OBGYN Physical Exam PDF

BREAST EXAM Introduce yourself “Hi! My name is ____, I am a Bay Path PA Student. I go by she/her pronouns. I am working with my preceptor ___. H...

BREAST EXAM Introduce yourself “Hi! My name is ____, I am a Bay Path PA Student. I go by she/her pronouns. I am working with my preceptor ___. How would you like me to refer to you?” Explain the purpose of the exam and get consent “I will be doing a breast and pelvic exam. This consists of inspecting and palpating your breasts in various positions as well as performing a pelvic examination and obtaining a pap smear. Do I have your consent?” Allow patient to change “I would provide my patient with a gown, and ask them to leave it open in the front. I would let them know I am stepping out of the room to allow for privacy to change at which time I will gather all of my supplies as well as a chaperone who will be present during the examination.” (This way once you complete the breast examination you can start by positioning your patient for the pelvic examination and your materials and chaperone are already in the room) Once you return → Wash your hands PATIENT STANDING Inspect the breasts and nipples Ask the patient to stand and lean forward “Inspecting the breasts for size, shape, contour, dimpling, skin color, edema, and venous pattern.” “Inspecting the nipples for size, shape, direction each one points, rashes, and ulceration.” PATIENT SITTING Inspect the breasts and nipples Ask the patient to keep their hands at their side “Inspecting the breasts for size, shape, contour, dimpling, skin color, edema, and venous pattern.” “Inspecting the nipples for size, shape, direction each one points, rashes, and ulceration.” ***Given that you have already noted inspecting for the above you do not need to say this again, you can state that you are inspecting for all of the same things in these three other positions. For example, once you have done the above while patient is standing you could say, “I will now as you to sit and will inspect for all of the same things with your hands by your sides (inspect), hands on your hips (inspect), and hands pressed together (inspect) Repeat with the patient having their hands on their hips, and then their hands pressed together overhead.  PATIENT LYING DOWN Palpate the breasts Ask the patient to lay down, and put their right hand behind their head while you examine the right breast. “I would offer my patient a pillow to keep them comfortable” Palpate the breast in a linear pattern with the pads of your three fingers, and note the tail of spence & 4 quadrants & the areola. Identify any masses Use your fingertips to evaluate a mass & describe the mass in terms of its Location (quadrant, clock, and proximity to the nipple) Size Shape Mobility Consistency Tenderness Example: “An approximately 1 x 1 cm single, round, firm, mobile, well circumscribed, (remember to ask patient if tender) nontender mass located in the upper outer quadrant of the left breast at the 1 o’clock position, 2 cm from the nipple.” Palpate the nipples Palpate the nipples using your thumb and index finger. “Noting the elasticity and any presence of discharge of the nipple”  GU/PAP SMEAR Gather supplies Vial with a label Gloves Cervical broom (swab) Lubricant Medium size speculum Tissues Explain the need for a chaperone “I have a chaperone here to help assist me with the exam, is that ok?” Put on your gloves Position the patient appropriately “I am going to ensure that you are in the proper position for the examination” Extend the stirrups, and ask the patient to move their buttocks to the end of the examination table, place their heels in the stirrups, and lie back in the lithotomy position. “Here is a drape or sheet to use for privacy” Inspect the external genitalia Once the patient is in the proper position and the examiner is seated, move the sheet and begin the external evaluation. “I am inspecting the mons pubis, labia majora, and labia minora.” “Visualizing the urethra, clitoris, and vaginal introitus.” “Inspecting the perineum and anus.” Inspect and palpate Skene’s and Bartholins glands “I am inspecting and palpating Skene’s and Bartholins glands” Inspect for cystocele, incontinence, and rectocele Ask your patient to cough and bear down. “No cystocele, incontinence, or rectocele noted” Lubricate the speculum & insert “I am going to gently insert the speculum. Take some deep breaths to relax” Place your index finger in the posterior vaginal opening, and GENTLY pull down. Insert the closed lightly lubricated speculum at a 30-45° angle. Once inserted move the speculum to the horizontal position and aim downward toward the cervix (think of aiming towards the L-spine). Slowly open the speculum and move your wrist upward to get the cervix into view. Once the cervix is in view, lock the speculum in place. Identify any cervical abnormalities, and the “I am examining the cervix for any abnormalities.” transformation zone “I am visualizing the transformation zone.” Collect the sample for the pap smear Inform the patient that you will be obtaining a pap smear. Grab the swab and insert it so the brush is parallel with the cervix. The long bristles should enter the cervical os and the short bristles should be flush against the cervix. Rotate the brush 3-5 times in both directions against the cervix. Place the collected sample in the labeled vial “I would then have this sent to the lab” Remove the speculum Gently close the speculum while being careful to not pinch the vaginal wall. Slowly rotate it as you pull it out to remove it at the same angle you inserted. Discard the speculum. Palpate for cervical motion tenderness “I am now going to perform the bimanual examination. This will require me to insert two fingers to assess the cervix. I will also be palpating the uterus and adnexal spaces.” Insert 2 lubricated fingers inside the vaginal canal and with a sweeping motion under the cervix assess for cervical motion tenderness. “Any tenderness” Then push up on the cervix while applying pressure to the mid lower abdomen with your nondominant hand to assess the uterus. Palpate the ovaries, adnexa, and uterus Move your fingers to the right adnexa internally while palpating the right lower abdomen with the nondominant hand “Palpating the ovaries and adnexa” Repeat on the other side. Discard appropriate materials Throw away your gloves Provide tissue for the patient to clean themselves Give them tissues