What are some good ways to make a patient more comfortable during sensitive exams?
Have the patient avoid intercourse, douching, or vaginal suppositories for 24-48 hours before exam. Have the patient empty their bladder before the exam. Have pt lie supine with head and shoulders elevated, arms either at sides or folded across chest to enhance eye contact and reduce tightening of abdominal muscles.
What techniques will help a woman relax during a GYN exam?
Explain each step of the examination to the patient in advance. Drape patient from midabdomen to knees, depress drape between knees to provide eye contact with the patient. Avoid unexpected or sudden movements. Warm the speculum with tap water. Monitor the comfort of the examination by watching the patient’s face and pay attention to clues. Use excellent but gentle technique, especially when inserting the speculum.
What are Tanner's stages of sexual maturation?
Stage 1= prepubertal
Stage 2= presence of palpable subareolar breast buds, presexual pubic hairs- short, light, straight, and not obvious on exam at first.
Stage 3= enlargement and elevation of whole breast, sexual pubic hairs- long, dark, curly, and appearing on labia majora.
Stage 4= areolar mounding (transient), progression of pubic hair on pubis, but not to medial surface of thighs.
Stage 5= attainment of mature breast countour, progression to mature female escutcheon (inverted triangular pattern).
Know the normal anatomical structures of the vulva.
The vulva includes:
Mons pubis- a hair covered fat pad overlying the symphysis pubis
Labia majora- outer, rounded folds of adipose tissue
Labia minora- inner, thinner pinkish red folds that extend anteriorly to form the
Prepuce- where the labia minora come together
What is the normal location of Bartholin's glands?
Bartholin’s glands are located posteriorly on either side of the vaginal opening, situated deeply and usually not visible.
What is the normal location of Skene's glands?
Skene’s glands are just posterior and lateral to the urethral meatus. These are also known as the paraurethral glands.
What are condyloma acuminata from Human Papilloma Virus (HPV)? What is the relationship of HPV to cervical dysplaia?
Condyloma acuminate are genital warts caused by specific HPV strains, especially HPV types 6 and 11. HPV types 16 and 18 account for 70% of all cases of cervical cancer.
What is the difference between a Pederson and a Graves speculum? When would you use one versus the other?
Pedersen and Graves both come is small, medium and large sizes. Pedersen has straight edges, and Graves is wider with a spooned tip. The medium Pedersen is usually suitable for sexually active women. The narrow-bladed Pedersen is best for the patient with a relatively small introitus, such as a virgin or an elderly woman. The Graves is best suited for parous women, or women with vaginal prolapse.
What is the technique for assessing vaginal tone?
Inform the patient that you are going to check for pelvic support. Insert a gloved index finger just inside the introitus. Depress the posterior wall and ask the patient to “bear down" or "squeeze" as if they are cutting off a stream of urine. Check tone of lateral and anterior walls. Observe for anterior or posterior wall bulging.
What is a cystocele?
A cystocele is a prolapsed urinary bladder that pushes on the anterior part of the vaginal wall. The bulge may push toward the introitus (grade II) when the patient bears down, or the bulge might come all the way to the introitus (grade III) or even "fall out" and have to be put back in (grade IV). It can cause difficulty with urination. A cystocele may result from muscle straining while giving birth. Other kinds of straining—such as heavy lifting or repeated straining during bowel movements—may also cause the bladder to fall. Estrogen helps maintain the vaginal wall so cystoceles are more likely after menopause. I suspect there may be an increased risk of this also post hysterectomy, though I haven't found the scoop on that yet.
What is a rectocele?
A rectocele is bulging of the posterior part of the vaginal wall that comes down to the introitus when the patient bears down.
What is the best method for visualizing the cervix using a speculum?
Hold the speculum in the dominant hand, the index finger wrapped around the blades to keep them closed. Hold it obliquely at the introitus and slowly insert it into the vagina with downward pressure at about a 45 degree angle downward. When the speculum is partially inserted, grasp the handle with the non-dominant hand and complete insertion. Have your assistant adjust the light. Gently open the speculum until the cervix is visualized then tighten the thumbscrew and release the handle. If the cervix is not visible when you begin opening the speculum, slightly sweep it upward and look for the cervix to come into view. If it is still not visible, withdraw the speculum and re-insert it on another plane.
Once the cervix is visible, note any discharge. Observe the size, position, color, and consistency of the cervix. See if the squamocolumnar junction is visible on the ectocervix. Assess the character of the transformation zone. Ask patient if she would like to view her cervix with a mirror and explain the anatomy.
What is the significance of finding columnar epithelium on the ectocervix? What is the term (s) for this?
Columnar epithelium encircles the os during puberty (this area is called ectropion aka cervical erosion) and is gradually replaced by squamous epithelium. Cervical ectropion is the area where the central columnnar epithelium is present external to the os of the cervix. Ectropion mb assoc w/non-purulent vaginal discharge due to the increased surface area of columnar epithelium containing mucus-secreting glands. May cause post-coital bleeding. Normal in younger women and those on OCP's.
Where the columnar meets squamous is called the transformational zone and this is normally observed on the ectocervix. This area is at highest risk for dysplasia.
What is the technique for obtaining the PAP smear? Be prepared to demonstrate this during the practical.
A three site pap smear is obtained as follows:
1. place slide in non-dominant hand and dominant hand will reach for swabs
2. obtain vaginal cells from lateral fornix w/ rounded end of spatula
3. plate it on the slide in the area marked V
4. discard spatula
5. using V-shaped end, insert the longer pole into the os and rotate 360 degrees w/ moderate pressure making sure your sample is from the squamocolumnar junction if it is visible
6. plate it and discard spatula
7. insert cytobrush or moistened swab into the os to the depth of the cotton and rotate it once gently to obtain cells from the endocervix.
8. plate it
9. transfer slide to dominant hand and drop it into ether alcohol, fixative, or fix w/ spray immediately
10. remove speculum
What is the significance of cervical motion tenderness?
Cervical motion tenderness (aka positive Chandelier sign) suggests pelvic pathology including infection (PID), ectopic pregnancy and endometriosis. It can narrow a differential between PID and appendicitis. Adnexal tenderness may also indicate ovarian cyst, torsion, etc.
What are the normal shape, size and configuration of the uterus?
--usu at almost a right angle to vagina
--fibromuscular structure shaped like inverted pear
--two parts: body (fundus) is convex, and cervix (protrudes into vagina) joined by isthmus
--average adult uterus is about 3 inches long, 2 inches wide, and 1 inch thick
--thickness changes with the woman’s cycle
--uterine enlargement suggests pregnancy or benign/malignant tumors
--usu anteverted- cervix faces forward and uterus points upward w/slight tilt forward, palpable through abdomen and rectum, anterior sfc concave
--anteflexed uterus, fundus point forward relative to the cervix, only palpable by the abdominal hand
--retroverted: convex cervix faces forward, uterine body tilts posteriorly, cannot be felt by the abdominal hand.
--moderate retroversion: uterus cannot be felt by either hand.
--marked retroversion: uterus can only be felt posteriorly either thru the posterior fornix or thru the rectum
--retroflexed uterus: concave cervix that faces forward and a body that flexes backward, only felt posteriorly thru posterior fornix or rectum.
What is the difference between uterine retroversion and retroflexion of the uterus? How are they best palpated?
--retroverted tilts back, may not be palpable (moderate retroversion), poss palp thru posterior fornix or rectum (marked retroversion)
--retroflexion bent back, palpable thru post fornix or rectum
What are leiomyoma? What do they feel like on bimanual palpation?
Leiomyomas are uterine fibroids: benign smooth muscle neoplasms. They feel like firm, irregular nodules contiguous with the uterine surface. May lead to excessive menstrual bleeding (menorrhagia), cause anemia or infertility. Enucleation is removal of fibroids without hysterectomy, both are common tx. Laser surgery (called myolysis) is increasingly used, and provides a viable alternative to surgery. Uterine leiomyomas originate in the myometrium and are classified by location: submucosal, intramural, subserosal, mb pedunculated. Estrogen and progesterone stimulate their growth, and they often resolve spontaneously after menopause.
What is the normal size of an ovary? What do they feel like on bimanual palpation?
Ovaries are usually 2-4 cm in women of reproductive age. Patients will feel a slight twinge as the ovary is palpated. The examiner may feel the ovary slipping under the fingers of the internal hand as they pull inferiorly along the adnexa.
Be able to discuss the objectives of a bimanual and rectovaginal exam. When is the rectovaginal indicated?
The purpose of a bimanual exam is to assess the health of the vaginal walls, cervix, uterus, and ovaries. The rectovaginal exam is indicated when the patient is over 40, and/or there is reason to suspect posterior placement of the uterus or pathology posterior to the vagina (such as ovarian CA). It is the best way to assess a retroverted or retroflexed uterus, uterosacral ligaments, and cul-de-sac. One may be able to palpate the ovaries with either exam. An occult blood test may also be done after the rectal portion.
Clinical Breast Exam
Be familiar with Tanner’s stages of sexual maturity.
For female breast: (stages also apply to genital development in male and female)
Stage 1= pre-adolescent, elevation of nipple only
Stage 2= breast bud stage. elevation of breast and nipple as a small mound, enlargement of areolar diameter.
Stage 3= further enlargement and elevation of breast and areola, with no separation of their contours.
Stage 4= projection of areola and nipple to form a secondary mound above the breast
Stage 5= mature stage; projection of nipple only. Areola has receded to general contour of the breast (in some it may continue to have a secondary mound).
Be able to explain the CBE procedure to a patient.
Before the patient disrobes, explain that part of routine screening includes a breast exam. The purpose of the exam is to assess the health of the breast tissue.
Be able to teach self-breast exam.
The best place to do a self-breast exam is in the shower and the best time to do one is just after menstruation, when hormonal stimulation of breast tissue is low. With one arm behind your head, use your other hand to palpate your breast (opposite of the hand palpating). Use the finger pads of your three middle fingers pressing lightly, medium and deeply in a circular motion sliding up and down your breast in a zig-zag pattern. Start from just underneath your collar bone to below the breast. If you feel a lump on one breast, check that same spot on the other breast to see if it is a part of your normal tissue or if it is an abnormality. Remember, normal breast tissue has a lumpy feel, so getting to know what is normal for you is an important way to assess when something abnormal arises. If you find any masses, lumps or skin changes, see your doctor right away.
Why is it important to palpate the tail of the breast during the examination? What are the most common sites of breast cancer?
The “tail” of the breast is the upper, outer region of the breast near the axilla. It is in this region that approximately half of all breast cancers occur.
What are the most significant risk factors for breast cancer?
Hx of cancer in one breast
Family Hx of both a mother and a sister with breast cancer
Daily alcohol intake more than 2 glasses per day
High premenopausal blood insulin-like growth factor (IGF)-1 levels
High postmenopausal blood estrogen level (hormone therapy)
Which lymph nodes are palpated as part of the breast exam?
Axillary and supraclavicular lymph nodes
When is nipple discharge normal and abnormal?
Nipple discharge is normal during pregnancy or lactation. It is abnormal at any other time.
When is the best time of a women’s cycle to do self-exam?
The best time to do a self breast exam is just after menstruation when hormonal stimulation of breast tissue is low, this is the time when the breast tissue is least tender and nodular.
Understand the characteristics on exam of breast carcinoma versus fibrocystic disease and fibroadenoma. Know what is normal on palpation and what is abnormal
Fibroadenomas occur in young women, age 15-25, but may be seen up to age 55. They are usually single lesions but mb multiple, they are round, disc-like or lobular, usually firm but mb soft, very mobile, usu nontender and without retraction signs.
Cysts appear at age 30-50 and regress after menopause except with hormone therapy. They are single or multiple, round, soft to firm and usually elastic. They are mobile and often tender. Retraction signs are absent.
Cancer appears in women age 30-90, with the most in women over 50. Lesions are usually single but may co-exist with other nodules. The shape is irregular or stellate, consistency is firm or hard, and the lesions will be fixed or immobile. They are usually non-tender and retraction signs may be present.
What information would you want to record about a mass, palpated during a clinical breast exam?
Quadrant mass is located, size, symmetry, texture, mobility, tenderness/pain, consistency, number of nodules, shape, delimitation, lymphadenopathy, retraction signs.
Peripheral Vascular Exam
What is Allen’s test?
Have the patient rapidly open and close fists holding hands upright at 90 degree angles. Ask the patient to make a tight fist w/ one hand then compress both the radial and ulnar arteries firmly and have pt bring arms down to rest. Release your pressure over the ulnar artery, if the ulnar artery is normal, perfusion of blood rushes back within 2-3 seconds. Repeat this sequence unobstructing the radial artery. If either artery takes longer than 2-3 seconds, that is a positive result indicating Berger’s disease.
Be able to palpate the radial, ulnar, brachial, femoral, popliteal, posterior tibial, dorsalis pedis pulses. Also the epitrochlear & inguinal lymph nodes.
Radial- on thumb side of wrist
Ulnar- on pinkie side of wrist
Brachial- mid-forearm near elbow
Femoral- below inguinal ligament and midway between ASIS and symphysis pubis
Popliteal- press into popliteal fossa just behind the knee
Posterior tibial- behind and slightly below the medial malleolus of the ankle
Dorsalis pedis- between first and second toe on dorsum of foot
Epitrochlear nodes- between biceps and triceps of medial arm near epicondyle
Inguinal nodes- from ASIS to symphysis pubis along the panty line
Which parts of the arm do the epitrochlear nodes drain, which part drain to the axillary nodes?
The epitrochlear nodes drain the hand are forearm, these should never be palpable, so if they are, consider an infection in the hand or forearm.
The axillary nodes are considered a 4-walled structure, since lymphatic drainage is different for each wall:
•Central & apical axillary lymph nodes (chest wall lymph nodes) drain chest, breasts, arms.
•Lateral axillary (medial arm) nodes drain the arms.
•Anterior axillary nodes (pectoral area) drain the breasts and chest wall.
•Subscapular posterior axillary nodes drain posterior arm and part of post. chest wall.
Which pulse may be congenitally absent in some patients?
How is capillary refill assessed?
Hold patient’s hand at heart level and compress a nail for 5 seconds. The time (seconds) it takes for the nail to regain its normal color is the capillary refill time. Normal is 2 seconds for children and adult men, 3 seconds for adult women, and 4 seconds for the elderly.
What test do you do when coarctation of the aorta is suspected?
Femoral pulses will be delayed or diminished compared to brachial or radial pulses in aortic coarctation. Take blood pressures of all 4 extremities, and this should yield systolic pressures lowered by 10-20 mmHg (than the patient’s normal), compared to the legs. In other words, with coarctation of the aorta, higher pressures in the upper extremities are found.
Know how to assess and rate edema.
Have the patient seated with their legs hanging off the table (feet and legs exposed) and press firmly with your thumb for at least 5 seconds starting at the lower pre-tibial area and working your way up. Note the degree of pitting in millimeters or centimeters.
Scale Degree Response
1+ Trace Slight Rapid
2+ Mild 0-0.6 cm 10-15 seconds
3+ Moderate 0.6-1.3 cm 1-2 minutes
4+ Severe 1.3-2.5 cm 2-5 minutes
Understand the tests for DVT and thrombophlebitis in the calf.
Homan’s Sign- have patient lie supine with knees bent, both hands squeeze opposite sides of calf. The test is positive if the pt experiences pain or will not let you perform the test.
Also, palpate behind the knee to find if there is a cord, if so, this indicates phlebitis.
Another DVT test is to have the pt supine with legs flat and relaxed, quickly dorsiflex the patient’s foot. If the pain is reproduced, this indicates DVT.
Know the characteristics on physical exam of ulcers caused by arterial insufficiency, venous insufficiency and diabetes.
First note pallor, ulcers, loss of normal hair distribution and pulses on legs.
Beurger’s Test- with the patient supine, note the color of the feet soles. They should be pink. Then elevate both legs to 60 degrees until maximum pallor develops (usually one minute). Observe the soles. If there is marked pallor (whiteness), ischemia should be suspected. Have the patient sit up and if it takes more than 10 seconds for color to return to their legs, suspect arterial insufficiency.
Know how to do and interpret the retrograde filling test and the test for arterial insufficiency.
Trendelenburg tests the competency of the superficial and deep leg veins. Trendelenberg Test (assessment of valvular competence if varicose veins are present):
With the patient supine (one leg at a time), empty the superficial veins by 'milking' the leg in the distal to proximal direction. Press with your thumb over the saphenofemoral junction (2 cm below and 2 cm lateral to the pubic tubercle) and ask the patient to stand while you maintain pressure. If the leg veins now refill rapidly, the incompentence is located below the saphenofemoral junction, and vice versa. This test can be repeated using pressure at any point along the leg until the incompetence has been mapped out.