Female Exam Flashcards
(58 cards)
1
Q
Clinical breast exam.
A
Chaperone present at all times. Introduction: -Introduce yourself to the patient. -Confirm the patient’s name and how she wants to be addressed. -Explain the purpose of the exam. -Wash hands. 4 Components: Introduction Breast inspection Lymph node palpation Breast palpation
2
Q
Breast palpation.
A
This may be done with patient supine or seated:
-Arm behind head
-Four quadrants
-Tail of Spence (up to clavicle and towards axilla)
-Nipple
-Areola
Examine all areas completely and systematically.
*Inform the patient before each maneuver.
*Keep drape over areas not currently being examined.
*Ask patient if the amount of pressure is comfortable during palpation.
3
Q
Lymph nodes.
A
Use proper technique to palpate:
-Supraclavicular lymph nodes
-Axillary lymph nodes (3 sweeps) and lateral chain
–Rich network with primary lymphatic drainage to axillae; secondary drainage to internal mammary
–Can also drain to supraclavicular and jugular nodes
Axillary, supraclavicular and infraclavicular areas.
4
Q
Five segments of the breast.
A
Upper outer quadrant Upper inner quadrant Lower inner quadrant Lower outer quadrant Tail of Spence
5
Q
Clock positions of the breast.
A
12 is midaxillary line above nipple. Count around.
If a mass is at 1:30 on the L breast, it is in the upper outer segment.
6
Q
How to perform breast palpation.
A
Utilize dim-sized circles when performing palpation. Use finger pads. 3 levels of pressure. Vertical strip/lawnmower/ladder. Concentric circles. Radial spoke. Look for tissue consistency. Various tissues feel differently: adipose, glandular, and ductal. Take note of: Nodules Indurations Masses Tenderness Nipple discharge
7
Q
Duration of the palpation part of breast exam.
A
Bra size B:
3 minutes per breast
6 minutes total
8
Q
Nipple discharge.
A
Check for nipple discharge by placing two fingers from each hand at edge of areola:
-Press down, inward toward nipple, then up & back down.
-Repeat at 90 degrees to first position.
Light milky discharge may be normal.
Serous or bloody discharge typically abnormal.
9
Q
Special examinations.
A
Mastectomy or Breast augmentation:
-Examine scar and axilla
-Lymphedema
Treat as a normal breast. Pay attention to the scars because cancer is likely to recur in the scar.
10
Q
Interview/documentation pointers.
A
Documentation:
-Inspection – size (pendulous), symmetry, shape, contour, skin, scars.
-Palpation – consistency, tenderness, nodules, lymphadenopathy.
Example:
“No chest deformity or asymmetry. Normal contour. No nodules, masses, tenderness, or axillary adenopathy. No nipple discharge.”
Do not write breast exam normal!
11
Q
Pertinent questions for the breast exam:
A
Self-examination? Lumps, nodules, enlargement, tenderness? Nipple discharge? Imaging? PMHx: Breast disease or cancer, obesity, history of radiation to chest. Reproductive history: age at menarche, age at first pregnancy, menopause status, breastfeeding history. PSHX: Breast biopsies Social: Smoking, alcohol use, exercise. Family Hx: Breast or ovarian cancer. Which other cancers may be pertinent? Medications: OCPs or hormones.
12
Q
Common complaints for PTs in the breast exam.
A
Breast lump.
Breast pain/discomfort.
Nipple Discharge.
13
Q
Things to note during the physical breast exam with CC of breast lump.
A
Location Size Shape Consistency Delimitation Tenderness Mobility
14
Q
Questions to ask during breast exam with CC of breast lump.
A
HPI: Location (unilateral vs. bilateral) How was it found? How long has it been present? Changed in size? Change with menstrual cycle? Nipple discharge? Pain? Skin changes?
15
Q
Questions to ask during breast exam with CC of nipple discharge.
A
HPI: Location (unilateral vs. bilateral) When? How long? Color? Milky, brown, green, or bloody? Consistency? Associated lumps Pain? Menstrual cycle Pregnancy
16
Q
Things to note during physical breast exam with CC of nipple discharge.
A
PE: Identify involved duct Color Consistency Quantity
17
Q
Questions to ask during breast exam with CC of pain or discomfort.
A
HPI: Location (unilateral vs. bilateral) When? How long? Associated lumps Menstrual cycle Pregnancy
18
Q
Skin changes: dimpling.
A
- Inspect nipples for eversion or inversion.
- Recent onset of unilateral nipple inversion is suggestive of a underlying malignancy.
19
Q
Inspection.
A
Inspect both breasts with: Patient sitting, arms at sides Patient sitting, arms above head Patient sitting, hands pressed to hips Patient leaning forward, supporting them. Looking for: -Size -Symmetry (some variation is normal) -Shape -Contour (flattening, masses, and dimpling) -Skin (color, edema, rashes, lesions, thickening, and venous pattern) -Scars (previous surgery, injuries)
20
Q
What are the borders of the breast?
A
Lower: 6th rib.
Upper: clavicle.
Lateral: midaxillary line.
Medial: sternum border.
21
Q
During the breast exam, what language is preferred?
A
Place or insert the speculum.
Remove the speculum.
Place my finger.
Place my hand.
Everything appears normal or I don’t see anything concerning.
Would you mind bringing your gown down to your waist?
Examine by touch.
22
Q
Language to avoid during the breast exam.
A
Stick Feel Pull Feel Ok, looks good! Feel Can I pull your gown down? Feel Palpate
23
Q
Divide pelvic exam into four parts.
A
Vulva and introitus (inspection: external exam). Speculum exam (inspection: internal exam). Obtaining samples (pap, HPV test, cultures, biopsy). Bimanual exam (palpation). Rectal/Rectovaginal exam.
24
Q
Patients at increased risk for discomfort during pelvic exam.
A
History of sexual abuse/assault. History of painful speculum exams. Difficulty with tampon use Painful intercourse. Sexually inexperienced First speculum exam. Inaccurate beliefs about body/anatomy.
25
Reminders for the pelvic exam.
Wash your hands.
Wear gloves on both hands throughout the examination.
-Ask about any latex allergy.
Use appropriate draping and limit exposure.
Have an assistant (chaperone) in room with needed supplies.
Keep all movements smooth, gentle & controlled.
As much as possible, give “control” of the situation to the patient:
“Please tell me if I am causing you any discomfort.”
“Please tell me if you’d like me to stop the exam at any point.”
Explain what you are doing and your findings as you proceed.
26
Pelvic exam equipment.
```
Chaperone
Drape
Exam table with foot rests
Exam light
-Floor light for external exam
-Portable, placed within speculum
Speculum of proper size
Water-based lubricant
Pap smear supplies
Gloves
Guiac/Hemoccult cards if needed
Make sure everything is ready and set up prior to starting the exam.
```
27
Patient positioning for the pelvic exam.
Elevate head of table to permit eye contact.
Help patient into correct position.
Turn on and adjust floor lamp.
Ascertain the patient is comfortable.
Adjust drapes to maintain eye contact.
Push drape down, like a V.
Offer mirror to patient
Refer to “heel rests” or “foot rests” instead of “stirrups”.
Ask the patient to move down until she feels her hips extend slightly beyond the edge of the table.
Wash hands and put on gloves.
28
Inspection during the external pelvic exam.
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Skin: changes, nevi, lesions.
Labia majora and minora.
Perineal body/ perineum.
Anus:
-Using the back of your hands, lift up and out to retract the buttocks.
```
29
Inspection/palpation of the pelvic exam.
```
Inspect:
-Clitoris
-Urethral meatus
-Introitus and hymen
-Paraurethral (Skene’s) gland
Palpate:
-Mons pubis
-Labia majora & minora
-Prepuce
-Bartholin’s duct (slides 49, 50).
```
30
To begin the internal pelvic exam (speculum exam).
Patient education:
- Show the speculum to the patient.
- Demonstrate how it opens and closes.
- Inform patient:
- -It may make a clicking sound
- -Patient may feel some pressure
- -It should not be painful
31
To insert speculum.
Prepare to insert the speculum.
Hold it in your dominant hand.
Lubricate with warm water or lubricating gel.
Insert the speculum with speculum rotated slightly so as to make entry easier and to avoid injury to urethra.
Separate labia.
Keep labia apart.
Blades remain closed until fully inserted.
Blade can be at a 45 degree angle.
Use downward pressure.
Open blades, locate cervix.
Lock speculum in place.
32
Speculum examination.
Insert speculum at slight angle.
Apply posterior pressure to vagina with the speculum.
Open the speculum 1 or 2 clicks, depending on what is needed for full visualization.
-If necessary, remove speculum and reinsert.
-May do bimanual exam first if having trouble locating the cervix.
33
Speculum examination.
Insert speculum at slight angle.
Apply posterior pressure to vagina with the speculum.
Open the speculum 1 or 2 clicks, depending on what is needed for full visualization.
-If necessary, remove speculum and reinsert.
-May do bimanual exam first if having trouble locating the cervix.
34
Normal nulligravid cervix.
The external os is small, smooth circular opening.
35
Normal parous cervix
The external os is large, transverse, and stellate slit.
36
Squamo-columnar junction.
Junction of pink cervical skin and red endocervical canal
Inherently unstable
Key portion of the cervix to sample
Most likely site of dysplasia
37
Lacerations of cervix during delivery.
Unilateral transverse.
Bilateral transverse.
Stellate.
38
Abnormal findings of the cervix.
Cervicitis: normal, won't know its there unless seen on exam.
Polyps: can bleed during intercourse.
Carcinoma.
Nabothian cyst.
39
Thinprep system for Pap smear.
Broom cervical sampling device.
| Cytobrush (external os) /spatula (external epithelia) cervical sampling device.
40
To perform the Pap smear.
Insert the spatula into the cervical os; rotate 360 degrees.
Rinse by swirling in the solution at least 10 time.
Introduce the endocervical brush into cervical os and rotate ½ turn in one direction
Rinse the brush by swirling at least 10 times in the solution. Discard the brush.
41
To perform the Pap smear.
Insert the spatula into the cervical os; rotate 360 degrees.
Rinse by swirling in the solution at least 10 time.
Introduce the endocervical brush into cervical os and rotate ½ turn in one direction
Rinse the brush by swirling at least 10 times in the solution. Discard the brush.
42
Process to remove the speculum.
To remove the speculum, open the speculum one more click.
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.
43
Bimanual exam tips.
Inform patient prior to starting.
Lubricate internal fingers.
Non-dominant hand on abdomen.
Dominant hand internal.
44
To perform the bimanual exam.
Tell patient what to expect:
-“I’ll be inserting two fingers into your vagina to check your uterus and ovaries”.
Palpate the cervix:
-Palpate the circumference of the cervix.
-Gently rock the cervix from side to side.
-Palpate the cervix for firmness.
Palpate the uterine fundus:
-Place internal fingers on posterior side of cervix and outer hand on lower abdomen.
-Gently palpate each side of the uterus.
Expected findings:
-Pear-shaped, rounded, firm & smooth.
45
To perform the bimanual exam.
Tell patient what to expect:
-“I’ll be inserting two fingers into your vagina to check your uterus and ovaries”.
Palpate the cervix:
-Palpate the circumference of the cervix.
-Gently rock the cervix from side to side.
-Palpate the cervix for firmness.
Palpate the uterine fundus:
-Place internal fingers on posterior side of cervix and outer hand on lower abdomen.
-Gently palpate each side of the uterus.
Expected findings:
-Pear-shaped, rounded, firm & smooth.
Palpate the ovaries:
-Move internal and external fingers lateral to uterus and use 3 sweeps moving from distal point toward pubic hair line, attempting to palpate the ovaries.
Expected findings:
-Smooth & ovoid, mildly tender to palpation, similar to an almond.
-May not be palpable (post-menopausal).
46
Variations in uterine positions.
Antiverted: most common (pointing anteriorly).
Anteflexed: (more flexion forward).
Retroverted (fundus points upward).
Retroflexed (fundus is backwards).
47
Variations in uterine positions.
Antiverted: most common (pointing anteriorly).
Anteflexed: (more flexion forward).
Retroverted (fundus points upward).
Retroflexed (fundus is backwards).
48
To finish the bimanual exam:
Pull drape down to cover patient.
Keep hands down, out of view of patient as you remove your gloves.
Instruct patient to push back from the edge of the table and take feet out of foot rests.
Help the patient sit up.
Clean up.
49
The rectovaginal exam.
Purpose:
Palpate a retroverted or retroflexed uterus.
Palpate uterosacral ligaments.
Palpate the cul-de-sac and adnexa.
Screen for colorectal cancer.
Assess pelvic pathology.
Technique:
Index finger inserted into vagina while middle finger inserted into rectum.
Straining can help relax anal sphincter.
Apply pressure with fingers to anterior and lateral walls while hand on abdomen applies downward pressure.
50
Pelvic exam summary.
Explain what you are doing and why you are doing it.
Talk with the patient throughout the exam.
Common courtesy :
-Help the patient sit up after the exam is over.
-Put the foot rests away when you are done with the pelvic examination.
-Clean up your materials.
51
Pelvic exam summary.
Explain what you are doing and why you are doing it.
Talk with the patient throughout the exam.
Common courtesy :
-Help the patient sit up after the exam is over.
-Put the foot rests away when you are done with the pelvic examination.
-Clean up your materials.
52
Menstrual history common complaints.
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Irregular periods
-Irregular
-Heavy flow
-Missed period
-Intermenstrual
Postcoital bleeding
Postmenopausal bleeding
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53
Questions to ask for menstrual history.
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Menarche
LMP & LNMP
Length of periods
Cycle length
Menstrual flow
Recent changes in periods
Age at menopause
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54
OB/GYN pertinent medical history if there is a GYN complaint.
Medical history:
-History of salpingitis, endometritis, tubo-ovarian abscess.
-History of uterine fibroids, ovarian cysts, endometriosis.
-Gynecologic cancers, breast cancer, colon cancer or history of radiation to pelvis.
Family history:
-Gynecologic cancers, breast cancer, colon cancer, inherited genetic disorders.
-Timing of menarche/menopause in mother/grandmother.
Surgical history:
pelvic surgery, hysterectomy, sterilization.
55
OB/GYN pertinent symptoms if there is a GYN complaint.
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Peri/post menopausal symptoms:
-Anxiety / nervousness
-Mood fluctuations
-Fluid retention
-Food cravings
-Difficulty sleeping
-Cramps and discomfort
-Hot flushes
-Decreased vaginal lubrication
-Altered libido
-Pelvic pain (OLDCARTS)
Gynecologic symptoms:
-Abnormal vaginal discharge
-Itching
-Sores/lesions
-Dyspareunia
-Abnormal or painful periods
-PMS
-Sexual dysfunction
-Abnormal vaginal bleeding
Urinary symptoms:
```
56
OB/GYN sexual history if there is a GYN complaint.
Currently or ever been sexually active.
Number of sexual partners (current, lifetime, new).
Partners' sex and partners’ sexual history (if known).
STI protection, past history of STIs, and any behaviors that may put them at high risk for HIV, hepatitis, or other STIs.
Participation in vaginal, oral, or anal sex:
-If pertinent, include ROS questions for symptoms involving mouth, throat, anus and/or rectum.
Current and past methods of contraception:
-Method
-When it was begun
-Problems or complications
-Patient satisfaction with method
-Prior methods and why they were discontinued
-If no contraception, inquire as to why.
57
OB/GYN obstetrical history if there is a GYN complaint.
Gravidity = number of pregnancies.
Parity ("Tennessee Power And Light"):
-Term births (≥37 weeks gestation)
-Premature births
-Abortions (spontaneous or induced)
-Live births
Record details about birthweight of infant, sex, number of weeks at delivery, type of delivery.
Pregnancy complications
Diabetes
Hypertension
Preeclampsia
History of depression before or after a pregnancy
Breastfeeding history
History of infertility
Prior diseases or surgery that may affect fertility
Pregnancy histories with same or other partners
Duration that conception has been attempted
Frequency and timing of sexual intercourse
58
OB/GYN obstetrical history if there is a GYN complaint.
Gravidity = number of pregnancies.
Parity ("Tennessee Power And Light"):
-Term births (≥37 weeks gestation)
-Premature births
-Abortions (spontaneous or induced)
-Live births
Record details about birthweight of infant, sex, number of weeks at delivery, type of delivery.
Pregnancy complications:
-Diabetes
-Hypertension
-Preeclampsia
-History of depression before or after a pregnancy
Breastfeeding history:
History of infertility:
-Prior diseases or surgery that may affect fertility
-Pregnancy histories with same or other partners
-Duration that conception has been attempted
-Frequency and timing of sexual intercourse
