Gyn Phys Di Flashcards
List the ROS for the female genital tract
- Age of Menarche
- LMP (last menstrual period)
- Regularity
- Duration
- Amount of bleeding
- Metrorrhagia: irregular/between periods
- Dysmenorrhea: painful menstruation
- Discharge
- Odor
- Irritation
- Lesions, Rash, Mass
List the ROS for the female genital tract
- Sexual Activity/Orientation
- Last Pap Results
- PMS symptoms
- Contraception
- History of STDs and treatment
- Gravida - TPAL
- Complications of Pregnancy
- Age at Menopause
- Menopausal symptoms
- Post-Menopausal Bleeding
- Dyspareunia
- Libido and Satisfaction
Define “TPAL” in regards to gravida (pregnancy)
Term
Pre-term
Abortions
Living
List the ROS for breasts
- Appearance – changes
- Pain
- Masses
- Nipple Discharge
- Self-Breast Exam
- Last Mammogram
- Last Breast Exam (non-self)
List the parts of the HPI for abnormal bleeding
- flow (how many pads, tampons)
- associated symptoms (pain, cramping, pelvic fullness)
- meds (oral contraception), character (interval between periods)
- amenorrhea (primary vs. secondary)
- prolonged bleeding
- postmenopausal bleeding
- spotting
List the parts of HPI for pain
Big 8: O - onset L - location D - duration C - character A - alleviating/aggravating R - radiating T - timing S - severity P - past
List the parts of HPI for vaginal discharge
- douche
- color
- odor
- sexual hx
- associated symptoms
- medications
List the parts of HPI for premenstrual symptoms
- HA
- weight gain
- bloating
- cramping
- breast tenderness
- mood changes
List the parts of HPI for menopausal symptoms
- age onset
- bleeding
- self-image
- sex
- medications
List the parts of HPI for infertility
- length of time
- any known abnormalities
- nutritional status
List the parts of HPI for urinary symptoms
- dysuria
- hematuria
- nocturia
- polyuria
- force of stream
- incontinence
- frequency
- urgency
- hesitancy
- h/o infections
- h/o stones
List the parts of menstrual history
- age on menarche
- LMP
- days in cycle
- regularity
List the parts of obstetrical history
GTPAL and complications G: Gravida- total number of pregnancies T: Total of term pregnancies P: Number of preterm pregnancies A: number of Abortions, spontaneous or induced L: number of Living children
List the parts of menopausal history
- age of menopause
- familial factors
List the parts of gynecological history
- prior PAP
- HPV testing
- results
- abnormal results
- procedures
- STI
- PID
- cancers
- diabetes
Pertinent medical history
- Vaginal prolapse
- Menopausal symptoms
- Urinary and fecal incontinence
- Sexual practices/satisfaction
List the components of the physical exam
- Height
- Weight
- BMI
- Blood pressure
- Neck: adenopathy, thyroid
- Breast and axillae
- Abdominal exam
- Pelvic exam
- Rectal exam
- Any other exam clinically appropriate
What general considerations should you use in exam?
- Introduces self and explains purpose and procedure of exam – always do this with younger patients
- Addresses patient’s potential anxiety or discomfort
- Avoids anxiety provoking or sexually suggestive language
- Maintains eye contact as appropriate
- Use “talk before touch” principle throughout exam
What are other general considerations in exam?
- Wash hands/warm hands
- Use gloves
- Get chaperone and document
- Make sure all supplies are ready/available before starting the exam
- Make sure you understand how to use the equipment
- Leave room while patient undresses
What are other general considerations in exam?
- Make sure they have a gown and sheet
- Make sure room is a comfortable temperature
- Proper lighting
- Position patient properly – help them up and down, position pillow, help with drape and gown
- Be mindful of the area that you are exposing, only expose what you need to work with/view
What are the steps to breast inspection?
Inspect with patients performing 3 arm maneuvers:
- overhead
- on waist
- leaning forward
Talk and teach patient during exam.
Breast inspection skin changes
-Peau d’orange
Skin thickening, large pores from edema of breast secondary to blocked lymph glands (usually from cancer)
Breast inspection skin changes
-Paget disease
- Surface manifestation of underlying ductal cancer
- Red scaling, crusty patch on nipple areola and surrounding skin
Breast inspection skin changes
-Dimpling
- Mass pulls on suspensory ligament of Cooper
- Clinical sign of cancer
Breast inspection
-contour and symmetry
- Contour: breast vary in shape / compare side to side
- Symmetry: common for one breast to be somewhat smaller
Breast inspection
-nipple inversion/supernumerary
Inversion: important to ask if lifetime or new finding
Supernumerary nipples: appear as one or more extra nipples located along the “milk line”; commonly mistaken for moles
Breast inspection
- nipple discharge
- montgomery tubercle
Nipple Discharge: if present note its color
Montgomery tubercles: normal finding on areola
-Non-tender, small nodules
Steps to breast palpation
- pt in the supine position
- ask pt to put her arm overhead during the supine palpation
- this helps to stretch the breast tissue against the chest wall
- using the flat part of the fingers (and a rotary motion) against the chest wall using a radial or spiral pattern without missing areas, compress the breast tissue against the chest wall in all quadrants
- make sure to continue up the chest wall to clavicle, towards the axilla, and always include the tail of spence.
Note: tissue consistency, elasticity, nodules, indurations, masses, and tenderness
Palpation of the breast
- include inspection and palpation of nipple, looking for size, shape inversion, rashes, ulceration, discharge, scaling, retraction, areolar edema, and masses
- gently grasp and compress the nipple and areolar tissue between thumb and index finger, noting the color consistency and quantity of any discharge
- use flats of fingers; several methods of palpation so pick one method and be consistent
What areas are included in breast palpation?
Four quadrants (upper outer, lower outer, upper inner, lower inner) plus the ‘tail of spence’ *Most cancers occur in the upper outer quadrant / tail of spence of the breast
Breast abnormalities
-fibrocystic disease
- Benign cysts, usually bilateral, multiple and mobile.
- Tender/painful with increase in symptoms premenstrual
Breast abnormalities
-fibroadenoma
- Benign neoplasm, usually bilateral, and mobile
- Usually non-tender, does not vary with menstrual cycle
Breast abnormalities
-malignant breast tumors
- Usually unilateral, single, fixed (non-mobile)
- Usually nontender, does not vary with cycle
Breast abnormalities
-gynecomastia
- Increased breast tissue in males, can be bilateral or unilateral
- Can be caused by testicular, pituitary tumors, liver failure, medications, pot smoking
Breast abnormalities
-galactorrhea
- Lactation not associated with child-bearing
- Caused by medications, prolactin secreting tumors, hypothyroidism
Breast abnormalities
-mastitis
- Infection and inflammation of breast tissue
- Most common in lactating women, but may occur at any time
Inspection of external genitalia (vulva)
- Mons pubis (symphysis pubis covered by pad of adipose tissue)
- Labia majora
- Labia minora
- Clitoris
- Vestibular glands
- Vaginal vestibule
- Vaginal orifice
- Urethral orifice/opening
- Anus/Rectum
Explain patient prep for external exam
- Draping should allow minimal exposure
- Cover patient’s knees and symphysis, depressing the drape between her knees – allowing you to see the patient’s face
- Arrange lamp before washing hands
- Glove both hands – can multiple glove and remove one as you need a clean one
- Never try to spread the patient’s legs forcibly or even gently
- Tell patient when you plan to begin, then start with neutral touch on her lower thigh, moving your examining hand along the thigh without breaking contact, to the external genitalia
Female genitalia, external
-mons pubis
This is the symphysis pubis covered by a pad of adipose tissue
Female genitalia, external
-labia majora
- Look for excoriation/rash/lesions
- Labial swelling, redness, or tenderness, particularly if unilateral, may be indicative of a Bartholin gland abscess
Female genitalia, external
-labia minora
- Encloses the area designated as the vestibule
- Inner surface should be dark pink and moist
- Should be no tenderness
- Look for inflammation, irritation, excoriation, or caking
- Feel for irregularities or nodules
Female genitalia, external
-clitoris
- Inspect for size: usually 2 cm or less in length
- Enlargement may be a sign of masculinizing condition
Female genitalia, external
-urethral orifice
- Appears as an irregular opening or slit
- May be close to or slightly within vaginal introitus
- Usually midline
- Inspect for discharge/polyp/fistulas – can indicate UTI
Female genitalia, external
-vaginal introitus
- May be thin vertical slit or large orifice
- Tissue should be moist, look for swelling/discharge/lesions
- Look for swelling, discoloration, discharge, lesions, fistulas or fissures
Palpation of the glands
Skene glands
- Drain a group of urethral glands/opens on either side of urethra
- Milk glands observing for any discharge (should not have)
Bartholin glands
- Located posterolateral portion of vaginal opening
- Secrete mucous for lubrication during intercourse
Palpation of the perineum
- Inspect and palpate
- Should be smooth
- Episiotomy scarring possible women who have borne children
- Look for inflammation, fistulas, lesions, growths
Palpation of the anus
- Anal surface is more darkly pigmented
- Skin may appear coarse
- Should be free of scarring, lesions, inflammation, fissures, lumps, skin tags, excoriation
Preparation for female genitalia internal exam
- Know how to use speculum BEFORE you begin the exam
- Lubricate speculum with warm water helps warm the speculum, too.
- Can also warm speculum in hand or under the lamp
Internal exam
-insertion of speculum
- Tell patient she will feel you touching her again
- Apply pressure downward, asking patient to breathe slowly and consciously relaxing her muscles
- When she relaxes, separate the labia minora widely until opening becomes clearly visible
- Slowly insert closed speculum along path of least resistance, slightly downward, avoiding trauma to urethra and vaginal walls
- May insert speculum at oblique angle, or horizontally
- AVOID touching the clitoris, catching pubic hair, or pinching the labial skin
- Insert speculum the FULL length of the vagina
Internal exam cont.
- Open speculum, and slowly sweep it upward until the cervix comes into view
- Gently reposition, if necessary, to locate the cervix
- Once visualized, lock the speculum in the open position.
Internal exam
-cervix
Position of cervix correlates with position of uterus:
- If points anteriorly, uterus is retroverted
- If points posteriorly, uterus is anteverted
- A cervix in the horizontal position indicates a mid-position uterus
- The cervix SHOULD be MIDLINE
- -Deviation to side may indicate pelvic mass, adhesions or pregnancy
Internal exam
-color
- should be pink
- a bluish color indicates increased vascularity which may be sign of pregnancy
- red, friable areas indicate infection
Internal exam
-surface characteristics
should be smooth, Nabothian cysts are normal finding (small, white or yellow cysts)
Internal exam
-discharge
- note any
- determine source of d/c – from cervix or vaginal origin.
- usually discharge is odorless; may be creamy or clear; may be thick, thin or stringy
Internal exam
-size and shape
nulliparous / multiparous
Differences in internal exam nulliparous vs. multiparous
Nulliparous woman – small, round, or oval os
Multiparous woman – horizontal slit, or may be irregular and stellate
Explain the pap smear using a spatula
Vaginal specimens are obtained while speculum is in place, but after cervix and surrounding tissue have been inspected
Endocervical sample collected first
- Spatula (rarely used)
- Longer projection into os: rotate 360º
- Withdraw, and smear a single light stroke of specimen onto glass slide
Explain the pap smear using a brush device
- Insert into the os until only the bristles closest to handle are exposed
- Rotate one half to full turn
- Remove and roll/twist brush with moderate pressure across a glass slide
Explain the pap smear using a cervex-brush
- Collects both endo- and ectocervical cells at same time
- Insert central long bristles into os until lateral bristles bend fully against ectocervix.
- Rotate handle between thumb and finger 3 - times to left and right while maintaining gentle pressure
- Causes less bleeding
During the bimanual exam, what are you feeling for of the cervix?
- Feel for size, length, shape
- Should feel firm, in pregnancy will be softer
- Move cervix side to side, if painful think PID
During the bimanual exam, what are you feeling for of the uterus?
- Feel for size, length, shape
- Should be pear shaped, mobile (approx. 5x8 cm)
- Fibroids- common, benign, uterine tumors, feel firm and irregular
- Prolapse- uterus descends into vaginal canal
During the bimanual exam, what are you feeling for of the adnexa and ovaries?
IF PALPABLE should feel firm, smooth and approx. 3x2x1cm
Outline the steps to the Bimanual Exam/Rectovaginal
- Determine if 1 or 2 fingers will be used by the ease of the speculum exam.
- Index finger (or index & middle – preferred - fingers in vagina).
- Slide both fingers in as far as they will go
- Palpate for masses, polyps, nodules, fissures in vaginal floor
- Feel uterus, adnexa
- If palpating something abnormal in vaginal floor then insert left index finger in rectum with right index finger in the vagina to explore the perineal layer between the 2 canals.
- If symptoms require rectal exam change gloves and use dominant index in rectum to palpate more extensively.
- Check stool for occult blood
Outline the steps to the rectal exam
- With digital rectal examination, one can assess anal resting tone.
- Sample for gross or occult blood, and palpate masses or fecal impaction.
- In addition, squeeze pressure can subjectively be judged during voluntary patient contraction of the EAS around a gloved finger inserted into the anorectum.
- Last, during patient Valsalva maneuver, one observes for excessive perineal body descent, vaginal wall prolapse, rectal prolapse, or muscle incoordination
Common abnormalities include…
- PMS
- Endometriosis
- Lesions from STDs
Abnormalities
-endometriosis
- Growth of endometrial tissue outside of uterus
- Causes pelvic pain, dysmenorrhea
- Diagnosis confirmed by laparoscope
Abnormalities
-lesions from STDs
- Condyloma acuminatum (genital warts)
- Condyloma latum- secondary lesions of syphilis
- Syphilitic chancre-painless ulcer of primary syphilis
- Herpes- painful lesions (vesicular then ulcers)
Vaginal discharge/infections
-trichomonas
- Frothy green discharge, “strawberry cervix”
- Wet prep: pear shaped protozoa (swimming footballs)
Vaginal discharge/infections
-bacterial vaginosis
- Thin white or gray discharge with “fishy odor”
- Whiff test with or without KOH
- Wet prep: clue cells
Vaginal discharge/infections
-candida
- White curdy discharge with itching
- Wet prep with KOH: budding yeast
Vaginal discharge/infections
-gonorrhea
- May be asymptomatic, symptoms of PID
- Purulent discharge from cervical os
- DNA probe
Vaginal discharge/infections
-chlamydia
-May be asymptomatic
-Symptoms of PID
+/- purulent discharge
-DNA probe
Pelvic organ prolapse
-anterior vaginal wall
anterior wall defect in which the bladder is associate with the prolapse: cystocele
Pelvic organ prolapse
-posterior vaginal wall
rectocele
Pelvic organ prolapse
-middle
- uterine prolapse
- anterior and posterior vaginal relaxation
- as well as incompetence of the perineum, often accompanies prolapse of the uterus
Symptoms of pelvic floor prolapse
- Sensation of vaginal fullness, pressure, heaviness, “something fall out”
- Sensation of “sitting on a ball”
- Discomfort in the vaginal area
- Presence of a soft, reducible mass bulging into the vagina and distending through the vaginal introitus
- With straining or cough, there is increased bulging and descent of the vaginal wall
- Back pain and pevic pain
Symptoms of pelvic floor prolapse cont.
-urinary symptoms
- Urinary symptoms: feeling of incomplete emptying of bladder
- Stress incontinence (40% of females with POP)–A condition in which underlying urinary incontinence is masked by kinking of the urethra and causing functional continence.
- Urinary frequency
- Urinary hesitancy
- Perhaps the need to push the bladder up in order to void (splinting)
Symptoms of pelvic floor prolapse cont.
- defecatory sx
- sexual function
Defecatory symptoms: incomplete emptying, straining, laxative use, incontinence
Sexual function: embarrassment
Grade of Pelvic Organ Prolapse
- Descent above (superior) to the hymen
- Descent to the hymen
- Descent beyond the hymen
- Total prolapse
