Test I Flashcards
why are hemorrhoids common during pregnancy
constipation
decreased venous return from the pelvis
decreased activity level
components of a general SOAP note
A (assessment)
diagnosis with or with out differentials
goals of a inspection during the pelvic exam
visualize vulvar skin lesions
observe for signs of trauma
check for signs of pelvic relaxation
describe breast development stage 3
enlargement of elevation of breast and areola, no separation in their contours
nutrition reccomendations for pregnancy
take a prenatal
avoid unpasturized milk and undercooked foods (eggs, meat)
stay away from processed meat (hot dogs, lunch meat)
plan to gain weight
how does gestational age correlate with uterine size
height in cm roughly equals weeks of gestation
four fetal vertex positions
exercise indications for pregnancy
exlcusions
>30mins of moderate exercise daily unless contraindicated
no hot water exercise, no supine exercises after the 1st trimester, no contact sports
cervical polyp
what typically causes atrophic vaginitis
is there any discharge
what is the major symptom
menopause
decreased from normal
dysparenunia
describe the management of a Rh negative mother
check Rh(D) an antibodies on first visit, then again at 28 wks
treat wth anti-D Ig at 28wks and within 3 days of delivery to prevent sensitization
when should breast cancer screening start
early as 20s with family Hx, reccommended 50-74 biennialy
describe breast development stage 1
preadlolescent, elevation of the nipple only
how does a SOAP note for rounds differ from one used in the office
plan
what needs to be done
discharge planning
10 gyn ROS questions
- ask if they are sexually active, dating, in a relationship?
- how wouAre you or have you ever been sexually active?
- Have you ever used contraception? With which partners? What type?
- Pregnancy/delivery history
- if teenager, ask how she learned about monthly periods, how she felt when they started, regularity of periods?
- ask age of menarche?
- LMP, how often are periods, how long they last, regular or irregular, flow assessment (soaking pad or tampon, measurement of blood in diva cup)?
- is there bleeding between periods?
- is there bleeding after intercourse?
- dysmenorrhea (pain with periods)- describe pain, how long it lasts, if it interferes with activities, associated symptoms?
- PMS (emotional and behavioral symptoms)
- history of amenorrhea?
- history of AUB?
- hx of menopause and/or symptoms of menopause?
- hx of pregnancy? how many times, how many living children, hx of miscarriage? GPFPAL
- Vaginal discharge and/or itching? lumps or sores in the vulvar area and if they are painful?
- sexual health and activity questions, is protection used, sexual abuse concerns? What types of sex are you participating in?
when should a pregnant patient be screened for domestic abuse
three questions to ask
once a trimester
since you have been pregnant or within the last year have you bee hit
are you in a relationship with someone who threatens/hurts you
has anyone forced sexual activity on you that made you uncomfortable
two reasons to order and early pregnancy ultrasound
concerned about ectopic pregnancy
concerned about threatened SAB
how can hegar’s sign be felt
a anteroflexed parous uterus will feel like the fundus and cervix are separated on bimanual exam
T/F enlarged thyroid, goiters, nodules are all normal during pregnancy
false, modest enlargement is ok
two diseases all sexually active women under 25 and older women with risky sexual behavior should be tested for
chlamydia and gonorrhea
5 bad dictation habits
breathing into the mic
multitasking
whispering
speaking mechanically
using abbreviations
nagele’s rule
EDD = LMP + 1year and 7 days - 3 months
what patients would a peterson speculum be best for
graves
medium peterson for sexually active women
narrow for women with a small introitus (virgins, elderly)
graves use for parous women and vaginal prolapse
candida vaginitis
cause
discharge
other symptoms
candida albicans with possible predisposing factors
white, curdy, usually thick, not malodorous
pruritis, vaginal soreness, dryness, dysparunia
T/F modern breast augmentation does not impair the efficacy of inspection and palpation during the breast exam
true
T/F a lesion significant enough to cause dimpling may not be palpable
false, they usually are
what part of the HP should be excluded from the oral presentation unless it has direct bearing on the CC/HPI
family/socal Hx and ROS
total expected weight gain during pregnancy broken down by BMI
<18.5, 28-40lbs
18.5-24.9, 25-35lbs
25-29.9, 15-25lbs
>30, 11-20lbs
when does cervical cancer screening begin
what if there is prior sexual activity
21, unless there has been prior sexual activity
breast exam by palpation
use your fingertips
employ concerntric circles or quadrants
use an appropriate amount of time (15-30s)
end by checking the areola nipple mass and discharge
Describe the form of a SOAP note
Subjective (CC, HP, Med, Histories, ROS)
Objective (PE)
Assessment (Dx, DDx)
Plan (Labs, Rx, education, return)
T/F you should always include family, social hx in the oral presentaiton
false, only if there are particularly relevant
what the parts of a the plan in a soap note
testing
meds
holistic/humanistic
education
referreal
return
T/F chlamydia, syphyillis, hep B, HIV should be screened for in all pregnant women
treu
three tests for selected patients at the prenatal visit
HIV testing
genetic testing
metabolic panel
what is the purpose of a focused noted
exploring and characterizing the main health concern with pertinent positives/negatives to help support or disprove a possible cause
describe the process of performing a breast self exam
lie supine with a pilllow under you shoulder and arm behind your head
use fingers to feel for a lump with overlapping dime-sized circles
stand in front of a mirror to look for dimpling, redness, scaliness
examine the axilla
what is the main focus of a breast exam
early detection of breast cancer
when would HIV testing be indicated
at least once between 13 and 64
yearly for anyone having unsafe sex or using IV drugs
three chracteristics of a breast mass
cystic vs solid
fixed vs mobile
painful vs non painful
goals of the diagnosis/confirmation exam
methods
confirmation of the pregnancy; determine if the pregnancy is progressing normally
HP, Lab tests, Pelvic, US
three STI screens for LBGTQ patients
chlamydia, gonorrhea, syphilis anually
steps of the prenatal visit
vital signs
pertinent recent history
abdominal exam
digital vaginal exam
common prenatal lab testing for everyone
CBC
UA
Blood type with antibody screen
STI screen
glucose challenge
modifiable risk factors for breast cancer
breastfeeding for less than one year
post menopausal use of HRT
smoking
alcohol
sedentary
type of contraception
dimpling
when would you take a sample of vaginal secretions
how can you get a sample
suspected vaginitis (itching, discharge)
collect it on the lower end of your speculum
basic structure of the oral presentation
ID
CC
HPI
active medical issues
PE key findings
labs
assessment
plan
six suggestive symptoms of pregnancy
amenorrhea
breast tenderness
fatigue
syncope
urinary frequency
nausea
first considerations for a female breast and pelvic exam
alleviate patient anxiety
protect patients privacy
uterine relaxation
four signs that allow for the presumption of pregnancy when present
palpable fetal movements
uterine enlargement
softening of the uterus
cervical vascular changes
when is it difficult to palpate the ovary
if the patient is obese
postmenopausal
when should an oral glucose test be given
when should a rectal vaginal swab be taken
24-28 weeks
35-27 weeks
leukorrhea
assymptomatic milky white discahrge from vaginal and cervical epithelium due to vasocongestion and hormonal changes during pregnancy
T/F patient always dresses and undresses in private
true
cervical cancer
assessment of the uterus
size
position (anteverted/retroverted)
shape (symmetrical vs irregular)
pain on palpation or motion
describe pubic hair development stage 4
more coarse hair spreading further than stage 3 but not onto the thighs
sequence of the pelvic exam
inspection
palpation of the external genetalia if needed
visualize cervix with speculum
take samples if needed
rectovaginal exam if needed
five questions to ask for GU ROS
quiestions to confirm pregnancy
sexually active and monogamous
use of contraception
TPAL
STI Hx
patient presents with 1st trimester bleeding and flank pain.
What would the US on the left indicate
What about the one on the right
right would be worrisome for ectopic pregnancy
left would be worrisome for a threatened SAB
T/F a nulliparous patient should not have milky nipple discharge
true, a multiparous patient might
six guidelines for a good oral presentation
<5 minutes
don’t read from notes
eye contact
only give the facts needed to understanding the current issue
emphasis on HPI, assessment, plan
5 sexual history ROS questions
- Are you or have you ever been sexually active?
- Have you ever used contraception? With which partners? What type?
- Pregnancy/delivery history
- How many lifetime partners have you had?
- Are you in a monogamous relationship/do you have any partners outside of your marriage/partnership?
- Have you ever been treated for an STI?
- Have you ever had a pap smear/pelvic exam? When was the most recent one?
- If so, have you ever had an abnormal result?
- Do you do self-testicular exams?/Have you ever had a prostate exam? If so, when was last one?
- Have you ever been a victim of sexual or physical abuse?
ways to reduce pelvic anxiety
be congenial
eudcate the patient on what is happening
be professional
always have a female assistant with you
1st-4th leopold manuver
palpate the fundus to feel for head or butt
palpate sides to determine where the fetal back is
palpate lower pole to confirm presenting part
palpate uterine sides again to confirm presening part
how will the vulva/vaginal wall appear with atrophic vaginitis
what lab work should be done
pale, smooth vaginal mucosa, small cervix, small introitus
menopausal labs
notable things on PE inspection of the breast
skin dimpling, nipple retraction, orange skin, exfoliating rash
patient 20 weeks pregnant presents with a fundal height of 16 cm
what might you suspect
what if it were 25 cm
in either case, what should be done
multiple gestation, large fetus, polyhydraminos, fibroid
oligohydraminos, missed SAB, IUGR, fetal anomaly
both conditions need utral sound
baterial vaginosis
cause
discharge
other symptoms
bacterial overgrowth from sexually transmitted anaerobes
gray/white, homogenous, malodorous coating of the vaginal walls
unpleasant fishy small reported after intercourse
where is the best place to listen for fetal hear tones
how can you differentiate between FHT and maternal HR
the fetal back or umbillical cord
the FHR 120-160, maternal HR is less than 100
how will a breast cancer lesion feel on palpation
what age groups is this commonly found in
irregular, firm, can be mobile or fixed
25-50 or 50+
describe pubic hair development stage 5
hair adult in quantity and quality that spreads on the medial thigh but not up the abdomen
point of note during inspection of the breast
skin dimpling; retracted nipple; edema; abnormal vasculature; exfoliating skin disease around the nipple
nine prenatal lab screenings
blood type
Rh/antibody
CBC
rubella
syphilis
hep B
HIB
STI for gonorrhea/chlamydia
urinalysis w/ culture
five guidelines for the oral presentation
less than 5 minutes
delivered mostly from memory
make eye contact
only convey what is needed
emphasize HPI, assessment, plan
when should cervical cancer screening start
how frequent should they be between 21-29
30-65
when can you stop
at 21
every 3 years
3-5 years
after 65 or after hysterectomy
how to do a bimanual exam
one hand in the vagina against the cervix, one hand suprapubic palpating the uterus
four STIs that pregnant women should be screened for
Chlamydia, syphilis, Hep B, HIV
how frequent should HIV testing be for an average person
what about they having unsafe sex and/or using IV drugs
at least once in their lifetime
one a year
goodells sign
softening of the cervix indicative of pregnancy
what will the vaginal vulvar mucus look like in trichomonasis
how can it be evaluated in a lab
vestibule, labia minora, and vaginal mucosa can be erythmatous, with petechiae on the posterior fornix
look for flagellates on wet moutn
what is the purpose of the oral presentation
to summarize the HP, diagnostic results, and clinical reasoning leading to a Dx
criteria for hyperemesis gravidarum
loss of more than 5% pre-pregnancy weight from NV
Components of a general SOAP note
S (subjective)
CC, HPI, meds, allergies, medical/surgical/family/social Hx, ROS
head and neck issues found in PE of a pregnant patient
chloasma/melasma
facial edema
mild hirsuitism
nose bleeds and nasal congestion
gingival enlargement
how to determine fetal position
careful uterine palpation on a relaxed uterus with leopold manuvers
three OB exam scenarios
diagnosis and confirmation of pregnancy
intial visit
prenatal checkup
what is the percent breakdown of breast cancer by location on the breast
when should the cervix be assessed in a pregnant patient
14-18 weeks
weekly past 35 weeks
adnexal assessment
ovarian size
enlargement (cystic vs solid)
mobility
pain
menstrual cycle information to update
LMP
frequency
amount/duration of bleeding
pain associated with cycles
how is obstetrical dating done
week completed since the 1st day of the LMP
GYN to update during a routine exam
menstrual cycle info
contraception changes
bladder or bowel problems
when is necessary to do a pelvic exam
if the patient has GYN symptoms
if the patient is due for a cervical cancer screening
probably not as part of a routine annual exam in family practice
points interest on inspection of the breast
skin dimpling
retracted nipples
edema (orange skin)
abnormal vasculature
exfoliating skin especially around the nipple
four parts to the cervical assessment
effacement
cervical dilation
confirm presenting part
determine if the fetus is engaged to the pelvis
three aspects of the abdominal exam during the prenatal visist
measure uterus
determine fetal lie
listen for fetal heart tones
typical cause of atrophic vaginitis
menopause
what are the safe immunizations during pregnancy
unsafe
pneumococcal, meningitis, Hep b, hep A
MMR, polio, varicella
characterize a breast cyst
fibrocystic changes
what age groups are they found in
usually soft to firm, round, mobile, often tender
nodular, rope like
25-50
breast inspection positions
hands on hips
arms over head
bending forward
components of a rounding SOAP note
A (assessment)
diagnosis, status, progression, complications
what is the purpose of the oral presentation
to summarize the patients HP, testing results, and what these items indicate clinically
parts of the annual GYN exam
vital signs
update HP
specific exam based on complaints and dominant history
breast exam
abdominal and pelvic exam
what is the earliest uterine contractions will start
at what point can they be induced with palpation
12 weeks
3rd trimester
trichomonasis
cause
discharge
other symptoms
protozoan that can be sexually acquired
yellow green discharge that can be frothy or malodorous that will pool in the vaginal fornix
pruritis, dysuria, dyspareunia
T/F it is not possible to pass HPV from the vagina to the rectum
false, you should change gloves before doing an RV exam
most breast cancers occur in what area
ductal vs glandular
what position should the pregnant person be in during the adominal exam
legs up with knees into chest
what will the vulva/vaginal mucosa look like with yeast infection
how can it be evaluated in a lab
inflammation of the vulva and surrounding skin
erythmatous mucosa with white discharge
slide with KOH will show budding yeast
5 questions to ask for breast ROS
masses
nipple discharge
unilateral or bilateal symptoms
skin discoloration
lesions or ulcerations
T/F masses less than 1cm are very hard to palpate
true
cystocele vs rectocele
cystocele is anterior wall relaxation
rectocele is posterior wall
lymph nodes most closely associated with te breast
axiallary, supraclavicular
characteristics of a breast mass
llocations by quadrant
size
shape
consistency
deliniation
tenderess
mobility
lymph nodes
reccomended inclusions to a prenatal vitamin
400 micrograms for folic acid
600 IU of vitamin D
27mg iron
1g Ca
150-290 micrograms of iodine
describe breast development stage 2
brest development stage, elevation of the breast and nipple as a small mound with enllargement of the areolar diameter
indications for RV exam
colorectal screening
evaluation of cul de sac or nodularity
ROS questions for female sexual Hx
cervcitis
goals of leopold manuvers
determine if the fetus is longitudinal or transverse
determine if vertex or breech
determine the location of the fetal back
the main scenarios that would lead to an ob gyn exam
annual check up
examine a new complaint
follow up visit for a new complaint
describe breast development stage 5
mature state with projetion of the nipple only
why is increased urinary frequency common during pregnancy
increase blood volume increases GFR
gravid uterus puts pressure on the bladder
hegars sign
softening of the uterine neck
pertinent medical history related to the breast exam
nodules, masses, pain, nipple discharge
two situations that would call for a SOAP note
office setting for short visits or follow up
hospital rounding
how does a SOAP note for rounds differ from one used in the office
objective
the whole PE isn;t needed
important to note I&O from drains, catheters, oral
labs and imaging review
describe breast development stage 4
projection of the areola and nipple to form a secondary mound
how to do a recrovaginal exam
like a bimanual exam except the index infinger ins in the vagina, middle in the bladder
how often should a cervical cancer screening be done bewteen 21-29
30-65
what does screening stop
every 3 years
3-5 years
after 65 or hysterectomy
how does a SOAP note for rounds differ from one used in the office
assessment
reconfirm diagnosis
record patient status
progression
complications
describe pubic hair development stage 2
sparse growth of long, slightly pigmented, downy hair chiefly along the labia
5 bad dicatation habits
making noise
not speaking clearly
using abbreviations
speaking too fast or too quiet
multitasking
when would inverted nipples be an indication of a subareolar mass
when they don’t normally look like that
three problems that can confound obstetrical dating
amenorrhea
irregular menstrual cycles
variable folicular phase lengths
when should pregnant women get a Tdap if not immune
what happens after delivery
27-36 weeks, then check for rubella immunity and immunize after delivery if needed
components of a rounding SOAP note
P (plan)
what needs to be done
when will the patient be discharged
goals of the bimanual exam
assess the uterus
assess the left and right adnexa
assess the cul de sac
describe pubic hair development stage 1
preadolescent, no pubic hair
what makes heartburn common in any stage of pregnancy
progesterone relaxes the esophageal sphincter
gravid uterus pushes on the stomach
T/F a breast mass in a female under 25 is always considered breast cancer until proven otherwise
false, lesion over 50 is breast cancer
chadwick’s sign
blue coloration of the cervix indicative of pregnancy
uterine growth landmarks
non pregnant/nulliparous: size of fist or smaller
12 weeks palpable just at or above the pubic symphysis
20 weeks palpable at the umbilicus
36 weeks palpable at the xiphoid
5 good dicatation habits
be ready
ID yourself at the beginning
start with a greeting
correct errors
speak with inflection
how does pagets disease present
why is it commonly misdiagnosed
nipple erosion or superficial ulceration
misdiagnosis as dermatitis
peau de orange
tough dimpled skin indicative of breast cancer
6 ROS questions for OB
- confirmation of pregnancy questions.
- has pt had missed periods, breast tenderness, n/v, fatigue, or urinary frequency?
- how does the pt feel about the pregnancy?
- who plans to be involved?
- what does her support system look like?
- what are past medical conditions?
- past ob hx?
- does she use tobacco, alcohol, illicit drugs?
- what is the family hx of her and the father?
- does she plan to breastfeed?
- are there plans for postpartum contraception?
ROS for breast
mass
nipple discharge (milk-like, bloody, other)
pain (bilateral vs unilateral, relationship to menstrual cycle)
ladin’s sign
softening of the anterior uterine wall
how should the gravid uterus be measured
10-12 weeks with bimanual exam
past 12 weeks measure the pubis from the top of the fundus with a tape or caliper
components of a general SOAP note
O (objective)
includes every positive finding to confirm and any negative items related to the chief complaint that can rule in/out a differential
four indications for a pelvic exam on an adolescent
suspected abuse
foreign body
vaginal discharge
trauam
pagets disease of the breast (pagets carcinoma)
subareolar ductal carcinoma or carcinoma in situ that causes irritation of the skin
five good dictation habits
give correct information
speak with inflection
ID self
be in a quiet area
have your materials ready ahead of time
vulvar warts
when to screen for chlamydia
all sexually avtive women less than 25 OR older women with risk factors
continuous mammary souffle
a blowing sound heard on ausculation over the gravid breasts, strongest over the 2nd adn 3rd intercostal
characterize a fibroadenoma
what age groups are they found in
smooth, rubbery, round, mobile, non-tender
15-25
main goals of a new OB visit
identify health problems that may influence or be influenced by the pregnancy
educate the patient
plan any referrals and consultation
plan lab testing
descriptors for a breast mass
size in cm
location quadrant
characteristics
are there palpable axillary or supraclavicular lymph nodes
basic structure of the oral presentation
ID patient
CC
HPI
other pertinent Hx
PE findings
labs
assessment and plan
quardrants of the breast for exam
upper inner
upper outer
lower inner
lower outer
bonus tail of spence
describe pubic hair development stage 3
darker, coarser hair spreading over the pubic symphysis
components of a rounding SOAP note
O (objective)
vitals, weights, intake/output (urine, IVF, drains), labs, imaging, physical findings
how does a SOAP note for rounds differ from one used in the office
subjective
Subjective includes patient, family, and staff observations
Objective (
what is the appearance of the vulva/vaginal mucosa with bacterial vaginosis
what is the lab test
usually normal
wet mount for clue cells, sniff for fishy odor
breast dimpling is a sign of what
breast cancer
non-modifiable factors for breast cancer
age, famly Hx, BRCA1/2, high levels of test/estrogen, early menarche
components of a rounding SOAP note
S (subjective)
patient comments
observations by family and other staff
anterior wall relaxation
components of a general SOAP note
P (plan)
testing, medications, alternative treatments, referral, return plan
most important finding on the breast exam should be visible in what position
supine
