History and Physical 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.
-1% of pts
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
-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
-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
-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
-Frequency of screening individualized for these pts
intimate partner violence (IPV)
-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
how to screen for IPV and what to do with positive screen
-Ask:
-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
-Refer:
-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
-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
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
-Use water-based lubricant
-Use smallest speculum necessary
-Inspect vaginal walls
-Obtain cervicovaginal swab with complaints of malodorous discharge or pruritus
cervix and collection of pap smear and testing for STIs and vaginitides
-Inspect cervix
-Parous or nulliparous
-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 -> due to estrogen (pregnant, OCP etc.)
-long os means the patient has delivered
-nulliparous os (r.)
-transformation zone is gone
bimanual exam
-Stand up
-Insert one or two fingers (index and middle finger) in vagina
-Volar aspect of wrist facing up, palpate cervix
-Length
-Position
-Is internal os open or closed?
-Cervical motion tenderness
-Palpate uterus with abdominal hand
-Make a “sandwich” of uterus between abdominal and vaginal hands
-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
my documentation of normal pelvic exam
-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
-measure until pubic sympysis
-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
