L7: Breast & Pelvic Exam

Question 1

Breast Anatomy

Answer 1

Question 2

Lymphatic Drainage

Primary drainage?

Secondary drainage?

Other drainage?

Answer 2

• Rich network
• Primary lymphatic drainage to axillae
• Secondary drainage to internal mammary nodes
• Can also drain to supraclavicular & infraclavicular nodes

Question 3

What are the 5 segments of the breast?

Answer 3

• Five segments (for PE purposes and documentation)
  
  • Upper outer quadrant
  • Upper inner quadrant
  • Lower inner quadrant
  • Lower outer quadrant
  • Tail of Spence

Question 4

How is a clock used to describe findings on the breast?

Answer 4

Question 5

What are some Common/Concerning Symptoms?

Answer 5

• Breast lump or mass
• Breast discomfort or pain
• Nipple discharge

Question 6

History:

What types of changes/features are you looking for?

Answer 6

• Unilateral v. bilateral
• Skin changes
• Pain/tenderness
• Lumps/mass
• Nipple discharge
  
  • Spontaneous v. induced
  • Bloody? Color?

Question 7

P’eau d’orange

Answer 7

Question 8

What are the 4 motions of breast inspection?

Answer 8

• Inspection with four motions:
  
  • Arms overhead with palms together
  • Hands on hips and press down
  • Shrug shoulders
  • Lean forward

Question 9

What are you inspecting the breasts for?

Answer 9

• Inspect breasts for:
  
  • Size
  • Symmetry (some difference is common /normal)
  • Contour
  • Skin texture
  • Color
  • Lesions

Question 10

Skin changes:

Dimpling

Answer 10

Question 11

Skin Changes:

Nipple Inversion

Answer 11

• Inspect nipples for eversion or inversion
• Recent onset of unilateral nipple inversion is suggestive of an underlying malignancy
• Some patients may report longstanding inversion (their normal)

Question 12

Skin Changes:

Supernumerary nipple

Answer 12

Question 13

How to perform the breast exam

Answer 13

• Use a systematic approach to palpate the breast
  
  • Palpation is best performed with the breast tissue flattened.
  • Use the pads of your 2nd, 3rd and 4th fingers
  • Palpate the Tail of Spence & under the nipple
  • Most breast cancers are located in the upper outer quadrant
• Complete the examination in the supine position
• Ask patient to put hand under head
• Use pads of 2nd, 3rd and 4th fingers together
  
  • Use 3 levels of pressure: light, medium, then deep (to chest wall)
  • Keep contact with skin to cover all areas
    
    • Avoid jumping from one area of breast tissue to the next
• Gently move/lift breast tissue as needed
  
  • Avoid cupping the breast

Question 14

Clinical breast examination

What are you palpating for?

Answer 14

• Texture & consistency
  
  • Masses
  • Single v. multiple
  • Mobile v. fixed
  • Tenderness
  • Borders
• Nipple discharge?
  
  • milky
• Lymphadenopathy

Question 15

Clinical breast examination:

Search Patterns

Answer 15

• Concentric Search Pattern
  
  • Begin with Tail of Spence and move in concentric circular fashion progressing from outer breast, ending up near the nipple.
  • Palpate the areola, then region beneath nipple (all the way down to chest wall)
    
    • Inform the patient before each maneuver
    • Assess for loss of nipple elasticity

Question 16

Nipple Discharge

If there is history of nipple discharge?

What type of nipple discarge may be observed?

Answer 16

• If there is history of nipple discharge, attempt to assess origin by placing index finger(s) at edge of areola:
  
  • Press down and inward (toward nipple)
  • Repeat at 90° angle or in radial positions around the nipple
• Nipple discharge:
  
  • Light milky discharge may be normal
  • Serous or bloody discharge typically abnormal

Question 17

Examination of axillary nodes

In what position should the exam be performed?

What are the 4 hand sweeps?

Answer 17

• Performed seated or supine- following breast examination
• Rest patient’s arm on your arm
• 4 hand sweeps:
  
  • 1^st sweep: anterior axillary region, to include under the pectoralis muscle
  • 2^nd sweep: mid-axillary high into apex
  • 3^rd sweep: posterior axillary region beneath teres minor muscle
  • 4^th sweep: down medial aspect upper arm

Question 18

Female Pelvic Anatomy

Answer 18

Question 19

Common/Concerning Symptoms

Answer 19

• Menarche, menstruation, menopause, postmenopausal bleeding
• Pregnancy
• Vulvovaginal symptoms
• Sexual health
• Pelvic pain – acute and chronic
• Sexually transmitted infections (STIs)

Question 20

lithotomy position

Answer 20

Question 21

Pelvic Exam: External Examination

What structures are you inspecting?

Answer 21

• Inspect the vulva, clitoris, and urethral meatus
  
  • Use one finger of each hand to lift up and out on the clitoral hood
• Inspect the labia majora, labia minora and labial folds
  
  • Separate the labia minora from the labia majora

Question 22

Pelvic Exam: External Examination

When to perform speicalized exams?

What are you examining?

How to perform the specialized exams?

Answer 22

Specialized exams:

• If the patient complains of labial swelling examine the Bartholin glands
  
  • r/o cyst, abscess, etc.
• Milk the urethra if concern about infection of Skene’s glands (e.g. enlarged, tender)
  
  • Gently spread the labia to visualize the urethral meatus.
  • Insertyourindexfinger into vagina and gently apply pressure to the anterior vaginal wall as you slide your finger toward you.
  • Note the presence of any discharge (culture d/c).

Question 23

Pelvic Exam: Internal Exam

How to insert the speculum

Answer 23

• Lubricate the speculum with your non-dominant hand
  
  • K-Y jelly may be used with the SPs, but should not be used if a Pap or any other specimen collection is planned (lubricate with warm water instead)
• Talk before touch!
  
  • Let the patient know you will be starting the internal examination
  • They can expect to feel pressure
  • Let them know they can communicate with you as well!
• Insert your index and middle fingers of non- dominant hand into vagina up to 2nd knuckle
• Pull straight down on the perineum; slightly spread fingers to create a triangular opening for the speculum
• If symptomatic, ask patient to bear down (Valsalva) in order to check for a cystocele or rectocele
• Separate labia with index/middle finger of non- dominant hand
• Insert speculum at slight angle, remove non- dominant hand, then straighten speculum

Question 24

Pelvic Exam: The Speculum Exam

How to insert & open the speculum

How to remove the speculum

Answer 24

Inserting the Speculum

• Insert the speculum with speculum rotated slightly so as to make entry easier and to avoid injury to urethra
  
  • Be sure to spread the labia while inserting the speculum to avoid “pulling” in!
• Apply posterior (downward) pressure to vagina with the speculum and insert to full length
• Stabilize the speculum with other hand if needed
• Open the speculum 1, 2, or 3 clicks, depending on what is needed for full visualization
  
  • If necessary, close & slightly withdraw (NOT FULLY) then redirect
  • Consider bimanual exam if having trouble locating the cervix
• To remove the speculum, open the speculum slightly without locking
• 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 in a straight fashion maintaining downward pressure

Question 25

Normal Cervix ## Footnote **Parous vs. nonparous cervix**

Answer 25

* Parous vs. nonporous * **Nonparous:** has a smooth, round external os * **Parous:** os is uneven and wide, often described as having a “fish mouth” appearance * The parous cervix is more bulky than the nonparous cervix

Question 26

**The Pap Smear: Spatula/Brush Protocol**

Answer 26

* Introduce the endocervical brush into cervical os just until the end bristles are visible, and rotate 1⁄2 turn in one direction (180 degrees) * Rinse the brush by swirling at least 10 times in the solution. Discard the brush. * Insert the spatula into the cervical os; let the longer portion rest on the cervix, rotate 360 degrees * Rinse by swirling in the solution at least 10 times

Question 27

**The Pap Smear: Broom Protocol**

Answer 27

* Insert central bristles into endocervical canal, shorter bristles contacting ectocervix and rotate clockwise 5x. * Push broom on bottom of vial 10x, then swirl vigorously. Discard broom.

Question 28

**The Pap Smear: Advantages of the ThinPrep^TM and SurePath^TM**

Answer 28

* Improved specimen adequacy and uniform preparation of cells on each slide * Decreased blood, decreased mucus, decreased artifact * Increased disease detection * Decreased incidence of equivocal results * Concurrent testing for HPV and GC/Chlamydia * *Trichomonas vaginalis* and *Mycoplasma genitalium also able to be obtained*

Question 29

**The Bimanual Exam** What are you palpating for? What are the expected findings?

Answer 29

* **Stand up;** apply lubricant to 2 fingers of dominant hand and tell patient what to expect: * “I’ll be inserting two fingers into your vagina while also pressing on your abdomen to check your uterus and ovaries...” * **Tuck thumb** under 4th and 5th fingers * **Palpate** the cervix: * Palpate the circumference and consistency of the cervix (should be firm) * Place index and 3rd finger on sides of cervix and gently rock from side-to-side * **Palpate** the uterine fundus: * Place internal fingers on posterior side of cervix and elevate cervix and uterus * Place outer hand on lower abdomen * Gently palpate each side of the uterus * _Expected findings:_ * Pear-shaped, rounded, firm & smooth * Described as similar in shape and consistency as a fist * **Palpate** the ovaries: * Place abdominal hand on RLQ and pelvic hand in right lateral fornix. Press abdominal hand in and down (sweeping motion) toward your pelvic hand. Repeat on left side. * _Expected findings:_ * Smooth & ovoid, mildly tender to palpation, like an almond * May not be palpable – this is normal!

Question 30

**Uterine Position** What are the variations in uterine position? Which position is most common?

Answer 30

* **Anteverted** (most common): uterus tilts forward at your cervix, towards abdomen * **Anteflexed:** anterior tilt of the cervix is severe * **Retroverted:** uterus is tipped backwards so that it aims towards the rectum * **Retroflexed:** uterus is tipped backwards so that it aims towards the rectum

Question 31

**The Rectovaginal Examination** When indicated? How to perform?

Answer 31

* ***_If_*** indicated: * *To palpate a retroverted uterus/uterosacral ligaments/cul-de-sac/adnexa* * *To screen for colorectal cancer in women ages 50 years or older* * *And to assess pelvic pathology* * Lubricate gloves again, if necessary * Slowly introduce index finger into vagina and middle finger into rectum * Ask patient to bear down as you do this, to help relax the anal sphincter * Repeat the maneuvers used during bimanual exam; give special attention to region posterior to cervix.