Pelvic exam script Flashcards
(8 cards)
What should you do and say after you’ve done the breast exam, before the pelvic exam?
Sanitize, Make eye contact and give instructions
“We will now begin the pelvic exam. You will first hear me discuss with my proctor as I begin the examination. I will start by inspecting the outer structures of the vagina and will inspect for any lesions, masses, or swelling. Then I will be using a speculum to visualize the cervix and the vaginal walls.
After that I will be performing a bimanual exam where I will be using my hands to palpate structures and assess for consistency and any masses. Please let me know if you have any pain or would like to stop at any time and I will continue to explain these steps of the exam as we go through them together.”
Describe how to visually inspect the labia and what to say
Don gloves
*assist patients in stirrups and have them scoot all the way to the end of the bench, keep them covered!
“I will now begin the exam by lifting up the drape. You will feel my hands as I start to inspect the vagina”
- I see no lesions, masses, swelling, or erythema on the labia minora or labia majora. I am inspecting the mons pubis, clitoris, and urethral meatus and see no swelling, masses, or infestations as well and the hair is evenly distributed.
Describe how to do the speculum exam and what to say
“I’m applying some lubricant to the speculum, and you will feel my hand on your leg and some pressure as I insert the speculum. The speculum may feel a little cold at first. The clicking sounds you hear will be from me opening the speculum to visualize the cervix.”
- The cervix color is pink and is free of erosions, lesions, or cysts
- The cervical os is circular/slit shaped indicating nulliparity/parous/multiparous, and is free of bleeding or discharge
- The vaginal walls and mucosa are pink and free of inflammation, lesions, or masses
“I will now withdraw the speculum and prepare for the bimanual exam”
Describe what to say before you do the bimanual exam
“For the internal exam you will feel my hands as one hand will be palpating the cervix and the other hand will be positioned on the abdomen. I will be assessing the cervix, the uterus, the adnexa, and the ovaries. Let me know if there is any pain or tenderness or if you would like to stop the exam at any time”
lubricate fingers
“I am going to lift the drape a bit higher so I can palpate the lower abdomen as I perform the exam. You will slight pressure from my hand internally, and my other hand on your abdomen”
Describe what to say during the bimanual exam
- The cervix is firm, mobile, and nontender, the fornices are free of masses
- The uterus is free of masses, is soft, nontender, and not enlarged
- The left and right adnexa are nontender with no masses
*Pressing at the inguinal ligament and sliding towards the symphysis pubis to feel the ovaries. - The ovaries are nonpalpable
“I will now remove my fingers and reposition the drape for you”
Move stirrups and help up patient
List the age-based recommendations for:
1) Clinical breast exam
2) Mammography
1) ● Clinical Breast Exam
○ 25-39 y/o: every 1-3 year
○ 40+ y/o: annually
2) ● Mammography
○ 40-75 y/o: yearly or biennially
○ 75+ y/o: shared decision making
List the age-based recommendations for cervical cancer
○ <21 y/o: none unless HIV or immunocompromised
○ 21-29 y/o: cytology alone every 3 years
○ 30-65 y/o:
■ cotesting w/ cytology and HPV every 5 years
■ Cystoscopy every 3 years
■ High-risk HPV every 5 years
○ 65+ y/o: d/c unless CIN2+
What are the age-based recommendations for colon cancer screening (colonoscopy)?
○ 45-75 y/o: every 10 years
○ 76-85 y/o: shared decision making
