PET Exam 4 - Female Genitalia, Breast, and Axilla

Discussion with the patient prior to beginning

What is required prior to starting a pelvic exam due to its invasive nature?

An observer and an assistant

What dual role does a chaperone serve during a female genital exam?

Adjustable table with footrests, a stool, and necessary equipment

What table setup and equipment are required for a pelvic exam?

Provide privacy to gown and remove undergarments

What privacy measure must be provided to the patient prior to the exam?

Allow the patient the opportunity to urinate

What step should be offered to the patient immediately before starting the pelvic exam?

Gently with clear explanations provided prior to each step

How should all exam maneuvers be performed?

Supine position

What is the body position of the patient during a female genital exam?

30 degrees

To what angle should the head of the table be elevated for a pelvic exam?

Scoot toward the end of the table so the bottom reaches the edge

How should the patient position their pelvis relative to the exam table?

Drape to cover up to the knees and relax legs slightly to the side

How should the drape sheet and patient's legs be arranged?

Vulva

What term refers to the external female genitalia?

Vagina

What musculomembranous tube extends upward and posteriorly between the bladder/urethra and the rectum?

Sexual maturity assessment

What assessment is performed on the external genitalia in adolescent patients?

Mons pubis, labia, and perineum

What three main external structures are inspected during the external female genital exam?

Inflammation, ulceration, discharge, swelling, nodules, or lesions

What abnormal physical findings are specifically sought during external inspection of the vulva and perineum?

Skene glands

What periurethral glands located just inside the urethral meatus can become infected or fluid-filled?

Bartholin glands

What glands located in the posterior labia majora region can develop an abscess or cyst?

Urethral caruncle

What is the term for a solid mass located at the urethral meatus?

Urethral prolapse

What condition presents as a circumferential protrusion of mucosal tissue around the urethral opening?

Ambiguous genitalia

What newborn finding involves atypical external genital structure requiring referral to a specialist rather than staging by the student?

Select appropriate speculum size and lubricate with warm water

What initial preparation steps are taken before introducing the speculum?

Gently separate labia minora and introduce closed speculum at an angle

How is the speculum introduced into the vaginal introitus?

Insert to full length before opening

How far should the speculum be inserted before opening the blades?

Open the speculum blades to visualize the cervix

What action is taken once the speculum is inserted to full length?

Color, position, surface characteristics, ulcerations, nodules, masses, bleeding, or discharge

What characteristics of the cervix are inspected once visualized through the speculum?

Inspect the vaginal walls for masses, lesions, abnormal discharge, or bleeding

What step is performed as the speculum is slowly withdrawn from the vagina?

Nulliparous cervix

What normal cervical os appearance is small, round, or oval in a woman who has not given birth?

Parous cervix

What normal cervical os appearance presents as a transverse slit after childbirth?

Unilateral, bilateral, or stellate lacerations

What are three potential laceration configurations visible on a parous cervix?

Nabothian cysts

What benign, yellowish mucus-retention cysts are commonly observed on the surface of the cervix?

Cervical eversion or ectropion

What benign anomaly occurs when a portion of the endocervical columnar lining protrudes onto the ectocervix?

Cervical canal

What structure is the primary source of vaginal mucus, given that the vagina lacks mucous glands?

Cervical cancer screening via PAP smear

What is the primary screening purpose for performing a pelvic exam in an asymptomatic woman?

Age 21

At what age is cervical cancer screening with a PAP smear first offered to average-risk women?

Cervical cytology alone every 3 years

What is the recommended cervical cancer screening method and interval for average-risk women aged 21 to 29?

High-risk HPV screening every 5 years

What is the primary cervical cancer screening recommendation for average-risk women aged 30 to 65?

Colposcopy and biopsy

What follow-up diagnostic procedures are indicated when a PAP smear yields abnormal results?

Cervical Intraepithelial Neoplasia

What staged pre-invasive changes of the cervix are detected by PAP smears to prevent invasive cancer?

Cervical cyanosis

What blueish discoloration of the cervix can be an early sign of pregnancy, normal in 25% of women, or associated with pelvic tumors or CHF?

Hypertrophic cervix

What cervical finding presents with enlargement and can easily be confused with uterine prolapse?

Palpate the cervix, uterus, ovaries, and pelvic floor muscles

What four key structures are evaluated during the bimanual pelvic examination?

Fingers beneath the cervix lift the uterus upward while abdominal hand detects pressure at the fundus

How are the examiner's hands positioned to palpate the uterus during a bimanual exam?

Size, mobility, and tenderness

What three physical characteristics of the uterus are assessed during the bimanual exam?

Retroverted uterus

What anatomical variation should be suspected if the cervical os is difficult to locate on speculum or bimanual exam?

It is very difficult to feel normal adnexa

What is the expected palpability of normal adnexa during a bimanual exam?

Laterality, size, tenderness, and position felt

What four parameters must be documented when an adnexal mass is identified?

Retroverted uterus, assessment of the cul-de-sac or adnexa, or pelvic pathology

What are three clinical indications for performing a rectovaginal examination?

Ectopic pregnancy, PID, benign ovarian mass, malignant ovarian mass, or large cysts

What is the differential diagnosis for an adnexal mass?

Fibroids, cancer, or pregnancy

What is the differential diagnosis for uterine enlargement or a uterine mass?

Assess muscle strength and tone

Why are pelvic floor muscles evaluated during the bimanual exam?

Yeast infection

What common fungal infection causes thick white vaginal discharge and vulvar inflammation?

Bacterial vaginosis

What condition is associated with thin grey vaginal discharge?

Trichomoniasis

What infection causes yellow-green discharge and a strawberry cervix?

Strawberry cervix

What classical speculum examination finding characterized by punctate hemorrhages is associated with Trichomonas?

Gonococcal or Chlamydia infection

What pathogens frequently cause purulent cervical discharge accompanied by tenderness?

Menstruation, irregular periods, or cervical cancer

What are three potential causes of red or brown vaginal discharge?

Sexual activity or implantation bleeding

What are two potential causes of pink vaginal discharge?

Syphilis

What STI typically causes a single painless genital ulcer?

Chancroid

What STI typically causes painful genital ulcerations?

Herpes simplex virus

What viral infection presents as clusters of painful genital vesicles?

Cystocele

What prolapse condition involves weakening of the anterior vaginal wall allowing the bladder to protrude into the vagina?

Rectocele

What prolapse condition involves weakening of the posterior vaginal wall allowing the rectum to protrude into the vagina?

Uterine prolapse

What condition presents with the cervix positioned lower in the vagina than normal or protruding out?

Have the patient perform a Valsalva maneuver during speculum withdrawal

How is a cystocele or rectocele dynamically assessed on physical examination?

Imperforate hymen

What congenital condition occurs when the hymen completely blocks the vaginal opening?

Lichenification

What skin change describes thickening of the vulvar skin with darkening or whitening due to chronic irritation?

Atrophic vulvovaginitis

What condition presents with thinned vaginal walls, loss of elasticity, loss of rugations, and petechial atrophy?

Vulvar hematoma

What painful vulvar swelling can occur secondary to trauma, late term pregnancy, or obstructed labor?

Bucket handle cervical tear

What cervical laceration can lead to postpartum hemorrhage?

Cervical polyp

What benign growth can arise from the cervical canal and protrude through the os?

Organs of lactation

What is the primary function of female breasts?

Pectoralis major and serratus anterior

Over which two muscles does the female breast tissue lie?

15 to 20

Into how many segments or lobes is the female breast divided?

Lactiferous ducts and sinuses

Through what ductal structures do breast lobes converge to open onto the nipple?

Clavicle

What structure forms the superior boundary of the breast?

Inframammary crease

What structure forms the inferior boundary of the breast?

Sternum

What structure forms the medial boundary of the breast?

Axilla

What structure forms the lateral boundary of the breast?

Physiologic nodularity

What term describes the normal lumpy or nodular feel of adult female breast tissue?

Smooth muscle

What type of muscle in the nipple and areola contracts during tactile stimulation or milk expression?

Four quadrants and the Tail of Spence

Into what five anatomical areas is the breast divided for clinical findings?

Clock face location and distance in cm from nipple

Besides quadrants, what two parameters can describe a breast finding location?

Mammography

What screening modality has strong evidence supporting its routine use for early breast cancer detection?

Every 1 to 3 years

What is the recommended screening CBE interval for asymptomatic average-risk women aged 25 to 39?

Annually

What is the recommended screening CBE interval for asymptomatic average-risk women aged 40 and older?

Discrete masses

What physical finding reported by a patient is most concerning for potential breast malignancy?

Infectious, physiologic, or traumatic etiologies

What are the most common causes of breast pain or tenderness?

Bloody discharge

What type of nipple discharge is most concerning for malignancy?

Inappropriate prolactin secretion from the pituitary

What does non-pregnant galactorrhea (milky nipple discharge) suggest?

Infection or inflammation

What does redness or discoloration of the breast skin typically indicate?

Peau d'orange

What orange-peel skin texture is caused by lymphatic system congestion by tumor cells?

Small nipple and areola with a thin disc of undeveloped ductal tissue

What are the anatomical components of the male breast?

Gynecomastia

What condition is defined as more than 2 cm of palpable glandular tissue in a male?

Open in the front

How should the patient's exam gown be positioned to facilitate single-breast exposure?

Arms down, arms raised, hands on hips, and leaning forward

What four body positions are used during visual inspection of the breasts?

Arms elevated overhead

What position accentuates dimpling or nipple elevation caused by a mass fixed to pectoral fascia?

Leaning forward

What position allows pendulous breasts to hang free to make retraction and masses more evident?

Supine with the ipsilateral arm abducted behind the head

How is the patient positioned for breast palpation?

Three minutes per breast

How much time should be spent palpating each breast during a clinical exam?

Pads of the 2nd, 3rd, and 4th fingers

What part of the hand is used to perform breast palpation?