Female Exam Flashcards
1
Q
What are the borders of the breast?
A
- Superior border: Clavicle
- Inferior border: 6th rib
- Medial border: Sternum
- Lateral border: midaxillary
2
Q
What are the four components to a clinical breast exam?
A
- Introduction
- Breast Inspection
- Lymph node palpation
- Breast palpation
3
Q
What is the order of inspecting both breast?
A
- Patient sitting, arms at sides
- Patient sitting, arms above head
- Patient sitting, hands pressed to hips
- Patient leaning forward, supporting them
4
Q
What should you note during your inspection?
A
- Size
- Symmetry (some variation is normal)
- Shape
- Contour (flattening, masses, and dimpling)
- Skin (color, edema, rashes, lesions, thickening, and venous pattern)
- Scars (previous surgery, injuries)
- Nipple eversion or inversion
- resent onset of unilateral nipple inversion is suggestive of underlying malignancy
5
Q
What lymph nodes would you palpate on a breast exam?
A
- Supraclavicular lymph nodes
- Axillary lymph nodes (3 sweeps) and lateral chain
- Rich network with primary lymphatic drainage to axillae; secondary drainage to internal mammary
- Can also drain to supraclavicular and jugular nodes
6
Q
How should you palpate a patients breast during examination?
A
This may be done with patient supine or seated:
- Arm behind head
- Four quadrants
- Tail of Spence (up to clavicle and towards axilla)
- Nipple
- Areola
- Keep drape over areas not currently being examined
- Ask patient if the amount of pressure is comfortable during palpation
7
Q
What are the five segments of the breast?
A
- Upper outer quadrant
- Upper inner quadrant
- Lower inner quadrant
- Lower outer quadrant
- Tail of Spence
8
Q
When notating the location of a mass/lesions?
A
Clockwise
9
Q
What patterns can be used during breast palpation?
A
Vertical strip / lawnmower / ladder
Concentric circles
Radial spoke
- Utilize the pads of the fingers
10
Q
What should you note during breast palpation?
A
Nodules Indurations Masses Tenderness Nipple discharge
11
Q
What is the duration of palpation for a breast exam?
A
- Bra size B:
- 3 minutes per breast
- 6 minutes total time
Average time physicians spent in one study- 1.8 minutes to examine both breasts
12
Q
How should you expect when assessing for nipple discharge?
A
Check for nipple discharge by placing two fingers from each hand at edge of areola:
- Press down, inward toward nipple, then up & back down
- Repeat at 90 degrees to first position
Light milky discharge may be normal
Serous or bloody discharge typically abnormal
13
Q
What are the special examinations?
A
- Mastectomy or Breast augmentation
- Examine scar and axilla
- Lymphedema
14
Q
How should you document a breast examination?
A
- Inspection – size, symmetry, shape, contour, skin, scars
- Palpation – consistency, tenderness, nodules, lymphadenopathy
Example:
“No chest deformity or asymmetry. Normal contour. No nodules, masses, tenderness, or axillary adenopathy. No nipple discharge.”
15
Q
What are some pertinent questions during an interview? (Breast)
A
Pertinent questions:
- Self-examination?
- Lumps, nodules, enlargement, tenderness?
- Nipple discharge?
- Imaging?
16
Q
What should you look for a past medical history? (Breast)
A
PMHx: Breast disease or cancer, obesity, history of radiation to chest
17
Q
Reproductive history:
A
Age at menarche, age at first pregnancy, menopause status, breastfeeding history
18
Q
What additional information should you ask about during an interview? (Breast)
A
PSHX: Breast biopsies
Social: Smoking, alcohol use, exercise
Family Hx: Breast or ovarian cancer
Medications: OCPs or hormones
19
Q
What are some common complaints? (Breast)
A
Breast lump
Breast pain/discomfort
Nipple discharge
20
Q
How should you take a patients HPI for a CC: Breast Lump?
A
HPI: Location (unilateral vs. bilateral) How was it found? How long has it been present? Changed in size? Change with menstrual cycle? Nipple discharge? Pain? Skin changes?
PE Location Size Shape Consistency Delimitation Tenderness Mobility
21
Q
How should you take a patients HPI for a CC: Nipple discharge?
A
HPI: Location (unilateral vs. bilateral) When? How long? Color? Milky, brown, green, or bloody? Consistency? Associated lumps Pain? Menstrual cycle Pregnancy
PE: Identify involved duct Color Consistency Quantity
22
Q
How should you take a patients HPI for a CC: Pain or discomfort?
A
HPI: Location (unilateral vs. bilateral) When? How long? Associated lumps Menstrual cycle Pregnancy
23
Q
What are the four parts of a pelvic exam?
A
- Vulva and introitus (inspection: external exam)
- Speculum exam (inspection: internal exam)
- Obtaining samples (pap, HPV test, cultures, biopsy) - Bimanual exam (palpation)
- Rectal/Rectovaginal exam
24
Q
What are some patients at increased risk for discomfort?
A
- History of sexual abuse/assault
- History of painful speculum exams
- Difficulty with tampon use
- Painful intercourse
- Sexually inexperienced
- First speculum exam
- Inaccurate beliefs about body/anatomy
25
What pelvic equipment is needed for a pelvic exam?
```
Chaperone
Drape
Exam table with foot rests
Exam light
Floor light for external exam
Portable, placed within speculum
Speculum of proper size
Water-based lubricant
Pap smear supplies
Gloves
Guiac/Hemoccult cards if needed
```
26
How should you position the patient for a pelvic exam?
- Elevate head of table to permit eye contact
- Help patient into correct position
- Turn on and adjust floor lamp
- Ascertain the patient is comfortable
- Adjust drapes to maintain eye contact
Push drape down, like a V
- Offer mirror to patient
- Refer to “heel rests” or “foot rests” instead of “stirrups”
- Ask the patient to move down until she feels her hips extend slightly beyond the edge of the table
- Wash hands and put on gloves
27
How should you expect the external Vulva and Introitus?
- Skin: changes, nevi, lesions
- Labia majora and minora
- Perineal body/ perineum
- Anus
Using the back of your hands, lift up and out to retract the buttocks
28
Inspection/Palpation of External Vulva and Introitus?
Inspect:
- Clitoris
- Urethral meatus
- Introitus and hymen
- Paraurethral (Skene’s) gland
Palpate:
- Mons pubis
- Labia majora & minora
- Prepuce
- Bartholin’s duct
29
What are some Vulvar lesions?
```
Aphthous ulcers
Genital herpes
Epidermal inclusion cyst
Warts
Vulvar neoplasia
```
30
How should you use the speculum in a pelvic examination?
- Prepare to insert the speculum
- Hold it in your dominant hand
- Lubricate with warm water or lubricating gel
- Insert the speculum with speculum rotated slightly so as to make entry easier and to avoid injury to urethra
31
Speculum Insertion
- Separate labia (using less dominant hand)
- Keep labia apart
- Blades remain closed until fully
- inserted
- Blade can be at a 45 degree angle
- Use downward pressure
- Open blades, locate cervix
- Lock speculum in place
32
Speculum Examination
- Insert speculum at slight angle
- Apply posterior pressure to vagina with the speculum
- Open the speculum 1 or 2 clicks, depending on what is needed for full visualization
- If necessary, remove speculum and reinsert
- May do bimanual exam first if having trouble locating the cervix
33
What is the site for PAP smear?
Squamo-columnar junction of the cervix
34
What are some cervical variations of normal?
Unilateral transverse
Bilateral transverse
Stellate
35
What are some abnormal findings of the cervix?
Cervicitis
Polyps
Carcinoma
Nabothian Cyst
36
PAP Smear
- Insert the spatula into the cervical os; rotate 360 degrees
- Rinse by swirling in the solution at least 10 times
- Introduce the endocervical brush into cervical os and rotate ½ turn in one direction
- Rinse the brush by swirling at least 10 times in the solution. Discard the brush.
37
How do you remove the Speculum?
- To remove the speculum, open the speculum one more click
- Tip the front of the speculum down and gently pull back a short distance
- Ensure the blades of the speculum are free from the edges of the cervix to avoid pinching
- When blades of the speculum are free from the cervix, close the speculum and remove
38
How should you perform a bimanual pelvic exam?
- Inform patient prior to starting
- Lubricate internal fingers
- Non-dominant hand on abdomen
- Dominant hand internal
39
What are some external vulva, vagina, and urethra findings?
Cystocele
Cystourethrocele
Urethral Caruncle
Prolaspe of the Urethral Mucosa
40
How to perform a bimanual examination?
Palpate the cervix:
- Palpate the circumference of the cervix
- Gently rock the cervix from side to side
- Palpate the cervix for firmness
Palpate the uterine fundus:
- Place internal fingers on posterior side of cervix and outer hand on lower abdomen
- Gently palpate each side of the uterus
Expected findings:
- Pear-shaped, rounded, firm & smooth
Palpate the ovaries:
- Move internal and external fingers lateral to uterus and use 3 sweeps moving from distal point toward pubic hair line, attempting to palpate the ovaries.
Expected findings:
- Smooth & ovoid, mildly tender to palpation, similar to an almond
- May not be palpable
41
What are the various positions of uterine positions?
Anteverted (most common)
Anteflexed
Retroverted
Retroflexed
42
Rectovaginal Exam
Purpose:
- Palpate a retroverted or retroflexed uterus
- Palpate uterosacral ligaments
- Palpate the cul-de-sac and adnexa
- Screen for colorectal cancer
- Assess pelvic pathology
Technique
- Index finger inserted into vagina while middle finger inserted into rectum
- Straining can help relax anal sphincter
- Apply pressure with fingers to anterior and lateral walls while hand on abdomen applies downward pressure
43
Pelvic Exam Documentation
Pelvic:
External genitalia without erythema, lesions,or masses. Normal female hair pattern. Urethral meatus without erythema or lesions. Bladder non-tender to palpation
Vagina pink and moist without discharge or lesions.
Cervix smooth without lesions, discharge or cervical motion tenderness
Uterus mobile, nontender and nonenlarged, smooth contour
No rectocele or cystocele.
Ovaries palpable, without masses bilaterally . No adnexal masses or tenderness.
44
Rectal Exam Documentation
Sphincter tone intact. No external masses, lesions, or hemorrhoids. Stool hemoccult negative
45
OB/GYN Menstrual History:
```
Menarche
LMP & LNMP
Length of periods
Cycle length
Menstrual flow
Recent changes in periods
Age at menopause
```
46
OB/GYN Menstrual History: Common complaints
```
Irregular periods
- Irregular
- Heavy flow
- Missed period
- Intermenstrual
Postcoital bleeding
Postmenopausal bleeding
```
47
OB/GYN Pertinent Medical History
Medical history
- History of salpingitis, endometritis, tubo-ovarian abscess
- History of uterine fibroids, ovarian cysts, endometriosis
- Gynecologic cancers, breast cancer, colon cancer or history of radiation to pelvis
48
OB/GYN Pertinent Family History
Family history:
- Gynecologic cancers, breast cancer, colon cancer, inherited genetic disorders
- Timing of menarche/menopause in mother/grandmother
49
OB/GYN Pertinent Surgical History
Surgical history: pelvic surgery, hysterectomy, sterilization
50
OB/GYN Pertinent Peri/post menopausal & Gynecologic symptoms
Peri/post menopausal symptoms
- Anxiety / nervousness
- Mood fluctuations
- Fluid retention
- Food cravings
- Difficulty sleeping
- Cramps and discomfort
- Hot flushes
- Decreased vaginal lubrication
- Altered libido
- Pelvic pain (OLDCARTS)
Gynecologic symptoms
- Abnormal vaginal discharge
- Itching
- Sores/lesions
- Dyspareunia
- Abnormal or painful periods
- PMS
- Sexual dysfunction
- Abnormal vaginal bleeding
Urinary Systems
51
OB/GYN Obstetrical History
Pregnancy complications
- Diabetes
- Hypertension
- Preeclampsia
- History of depression before or after a pregnancy
Breastfeeding history
History of infertility
- Prior diseases or surgery that may affect fertility
- Pregnancy histories with same or other partners
- Duration that conception has been attempted
- Frequency and timing of sexual intercourse
