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L|E|C|O|M primary

SPEC
SENSITIVE PATIENT EXAMINATION COMMITMENT
DEPARTMENT OF PRIMARY CARE EDUCATION

S.P.E.C. Student Manual Class of 2014

| 2011 ~ 2012 |

Established 1996

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Sensitive Patient Examination Commitment

Table of Contents

HEADINGS PAGE #
Administrative Guidance.........................................................3 SPEC Mission..........................................................................4 SPEC History.......................................................................... .............................................................................................5 Student Rights & Responsibilities............................................6 SPEC Schedule........................................................................7 - 8 Breast Exam........................................................................... .............................................................................................9 10 Female Pelvic Exam................................................................ .............................................................................................11 15 Male Sensitive Pelvic Exam.....................................................16 21 The Rectal Exam.............................................................22 Screenings.............................................................................2324 Bladder Catherization ............................................................25 -27

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Sensitive Patient Examination Commitment

Administrative Director: Program Director: Program Instructors:

RICHARD A. ORTOSKI, DO, FACOFP Prof. & Chair, Department of Primary Care Education LYNN MCGRATH, MSN, CRNP ROSEMARIE MALEC, CRNP JAN NEWCAMP, RN, MSN ELLEN JACKSON, DC ROBERT E. EVANS, D.O. As designated

Supervising Physician: Teaching Associates:

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SPEC Sensitive Patient Examination Commitment MISSION

The respectful, informative communication with the client and the proper techniques in physical examination are mandatory for the physician / nurse practitioner. The teaching of the techniques of the gynecological examination and the male genital / rectal examination has presented a problem for both student and teacher. Our mission is to provide an educational opportunity in which participants acquire or enhance the skills necessary to provide competent and sensitive exams. The philosophy of the SPEC program is to foster the commitment within the student in order that a sensitive patient examination be accomplished. Our teaching philosophy is based on the belief that people learn best in a low-anxiety, nonjudgmental atmosphere which encourages dialogue between all group members. We believe that women and men are entitled to the highest quality health care throughout their lifetime without regard to their race, ethnicity, economic status or sexual orientation. The goal of the SPEC program is to teach medical students and nurse practitioner students the skills of performing a gynecological examination and male genital / rectal examination which are diagnostically thorough as well as comfortable and educational for the client. The ability to perform such an examination requires some basic technical and communication skills. Well-trained women and men can provide this opportunity to practice, while furnishing instruction and feedback on the student's technique and style, using their own bodies as teaching aids. Obviously, this unique and essential opportunity far surpasses the experience obtained by students trained on anesthetized patients or plastic anatomical models. This program emphasizes performance of an educated oriented examination.

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SPEC Sensitive Patient Examination Commitment HISTORY

This program has been inspired by two well established programs: the SPEC program in Philadelphia pioneered by Kate Webster in 1980 and another similar program introduced at Wright State University in Ohio. Also of note is the contribution made by The Pennsylvania State University Program at Hershey, Pennsylvania. These programs have been blended and tailored to fit the needs of our medical and nurse practitioner students. In 1995, two nurse practitioners, Lynn McGrath and Lisa Quinn, contacted Dr. Silvia Ferretti, Dean at Lake Erie College of Osteopathic Medicine, about the possibility of starting such a program in the Erie area. A committee headed by Dr. Richard A. Ortoski was formed and the SPEC Program was established within the Clinical Osteopathic Diagnosis Applications (C.O.D.A.) Course. A major role had been played by Millcreek Community Hospital by providing the original location for this examination experience. Our hope is to involve the entire medical community to afford a training program that includes new students and established practitioners who may want to improve and update their exam skills. The teaching associates or patient models are themselves medical professionals or have had extensive training to be able to provide this educational experience. Each one has a commitment of her/his own to assist in the training of these professional students with the satisfaction of knowing that a more sensitive and knowledgeable examination will be performed on the female and male patients.

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Students Copy

SPEC Sensitive Patient Examination Commitment STUDENT RIGHTS & RESPONSIBILITIES

Student Name: __________________________________ Pathway (circle): ISP LDP PBL PCSP

RIGHTS: 1. 2. You have the right to expect an organized and thorough program to give you an educational experience in sensitive examinations. You have the right to expect resolution of any disagreement following protocol of the student handbook.

RESPONSIBILITIES: 1. 2. The Teaching Associate (patient) has the right to respectful care given by the student. The Teaching Associate (patient) has the right to expect every consideration for her/his privacy and to full confidentiality regarding the physical exam and personal identity. The Teaching Associate (patient) has the right to expect that the students will maintain decorum and a professional attitude during these exams and program activities.

3.

Due to the complexities, the sensitive nature of the course, and the large number of participants involved, it is very important that strict confidentiality for the Teaching Associates be adhered to and all of the above rights and responsibilities be taken as fitting and proper for every student. I have read and agree to abide by the above statements. My signature below attests to my commitment in this educational endeavor which is held during the 2010-2011 college year. _________________________________________ Student Signature per the LECOM Honor Code ______________________ Date

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SPEC Sensitive Patient Examination Commitment SCHEDULE

VIDEOS & INTRODUCTIONS 7:30 A.M. S.P.E.C. QUIZ 7:40 A.M. INSTRUCTIONAL VIDEOS 1. Breast Exam 2. Female Pelvic Exam 3. Male Genitalia & Hernia Exams 4. Rectal Examination REMARKS ON VIDEO 1. Placement of hands on the standing patient 2. Asking for patient assistance during any part of the exam 3. Palpate the testes 4. Location of the external inguinal ring - more internal than illustrated 5. 6. 7. 8. 9. 10. Bear down, cough, half sit-up Rectal examination positioning Tip of KY tube Anal canal pain sensors Bear down with insertion of finger Stool for hemeoccult

INTRODUCTION TO PROGRAM Remind about Rights and Responsibilities Schedule and Student Manual Out Overview No long finger nails or "high" rings permitted Please have long hair pulled back Keep ties back with tie bars or have tucked away. MANNEQUIN ROOM MALE MANNEQUIN ORIENTATION FEMALE MANNEQUIN ORIENTATION GROUP ASSIGNMENTS & SEQUENCE OF EVENTS Group A Female Mannequin Pelvic Mannequins Catherization Male Mannequin Testes / Prostate Female Mannequin Breast Group B Mannequin Catherization Male Mannequin Testes / Prostate Female Mannequin Breast Female Mannequin Pelvic Group C Male Mannequin Testes / Prostate Female Mannequin Breast Female Mannequin Pelvic Mannequin Catherization Group D Female Mannequin Breast Female Mannequin Pelvic Mannequin Catherization Male Mannequin Testes / Prostate

FEMALE MANNEQUIN INSTRUCTIONALS Practice Sessions with Pelvic Models Examination with Different Uteri; Cervices Speculum Handling; Examination of Mechanisms Huffman, Pederson, Graves Review of Screening Recommendations from SPEC Student Manual Breast Examination on Mannequin Self Breast Exam Review Students Experience the Pelvic Exam Position on the Table MALE MANNEQUIN AND CATHERIZATION TABLE INSTRUCTIONALS Hemeoccult Slides Urethral Swabs - GC/CT DNA Probe - Males should not urinate prior to this exam

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Insertion of Urinary Catheters, Male & Female Sterile Technique French Calibration Straight Cath vs. Foley Catherization Maximum Single Catheterized Amount of Urine 750 - 1000 cc of Urine Hypotension with Vaso-vagal Response Testicular Examination Review - Self Testicular Exam Review Prostate Mannequin Review and Practice Review of Screening Recommendations from SPEC Student Manual EXAMINATION ROOMS EXAMINATION WITH TEACHING ASSOCIATES All Students Observe Positioning and Technique of Performing a Male Rectal Exam All Students Observe Positioning and Technique of Performing a Standing Male Exam FEMALE EXAM GROUPS A&B, then C&D Practice Slide & Pap & Vaginal Cultures Role Play Instructor & Teaching Associate Breast Exam by Instructor 3. Hand Washing 4. Student Instructional Insertion of the Speculum Bimanual Examination 1. 2. 1. MALE EXAM GROUPS C&D, then A&B Students Instructional Perform Standing Male Genital & Hernia Exams Perform Supine Male Genital & Hernia Exams

Instructors & T.A. Complete Evaluation Forms Student Individual Review of Evaluations with Instructor & Teaching Associate Evaluation Signed and Returned to Directors Students Complete Program Evaluation 1:45 P.M. 2:00 P.M. Closing Activities Students Exit

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SPEC Sensitive Patient Examination Commitment Breast Exam

I. Visual Examination: Five positions: 1. 2. 3. 4. 5. Patient sitting up on edge of table; good lighting Arms at side Arms raised Arms flexed, hands on neck with elbows pushed back Pushing hands in at waist to contract pectoral muscles Leaning forward from waist to permit breasts to fall freely

Observe for:

Symmetry Venous Pattern Masses Texture Dimpling Discharge Color Lesions Changes in breasts with positioning -Stand back 4-6 feet -Patient can lower own gown -Language awareness: i.e., "Breasts look normal", avoid "Fine", "Good", "OK" -Only expose breasts for as long as necessary for exam -"You can do this at home in front of a well-lighted mirror." Teach what to look for, arm positions -Have gown up while teaching: it may be difficult for the patient to pay attention while her breasts are uncovered -Be aware that stressors, such as fear of cancer diagnosis or embarrassment, may affect readiness to learn -Provide written instructions

Patient Comfort:-

Teaching:-

II.

Lymph Nodes: Palpate: Supraclavicular nodes Axillary node Observe for tenderness, swelling -Explain what you are going to do before touching patient -Approach from and stand to side of patient -Show location of nodes -Explain location of nodes -Explain meaning of abnormal findings

Patient Comfort: Teaching:

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III.

Palpation of Breasts: Method:

Patient supine, arm above head with gown lowered on side to be examined -Systematic: Consciously choose pattern and starting place, i.e., vertical or horizontal strips, spokes of a wheel, pie wedges or concentric circles; 6 o'clock, 12 o'clock -Teaching of Palpation: -Two handed - bottom hand is passive, guided by top hand -Use pads of fingers -Rolling, flowing motion in dime-sized circles -Pressure is applied gradually, by repeating the circles at 3 levels: -Fingers lightly resting on skin -Medium press -Enough pressure to palpate chest wall (but no more) -Thorough: Palpate one inch beyond where you think breast tissue ends. Go out to sternum, up to clavicle. The axillary tail should be identified and its significance explained to the patient -Patient can lower her own gown -Instruct to "lower" gown (avoid "expose") only one side at a time -Stand on the side you are examining (if possible) -Warm your hands first - another reason to wash! -Language awareness: avoid "feel" -use "check", "examine" -Self Breast Examination -Explain and demonstrate technique and system of palpation -Explain what to look for: "Any change from what is normal for you...not just looking for lumps, thickening may be significant also" -Share findings with patient. Help her to be aware of her normal textures so that she has a baseline to compare to B.S.E. -Picture/diagram of findings may help -If she is comfortable, have her palpate her breasts and discuss findings with you -Has she noticed any changes or textures, now or at home, that you have not discussed with her? Check for secretions by gently "milking" -Two-handed technique may be more comfortable than "pinching" method -If patient notes that she has a discharge, she may be more comfortable in milking it out herself -Instruct patient to let you know if she develops a secretion (if she doesn't have one) or if her secretions change

Patient Comfort:

Teaching:

IV.

Nipple Discharge: Patient Comfort:

Teaching:

SPEC Sensitive Patient Examination Commitment Female Pelvic Exam

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Preparation Check equipment -Light -Table positioning -Supplies -Inspection of speculum (warm water as lubricant if necessary) Positioning, Draping -Lithotomy position -Offer options: raised table - to allow for patient-physician eye contact and for patient comfort; mirror -for patient to observe the exam; draping - cover legs -Check client comfort *Male students and female students will be required to lie on the examining table and place their feet in stirrups in both table positions, flat down and with the back of the table raised Wash hand and glove -Clean not sterile technique -A pair of gloves, i.e., one glove each hand Communication -Instruct patient to inform you of any discomfort -Encourage your patient to ask questions: more detailed and technical explanations may be given if appropriate and desired by the patient -Observe for nonverbal cues your patient may be giving you -Tell your patient you will let her know what you are going to do before you do each step of the procedure -Tell her that you will slow down and stop if she asks *The patient is sensitive to subtle nuances in the physician's words or facial expression. The demeanor of the physician is extremely important in establishing and maintaining rapport. FEMALE PELVIC EXAMINATION The Instructor will demonstrate the pelvic exam, asking the "client" to position herself for the exam and assisting with this movement only if she is unable to do it herself. The Instructor positions the drape sheet for client comfort, but to not allow it to create a barrier between the "client" and the Instructor. They will discuss the exam, equipment and testing before the speculum is in place. The Instructor will then demonstrate how to "contract" with the client "If anything I do is uncomfortable, please let me know." ... etc. Each student will demonstrate a pap on the hand, not on the cervix. The client position and light will be adjusted. Gloves will be placed. Anatomy including bartholins and skenes glands will be pointed out. Normal tissue and common variations (discharge, condyloma, cystocele, etc.) will be reviewed. Stress clean technique, whether one or two gloved technique, will be utilized.*

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*Clean technique means having one "patient" and one "room" hand. Some say "clean" vs. "dirty" but this becomes confusing as some clinicians use the "clean" hand for the patient, while others use the "clean" hand for the room. The "patient" hand only touches the patient and the "room" hand only touches the items in the room (e.g., lamp, stool, drawers, pap spatulas, etc.). This is why it is perfectly acceptable to glove only the patient hand, as contamination is impossible, if using good clean technique. If you feel unable to perform the examination of external genitalia with only one gloved hand, it is okay to glove and use two hands, but then the "room" hand must be ungloved before touching anything other than the patient. For the bimanual, the external hand must be ungloved, as is our belief that it is entirely unnecessary and is also gross to use a gloved hand on healthy, bare skin. We should be teaching students that, if they make a mistake and grab the light or other equipment in the room with their "patient" hand, then they should stop immediately, change gloves and clean the area of contamination at a later, more appropriate time. It is exactly because of these "mistakes" - patient fluids accidentally put on some room objects - that we practice clean technique. During model menses, it is appropriate to use two gloves but you must remember to use the concept of clean technique, one "patient" hand and one "room" hand even though both hands are gloved. Models should always feel free to insist on clean technique and point out (politely, of course) any violations of clean technique. Remember, clean technique does not mean protecting only the examiner; clean technique is used to protect everyone (clinician, client, room environment and every person who follows in that room). I. External Genitalia: First tell the patient that the exam will begin; tell her that she will feel the back of your hand as you touch the examining hand low on the patient's inner thigh which signals the start of the exam. -Inspect: Labia Majors and Minora Clitoral Area Urethra Vaginal Orifice Hair Pattern Inflammation Discharge Nodules Ulceration Swelling Lesions

A.

Visual Exam:

Look for:

B.

Manual Exam: 1. 2. Skene's Glands (Para-Urethral): Gently milk-culture any discharge Bartholin's Glands (Greater Vestibular) Palpate: Note swelling, tenderness, discharge -culture any discharge - DNA Probe Pelvic Muscle Support While inserting one or two gloved fingers, depress the perineum to create an opening into the vagina, ask the patient to cough and observe for: a. Incontinence b. Cystocele - protrusion of the anterior vaginal wall propelled from behind the bladder c. Rectocele - protrusion of the posterior vaginal wall propelled from behind the rectum d. Enterocele - similar protrusion propelled by the small intestine

3.

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4. 5.

e. Uterine prolapse - cervix comes into view (normally it does not) Location of cervix - Use of the index finger may aid the beginning practitioner with the speculum exam Patient Comfort a. Use slow, continuous, gentle touch b. Avoid extraneous movements c. Hold hand low to avoid touching urethra/clitoris (thumb and middle finger on labia majorum can be used to expose tissue and structures with one movement) d. No lubricant if PAP is to be performed

II.

Speculum Exam: A. Insertion: 1. Speculum a. Check for mechanical defects b. Let patient know you will be inserting the speculum - show her the blades (with patients having their first pelvic exam a prior demonstration of the speculum may have been appropriate) c. Check speculum against back of your right hand for speculum temperature Insert tip of index finger into vagina, spread pubic hair and labia away from vaginal orifice Help patient relax a. Identify posterior vaginal wall with mild pressure and direct patient to relax it b. A deep breath may help patient to relax Insert blades obliquely with pressure exerted towards the posterior vaginal wall, avoiding the more sensitive anterior wall and urethra - avoiding pulling or pinching hairs or tissue during insertion Rotate blades horizontally and maintain posterior pressure Open blades: maneuver speculum slowly, avoiding sudden motions, so that cervix is in view Open blades just wide enough to observe cervix Avoid clamping down on cervix - cervical contusion Tighten screw gently to avoid vibrations

2. 3.

4. 5. 6. 7. 8.

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B.

Cervix: Observe: Color NodulesDischarge PositionMasses Os Bleeding Ulcerations

C.

Specimens:

Pap Smear "The Papanicolaou Smear" Gonococcal Culture / CT - DNA Probe Vaginal Cultures

D.

Vaginal Walls: Inspect while removing the speculum. Be careful not to trap the cervix in the blades. Apply inward pressure while rotating speculum slowly to inspect vaginal walls. Observe for: Color Ulcers Discharge Inflammation Masses Close blades fully before withdrawing the speculum.

III.

Bimanual Exam: A. Cervix & Fornix: Note: PositionRegularity Shape Mobility Consistency Tenderness Observe for patient comfort Gently palpate Avoid sudden motions Lesions Uterus: Note: Size Shape Position C. Consistency Mobility Tenderness Masses Most pressure is with abdominal hand

B.

Adnexa: Internal hand senses; downward pressure from external hand Identify: Ovaries (if possible) Any masses or tenderness Points for Comfort:Bladder should be empty Avoid sudden movements - move slowly Keep internal hand relaxed Avoid anterior pressure: lower arm/hand posteriorly Lubricate all sides of index and middle fingers of gloved hand prior to insertion

D.

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IV.

Rectovaginal Examination: -Change the glove on the internal examining hand to prevent possible transfer of infection from vagina to the rectum -Insertion: -Lubricate second and third fingers of the examining hand -Ask the patient to "bear down" to relax the anal sphincter during insertion -Apply gradual, steady pressure to the anus with your finger pad until the sphincter relaxes: this may take several seconds -Slowly insert your third finger for about 1 inch along the axis of the anus (toward the umbilicus) -Then slowly raise your hand to insert your second finger into the vagina along its axis (usually towards the hollow of the sacrum) -Palpation: -Avoid any sudden or fast movements, keep the examining fingers relaxed -Perineum and rectovaginal septum (should be firm, thin, smooth and pliable) between your fingers -Rectal vault (cul-de-sac) -Posterior/lateral uterus -Uterosacral ligaments -Hemoccult Test: -Withdrawal of fingers should be gradual to prevent spasms

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SPEC Sensitive Patient Examination Commitment Male Sensitive Pelvic Exam Outline
Using Male Mannequins and Male Teaching Associates I. Preparation

Check Equipment
Light - Stand, Pen light Table Stool Positioning Supplies Gloves Lubrication Culture Swabs - DNA Probe

Check Patient Comfort Wash Hands Clean - Not Sterile Technique

II. Communication Instruct Patient to inform you of any discomfort. Encourage your patient to ask questions; more detailed and technical explanation may be given. Use this opportunity to teach patient self testicular exam. The demeanor of the physician/NP is extremely important in establishing and maintaining rapport. Male Genital Exam A. Approach to the Patient

III.

Supine vs. Standing Patient Assistance During Exam

B. Inspect Exterior Appearance

Hygiene Eschucion Pubic Hair Pattern General Genital Appearance Look for: Scars Circumcision Discharge Size of genitalia Nodules Ulcerations Edema Lesions Vascularity Crab Lice - pediculosis
C. Groin and Inguinal Area Manual Exam

Palpate for Nodes or Edema Inguinal or Femoral Bulges

D. Scrotal Content Manual Exam primary care medicine/LECOM

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One Handed vs. Two Handed Exam Scrotum Appearance Physiologic Reason For Testicle Location Lift to See Perineum - Rashes Testicles Appearance Shape Roll the testicles vs. Palpate them Epididymus Vas Deferens Spermatic Cord Varicocele vs. Hernia Transillumination
E. Penis

Anatomical Position of the Penis Retract Foreskin Glans, Corona Phimosis vs Paraphimosis Return to Original Position Urethral Meatus Stenosis Hypospadia vs Epispadia Penile Palpation Peyronies Disease Urethral Palpation through the Corpus Spongiosum Glans, Shaft, Proximal Penis Milking Cultures /Specimens
F. Digital Hernia Exam

Definition of Hernia Types - Femoral vs. Inguinal Types of Inguinal - Direct vs. Indirect Females: Abdominal Half Sit Up Males: Slow continuous gentle touch Indent, invaginate scrotal skin from lateral mid portion of testicle Follow spermatic cord laterally into the inguinal canal at the external inguinal ring located beneath the abdominal wall Avoid pulling scrotal skin Turn your head and cough. Hernial Impulse Reducible Hernia Refer to Pictures in Course Swartz Text Chapter 16

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G.

Manual Exam - Looking for Pathology

Testicular Torsion Epididymitis Trauma Hydrocele Spermatocele Varicocele Testicular Neoplasm Cryptorchidism Hypospadia / Epispadia Phimosis / Paraphimosis STDs Condyloma Accuminata Herpes Syphilis Chancre Chancroid Discharge Molluscum Contagiosum Condylomata lata
III. Rectal Exam A. Positions - 3 Possible B. Lubrication / Exam Gloves / Do Not Touch the Tip of the KY Lubricant Tube C. External Exam

Anus External Hemorrhoids Lesions - Tears, STDs, Scabies Internal Exam Touch Anus Bare Down Internal Hemorrhoids Rectum Rectal Polyps Prostate Slow Purposeful Entrance towards Prostate in Males Examine Prostate Rubber ball consistency - tip of nose (cervix) Heart Shaped Boggy in infection Hard, firm in cancerous states or BPH Avoid repetitive in & out motion Examine Canal on Exit Remove Finger slowly, purposefully to avoid rectal spasm Hemmocult Stool or Fluid with every rectal exam

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SPEC Sensitive Patient Examination Commitment Male Sensitive Pelvic Exam Procedures
MALE GENITALIA, HERNIA, & RECTAL EXAMS Swartz Chapter 18 & 17 MALE GENITALIA PHYSICAL EXAM OVERVIEW Source of Stimulation - The examiners touch during this examination may be unintentionally arousing to the patient. The best advise is to continue the exam if the patient has been acting appropriately throughout the examination. If he/she has been forward in his/her actions then an immediate cessation of the exam should occur with quick acquisition of a third party observer to make known to the patient that the examiners intentions are only medical in nature and that the patient is acting inappropriately. The exam should then be completed unless the examiner still feels threatened by the continuation. 1 vs. 2 Handed - As a student learning this sensitive area examination, he/she may need to examine using both hands to adequately understand the exam and the anatomy found. There are reasons that a single handed exam may be more appropriate for both patient and examiner. If the patient has a disease state, an infestation, or a noxious odor, it may be more desirable to use a one handed approach which allows further distance to exist between the patient and the examiner. These findings should not hinder the examiner from performing the appropriate exam, for other actions could be done to avoid these concerns such as using protective facial or body barrier gear. Exam Gloves - These gloves or latex free gloves proven to protect both the patient and the examiner must be used during both male and female exams. Patient Assistance - Most men are probably not interested in assisting during the examination of their genitals. Only in specific individual cases would it be appropriate to commandeer their assistance in holding the penis to the side or retracting the foreskin. In most cases there exists no reason the examiner cannot do the exam on his/her own. Patient Positions - For completeness, the examination of the male genitalia should be performed in both the standing and the supine positions. If the lighting is adequate and a known area of a patients complaint can be visualized, the entire exam may be completed in the standing position. For closer proximity, observation, or concentration; the supine position may be better utilized. Systematic approach - Students are taught an approach that follows a definite pattern with a logical approach to the exam. When available, a reason for the logic is given. The full examination of the body area is covered in this approach and may be augmented as the student wishes later in his/her career. THE PROCESS & ORDER OF THINGS Exterior Appearance Inspect hygiene, eschutcheon, pubic hair pattern, and general genital appearance. Look for scars, circumcision, discharge, size of genitalia, nodules, ulcerations, edema, lesions, vascularity, and lice. In regards to Tanner staging, for both males and females the patient does not reach Tanner V until inner thigh hair is present. Groin and Inguinal Area Manual Exam Palpate for nodal enlargement, edema, and inguinal or femoral bulges. The Scrotal Content Manual Exam The scrotum is probably the least welcomed place during the male examination. There are two approaches; the one handed exam and the two handed exam (milking a cow). Exam the scrotum and scrotal content. Lift the scrotum to see the perineum; look for rashes . Look at the appearance of the scrotal skin. Examine one side at a time, looking at size and shape. size, shape,

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DO NOT palpate the testicle as taught in OMM lab when palpating the back musculature. ROLL the testicle between the thumb and fingers as if rolling an egg. Perform this exam systematically covering the entire surface area by going side to side as you move top to bottom and going top to bottom as you go side to side. Purposely exam the inferior pole, then the superior pole with the epididymus. Examine the surface only since there is nothing deep in the testicle that needs to be examined. Consistency of the testes is examined with a light pressure. Examine the vas deferens and spermatic cord with its spaghetti like strands. The vas is the most prominent structure. Transilluminate the scrotum if needed looking for scrotal masses, a hydrocele, or spermatocele near the epididymis. The Penis Exam Start distal and go proximal for this exam. Look at natural appearance and lesions. Retract the foreskin if present, observing for a phimosis or a paraphimosis. Return the foreskin to its original position when finished. Observe the urethral meatus, looking for the caliber as well as any stenosis; check the location of the meatus, looking for a centrally placed meatus versus a hypospadius or epispadius. Look for a discharge and warts. Observe the glans, while uncovering every wrinkle to observe the entire corona and frenulum as the penis is revolved to right 1800 and then to the left 1800. Look for ulcers, warts, nodules, scars, and inflammation. Observe the shaft, while uncovering every wrinkle from the glans to the pubic symphysis as the penis is again revolved. Palpate the penis using the full hand approach , engulfing the entire penis with one hand. Palpate the urethra through the corpus spongiosum while milking the urethra for possible unobserved discharge. Peyronies Disease may be diagnosed in the flaccid state by palpating calcified beads in the penis. Take cultures or specimens as needed. The Digital Hernia Exam The man believes that turning his head and coughing concludes the exam in this area. Femoral and inguinal hernias are the two types found in the genital area. There are two types of inguinal hernias, direct and indirect. The purist definition of a hernia might be a bodily organ tearing through muscle. A direct hernia would be closest to this definition. A direct inguinal hernia tears through the muscle around the inguinal canal and is palpated medial to the external inguinal ring. The inguinal canal is a potential space left behind from the descent of the testes. A hernia through this potential space palpated at the external inguinal ring does not meet the criteria of the purist definition of a hernia. It is denoted as an indirect inguinal hernia. In females, these hernias are examined by having the patient perform a half sit up while the examiner places both hands along the inguinal canal area. In males, the following lists a stepwise approach to the process, using a slow continuous gentle touch, staying in the plane of the patient until the very end of the examination: 1) the examiner indents, invaginates, the scrotal skin from the anterial lateral distal aspect of the testicle with a specified finger of his/her choice, using the palmer aspect of the finger aimed towards the posterior aspect of the patient. 2) the examiner follows the spermatic cord proximally, entering the area under the abdominal wall [Ortoskis pouch] slowly until a slight resistance is felt. 3) the examiner then rotates his/her hand within the same plane as the patient, without going posterior, to a 45o angle. 4) then and only then the examiner advances the finger 1-2 cm. until resistance is met again. 5) at this point, and this point only, the examiner breaks the plane of the patient with his/her finger tip, bending the DIP joint to enter the external inguinal ring - a divot, naval, or indentation.

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6)

7)

Statistically: Men have more inguinal hernias then women. Women have more femoral hernias then men. Men have more inguinal hernias than femoral hernias. Look for Pathology Balanitis and balanoposthitis is an inflammation of the shaft and the glans of the penis with an expected fungal etiology. Varicocele vs. Hernia Testicular Torsion Epididymitis Trauma Hydrocele Spermatocele Varicocele If found on the right, the examiner must rule out an obstruction due to the usual uninhibited flow into the Inferior Vena Cava . This may be a normal finding on the left due to the more acute entry into the renal vein on the venous return pathway; the examiner needs to investigate more if this is an acute finding or is symptomatic to rule out an obstructive phenomena such as found with a tumor. Testicular Neoplasm Cryptorchidism Hypospadia / Epispadia Phimosis / Paraphimosis Peyronies Disease STDs Condyloma Accuminata Herpes Syphilis Chancre is usually painless. Condylomata lata is found in secondary syphilis. Early latent syphilis is a diagnosis given when the contact to syphilis is determined to be less than a year from treatment. Late latent syphilis is a diagnosis given when the contact to syphilis is determined to be more than one year from treatment. Chancroid lesion is usually painful. Discharge Molluscum Contagiosum Nonpathologic findings ectopic sebacious glands PPP - penile papule pearls - corona of the glands

the examiner instructs the patient to increase intra-abdominal pressure by: - turning his head and coughing. - bearing down as with a bowel movement. - performing a half sit up if lying supine. the examiner is looking for a hernia impulse where the herniated object hits the finger tip. The examiner should avoid pulling scrotal skin by initially indenting enough scrotal tissue to advance the entire distance of the pathway described above.

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The Rectal Exam There are three usual positions for performing the rectal examination on a man: the modified lithotomy with the patient lying supine, the sims position with the patient lying lateral recumbent with the upper leg pulled toward the chest, and standing position with the patient bent at the waist over a table. In whatever position the patient is placed, locate yourself so that on entering the rectum the ventral palmar aspect of your finger is facing the patients anterior view; this position gives the best yield for the prostate exam. Lubrication is used for comfort; it does not interfere with hemmocult testing. Gloves are used to protect the examiner. The tip of the lubricant must not be touched with the glove when using a multiple use tube. External Exam The anus: Look for signs of inflammation, ulcerations, excoriations, nodules, fistulas, tears, scars, tumors, or hemorrhoids; palpate sphincter tone for trauma. Internal Exam Touch the anus first; the patient will contract the anal sphincter as a reflex. Wait until the patient relaxes the sphincter. Ask the patient to bare down as you push your finger through the relaxed anal sphincter. When you have placed your entire finger into the rectum with a slow but purposeful entrance, stop your fingers motion and ask the patient to relax something - relax your muscles, relax your bottom, etc.; the sphincter relaxes. The pain fibers are located in the anal sphincter area; once through this area avoid repetitive in & out motions; side to side and rotating motions are less irritating to the patient. Palpate the prostate gland with attention to size, surface area, consistency, sensitivity, and shape. Feel the medium sulcus of the prostate; move side to side comparing the size and rise from the sulcus looking for asymmetry. The prostate is heart shaped with a base and an apex; palpate for nodules in the prostate. The prostate should have a rubber ball consistency as does the tip of the nose or the cervix; a boggy feeling may indicate infection; a hard firmness may be palpated in cancerous states or with Benign Prostatic Hypertrophy. Revolve your finger 180O in the clockwise direction and then the counter clockwise direction as you slowly remove your finger from the rectum and anus; your entire finger surface is palpating the rectal wall for lesions, polyps, as you exit. If the patient tries to expel your finger from the rectum, do not let it happen; when the patient squeezes, your finger should remain stable to avoid undo discomfort on expelling your finger; be in control of your fingers position at all times. On exiting the anus, leave your finger for a second at the sphincter until it relaxes as to avoid an uncomfortable spasm. Use a tissue to wipe away any residue of fecal material and lubricant at this time; the patient be anxious enough to not cleanse himself after you are finished. Always hemmocult the fluid or material left on your gloved finger. Always give your patient permission to robe or pick up his garments when you have finished with the exam. Each of these directives will assist the examiner in providing a necessary exam with the most comfortable method to ensure that the patient will return for his next scheduled exam.

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SPEC Sensitive Patient Examination Commitment Screenings

BREAST CANCER FACTS
-Most commonly diagnosed cancer -2nd leading cause of cancer death among women in the USA -109/100,000 Lung cancer #1 -1991 - 43,583 women died of breast cancer - 27/100,000 -Incidence of breast cancer in women > 65 is 3 X higher than ages 35-64. -1991 - PA was 3rd in the number of breast cancer deaths (2633) California - 4330 New York - 3646 -1992 - A median of 50% of women over 50 had a breast exam and mammogram within two years. -Mammograms should be done by age 40 - Baseline then every 2 years. Those women 50 and over once a year. -Mammography detects cancer on an average of 1.7 years before it is palpable. -By timely referrals, death rates can be lowered for both breast and cervical cancer. -Primary care providers have a great responsibility for this. It is up to you to communicate the urgency for this screening. -Early exams, timely referrals -Women of greater risk are less likely to obtain these exams. -Medicare B will cover exams every year if over 40. There is no deductible limit. -HMO's and PPO's all differ in payment for these services. -As primary care providers, you will be the most important source for information, care and proper referrals for women of all ages. -All 50 states have cancer registries for the purpose of authorization, legislation and enabling regulations plus gathering important statistics both regional and nationwide.

BARRIERS TO SCREENING: BOTH BREAST AND CERVICAL

1. 2. Lack of provider recommendations Fear a. of finding cancer b. of the mammogram or pap itself c. of radiation exposure d. of self breast exam e. negative experiences Cost Lack of time Inconvenience Distance of screening site Lack of concern and apathy Less desire for control over health Smokers are less likely to be screened Ethnic background Knowledge to perform exam

3. 4. 5. 6. 7. 8. 9. 10. 11.

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FACTORS FACILITATING BREAST SCREENING / PAP

1. 2. 3. 4. 5. 6. 7. Higher level of education of the individual Previous exams/mammography Perceived importance Age - young women are more likely than the older women to be screened. They often feel that after child bearing years, they no longer need this screening. Family history of cancers of the breast or cervix Individuals interpersonal network Living in an urban area

TEACHING SHOULD BE KEPT SIMPLE. USE THE "kiss" METHOD

1. 2. 3. 4. 5. 6 The physician needs to emphasize an individual's ability to affect health through their own actions. Give reassurance to overcome past negative experiences. Search out community support through social services in the community such as in Erie you can obtain free mammography screening if you can't afford it. Become comfortable with performing these exams. Take a complete family and patient history. Physician - patient interaction, of course, still determines patient compliance.

SCREENING RECOMMENDATIONS ACOG PAP SMEAR

Sexually Active/BCP q year 18 & Older q year TAH 18 M. to 2 Yrs.

ACS PAP SMEAR

Sexually Active/BCP 18 & Older TAH q year q year 2-3 Yrs.

ACOS

MAMMOGRAMS
35-40 y/o 40-50 y/o 50 - more Baseline q 2 years q 1 year

MAMMOGRAMS
40 y/o 40-50 y/o 50 - more Baseline q 1-2 years q 1 year

MAMMOGRAMS
50 and older annual

PROSTATE
40 - more High Risk 40 - more 50 - more Digital Exam q 1 year Digital exam q yea & PSA Digital Exam q year & PSA 40 - more High Risk 40 - more 50 - more

PROSTATE
Digital Exam q 1 year Digital exam q yea & PSA Digital Exam q year & PSA

ACOG American College of Obstetrics & Gynecology ACS - American Cancer Society ACOS - American College of Surgeons

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SPEC Sensitive Patient Examination Commitment Bladder Catherization

Urinary catherization is a sterile technique. The catheters are sized using a French calibration. The higher the number the larger the diameter of the catheter. There are two major types of urinary catheters. A straight catheter is a single lumen catheter used to empty the bladder as a temporary procedure. A Foley Catheter is a double lumen catheter used to keep the urine flowing for an extended period of time. One lumen is for urinary flow and the other is for filling the catheter balloon that keeps the catheter in place ithin the bladder. The maximum single catheterized amount of fluid should be limited to 1000 cc to avoid a vasovagal response; in a smaller patient weighing less than 100 pounds, the maximum should be 750 cc.

Technique
Preparation 1. 2. 3. 4. 5. Evaluate the patient for need for catherization. If patient status and circumstances allow, explain the procedure to the patient and obtain consent. Prepare and locate materials: sterile gloves, catherization kit, and proper catheter (size and type). Open and prepare all equipment before placing sterile gloves on hands. Put on sterile gloves using the proper technique. Optional :Fill the syringe with the amount of sterile water needed to inflate the balloon. Attach the syringe to the non draining end (the second lumen port) of the catheter and gently inflate the balloon to test it and then deflate it completely. Consider that this action may increase the risk of contamination. Empty the packet of sterile lubricant onto the tray.

6.

Bladder Catherization of the Female Patient At each step let the patient know what you are doing. {K} indicates items that are usually found in the catherization kits. 1. 2. 3. 4. 5. 6. Position the patient supine with knees bent and legs rotated and adducted at the hip. (The infant or small child should be placed in the supine frog leg position. Two assistants may be needed: one to hold the child and the other to assist with the catherization.) Place a sterile towel {K}under the hips of the patient, keeping the fingertips sterile by covering them with the folded end of the towel. A second towel with a center cut, fenestrated window, is usually included to place over the genitalia. Place a sterile basin or urine collection cup {K} near the vulva. Stand near the patients hip facing the patient's head so that your dominant hand is nearest the patient. Separate the labia majora and minora with your non dominant hand. Remember, this hand is now contaminated and should not touch the catheter. Tell the patient that you will be touching her and that it will feel cold. Cleanse the labia minora and the urethral opening with your dominant hand using a Betadine-soaked cotton ball {K} held with the sponge forceps {K}or a presoaked Betadine swab stick. The area will be cleansed three times. Each cotton ball or swab should be used only once, wiping with a gentle downward stroke. A dry cotton ball is included in most kits to wipe away excess Betadine so as not to introduce this substance into the bladder. Hold the catheter 2 inches from the tip with your dominant hand, and coil the remainder in your hand. Lubricate the catheter tip with the lubricant you have already prepared. Let the patient know that you will be inserting the catheter, and ask her to try to relax. Gently insert the catheter. If you meet resistance, or if the patient appears to be in an unusual amount of discomfort, stop and request the assistance of a senior physician. Collect the urine in the sterile container.

7. 8. 9. 10. 11.

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12. 13. 14. 15. 16.

The straight catheter can be removed when all the urine is drained. The Foley catheter should be inserted to the Y if possible and the balloon then inflated. Pull the Foley catheter back until the balloon can be felt to be abutted against the inferior bladder wall. Attach the end of the Foley catheter to the drainage bag {K}. If no urine is obtained, the bladder may be empty or the catheter may be in the vagina. Do not remove this catheter - leave it in place and reexamine the patient to locate the urethral meatus. This first catheter will mark the wrong spot and prevent you from making the same mistake again. Secure a Foley catheter with tape on the skin of the proximal inner thigh.

Bladder Catherization of the Male Patient At each step let the patient know what you will be doing. {K} indicates items that are usually found in the catherization kits. 1. 2. 3. 4. 5. Position the patient supine with his legs somewhat adducted. (The infant or small child should be placed in the supine frog leg position. Two assistants may be needed: one to hold the child and the second to assist with the catherization.) Place a sterile towel {K} under the penis and across the thighs of the patient, keeping the fingertips sterile with the folded edges. A second towel with a center cut, fenestrated window, is usually included to place over the genitalia. Place a sterile basin or cup {K} between the patients thighs. Stand near the patients hip facing the patients head so that your dominant hand is nearest the patient. Tell the patient that you will be touching him and that it will feel cold. Grasp the penis with your non dominant hand, and gently retract the foreskin. This may not be possible in some male infants, and the urine sample will need to be obtained by supra pubic aspiration. Remember, this hand is now contaminated and should not touch the catheter. Cleanse the urinary meatus with Betadine{K}using a hemostat or sponge forceps {K} to grasp the cotton balls or gauze or use prepackaged Betadine swabsticks. Cleanse in a circular patter from the meatus to the midpoint of the shaft of the penis. Remember not to return to the meatus and to cleanse around the corona of the glans. Pull the penis gently upward and slightly superior to straighten the urethra. Hold the catheter with your dominant hand 2 inches from the tip and coil the remainder in your hand. Lubricate the catheter tip with the lubricant you have already prepared. Let the patient know that you will be inserting the catheter, and ask him to try to relax. Gently insert the catheter. If you meet resistance or the patient appears to be in an unusual amount of discomfort, stop and request the assistance of a senior physicians. Collect the urine in a sterile container. The straight catheter is removed when all the urine is drained. The Foley catheter should be inserted to the Y if possible and the balloon then inflated. Pull the Foley catheter back until the balloon can be felt to be abutted against the inferior bladder wall. Attach the end of the Foley catheter to the drainage bag {K}. If no urine is obtained, the bladder may be empty or the catheter may be in the proximal urethra. Do not remove this catheter - leave it in place and reexamine the patient to locate the urethral meatus. The balloon should be deflated and the senior physician should be asked for assistance. Secure a Foley catheter with tape on the skin of the proximal inner thigh.

6.

7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17.

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Complications Introduction of infection Pain and injury to the proximal urethra due to inflation of the balloon Bruising or irritation of the urethra or bladder wall causing hematuria (Persistent gross hematuria is uncommon.) Vaginal catherization Intravescicular knotting Pearls and Pitfalls 1. Difficult catherization in males with enlarged prostates may be facilitated if a coude catheter is used. An attempt with a larger catheter may also be attempted with caution. 2. It is sometimes helpful, especially in males, to first fill the urethra with lidocaine jelly using a Toomy syringe. This provides some anesthesia and better lubrication. 3. Trauma victims should not undergo urethral catherization until a rectal examination has been performed to rule out urethral disruption or if there is blood at the urethral meatus or a perineal hematoma. If there is any suspicion of a urethral disruption a retrograde urethrogram should be obtained before any attempt at bladder catherization is done.

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