Exam 10 Flashcards
What are the components of a basic OB/Gyne history?
- CC
- Present illness
- Menstrual history
- Obstetric history
- Other (contraceptive, gynecologic, endocrine, family, social, sexual)
Define polymenorrhea.
Cycle being more frequent than every 21 days
Define oligomenorrhea
Cycle greater than 35 days
What are the aspects of the menstrual history?
- Menarche/menopause/cycle length
- Menorrhagia
- Post-coital bleeding
- Dysmenorrhea/PMS
What are the aspects of the obstetric history?
- Infertility
- Spontaneous/elective abortions
- Vaginal deliveries/C sections/pregnancy complications
Explain the GP system.
G (gravita) - number of pregnancies
P (para) - number of full-term pregnancies, number of pre-term pregnancies, number of abortions, number of living children
All pelvic and breast exams should be ___.
Chaperoned
What should be done prior to the basic pelvic exam?
- Have the patient empty their bladder
- Defer if menstruating
- Assume lithotomy position
- Drape patient with sheet
What is the exam for pelvic relaxation?
Ask the patient to strain and/or cough. Observe for signs of stress incontinence and/or abnormal bulging of walls of vagina
What are the 4 types of speculum?
- Graves
- Pederson
- Pediatric
- Oncology
What is the shape of the Graves speculum and which populations is it used for?
Duckbill; sexually active and multiparous women
What is the shape of the Pederson speculum and which populations is it used for?
Stilleto; virginal, nulliparous, elderly women
The pediatric speculum is a miniature ___.
Peerson
The oncology speculum is used in patients who have had a ___.
Vulvectomy
What should be done prior to the speculum exam?
- Warm speculum with water
- Touch inner thigh with patient for temperature
- Ask patient to lower knees laterally and to relax perineal musculature
- Press fingers on perineal body and assess relaxation
- Make sure blades are closed and thumbscrew loosened (if metal)
Insert the speculum at ___ (angle).
45 degrees
What are the symptoms of bacterial vaginosis?
Often no symptoms; some have malodorous homogenous discharge
What are the components of the Ansel criteria?
- pH>4.5
- Clue cells (20%)
- Whiff test
- Adherent milky white discharge
(3/4)
What are the symptoms of trichomonoiasis?
Frothy gray/green discharge, pruritis, may be asymptomatic; strawberry cervix
What are the symptoms of vulvovaginal candidiasi?
Pruritis, dyspareunia, burning, discharge
What are the USPSTF recommendations regarding screening for cervical cancer?
F, age 21-65 - pap smear every 3 years OR F, age 30-65, pap smear + HPV screening every 5 years
How is the pap smear performed?
Use the cytobrush (broom), rotate 5 times, put into liquid medium, send to lab; avoid cytobrush in pregnancy
When should a woman be referred for colposcopy?
- All women with clearly recognizable dysplasia
- Atypical squamous cells of undetermined significance + any risk factor for cervical neoplasia
- 2 sequential pap smears with ASC-US (repeated within 1 year) and no risks
What are risk factors for cervical neoplasia?
- Multiple sexual partners
- History of STDs
- High risk HPV infection
- Previous malignant or pre-malignant lower genital tract condition
What are the recommendations regarding chlamydia and gonorrhea testing in women?
- All sexually active women 24 y/o or younger, including adolescents OR
- High risk - history of STDs, new or multiple partners, inconsistent condom use if not in mutually monogamous relationship, exchanging sex for money/drugs, incarceration, military recruits, patients receiving care at STI clinics
What is examined in the bimanual exam?
Vagina, cervix, uterus, adnexa
What is the normal shape and size of ovaries?
3.5 x 2 x 1.5 cm
Almond shape
The name of the warts caused by HPV is called ___.
Condyloma accuminatum
The name of the warts caused by secondary syphilis is called ___.
Condyloma lata
What are signs of pelvic relaxation seen with aging?
- Cystocele
2. Urinary incontinence
What are the components of the male GU exam?
- Abdominal (kidney, ureter, bladder)
- External genitalia (penis, scrotum/testes, epididymis, vas deferens, spermatic cord)
- Hernia exam
- Inguinal node exam
- Upright exam
- Digital rectal exam (prostate, seminal vesicles)
What are the steps of the abdominal exam?
- Inspection
- Light palpation
- Deep palpation
- Bladder
- Flank
- Kidney
When is the kidney palpable?
Children, lean adults, abnormality
What are causes of kidney enlargement?
- Hydronephrosis
- Mass
- Polycystic kidney disease
- Compensatory hypertrophy
- Perinephric pathology (adrenals, retroperitoneum)
What are causes of renal pain (CVA tenderness)?
- Pyelonephritis
2. Urolithiasis
How do patients with polycystic kidney disease present?
30-50 y/o, flank pain, hematuria, proteinuria, renal failure, HTN; can progress to ESRD
The bladder is a ___(peritoneal) organ.
Extraperitoneal
Where and when is the bladder palpable?
Above pubic symphysis in the midline; not palpable if empty
The bladder is ___ to percussion when full.
Dull
What are causes of bladder pain with palpation?
- Cystitis
- Stone
- Mass
- Interstitial cystitis/bladder pain syndrome
What are causes of bladder distention?
Urinary retention due to BPH, urethral stricture, bladder stone, MS, spinal cord injury
What are causes of bladder masses?
Invasive bladder tumors (superficial bladder tumors are typically not palpable)
True or false - the ureter is not palpable.
True (except when massively dilated in the pediatric population)
How should the ureter be examined?
Radiologically
What are the effects of a ureteropelvic junction obstruction and how is it treated?
Hydronephrosis and obstruction; treat with pyeloplasty
How should the penis be examined?
- Note circumcised or uncircumcised (retract foreskin if present)
- Hold by plans to check for skin lesions
- Open meatus gently (masses, stenosis, discharges, condyloma)
- Palpate shaft for masses in corporal bodies
What are some causes of skin lesions of the penis?
Herpes, condyloma, syphilis, chancroid, penile SqCC
What are some lesions of the foreskin?
Phimosis, paraphimosis, penile cancer, lichen sclerosis
What are some meatal abnormalities?
Hypospadias, meatal stenosis, condyloma, penile cancer
What are causes of corporal body masses?
Peyronie’s disease, penile fracture, penile or urethral cancer
What are some scrotal skin lesions?
Sebaceous cysts, condyloma
What are some causes of scrotal or testicular enlargement?
Hydrocele, hernia, mass
True or false - a mass in the testis is cancer until proved otherwise.
True
What are some causes of epididymal masses?
Cysts, spermatocele, adenomatoid tumor
What component of the male genitalia feels like linguini upon palpation?
Vas deferens
Blunt injury to the scrotum can cause…
…testicular rupture, hematoma, dislocation of testis, or testicular torsion
How is the hernia exam performed?
- Place the examining finger underneath the peripubic fat pad at the external ring
- Direct the patient to perform a Valsalva maneuver
- Repeat in standing position
What is an indirect hernia?
Follows the same pathway as the testicle through the internal ring and into the scrotum
What is a direct hernia?
Directly through the inguinal canal floor made of transversalis fascia medial to the epigastric vessels
How is the inguinal node exam performed?
- Identify ASIS (top of inguinal ligament)
2. Palpate in gentle, circular motion
What is the purpose of the upright hernia exam?
Assess for varicoceles
What are varicoceles?
Dilated veins of the spermatic cord; feels like a bag of worms
What are normal prostate physical exam findings?
Smooth and rubbery
What are some causes of prostate enlargement?
BPH, prostatitis, cancer
What can cause nodularity of the prostate?
Cancer (prostate and rectal), BPH nodules, prostate calcifications
What can cause bogginess and tenderness of the prostate?
Infection, prostatitis
What can cause seminal vesicle pathology?
Tumor or ejaculatory duct obstruction
What is the most common non-cutaneous malignancy in US men?
Prostate cancer
The Emergency Medical Treatment and Active Labor Act requires hospitals with EDs to provide a ___ to any individual who comes to the ED and requests such an examination. It also prohibits hospitals with EDs from ___ to examine or treat individuals with an emergency medical condition.
Medical screening examination; Refusing
What is the Illinois Good Samaritan Act?
Grants good-faith immunity to individuals who provide emergency assistance without charging a fee
What is the Illinois Health Care Surrogate Act?
Enables family members, friends, or guardians to make medical treatment decisions for people who lack the ability to make and communicate decisions about medical care, and who do not have a Power of Attorney.
The Illinois Health Care Surrogate Act permits a surrogate decision maker to forgo life sustaining treatment only if what three conditions are met?
- Patient has no valid Health Care Power of Attorney or Living Will Declaration in Place, or one is in place but it does not apply to the patient’s condition or is invalid for some reason
- Patient must lack decisional capacity
- Patient must have a qualifying condition
What is the order of priority as described by the Illinois Health Care Surrogate Act?
- Patient’s guardian of the person
- Patient’s spouse
- Any adult son or daughter of the patient
- Either parent of the patient
- Any adult brother or sister of the patient
- Any adult grandchild of the patient
- Close friend of the patient
- Patient’s guardian of the state
What provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information? At the same time, it is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes?
The HIPAA Privacy Rule of the health Insurance Portability and Accountability Act
What specifies a series of administrative, physical, and technical safeguards for covered entities to use to assure the confidentiality, integrity, and availability of electronic protected health information?
The Security Rule of HIPAA
What is HIPAA’s Breach Notification Rule?
Requires hospitals to tell the government and the patient about situations that involve an impermissible use or disclosure of the patient’s protected health information, except those in which the hospital demonstrates that there is a low probability that the protected health information is compromised
What prohibits a physician from making a referral for certain designated health services to an entity in which the physician (or an immediate member of his or her family) has an ownership/investment interest or with which he or she has a compensation arrangement, unless an exception applies?
Physician Self-Referral Law (Stark Law)
Note - also prohibits the entity from presenting or causing to be presented claims to Medicare for those referred services; establishes a number of exceptions and grants the Secretary the authority to create regulatory exceptions for financial relationships that do not pose a risk of program or patient abuse
What is the Excluded Provider Rule?
OIG has the authority to exclude individuals and entities from federally funded health care programs pursuant to section 1128 of the SSA and maintains a list of all currently excluded individuals and entities
The ___ makes it a criminal offense to knowingly and willfully offer, pay, solicit, or receive any remuneration to induce or reward referrals of items or services reimbursable by a federal health care program.
Anti-kickback Statute
The ___ protects the government from being overcharged or sold substandard goods or services. It imposes civil liability on any person who knowingly submits, or causes to be submitted, a false or fraudulent claim to the Federal Government.
False Claims Act
A defensible case can be made indefensible by ___.
Poor documentation
True or false - the patient’s medical record should not be used to place blame for a bad outcome.
True
When in doubt about a patient outcome, what should you do?
Contact risk management/patient safety department; do not document in the patient chart that you called risk management
What is upcoding?
Billing for a higher service than the one actually performed
What is phantom billing?
Billing for a service that was never performed
True or false - not billing for a service insulates a provider from liability.
False - it does not insulate a provider from liability
Who should make the decision regarding writing-off a bill?
Risk management or another department
Under the False Claims Act, every service provided to a ___ patient must be billed to CMS.
Medicare
