Clinical Medicine 2 Well Woman Lab Instructions for the actual exam.

Your first activity will be to observe the student scheduled before you as they are performing their physical exam. (If you are the
first student you will observe the faculty).

After this is done, the faculty, the student scheduled ahead of you, and yourself will exit the exam room. You can listen while the
faculty member gives feed back to that student.

You and the faculty member will re-enter the exam room together. As you enter, you will greet the patient and then proceed with
the focused history with her Chief Complaint being Im here for my annual exam.

Your history should include all aspects of the sexual and gynecologic history, as well as a concise past personnel history.

When you have completed your history you will exit the room with the faculty member and receive feedback on your interview.
During this time the nurse will enter the exam room and assist the patient in getting gowned. She will let you know when the
patient is ready for you to reenter the room to begin your physical exam.

You will then reenter the exam room with the faculty member and the student who is after you on the schedule. You will perform a
complete gynecologic exam including the breasts, lymph nodes, external genitalia, speculum exam of the vagina and
cervix, bimanual internal exam, and inspection of the perianal area. You will not do a digital rectal exam, nor will you do the
actual Pap smear sampling from the cervix or the endocervical canal.

After you have completed your exam, all will exit the exam room. During this time you will receive feedback on your exam.
Following this, you are to complete your write-up of your history and physical exam. You may refer to your text, notes,
handouts, etc to complete this portion of the exercise. Remember to use proper terminology to describe your findings. Be complete
but concise.

Practical Pointers for the Speculum Exam

1. Introduce the speculum at a 45 degree angle and rotate to horizontal position

2. Keep posterior pressure on the perineal body

3. Be careful of the sharp 90 degree corner at the base of the blades

4. Do not let the blades close completely when removing the speculum

5. Use K/y jelly since we are not doing a pap smear

Open slightly the blades of the speculum at the base. Keep your thumb on the thumb press at all times. Do not apply
pressure until you have placed the speculum inside the vagina.

With one hand, place 2 fingers (index and middle) on the perineal body and apply downward pressure. Separate your
fingers slightly and slide the speculum over the top of your fingers. Avoid the urethra and anterior structures. Remove
your fingers as you insert the speculum.

You may have to reposition the tips of the blades slightly to find the cervix. Open the blades gently 1 or 2 notches.

When removing the speculum, once it is away from the cervix, apply only enough pressure on the thumb press to
allow you to inspect the vaginal walls. As you exit the vaginal orifice, make sure the speculum blades are completely
closed.
History

Surgeries, Allergies, known STD, PMHx, FamMHx,

Menstruation: current, history, timing, regularity, pain, first, end, last, abnormal bleeding, PMS, menopause sx,
Discharge, itching, sores, lumps, spasms,
Gravida(total),Para(outcomes): aborts, miscarriage,
Sexual Hx: active now, use condoms, orientation, satisfaction w/ sex or no sex, response,

Exam: torso elevated, cover knees to umbilicus, buttocks beyond edge, check pt face for anxiety, face to face, light,
explain procedure,

mons pubis, perineum, labia, hair distribution, urethral opening, Inguinal lymph nodes, bartholin glands, Vaginal
opening, clitoris,
Note lesions: inflam, bruise, excoriation, swelling, varicosity, nodes, discharge, nodules, b-d-e-i-n-n-s-v
Palpate lesion: tenderness, consistency, Bartholin: Hx or swelling, then internal
note what you are to do: fingers touch vagina, thighs,

Internal

cervix: separate labia, bear down

walls: cystocele, rectocele,
perianal: note lesions/bulging, ulcer, redness, rash, excoriation, palpate lesion
anal: bear down: hemorrhoids, lesions,
detect position of cervix: index finger, warm water, downward motion to relax sphincter, feel for opening,

speculum: two finger downward, closed, 45 degree, downward angle, against fingers/post wall, rotate, open, direct
until see cervix, lock speculum,

Os: color, position, surface, bleeding, ulcer, nodule, discharge, (normal: thick-thin, clear-white, ordorless)

Vaginal withdrawl: observe mucosa, color, odor

Finger bimanual, exam: vocalize, lubricate, post pressure, palpate walls, tenderness, urethra, bladder, lat, ante, post,

cervix: nodularity, tenderless, consistency, mobility, size, shape, regularity,

uterus: masses, tenderness, firm and mobile ; ovaries, both sides: same