Performing the exam  

gynodoc69 55M
12 posts
12/11/2005 2:12 pm

Last Read:
3/5/2006 9:27 pm

Performing the exam

This is the general procedure I use when performing an exam. I know there are many "Doctors" out there and everyone does things differently, but this seems to work best for me.
I have been doing mostly house calls lately because, although I have a body piercing shop with a beautiful gyno table, I have had some near catostrophic close calls with employees showing up at inconvenient times. on the up side, it does give me access to the autoclave to keep everything sterile.
Upon arrival, I give the patient a cotton gown and ask her to change into it while I get out my instruments and prepare for the exam. As the doctor, you must keep in mind that while a gynecologist would want to minamize apprehension, you do not necessarly want to do so. lay out your equipment and let her SEE it. This is a big part of it for her. I begin by asking her some questions. I have a form I fill out, and actually make a "file" for each patient so I can see what we have explored, and her general history. I ask about allergies. This is important because I use latex gloves, If she is allergic to latex, I will use non-latex gloves and make a note in the chart. I also occasionally use lidocaine jelly, and benzocaine, so allergies are important. After going through my questionare, I begin by taking her pulse, respiration, and blood pressure. Take your time, this is an important part of the exam, giving her time to think about what is happening. I claen the head of my stethoscope with an alcohol pad, She will find the smell of the alcohol familiar, I use my stethoscope, opening the back of the gown and listening to her lungs. Remember, take your time. Unless the stethoscope is very cold, I do not warm it, I want her to feel the coldness of the stethoscope as I listen to her lungs. I have her face me and look streight ahead as I check her pupils with my penlight.I palpate the lymph nodes in her neck,and notice any enlargement or tenderness. I use a toungue depressor, and check her throat with my penlight. Do not insert the tongue depressor too far back, she will gag,and its not nice. I then use my otoscope and check her ears, Gently pull the ear lobe backwards and insert the otoscope. I then go back to my stethoscope, this time opening the front of the gown and listening to her heart. By now, she is done being terrified,but is still quite apprehensive. I ask her to lay down on her back, and put one arm behind her head, and begin the breast exam. DONT stare at the breast. I carefully work my way over the breast and into the armpit noting any tenderness or abnormal lumps in the lymph nodes. I Lightly squeeze the nipple and notice any drainage.I Perform the exam on the other breast using the same technique. When I am done,I replace the gown, and make a notation of my findings in her chart. I then open a 4X4 sponge and squeeze some surgilube on it. I get out my rectal thermometer, clean it with an alcohol swab, place the tip in the surgilube, Prepare a guiac slide and place the bottle of developer by the slide.and glove my hand (Im left handed, so I glove my left hand) It is important to let her watch you do this, remember, for her, this uses all her senses, she smells the alcohol, she sees you preparing the equipment, she hears the surgilube coming out of the tube, and hears the glove being put on.I ask her to roll over onto her side, and with the ungloved hand, gently seperate her buttocks and insert the thermometer with the gloved hand, and while holding it in place, cover her with the gown. I normally rest the unused hand on her hip.I leave the thermometer inside her for about 2 minutes. I take this time to ask her questions , but I keep it light hearted,(DO NOT whistle a tune to yourself, use this time to talk with her.) When about 2 minuites have elapsed, I remove the thermometer and read it. Then I Tell her I am going to perform a quick rectal exam.I Lubricate the index finger of my gloved hand and while asking her to bear down, insert it fully into her rectum. moving the finger around in the rectum, I pay attention to any masses felt,also, the tone of the muscles. (this will help to determine her willingness/ ablilty for more invasive anal procedures later.If she expresses discomfort,I re-assure her in a soft calming voice. Remove the finger and ask her to roll back over onto her back.I do not wipe off the lube. I let her feel it for a bit.I then wipe the fingertip of the gloved finger onto the guiac slide and add a few drops of developer.If the slide turns blue,I make a notation in her chart. Now I lift up the gown and listen to her bowel sounds with the stethoscope.I Palpate the abdomen firmly but not so deeply as to cause any extreme discomfort, and Note any abnormalities on her chart (tenderness, ect)

Now we get to the pelvic part of the exam. Up to this point, the exam is exactly the same for a genetic girl as it is for a transgender girl. Since over a third of my patients are transgendered women, I will detail the pelvic exam for both in seperate posts. I hope I have stressed the importance of taking your time, and stimulating all her senses, as this is very important for her enjoyment, which is, after all, why were doing this.

Dr Eric


gynodoc69 55M

12/16/2005 7:28 pm

PELVIC EXAM FOR GENETIC WOMEN

This is my general guidelines as you have to accomidate different situations. Sometimes Ill do an exam at a patients home with them on their bed, I also have a portable exam table with stirrups, as well as my regular exam table. It is possible to easily do the exam without stirrups.

I will select my speculums, with a patient I havent examined before, I will select a medium and large Graves speculum, and perhaps a size 2 anoscope if she didnt mind the DRE (Digital Rectal Exam) too much, as well as several 8" cotton tipped swabs, and a tube of surgilube. I try to have everything I will need handy, This also gives her an opportunity to see the instruments.
I ask her to move to the end of the table, Lie on her back with her feet raised and supported by stirrups. (Most gynecologists have a problem with the patient not wanting to get close enough to the edge of the table, but I seldom run into this problem)This allows me to examine her vulva, urethra, vagina, and other reproductive organs.

The external exam:
During the external exam,I Check her vulva and the opening of her vagina for signs of redness, irritation, discharge, cysts, genital warts, and other abnormal conditions.
I check inside her vagina with my gloved finger for any cysts or pus coming from the Bartholin glands.I gently massage each bartholin gland between my thumb and index finger and notice any discharge. the glands are located on the bottom of the vaginal opening, at the 4 and 6 o-clock positions.I try to talk with her and explain what im doing as im doing it.
Next, the Bimanual exam:
I insert one or two gloved fingers of one hand into her vagina while placing my other hand on her lower abdomen. By pressing down on the abdomen and moving the fingers around inside her vagina, I locate and determine the size, shape, and consistency of the uterus, ovaries, and fallopian tubes. Any unusual growths, tenderness, or pain can also be identified.
The rectovaginal exam:
For this exam, I will insert one finger into her rectum and one into her vagina. This helps to evaluate her ovaries, fallopian tubes, and uterus ligaments.
The speculum exam: After doing the bimanual exam, I will know which size speculum to use. I gently insert the speculum into her vagina.with the blades facing vertically, as the speculum is inserted it is slowly rotated 45 degrees so that the shorter blade is facing up, the longer blade is facing down, and the handle is facing downward.This takes a little practice, so expect to get smacked in the head the first few times you try this.After practicing this several time, you should hear nothing more than a quiet moan when the speculum is inserted. Unless the speculum is very cold, I choose not to heat it, and most patients will appreciate the "cold steel" feel of the speculum slowly sliding in. I then open the speculum, spreading apart the vaginal walls, allowing the inside of the vagina and the cervix to be examined.I check the walls of her vagina and her cervix for damage, growths, inflammation, unusual discharge, or discoloration. If there is alot of fluid present, (happy girl) I will use a cotton swab to clean the area up a bit so everything can be visualized. (you can about count on having to do this) I then slowly remove the speculum.This is where you will sustain the most severe head, neck, and throat trauma if you are not careful. I hold the speculum open, and loosten the retaining nut all the way, then slowly withdraw the speculum closing it slowly as necessary to remove it. DO NOT just loosen the nut and allow it to close while it is inside her vagina or she will kill you! Remember, talk to her, and let her know what your doing durring the exam, and follow her lead, If an area needs further examination, youll know by the way she is responding to the exam, At this time, I may do another vaginal exam with a larger speculum, have her roll over and do an anoscopic exam, or simply be done with the examination. Each persons tolerance is different so let the way she responds to the exam guide you.

Note: the vast majority of patients will get a little uncomfortable durring the bimanual exam, this is normal, and something she has experienced since her first gynecological exam. This doesnt mean you ignore her discomfort, talk to her, she knows youll be finished with that part of the exam soon.

If you are performing the exam on a bed, have her move all the way to the end of the bed, bend and spread her legs and hold her knees. This works well of you dont have a table with stirrups.

As I said, this is a general guideline for a first time exam on a new patient. If shes a patient youve examined before, you will know what size speculums to use and what she can and cannot tolerate.

NOTE V2.0 the spell checker wouldnt work, and im a poor typer, sorry bout that.

Have fun.

Doc


gynodoc69 55M

12/17/2005 3:46 pm

PELVIC EXAM FOR TRANSGENDERED WOMEN

This is the procedure I use with transgendered patients. If the patient is post-op, then use the procedure for GG exams. although remember, the vaginal tissue of the post-op patient is not quite as flexable as that of a GG. I would recommnd starting with a small graves speculum, then moving to a larger size if she can accomidate it.Depending on how much progress she has made with her dilation, a small speculum may be all she can accomidate.If she is still using dilators, you may ask her to dilate with the largest size she currently uses before the exam.Take your time, and pay attention to how she reacts to the procedure.

Now, on to pre-op Transgender Exams:
Sometimes Ill do an exam at a patients home with them on their bed, I also have a portable exam table with stirrups, as well as my regular exam table. It is possible to easily do the exam without stirrups.For most TG exams, I will place a pillow under her to raise and tilt the pelvis.

I will select my speculums based on the anal tone noted durring the DRE (digital rectal exam) earlier. with a patient I havent examined before, I will select a small and medium Graves speculum, and perhaps a size 2 anoscope if she didnt mind the DRE too much, as well as several 8" cotton tipped swabs, and a tube of surgilube. I try to have everything I will need handy, This also gives her an opportunity to see the instruments.
I ask her to move to the end of the table, Lie on her back with her feet raised and supported by stirrups.Do not assume that all transgendered women have extensive anal experience, many do not. You need to take your time and treat her with the same respect given to your GG patients.

The external exam:
During the external exam,I Check her penis, scrotum, and anus for signs of redness, irritation, discharge, cysts, genital warts, and other abnormal conditions. With my gloved hand,I insert a finger into the scrotal sac, just over the top of the pubic bone and I ask her to bear down as I check for hernia.This is done on each side, and can be mildly umcomfortable.
I check inside her anus with my gloved finger for any cysts or fistulas, and notice any drainage.(In TG women with extensive anal experience, quite a bit of natural lubrication may be present, this is normal.) I try to talk with her and explain what im doing as im doing it.
Next, the Bimanual exam: this is the same as for a GG exam,
I insert one or two gloved fingers of one hand into her rectum while placing my other hand on her lower abdomen. By pressing down on the abdomen and moving the fingers around inside her rectum, I take notice of any unusual growths,masses, tenderness, or abdominal pain.
Durring the bimanual exam, many TG women will experience erection. although this will be less prevelent with patients on hormone therapy. This is normal, and should be ignored.

The speculum exam: After doing the bimanual exam, I will know which size speculum to use. I gently insert the speculum into her rectum so that the shorter blade is facing up, the longer blade is facing down, and the handle is facing downward.(This is differant than the GG exam. The speculum on the TG exam is inserted streight in, NOT twisted)This takes a little practice, so expect to get smacked in the head the first few times you try this.After practicing this several time, you should hear nothing more than a quiet moan when the speculum is inserted. Unless the speculum is very cold, I choose not to heat it, and most patients will appreciate the "cold steel" feel of the speculum slowly sliding in. I then open the speculum, spreading apart the rectal walls, allowing the inside of the rectum to be examined.I check the walls of her rectum for damage, growths, inflammation, unusual discharge,scarring, or discoloration. If there is alot of fluid present, (happy girl) I will use a cotton swab to clean the area up a bit so everything can be visualized. I then slowly remove the speculum. This is where you will sustain the most severe head, neck, and throat trauma if you are not careful. I hold the speculum open, and loosten the retaining nut all the way, then slowly withdraw the speculum closing it slowly as necessary to remove it. DO NOT just loosen the nut and allow it to close while it is inside her rectum or she will kill you! Remember, talk to her, and let her know what your doing durring the exam, and follow her lead, If an area needs further examination, youll know by the way she is responding to the exam, At this time, I may do another rectal exam with a larger speculum, have her roll over and do an anoscopic exam,or a proctoscopic exam.give her a prostate massage, or simply be done with the examination. Each persons tolerance is different so let the way she responds to the exam guide you.

NOTE: If you are going to perform a prostate massage, and she is erect, you might want to apply a condom.

If you are performing the exam on a bed, have her move all the way to the end of the bed, bend and spread her legs and hold her knees. This works well of you dont have a table with stirrups.

As I said, this is a general guideline for a first time exam on a new patient. If shes a patient youve examined before, you will know what size speculums to use and what she can and cannot tolerate.

NOTE V2.0 the spell checker wouldnt work, and im a poor typer, sorry bout that.

Have fun.

Doc


LuckyLady4711 45F

12/24/2005 12:09 am

I think my pussy needs an examination. You wanna do this? I can't wait..


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