Pelvic Exam - When is it really useful?

[future_dr_house]

A magical little phone radio thingy. You hit a button and say "Call Stephanie RN" and it will put you through to nurse Stephanie. Or "Call ED Xray" and you can ask the tech why you have been waiting 2 hours for a chest xray. Usually just used for intra-departmental use.

I tend to think of it as a well intended piece of junk which very often gets poorer reception than my phone and costs twice as much. The best thing about it though is being able to answer it during a procedure without ungowning etc. Also you can teach it a name like Siri. Our director is named "the dude" on it.


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[Angry Birds]

I tend to think of it as a well intended piece of junk which very often gets poorer reception than my phone and costs twice as much. The best thing about it though is being able to answer it during a procedure without ungowning etc. Also you can teach it a name like Siri. Our director is named "the dude" on it.


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I had Vocera in residency. Everyone complained about it then. But let me tell you: I miss it now and wish we had it. The best part of it is using it to convey an order to a nurse. Very good for closed loop communication, even if it annoyed the crap out of nurses.

 

[katmandu]

I remember reading a study on the inter-rater reliability of pelvic exam findings being low enough to question utility.

However, there are a few exceptions and surprises. Like the week old tampon that I found on a pelvic I did last night for vaginal discharge. Maybe she would have felt it if I had tried the self swab technique....?

 

[The White Coat Investor]

Pelvic pain, vaginal bleeding, vaginal discharge patients pretty much all get a pelvic from me.

Random abdominal pain? Probably not, but if everything else were negative, I might offer it. I'd probably do it for dysuria with clear urine too.

 

[deleted77919]

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[Arcan57]

I had retained tampons on two consecutive shifts last week. One's CC was retained tampon but the other's was LLQ pain. It seems poor patient care to pick up a retained tampon on CT.

 

[RustedFox]

My patients refuse pelvics left and right. I say 3 or 4 out of 5 refuse.

 

[shoal]

My patients refuse pelvics left and right. I say 3 or 4 out of 5 refuse.

how the hell do you get a refusal rate that high? i get maybe one refusal per 500

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[DeadCactus]

how the hell do you get a refusal rate that high? i get maybe one refusal per 500

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A mustache, a big smile, and one of the jumbo speculums in hand when you ask.

 

[Psai]

how the hell do you get a refusal rate that high? i get maybe one refusal per 500

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Comes with experience I guess

 

[RustedFox]

how the hell do you get a refusal rate that high? i get maybe one refusal per 500

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Give them the option. Pelvic, or empirical therapy.

 

[hundreddaysoff]

how the hell do you get a refusal rate that high? i get maybe one refusal per 500

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Gracefully getting pts to refuse things is one of the best tricks I've learned as an intern this year.

 

[Apollyon]

Give them the option. Pelvic, or empirical therapy.

I woulda guessed that it was because your average pt age is, like, 90.

 

[RustedFox]

I woulda guessed that it was because your average pt age is, like, 90.

That helps. It also helps that they've all had TAH/BSO if they're over 60.

But for real. Those completely nontoxic females with the sketchy social history?

Me: "Okay, I understand your concern - especially given the history. We can either get some cultures and wait several days and see what answers we get, or we can simply skip the exam and cultures, and very easily treat for most treatable STDs with a simple 'shot and a pill'.

Before I finish, most times I'm interrupted with "lets just do the shot and the pill".

 

[Rendar5]

That helps. It also helps that they've all had TAH/BSO if they're over 60.

But for real. Those completely nontoxic females with the sketchy social history?

Me: "Okay, I understand your concern - especially given the history. We can either get some cultures and wait several days and see what answers we get, or we can simply skip the exam and cultures, and very easily treat for most treatable STDs with a simple 'shot and a pill'.

Before I finish, most times I'm interrupted with "lets just do the shot and the pill".

From a public health perspective not a very good way of treating. At least send the urine gc/chlamydia. Otherwise they're just getting reinfected from their partners who aren't even told to go to the health dept. getting cultures doesn't mean don't treat

 

[RustedFox]

From a public health perspective not a very good way of treating. At least send the urine gc/chlamydia. Otherwise they're just getting reinfected from their partners who aren't even told to go to the health dept. getting cultures doesn't mean don't treat

1. We don't have urine GC/Chlamydia.
2. I treat no matter what. The "answers we get" ultimately won't matter; that's the idea of the post. This was not clear in my original post - I was between making coffee and yelling at my cats to "get down from there". My bad.
3. You're right; this is a public health matter.... that can and should be handled by the public health department - not in the ER. All recent discussions about the viability of "layup cases" etc. be damned.

 

[Rendar5]

1. We don't have urine GC/Chlamydia.
2. I treat no matter what. The "answers we get" ultimately won't matter; that's the idea of the post. This was not clear in my original post - I was between making coffee and yelling at my cats to "get down from there". My bad.
3. You're right; this is a public health matter.... that can and should be handled by the public health department - not in the ER. All recent discussions about the viability of "layup cases" etc. be damned.

If you believe that should all be handled by public health department, then why are you even bothering to treat thim? Sounds kind of like You're just creating a false dichotomy (Either get an exam with delayed treatments, or treatment right now if you don't get the exam) to get yourself out of an exam you don't feel like doing

I can't really blame you, I kind of do something similar to get out of lumbar puncture's. I just don't think it's really a good idea in thi case. The culture that I grab gets passed on to the health department if it's a positive. The health department has to perform test of cure. And they then deal with any partners that the patient had. thats one less ED patient for me next month.

 

[DeadCactus]

http://hqmeded.com/blind-swab-vs-speculum-assisted-endocervical-swab/

 

[RustedFox]

If you believe that should all be handled by public health department, then why are you even bothering to treat thim? Sounds kind of like You're just creating a false dichotomy (Either get an exam with delayed treatments, or treatment right now if you don't get the exam) to get yourself out of an exam you don't feel like doing

I can't really blame you, I kind of do something similar to get out of lumbar puncture's. I just don't think it's really a good idea in thi case. The culture that I grab gets passed on to the health department if it's a positive. The health department has to perform test of cure. And they then deal with any partners that the patient had. thats one less ED patient for me next month.

Some of the people that I work with simply discharge these, period. If the chief complaint is "STD check", they simply perform the MSE and say - "Thank you, but you need public health."
Even thought it "should" be handled by p.health, I still handle treatment because hey; its already here.

I always offer the exam, and offer the swab/culture. Once they hear "results aren't instant, and I will treat you no matter what", then they lose interest in the results.

 

[Arcan57]

How are you determining cervicitis vs. PID without a pelvic? At least according to CDC guidelines, you're going to be undertreating PID by a wide margin without the physical exam.

 

[RustedFox]

How are you determining cervicitis vs. PID without a pelvic? At least according to CDC guidelines, you're going to be undertreating PID by a wide margin without the physical exam.

I'm not determining anything exactly without an exam. The patient declines the exam.

 

[Rendar5]

I'm not determining anything exactly without an exam. The patient declines the exam.

You mean you offered to not do it and they accepted.

 

[RustedFox]

... and they declined in both word and in gesture. Pretty clear that the answer is "no".

 

[Rendar5]

I'm not really disputing the fact that they preferred not to get the exam. I'm just pointing out that you told them it's OK to skip the exam and that's your opinion. Based on that You appear to think you don't need to go looking for pid or the source of discharge in non toxic women, nor perform public health services in the ED. You should just own it. I don't believe in plenty of ED public health initiatives, this just doesn't happen to be one of them.

Im sure you do perform them on the sick and more emergent cases and wouldn't imply you avoid it when it is objectively necessary

 

[RustedFox]

It is okay to skip the exam. After all, the thread title is - "When is a pelvic useful?"

Sure, if you sense danger - you do the right thing. But the gals who come in because they have discharge and give a flimsy story and are totally nontoxic and are more interested in their cellphone than actively participating in their own care? Bye.

"Discussion held regarding risk/benefit ratio and low yield of pelvic exam. Patient (after consideration) declined exam in both word and in gesture - adding that she prefers empiric therapy."

 

[shoal]

i dont treat empirically for gc chlamydia without an exam or a positive partner... abx have risks

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[RustedFox]

i dont treat empirically for gc chlamydia without an exam or a positive partner... abx have risks

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I hate pedantic arguments, but I'm going to make one.

Which is greater? The risk of adverse reactions from abx, or the risk of total bull****asaurus complaints from doing pelvics? Or not doing pelvics (to smite my own tail)?

Here's your antibiotics. KthxBye.

 

[shoal]

I hate pedantic arguments, but I'm going to make one.

Which is greater? The risk of adverse reactions from abx, or the risk of total bull****asaurus complaints from doing pelvics? Or not doing pelvics (to smite my own tail)?

Here's your antibiotics. KthxBye.

fair arguement.

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[Angry Birds]

Give them the option. Pelvic, or empirical therapy.

...

I always offer the exam, and offer the swab/culture. Once they hear "results aren't instant, and I will treat you no matter what", then they lose interest in the results.

You, sir, are a genius.

 

[Brigade4Radiant]

How are you determining cervicitis vs. PID without a pelvic? At least according to CDC guidelines, you're going to be undertreating PID by a wide margin without the physical exam.

Just give everyone the treatment for PID