Female exam Flashcards

Question

a discussion of the skin

Answer 1

``` From the transformation zone (TZ) on the cervix, all the way out to the external vulva, it’s all SQUAMOUS EPITHELIUM. Cell turnover = “physiologic discharge” = NORMAL Vagina extremely estrogen-sensitive. Vaginal rugae Flexible, elastic, strong Low estrogen = less and less of above ```

Answer 2

Insertion of the Speculum - Select appropriate size speculum. - Warm and lubricate with warm water or gel. - Hold HORIZONTALLY and point downward or posterior. - Put gentle downward pressure on the posterior introitus. COACH!! - Once in the vagina, straighten the speculum and gently advance, maintaining posterior pressure. - Slowly open the speculum to visualize the cervix.

Answer 3

The Cervix - Color - Position - Surface Characteristics - Discharge - Size and shape of the os Procedures - PAP smear - Sample of vaginal secretions for wet mount - DNA probe - STD ``` Os (ext.) Shape Polyps Pus Cancer Cysts ``` Transformation Zone

Answer 4

``` Variable location Posterior “Deep” Anterior – even behind symphysis OK to stop and do brief bimanual exam ```

Answer 5

Where premalignant changes and neoplasia occur under influence of HPV (16+18) virus Encompasses immature and mature squamous metaplasia - which cell am I going to be?? TZ moves “inward” with age TZ may move “outward” with childbirth

Answer 6

cervix in fertile phase: os is open, soft, with fertile mucus cervix in infertile phase: os closed, hard, with no mucus

Answer 7

Show pt the polyp Polypectomy – very rare to be CA, but often cause PCB Don’t needle or biopsy nabothian cysts COLPOSCOPY/BIOPSY any “lesion” – EVEN IF THE PAP IS NORMAL NO cervix or double cervix – REFER to Gyn

Answer 8

Huge controversy Not before age 21 or after age 65 Not ever again if hysterectomy with cervix removed – and no hx cervical problems Yearly if + history of dysplasia HPV testing at 30. If neg, Pap q3-5 years. Best guideline = from ACOG (acog.org)

Answer 9

To find “pre-cancerous” (i.e., DYSPLASIA) lesions of the cervix NOT to find existing CA of cervix – may hint, but “inspection” very/more important NOT to find ovarian CA NOT to find endometrial CA - may hint at endometrial CA – but NOT reliable

Answer 10

Plastic or wood spatula 2 sizes swab Brush or “broom”

Answer 11

``` Speculum “locked” Wipe w/ large swab Paddle - 360 deg rot. Rotate brush – 360 Expect blood – large swab #2 Scrape brush into jar of alcohol – don’t just swish! ```

Answer 12

``` Cervix Tenderness, size, position, mobility Uterus Size, shape, consistency, mobility Position Fibroids (nodules) Ovaries Size, shape, mobility, tenderness Remember to palpate bilaterally Strength of Pelvic Floor ``` Internal hand-- dominant hand

Answer 13

Version is the relationship between the fundus of the uterus and the vagina Flexion is the relationship between the fundus of the uterus and the cervix – think of uterus as having a HINGE at internal os of cervix

Answer 14

The rectovaginal examination has three primary purposes: To palpate a retroverted and retroflexed uterus and the uterosacral ligaments To screen for colorectal cancer in women 50 years or older To assess pelvic pathology in the posterior rectovaginal pouch (Pouch of Douglas)

Answer 15

``` Routine? What age to begin? For sure age 50 w/ hemoccult Patients don’t have to “hate” this! Explain – even blame the ACS Consider rectal only and not “RV” If uterus RV/RF, fixated, tender nodules = endometriosis should be high in your ddx ```

Answer 16

``` BUS = Bartholin’s glands, urethra, Skene’s glands CMT = cervical motion tenderness AV/AF = anteverted, anteflexed ```

Answer 17

The mature female breast extends from the level of the second rib to the inframammary fold at the sixth rib. It extends transversely from the lateral border of the sternum to the mid axillary line. The deep or posterior surface of the breast rests on the fascia of the pectoralis major, serratus anterior, and external oblique abdominal muscles, and the upper extent of the rectus sheath. The axillary “tail of Spence” extends laterally across the anterior axillary fold. The upper outer quadrant of the breast contains a greater volume of tissue than do the other quadrants. The breast is composed of 15 to 20 lobes which are each composed of several lobules. Fibrous bands of connective tissue travel through the breast (suspensory “ligaments of Cooper”), insert perpendicularly into the dermis, and provide structural suppo t. Each lobe of the breast terminates in a major (lactiferous) duct (2 to 4 mm in diameter), which opens through a constricted orifice (0.4 to 0.7 mm in diameter) into the ampulla of the nipple. Deep to the nipple-areola complex, each major duct has a dilated portion (lactiferous sinus), which is lined with stratified squamous epithelium. Major ducts are lined with two layers of cuboidal cells, while minor ducts are lined with a single layer of columnar or cuboidal cells.

Answer 18

The breast receives its principal blood supply from three sources, which combine for a GENEROUS blood supply: (1) perforating branches of the internal mammary artery (2) lateral branches of the posterior intercostal arteries (3) branches from the axillary artery, including the highest thoracic, lateral thoracic, and pectoral branches of the thoracoacromial artery. The second, third, and fourth anterior intercostal perforators and branches of the internal mammary artery arborize in the breast as the medial mammary arteries. The lateral thoracic artery gives rise to lateral mammary branches.

Answer 19

Axillary tail drains into the subscapular group of axillary nodes. Upper portion of the breast drains into infra clavicular group. Medial part of the breast is drained by sub mammary plexus of the opposite breast and also to the lymph glands along the internal thoracic artery and then to the mediastinal nodes Most of the lymph from subareolar and submammary plexus is drained to the anterior or pectoral group of axillary nodes The inferior part of the breast is drained by the lymphatics of abdominal wall and to the extra peritoneal lymphatic plexus.

Answer 20

Adopt a reassuring attitude Respect the patient’s modesty – gown opens in the BACK Consider exposing one side at a time! The optimal time to examine the breast 5-7 days following the end of the LMP ……FYI – conveniently, this is also a great time for Pap, but you may palpate a CL cyst on 1 ovary

Answer 21

With the patient in the seated position Inspect the breasts with the arms at the sides, then inspect the breast in four additional positions: Arms over head Hands against hips Palms pressed together Arms extended and bent forward at the waist Note Be sensitive. And be efficient. Women feel very vulnerable during this portion of the examination. ``` Begin inspection with the patient in a seated position Observe the breast for: Development Size and symmetry Contour Retractions or dimpling of skin Skin color and texture Venous engorgement ```

Answer 22

``` Retraction unilateral or bilateral Discharge Darkening Rash, crusting or ulcerations Supernumerary nipples ```

Answer 23

Perform the examination with the patient supine and the ipsilateral arm above the head Use your finger pads not fingertips Palpation can be done in vertical strips or concentrically or “spiraling” Flatten the breast tissue against the chest wall Motion should be continuous-Do not lift your hand off the breast. Use your other hand to help! Methodically palpate the entire breast by quadrant and the Tail of Spence Use three different levels of pressure to feel all the breast tissue. Light pressure is needed to feel the tissue closest to the skin; medium pressure to feel a little deeper; and firm pressure to feel the tissue closest to the chest and ribs. Use each pressure level to feel the breast tissue before moving on to the next spot.

Answer 24

From an imaginary line drawn straight down from the axilla to another line down the middle of the sternum From clavicle to costal margin - supraclavicular region is included Like the abdomen, think of FOUR QUADRANTS: UOQ, UIQ, LOQ, LIQ Preface with R or L………. e.g. “RUOQ”

Answer 25

Not routinely necessary, but can be very helpful for upper ½ if large or pendulous Leave gown on one side, expose the other Hand on hip Exam one side then switch gown for exam of other side

Answer 26

There is some evidence from the American Cancer Society to suggest that the vertical pattern is the most effective pattern for covering the entire breast without missing any breast tissue. I like the “spiral” best. Develop your own “pattern” and do it the same way every time!

Answer 27

Have patient feel what you’re feeling Be sure you agree! If pt found her own lump, have you correctly located what she is talking about???!!! Many techniques to focus on one spot: Side position, sitting position, pillow under shoulder, lube or soap Always take pt seriously – you may think your exam is normal – get and US and dx mammogr

Answer 28

Not necessary to “pinch” nipples during routine exam. Patient will tell you if she’s seeing discharge. Pt helps you collect sample onto slide and hemoccult card. Micro = look for fat globules More to come on this in your second year!