2 Gynexam

GYNECOLOGICAL EXAM
SFC WARD
Joint Special Operations Medical Training Center
Do a Complete Physical Assessment HEENT

CV Lungs Breasts Abdomen Pelvic/rectal Neuro Musculoskeletal
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.
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
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
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.
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.)
Supernumerary Nipple
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
Nipple Laceration
Pagets Disease
Inverted Nipple
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

Palpate axillary region

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

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.

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.
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.
Breast Exam Video
PELVIC EXAM
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.
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.

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

Separate the labia and inspect the labia minora:
Labia minora Clitoris Urethral orifice Hymen Vaginal orifice

Note the following:
Discharge Inflammation Edema Ulceration Lesions

Note abnormalities such as:
Bulges and swelling of vulva and vagina Enlarged clitoris Syphilitic chancres Sebaceous cyst
Primary Syphilis Joint Special Operations Medical Training Center

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.

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

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.

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).

Inspect the anus at this time, note presence of lesions and hemorrhoids
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.


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

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
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.


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 Joint Special Operations Medical Training Center

Inspect the cervix
Discharge:
Endocervical vs. from vaginal vault Physiological discharge--odorless, colorless Culture any discharge.

Inspect the cervix
Os:
Nulliparous--small, round, oval Parous/multiparou s--linear, irregular, stellate
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.

Obtain specimens
Wet mount of normal saline:
WBCs--evidence of infection/inflammatory process Flagellated trichomonads--trichomonas Granulated epithelial cells,"clue cells"-Gardnerella

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.

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
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
Perform a Bimanual Examination

From a standing position, introduce the index finger and middle finger of your gloved hand into the vagina Exert pressure posteriorly Your thumb should be adducted with the ring finger and little finger into your palm to avoid touching the clitoris.

Palpate the vaginal walls as you insert your fingers for tenderness, cysts, nodules, masses or growths Identify the cervix, noting the following:
Position--anterior or posterior Shape--pear-shaped Consistency--firm or soft Regularity Mobility--move from side to side 1-2 cm in each direction Tenderness

Palpate the fornix around the cervix The os should admit your fingertip 0.5 cm Place your free hand on the patient's abdomen midway between the umbilicus and symphysis pubis and press downward toward the pelvic hand

Many vaginal orifices will readily admit a single examining finger. The technique can be modified so that the index finger alone is used. Special small speculum or nasal speculum may make inspection possible also. When the orifice is even smaller, a fairly good bimanual examination can be performed with one finger in the rectum.

Your pelvic hand should be kept in a straight line with your forearm and inward pressure exerted on the perineum by your flexed fingers. Support and stabilize your arm by resting your elbow either on your hip or on your knee which is elevated by placing your foot on a stool
(Bimanual Examination) Identify the Uterus Noting the Following:

Size--uterine enlargement suggests pregnancy, benign or malignant tumors. The uterus should be 5.5-8.0 cm long Shape--pear-shaped Consistency--firm or soft.
(Bimanual Examination) Identify the Uterus Noting the Following:

Mobility--should be mobile in the anteropostero plane and deviation to the left or right is indicative of adhesions, pelvic masses of pregnancy Tenderness--suggests PID process or ruptured tubal pregnancy Masses.
Place your abdominal hand on the right lower quadrant Place your pelvic hand in the right lateral fornix Maneuver your abdominal hand downward Use your pelvic hand for palpation.
(Bimanual Examination) Identify Right Ovary and Masses in the Adnexa
Felt with the vaginal hand. The ovary has the size and consistency of a shelled oyster Note the size, shape, consistency, mobility and tenderness of any palpable organs or masses
Repeat the procedure on the left side The normal ovary is somewhat tender when palpated Withdraw Fingers from Vagina and Change Gloves
Techniques of a Rectovaginal Examination

The rectovaginal exam allows the examiner to reach almost 1" higher into the pelvis The rectovaginal exam is usually performed after the bimanual examination.

There is a risk of spreading infection between the vagina and rectum. Gonorrhea may infect the rectum, as well as the female genitalia. It is recommended that gloves be changed between bimanual and rectovaginal examination, in order to avoid spreading gonococcal infection. In order to avoid fecal soiling, gloves should always be changed, if for some reason the practitioner examines the vagina after the rectum.

Tell the patient that this may be somewhat uncomfortable, and will make her feel as if she has to move her bowels Lubricate dominant gloved hand Inspect the perianal area for lesions, discoloration, inflammation and hemorrhoids.

Client is instructed to bear down as though she as having a bowel movement, caution her; she will feel as though she must pass a bowel movement As the anal sphincter relaxes, insert your fingertip of the second finger gently into the anal canal and the 1st finger into the vagina. Sphincter tone is palpated

Palpate the anorectal junction. Tell the woman to bear down, palpate the anterior rectal wall and check for sphincter tone. A loose sphincter may be present due to neurologic deficit or 3d degree perineal laceration after childbirth

Insert fingers as far as they will go. Tell the woman to bear down, and that should bring another centimeter of palpation. Check the rectal walls, rotating your finger, checking for masses, polyps, irregularities or tenderness.

Palpate the rectovaginal septum for tone and thickness With your vaginal finger in the posterior fornix, perform a bimanual exam and palpate the bottom of the uterus and adnexa completely. Withdraw your fingers and evaluate the posterior rectal wall.

Prepare guaiac of rectal finger Give the patient a towel or tissues to cleanse herself
Common Abnormalities
Vulva
Bartholin's cyst Condyloma acuminatum
Cervix
Polyps Discharge Discoloration
Uterus--enlarged
Pregnancy Fibroids
Adnexa
Ectopic pregnancy Ovarian tumor or cyst
PELVIC EXAM VIDEO
SUMMARY
BREAST EXAM
Inspect Palpate Axilla Palpate Breast Palpate Nipple
SUMMARY
PELVIC EXAM
Inspect Externally Palpate Skenes Glands Palpate Bartholins Glands Assess Outlet Speculum Exam Bimanual Exam
Vagina, Cervix, Uterus, Adnexa
SUMMARY
RECTOVAGINAL EXAM
Palpate sphincter tone Palpate rectal wall Palpate rectovaginal septum Palpate Uterus Palpate Adnexa Guaiac

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GYNECOLOGICAL EXAM

Joint Special Operations Medical Training Center

Do a Complete Physical Assessment HEENT

Joint Special Operations Medical Training Center

Essentials for an Adequate Examination--Relaxation

Essentials for an Adequate Examination

Correct Examining Position of the Patient

Male examiners should always be attended by female assistants

Joint Special Operations Medical Training Center

Breast Examination (note the following):

Joint Special Operations Medical Training Center

Breast Examination (note the following): Nipples

Joint Special Operations Medical Training Center

Sequence of Breast Exam

Sequence of Breast Exam

Joint Special Operations Medical Training Center

Sequence of Breast Exam

Sequence of Breast Exam

Sequence of Breast Exam

Joint Special Operations Medical Training Center

Breast Exam Video

Joint Special Operations Medical Training Center

Joint Special Operations Medical Training Center

Sequence of a Pelvic Examination

Joint Special Operations Medical Training Center

Sequence of a Pelvic Examination

Sequence of a Pelvic Examination

Joint Special Operations Medical Training Center

Sequence of a Pelvic Examination

Joint Special Operations Medical Training Center

Sequence of a Pelvic Examination

Sequence of a Pelvic Examination

Joint Special Operations Medical Training Center

Sequence of a Pelvic Examination

Joint Special Operations Medical Training Center

Sequence of a Pelvic Examination

Joint Special Operations Medical Training Center

Sequence of a Pelvic Examination

Joint Special Operations Medical Training Center

Sequence of a Pelvic Examination

Joint Special Operations Medical Training Center

Speculum Examination of Internal Genitalia

Medium to large speculum may be used if female has had children.

Speculum Examination of Internal Genitalia

Joint Special Operations Medical Training Center

Speculum Examination of Internal Genitalia

Joint Special Operations Medical Training Center

Examination/Collection Specimen of the Cervix

Pale--anemia Bluish--Chadwick's sign, presumptive sign of pregnancy.

Examination/Collection Specimen of the Cervix

Examination/Collection Specimen of the Cervix

Joint Special Operations Medical Training Center

Examination/Collection Specimen of the Cervix

Joint Special Operations Medical Training Center

Examination/Collection Specimen of the Cervix

Joint Special Operations Medical Training Center

Examination/Collection Specimen of the Cervix

Joint Special Operations Medical Training Center

Examination/Collection Specimen of the Cervix

Joint Special Operations Medical Training Center

Examination/Collection Specimen of the Cervix

Joint Special Operations Medical Training Center