Exam 3 - End of Study Guide Flashcards
Guidelines for pregnancy & nicotine use
Nicotine increases chance of miscarriage and low birth weight; goal is cessation but any decrease is beneficial
Guidelines for pregnancy & alcohol use
No safe amount of alcohol is known due to the risk of fetal alcohol syndrome; women should not drink any alcohol during pregnancy
Guidelines for pregnancy and illicit drug use
Various drugs have various effects, but women should be referred to treatment immediately if addicted to support quitting
Characteristics & presentations of condyloma acuminatum
Genital warts - single or multiple papules or plaques of variable shapes that may be round, acuminate (pointed), or thin and slender. May be raised, flat, or cauliflowerlike (verrucous). Can arise on any part of genitalia , groin, thighs, or anus. Usually asymptomatic but may cause itching or pain. Incubation of HPV for weeks or months before appearance; may disappear w/o treatment, but this is unlikely.
Characteristics & presentations of genital herpes
Small scattered or grouped vesicles 1-3mm in size on glans or shaft; appear as erosion if vesicles break; HSV 2 (double stranded DNA virus) ﾖ 2-7 days after exposure; Primary episode may be asymptomatic; subsequent episodes usually less painful/shorter
Characteristics & presentations of primary syphilis
small red papule that becomes a chancer (painless erosion) up to 2 cm in diameter; base of chancer is smooth, clean, red, & glistening; borders are raised and indurate. Chancer heals in 3-8 wks. Caused by Treponema palliduma spirochete. Incubates 9-90 days before symptoms appear. Inguinal lymphadenopathy may occur within 7 days with rubbery, non-tender, mobile lymph nodes. 20-30% of patients develop secondary syphilis while chancer is still present (suggest coinfection of HIV). Must distinguish from genital herpes, chancroid, granuloma inguinale
Characteristics & presentations of secondary syphilis
A continuation of primary syphilis due to lack of treatment; syphilis infection becomes systemic. Occurs 2-8 wks after developing primary syphilis and usually marked by a non-itchy rash that may be confined to one region, or may present in several regions. A common manifestation is rough, reddish-brown dots on bottoms of feet and palms of hands that may be scaly or smooth.
Steps of a pelvic exam
External exam (inspect & palpate); Internal exam (speculum exam including PAP smear & screenings; bimanual; rectal; bimanual rectal)
Equipment needed for a pelvic exam
Vaginal speculum; water-soluble lubricant; specimen collection materials; large cotton tips swabs and sterile swabs; gloves (2 pair); hemoccult card & reagent; light source
Equipment needed for a PAP smear
Cervical brush and wooden/plastic spatula OR cervical broom; liquid prep media OR glass slide and cytologic fixative; culture plate or media; sterile cotton swabs; DNA probe (for chlamydia and gonorrhea)
Describe how a female patient should be positioned for the pelvic exam.
Lithotomy - elevated head of bed; feet in extended stirrups; buttocks near edge of table; knees “dropped to the side”; patient appropriately draped to cover while maintaining good eye contact
Describe the process of performing an external examination of the female pelvis.
Inspection & palpation of hair (pattern, presence of lice), mons veneris (lesions/swelling); vulva (excoriations, masses, redness, leukoplakia, or pigmentation); labia (lesions, ulcers, discharge, warts, trauma, swelling, atrophic changes, masses); urethral meatus (pus or inflammation); clitoris (size, lesions); Bartholin’s glands (palpate for tenderness, swelling, pus; normal glands not see or felt); perenium (masses, scars, fissures, or fistulae); anus (hemorrhoids, irritation, fissures)
Describe the process of performing an internal examination of the female pelvis.
Position CLOSED speculum as far into the vagina as possible. When completely inserted, rotate speculum so handles point downward. SLOWLY open speculum. With blades open, visualize vaginal walls and cervix. Remove obscuring discharge with large cotton-tipped applicator to allow inspection. Position light to visualize well. May need to reposition the speculum. (Slightly withdraw speculum and reposition.) Cervix should rest within blade of speculum. Inspect cervix. (color, discharge, surface, bleeding, erythema).
Describe how to properly obtain a PAP smear.
Use Endocervical Spatula first. Longer end of spatula into the cervical os. Press, turn, scrape in a full circle clockwise. Make sure to include transformation zone and squamocolumnar junction. Place in cytologic solution. Do it first to minimize obscuring cells with blood. Use endocervical brush 2nd. Place into os. Roll between thumb and index finger. Remove and place in cytologic solution. OR Use an endocervical broom. Allows for collect of single specimen containing all necessary cells (both squamous & columnar epithelials).
Describe the process of performing a bimanual examination on a female.
Lubricate index and middle fingers of dominant hand. From a standing position, insert vertically into the vagina. Apply downward pressure toward perineum. Flex 4th and 5th fingers into palm, extend thumb. Avoid touching the clitoris. Note nodularity or tenderness in vaginal wall. Once fingers inserted, rotate hand 90 degrees so palm facing upward. Place left hand on abdomen, approx 1/3 of the way to the umbilicus from the pubic symphysis. Vaginal hand pushes pelvic organs up and out of pelvis and stabilizes them while they are palpated by the abdominal hand. Push cervix up and back toward the abdominal hand as the abdominal hand pushes downward. This tips an anteverted, anteflexed uterus forward to make palpation easier. Retroverted uterus is not easily felt on bimanual. (remember retro ﾖ toward rectum). Normally can move cervix somewhat without pain, 2 ﾖ 4 cm in any direction. (Extreme cervical motion tenderness ﾓChandelier signﾔ). Palpate fornices. Palpate the body of the uterus between your hands. Pelvic fingers feels anterior surface of the uterus. Abdominal hand feels part of the posterior surface. Palpate adenexa. Abdominal hand on right lower quadrant & pelvic hand in right lateral fornix. Press your abdominal hand in & down, trying to push the adnexal structures toward your pelvic hand. Try to identify the right ovary or any adjacent adnexal masses. Move your hands slightly & slide the adnexal structures between your fingers. Repeat on left side. Move fingers to posterior fornix. Palpate uterosacral ligaments and Pouch of Douglas. Tenderness and nodularity suggest endometriosis.
Explain what is being evaluated in a female bimanual exam.
Evaluate uterus (size, shape, consistency, mobility, and ID any tendernes or masses). Evalute adenexa (size, shape, consistency, mobility, and tenderness). Normal adenexa are slighty tender when palpated and more palpable in slender women. Adnexal tenderness/enlargement is relatively specific for pathology. Tenderness/nodularity of uterosacral ligaments or Pouch of Douglas suggests endometriosis.
Describe the characteristics & expected findings of a retroflexed uterus.
A straighter uterus that is angled toward the rectum.
Describe the characteristics & expected findings of a retroverted uterus.
A uterus that is curved backward toward the rectum. Not easily palpable on a bimanual exam.
Describe the characteristics & expected findings of an anteroflexed uterus.
A straighter uterus that is angled toward the umbilicus. Palpable during bimanual exam, especially when cervix is pushed up and toward abdominal wall.
Describe the characteristics & expected findings of an anteroverted uterus.
Uterus that is curved toward the umbilicus. Palpable during bimanual exam, especially when cervix is pushed up and toward the abdominal wall.
Describe draping techniques for a female pelvic exam.
Sheet over patient’s legs, to the knees. Indent sheet between knees to maintain eye contact with patient while performing pelvic exam.
What are you evaluating during the external examination of the female pelvic exam?
Hair, mons veneris, skin of vulva, urethral meatus, labia, clitoris, Bartholin’s glands; perineum; anus; pelvic relaxation
Describe abnormal findings of the female external pelvic examination.
Presence of lice/nits in HAIR; lesions/swelling of MONS VENERIS; excoriation/masses/redness/leukoplakia/pigment changes of VULVA; pus/inflammation of URETHRAL MEATUS; lesions/ulcers/discharge/warts/trauma/swelling/atrophic changes/masses of LABIA; size changes/lesions of CLITORIS; palpable/tender/swollen/pus of BARTHOLIN’S GLANDS; masses/scars/fissures/fistulae of PERINEUM; hemorrhoids, irritiation, fissues of ANUS;
Describe abnormal findings of the female pelvic relaxation portion of the external pelvic examination.
Process - patient coughs or bears down while labia are spread. Abnormal findings are cystoceles (bulging of anterior wall); retroceles (bulging of posterior wall); uterine prolapse (displacement of cervix toward introitus); stress incontinence
What are you evaluating during the speculum examination of the female pelvic exam?
Color, discharge, surface characteristics, bleeding, and erythema of cervix. Walls of vagina for color of mucosa, presence of inflammation, characteristics of discharge, presence ulcers/lesions
Describe expected and abnormal findings of a speculum examination.
Redness, ulcers, masses, scarring, bleeding, erythema of cervix. Patchy, gray, grayish-yellow, white, or greenish-yellow discharge on cervix; fishy odor; purulent, bubbled, cottage-cheese like, or muco-purulent discharge; red spots on cervix. Abnormal vaginal wall findings include redness, inflammation, discharge (other than normal white/clear); ulcers/lesions, cystoceles, uretocele, rectocele, enterocele, and uterine prolapse
Describe expected findings of a bimanual examination.
Cervix - non-tender with motion; smooth, consistent, regular, mobile Body of uterus - should be palpable unless retroverted; non-tender, mobile, consistent, no masses, symmetrical Ovaries - are normally slightly tender to palpation; may not be palpable in obese or tense women; symmetrical and equal on left/right; smooth; mobile
Describe abnormal findings of a bimanual examination.
Cervix - Chandelier’s sign; redness, masses, tenderness, asymmetry, hardness, or inconsistent texture of cervix, uterus, or ovaries. Tenderness or nodularity when palpating uterosacral ligaments and Pouch of Douglas suggests endometriosis.
What are you evaluating during the rectal examination of the female pelvic exam?
Assessing rectal canal for masses/tenderness, sphincter tone, fecal occult blood, and possibly exam of retroverted uterus
Describe expected findings of a rectal examination.
No masses, tenderness, or blood in stool. Sphincter tone = resistance around phalange
Describe abnormal findings of a rectal examination.
Any masses, tenderness. Positive fecal occult blood test. Lack of resistance around phalange (lack of sphincter tone)
Describe how to properly position and use the speculum in a pelvic exam.
Lubricate speculum. Separate labia majora. Enlarge Posterior or Lateral Introitus with index (posterior) or index and middle fingers (lateral). Insert closed speculum tilted slightly toward coccyx and handle angled about 30 degrees. Slide along posterior wall, slowly rotating to a neutral position where handle is vertical. Remove fingers. Slowly open speculum to expose cervix.
Describe the tools used to collect specimens from the cervix and how to use these.
Cervical spatula - used before brush. Place longer end of spatula into cervical os. Press, turn, and scrape 360 degrees clockwise AND counterclockwise. Place in cytologic solution. Endocervical brush - used after spatula. Placed into os. Roll between thumb and index finger. Remove and place in cytologic solution. Endocervical broom - may be used in place of spatula and brush. Procede with same instructions as brush.
What information should be elicited for related to breast history (HPI)?
Timing/Onset - How long? Does lump come and go? Is it always present? Relationship to menses? Symptoms - Tenderness or pain? Dimpling or change in breast contour? Changes in lump ﾖ Size; Character; Unilateral or bilateral. Associated symptoms - Nipple discharge/retraction; Tender lymph nodes. Medications ﾖ Nonprescription; Prescription
What information should be elicited for related to breast history (PMH)?
Changes in characteristics - Discharge; Lumps; Pain; Size or shape changes; Skin changes; Tenderness. Changes with menses - Lymph nodes enlarged; Pain; Swelling; Tenderness. Surgeries ﾖ Aspiration; Breast biopsies; Implants; Oophorectomy; Reductions. Mammography history ﾖ Frequency; Last mammo; Results. Previous breast disease ﾖ Cancer; Fibroadenoma; Fibrocystic changes. Known hereditary cancer - BRCA1 or BRCA 2; Hereditary, nonpolyposis colorectal cancer. Previous, related cancers ﾖ Colorectal; Endometrial; Ovarian. Breast cancer risk factors
