exam 1 - hx and PE Flashcards
(34 cards)
A 23 yo patient had a normal vaginal delivery a few hours ago and then complained of severe RUQ pain. Two resident physicians saw her and performed a cursory history and physical exam.
They decided she was being dramatic and administered lorazepam.
She died about an hour later from a ruptured liver capsule secondary to hemolysis, elevated liver function tests, and low platelets (HELLP) syndrome.
But she really died from the lack of care she received from the two residents.
They decided she was being dramatic and administered lorazepam.
She died about an hour later from a ruptured liver capsule secondary to hemolysis, elevated liver function tests, and low platelets (HELLP) syndrome.
But she really died from the lack of care she received from the two residents.
-1% of pts
How should you approach OBGYN patients?
Be extremely careful about privacy with all patients, but especially with the ob-gyn patient
Take your history:
- With your patient dressed
- With only the pt present if at all possible: once of reproductive age, can be seen alone
- You will ask questions of your pt that she may not want to have anyone else overhear, otherwise might not get the right story
- She will probably not be able to anticipate these very private inquiries
- If the patient wants someone present for the physical exam, that is fine
- Lazy, stupidity and ARROGANCE (requirement) can kill people
Gravidity
-gravidity = # of pregnancy in pts life
-0= nulligravid- never pregnant
-gravida 3 = 3 pregnancies
Parity
-outcome of the pregnancy noted in gravidity
-4 columns from L to R
-1st- # of full term (>37 weeks)
-2nd- # of preterm (20-36 weeks, 6 days of gestation after LMP)
-3rd- # of episodes of fetal wastage (< 20 weeks) -> includes ectopic pregnancies and abortions
-4th- # of neonates living >28 days after delivery
G4, P1031
How many full term pregnancies has she had
1
LMP
- the first day of normal menses = LMP
-If month since LMP premenopausal -> pregnancy test
-stop testing pregnancy >50-55 yo with irregular menses or menopausal, or certainly if pt had hysterectomy or castration
past OB history: how many pregnancies do you document? and what components in all deliveries?
-Document at least last 5 pregnancies in reverse chronological order
For all deliveries, list:
-Month and year
-Gestational age
-Route of delivery- If via Caesarean section or operative vaginal delivery, why?
-forceps delivery, vacuum extracted delivery
-Neonatal wt and gender
-Complications, if any, in pt or neonate(s)
past Gyn history: menstral and sexual hx
menstrual history:
-Age at 1st period (menarche)- avg 12
-Length of menstrual CYCLE (# of days from 1st day of bleeding to day before next period starts)
-Length of menstrual PERIODS (# of days of bleeding)
sexual history:
-# of partners now
-# of partners in lifetime
-Age at 1st sexual encounter (coitarche)- increase risk of HPV if encounter before 18
-Sexual orientation
-With what gender does patient most identify?
-With what gender does/do partner(s) identify?
trimesters
-first trimester - 14 weeks
-preterm- 20-36 weeks
-full term - 37+ weeks
-20 weeks not viable
-22- unlikely
-23- grey area
-24- survivable
OB pt with cancer
-chemo- okay
-radiation- no
gyn history: contraceptive hx and health maintenance
contraceptive hx:
-not everyone needs or wants contraception!
-Ask plans for family or pregnancy in the next year
-Ask about any previous form(s) of contraception used
health maintenance:
-Last screening for cervical neoplasia and result
-pts 13-65yo : Last HIV test (in NYS)
-For patients of any age, but primarily <26 yo, last STI screening
-Individualize for other STIs depending on risks, history, and population
USPSTF recommendations for STI screening
-chlamydia, gonorrhea, HIV and syphilis for cisgender women <25 of >25 with increased risk
-NYS recommends screening for HBV (hep B) for all pts at least 1x in their lives
USPSTF screening recommendation for cervical cancer
- recommends cervical cancer screening for AVERAGE risk pts
-dont need a pelvic exam in anyone until 21 unless problem
-primary HPV testing is better
cervical cancer: who is NOT average risk
-Pts with a hx of:
-Abnormal cervical neoplasia in past 10-20 years
-Precancerous cervical disease or h/o cervical CA
-Compromised immunity
-Exposure in utero to a teratogen, diethylstilbestrol (DES) that increases the risk of clear cell adenocarcinoma of the vagina (additional screening q6 months)
-Frequency of screening individualized for these pts
intimate partner violence (IPV) overview/stats
-Up to 71% of pts are affected by IPV worldwide
-up to 13.5% of pregnancies
-OBGyn may be only person who pt has chance to see for intimate partner violence (during pregnancy)
-leading cause of injury to U.S. women
-American woman is assaulted or beaten every 15s
Includes:
-Physical abuse (kicking, hitting, biting, shoving, choking, assaults with weapons, death)
-Sexual violence
-Emotional or psychological abuse
-Reproductive coercion- poking hole in condoms, hiding OCP, taking out IUD
-Stalking
IPV risk factors
-Younger age
-Young pregnant people
-pts <25 yo and pregnant -> risk of dying from murder doubles
-Limited education
-Lower socioeconomic status
-Indigenous people
-Drug and alcohol use disorder
Why does intimate partner violence occur
-unknown
-Inequality and gender discrimination probably play a part
-Many assailants witnessed domestic violence as children
-Assailants use physical force and violence as a way of resolving anger and other emotions
-The assailant usually exhibits impulsive behavior and has little self-control
IPV cycle of abuse
- abuse
- honeymoon
- tension building
how to screen for IPV and what to do with positive screen
Screen:
-Do you feel safe in your relationship?
-Are you afraid of your partner?
-Has your partner ever hurt you?
What to do with a positive answer:
-Express support
-Tell patient you are concerned
-Help to build self esteem
-you dont deserve that (these pts are severely insecure usually)
-im concerned about you
- NYS: IPV is not reportable event unless sexual assault
Refer to:
-Police- can be more harmful in some cases
-Social worker**
-Hotlines
-Offer advice
15 year old, sexually active, wants to be on OCP. Do they need an exam?
-do a urine STI screen and pregnancy test
-no pelvic exam necessary
remainder of history, -If you perform a pelvic:
-Collect family hx, psychosocial hx, Rx, allergies, ROS as per usual
-Consider whether pt needs a pelvic exam! -> Not every pt needs one
-If you perform a pelvic:
-empty the bladder
-Collect urine if ANY chance you will want it for any studies
-Have pt remove needed clothing only
-a full bladder can push the uterus up and make it seem enlarged
do you need a chaperone during pelvic exam
-Depends on state law, hospital and practice policies
-You should always have a chaperone, no matter your gender!
-Insist on one from the outset of your career
the transformation zone
-columnar cell -> squamous cell -> metaplasia -> vulnerable to HPV
physical exam
-Breast exam if indicated
-Abdominal exam
Pelvic exam:
-Inspection of external genitalia
-Speculum exam
-Vagina- Collection of discharge for wet mount or NAAT for vaginitides, if indicated
-Cervix- Pap, GC/CT nuclear acid amplification -> Urine is also acceptable
-Bimanual exam
-soft uterus -> pregnancy
-Rectovaginal exam, if indicated (suspected malignancy, endometriosis)
