Exam 2 - GU Exam Flashcards
PMHx: Screening
**Age appropriate female GU screening
Date of last pelvic exam Date of last PAP smear and results Date of last breast exam Date of last mammogram and results Date of last DEXA and results Gardasil? Zostavax?
Whats in Female GU ROS?
Frequency of urination, polyuria, nocturia, burning or pain on urination, hematuria, urgency, reduced caliber or force of stream, hesitancy, incontinence, urinary retention, stones.
Age at menarche, regularity, frequency, and duration of menses, amount of bleeding, bleeding between periods or after intercourse, LMP, dysmenorrhea, premenstrual tension.
Age at menopause, menopausal symptoms, postmenopausal bleeding; vaginal discharge, itching, lesions, lumps, STIs and their treatments, exposure to HIV, precautions against HIV and STIs.
Number of pregnancies, number and type of deliveries, number of abortions (spontaneous and induced), complications of pregnancy, methods of contraception.
Sexual interest, orientation, function, satisfaction, problems including dypareunia.
G3P1A0
What is G?
What is P?
What is A?
Number of pregnancies = gravida = G = 3
Number of deliveries > 20 wks = parity = P = 1
Number of abortions = A= 0
What is TPAL format?
This can be more specifically written in “tpal” format, G3P1102, where 1102 means
Number of full term births (37 wks) = 1
Number of preterm births (20-36 wks) = 1
Number of abortions (elective or spontaneous) = 0
Number of living children = 2
What does nulliparous mean?
Nulliparous = one who has not borne offspring
What does multiparous mean?
Multiparous = given birth to one or more offspring
LMP?
EDC?
EDD?
LMP = date of last menstrual period EDC = estimated date of confinement = due date EDD = estimated date of delivery = due date
What is Naegle’s Rule? What is it used for?
Naegle’s Rule = to calculate EDC = LMP + 7 days - 3 months + 1 year
Or you can use a pregnancy wheel
What do you ask about menarche?
Menarche
Age at menarche, cycle length (regularity)
Length of time between periods (frequency)
Count as first day to first day, not end to beginning
Duration
3 to 7 days
What do you ask a patient about their LMP?
Date of Last Menstrual Period (LMP)
…First day of last cycle
Character of Flow = light, medium, heavy
“How often do you have to change pads or tampons?”
Presence of clots (heavy flow)
If a patient has dysmenorrhea, what do you ask them?
Dysmenorrhea
Duration, frequency, relief
Intermenstrual bleeding/spotting
>Amount, duration, frequency, timing
>Post coital
What do you ask a patient if they have premenstrual tension?
Premenstrual tension
Headaches, weight gain, breast tenderness, mood changes, relief measures
Post Coital
occurring or done after sexual intercourse.
What do you ask a patient about menopause?
> Age at menopause
>Menopausal symptoms Hot flashes, night sweats, Vaginal dryness Dry/thin skin; dry/brittle hair Estrogen therapy Psychological changes Mood swings Loss of concentration or memory Anxiety, irritability Decreased libido
> Postmenopausal bleeding
What do you ask a patient if they are having vaginal discharge?
Vaginal discharge >Itching >Lesions >Lumps >STIs and their treatments >Exposure to HIV >Precautions against HIV and STIs >Date of last pelvic, PAP smear >History of abnormal PAP smears and their treatments >History of cervical, endometrial, ovarian neoplasm; fibroids, endometriosis, polyps, cysts >DES (diethylstilbestrol) exposure
What do you ask a patient if they have urinary habit changes?
Urinary habit changes (incontinence)
>Frequency
>Urgency
What’s included in obstetric history?
Number of pregnancies Number and type of deliveries Year each child was delivered Gender and weight of each baby Method of delivery: NSVD, CS, vacuum/forceps assist Number of abortions Spontaneous and induced Complications of pregnancy Includes complications of delivery
Whats included in a sexual history?
Sexual interest, orientation, and function
Age of first coitus
Number of sexual partners
Satisfaction, problems, dypareunia
Open ended questions
“Please tell me about your sexual partner(s)”
Abuse
“Have you ever been forced to do something sexual against your will?”
Contraception/protection
Privacy
What’s in a contraceptive history?
Current method
>Satisfaction
>Consistent use
>Side effects
Previous methods
>Duration
>Side effects
>Reason for discontinuation
Contraceptive failures
Female Pelvic Exam - Explain patient concerns and how to acknowledge as a provider.
Patient concerns
>Previous experience unpleasant or demeaning
>Fear of findings such as an STI or cancer
>Previously raped or abused
>First exam or virginal patient
Understand a patient’s apprehension
Acknowledge any embarrassment or self-consciousness
Inquire about tampon use
Show patient instrumentation, allow patient to hold speculum and PAP smear collection devices
Reassure “nothing sharp” will be used
The discomfort is only pressure- there will be no pain
What is the positioning for a pelvic exam?
Dorsal Lithotomy Position, in stirrups
Patient responsibilities before a pelvic exam?
Avoid intercourse 24-48 hrs before the exam
Empty bladder before the exam
Try to relax abdominal and vaginal muscles
No lubricants, vaginal inserts, douching before exam
Provider responsibilities of a pelvic exam?
Explain each step of exam first
Drape patient correctly
»From mid abdomen to knees; depress drape between knees to allow eye contact with patient
Offer the patient a mirror
»Allows her to view the exam
»Helps relax the patient
Always state what you are about to do before you touch your patient
Avoid unexpected or sudden movements
Monitor comfort of exam (watch patient’s face)
Be gentle when inserting speculum – warm it first
Female Pelvic Exam Instrumentation
You need good lighting within easy reach
Vaginal speculums
Plastic vs. metal
Plastic specula have a removable light source in the handle
Pediatric and Adult sizes
Water-Soluble lubricant (K-Y jelly)
Glass slides or ethyl alcohol solution (Thin Prep PAP)
Cytobrushes/Spatulas
What patients would you use a small speculum on?
> > Use small for children, elderly, and females who have not had intercourse
When is it appropriate to use a wider, larger speculum?
> > Use a wider, larger speculum in those who are obese, multiparous, and are sexually active
Communication approach in exam:
Inform the patient you are going to touch her inner thigh (at the knee).
Communicate to her that you are going to start the exam, in a reassuring, soothing tone.
Spread the labia majora with your first two fingers so that you can see the labia majora, labia minora, the clitoris and the urethra.
Look for ulcers, lice, warts, and erythema.
Female External Genitalia Exam
Assess the sexual maturity of an adolescent patient
>Tanner Stages
The aging patient
>Pubic hair sparse and gray
>Labia and clitoris smaller
>Vagina narrows and shortens
Inspect external structures
Mons pubis, labia majora/minora, clitoris, urethral meatus, vaginal introitus , Bartholin’s and Skene’s glands, perineum, anus
Check for inflammation, lesions ,ulcers, swelling, discharge
How do you inspect a female for a hernia?
Females and males are examined the same
Femoral hernia > Inguinal hernia in females
Although both are not common
Palpate in the labia majora
Go upward just lateral of pubic tubercles
Bartholin’s Glands - What do they do?
Responsible for vaginal lubrication.
Bartholin’s Glands - Where are they located?
Located at 5:00 and 7:00 at the introitus.
Introitus
Entrance to canal
How do you examine Bartholin’s Glands?
Tell the patient you are going to insert one index finger into the vaginal vault.
Insert the finger and pull back.
Use the external thumb of the same hand to lightly palpate at 5:00 and 7:00.
Obstruction of these glands will lead to pain, enlargement, and possible discharge.
How do you insert a speculum?
Decrease pressure on the urethra by holding the speculum blades obliquely and inward along the posterior wall of the vagina.
Rotate speculum horizontally .
Maintain pressure in the posterior direction.
Insert speculum to its full length.
Steps of Pelvic Exam (After speculum is inserted):
Open speculum carefully and “cup” the cervix
Rotate or adjust speculum until cervix is in full view
>If uterus retroverted cervix usually points anteriorly
If difficult finding cervix, withdraw speculum slightly and reposition it
Wipe discharge with large cotton swab if necessary
Inspect cervical os
>Note color of cervix, position, ulceration, masses, bleeding, discharge
Describe Nulliparous Os:
Nulliparous: round os
Have not had a baby, small rounded circle
Describe Multiparous Os:
Multiparous: Transverse os
Stretched to a :)
Cervical variations
Look at pictures
What is the full name of a pap smear?
Known as the Papanicolaou Smear
What is the purpose of this test?
What type of cancer?
Checks for abnormal cells (dysplasia) and or cancerous cells on the cervix and within the endocervical canal
**This is NOT a check for uterine cancer- this is only for cervical cancer**
How many samples are taken?
You are taking 2 samples for the PAP smear using both a cytobrush and spatula
Steps of a Pap Smear?
Insert endocervical brush into the cervical os and gently twist.
>Collects both squamous and columnar cells
>Remove the brush place into Thin Prep solution
The spatula has a notched end that resembles a mitten.
>Insert the “fingers” of the mitten into the cervical os, and turn it 360°.
>Covers transformation zone and squamocolumnar junction
>Remove the spatula and place into Thin Prep solution
Send these to the lab. Results known within 48⁰
What cultures are taken from cervix?
Gonorrhea and Chlamydia cultures are taken from the cervix
What cultures are taken from vagina?
Bacterial vaginosis, trichomonas, candidal swabs taken from vagina
How is discharge from vagina inspected? What is this also done on?
Vaginal discharge should be inspected and have a pH, wet-mount, and potassium hydroxide (KOH) analysis performed on it.
Repeat the process with a Chlamydia swab, placing the swab in a special culture tube.
>Gen Probe
Vaginal inspection and removal of speculum process –
Withdraw as you close speculum slowly and observe the vaginal mucosa.
As speculum is withdrawn, keep it in a slightly open position with your thumb.
Close speculum as it emerges from the introitus.
Close the speculum, and rotate it 90° counterclockwise back to vertical.
Put pressure on the posterior introitus as you slowly remove it.
Avoid pinching and excessive stretching
Inspect for color, inflammation, discharge, ulcerations or masses (polyps)
Bimanual pelvic exam - What is the purpose?
Allows to palpate adnexal organs (appendages of uterus) and cervix “blindly”
How is the bimanual pelvic exam done?
You perform this exam standing up
Lubricate index and middle finger of one hand
Insert them in the vagina posterior introitus
Thumb abducted; ring and small finger flexed in palm
Why do we supinate hand in bimanual exam, specifically?
How do we palpate the cervix?
Supinate your hand
>Feel for nodules, tenderness in vaginal wall
>Palpate cervix (spread fingers to cup the cervix); note position, consistency, mobility, tenderness
>Cervix can be moved without pain - normally
>Feel for the fornices of the cervix (anterior/posterior)
How is uterus palpated in bimanual exam?
Palpate uterus by placing left hand on abdomen
Elevate cervix with 2 fingers of the right hand while pressing down on lower abdomen with left hand
Capture uterus between your two hands
>Feel for uterine size, masses, and tenderness
How are ovaries palpated in bimanual exam?
Palpate ovaries by placing left hand on lower abd quadrants
Place right hand in corresponding fornix in pelvis
Press in and down on abdomen, ensuring you capture both RLQ and LLQ
Gently roll your hands back and forth to capture the ovary
>Check for size, shape, mobility, tenderness masses
What is normal ovary size? What is enlarged?
> Normal ovary is 1-3 cm.
>Larger suggests cysts or cancer.
How do you palpate fallopian tube in bimanual exam?
Fallopian tubes not normally palpable
Palpate the lateral vaginal wall using the same technique.
Because the fallopian tubes open into the abdominal cavity, infections can be deposited along the vaginal wall as tubo-ovarian abscesses.
If present, you will feel an enlarged, tender mass.
When is it apropriate to perform a rectovaginal exam?
The recto-vaginal examination is not always performed.
Perform if colon cancer, incontinence, rectocele, cul-de-sac tumors or infections are suspected.
Completion of pelvic exam:
Always remove your gloves outside of the view of the patient.
Re-drape her after completing the exam, and ask her to move her buttocks up onto the table before taking her feet out of the stirrups.
Offer a tissue, tampon or sanitary napkin after the examination.
Allow her to get dressed prior to discussing the findings
If the findings were normal, tell her immediately!!
Pelvic documentation
“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.”
“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 cervix, no discharge visible in cervical os. Uterus midline; no adnexal masses. Rectal vault without masses. Stool brown and hemoccult negative.”
Dysphasia
Abnormal cells
nsvd
Normal Spontaneous Vaginal Delivery
dypareunia
which is defined as persistent or recurrent genital pain that occurs just before, during or after intercourse.
