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Physical Diagnosis Module II > Female GU Exam > Flashcards

Female GU Exam Flashcards

1
Q

lithotomy position

A
  • Vulnerable position
  • Difficult to maintain
  • Make the patient as comfortable as possible - adjust the stirrups, feet, bed
  • Remove bed extension, uncover
  • Have pt “scoot down” to edge of bed
  • -Can say “move down until you feel my hand”
  • Prepare everything before positioning
  • Position pt last thing before the exam
  • If you need to leave, out of stirrups, cover
  • Assistant can hold legs, support pt during the exam to help with “shakey legs”
  • Help patient out of position when done
  • Re-cover patient, reassure
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2
Q

Before beginning exam

A
  • Insure privacy
  • Gloves that fit
  • Speculum - select size
  • Pap kit
  • Cultures - Gonorrhea and Chlamydia
  • Slides, cover slips, cotton swabs
  • Normal saline, KOH, pH paper
  • KY jelly
  • Stool guaiac card if doing a rectal
  • Light that works
  • Seat for you
  • Male examiner - female assistant
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3
Q

External female GU exam elements

A

inspection, palpation

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4
Q

internal female GU exam elements

A

inspection with speculum, palpation via bimanual exam

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5
Q

Elements of female GU exam

A

External, internal, rectovaginal

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6
Q

Inspecting Mons

A
  • Tanner stage

- Parasites (lice), skin lesions

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7
Q

Inspecting Labia majora

A

-Masses, pain, hernias

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8
Q

Inspecting Labia minora

A

-Swelling, lesions, discoloration

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9
Q

Inspecting the Clitoris, clitoral hood

A
  • Inspect for discoloration, masses
  • Thumbs at top, sides of hood, slide up
  • Avoid touching clitoris
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10
Q

Inspecting the urethra

A
  • Inspect for redness, masses

- Two thumbs, pull apart to expose opening

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11
Q

inspecting the introitus

A
  • Vaginal opening, hymenal remnants
  • Inspect for lesions, discharge
  • Pt “bears down” to expose any bulge:
  • -Cystocele - superior vaginal wall
  • -Rectocele - inferior vaginal wall
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12
Q

inspecting posterior forchette

A
  • Base of introitus - where labia minora meet

- Inspect for lesions, redness

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13
Q

Inspecting Bartholin’s glands

A
  • Thumb at base labium, index just inside vaginal opening
  • Palpate lower 1/3 bilaterally
  • Note swelling, mass, pain, discharge
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14
Q

Inspecting Skene’s glands

A
  • Rotate index, thumb upward, spread labia
  • Palpate lateral bases of urethral opening
  • See ducts, note discharge; milk glands if discharge
  • Careful not to palpate clitoris
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15
Q

Inspecting Perineum

A
  • Area between base of vaginal opening and anus
  • Inspect for lesions, redness, swelling
  • Palpate for masses, tenderness
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16
Q

Inspecting anus

A
  • Inspect by spreading buttocks, both hands
  • Ask pt to bear down to evert anal folds
  • Inspect for lesions, bleeding, redness
17
Q

Speculum sizes and types

A
  • 90% size medium
  • Pedersen – narrow throughout – most commonly used
  • Graves – wider body, end – best in large or multiparous women
  • Check speculum for imperfections, working order before insertion
  • warm speculum before insertion
18
Q

The speculum exam

A
  • Separate labia minora with one hand to expose introitus
  • Index finger at base of introitus
  • Can insert one finger into vagina, holding pressure on muscle at base of introitus to relax opening
  • May also feel cervical orientation, angle of vagina
  • Hold speculum, closed, at base of “bills”
  • Touch patient briefly with tip at introitus
  • Speculum closed with tip slightly rotated ~45 degrees
  • Insert, downward pressure as you go
  • -Downward pressure on muscle at inferior vaginal opening is key!
19
Q

cervix and vaginal walls appearance

A

cervix - smooth and shiny

vaginal walls - have rugae

20
Q

Steps of the speculum exam

A

1: insert speculum
2: insert speculum
3: Open speculum

21
Q

Os types

A 
pinpoint = never had a child
smile = cervix has been dilated for labor
22
Q

What to look for on speculum exam

A
  • Discharge – amount, color, odor
  • Blood – amount, color, clots
  • Vaginal walls – lesions, color, texture
  • Cervix – lesions, discoloration
  • Os – shape, discharge, lesions, squamo-columnar junction
  • -Is the os open or closed?
23
Q

removing speculum

A
  • Removal can be tricky
  • Unlock speculum
  • Unhook cervix by opening slightly and pulling back with side-to-side motion
  • Watch unlocked bills come together
  • Slide speculum out closed
  • Deal with your samples
24
Q

Palpation on bimanual exam

A

uterus, adnexa, cervix

25
Q

palpation of the uterus

A
  • Size
  • -Can feel pregnancy at 10-12 weeks
  • Position
  • Irregular surface or masses
  • Consistency
  • Mobility
  • Tenderness
26
Q

palpation of the adnexa

A
  • Symmetry or masses
  • Tenderness
  • Mobility
27
Q

Palpation of the cervix

A
  • Tenderness
  • Nodules
  • Size
  • Position
28
Q

how to do the bimanual examination

A
  • Lubricate the index and middle fingers of the gloved hand
  • Gently insert those two fingers into the vagina, palm sideways
  • Downward pressure
  • Fold ring and pinky into palm
  • Turn hand so palm is up
  • Ring and pinky against perineum
29
Q

bimanual exam: cervix

A
  • Avoid thumb on clitoris
  • One hand on lower abdomen
  • Locate the cervix and palpate it
  • -Note position, shape, masses, consistency
  • Move the cervix up/down, left/right
  • -Looking for cervical motion tenderness
  • Palpate fornices – behind cervix
  • -Anterior, posterior, 2 lateral
30
Q

bimanual exam: uterus

A
  • Elevate cervix and uterus with pelvic hand
  • Abdominal hand between umbilicus and symphysis pubis
  • Fingers together, firm – press in and sweep toward yourself
  • “Sandwich” the uterus between your hands
  • Palpate the fundus of uterus
  • Move pelvic hand fingers above cervix and repeat with abdominal hand to feel body of the uterus
31
Q

Bimanual exam: adnexa

A
  • Move pelvic hand fingers to right of cervix
  • Move abdominal hand to low/center RLQ
  • “Sandwich” ovary between hands
  • Repeat on left
  • Difficult to feel normal ovaries
  • -If ovary is easy to feel, it is probably enlarged
32
Q

Bimanual exam: vaginal tone

A
  • Assess the muscles of the pelvis
  • Move fingers off cervix and separate
  • Ask patient to squeeze your fingers and push them out of her vagina
  • -Holds for 3 seconds and moves your fingers is good tone
  • -Check for pelvic organ prolapse as remove fingers
33
Q

Rectovaginal exam

A
  • When uterus is retroverted or retroflexed, this may be helpful
  • Indicated in women >50 yo for screening
  • Remove hand and re-lube/change gloves
  • Insert middle finger into rectum and index into vagina
  • Fold ring and pinky, watch thumb
  • Repeat abdominal palpation
34
Q

Lymphatic system of female GU

A
  • Usually follow venous distribution
  • External genitalia generally drain to the superficial inguinal nodes or superficial femoral nodes
  • Uterus and cervix drain via several chains of lymph nodes into para-aortic chains
  • Oviducts and ovaries have retroperitoneal drainage into para-aortic chains
35
Q

Patient education

A
  • How often to have pelvic exam and Pap smear
  • STI prevention
  • Contraception
  • Sexual health and personal hygiene
  • -Self vulvar exam
36
Q

Key points of GU exam

A
  • Explain what you are doing as you go – don’t touch without talking
  • Pelvic exam itself should not be painful; check your technique, reposition
  • Downward pressure is key
  • Use smallest speculum needed
  • Get help to hold “shaky legs” and let the patient rest if needed
  • Watch out for the clitoris and urethral area
  • Move the labia out of the way of the speculum
  • Don’t ever leave a patient in lithotomy position
  • Don’t remove an open speculum – pay attention
37
Q

Pediatric patient exam

A
  • Place patient in frog-legged position in parent’s lap
  • External exam in this position
  • Speculum exam, digital exam may require sedation/anesthesia
  • Use pediatric speculum
38
Q

geriatric patient exam

A
  • Lithotomy position may not be possible
  • Can examine with pt lying on side
  • Vaginal thinning and atrophy
  • Lack of lubrication
  • Use very small (maybe pediatric) speculum
39
Q

special circumstances for GU exam

A
  • Cultural Sensitivity
  • -Watch your own agenda
  • Minors
  • -Parent in or out as patient desires
  • -Talk to patient alone at some point
  • Men must have female chaparone
  • Women should also use a chaperone
  • “I don’t want a student!”

Physical Diagnosis Module II (10 decks)

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