2General Examination Introduction and smile! General examination of hands and mucous membranesSupra-clavicular lymph nodes should be feltThyroid gland should be palpated‘Chest & Breasts’Proceed with abdominal and pelvic examination
3Abdominal examination Patient preparation!InspectionPalpationPercussionAuscultation (if appropriate)Inspection – look at contour, any obvious mass or distensionPresence of surgical scars, dilated veins or stretch marksRaise her head and cough-checking for herniasPalpation-pain ask for site of pain (leave until last) palpate in 4 quadrantsExamination for masses and organomegalyCharacteristic of pelvic mass is that you cant palpate below itLook for signs of peritonism (guarding and rebound tenderness)Inguinal herniae and lymph nodesPercussion- useful if free fluid suspected (?asities)Shifting dullness/fluid thrillEnlarged bladder will be stony dull to percussAuscultation-not specifically useful in gynae but a pt will sometimes present with an acute ado ?bowel obstruction/ post op with ileus so you could listen for bowel sounds
4Pelvic Examination Patient informed consent and chaperone Inspection of external genitaliaAsk patient to strain and/or coughSpeculum examinationBimanual examination
9Preparation Explain details of the procedure and gain verbal consent Ask the patient to empty her bladder & remove any sanitary protection.Allocate a separate private area for the patient to undress.Chaperone should always be present.
10Equipment Gloves Speculum Lubricating jelly Examination couch and a ‘modesty sheet’Adequate lightingEnsure speculum is warmed and all equipment is in working order
11Positioning Patient should be supine. Place heels together with knees bent & allow legs to ‘fall’ apart.The light should be adjusted to allow a good view of the vulva and perineum.
12Inspection Hair distribution Vulval skin Look at the perineum for scars/tearsGently part labia – inspect urethraLook for discharge, prolapse, ulcers, wartsHair extending towards umbilicus and onto inner thigh can be associated with disorders of androgen excess and clitoromegaly.Vulva can be a site of chronic skin conditions such as eczema, psoriasis, Lichen sclerosis and warts, cysts of the Bartholin’s gland and cancers. Ulceration may imply herpes, syphilis, trauma or malignancy.Perineal scars maybe secondary to childbirth.
13InsertionHold speculum so blades are orientated in direction of vaginal openingPart the labia and slowly insert, rotating the speculum until its blades are horizontal
14Visualisation of Cervix Inspect for:DischargeWartsTumoursSize of cervical osBleeding
15Univalve Speculum Positioning Position patient in the left lateral positionKnees drawn up to chestHold back anterior vaginal wall with lubricated speculum
16FindingsAsk the patient to cough:RectoceleCystoceleLiquor
18When and why?Women are invited to have routine smears performed every 1-3 yearsNeeds to be done in the mid-late follicular phase and NOT during menstruationWorldwide- Ca Cx second most common malignancy
19Taking a cervical smear Following insertion of bivalve speculumEquipment:Aylesbury spatulaConfirm name, DOB, hosp number etcLabel frosted end of slideExplain that the procedure may be uncomfortable
20Taking a Cervical smear Rest point of spatula within the os and rotate clockwise 360° then rotate 360° anti-clockwise.Exert light pressure (pencil).Ensure contact with cervix throughout.
22Concluding Cervical Smear Spread both sides of the spatula onto the slide.Place immediately into the fixative for between 10 – 90 mins.High-risk specimens should be left in for a minimum of 1 hour.Inform the patient how long the results will take and how they will be delivered.
23What do the results mean? Normal- means you have very low chance of developing ca of the cx but not 100% guarantee)Inadequate- no true result can be given as ‘inadequate’ sample. Repeat smear indicatedAbnormal- minor changes are quite common, repeat smear 3-12 months advised
24Bimanual Examination Separate labia with gloved left hand Inserted index finger into vagina then slowly insert middle finger to palpate cervixLeft hand then palpates uterus abdominally
25Tips of the vaginal fingers placed into each lateral fornix and the adnexae are examined on each sideThe uterosacral ligaments can be felt in posterior fornix