[GET] Gu Exam Female Write Up
Hydroceles have a characteristic texture that is different from that of testicular tissue. You can also distinguish them from the body of the testis by trans-illumination. To do this, shut off the lights in the exam room and place a flash light on...
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Female GU Exam
No transillumination is seen picture on right as the inflamed testis does not allow the passage of light as opposed to hydrocele shown above, which readily conducts light. This is not always the case, as sometimes orchitis will cause a "reactive hydrocele" to form, which will transilluminate. The epididymis is a discrete structure which lies towards the top and back of each testis. If there is any testicular pain, it may be easier to perform the exam while the patient is supine. Diagram of male genital anatomy. The vas can be distinguished from the rest of these stuctures as it lies along the posterior aspect of the bundle and feels firm and wire-like. You will normally be unable to specifically identify the remaining structures.
Newborn Physical Exam Medical Transcription Samples
Identify any discrete swellings within this collection of tissues. If present, note their relationship to the testes and inguinal canal. Dilated veins, referred to as a varicocele feels like a bag of worms Evaluation for inguinal hernias: If you detect a diffuse swelling amidst the cord structures or note the inguinal canal area to be protuberant, the patient probably has an inguinal hernia. The following examination, however, should be performed on all male patients, regardless of whether you suspect any underlying abnormality.
Cheat Sheet: Normal Physical Exam Template
Before palpating this region, have the patient bear down i. Right Inguinal Hernia If you are examining the right inguinal region, place the index finger of your right hand along the spermatic cord, inverting the scrotal skin as you trace the cord to where it emerges from the external ring of the inguinal canal. You may be able to put the tip of your finger into this narrow opening. Put the fingers of your left hand over the inguinal canal, which runs obliquely towards the patient's anterior-superior iliac crest, or on top of any noticeably swollen area.
The Pelvic Exam
Have the patient repeat the above maneuvers that increase intra-abdominal pressure and note if you can feel, with either hand, any bulging tissue that would be consistent with a hernia. Hernia Exam Exam of the left inguinal area is done in the same way, though hand positioning is reversed. Hernias are generally non-tender and there should be no evidence of acute inflammation i. Inguinal hernias come in all sizes. Distinguishing direct from indirect hernias on the basis of exam is rather difficult and not clinically important as both should generally be repaired and the final determination can be made at the time of surgery. Some hernias will be barely palpable by the index finger placed in the external ring of the inguinal canal.
Normal Physical Exam Template Samples
Others can be quite massive. In this setting, it may be difficult to distinguish the cord structures or testis from the contents of the hernia, though give it a try. The testis should be located at the bottom of the scrotum. Large right inguinal hernia: Prominently seen in picture on left. Picture on right demonstrates appearance in same patient after manual reduction. Auscultation on top of a hernia may allow the detection of bowel sounds, which can be useful information if you are unsure as to the nature of an inguinal bulge. In the event that the patient is unable to stand, the above examination can be performed as described with the patient supine. This may actually be a better position for evaluating the inguinal canal if you are concerned that it may contain a discrete mass, as in the case of a suspected undescended testicle.
Vaginal Examination (PV) – OSCE Guide
This gives you an opportunity to perform the exam while providing the patient with something to lean against for support. You can remain seated. Separate the cheeks of the buttocks and look at the peri-anal area. Make note of any skin abnormalities, bleeding sites, fissures or hemerrhoids. Thrombosed External Hemerrhoid Rectal Fissure and Prominent Skin Tag The digital rectal exam can provide information about several important organ systems, including: Gross inspection of the stool. Is there obvious evidence of blood, which generally implies that the bleeding site is close to the anus? In such cases it will also have a characteristic odor.
Pregnant Abdomen Examination
Normal appearing stool should be tested with a special agent designed to detect hemoglobin see below. This is referred to as checking for occult blood i. In these cases, the source of bleeding is most frequently within the colon, although it can be from anywhere in the GI tract. Palpation upwards, posteriorly, and laterally will allow you to feel for rectal based masses. Feeling anteriorly will allow you to examine the prostate gland. For additional information see: Digital DDx: Anorectal Symptoms Before proceeding, provide the patient with a box of tissue paper that they can use for cleaning themselves at the end of the exam. Open a stool guiac card and place it on the exam table next to the patient. Then: Put a lot of lubricant a. Tell the patient that you are going to place your finger in their rectum. Remember, this is a delicate aspect of the exam, and the patient often feels quite vulnerable.
Male GU Exam
Thus, it's a good idea to talk them through each step. Place your well lubricated index finger against their anus, but do not yet insert it into the rectum. Ask the patient to bear down as if they are trying to have a bowel movement. This helps to relax their external sphincter and should decrease discomfort. As they bears down, gently push forward until you have placed the entire finger within the anal canal. Pay attention to the following: As your finger enters, make note if you hit any resistance.
Sports Physicals
You may run into some stool, which should easily move out of the way. A mass e. If this occurs, do not force your finger forward. By gently rotating your hand, you can use the pad of your index finger to feel to the left, right and then directly backwards i. What you encounter will vary with the clinical situation. You might, for example, feel a fluctuant collection in a patient with a pelvic abscess associated with a perforated appendix. Orient your finger so that it is directed anteriorly i. It should now be resting on the prostate gland, which is palpated through the wall of the rectum. Make note of the following: The prostate has two lobes with a cleft running between them. Can you feel each lobe distinctly? Do they feel symmetric? Are their any discretely firm areas referred to as nodules? Normal prostatic tissue feels more or less like the tip of your nose.
Smith & Tanagho's General Urology, 18e
Anything firmer is suspicious for malignancy. If you feel a firm area, check and see if the prostate is freely mobile or if it feels fixed to the pelvis, which can occur via direct extension of a malignancy. Does the prostate gland feel big? You will obviously have no idea until you have had an opportunity to examine many to get a sense of the range of normal. In general you should be able to get you finger over the top of the gland. One helpful way of trying to feel the full extent of the prostate is to make sure that the patient is leaning over the exam table, which has the effect of directing the prostate out towards you. Then take your left arm and wrap it around their waist, enabling you to draw the patient towards you as you push with your examining finger.
Physical Exam of the Newborn
Any pain on palpation, which is suggestive of prostatic infection? Does the gland feel swollen? Again, this is a very subjective finding which is only apparent after examining many normal prostates. It occurs in the setting of infection. Try to have the patient distinguish between the discomfort of the exam in general from any pain specifically produced by pushing on the prostate. Assessment of rectal tone. This can be done either at the beginning or the end of the examination.
Playing Doctor
HEAD: Normocephalic. External auditory canals and tympanic membranes clear bilaterally, hearing grossly intact. No nasal discharge. Oral cavity and pharynx normal. Teeth and gingiva in fair condition. NECK: Supple, non-tender, no adenopathy, masses, or thyromegaly. Good excursions. Bowel sounds are active. Vagina and cervix show no lesions, inflammation, discharge or tenderness. No cystocele.
OB/GYN – H&P
No edema. Peripheral pulses intact. No varicosities. SKIN: normal. There are 0 form elements. Result - Copy and paste this output: Email the output.
Annual GYN Exam Medical Transcription Sample Reports
No scleral icterus. Pupils are equal, round, and reactive to light and accommodation. No conjunctival injection is noted. Oropharynx is clear. Mouth revealed good dentition, no lesions. Tympanic membranes are clear. NECK: Supple. Trachea is midline. No evidence of thyroid enlargement. No lymphadenopathy or tenderness. Nontender to palpation. No wheezes, rhonchi, or rales. No murmurs, gallops, or rubs.
Oh, no! I'm the first patient these 23 med students have ever examined.
No skin or nipple retractions. No nipple discharges or masses. No mass, tenderness, guarding, or rebound. No organomegaly or hernia. Bowel sounds are present. No CVA tenderness or flank mass. The phallus is circumcised. There are no penile plaques or genital skin lesions. The glans is normal. The meatus is orthotopic, patent, and clear. The testicles are descended bilaterally without masses or tenderness. The epididymis and cords are normal. The perineum is normal. External genitalia normal. Vagina and cervix without lesions or masses. Uterus is normal. Adnexa negative for masses or tenderness. Urethral meatus is normal. Perineum and anus are normal. Normal sphincter tone. No masses. Prostate is smooth and nontender and without nodules or fluctuance. No masses or tenderness. Gait is normal. Deep tendon reflexes are intact. Recent and remote memory is intact. Appropriate mood and affect. SKIN: Warm, dry, and well perfused.
Pelvic Exam | Stanford Medicine 25 | Stanford Medicine
Good turgor. No lesions, nodules or rashes are noted. No onychomycosis. Eyes: Extraocular muscles are intact. Pupils are round and reactive to light. Conjunctivae are pink and moist. Sclerae are white and nonicteric. Nose: Nasal mucosa is pink and moist. Septum is midline. Mouth: Oral mucosa is pink and moist. Dentition is good. There is no jugular venous distention noted. There are no carotid bruits noted. There are no palpable masses. There are no crackles, wheezes or rhonchi noted.
Exam Documentation: Charting Within the Guidelines
There is no crepitus on palpation. No murmurs are noted. There are no lifts, heaves or thrills noted on palpation. There are good bowel sounds. There is no rebound or guarding. There is no evidence of hernia. SKIN: There are no rashes, lesions or ulcers noted. Warm and dry with good turgor. There is no clubbing, cyanosis or edema. Sensation to light touch and pain is intact bilaterally. There is no apparent mood disorder. Vital Signs: T: [x] degrees.
Gonorrhea physical examination - wikidoc
P: [x] beats per minute. R: [x] breaths per minute. BP: [x] mmHg. Face: No lesions. Eyes: Conjunctiva pink. Sclera are anicteric. EOMs are full. Ears: The right and left ear canals are clear. Both tympanic membranes are intact. Nose: No external or internal nasal deformities. Nasal septum is midline. Mouth: The lips are within normal limits. The dentition is good. Tongue is midline with no lesions. The oral cavity is clear. Pharynx: Tonsils are normal size and clear. No exudates. Neck: Supple. No lymphadenopathy. Thyroid: No thyromegaly or masses.
Ventura Family Medicine - Well Child Check Visit Notes
Chest: Clear to auscultation and percussion. Heart: Regular sinus rhythm. No gallops or murmurs. Abdomen: Soft, nontender. Normoactive bowel sounds. No organomegaly or masses. Extremities: No cyanosis, edema or deformities. Neurologic: Grossly intact. Skin: No lesions.
Pelvic Exam I: Assessment of the External Genitalia
Expanded problem focused exam — a limited exam of the affected body area or organ system and any other symptomatic or related body area s or organ system s. Detailed exam — an extended exam of the affected body area s or organ system s and any other symptomatic or related body area s or organ system s. Comprehensive exam — a general multisystem exam, or a complete exam of a single organ system and other symptomatic or related body area s or organ system s. The guidelines include a detailed chart that specifies the exam elements that must be performed and documented to justify each level of exam. In the chart, the shaded headings list the organ systems and body areas as CPT categorizes them. These body areas and systems are worth some attention. Look closely at the terms and the way they are grouped; they may not correspond exactly to those you are used to running through in your mind.
Case 18: Cough
This presumably represents recognition that these systems are easier to ask about than to examine. Now, back to the multisystem exam chart. Parenthetical examples provide clarification and guidance within the chart. Finally, CMS urges you to keep in mind that the use of the documentation guidelines is not a substitute for medical necessity. A well documented service won't automatically be assumed to have been medically necessary.
Vaginal Examination (PV) - OSCE Guide | Geeky Medics
The patient denies domestic safety concerns. The patient is a nonsmoker. No alcohol abuse. Most recent bone mineral density was read as low-normal mineralization of the hip and normal bone density of the spine. The patient is followed by Dr. Jane Doe for her thyroid disease and is scheduled to see her this month. Lymph node survey: Unremarkable. No supraclavicular, axillary or inguinal lymph nodes palpable. Breasts: Breast examination in the supine position is negative for masses, lumps and nipple discharge. Abdomen: Soft, nontender to palpation.
Genitourinary system
No hepatosplenomegaly or masses palpated. Pelvic: Pelvic exam revealed normal female external genitalia, urethra, and vagina with skin intact and no lesions noted. Internal exam revealed vaginal vault free of bleeding and discharge. Cervix is well visualized. Bimanual Exam: No masses and no tenderness. Adnexa negative. Rectovaginal Exam: No masses, no tenderness. Normal postmenopausal gynecologic exam. John Doe unless otherwise indicated. Health maintenance. Encouraged continued increase in cardiovascular and weightbearing exercise, continued calcium supplementation, and monthly self-breast exams.
UC San Diego's Practical Guide to Clinical Medicine
The patient was last seen here in our department in November and had a Pap that was negative. The patient is postmenopausal now with no complaints, was on hormone replacement therapy for approximately 5 years, and is off that now for the past 4 years. No complaints of any postmenopausal vaginal bleeding. No discharge, itching, burning. No abdominopelvic pain or any change in her elimination pattern. The patient has had no change in her medical or surgical history since her last visit here. She did specifically quit smoking in XXXX , which she is quite happy with. Negative alcohol abuse. Positive for exercise with walking and jogging and positive for calcium-rich foods, including milk and yogurt.
2.5 Head-to-Toe Assessment
Vital Signs: Height is 5 feet 5 inches. Weight is pounds. She has pain 0 on a scale of 1 to No supraclavicular, axillary or inguinal nodes palpated. Breasts: Exam in the supine position with no masses, no lumps, and no nipple discharge. Abdomen: Soft, nontender to palpation with no hepatosplenomegaly or masses palpated. Pelvic: Examination revealed normal female external genitalia, urethra and vagina with her skin intact and no lesions noted. Internal Examination: Vaginal speculum was used. Vaginal vault was free of any bleeding or discharge.
Content Blueprint for PANCE
Atrophic changes are present. Cervix: Well visualized, small, smooth, no CMT. Pap was obtained as well as Digene for human papillomavirus DNA. Bimanual exam revealed no masses, no tenderness. Adnexa nonpalpable. Rectovaginal Examination: No masses, no tenderness. Annual gynecological examination: Pap was obtained today as well as Digene for human papillomavirus deoxyribonucleic acid. We discussed with the patient the current guidelines regarding Pap and deoxyribonucleic acid testing that if both results are negative, she should still follow up annually for a breast and pelvic exam, but she would not need a Pap for 3 years. Health maintenance: Encouraged annual mammogram surveillance. The patient is due next month. We encouraged annual screening, monthly breast self-examinations, regular exercise and vitamins, calcium mg a day, vitamin D in divided doses. All of her questions were answered today. We will send her a note with the results.
Gonorrhea physical examination
Her bone density in November revealed some mild osteopenia. Encouraged the patient to try to be consistent with her calcium. Recommended she could try some Viactiv chews if she is unable to tolerate the Caltrate as well as the calcium-rich foods. We will repeat a bone density next year. Related Posts.
Speculum Examination
Introduction The female external genitalia is fascinating due to the fact it is made up of both urinary tract and reproductive structures. These structures collectively fall under the term vulva. The definition of "vulva" is covering or wrapping. From the exterior observation of the female external genitalia, it does appear to be covered or wrapped by skin folds. These skin folds are called the labia majora and labia minora. Both labia majora and labia minora are part of the vulva. The components of the entire vulva are the mons pubis, labia majora, labia minora, clitoris, urethra, vulva vestibule, vestibular bulbs, Bartholin's glands, Skene's glands, and vaginal opening.
PANCE Content Blueprint - NCCPA
The external female genitalia serves the purposes of reproduction and urination. Structure and Function Vulva The vulva is the global term that describes all of the structures that make the female external genitalia. The components of the vulva are the mons pubis, labia majora, labia minora, clitoris, vestibular bulbs, vulva vestibule, Bartholin's glands, Skene's glands, urethra, and vaginal opening. Mons Pubis The mons pubis is a tissue mound made up of fat located directly anterior to the pubic bones. This mound of tissue is prominent in females and is usually covered in pubic hair. The mons pubis functions as a source of cushioning during sexual intercourse. The mons pubis also contains sebaceous glands that secrete pheromones to induce sexual attraction.
Vaginal Examination (PV) - OSCE Guide | Geeky Medics
Labia Majora The word "labia majora" is defined as the larger lips. The labia majora are a prominent pair of cutaneous skin folds that will form the lateral longitudinal borders of the vulval clefts. The labia majora forms the folds that cover the labia minora, clitoris, vulva vestibule, vestibular bulbs, Bartholin's glands, Skene's glands, urethra, and the vaginal opening. The anterior part of the labia majora folds comes together to form the anterior labial commissure directly beneath the mons pubis. While the posterior part of the labia majora comes together to form the posterior labial commissure.
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