GYNECOLOGICAL EXAM

1. GYNECOLOGICAL EXAM SFC WARD

2. Do a Complete Physical Assessment • HEENT • CV • Lungs • Breasts • Abdomen • Pelvic/rectal • Neuro • Musculoskeletal

3. Essentials for an Adequate Examination--Relaxation • Patient should be given an opportunity to empty her bladder prior to the exam-- Routine UA specimen may be obtained at this time • Explain what is to take place during the exam • Drape her appropriately, cover extending at least over her knees • Arms should be at her side or folded across her chest.

4. Essentials for an Adequate Examination • Examiner's hands should be warmed, also warm the speculum before the exam • Have eye to eye contact with the patient during the exam • Explain in advance each step in the examination, avoiding any sudden or unexpected movements

5. Correct Examining Position of the Patient • The Lithotomy Position/or Semi-Sitting Lithotomy Position • Lying in supine position • Thighs flexed and abducted • Feet resting in stirrups • Buttocks extended slightly beyond edge of exam table • Head supported with a pillow

7. Male examiners should always be attended by female assistants • Hx should be taken prior to patient disrobing. • Do not enter the room with an unclothed patient unless you have a female chaperone.

8. Breast Examination (note the following): • Breast development • Size, symmetry, contour and appearance of the skin (Variation in breast contour may include the presence of masses, dimpling, or flattening.)

9. Supernumerary Nipple

10. Breast Examination (note the following): • Nipples • Direction of the nipples may provide a clue to masses when there is asymmetry • Discharge may indicate disease or may merely occur with the hormonal fluctuation of the menstrual cycle • Ulcerated areas and other nipple lesions require further exploration • Lymph node, have patient press hands against hip contracting pectoral muscles, palpate lateral group of axillary lymph nodes

11. Nipple Laceration Paget’s Disease Inverted Nipple

12. Sequence of Breast Exam • Patient sitting or standing--press hands on hips to contract pectoral muscles (This maneuver accentuates any existing tissue retraction.) • Observe size and contour and appearance of the skin • Observe direction of nipples

14. Sequence of Breast Exam • Palpate axillary region

15. Sequence of Breast Exam • Have patient lying flat with arm abducted and hand under head (This helps flatten breast tissue evenly over the chest wall.) • Palpate entire breast and lymph nodes, (axillary and infraclavicular) • Palpation is performed in a rotary motion using an organized approach

17. Sequence of Breast Exam • Some examiners start in the upper outer quadrant where tumors develop most frequently • Breasts of young clients are firm and elastic • Older clients, the tissue may feel stringy and nodular.

18. Sequence of Breast Exam • Palpating large pendulous breasts, use a bimanual technique. The inferior portion of the breast is supported in one hand while the other hand palpates breast tissue against the supporting hand • Special attention is given to palpate the nipples, and areola • Entire surface is gently palpated • With thumb and index finger compress the nipple; note any discharge.

19. NOTE: If client complains of a mass or tenderness of one breast, examine the opposite breast first to ensure an objective comparison of normal and abnormal tissue.

20. Breast Exam Video

21. PELVIC EXAM

22. Sequence of a Pelvic Examination • Inspect the client's external genitalia • Perineal area must be well illuminated • Both hands are gloved to prevent the spread of infection • Perineum is sensitive and tender, warn the client by touching the neighboring thigh first before advancing to the perineum.

23. NOTE: A client suffering pain or deformity of the joints may be unable to assume a Lithotomy position. It may be necessary to have the client abduct only one leg or have another person assist in separating the client's thighs.

24. Sequence of a Pelvic Examination • Mons pubis--note quantity and distribution of hair growth • Labia--usually plump and well-formed in adult female • Perineum--slightly darker than the skin of the rest of the body. Mucous membranes appear dark pink and moist

25. Sequence of a Pelvic Examination • Separate the labia and inspect the labia minora: • Labia minora • Clitoris • Urethral orifice • Hymen • Vaginal orifice

26. Sequence of a Pelvic Examination • Note the following: • Discharge • Inflammation • Edema • Ulceration • Lesions

28. Sequence of a Pelvic Examination • Note abnormalities such as: • Bulges and swelling of vulva and vagina • Enlarged clitoris • Syphilitic chancres • Sebaceous cyst Primary Syphilis

29. Sequence of a Pelvic Examination • Skene's glands • Near the urethra • Suspect inflammation; check for urethral discharge (Dc = Infxn Most likely GC) • Insert index finger with palm facing you into the vagina up to the 2d joint. Apply pressure upwards and milk the Skene's gland by moving your fingers outward • Do this on both sides and note COCA on any discharge. Obtain specimen for culture. • Change glove if discharge is found.

31. Sequence of a Pelvic Examination • If there is history or appearance of labial swelling check Bartholin's glands • Insert index finger up to first knuckle • With your index finger and thumb, palpate the posterolateral area of the labia majora noting any: • Swelling • Tenderness • Masses • Heat or discharge

32. Sequence of a Pelvic Examination • Bartholin's glands (CONT) • A painful abscess is pus filled and usually staphylococcal or gonococcal in origin and should be incised and drained to perform C+S.

34. Sequence of a Pelvic Examination • Assess the support of the vaginal outlet: • With the labia separated by middle and index finger • Ask patient to strain down • Note any bulging of the vaginal walls (cystocele and rectocele).

35. Sequence of a Pelvic Examination • Inspect the anus at this time, note presence of lesions and hemorrhoids

36. Speculum Examination of Internal Genitalia • Select a speculum of appropriate size, lubricate and warm with warm water (Commercially prepared lubricants interfere with pap smear studies) • Small--not sexually active female • Medium--sexually active • Large--women who have had children • Medium to large speculum may be used if female has had children.

38. Speculum Examination of Internal Genitalia • Hold speculum in right hand • Place two fingers just inside or at the introitus and gently press down, this will help guide the speculum into the vagina opening • The speculum has to be closed • Insert closed speculum obliquely into vagina at a 45 degree angle rotating 50 degrees counterclockwise

40. Speculum Examination of Internal Genitalia • Avoid trauma to the urethra • Care is taken to avoid pulling pubic hair or pinching the labia • Maintaining downward pressure, open blades slowly after full insertion and position the speculum so that the cervix can be visualized • When the cervix is in full view, the blades are locked in the open position

42. Examination/Collection Specimen of the Cervix • Inspect the cervix • Color should be uniformly pink • Erythema around os: • Ectropion--expressed columnar epithelium • Erosion--term has been used to describe both the exposed columnar epithelium and the erythema seen with cervicitis • Pale--anemia • Bluish--Chadwick's sign, presumptive sign of pregnancy.

43. Examination/Collection Specimen of the Cervix • Inspect the cervix • Lesions/cysts: • Nabothian cyst--endocervical retention cysts usually secondary to cervical infection/inflammation • Friable, granular, red or white patchy areas--be suspicious of dysplasia, needs to be evaluated with colposcopy • Ulcerative lesions--may be herpetic; do viral culture of lesions and refer for colposcopy • Polyps--soft, friable mass protruding through os; may bleed if traumatized; refer for eval/removal

44. Examination/Collection Specimen of the Cervix • Inspect the cervix • Discharge: • Endocervical vs. from vaginal vault • Physiological discharge--odorless, colorless • Culture any discharge.

45. Examination/Collection Specimen of the Cervix • Inspect the cervix • Os: • Nulliparous--small, round, oval • Parous/multiparous--linear, irregular, stellate

46. Examination/Collection Specimen of the Cervix • Obtain specimens • Chlamydia culture--most prevalent STD • GC culture--gram stain not reliable, done for screening, must do Thayer-Martin for confirmation • PAP smear for cytology--sites of collection: • Endocervical brush--all patients • Endocervical scrape with spatula--all patients • Posterior fornix--all • Vaginal cuff and area of former posterior fornix for post-hysterectomy patient.

47. Examination/Collection Specimen of the Cervix • Obtain specimens • Wet mount of normal saline: • WBCs--evidence of infection/inflammatory process • Flagellated trichomonads--trichomonas • Granulated epithelial cells,"clue cells"--Gardnerella

48. Examination/Collection Specimen of the Cervix • Obtain specimens • KOH prep--budding yeast--candidiasis + "whiff" (fishy odor)--Gardnerella • Viral cultures of suspected lesions • Others: • STS (RPR/VDRL)--if suspected STDs • Beta HCG--if pregnancy suspected.

49. Examination/Collection Specimen of the Cervix • Obtain specimens • Collect during routine PAP smear/pelvic exam: • Wet mount if suspicious discharge • KOH prep if suspicious discharge • Thayer-Martin of Transgrow cultures • Chlamydia cultures

50. Inspection of the Vagina • Withdraw the speculum slowly while observing the vaginal wall • Close blades as the speculum emerges from the introitus • Inspect vaginal mucosa as the speculum is withdrawn