Pelvic and rectal exams

[yohimbine1]

Hey...how often did you actually do these during M3? All I've done so far is observed them with a group of students. I wouldn't even know what to feel for. And I think a patient would sense my ineptitude if I tried doing one. And what about breast and testicular exams...

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[surrender903]

i performed two or three pelvics on gyn service, never needed to do a rectal. just luck of the draw really.

 

[UCLAstudent]

Plenty of pelvic exams were done on Ob/Gyn and even more on family med. I did rectals on surgery (1 week of urology), internal medicine, and neuro. In terms of ineptitude --- I was always supervised by a resident or attending. You'll get more comfortable with it over time.

 

[psychbender]

My right index finger got really dirty on my FM and EM months. It took quite a bit of surgilube before I felt comfortable with what I was feeling. As for pelvics, I did a bunch of speculum exams and checked plenty of cervixes on OB, but haven't done a bimanual exam since second year Gyn ECE.

For quite a while, you'll have no idea what you're feeling, but you'll eventually get your fingers calibrated.

 

[Ashers]

In OB/gyn clinic, I somehow got out of all but 1 pelvic (I got weird patients usually that didn't require pelvics), but there were the presurgery ones on the gyn service. On Family Practice, I had to do a lot more. I can't feel anything except a cervix.

Rectals... only had to do them on surgery with the Exam Under Anesthesia (then I think a total of 3). Don't know what I'm feeling for either. IM none. FP rectal only to check a lady for saddle anesthesia.

 

[AmoryBlaine]

There's really not a ton to doing a rectal. You lube up, slide it in there. Only things you can really feel for are tone, prescence/abscence of stool, is there a hard knob in the prostate, is there any tenderness in the rectum, then test the stool for occult blood.

 

[Law2Doc]

i performed two or three pelvics on gyn service, never needed to do a rectal. just luck of the draw really.

You had it awfully easy. We were doing 3+ pelvics per day on parts of gyn.
Rectals were more sporadic -- a few here and there in medicine, and checking for rectal tone/anal wink on neuro and emergency type rotations. Saw some real nastiness, and learned on the fly how to double (and triple) glove with regular latex gloves, which is a lot harder than the size specific indicator and exterior gloves they let you use in the OR. As the prior poster indicated, there isn't much to it, but it's probably something you should get over your shyness about doing while a med student, because it's not something you want to seem embarrassed about doing as a resident.

 

[surrender903]

You had it awfully easy. We were doing 3+ pelvics per day on parts of gyn.
Rectals were more sporadic -- a few here and there in medicine, and checking for rectal tone/anal wink on neuro and emergency type rotations. Saw some real nastiness, and learned on the fly how to double (and triple) glove with regular latex gloves, which is a lot harder than the size specific indicator and exterior gloves they let you use in the OR. As the prior poster indicated, there isn't much to it, but it's probably something you should get over your shyness about doing while a med student, because it's not something you want to seem embarrassed about doing as a resident.

the service i was on didnt let students do pelvics. they were reserved for interns/residents.

 

[BigRedBeta]

Definitely in double digits for both during M3...my school requires you to document having performed at least 5 pelvics and 5 rectals. Got most of mine completed while on Family, then filled in the rest on OB/GYN and IM respectively (there are lots of opportunities at the VA for rectals).

I actually got "really" good at rectals during the summer after M1 when I worked with a surgeon in a rural town. We were doing 25-30 colonoscopies a week and I had to give rectals to everyone. It was a lot easier when they were knocked out.

As for the "not knowing what to feel for". It's just like everything else, you get better with practice. When you first listened to breath sounds, you probably couldn't pick out crackles or wheezes either, or you couldn't pick up a murmur when you first started listening to the heart. But you do it over and over again, and you get used to what's normal variation and it makes the abnormal things stick out.

 

[Law2Doc]

(there are lots of opportunities at the VA for rectals).

I think it's not so much an "opportunity" issue. You are never wrong in doing a rectal exam as part of the physical exam. It's just not necessarily a part of the exam focused on a given, non-GI or oncology associated chief complaint. When someone has a staph abscess on his arm, it's hard to explain to him why you are doing it. But no attending or resident would have a problem with you doing it, some insist on it, and there's a place for the results on every H&P form.

 

[CCLCMer]

Hey...how often did you actually do these during M3? All I've done so far is observed them with a group of students. I wouldn't even know what to feel for. And I think a patient would sense my ineptitude if I tried doing one. And what about breast and testicular exams...

Wow, you never had to do any of these exams before third year at your school? We learned to do them all on standardized patients in fall of second year at Case. The standardized patients walk you through the steps of each exam. That is a lot weirder than doing the exams on a real patient because they're correcting your technique while you do it. Pretty much what you're palpating for is something that's hard or lumpy and doesn't feel like the rest of the breast, prostate, or testis. I can't ever find anyone's ovaries (good luck with that anyway if she's obese), but you can usually palpate the cervix and uterus at least.

I think it's helpful if you review the exam before you go to do one so that you feel more confident when the preceptor is walking you through the steps. Here's a webpage that someone else posted that has instructions for most of the exams: http://meded.ucsd.edu/clinicalmed/clinic.htm Also the NEJM has some good videos, like this one on doing pelvics: http://content.nejm.org/cgi/content/short/356/26/e26 We had to watch this video before we worked with the standardized patients last year.

 

[yohimbine1]

Thanks all--as with most things I'm gonna be bad at this to start off with but I'll just try my best and be serious and willing.

I think it's helpful if you review the exam before you go to do one so that you feel more confident

Ha yeah I will have to review this for every part of the physical exam...we've had standardized patients but none of them had real findings. Also we never performed rectal or genital exams on actors, we just observed that and felt some dummies/models.

 

[tkim]

You lube up, slide it in there.

Dude.

 

[Ypo.]

On our IM rotation, we weren't allowed to do rectals without a resident in the room. And since the residents never wanted to do them, I never got a chance. On the surgery rotation some of the residents seemed to expect us to do them on our own, but I just said we weren't allowed to do them without supervision. So I ended up doing about four, which was enough for me.

 

[DragonWell]

I've only been in the ER for a week and have already done a rectal and 2 pelvics, as well as a foley, many IVs, sutures, staples. The emergent nature of things in the ER seems to lend itself well to students getting in these exams/procedures, since patients are usually somewhat desperate for treatment and don't care as much who is performing the exam. Also, since you need to get as much ruled in or out as possible in one examination, the index of suspicion for performing a rectal or pelvic seems pretty low.

BTW, the advice you always hear about making nice with the nurses has proven to be very true in my experience. Once I introduced myself, helped with some patient care, and let them know that I was interested in learning some procedures, they were more than happy to teach.

 

[heyjack70]

Do a rectal on every patient you admit. You never know when that patient is going to be going to surgery, or put on anti-coagulation, or whatever. Knowing about occult rectal bleeding is important, so just do it. It's good experience plus the patient gets the full hospital experience. It's win win.

 

[LadyWolverine]

I started family medicine yesterday. In only 1.5 days of actual work, I have done 3 pelvic exams. The doc that I work with had me watch her do one, and then she had me do the next 3. I almost can't believe how trusting some people are. I certainly doubt I'd let a green medical student examine me.

I also felt ovaries for the first time ever on this rotation. You need a really thin patient. They feel like grape tomatoes.

 

[deleted29780]

Hey...how often did you actually do these during M3? All I've done so far is observed them with a group of students. I wouldn't even know what to feel for. And I think a patient would sense my ineptitude if I tried doing one. And what about breast and testicular exams...

Don't worry, its a passing phase you will do just fine...we sometimes make too much of a fuss about simple procedures....rectal exam, pelvic exam...so what?
No medical student will be allowed to perform a gastrectomy, Endoscopic retrograde cholangiography or some high profile stuff - thats what i call a challenge. So please go through simple undergrad training in med school and enjoy it. The real challenge is residency and practice.

 

[-Goose-]

I probably average 7-8 cervix exams per day on Ob-Gyn L&D service. It's actually not as bad as I had anticipated.

 

[WestcoastMedicine]

On medicine I was doing heme-occults daily with admissions. GYN we had clinic 2 days a week for women without health insurance and did a few pelvics there each shift. In the ED you will get to do alot also, depending on the demographics of the area and common pathology.

 

[DickyV]

I think it's not so much an "opportunity" issue. You are never wrong in doing a rectal exam as part of the physical exam. It's just not necessarily a part of the exam focused on a given, non-GI or oncology associated chief complaint. When someone has a staph abscess on his arm, it's hard to explain to him why you are doing it. But no attending or resident would have a problem with you doing it, some insist on it, and there's a place for the results on every H&P form.

Well, there are only two contraindications to a rectal exam:

1. The patient doesn't have a rectum.
2. The examiner doesn't have a finger.

. . . and even the second one is questionable.

 

[vtucci]

It will depend on the service.

You will see alot of them on emergency medicine. It is a rare shift when I do not have at least one pelvic or rectal exam in the ED.

For pelvics and speculum exams, I did far more on EM and Family medicine than I did in OB. It was pretty much a rule that students did not do speculum exams on pregnant patients.

Rectals- real big in EM and neuro as mentioned (checking the sphincter tone). Also had a few in family medicine.