Evaluate the body of the uterus for:
a. Position
b. Architecture, size, shape, symmetry, tumor
c. Consistency
d. Tenderness
e. Mobility
3. Continue bimanual palpation and evaluate the cervix for position architecture, consistency and tenderness especial on the mobility of the cervix, then explore the anterior, posterior and lateral fornices
4. Place the “vaginal” fingers in the right lateral fornix anf the “abdominal” hand on the right lower fornices a. outline the adnexa b.normal tube- not palpable c. normal ovary (4x2x3 cm) often not palpable d. adnexal mass
5. Palpate the left adnexa region, repeating technique described above
6. Follow the bimanual examination with a rectovaginal abdominal examination
7. In virgins – rectal- abdominal technique

E. Rectal Examination 1. Inspect the perineal and anal area, the pilonidal (sacrococcygeal) region and perineum for color and lesion 2. Instruct the patient to “strain down” 3. Palpate the pilonidal and anal area, ischiorectal fossa, perineum and the region before inserting the gloved finger into the ana canal 4. Palpate the anal canal and the rectum with well lubricated gloved index finger 5. Evaluate the anal canal for: a. tonus 1.external sphincter muscle 2. anorectal ring b. tenderness 1. tight sphincter 2. anal fissure 3. painful hemorrhoids c. tumor or irregularities, specially the pectinate line d. superior aspect examine the finger
1. Blood
2. Pus
3. Other alteration, smear, stool
e. Evaluate the rectum
a. Anterior wall
b. Right lateral wall, left lateral, posterior wall, superior aspect, test for the occult blood

ABDOMINAL EXAMINATION
Supine position Relaxed position Pillow under the head
Inspect for signs of intraabdominal mass, organomegaly or distention
Initial Palpation Liver Spleen Other abdominal contents, mass effect
All four quadrants
Systemic approach – e.g. clockwise
Percussion to measure the liver
Auscultaion
Bowel sounds Intestinal obstruction: “rushes” or high pitched Ileus: less frequent but same pitched as normal vowel
PELVIC EXAMINATION Patient in dorsal lithotomy position Vulva and perineal area inspected for Lesions Erythema Pigmentations Masses Irregularity Speculum Examination (Graves or Pederson) Smallest with adequate visualization Speculum warmed with warm water Cervix and vagina carefully inspected PAP smear Biopsy of any lesion Endometrial biopsy Culture of purulent discharge A vaginal and cervical cytology done as a screening tool for cervical neoplasm

PAP SMEAR Has reduce incidence of invasive cervical CA by 50% Initial screening at age 18 Annual screening for high risk patients 1-2 years screening for low risk patients

Instructions: No douche for 48 hours before procedure No vaginal creams 1 week before No coitus for 24 hours in advance

Technique: Samples from both endocervix and exocervix Saline moistened cotton-tipped swab
1. No lubricant
2. Place the endocervical brush or cotton swab inside the endocervix and roll it firmly against anal canal
3. Remove the brush or swab and place sample on slide
4. Place the spatulas vs. cervix with longer protrusion in cervical canal
5. Rotate spatula clockwise 360 firmly vs. cervix; rotate it enough to cover entire transformation
6. Immediately place the sample from spatula onto the glass slide by rotating spatula vs. slice in a clockwise manner
7. Immediately fix the slide with wither spray fixative or 95% ethanol ficative
Four Sources of Errors: Improper collection Poor transfer from collecting device to slide air drying Contamination with lubricant
BI-MANUAL EXAMINATION After speculum is removed  1st and 2nd fingers are inserted gently into the Vagina Fornices Cervix Opposite hand placed on patients abdomen (above symphysis pubis) Uterus assessed well Adnexa, gently palpated on both sides

RECTAL EXAMINTAION On postmenopausal and premenopausal women whom there is difficulty in ascertaining adnexal structure Also rule out possibility of concurrent rectal disease Check on: Sphincter muscle Support pelvis Masses and hemorrhoids At completion of examination, patient should be informed about the findings.

EXAMINATION OF PEDIATRIC PATIENT Careful examination Familiarity with normal appearance prepubertal genitalia  midly erythematous Position Young child: in frog-leg position Toddler or infants: Held in mother’s arm Mother (clothed) on examination table (feet in stirrup) with children in her lap Others: Knee-chest position Use of anesthesia Hysteroscope, cytoscope

EXAMINATION OF ADOLESCENT PATIENT Inadequate or poorly revealing Very careful and gently technique Indication for pelvic examination History of intercourse (+) pregnancy test With abdominal pain Marked edema Heavy bleeding Brief explanation of planned examination Use of anesthesia Confidentiality: an important issue in adolescent health care

FOLLOW-UP Routine care patients with no disease Further assessment, treatment plan for those with S/S referral to other specialist if needed