exam 1 - hx and PE Flashcards
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)
inspection genitalia and vagina
Inspect:
-Mons veneris
-Labia majora (pl.) (s.: labium majus)
-Labia minora (pl.) (s.: labium minus)
-Clitoris
-Urethra
-Skene’s and Bartholin’s glands
Inspect all structures for ulcerations, erythema, change in pigmentation, verrucae (warts from HPV), evidence of trauma, rashes, any discharge
speculum exam rules
-Use water-based lubricant
-Use smallest speculum necessary
-Inspect vaginal walls
-Obtain cervicovaginal swab with complaints of malodorous discharge or pruritus
inspecting the cervix and collection of pap smear and testing for STIs and vaginitides
Inspect cervix
-Parous : previous delivery, elongated os
- nulliparous: transformation zone gone + retracted into the canal, small circular os
-Lesions
-Cervical discharge
Perform cervical neoplasia screening if indicated
Collect nuclear acid amplification (NAA) swab for STIs and vaginitides if indicated
-May also collect urine for screening for STIs
cervical ectropion surrounding multiparous os (l.)
-red part is ectropion
-long os means the patient has delivered
-red part is ectropion
-long os means the patient has delivered
-nulliparous os (r.)
-transformation zone is gone
bimanual exam steps
-1. Stand up
-2. Insert one or two fingers (index and middle finger) in vagina
-3. Volar aspect of wrist facing up, palpate cervix
-Length
-Position
-Is internal os open or closed?
-Cervical motion tenderness
-4. Palpate uterus with abdominal hand
-5. Make a “sandwich” of uterus between abdominal and vaginal hands
-6. Sweep over to L and R to palpate adnexa
rectovaginal exam
No need to perform it routinely. indicated in pts with suspected or known:
-Pelvic malignancy
-Endometriosis
-Retroverted uteri
Remove fingers and change gloves for rectovaginal exam, if indicated
-Insert one finger in rectum and one in vagina (index finger in vagina, middle finger in rectum)
-Palpate for: sphincter tone, masses, tenderness, integrity of rectovaginal septum, posterior wall of uterus, uterosacral ligaments
-May also yield stool for guaiac, if indicated
at the end of exam
-Ask patient to move back toward top of table and to sit up
-Offer assistance, if indicated
-Offer a tissue (to clean up from lubricant)
-Allow pt to dress privately
-Then review findings, assessment and plan
-Answer all questions
- Review findings right after ; pt worried if you leave for a min w no results
my documentation of normal pelvic exam - ex documentation
-External genitalia- No lesions noted
-Vagina- Normal rugae, no lesions, no abnormal discharge
-Cervix- Long, closed, posterior, no CMT, no lesions, no discharge
-Uterus- Anteverted, normal size, nontender, no masses
-Adnexa- No masses, normal size, nontender
-Rectovaginal exam- Normal sphincter tone, no masses, nontender, rectovaginal septum grossly intact, no nodularity noted of uterosacral ligaments, no masses or tenderness noted of posterior uterus (if palpable)
fundal ht
-fundal ht is top of uterus during pregnancy
-highest it goes is xiphoid
-start at the xiphoid to palpate
-after 20 weeks -> ht = weeks + or - 2
-20 weeks is umbilicus
-Assess uterine size every prenatal visit
-Measuring fundal height with tape measure performed every prenatal visit after 20 weeks
-fundal height = +/- 2 cm of gestational age in a well dated, normal, singleton pregnancy after 20 weeks GA
leopolds maneuvers
-at the right side of the pt
-doppler at the back of the neck
-first 3 maneuvers -> stand at pt’s R knee and face the L shoulder
-1st maneuver: fetal lie (transverse or longitudinal)
-2nd maneuver: localization of the fetal spine
-3rd maneuver: localization of the fetal head
-4th maneuver -> stand at pt’s R shoulder and face the L knee
-4th maneuver: palpation of small parts (elbows, knees, etc.) - from above
