Breast and Pelvic Exam
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Questions and Answers

What does LMP stand for and why is it important in patient history?

Last Menstrual Period

Which of the following are common complaints that would warrant a gynecological exam? (Select all that apply)

  • Pain (correct)
  • Swelling (correct)
  • Infections (correct)
  • Neurological conditions

    • Consent is required before starting a pelvic examination.

    True

    The basic equipment needed to perform a pelvic exam includes an examining table with __________.

    <p>stirrups</p> Signup and view all the answers

    What areas should be inspected during the external exam of the genitalia?

    <p>Mons pubis, labia, perineum</p> Signup and view all the answers

    What structures are evaluated during a bimanual exam?

    <p>Cervix, uterus, ovaries, pelvic floor muscles</p> Signup and view all the answers

    What are some common external genitalia abnormalities that may be observed?

    <p>Thin mucosal appearance</p> Signup and view all the answers

    It is important to explain the speculum exam procedure to the patient before starting.

    <p>True</p> Signup and view all the answers

    How should the speculum be inserted during the exam?

    <p>Apply downward pressure with a finger in the vagina and insert the speculum sideways with angled pressure.</p> Signup and view all the answers

    What can be the position of a normal uterus?

    <p>Anteverted, mid-position, retroverted</p> Signup and view all the answers

    What is a cystocele?

    <p>A bulge of the upper 2/3s of the anterior vaginal wall with the bladder above it due to weakened supporting tissues.</p> Signup and view all the answers

    What may be the cause of pain on palpation/movement of the cervix?

    <p>Cervical infection</p> Signup and view all the answers

    After menopause, the ovaries may no longer be palpable. (True/False)

    <p>True</p> Signup and view all the answers

    What defines a cystourethrocele?

    <p>Involvement of the urethra and bladder with a groove defining the border between them</p> Signup and view all the answers

    Urethral caruncle mainly occurs in young women.

    <p>False</p> Signup and view all the answers

    Increased frequency, increased flow, or bleeding between periods may have systemic causes or may be ______.

    <p>dysfunctional</p> Signup and view all the answers

    Match the following diseases with their descriptions:

    <p>Epidermoid cyst = Small, firm, round cystic nodule in the labia Genital herpes = Shallow, small, painful ulcers on red bases Syphilitic Chancre = A firm, painless ulcer Bacterial vaginosis = Gray or white, thin, homogeneous, malodorous discharge</p> Signup and view all the answers

    Mucopurulent ______ usually produces purulent yellow drainage from the cervical os due to infections like chlamydia trachomatis, Neisseria gonorrhoeae, or herpes infection.

    <p>cervicitis</p> Signup and view all the answers

    Match the following types of masses with their characteristics:

    <p>Ovarian cysts and tumors = May be benign or malignant, smooth vs. solid nodular, usually not tender Ruptured tubal pregnancy = Severe abdominal pain, tenderness, signs of hemorrhage Pelvic inflammatory disease = Result of sexually transmitted infections, associated with very tender, bilateral adnexal masses</p> Signup and view all the answers

    Study Notes

    Breast and Pelvic Exam

    • History Taking:
      • Setting: quiet, private, well-lit room with patient dressed, and intimidating instruments covered.
      • Be welcoming and minimize family members' presence.
      • Interpreter if necessary.
      • Allow patient to change privately and use the bathroom after history taking.

    OB/GYN History and ROS Components

    • Pap Smear History:
      • Date and results of most recent Pap smear.
      • Prior abnormal results, including evaluation, treatment, and follow-up.
    • Infections and STDs:
      • Vaginal, pelvic infections.
      • Sexually transmitted diseases (STDs).
    • Contraceptive History:
      • Dates, methods, complications, and reasons for changes.
    • Sexual History:
      • Sexual activity, types of relationships, satisfaction, and dysfunction.
    • Infertility History:
      • Evaluation, treatment, and outcome.
    • Urinary or Fecal Incontinence:
      • Evaluation, treatment, and outcome.
    • Abdominal or Pelvic Symptoms:
      • Pain, bloating, bowel, bladder, weight gain or loss, vaginal discharge, irregular bleeding, and dyspareunia.
    • Abdominal or Gynecologic Surgery:
      • Tubal ligation, dilation and curettage, termination of pregnancy, laparoscopy, hysterectomy, and pelvic reconstruction.
    • History of Assault or Domestic Violence:
      • Breast disorder or surgery.

    Obstetrics History

    • Duration and Year of Pregnancy:
      • Weight of baby, gender, type of delivery, and current condition of the baby.
    • Complications:
      • Termination of pregnancy, gestational age, type of procedure, and associated medical conditions.
    • Spontaneous Abortions:
      • Gestational age, need for uterine instrumentation, and complications.
    • Ectopic Pregnancies:
      • Location of pregnancy and treatment.

    Common Terms

    • Gravity (G):
      • Number of pregnancies, including present pregnancy.
    • Parity (P):
      • Pregnancy outcome of prior pregnancies.
    • Nulligravida:
      • Never been pregnant and not currently pregnant.
    • Primipara:
      • Delivered one baby beyond 20 weeks.
    • Parturient:
      • Currently in labor.
    • Puerpera:
      • Has recently given birth.

    Summary of History/Example Questions

    • Menstrual History:
      • Age at menarche and menopause.
      • Last menstrual period (LMP).
      • Frequency, duration, and quantity of menses.
      • Premenstrual symptoms or pain with menses.
      • Vaginal discharge or discomfort.
    • Sexual History:
      • Engagement in sexual activity.
      • Number of sexual partners.
      • Pain with sexual activity.
      • Level of sexual satisfaction.
      • History of sexually transmitted infections (STIs).
    • Contraception:
      • Method used in the past or currently.
      • Method to protect against STIs.
    • Pap Smear Screening:
      • Last Pap smear and frequency of exams.
      • Prior abnormal Pap smears.
    • Breast Cancer Screening:
      • Mammogram screening done.
      • Frequency and results.
      • Prior abnormal mammograms.

    Gynecologic Exam

    • ACOG Recommendations:
      • Discontinued recommendation for annual routine pelvic examination.
      • Shared decision-making with the patient.
      • Counseling asymptomatic, nonpregnant women about benefits, harms, and lack of data.
    • Complaints Warranting a Gynecological Exam:
      • STI testing or screening.
      • Screening exams in females above 21.
      • Pain, discharge, pregnancy, or postpartum.
      • Infection, itching, swelling, bleeding, or menstrual abnormalities.
      • Sexual development abnormalities, sexual or physical trauma, or neurological conditions.
      • Incontinence or pelvic floor disorders.
    • Patient Consent:
      • Request permission before starting a pelvic examination.
      • Written consent is not required, except for examination under anesthesia.
      • Lack of consent is a contraindication for the exam.

    Clinical Pearls

    • Allow Adequate Time:
      • Be prepared to answer questions.
      • Ensure patients have a sense of control during the exam.
      • Thoroughly explain the procedure.
      • Allow the patient to participate in decision-making.
      • Reassure the patient that the exam can be discontinued at any point.
    • Talk to the Patient During the Exam:
      • Explain what is coming next.
      • Comment on findings.
      • Maintain eye contact.
    • Good Habits:
      • Warming instruments and being gentle during the exam.

    Equipment

    • Basic Equipment:
      • Examining table with stirrups.
      • Good light source.
      • Speculum of appropriate size.
      • Materials for obtaining cervical cytology.
      • Materials for testing common infections.
      • Cotton swabs for obtaining samples of vaginal discharge.
      • pH indicator paper.
      • Dropper bottles of saline and potassium hydroxide.
      • Large cotton swabs to absorb excess vaginal discharge or blood.
      • Water-soluble lubricant, disposable gloves, and material to drape the patient.

    Gynecologic Exam Steps

    • 1. Observation and Visual Inspection:
      • External genitalia.
      • Identify external structures (mons pubis, labia, clitoris, urethral opening, vaginal opening, Bartholin glands, perineum, anus).
      • Evaluate for developmental abnormalities, skin lesions, masses, and evidence of trauma or infection.
    • 2. Speculum Exam:
      • Inspect the cervix (color, position, surface characteristics, any ulcerations, nodules, masses, bleeding, discharge).
      • Inspect the vagina (masses, lesions, or abnormal discharge or bleeding).
    • 3. Bimanual Exam:
      • Palpate the cervix (position, shape, consistency, mobility, tenderness).
      • Palpate the uterus (size, shape, consistency, mobility, and tenderness or masses).
      • Palpate the ovaries (size, shape, consistency, mobility, and tenderness).
      • Assess the pelvic floor muscles (strength and tenderness).

    Rectovaginal Exam (if Indicated)

    • Tips for a Successful Exam:
      • Patient: avoid intercourse, douching, or using vaginal suppositories for 24 to 48 hours before the exam.
      • Patient: empty the bladder before the exam.
      • Patient: lie supine, with head and shoulders elevated, and arms at the sides or folded across the chest.
      • Examiner: obtains permission, selects a chaperone, and explains each step of the exam.
      • Examiner: drapes the patient, avoids unexpected movements, and chooses the correct speculum size.
      • Examiner: warms the speculum, monitors the patient's comfort, and uses excellent technique.
      • Examiner: positions the patient, arranges the sheet, and asks the patient to position their legs.
      • Examiner: uses verbal cues to assist the patient in positioning their legs.

    External Exam–Common Abnormalities

    • Mucosal Appearance:
      • Thin, reflecting atrophy, or decreased lubrication.
    • Discharge:
      • Normal: small to moderate amount, without strong odor.
      • Abnormal: HSV infection, ulcers, masses, skin or mucosal findings.
    • Ulcers, Masses, or Skin Lesions:
      • Typically genital or perianal area.
      • Can be isolated or have a cauliflower-like appearance.
    • Speculum Exam:
      • Gain comfort with the speculum prior to using it with a patient.
      • Show it to the patient, describe the process, and continue to explain the steps.
      • Use a water-soluble lubricant, and warm the metal specula with water.
      • Insert the speculum sideways, apply steady downward pressure, and open the bills while observing through the opening.
      • If the cervix is not visible, close the bills, withdraw the speculum, reposition, and open again.### Gynecological Examination
    • A gentle painting motion is used to avoid destroying cells when collecting a Pap smear.
    • A cotton-tipped applicator moistened with saline is recommended for pregnant women instead of an endocervical brush.

    Gonorrhea and Chlamydia Testing

    • Testing methods include PCR amplification of urine or cervical discharge samples and nucleic acid amplification testing (NAAT).

    Herpes Testing

    • Culture or PCR and typing are used to diagnose herpes.

    Removing the Speculum

    • Care should be taken to avoid discomfort when removing the speculum.
    • Steps to remove the speculum include:
      • Pulling the speculum back to clear the cervix.
      • Closing the speculum halfway.
      • Observing the vaginal walls for any abnormalities.
      • Closing the bills and taking pressure off the thumb piece before fully removing the speculum.

    Bimanual Exam

    • Explain the exam to the patient before proceeding.
    • Use a lubricated finger to gently move the cervix and note any pain or discomfort.
    • Palpate the uterus, noting its size, shape, consistency, mobility, and any pain caused by manipulation.
    • Use the other hand to palpate the lower abdomen and note the position of the uterus.
    • Check for any adnexal masses or tenderness.

    Rectovaginal Examination

    • This exam allows for optimal palpation of the posterior cul-de-sac and uterosacral ligaments.
    • It is used to screen for colorectal cancer, detect endometriosis, and evaluate symptoms in the rectal area.
    • Use a lubricated examining glove and ask the patient to bear down to relax the sphincter and decrease discomfort.

    Concluding the Exam

    • Provide the patient with privacy to clean up and get dressed.
    • Return to answer questions, review findings, and discuss next steps.

    Expected Lifespan Variations

    • Ovarian function usually starts to diminish in a woman's 40s, and menstrual periods cease between ages 45 and 52.
    • Physical changes associated with menopause include:
      • Sparse and gray pubic hair.
      • Smaller labia and clitoris.
      • Narrowing and shortening of the vagina.
      • Thinning of the vaginal mucosa.
      • Decrease in size of the uterus and ovaries.

    Tanner Staging

    • A system used to document and track the development and sequence of secondary sex characteristics in children.
    • Stages:
      • Stage 1: Preadolescent, no sexual hair.
      • Stage 2: Sparse, pigmented, long, straight hair.
      • Stage 3: Darker, coarser, curlier hair.
      • Stage 4: Adult, but decreased distribution.
      • Stage 5: Adult in quantity and type, with spread to medial thighs.
    • Dates of previous periods may indicate possible pregnancy or menstrual irregularities.
    • Abnormal bleeding patterns, such as excessive flow, bright red color, or presence of "clots," may indicate underlying conditions.
    • Postmenopausal bleeding raises the question of endometrial cancer.
    • Other causes of secondary amenorrhea include low body weight, stress, chronic illness, and hypothalamic-pituitary-ovarian dysfunction.
    • Delayed puberty may be due to familial or chronic illness.
    • Excoriations or itchy, small, red macules or papules suggest pediculosis pubis.
    • Clitormegaly, imperforate hymen, and sexual dysfunctions may be identified during the exam.

    Diseases

    • Epidermoid cyst: a small, firm, round cystic nodule in the labia.
    • Venereal wart: warty lesions on the labia and within the vestibule.
    • Genital herpes: shallow, small, painful ulcers on red bases.
    • Syphilitic chancre: a firm, painless ulcer.
    • Carcinoma of the vulva: an ulcerated or raised red vulvar lesion in an elderly woman.
    • Bacterial vaginosis: a gray or white, thin, homogeneous discharge with a malodorous odor.

    Bacterial Infections

    • Trichomonal vaginitis: a yellowish-green or gray discharge, often profuse and malodorous.
    • Candidal vaginitis: a white and curdy discharge, often thick and not malodorous.
    • Bacterial vaginosis: a gray or white, thin, homogeneous discharge with a malodorous odor.

    Other Conditions

    • Cystocele: a bulge of the upper 2/3s of the anterior vaginal wall, together with the bladder above it.
    • Cystourethrocele: a bulge of the entire anterior vaginal wall, together with the bladder and urethra.
    • Urethral caruncle: a small, red, benign tumor visible at the posterior part of the urethral meatus.
    • Prolapse of the urethral mucosa: a swollen red ring around the urethral meatus.
    • Bartholin's gland infection: a tense, hot, very tender abscess.
    • Rectocele: a herniation of the rectum into the posterior wall of the vagina.
    • Mucopurulent cervicitis: a purulent yellow drainage from the cervical os.
    • Carcinoma of the cervix: a growth that begins in an area of metaplasia.
    • Myomas of the uterus: benign uterine tumors that may be single or multiple.
    • Prolapse of the uterus: a weakness of the supporting structures of the pelvic floor, often associated with a cystocele and rectocele.### Pelvic Inflammatory Disease (PID)
    • PID is often a result of sexually transmitted infections of the fallopian tubes (salpingitis) or the tubes and ovaries (salpingo-oophoritis)
    • Caused by Neisseria gonorrhoeae, Chlamydia trachomatis, and other organisms
    • Acute disease is associated with: • Very tender, bilateral adnexal masses • Pain and muscle spasm making it impossible to delineate them • Pain upon movement of the cervix
    • If left untreated, a tubo-ovarian abscess and infertility may ensue
    • Infection of the fallopian tubes and ovaries may occur after: • Delivery of a baby • Gynecologic surgery

    Speculum Types

    • Graves Speculum: • Wider, higher, and curved on the sides • Suitable for parous women with loose vaginal walls • Available in pediatric sizes for virginal adults or young children
    • Pederson Speculum: • Flat and narrow blades with minimal curvature on the sides • Suitable for nulliparous women and menopausal women with atrophic vaginas • Available in pediatric sizes for virginal adults or young children

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    Breast and Pelvic Exam History PDF

    Description

    Learn about the setting and procedures for conducting a breast and pelvic exam, including creating a comfortable environment for the patient and taking a thorough history.

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