Beruflich Dokumente
Kultur Dokumente
CervicalCytology,
WetPrepandCervical
CultureCollection
AssociationofProfessorsofGynecologyandObstetrics(APGO)
UndergraduateMedicalEducationCommittee2008
CervicalCytology,WetPrep
andCervicalCultureCollection
TableofContents
IntendedLearningOutcomes
DescriptionoftheCervicalCytology,WetPrepandCervical/
VaginalCultureCollectionProcedure
BestPractices
Checklist
PerformanceAssessment
PracticalTips
Resources
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IntendedLearningOutcomes
DifferingonlyslightlyfromtheAmericanCancerSociety(ACS)andtheU.S.Preventive
ServicesTaskForce(USPSTF)recommendations,theAmericanCollegeofObstetricians
andGynecologists(ACOG),initsCervicalCytologyScreeningTechnicalBulletin,
publishedin2003,recommendstheinitiationofscreeningcervicalcytologyby21years
ofageorwithinthree(3)yearsofcoitarche,andcontinuingannuallytoage30years.12
Afterthree(3)consecutivenormalcytologies,cervicalcytologycanbedoneeverytwoto
three(23)yearssolongasitremainsnormal.IfHPVtesting,riskprofileandcytologyis
negative,thencombinedscreeningshouldberepeatednomorethaneverythreeyears.
Ifthereisnohistoryofcervicalabnormalities,thepatientandclinicianmaydecideto
discontinuescreeningcytologyatage6570yearsorfollowingahysterectomy(for
benignindications).
Thecollectionofcervical/vaginalmaterialforculturesandwetprepisgenerallydone
foraspecificindication,suchasvaginitisorforscreeningforsexuallytransmitted
infections.Variousvaginalconditions,includingvulvovaginalcandidiasis,bacterial
vaginosis,trichomoniasisandleukocytosis,canbevisualizedonwetprep.
Thecervicalcytologyscreeningvisitisalsoanopportunitytoaddressandcounsel
patientsonvariousadditionalissues.
Thelearningobjectivesofcervicalcytologycollectionareto:
1. Demonstrateunderstandingofthebackground,techniqueandinterpretationof
traditionalslideandliquidbasedcervicalcytology
2. Demonstratetheappropriatetechniqueincollectingcervicalcytology
3. Describethescreeningintervalsindifferentagegroups
4. Counselpatientsappropriatelyabouttheroleofcervicalcytologyinthe
detectionofcervicalcanceranddysplasia
5. Communicatewiththepatientinarespectful,sensitivemannerduringthe
examination
DescriptionoftheCervicalCytologyandCervical/VaginalCulture
CollectionProcedure
GeneralApproach/CommunicationSkills
Thestudentshould:
1. Introducehimorherselftothepatient,confirmthepatientsnameandhowshe
wishestobeaddressed.
2. Washhands(oruseanalcoholbasedantiseptic)anddonnonlatexgloves.If
thesearenotavailable,aninquiryaboutlatexallergyisnecessarybefore
proceeding.
3. Explainthepurposeoftheexaminationandgeneralstepsbeforebeginning.If
thisisthepatientsfirstexamination,thestudentshouldexplainthoroughly,and
showthespeculumandcervicalcytologycollectiondevicestothepatient.
4. Drapepatientappropriately.
5. Besensitivetopatientdiscomfortthroughouttheexaminationandprovide
opportunitiesforthepatienttoaskquestions.
CervicalCytologyCollection
Thestudentshould:
1. Selecttheappropriatesizedspeculum,warmspeculumandtestspeculumon
patientslegforcomfortabletemperature.
2. Informpatientpriortospeculuminsertion.
3. Insertspeculumat45degreedownwardangle,thenrotateandopenwhen
completelyinserted.
4. Visualizethecervixbyadjustingthespeculumanteriorlyorposteriorly.
TraditionalSlideCytologyCollection
Thestudentshould:
5. Usethespatulacloverleafendtocollectectocervicalcells,orspatulaendfor
vaginalcuffcells,andthensmeartheminathinlayerontheslide.
6. Onthesameslide,smearendocervicalcellscollectedusingacytobrush.Only
insertcytobrushsuperficiallyinpregnancy.
7. Thestudentorassistantshouldspraytheslidewithcytologyfixative
immediatelyaftercytologycollectionandplaceitintheappropriatecontainer.
8. Thestudentorassistantshouldlabelthecontainerappropriately.
LiquidBasedCytologyCollection:
9. Studentshouldfirstusetheplastic(notwood)spatulatocollectectocervicalcells
(rotate360degrees),thenbrushlikedevice(rotate180degrees)tocollect
endocervicalcells.Onlyinsertbrushsuperficiallyinpregnancy.
10. Bothspatulaandbrushshouldbesweptaroundtheinsideoftheliquidbased
cytologyspecimencollectioncontainer10timestoloosenthemaximumnumber
ofcervicalcellsintosolution.
11. Thestudentorassistantshouldlabelthecontainerappropriately.
TraditionalCytologySmearCollection
TraditionalSlidePreparation
LiquidBasedCytology
LiquidCytologyPreparation
NormalCervix
Cervical/VaginalCultureCollection
Thestudentshould:
1. Selectappropriatesizedspeculum,warmspeculumandtestspeculumonthe
patientslegforcomfortabletemperature
2. Informpatientpriortospeculuminsertion
3. Insertspeculumat45degreeanglethenrotateandopenwhencompletely
inserted
4. Visualizethecervixbyadjustingthespeculumanteriorlyorposteriorly
5. Usetheappropriatecollectionvialwiththecorrectattachedswabforeach
culture
6. ForChlamydiaandGonorrheacervicalcultures,inserttheswabintothe
endocervixforapproximately10seconds(insertonlysuperficiallyinpregnancy)
7. Forvaginalcultures,obtainaspecimenfromtheposteriorfornix
8. Inserttheswabintothevial,breakofftheexcessswabandcapoffthecollection
vial/tubesecurelyandlabelthespecimen
WetPrepInterpretation
Thestudentshould:
1. Proceedasforvaginalculturecollectionandobtainasampleofvaginalfluid
2. Onasingleglassslide,placeadropofNaCl.andadropofKOH
3. Mixasmallamountofvaginalfluidwitheachsolutionandapplycoverslip
4. Immediatelyafterpreparation,takethepreparedslidetothemicroscopeanduse
lowmagnification(10x)tofocus
5. Lookforcluecells,whitecellsandtrichomonadsontheNaClfield,andfor
buddinghyphaeontheKOHfield
6. Performawhifftestand,ifavailable,checkforpH
7. Discussfindingsandtreatmentwithsupervisingclinicianandpatient
BestPractices
Wefoundthatmoststudentsareintroducedtothesebasicskillsduringclinicalskills
courses.Insomeinstances,opportunitiestoperformtheseskillsongynecologicexam
instructorsorstandardizedpatientswouldfollow.Thereiscurrentlyadearthof
simulationtypeorWebbasedopportunitiestopracticetheseskillsoutsidetheclinical
arena.Moststudentsgainthemajorityofopportunitiestoperformtheskillsduringtheir
clinicalclerkshipintheformofsupervisedclinicalcontact.
Aninformalsurveyof17medicalschoolsaroundthecountryconfirmedthesefindings.
Weprovidethefollowingmaterialstohelpstandardizetheinstructionandevaluation
processinamannerconsistentwiththebestpracticesofacademicinstitutionsacrossthe
country.
Thereforewesuggestintroducinginstructionofcytology,cervicalculturecollectionand
wetprepasasimulationusingapelvicmodelandpreparedslidesofwetprepfindings,
andthensupplementingclinicalexperienceduringtheObstetricsandGynecology
clerkshipwithstandardizedpatientexperience.
Checklist
GeneralApproachand
CommunicationSkills
Properlyintroducedhimorherself
tothepatient
Establishedandmaintainedrapport
withthepatient
Washedhandsorusedanantiseptic
wash
Usedappropriatedraping
techniques
Performedtheexaminanorganized
fashion
Madethepatientfeelcomfortable
Usedgoodnonverbalskills
Closedtheexaminanappropriate
manner
CervicalCytologyCollection
Selectedappropriatesizedspeculum
andwarmedit
Insertedthespeculumcorrectlyand
visualizedthecervix
Collectedthecervicalcellscorrectly
usingspatulaandcytobrushtothe
pelviccurve
Usedcorrecttechniquetocollect
cellsintothevial
Labeledthespecimenappropriately
Cervical/VaginalCultureandWet
PrepCollection
Selectedappropriatesizedspeculum
andwarmedit
Insertedthespeculumcorrectlyand
visualizedthecervix
Usedtheappropriatecollectionvial
forthespecimen
Foracervicalculture,placedthe
swabintheendocervixfor10
seconds
Well
Done
Needs
Improvement
Not
Done
Cannot
Recall
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Foravaginalculture,obtained
specimenfromtheposteriorvaginal
fornix
Cappedoffandlabeledspecimen
appropriately
Preparedslideforwetprepcorrectly
Correctlyidentifiedyeast,cluecells,
trichomonas,squamouscellsand
whitebloodcells,ifpresent
Appropriatelydiscussedfindings
andtreatmentwithsupervising
clinician
GlobalAssessment
Studentsoverallperformancewas:
ExcellentVeryGoodGoodFairPoor
PerformanceAssessment
Thecervicalcytologyandcervical/vaginalculturecollectionskillsarebestassessed
throughdirectobservationofeitheraclinicalencounter,astandardizedpatient
encounterorsimulatedsessionusingapelvicmodel.Thewetprepcollectionand
interpretationskillsarebestassessedusingvaginalfluid,ifavailable,orothersimilar
material(suchashandlotion).Ifthelatterisused,thestudentshouldhaveaccessto
preparedslidesdemonstratingthefindingscommonlyseenonawetprep,suchasclue
cells,whitecells,trichomonadsorhyphae.
Theprecedingchecklistcanbeusedforperformanceassessmentofaclinicalencounter.
Belowisacasescenario,whichcanbeusedforstandardizedpatientstation,followedby
anexampleofapostencounternote,ifdesired(modeledafterUSMLEClinicalSkills
Exam).
InstructionsfortheCervicalCytology,Cultures,WetPrepStation
Thisstationis30minutesinlength.Thefirst15minutesarespentinterviewingthe
patientandperformingappropriatephysicalexam.Thelast15minutesarespent
writingapostencounternote,whichincludespertinenthistory,physicalexamfindings,
differentialdiagnosis,anddiagnosticworkupplan.
Pleasenotethatstudentsareexpectedtoobtainafocusedhistory,familyhistory,social
historyandmedications,andtocollectacervicalcytology,cervicalandvaginalcultures,
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andadditionalvaginalfluidforthepreparationofawetprep.Makesuretheydiscuss
withthepatienttheirinitialdiagnosticimpressionandworkupplan.
Oncestudentsleavetheexaminationroom,theymaynotreenter.Theyareexpectedto
completetheirnoteandgiveittothestaffwhenfinished.
CaseScenario
Thisisa15minutestation;thestaffmemberwillknockonthedoorwhenfive(5)
minutesremainandattheendofthesession.
MissJonesisa22yearoldwomancomingtotheclinicbecauseofvaginalitchingand
burning.Shehasneverhadapelvicexam.
Vitalsigns:BP120/80 P70/min
R14/min
Temp98.6degreesF
Thestudentstasksareto:
1. Obtainafocusedhistory
2. Performarelevantphysicalexaminationandspecimencollection,includingwet
prep
3. Discussinitialdiagnosticimpressionandworkupplanwiththepatient
4. Afterleavingtheroom,completepatientnoteontheformprovided
PostEncounterNote
History:Includesignificantpositivesandnegativesfromhistoryofthepresentillness,
pastmedicalhistory,reviewofsystems,socialhistory,andfamilyhistory.
HPI:Gravida/Para,duration,severityandnatureofsymptoms,LMP,whetherpregnant,
whethersexuallyactive,lengthoftimewithcurrentpartner,previouspartners,LMP
normal?
PMHx:h/oSTIs,abnormalpapsmears,HPV;ageatmenarche,coitarche
PSHX:cervicalsurgery
Social:Smoking,alcoholuse,#ofsexualpartnersinlifetime
FamilyHx:Breast,cervicalorovariancancer
Medications:hormonalcontraception,HRT
PhysicalExamination:Indicateonlypertinentpositiveornegativefindingsrelatedtothe
patientschiefcomplaint.
Cervicalandvaginalappearance
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?bleedingwithcytologycollection
Vaginaldischargecolor,consistency,odor,amount
Wetprepfindings
DifferentialDiagnoses:Inorderof
likelihood(with1beingthemostlikely),
listupto5potentialorpossible
diagnosesforthispatientspresentation
(inmanycases,fewerthan5diagnoses
arelikely):
1.Vulvovaginalcandidiasis
DiagnosticWorkup:Listimmediate
plans(upto5)forfurtherdiagnostic
workup:
1.Wetprep
2.Bacterialvaginosis
2.CervicalcytologywithreflexHPV
3.Physiologicdischarge
testing
4.
3.HPVvaccine
5.
4.CervicalculturesforGC/chlamydia
5.
PracticalTips
Wesuggestthatthecervicalcytology,culturesandwetprepskillsexaminationbe
introducedtostudentsduringthefirsttwoyearsofmedicalschoolintheformof
didactics,practiceonmodelsandastandardizedpatientexercise(SP).TheSPshouldbe
repeatedduringtheclinicalyears,iffeasible,tosupplementthestudentsclinical
experience.Theperformanceassessmentshouldoccuraspartofanobjectivestructured
clinicalexaminationatendoftheObstetricsandGynecologyclerkshiporattheendof
thethirdyear.
Resources
1.AmericanSocietyforColposcopyandCervicalPathology;www.asccp.org.
2.AmericanCollegeofObstetriciansandGynecologistsTechnicalBulletin:Cervical
cytologyscreening,2003.
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