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(BQ) Part 2 book Macleod''s clinical examination has contents: The reproductive system, the nervous system, the visual system, the ear, nose and throat, the musculoskeletal system, the frail elderly, conirming death, assessment for anaesthesia and sedation,... and other contents.
SECTION SYSTEM EXAMINATION Elaine Anderson Colin Duncan Jane Norman Stephen Payne The reproductive system 10 THE BREAST EXAMINATION 212 THE OBSTETRIC EXAMINATION 227 THE MALE GENITAL EXAMINATION 232 Anatomy 212 Anatomy 227 Anatomy 232 Symptoms and deinitions 212 Breast lump 212 Breast pain 213 Skin changes 213 Nipple changes 214 Gynaecomastia 214 Symptoms and deinitions 234 Scrotum 234 Penile and urethral abnormalities 234 Prostate abnormalities 235 Bladder problems 235 Symptoms and deinitions 218 Menstrual cycle 218 Abnormal uterine bleeding 219 Urinary incontinence 220 Prolapse 220 Pain 220 Vaginal discharge 220 Pelvic masses 221 Dyspareunia 221 Symptoms and deinitions 227 Last menstrual period 227 Estimated date of delivery (EDD) 227 Parity 227 Gestation 227 The lie 227 The presentation 227 Oligoamnios and polyhydramnios 227 Miscarriage 227 Live birth 227 Stillbirth 228 Viability 228 Puerperium 228 Linea nigra 228 Striae gravidarum 228 Liquor 228 Fetal movements 228 Physiological symptoms 228 Bleeding in pregnancy 228 Pre-eclampsia 228 Pruritus 228 Breathlessness 228 The history 221 The history 229 The physical examination 222 The physical examination 230 Investigations 226 Investigations 232 The history 214 The physical examination 215 Investigations 217 THE GYNAECOLOGICAL EXAMINATION 218 Anatomy 218 The history 235 Physical examination 236 Investigations 238 211 THE REPRODUCTIVE SYSTEM 10 THE BREAST EXAMINATION ANATOMY SYMPTOMS AND DEFINITIONS The breasts are modiied sweat glands Pigmented skin covers the areola and the nipple, which is erectile tissue The openings of the lactiferous ducts are on the apex of the nipple The nipple is in the fourth intercostal space in the mid-clavicular line, but accessory breast/nipple tissue may develop anywhere down the nipple line (axilla to groin) (Figs 10.2 and 10.3) The adult breast is divided into the nipple, the areola and four quadrants, upper and lower, inner and outer, with an axillary tail projecting from the upper outer quadrant (Fig 10.4) The size and shape of the breasts are inluenced by age, hereditary factors, sexual maturity, phase of the menstrual cycle, parity, pregnancy, lactation and general state of nutrition Fat and stroma surrounding the glandular tissue determine the size of the breast, except during lactation, when enlargement is mostly glandular The breast responds to luctuations in oestrogen and progesterone levels Swelling and tenderness are more common in the premenstrual phase The amount of glandular tissue reduces and fat increases with age, so that the breasts are softer and more pendulous Lactating breasts are swollen and engorged with milk, and are best examined after breastfeeding Breast lump Breast cancer Cancers are solid masses with an irregular outline They are usually, but not always, painless, irm and hard, contrasting in consistency with the surrounding breast tissue The cancer may extend directly into the overlying tissues such as skin, pectoral fascia and pectoral muscle, or metastasise to regional lymph nodes or the systemic circulation In the UK, this cancer affects in women The incidence increases with age, but manage any mass Breast pain • Pregnancy • Cyclical mastalgia • Mastitis/breast abscess Fig 10.2 Accessory breast tissue in the axilla Nipple discharge • Pregnancy • Duct papilloma • Duct ectasia • Mastitis/breast abscess • Ductal carcinoma in situ Breast lump • Breast cancer • Cyst • Abscess • Fibroadenoma • Fibrocystic change • Fat necrosis • Lipoma Breast lumpiness • Fibrocystic change Fat Chest wall/ rib cage Lobules Ducts Dilated section of duct to hold milk Pectoralis major muscle Nipple Bone pain • Metastatic breast cancer Normal duct cells Basement membrane Lumen (centre of duct) 212 Fig 10.1 Conditions affecting the breast Fig 10.3 Cross-section of the female breast Symptoms and definitions Tail of Spence Upper outer Upper inner Lower outer Lower inner Fig 10.5 Mamillary istulae at the areolocutaneous border 10 Fig 10.4 The adult right breast as potentially malignant until proven otherwise Cancer of the male breast is uncommon and can have a strong genetic factor Fibrocystic changes Fibrocystic changes are rubbery, bilateral and benign, and most prominent premenstrually, but investigate any new focal change in young women which persists after menstruation These changes and irregular nodularity of the breast are common, especially in the upper outer quadrant in young women Fibroadenomas These smooth, mobile, discrete and rubbery lumps are the second most common cause of a breast mass in women under 35 years old These are benign overgrowths of parts of the terminal duct lobules Fig 10.6 Skin dimpling due to underlying malignancy 10.1 Characteristics of mastalgia Cyclical mastalgia • Related to the menstrual cycle; usually worse in the latter half of the cycle and relieved by the period Non-cyclical mastalgia • No variation Breast cysts These are smooth luid-illed sacs, most common in women aged 35–55 years They are soft and luctuant when the sac pressure is low but hard and painful if the pressure is high Cysts may occur in multiple clusters Most are benign, but investigate any cyst with bloodstained aspirate or a residual mass following aspiration, or which recurs after aspiration Breast abscesses There are two types: • lactational abscesses in women who are breastfeeding, usually peripheral • non-lactational abscesses, which occur as an extension of periductal mastitis and are usually found under the areola, often associated with nipple inversion They usually occur in young female smokers Occasionally, a non-lactating abscess may discharge spontaneously through a istula, classically at the areolocutaneous border (Fig 10.5) Breast pain Most women suffer cyclical mastalgia at some stage (Box 10.1) Chest wall pain may be confused with breast pain Skin changes Simple skin dimpling The skin remains mobile over the cancer (Fig 10.6) Indrawing of the skin The skin is ixed to the cancer Lymphoedema of the breast The skin is swollen between the hair follicles and looks like orange peel (peau d’orange; Fig 10.7) The most 213 THE REPRODUCTIVE SYSTEM 10 Fig 10.9 Breast cancer presenting as indrawing of the nipple Note Fig 10.7 Peau d’orange of the breast the bloody discharge on the underclothing 10.2 Nipple inversion Benign • Symmetrical • Slit-like Malignant • Asymmetrical • Distorting Fig 10.8 Paget’s disease of the nipple common causes are infection or tumour and it may be accompanied by redness, warmth and tenderness Investigate any ‘infection’ which does not respond to one course of antibiotics to exclude an inlammatory cancer These are aggressive tumours with a poor prognosis Eczema of the nipple and areola This may be part of a generalised skin disorder If it affects the true nipple, it may be due to Paget’s disease of the nipple (Fig 10.8), or invasion of the epidermis by an intraductal cancer Nipple changes Nipple inversion Retraction of the nipple is common and is often benign; however it can be the irst subtle sign of malignancy when it is usually asymmetrical (Fig 10.9 and Box 10.2) Nipple discharge 214 A small amount of luid may be expressed from multiple ducts by massaging the breast It may be clear, yellow, white or green in colour Investigate persistent single • Nipple pulled to the side duct discharge or blood-stained (macroscopic or microscopic) discharge to exclude duct ectasia, periductal mastitis, intraduct papilloma or intraduct cancer Galactorrhoea Galactorrhoea is a milky discharge from multiple ducts in both breasts due to hyperprolactinaemia It often causes hyperplasia of Montgomery’s tubercles, small rounded projections covering areolar glands Gynaecomastia Gynaecomastia is enlargement of the male breast and often occurs in pubertal boys In chronic liver disease gynaecomastia is caused by high levels of circulating oestrogens which are not metabolised by the liver Many drugs can cause breast enlargement (Box 10.3 and Fig 10.10) THE HISTORY Benign and malignant conditions cause similar symptoms but benign changes are more common Not all patients have symptoms Women may have an abnormality on screening mammography; asymptomatic women may present with concerns about their family history Breast cancer may present with symptoms of metastatic disease Men may present with gynaecomastia Explore the patient’s ICE (p 8) Women are often worried that they have breast cancer The physical examination Presenting complaint 10.3 Causes of gynaecomastia • How long have symptoms been present? • What changes have occurred? • Is there any relationship to the menstrual cycle? • Does anything make it better or worse? Evaluate potential risk factors (Box 10.4) and menopausal status Use a pain chart to establish the timing of symptoms (Fig 10.11) Drugs, including • Cannabis • Oestrogens used in treatment of prostate cancer Decreased androgen production • Klinefelter’s syndrome Increased oestrogen levels • Chronic liver disease • Thyrotoxicosis THE PHYSICAL EXAMINATION • Spironolactone • Cimetidine • Digoxin • Some adrenal tumours Offer a chaperone and record that person’s name; if the patient declines, note this Male doctors should always have a chaperone Ask the patient to undress to the waist and sit upright on a well-illuminated chair or on the side of a bed 10 10.4 Indicators of breast cancer risk* • Female • Increasing age • Family history, especially if associated with: • Early age of onset • Multiple cases of breast cancer • Ovarian cancer • Male breast cancer • Early menarche Fig 10.10 Drug-induced gynaecomastia caused by cimetidine • Nulliparity or late age of irst child • Late menopause • Prolonged hormone replacement therapy use • Postmenopausal obesity • Mantle irradiation for Hodgkin’s disease, especially at young age (