1
Q
What are some good ways to make a patient more comfortable during sensitive exams? What techniques will help a woman relax during a GYN exam?
A
• Explain, intentional language, container, appropriate warnings
2
Q
What are Tanner’s stages of sexual maturation?
A
I. Prepubertal
II. Palpable subareolar breast buds, prexual pubic hairs (short, light, straight, not obvious)
III. Enlargement and elevation of whole breast, sexual pubic hairs (long, dark, curly, appear on labia majora)
IV. Areolar mounding, progression of pubic hair on pubis (not on thighs)
V. Attain mature breast countour, escutcheon
3
Q
Know the normal anatomical structures of the vulva.
A
- Mons pubis
- Prepuce of clitoris
- Frenulum of clitoris
- Urethra
- Lesser vestibule
- Hymen
- Labia minora and majora
- Introitus
- Bartholin’s glands
- skenes’s glands
4
Q
What is the normal location of Bartholin’s glands?
A
• 5 and 7 oclock, slightly deep to vaginal introitus
5
Q
What is the normal location of Skene’s glands?
A
• Urethtal orifice
6
Q
What are condyloma acuminata from Human Papilloma Virus (HPV)? What is the relationship of HPV to cervical dysplaia?
A
- Genital wart from HPV 6 and 11
* HPV cause of dysplasia. Not cancerous, but has malignant potential.
7
Q
What is the difference between a Pederson and a Graves speculum? When would you use one versus the other?
A
- Pederson: for nulliparous women
* Graves: blades flare out
8
Q
What is the technique for assessing vaginal tone?
A
• Insert index finger and have pt “stop the flow of urine”
9
Q
What is a cystocele? Rectocele?
A
- C: Bulging of anterior wall
* R: Bulging of posterior wall
10
Q
What is the best method for visualizing the cervix using a speculum?
A
• Downward pressure and lube are a girl’s best friend
11
Q
What is the significance of finding columnar epithelium on the ectocervix? What is the term (s) for this?
A
Ectopy: may be normal. Ectropian-squamous columnar junction on the surface of the os may be common for young F
12
Q
What is the technique for obtaining the PAP smear? Be prepared to demonstrate this during the practical.
A
- Broom: Using “v” shaped brush, insert into os and rotate 360 w moderate pressure. Obtain sample from squamocolumnar junction, if visible. Drop into container w saline.
- Brush: insert into os, rotate once gently (avoid IUD strings, please). Drop into container w saline.
13
Q
What is the significance of cervical motion tenderness?
A
• If positive, may indicate adhesions of PID or endometriosis.
14
Q
What are the normal shape, size and configuration of the uterus?
A
- 6cm x 4cm
- Anteverted, anteflexed, retroverted, retroflexed
- Mobile, smooth, nontender
15
Q
What is the difference between uterine retroversion and retroflexion of the uterus? How are they best palpated?
A
• Retroversion -uterus and cervical axis oriented toward the sacrum
Retroflexion – uterus oriented toward the sacrum, with the anterior portion of uterus convex
16
Q
What are leiomyoma? What do they feel like on bimanual palpation?
A
- Uterine fibroids. Overgrowth of smooth muscle and CT of uterus.
- Solid, firm, mobile, near adnexa/midline
17
Q
What is the normal size of an ovary? What do they feel like on bimanual palpation?
A
- Reproductive age: 3x2x2cm
- Menopausal age: 1 x 0.7 x 0.5cm
- Almond shaped, firm, movable
18
Q
What are the objectives of a bimanual exam?
A
- Not any nodularity of vaginal wall (sweep 2 fingers to left, right, around)
- Cervix: consistency of surface, CMT (if infx, endometriosis, etc)
- Uterus: size, shape, tenderness; most in anterior, mid, or posterior position; anteverted, anteflexed, retroverted, retroflexed
- Adnexa: size, shape, tenderness, masses (BL/UL, cystic/solid, smooth/irregular, fixed/movable, tender/NT); often non-palpable
19
Q
What are the objectives of a recto-vaginal exam? When is it indicated?
A
- assess septum, uterosacral ligaments, uterus, cul-de-sac, adnexae, cervix
- palpate rectovaginal septum for thickness and masses
- posterior surface of uterus: note nodularity or asymmetry (displace uterus to retroverted position, palp w rectal finger)
- re-evaluate adnexa
- in F >40 (screen for colorectal CA)
- or if suspect endometriosis (mass in RV sepetum), CA, retroverted/flexed uterus
20
Q
What are 4 general steps of the pelvic exam?
A
o Preparation
o External exam
o Internal exam
o Bimanual exam
21
Q
What are steps in preparation for pelvic exam?
A
o Explanation and preparation, Wash hands o Explain and teach the breast exam o Inspect the breasts o Examine axilla and supraclavicular area o Palpate breasts in supine position o Lithotomy position, draping o Adjust drape, offer mirror o Glove hands
22
Q
• What are steps for external gyn exam?
A
o Be seated, Signal beginning of exam
o Inspect pubic hair labia, urethra, clitoris
o Palpate Bartholin’s and Skene’s glands, milk urethra
o Assess Pelvic support
o Separate labia
23
Q
• What are steps for internal gyn exam?
A
o Insert Speculum o Observe cervix o Wet prep o GC/Chlamydia probe (Walk through) o Pap smear (Walk through traditional PAP and Thin Layer) o Remove speculum
24
Q
• What are steps for bimanual exam?
A
o Remove one glove, apply lubricant o Examine vaginal walls o Palpate cervix o Palpate Uterus o Palpate adnexa
25
• What are steps for recto-vaginal exam?
o Fresh glove
o Assess rectal/vaginal septum and cul-de sac as indicated
o Palpate posterior uterine surface
o Re-evaluate adnexa
o Withdraw fingers, check for occult blood
o Hand patient tissue, leave room for her to change,
o Return to discuss findings
26
• How do you collect samples in speculum exam?
o pH
o wet prep: cotton-tip swab of cervical d/c; break off into test tube; pt holds in hand to keep warm
o GC/CT probe: swab cx d/c, place in culture tube w medium
o pap: scopette to clear any d/c around cx; V brush around cx 5x; bristle in os 360, or 2 180s if IUD; both brushes are released into container
27
Be able to explain the clinical breast exam (CBE) procedure to a patient.
* Pillow under shoulder, arm over head, knees roll to opposite side to flatten breast tissue over chest wall
* Vertical strip pattern, 3 depths, dime-size circular motion
* 1 second per circular motion at each of 3 depths. 6-8 minutes per breast.
* Breast perimeter: Clavicle, sternum, inframammary fold, latissiumus dorsi, b/w clavicle & axilla
* Have pt elevate nipple/areola to palpate the tissues underneath
28
Be able to teach the self-breast exam.
* (not as sensitive as previously thought)
* Assure: breasts are rarely symmetrical, inverted nipples common!
* Lie down with pillow under R shoulder, place arm behind head
* Use 3 finger pads, vertical strip pattern. Repeat other side
* Stand in front of mirror, pressing hands onto hips, to look for changes of size, shape, contour, dimpling, redness, scaling
29
Why is it important to palpate the tail of the breast during the examination? What are the most common sites of breast cancer? Others?
* Tail (upper outer quadrant): 50%
* Areola-nipple complex: 18%
* Upper inner quad: 15%
* Outer lower quad: 11%
* Inner lower quad: 6%
30
What are the most significant risk factors for breast cancer?
* Family history, diet (esp hi-fat), lifestyle (western), obesity (big risk)
* Gender (100 x more likely in F)
* Aging . 77% F w breast CA >50; 18% in 40s
* Genetics: BRCA1/2 80% chance develop breast CA, younger. 1st degree FHx
* Early menarche, late menopause
* Later pregnancy (1st > 30, or no prego)
* Alcohol (2-5 drinks per day)
* HRT
* Ionizing radiation exposure
31
• What are protective factors for breast CA?
o Physical activity: 1.25-2.5 hrs per week ↓ risk by 18%
o Parity
o ↓ PM BMI
o Breast feeding 16 months
32
• What should you instruct pt on with CBE?
o Ask if they do SBE
o If she has noticed lumps or d/c
o Best time to do SBE is after menses (↓ hormonal breast stimulation)
33
• When and how do you do breast inspection?
o Only for abn exams (very insensitive)
o Color. Redness in mastitis and some inflammatory cancer.
o Thick skin w prominent pores (Peau d’orange). indicator of malignancy
o Size and Symmetry. Note Tanner’s sexual maturity scale in young women.
o Contour. Look for masses, dimpling or flattening of normal contour
o Nipples. Note inversion, retraction, dermatitis around areola. Consider Paget’s dz of breast (usu assoc w mass). Nipples should point in symmetrical directions. Note any d/c
o Ask pt: raise hand over head, then press hands on hips; lean forward if breasts are pendulous
34
Which lymph nodes are palpated as part of the breast exam? How?
* Axillary, supraclavicular, infraclavicular
* Pt sits up w gown on
* Support their arm to relax pectoral mm
* Palp 4 quadrants of axilla
* Above and below clavicle
* Repeat other side
35
When is nipple discharge normal? When is it abnormal? Types?
* Normal: Pregnancy, stopping breastfeeding, stimulation
* Abnormal: Fibrocystic breast changes, mammary duct ectasia, galactorrhea (pituitary prolactinoma, dopamine agonists, hypothyroid), infx, breast CA, Paget’s dz
* Paget’s: rare, eczema-like lesion, dermatitis of areola and nipple
* Bloody: further eval! Non-bloody usually benign
* Types: serous, sanguine, purulent, milky
36
When is the best time of a woman’s cycle to do self-exam?
• Monthly, last day of her menses.
37
• What are characteristics of fibroadenoma on CBE?
```
o Usu Age: 15-25 (up to 55)
o #: Single
o Shape: Round, disc-like, lobular
o Consistency: mb soft, usu firm
o Delimitation: Well delineated
o Mobility: Very mobile
o Tenderness: Non-tender
o Retraction signs: Absent
```
38
• What are characteristics of fibrocystic dz on CBE?
```
o Usu Age: 30-50 (regress after menopause)
o #: Single or multiple
o Shape: Round
o Consistency: Soft-firm, elastic
o Delimitation: Well delineated
o Mobility: Mobile
o Tenderness: Tender
o Retraction signs: Absent
```
39
• What are characteristics of breast CA on CBE?
```
o Usu Age: 30-90 (most common >50)
o #: Usu single
o Shape: Irregular or stellate
o Consistency: Firm/hard
o Delimitation: Poor
o Mobility: Fixed to skin/tissue
o Tenderness: Non-tender
o Retraction signs: present
```
40
• What are common errors to avoid in CBE?
o Missing the axillary tail
o Not palpating the nipple/areola complex
o Inconsistent pressure
o Pattern of search doesn’t extend to entire breast perimeter
41
• What are characteristics of breast masses suspicious for CA?
o Fixed mass
o Poorly delimited mass
o Hard mass
42
• When are CBE and mammography useful?
o CBE more important in younger F dt ↑ density tissue, and less use of mammo
o Mammo more for older
o CBE: low sensitivity, high spec
o Mammo: moderate sense, high spec
43
• What is the incidence of breast CA in US?
o 1/9 women
44
• What is CBE good for?
o Can detect tumor as small as 3mm
| o Smaller tumors have better px
45
What information would you want to record about a mass palpated during a clinical breast exam?
* Note any lumps diff from normal tissue; tenderness; any nodules or masses
* Location, size, shape, consistency, delimitation, mobility (into skin, fascia, chest wall)
* Palpate for retraction phenomenon—as breast cancer advances, causes fibrosis→ dimpling, changing in contour, retraction, or deviation of nipple (other causes of retraction=fat necrosis and mammory duct ectasia)
46
• How do you inspect arms in PV exam?
o Symmetry, size, color, texture of skin and nail beds
o Venous pattern
o Edema
o Compare both sides
47
What is Allen’s test?
* Purpose: Assess patency of ulnar and radial arteries and arteries of hand
* Hands above heart, pump fists for 30 seconds (one side at a time)
* Clamp into tight fist, bring hands down, compress both arteries
* Patient opens hand into relaxed position, release and palm should flush in 3-5 seconds
* Upper limit of normal is 7-10 seconds
* Do each hand 2x, for each artery
48
• What arteries do you palpate in PV exam? Lymph nodes?
o radial, ulnar, brachial, femoral, popliteal, posterior tibial, dorsalis pedis pulses
o on both arms, alone and simultaneously
o note pulse: increased (bounding), normal, diminished, absent
o Epitrochlear LN: bw grooves of biceps and triceps, 3cm proximal to medial epicondyle
o Inguinal LN: both horizontal and vertical groups. NT palpable nodes common
49
Which aspect of the hands do the epitrochlear nodes drain? axillary nodes?
* Epitrochlear: ulnar 2-3 fingers
| * Axillary: radial side of hand
50
• How do you inspect legs in PV exam?
o Both legs and feet for size, symmetry, color, texture of skin and nails
o Hair distribution (hairy toes=healthy!)
o Ulceration
o Venous pattern or enlargement
o Edema
o Great and small saphenous veins for varicosities (lying and standing)
51
• How do you palpate legs in PV exam?
o Superficial inguinal nodes and femoral pulse (radial and femoral simultaneously)
o Popliteal pulse w knee bent 90 degrees
o Dorsalis pedis pulse on both feet (just lateral to extensor hallucis longus)
o Posterior tibial pulse (behind medial malleolus)
o Palpate calf for signs of deep phlebitis (Homan’s sign) and for cords over any suspicious veins
52
• How do you asses temp of legs in PV exam?
o W back of hand, compare both sides (feet and legs)
53
• How is edema graded?
o 1+= trace: slight, rapid
o 2+= mild: 0-0.6cm, 10-15 sec
o 3+= mod: 0.6-1.3cm, 1-2 min
o 4+= severe: 1.3-2.5cm, 2-5 min
54
Which pulse may be congenitally absent in some patients?
• Dorsalis pedis
55
How is capillary refill assessed?
* To assess volume status
* Hold patient’s hand at heart level and compress nail for 5s. amount of time to regain color=capillary refill time
* N: children & adult men 2s; adult women 3s; elderly 4s (at room temp)
56
What test do you do when coarctation of the aorta is suspected?
* If diminished/delayed femoral pulses compared to brachial or radial pulses
* 4 extremity systolic BP measurements
* Normal: UE < LE (by 10-20 mmHg)
* Coarctation: UE > LE
57
• What are key PE findings for DVT?
o Pain/tenderness along major veins
o Unilateral pitting edema
o Swelling of entire leg
o Calf swelling > 3 cm in one leg
58
• What are the tests for DVT?
o NOT moses sign and homan sign
o Wells criteria
o ABI
o Can r/o w serum D-dimer (if low Wells score)
o If (+) D-dimer or high Wells: need compression US
59
• What are wells criteria?
o 2+ DVT likely; 1 or 3cm (one leg)
o 1- pitting edema (one leg)
o 1- collateral SV
o -2: alt dx more likely than DVT
60
• How do you measure ABI?
```
o Use Doppler US for both brachial and posterior tibial artery BP
o ABI= ankle/arm BP
o N= 1.0-1.4
o Abn= < 0.9 (suggests PAD)
o 0.9-1.0= borderline
```
61
• What is PE found for ulcers dt arterial insufficiency?
o Pain: Intermittent claudication
o Mechanism: Tissue ischemia
o Ulcer Location: distal, over bony prominences, mb toes
o Ulcer appearance: round or punched-out, well-demarcated
o Pulses: Decreased/absent
o Color/skin: Pale; Thin, shiny, atrophic
o Temp: Cool?? Rubor dt neovascularization
o Edema: Absent-mild
o Gangrene: May develop
o ABI: < 0.9, severe < 0.5
62
• What is PE found for ulcers dt venous insufficiency?
o Pain: Yes!
o Mechanism: Venous HTN
o Ulcer Location: bw malleolus (usu med) and lower calf
o Ulcer appearance: shallow, non-discrete margins, small or large
o Pulses: normal
o Color/skin: Normal, cyanotic or petechiae/brown (pigmentation); stasis derm
o Temp: Normal
o Edema: present
o Gangrene: Does not develop
o ABI: normal, > 0.9
63
• What is PE found for ulcers dt diabetes?
```
o Pain: no, paresthesia
o Mechanism: neuropathi
o Ulcer Location: sites of pressure (bottom of feet)
o Ulcer appearance: around callus, mb infx; black, gray, yellow base
o Pulses: present
o Color/skin: pale, reticulated, purpura
o Temp: normal
o Edema: mb
o Gangrene: can develop
o ABI: normal, unreliable
```
64
• What are the special maneuvers for PV exam?
o Retrograde filling test (Trendelenburg test)
o Beurger’s test (test for arterial insufficiency)
o Tests for coarctation of the aorta
o ABI
65
• What is the retrograde filling test?
o assesses competency of superficial and deep veins of legs
o leg flexed at hip, above heart: veins empty dt gravity
o tourniquet around upper thigh
o leg lowered and stand
o w tourniquet on: only SV are blocked, test DV; if no refill= DV insufficiency (superficial saphenous v should refill in 3-5s)
o tourniquet off: test SV; no refill= SV insufficiency
66
• what is the test for arterial insufficiency (Beurger’s test)?
o if note pallor, ulcers, loss of normal hair dist, diminished pulses →have pt raise leg to 60 degrees for ~60s
o lower legs
o marked pallor or increased time for color to return to legs suggests arterial insufficiency
o N: <10 sec
67
• What are some findings w PVD?
o Inspection: wounds/sores on feet; foot color abn pale, red, or blue; atrophic skin; absent lower limb hair
o Palpation: foot asymm cooler; no femoral pulse; no posterior tibial, dorsalis pedis pulse
o Auscultation: limb bruit
o Ancillary tests: great toe capillary refill > 5 sec; venous filling time > 20 sec
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