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OSCEAZY The Obs & Gynae Station - Examination Varshika BObs & Gynae Examinations Breast examination Common breast pathologies Bimanual examination Speculum examination Common gynaecological pathologiesBreast Examination SPOT DIAGNOSIS A 35-year old female presents with a painless, mobile breast lump in the left upper quadrant of her left breast. On examination, it is well-defined, smooth and non-tender. Fibroadenoma A 45-year-old woman who complains of a sudden onset of multiple soft, fluctuant lumps scattered throughout her right breast. On examination, the lumps are well-defined, mobile, Breast cysts and tender to palpation. There are no skin changes or nipple discharge. A 62 year old woman returns for a follow up 2 weeks post lumpectomy for a benign breast lesion. She presents with widespread bruising, tenderness and a palpable firm mass near Fat necrosis the surgical site. There are no signs of infection a 55-year-old female who complains of persistent itching and redness on her left nipple, accompanied by occasional Paget’s disease of the breast discharge. On examination, there's notable erythema and crusting of the nipple and areola, with no palpable breast masses. • W – Wash hands, PPE (gloves) • I – introduce; “Hello, my name is....and I am a medical student. Please can I confirm your name and age?” • P – permission; Today I’ve been asking to perform an examination of Start of Exam your breasts. That would involve me having a look and feel of your breasts, your armpit and your neck. Does that sound okay? • E – Expose; Would you be comfortable taking your top off for the examination? In a moment, I will bring a chaperone into the room. Do I have your consent? • 3 Cs of intimate exams – Consent, chaperone, close the door General Inspection General Inspection • Patient sitting on side of bed, with • Repeat inspection with patient hands on thighs pressing their hands into their hips to contract the pectoralis muscles • Assess for - scars, asymmetry, • Observe if any visible masses move Nipple retraction, peau d’orange skin masses, nipple abnormalities, changes, dimpling, visible discharge, simultaneously, or if puckering is puckering skin changes bilaterally accentuated General Inspection • Ask patient to place their hands behind their head and lean forward so that the breasts are pendulous • exaggerates any symmetry, skin dimpling or Mass moves à tethering to the underlying tissue (e.g. invasive breast malignancy) puckering Puckering accentuated à mass invading the • Lift each breast with the dorsum of the hand Cooper’s ligaments which are also tethered to the pectoralis muscles and inspect under the inframammary fold • Reposition bed to 45º Palpation • Use the flats of the 3 • Ask patient to lie down • Begin on asymptomatic breast first middle fingers to compress the breast tissue with hands behind their • Clock face method – palpate in a head against the chest wall clockwise fashion, covering all 4 • “sunning yourself at the quadrants, from peripheral to • Use both hands in a beach” nipple wiping fashion Nipple – Areolar Complex Lymph Nodes Axillary Tail • Ask about shoulder pain, take the • Compress the areolae tissue towards the • Most cancers develop in nipple and inspect for nipple discharge weight of the patient’s arm, palpate • If there is Hx of nipple discharge but the upper outer quadrant axillary lymph nodes • Palpate towards the none visible, ask the patient to attemp• Assess cervical, clavicular (supra & to express discharge from the nipple axilla infra) and parasternal lymph nodes • COLOUR (blood stained, green, • White/clear/cloudy – • Explain that the yellow) hypothyroidism, • CONSISTENCY (thick, watery) examination is finished prolactinoma • Volume • Provide them with • MILKY: normal during pregnancy & • Yellow – infection breastfeeding. Pathological – • Green/brown/black – duct privacy to get dressed ?prolactinoma à galatorrhea ectasia, intraductal • Thank them • PURULENT: thick yellow, green or papilloma brown with offensive smell due to • Dispose of PPE and • Red/pink/bloody – mastitis or abscess wash hands • WATERY & BLOODY: DCIS malignancy Nipple Discharge Pathology & discharge colour Completing the examPatient details and general Closer inspection – scars, gross Palpation – masses (describe them), inspection – age, gender, presenting abnormalities, red flags, relevant lymphadenopathy, pain (relevant complaint, general appearance negatives characteristics) SUMMARIZE FINDINGS Management Further investigations: USC referral if: DDx & why • Bedside – full history, basic obs • Breast abscess ≥ 30 + an unexplained breast lump with • Bloods – tumor markers, hormone or without pain panel, FBC, TFTs, U&Es • Breast cyst ≥ 30 + unexplained axillary lump • Fibroadenoma ≥ 50 with discharge, retraction or other • Imaging – ultrasound (<35 y/o), concerning changes mammography (>35 y/o) • Fat necrosis Skin changes suggestive of malignancy • Special tests – FNA/core biopsy • Melignancy SIZE - approximate the LOCATION – mention the dimensions SHAPE – well- quadrant, distance from nipple defined? Irregular? CONSISTENCY – Describing a breast lump smooth/firm/rubbery? MOBILITY – moves freely? FLUCTULANCE – is OVERLYING SKIN Moves with pectoralis it fluid filled? CHANGES – contraction maneuvers? erythema/puckering? Fibroadenoma Breast abscess COMMON • Complication of mastitis • Benign tumor of fibrous and • Fluid filled fluctuating mass glandular tissue • Systemic symptoms BREAST • Young < 35 y/o • Breast pain, erythema, edema, • Single, non-tender, mobile mass purulent discharge from nipple of LUMP DDx • Well defined, rubbery consistency affected breast Breast cancer Breast cyst Fat necrosis • Age > 65 • Affects premenopausal women • Benign inflammation of adipose • Increased exposure to oestrogen (35-50) tissue in the breast after • Single, nontender and firm lump • Single or multiple smooth masses, trauma/surgery • Poorly defined margins may be fluctuant • Most commonly upper outer • Tender, variable in size and • Nontender periareolar mass with quadrant texture irregular borders • May have skin dimpling, • Usually mobile retractions, nipple alteration • Fluctuates with hormonal changes • Skin retraction, erythema, ecchymosis Further investigations ANY BREAST LUMP BREAST CANCER BREAST ABSCESS FIBROADENOMA 1. Basic obs Bedside 2. Lymph node exam 3. Consider referral for triple assessment Tumour markers – AFP , Bloods FBC CA153, CEA Breast ultrasound if < 30 Consider breast Breast ultrasound if < 30 Imaging & Special Mammography if > 30 milk cultures if no Mammography if > 30 Tests Erect chest xray Biopsy via fine-needle response to initial Biopsy via fine-needle aspiration/core needle treatment aspiration or core needle biopsy biopsy Breast Cancer Management Wide Local Excision Mastectomy • Types – skin sparing, nipple sparing, total mastectomy • Lumpectomy + sentinel node biopsy (including • Indications – multifocal or central tumor, large lesion in extra 1cm margin around the lesion) small breast, DCIS >4cm, BRCA positive • Indications – solitary or peripheral tumor, small • Recommended if previous wide local excision or radiotherapy for breast CA lesion in large breast, DCIS < 4cm Sentinel Node Biopsy Pharmacology • To assess whether cancer cells have spread to the • Chemotherapy – neoadjuvant or adjuvant therapy; axillary lymph nodes for triple negative and HER-2 positive breast CA • Helps to identify the axillary lymph node that initially • SERMs – tamoxifen or raloxifene ] if pre drains the tumorous breast tissue menopausal; used for 5-10 years following tumour • Indicated for all patients with no clinical signs of removal axillary lymph node infiltration • Complications – damage to thoracodorsal nerve, • Aromatase inhibitor – Letrozole ] if post menopausal shoulder pain, lymphoedema, stiff shoulder • HER2/NEU monoclonal antibody – TrastuzumabBimanual Examination SPOT DIAGNOSIS A 45 year old woman presents with a 2 week history of post coital bleeding. Bimanual examination reveals an enlarged, fixed Cervical cancer uterus and an irregular external os. A 23 year old woman presents with abdominal pain and purulent cervical Pelvic inflammatory disease discharge. She reports severe pain and tenderness upon palpation of the cervix. A 36 year old multiparous woman presents with severe, prolonged, painful periods. On Adenomyosis examination, the uterus is enlarged, tender and feels bumpy. Inspect the vulva for: • Explain – use patient friendly • Ulcers – assoc. w/ genital herpes language to explain 2 handed • Abnormal PV discharge – STIs, approach vaginal candidiasis • Scarring – if Hx of episiotomy, • 3 Cs – consent, chaperone, close door • Prepare equipment – gloves, or lichen sclerosis • Atrophy – in older women 1. Lymphogranuloma venereum – lubricant, paper towels • (White) lesions/masses – chlamydial infection resulting in • Position – modified lithotomy position Bartholin’s cyst, vaginal transient papule or shallow ulcer • “Bring your heels towards your on cervix, vulva or posterior malignancy vaginal wall bottom and then let your knees fall to • FGM – total or partial removal 2. Painful inguinal of clitoris and/or labia the sides.” lymphadenopathy common in • Prolapse – ask patient to cough HSV2 (genital herpes) WIPER Inspect Inguinal lymph nodes V aginal Inspection BARTHOLIN CYSTS - GENITAL HERPES - painFUL Due to blockage of grouped vesicles on an Bartholin gland duct erythematous ground due to Often asymptomatic HSV2 but can cause mild GENITAL WARTS – painless dyspareunia, VAGINAL PROLAPSE - a bulge lesions due to HPV 6 & 11 unilateral, fluctuant visible protruding from the LICHEN SCLEROSIS – chronic VAGINAL CANDIDIASIS - mass, which may or vagina due to insufficiency of inflammatory skin condition, White, crumbly and sticky may not be tender pelvic floor muscles presenting intensely pruritic, “cottage cheese” discharge with white thickened patches, due to Candida albicans. Risk destructive scarring and factors - pregnancy, adhesions; never involves immunodeficiency, diabetes, vaginal mucosa use of topical steroids, ABx treatment Erythematous vulva and vagina PC - strong pruritus, dysuria, dyspareunia BIMANUALLY palpate the uterus: Adnexa - area that includes the ovaries and • LUBRICATE the gloved index and middle fingers of your DOMINANT hand. 1. Place your non-dominant hand just above fallopian tubes • Separate the labia using the thumb and the pubis symphysis. 1. Position your internal fingers in the left index finger of your NON-DOMINANT 2. Place two fingers into the posterior fornix. lateral fornix. 3. Push upwards with the internal fingers and 2. Position your external hand onto the left hand. • Gently INSERT the lubricated fingers of palpate the lower abdomen with your iliac fossa. your dominant hand into the vagina. non-dominant hand. 3. Perform deep palpation of the left iliac • Make sure your PALM FACING You should be able to feel the uterus between fossa whilst moving your internal fingers your hands. Assess: LATERALLY and then ROTATE 90 so that upwards and laterally (towards the left) your palm is facing upwards. - Size: ~ orange-sized is average 4. Feel for any palpable masses, noting • Cervix - position, consistency, cervical - Shape & position their size and shape - ovarian cyst, ovarian motion tenderness? - Surface characteristics: smooth/nodular. tumour, fibroid? - Tenderness • Fornices – for masses 5. Repeat adnexal assessment on right Vaginal Examination Palpate Uterus Ovaries and Uterine TubeAnteverted uterus - orientated Retroverted uterus - orientated Adenomyosis - condition where the inner posteriorly, towards the spine, lining of the uterus (endometrium) breaks forwards towards the bladder, most common position of the uterus. present in approximately 1 in 5 through the muscle wall of the uterus women. (myometrium). Uterus is enlarged, boggy, irregular, tender on movement Vaginal Exam Findings Uterine fibroids – Cervical cancer – common palpable Cervical excitement – severe pain and masses/firm tenderness upon palpation of the cervix, presenting features are post coital implies active pelvic inflammation bleeding, intermenstrual bleeding uterus. Most and irregular cervix on palpation common variant is Pelvic inflammatory disease – secondary an intramural to chlamydia or gonorrhea infection + dysparaeunia + pelvic pain fibroid Further investigations PELVIC CERVICAL CANCER FIBROIDS INFLAMMATORY ADENOMYOSIS DISEASE 1. Basic obs 2. Full history Bedside 3. Abdominal exam + vaginal swab 4. Speculum exam 5. Beta-HCG pregnancy test FBC, U&Es, LFTs FBC – polycythaemia can Bloods occur rarely HPV & cytology Colposcopy Transvaginal ultrasound Consider Imaging & Special Endometrial biopsy transvaginal Transvaginal ultrasound is first Tests Punch biopsy of line for diagnosis transformation zone MRI prior to surgery ultrasound CIN = cervical intraepthielial neoplasia → grading system for precancerous change CIN I : mild, 1/3 thickness of epithelium CIN II : moderate, 2/3 thickness of epithelium CIN III : severe, very likely to progress to canc • Conservative: - Counsel on diagnosis and prognosis Management of - Symptom management (?palliative care input) Cervical Cancer 1. CIN and early-stage 1A→LLETZ or cone biopsy 2. Stage 1B-2A→Radical hysterectomy and removal of lymph nodes + CRT 3. Stage 2B-4A→Chemotherapy and radiotherapy 4. Stage 4B→combination of surgery, radiotherapy, chemotherapy and palliative care Other Management Always think conservative à medical à surgical ! Fibroids Pelvic Inflammatory Disease Adenomyosis Antibiotic regime • If < 3cm: • symptomatic treatment: 1. A single dose of IM • Mirena coil to reduce ceftriaxone 1g (gonorrhoea) tranexamic acid to bleeding 2. Doxycycline 100mg BD for 14 manage menorrhagia • NSAIDs, tranexamic acid days (Chlamydia and • GnRH agonists - • COCP Mycoplasma genitalium) Leuprolide, goserelin • If > 3cm: 3. Metronidazole 400mg BD for • Uterine artery • Surgical referral 14 days (anaerobes such as embolisation • Endometrial ablation, Gardnerella vaginalis) • Hysterectomy – definitive myomectomy, (if systemically unwell, may require tx hysterectomy IV antibiotics in hospital)Speculum Examination SPOT DIAGNOSIS An 18 year old female presents to the GP with dyspareunia and vaginal itching. She describes having yellow-green frothy Trichomoniasis discharge that is malodorous. On speculum exam, the cervix has a studded appearance. A 45 year old female presents for routine smear testing. She reports some mild spotting between menstrual cycles. On Cervical Ectropion speculum exam, the cervix is erythematous and appears inflamed. A 26 year old female presents with thin, greyish white Bacterial Vaginosis discharge that smells “fishy”. The vaginal pH is noted to be 4.7. A 16 year old male presents with painful genital ulcers. On examination, there are multiple grouped vesicles on an Genital herpes erythematous base, some of which are crusted over. There is associated inguinal lymphadenopathy • WIPER – always start every exam with PPE + introduction • 3Cs of intimate exams • Reposition – modified lithotomy position Introduction • Explain - “Today I need to carry out a speculum examination. The procedure will involve me inserting a small plastic device called a speculum into the vagina. This will allow me to visualise the neck of the womb. It shouldn’t be painful, but it will feel a little uncomfortable. You can ask me to stop at any point. You may experience some light vaginal bleeding after the procedure.” • Equipment – gloves, lubricant, speculum, light source, paper towels Speculum Insertion Angulation Tighten • Tighten the locking nut to fix the • Choose the right size – usually • Gently insert the speculum SIDEWAYS, medium with blades closed and angled blades of the speculum in position. • Apply lubricant jelly to the downwards. speculum • Once inserted, ROTATE THE • INSPECT THE CERVIX: cervical, os, • Use non-dominant index and SPECULUM BACK 90° so that the handle is facing upwards. masses, ulceration, abnormal thumb finger to separate the • Open the speculum blades until the labia cervix can be visualised effectively discharge Inspect cervix Speculum removal Speculum removal • Gently remove the speculum Inspect the cervix: • With non-dominant hand, hold • Identify the cervical os whilst slowly closing the blades - the blades of the speculum • Inspect for erosions around the os remember to simultaneously • Cervical masses open. • Loosen the locking nut with your inspect the walls of the vagina. • Ulceration – genital herpes • Explain that the examination is • Abnormal discharge - STIs dominant hand. over. Cervical Inspection Bacterial vaginosis: caused by Gardnerella vaginalis, presents with Cervical Intraepithelial grey-white thin discharge that is malodorous, raised Neoplasia: visualized with vaginal pH, smells “fishy” Cervical ectropion: epithelium acetic acid Trichomoniasis: Caused Tx: metronidazole and of cervical canal extends onto by Trichomonas vaginalis, clindamycin surface of outer paler cervical presents with strawberry epithelium cervix, yellow-green frothy Varies across cycle and is discharge that smells normal but can cause increased unpleasant contact bleeding or discharge Tx: metronidazole + contact tracing Sexually Transmitted Infections Investigations Management • Bedside à bloods à imaging – abdominal exam, full • Conservative – advice about contraception and safe sex • Medical: history, b-HCG test Chlamydia → PO doxycycline 7 days • Charcoal swabs – for Microscopy, culture and sensitivities (+azithromycin/erythromycin) Gonorrhoea→IM ceftriaxone one-off OR oral • Nucleic acid amplification test (NAAT) - for chlamydia ciprofloxacin if sensitivities known and gonorrhoea; can be vulvovaginal or high-vaginal Syphilis → IM benzathine benzylpenicillin one-off Trichomonas → metronidazole • Blood tests - Syphilis and HIV Genital herpes→acyclovir and symptomatic management • Antibody testing: Syphilis (T. palladium) HIV→Highly active anti-retrovirus therapy (HAART) + specialist input BV/Thrush investigations and Mx History and exam Vaginal pH – swab and pH paper strip Charcoal swab + NAAT Bacterial vaginosis Candidiasis Clotrimazole Metronidazole (cream/pessary)Always think about pregnancy test in Transvaginal ultrasound is usually women of reproductive age; Hormonal treatments are even if the pregnancy isn’t better than pelvic ultrasound for not without risk causing/exacerbating the symptoms, it gynaecological issues will affect management plan SUMMARY Further investigations? Bedside à bloods à imaging à special tests Always be systematic with Always think about future examinations – try to look slick Remember to structure your pregnancy plans when Management options? offering management options Conservative à medical à summaries in gynae surgicalPLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEK