Flashcards in Chapter 6 - GYN History & Physical exam Deck (22):
Gynecology is the branch of medicine that deals with diseases and routine physical care of the reproductive system of women.
Greek: gyne meaning "woman - more as queen"
The purpose of the health history ...
To establish a relationship with a woman while learning about her health.
Optimally: comfortable, confidential, private setting, sufficient time, fully clothed, equality in seating, no interruptions, client receives clinician's undivided attention, etc.
Health history provides ...
About 90% of the information needed for an accurate diagnosis.
General health history, initial portion ...
Clinician introduction, statement of purposes of the interview, invitation of questions at any time, confirmation of basic demographic information, puts woman at ease.
Reason for visit or chief concern, questions ...
How may I help you today?
What has brought you in today?
Client should describe in her own words her reason for this visit. Try not to interrupt.
History of present illness ...
Allows clinician to give structure to the present problem, arranges events chronologically, giving sequential framework. At minimum, need the answers to:
What were the circumstances at the time the problem started?
What has been the sequence of events for the symptoms?
Has the problem occurred before? If so, what were the circumstances of the previous occurrence(s) and what lead to its disappearance?
To what extent is the problem interfering with daily life or relationships?
Which questions does the woman want answered today? What are the expectations for today's visit?
Have other steps been taken to solve the problem? If so, what were they and how effective have they been?
General medical history ...
List significant health problems, all hospitalizations, surgical procedures.
Ask about specific, population frequent conditions: DM, HTN, respiratory illnesses, infectious diseases, mental health problems, etc.
General medical history, additional important information ...
Medications and allergies - prescribed, OTC, complementary, allergies to meds, foods, other substances.
Substance abuse - tobacco (past & current use, daily #, length of time smoking, desire to quit), alcohol (type, amount per day/week, binge drinking habits), illicit substances (types, amount, route, frequency of use) - this is information gathering time, not educational, cessation time.
Family Heath History - 1st degree relatives - parents, grandparents, siblings, children. Need: serious illnesses, cause of death, age at time of death, congenital malformations, unexplained intellectual and developmental disabilities,
Social & occupational history - highest educational level, marital status/significant relationships, employment or vocational history, housing, financial status, family relationships, potential and actual stressors or social problems.
Safety issues: seat belts, helmets, firearms, intimate partner abuse.
Personal habits: exercise, sleep, nutritional patterns
Gynecologic health history
Menstrual history: age at menarche, date of last menstrual period (LMP), length of cycle, average # of days of menses, characteristics of menstrual flow, regularity of cycles, descriptions of irregularities.
Pregnancy history: # of times pregnant, describe each pregnancy (year, spontaneous or assisted vaginal birth, cesarean, sex and weight of baby, complications, is child alive and well). Number of abortions: spontaneous, induced, ectopic pregnancies, molar pregnancies. Collect: gestational age, procedure, complications, outcome.
History of vaginal and pelvic infections: what types, treatments, how frequent, complications. Screen for HIV. # of sexual partners at present and lifetime, currently sexually active, contraception and condom use.
Douching: frequency, medication or solutions used, reasons
Gynecological surgical procedures: minor (endometrial biopsies, laparoscopic procedures) and major (female genital mutilation). Year, indication for procedure, significant complications, outcomes.
Urologic Health: occurrence and frequency of bladder infections, renal infections, incontinence, or other abnormal symptoms.
Cervical Cancer Screening: previous cervical cytology screening, date, results, if abnormal, what follow-up occurred, and have subsequent screenings been normal.
Sexual Health: sexually active, with men, women, or both, satisfaction, self and partner, concerns
Contraceptive Use: method, use, desire for change
Abnormal symptoms: problems need full description, relationship to monthly cycle, non-menstrual vaginal bleeding
Gynecological Health History, conclusion
"I've finished with my questions about your health. Is there anything I have omitted or not covered, or that you would like to add to help me better understand your health or problem today?"
General Physical Examination
Physical measurements: ht, wt, BP, HR, temperature, BMI and BP are screening tools.
General appearance: posture, striking or obvious characteristics or limitations, general emotional state, appropriateness of dress, speech pattern, social interaction during visit
Eyes, ears, nose, and throat: inspect the physical health of eyes, nose, and ear. Inspect the lips, teeth, gums for dental health, visualize the oral cavity for mucosal color, lesions, and tonsillar edema or exudates.
Neck: ROM, palpate lymph nodes in the neck and clavicular area
Thryoid: Palpate the gland and isthmus
Chest and lungs: auscultate the posterior, lateral, and anterior lobes.
Spine: palpate vertebral column, inspect skin.
Kidneys: check costovertebral tenderness
Reflexes: elicit patellar and additional reflexes as indicated
Peripheral circulation and varicosities: inspect legs and feet
Abdomen: inspect the skin, palpate superficially and deeply in all quadrants and palpate inguinal lymph nodes
BSE, ongoing controversy about efficacy and necessity.
Clinical breast examination remains a part of the general physical exam.
Involves: inspection and palpation
Breast exam, inspection
Compare two breasts for size, symmetry, contour, skin color, texture, venous patterns, lesions.
Lift breasts to inspect lower and lateral aspects.
Skin texture should be smooth, contours uninterrupted bilaterally, and venous patterning similar in both breasts.
Arm positions: initially at the side, but have patient raise arms over the head and pressed against the hips. Then have patient lean forward. Check contour and symmetry throughout.
Nipple and areolae exam, inspection
Areolae should be round or oval, bilaterally nearly equal in configuration with a smooth surface.
Nipples should be equal or nearly so. If one or both are inverted, ask if inversion has been a lifelong characteristic. New inversion suggests pathology. Nipple retraction or flattening is another abnormal finding. Look at nipple orientation. If not aligned, malignancy may be cause.
Very small sebaceous glands found on the areolae may be seen as slightly raised fleshy protuberances, common finding.
Have woman sitting with arms resting freely at her sides. Face patient, palpate with finger pads d/t greater sensitivity. Palpate all four quadrants for nodules and lumps. Press firmly enough to get a good sense of underlying tissue but not so firmly that the tissue is compressed against the rib cage. Rotate the fingers in a clockwise or counterclockwise direction. Systematic approach is important. Two patterns: concentric circles starting from outer edge and spiraling inward to the nipple. Or, top to bottom in vertical strips. Light palpation, followed by deep palpation.
First sitting, then supine.
The feel of breast tissue
Adult women: breast tissue feels dense, firm, and elastic. Prior to and during menstruation, some women experience cyclical tenderness, swelling, and nodularity.
If a mass if felt, note: location, size, shape, consistency, tenderness, mobility, and demarcation of borders.
Tail of Spence
Breast tissue that extends from the upper outer quadrant toward the axilla. Most malignancies develop in the upper outer quadrant. Have patient raise arms over her heard and gently compress the tissue between the thumb and fingers.
Once entire breast has been examined, palpated nipple gently. Compress the nipple between the thumb and index finger to inspect for discharge. This can be painful.
Lymph Node exam
Have the woman sit with the arms flexed at the elbow. Reach deeply into the axillary hollow and press firmly upward with the palmar surfaces of the fingers. Then bring the fingers downward to gently roll the soft tissue against the chest wall. Be sure to examine not only the apex, but also the central and medial aspects along the rib cage, the lateral aspect along the medial surface of the arm, the anterior wall along the pectoral muscles, and the posterior wall along the border of the scapula.
Axillary lymph nodes are usually not palpable in adults.
Explain what you are going to do before you do it. Repeat.
Ask woman if she has any special concerns or questions.
Maintain eye contact throughout, as much as possible, even if she doesn't return eye contact.
Ask woman to indicate if she feels any discomfort.
Ensure privacy for the exam. Close, lock, the door.
Invite the woman to have someone accompany her for support during the exam.
If male clinician, have a female assistant present.
Have woman empty her bladder.
Offer a drape.
Raise top of exam table to at least 30 degrees and have a pillow at the head of the table.
Lithotomy position with feet in footrests.
Buttocks extend slightly beyond edge of the exam table to allow correct positioning of the speculum.
WASH your hands.
Ask woman to separate her legs, never do it for her.
If woman becomes tense, stop exam, find out if there is a problem, continue only once woman is at ease.