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336 Cards in this Set
- Front
- Back
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rib levels of breast
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clavicle and 2nd rib to 6th rib
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tail of Spence
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axillary tail of breast tissue
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which kind of tissue forms lobes in the breast?
where do the lobules drain? |
glandular tissue (secretory tuboalveolar glands and ducts)
they drain into milk-producing ducts and sinuses that open onto the areolar surface |
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which kind of tissue provides structural support to the breast?
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fibrous connective tissue
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when may nodularity of the breasts increase?
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before menses
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where do the lymphatics drain to from the breast?
which nodes drain the anterior chest wall and much of the breast? which nodes drain the posterior chest wall and a portion of the arm? which nodes drain most of the arm? |
to the axilla (central nodes are most frequently palpable)
pectoral nodes (anterior) subscapular nodes (posterior) lateral nodes |
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when is the best time to perform a self breast exam?
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when estrogen is lowest - 5-7 days after onset of menses
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when is galactorrhea abnormal?
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when it occurs 6+ months after childbirth or cessation of breastfeeding
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fine, round, mobile, nontender, usually single breast masses most common in ages 15-25
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fibroadenomas
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soft to firm, round, mobile, tender
breast masses nodular, ropelike breast masses both common in ages 25-50 |
cysts
fibrocystic changes |
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most common cause of cancer in women worldwide and the second leading cause of cancer death in women
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breast cancer
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lifetime risk of developing breast cancer
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12% of 1 in 8; increases by decade
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highest mortality rates of breast cancer are found in which age groups?
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<35 yo or >75 yo
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2 reasons why the # of new cases of breast cancer has been falling
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1. decreased mammograms
2. decreased us of HRT |
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which group has the higher risk for breast CA early, larger, and more deadly?
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African American women
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does breastfeeding increase or decrease risk of breast CA?
use of contraceptives? HRT? |
breastfeeding - decreases risk
OCPs - increases risk HRT - increases risk |
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what is the increased risk of breast CA if the BRCA1 and BRCA2 genes are present?
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BRCA1 - 65% by age 70
BRCA2 - 45% by age 70 |
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5 risk factors as criteria for identifying women at risk for the BRCA1/2 genes
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1. 1st degree relative w/ a mutation
2. 2+ relatives w/ breast CA <50 yo, and 1+ is a 1st degree relative 3. 3+ relatives w/ breast CA, 1+ <50 yo 4. 2+ relatives w/ ovarian CA 5. 1+ w/ ovarian CA and 1+ w/ breast CA |
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this is a strong independent risk factor for breast CA even after adjusting for the effects of other risk factors; underused risk factor
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mammographic breast density
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women w/ radiographic density of this much have a 4-6x greater risk of breast CA
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60-75%
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what is the recommendation for mammograms in women 40-50 yo? 50-70 yo?
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40-50 - every 1-2 years (controversial)
50-70 - every year |
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what is the recommendation for CBE? BSE?
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every 3 years in women 20-40
every year >40 American Cancer Society no longer recommends monthly BSE, but still a good idea to teach patients |
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what is the recommendation for breast MRIs?
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women at high lifetime risk or risk of >20%
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2 prophylactic treatments to prevent breast CA
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1. chemoprevention w/ estrogen-receptor modulators
2. bilateral mastectomy |
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4 views of inspection of the breasts
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1. arms at sides
2. arms over head 3. arms pressed against hips 4. leaning forward |
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thickening and prominent pores of the skin over the breast suggests...
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breast CA
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masses, dimpling, or flattening of the normally convex breast suggests...
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breast CA
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asymmetry of directions of nipples and retraction of nipple that is broadened and thickened suggest...
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underlying breast CA
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rash or ulceration of the breast suggests...
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Paget's disease
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dimpling and retraction of skin of the breast may suggest something other than cancer like...
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1. posttraumatic fat necrosis
2. mammary duct ectasia |
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best technique for detecting breast masses
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vertical strip pattern, palpating in small concentric circles
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what portion of the breast are you palpating if you have the pt roll onto the opposite hip placing her hand on her forehead and keeping her shoulders on the table?
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lateral portion
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what portion of the breast are you palpating if you have the pt place her hand at her neck and lift her elbow until it is even with her shoulder?
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medial portion
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tender cords in the breast tissue suggest...
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mammary duct ectasia (dilated ducts w/ surrounding inflammation)
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hard, irregular, poorly circumscribed nodule fixed to the skin suggests...
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breast CA
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enlarged, firm disc of glandular enlargement in male breast
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gynecomastia
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peak age of male breast CA
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71
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which position is preferable for examining the axilla?
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sitting
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hidradenitis suppurativa
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sweat gland infection in the axilla
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deeply pigmented, velvety axillary skin in the axilla
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acanthosis nigricans (one form is associated w/ internal malignancy)
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nonpuerperal galactorrhea
what's it caused by? |
milky discharge unrelated to prior pregnancy and lactation
caused by hypothyroidism, pituitary prolactinoma, dopamine agonists |
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bloody discharge from one or two ducts suggests 1 of these 3 things...
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1. intraductal papilloma
2. carcinoma in situ 3. Paget's disease |
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most common quadrant of the breast to have a malignancy
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upper outer
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3 most common kinds of breast masses
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1. fibroadenoma
2. cysts 3. cancer |
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are fibrocystic changes considered a risk factor for cancer?
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no
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peau d'orange sign
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edema of the skin caused by lymphatic blockade that appears as thickened skin w/ enlarged pores
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suspect this in any persisting dermatitis of the nipple or areola
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Paget's disease
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what are Montgomery glands?
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sebaceous glands on the areola
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one of the first signs of puberty in girls?
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physical changes in breasts
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age range of secondary sex characteristics appearing in girls
how long does the maturational change usually take |
8-13 yo
about 4 years |
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how long after the beginning of breast development does menarche often occur?
what Tanner stage are girls at when they reach menarche? |
within 1 year
usually Tanner 3 or 4 |
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7 factors for describing a nodule that is palpated
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1. location
2. size 3. consistency 4. mobility 5. shape 6. delimitation 7. tenderness |
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how do you palpate the axilla?
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using the opposite hand
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characteristics of normal central nodes when palpated
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soft, small (<1 cm), nontender
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3 columns of vascular erectile tissue in the penis
which contains the urethra and ends in the glans? |
corpus spongiosum and 2 corpora cavernosa
the corpus spongiosum contains the urethra and ends in the glans |
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which testis usually lies lower?
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the left
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these produce spermatozoa and testosterone
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testes
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this serous membrane covers the testis except posteriorly
what covers it posteriorly? |
tunica vaginalis
the epididymis |
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this provides reservoir for storage, maturation, and transport of sperm from the testis to the vas deferens
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epididymis
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transfers sperm to the urethra
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vas deferens
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these two structures merge to form the ejaculatory duct
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vas deferens and seminal vesicle
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what makes up the spermatic cord?
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vas deferens, blood vessels, nerves, muscle fibers
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lymphatics of penile and scrotal surfaces drain to...
lympathics of the testes drain to... |
inguinal nodes
abdomen |
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where is the femoral canal located?
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medial to the femoral artery and vein
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approximately what percentage of patients may have same-sex, bisexual, or transgender partner preferences?
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~10%
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3 causes of loss of libido
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1. depression
2. endocrine dysfunction 3. medications |
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what is a sign that erectile dysfunction is psychogenic?
what are 3 other causes of ED? |
early morning erection is preserved
1. decreased testosterone 2. decreased blood flow 3. impaired neural innervation |
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lack of orgasm w/ ejacutation suggests...
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psychogenic cause
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color of penile discharge from:
gonococcal urethritis nongonococcal urethritis |
yellow
clear or white |
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which developed country has the highest rate of STDs?
which STD is most common |
US
Chlamydia most common, followed by gonorrhea and then syphilis |
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which STDs don't have to be reported?
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HPV, genital herpes
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what % of people with STDs don't know they have them?
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25%
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7 groups that are recommended to get HIV screening and counseling
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1. MSM
2. people having unprotected sex w/ multiple partners 3. past or present IV drug users 4. sex workers 5. past or present sex partners w/ hx of STDs, HIV, IVDA, or bisexual practice 6. received blood transfusions b/w 1978-1985 7. those requesting testing |
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what position should the man be in for genital exam? for hernia check?
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genital exam - standing or supine
hernia check - standing |
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tight prepuce that cannot be retracted over the glans
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phimosis
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tight prepuce that once retracted cannot be returned; edema ensues
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paraphimosis
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balanitis vs. balanoposthitis
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balanitis - inflammation of glans
balanoposthitis - inflammation of glans and prepuce |
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congenital ventral displacement of the meatus on the penis
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hypospadias
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induration along the ventral surface of the penis suggests...
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1. urethral stricture
2. carcinoma |
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dome-shaped white or yellow papules or nodules formed by occluded follicles filled w/ heratin debris of desquamated follicular epithelium found on the scrotum; frequently multiple and benign
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epidermoid cysts
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cryptorchidism
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undescended testicle
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painless nodule in the testis
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testicular cancer
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peak incidence of testicular cancer
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ages 15-35
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varicocele
which side is this usually found? |
multiple tortuous veins in the area of the spermatic cord
on the left |
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hydrocele
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cystic structure in the spermatic cord
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which light up by transillumination: hydrocele, tumor, hernia?
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only hydrocele will transilluminate
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bulge near external inguinal ring suggests...
bulge near internal inguinal ring suggests... |
direct
indirect |
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if a bulge returns the abdomen when a man lays down, that suggests...
if not, but you can get your fingers above the mass in the scrotum, that suggests... what else can you do to distinguish the two? |
hernia
hydrocele auscultate the mass - bowel sounds suggest hernia |
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when should you not try to reduce a hernia? what do these sx suggest?
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if there's pain or hx of N/V
suggests strangulation |
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most common cancer of young men 15-35
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testicular CA
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2 conditions in which you may see scrotal edema?
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1. CHF
2. nephrotic syndrome |
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palpable, nontender, hard plaques found just beneath the skin usually along the dorsum of the penis; pt complains of painful, crooked erections
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Peyronie's disease
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in which men is penile CA more common
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uncircumcised men
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incubation period of genital herpes
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2-7 days after exposure
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bacteria that causes chancroids
presentation of chancroid |
H. ducreyi
painful lymphadenopathy and buboes |
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small firm testis seen in this disorder
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Klinefelter's
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acutely inflamed painful tender and swollen testis; usually due to viral infx like mumps
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acute orchitis
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spermatocele and cyst of the epididymis - do they transilluminate?
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yes
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coexisting UTI or prostatitis supports this dx
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acute epididymis
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acutely painful, swollen testis that is retracted upward in the scrotum; red and edematous; not associated w/ UTI; surgical emergency
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torsion of spermatic cord
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thickening or beading of epididymitis
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tuberculous epididymitis
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most common hernia type
which is more common in women? |
indirect hernia
femoral hernia |
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which hernia type commonly goes into the scrotum?
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indirect hernia
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stroking the ipsilateral thigh and notice that testicle rise
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cremasteric reflex
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ADC VAAN DIMLS
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Admit to
Diagnosis Condition/Code status Vitals Activity Allergies Nursing orders Diet Ins and outs Medications Labs Special orders |
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order of directed H&P
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CC
HPI PE Lab Results Impression Plan - ADC VAAN DIMLS (admission orders) |
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order of SOAP note
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S - CC (only outpatient), how pt feels, other complaints, changes in sx, response to therapy
O - PE, labs A/P - assessment/plan |
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solutions w/ small molecules that flow easily from the bloodstream into cells and tissues
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crystalloids (isotonic, hypertonic, or hypotonic)
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solutions w/ larger molecules used to expand plasma in patients who don't respond to other things
example? |
colloids (always hypertonic)
plasma protein factor or albumin |
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used to replace fluid loss and dehydration; treats hyperNa; need to be careful in pts w/ renal/cardiac disease b/c of fluid overload
is this iso-, hyper-, or hypotonic? |
dextrose 5% in water (D5W)
isotonic |
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used to perform fluid challenge or treat shock, DKA, hyperCa, hypoNa, or metabolic alkalosis; need to be careful in CHF, edema, or hyperNa
is this iso-, hyper-, or hypotonic? |
NSS or 0.9% NaCl
isotonic |
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used to treat acute blood loss, burns, dehydration, and lower GI tract fluid loss; have to caution w/ renal failure b/c K is in this
is this iso-, hyper-, or hypotonic? |
Lactated Ringer's
isotonic |
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hypertonic solutions cause ______ of cells
hypotonic solutions cause ______ of cells |
shrinking
swelling |
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hypertonic solution used to tx DKA after initial tx w/ NSS and once the glucose falls below 250; prevents hypoglycemia and cerebral edema
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D5 1/2 NSS or D5 in 0.45% NSS
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hypertonic solution used to tx SIADH or hypotonic dehydration; caution in cardiac or renal pts b/c can cause CHF or pulmonary edema
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D5 NSS or D5 in 0.9% NSS
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used to replace gastric fluid loss from NG tube or suctioning; tx hypertonic dehydration, sodium and chloride depletion
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0.45% NS
hypotonic |
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what can 0.45% NS cause?
when should it not be used? |
CV collapse or increased ICP
trauma or burns |
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maintenance fluid equation
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30 cc/kg/24 hr
for a 70 kg person --> NSS @ 87 cc/hr x 24 hr or 2 L |
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how should fluids be given for dehydration or hypovolemia
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NSS @ 1 L bolus IV
NSS @ 2500 bolus IV, then 100 cc/hr x 1 L |
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where are Skene's glands found?
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paraurethral region (posterior and lateral to the urethral meatus)
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2 parts of the uterus
how are the connected? |
corpus (body) and cervix
connected by isthmus |
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convex upper surface of the body of the uterus
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fundus
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the distal cervix divides the upper portion of the vagina into these 3 recesses
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posterior, anterior, and lateral fornices
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this marks the opening of the endocervical canal
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external os
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red columnar epithelium vs/ pink squamous epithelium
which is found in the ectocervix? |
red columnar - endocervical canal
pink squamous - vagina both |
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average size of ovary
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3.5x2x1.5 cm
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ovaries, tubes, and supporting tissues
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adnexa
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2 primary functions of the ovary
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production of ova
secretion of hormones |
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parietal peritoneum extending downward behind the uterus
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rectouterine pouch (pouch of Douglas)
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lymph from vulva and lower vagina drains to...
lymph from the internal genitalia including the upper vagina drains to... |
inguinal nodes
pelvic and abdominal nodes |
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range of ages for menopause
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48-55
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postmenopausal bleeding is considered bleeding occurring...
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6 months or more after cessation of menses
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for PMS to be diagnosed, when and how often do sx have to occur
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5 days before menses for at least 3 consecutive cycles
resolves within 4 days after onset of menses interferes w/ daily activities |
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range of ages for menarche
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9-16
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range of interval b/w periods
range of length of period |
24-32 days
3-7 days |
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% of women who present w/ dysmenorrhea
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50%
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caused by increased prostaglandin production during the luteal phase of the menstrual cycle, when estrogen and progesterone decline
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primary dysmenorrhea
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causes of secondary dysmenorrhea
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endometriosis, adenomyosis, PID, endometrial polyps
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failure of periods to initiate
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primary amenorrhea
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cessation of periods after they have been established
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secondary amenorrhea
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1. fewer than 21-day intervals b/w menses
2. infrequent bleeding 3. excessive flow 4. intermenstrual bleeding |
1. polymenorrhea
2. oligomenorrhea 3. menorrhagia 4. metorrhagia |
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amenorrhea followed by heavy bleeding suggests...
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threatened abortion or dysfunctional uterine bleeding related to lack of ovulation
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2 most common vulvovaginal sx
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discharge and itching
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3 phases of sexual response
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desire
arousal orgasm |
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involuntary spasm of the muscles surrounding surrounding the vaginal orifice that make penetration during intercourse painful or impossible
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vaginismus (may be physical or psychological)
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most common type of cervical cancer
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squamous cell carcinoma
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screening for cervical cancer
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1. initial - 3 yrs after sex or age 21
2. < 30 - annually 3. >30 - every 2-3 yrs 4. hysterectomy - d/c unless cervix is spared; annual if pt had CA until 3 consecutive are negative 5. >70 - d/c if 3 consecutive are negative, unless hx of cervical CA, DES exposure, HIV, or immunocompromised |
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ASC(-US)
LSIL HSIL |
ASC(-US) - atypical squamous cells (undetermined significance)
LSIL - low-grade squamous intraepithelial lesions HSIL - high-grade squamous intraepithelial lesions |
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prevalence of HPV in girls 14-19
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40%
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4 screening methods for women at high genetic risk for ovarian CA
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1. BSO
2. frequent pelvic exams 3. CA-125 levels 4. transvaginal US |
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most common STD in the US
most common reported STD in the US most common STD in women |
HPV
Chlamydia Chlamydia |
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what happens if Chlamydia is left untreated?
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40% get PID
20% become infertile |
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in whom are HIV and AIDS infx rising fastest? which race?
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women
African-American (60%) |
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4 red flags for HIV infx
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1. recurrent candidiasis
2. concurrent STDs 3. abnormal Paps 4. HPV infx |
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what is usually the most comfortable speculum for sexually active women?
for women w/ small introitus (elderly, virgin)? for parous women w/ vaginal prolapse? |
medium Pedersen
narrow-bladed Pedersen Graves specula |
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when the uterus is retroverted, the cervix points more...
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anteriorly
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3 risk factors for Chlamydial infx
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1. <25 yo
2. multiple partners 3. prior hx of STDs |
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2 options for obtaining the pap smear
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1. cervical scrape + endocervical brush
2. cervical broom |
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what should be used in place of the endocervical brush in pregnant women
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moistened cotton-tip applicator
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2 risk factors for vaginal CA
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1. DES exposure in utero
2. HPV infx |
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pain on movement of the cervix + adnexal tenderness =
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PID
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nodules on the uterine surface suggest...
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myomas
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pelvic pain, bloating, increased abdominal size, and urinary tract sx suggest...
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ovarian CA
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when are the ovaries nonpalpable?
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3-5 years after menopause
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how do you know if the pt has full strength of her pelvic muscles?
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they compress your fingers snugly, they move your fingers upward and inward, and it lasts 3+ seconds
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3 reasons for doing a rectopelvic exam
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1. palpate a retroverted uterus, the uterosacral ligaments, cul-de-sac, and adnexa
2. screen for colorectal CA in women >50 3. assess pelvic pathology |
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in the rectopelvic exam, where do you apply pressure?
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the anterior and lateral walls with the examining fingers and the abdomen with the other hand
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where do you palpate for an indirect hernia in women?
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labia majora and upward to just lateral to the pubic tubercle
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firm painless ulcer, often found internally in women
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chancre of syphilis
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slightly raised, round or oval, flat-topped papules covered by a gray exudate
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condyloma lata which may be a manifestation of secondary syphilis
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small painful ulcers on red bases; initial infection may be extensive, but following infx are usually smaller
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herpes
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bulge of the upper 2/3 of the anterior vaginal wall
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cystocele
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entire anterior vaginal wall w/ the bladder and urethra bulge
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cystourethrocele
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small, red, benign tumor at the posterior part of the urethral meatus found usually in postmenopausal women w/ no sx
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urethral caruncle
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swollen red ring around the urethral meatus usually occurring before menarche or after menopause
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prolapse of urethral mucosa
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herniation of the rectum into the posterior wall of the vagina
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rectocele
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translucent nodules found on the cervical surface due to increased estrogen causing columnar epithelium to transform into squamous
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retention or nabothian cysts
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benign, bright red, soft, fragile nodule on the cervix
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cervical polyp
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causes columnar epithelium to cover cervix and extend to the vaginal wall (vaginal adenosis); also causes circular collar or ridge of tissue b/w the cervix and vagina
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DES exposure in utero
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tilting backward of entire uterus, including the body and cervix; mobile and asymptomatic
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retroversion of the uterus
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backward angulation of the body of the uterus in relation to the cervix
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retroflexion of the uterus
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1st degree prolapse
2nd degree prolapse 3rd degree prolapse |
1st - cervix is well within the vagina
2nd - cervix is at the introitus 3rd - cervix and vagina are outside the introitus |
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how do ovarian cysts and tumors feel different?
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cysts - smooth and compressible
tumors - solid and often nodular |
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dx of PCOS rests on the exlusion of other endocrine disorders and 2 of the 3 following features:
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absent or irregular menses
hyperandrogenism confirmation of polycystic ovaries on US |
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what 2 features do the labia majora have that the labia minora don't have?
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hair follicles
underlying adipose tissue |
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which is longer, the anterior or posterior fornix?
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posterior by 2 cm
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cornua
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where the fallopian tubes enter the uterus
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serrated line marking the change from skin to mucous membrane demarcating the anal canal from the rectum
|
dentate line
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how many lobes of the prostate? where are they located?
|
2 lateral lobes are anterior to the rectal wall (feel like rounded, heart-shaped structure 2.5 cm long) - separated by median sulcus
1 median lobe anterior to the urethra |
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these are shaped like rabbit ears above the prostate
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seminal vesicles
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what is palpable through the anterior wall of the rectum in women?
|
cervix
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what are the 3 inward foldings of the rectal wall?
can they be felt? if so where? |
valves of Houston
the lowest may be felt usually on the pt's left |
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which part of the rectum is covered by peritoneum?
|
anterior surface
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mucus in the bowel movements may accompany...
|
villous adenoma
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2 things that increase risk for colon cancer
|
FH of colon polyps or CA
hx of IBD |
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itching, anorectal pain, tenesmus, d/c or bleeding suggest
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proctitis
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leading cancer in men in the US
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prostate CA
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3 leading causes of cancer deaths in men
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1. lung
2. colon 3. prostate |
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3 primary risk factors of colon cancer
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1. age (increases after 50)
2. ethnicity (higher in AA) 3. FH (15% w/ 1st degree relative) |
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recommendation for screening for prostate cancer
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DRE+PSA beginning at 50 yo or 40 yo in AA men and men w/ + FH
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swollen, thickened, fissured perianal skin w/ excoriations suggests...
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pruritis ani
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tender purulent, reddened anal mass w/ fever and chills suggests...
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anal abscess
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which direction should your finger point when entering the anus?
which way do you need to rotate your finger to examine the prostate? |
toward the umbilicus
counterclockwise |
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what does a normal prostate feel like?
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rubbery and nontender
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what position is best for rectal exams?
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left lateral decubitus
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common congenital abnormality located in the midline superficial to the coccyx of lower sacrum; usually asymptomatic
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pilonidal cyst
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what does an anal fissure look like and where is it usually located?
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oval ulceration of the anal canal located in midline posteriorly
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inflammatory tract or tube that opens at one end into the anus or rectum and at the other end onto the skin surface or into another viscus
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anorectal fistula
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firm to hard nodular rectal shelf in the area of the peritoneal reflection anterior to the rectum
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widespread peritoneal mets
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tender, swollen, boggy, warm prostate w/ associated fever, UTI sx, and incomplete voiding
what usually causes it? |
acute bacterial prostatitis
E. coli, Proteus, enterococcus, or GC/Chlamydia |
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obstructive or irritative urinary sx on voiding but no evidence of prostate infx or UTI
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chronic pelvic pain syndrome
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this stimulates lactotrophs in the anterior pituitary to triple in size and increase prolactin output to ready the breast tissue for lactation
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estradiol
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2 hormones released by the posterior pituitary
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oxytocin --> lactation
ADH --> conserves water |
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this resets the receptors for thirst and ADH release, leading to decreases in serum [Na] and sometimes polyuria
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HCG
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this effects thyroxine-binding globulin
this stimulates TSH receptors both of these lead to fluctuations in T4 and T3 levels and in TSH |
estrogen
HCG |
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these contribute to insulin resistance and a shift from carb to fat metabolism
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placental hormones
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at the end of pregnancy, increases in these 2 hormones causes a state of relative hypercortisolism that may trigger labor
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placental CRH and adrenal ACTH
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tidal volume and minute ventilation increase in pregnancy due to...
this also relaxes tone and contraction of the ureters (hydronephrosis) and the bladder (increased risk of bacteriuria) |
progesterone
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these lower esophageal sphincter tone causing heartburn and reflux
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progesterone and estradiol
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which rises more: RBC mass or plasma volume? what does this case?
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plasma volume
causes a relative hemodilution and physiologic anemia |
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do the following increase or decrease during pregnancy:
CO BP SVR |
CO increase
BP and SVR decrease |
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secreted in the corpus luteum and placenta; causes lumbar lordosis and ligamentous laxity of sacroiliac joints and pubic symphysis
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relaxin
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when in pregnancy do the breasts become more nodular?
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by the 3rd month
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5 breast changes in pregnancy
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1. nipples larger and more erectile
2. colostrum 3. areola darker 4. Montgomery's glands more pronounced 5. venous pattern more visible |
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when is the uterus most easily palpated?
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beyond 12-14 wks
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when is the uterus at the level of the umbilicus?
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20 weeks
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vagina has bluish or violet color
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Chadwick's sign
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what is the character of the discharge during pregnancy?
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thicker, white, more profuse, and more acidic
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palpable softening at the isthmus of the uterus during pregnancy
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Hegar's sign
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increase in weight and volume of uterus during pregnancy
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50-70 g --> 800-1200 g
10 ml --> 5 L |
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when does the uterus rise out of the pelvis?
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after 12 weeks
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red velvety mucosa appearing on the cervix in pregnancy
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cervical erosion or eversion
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diastasis recti
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when the rectus abdominis muscles separate at the midline during pregnancy
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this hormone has a sedative effect, causing fatigue in 1st and 3rd trimesters
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progesterone
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best confirmation of pregnancy
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urine bHCG
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menstrual age
conception age |
count in weeks from 1st day of LMP
count in weeks from date of conception |
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4 things to check on f/u visits of pregnant women
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1. BP and weight
2. palpation of fundus to access fetal growth 3. verification of FHTs 4. determine fetal presentation and activity |
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how much more should a pregnant woman eat?
how much protein, iron, calcium, and folic acid? |
300 extra Calories
protein - 10-15 g iron - 15 mg calcium - 250 mg folic acid - 400-800 mcg |
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shark
swordfish king mackerel canned albacore tuna |
higher levels of mercury - avoid these in pregnancy
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average weight gain during pregnancy
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28 lb (10 kg)
not a lot during 1st trimester; most during 2nd trimester; slowing of increase during 3rd trimester |
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how much exercise during pregnancy?
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30 minutes of moderate exercise on most days
avoid supine exercise after 1st trimester |
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gestational HTN is:
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systolic >140 and diastolic >90 first occurring after week 20 and w/o proteinuria
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chronic HTN
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systolic >140 and diastolic >90 before 20 weeks and for at least 12 weeks postpartum
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preeclamspia
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SBP >140, DBP >90 after 20 weeks w/ proteinuria
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1st trimester wt loss should not exceed...
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5% of prepartum weight
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irregular brownish patches around forehead and cheeks, across nose, or along jaw; mask of pregnancy
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chloasma
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changes in nose and mouth during pregnancy
changes in thyroid |
nose - congestion and nosebleeds are more common
mouth - gingival enlargement w/ bleeding is common thyroid - moderate symmetric enlargement is normal |
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which metabolic disturbance is expected in pregnancy
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resp alkalosis
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normal murmurs in pregnant women
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venous hum and systolic or continuous mammary souffle
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when can fetal movements be felt by mom? by examiner?
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mom - 18-20 weeks
examiner - 24 weeks |
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when do you start measuring fundal height?
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week 20
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location of FHR at different weeks
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12-18 weeks in the midline of lower abdomen
after 28 weeks over the fetal back or chest |
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normal FHR in different trimesters
when does rate increase w/ movement |
early - 160s
late/near term - 120-140s after 32-34 weeks |
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pink cervix or vagina suggests...
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non-pregnant state
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how long should cervix be prior to 34-36 weeks
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normal length - 1.5-2 cm
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when do you start doing Leopold's maneuvers?
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28 weeks
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2 most serious findings on Leopold maneuvers
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1. transverse lie close to term
2. slowed fetal growth which could represent IUGR |
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Leopold's maneuvers
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1. upper pole
2. sides of maternal abdomen 3. lower pole 4. confirmation of presenting part |
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difference b/w fetal butt and head
difference b/w fetal back and arms/legs |
butt - firm but irregular
head - firm, round, and smooth back - smooth,firm surface the length of your hand at 32 weeks arms/legs - irregular bumps |
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if the hands diverge w/ downward pressure when palpating the lower pole, it means...
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the presenting part is descending into the pelvic inlet
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FDA categorization of drug risks to fetus
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A - controlled studies in women; no risk
B - no risk in animal studies but no studies in women or adverse effect in animal studies but none in studies of women C - risk in animal studies and no studies have been done in women or no studies done at all; only give if the benefit justifies the risk to the fetus D - evidence of human fetal risk but benefits may be acceptible despite the risk X - evidence of fetal risk which clearly outweighs any benefit |
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4 principles of child development
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1. predictable pathway (loss of milestones is concerning)
2. wide range of normal development 3. variety of factors affect development and health 4. child's developmental level decides how to conduct H&P |
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most rapid rate of growth occurs when?
in this time, how much does weight and height increase? |
1st year of life
weight triples, height increases by 50% |
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how does neurologic development progress?
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central to peripheral
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neonatal period
postneonatal period infancy |
first 28 days
29 days-1 year first year |
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when are newborns most responsive?
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1-2 hours after feeding
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5 components of Apgar scoring system
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1. HR
2. respiratory effort 3. muscle tone 4. reflex irritability 5. color |
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when do you perform apgar scores?
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1 and 5 minutes
every 5 minutes therafter if the score is 7 or less |
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birth weights:
1. extremely low 2. very low 3. low 4. normal |
1. <1000 g
2. <1500 g 3. <2500 g 4. >= 2500 g |
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SGA
AGA LGA |
<10th%
10-90th% >90th% |
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posture of breech babies postpartum
posture of frank breech babies postpartum |
breech - legs and head extended
frank breech - legs abducted and ER |
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motor activity at:
3 months 6 months 1 year |
3 mo - lift head and clasp hands
6 mo - roll over, reach for objects, turn to voices, sit w/ support 1 year - stand, put things in mouth |
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language development
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2 mo - cooing
6 mo - babbling 1 year - 1-3 words |
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4 domains of development from DDST
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1. personal-social
2. fine motor-adaptive 3. language 4. gross motor |
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recommended times for health promotion visits for infant
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birth, one week, 1, 2, 4, 6, 9, 12 months
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7 critical measurements for infants
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1. weight
2. height 3. head circumference 4. BP 5. HR 6. RR 7. temp |
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inadequate weight gain for age
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failure to thrive
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until what age should you measure head circumference
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first 2 years
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head size >97th%
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macrocephaly
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at what age can you start taking oral temps?
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>7
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where should you palpate infants HR?
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femorals, brachials, anterior fontanelle
auscultate heart |
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what is tachypnea for the following age groups:
birth-2 mo 2-12 mo |
>60
>50 |
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normal temp until age 3
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>99
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common skin appearance in preterm infants and congenital hypothyroidism or Down syndrome
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cutis marmorata (mottled, lattice-like appearance)
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if acrocyanosis is not gone w/in 8 hours or with warming, consider...
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cyanotic heart disease
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Waxy, “cheesy” substance coating the skin of the newborn; secreted by the fetus’ sebaceous glands in utero
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vernix caseosa
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best place to look for central cyanosis
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tongue and oral mucosa
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fine, downy hair over entire body
disappears within 2 weeks |
lanugo
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if jaundice occurs w/in first 24 hours of birth, consider...
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hemolytic disease of the newborn
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jaundice lasting beyond 2 weeks suggests one of these 3
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hemolytic disease of the newborn
biliary obstruction liver disease |
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pale yellow skin primarily present on the soles of the feet, palms, nose, and naso-labial folds
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carotenemia
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pin-head sized, smooth, raised, white areas without surrounding erythema; usually appear in 1st few weeks and disappear within 1-2 weeks
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milia
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erythematous grouped papules or vesicles; usually on the face and trunk; disappears on its own
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miliaria rubra
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erythematous macules w/ central pinpoint vesicles or wheals over the entire body; disappear w/in a week of birth
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erythema toxicum
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open and closed comedomes appearing at 4-6 weeks and resolving in 6-12 mo
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acne neonatorum
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salmon patch/story bite
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nevus simplex on back of neck
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angel kisses
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nevus simplex on upper eyelids, forehead, or upper lip
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port wine stains
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not likely to fade, dark and large; if on ophthalmic branch of trigeminal nerve, may be a sign of Sturge-Weber syndrome
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seziures, hemiparesis, glaucoma, and MR
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Sturge-Weber syndrome
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newborn's head accounts for how much of length and weight
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1/4 of length
1/3 of weight |
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size and time of closure of fontanelles
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anterior - 4-6 cm in diameter; closes at 4-26 mo
posterior - 1-2 cm in diameter; closes at 2 mo |
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enlarged posterior fontanelle
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congenital hypothyroidism
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depressed anterior fontanelle
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dehydration
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premature closure of one or more sutures resulting in alteration in head shape
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craniosynostosis
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asymmetry of cranial vault
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plagiocephaly
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relatively long occipitofrontal diameter and narrow bitemporal diameter
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dolichocephaly
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micrognathia may be part of this syndrome
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Pierre Robin syndrome
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when is nystagmus normal in an infant?
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immediately after birth
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scattered white spots on the iris; indicative of Down’s Syndrome, but may be present in some normal infants
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Brushfield spots
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reduced vision in an otherwise normal eye; caused by disuse
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amblyopia (seen in early childhood)
caused by strabismus or anisometropia |
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at what age might you be able to accurately measure visual acuity
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3 yo
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small, deformed, or low-set ears may indicate associated congenital defects, such as...
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renal agenesis = Potter's syndrome
fetal alcohol syndrome |
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how can you test an infant's hearing?
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acoustic blink reflex
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which sinuses are developed at birth?
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ethmoid sinuses only
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tiny white or yellow rounded mucous retention cysts located along the posterior midline of the hard palate; disappear w/in months
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Epstein's pearls
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notching of posterior margin of hard palate or bifid uvula; +/- hypernasal speech
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submucosal cleft palate
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breathing is predominantly _______ in infants
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abdominal
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funnel chest
chicken breast deformity |
pectus excavatum
pectus carinatum |
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apnea is cessation of breathing for how long
what often accompanies apnea? |
>20 s
bradycardia |
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respiratory pattern of infants
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normal breathing at 30-40/min alternating w/ periodic breathing during which breathing slows markedly or ceases for 5-10 seconds
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4 things to look/listen for in respiratory assessment of infants
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1. nasal flaring
2. wheezing 3. grunting 4. lack of breath sounds |
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which part of the lung exam is not useful in infants?
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percussion
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absence or diminution of femoral pulses may indicate...
weak or thready pulse may indicate... |
coarctation of the aorta
myocradial dysfunction or CHF |
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most common potentially harmful dysrhythmia in infants
common normal sinus dysrhythmia |
paroxysmal SVTs or paroxysmal atrial tachy (>240)
increased HR on inspiration, decreased on expiration |
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how can you tell b/w a benign and malignant murmur in children?
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benign murmurs have NO associated abnormal findings
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RUQ or midline "olive" mass
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pyloric stenosis
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at what age is there full retraction of the foreskin
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not until 3-4 yo
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how can you tell the difference from a true deformity from a transient deformity
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true deformities don't return to neutral position w/ manipulation
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abduction of each hip to assess dislocation; if + hear an audible clunk
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Ortolani test
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adduction of each hip to assess for dislocation; feel for movement of femur laterally
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Barlow test
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optic blink reflex (dazzle reflex)
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infants will close eyes in response to bright light
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infant supported upright under axillae
head maintained in midline with legs flexed at the hip and knee disappears after 4 months |
vertical suspension positioning
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have one sole touch tabletop, knee and hip will flex and the other foot steps forward
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placing and stepping reflexes
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baby supine, arms/legs on side that the head is facing will extend, the other side will flex; disappears at 2 mo
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asymmetrical tonic neck reflex (fencing reflex)
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Hold the baby supine, supporting head, back and legs; abruptly lower the entire body ~2 feet; baby will abduction of arms, flexion of legs, startle cry
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moro reflex (startle reflex)
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rolls to prone position, pushes off the floor with arms, climbs up the legs to gain an upright position
found in certain forms of muscular dystrophy; indicative of weakness of hips in early and late childhood |
Gower's sign
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