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My PCM 2 > Female exam > Flashcards

Female exam Flashcards

1
Q

failures of examiner

A 
Wrong  or COLD speculum              CHECK IT !!
No lubrication (water or gel)
Set-screws used incorrectly – RELEASE after!
Using “vertical orientation”  OMG
Wrong position – HOB up 30-40 deg
No eye contact
Supplies not checked
No REHEARSAL – with MA or RN
Wrong use of lower drape – see slide 36
Incandescent light
         Welch Allyn fiberoptic box and WAND
Wrong placement of hinges on door!
SILENCE – 99.999% want explanation
Interruptions and distractions
TOO FAST, OR TOO SLOW (2-3 mins)
YOU are uncomfortable – type I
YOU are uncomfortable – type II
It’s a “footrest”, not a “stirrup”
Wrong time/place for detailed post-exam consult
Ungraceful handling of pt’s child
Failure to coach WHERE to “relax”
Failure to touch (“neutral”) inner thigh at start
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2
Q

attendant/ chaperone

A 
Needed every time because:
Keeps YOU out of trouble  BIG TROUBLE
Assistance is very helpful, with
Pap collection
STD sample collection
Raising HOB
Labeling/submitting samples
Etc.
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3
Q

menarche

A

age at onset of menses

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4
Q

menopause

A

absence of menses for 12 consecutive months (usually 48-55 years old)

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5
Q

post-menopausal bleeding

A

bleeding occurring 6 months or more after cessation of menses. Definition depends on risk factors

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6
Q

amenorrhea

A

absence of menses

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7
Q

dysmenorrhea

A

pain with menses

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8
Q

polymenorrhea

A

menses at abnormally frequent intervals

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9
Q

oligomenorrhea

A

abnormally scant or infrequent menses

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10
Q

menorrhagia

A

excessive bleeding

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11
Q

metrorrhagia

A

bleeding between periods

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12
Q

post-coital bleeding

A

bleeding after sexual intercourse

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13
Q

gynecologic history

A 
Last menstrual period
Regularity of periods
Usual time between periods – d.1 to d.1
Number of days of flow
Amount of flow – getting up in the night?
Pain with periods  -  see next slide for more info
Bleeding between periods
Age of menarche
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14
Q

gravida-para notation

A 
G2 P1011
G – gravida-number of pregnancies     2
P – para-outcome of pregnancies
T = term > 37 weeks gestation         1
P = premature                                     0
A = abortion
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15
Q

some examples of obstetric history

A

G3P3003 3 pregnancies, 3 term deliveries and all living
G5P2032 5 pregnancies, 2 term deliveries, 3 abortions, 2 living
G4P3205 4 pregnancies, 3 term deliveries, 2 preterm deliveries, 5 living (prem = twins)
G3P3002 3 pregnancies, 3 term deliveries, 2 living (1 dec from SIDS)

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16
Q

ob/lnmp history

A

H&P/SOAP for a female patient isn’t complete without the OB/LNMP history!!!!
Best place is the very first sentence of the HPI
Second-best place is in the PMH – as a separate sub-category
Omission is unacceptable!
LNMP = day 1 of a normal, on-time menses

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17
Q

urological related complaints or problems

A 
Frequency
Burning
Incontinence (stress , urge, overflow)
Urgency
Nocturia
Hematuria    WORK THIS UP!!!!!!!!!!!!!!!!
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18
Q

common chief complaints

A 
Amenorrhea		
Dysmenorrhea
Metrorrhagia					
Vaginal discharge/itching
Abdominal/pelvic pain
Dyspareunia – painful intercourse
Infertility
Pre-menstrual  syndrome  = “PMS”
(PMDD - Premenstrual dysphoric disorder)
Changes in urinary patterns
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19
Q

dysmenorrhea

A

How does it affect pt’s life?
Usual onset = with or very shortly before flow
2-3 days before flow = endometriosis?
Unilateral – careful exam and US
NSAID’s – start before needed, regular doses
NSAID’s – naproxyn (Aleve) 2 PO Q8H
BC pills

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20
Q

dysmenorrhea ddx

A 
“normal” – minimal to severe sx
Endometriosis
Cervical stenosis
Infection
Congenital anomaly – rudimentary horn
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21
Q

exam preparation

A 
Performed best with empty bladder
Patient comfort and better exam
Have all necessary materials
Rolling “mayo” stand with tray and paper
Gloves – 1 or 2 ?????
Speculum(metal or plastic) – appropriate size
Light sources  - STAFF TESTS DAILY
Cotton-tipped swabs – SMALL/ 2 LARGE
Lubricant - put it on paper on the tray!!
Pap materials (brush/spatula/broom)
Liquid Pap media  - HAVE BACKUP IN ROOM
pH paper, culture, slides, KOH/saline/VIP, DNA probes
MIRROR
22
Q

notes on hymen

A

Hymen isn’t “torn”, it is “non-virginal”
Hymen “tags” are NORMAL
Labia minora – variable length - this can be a cause of considerable angst for the pt

23
Q

palpation of external genitalia

A

(lower) drape
Palpation of Skene’s Glands and Bartholin’s Glands
Skene’s Glands – 10 and 2 o’clock – “stripping” of urethra
Bartholin’s Glands – 4-5 and 7-8 o’clock

24
Q

two types of vulvar lesions (consult slides to see pictures)

A

Condylomata – warts – raised, variable size, firm, cauliflower-like, NT
Herpes – 1 or more open vesicles with whitish border and reddish base; very tender to touch with Q-tip; variable size; early = closed vesicles

25
Q

a discussion of the skin

A 
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
26
Q

Examination of the Internal Genitalia

A

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.
27
Q

The examination of the cervix and procedures

A

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

28
Q

Finding the cervix

A 
Variable location
Posterior
“Deep”
Anterior – even behind symphysis
OK to stop and do brief bimanual exam
29
Q

Transformation Zone (TZ)

A

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

30
Q

cervical changes with cycle

A

cervix in fertile phase: os is open, soft, with fertile mucus

cervix in infertile phase: os closed, hard, with no mucus

31
Q

Cervix polyps do’s and don’ts

A

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

32
Q

When to do Pap smear

A

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)

33
Q

Purpose of Pap smear?

A

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

34
Q

PAP Smear Equipment

A

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

35
Q

pap smear technique

A 
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!
36
Q

Palpation: Bimanual Exam

A 
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

37
Q

Version and Flexion

A

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

38
Q

Rectovaginal Exam

A

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)

39
Q

RECTAL EXAM - TIPS

A 
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
40
Q

acronyms for exam

A 
BUS = Bartholin’s glands, urethra, Skene’s glands
CMT = cervical motion tenderness
AV/AF = anteverted, anteflexed
41
Q

functional anatomy of the breast

A

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.

42
Q

arterial supply to the breast

A

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.

43
Q

lymph drainage of the breast

A

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.

44
Q

preliminaries for breast exam

A

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

45
Q

Breast Inspection

A

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
46
Q

Observe the nipple for:

A 
Retraction unilateral or bilateral
Discharge
Darkening
Rash, crusting or ulcerations
Supernumerary nipples
47
Q

Palpation (breast)

A

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.

48
Q

palpation of breast- the zone is:

A

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”

49
Q

Palpation in sitting position

A

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

50
Q

palpation pattern

A

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!

51
Q

important tips about palpation of breast

A

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

52
Q

Discharge? Nipple exam

A

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!

My PCM 2 (5 decks)

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