Teaching: Per Speculum & Pap smear

Casebank Combined
1

Where you are:
You are an FY2 in Gynecology and obstetric Department.

Who the Student is:
Sam Peterson is a 5th year medical student who is attending a rotation at your department, and he wants you to teach him about per speculum examination.

Other information:
None.

Special Note:
None.

What you must do:
Talk to Sam and teach him how to perform per speculum examination.
Speculum examination stations come as PAP Smear routine test, Menorrhagia, PID, and follow up test results.

This Station can come as a teaching station or a procedure / examination station in the exam, so learn it in both ways following the structure of the either way.

APPROACH

Smile

  1. Introduction/ ID check:
  2. build rapport:
  3. Main concern: ( Always copy from the notes ). I understand that you came today to learn about Per speculum examination, Am I right?
  4. Assess knowledge (4 W): So before we start could you tell me?
    – What do you know about it in particular?
    – What exactly do you want to know about it?
    – How to perform per speculum examination?
    – Why do you want to know about it any reasons in particular?
    – Do you know Why and When we do it? (Brainstorming for colleague).

Speculum Examination: a device is used to look inside in the vagina and observe the cervix. A speculum examination is often performed alongside a bimanual examination, as part of a complete gynaecological workup.

PAP Smear or Cervical screening: is a test to check the health of the cervix and help prevent cervical cancer by checking for HPV which is the biggest risk factor for cervical cancer. It’s offered to women and people with a cervix aged 25 to 64.

  • a small sample of cells will be taken from the cervix.
  • The sample is checked for certain types of human papilloma virus (HPV) that can cause changes to the cells of your cervix. These are called “high risk” types of HPV.
  • If these types of HPV are not found, you do not need any further tests.
  • If these types of HPV are found, the sample is checked for any changes in the cells of your cervix. These can be treated before they get a chance to turn into cervical cancer.
  1. Teach:
  • Now we will talk how to approach if Examination station. And if it comes as teaching you just need to apply the structure.
  • The diagram is for all examination station, as Time management is the key to pass them.
  • You should always manage the time of the station properly.

2 mins History + 4 mins Examination or Procedure + 2 mins Management.

History Taking: (2 mins):

  • Take history according to the case and the presenting complaint.
  • Explore presenting complaint properly.
  • Ask about other associated symptoms.
  • Ask 4Ps.
  • Ask about previous PAP Smear or speculum, what was the outcome? Any complications? The results?
  • Ask about the contraindications of PAP Smear and Speculum Examination.

PAP Smear contraindications:

  • Active menstruation.
  • Active vaginal bleeding.
  • Recent sexual intercourse.
  • Recent use of spermicidal gel.
  • Pregnancy.

Speculum Examination contraindications:

  • Uterine prolapse.
  • Cysts.

Do the procedure or examination: (4 mins).

I need to check your Vitals, Blood Pressure, Body temperature, Pulse rate, Respiratory rate.

Before the examination / Procedure:

  1. Explain the procedure (PEPCC):
    – Procedure/Purpose: This will involve me inserting a Lubricated instrument called speculum into your vagina to visualize +/- (take a sample of cells from the) neck of you womb.
    – It shouldn’t be painful, but it will feel a little uncomfortable. I will be as gentle as possible, but you
    can ask me to stop at any point.
    – Exposure: For the purpose of this exam I need you to be bare below the waist, including your
    undergarment.
    – Position: you need to remove your underwear, lie down on your back, Bring your heels towards your
    bottom and then let your knees fall to the sides making it wide apart.
    – Chaperone: “One of the female ward staff members will be present throughout the examination, acting as a chaperone, and I will ensure your privacy.
    – Consent: to proceed with the examination/ procedure: “Do you understand everything I’ve said? Do you have any questions?
    – Do I have your consent to proceed? Can I proceed with my examination?
  2. Gather materials / equipment:
    – Gloves.
    – Lubricant.
    – Speculum.
    – Light source for the speculum.
    – Paper towels.
    – A pot of cytology preservative solution: Sure path or Thin prep.
    – Cervical brush.
    – Clinical waste bin.

Do the Examinations/Procedure:

  1. Give time for the Patient to undress/change herself.
  2. Provide the patient with the opportunity to pass urine to empty her bladder before the examination procedure.
  3. Ask the patient if they have any pain before doing the clinical examination.
  4. Make sure you adjust the light before proceeding to the procedure.
  5. Don an apron, and a pair of non-sterile gloves if gloves are available. (Assume I am gloved if gloves not available).

Make sure the Lubricant bottle or Packet is kept open before you start the procedure/ examination.

On inspection/Palpation:

  • Warn the patient that you are going to touch and inspect their front passage. Verbalize these: There is no redness, swelling, bleeding, Ulcers, vaginal discharge, Scarring, Vaginal atrophy, White lesions, Masses, Varicosities, Female genital mutilation/ Injury
  • Separate the labia gently with your left index and left thumb and inspect the inside of the labia.
  • Ask the patient to cough and inspect for prolapse.

Speculum ( Go in ):

  • Apply some lubricant to the blades of the speculum.
  • Verbalise about the light source.
  • Warn the patient you are about to insert the speculum.
  • Gently insert the speculum sideways (blades closed, angled downwards).
  • Once inserted, rotate the speculum 90° so that the handle is facing upwards.
  • Open the speculum blades until an optimal view of the cervix is achieved.
  • Tighten the locking nut to fix the position of the blades.
  • fix the position of the blades. Hold the speculum with your hand and make sure that you do not
    leave it.
  • Verbalize “ I am Inspecting the cervix and vaginal walls.
  • External os: Open/Closed.
  • Cervical erosion /Masses /Ulcers/ Discharge / Bleeding.

+/- PAP Smear

  • Verbalize “I am inserting the brush deep into the endocervical canal to reachthe cervix.
  • brushing carefully around the external os, 5 times, 360 degrees, in a clockwise direction to obtain a sample of cells.
  • Gently removing the brush, avoid touching the speculum or the vaginal walls with the brush.
  • SurePath: Drop the detachable brush end into the SurePath sample pot and discard the rest into the
    clinical waste bin. Place the cap on the pot and tighten.
  • ThinPrep: dip the brush into the ThinPrep sample pot 10 times. Then discard it into the clinical
    waste bin. Place the cap on the pot and tighten.

Speculum ( Go out ):

  • Warn the patient you are about to Withdraw the speculum.
  • Loosen the locking nut on the speculum and partially close the blades.
  • Rotate the speculum 90°, back to its original insertion orientation, while gently removing the speculum,
    inspecting the walls of the vagina as you do so. Do not completely close the speculum (to avoid pinching / damaging the vaginal walls.)
  • Inspect the Speculum for any blood or Discharge

After the Procedure/Examination:

  • Document the procedure in the medical notes, and Thank the patient for their time.
  • Summarise your findings: ( mention only positive )
  • Explain to the patient that her smear results will be sent to her GP in approximately 2 to 3 weeks.

Safety Netting:

  • It is normal to have some vaginal spotting after the examination for a few hours.
  • If the spotting persists or it turn into heavy bleeding, go to see the GP or go to the hospital immediately.

Management: ( 2 mins ).

Pelvic Inflammatory Disease:

  • Pain Killer.
  • Antibiotics.
  • If diagnosed at an early stage, PID can be treated with a course of antibiotics, +/- 14 days.
  • Remind the patient of the importance of completing the whole course.
  • Avoidance of sexual intercourse during treatment.
  • Sexual health clinic will help with partner notification, contact tracing, STI screening, swab test (swab test can be done at GP).

Menorrhagia ( Fibroid ):

  • Medicines are available that can be used to reduce heavy periods, but they can be less effective the larger your fibroids are.
  • Levonorgestrel intrauterine system (LNG-IUS).
  • Tranexamic acid.
  • Anti-inflammatory medicines ( IPUPRUFEN).
  • Surgery to remove your fibroids may be considered if your symptoms are particularly severe and medicine has been ineffective.
  • Hysterectomy is a surgical procedure to remove the womb.
  • Myomectomy is surgery to remove the fibroid from the wall of your womb. It may be
    considered as an alternative to a hysterectomy if you’d still like to have children.
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2

HPV is written as HBV here. I recommend a revision for that.

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