ASSOCIATION OF PROFESSORS OF GYNECOLOGY AND OBSTETRICS

Perform a physical examination of a reproductive-aged woman

Learner Task: Perform a physical examination of a reproductive-aged woman.
 
Educator Script: Provide the following information as asked by the learner:

• Vital signs: BMI 37, HR 80, BP 120/60, Temperature 98.4° F

 
Educator Notes and Diagrams: Breast Examination

• Learners should:
  • Wash their hands with soap and warm water or alcohol-based antiseptic.
  • Learners should inform the patient that they are performing a breast exam. This is a good time to ask the patient if they have noticed any lumps or other problems with their breasts.
  • Be organized and have the patient properly draped, i.e. cover areas not being examined.
• Inspection:
  • Asking the patient to lower the gown, learners should visually inspect the breasts from front and sides.
  • Learners should look for size, symmetry (some variation is normal), shape, contour (flattening, masses, and dimpling), skin (color, edema, rashes, thickening, and venous pattern), and scars (previous surgery, injuries).
  • Learners should do the inspection with the patient performing arm maneuvers: overhead (#1), waist (#2), and leaning forward (#3). Learners are looking for any retraction when the patient is leaning forward, or contracting the pectoral muscles.

• Palpation
  • Lymph nodes
    • Cervical nodes: These nodes are found along the sides of the neck.
    • Axillary nodes: The patient is in a seated position using appropriate draping technique. With patient’s arm at their side and the examiner lifting the arm away from side to access nodes (#4).
    • Supraclavicular nodes: These nodes are found along a line immediately above the clavicle. This is done by learners stepping around behind the patient.

• Bimanual palpation while patient sitting
  • Learners should perform bimanual palpation with the patient in a seated position, using appropriate draping technique.
  • Learners should use the right hand above/left hand below to palpate the right breast. Learners should use the pads of the fingertips to compress the breast tissue between fingertips. Using this technique, learners can check for consistency, nodules, masses, and tenderness, which might not be felt in supine breast exam. Repeat for left side by standing on patients’ left side and reversing hands (left on top, right on bottom).
  • Complete breasts palpation while patient is supine
    • Learners should pull out the footrest, and ask the patient to put their arm overhead during supine palpation. The arm overhead helps to stretch the breast tissue against the chest wall.
    • Learners should then perform a complete palpation of the breasts. Learners should use the flat part of the fingers (and a rotary motion) against the chest wall using a radial or spiral pattern without missing areas, compressing the breast tissue against the chest wall in all quadrants of the breast (#5). Learners should be noting tissue consistency, elasticity, nodules, indurations, masses, and tenderness.

• Learners should palpate all of the breast, which continues up the chest wall to the clavicle (collar bone) and towards the axilla (armpit).
• Learners should inspect and palpate the nipples (#6), looking for size, shape, inversion, rashes, ulceration, discharge, scaling, crusting, elasticity, retraction, areolar edema and masses. Learners should gently grasp and compress the nipple and areolar tissue between thumb and index finger, noting the color consistency and quantity of any discharge (#7).

 
Educator Checklist: Breast Examination 
Mark the appropriate column to indicate whether the learner included each element in his or her response. When completed, tally the “Included” column to calculate the learner’s score.
 

Educator Notes and Diagrams: Pelvic Examination

• Learners should:
  • Select the appropriate sized speculum, warm speculum and test speculum on patient’s leg for comfortable temperature.
  • Inform patient prior to speculum insertion.
  • Insert speculum at 45-degree downward angle, then rotate and open when completely inserted.
  • Visualize the cervix by adjusting the speculum anteriorly or posteriorly.
  • Use the appropriate collection vial with the correct attached swab for each culture
  • For Chlamydia and Gonorrhea cervical collection, insert the swab into the endocervix for approximately 10 seconds (insert only superficially in pregnancy)
  • For vaginal cultures, obtain a specimen from the posterior fornix
  • Insert the swab into the vial, break off the excess swab and cap off the collection vial/tube securely and label the specimen
  • Traditional Slide Cytology Collection
    • Learners should use the spatula clover leaf end to collect ectocervical cells, or spatula end for vaginal cuff cells, and then smear them in a thin layer on the slide.
    • On the same slide, learners should smear endocervical cells collected using a cytobrush. Only insert cytobrush superficially in pregnancy.
    • The learner or assistant should spray the slide with cytology fixative immediately after cytology collection and place it in the appropriate container.
    • The learner or assistant should label the container appropriately.
  • Liquid-Based Cytology Collection
    • Learner should first use the plastic (not wood) spatula to collect ectocervical cells (rotate 360 degrees), then brush-like device (rotate 180 degrees) to collect endocervical cells.
    • Both spatula and brush should be swept around the inside of the liquid-based cytology specimen collection container 10 times to loosen the maximum number of cervical cells into solution.
    • The learner or assistant should label the container appropriately.

 
Educator Checklist: Cervical Cytology
Mark the appropriate column to indicate whether the learner included each element in his or her response. When completed, tally the “Included” column to calculate the learner’s score.