Approach to Patients with Vaginal Bleeding

GYNECOLOGIC PHYSICAL EXAM

by NMD Clerk #20 INGUILLO, VICTORIA ELIZA B.

Preceptor: DR.RUBY E. ROBISO, FPOGS

 01 Hypogastric Exam
02 Pelvic Exam
OUTLINE 03 Speculum Exam
04 Bimanual Exam
 Before anything else,
PREPARE THE PATIENT
v Greet patient and introduce yourself
v Explain the procedure and secure consent
v Let the patient empty her bladder
v Offer chaperone during procedure
v Position the patient in a dorsal lithotomy
position upon pelvic exam
v Drape the patient and expose the perineum
 01
HYPOGASTRIC EXAM
PURPOSE: To assess for pregnancy & possible
tumors that can occupy the abdomen
MATERIALS NEEDED: Gloves, stethoscope
 HYPOGASTRIC EXAM: PROCEDURE
INSPECTION
v Assess the abdomen tangentially and check for symmetry, scars,
distension, visible organomegaly, and hair pattern
v Let patient sit halfway to check for abdominal wall mass

AUSCULTATION
v Using the diaphragm, listen and count for the bowel sounds
v Using the bell, listen for aortic and femoral artery bruits
 HYPOGASTRIC EXAM: PROCEDURE
PERCUSSION
v Percuss the abdomen starting from the RUQ and ending at RLQ
v Check for any tenderness and dullness and differentiate fluid
waves if present.

PALPATION
v Perform light palpation
v Perform deep palpation
v Check for organomegaly, adnexal masses, fluid waves, rigidity,
and rebound tenderness.
v Palpate groin for any adenopathies and inguinal hernia
 02
PELVIC EXAM
PURPOSE: For reproductive health screening,
lower abdominal/vaginal symptoms, and
monitoring or preventive care
MATERIALS NEEDED: Gloves, good light source
 PELVIC EXAM: PROCEDURE
v Check the skin around the vulva, perineum, and towards the anus
v Use thumb and forefinger of right hand to separate the labia majora
v Inspect and palpate the labia minora, clitoris, Bartholin and Skene glands, and
urethral orifice
v Check for:
v Glandular enlargements
v Urethral/Vaginal discharge
v Caruncles and other abnormalities
v Ask patient to bear down and assess muscular tone of pelvic floor
 03
SPECULUM EXAM
PURPOSE: To inspect vagina and cervix and
collect sample for pap smear
MATERIALS NEEDED: Gloves, lubricant,
speculum
SPECULUM EXAM: PROCEDURE
v Choose the appropriate speculum size and warm it.
v Lubricate the speculum and insert gently
v Inspect the cervix
v Check for: appearance and color of the cervix, discharge, bleeding, and
growth/mass and describe if present.
v Collect sample for Pap Smear
v Unlock speculum and withdraw gently
v Label sample properly
 04
BIMANUAL EXAM
PURPOSE: To palpate and assess the cervix,
uterus, and adnexa
MATERIALS NEEDED: Gloves, lubricant
 BIMANUAL EXAM: PROCEDURE
v Lubricate index and middle fingers of the right
hand
v Use finger and thumb of left hand to separate
the labia
v Enter with the lubricated fingers on a vertical
axis while tucking in the ring and little fingers
v Position the fingers on a horizontal axis

v Feel the cervix above your fingers and push up

on the cervix. At the same time, place the left
hand on the patient’s abdomen at the
suprapubic region.
v Check for: Position, size, shape, consistency, and
mobility of the cervix and uterus
 BIMANUAL EXAM: PROCEDURE
v To feel for a retroverted uterus, sweep fingers to the posterior fornix and the
abdominal wall is pressed downward.
v To feel for the right adnexa, move the fingers into the right fornix and the
abdominal hand over to the patient’s right iliac fossa.
v Do the same for the left adnexa. Check for palpable abnormalities.
v Slowly remove examining fingers and check for presence of blood and discharge.
CONCLUDING THE EXAM
v Wipe the patient’s genitalia from
front to back with a single stroke
v Offer more tissue to the patient
v Give the patient some privacy to
fix herself and get dressed
v Review findings and discuss next
steps if needed
v Answer patient’s questions
End of Presentation

THANK
YOU!
 REFERENCES
v Comprehensive Gynecology 7th Edition, Lobo et al.
v Bates’ Guide to Physical Examination and History Taking 12th Edition, Bickley et al.
v https://meded.ucsd.edu/clinicalmed/pelvic.html
v DMSF Ob-Gyn Skills Lab Manual
v DMSF iLearn Ob-Gyn Procedure Videos