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Physical Dx > L7: Breast & Pelvic Exam > Flashcards

L7: Breast & Pelvic Exam Flashcards

1
Q

Breast Anatomy

A
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2
Q

Lymphatic Drainage

Primary drainage?

Secondary drainage?

Other drainage?

A
  • Rich network
  • Primary lymphatic drainage to axillae
  • Secondary drainage to internal mammary nodes
  • Can also drain to supraclavicular & infraclavicular nodes
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3
Q

What are the 5 segments of the breast?

A
  • Five segments (for PE purposes and documentation)
    • Upper outer quadrant
    • Upper inner quadrant
    • Lower inner quadrant
    • Lower outer quadrant
    • Tail of Spence
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4
Q

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

A
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5
Q

What are some Common/Concerning Symptoms?

A
  • Breast lump or mass
  • Breast discomfort or pain
  • Nipple discharge
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6
Q

History:

What types of changes/features are you looking for?

A
  • Unilateral v. bilateral
  • Skin changes
  • Pain/tenderness
  • Lumps/mass
  • Nipple discharge
    • Spontaneous v. induced
    • Bloody? Color?
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7
Q

P’eau d’orange

A
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8
Q

What are the 4 motions of breast inspection?

A
  • Inspection with four motions:
    • Arms overhead with palms together
    • Hands on hips and press down
    • Shrug shoulders
    • Lean forward
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9
Q

What are you inspecting the breasts for?

A
  • Inspect breasts for:
    • Size
    • Symmetry (some difference is common /normal)
    • Contour
    • Skin texture
    • Color
    • Lesions
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10
Q

Skin changes:

Dimpling

A
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11
Q

Skin Changes:

Nipple Inversion

A
  • 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)
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12
Q

Skin Changes:

Supernumerary nipple

A
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13
Q

How to perform the breast exam

A
  • 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
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14
Q

Clinical breast examination

What are you palpating for?

A
  • Texture & consistency
    • Masses
    • Single v. multiple
    • Mobile v. fixed
    • Tenderness
    • Borders
  • Nipple discharge?
    • milky
  • Lymphadenopathy
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15
Q

Clinical breast examination:

Search Patterns

A
  • 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
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16
Q

Nipple Discharge

If there is history of nipple discharge?

What type of nipple discarge may be observed?

A
  • 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
17
Q

Examination of axillary nodes

In what position should the exam be performed?

What are the 4 hand sweeps?

A
  • Performed seated or supine- following breast examination
  • Rest patient’s arm on your arm
  • 4 hand sweeps:
    • 1st sweep: anterior axillary region, to include under the pectoralis muscle
    • 2nd sweep: mid-axillary high into apex
    • 3rd sweep: posterior axillary region beneath teres minor muscle
    • 4th sweep: down medial aspect upper arm
18
Q

Female Pelvic Anatomy

A
19
Q

Common/Concerning Symptoms

A
  • Menarche, menstruation, menopause, postmenopausal bleeding
  • Pregnancy
  • Vulvovaginal symptoms
  • Sexual health
  • Pelvic pain – acute and chronic
  • Sexually transmitted infections (STIs)
20
Q

lithotomy position

A
21
Q

Pelvic Exam: External Examination

What structures are you inspecting?

A
  • 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
22
Q

Pelvic Exam: External Examination

When to perform speicalized exams?

What are you examining?

How to perform the specialized exams?

A

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).
23
Q

Pelvic Exam: Internal Exam

How to insert the speculum

A
  • 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
24
Q

Pelvic Exam: The Speculum Exam

How to insert & open the speculum

How to remove the speculum

A

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
25
Q

Normal Cervix

Parous vs. nonparous cervix

A
  • 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
26
Q

The Pap Smear: Spatula/Brush Protocol

A
  • 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
27
Q

The Pap Smear: Broom Protocol

A
  • 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.
28
Q

The Pap Smear: Advantages of the ThinPrepTM and SurePathTM

A
  • 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
29
Q

The Bimanual Exam

What are you palpating for?

What are the expected findings?

A
  • 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!
30
Q

Uterine Position

What are the variations in uterine position?

Which position is most common?

A
  • 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
31
Q

The Rectovaginal Examination

When indicated?

How to perform?

A
  • 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.

Physical Dx (11 decks)

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