Chapter 6 - GYN History & Physical exam Flashcards
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.
Gynecology
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”
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.
Review immunizations
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
Heart: auscultate
Abdomen: inspect the skin, palpate superficially and deeply in all quadrants and palpate inguinal lymph nodes
Breast Examination
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.
Montgomery’s tubercles
Very small sebaceous glands found on the areolae may be seen as slightly raised fleshy protuberances, common finding.
