NR 509 Final Exam Study Guide (Version 2) / NR509 Final Exam Study Guide (New 2022/2023):, Study Guides, Projects, Research of Nursing

Download NR 509 Final Exam Study Guide (Version 2) / NR509 Final Exam Study Guide (New 2022/2023): and more Study Guides, Projects, Research Nursing in PDF only on Docsity!

Final Study Guide WEEK 5 Chapter 10 Breast/Axillae Assessment  Any lumps, discomfort, pain- lumps may be physiologic or pathologic ranging from cysts and fibroadenomas to breast CA  Breast pain (Mastalgia) alone is not considered CA risk factor. CBE is warranted. Focal breast pain more likely to merit DI. Medical issues assoc w breast pain are hormones, SSRIs, spironolactone and digoxin  Any discharge from nipples and when it occurs? Discharge of fluid unrelated to pregnancy or lactation is more likely to be pathologic when it is bloody or serous, unilateral, spontaneous, assoc w a mass and occur in women over 40 Normal VS. Abnormal Findings and Interpretation  Age 15-25- common mass is fibroadenoma- smooth, rubbery, round, mobile. Nontender  Age 25-50- cysts- usually soft to form, round, mobile, often tender o Fibrocystic changes- nodular, ropelike o Cancer- irregular, firm, may be mobile or fixed to surrounding tissue  Over 50- cancer until proven otherwise  Pregnancy- lactating adenomas, cysts, mastitis, cancer  Arms at side inspection- note color, thickening, size and symmetry, contour, characteristics of nipple. (redness suggests local infection or inflammatory carcinoma, thickening suggest CA, flattening of normally convex breast suggests CA, asymmetry due to change in nipple direction suggests CA(inverted)).  Have pt put arms over head, on hips and lean forward to bring out dimpling or retraction that may be invisible  Palpation best performed when breast tissue is flattened- from midsternal line to posterior axillary line into tail (vertical strip pattern) Breast Cancer  2 nd^ leading cause of cancer death in women  Most important risk factor is age  Non modifiable risk factors family history of breast and ovarian CA, inherited genetic mutations, personal hx breast CA, high levels of endogenous hormones, breast tissue density, lesions on breast biopsy  Modifiable risk factors- breastfeeding less than 1 year, postmenopausal obesity, use of HRT, smoking, alcohol, physical inactivity, contraception  Risk factors for male breast CA- radiation exposure, BRCA1 AND 2 mutations, Klinefelter syndrome, testicular disorders, fam hx, etoh or cirrhosis and obesity  Gail and Claus model estimate absolute lifetime risk of breast CA

 Gail-incorporates age, race, 1st^ degree relatives w breast ca, previous biopsies, hyperplasia, age of period, age 1st^ delivery. Shouldn’t be used to women w hx breast CA or radiation exposure or those under 35.  Claus- incorportates family hx male and female, age  Also ask about fam hx ovarian CA  Screening recommendations Mammogram CBE BSE US Preventative Services 50-74-biennially <50 based on pt specific factors

40 not enough evidence to assess harm or benefit of CBE Recommends against teaching BSE American CA Society 40-45 optional annual 45-54-annual 55-biennial Not recommended Not recommended American college of OBGYN 40 annually 20-39 every 1-3 yrs 40 annually Encourage BSE  Mammogram- low sensitivity and specificity- high false positives. Perform better in younger women and with higher breast density Self-Breast Examination  Because breasts tend to swell and become more nodular before menses from increasing estrogen stimulation, the best time for examination is 5 to 7 days after the onset of menstruation Chapter 11 and Chapter 15 Abdominal/Peritoneal/Rectal Assessment and Modification for Age Abdominal assessment: Sequence: Inspection, auscultation, percussion, palpation Auscultation: for bowel sounds, bruit, and friction rub. Possible abnormal sounds: increased or decreased motility, bruit of renal artery stenosis, liver tumor, splenic infarct.. Percuss the abdomen for patterns of tympany and dullness. Possible abnormalities: Ascites, GI obstruction, pregnant uterus, ovarian tumor Palpate all quadrants of the abdomen for abdominal tenderness. Light palpation for guarding, rebound, and tenderness. Possible abnormalities: Firm, board like abdominal wall— suggests peritoneal inflammation. Guarding if the patient flinches, grimaces, or reports pain during palpation. Rebound tenderness from peritoneal inflammation; pain is greater

when you withdraw your hand than when you press down. Press slowly on a tender area, then quickly “let go. If you feel a mass, examine with the abdominal muscles tensed, usually, abdominal wall masses can be observed, whereas intra-abdominal masses are more concerning. A left upper quadrant mass is more likely to be a kidney if there is no palpable “notch,” you can push your fingers between the mass and the costal margin, there is normal tympany over this area, and you cannot push your fingers medial and deep to the mass Rectal assessment: Rectal assessment is a part of regular GI assessment over age of 40. Inspection: Check for fissures, lesions, scars, inflammation, discharge, rectal prolapse, skin tags, and external hemorrhoids. Palpation: The rectal walls should feel soft and smooth, without masses, fecal impaction, or tenderness. Peritoneal assessment: Check for ascites, a large accumulation of fluid in the peritoneal cavity caused by advanced liver disease, heart failure, pancreatitis, or cancer. Do not palpate a rigid abdomen. Peritoneal inflammation may be present, in which case palpation could cause pain or rupture an inflamed organ Normal VS. Abnormal Findings and Interpretation  Visceral pain- occurs when hollow abd organs are distended or stretched- in RUQ suggests liver distention  Visceral pain may be gnawing, burning, cramping or aching- visceral periumbilical pain suggests early acute appendicitis

 Parietal pain originates from inflammation of parietal peritoneum called peritonitis. Typically aggravated by moving or coughing  Referred pain is felt in more distant sites, pain may also be referred to abd from chest, spine, pelvis  Timing of pain? Acute or chronic? Where does pain start does it radiate  Factors that aggravate and relieve- pay special attention to body position, assoc w meals, alcohol, meds, stress, antacids Pancreatitis  In acute pancreatitis, epigastric tenderness and rebound tenderness are usually present, but the abdominal wall may be soft. Intrapancreatic trypsinogen activation to trypsin and other enzymes, resulting in autodigestion and inflammation of the pancreas. Epigastric, may radiate straight to the back or other areas of the abdomen; 20% with severe sequelae of organ failure  Chronic pancreatitis: Usually steady. Irreversible destruction of the pancreatic parenchyma from recurrent inflammation of either large ducts or small ducts. Epigastric, radiating to the back Severe, persistent, deep. Peptic Ulcer Disease  Mucosal ulcer in stomach or duodenum >5mm, covered with fibrin, extending through the muscularis mucosa; H.pylori infection in 90 % of peptic ulcers  Location-epigastric, may radiate straight to the back  Quality-Variable, epigastric gnawing or burning(dyspepsia) may also be boring or aching, or hunger like  Timing- wakes patient up at night. Occurs immediately over a few weeks, disappears for months, then recurs  Aggravating factors- variable  Relieving factors-food and antacid may bring relief  Associated symptoms- n/v, belching, bloating, heartburn, weight loss  Gastric ulcers: over 50 yrs old  Duodenal ulcer: 30-60 years old GERD

 Rising retrosternal burning pain or discomfort, aggravated by foods such as etoh, chocolate, citrus, coffee, onions, peppermint or positions like bending over, exercise, lifting, lying supine  Some pts w GERD have atypical respiratory symptoms- CP, cough, wheezing, aspiration pna  Alarm symptoms- dysphagia, pain w swallowing, vomiting, GIB, satiety, wt loss, anemia, gastric CA, palpable mass, painless jaundice- need endoscopy  If patient reports heartburn and regurgitation together or more than once a week, the accuracy of diagnosis of GERD is 90 %. H.pylori may be present. Usually occurs after meals, especially spicy foods.  Relieved by-Antacids, PPI, avoiding alcohol, smoking, fatty meals, chocolate, theophylline, CCB  Risk factors- salivary flow which prolongs acid clearance by damping action of the bicarbonate buffer; obesity; delayed gastric emptying; selected medications; hiatal hernia. Appendicitis  Because it empties into the colon inefficiently and its lumen is small, it is prone to becoming obstructed and is vulnerable to infection (appendicitis). The obstructed appendix becomes inflamed and edematous and eventually fills with pus. It is the most common cause of acute inflammation in the right lower quadrant of the abdominal cavity and the most common cause of emergency abdominal surgery. Males are affected more than females, teenagers more frequently than adults.  In the elderly, signs and symptoms of appendicitis may vary greatly. Signs may be very vague and suggestive of bowel obstruction or another process; some patients may experience no symptoms until the appendix ruptures. The incidence of perforated. Appendix is higher in the elderly because many of these people do not seek health care as quickly as younger people.  In women, consider pelvic inflammatory disease, ruptured ovarian follicle, and ectopic pregnancy. Combining signs with laboratory inflammatory markers and CT scans markedly reduces misdiagnosis and unnecessary surgery.  Obturator sign: right hypogastric pain with the right hip and knee flexed and the hip internally rotated CLINICAL MANIFESTATIONS  Lower right quadrant pain usually accompanied by low-grade fever, nausea, and sometimes vomiting.

 At McBurney’s point (located halfway between the umbilicus and the anterior spine of  the ilium), local tenderness with pressure and some rigidity of the lower portion of the right rectus muscle.  Rebound tenderness may be present; location of appendix dictates amounts of tenderness, muscle spasm, and occurrence of constipation or diarrhea.  Rovsing’s sign (elicited by palpating left lower quadrant, which paradoxically causes pain in right lower quadrant).  If appendix ruptures, pain becomes more diffuse; abdominal distention develops from paralytic ileus, and condition worsens. ASSESSMENT AND DIAGNOSTIC METHOD  Leukocyte count greater than 10,000/m  Neutrophil count greater than 75%;  Abdominal radiographs, ultrasound studies, and CT scans may reveal right lower quadrant density or localized distention of the bowel.  Surgery is indicated if appendicitis is diagnosed and should be performed as soon as possible to decrease risk of perforation.  Administer antibiotics and intravenous fluids until surgery is performed.  The major complication is perforation of the appendix, which can lead to peritonitis  Quality- mild but increasing, possibly cramping, steady and more severe  Timing- last 4-6 hrs., depending on intervention  Aggravating factors- movement or cough  Relieving factors- it if subsides temporarily suspect perforation of the appendix  Associated factors- anorexia, nausea and possibly vomiting following onset of pain, low fever  Twice as likely in the presence of RLQ tenderness, Rovising sign, and the psoas sign; it is three times more likely if there is McBurney point tenderness. Localized tenderness anywhere in the RLQ, even in the right flank suggests appendicitis.  Psoas Sign Positive : increased abdominal pain while placing your hands just above the patient’s knee and ask to raise thigh against hand. Then asking patient to turn onto left

side. Then extend the right leg at the hip. Flexion of the leg at the hip makes the psoas muscle contract; extension stretches it.  Classic Sign= Begins near the umbilicus, then migrates to the RLQ. Diverticulitis  Diffuse abd pain LLQ w distension, high pitched hyperactive bowel sounds, tenderness of palpation  Deep palpation is usually required to delineate the liver edge, the kidneys, and abdominal masses. The pain may be cramping at first, then steady.  Diverticulosis is necessary for the development of diverticulitis.  Diverticulosis is a condition in which outpouchings, or diverticula, develop in the colon. The majority of patients with diverticulosis are asymptomatic. However, 1–4% of patients with diverticulosis will develop diverticulitis. Low dietary fiber intake, high red meat intake, obesity, physical inactivity and smoking are all associated with an increased risk of diverticulitis.  The diverticula of the colon often have no symptoms unless inflammation causes diverticulitis. The pain is constant in nature and tends to be worse with movement. The left-sided predominance of pain is due to the fact that most diverticulitis occurs in the sigmoid or descending colon. If the sigmoid colon is redundant there may be suprapubic or right-sided pain. Look for localized peritoneal signs and a tender underlying mass.  The clinical presentation of acute diverticulitis ranges from mild abdominal pain to peritonitis with sepsis. The diagnosis can often be made based on clinical features alone, but imaging is necessary in more severe presentations to rule out complications such as abscess and perforation.  Assess for guarding, rebound, and distention of the left lower quadrant. The treatment of diverticulitis depends on the severity of the presentation, presence of complications and underlying comorbid conditions.  Foods that can get stuck in a diverticula (such as popcorn, nuts, and corn) should be avoided. Hepatitis Visceral pain in the RUQ. Liver span decreases. Jaundice- is a striking yellowish discoloration of the skin and sclera from increased levels of bilirubin, Hepatitis -Hepatitis, or inflammation of the liver, can be caused by several different viruses. Symptoms of hepatitis are universal, regardless if caused by an infectious agent or chronic condition, and can include fatigue, anorexia, abdominal pain, fever, diarrhea, vomiting, jaundice,

dark urine, and pale clay-colored stools. The mode of transmission, communicability, and incubation period differ greatly with the type of virus. In the United States, hepatitis A, B, and C are the most common viruses that cause hepatitis and are of great public health significance. The best strategy for preventing infection and transmission of hepatitis A and B is vaccination. Also, educate patients about how the hepatitis viruses spread and behavioral strategies to reduce the risk of infection. Screen high-risk groups for hepatitis B. Hepatitis A.

• Transmission of hepatitis A virus (HAV) is through a fecal– oral route. Fecal shedding followed by poor hand washing contaminates water and foods, leading to infection of household and sexual contacts. Infected children are often asymptomatic, contributing to spread of infection. To reduce transmission, advise hand washing with soap and water after bathroom use or changing diapers (daycare workers), and before preparing or eating food. Diluted bleach can be used to clean environmental surfaces. HAV infection is rarely fatal—fewer than 100 deaths occur each year—and usually only in people with other liver diseases; it does not cause chronic hepatitis.
• The vaccine alone may be administered at any time before traveling to endemic areas. Healthy unvaccinated individuals should receive either a hepatitis A vaccine or a single dose of immune globulin (preferred for those ≥age 40 years) within 2 weeks of being exposed to HAV. These recommendations apply to close personal contacts of persons with confirmed HAV, coworkers of infected food handlers, and staff and attendees (and their household members) of childcare centers where HAV has been diagnosed in children, staff, or households of attendees. Hepatitis B.
• Hepatitis B virus (HBV) infection is a more serious threat than infection with hepatitis A. The fatality rate for acute infection can be up to 1% and HBV infection can become chronic. Approximately 95% of infections in healthy adults are self-limited, with elimination of the virus and development of immunity. Risk of chronic HBV infection is highest when the immune system is immature—chronic infection occurs in 90% of infected infants and 30% of children infected before age 5 years. About 15% to 25% of those with chronic HBV infection die from cirrhosis or liver cancer, accounting for nearly 3,000 deaths each year in the United States.
• Most persons with chronic infection are asymptomatic until the onset of advanced liver disease. Screening. The USPSTF recommends screening for HBV in persons at high risk for infection (grade B), including those born in countries with a high endemic prevalence of HBV infection, persons with HIV, injection drug users, men who have sex with men, and household contacts or sexual partners of HBV-infected persons. The CDC recommends screening all pregnant women, ideally in the first trimester, and universal vaccination for all infants beginning at birth. For adults, vaccine recommendations also target high-risk groups, including those in high-risk settings. Hepatitis C.
• There is no vaccination for hepatitis C, so prevention targets counseling to avoid risk factors. Screening should be recommended for high-risk groups.
• Hepatitis C virus (HCV), transmitted mainly by percutaneous exposures, it is the most prevalent chronic bloodborne pathogen in the United States. Anti-HCV antibody is

detectable in just under 2% of the population, though prevalence is markedly increased in high-risk groups, particularly injection drug users.

• Additional risk factors for HCV infection include blood transfusion or organ transplantation before 1992, transfusion with clotting factors before 1987, hemodialysis, health care workers with needle stick injury or mucosal exposure to HCV-positive blood, HIV infection, and birth from an HCV-positive mother. Sexual transmission is rare.
• Hepatitis C becomes a chronic illness in over 75% of those infected and is a major risk factor for subsequent cirrhosis, hepatocellular carcinoma, and need for liver transplant for end-stage liver disease.
• However, the majority of persons with chronic HCV are unaware of being infected. Response to antiviral therapy (undetectable HCV RNA 24 weeks after completing treatment) ranges from 40% to over 90% depending on the viral genotype and the combination of drugs used for treatment. Consequently, the USPSTF has concluded that screening for hepatitis C infection is of moderate benefit for persons at high risk for infection as well as those born between 1945 and 1965 (grade B). a bile pigment derived chiefly from the breakdown of hemoglobin. Acholic stools-occur in viral hepatitis briefly A-Travel or meals in areas of poor sanitation, ingestion of contaminated water or foodstuffs. FECAL or ORAL route. Fecal shedding by poor hand washing contaminates water and foods, leading to infection of household and sexual contact. Infected children are asymptomatic. Vaccine: all children under 1y; chronic liver disease; traveling to areas with high endemic rates; men who have sex with men; injection and illicit drug users; person who have clotting disorders If exposed: healthy unvaccinated shoulder with get a hepatitis A vaccine or a single dose of immune globulin within 2 weeks of exposure B-Parenteral or mucous membrane exposure to infectious body fluids: blood, serum, semen, saliva through sexually contact or injection of needle. C- illicit injection drug use or blood transfusion. No vaccine. Becomes a chronic illness of those infected and is a major risk factor for subsequent cirrhosis, hepatocellular carcinoma, and need for liver transplant. IBS  Change in frequency or form of BM linked to luminal and mucosal irritants that alter motility, secretion and pain sensitivity  Commonly exacerbated by excess stress. It may be classified as diarrhea predominant or constipation predominant. In some cases, it may alternate between the two.  Irritable bowel syndrome (IBS) is a chronic functional bowel disorder associated with abdominal pain or discomfort, bloating, and altered bowel habits that continue for 3 months with onset 6 months before diagnosis and occurs in the absence of any structural or biochemical abnormalities.  Change in bowel habits with a mass lesion warns of colon cancer. Intermittent pain for 12 weeks of the preceding 12 months with relief from defecation, change in frequency of

bowel movements, or change in the form of stool (loose, watery, pellet-like), linked to luminal and mucosal irritants that alter motility, secretion, and pain sensitivity suggests irritable bowel syndrome.  Worse in the morning; rarely at night. Crampy lower abdominal pain, abdominal distention, flatulence, nausea; urgency, pain relieved with defecation.  Altered motility or secretion from luminal and mucosal irritants that change mucosal permeability, immune activation, and colonic transit, including mal-digested carbohydrates, fats, excess bile acids, gluten intolerance, enteroendocrine signaling, and changes in microbiomes.  Irritable bowel syndrome will cause loose bowel movements with cramps but no systemic symptoms of fever, weight loss, or malaise. This syndrome is more likely in young women with alternating symptoms of loose stools and constipation. Stress usually makes the symptoms worse, as do certain foods.  IBS diagnose guidelines recommend that providers use a symptom-based strategy based on routine physical examination and standardized criteria, such as the Rome III.  Hypothyroidism can cause constipation Treatment Plan.  Increase dietary fiber. Supplement fiber with psyllium (Metamucil or Konsyl), methylcellulose (Citrucel), wheat dextrin (Benefiber). Start at a low dose (causes gas).  Avoid gas-producing foods: Beans, onions, cabbage, high-fructose corn syrup. If poor response, use a trial diet of lactose avoidance or gluten avoidance.  Antispasmodics for abdominal pain: Administer dicyclomine (Bentyl) or hyoscyamine as needed.  IBS with constipation: Begin a trial of fiber supplements, polyethylene glycol (osmotic laxative). If severe constipation: Prescribe lubiprostone or linaclotide (contraindicated in pediatric patients younger than 6 years, has caused death from dehydration).  IBS with diarrhea: Take loperamide (Imodium) before regularly scheduled meals. • Severe diarrhea–predominant IBS: Administer alosetron (warning: ischemic colitis, which can be fatal). Decrease life stress. Address anxiety/stress with patient and offer treatment strategies. Rule out: Amoebic, parasitic, or bacterial infections; inflammatory disease of the GI tract; and so forth. Check stool for ova and parasites (especially diarrheal stools) with culture  Osmotic diarrhea: usually related to lactose intolerance, watery diarrhea often follows meal ingestion. Crampy abdominal pain, distension, and gas often accompany symptoms.

Diarrhea is often provoked by pizza, milkshakes, yogurt, and other lactose-containing foods Colon/Anorectal Cancer

• Very gradual (years) with vague GI symptoms. Tumor may bleed intermittently, and patient may have iron-deficiency anemia. Changes in bowel habits, stool, or bloody stool. Heme positive stool, dark tarry stools, mass on abdominal palpation. Older patients (older than 50 years of age), especially with history of multiple polyps or inflammatory bowel disease such as Crohn’s disease (CD) or ulcerative colitis (UC).
• Screening for Colorectal Cancer: Screening tests include stool tests that detect occult fecal blood, such as fecal immunochemical tests, high-sensitivity guaiac-based tests, and tests that detect abnormal DNA. Endoscopic tests are also used for screening, including colonoscopy, .Imaging tests include double-contrast barium enema and CT colonography. Any abnormal finding on a stool test, imaging study, or flexible sigmoidoscopy warrants further evaluation with colonoscopy.
• Colorectal cancer is the third most frequently diagnosed cancer among both men and women (over 140,000 new cases) and the third leading cause of cancer death (nearly 50,000 deaths) each year in the United States.
• The strongest risk factors for colorectal cancer are: increasing age; personal history of colorectal cancer, adenomatous polyps, or longstanding inflammatory bowel disease; and family history of colorectal neoplasia—particularly those with affected multiple first-degree relatives, a single first-degree relative diagnosed before age 60 years, or a hereditary colorectal cancer syndrome.
• The most effective prevention strategy is to screen for and remove precancerous adenomatous polyps. Screening programs using fecal blood testing or flexible sigmoidoscopy have been shown in randomized trials to reduce the risk of developing colorectal cancer.
• Physical activity, aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs), and postmenopausal combined hormone replacement therapy (estrogen and progestin) are also associated with decreased risk of colorectal cancer. Chapter 13 Male Genitalia Assessment and Modification for Age Undescending testes: In infant, testis must often be “milked” into the scrotum from the inguinal canal The scrotum is divided into two compartments, each containing a testis or testicle. Covering the testis. The internal opening of the canal, the internal inguinal ring, is approximately 1 cm above the midpoint of the inguinal ligament. Neither the canal nor the internal ring is palpable through the abdominal wall. The exterior opening of the tunnel, the external inguinal ring, is a triangular slit-like structure palpable just above and lateral to the pubic tubercle. When loops of bowel force their way through the inguinal canal, they produce inguinal hernias. Another route for a herniating mass is the femoral canal, below the inguinal ligament. Although this canal is not visible, you can estimate its location by placing your right index finger, from below, on the right femoral artery. Your middle finger will then overlie the femoral vein; your ring finger, the femoral canal. Femoral hernias protrude at this location. Ask about any discharge from the penis, dripping, or staining of underwear. If penile discharge is present, clarify the amount, color, and

any fever, chills, rash, or associated symptoms. Inquire about sores or growths on the penis. Ask about swelling or pain in the scrotum. Inspect the penis, including: The skin. Inspect the skin on the ventral and dorsal surfaces and the base of the penis for excoriations or inflammation, lifting the penis when necessary. The prepuce (foreskin). If present, retract the prepuce or ask the patient to retract it. This step is essential for the detection of chancres and carcinomas. Smegma, a cheesy, whitish material, may accumulate normally under the foreskin. The glans. Look for any ulcers, scars, nodules, or signs of inflammation. The urethral meatus. Inspect the location of the urethral meatus. Compress the glans gently between your index finger above and your thumb below. This maneuver should open the urethral meatus and allow you to inspect it for discharge. Normally, there is none. If the patient has reported a discharge that you are unable to see, ask him to strip, or milk, the shaft of the penis from its base to the glans. Alternatively, do this yourself. This maneuver may expel some discharge from the urethral meatus for appropriate examination. Have a glass slide and culture materials ready. Palpate the shaft of the penis between your thumb and first two fingers, noting any induration. (This may be omitted in a young asymptomatic male patient.) Palpate any abnormality of the penis, noting any induration or tenderness. If you retract the foreskin, replace it before proceeding on to examine the scrotum. Inspect the scrotum, including: The skin. Lift up the scrotum so that you can inspect its posterior surface. Note any lesions or scars. Inspect the pubic hair distribution. The scrotal contours. Inspect for swelling, lumps, veins, bulging masses, or asymmetry of the left and right hemiscrotum. The inguinal areas. Note any erythema, excoriation, or visible adenopathy. There may be dome-shaped white or yellow papules or nodules formed by occluded follicles filled with keratin debris of desquamated follicular epithelium. Such epidermoid cysts are common, frequently multiple, and benign. Palpation. If using a one-handed technique, palpate each testis and epididymis between your thumb and first two fingers. If using two hands, cradle the testis at both poles in the thumb and fingertips of both hands. Palpate the scrotal contents as you gently slide them back and forth from the fingertips of one hand to the other, without changing the position of your hands as they cup the scrotum. This technique is comfortable for the patient and allows a subtle controlled and accurate examination. The testes should be firm but not hard, descended, symmetric, nontender, and without masses. For each testis, assess size, shape, consistency, and tenderness; feel for any nodules. Pressure on the testis normally produces a deep visceral pain. Palpate the epididymis on the posterior surface of each testicle without applying excess pressure, which can cause discomfort. The epididymis feels nodular and cord-like and should not be confused with an abnormal lump. Normally, it should not be tender. Palpate each spermatic cord, including the vas deferens, between your thumb and fingers, from the epididymis to the external inguinal ring. The vas feels slightly stiff and tubular and is distinct from the accompanying vessels of the spermatic cord. Palpate any nodules or swellings. Swelling in the scrotum apart from the testicles can be evaluated by transillumination. After darkening the room, shine the beam of a strong flashlight from behind the scrotum through the mass. Look for transmission of the light as a red glow Prostate Issues and Cancer  Prostate Cancer: 2nd leading cause of cancer of cancer in the US.

 Risk Factors:<40, African American men, genetics, (potentially exposure to agent orange, diets high in animal fats, smoking, obesity.  Prevention: PSA TESTING (normal levels are >4.0). False positives are caused by BPH, prostate infections, and ejaculation.  Digital Rectal Exam: finds palpable nodules in the posterior and lateral areas of the prostate gland. It is unable to detect cancer in the anterior and central areas of the gland. The exam is performed by having the pt bear down and note any irregularities or nodules. Sweep your finger carefully over the prostate gland, identifying it’s lateral lobes and the groove of the median sulcus. Note shape, mobility, and consistency of the prostate.  Screening: Patients with average risk should begin screening between 50-55 years of age. PSA screening should continue every 1-2 years. High risk screening: should start at 40- years of age STI (Male)  Gonorrhea-yellow penile discharge  Chlamydia-white discharge MOST COMMON STI  Disseminated gonorrhea- rash, tenosynovitis, monoarticular arthritis, even meningitis,not always urogenital symptoms  Genital warts (condylomata Acuminata)- single or multiple papules or plaques of carriable shapes. Caused by HPV. Incubation-weeks to months; infected person may not have visible warts  Herpes: BURNING pain, vesicles  Genital warts (condylomata Acuminata)- single or multiple papules or plaques of carriable shapes. Caused by HPV. Incubation-weeks to months; infected person may not have visible warts  Syphilis- small red papule that becomes chancre, a painless erosion up to 2 cm in diameter. Syphilis is fairly uncommon but does occur in the highly promiscuous population, especially when coupled with illegal drug use. Base of chancre is clean, red, smooth, and glistening; borders are raised and indurated. Chancre heals within 3 to 8 weeks. Cause-treponema pallidum, a spirochete. Incubation 9-90 days after exposure. May develop inguinal lymphadenopathy within 7 days, lymph nodes are rubbery, non- tender, mobile. Patients develop secondary syphilis while chancre still present (suggests coinfection of HIV)  Chancroid- red papule or pustule initially, then forms a painful deep ulcer with ragged nonindurated margins; contains necrotic exudate, has a friable base. Cause- Haemophilus

ducreyi, an anaerobic bacillus. Incubation- 3 to 7 days after exposure. Painful inguinal adenopathy Testicular Disorders and Cancer Acute orchitis: The scrotum will be red and tense. Orchitis is usually unilateral and often associated with viral infections such as mumps. Varicocele: Varicoceles are varicose veins surrounding the spermatic cord, coming through the inguinal ring. These veins feel like spaghetti and are often referred to as a “bag of worms.” The increased number of veins affects the temperature of the testes, often causing infertility problems. Like most varicose veins in any area, varicoceles can cause a nonspecific aching. Although usually benign, a unilateral varicocele on the right or a varicocele which does not resolve in the supine position deserves further workup Hydrocele: Fluid-filled cyst originating within the tunica vaginalis. An examining finger can be placed over the mass into the inguinal ring. An outside light source can be placed beneath the scrotum. Hydroceles often transilluminate light, whereas solid tumors do not. Erectile Dysfunction May be a from psychogenic causes, especially if early morning erection is preserved; it may also reflect decreased testosterone, decreased blood flow in the hypogastric arterial system, impaired neural innervation, and diabetes. Erectile dysfunction, or the inability to maintain an erection, affects approximately 50% of older men. Vascular causes are the most common, from both atherosclerotic arterial occlusive disease and corpora cavernosa venous leak. Chronic diseases such as diabetes, hypertension, dyslipidemia, and smoking, as well as medication side effects, all contribute to the prevalence of erectile dysfunction Men with screen-detected cancers who undergo aggressive treatment with surgery or radiation frequently leads to complications such as erectile dysfunction, urinary incontinence, and bowel problems that adversely affect the quality of life. Arterial ischemia in iliac–pudendal leads to erectile dysfunction. Erectile dysfunction can be due to psychogenic causes, especially if early morning erection is preserved. Decreased testosterone, decreased blood flow in hypogastric arterial system, impaired neural innervation, and diabetes can also cause Erectile Dysfunction. Tanner Staging (Male)

1. Prepubertal
2. Enlargement of scrotum, testes, scrotal skin reddens and changes in texture
3. Enlargement of penis, further growth of testes
4. Increased size of penis with growth in breadth and development of glands, testes and scrotum larger, scrotal skin darker
5. Adult genitalia Incontinence (Male) If the patient reports incontinence, ask if the patient is leaking small amounts of urine due to increased intra-abdominal pressure from coughing, sneezing, laughing, or lifting. *Stress incontinence Or following an urge to void, is there an involuntary loss of large amounts of urine? Is there a sensation of bladder fullness, frequent leakage, or voiding of small amounts but difficulty emptying the bladder?

In stress incontinence, increased abdominal pressure causes bladder pressure to exceed urethral resistance—there is poor urethral sphincter tone or poor support of bladder neck. Arises from decrease intraurethral pressure. · Causes: childbirth and surgery. Local conditions affecting urethral sphincter such as postmenopausal atrophy of mucosa and urethral infection; in men, stress incontinence may follow prostate surgery. · Symptoms: Occurs with coughing, laughing, and sneezing while in upright position. Urine loss if unrelated to conscious urge to urinate. · Physical signs: Atrophic vaginitis may be evident. Bladder distention absent. In urge incontinence, urgency is followed by involuntary leakage due to uncontrolled detrusor contractions that overcome urethral resistance. · Bladder typically small. · Occur from decreased cortical inhibition of detrusor contractions from stroke, brain tumor, dementia, and lesions of the spinal cord above sacral level. o Symptoms: Involuntary urine loss followed by urge to urinate. Volume moderate. o Physical signs: small bladder not detectable on examination. · Also from Hyperexcitability of sensory pathways as in bladder infections, tumors, and fecal impactions. o Symptoms: urgency, frequency, nocturia with small-mod amounts. If acute inflammation is present, pain on urination. o Physical signs: decreased cortical inhibition will shows mental deficits or motor signs of central nervous system disease · Also from deconditioning of voiding reflexes such as frequent voluntary voiding at low bladder volumes. o Symptoms: possibly pseudo-stress incontinence – voiding 10-20sec after stresses such as change in position, going up and down stairs, possibly laughing, coughing, sneezing. o Physical sign: signs of local pelvic problems or fecal impaction may be present. In overflow incontinence, neurologic disorders or anatomic obstruction from pelvic organs or the prostate limit bladder emptying until the bladder becomes overdistended. Detrusor contractions are insufficient to overcome urethral resistance, causing urinary retention. · Mechanisms: Obstruction of the bladder outlet, as in benign prostatic hyperplasia or tumor. Weakness of the detrusor muscle associated with peripheral nerve disease at S2–4 level. Impaired bladder sensation that interrupts the reflex arc, as in diabetic neuropathy. · Symptoms: When intravesicular pressure overcomes urethral resistance, continuous dripping or dribbling incontinence ensues. Decreased force of the urinary stream. Prior symptoms of partial urinary obstruction or other symptoms of peripheral nerve disease may be present. · Physical signs: Examination often reveals an enlarged, sometimes tender, bladder. Other signs include prostatic enlargement, motor signs of

peripheral nerve disease, a decrease in sensation (including perineal sensation), and diminished to absent reflexes. Bladder control involved neuroregulatory and motor mechanism. Central and peripheral severe lesions affect S2 to S4 can affect normal voiding. Ask: does patient feel when bladder is full, when voiding: functional and mixed incontinence. Functional incontinence arises from impaired cognition, musculoskeletal problems, or immobility. Patient functionally unable to reach the toilet in time because of impaired health or environmental conditions. · Mechanism: problems in mobility resulting from weakness, arthritis, poor vision, or other conditions. Environmental factors such as unfamiliar setting, distant bathroom, bed rails, or physical restraints. · Symptoms: Incontinence on way to toilet or only early morning. · Physical signs: Bladder not detectable on exam; look for physical or environmental clues as the cause. Mixed incontinence is combined stress and urge incontinence Incontinence secondary to medications: Sedatives, tranquilizers, anticholinergics, sympathetic blockers, and potent diuretics Chapter 14 Female Genitalia and Modification for Age External Genitalia (Vulva) includes mons pubis overlying the symphysis pubis; labia majora; labia minora; prepuce and clitoris. The opening into the vagina is the introitus (in virgins may be hidden by the hyman). The perineum refers to tissue between introitus and anus. The urethral meatus opening is between the clitoris and vagina. Paraurethral (Skene) glands are just posterior and adjacent to the meatus on either side. The Bartholin glands are posteriorly on both sides but not always visible. Internal Genitalia: Locate the cervix with a gloved and water-lubricated index finger. Assess support of vaginal outlet by asking patient to strain down. Enlarge the introitus by pressing its posterior margin downward. Insert a water-lubricated speculum of suitable size. Start with speculum held obliquely, then rotate to horizontal position for full insertion. Open the speculum and inspect cervix. Observe: ● Position ● Color ● Epithelial surface Any discharge or bleeding ● Any ulcers, nodules, or masses Obtain specimens for cytology (Pap smears) with: An endocervical broom or brush with scraper (except in pregnant women), to collect both squamous and columnar cells ● Or, if the woman is pregnant, use a cotton-tipped applicator moistened with water Inspect the vaginal mucosa as you withdraw the speculum. Palpate, by means of a bimanual examination: ● The cervix and fornices

● The uterus ● Right and left adnexa (ovaries) Assess strength of pelvic muscles. With your vaginal fingers clear of the cervix, ask patient to tighten her muscles around your fingers as hard and long as she can. Perform a rectovaginal examination to palpate a retroverted uterus, uterosacral ligaments, cul-de- sac, and adnexa or screen for colorectal cancer in women 50 years or older. Normal VS. Abnormal Findings and Interpretation Normal: No inguinal adenopathy. External genitalia without erythema, lesions, or masses. Vaginal mucosa pink. Cervix parous, pink, and without discharge. Uterus anterior, midline, smooth, and not enlarged. No adnexal tenderness. Pap smear obtained. Rectovaginal wall intact. Rectal vault without masses. Stool brown and Hemoccult negative. Abnormal: Weakness of the pelvic floor muscles may cause pain; urinary incontinence; fecal incontinence; and prolapse of the pelvic organs that can produce a cystocele, rectocele, or enterocele. Risk factors are advancing age; prior pelvic surgery or trauma; parity and child-birth; clinical conditions (obesity, diabetes, multiple sclerosis, Parkinson disease); medications (anticholinergics, a-adrenergic blockers); and chronically increased intra-abdominal pressure from chronic obstructive pulmonary disease (COPD), chronic constipation, or obesity. Loss of urethral support contributes to stress incontinence. Weakness of the perineal body from childbirth predisposes to rectoceles and enteroceles. Epidermoid Cyst A small, firm, round cystic nodule in the labia suggests an epidermoid cyst. They are yellowish in color. Look for the dark punctum marking the blocked opening of the gland Carcinoma of the Vulva An ulcerated or raised red vulvar lesion in an elderly woman may indicate vulvar carcinoma. Trichomonas vaginitis Discharge: Yellowish green, often profuse, may be malodorous Other Symptoms: Itching, vaginal soreness, dyspareunia Vulva: May be red Vagina: May be normal or red, with red spots, petechiae Laboratory Assessment: Saline wet mount for trichomonads Candida vaginitis Discharge White, curdy, often thick, not malodorous Other Symptoms: Itching, vaginal soreness, external dysuria, dyspareunia Vulva: Often red and swollen Vagina: Often red with white patches of discharge Laboratory Assessment: KOH preparation for branching hyphae STI (Female) Test women younger than 26 years and pregnant women for Chlamydia; in women at increased risk and pregnant women, test for gonorrhea, syphilis, and HIV. For sexually transmitted infections (STIs) and diseases, identify sexual preference (male, female, or both) and the number of sexual partners in the previous month. Ask if the patient has concerns about HIV infection, desires HIV testing, or has current or past partners at risk.

Chlamydial infection is a cause of urethritis, cervicitis, PID, ectopic pregnancy, infertility, and chronic pelvic pain. Risk factors include age younger than 26 years, multiple partners, and prior history of STIs. Chlamydia and gonorrhea screening annually for all sexually active women ages <25 years and older women with risk factors such as new or multiple sex partners, or a sex partner infected with an STI. Chlamydia, syphilis, hepatitis B, and HIV screening for all pregnant women and gonorrhea screening for at-risk pregnant women starting early in pregnancy, with repeat testing as needed to protect the health of mothers and their infants. Chlamydia, gonorrhea, and syphilis screening at least once a year for all sexually active gay, bisexual, and other MSM. MSM who have multiple or anonymous partners should be screened more frequently for STIs (i.e., at 3-to 6-month intervals). ● HIV testing at least once for all adults and adolescents from ages 13 to 64 years. ● ● HIV testing at least once a year for anyone having unsafe sex or using injection drug equipment. Sexually active gay and bisexual men may benefit from testing every 3 to 6 months. Venereal Wart (Condyloma Acuminatum) Warty lesions on the labia and within the vestibule suggest condylomata acuminata from infection with human papillomavirus. Genital Herpes Shallow, small, painful ulcers on red bases suggest a herpes infection. Initial infection may be extensive, as illustrated here. Recurrent infections are usually confined to a small local patch. Syphilitic Chancre A firm, painless ulcer suggests the chancre of primary syphilis. Because most chancres in women develop internally, they often go undetected Secondary Syphilis (Condyloma Latum) Slightly raised, round or oval flattopped papules covered by a gray exudate suggest condylomata lata, a manifestation of secondary syphilis. They are contagious. Bacterial Vaginosis Discharge: Gray or white, thin, homogeneous, scant, malodorous Other Symptoms: Fishy genital odor Vulva: Usually normal Vagina: Usually normal Laboratory Assessment: Saline wet mount for “clue cells,” “whiff test” with KOH for fishy odor Example of physical exam findings: Bilateral shotty inguinal adenopathy. External genitalia without erythema or lesions. Vaginal mucosa and cervix coated with thin white homogeneous discharge with mild fishy odor. After swabbing the cervix, no discharge visible in the cervical os. Uterus midline; no adnexal masses. Rectal vault without masses. Stool brown and negative for fecal blood. pH of vaginal discharge >4.5” Menstruation  Menarche- age of onset  Pain? PMS, amenorrhea, abnormal bleeding, menopause, post menopausal bleeding

Cervical Disorders Endocervical polyp A bright red, smooth mass that protrudes from the os suggests a polyp. It bleeds easily. Mucopurulent cervicitis A yellowish exudate emerging from the cervical os suggests infection from Chlamydia, gonorrhea (often asymptomatic), or herpes. Carcinoma of the cervix An irregular, hard mass suggests cancer. Early lesions are best detected by colposcopy following abnormal Pap smear from of high risk of HPV. Fetal exposure to diethylstilbestrol (DES) Several changes may occur: a collar of tissue around the cervix, columnar epithelium that covers the cervix or extends to the vaginal wall (then termed vaginal adenosis), and, rarely, carcinoma of the vagina. Relaxations of the Pelvic Floor A cystocele is a bulge of the anterior wall of the upper part of the vagina, together with the urinary bladder above it. A cystourethrocele involves both the bladder and the urethra as they bulge into the anterior vaginal wall throughout most of its extent. A rectocele is a bulge of the posterior vaginal wall, together with a portion of the rectum. A prolapsed uterus has descended down the vaginal canal. There are three degrees of severity: first, still within the vagina (as illustrated); second, with the cervix at the introitus; and third, with the cervix outside the introitus. Positions of the Uterus and Uterine Myomas An anteverted uterus lies in a forward position at roughly a right angle to the vagina. This is the most common position. Anteflexion—a forward flexion of the uterine body in relation to the cervix— often coexists. A retroverted uterus is tilted posteriorly with its cervix facing anteriorly. A retroflexed uterus has a posterior tilt that involves the uterine body but not the cervix. A uterus that is retroflexed or retroverted may be felt only through the rectal wall; some cannot be felt at all. A myoma of the uterus is a very common benign tumor that feels firm and often irregular. There may be more than one. A myoma on the posterior surface of the uterus may be mistaken for a retrodisplaced uterus; one on the anterior surface may be mistaken for an anteverted uterus Cervical Cancer Screening  Most important risk factor for cervical ca is persistent infection with HPV 16 or 18, others include smoking, immunosuppression, OC  Screening begins at 21, every 3 years until age 65. Screening ends age 65 with 3 consecutive prior negative results. No screening recommended after hysterectomy Tanner Staging (Female) ADOLESCENT GIRLS: Assessing sexual maturity is done by rating pubic hair Stage 1- Preadolescent girls have no pubic hair but may have fine, vellus hair Stage 2- Sparse growth of long, slightly pigmented, curly or straight hair along labia

Stage 3- Darker coarser hair spreading to pubic symphysis Stage 4- Coarse and curly hair as in adults; but not as much and not including thighs Stage 5- Adult hair quantity and quality- spreads to medial surface of the thighs not on abdomen Considerations for Adolescent girls: first examination should be done by experienced provider. Adolescent Initial sign of puberty: hyman thickening and redundancy secondary to estrogen, widening of the hips, beginning of height spurt - these changes may be difficult to detect. The first easily detectable sign of puberty is the appearance of breast buds although pubic hair may be seen earlier. Chapter 18 Newborn/Infant/Pediatric Assessment and Modification for Age  APGAR- HR, RR, Muscle tone, reflex irritability, color  Normal VS. Abnormal Findings and Interpretation Newborn Skin Disorders  Ruddy (reddish purple color) newborn with polycythemia  Cutis marmorata-prominent in premature infants or infants with congenital hypothyroidism and Down syndrome. If acrocyanosis does not disappear within 8 hours or with warming, cyanotic congenital heart disease should be considered.  Central cyanosis in a baby or child of any age should raise suspicion of congenital  heart disease. The best area to look for central cyanosis is the tongue and oral mucosa

 café-au-lait spots Pigmented light-brown lesions (<1 to 2 cm at birth) but multiple lesions may suggest neurofibromatosis   Midline hair tufts over the lumbosacral spine region - a possible spinal cord defect. 

 Jaundice within the first 24 hours of birth may be from hemolytic disease of the newborn.  Late-appearing jaundice or jaundice that persists beyond 2 to 3 weeks should raise suspicions of biliary obstruction or liver disease. A common source of jaundice during the first couple of weeks is breastfeeding jaundice, which resolves around 10 to 14 days of life. Persistent jaundice requires evaluation.  A unilateral dark, purplish lesion, or “port wine stain” over the distribution of the ophthalmic branch of the trigeminal nerve may be a sign of Sturge–Weber syndrome, which is associated with seizures, hemiparesis, glaucoma, and mental retardation.  Significant edema of the hands and feet of a newborn girl may be suggestive of Turner syndrome. Other features such as a webbed neck would reinforce this diagnosis. Birthmarks Eyelid Patch: This birthmark fades, usually within the first year of life. Salmon Patch: called “stork bite,” or “angel kiss,”splotchy pink mark fades with age. Café-au-lait Spots: These light-brown pigmented lesions usually have borders andare uniform. Noted in more than 10% of black infants. If > 5 café-au-lait spots exist, consider the diagnosis of neurofibromatosis Slate Blue Patches- more common among dark-skinned babies. to note that are not mistaken for bruises. Childhood Vaccinations

Primitive Reflexes  Develop during gestation and are demonstratable at birth and disappear at defined aged. Abnormalities suggest neurologic drsease  Plantar grasp- birth -4 months  Plantar grasp relex toes- birth to 6-8 mo  Rooting- birth to 4 mo  Moro (startle)- birth to 4 mo  Tonic neck reflex- birth to 2 mo  Trunk incurvation- birth to 2 mo  Landau- birth to 6 mo Developmental Milestones  Early childhood (1-4 years): after infancy, physical growth slows by ½; after 2 years, toddlers gain 2-3 kg and grow 5 cm/year. Gross motor skills: Walk by 15 months, run by 2 years, tricycle/jump by 4 years. Drawing/Fine motor: 18-month old scribbles, 2-year old draws lines, 4-year old makes circles; Cognitive: toddlers move from sensorimotor to symbolic thinking. 18-month old: 10-20 words, 2-year old: three-word sentences; 4-year old: complex sentences. Toddlers are impulsive with poor self-regulation= common temper tantrums.

 Middle Childhood (5-10 years): Physical growth: steadily and slowly, strength and coordination improve. More awareness of physical disability limitations. Cognitive: “concrete operational,” meaning capable of limited logic and more complex learning. Limited ability to understand consequences and are greatly influenced by school, family, and environment. + language complexity. Social: more independent, start activities, enjoy accomplishments (this helps with self-esteem), + self-identity evolves. + Guilt and poor self-esteem may emerge. Clear sense of “right” and “wrong.”  Adolescents (11-20 years): Physical growth: pubertal transformation over several years (age 10-14 years in girls, 11-16 years in boys ); Cognitive: progression from concrete to formal operational thinking, ability to reason w/ abstract thinking; Social: family- influence versus autotomy and peer influence. + struggle for identity, independence, intimacy, stress, health-related problems, and high-risk behaviors. Chapter 19 Pregnancy and Assessment Prenatal care focuses on optimizing health and minimizing risk for the mother and fetus. The goals of the initial prenatal visit are to define the health status of the mother and fetus, confirm the pregnancy and estimate gestational age, develop a plan for continuing care, and counsel the mother about her expectations and concerns. During subsequent visits, you should assess any interim changes in the health status of the mother and fetus, review specific physical examination findings related to the pregnancy, and provide counseling and timely preventive screenings. Initial prenatal history ● Confirmation of pregnancy ● Symptoms of pregnancy ● Concerns and attitudes toward the pregnancy ● Current health and past clinical history ● Past obstetric history ● Risk factors for maternal and fetal health ● Family history of patient and father of the newborn ● Plans for breastfeeding ● Plans for postpartum contraception ● Determining gestational age and expected date of delivery Weight loss due to nausea and vomiting that exceeds 5% of prepregnancy weight is considered excessive, representing hyperemesis gravidarum, and can lead to adverse pregnancy outcomes. Measure the blood pressure at every visit. Blood pressure parameters in pregnancy. Baseline pre pregnancy readings are important for determining the patient’s usual range. In the second trimester, blood pressure normally drops below the no pregnant state. Hypertensive disorders affect 5% to 10% of all pregnancies, so all elevations in blood pressure must be closely monitored. Hypertension can be both an independent diagnosis and a marker of preeclampsia syndrome. This syndrome is “a pregnancy-specific syndrome that can affect virtually every organ system. new recommendations on hypertension in pregnancy in 2013 that no longer depend on proteinuria, recognizing that preeclampsia cannot only be lethal for the mother and fetus, but doubles the risk of later-life cardiovascular disease. Preeclampsia increases cardiovascular disease risk eight-to nine fold in women with preeclampsia giving birth before 34 weeks’ gestation.34 Definition of Preeclampsia is SBP ≥140 or DBP ≥90 after 20 weeks on two occasions at least 4 hours apart in a woman with previously normal BP or BP ≥160/110 confirmed within minutes and proteinuria ≥300 mg/24 hours, protein: creatinine ≥0.3, or dipstick 1+; OR new onset hypertension without proteinuria and any of the following: thrombocytopenia (platelets <100,000/μL), impaired liver function),

new renal insufficiency (creatinine >1.1 mg/dL or doubles in the absence of renal disease), pulmonary edema, or new onset cerebral or visual symptoms. Head and Neck Face: With the patient seated, inspect the head and neck, paying particular attention to the following features: ■ Face. Irregular brownish patches around the forehead, cheeks, nose, and jaw are known as chloasma or melasma, the “mask of pregnancy,” a normal skin finding during pregnancy. ■ Hair. Hair may become dry, oily, or sparse during pregnancy; mild hirsutism on the face, abdomen, and extremities is also common. 942 Facial edema after 20 gestational weeks is suspicious for preeclampsia and should be investigated. Localized patches of hair loss should not be attributed to pregnancy (though postpartum hair loss is common). ● Gestational hypertension is systolic blood pressure (SBP) >140 mm Hg or diastolic blood pressure (DBP) >90 mm Hg first documented after 20 weeks, without proteinuria or preeclampsia, that resolves by 12 weeks postpartum. ● Chronic hypertension is SBP >140 or DBP >90 that predates pregnancy. Chronic hypertension affects almost 2% of U.S. births. Facial edema after 20 gestational weeks is suspicious for preeclampsia and should be investigated. Localized patches of hair loss should not be attributed to pregnancy (though postpartum hair loss is common). Anemia may cause conjunctival pallor. Erosions and perforations of the nasal septum may represent use of intranasal cocaine. Dental problems are associated with poor pregnancy outcomes, so initiate prompt dental referrals for tooth and gum pain or infections. Thyroid enlargement, goiters, and nodules are abnormal and require investigation. Dyspnea accompanied by increased respiratory rate, coughing, rales, or respiratory distress point to possible infection, asthma, pulmonary embolism, or per- partum cardiomyopathy Assess dyspnea and signs of heart failure for possible peripartum cardiomyopathy, particularly in the late stages of pregnancy. Murmurs may signal anemia. Investigate any diastolic murmur. Gestational Issues and Disorders Vaccinations and Laboratory Testing The standard prenatal screening panel includes blood type and Rh, antibody screen, complete blood count—especially hematocrit and platelet count, rubella titer, syphilis test, hepatitis B surface antigen, HIV test, STI screen for gonorrhea and chlamydia, and urinalysis with culture. Scheduled screenings include an oral glucose tolerance test for gestational diabetes around 24 to 28 weeks and a rectovaginal swab for group B streptococcus between 35 and 37 weeks. Because obesity is associated with insulin resistance, the obese pregnant patient is at increased risk of both gestational diabetes and type 2 diabetes mellitus. Both ACOG and the American Diabetes Association recommend testing for glucose tolerance in the first trimester for obese pregnant patients. if indicated, pursue additional tests related to the mother’s risk factors, such as screening for aneuploidy, Tay–Sachs disease, or other genetic diseases, and amniocentesis Tdap each pregnancy at 27-36 weeks. Caretakers in direct contact w infant should also receive MMR, Polio and varicella not safe during pregnancy All women should have rubella titers drawn during pregnancy and be immunized after birth if found to be nonimmune. Check Rh (D) and antibody typing at the first prenatal visit, at 28