Gynecologic History and Physical Examination Flashcards
Why do women seek gynecologic care?
To enhance or maintain health.
To identify and treat specific concerns or issues.
How should the health history be obtained?
In a private, comfortable setting.
With open-ended questions and non-medical language to encourage detailed responses.
By listening attentively and remaining focused.
What are the components of a general health history?
Demographic information.
Reason for seeking care or chief concern.
History of present illness.
General medical and mental health history.
Medications, allergies, and substance use.
Family and social histories, safety, occupation, and habits.
What specific topics are included in a gynecologic health history?
Menstrual and pregnancy history.
Sexual health and contraceptive use.
History of infections and hygiene practices.
Past gynecologic surgeries and procedures.
Urologic and rectal health.
Screening history (e.g., cervical cancer).
How should the health history conclude?
Offer the patient a chance to ask questions or add comments.
Summarize findings and discuss next steps.
Document the information accurately.
What does a physical examination for a gynecologic visit typically include?
General health assessment from head to toe.
Breast and pelvic examinations as needed.
Ensuring patient comfort and explaining all steps of the exam.
How should a pelvic examination be prepared for?
Offer a bathroom break and the option of a drape.
Position the patient in the lithotomy position with proper support.
Adjust lighting and wash hands before donning gloves.
Proceed only when the patient is ready.
What is examined during the external genitalia and vaginal orifice inspection?
Mons pubis, labia majora/minora, urethral orifice, clitoris, vaginal introitus, and vaginal walls.
Muscle tone, Bartholin’s glands, and optional Skene’s glands.
What are the steps for a speculum examination?
Choose and warm the speculum.
Insert and gently rotate to visualize the cervix.
Collect samples for cytology or infection screening.
Carefully remove the speculum and address patient concerns.
What is assessed during a bimanual examination?
The vaginal canal, cervix, uterus, ovaries, and surrounding structures.
Tenderness, masses, and abnormalities.
The exam is concluded gently.
When is a rectovaginal examination recommended?
If the uterus is retroflexed or retroverted.
To evaluate abnormalities or pain in adjacent structures.
Performed with careful explanation and patient consent.
How should findings from a gynecologic exam be documented?
Describe normal findings as ‘healthy’ or ‘within normal limits.’
Provide clear explanations for abnormalities and follow-up plans.
Ensure concise, accurate, and patient-focused documentation.
What is a key aspect of patient control during the gynecologic examination?
Women should always have control over the gynecologic examination process.
Exams can be modified and individualized based on patient preferences.
What are specific tips for the pelvic exam?
Always explain the process in understandable language.
Make eye contact when possible and avoid reacting to unexpected findings.
Proceed gently and allow the patient to pause the exam if needed.
What is involved in cervical cytology screening?
Use a spatula or endocervical brush for specimen collection.
Liquid-based cytology methods are preferred over conventional methods.
Follow specific guidelines for sampling.
