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179 Cards in this Set
- Front
- Back
Anatomy |
Penis Scrotum Testes Prostate |
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Penis |
Shaft and glans |
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External anatomy of Penis |
Darter than other surrounding skin, hairless Visible dorsal vein Urethra at tip of glans Glans: may be covered by foreskin |
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Circumcised |
Surgical removal of foreskin Becoming less popular No clear medical guidelines for or against Common in US among caucasians and Jewish Less common in African Americans and Hispanics Slight risk of surgical complications: infection, ischemia, necrosis May have decreased risk of HIV |
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Uncircumcised |
Increased risk of some STIs: syphilis, genital herpes, chlamydia Increased risk of penile cancer Increases risk of cervical cancer in female partners Smegma |
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Penile cancer |
Rare r/t poor hygiene |
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Smegma |
White cheesy material on glans in uncircumcised male Formed from sebaceous material (from glans) Formed from desquamation of epithelial cells (from foreskin) |
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Proper hygiene of uncircumcised penis |
Retraction of foreskin so smegma doesn't accumulate |
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Internal anatomy of Penis |
2 Types of tissue: - Corpus cavernosa - Corpus spongiosum Bulbourethral gland |
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Corpus cavernosa |
Dorsum/Top Sides |
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Corpus spongiosum |
Ventral/Underneath Contains urethra |
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Bulbourethral gland |
Cowper's gland Produces pre-ejaculate fluid Parallels Bartholin's gland in females Lubricates the urethra for sperm to pass through and neutralizes acidic urine |
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Scrotum |
Darker than other skin, scant hair Rugae with deeply pigmented skin and large sebaceous follicles Scrotal sac divided by septum Contains testis |
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Rugae |
Skin folds on scrotum |
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Testes |
4x3x2 cm Left usually lower than righ Produces sperm and testosterone Epididymis Cremaster muscle |
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Epididymis |
Posterior side of testes Collects and provides transit for sperm |
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Sperm travel |
Through vas deferens Spermatic cord Seminal vesicles Ejaculatory duct Into urethra |
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Seminal vesicles |
Secretes a fluid that nourishes sperm |
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Spermatic cord |
Consists of arteries, veins, lymphatics, nerves |
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Cremaster muscle |
Raises and lowers testes Regulates temp, maintain sperm viability Cold: pulls testes in to body Hot: lowers testes |
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Prostate |
2.5 x 4 cm Surrounds the urethra at the bladder neck Secretes ejaculatory fluid to help sperm mobility 2 lobes, separated by a median sulcus Palpate through anteriorectal wall |
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Prenatal Development |
Testes located in abd and descend down inguinal canal to scrotum prior to birth |
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External inguinal ring |
Later in life, enlarges the intestines may prolapse into scrotal sac causing an inguinal hernia |
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Puberty |
Begins between ages of 9 and 13 Usually takes 3 yrs Tanner's Stages |
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Tanner's Stages |
First, enlargement of the testes: testosterone produced, leads to the other changes Pubic hair growth Enlargement of the penis Prostate doubles in size |
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Adult development |
Prostate enlarges throughout life Testosterone production gradually declines after 60 yrs |
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Benign prostatic hypertrophy |
BPH Prostatism May gradually impede urine flow Bladder outlet obstruction |
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Testosterone reduction r/t to age |
Leads to lower sperm count: decreased fertility Erectile dysfunction: decreased firmness of erections |
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Urinary Symptoms |
Related to BPH, STI, UTI |
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BPH urinary symptoms |
Frequency Urgency Hesitancy Decreased force of stream (FOS) Post void dribbling Post void fullness/residual Nocturia |
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STI urinary symptoms |
Frequency Dysuria Urethral discharge
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UTI urinary symptoms |
Frequency Urgency Dysuria Pyuria |
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Frequency |
Voiding every 15 min r/t bladder irritation (UTI) r/t Urethritis (STI/chlamydia) r/t Tumor (BPH) |
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Urgency |
Must go "now" r/t UTI, BPH |
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Hesitancy |
Difficulty starting urine flow r/t BPH |
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Decreased force of stream |
decreased FOS r/t BPH |
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Post void dribbling |
r/t BPH |
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Post void fullness/residual |
r/t BPH |
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Nocturia |
Awakening in the night to urinate r/t incomplete bladder emptying (BPH) r/t mobilization of fluid and increased renal blood flow in recumbant position (heart failure) |
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Dysuria |
Pain or burning with urination r/t UTI, STI |
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Pyuria |
Pus in urine r/t infection |
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Urethral discharge |
Discharge at urethral meatus r/o STI |
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Purulent urethral discharge |
Gonorrhea |
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Clear urethral discharge |
Chlamydia |
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Polyuria |
Frequent, massive amounts of urine Seen with DM High glucose levels cause osmotic diuresis |
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Enuresis |
Bed wetting Nighttime incontinence after age 5-6 may be psychologic or structural problem with urinary tract |
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LUTS |
Lower Urinary tract symptoms BPH symptoms |
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LUTS/BPH Symptoms |
Frequency Urgency Hesitancy Decreased FOS Post void dribbling Post void residual/fullness Nocturia |
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Incontinence |
Involuntary loss of urine |
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Overflow incontinence |
r/t incomplete bladder emptying, overdistended bladder Prostatism |
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Stress incontinence |
Associated with rapid movement of the diaphragm Coughing, sneezing, laughing More common in women r/t shorter urethra |
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Urgency incontinence |
Seen with infection, prostatism, neurologic disorders No immediate access to toileting |
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Hematuria |
Blood in urine Always a significant finding that needs further evaluation |
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Macrohematuria |
Visible Red/Pink urine |
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Microhematuria |
Seen with microscope |
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Hematuria originates |
Kidney Ureters Bladder Prostate |
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Hematuria causes |
Hemorrhagic: clotting disorders Infection: UTI Tumor, trauma, TB of kidney Stone: nephrolithiasis |
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TB of kidneys |
Painless bleed in the urine |
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Testicular masses |
Benign or malignant Heaviness Undescended testicle May affect fertility |
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Sexual history |
Number of partners, time with current partner, mutually monogamous: indicates sexual risk Reproductive function, contraception Use of barrier protection hx STIs, treatment Difficulties, concerns, problems, satisfaction, performance, sexual preference Erectile dysfunction: ask about meds Family hx: prostate cancer in 1st degree relative, age of diagnosis |
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Meds that cause ED |
Antihypertensives |
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Physical examination: genitilia |
Best if pt standing Examiner sitting |
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Mons pubis/pubic hair |
Distribution: diamond pattern Infestations: lice, nits (lice eggs) |
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Lesions |
Grouped vesicles Papules Chancre |
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Grouped vesicles |
Herpes |
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Papules |
Condyloma accuminata External genital warts (EGW) STI |
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Chancre |
Painless sore from syphilis |
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Penis: inspection |
All surfaces for lesions |
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Inspect glans |
Retract prepuce |
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Prepuce |
foreskin |
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Phimosis |
Foreskin can't be retracted Associated with poor hygiene Accumulation of smegma |
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Balanitis |
Occurs in uncircumcised Inflammation of glans: bacterial or fungal More common with DM Under foreskin, seen with phimosis |
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Paraphimosis |
Foreskin permanently retracted backward r/t penile edema Turnicate-like affect |
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Priapism |
Prolonged painful erection Serious if lasting > 4hrs Occurs with leukemia, hemoglobinapathies, meds May cause sterility |
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Hemoglobinapathies |
Sickle cell trait |
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Meds that cause priapism |
Viagra, Cialis, Levitra, Trazadone |
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Peyronie's disease |
Corpus cavernosis develops scar tissue Etiology unknown Thought to be genetic Usually occurs after 45 yrs Penis curves when erect Usually doesn't affect sex life or fertility |
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Hypospadias |
Urethra ventral/underneath Most common |
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Epispadias |
Urethra dorsal/top Rare |
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Discharge at the Urethral Meatus |
Milk urethra by compressing the base of penis with thumb and index finger toward the glans |
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Urethritis |
Usually related to STI Inflammation of urethra |
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GU |
Gonococcal Urethritis |
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NGU |
Non gonococcal urethritis Chlamydia |
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Inspect/Palpate scrotum |
Scrotal lumps Scrotal Edema Hydrocele |
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Scrotal lumps |
Common R/t sebaceous cysts Important to differentiate from testicular lumps |
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Scrotal edema |
CHF Renal failure Differentiate from masses or lumps |
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Hydrocele |
Serous fluid around testicle Often r/t trauma (bike seat) Resolves spontaneously Transilumination: fluid glows red as light reflects off fluid |
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Cryptorchidism |
Undescended testicle Decreased spermatogenesis Decreased fertility |
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Orchitis |
Acute inflammation of testis Seen with mumps if not immunized |
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Testicular masses |
Testicular cancer Rare Ages 17-35 |
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Epididymitis |
Acute infection of epididymis Painful lump in epididymis Pain improves when lifting scrotum "It hurts without underwear" r/t prostatitis, STI, urethral instrumentation < 35 yrs, likely r/t GC or Chlamydia > 35 yrs, likely r/t enterobacter or pseudomonas |
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Spermatocele |
Retention cyst Collection of sperm in epididymis Most common after vasectomy |
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Vasectomy |
Male sterilization Vas deferens ligated Sperm cannot move forward |
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Testicular torsion |
Compromised arterial flow Ischemic pain Sudden twisting of spermatic cord, more common on left Rare after 20 yrs May occur spontaneously (during sleep) or after trauma Surgical emergency r/t compromised blood supply |
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Varicocele |
Dilated veins of spermatic cord More common on left side May be visible when pt stands Feels like a bag of worms May cause infertility r/t increased venous pressure and testicular temp Symptoms: dull ache along spermatic cord, scrotal pain or heaviness |
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Lymph nodes |
Often able to palpate normally - 1 to 2 cm, mobile Penis drains into inguinal nodes (palpable) - LAD with penile lesion Testes drain into Abd nodes (not palpable) and left supraclavicular nodes - distant metastatic site |
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Hernia |
Prolapse of organs into inguinal canal |
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Examine for hernia |
Pt standing, gravity effect Finger up through scrotum into inguinal canal - 2 inches long Ask pt to cough: soft tissue of intestines if hernia is present |
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Indirect hernia |
Most common Herniation into inguinal canal More common in children and young males |
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Direct hernia |
Second most common Herniation through external inguinal ring - Bulge seen over inguinal canal More common in men after 40 yrs |
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Femoral hernia |
Least common Herniation through femoral ring Bulge seen in groin over femoral artery Higher incidence in women |
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Incarcerated hernia |
Non-reducible May lead to compromised blood supply Surgical emergency |
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Reducible |
Able to push tissue |
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Anus anatomy |
Anus Rectum Sigmoid colon |
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Anus |
Terminal end of the GI tract 2.5 - 4 cm long Distal end opens to perianal area Proximal end merges with rectal mucosa at the anorectal junction |
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Sphincters of Anus |
Internal sphincter External sphincter |
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Internal sphincter |
Involuntary control When rectum fills with stool, internal sphincter relaxes and results in the urge to defecate |
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External Sphincter |
voluntary control of defecation |
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Anal columns |
Vertical folds of mucosa containing arteries and veins |
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Hemorrhoids |
Varicose anal veins r/t chronic increased venous pressure Constipation/straining with BM |
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Rectum |
Distal portion of the GI tract 12 cm long |
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Sigmoid colon |
S Shaped 40 cm long |
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Flexible sigmoidoscope |
Visualizes up to 60 cm Misses proximal lesions Anus 4 cm + rectum 12 cm + sigmoid 40 cm = 56 cm Does not require conscious sedation, quick procedure |
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Colonoscopy |
Scopes the entire colon Gold standard Requires conscious sedation |
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Newborns/infants |
First meconium: 24-48 hrs s/p birth
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Meconium |
Dark green, sticky stool Substances swallowed in utero, amniotic fluid |
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Gastro-colic reflex |
Newborn/infants Causing increased peristalsis, BM after each feeding |
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Imperforate anus |
No outlet for stools |
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Toddlers |
No voluntary control of external sphincter until mylinization of nerves 1.5 - 2 yrs old |
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Older Adults |
Fecal incontinence Constipation |
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Fecal incontinence: older adults |
May occur with loss of internal sphincter tone |
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Constipation: older adults |
Occurs with degeneration of afferent rectal nerves Poor internal sphincter relaxation in response to stool in rectum |
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Bowel habits |
There is no normal, assess for changes Controlled by many factors: colon size, diet, exercise, response to stress, medication Number, frequency, consistency, color of BMs, presence of blood, pungent odor |
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Constipation |
Fluids, fiber, exercise |
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Diarrhea |
Infection: fever, chills Foreign travel: infection, parasites Meds Timing |
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Psychosomatic diarrhea |
No nocturnal stools |
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Physiologic diarrhea |
Nocturnal stools present |
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Melena |
Dark, tarry stools Foul odor Upper GI bleed Gastric/duodenal ulcer or cancer |
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Iron, bismuth stools |
Black stools r/t meds Iron, peptobismal Not tar-like |
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BRBPR |
Bright red blood per rectum Drips of blood in toilet or on tissue Hemorrhoids, polyps, tumor |
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Hematochezia |
Maroon stools Lower GI bleed Upper GI bleed with rapid motility |
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Clay colored stools |
Absence of bile pigment Bile gives stool brown color Biliary obstruction, liver disease or cancer, gallstones |
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Rectal pain |
External hemorrhoids Internal hemorrhoids Fissures Burning/itching |
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External hemorrhoids |
Most common cause of painful BMs Dilated rectal veins around rectal openings |
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Internal hemorrhoids |
Not painful unless prolapsed, infected, or thrombosed May result in significant bleeding |
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Thombosed hemorrhoids |
Incised to evacuate clot Relieve symptoms |
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Fissures |
Mucosal tear r/t passage of large, hard stool Results primarily from constipation and straining with BM May require corrective surgery Results in painful BMs |
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Pruritis ani |
Burning and itching of the rectum Common, etiology may never be found r/o fungal infection, external hemorrhoids, parasites |
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Pinworm |
Parasite Scotch tape over anus at bedtime to diagnose |
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Bowel meds |
Laxatives Constipating medicines |
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Bulk laxative |
Add fiber Psyllium |
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Osmotic laxative |
MOM Magnesium citrate - very potent, bowel prep Golytely - very potent, bowel prep Miralax Pull fluid into GI tract |
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Chemical stimulant |
Ex-lax Senokot Habit forming |
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Constipating medication |
Especially problematic for elderly Antidepressants Antihistamines: benadryl Calcium channel blocker: verapamil Iron |
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ROS |
n/v, cramping, pain, distention, flatus, unintentional weight loss Mucus Stool character Medical history |
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Pencil-like stools |
Spasm, stenosis/scarring, mass, decreased fiber |
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Mucus in GI tract |
Intestinal inflammation |
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Steatorrhea |
Excessive fat in stool Pancreatic problem, malabsorption Foamy, frothy, pungent |
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Fecal incontinence |
May be related to neurological disorder |
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Medical history of GI tract |
Irritable bowel syndrome Inflammatory bowel disease |
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IBS |
Irritable bowel syndrome Common change in stools Diarrhea to constipation Exacerbated by psychological stress |
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IBD |
Inflammatory bowel disease Crohns disease Ulcerative colitis Increased colon cancer risk 10 yrs after diagnosis Severe disability |
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Colorectal cancer risk |
> 50 yrs High fat/low fiber diet Obesity Smoking Precancerous intestinal polyps Family hx IBD |
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Fiber in diet |
Fiber absorbs fat May absorb toxins and carcinogens |
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Hypoplastic polyps |
Benign No risk for cancer |
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Adenomatous |
Precancerous Must be re-evaluated by colonoscopy more frequently than 10 yrs per recs of GI doc |
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Purposes of rectal exam |
Assess anorectal area Prostate exam in males Bi-manual recto-vaginal exam in women |
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Positioning |
Pt stands and leans over exam table Lithotomy position: as part of pelvic exam Left-lateral knee-chest position: bedridden |
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Inspect perianal area |
Spread buttocks Assess for lesions, warts, skin tags, parasites, abscess, scars, fissures, external hemorrhoids |
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Perianal skin |
Darker With hair |
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Pilonidal cyst |
Located over coccyx/sacrum Pain or tender Usually between 15-24 yrs Cyst: may be r/t ingrown hair aggrivated by prolonged sitting or trauma Sinus tract opening: may contain hair and skin debris with erythema, swelling, tendernes at coccyx |
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Digital rectal exam |
Apply pressure to anal opening with lubricated gloved index finger - pt bear down to relax external sphincter Insert finger and palpate anterior, lateral, posterior surfaces Pt to tighten external sphincter to assess tone Note nodule, massess, polyps, tenderness (fissure/fistula), internal hemorrhoids (not usually palpable or painful, may bleed) |
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Decreased external rectal tone |
Neurologic deficit |
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Tight external sphincter |
Scarring r/t fissure/lesion, inflammation, anxiety |
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Prostate exam |
Press down on anterior rectal wall Only posterior surface assessed Palpate both posterior lobes: vertical groove separates lobes |
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Prostate size |
Normal: no protrusion into rectum 1+ : protrudes 1-2 cm into rectum 2+ : protrudes 2-3 cm into rectum 3+ : protrudes 3-4 cm into rectum 4+ : protrudes > 4 cm into rectum |
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Size and symptoms of prostate |
Size does not correlate with symptoms May have significant LUTS with normal prostate exam Anterior prostate may be significantly enlarged but not change prostate exam |
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Prostate norms |
Smooth, firm, non-tender: tip of nose |
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BPH physical exam |
Symmetrically enlarged Soft, non-tender |
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Prostate cancer physical exam |
Nodular Asymmetrical Non-tender Middle groove may be obliterated |
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Acute prostatitis physical exam |
Boggy, tender |
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Monthly screening |
Genital self exam (GSE) Testicular self exam (TSE) |
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Annual screening |
DRE PSA FOBT |
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Screening every 5 yrs |
Flexible sigmoidoscopy Starting at age 50 |
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Screening every 10 yrs |
Colonoscopy Starting at age 50 |
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DRE |
Digital rectal exam Screen for prostate and colon cancer Reaches 7-8 cm and detects 10% of cancers > 50 yrs all men > 40 yrs at risk: African Americans, family hx |
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PSA |
Non specific blood test for prostate cancer Increase with inflammation and BPH PSA screening is controversial because of high false positive and false negative rate |
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FOBT |
Fecal occult blood test, guiac test Only detects 2-11% of colon cancers + FOBT: colonoscopy recommended |
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Genetic risk |
First degree relative: parent, child, sibling Second degree: grandparent, aunts, uncles Third degree: great-grandparents, cousins |