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RGU 1 > GYN History and Physical > Flashcards

GYN History and Physical Flashcards

1
Q

What is the order of the GYN History?

A
  1. CC: “in patient’s words”
  2. HPI: Age, Gravidy, Parity, FDLMP, details of chief complaint.
  3. Allergies
  4. Medications (birth control)
  5. PMH (Past medical history).
  6. PSH (Past surgical history).
  7. Past OB Hx
  8. Past GYN Hx
  9. FH (Family Hx)
  10. SH (Social Hx)
  11. ROS
  12. PE
  13. Assessment
  14. Plan
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2
Q

What are the G’s and P’s?

A
  • G= gravida (number of pregnancies).
  • P= para (number of births).
  • Parity= FPAL
    F= full term 37+ weeks
    P= pre-term 20 to less than 37 weeks.
    A= abortion
    L= living
    *Ex. G4P1122
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3
Q

What must be included in the Obstetrical History for each pregnancy?

A
  • Date
  • Gestational Age
  • Mode of delivery (NSVD, VAVD, FAVD, C-section).
  • Sex
  • Birth Weight
  • Labor
  • Complications (maternal & fetal).
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4
Q

What are some important points to remember about the GYN history?

A
  • avoid making assumptions (i.e. that she is heterosexual or is sexually active).
  • begin with an open-ended question that will elicit the woman’s gynecologic concerns.
  • ask sensitive questions later in the history.
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5
Q

What are the basic components of the gynecologic history?

A
  • menstrual history= age of menarch (onset of menses) x cycle length x number of days of bleeding (ex. 13x28x5).
  • Contraceptive history= type of contraception, past and current, satisfaction with method, and condom use. Also HRT/ERT (hormone replacement therapy) current and past use.
  • cervical screening
  • other screening tests
  • Hx of other gynecologic problems.
  • symptoms of pelvic organ prolapse or urinary or anal incontinence.
  • Hx of gynecologic procedures (endometrial biopsy, D&C, D&E, laparoscopy, hysterectomy)- date, indication, complications.
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6
Q

What else must you ask about the “menstrual history”?

A
  • menstrual dysfunction (DUB, AUB, BTB, menometrorrhagia (heavy untimely bleeding), post-coital bleeding).
  • PMS/PMDD (premenstrual dysphoric disorder), dysmenorrhea
  • peri vs postmenopausal and associated symptoms (vasomotor, vaginal dryness, dyspareunia, PMB…)
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7
Q

What must you ask about “cervical screening”?

A
  • date and results of last testing (pap + HPV; high risk types 16 and 18), date and treatment of any abnormal testing; HPV immunization status (Gardasil).
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8
Q

What must you ask about “other screening tests”?

A

Mammograms, DEXA scan, pelvic US, colonoscopy, date of last screening and any Hx of abnormal results

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9
Q

What must you ask about “hx of other gynecologic problems”?

A
  • ovarian cysts, uterine fibroids, polyps, endometriosis, adenomyosis, polycystic ovarian syndrome, DES exposure, infertility/ART
  • mode of diagnosis and treatment
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10
Q

What must you ask about sexual history?

A
  • sexual activity: “Are you currently sexually active?” Length of time with current partners, date of first encounter, lifetime total of partners, gender of current and past partners.
  • STD/PID
  • Condom use
  • HIV testing/status
  • Screening for Intimate Partner Violence (IPV)
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11
Q

What are the most common gynecologic concerns?

A
  • vaginal discharge
  • abnormal bleeding
  • pelvic pain
  • urinary problems
  • sexual dysfunction
  • infertility
  • when a patient identifies one of these issues, detailed questioning can guide further evaluation and diagnosis.
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12
Q

Do many women of reproductive age have daily vaginal discharge?

A
  • YES. Normal= mucoid endocervical secretions in combination with desquamated vaginal wall epithelium and normal bacteria.
  • physiologic discharge is typically clear, white, or light yellow.
  • volume varies among women and timing in the menstrual cycle.
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13
Q

What questions should you ask about vaginal discharge?

A
  • onset, duration, frequency, color, consistency, volume and odor of the flow.
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14
Q

What type of discharge requires investigation?

A
  • discharge that is malodorous, pruritic, copious, purulent, bloody, or accompanied by fever.
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15
Q

What does abnormal genital tract bleeding most often represent?

A

uterine problems, but the source may be any part of the genital tract, or the urinary or gastrointestinal tracts. Pregnancy should be excluded.

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16
Q

Whatmakes uterine bleeding abnormal?

A
  • when it is associated with a change in the woman’s normal menstrual pattern and occurs after menopause.
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17
Q

What is the average menstrual cycle?

A
  • lasts up to 7 days and the amount of blood loss is 35 to 40 mL per cycle, but the range is wide.
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18
Q

** What is menorrhagia?

A

menstrual blood loss greater than 80 mL. It is applied variable to ovulatory or anovulatory uterine bleeding.

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19
Q

** How are prolonged menses defined?

A
  • longer than 7 days of bleeding
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20
Q

** What is menopause?

A
  • 12 months of amenorrhea (no periods) after the final menstrual period.
  • average age is 51
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21
Q

What do you call any bleeding after menopause?

A
  • postmenopausal bleeding (PMB)
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22
Q

What are some questions to ask to help quantify blood loss during meses?

A
  1. How often do you change your pad/tampon during peak flow days?
  2. How many pads/tampons do you use over a single menstrual period?
  3. Do you need to change the pad/tampon during the night?
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23
Q

What is important to know about urinary incontinence?

A
  • occurs among women of all ages and requires evaluation when the involuntary loss of urine is bothersome.
  • leakage of urine with physical activity (exercise, lifting, coughing, sneezing) versus an overwhelming urge to void with leakage of urine before reaching a toilet, can help to differentiate stress incontinence from the detrusor instability.
24
Q

What are the symptoms of pelvic organ prolapse (POP)?

A
  • vaginal bulge, vaginal pressure, or the need to place a finger in the vagina to void or defecate.
25
Q

Are many women reluctant to express concerns about sexual dysfunction?

A

YES, so welcome them in an open and compassionate manner.

*only 18% of physicians ask about sexual health!

26
Q

What are some good questions to ask about sexual health?

A
  • Do you have sexual concerns?
  • Are you currently having or have you ever had sexual relations?
  • If not, when did you last engage in sexual activity?
  • If so, with men or women or both?
  • How many partners?
27
Q

How is infertility defined?

A
  • failure of a couple to conceive after 12 months of regular intercourse without use of contraception in women less than 35 or after 6 months of regular intercourse in women over 35.
28
Q

On what 3 factors should an infertility history focus most?

A
  1. ovulation
  2. tubal and uterine problems
  3. male factors
29
Q

When is a pelvic exam indicated?

A
  • in any patient with genital or pelvic symptoms and in other patients for preventive care.
30
Q

At what age should you begin pelvic examination?

A
  • only if indicated under age 21.
31
Q

When should we initiate cervical cancer screening (pap smears)?

A
  • age 21
32
Q

When should annual screening begin for gonorrheal or chlamydial infection?

A

all sexually active adolescents

33
Q

What is very important to remember when doing pelvic exams?

A
  • communicate and reassure
  • EDUCATE and let pt know everything you are doing every step of the way! “Ma’am, I will need be inserting a speculum…”
34
Q

Are pap smears the same as a pelvic exam?

A

NO (some pts think these are the same though). Educate them.

35
Q

Is there evidence that we are reducing morbidity and mortality by doing annual pelvic exams?

A

NO bc by the time we find ovarian cancer on a pelvic exam, it is too far advanced.

36
Q

What is required to prepare for the pelvic exam?

A
  • you need the pt’s CONSENT
37
Q

May adolescents undergo a pelvic examin without their parents’ knowledge or permission?

A

ONLY if you think they have an STD.

*otherwise parental consent is required!

38
Q

Is a chaperone required to do a pelvic exam?

A

NO, but it is still a good idea in case a pt tries to accuse you of inappropriate behavior.

39
Q

Do some women have anxiety during the pelvic exam?

A

YES due to past experiences with abuse or assault and may manifest as tense and withdrawn body language, extreme discomfort or refusal to have the exam at all.

40
Q

Why don’t patients like the pelvic exam?

A
  • physical discomfort (duh it hurts).
  • embarrassment
  • disliking the attitude of the examiner
  • problems during previous exam
41
Q

How do we make the pelvic exam better?

A
  • talk to them
  • warm the instruments
  • be gentle
  • maintain eye contact
  • use one finger or a narrow speculum
  • GIVE THEM SOME CONTROL!!!
42
Q

How do you position a woman for her pelvic exam?

A
  • DORSAL LITHOTOMY (on her back with legs up in the stirrups or on sides of table).
  • elevate head of table to 30 degrees to make it nicer for the pt :)
43
Q

** What equipment do you need for the pap smear? (TEST QUESTION)

A
  • examining table, good light source, speculum, spatula and brush (for cervical cytology/HPV), cotton swabs (for obtaining vaginal discharge samples), lubricant, disposable gloves, and dropper bottles with saline and potassium hydroxide for performing wet preps).
44
Q

What are the components of the pelvic exam?

A
  • internal and external genitalia (inspect and palpate), and pelvic organs
  • also include urethra, anus, and rectum
45
Q

What else do you include in a GYN exam?

A
  • everything else like a normal physical: abdomen, heart, lungs, kidneys…
46
Q

What are you inspecting in the external genitalia portion of the pelvic exam?

A
  • hair distribution, skin, labia minora and majora, perineal body, clitoris, urethral meatus, vestibule, and introitus.
  • you are looking for developmental abnormalities, skin lesions, masses, and evidence of trauma or infection
47
Q

What should you do if you see visible vulva lesions?

A
  • culture or biopsy them
48
Q

What are the bartholin glands?

A
  • gland openings that secrete mucus to lubricate the vagina and are located at the 4 and 8 o’clock positions just outside the hymenal ring.
  • They are NOT palpable when healthy.
49
Q

What are the periurethral glands found?

A
  • the largest (Skene’s glands) are adjacent to the distal urethra.
  • if enlarged or tender, attempt to express exudate (indicates infection).
50
Q

How do you do the speculum exam?

A
  • the vagina is fist inspected (lubricate and warm first).

- atraumatic insertion (have pt relax her legs to the sides).

51
Q

What is normal pH of physiologic vaginal discharge?

A

less than 4.5

*elevation above this may indicate infection or exogenous substances (semen).

52
Q

What is the bimanual examination?

A
  • index and middle fingers (one for younger patients) of the dominant hand are normally used to examine the vagina and uterus.
  • the abdominal hand on the abdomen should be used to sweep the pelvic organs downward, while the vaginal hand is simultaneously elevating them.
53
Q

Does the uterine size and consistency vary according to reproductive status?

A

YES. The position or axis of the the uterus is described by its variation in the anterior-posterior (sagittal plane)

54
Q
  • *** What are the different terms of uterine positions? (TEST QUESTION)
  • she said just know what axis it is connected to.
A
  • AXIAL= axis of the uterus is the same as the vaginal axis.
  • VERSION= position of the entire uterus relative to the axis of the vagina (ANTEverted, RETROverted).
  • FLEXION= position of the uterine fundus relative to the axis of the cervix (ANTEflexed, RETROflexed).
  • remember version is the vagina (think V with V).
55
Q

What are adenexal areas?

A
  • areas next to the uterus (aka feeling for the ovaries).

* check for presence of appropriately sized, mobile ovaries (2x3x3 cm). These are very difficult to palpate.

56
Q

Are palpable ovaries in postmenopausal women normal?

A

NO. This requires further investigation.

57
Q

When should you do a rectovaginal examination?

A
  • if you find something abnormal. No guidelines that state necessity to do this.
  • use lubricated examining glove and ask patient to strain against the examiner’s finger. this allows the sphincter to RELAX and decrease discomfort. The same finger should not be used to examine the vagina and rectum.

RGU 1 (17 decks)

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