Focus on Clinical Skills
Part 1: Advanced Skills to Examine Injuries of the Shoulder, Knee, Back and Ankle
Part 2: Injection technique, Pelvic Exam and IUD placement
Family Medicine Clerkship – 2014/2015
***Sources used in Handout:
1. Essentials of Musculoskeletal Care 3rd edition;
BMJ 1995, Bandolier 1998.
2. Essentials of Family Medicine 6th edition; LWW
2011.
3. Pfenninger and Fowler’s Procedures for Primary
Care 2nd edition; Mosby 2003.
Use of a Pressurized Metered-Dose Inhaler
1) Shake the inhaler well immediately before each use
2) Remove the cap from the actuator mouthpiece
3) Breathe out fully through your mouth
4) Place the mouthpiece fully into your mouth, holding the inhaler in a mouthpiecedown position, and close your lips around the mouthpiece, making sure that your
tongue does not obstruct the mouthpiece.
5) While breathing in deeply and slowly, depress the top of the metal canister (at
the beginning of the breath)
6) Hold your breath for up to 10 seconds
7) Replace the cap on the mouthpiece
** Priming
Shake the inhaler well
Release 1–4 test sprays into the air, away from your face, before using for the
first time or when the inhaler has not been used for more than 3 days.
**Clean the actuator or mouthpiece at least once a week. Wash the actuator by
rinsing it under running water, shake off the water, and let the device air dry.
**Discard the canister after you have used the labeled number of doses. Never
immerse the canister in water to determine how full the canister is.
Use of a Pressurized Metered-Dose Inhaler with a Valved Holding Chamber
(Spacer)
**Spacers are used with MDIs. They make the inhaler much easier to use and
increase the amount of medication received.
1) Take cap off the pMDI boot and insert into chamber
2) Shake pMDI with chamber
3) Spray 1 dose into chamber
4) Inhale from the chamber for several breaths
5) Slow deep breath with breath hold if possible (adults should do three breaths),
or tidal breathing (Infants: ≤10 breaths or 30 seconds tidal breathing)
6) Remove MDI from chamber
7) Replace cap on MDI and chamber
8) Store both chamber and MDI properly
**Spacer maintenance: Periodically wash spacer in warm soapy water, rinse, and air
dry
Use of a Dry Powder Inhaler (DPI), eg Advair, Serevent, Flovent (also comes as
an MDI)
1) Open the device
2) Slide the lever to load dose
3) Keep device level
4) Exhale away from device, to residual volume
5) Inhale rapidly and fully
6) Breath-hold, ideally for at least 10 seconds
7) Remove device from mouth and exhale away from device
8) Close the device and store in a cool, dry place
Use of a Peak Flow Meter
1) Stand up or sit up straight.
2) Make sure the indicator is at the bottom of the meter (zero).
3) Take a deep breath in, filling the lungs completely.
4) Place the mouthpiece in your mouth; lightly bite with your teeth and close your
lips on it. Be sure your tongue is away from the mouthpiece.
5) Blast the air out as hard and as fast as possible in a single blow.
6) Remove the meter from your mouth.
7) Record the number that appears on the meter and then repeat twice.
**Calculate predicted peak flow using chart that comes with the meter or an online
calculator
Nebulizers vs Inhalers

When used properly, they are equally efficacious

There is ONE reason to use nebulizers over inhalers: the patient is physically
unable to use an inhaler (too young, past stroke, tachypneic, etc)
The Back
I. Lessons from ICM:
- Inspection – general appearance (comfort level, leaning forward or
backward), deformity, symmetry
- Palpation – palpate for tenderness: SI joints, spinous processes,
paraspinal muscles and soft tissue
- Range of Motion – flexion - 40-60 degrees
extension - 20-35 degrees
side flexing - 15-20 degrees
- Strength – hip flexors, quadriceps, hamstrings, lower leg, great toe.
- Neuro Exam - sensory function on medial, dorsal and lateral aspects
of the feet.
- DTR of patellar and achilles.
- walk on heels and toes.
- Babinski - positive (upgoing toes) if there is an upper
motor neuron lesion (cord compression)
Lumbar Neuro Exam Findings:
Sensory Loss
Motor
Screening
weakness
exam
Medial foot Knee extension
Squat and rise
Herniation
Nerve root
L3-4 disc
L4
L4-5 disc
L5
Dorsal foot
L5-S1 disc
S1
Lateral foot
Dorsiflex
ankle/great toe
Plantarflex
ankle/toes
Reflex
Patellar
Heel walking
None
Toe walking
Achilles
The RED FLAGS of back pain: These may indicate more serious disease and a more
urgent need for imaging, treatment and/or referral.
IV drug use
h/o osteoporosis
h/o cancer
chronic steroid use
immunosuppression
significant trauma
fever/chills
unexplained weight loss
saddle anesthesia
urinary retention/incontinence
fecal incontinence
unrelenting pain at night or pain at rest
progressive motor or sensory deficit
II. Common injuries/illnesses with associated symptoms & physical exam signs:
Lumbar strain/sprain
The most common cause of back pain.
Symptoms:
Lumbar pain that can radiate to the buttocks or legs.
Physical Exam:
Neuro exam is normal. Typically decreased ROM of spine and soft tissue tenderness.
Special Tests – Straight leg raise (SLR)
With patient laying supine elevate the symptomatic
leg. The test is positive if this reproduces radiating
pain down the raised leg at 30-60 degrees.
- Reasonably sensitive, not specific for herniation
- Crossed SLR is pain on lifting the opposite leg
More specific less sensitive
Spinal stenosis
Typically in older individuals, degenerative changes in the spine.
Symptoms:
Leg pain, numbness, paresthesias. Pain is better when
leaning forward (flexion) Pseudoclaudication - the leg
symptoms get worse with exercise.
Physical Exam:
Sensory loss, muscle weakness
Herniated disc = sciatica
Symptoms:
Pain radiates in dermatomal pattern below the knee. (This is key!).
Physical Exam:
Potential muscle weakness, sensory loss and/or diminished reflexes.
Pain is aggravated by valsalva maneuvers or sitting and is worse with flexion.
Cauda equina syndrome
Surgical emergency. Most commonly caused by central disc herniations and tumors
Symptoms:
Bladder dysfunction (urinary retention), bowel incontinence, saddle anesthesia, bilateral
neurologic deficits and pain.
Physical Exam:
Decreased rectal tone, sensory deficits, neurologic deficits
Vertebral compression fracture
Risk factors include older age, osteoporosis and cancer.
Symptoms:
Pain is typically worse with activity, palpation over the
spine and flexion. Can occur without trauma.
Physical Exam:
Bony tenderness, increased pain with flexion.
When to Image???
- Consider imaging in patients with any Red Flags
described above.
- Plain x-rays should be used initially to evaluate for
tumor, infection and fracture. However, X -rays are
not useful for identifying herniated discs.
Spondylolysis – a fracture in the
pars interarticularis of the
vertebrae. Look at the neck of
the ‘Scotty Dog’ on plain films
L4-L5 Herniated disc on MRI
- The initial treatment for a herniated disc
is similar to that for lumbar strain: NSAIDS,
muscle relaxants, physical activity as
tolerated or physical therapy.
However, MRI is indicated for patients who
have radicular symptoms that have not
improved after 6 weeks of conservative
treatment.
- MRI or CT should be ordered earlier for
patients in whom you suspect tumor,
infection, cauda equina syndrome or patients
with progressive neurologic deficits
Osteolytic
lesions
from
metastatic
disease
The Shoulder
I. Lessons from ICM:
- Inspection – symmetry, muscle atrophy, swelling, erythema, ecchymosis
- Palpation – AC joint, subacromial bursa, coracoid process, long head of
the biceps tendon
- Range of Motion – flexion/elevation 160-180 degrees, adduction,
abduction, external and internal rotation 90 degrees
- Strength – deltoid, biceps, infraspinatous/teres minor, supraspinatous,
serratus anterior
Range of Motion
II. Common injuries with associated symptoms & physical exam signs:
AC Joint Separation
Symptoms:
pain and deformity over superior aspect of shoulder after
falling directly on shoulder
Physical Exam:
Palpation of AC joint – any abduction causes pain
Cross body adduction to assess for arthritis of AC joint
Arm is forward flexed to 90
degrees and then horizontally
adducted as far as possible –
positive is pain over AC joint
Shoulder Dislocation (joint separation)/Subluxation (sensation of ‘slipping’)
Described by the direction of the humerus in relation to the glenoid fossa (anterior vs
posterior) Traumatic dislocations are >90% anterior dislocations.
Symptoms:
sensation of shoulder slipping out of joint with initial insult being fall or forceful
throwing motion but simple changes in position may provoke subsequent dislocation.
Physical Exam:
Apprehension test: place arm in 90 degrees abduction with elbow at 90 degrees and then
maximally externally rotate the humerus. Checks for anterior instability.
Sulcus Sign – more than 2cm is typically positive for glenohumeral instability
Rotator Cuff Syndrome = Impingement Syndrome/Rotator Cuff
tendonitis/Subacromial bursitis
Typically starts as mild inflammation of the bursa or rotator cuff tendons and can
progress to chronic pain, decreased range of motion and rotator cuff weakness. When
severe can progress to a partial thickness or full thickness tear.
Symptoms: The symptoms are secondary to repeat mechanical insult as rotator cuff
tendons pass under the coracoacromial arch consisting of coracoid process, the
coracoacromial ligament, the acromion, and AC joint capsule. Uncommon in young
patients and often co-exists with adhesive capsulitis (frozen shoulder). Chronic pain can
be referred to lateral deltoid region and exacerbated by overhead activities. May cause
night time pain which makes sleeping on affected side difficult.
Over time the humeral head migrates superiorly compressing the bursa and the rotator
cuff tendons against the acromion, causing impingement.
Coracoacromial arch
(in yellow)
Physical exam:
Assess for muscle atrophy and weakness
Neer impingement sign: depress scapula with one hand while lifting arm with other
Hawkins impingement sign: abduct arm 90, flex elbow, internally rotate humerus
Isolate muscles of the rotator cuff:
Isolate supraspinatous with arm in same position and thumbs down and push down
Isolate Infraspinatous and teres minor with arms down and elbows extended resisting
external rotation
Isolate subscapularis with lift off hand behind back with palm away from body.
Rotator Cuff Tear
Symptoms: Weakness and loss of active elevation and external rotation.
Physical exam:
Significant weakness when muscles of rotator cuff are isolated
Muscle atrophy depending on time course of injury
Cases:
1- A 22 year old male presents to your office complaining of right shoulder pain. He
is a baseball pitcher for a neighborhood league and has been having increasing
pain after games. It is difficult to lift his arm to the side and he complains of pain
more on the outside of his shoulder. He is unable to sleep on his right side.
Exam findings?
Diagnosis?
Treatment?
2- A 32 year old female presents to your office complaining of right shoulder pain.
She was playing basketball and fell, landing on her shoulder. She did not hear a
‘pop’ and can still move the arm but it hurts, especially on the ‘top of the
shoulder’.
Exam findings?
Diagnosis?
Treatment?
The Knee:
I. Lessons from ICM:
- Inspection – symmetry, valgus/varus, atrophy, swelling, erythema,
ecchymosis, gait
- Palpation – effusion, patellar tendon and ligament, joint line, pes
anserine bursa, tibial tuberosity, popliteal fossa, warmth
- Range of Motion – (active and passive) flexion 135-145 degrees,
extension to 0 degrees (flat)
- Strength – quadriceps, hamstrings
Range of Motion
II. Common injuries with associated symptoms & physical exam signs:
Fractures, especially patella:
Symptoms: significant pain after blunt trauma or a fall
Physical Exam:
Swelling and significant pain
apply Ottowa rules (see appendix)
Patellar Dislocation
Symptoms: acute onset of pain after sudden movement or contraction of the quads when
decelerating quickly (especially in sports)
Physical Exam:
Pain and swelling that occurs within hours of the dislocation
The patella usually relocates once the leg is straightened making the dx more difficult
Typically a lateral displacement as the vastus lateralis is stronger than vastus medialis
Patellar Apprehension Test: displace patella laterally and flex knee to 30 degrees
Meniscal injuires:
Symptoms: usually caused by trauma in the young, older pts require less force for injury.
Locking sensation after twisting injury
Physical Exam:
Joint line tenderness
Valgus vs Varus stress – can tell you the location of injury
McMurrays: external rotation in flexion then extend to stress medial meniscus, then do
same with internal rotation to stress lateral meniscus
Collateral Ligament injury
Symptoms: trauma from the side (medial or lateral)
Physical exam:
Valgus stress to test MCL and Varus stress to test LCL both with knee flexed 25 degrees
Anterior Cruciate Ligament injury: (sprain vs rupture)
Symptoms: popping sound at time of injury, immediate tense effusion
Physical exam:
Lachman: pull anterior on tibia while knee is flexed 25 degrees
Anterior Drawer test: less sensitive than Lachman. Pull tibia forward at 90 degree flexion
Patellar Tracking Syndrome
Symptoms: pain behind the patella, gritty sound or feeling when moving the patella
Physical Exam:
Caused by wear on the back of the patella, asymmetry of the posterior surface
Pain with quadriceps contraction while pushing patella toward the femoral groove
Osgood-Schlatter Disease
Symptoms: occurs generally in rapidly growing adolescents
Physical Exam:
Tenderness over the tibial tuberosity
Cases:
1- A 78 year old male presents to your office for left knee pain. He has been
working in the garden lately and yesterday when he stood up from a kneeling
position he felt a sharp pain in the knee. Now the knee is slightly swollen and
has a clicking sensation when he bends it. He has always had arthritis in that
knee, but this is a new type of pain.
Exam findings?
Diagnosis?
Treatment?
2- A 30 year old female presents with left knee pain. She was playing soccer and
fell, twisting her knee. The knee is swollen and very painful. She comes to
your office on crutches.
Exam findings?
Does this patient need an xray?
The Ankle and Foot
I. Lessons from ICM:
Inspection - swelling, erythema, ecchymosis, alignment of heels, toes, high
arches or pes planus, calluses, gait (intoeing, outtoeing, limp)
- Palpation - medial and lateral malleoli, Achilles tendon, plantar fascia
- Range of Motion - zero starting position is with the foot perpendicular
to the tibia
Range of Motion
II. Common injuries with associated symptoms & physical exams:
Fractures vs Sprain
Ankle sprains are the most common injury in sports. 85% of sprains involve the lateral
ligaments. The weakest lateral ligament is the anterior talofibular ligament.
Symptoms:
Pain, swelling and inability to bear weight comfortably. Ankle “gives out”, typically
rolls laterally.
Physical Exam:
Ankle sprain is a clinical diagnosis.
Apply Ottowa rules (see appendix)
Anterior Drawer test: grasp hindfoot and pull
forward with 20 degrees of plantar flexion to assess
anterior talofibular ligament (remember, the
weakest of the lateral ligaments) This test is most
sensitive about 4 days after injury as pain improves.
Talar Tilt test: when foot is in plantarflexion this
tests the anterior talofibular ligament. When foot is
in neutral flexion it tests the calcaneofibular
ligament.
Reverse Talar Tilt test: tests the deltoid ligament for medial ankle sprains
Syndesmotic Sprain – High ankle Sprain
These sprains generally occur when the ankle is externally rotated and hyperdorsiflexed
(like being tackled).
Symptoms:
Patients will have pain but less swelling than a
lateral ankle sprain.
Physical Exam:
Tenderness over the anterior inferior tibiofibular
ligament and interosseous membrane.
Squeeze test: squeezes the tibia and fibula putting
pressure on the interosseous membrane
Plantar Fasciitis:
The most common cause of heel pain in adults. Caused by repetitive microtears in the
plantar fascia. Little or no inflammation involved.
Symptoms:
Pain in the heel, worse with the first few steps in the morning or after rest. Improves with
walking. Occurs more commonly in patients with flat feet or high arches.
Physical Exam:
Diagnosed clinically, typically no need for xrays.
Pain is worse when standing on tip toes.
Heel Spurs DO NOT cause this pain and don’t need to be removed.
Maximal pain is at the medial tubercle on the plantar aspect of the calcaneus.
Achilles Tendonosis:
Risk factors include running, overuse, increase in hill running, decreased calf and
hamstring flexibility
Symptoms:
Pain related to activity that is localized to the Achilles tendon.
Typically the patient has had a change in shoes or an increase in training intensity
Physical Exam:
Tenderness and swelling about 3-4 cm above the insertion of the tendon at the calcaneus.
If concerned about tendon rupture – while the patient is sitting, squeeze the calf and there
should be reflexive plantar flexion. If there is no flexion there is concern for a complete
tear.
Tarsal Tunnel Syndrome:
Entrapment of the tibial nerve in the tarsal tunnel (the space behind the medial malleolus
covered by the flexor retinaculum. Can be caused by chronic ankle sprains, fractures,
dislocations, repetitive stress, flat feet.
Symptoms:
Heel pain, paresthesias (tingling) around the medial aspect of the heel
Worse with weight bearing and walking
Physical Exam:
Pressure or tapping over the posterior tibial nerve reproduces symptoms (Tinel’s sign).
EMG and nerve conduction studies confirm the diagnosis.
Hallux Valgus (Bunions):
Lateral deviation of the great toe with respect to the 1st metatarsal
Treatment includes wider shoes, padding the area to avoid direct pressure, arch supports,
and surgery.
Symptoms:
Pain on the medial aspect of the forefoot
Worse with tight fitting shoes
Physical Exam:
Red, swollen, painful area on the medial aspect of the 1st metatarsal head
Morton’s Neuroma:
Interdigital neuroma typically in runners and dancers. Caused by entrapment of the
plantar nerve between the metatarsal heads – usually between the 3rd and 4th toes.
Treatment includes metatarsal pads, arch supports, steroid injections and surgery.
Symptoms:
Numbness and tingling in toes and burning in the distal forefoot
Made worse by tight fitting shoes, walking on hard surfaces
The patient can occasionally feel a “painful ball” between the metatarsal heads
Physical Exam:
Occasionally the neuroma can be palpated between the 3rd and 4th metatarsal heads.
Palpating the area of pain and squeezing the forefoot at the same time will worsen the
pain.
Jones Fracture:
A fracture of the 5th metatarsal occurring and the diaphyseal-metaphyseal junction. (near
the base of the metatarsal)
Symptoms:
Typically a results of forced adduction of the forefoot. Commonly occur in soccer and
football players.
Sudden pain in the lateral forefoot.
Physical Exam:
Localized tenderness over the fracture site.
Cases:
1- A 48 year old female marathon runner presents with right ankle pain. She has
been intensifying her training schedule over the past few days and has noted a
gradual worsening of the pain. The pain is worse at the beginning of a run,
resolves after a mile or two and also resolves with rest.
Exam findings?
Does this patient need an xray?
2- A 19 year old male presents to your office with ankle pain. He was at a football
game the night before and tried to jump off the side of the bleachers, landing on
his left ankle. He can’t bear weight on it and is worried it might be broken.
Exam findings?
Does this patient need an xray?
Large Joint Injections
I. Risks of Steroid Injections – increased risk with repeated injections
- infection (very rare)
- steroid flare causing worse pain for 24 hours
- bleeding (rare)
- failure to obtain relief
- skin atrophy, depigmentation and/or slight indentation
- increase glucose levels in diabetics for 24 hours
II. Indications
- Osteoarthritis
- Crystal arthritis
- Bursitis
- Tenosynovitis/tendonitis
- Costochondritis
III. Procedure
- Draw up 5-10 ml lidocaine/marcaine with 1 ml steroid (usually 40mg
triamcinalone or methylprednisolone)
- Identify the entry site (use landmarks!) and mark it (thumbnail or a pen)
- Clean area with alcohol or povidone-iodine
- May use ethyl chloride spray for 1-2 seconds for anesthesia
- Insert needle, pull plunger to make sure you aren’t in a vessel, then inject
- Remove the needle slowly
IV. Knee
- Intra-articular Injection – typically used for relief of pain caused by
degenerative disease (osteoarthritis) – 21 gauge needle, 1 ½ inch
o Patient is either lying down with knee flexed and towel underneath
for support or seated with knee flexed at 90 degrees.
o The joint space is large and can be entered from several directions.
o Anterior approach – (best used with patient seated) Insert the
needle at the medial or lateral border of the patellar tendon.
Direct the needle toward the center of the knee, insert about 1 ½
inches, the medication should flow easily.
o Lateral approach – (best used with patient supine) Locate the
superior lateral margin of the patella and insert the needle 1cm
superior and lateral to this point.
-
Aspiration – indicated for relief of pain caused by an effusion or
diagnostic purposes using fluid analysis (gout, infection etc) - 18-22 gauge
needle, 1 ½ inch, 60-mL syringe
o The lateral approach used above is also used for aspiration.
o If infection is not suspected the needle can be kept in place after
aspiration and a new syringe containing the steroid can be injected
through the same needle.
o After aspiration of a tense effusion, apply compression dressing to
prevent recurrence.
-
Anserine Bursa – indicated for bursitis – 25 gauge needle, 5/8 inch
o The bursa lies beneath the common insertion of the sartorius,
semitendinous, and gracilis tendons on the medial aspect of the
tibia.
o Locate the point of maximal tenderness.
o Insert the needle perpendicular to the tibia.
o When you hit the bone, withdraw 2-3mm and inject
-
Iliotibial Band Syndrome – injection is done to relieve the inflammation
caused by the IT band as it crosses the lateral femoral condyle – 25 gauge,
5/8 inch
o Locate the lateral femoral condyle and Gerdy’s tubercle on the
anterolateral tibia
o Identify the point of maximal tenderness
o Insert the needle angled posterior, avoiding the IT band itself.
o The intent is to inject the medication between the IT band and the
epicondyle.
V. Shoulder
- AC Joint – 25 gauge needle, ½ to 1 inch
o Follow the clavicle laterally until you reach a prominence, about
1.5-2cm inward from the lateral edge of the acromion
o Pushing down on the distal clavicle while your finger is on the AC
joint will help verify the location
o Insert needle from anterior/superior position and angle medially
- Intraarticular shoulder – for osteoarthritis – 25 gauge needle, 1 ½ inch
Anterior approach – (star) rotate
shoulder outward, palpate the
coracoid process and insert
needle 1cm inferior and 1cm
lateral to coracoid process.
Direct the needle slightly
laterally.
It should not hit bone.
Posterior approach – arm is
resting at side, medially rotated.
Find the inferior-posterior
aspect of acromion with thumb,
find coracoid process with index
finger. Insert needle below
acromion and aim for coracoid
process.
-
Subacromial Bursa – typically used for bursitis – 21 gauge needle, 1 ½
inch
o Locate the posterolateral edge of the acromion and find the soft
spot between that edge and the head of the humerus (about 1 inch
inferior). That is the subacromial bursa.
o Direct the needle perpendicularly and insert through the deltoid
and into the bursa (approx 1-1 ½ inches). The medication should
flow in easily, if not you may be in too far and should withdraw
the needle slightly.
Basic Injection Technique
I. Intramuscular injections – ‘IM’
- Indications – typically used for drugs of greater volumes or that are not
very soluble
o Immunizations – Gardasil (HPV), Hepatitis A and B, Hib, DTaP
o Medications – prednisone, naloxone, penicillin
- Contraindications
o Thrombocytopenia, coagulopathy – can lead to hematomas
- Locations – the goal is to minimize the chance of hitting a nerve or vessel
o Middle third of deltoid
o Upper outer quadrant of buttock
o Anterior lateral surface of thigh
- Procedure
o Use a needle at least 1 inch long
o Prepare the syringe, depress the plunger to remove any air
o Clean the skin with alcohol
o Quickly insert the needle at a 90 degree angle through the skin
and into the muscle
o Draw back on the plunger to verify that the needle is not in a
vessel. If you get immediate blood return, withdraw and start over
with a new needle. (when injecting immunizations it is not
necessary to draw back on the plunger)
o Smoothly inject and withdraw the needle
o Apply a band-aid if necessary
II. Subcutaneous injections – injections into the loose subcutaneous tissue just under
the epidermal and dermal layers - ‘SC’
- Indications – volumes of less than 2cc, non-irritating drugs
o Immunizations – MMR, varicella, zoster
o Medications - Insulin
- Locations – fatty areas are best
o Upper arm
o Abdomen
o Lateral thigh
- Procedure
o Use a needle 3/8 to 5/8 inches long
o Prepare the syringe, depress the plunger to remove any air
o Clean the skin with alcohol
o If necessary gently pinch up the skin to avoid injecting into the
muscle
o Insert the needle at a 45 degree angle (again to avoid injecting into
muscle)
o Smoothly inject and withdraw the needle
Subcutaneous Injection Sites
Intramuscular Injection Sites
Cryotherapy
I. Indications
- Actinic keratoses
- Skin tags
- Warts
- Seborrheic keratoses
- Condyloma
- Hypertrophic scars
- Basal cell CA
II. Advantages
- Minimal scarring
- No anesthesia
- No skin preparation
- No sutures
- Infection is rare
III. Disadvantages
- Complete healing may take 6-8 weeks
- Loss of pigment possible
- No tissue to send for pathology
- Cannot use in area of poor circulation
- Can cause peripheral neuropathy if adjacent nerve is frozen
- Sun damaged skin, newborn skin, elderly skin are all more sensitive to
freezing
IV. Materials
- Liquid nitrogen
- Oranges (for today’s exercise)
V. Procedure
- Debride the keratin cover if possible (especially on warts).
- Apply water soluble gel over the lesion to help freeze more evenly.
- Apply the tip of the liquid nitrogen canister directly on the lesion.
- Freeze the tissue until the ice ball extends 2-3mm beyond the benign
lesion and 5mm beyond the premalignant or malignant lesion.
- It should take 2-3 minutes for a benign lesion to completely thaw and 3-5
min for malignant.
- After complete thawing, freeze again.
The Pelvic Exam
I. Typically consists of external exam, pap smear and bimanual exam
II. Indications
- Screening
- Abdominal pain
- Pelvic pain
- Abnormal vaginal discharge
- Abnormal vaginal bleeding
- Genital lesions or rashes
III. Preparation
- Discuss exam with patient fully clothed
o Ask about previous exams – first exam? previous difficulties?
o Explain each part of the exam and the equipment
o The exam should not be painful!
o Some light spotting is normal after a pap smear
o Allow her to dress in private, offer tissues if necessary
o Explain how she will be notified of results
- Materials
o Gloves (non-sterile)
o Speculum with light (various sizes, warmer?)
o Water-soluble lubricant
o Large cotton swabs
o Spatula and endocervical brush
o Culture/swabs for infections if necessary
IV. External Exam
- The patient should be
positioned comfortably all the
way at the edge of the table
with her feet in stirrups and
knees bent and relaxed to the
sides.
- Vulva– look for any skin
changes, erythema, lesions,
nodules
- Reassure patient if everything
looks normal (use the word
normal!)
V. Bimanual Exam – Typically done after the pap smear
- Evaluate for smooth cervix,
cervical motion tenderness,
smooth uterus, uterine
position and size, adnexal
tenderness, masses
Cervical Cancer Screening
I. Typically use ThinPrep method and not Pap smear
II. Procedure
- Small amount of water soluble lubricant on warmed speculum
- Use one hand to gently separate the labia, insert the speculum at an angle,
then straighten and aim posteriorly at 45 degrees.
- Examine the vaginal walls for lesions, discharge, healthy mucosa
- For redundant mucosa – make a speculum sleeve from a glove finger cut
at both ends
- Visualize the cervix. Check for inflammation, discharge, lesions
- Identify cervical landmarks (see appendix)
-
Attempt to sample the entire transformation zone and endocervical canal
using either a spatula and brush or the broom
Consider cervical sampling for gonorrhea and chlamydia
IUD Insertion
I. Indications
- Contraception
- per American College of Obstetricians and Gynecologists (ACOG) candidates
for IUD are . . .
- multiparous and nulliparous women at low risk for STIs
- women who desire long-term reversible contraception
- women with the following medical conditions: diabetes,
thromboembolism, menorrhagia/dysmenorrhea, breastfeeding, breast
cancer, and liver disease
- Menorrhagia/dysmenorrhea
II. Contraindications
- acute pelvic inflammatory disease (PID)
- mucopurulent cervicitis
- current high risk sexual behavior (multiple partners, no condoms)
- suspected uterine or cervical cancer
III. IUD Advantages
- High efficacy
- Decreases risk of ectopic pregnancy
- Long duration of effect
- Convenient
- Low risk of side effects
- Cost effective
- Levonorgstrel IUD reduces blood loss with menses and can be used to treat
menorrhagia
IV. IUD Disadvantages
- Menstrual irregularities (heavier menses with copper IUD, irregular bleeding and
light spotting with copper or Levonorgstrel IUD are possible)
- Cramping at time of insertion
- Expulsion - 2-10% are expelled within first year
- Perforation at time of insertion. Risk with a skilled operator is less than 1 per 1000
insertions.
- Infection - risk is extremely low
V. Patient Visit
- Discuss risks and benefits of IUD
- Consent form
- Discuss past medical history
- Pelvic exam with bimanual exam and cervical cultures for gonorrhea/chlamydia,
Pap if due
VI. IUD Insertion
- Materials
Nonsterile gloves, lubricant, betadine and large swabs
Sterile gloves, speculum, tenaculum, uterine sound, IUD, scissors
- Procedure
Bimanual exam to determine position of uterus
Insert speculum and locate cervix
Use large swabs and betadine to thoroughly clean cervix 3 times
Grasp anterior lip of cervix horizontally with the tenaculum - close slowly to one
click
Place light tension on tenaculum and insert uterine sound until resistance is felt at
the fundus
Note the distance in cm on the sounding device - should be 6-9cm.
Change to sterile gloves
Copper IUD – ParaGard
- Use sterile gloves to fold the IUD arms back into the inserter. Insert the rod into the
insertion tube from the bottom until it touches the IUD
- After sounding the uterus, hold the inserter next to the sound and move the flange to
the sounding depth
- Hold traction on the tenaculum and insert the IUD until resistance is felt at the fundus
- the flange should now be at the external os
- Let go of the tenaculum, hold the rod with one hand and withdraw the inserter tube
1/2 inch to release the IUD arms
- Gently push the inserter tube to the top of the fundus to ensure fundal placement of
the IUD
- Hold the inserter tube stable and withdraw the white rod.
- Remove the inserter tube
- Cut the strings to 2-3 cm - longer is better because you can always cut them shorter!
Levonorgstrel IUD – Mirena
- After sounding the uterus, use sterile gloves to release the strings on the inserter
- The slider should be in the position farthest from you
- Align the arms of the IUD so they are horizontal
- Pull on the threads to draw the IUD into the insertion tube and fasten the threads
tightly in the groove at the end of the tube
- Hold the inserter tube next to the uterine sound and move the flange to the sounding
depth
- Hold traction on the tenaculum and insert the IUD until the flange is 1 1/2 or 2cm
from the external os. (note difference from Copper IUD insertion)
- Hold the inserter steady and pull the slider back to the mark to release the arms of the
IUD
- Advance the inserter until the flange is at the external os to ensure fundal placement
of IUD
- Holding the inserter steady, pull the slider all the way back to release the strings and
withdraw the inserter (careful not to pull out the IUD)
- Cut the strings to 2-3 cm
V. Post Insertion
- Schedule visit at 6-8 weeks for string check
- Instruct patient on how to check IUD strings
- Review signs of infection, expulsion
- Remind that spotting can be expected for several months and is normal. Cramping on
day of insertion can be treated with NSAIDS
Wet Prep/KOH
I. Indications
- vaginal discharge
- vaginal or vulvar pain
- abnormal vaginal secretions
II. Materials
 Speculum
 Normal saline in small test tube
 Small cotton tipped applicators
 10% KOH solution
 Glass slides and coverslips
 Microscope
 pH test tape - results may be invalid if blood, semen or douche solution is
present
III. Procedure
 While speculum is in place, obtain a sample of the vaginal secretions by
rubbing a cotton-tipped applicator over the vaginal walls and in the fornices.
 Place the applicator in the test tube with normal saline – keep it there until
you are ready to prepare the slides.
 Remove the speculum
 Prepare the wet prep in the laboratory using 2 separate slides
 Place one drop of fluid on one slide and cover with cover slip
 Place one drop of fluid on the other slide and add a drop of KOH solution,
then put the coverslip on top
 Examine under low and high power
IV. Slides
- Saline – look for lactobacillus (normal vaginal flora), leukocytes,
trichomonads, clue cells (large epithelial cells with indistinct borders and
adherent coccobacilli organisms)
- KOH – look for hyphae, budding spores, leukocytes vs squamous cells (if
WBCs > squamous cells suspect inflammation)
Differential Diagnosis for Vaginitis
Clinically
Normal
Bacterial Vaginosis
Candidiasis
no complaints
increased discharge, bad
odor that is worse after
discharge, intense
intercourse, possible
itching and burning
itching
Trichomonas
discharge, bad odor,
vulvar itching, dysuria
white/clear, looks like
sometimes increased - increased discharge Discharge
typically increased - thin,
egg whites during
thick, white, 'cottage thin, frothy,
(typically)
white
ovulation
cheese like',
yellow/green
Whiff test
(amine
odor)
none
positive (fishy odor)
none
might be positive
pH
< 4.5
> 4.5
4-5
> 4.5 (typically > 6)
clue cells , no WBC
6. budding yeast on
KOH
7. hyphae
increased WBC to >10
per high power field,
trichomonad
organisms
Microscope
1. lactobacilli
2. epithelial cell
Appendix:
Ottawa knee rules
In most situations a knee x-ray is not needed for knee injury patients in the absence of the
following findings:





age 55 or over
isolated tenderness of the patella (no bone tenderness of the knee other than the
patella)
tenderness at the head of the fibula
inability to flex to 90 degrees
inability to weight bear both immediately and in the office/ED (4 steps - unable to
transfer weight twice onto each lower limb regardless of limping).
Ottawa ankle and foot rules: Sensitivity of almost 100%, reduces unnecessary Xrays
by 30-40%
An ankle x-ray is generally required only if there is any pain in malleolar zone and any of
these findings:



bone tenderness at A
bone tenderness at B
inability to weight bear both immediately and in the office/ED.
A foot x-ray is required if there is any pain in the midfoot zone and any of these findings:



bone tenderness at C
bone tenderness at D
inability to weight bear both immediately and in the office/ED.
Vocabulary
Bursa – fluid filled sack that helps to decrease friction – e.g. between a
tendon and bone
Dislocation – complete displacement of a joint
Subluxation – partial displacement of a joint
Sprain – stretching of a ligament
Strain – stretching and damage to a muscle or tendon
External rotation – movement away from the center of the body
Internal rotation – movement toward the center of the body
Eversion – turning outward
Inversion – turning inward
Abduction – moving away from the midline
Adduction – moving toward the midline
Valgus – abnormal displacement of a limb or joint away from the midline
(valgus stress of the knee is so named because of the direction of the
force applied – which is away from the midline)
Varus – abnormal displacement of a limb or joint toward the midline