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
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
3
Q
External female GU exam elements
A
inspection, palpation
4
Q
internal female GU exam elements
A
inspection with speculum, palpation via bimanual exam
5
Q
Elements of female GU exam
A
External, internal, rectovaginal
6
Q
Inspecting Mons
A
- Tanner stage
- Parasites (lice), skin lesions
7
Q
Inspecting Labia majora
A
-Masses, pain, hernias
8
Q
Inspecting Labia minora
A
-Swelling, lesions, discoloration
9
Q
Inspecting the Clitoris, clitoral hood
A
- Inspect for discoloration, masses
- Thumbs at top, sides of hood, slide up
- Avoid touching clitoris
10
Q
Inspecting the urethra
A
- Inspect for redness, masses
- Two thumbs, pull apart to expose opening
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
12
Q
inspecting posterior forchette
A
- Base of introitus - where labia minora meet
- Inspect for lesions, redness
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
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
15
Q
Inspecting Perineum
A
- Area between base of vaginal opening and anus
- Inspect for lesions, redness, swelling
- Palpate for masses, tenderness
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
palpation of the uterus
- Size
- -Can feel pregnancy at 10-12 weeks
- Position
- Irregular surface or masses
- Consistency
- Mobility
- Tenderness
26
palpation of the adnexa
- Symmetry or masses
- Tenderness
- Mobility
27
Palpation of the cervix
- Tenderness
- Nodules
- Size
- Position
28
how to do the bimanual examination
- 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
bimanual exam: cervix
- 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
bimanual exam: uterus
- 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
Bimanual exam: adnexa
- 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
Bimanual exam: vaginal tone
- 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
Rectovaginal exam
- 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
Lymphatic system of female GU
- 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
Patient education
- How often to have pelvic exam and Pap smear
- STI prevention
- Contraception
- Sexual health and personal hygiene
- -Self vulvar exam
36
Key points of GU exam
- 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
Pediatric patient exam
- 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
geriatric patient exam
- 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
special circumstances for GU exam
- 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!”
