Hx/Px Specialized

Breast

History

• Pain
• Masses (size, shape, symmetry, skin changes)
• Nipple changes (ulceration, discharge)
• Constitutional sx (fever, wt loss, sweats/chills, appetite)

Inspection

• Sit upright, arms on thighs facing examiner
• Comment on Size, Symmetry, shape, skin changes
• Nipples: Size, Symmetry, Shape, skin, secretion, supernum. Nipples

Palpation:

Nodes: (patient sitting upright)

• Supraclavicular
• Infraclavicular
• Axillary (pectoral/anterior, subscapular/post., lateral, central)

Breast: (patient supine, arms at sides)

• Start with Axymptomatic breast
• Masses: (location, size, shape, consistency, tenderness, mobility)
•  

Urologic

History

• Irritative: Frequency, urgency, nocturia, dysuria
• Obstructive: Straining, hesitancy, incomplete empty…
• Hematuria: pain/clots, part of stream?
• Stress incontinence?
• Erectile dysfunction? Firmness, initiating, maintaining, ejaculation
• Blood in semen
• Discharge
• Swelling/masses

Exam

Penis

• Size
• Skin
• Curvature
• Glans (ask to retract: check for phimosis, or paraphimosis)
• Meatus (hypospadius?) discharge?
• Palpate: using both hands along corpora cavernosa (peyronie’s disease?)
  • Open urethra to check for secretions

Testes

• Inspect: swelling, masses, varicoceles, skin changes
• Warm hands…
• Palpate both hands (one hand top/bottom, other left/right)
  • Comment size/shape/consistency/tenderness/nodules/masses
• If mass present, transilluminate (solid vs cystic)
• Palpate: epididymus, spermatic cord

Inguinal

• Masses/swellings (ask to valsalva for hernias)
• Stand up?
• Palpate (standing?): palpate each inguinal region
  • Put index finger through scrotum along spermatic cord to external and then internal ring, ask to cough.
• Auscultate for bowel sounds (maybe?)

Other:

• Inguinal, left supraclavicular nodes

Kidneys

• Percuss bilaterally?  Maybe do the hand strike technique?

Prostate

• Patient in Sims position, glove both hands, lubricate finger
• Use non-exam hand to spread buttocks for exam
• Inspection: inflam, warts, nodules, tumors, bleeding, hemorrhoids
• Palpation:
  • Warn pt that lube will feel cold,
  • ask to take deep breath in
  • Check sphincter tone, resistance
  • Turn finger to examine rectal wall (polyps, masses, irregularities)
  • Palpate anterior rectum + prostate
    • Median sulcus
    • Lateral lobes
    • Look for size, symmetry, masses, tenderness, nodules
    • Warn before withdrawing
    • Normal: bilobed, heart-shaped, 4cm diam, smooth, firm

ENT

Ophthalmic exam

• Hx burning, tender, red, pain, pain movement, headache/nausea, discharge
• Exam
  • Visual acuity
  • Visual fields
  • EOM
  • Inspect:
    • Ocular symmetry
    • Orbit (exophthalmos)
    • Eye lids
    • Conjunctiva, etc.
  • Opthalmoscope:
    • Approach 15’’ away, at 15°, move to 2’’ from eye
    • Optic disk
      • Margins: (sharp)
      • Color: (pinkish or yellow-orange)
      • Cup: (central, C:D is <0.5)
      • Papilledema?
    • Retinal vessels (normal, slight venous pulstations)
    • Macula:
      • Colour: (reddish orange, no lesions)

Peripheral Vascular

• Pain? SEVERE?
• 6 P’s: Pain, pallor, Paralysis, parasthesia, pulsenessness, polar
• Claudication: Pain with exercise, Predictable (same exercise), Disappears at rest.
• Critical ischemia?: Rest Pain, Numbness, Night Pain, Non-healing ulcers
• Ulcers?  Where? (brownish ulcers near ankle – venous; ulcers at distal,lateral,dorsal – arterial; bottom of foot btwn toes - diabetic)
• Risk factors:  smoking, HTN, DM, dyslipidemia, FHx, Lifestyle, dialisys
• Recent surgery, cancer, OCP, pregnancy, FHx clotting.
• Inspection:
  • Size, symmetry
  • Edema
  • Varicose/dilated veins
  • Skin thickness
  • Ulcers
  • Pallor
  • Nails
  • Lips
• Palpation
  • Tempearture (warmth, erythema = venous; cold = art.)
  • Edema (pitting, venous)
  • Leg sizes (smallest ankle, largest calf, thigh – compare both sides > 2cm = change atrophy or swelling è venous)
  • Cap refill (norm <3s)
  • Pulses
    • Carotid, brachial, radial, AA, renal, femoral, popliteal, post. Tibial, dorsalis pedis (0-4, 2 norm)
• Special Tests
  • Allen test – make tight first, occlude ulnar and rad arteries, release each one and see how long to return pink color to hand (try each first)
  • Pallor/Rubor – Normal: pink color returns 10 s, veins refill @ 15s. 
  • ABI

HIV Exam

• Inspection
  • Skin: Kaposi sarcoma.  Check entire skin (cancer of connective tissue, painless purplish-red to brown plaquelike lesions).
  • Pharynx: Thrush, oral hairy leukoplakia (EBV - raised white plaques on sides of tongue).
• Palpate
  • Neck, Clavicle, Axillae & Groin for LN enlargement by NH-Lymphoma.
  • Examine abdomen for hepatic/splenic enlargement. 
• +++ TODO.. other exam features (section unfinished)