Well Woman Exam

Question 1

While taking an obstetric history, it is important to list each prior pregnancy in chronological order. What are the 8 components of obstetric history that should be collected?

Answer 1

Date of delivery (or termination)

Hospital

Gestational age, sex, and birth weight (Gs and Ps)

Type of delivery

Duration of labor

Type of anesthesia

Maternal complications

Fetal complications

Question 2

_______ refers to the number of times a woman has been pregnant while ______refers to the number of pregnancies that led to a birth at or beyond 20 weeks or of an infant weighing more than 500 grams

Answer 2

Gravidity; parity

Question 3

4 components of parity that are listed with Gs and Ps

Answer 3

Term (37-42 wks)

Preterm (20-36+6)

Abortion (all pregnancy losses before 20 wks including elective AB, spontaneous AB, ectopics, etc.)

Living

[TPAL]

Question 4

The average age of menarche is ______. Primary amenorrhea means that the pt has not yet had a period by age ____

Answer 4

12-13; 16

Question 5

Average interval cycle

Answer 5

21-35 days

Question 6

2 Most common causes of amenorrhea

Answer 6

Pregnancy

Menopause

Question 7

Components of gynecologic history

Answer 7

Age at menarche

Interval cycles

Days of menses (avg 5-7)

Abnormal vaginal bleeding

Pain/cramps

LMP

Sexual hx (orientation, age at first intercourse, # total partners)

Abnormal paps or hx of STDs

Preconception planning/counseling

Question 8

Hx of post-coital bleeding should raise concern for _____ _____

Post-menopausal bleeding should raise concern for ________ ______

Heavy bleeding, passing clots, etc. indicates possible structural abnormality like fibroids or polyps

Answer 8

Cervical cancer

Endometrial/uterine cancer

Question 9

What is Naegels rule?

Answer 9

Establishes estimated date of confinement (EDC)

Subtract 3 months and add 7 days (or add 9 months and 7 days

[ex: LMP 7/20/2016, EDC of 4/27/2017]

Note: requires normal/regular 28 day cycles

Question 10

ACOG recommendations regarding clinical breast exam

Answer 10

Every 1-3 years for women age 20-39

Every year with annual mammograms for women age 40+

Question 11

ACOG recommendations regarding pelvic exams

Answer 11

Begin annual pelvic exams at age 21

[begin at ages 19-20 when indicated by medical history]

Question 12

ACOG recommends the initial visit to the OB/GYN for screening and the provision of preventative health care services and guidance to take place between the ages of ____-____ and typically does not require a _____ exam unless indicated by hx

Answer 12

13-15; pelvic

[if hx includes vaginal discharge, menstrual d/o, pelvic pain, etc. proceed with pelvic exam]

Question 13

Additional test that should be done at age 13-18 if pt is sexually active

Answer 13

Chlamydia and gonorrhea testing (via urine-based screening — does not require speculum exam)

HIV testing

Question 14

Evaluation and counseling considerations for well woman exams age 13-18

Answer 14

Address high risk sexual behaviors (# of partners)

Contraception options

STD prevention — discuss barrier protection

Question 15

Important components of evaluation and counseling during well woman exams in terms of psychosocial evaluation

Answer 15

Sexual abuse by family or partner

Age 19-39 should also be evaluated for intimate partner violence and counseled on acquaintance rape prevention

Question 16

What vaccine should be given once between age 11-18?

Answer 16

Diphtheria and reduced tetanus toxoids and acellular pertussis (Tdap) booster

Question 17

One series of ____ vaccines should be given for those who are not previously immunized between ages 9-45

Answer 17

HPV

[cervarix covers 16,18; gardasil covers 6, 11, 16, 18; gardasil 9 covers 6, 11, 16, 18, 31, 33, 45, 52, and 58]

Question 18

Besides tdap and HPV, what additional vaccines are given at ages 13-18 if not previously immunized?

Answer 18

Hep B, influenza annually, MMR

[also varicella if no evidence of immunity]

Question 19

ACOG recommendations regarding cervical cytology

Answer 19

Age 21-29 years: screen q3 years w/ cytology alone

Age 30+: screen q3 years w/cytology alone, or co-test cytology+HPV testing q5 years

Question 20

Recommendations regarding STI testing for ages 19-39

Answer 20

If aged 25 or younger and sexually active, test for chlamydia and gonorrhea

Ages 26 and older at high risk should be screened routinely

Test everyone for HIV

Question 21

At ages 19-39 well women exams, health risk assessment includes instruction on breast self-awareness (may include self-breast exam), and chemoprophylaxis for breast cancer for high-risk women aged ___and older

Answer 21

35

Question 22

In addition to the history components asked at most well women exams, what additional history questions may be addressed in the age group 40-64?

Answer 22

Pelvic prolapse hx

Menopausal sxs (avg age of menopause = 51)

Question 23

ACOG recommendations regarding colorectal cancer screening

Answer 23

Begin at age 45 in African Americans because of increased incidence and earlier onset of colorectal cancer, otherwise begin at age 50

Colonoscopy q10 years is preferred method

[other options include FOBT annually, flex sig q5y, double contrast barium enema q5y, CT colonography q5y]

Question 24

Lipid profile screening guidelines (age and frequency)

Answer 24

Begin at age 45 and q5y

Question 25

Mammography screening guidelines

Answer 25

Yearly after age 40

Question 26

TSH screening guidelines

Answer 26

Begin at age 50 and q5y

Question 27

Screening guidelines for diabetes

Answer 27

Begin at 45, then q3y

Question 28

Preconception counseling in ages 40-64 should include ____ counseling

Answer 28

Genetic

Question 29

Aspirin prophylaxis guidelines

Answer 29

Aspirin prophylaxis to reduce risk of stroke in ages 55-79

Question 30

Varicella zoster vaccination is recommended at what age?

Answer 30

60+

Question 31

When is it reasonable to discontinue the pelvic exam in ages 65+?

Answer 31

When a woman’s age or other health issues are such that she would choose not to intervene on conditions detected during routine exam

Question 32

Cervical cytology guidelines in women age 65+

Answer 32

Can discontinue in women with no hx of CIN 2 or higher (requires 3 consecutive negative prior cytology results OR 2 consecutive negative co-tests within the previous 10 years) If there is history of CIN 2, CIN 3 — need to continue pap x20 years after, even if it extends beyond 65 years old

Question 33

Ages 65+ typically requires bone mineral density screening. In the absence of new risk factors, this should NOT be screened more frequently than ______

Answer 33

q2y

Question 34

Additional psychosocial counseling done at ages 65+ well woman exam

Answer 34

Advanced directive counseling

Question 35

In addition to aspirin prophylaxis, breast self-awareness, and chemoprophylaxis for breast cancer in high risk women, health risk assessment in ages 65+ requires ....

Answer 35

Injury prevention (prevention of falls)

Question 36

When is the pneumococcal vaccine recommended?

Answer 36

Once at age 65 or older

Question 37

High-risk factors for all ages that require earlier bone mineral density screening

Answer 37

Screen younger in postmenopausal women <65 y/o if high-risk factors are noted: History of fractures, body weight <127 lbs, medical causes of bone loss (meds and/or diseases — smoking, alcoholic, RA, etc)

Question 38

High-risk factors for all ages that require earlier mammography

Answer 38

Screen younger than 40 y/o if ... +history of breast cancer or FHx of relatives who have hx of premenopausal breast or breast and ovarian cancers +test for BRCA1 or BRCA2 mutations +history of high-risk breast biopsy results (atypical hyperplasia and lobular carcinoma in situ)

Question 39

High-risk factors for all ages that require earlier lipid profile assessment

Answer 39

Screen earlier than 45 y/o if .... Personal hx of CAD or noncoronary atherosclerosis (AAA, PAD) Obesity (BMI >30) Personal or FHx of DM, PVD Multiple coronary heart disease risk factors (HTN, tobacco use, etc) FHx of familial hyperlipidemia FHx of premature cardiovascular disease (<50 y/o in men, <60 y/o in women)

Question 40

High-risk factors for all ages that require earlier colorectal cancer screening

Answer 40

Family hx of colorectal cancer or adenomatous polyps in a first degree relative younger than 60 or in 2+ first degree relatives of any age Family hx of FAP, hereditary nonpolyposis colon cancer Hx of colorectal cancer, adenomatous polyps, IBD, UC, or Crohns

Question 41

High-risk factors for all ages that require earlier diabetes testing

Answer 41

Screen before 45 if ... BMI >25 First degree relative with DM High risk race (Native American, Latina) Prior birth > 9 lbs Hx of gestational DM, PCOS

Question 42

High-risk factors for all ages that require earlier thyroid testing

Answer 42

Screen before 50 y/o if... Strong family hx of thyroid disease

Question 43

High-risk factors for all ages that require earlier STI testing

Answer 43

Hx of multiple sexual partners or infections Sexual contact with individual with culture-proven STI Sexually active adolescents who exchange sex for drugs or money, IV drug users who are entering a detention center

Question 44

High-risk factors for all ages that require earlier meningococcal vaccination

Answer 44

Adults w/anatomic or functional asplenia First-year college students living in dorms, military recruits Pts that are traveling to hyperendemic or epidemic areas

Question 45

_______ is pigmentation over the bridge of the nose and under the eyes and may be a sign of pregnancy noted during head/neck exam

Answer 45

Chloasma

Question 46

Darkening of the ___ ___ in the midline of the abdomen can be a sign of pregnancy noted on abdominal exam

Answer 46

Linea nigra

Question 47

2nd leading cause of cancer-related death in american women

Answer 47

Breast cancer [1st is lung, 3rd is colorectal]

Question 48

Describe breast exam with pt in upright sitting position

Answer 48

Palpate all quadrants of breast systematically, pushing gently but firmly toward the chest Inspect each breast and compare size, symmetry, contour, venous pattern, skin, and/or nipple abnormalities Compress nipple between thumb and index finger and inspect for discharge

Question 49

Describe breast exam with pt in supine position

Answer 49

Have pt raise arm behind head — allows breast tissue to spread more evenly over the chest wall and can allow deeper palpation Otherwise same steps as seated

Question 50

If a mass or lump is identified on clinical breast exam, it should be characterized based on what 5 qualities?

Answer 50

``` Location Size Shape Mobility Retraction ```

Question 51

Steps to set up for pelvic exam

Answer 51

Set head of bed up at about 30 degrees Inform pt on proper position (dorsal lithotomy) and help guide her feet into stirrups if needed, then have her slide down until bottom is barely off end of table Warm up speculum and confirm you have all supplies (cyto brush, spatula, cultures, etc)

Question 52

Steps of pelvic exam

Answer 52

Adjust sheet to allow inspection of vulva and perineal region; examine external genitalia thoroughly Hold speculum in dominant hand and place it on inner left thigh so she can assess temp. Take left hand and separate labia minora and majora to expose introitus. Once tip of speculum is inserted, initially direct it at 45 degree angle so it slides into vaginal vault with minimal resistance. Open speculum in a smooth and well-controlled fashion; slight tilting often allows cervix to slide into view Once specimens are obtained, unlock and remove speculum while looking at vaginal rugae

Question 53

Speculum with narrower blades that is more appropriate in nulliparous females

Answer 53

Pederson speculum

Question 54

Speculum with wider blades that is more appropriate in multiparous females

Answer 54

Graves speculum

Question 55

T/F: during pelvic exam, if cervix is not in view right away, the speculum should be pulled out

Answer 55

False — if cervix is not in view, angle the speculum superior or inferior as it may be in the anterior or posterior fornix region. DO NOT pull the speculum out initially if cervix still cannot be found after readjustment, remove speculum and perform bimanual exam. Review her surgical hx and ask if she has had any “female” surgeries

Question 56

What is Chadwick’s sign?

Answer 56

Bluish hue to vagina and cervix that may indicate pregnancy

Question 57

Yellowish green vaginal discharge and punctate hemorrhages on ectocervix (“strawberry cervix”)

Answer 57

Trichomonas vaginalis

Question 58

Most common type of vaginal infection

Answer 58

Bacterial vaginosis — characterized by foul smelling thin grey homogenous discharge

Question 59

White adherent vaginal discharge indicates ____ _____

Answer 59

Yeast vaginitis

Question 60

What method is utilized for testing cervical discharge for gonorrhea/chlamydia?

Answer 60

Swab inserted into cervical os x45 seconds

Question 61

Steps of cervical cytology (PAP)

Answer 61

Spatula is used to gently scrape the ectocervix Cytobrush is then used to obtain endocervical cells Slide: On 1/2 the slide, wipe one side of spatula, then wipe the other 1/2 of the slide with the cytobrush [obtains specimen for cytology] Thin-prep: may swish or actually remove tip of swab and send in media [advantage is that single specimen can be used to perform cytology, HPV testing, evaluate ASCUS cytology, and test for gonorrhea and chlamydia]

Question 62

Steps of internal bimanual exam (IBE)

Answer 62

Stand up and inform pt that you are going to do an internal exam checking her cervix, uterus, and ovaries The nurse will place lubricant on index and middle fingers. Insert lubricated gloved fingers into vagina and press downward, waiting for muscle to relax, place your left hand on the suprapubic region. Palpate the vaginal walls feeling for cysts, nodules, masses, or growths. Move the cervix gently side to side and observed the patient for any expression of pain or discomfort (PID) Palpate the uterus by placing your left hand above the pts pubic symphysis and the right intravaginal fingers in the posterior fornix behind the cervix; with abdominal hand press downward firmly. With vaginal hand lift uterus upward thus entrapping the uterus. Place fingers of abdominal hand on right lower quadrant; with intravaginal hand place both fingers in right lateral fornix. Intravaginal fingers should press upward toward the abdominal hand and abdominal hand should press inwardly and obliquely downard toward pubic symphysis

Question 63

In pregnancy, the uterine consistency becomes softer and you may be able to palpate between the cervix and fundus, this is known as _______

Answer 63

Hegar’s sign

Question 64

How would normal ovaries feel on bimanual exam

Answer 64

Normal ovaries if palpable should feel firm, ovoid, slightly tender and be approx. 3 x 2 x 1 cm in size Often they are difficult to palpate secondary to their location, size, and pts body habitus

Question 65

Describe rectovaginal exam

Answer 65

Used to assess anal sphincter, rectal walls, and for uterosacral nodularity (endometriosis); also can be helpful in differentiating between a rectocele and an enterocele Usually performed w/index finger in vagina and middle finger in rectum. Evaluate sphincter tone (tight, lax, absent) Advance vaginal and rectal gloved fingers and ask pt to bear down; the rectal walls should feel smooth. Check rectal wall for masses, polyps, strictures, or tenderness