3: Gynecologic Hx and Physical Exam Flashcards by allie see

When using 2 devices on a pelvic exam, do you use the endo- or ectocervical device first?

Ectocervical first.

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During the bimanual exam, how do you feel a retroverted uterus?

Keeping the hand palm-up, place the vaginal fingers together in the posterior fornix with the abdominal hand at the pubis.
Press firmly downward with the abdominal fingers.
With the vaginal fingers turned upward, press up against the cervix moving it inward.

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T/F “Declines breast examination” or “Prefers pelvic examination to be included at a different visit,” avoids negative connotation association with, “Refused bimanual examination.”

True

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How do you assess perineal muscle tone?

Ask the woman to tighten her muscles around your vaginal examining fingers.

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How high should the top of the exam table be raised for pelvic exams?

At least 30 degrees.

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This acronym is used to discover history of the present illness (and frequently used for pain).

OLDCARTS

Onset
Location
Duration
Characteristics
Associated symptoms
Relieving factors
Timing
Severity

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Areas lateral to the uterus.

Adnexa

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How does KOH make visualization of candida (yeast) infections easier?

Potassium hydroxide lyses trichomonads, white blood cells, and most bacteria, making visualization of Candida species easier.

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What size is the cervix?

Diameter is 2-3 cm. Length is 3 cm.

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What does GTPAL stand for?

Gravida
Term births (37-42 weeks)
Preterm births (20-37 weeks)
Abortions (less than 20 weeks, spontaneous or induced)
Living children

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When would anorectal cytology screening be recommended?

When individuals test positive for HPV on cervical screening and have had anal sex.

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During a bimanual exam, what positions of the uterus allow for the fundus to be felt at the level of the pubis?

Anteflexed
Anteverted

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What could significant cervical deviation from midline indicate?

Pelvic mass or adhesions.

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T/F Symmetric, circumscribed erythema around the os is a normal finding caused by exposing, or everting, the columnar epithelium lining of the endocervical canal.

True. It occurs due to pressure of the speculum blades against the anterior and posterior fornices.

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Why is Skene’s gland palpation usually omitted?

Causes pain. Usually omitted unless specific concern, such as exam for gonorrhea.

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How much should a cervix move without pain or tenderness?

It should move 1-2 cm laterally if no pelvic inflammation.

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How do you palpate Bartholin’s glands?

Palpate the Bartholin’s glands by inserting the index finger of the examining hand about 2 cm into the vagina near the perineum, turning the hand laterally, and gently palpating the tissue behind the vaginal wall between the thumb and index finger on one side; then, after rotating the examining hand, palpate in the same manner on the other side of the vagina.

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Are Bartholin’s glands palpable?

Healthy Bartholin’s glands are not palpable, but if they are inflamed palpating will elicit notable pain. If a cyst is present, a fluctuant, nontender mass will be palpable. If an abscess is present, the site of the mass will be tender and warm. Many clinicians omit this portion of the examination unless a specific concern is identified.

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How do you collect a vaginal swab specimin?

The swab is inserted into the vagina about 2 inches past the introitus and gently rotated for 10 to 30 seconds. The swab should touch the walls of the vagina to absorb moisture.

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When the uterus is retroflexed or retroverted, this exam can allow an additional depth of 2.5 cm on manual exam and can be useful.

Rectovaginal exam

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Asking “How may I help you today?” or “What brought you here today?” are good ways to elicit what?

Chief Complaint/Concern

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Breast tissue that extends from the upper outer quadrant toward the axilla.

Tail of Spence

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Where do most cervical cancers occur?

The squamocolumnar junction SCJ, or transformation zone, where columnar endocervical epithelium and squamous ectocervical epithelium meet, is where most cervical cancers arise.

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What position is best for palpating the Tail of Spence?

Arms over head.

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For individuals who are pre-coitarche but still require an internal examination, nulliparas, postmenopausal women, transgender men on testosterone, or transgender women with neovaginas, what speculum should be used?

Pederson

Are nonmedical pricking, piercing, incising, scraping, and cauterization of female genitalia considered mutilation?

Yes

How should a novice clinician decide how specific the physical exam should be? Ie should it include palpation of precordium or just ausculation of the heart?

Be able to state the rationale for including or excluding any assessment maneuver or particular feature of any organ system. If a rationale for performing a maneuver and obtaining the specific information that maneuver provides can be stated, then including it would be justified.

When seated, you should be at eye level with the _____ during a pelvic exam.

When seated, you should be at eye level with the **_perineum_** during a pelvic exam.

\_\_\_\_\_ cysts may be seen as small white or yellow, raised areas; these retention cysts of endocervical glands are a normal variation of the cervix.

**_Nabothian_** cysts may be seen as small white or yellow, raised areas; these retention cysts of endocervical glands are a normal variation of the cervix.

For an anorectal sample, how far do you insert the swab and how many times do you rotate?

1. 5-6 cm into anal canal. 2. Rotate 360 degrees and then continue rotating as you exit. 3. This ensures transition zone cell collection.

Why would a pediatric speculum be used?

The shape and size minimizes pressure on the anterior and posterior vaginal walls, promoting a more comfortable examination.

Which 3 specimens are normally collected during a pelvic exam?

1. Cervical cells for cytology screening. 2. A vaginal or endocervical sample for gonorrhea, chlamydia, and trichomoniasis testing. 3. Vaginal secretions for microscopy. Separate samples are not always needed (usually with liquid based medium).

T/F Extra nipples are usually bilateral.

False. Usually unilateral.

If a patient has her arms flexed at the elbows and the clinician is palpating deeply into the axillary hollow with the palmar surfaces of fingers, what is being examined?

Lymph nodes

What happens on palpation of Skene's glands if there is infection?

Discharge at the urethral meatus with palpation of the Skene’s glands usually indicates infection.

Type of genital cutting that involves partial or total removal of the clitoris and/or the prepuce.

Clitoridectomy

What kind of questions yield the best responses for history taking?

Open ended

T/F Candida albicans, Trichomonas vaginalis, clue cells (epithelial cells with indistinct borders due to adherent bacteria) associated with bacterial vaginosis, and white blood cells can be seen in normal saline solution.

True, but microscopy has poor sensitivity for trich. NAAT testing should be used to confirm.

For women with significant pelvic or genital adipose tissue, lax vaginal walls, or grand multiparity, which speculum should be used?

Large Graves speculum

How do you determine cycle length of menses?

Count from the first day of one menses until the first day of the next.

Should water or water-soluble gel be used on the speculum.

Either. The gel does not affect the specimen and could provide more comfort.

T/F Axillary lymph nodes are usually palpable in women of childbearing age.

False. Not usually palpable in anyone.

Which device for cytology screening is rotated 5 times and which is rotate 1/2-1 time?

1. 5 times = Broom 2. _^1/2-1 = Endocervical brush

What can cause distinct discomfort when the speculum or examining fingers enter and exit the vagina?

The very close proximity of the urethra and the pubic bone to the anterior vaginal wall.

T/F Liquid based screening is diagnostic for trichomoniasis.

False. If positive a **NAAT** should follow for confirmation of trich.

Do you exert posterior or anterior pressure on the vaginal when performing a bimanual exam?

Posterior

How does the Pederson speculum differ from the Graves?

Its blades are the same length as those of the Graves speculum, but are narrower and flat rather than curved.

Type of genital cutting that involves partial or total removal of the clitoris and labia minora, with or without excision of the labia majora.

Excision

Type of genital cutting that involves narrowing of the vaginal orifice with creation of a covering seal by cutting and repositioning the labia minora and/or the labia majora, with or without excision of the clitoris.

Infibulation

T/F Palpable ovaries in women of childbearing age are reason for concern and require follow-up.

False. Palpable ovaries in **postmenopausal** women are reason for concern and require follow-up.

T/F If the uterus is midline, it is not possible to palpate the fundus with the abdominal hand during a bimanual exam.

True

What position is used for pelvic exams?

Lithotomy

What finding during a pelvic exam might indicate vulvodynia, pelvic pain, or a history of forced vaginal entry?

Visualizing the vaginal muscles clamping closed.

T/F Vaginal swabs should be clinician-obtained for accuracy.

False. The sample may be self-collected by the woman or obtained by the clinician, and self-obtained vaginal swabs are as accurate as or **more** accurate than clinician-obtained specimens.

This area is very important. Some clinicians even posit that 90% of the information needed for an accurate diagnosis comes from here.

Health history

How far do you insert the index and third fingers into the vagina during a pelvic exam?

2nd joint

How do you assess for pelvic organ prolapse?

Ask the woman to **cough** or **bear down**. If she has a cystocele the anterior vaginal wall will bulge with this maneuver. Observe also for rectocele or bulging of the posterior vaginal wall; this is a far less common finding.

What area of the cervix yields cells for cervical cytology screening?

Use the cervical squamocolumnar junction (SCJ) for cytology screening.

What is the normal color of the cervix?

Pink

What could nipples pointing in different directions indicate?

Malignant tissue

When lying supine, a woman’s vagina inclines posteriorly about \_\_\_\_\_° downward from the vaginal opening toward the sacrum. This is why an oblique angle should be used with the speculum.

When lying supine, a woman’s vagina inclines posteriorly about **_45_**° downward from the vaginal opening toward the sacrum. This is why an oblique angle should be used with the speculum.

Which sample is preferred for trichomonias NAAT testing?

Vaginal, endocervical, and urine are **all** acceptable and detection is similar among them.

T/F Palpation of clitoris is part of the pelvic exam.

False. Palpate the mons pubis, labia majora, labia minora, and perineum.

The os of a _____ woman is small and round, while a _____ os is usually a horizontal slit or may be irregular or stellate.

The os of a **_nulliparous_** woman is small and round, while a **_multiparous_** os is usually a horizontal slit or may be irregular or stellate.

Which speculum is used most with parous women?

Standard Graves speculum

This pertinent negative regarding bleeding should be noted in all menopausal women.

No vaginal bleeding since menopause.

How do you palpate Skene's glands?

Palpation of the Skene’s glands, which lie immediately lateral to the urethral meatus, is performed by turning the examining hand upward, inserting the index finger into the vagina to the second knuckle, pressing gently upward, and then pulling this finger outward while pressing against the vaginal tissue.

Where is it normal to find a firm transverse ridge of compressed breast tissue?

Lower edge of the breast.

A _____ cervix will be firm, like the tip of the nose, while during _____ it is softer. A _____ cervix may allow easy palpation inside the external os.

A **_nonpregnant_** cervix will be firm, like the tip of the nose, while during **_pregnancy_** it is softer. A **_multiparous_** cervix may allow easy palpation inside the external os.

T/F When collecting an anorectal sample for cytology screening, water-based lubricant helps promote comfort.

False. Lube can obscure results. Must be collected with only water as a lubricant.

When vaginal secretions are added to KOH, which conditions have a positive whiff test?

1. Bacterial Vaginosis 2. Trichomoniasis It is associated with, but **not** diagnostic for these conditions.

Where do most malignancies develop?

In the upper outer quadrant (Tail of Spence is near here).

What color should vaginal mucosa be?

Almost the same color as the cervix (pink).

At the beginning of a pelvic exam, the bladder should be emptied. Why?

1. More comfortable for the patient. 2. Makes palpation of pelvic organs easier.

What specimens in women can be used for NAAT tests?

1. Vaginal swabs 2. Endocervical swabs 3. Urine specimens

What buttocks position allows for correct positioning of the speculum?

The buttocks should be slightly beyond the edge of the exam table.

T/F The position of the cervix correlates to the position of the uterus.

True

The preferred sample type of chlamydia and gonorrhea NAAT tests.

1. Vaginal swabs 2. Endocervical are acceptable if a pelvic exam is necessary.

What is the most common position of the cervix and where would that put the uterus?

Posterior, indicating an anteverted uterus.

What 2 maneuvers are performed in a clinical breast exam?

1. Inspection 2. Palpation

How do you collect an endocervical swab specimin?

1. Visualize the cervix using the speculum. 2. Remove all secretions and discharge from the cervix with a large swab. 3. Insert the swab supplied by the manufacturer 1 to 2 cm into the cervical os, rotate it firmly at least twice against the walls of the canal, and allow it to remain in the os for the time recommended by the manufacturer

The hymen can be mistaken for what?

**Vaginal septum**. If a septum is noted, a bimanual examination must be considered prior to speculum examination to determine the extent of the septum, if there are possibly two complete vaginas or cervices or uteri that may need evaluation, and whether consultation is necessary.

Can conventional pap or liquid based methods use the same sample for STI testing?

Liquid based

Is discharge normally vaginal or cervical in nature?

Vaginal. Normal vaginal discharge is odorless, creamy or clear, and thick or thin, depending on time in the menstrual cycle.