness: Lethargic patients are drowsy, but open their eyes and look at you, respond to questions, and then fall asleep. Obtunded patients open their eyes and look at you, but respond slowly and are somewhat confuse. Posture and Motor Behavior: Look for tense posture, restlessness, and anxious fidgeting; the crying, pacing, and hand-wringing of agitated depression; the hopeless slumped posture and slowed movements of depression; the agitated and expansive movements of a manic episode. Dress, Grooming, and Personal Hygiene: Grooming and personal hygiene may deteriorate in depression, schizophrenia, and dementia. Excessive fastidiousness may be seen in obsessive–compulsive disorder. One-sided neglect may result from a lesion in the opposite parietal cortex, usually the nondominant side Facial Expression: Note expressions of anxiety, depression, apathy, anger, elation, or facial immobility in parkinsonism. Manner, Affect, and Relationship to People and Things: Watch for the anger, hostility, suspiciousness, or evasiveness of patients with paranoia; the elation and euphoria of mania; the flat affect and remoteness of schizophrenia; the apathy (dulled affect with detachment and indifference) of dementia; and anxiety or depression. Hallucinations occur in schizophrenia, alcohol withdrawal, and systemic toxicity Speech and Language: Quantity, Rate, Volume: Note the slow speech of depression; the accelerated louder speech of mania Articulation of Words: Dysarthria refers to defective articulation. Aphasia is a disorder of language. Dysphonia results from impaired volume, quality, or pitch of the voice. Fluency: Hesitancies and gaps in the flow and rhythm of words. Disturbed inflections, such as a monotone. Circumlocutions, in which phrases or sentences are substituted for a word the person cannot think of, such as “what you write with” for “pen”. These abnormalities suggest aphasia from cerebrovascular infarction. Aphasia may be receptive (impaired comprehension with fluent speech) or expressive (with preserved comprehension and slow non-fluent speech). Paraphasias, in which words are malformed (“I write with a den”), wrong (“I write with a bar”), or invented (“I write with a dar”). Testing for Aphasia: Word Comprehension - Ask the patient to follow a one-stage command, such as “Point to your nose.” Try a two-stage com-mand: “Point to your mouth, then your knee.” Repetition - Ask the patient to repeat a phrase of one-syllable words (the most difficult repetition task): “No ifs, ands, or buts.” Naming - Ask the patient to name the parts of a watch. Reading Comprehension - Ask the patient to read a paragraph aloud. Writing - Ask the patient to write a sentence These questions help identify the type of aphasia. Check for deficits in vision, hearing, intelligence, and education which may affect responses. Two common kinds of aphasia —expressive (Broca aphasia) and receptive (Wernicke aphasia) Mood: Ask the patient to describe his or her mood, including usual mood level and fluctuations related to life events. Moods range from sadness and melan-choly; contentment, joy, euphoria, and elation; anger and rage; anxiety and worry; to detachment and indifference. Thought and Perception: Circumstantiality: The mildest thought disorder, consisting of speech with unnecessary detail, indirection, and delay in reaching the point. Some topics may have a meaningful connection. Many people without mental disorders have circumstantial speech. Circumstantiality occurs in people with obsessions Derailment (loosening of associations): “Tangential” speech with shifting topics that are loosely connected or unrelated. The patient is unaware of the lack of association. Derailment is seen in schizophrenia, manic episodes, and other psychotic disorders. Flight of Ideas: An almost continuous flow of accelerated speech with abrupt changes from one topic to the next. Changes are based on understandable associations, plays on words, or distracting stimuli, but ideas are not well connected. Flight of ideas is most frequently noted in manic episodes. Neologisms: Invented or distorted words, or words with new and highly idiosyncratic meanings. Neologisms are observed in schizophrenia, psychotic disorders, and aphasia. Incoherence: Speech that is incomprehensible and illogical, with lack of meaningful connections, abrupt changes in topic, or disordered grammar or word use. Flight of ideas, when severe, may produce incoherence. Incoherence is seen in severe psychotic disturbances (usually schizophrenia) Blocking: Sudden interruption of speech in midsentence or before the idea is completed, attributed to “losing the thought.” Blocking occurs in normal people. Blocking may be striking in schizophrenia Confabulation: Fabrication of facts or events in response to questions, to fill in the gaps from impaired memory. Confabulation is seen in Korsakoff syndrome from alcoholism Perseveration: Persistent repetition of words or ideas. Perseveration occurs in schizophrenia and other psychotic disorders. Echolalia: Repetition of the words and phrases of others. Echolalia occurs in manic episodes and schizophrenia Clanging: Speech with choice of words based on sound, rather than meaning, as in rhyming and punning. For example, “Look at my eyes and nose, wise eyes and rosy nose. Two to one, the ayes have it!” Clanging occurs in schizophrenia and manic episodes. Abnormalities of Thought Content: Compulsions: Repetitive behaviors that the person feels driven to perform in response to an obsession, aimed at preventing or reducing anxiety or a dreaded event or situation; these behaviors are excessive and unrealistically connected to the provoking stimulus. Compulsions, obsessions, phobias, and anxieties often occur in anxiety disorders. Obsessions: Recurrent persistent thoughts, images, or urges experienced as intrusive and unwanted that the person tries to ignore, suppress, or neutralize with other thoughts or actions (for example, performing a compulsive behavior) Phobias: Persistent irrational fears, accompanied by a compelling desire to avoid the provoking stimulus Anxieties: Apprehensive anticipation of future danger or misfortune accompanied by feelings of worry, distress, and/or somatic symptoms of tension Feelings of Unreality: A sense that the environment is strange, unreal, or remote. Feelings of Depersonalization: A sense that one’s self or identity is different, changed, unreal; lost; or detached from one’s mind or body Delusion: False fixed personal beliefs that are not amenable to change in light of conflicting evidence; types of delusions include: ● Persecutory ● Grandiose ● Jealous ● Erotomanic—the belief than another person is in love with the individual ● Somatic— involves bodily functions or sensations ● Unspecified—includes delusions of reference without a prominent persecutory or grandiose component, or the belief that external events, objects, or people have a particular and unusual personal significance (for example, commands from the radio or television). Delusions and feelings of unreality or depersonalization are often associated with psychotic disorders. For official diagnostic criteria of psychotic disorders, see Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Delusions may also occur in delirium, severe mood disorders, and dementia. Abnormalities of Perception: Illusions: Misinterpretations of real external stimuli, such as mistaking rustling leaves for the sound of voices. Illusions may occur in grief reactions, delirium, acute and posttraumatic stress disorders, and schizophrenia. Hallucinations: Perception-like experiences that seem real but, unlike illusions, lack actual external stimulation. The person may or may not recognize the experiences as false. Hallucinations may be auditory, visual, olfactory, gustatory, tactile, or somatic. False perceptions associated with dreaming, falling asleep, and awakening are not classified as hallucinations. Hallucinations may occur in delirium, dementia (less commonly), posttrau-matic stress disorder, schizophrenia, and alcoholism. Insight. Patients with psychotic disorders often lack insight into their illness. Denial of impairment may accompany some neurologic disorders. Judgment. Judgment may be poor in delirium, dementia, intellectual disability, and psychotic states. Anxiety, mood disorders, intelligence, education, income, and cultural values also influence judgment Remote Memory. Inquire about birthdays, anniversaries, social security number, names of schools attended, jobs held, or past historical events such as wars relevant to the patient’s past. Remote memory may be impaired in the late stage of dementia. Recent memory is impaired in dementia and delirium. Amnestic disorders impair memory or new learning ability and reduce social or occupational functioning, but lack the global features of delirium or dementia. Anxiety, depression, and intellectual disability may also impair recent memory Information and vocabulary are relatively unaffected by psychiatric disorders except in severe cases. Testing helps distinguish adults with life-long intellectual impairment (whose information and vocabulary are limited) from those with mild or moderate dementia (whose information and vocabulary are fairly well preserved). Calculating Ability. Poor performance suggests dementia or aphasia, but should be measured against the patient’s fund of knowledge and education Abstract Thinking. Proverbs. Ask the patient what the following proverbs mean: A stitch in time saves nine. Don’t count your chickens before they’re hatched. The proof of the pudding is in the eating. A rolling stone gathers no moss. The squeaky wheel gets the greas. Concrete responses are common in people with intellectual disability, delirium, or dementia, but may also reflect limited education. Patients with schizophrenia may respond concretely or with personal and bizarre interpretations Constructional Ability. The task here is to copy figures of increasing complexity onto a piece of blank unlined paper. Show each figure one at a time and ask the patient to copy it as well as possible. With intact vision and motor ability, poor constructional ability suggests dementia or parietal lobe damage. Intellectual disability can also impair performance. Mini-Mental State Examination (MMSE). This brief test has been widely used to screen for cognitive dysfunction or dementia and follow their course over time. MMSE Sample Items: Orientation to Time “What is the date?” Registration “Listen carefully. I am going to say three words. You say them back after I stop. Ready? Here they are . . . APPLE (pause), PENNY (pause), TABLE (pause). Now repeat those words back to me.” (Repeat up to five times, but score only the first trial.) Naming “What is this?” (Point to a pencil or pen) Reading “Please read this and do what it says.” (Show examinee the words on the stimulus form.) CLOSE YOUR EYE “Mental Status: The patient appears sad and fatigued; clothes are wrinkled. Speech is slow and words are mumbled. Thought processes are coherent, but insight into current life reverses is limited. The patient is oriented to person, place, and time. Digit span, serial 7s (Serial sevens, counting down from one hundred by sevens, is a clinical test used to test mental function; for example, to help assess mental status after possible head injury or in suspected cases of dementia), and calculations accurate, but responses delayed. Clock drawing is good. - These findings suggest depression. Screening for Depression Generalized Anxiety Disorder Depressive Disorders Schizophrenia Suicide Risk and Prevention Chapter 10 Breast/Axillae Assessment Male: Some men develop benign breast enlargement from gynecomastia, a proliferation of palpable glandular tissue, or pseudogynecomastia, the accumulation of subareolar fat. Causes of gynecomastia include increased estrogen, decreased testosterone, and medication side effects. it is not a risk factor for male breast cancer. A hard, irregular, eccentric, or ulcerating painless dominant mass suggests breast cancer 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. 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. 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. Female: Galactorrhea, or the discharge of milk-containing fluid unrelated to pregnancy or lactation, is more likely to be pathologic 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, ductal carcinoma in situ, or Paget disease of the breast. Clear, serous, green, black, or nonbloody discharges that are multiductal are usually benign. 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. • Normal VS. Abnormal Findings and Interpretation 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 car-cinoma 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. Arms Over Head; Hands Pressed Against Hips; Leaning Forward. - 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 posttraumatic fat necrosis or mammary duct ectasia, but should always be further evaluated. Nodules in the tail of the breast in the axilla (the tail of Spence) are some-times mistaken for enlarged axillary lymph nodes 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 Mastectomy - Masses, nodularity, and change in color or inflammation, especially in the incision line, suggest recurrence of breast cancer. • Breast Cancer - Hard irregular poorly circumscribed nodules, fixed to the skin or underly-ing tissues, strongly suggest cancer. Check for cysts and inflamed areas; some cancers may be tende Thickening of the nipple and loss of elasticity suggest an underlying cancer. The three most common breast masses are fibroadenoma (a benign tumor), cysts, and breast cancer. The clinical characteristics of these masses are listed below. However, any breast mass should be carefully evaluated and usually warrants further investigation by ultrasound, aspiration, mammography, or biopsy. Palpable Masses: • (15-25) Fibroadenoma - Usually smooth, rubbery, round, mobile, nontender 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 Sign: Absent • (25-50) Cysts - Usually soft to firm, round, mobile; often tender Age: 30–50 years, regress after menopause except with estrogen therapy Number: Single or multiple Shape: Round Consistency: Soft to firm, usually elastic Delimitation: Well delineated Mobility: Mobile Tenderness: Often tender Retraction Sign: Absent • Fibrocystic changes - Nodular, ropelike - 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 Cancer - Irregular, firm, may be mobile or fixed to surrounding tissue 30–90 years, most common over age 50 years Usually single, although may coexist with other nodules Shape: Irregular or stellate Consistency: Firm or hard Delimitation: Not clearly delineated from surrounding tissues Mobility: May be fixed to skin or underlying tissues Usually nontender Retraction Sign: May be present Over 50 - Cancer until proven otherwise Pregnancy/ lactation - Lactating adenomas, cysts, mastitis, and cancer • Self-Breast Examination For interested or high-risk patients, instruct the patient about how to perform the BSE. A high proportion of breast masses are detected by women examining their own breasts. For screening, the BSE has not been shown to reduce breast cancer mortality, but may promote health awareness and earlier reporting of breast changes or masses, which may reduce unnecessary testing and biopsies compared to monthly self-examination. The BSE is best timed 5 to 7 days after menses, when hormonal stimulation of breast tissue is low. Lying supine: 1. Lie down with a pillow under your right shoulder. Place your right arm behind your head. 2. Use the finger pads of the three middle fingers on your left hand to feel for lumps in the right breast. The finger pads are the top third of each finger. Make overlapping, dime-sized circular motions to feel the breast tissue. 3. Apply three levels of pressure in each spot: light, me-dium, and firm, using firmer pressure for tissue closest to the chest and ribs. A firm ridge in the lower curve of each breast is normal. If you’re not sure how hard to press, talk with your health care provider, or try to copy the way the doctor or nurse does it. 4. Examine the breast in an up-and-down or “strip” pat-tern. Start at an imaginary straight line under the arm, moving up and down across the entire breast, from the ribs to the collarbone, until you reach the middle of the chest bone (the sternum). Remember how your breast feels from month to month. 5. Repeat the examination on your left breast, using the finger pads of the right hand. 6. If you find any masses, lumps, or skin changes, see your clinician right away Standing: 1. While standing in front of a mirror with your hands pressing firmly down on your hips, look at your breasts for any changes of size, shape, contour, or dimpling, or redness or scaliness of the nipple or breast skin. (The pressing down on the hips position contracts the chest wall muscles and enhances any breast changes). 2. Examine each underarm while sitting up or standing and with your arm only slightly raised so you can easily feel in this area. Raising your arm straight up tightens the tissue in this area and makes it harder to examine. • Breast Development Chapter 11 and Chapter 15 Anorectal pain, itching, tenesmus, or discharge or bleeding from infection or rectal abscess suggest proctitis. Causes include gonorrhea, chlamydia, lymphogranuloma venereum, receptive anal intercourse, ulcerations of herpes simplex, or chancres of primary syphilis. Itching in younger patients may be from pinworms. ■ Is there any history of anal warts or anal fissures? Genital warts may arise from human papillomavirus (HPV) or condylomata lata in secondary syphilis. Anal fissures are seen in proctitis and Crohn disease. • Normal VS. Abnormal Findings and Interpretation Visceral pain in the RUQ suggests liver distention against its capsule from the various causes of hepatitis, including alcoholic hepatitis. Visceral periumbilical pain suggests early acute appendicitis from disten-tion of an inflamed appendix. It grad-ually changes to parietal pain in the RLQ from inflammation of the adja-cent parietal peritoneum. For pain disproportionate to physical findings, suspect intestinal mesenteric ischemia Parietal pain originates from inflammation of the parietal peritoneum, called peritonitis. It is a steady, aching pain that is usually more severe than visceral pain and more precisely localized over the involved structure. It is typically aggravated by movement or coughing. Patients with parietal pain usually prefer to lie still. - In contrast to peritonitis, patients with colicky pain from a renal stone move around frequently trying to find a comfortable position. Pain of duodenal or pancreatic origin may be referred to the back, pain from the biliary tree, to the right scapular region or the right posterior thorax. Pain from pleurisy or inferior wall myo-cardial infarction may be referred to the epigastric area. Upper abdominal pain, discomfort and heartburn - Studies suggest that neuropeptides such as 5-hydroxytryptophan and substance P mediate interconnected symptoms of pain, bowel dysfunction, and stress. Doubling over with cramping colicky pain signals a renal stone. Sudden knife-like epigastric pain often radiating to the back is typical of pancreatitis. Note that angina from inferior wall coronary artery disease may present as “indigestion,” but is precipitated by exertion and relieved by rest. Angina from inferior wall coronary ischemia along the diaphragm may also present as heartburn. Bloating may occur with lactose intolerance, inflammatory bowel disease, or ovarian cancer; belching results from aerophagia, or swallowing air. Cramping pain radiating to the right or LLQ or groin may be a renal stone. Diffuse abdominal pain with abdominal distention, hyperactive high-pitched bowel sounds, and tenderness on palpation marks small or large bowel obstruction; Pain with absent bowel sounds, rigidity, percussion tenderness, and guarding points to peritonitis. Vomiting and pain indicate small bowel obstruction. Fecal odor occurs with small bowel obstruction and gastrocolic fistula. Diarrhea is common with use of penicillins and macrolides, magnesium-based antacids, metformin, and herbal and alternative medicines. If recent hospitalization, consider Clostridium difficile infection. Thin, pencil-like stool occurs in an obstructing “apple-core” lesion of the sigmoid colon. Obstipation signifies intestinal obstruction. Melena may appear with as little as 100 mL of blood from upper GI bleed-ing; hematochezia, if more than 1,000 mL of blood, is usually from lower GI bleeding, but if massive can have an upper GI source Stress incontinence arises from decreased intraurethral pressure In bladder infection, pain in the lower abdomen is typically dull and pressure-like. In sudden overdistention of the bladder, pain is often agonizing; in contrast, chronic bladder distention is usually painless. Painful urination accompanies cystitis (bladder infection), urethritis, and uri-nary tract infections, bladder stones, tumors, and, in men, acute prostatitis. Women report internal burning in urethritis, and external burning in vulvovaginitis. Urgency suggests urinary tract infec-tion or irritation from possible urinary calculi. Frequency is common in uri-nary tract infection and bladder neck obstruction. In men, painful urination without frequency or urgency sug-gests urethritis. Associated flank or back pain suggests pyelonephritis. Causes of polyuria include the high fluid intake of psychogenic polydipsia and poorly controlled diabetes, the decreased secretion of antidiuretic hormone (ADH) of central diabetes insipidus, and the decreased renal sensitivity to ADH of nephrogenic diabetes insipidus In stress incontinence, increased abdominal pressure causes bladder pressure to exceed urethral resis-tance—there is poor urethral sphinc-ter tone or poor support of bladder neck. In urge incontinence, urgency is followed by involuntary leakage due to uncontrolled detrusor contractions that overcome urethral resistance. In overflow incontinence, neurologic dis-orders or anatomic obstruction from pelvic organs or the prostate limit bladder emptying until the bladder becomes overdistended. Functional incontinence arises from impaired cognition, musculoskeletal problems, or immobility. Combined stress and urge incontinence is mixed incontinence Striae. Old silver striae or stretch marks are normal vs Pink–purple striae are a hallmark of Cushing syndrome Dilated veins. A few small veins may be visible normally. Vs Dilated veins suggest portal hyper-tension from cirrhosis (caput medusae) or inferior vena cava obstruction Ecchymosis of the abdominal wall is seen in intraperitoneal or retroperitoneal hemorrhage Observe for the bulging flanks of ascites, the suprapubic bulge of a distended bladder or pregnant uterus, and ventral, femoral, or inguinal hernias. A protuberant abdomen that is tympanitic throughout suggests intestinal obstruction or paralytic ileus. Asymmetry suggests a hernia, an enlarged organ, or a mass. Inspect for the lower abdominal mass of an ovarian or a uterine cancer. Inspect for the increased peristaltic waves of intestinal obstruction. Inspect for the increased pulsations of an abdominal aortic aneurysm (AAA) or increased pulse pressure. A periumbilical or upper abdominal mass with expansile pulsations that is ≥3 cm in diameter suggests an AAA. Screening by palpation followed by ultrasound decreases mortality, espe-cially in male smokers 65 years or older. Pain may signal rupture. Rup-ture is 15 times more likely in AAAs >4 cm than in smaller aneurysms, and carries an 85% to 90% mortality rate.7 If the patient has hypertension, auscultate the epigastrium and in each upper quadrant for bruits. Later in the examination, when the patient sits up, listen also in the CVAs - A bruit in one of these areas that has both systolic and diastolic compo-nents strongly suggests renal artery stenosis as the cause of hypertension. A total of 4% to 20% of healthy indi- viduals have abdominal bruits. Auscultate for bruits over the aorta, the iliac arteries, and the femoral arteries - Bruits with both systolic and diastolic components suggest turbulent blood flow from atherosclerotic arterial disease Auscultate over the liver and spleen for friction rubs. - Friction rubs are present in hepatoma, gonococcal infection around the liver, splenic infarction, and pancreatic carcinoma Involuntary rigidity typically persists despite these maneuvers, suggesting peritoneal inflammation. Signs of peritonitis include a positive cough test, guarding, rigidity, rebound tenderness, and percussion ten-derness. rigidity makes peritonitis almost four times more likely. Fluid or solids in the stomach or colon may also cause dullness in Traube’ space. A change in percussion note from tympany to dullness on inspiration is a positive splenic percussion sign, but this sign is only moderately useful for detecting splenomegaly Splenomegaly is eight times more likely when the spleen is palpable.74 Causes include portal hypertension, hematologic malignancies, HIV infec-tion, infiltrative diseases like amyloi-dosis, and splenic infarct or hematoma. A left flank mass can represent either splenomegaly or an enlarged left kid-ney. Suspect splenomegaly if there is a palpable notch on medial border, the edge extends beyond the midline, percussion is dull, and your fingers can probe deep to the medial and lateral borders but not between the mass and the costal margin. Suspect an enlarged kidney if there is normal tympany in the LUQ and you can probe with your fingers between the mass and the costal margin, but not deep to its medial and lower borders. Causes of kidney enlargement include hydronephrosis, cysts, and tumors. Bilateral enlargement suggests poly-cystic kidney disease Pain with pressure or fist percussion supports pyelonephritis if associated with fever and dysuria, but may also be musculoskeletal Suprapubic tenderness is common in bladder infection. In ascites, dullness shifts to the more dependent side, whereas tympany shifts to the top An easily palpable impulse suggests ascites. A positive fluid wave, shifting dullness, and peripheral edema makes the presence of ascites to three to six times more likely Assessing Possible Acute Cholecystitis. When RUQ pain and tenderness suggest acute cholecystitis, assess Murphy sign. - A sharp increase in tenderness with inspiratory effort is a positive Murphy sign. When positive, Murphy sign triples the likelihood of acute cholecystitis. Bruits: A hepatic bruit suggests carcinoma of the liver or cirrhosis. Arterial bruits with both systolic and diastolic components suggest partial occlusion of the aorta or large arteries. Such bruits in the epigastrium are suspicious for renal artery stenosis or renovascular hypertension • Pancreatitis Acute pancreatitis: Process: Intrapancreatic trypsinogen activation to trypsin and other enzymes, result-ing in autodigestion and inflammation of the pancreas Location: Epigastric, may radiate straight to the back or other areas of the abdomen; 20% with severe sequelae of organ failure Quality: Usually steady Timing: Acute onset, persistent pain Aggravating fact.: Lying supine; dyspnea if pleural effusions from capillary leak syn-drome; selected medications, high triglycerides may exacerbat Relieving fact.: Leaning forward with trunk flexed Associated Symptoms and Setting: Nausea, vomiting, abdominal distention, fever; often recurrent; 80% with history of alcohol abuse or gallstones Chronic Pancreatitis: Process: Irreversible destruction of the pancreatic parenchyma from recurrent inflamma- tion of either large ducts or small duc Location: Epigastric, radiating to the back Quality: Severe, persistent, deep Timing: Chronic or recurrent course Aggravating fact.: Alcohol, heavy or fatty meals Relieving fact.: Possibly leaning forward with trunk flexed; often intractable Associated Symptoms and Setting: Pancreatic enzyme insufficiency, diarrhea with fatty stools (steatorrhea) and diabetes mellitus • Peptic Ulcer Disease - Hematemesis may accompany esoph-ageal or gastric varices, Mallory–Weiss tears, or peptic ulcer disease. Process: Mucosal ulcer in stomach or duode-num >5 mm, covered with fibrin, ex-tending through the muscularis mu-cosa; H. pylori infection present in 90% of peptic ulcers Location: Epigastric, may radiate straight to the back Quality: Variable: epigastric gnawing or burning (dyspepsia); may also be boring, aching, or hungerlike. Timing: Intermittent; duodenal ulcer is more likely than gastric ulcer or dyspepsia to cause pain that (1) wakes the patient at night, and (2) occurs intermittently over a few wks, disappears for months, then recur Aggravating fact.: variable Relieving fact.: Food and antacids may bring re-lief (less likely in gastric ulcers) Associated Symptoms and Setting: Nausea, vomiting, belching, bloating; heartburn (more common in duodenal ulcer); weight loss (more common in gastric ulcer); dyspepsia is more com-mon in the young (20–29 yrs), gastric ulcer in those over 50 yrs, and duodenal ulcer in those 30–60 yrs • GERD - Many patients with chronic upper abdominal discomfort or pain complain of heartburn, dysphagia, or regurgitation. If patients report heartburn and regurgitation together more than once a week, the accuracy of diagnosing GERD is over 90% These symptoms or mucosal damage on endoscopy are the diagnostic crite-ria for GERD. Risk factors include reduced salivary flow, which prolongs acid clearance by damping action of the bicarbonate buffer; obesity; delayed gastric emptying; selected medications; and hiatal hernia. Heartburn is a rising retrosternal burning pain or discomfort occurring weekly or more often. It is typically aggravated by foods such as alcohol, chocolate, citrus fruits, coffee, onions, and peppermint; or positions like bending over, exercising, lifting, or lying supine. Some patients with GERD have atypical respiratory symptoms such as chest pain, cough, wheezing, and aspiration pneumonia. Others complain of pharyngeal symptoms, such as hoarseness chronic sore throat, and laryngitis. ■ Some patients may have “alarm symptoms,” such as ■ Difficulty swallowing (dysphagia) ■ Pain with swallowing (odynophagia) ■ Recurrent vomiting ■ Evidence of GI bleeding ■ Early satiety ■ Weight loss ■ Anemia ■ Risk factors for gastric cancer ■ Palpable mass ■ Painless jaundice Patients who have uncomplicated GERD that fails empiric therapy, age >55 years, and “alarm symptoms” war-rant endoscopy to evaluate possible esophagitis, peptic strictures, Barrett esophagus, or esophageal cancer. Of those with suspected GERD, ∼50% to 85% have no disease on endoscopy.14,15 Approximately 10% of patients with chronic heartburn have Barrett esopha-gus, a metaplastic change in the esoph-ageal lining from normal squamous to columnar epithelium. In those affected, dysplasia on endoscopy increases the risk of esophageal cancer Regurgitation occurs in GERD, esophageal stricture, and esophageal cancer. Gurgling or regurgitation of undigested food occurs in GERD, motility disorders, and structural disorders like esophageal stricture and Zenker diverticulum. Causes are generally mechanical/obstructive in younger adults and neurologic/muscular in older adults (stroke, Parkinson disease). Process: Prolonged exposure of esophagus to gastric acid due to impaired esopha-geal motility or excess relaxations of the lower esophageal sphincter; Helico-bacter pylori may be present Location: Chest or epigastric Quality: Heartburn, regurgitation Timing: After meals, especially spicy food Aggravating fact.: Lying down, bending over; physical activity; diseases such as scleroderma, gastroparesis; drugs like nicotine that relax the lower esophageal sphincter Relieving fact.: Antacids, proton pump inhibitors; avoiding alcohol, smoking, fatty meals, chocolate, selected drugs such as theophylline, calcium channel blockers Associated Symptoms and Setting: Wheezing, chronic cough, short-ness of breath, hoarseness, choking sensation, dysphagia, regurgitation, halitosis, sore throat; increases risk of Barrett esophagus and esophageal cancer • Appendicitis RLQ pain or pain that migrates from the periumbilical region, combined with abdominal wall rigidity on palpation, is suspicious for appendicitis. In women, consider pelvic inflammatory disease, ruptured ovarian follicle, and ectopic pregnancy. Combining signs with laboratory inflammatory markers and CT scans markedly reduces misdiagnosis and unnecessary surgery. Assess carefully for the peritoneal signs of acute abdomen and the additional signs of McBurney point tenderness, Rovsing sign, the psoas sign, and the obturator sign described on the next page. Assess carefully for the peritoneal signs of acute abdomen and the additional signs of McBurney point tenderness, Rovsing sign, the psoas sign, and the obturator sign described on the next page. Classically, “McBurney point” lies 2 inches from the anterior superior spinous process of ilium on a line drawn from that process to the umbilicus The pain of appendicitis classically begins near the umbilicus, then migrates to the RLQ. Older adults are less likely to report this pattern.17 Localized tenderness anywhere in the RLQ, even in the right flank, suggests appendicitis. Early voluntary guarding may be replaced by involuntary muscular rigidity and signs of peritoneal inflam-mation. There may also be RLQ pain on quick withdrawal or deferred rebound tenderness. Palpate for Rovsing sign and referred rebound tenderness. Press deeply and evenly in the LLQ. Then quickly withdraw your fingers - Pain in the RLQ during left-sided pres-sure is a positive Rovsing sign. Assess the psoas sign. Place your hand just above the patient’s right knee and ask the patient to raise that thigh against your hand. Alternatively, ask the patient to turn onto the left side. Then extend the patient’s right leg at the hip. Flexion of the leg at the hip makes the psoas muscle contract; extension stretches it. - Increased abdominal pain on either maneuver is a positive psoas sign, sug-gesting irritation of the psoas muscle by an inflamed appendix. Though less helpful, assess the obturator sign. Flex the patient’s right thigh at the hip, with the knee bent, and rotate the leg internally at the hip. This maneuver stretches the internal obturator muscle. - Right hypogastric pain is a positive obtu-rator sign, from irritation of the obtura-tor muscle by an inflamed appendix. This sign has very low sensitivity. Process: Acute inflammation of the appendix with distention or obstruction Location: Poorly localized periumbilical pain, usually migrates to the right lower quadrant Quality: Mild but increasing, possi-bly cramping Steady and more seve Timing: Lasts roughly 4–6 hrs, depend-ing on intervention Aggravating fact.: Movement or cough Relieving fact.: If it subsides temporarily, suspect perforation of the appendix Associated Symptoms and Setting: Anorexia, nausea, possibly vomiting, which typically follow the onset of pain; low fever • Diverticulitis LLQ pain, especially with a palpable mass, signals diverticulitis. Process: Acute inflammation of colonic diver-ticula, outpouchings 5–10 mm in di-ameter, usually in sigmoid or descend-ing colon Location: Left lower quadran Quality: May be cramping at first, then steady Timing: Often gradual onset Aggravating fact.: Relieving fact.: Analgesia, bowel rest, antibiotics Associated Symptoms and Setting: Fever, constipation. Also nausea, vomiting, abdominal mass with rebound tenderness Stool with Red Blood (Hematochezia): Upper gastrointestinal hemorrhage may also cause red stool, usually with large blood loss ≥1 - Diverticula of the colon - Often no symptoms unless inflammation causes diverticulitis Acute diverticulitis is a confined inflammatory process, usually in the left lower quadrant, that involves the sigmoid colon. If the sigmoid colon is redundant there may be suprapubic or right-sided pain. • Hepatitis Impaired excretion of conjugated bilirubin is seen in viral hepatitis, cirrhosis, primary biliary cirrhosis, and drug-induced cholestasis from drugs such as oral contraceptives, methyl testosterone, and chlorpromazine. painful jaundice is commonly infectious in origin, as in hepatitis A and cholangitis. Acholic stools may occur briefly in viral hepatitis; they are common in obstructive jaundice. Itching occurs in cholestatic or obstructive jaundice. Viral Hepatitis: Risk Factors, Screening, and Vaccination. The best strategy for preventing infection and transmission of hepatitis A and B is vaccination. Hepatitis A. Transmission of hepatitis A virus (HAV) is through a fecal–oral route. Fecal shedding followed by poor hand washing contaminates water and foods, leading to infection of household and sexual contacts. Infected children are often asymptomatic, contributing to spread of infection. To reduce transmission, advise hand washing with soap and water after bathroom use or changing diapers, and before preparing or eating food. Diluted bleach can be used to clean environmental surfaces. CDC Recommendations for Hepatitis A Vaccination ● All children at age 1 year ● Individuals with chronic liver disease ● Groups at increased risk of acquiring HAV: travelers to areas with high endemic rates of infection, men who have sex with men, injection and illicit drug users, individuals working with nonhuman primates, and persons who have clotting factor disorders The vaccine alone may be administered at any time before traveling to endemic areas. Postexposure Prophylaxis. Healthy unvaccinated individuals should receive either a hepatitis A vaccine or a single dose of immune globulin (preferred for those ≥age 40 years) within 2 weeks of being exposed to HAV. These recommendations apply to close personal contacts of persons with confirmed HAV, coworkers of infected food handlers, and staff and attendees (and their household members) of child care centers where HAV has been diagnosed in children, staff, or households of attendees. Hepatitis B. Hepatitis B virus (HBV) infection is a more serious threat than infection with hepatitis A. The fatality rate for acute infection can be up to 1% and HBV infection can become chronic. Approximately 95% of infections in healthy adults are self-limited, with elimination of the virus and development of immunity. Risk of chronic HBV infection is highest when the immune system is immature—chronic infection occurs in 90% of infected infants and 30% of children infected before age 5 years. Screening. The USPSTF recommends screening for HBV in persons at high risk for infection (grade B), including those born in countries with a high endemic prevalence of HBV infection, persons with HIV, injection drug users, men who have sex with men, and household contacts or sexual partners of HBV-infected persons.44 The CDC recommends screening all pregnant women, ideally in the first trimester, and universal vaccination for all infants beginning at birth.43 For adults, vaccine recommendations also target high-risk groups, including those in high-risk settings (see below). CDC Recommendations for Hepatitis B Vaccination: High-Risk Groups and Settings ● Sexual contacts, including sex partners of hepatitis B surface antigen-positive persons, people with more than one sex partner in the prior 6 months, people seeking evaluation and treatment for sexually transmitted infections, and men who have sex with men ● People with percutaneous or mucosal exposure to blood, including injection drug users, household contacts of antigen-positive persons, residents and staff of facilities for the developmentally disabled, health care workers, and people on dialysis ● Others, including travelers to endemic areas, people with chronic liver disease and HIV infection, and people seeking protection from hepatitis B infection ● All adults in high-risk settings, such as sexually transmitted disease (STD) clin-ics, HIV testing and treatment programs, drug-abuse treatment programs and programs for injection drug users, correctional facilities, programs for men having sex with men, chronic hemodialysis facilities and end-stage renal dis-ease programs, and facilities for people with developmental disabilities Hepatitis C. There is no vaccination for hepatitis C, so prevention targets counseling to avoid risk factors. Screening should be recommended for high-risk groups. Hepatitis C virus (HCV), transmitted mainly by percutaneous exposures, is the most prevalent chronic bloodborne pathogen in the United States. Anti-HCV antibody is detectable in just under 2% of the population, though prevalence is markedly increased in high-risk groups, particularly injection drug users.45 Addi-tional risk factors for HCV infection include blood transfusion or organ transplan-tation before 1992, transfusion with clotting factors before 1987, hemodialysis, health care workers with needle stick injury or mucosal exposure to HCV-positive blood, HIV infection, and birth from an HCV- positive mother. Sexual transmission is rare. Hepatitis C becomes a chronic illness in over 75% of those infected and is a major risk factor for subsequent cirrhosis, hepatocellular carcinoma, and need for liver transplant for end-stage liver disease.45– 47 However, the major-ity of persons with chronic HCV are unaware of being infected. Response to antiviral therapy (undetectable HCV RNA 24 weeks after completing treat- ment) ranges from 40% to over 90% depending on the viral genotype and the combination of drugs used for treatment. Consequently, the USPSTF has concluded that screening for hepatitis C infection is of moderate benefit for persons at high risk for infection as well as those born between 1945 and 1965 (grade B). Firmness or hardness of the liver, bluntness or rounding of its edge, and surface irregularity are suspicious for liver disease Tenderness over the liver suggests inflammation, found in hepatitis, or congestion from heart failure • IBS - Intermittent pain for 12 weeks of the preceding 12 months with relief from defecation, change in frequency of bowel movements, or change in form of stool (loose, watery, pellet-like), linked to luminal and mucosal irritants that alter motility, secretion, and pain sensitivity suggests irritable bowel syndrome. High-volume frequent watery stools are usually from the small intestine; small-volume stools with tenesmus, or diarrhea with mucus, pus, or blood occur in rectal inflammatory conditions. Types of primary or functional constipation are normal transit, slow transit, impaired expulsion (from pelvic floor disorders), and constipation-predominant irritable bowel syndrome. Secondary causes include medications and conditions like amyloidosis, diabetes, and CNS disorders. Process: Altered motility or secretion from luminal and mucosal irritants that change mucosal permeability, immune activation, and colonic transit, including maldigested carbohydrates, fats, excess bile acids, gluten intolerance, entero-endocrine signaling, and changes in microbiome Chronic Diarrhea - more than 30 days Characteristics of the stool: Loose; ∼50% with mucus; small to moderate volume. Small, hard stools with constipation. May be mixed pattern Timing: Worse in the morning; rarely at night Associated Symptoms: Crampy lower abdominal pain, abdominal distention, flatulence, nausea; urgency, pain relieved with defecation Setting, person at risk: Young and middle-aged adults, especially women Process: Functional change in frequency or form of bowel movement without known pathology; possibly from change in intestinal bacteria. Associated Symptoms: Three patterns: diarrhea—predominant, constipation— predominant, or mixed. Symptoms present ≥6 mo and abdominal pain for ≥3 mo plus at least 2 of 3 features (improvement with defecation; onset with change in stool frequency; onset with change in stool form and appearance) • Colon/Anorectal Cancer - Change in bowel habits with a mass lesion warns of colon cancer. For suspicion of a colorectal cancer consider lower endoscopy. Performing digital rectal examination is not recommended for colorectal cancer screening Higher-risk persons, based on personal history of colorectal neoplasia or long-standing inflammatory bowel disease, or a family history of colorectal neoplasia, should begin screening at a younger age, usually with colonoscopy, and get more frequent testing than average-risk adults. Stool with Red Blood (Hematochezia) – Colon cancer: Usually originates in the colon, rectum, or anus; much less frequently from the jejunum or ileum - Often a change in bowel habits, weight loss Change in stool caliber, especially pencil-thin stools, may warn of colon cancer. Blood in the stool may be from polyps, carcinoma, gastrointestinal bleeding, or hemorrhoids; mucus may accompany villous adenoma, intestinal infections, inflammatory bowel disease (IBD), or irritable bowel syndrome (IBS). A tender purulent reddened mass with fever or chills suggests an anal abscess. Abscesses tunneling to the skin surface from the anus or rectum may form a clogged or draining ano-rectal fistula. Fistulas may ooze blood, pus, or feculent mucus. Consider anoscopy or sigmoidoscopy for better visualization. Cancer of the rectum: firm, nodular, rolled edge of an ulcerated cancer. Cancer of sigmoid colon: Process: Partial obstruction by a malignant neoplasm Characteristics of the stool: May be blood-streaked Timing: variable Associated Symptoms: Change in usual bowel habits, crampy lower abdominal pain, constipation Setting: Middle-aged and older adults, especially older than 55 yrs • Ulcerative Colitis - Acute diarrhea, especially foodborne, is usually caused by infection. Chronic diarrhea is typically noninfectious in origin, as in Crohn disease and ulcerative colitis. Kidney pain is a visceral pain usually produced by distention of the renal capsule and typically dull, aching, and steady. Ureteral colic is a dramatically different severe colicky pain radiating around the trunk into the lower abdomen and groin, or possibly into the upper thigh, testicle, or labium. Ureteral pain results from sudden distention of the ureter and the renal pelvis. Ask about any associated fever, chills, or hematuria Flank pain, fever, and chills signal acute pyelonephritis Renal or ureteral colic is caused by sudden obstruction of a ureter, for example, from renal or urinary stones or blood clots Process: Mucosal inflammation typically extending proximally from the rec-tum (proctitis) to varying lengths of the colon (colitis to pancolitis), with microulcerations and, if chronic, inflammatory polyp. Chronic Diarrhea (more than 30 days) Characteristics of the stool: Frequent, watery, often containing blood Timing: Onset typically abrupt; often re-current, persisting, and may awaken at night Associated Symptoms: Cramping, with urgency, tenesmus; fever, fatigue, weakness; abdominal pain if complicated by toxic megacolon; may include episcleritis, uveitis, arthritis, erythema no-dosum Setting: Often young adults, Ashkenazi Jewish descendants; linked to altered CD4+ T-cell Th2 response; in-creases risk of colon cancer Stool with Red Blood (Hematochezia): Rapid transit leaves insufficient time for the blood to turn black from oxidation of iron in hemoglobin Chapter 13 • Male Genitalia Assessment and Modification for Age 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. • Normal VS. Abnormal Findings and Interpretation 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. Femoral hernias are more likely to present as emergencies with bowel incarceration or strangulation. A bulge near the external inguinal ring suggests a direct inguinal hernia. A bulge near the internal inguinal ring suggests an indirect inguinal hernia Pubic or genital excoriations suggest lice (crabs) or sometimes scabies in the pubic hair. 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. Balanitis is inflammation of the glans; balanoposthitis is inflammation of the glans and prepuce. Hypospadias is a congenital ventral displacement of the meatus on the penis • Prostate Issues and Cancer • STI (Male) 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. Look for an ulcer in syphilitic chancre and herpes; warts from human papillomavirus (HPV); swelling in mumps orchitis, scrotal edema, and testicular cancer; pain in testicular torsion, epididymitis, and orchitis. Profuse yellow discharge signals gonococcal urethritis; scanty white or clear discharge signals nongonococcal urethritis. Definitive diagnosis requires Gram stain and culture. Infections from oral–penile transmis-sion include gonorrhea, chlamydia, syphilis, and herpes. Symptomatic or asymptomatic proctitis may follow anal intercourse. • Testicular Disorders and Cancer Induration along the ventral surface of the penis suggests a urethral stric-ture or possibly a carcinoma. Tender-ness in the indurated area suggests periurethral inflammation from a urethral stricture. The Ameri-can Cancer Society does not have a recommendation for regular testicular self- examinations (TSEs), but does advise men to seek clinical attention for any of the following: a painless lump, swelling, or enlargement in either testicle; pain or discomfort in a testicle or the scrotum; a feeling of heaviness or a sud-den fluid collection in the scrotum; or a dull ache in the lower abdomen or the groin. 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 par-allels retroperitoneal venous flow from the renal vein and inferior vena cava, the primary site of lymph node involvement in testicular cancer To check for a varicocele, with the patient standing, palpate the spermatic cord about 2 cm above the testis. 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 spermatic cord indicates filling of abnormally dilated spermatic veins draining the testis • Erectile Dysfunction 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. Premature ejaculation is common, especially in young men. Less com-mon 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 psychogeni • Conditions of the Penis and Testicles 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 Erythema and mild excoriation point to fungal infection, not uncommon in this moist area. Tender painful scrotal swelling is present in acute epididymitis, acute orchitis, torsion of the spermatic cord, or a strangulated inguinal hernia. The vas deferens, if chronically infected, may feel thickened or beaded. A cystic structure in the spermatic cord suggests a hydrocele of the cord. 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. Transillumination of the scrotal mass may help identify a hydrocele from an intestine- containing hernia 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. If you can place your fingers above the mass in the scrotum, suspect a hydrocele. • Tanner Staging (Male) • Incontinence (Male) Chapter 14 • Female Genitalia and Modification for Age • Normal VS. Abnormal Findings and Interpretation 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, diabetes, 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. Loss of urethral support contributes to stress incontinence. Weakness of the perineal body from childbirth predisposes to rectoceles and enteroceles The Menstrual History—Helpful Definitions ● Menarche—age at onset of menses ● Dysmenorrhea—pain with menses, often with bearing down, aching, or cramp-ing sensation in the lower abdomen or pelvis 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. ● Premenstrual syndrome (PMS)—a cluster of emotional, behavioral, and physical symptoms occurring 5 days before menses for three consecutive cycles. Criteria for diagnosis are symptoms and signs in the 5 days prior to menses for at least three consecutive cycles; cessation of symptoms and signs within 4 days after onset of menses; and interference with daily activities ● Amenorrhea—absence of menses. 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 ● Abnormal uterine bleeding—bleeding between menses; includes infrequent, excessive, prolonged, or postmenopausal bleeding. Polymenorrhea, or less than 21-day intervals between menses. Oligomenorrhea, or infrequent bleeding. Menorrhagia, or excessive flow. Metrorrhagia, or intermenstrual bleeding. Postcoital bleeding (Postcoital bleeding suggests cervical polyps or cancer or, in an older woman, atrophic vaginitis). ● Menopause—absence of menses for 12 consecutive months, usually occurring between ages 48 and 55 years ● Postmenopausal bleeding—bleeding occurring 6 months or more after cessation of menses (Causes of postmenopausal bleeding include endometrial cancer, hormone replacement therapy (HRT), and uterine and cervical polyps). Amenorrhea followed by heavy bleeding suggests a threatened abor-tion or dysfunctional uterine bleeding related to lack of ovulation. The most common cause of acute pelvic pain is (pelvic inflammatory disease) PID, followed by ruptured ovarian cyst, and appendicitis.20 STIs and recent IUD insertion are red flags for PID. Always rule out ectopic pregnancy first with serum or urine testing and possible ultrasound. Also consider mittelschmerz (Mittelschmerz is one-sided, lower abdominal pain associated with ovulation. German for "middle pain," mittelschmerz occurs midway through a menstrual cycle — about 14 days before your next menstrual period. In most cases, mittelschmerz doesn't require medical attention), which is typically a mild