NR 304 PATHO 283 EXAM 3 NOTES & STUDY GUIDE GRADED A VERIFIED

Chapter 17: Breast’s and regional lymphatics Cultural competence • Timing of puberty is influenced by genetic and environmental factors • Research data indicate age differences in onset of puberty according to different ethnic groups. • Obesity contributes to the early onset of puberty. • Menses began at an average age of 12-16 years for African-American girls and age 13 for white girls. Cultural competence: Breast cancer I, II, III • Incidence of breast cancer varies in cultural groups o Women who inherit mutations of BRCA1 and BRACA2 on one or both sides are at an increased risk for developing breast or ovarian cancer o Women’s Health Initiative (WHI) study looked at increased risk linkage with use of combined hormone replacement therapy (HRT) and development of breast cancer o Screening mammography annual screening is recommended starting at age 40 • Lifestyle risk factors relate to risk. o Alcohol use increases risk o Physical activity reduces risk o Postmenopausal weight gain negates effects of physical exercise activity • Factors contributing to breast health care access: low income, lack of health insurance, geographical area, cultural and language barriers, and racial bias. • “Alcohol/Western” dietary pattern linked to increased risk of breast cancer, especially with estrogen or progesterone (+) tumors • “Mediterranean” dietary pattern linked to a modest protective effect against breast cancer • “BREAST”  Breast mass, Retraction, Edema, Axillary mass, Scaly nipple, Tender Breast cancer: Culture and Women • In Western culture, female breasts signify more than their primary purpose of lactation o Matters pertaining to breasts affect woman’s body image and generate emotional responses. • A woman who has found a breast lump may come to you with fear, anxiety, and panic. o Although many breast lumps are benign, women initially assume worst possible outcome, including cancer, disfigurement, and death. o While you are collecting subjective data, tune in to cues for these behaviors that call for a reasoned and straightforward attitude. • Caucasian women starting age 45 have higher risk for breast cancer. • African American Women before age 45 have higher risk for breast cancer and are more likely to die from breast cancer regardless of age. Subjective Data Breast • Pain -Lump -Discharge -Rash -Swelling -Trauma -History of breast disease -Surgery -Self-care behaviors -Perform breast self-examinations -Last mammogram Axilla • Tenderness -Lump -Swelling -Rash Subjective data questions • Self-care behaviors o Have you ever been taught breast self-examination?  (If the answer is yes) How often do you perform it? What helps you remember? It is an excellent way to be in charge of your own health; I would like you to show me your technique after we do your examination.  (If the answer is no) This will be an excellent way that you can take charge of your own health; you can make breast self-examination a very routine health habit, just like brushing your teeth; I will teach you the technique after we do your examination. • Axilla o Tenderness, lump, or swelling o Any tenderness or lump in the underarm area? o Where? When did you first notice this? • Rash o Any axillary rash? Please describe it. o Does it seem to be a reaction to deodorant? Additional history for preadolescent girl • Have you noticed your breasts changing? o How long has this been happening? • Many girls notice other changes in their bodies, too, that come with growing up. o What have you noticed? o What do you think about all this? Additional history for pregnant woman • Have you noticed any enlargement or fullness in the breasts? o Is there any tenderness or tingling? o Do you have a history of inverted nipples? • Are you planning to breastfeed your baby? Additional history for menopausal woman • Have you noticed any change in breast contour, size, or firmness? o Change may not be as apparent to obese woman or to woman whose earlier pregnancies have already produced breast changes. Risk profile for breast cancer • Breast cancer is second major cause of death from cancer in women. • However, early detection and improved treatment have increased survival rates. o The 5-year survival rate for localized breast cancer has increased from 78% in 1940s to 98% today. o If cancer has spread regionally, survival rate is 84%. -Cancer that has spread regionally means it has spread to lymph nodes, surrounding tissues, and organs Objective data Preparation • Woman sitting up facing examiner o An alternative draping method is to use a short gown, open at back, and lift it up to woman’s shoulders during inspection. • During palpation when woman is supine, cover one breast with gown while examining other. o Be aware that many women are embarrassed to have their breasts examined; use a sensitive but matter-of-fact approach. • After examination, be prepared to teach woman breast self-examination. Equipment • Small pillow • Ruler marked in centimeters • Pamphlet or teaching aid for breast self-examination (BSE) Inspection of the breast I, II, III General appearance • Note symmetry of size and shape; common to have a slight asymmetry in size; often left breast is slightly larger than right. Skin • Normally smooth and of even color • Note any localized areas of redness, bulging, or dimpling; also any skin lesions or focal vascular pattern. • Fine blue vascular network visible during pregnancy; pale linear striae, or stretch marks, follow pregnancy. • Normally no edema is present. Lymphatic drainage areas • Observe axillary and supraclavicular regions; note any bulging, discoloration, or edema. Nipple • Should be symmetric on same plane on both breasts • Nipples usually protrude, although some are flat and some are inverted. • Normal nipple inversion may be unilateral or bilateral and usually can be pulled out. • Note any dry scaling, any fissure or ulceration, and bleeding or other discharge. • Supernumerary nipple is normal variation. o An extra nipple along embryonic “milk line” on thorax or abdomen is congenital finding. o Usually below breast near midline and has no associated glandular tissue; looks like a mole, although a close look reveals a tiny nipple and areola. -”supernumerary nipple” = third nipple Maneuvers to screen for retraction • Direct woman to change position to check breasts for skin retraction signs; first ask her to lift arms slowly over head; both breasts should move up symmetrically. • Next ask her to push her hands onto her hips and then to push her two palms together; these maneuvers contract pectoralis major muscle; slight lifting of both breasts will occur. • Ask woman with large pendulous breasts to lean forward while you support her forearms; note symmetric free-forward movement of both breasts. Inspection and palpation of the Axillae • Examine axillae while woman is sitting. o Inspect skin, noting any rash or infection; lift woman’s arm and support it, so that her muscles are loose and relaxed; use right hand to palpate left axilla. o Reach fingers high into axilla; move them firmly down in four directions. o Move woman’s arm through range-of-motion to increase surface area you can reach. o Usually nodes are not palpable, although you may feel a small, soft, nontender node in central group. o Note any enlarged and tender lymph nodes. Palpation of the breasts I, II, III • Help woman to a supine position o Tuck a small pad under side to be palpated and raise her arm over her head to flatten breast tissue and displace it medially; any significant lumps will then feel more distinct. o Use pads of your first three fingers and make a gentle rotary motion on breast; vary pressure palpating light, medium, and deep tissue in each location. o Vertical strip pattern currently recommended to detect a breast mass, but two other patterns are in common use:  From the nipple palpating out to periphery as if following spokes on a wheel  Palpating in concentric circles out to periphery • In nulliparous women, normal breast tissue feels firm, smooth, and elastic. • After pregnancy, tissue feels softer and looser. • Premenstrual engorgement is normal from increasing progesterone. o Consists of slight enlargement, tenderness to palpation, and generalized nodularity; lobes feel prominent and their margins more distinct. • Normally you may feel a firm transverse ridge of compressed tissue in lower quadrants. • After palpating over four breast quadrants, palpate nipple; note any induration or subareolar mass. • With your thumb and forefinger, gently depress nipple tissue into well behind areola; tissue should move inward easily. • If woman reports spontaneous nipple discharge, press areola inward with your index finger; repeat from a few different directions; note color and consistency of any discharge. • If woman mentions a breast lump that she has discovered herself, examine unaffected breast first to learn a baseline of normal consistency for this woman. Characteristics of Lump or mass I, II • Location: as with clock face, describe distance in centimeters from nipple; or diagram breast in woman’s record and mark in location of lump. • Size: judge in centimeters in three dimensions: width, length, and thickness. • Shape: state whether lump is oval, round, lobulated, or indistinct. • Consistency: state whether lump is soft, firm, or hard. • Movability: is lump freely movable or fixed when you try to slide it over chest wall? • Distinctness: is lump solitary or multiple? • Nipple: is it displaced or retracted? • Skin over lump: is it erythematous, dimpled, or retracted? • Tenderness: is lump tender to palpation? • Lymphadenopathy: are any regional lymph nodes palpable? Palpation: Breast • Premenopausal women mid-cycle have tissue edema and mastalgia (pain) that make it hard to detect lesions. • If your findings are in question, consider asking woman to return for follow-up examination first week after menses when hormone levels are lower and edema is not present. Teach Breast Self-Examination (BSE) • Help each woman establish regular schedule of self-care. o The best time to conduct BSE is right after menstrual period, when breasts are smallest and least congested. o Advise pregnant or menopausal woman not having menstrual periods to select a familiar date to examine her breasts each month. o Stress that self-examination will familiarize woman with her own breasts and their normal variation; emphasize absence of lumps (not the presence of them). o Encourage her to report any unusual finding promptly. BSE: keep teaching simple • The simpler the plan, the more likely person is to comply. • Describe correct technique and rationale and expected findings to note as woman inspects her own breasts. • Teach woman to do this in front of a mirror while she is disrobed to waist. • At home, she can start palpation in shower, where soap and water assist palpation. • Then palpation should be performed while lying supine. • Encourage woman to palpate her own breasts while you monitor her technique. BSE: Teaching methods • Many examiners use a simulated breast model so that woman can palpate a “lump.” • Pamphlets are helpful reinforcers; give woman two pamphlets to take home and encourage her to give one to a relative or friend; this may promote discussion, which is reinforcing. Positive Aspects of BSE • Avoid citing frightening mortality statistics about breast cancer and generating excessive fear and denial that actually obstructs a woman’s self-care action. o Majority of women will never get breast cancer. o Great majority of breast lumps are benign. o Early detection of breast cancer is important; if cancer is not invasive, survival rate is close to 98%. Male Breast I, II • Examination of male breast can be abbreviated, but do not omit it. o Combine breast exam with that of anterior thorax. o Inspect chest wall, noting skin surface and any lumps or swelling. o Palpate nipple area for any lump or tissue enlargement; it should feel even, with no nodules. o Palpate axillary lymph nodes. • Normal male breast has flat disk of undeveloped breast tissue beneath nipple. o Gynecomastia is a benign growth of this breast tissue, making it distinguishable from other tissues in chest wall. o Feels like a smooth, firm, movable disk o Occurs normally during puberty and is temporary o The adolescent is acutely aware of his body image. o Reassure him that this change is normal, common, and temporary. Developmental competence I, II, III, IV, V, VI Infants and children • In neonate, breasts may be enlarged and visible due to maternal estrogen crossing placenta. o May secrete a clear or white fluid, called “witch’s milk” o This is not significant and is resolved within a few days to a few weeks. • Note position of nipples on prepubertal child. o Should be symmetric, just lateral to midclavicular line, between fourth and fifth ribs o Nipple is flat, and areola is darker pigmented. Adolescent girl • Breast development usually begins on an average between 8 and 10 years. o Expect some asymmetry during growth; record stage of development using Tanner staging. o Use chart to teach adolescent normal developmental stages and to assure her of her own normal progress. o With maturing adolescents, palpate breasts as you would with adult; note any mass. o Teach BSE now, so that technique will become a natural, comfortable habit by time girl becomes an adult. Pregnant woman • Breasts increase in size, as do nipples. o Delicate blue vascular pattern is visible over the breasts. o Jagged linear stretch marks, or striae, may develop if breasts have large increase. o Nipples become darker and more erectile. o Areolae widen; grow darker; and contain small, scattered, elevated Montgomery’s glands. o On palpation, breasts feel more nodular, and thick yellow colostrum can be expressed after first trimester. Lactating woman • Colostrum changes to milk production around the third postpartum day. o Breasts may become engorged, appearing enlarged, reddened, and shiny and feeling warm and hard. o Frequent nursing helps drain ducts and sinuses and stimulate milk production. o Nipple soreness is normal, appearing around twentieth nursing, lasting 24 to 48 hours, then disappearing. o Nipples may look red and irritated; may even crack but will heal rapidly if kept dry and exposed to air; frequent nursing is best treatment for nipple soreness. Aging woman • On inspection, breasts look pendulous, flat, and sagging. o Nipples may be retracted but can be pulled outward. o On palpation, breasts feel more granular; terminal ducts around nipple feel more prominent and stringy. o Thickening of inframammary ridge at lower breast is normal and feels more prominent with age. o Reinforce value of BSE. o Women over 50 years old have increased risk of breast cancer. o Older women may have problems with arthritis, limited range of motion, or decreased vision that may inhibit self-care. o Suggest aids to self-examination; for example, talcum powder helps fingers glide over skin. Summary checklist: Breasts and regional lymphatics • Inspect breasts as woman sits, raises arms overhead, pushes hands on hips and leans forward. • Inspect the supraclavicular and infraclavicular areas. • Palpate the axilla and regional lymph nodes. • With woman supine, palpate the breast tissue, including Tail of Spence, the nipples, and areolae. • Teach BSE. Abnormal findings: Retraction and inflammation • Dimpling -Nipple retraction -Fixation -Edema (peau d’orange) -Deviation in nipple pointing Abnormal findings: Breast Lump • Benign breast disease (formerly fibrocystic breast disease) -Cancer -Fibroadenoma Abnormal findings: Abnormal nipple discharge • Mammary duct ectasia -Carcinoma -Intraductal papilloma -Paget disease (intraductal carcinoma) Abnormal findings: Disorders during lactation • Plugged duct -Breast abscess -Mastitis Abnormal findings: Male breast • Gynecomastia -Male breast cancer Chapter 24: Male Genitourinary system Developmental competence: Infants • Prenatally, testes develop in abdominal cavity near kidneys o During later months of gestation testes migrate, pushing abdominal wall in front of them and dragging the vas deferens, blood vessels, and nerves behind o Descend along inguinal canal into scrotum before birth • At birth, testis measure 1.5 to 2 cm long and 1 cm wide • Only a slight increase in size occurs during prepubertal years • Cryptorchidism: is an indication that the testes never descended Developmental competence: Adolescents • Signs of puberty are appearing earlier in boys: o average age of 9 years in African Americans o average age of 10 for Caucasians & Hispanics • First sign is enlargement of testes • Next, pubic hair appears, then penis size increases • Stages of development are documented in Tanner’s sexual maturity ratings Developmental Competence: Adults & Aging Adults • Male does not experience a definite end to fertility as female does • Around age 40 years, production of sperm begins to decrease, although it continues into 80s and 90s • Testosterone production declines after age 30 but continues very gradually so resulting physical changes are not evident until later in life o Pubic hair decreases and penis size decreases o Due to decreased tone of dartos muscle, scrotal contents hang lower, rugae decrease, and scrotum becomes pendulous o Testes decrease in size and are less firm to palpation o Increased connective tissue is present in tubules, so these become thickened and produce less sperm Sexual Expression in Later Life • Chronologic age by itself should not mean a halt in sexual activity; physical changes need not interfere with libido and sexual pleasure • Older male is capable of sexual function as long as he is in reasonably good health and has an interested, willing partner • Danger is in male misinterpreting normal age changes as a sexual failure; once this idea occurs, it may demoralize man and place undue emphasis on performance rather than on pleasure • In the absence of disease, withdrawal from sexual activity may be due to: o Loss of spouse o Depression o Preoccupation with work o Marital or family conflict o Side effects of medications o Heavy alcohol use o Lack of privacy (living with adult children/nursing home) o Economic or emotional stress o Poor nutrition or fatigue Culture & Genetics: Circumcision During pregnancy or immediate neonatal period, parents may ask whether or not to circumcise male infant: • religious and cultural indications • prevention of phimosis and inflammation of glans penis and foreskin • decreasing incidence of cancer of penis • slightly decreasing incidence of urinary tract infections in infancy • lowers risk of certain STIs, specifically syphilis, chancroid, and somewhat reduced risk of genital herpes • circumcised men have a significantly lowered risk of acquiring genital HPV infection, and their partners have a lower risk of cervical cancer • epidemiological studies now suggest a potential reduction in acquisition of HIV in circumcised men -phimosis: condition in which the foreskin of the penis cannot be pulled back from the glans -chancroid is a bacterial infection that causes open sores on or around the genitals of men and women Subjective Data Questions Frequency, urgency, and nocturia: • Are you urinating more often than usual? • Do you feel as if you cannot wait to urinate? • Do you awaken during the night because you need to urinate? How often? Is this a recent change? o Nocturia occurs with frequency and urgency in urinary tract disorders; other origins include cardiovascular, habitual, diuretic medication Dysuria: • Any pain or burning with urinating? o Burning common with acute cystitis, prostatitis, and urethritis Hesitancy and straining: • Do you have any trouble starting urine stream? • Do you need to strain to start or maintain stream? • Has there been any change in force of stream? • Have you experienced dribbling, so that you must stand closer to toilet? • Afterward, do you still feel you need to urinate? • Have you ever had any urinary tract infections? Urine color: • Is usual urine clear or discolored, cloudy, foul-smelling, or bloody? Genitourinary history: • Have you had any difficulty controlling your urine? o True incontinence: loss of urine without warning o Urgency incontinence: sudden loss, as in acute cystitis • Do you accidentally urinate when you sneeze, laugh, cough, or bear down? • Do you have any history of kidney disease, kidney stones, flank pain, urinary tract infections, or prostate trouble? Penis • Have you had any problem with your penis, such as pain or lesions? o Any discharge? How much? Increased or decreased since start? Color? Odor? Discharge associated with pain or urination? Scrotum, self-care behaviors • Any problem with scrotum or testicles? o Any lumps or swelling on testes? Change in size of scrotum? History of undescended testicle as infant? Any bulge or swelling in scrotum? o Have you ever been told you have a hernia? Have you had any dragging, heavy feeling in scrotum? Sexual activity and contraceptive use: • Are you in a relationship involving sexual intercourse? o Are aspects of sex satisfactory to you and your partner? o Are you satisfied with the way you and your partner communicate about sex? o Occasionally a man notices a change in ability to have an erection when aroused. Have you noticed any changes? o Do you and your partner use a contraceptive? Which method? Is this satisfactory? Do you have any questions about this method? o How many sexual partners have you had in the last 6 months? o What is your sexual preference? Do you prefer a relationship with a woman, a man, or both? o When needed, phrase your questions so that the patient feels comfortable acknowledging a problem STI Contact Questions • Any known sexual contact with a partner having an STI, such as gonorrhea, herpes, AIDS, chlamydia, venereal warts, or syphilis? o When was this contact? Did you get the disease? o How was it treated? Were there any complications? o Do you use condoms to help prevent STIs? o Do you have any questions or concerns about any of these diseases? Additional History: Infants & Children • Does your child have any problem urinating? Does his urine stream look straight? • Any pain with urinating, crying, or holding the genitals? • Any urinary tract infections? o If child older than 2 to 2½ years of age • Has toilet training started? How is it progressing? • If child is 5 years old or older, does he wet bed at night? Is this a problem for child or for parents? What have you done? How does the child feel about it? • Any problem with child’s penis or scrotum, such as sores, swelling, or discoloration? • Have you been told if his testes are descended? • Has he ever had a hernia or hydrocele? • Does he have any swelling in his scrotum during crying or coughing? • Ask directly to preschooler or young school-age child: o “Has anyone ever touched your penis or in between your legs and you did not want them to?” o Tell him that sometimes that happens to children and it’s not okay o They should remember that they have not been bad o They should try to tell a big person about it o “Can you tell me three different big people you trust who you could talk to?” Additional History: Preadolescents & Adolescents • First ask questions that seem appropriate for boy’s age, but be aware that norms vary widely • When you are in doubt, it is better to ask too many questions than to omit something • Children obtain information (often misinformation) from media, internet, and from peers at surprisingly early ages • Ask direct, matter-of-fact questions; avoid sounding judgmental • Start with a permission statement: “Often boys your age experience . . . ” This conveys that it is normal and all right to think or feel a certain way o Try the ubiquity approach, “When did you . . . ” rather than “Do you . . . ” This method is less threatening because it implies that topic is normal and unexceptional o Do not be concerned if a boy will not discuss sexuality with you or respond to offers for information o If you do well to “open the door” adolescents may come back at a future time • “Around age 12 to 13, but sometimes earlier, boys start to change and grow around penis and scrotum; what changes have you noticed?” • “Have you ever seen charts and pictures of normal growth patterns for boys? Let’s go over these now.” • “Who can you talk to about your body changes and about sex information? How do these talks go? What about sex education classes at school? How about your parents? Is there a favorite teacher, nurse, doctor, minister, or counselor with whom you can talk?” • Boys around age 12 to 13 have normal experience of fluid coming out of penis at night, called nocturnal emissions, or “wet dreams” o “Have you had this?” o Teenage boys wonder if they are only ones who ever had them, like having an erection at embarrassing times, having sexual fantasies, or masturbating o Boys might have thoughts about touching another boy’s genitals and wonder if he might be homosexual o “Would you like to talk about any of these things?” • Often boys your age have questions about sexual activity • “What questions do you have? How about things like birth control, or STIs such as gonorrhea or herpes? Do you have any questions about these?” • “Are you dating? Someone steady? Have you had intercourse? Are you using birth control?” • “What kind of birth control do you use?” • “Has a nurse or doctor ever taught you how to examine your own testicles to make sure they are healthy?” • “Has anyone ever touched your genitals and you did not want them to?” o Another boy, or an adult, even a relative? o Sometimes that happens to teenagers o You should remember it is not your fault and you should tell another adult about it Additional History: Aging Adult • “Any difficulty urinating?” o “Have you experienced any hesitancy or straining, a weakened force of stream, dribbling, or incomplete emptying?” • “Do you ever leak water or urine when you don’t want to?” o “Do you use pads/tissue to catch urine in your underwear?” • “Do you need to get up at night to urinate?” o “What medications are you taking? What fluids do you drink in the evening?” Objective data: Preparation • Position male standing with underwear down and appropriate draping o Examiner should be sitting; alternatively, male may be supine for first part of examination and stand for hernia check o It is normal for a male to feel apprehensive about having his genitalia examined, especially by a female examiner o Younger adolescents usually have more anxiety than older adolescents o But any male may have difficulty dissociating a necessary, matter-of-fact step in physical examination from feeling this is an invasion of his privacy • Concerns are similar to those experienced by female during examination of genitalia: o Modesty, fear of pain, cold hands, negative judgment, or memory of previously uncomfortable examinations o Additionally, he may fear comparison to others, or fear having an erection during examination that would be misinterpreted by examiner o Apprehension becomes manifested in different behaviors:  Many act resigned or embarrassed and may avoid eye contact  Occasional man will laugh and make jokes to cover embarrassment; also man may refuse examination by female and may insist on male examiner • Take time to consider these feelings, as well as to explore your own o You may feel embarrassed and apprehensive, too o You may worry about your age, lack of clinical experience, causing pain, or even that your movements might “cause” an erection o Some examiners feel guilty when this occurs; you need to accept these feelings and work through them so that you can examine the male in a professional way  Discuss these concerns with an experienced examiner  Your demeanor is important; your unresolved discomfort magnifies any discomfort the man may have • Your demeanor should be confident and relaxed o Do not discuss genitourinary history or sexual practices while you are performing examination as it may be perceived as judgmental • Use a firm deliberate touch, not soft, stroking one o If erection does occur, do not stop the examination or leave the room; this only focuses more attention on the erection and increases embarrassment o Reassure the male that this is only a normal physiologic response to touch o Proceed with the rest of examination Objective Data: Equipment • Gloves: wear gloves during every male genitalia examination • Occasionally may require glass slide for urethral specimen • Materials for cytology • Flashlight Inspection & Palpation: Penis • Skin normally looks wrinkled, hairless, and without lesions; dorsal vein may be apparent • Glans looks smooth and without lesions; ask uncircumcised male to retract foreskin, or you retract it; it should move easily o Some cheesy smegma may have collected under foreskin; after inspection, slide foreskin back to original position • Urethral meatus positioned just about centrally • Compress glans anteroposteriorly between your thumb and forefinger; meatus edge should appear pink, smooth, and without discharge o If you note urethral discharge, collect smear for microscopic examination and culture o If no discharge shows but person gives history of it, ask him to milk shaft of penis; this should produce a drop of discharge o Palpate shaft of penis between your thumb and first two fingers o Normally, penis feels smooth, semifirm, and nontender Inspection & Palpation: Scrotum • Inspect scrotum as male holds penis out of the way; alternatively, you hold penis out of the way with back of your hand o Scrotal size varies with ambient room temperature; asymmetry is normal, with left scrotal half usually lower than right o Spread rugae out between your fingers; lift sac to inspect posterior surface. Normally, no scrotal lesions are present, except commonly found sebaceous cysts; these are yellowish, 1-cm nodules that are firm, nontender, and often multiple • Palpate gently each scrotal half between your thumb and first two fingers o Scrotal contents should slide easily; testes normally feel oval, firm and rubbery, smooth, and equal bilaterally, and are freely movable and tender to moderate pressure o Each epididymis normally feels discrete, softer than testis, smooth, and nontender • Palpate each spermatic cord between your thumb and forefinger, along its length from epididymis up to external inguinal ring o You should feel a smooth, nontender cord • Normally, no other scrotal contents are present; if you find a mass, note: o Is there any tenderness? o Is the mass distal or proximal to testis? o Can you place your fingers over it? o Does it reduce when person lies down? o Can you auscultate bowel sounds over it? • Transillumination o Perform this maneuver only if you note swelling or mass o Darken room; shine flashlight from behind scrotal contents o Normal scrotal contents do not transilluminate Inspection & Palpation: Hernia • Inspect inguinal region for bulge as person stands and strains down; normally none is present • Palpate inguinal canal o For right side, ask male to shift his weight onto left leg o Place your right index finger low on right scrotal half o Palpate up length of spermatic cord, invaginating scrotal skin as you go, to the external inguinal ring  It feels like a triangular slitlike opening, if it will admit your finger, gently insert it into canal and ask person to “bear down;” normally you feel no change  Repeat procedure on the left side • Palpate femoral area for a bulge o Normally you feel none Palpation of Inguinal Lymph Nodes • Palpate horizontal chain along groin inferior to inguinal ligament and vertical chain along upper inner thigh • Normal to palpate an isolated node on occasion; it then feels small, 1 cm, soft, discrete, and movable o Enlarged, hard, matted, fixed nodes are abnormal findings Testicular Self-Examination (TSE) • Encourage self-care by teaching every male from 13 to 14 years old through adulthood how to examine his own testicles o Overall incidence of testicular cancer is still rare, but testicular cancer most commonly occurs in young men age 15 to 35 • Early detection of cancer enhanced if male is familiar with his normal consistency • Points to include during health teaching are: o T – timing once a month o S – shower  warm water relaxes scrotal sac o E – examine check for and report changes immediately -Check testicles one at a time -Hold the testicle between your thumbs and fingers or both hands & roll it gently between your fingers -If you notice any of these symptoms… hard lumps, smooth or rounded bumps, changes in size, shape or consistency …don’t panic but see your GP straight away. TSE Teaching Points • Phrase your teaching something like this: o A good time to examine testicles is during shower or bath, when your hands are warm and soapy and scrotum is warm; cold hands retract scrotal contents o Procedure is simple; hold scrotum in palm of your hand and gently feel testicles using thumb and first two fingers o Testicle is egg-shaped and movable; it feels rubbery with a smooth surface o Abnormal lumps are very rare and usually not worrisome, but if you ever notice a firm, painless lump, a hard area, or an overall enlarged testicle, call your physician for further check Assessment of Urinary Function • Observe urine color • Note pH & specific gravity • Serum analysis of kidney function correlates with creatinine level which is relatively stable (end product of muscle metabolism) • BUN measures urea which can vary based on several factors (end product of protein metabolism) Developmental Competence: Infants & Children • Perform this procedure right after abdominal examination • In preschool-age to young school-age child, 3 to 8 years of age, leave underpants on until just before examination • In an older school-age child or adolescent, offer an extra drape, as with adult; reassure child and parents of normal findings • Inspect penis and scrotum o Penis size usually small in infants and in young boys until puberty o In obese boy, penis looks even smaller because of folds of skin covering base o In circumcised infant, glans looks smooth with meatus centered at tip o While child wears diapers, meatus may be ulcerated from ammonia irritation; more common in circumcised infants o If possible, observe newborn’s first voiding to assess strength and direction of stream o Inspect penis and scrotum  If uncircumcised, foreskin normally tight during first 3 months and should not be retracted because of risk of tearing membrane attaching foreskin to shaft • This leads to scarring and possibly to adhesions later in life • In infants older than 3 months of age, retract foreskin gently to check glans and meatus; it should return to its original position easily  Scrotum looks pink in white infants and dark brown in dark-skinned infants  Rugae well formed in full-term infant • Inspect penis and scrotum o Scrotum size varies with ambient temperature, but overall, infant’s scrotum looks large in relation to penis  No bulges, either constant or intermittent, are present • Palpate scrotum and testes o Cremasteric reflex is strong in infant, pulling testes up into inguinal canal and abdomen from exposure to cold, touch, exercise, or emotion; take care not to elicit reflex  Keep your hands warm and palpate from external inguinal ring down  Block inguinal canals with thumb and forefinger of your other hand to prevent testes from retracting o Inspect penis and scrotum  Normally, testes are descended and are equal in size bilaterally  Important to document that you have palpated testes • Once palpated, they are considered descended, even if they have retracted momentarily at next visit  If scrotal half feels empty, search for testes along inguinal canal and try to milk them down  Ask toddler or child to squat with knees flexed up; this pressure may force the testes down; or have child sit cross-legged to relax reflex o Inspect penis and scrotum  Migratory testes, physiologic cryptorchidism, is common because of strength of cremasteric reflex and small mass of prepubertal testes  Note that affected side has normally developed scrotum; these testes descend at puberty and are normal • With true cryptorchidism, the scrotum is atrophic  Palpate epididymis and spermatic cord as described in adult section o Inspect penis and scrotum  Common scrotal finding in boy under 2 is a hydrocele, or fluid in scrotum; appears as a large scrotum and transilluminates as faint pink glow  Usually disappears spontaneously o Inspect inguinal area for a bulge  If parent gives a positive history of one, try to elicit it by increasing intraabdominal pressure  Ask boy to hold his breath and strain down or have him blow up a balloon  If a hernia is suspected, palpate inguinal area  Use your little finger to reach external inguinal ring Developmental Competence: Adolescent • Adolescents show wide variation in normal development of genitals • Using SMR charts, note: (SMR = sexual maturity charts) o Enlargement of testes and scrotum o Pubic hair growth o Darkening of scrotal color o Roughening of scrotal skin o Increase in penis length and width o Axillary hair growth • Be familiar with normal sequence of growth Developmental Competence: Aging Adult • In older male, you may note thinner, graying pubic hair and decreased size of penis • Size of testes may be decreased and may feel less firm • Scrotal sac pendulous with less rugae • Scrotal skin may become excoriated if man continually sits on it Prostate gland • Prostate-specific antigen (PSA) is made by normal prostate gland • When prostate cancer develops, PSA levels increase • Other causes for increased levels: o Benign prostatic hypertrophy (BPH) – a noncancerous enlargement o Age o Prostatitis -look at the enlarged prostate and understand how BPH causes urinary difficulties due to its compression of the urethra Prostate Cancer Testing Prostate cancer typically detected by: • testing blood for prostate-specific antigen (PSA) and/or • digital rectal examination (DRE) • The DRE involves a gloved, lubricated finger being inserted into rectum and palpating for abnormalities Promoting a Healthy Lifestyle: Prostate Cancer • Discussion of prostate health and examination of prostate gland is a unique aspect of male health assessment o Gradual enlargement of prostate gland considered to be normal part of aging o (BPH) does not raise an individual’s risk for prostate cancer, yet symptoms for BPH and prostate cancer can be very similar o Men at higher risk for developing prostate cancer, such as African Americans and/or men who have a first-degree relative (father, brother, or son) diagnosed with prostate cancer at an early age (younger than 65) should be offered testing earlier Abnormal Findings: Male Genital Lesions • Genital herpes, HSV-2 infection • Syphilitic chancre • Genital warts, human papillomavirus (HPV) • Carcinoma o Begins as red, raised warty growth or as an ulcer, with watery discharge o As it grows, may necrose and slough o Usually painless; almost always on glans or inner lip of foreskin and following chronic inflammation; enlarged lymph nodes are common • Urethritis, urethral discharge, and dysuria o Infection of urethra, painful burning urination  Meatus edges are reddened, everted, and swollen; purulent urethral discharge is present; urine cloudy with discharge and mucous shreds o Cause determined by culture  Gonococcal urethritis has thick, profuse, yellow or gray-brown discharge  Nonspecific urethritis (NSU) may have similar discharge but often has scanty, mucoid discharge  About 50% are caused by chlamydia infection • Important to differentiate as antibiotic treatment differs Abnormal Findings: Urinary Problems • Renal calculi -Acute urinary retention -Urethral stricture Abnormal Findings: Abnormalities of the Penis • Phimosis -Paraphimosis -Hypospadias -Epispadias -Peyronie’s disease -Priapism Abnormal Findings: Abnormalities in the Scrotum • Absent testis, cryptorchidism • Small testis • Testicular torsion • Epididymitis • Spermatic cord varicocele • Spermatocele • Early testicular tumor • Diffuse tumor • Hydrocele • Scrotal hernia • Orchitis • Scrotal edema Abnormal Findings: Inguinal and Femoral Hernias • Indirect inguinal hernia o Sac herniates through internal inguinal ring; can remain in canal or pass into scrotum o Pain with straining; soft swelling that increases with increased intraabdominal pressure; may decrease when lying down o Most common; 60% of all hernias; more common in infants less than 1 year old and in males 16 to 20 years old o Congenital or acquired • Direct inguinal hernia o Directly behind and through external inguinal ring, above inguinal ligament; rarely enters scrotum o Usually painless; round swelling close to pubis in area of internal inguinal ring; easily reduced when supine o Less common, occurs most often in men over 40 age, rare in women o Acquired weakness; brought on by heavy lifting, muscle atrophy, obesity, chronic cough, or ascites • Femoral hernia o Through femoral ring and canal, below inguinal ligament, more often on right side o Pain may be severe, may become strangulated o Least common, 4% of all hernias; but more common in women o Acquired; due to increased abdominal pressure, muscle weakness, or frequent stooping Summary Checklist: Male Genitourinary System • Inspect & palpate the penis • Inspect & palpate the scrotum • If a mass exists, try to transilluminate it • Palpate for an inguinal hernia • Palpate the inguinal lymph nodes Prostate problems are NO “fun”.. Frequency, Urgency, Nocturia -Hematuria -Increased infection -Decreased urinary stream -Increased residual urine Chapter 25: Anus, Rectum, and Prostate Developmental Competence • Infants o First stool passed by newborn is dark green meconium; occurs within 24 to 48 hours of birth, indicates anal patency  From then on, infant usually has stool after each feeding o Gastrocolic reflex: wave of peristalsis in response to eating  Infant passes stools by reflex • Children and adults o At male puberty, prostate gland undergoes a very rapid increase to more than twice its prepubertal size; during young adulthood size remains fairly constant o Prostate gland commonly starts to enlarge during middle adult years; increases with age  Thought that hypertrophy caused by hormonal imbalance leading to proliferation of benign adenomas, which gradually impede urine output because they obstruct urethra Culture & Genetics: Prostate Cancer • More common in North America and northwestern Europe; less common in Central and South Americas, Africa, and Asia o Incidence higher for African American men than other racial groups, and more likely to be diagnosed at advanced stage o Mortality rates are two times higher for black men o Diets heavy in red meat or high-fat dairy products may be factor o Some evidence suggests that prostate cancer may increase with obesity Culture & Genetics: Prostate & Colorectal Cancer • Prostate cancer o Screening recommendations vary for racial groups  Men at high risk, black men, and men with first-degree relative with disease should begin screening at age 45 • Colorectal cancer also has racial variation o Incidence in black women and men is almost 20% higher than in white women and men o Mortality is 50% higher in black men and women than in white men and women Subjective Data Questions • Usual bowel routine • Change in bowel habits • Rectal bleeding, blood in stool • Medications: laxatives, stool softeners, iron • Rectal conditions: pruritus (itching), hemorrhoids, fissure, fistula • Family history • Self-care behaviors: diet of high-fiber foods, most recent examinations -(Iron darkens stool to make it look almost black). Usual Bowel Routine Questions • Do your bowels move regularly? How often? What is the usual color? Are they hard or soft? Any straining at stool; incomplete evacuation; or urge to go but nothing comes? Any pain with bowel movement? • Has there been any change in bowel habits? Any diarrhea? When did this start? Is it associated with nausea and vomiting, abdominal pain, or something you ate recently? o Have you eaten at a restaurant recently? Did anyone else in your group or family have the same symptoms? Rectal Bleeding Questions • Is there blood in your stool? Have you ever had black or bloody stools? When did you first notice blood in the stools? Is color bright red or dark red-black? How much blood was there? Was it spotting on toilet paper or outright passing of blood with stool? Do bloody stools have a particular smell? o Have you ever had clay-colored stools? o Have you ever had mucus or pus in stool? o Have you ever had frothy stool? o Do you need to pass gas frequently? -Dark stool: possibly upper GI bleed; blood has digested so appears black. Could also be medications (iron, etc). -Bloody stool: possibly lower GI bleed; fresh blood is also called “BRBPR” – “bright red blood per rectum.” Could also be a benign bleeding hemorrhoid, fissure, etc. Medication Questions • What medications do you take, including prescriptions and over-the-counter medications? Do you take laxatives or stool softeners? Which ones? How often? Do you take iron pills? Do you ever use enemas to move your bowels? How often? Rectal Condition Questions • Do you have any problems in rectal area, such as itching, pain or burning, or hemorrhoids? How do you treat these? Do you use any hemorrhoid preparations? Have you ever had a fissure or fistula? How was this treated? • Have you ever had a problem controlling your bowels? -anal fissure: a crack or tear in the anal canal FMH & Self-Care Behaviors • Family medical history (FMH) o Do you have a family history of polyps or cancer in colon or rectum, inflammatory bowel disease, or prostate cancer? • Self-care behaviors o Usual amount of high-fiber foods in your daily diet, such as cereals, apples or other fruits, vegetables, and whole-grain breads? Glasses of water each day? o What were the dates of last digital rectal examination, stool blood test, and colonoscopy? Men: When was your most recent PSA blood test? Additional History: Infants & Children • Have you ever noticed any irritation in your child’s anal area, such as redness, raised skin, or frequent itching? • How are your child’s bowel movements? How frequent are they? Are there any problems or pain or straining with bowel movement? Objective Data: Equipment • Penlight -Lubricating jelly -Glove -Guaiac test container -Occult blood tester Objective Data: Preparation • Perform rectal examination on all adults and particularly for those in middle and late years • Help person assume one of following positions: o Examine male in left lateral decubitus or standing position; instruct standing male to point his toes together; this relaxes regional muscles, making it easier to spread buttocks o Place female in lithotomy position if examining genitalia as well  Use left lateral decubitus position for rectal area alone Inspect Perianal Area • Spread buttocks wide apart, and inspect perianal region o Anus normally looks moist and hairless, with coarse folded skin more pigmented than perianal skin o Anal opening tightly closed; no lesions present • Inspect sacrococcygeal area; normally appears smooth and even • Instruct person to hold breath and bear down by performing a Valsalva maneuver o No break in skin integrity or protrusion through anal opening should be present • Describe any abnormality in clock-face terms, with 12:00 as the anterior point toward symphysis pubis and 6:00 toward coccyx Palpate Anus & Rectum • Instruct person that palpation is not painful but may feel like needing to move bowels • Drop lubricating jelly onto gloved index finger; place pad of index finger gently against anal verge o You will feel sphincter tighten, then relax; as it relaxes, flex tip of your finger and slowly insert it into anal canal toward umbilicus o Never approach anus at right angles with your index finger extended; such jabbing motion does not promote sphincter relaxation and is painful • Rotate examination finger to palpate entire muscular ring o Canal should feel smooth and even; note intersphincteric groove circling canal wall o To assess tone, ask person to tighten muscle; sphincter should tighten evenly around with no pain to person o Use a bi-digital palpation with your thumb against perianal tissue; press examining finger toward it; this maneuver highlights swelling or tenderness and helps assess bulbourethral glands • Above anal canal, rectum turns posteriorly, following curve of coccyx and sacrum o Insert examination finger farther and explore all around rectal wall; normally feels smooth with no nodularity o Promptly report any mass you discover for further examination Prostate Gland • On anterior wall in male, note elastic, bulging prostate gland o Palpate entire prostate in a systematic manner; note that only superior and part of lateral surfaces is accessible to examination o Press into gland at each location; when nodule occurs, it will not project into rectal lumen o Surface should feel smooth and muscular; search for any distinct nodule or diffuse firmness Prostate Gland Characteristics • Note the following characteristics: o Size: 2.5 cm long by 4 cm wide; should not protrude more than 1 cm into rectum o Shape: heart shape, with palpable central groove o Surface: smooth o Consistency: elastic, rubbery o Mobility: slightly movable o Sensitivity: nontender to palpation o Urge incontinence is among significant signs & symptoms often reported; it occurs when patients have a strong, sudden need to urinate. The bladder then squeezes, or spasms, and the patient loses urine Examination of Stool • Inspect any feces remaining on glove o Normally color is brown and consistency is soft o Test any stool on glove for occult blood using specimen container that your agency directs o Negative response is normal o If stool Hematest is positive, it indicates occult blood o Note that false-positive finding may occur if person has ingested red meat within 3 days of test o Enhance self-care by providing the average risk patient an at-home collection kit to screen for asymptomatic colorectal cancer and precancerous lesions Developmental Competence: Infants & Children • Newborn o Hold feet with one hand and flex knees up onto abdomen  Note presence of the anus  Confirm a patent rectum and anus by noting first meconium stool passed within 24 to 48 hours of birth o Check anal reflex to assess sphincter tone; gently stroke anal area and note quick contraction of sphincter o For each infant and child, note that buttocks are firm and rounded with no masses or lesions o Recall that Mongolian spot is a common variation of hyperpigmentation in African American, American Indian, Mediterranean, and Asian newborns • Perianal skin is free of lesions o Diaper rash is common in children younger than 1 year of age and is exhibited as generalized reddened area with papules or vesicles o Omit palpation unless history or symptoms warrant o When internal palpation is needed, position infant or child on back with legs flexed, and gently insert a gloved, well-lubricated finger into rectum  Your fifth finger usually is long enough, and its smaller size is more comfortable for infant or child  On withdrawing finger, scant bleeding or protruding rectal mucosa may occur Developmental Competence: Aging Adult • As an aging person performs Valsalva maneuver, you may note relaxation of perianal musculature and decreased sphincter control • Otherwise, full examination proceeds as that described for younger adult Colorectal Cancer (CRC) Screening • Currently second leading cancer killer in the U.S. o However, it should not be; if everyone age 50 or older had regular screening tests, 60% deaths from this cancer could be avoided o Screening identifies precancerous polyps so they can be removed before they become cancer o Screening can also find CRC early, when treatment can be effective o CRC is most often found in people age 50 and older o Older you get the higher your risk; both men and women get CRC CRC Screening Tests • CRC screening tests include o Fecal occult blood test (FOBT) o Flexible sigmoidoscopy o Combination of FOBT and flexible sigmoidoscopy o Colonoscopy o Double-contrast barium enema Abnormal Findings: Anus & Perianal Region • Pilonidal cyst or sinus -Anorectal fistula -Fissure -Hemorrhoids -Rectal prolapse -Pruritus ani Abnormal Findings: Rectum • Abscess -Rectal polyp -Fecal impaction -Carcinoma Abnormal Findings: Prostate Gland • Benign prostatic hypertrophy (BPH) -Prostatitis -Carcinoma Summary Checklist: Anus, Rectum, & Prostate • Inspect anus and perineal area • Inspect during Valsalva maneuver • Palpate anal canal and rectum on all adults • Test stool for occult blood Prostate Cancer -Weak stream -Frequency -Painful urination -Blood in the urine -Blood in the semen -Discomfort in pelvic area -Erectile dysfunction -Weakness -Fatigue Chapter 26: Female Genitourinary System Developmental Competence: Infants & Adolescents • At birth, external genitalia are engorged because of presence of maternal estrogen • At puberty, estrogens stimulate growth of cells in the reproductive tract and development of secondary sex characteristics • First signs of puberty: breast and pubic hair development, beginning between ages 8 and 10 • Menarche (first menstrual cycle) occurs during latter half of this sequence, just after peak of growth velocity Developmental Competence: Infants & Children • Preparation o Infant: place on examination table o Toddler/preschooler: place on parent’s lap  Frog-leg position: hips flexed, soles of feet together and up to bottom  Preschool child may want to separate her own labia  No drapes: young girl wants to see what you are doing o School-age child: place on examination table, frog-leg position, no drapes o During childhood routine screening limited to inspection of external genitalia to determine that (1) structures are intact, (2) vagina is present, and (3) hymen is patent Developmental Competence: Adolescent • Girl has special needs during genitalia examination o Examine her alone, without mother present o Assure her of privacy and confidentiality o Allow plenty of time for health education and discussion of pubertal progress • Assess her growth velocity and menstrual history, and use SMR charts to teach breast and pubic hair development – (SMR chart: sexual maturity rating chart (Tanner scale)) o Assure her that increased vaginal fluid (physiologic leukorrhea) is normal because of estrogen effect • Perform pelvic examination: o when contraception is desired o when girl’s sexual activity includes intercourse o at age 18 in virgins • Start periodic Pap smears when intercourse begins o Although techniques of examination are listed in adult section, you will need to provide additional time and psychological support for adolescent having her first pelvic examination Developmental Competence: Pregnant Woman • Shortly after first missed menstrual period, genitalia show signs of the growing fetus o Cervix softens (Goodell’s sign) at 4 to 6 weeks of gestation, and vaginal mucosa and cervix look cyanotic (Chadwick’s sign) at 8 to 12 weeks of gestation o Changes occur because of increased vascularity and edema of cervix and hypertrophy and hyperplasia of cervical glands o Isthmus of uterus softens (Hegar’s sign) at 6 to 8 weeks of gestation • Clot of thick, tenacious mucus forms in spaces of cervical canal (the mucus plug), which protects fetus from infection o Plug dislodges when labor begins at end of term, producing a sign of labor called “bloody show” o Cervical and vaginal secretions increase o Increased acidity occurs by action of Lactobacillus acidophilus, which changes glycogen into lactic acid o Acidic pH keeps pathogenic bacteria from multiplying in vagina, but increases in glycogen increase risk of candidiasis (yeast infection) during pregnancy Developmental Competence: Aging Woman • Female’s hormonal level decreases rapidly in contrast with slow decline in aging male o Menopause: cessation of menses  Usually this occurs around 48 to 51, although a wide variation of ages from 35 to 60 years exists  -Declining estrogen levels produce some physiologic changes in the female sexual response cycle  -Reduced amount of vaginal secretion and lubrication during excitement  -Shorter duration of orgasm; and rapid resolution  -However, these changes do not affect sexual pleasure and function  -Sexual desire and need for full sexual expression continue • To avoid painful examination, take care to lubricate instruments and examining hand adequately o Use Pedersen speculum, rather than Graves, because its narrower, flatter blades are more comfortable in women with vaginal stenosis or dryness o Menopause and resulting decrease in estrogen production cause numerous physical changes  Pubic hair gradually decreases, becoming thin and sparse in later years o Skin is thinner and fat deposits decrease, leaving mons pubis smaller and labia flatter o Clitoris size also decreases after age 60 years • Older women may have special needs and will appreciate following plans of care o For those with arthritis, taking a mild analgesic or anti-inflammatory before appointment may ease joint pain in positioning o Schedule appointment times when joint pain or stiffness is at its least o Allow extra time for positioning and “unpositioning” after examination; be careful to maintain dignity and privacy Culture & Genetics • Differences in how ethnic groups perceive the value of Pap Smear testing o Even though overall rates of cervical cancer have decreased in the U.S., the overall incidence of cervical cancer is increased in African American women o Pap test is also better at screening subtype squamous better than subtype adeno • Female circumcision, known as infibulation or female genital mutilation o Invasive surgical procedure (partial or total removal of the clitoris) usually performed on girls before puberty –- social custom o Practiced within Aboriginal, Christian, and Muslim families who have emigrated to U.S. from western and southern Asia, Middle East, and large areas of Africa Subjective Data • Menstrual history -Obstetric history -Menopause -Self-care behaviors -Acute pelvic pain --Urinary symptoms -Vaginal discharge -Past history -Sexual activity -Contraceptive use -Sexually transmitted infection (STI) contact -STI risk reduction Menstrual History Questions • Tell me about your menstrual periods o Age at first period? Date of your last menstrual period? o How often are your periods? o How many days does your period last? o Is your usual amount of flow light, medium, or heavy? How many pads or tampons do you use each day or hour? o Do you have any clotting? o Do you have any pain or cramps before or during your period? How do you treat them? Do they interfere with daily activities? Are there any other associated symptoms, such as bloating, breast tenderness, or moodiness? o Do you have any spotting between periods? Obstetric History Questions • Have you ever been pregnant? • How many times? • How many infants have you given birth to? • Have you had any miscarriages or abortions? • For each pregnancy, describe the duration, any complications, labor and delivery, and infant’s gender, birth weight, and condition • Do you think you may be pregnant now? What symptoms have you noticed? Menopause History Questions • Have your periods slowed down or stopped? • Do you have any associated symptoms of menopause, such as hot flashes, night sweats, numbness and tingling, headache, palpitations, drenching sweats, mood swings, vaginal dryness, or itching? Any treatment? • If you are using hormone replacement, how much? How is it working? Do you have any side effects? • How do you feel about going through menopause? Self-Care Behaviors Questions • How often do you have a gynecologic checkup? • When was your last Pap smear? What were the results? • Has your mother ever mentioned taking hormones while pregnant with you? Urinary Symptom History Questions • Any problems with urinating? Frequently and small amounts? Cannot wait to urinate? • Any burning or pain on urinating? • Do you awaken during night to urinate? • Is there blood in your urine? • Is your urine dark, cloudy, or foul smelling? • Do you have any difficulty controlling urine or wetting yourself? • Do you urinate when sneezing, laughing, coughing, or bearing down? Vaginal Discharge History Questions • Any unusual vaginal discharge? Increased amount? Is it white, yellow-green, gray, curdlike, or foul smelling? • When did this begin? • Is the discharge associated with vaginal itching, rash, or pain with intercourse? • Are you taking any medications? • Do you have a family history of diabetes? • What part of your menstrual cycle are you in now? • Do you use a vaginal douche? How often? • Do you use feminine hygiene spray? • Do you wear nonventilating underpants or pantyhose? • Have you treated the discharge with anything? What was the result? Past History Questions • Any other problems in genital area? Do you have any sores or lesions, now or in past? How were these treated? • Do you have any abdominal pain? • Have you had any surgery on uterus, ovaries, or vagina? Sexual Activity History Questions • Often women have a question about their sexual relationship and how it affects their health. Do you? • Are you in a relationship involving sex now? • Are aspects of sex satisfactory to you and your partner? • Are you satisfied with the way you and partner communicate about sex? • Are you satisfied with your ability to respond sexually? • Do you have more than one sexual partner? • What is your sexual preference: do you prefer a relationship with a man, with a woman, or with both? Contraceptive Use • Currently planning a pregnancy or avoiding pregnancy? • Do you and your partner use a contraceptive? Which method? Is this satisfactory? Do you have any questions about this or other methods? • Which methods have you used in the past? • Have you and your partner discussed having children? • Have you ever had any problems becoming pregnant? STI History Questions • Sexually transmitted infection (STI) contact o Any sexual contact with partner having an STI, such as gonorrhea, herpes, HIV, AIDS, chlamydial infection, venereal warts, or syphilis? When? How was this treated? Were there any complications? • STI risk reduction o Do you use any precautions to reduce risk of STIs? Do you use condoms at each episode of sexual intercourse? Additional Screening: Children & Adolescents • Has anyone ever touched your breast or genitals and you did not want them to? o A girl, a boy, an adult, even a relative? o You should remember it is not your fault and you should tell another adult about it Objective Data: