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PCM IV Final > 10. Well-women exam > Flashcards

10. Well-women exam Flashcards

1
Q

Well-women exam is a annual appointment where it is important to do what?

A

Get a thorough history

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2
Q

When getting a family history, what do we look for?

A

High-risk factors that may tell us pt needs early screening

    1. Cancer (breast, ovarian, uterine/endometrial, colorectal)
  • 2. DB
  • 3. Thyroid disease
  • 4. Familial hyperlipidemia
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3
Q

what do we record when getting surgical history?

A

Record chronologically and get [dates, hospital, surgeon and complications]

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4
Q

obstetric history

A

list each pregnancy in chronological order and note

  1. Date of delivery
  2. Hospital
  3. Gestational age, sex and BW (gravidity and parity)
  4. Type of delivery
  5. Duration of labor
  6. Type of anesthesia
  7. Maternal and fetal complications.
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5
Q

gravidity and parity

A

gravidivity = number of times W has been pregnant

parity = number of pregnancies that led to a birth at or beyond 20 weeks or bb weighing more than 500gms

[term, preterm, abortion and living]

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6
Q

term and preterm

A

term = >37 weeks

preterm = 20 - 36 weeks and 6 days

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7
Q

gynecologic history

A
  1. Menarche; average age of 1st period
  2. Interval cycles
  3. Days of menses
  4. Abnormal bleeding
  5. pain and cramps
  6. LMP
  7. sewxual history (orientation, age 1st sex and number of partners)
  8. ABNL pap/hx of STIs
  9. Type of contraeption
  10. Preconception planning and counselig
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8
Q

how to determine due date in person who knows LMP

A

Naegels Rule

[-3months + 7 days]

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9
Q

ROS for breasts

A

Pain

Discharge

Masses

Inverted nipples

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10
Q

ROS for GU

A

Discharge

Dysparenunia (pain with sex)

Menses

Incontinence

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11
Q

Recommendation for breast exam by ACOG

A

Age 20-39: ever 1-3 years and every year with annual mammogram >40YO

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12
Q

Recommendation for pelvic exam by ACOG

A

q year at 21 YO

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13
Q

ACOG recommendation for preventative health care services and guidance

A

13-15YO

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14
Q

what to ask in history when screening 13-18YO

A
  1. CC
  2. Health status: medical/surgical, menstrual, reproductive health
  3. FHx
  4. Dietary/nutritional assesment and activity
  5. Use of medications
  6. Tobacco, alcohol, drugs
  7. Emotional, physical and sexual abuse
  8. Sexual practices
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15
Q

PE in 13-18YO

A
  1. Height, weight and BMI
  2. BP
  3. Secondary sex characterisitcs (Tanner Staging)
  4. Pelvic exam if indicated by hisotry
  5. Abdominal exam
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16
Q

Labs in 13-18YO

A
  1. Gon and Chylam (if sexually active)
  2. HIV (if sexually active)
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17
Q

Evaluation and Counseling in 13-18YO

A
  1. Sexuality and STI prevention
  2. Fitness and nutrition
  3. Psychosocial evaluation and sexual abuse
  4. Tobacco, alcohol and drugs
  5. CV RF
  6. Health risk assessment
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18
Q

Immunizations in 13-18YO

A
  1. Tdap vaccine booster between 11-18YO
  2. HepB vaccine (if not immunized)
  3. HPV vaccine
  4. Influenza vaccine (annually)
  5. MMR (if not immunized)
  6. Varicella (if not immunized)
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19
Q

19-39YO history

A

Same +

  1. get history of sexual practices, including vaginal, anal and oral, sexual oritentation, number of partners and contraception
  2. Urinary and fecal incontinence
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20
Q

PE 19-39 YO

A
  • + breast exam q 1-3 years begining at age 20
  • + pelvic exam (19-20YO = when indicated by history; start after 21 YO)
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21
Q

Labs for 19-39 YO

A
  1. Cervical cytology (pap smear)
    1. 21-29YO = q 3 years with only cytology
    2. >30YO = q 3 years with only cytology OR cytology + HPV q 5 years
  2. Gon/Clylam testing
    1. <25YO if sexually active
    2. >26YO and high risk
  3. HIV
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22
Q

Evualation and Counseling for 19-39YO

A
  1. Sexual and reproductive planning: discuss reproductive plan, preconception, genetic counseling, STI prevention
  2. Psychosocial evaluation (intimate partner violents and rape prevention)
  3. Health risk assessment (breast self-awareness)
  4. T, A and Drugs
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23
Q

19-39 immunizations

A
  1. TDAP
  2. HPV
  3. Influenza MMR
  4. Varicella
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24
Q

extra things to ask during 40-64YO history

A
  1. Pelvic prolapse
  2. Menopausal symptoms
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25
Q

extra things to do in PE of 40-64YO

A

Breasts = yearly clinical breast exam

26
Q

Labs 40-64YO

A
  1. Cervical cytology (pap smear)
    1. cytology alone = q 3 years
    2. cytology + HPV = q 5 years
  2. Colorectal cancer screening
  3. Lipid profile assessment q 5 years begining at 45YO
  4. Mammogram q year >40YO
  5. TSH q 5years beginning at 50YO
  6. DB testing q 3 years begining at 45 YO
  7. HIV
27
Q

when do you do

- lipid profile assessments-

A

q 5 years >45YO

28
Q

when do you do

colorectal cancer screening

A

begining at 45-50 YO q 10 years

  • AA begin at 45 YO because increased incidence and earlier onset
29
Q

when do you do

mammogram testing

A

yearly after 40YO

30
Q

when do you do

TSH testing

A

q 5 years starting at 50 YO

31
Q

when do you do

DB testing

A

q 3 years begining at 45 YO

32
Q

+ should you add when evaluation and counseling 40-64 YO

A
  1. During psychosocial eval, screen for intimate partner violence and advanced directives
  2. 55-79YO = start ASA prophylaxis to reduce risk of stroke
  3. Breast self awareness
  4. Chemoprophlaxis for BC for high risk W 35Y or older
33
Q

+ immuniztion at 40-64YO

A

Varicella Zoster vaccine at 60YO or older.

34
Q

history for 65YO >

A

same as 40-64

35
Q

should pelvic exams be done after 65YO?

A

no, you can DQ is age or health issues intervene

36
Q

should pap smears be done after 65?

A

DQ if:

  1. no hx of CIN2 or higher on 3 prior consecutive (-) CYTOLOGY tests
  2. 2 consecutive (-) co-test within last 10 years

If hx of CIN2/3 => continue pap smears for 20 years after, even its past 65YO.

37
Q

extra labs to get after 65

A
  1. Bone mineral density screening: if no new RF = do NOT screen more than q2years
    • lipid progfile + mammogram + TSH + DB + UA
38
Q

+ evual and counseling in 65YO older

A
  1. Sexual function
  2. still ask intimiate partner violence and advanced directives
  3. injury prevention (prevention of falls)
39
Q

+ immunization of 65YO

A

Pneumococcal vaccine ONCE after 65YO

40
Q

When should BMD (bone mineral density) be screened for ealier

A
  1. post-menopausal W <65YO if high-risk factors like
    1. hx of fractures
    2. less htan 127 lbs
    3. medical cause of bone loss
41
Q

When should mammogram be screened for ealier

A

screen <40YO if high RF

    1. hc or breast cancer or ovarian canacer
      • for BRCA1/2
    1. hx of high-risk breast biopsy (atypical hyperplasia nad lobular CIS)
42
Q

When should lipid profile assessment be screened for ealier

A
  • screen earlier than 45 YO if RF
      1. Hx of CAD or noncoronary athersclerosis (AAA, PAD)
      1. Obsese
      1. Heart disese RF (HTN, smoking)
43
Q

When should colorectal be screened for ealier

A
  1. Fhx of colorectal cancer or adenomatous polyps in 1st degree relative <60YO or if in 2 or more 1st degree relatives at any age
  2. Fhx of FAP, HNPCC
  3. Hx of colorectal cancer, adenomatous polypls, IBD, UC, Crohns
44
Q

When should DB be screened for ealier

A
  1. Screen before 45YO if RF
    1. BMI >25
    2. High risk race
    3. Prior birth >9lbs
    4. Hx of gestational DM, PCOS
45
Q

1st thing to do in PE

A
  1. inform pt whts going to happen
  2. set out gown and sheet and tell pt how to put on
  3. knock on door and wait for answer
  4. bring chaperone/nurse
  5. wash hands
46
Q

order of gynocologic exam

A
  1. general appearance
  2. head and neck (chlasma = pigmentation on bridge of nose and under eyes can be a sign of PG)
  3. CV/lungs
  4. Breast
  5. abdomen
  6. Female exam
  7. Extremeties and neuro
47
Q

how to do breast exam

A
  1. pt sits upright (or supine with arms raised behind head to allow breast tissue to spread evenly and allow deeper palpation)
  2. palpate all quadrants and gently, bit firmly push to chest
  3. inspect each breast and compare (should be dense, firm and elastic)
    1. note size, sym, contour, venous pattern, skin, nipple abnormalities
    2. if mass = note location, size, shape, mobile?, retractable
  4. palpate nipple (squeeze between thumb and index to see if discharge)
  5. review how and when to perform self-brest exam at well-women exam (WWE)
48
Q

what to do if pts FIRST pelvic exam

A
  1. show her instrucments
  2. tell her why its important to test and obtain cervical cytology
49
Q

how to perform pelvic exam

A
  1. set head of bed to 30 degrees
  2. readjust pillow
  3. put pt in dorsal lithotomy position with buttox barely hanging off table
  4. warm speculum and make sure you have supplies
  5. adjust light
  6. gloves
  7. inspect: vulva, perineal, external genitalia
  8. Insert speculum
    1. make sure butt off table => warm => hold in dominant hand and place on inner LEFT thigh so she can assess temperature
    2. use L hand to seperate labia minora/majora and expose introitus
    3. Insert tip of speculum => move to 45 degree angle => slide into vaginal valut (adjust if prolapse) as far as it goes (entire speculum)
    4. Open smoothly
    5. Slighlty tilt to ciew cervix
50
Q

type of speculum for children exams

A

pediatric specculum bc very narrow blades

51
Q

type of specculum for nulliparous women

A

pederson speculum bc narrow blades

52
Q

type of speculum for multiparous/obese women

A

graves speculum

53
Q

what to do if you cant see cervix?

A
  • READJUST: move the speculum superior or inferior because it may be in the anterior or posterior forniz region, but DO NOT PULL OUT INITIALLY
54
Q

what to do if you cant see cervix after readjustment

A
  1. remove and perform bimanual exam
  2. review surgical history and ask if she had any female surgeries
55
Q

how to do cervical cytology (pap smear) during speculum exam

A
  1. Use spatula to scrape ectocervix
  2. Use cytobrush to obtain endocervical cells
  3. Put on slide or thin prep *** (swish or remove tip of swab and sent to path)
  4. Ulock and remove speculum gently, making sure to look at vaginal rugae as you retract
  5. dispose speculum or place metal in designated area
56
Q

pros of liquid vs conventual prep for pap smear

A

liquid prep also IDs HPV, ASCUS and gonorrhea and chlamydia

57
Q

how to conduct IBE (internal bimanual exam), after cervical cytology

A
  1. Stand up. Push the light out of your way with your arm so you don’t contaminate the light w/ your gloves.
  2. Tell patient that you are going to do an internal exam and check her cervix, uterus, & ovaries
  3. Nurse will place lubricant on your index & middle finger.
  4. Insert your lubricated gloved fingers into the vagina & press downward, waiting for the muscles to relax, place your left hand on the suprapubic region
    1. If this is uncomfortable or is pt’s first pelvic exam => use 1 finger
  5. Palpate vaginal walls for [cysts, nodules, masses or growth]
    1. Tell pt to let you know if unvcomfy and watch where you put thumb (dont touch urethra meatus or clit) and watch for language (dont say good)
  6. Palpate cervix with palamar surface of finger: look for motion tenderness and consistency
  7. Palpate the uterus by placing
    1. left hand above the pt’s pubic symphysis
    2. right intravaginal fingers in the post fornix, behind the cervix .
    3. press down with abdominal hand and lift uterus up with vaginal hand to entrap: size, shape, contour adnd movility
  8. Palpate ovaries
    1. put fingers of abdominal hand on RLQ
    2. hand in vagina => place both finers in right latera lfornix
    3. sweep abdominal fingers down to capture ovary
58
Q

what is hegars sign

A

In pregnancy the uterine consistency becomes softer and you may be able to palpate between the cervix and fundus.

59
Q

how should NL ovaries feel when palpated

A

firm, ovoid, slightly tender, 3x2x1 in size and often hard to palapate due to location, size and body habitus

60
Q

how to perform rectovaginal exam

A
  1. assess anal sphincter, rectal walls & for uterosacral nodularity; rectocele vs enterocele
  2. Usually performed with index finger in vagina & middle finger in rectum
    1. ​anal sphinter
    2. anal walls: move vaginal and rectal fingers and ask to bear down to look for masses, polyps, strictures or tenderness

PCM IV Final (12 decks)

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