Female Reproductive System Assessment
Assessing the female reproductive system includes a health history and a physical
examination. The health history focuses on the patient’s past genitourinary and
gynecological histories and their current and former medication use. The patient
must urinate before the pelvic examination, and if warranted, collection of urine
for assessment of characteristics is a good idea at this time. The physical
examination starts with inspection and palpation of external genitalia. Next,
internal genitalia is performed using a lubricated speculum and focuses on
examining the vaginal wall and cervix. After inspection, a Pap smear and additional
cultures are collected from in and around the cervix. Finish the assessment by
palpating the cervix and vaginal canal, and performing a bimanual examination of
the adnexa. Note and respond to any abnormal findings.
PLAY PICMONIC
HEALTH HISTORY
Past Genitourinary and Gynecological History
Past Medical History Form
This history includes an exploration of the patient’s menstrual and obstetric history (GPAL for pregnancies), preventive care (e.g. PAP smear history),
onset of menopause, acute pelvic pain and recurrence/onset of urinary tract signs and symptoms, vaginal discharge, sexuality (including preferred
gender identity) and sexual activity (e.g. heterosexual, homosexual, bisexual, etc.), contraceptive use (e.g. presence Long-Acting Reversible
Contraception) and history of sexually transmitted infections.
Current and Past Medication Use
Med-bottle
Current and past medication use can further reveal medical and social history. Contraceptives are a common medication used to prevent pregnancy.
Also, repeated use of AZO, an over-the-counter medication used to treat urinary discomfort symptoms, could lead to further clinical inquiry and
patient education on the treatment of possible urinary tract infections
Urine Collection and Characteristics
Urine Collections
In preparation for the pelvic examination, the patient will need to empty their bladder before the exam. If the collection of urine will contribute to
further clinical understanding of the patient’s genitourinary and gynecological health, then this is an optimal time to do so. Once collected, the
practitioner can note urine color and characteristics (e.g. presence of sediment, cloudiness, odor) before sending the specimen to the lab for
pathologic review.
EXTERNAL GENITALIA EXAM
Inspect External Genitalia
Inspect External Vagina-violet
With gloves on, spread the labia and locate the urethral meatus, which should be pink, irregular, and have a small opening at the midline, right above
the vagina. Note any discharge or ulcerations (signs of infections or STDs). Also, inspect the external genitalia and pubic hair. Gently spread the labia
majora and minora. They should be moist and free from lesions. Normal discharge varies from clear to stretchy before ovulation and white to opaque
after ovulation and should be odorless and non-irritating.
Palpate External Genitalia
Paw External Vagina-violet
Spreading the labia with one hand, palpate using the other hand. The labia should feel soft and the patient should not have any pain. If there is
swelling, hardness, masses or lesions, palpate to determine size, shape and consistency.
INTERNAL GENITALIA EXAM
Inspect Internal Genitalia Using Lubricated Speculum
Inspect Internal Vagina-violet
Select the appropriate speculum for the patient, as they come in various shapes and sizes. Hold the speculum under warm water to lubricate it and
make sure it is not too cold. While sitting at the foot of the exam table, tell the patient they will feel internal pressure while you insert the speculum.
Hold the speculum by the base with blades anchored between your index and middle fingers. Encourage the patient to take deep, slow breaths during
insertion.
Examine Vaginal Wall for Color, Texture, and Integrity
Examine Vagina-violet Wall
After inserting the speculum, examine the vaginal wall, observing color, texture and integrity. A white, thin, odorless discharge on the vaginal wall is
normal to be seen.
Examine Cervix for Color, Position, Size, Shape, Mucosal Integrity and Discharge
Examine Cervix-certificate
The cervix should be smooth and round. Examine the cervix for color, shape, dilation of the os, erosions, masses, discharge or bleeding. The central
cervical opening, called the cervical os, will be circular if the patient has not given birth vaginally, and will be a horizontal slit in a patient who has.
Obtain a specimen for a Pap test if required.
Palpate Internal Genitalia
Paw Internal Vagina-violet
Lubricate the index finger and middle fingers of your gloved dominant hand. While being at the foot of the exam table, spread the labia majora using
the non-dominant hand and insert your two lubricated fingers into the vagina. Note tenderness or nodules in the vaginal wall. Palpate the cervix by
sweeping fingers from side to side across the cervix and around the os. It should be smooth and firm, and be easy to move in all directions. Note any
irregularities or if the patient reports pain.
Note Abnormal Findings
Note Abnormal Findings
Note any abnormal findings, such as genital lesions, vaginal inflammation and discharge, cervical lesions and polyps, vaginal and uterine prolapse, and
rectocele.
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