THE "FEMALE" EXAM

Terry was in the family practice office for a physical examination which included a pap smear and a breast exam. She was 23-years-old with a medical history of depression and taking Wellbutrin XL. She was asked by the medical assistant if it would be alright if the nurse practitioner student (me) did the exam. Terry said it would fine. I was happy because of the opportunity to get another pelvic exam. I had to get 25 to meet the requirements for my nurse practitioner degree. The medical assistant asked Terry to get undressed and into one of their paper gowns. She then handed the chart to me.

I looked down at the chart to see what Terry’s vital signs were. This included looking at the height and weight. I looked to see Terry was 5’1” tall and weighed 225 pounds. I knew with the limited amount of pelvic exams under my belt finding her cervix could be a challenge. I hoped for the best and was ready to go into the room.

I lightly knocked on the door and walked into the room. When I walked in I saw Terry sitting on the exam table in the white paper gown with the paper drape over her legs. She smiled as I walked into the room and sat down on the roller stool. I asked her if she had any problems or complaints. She had none. I washed my hands before beginning the physical exam. Terry continued to sit on the examination table. I then proceeded to do my head to toe physical exam. I began on her upper body. Everything was normal. I then was ready for the breast exam. I had Terry lie down and put her arms over her head. I started to do the breast exam. She started to laugh and pull away from my hands. I asked her if there was anything wrong. She said no except she was very ticklish. I continued with her squirming throughout examining both breasts. Then it was time for the abdominal assessment. There too Terry was extremely ticklish and pulled away and laughed as I palpated her abdomen. Feeling for her femoral pulses about put her through the ceiling. Once completed with the physical exam I was ready for the pap smear.

Terry was placed in the stirrups and asked to scoot down to the end of the table. Before even beginning Terry held her legs tight together. I asked her to relax but that did not happen. I asked again to relax and used my hands to try to pry her legs apart. Once getting a visual of where I needed to go with the speculum I touched her to prepare her for the exam. The legs tensed up again. I felt like I was trying to break into Fort Knox.

Once I put the speculum in Terry continued to tighten up. Trying to find the cervix was a challenge to say the least. Every move of the speculum made Terry tighten up even more. I was glad I was using a metal speculum because if it was plastic it probably would have shattered. I asked her to relax and breath through the exam. That did not work very well. She continued to tighten up. Unfortunately her cervix was not midline and difficult to find. I tried to find it but the vaginal walls kept collapsing on me. The medical assistant prepared the smaller speculum because of how tense Terry was with the exam. This was where I made a mental note: if a patient weighs over 200 pounds…use the regular length speculum.

I found her cervix was way off to the left which made me maneuver the speculum even more than normal. This caused Terry to squirm and tighten even more. Asking her to breath and relax through the exam was not working. One observation I found was Terry was not ticklish “there.” I was not sure if that was a plus or not. At least she laughed at the ticklish spots but tensed up none the less.

The pap smear was finally completed and Terry was asked to get dressed. A 15 minute appointment turned into 30 minutes. Terry was told her results would be called to her within 2 weeks and everything looked normal. She left the office as I completed my charting. I had the feeling she thought I put her through some sort of torture chamber…the pelvic exam from hell.