The Female Physical Examination

1. The Female Physical Examination by Donald G. Hudson, D.O.,FACEP/ACOEP

2. The female physical is frequently more complex than the male examination • The history is absolutely important • History has to explore changes over time • Women tend to have more exams than men and have more detail concerning their health • Explore all self examinations done by the patient • Be sure to ask about all meds and surgeries • Ask about all Gyn issues, pregnancies, STD, number of sexual partners, pap smears, etc.

3. How to approach the problems • The patient will usually have a defined chief complaint that brought them to the office. • Initially limit your history to a directed history as related to the C/C. • As you develop some rapport with the patient you can expand your questions to include other systems, symptoms &/or issues

4. History • Family history of diabetes, ages of death, & other illness • Number of hospitalizations • Number and type of surgeries • Number of children, ages & health

5. What do you check? • All patients deserve a complete set of vital signs • Also a brief health history • It is important to look at the eyes, ears, mouth, develop an opinion concerning neuro status, listening to the heart & lungs, looking for edema of extremities • Weight & history of weight changes

6. When do you expand your history • Any positive findings requires a further investigation into them. • When, where, who, what made it worse or better • Did they seek medical care & what happened

7. Remember to check both sides

8. Men & Women will have many of the same illnesses • While women will have their own set of diseases different from men it is important to look at the usual diseases that effect both. • HTN, Diabetes, Obesity, upper respiratory infections, pneumonia, dental disease, urinary tract infections, & musculoskeletal problems

9. Breast Examinations • While breast examinations are not necessary at every visit the incidence of breast cancers are too high to ignore the question. • Confirm that the patient does her own breast exams, how often and the procedure she uses. • The incidence of fatal breast cancer is decreasing mostly because good & frequent examinations

12. Breast Examinations • Frequent (2-4 times monthly) will allow the patient to feel important changes like: • The new nipple discharge, brown, bloody or milky • Changes in the skin, new dimples, areas looking like an orange peel. • Any lumps, especially those growing larger

13. Breast Shape

14. The Breast Shape • The axilla can hide cancers quite easily • Many examiners forget that the breast is elliptical in shape with the smaller tip extending into the axilla. • Over 20% of the cancers (non-ductal) form initially high up in the axilla & are missed until they are large.

16. Breast Implants • These make breast examination very difficult • These are patients who need to do their own examinations but also need routine mammograms even at a young age • They do, however get a similar exam

17. Breast shape Examine Closely

18. Another area of concern is the reproductive tract • The incidence of cancer is high in the cervix • HPV is responsible for over 95% of the cervical & uterine cancers • The system is not easily visualized • The vaginal tract, cervix, labia & Bartholin glands can be a source for STD’s of many types • This area can be infected & infective for many years without the patients awareness

19. Condylomata Infections

20. More Condylomata Infections

21. The Cervix

22. The Cervix Infected Cervix's

23. The Cervix Cervical Infection IUD String

24. Condyloma in Males

25. Condylomata in Males

26. HPV Vaccines • Currently the females aged 6-26 with 4 or less sexual partners are eligible for the vaccine. • The major study groups expect it to be available for all age groups of both females & males in less than 4 years. • Immunizations are expected to decrease the incidence of cervical cancers & condolomata by 98%

27. More concerns • Pregnancy, intrauterine & ectopic • Tubal & Ovarian abscess • Endometrial Abscess • Free pus in the abdomen • Acute Appendix, Diverticulosis & urinary tract disease

28. Anatomy

29. Anatomy

30. More Anatomy

31. A Pelvic Examination

32. THIS IS A BI-MANUAL EXAM

33. Bi-Manual Examination • The purpose is to feel for painful areas or unusual structures, abscess or other unusual findings • The cervix should be located & moved upward checking for pain (a possible indicator of STD) • The vaginal & rectal openings are inspected for lesions, warts or other abnormal findings. • Describe them in your notes

34. Ovarian Abscess

35. Vaginas like humans come in all forms

36. Since Vaginas look so different you must take time to look because what you find inside maybe very different from outside

37. Other Anatomy

38. Don’t forget what you don’t expect to find may be found in either sex

39. While this is by no means a complete list or diagram of what to do for the female patient this is a guide for some of the usual items I see being missed far to often • This is designed to simply to raise your awareness of medical issues to watch for. • Remember you may be the first & last medical provider to see this patient before they develop a major problem