Well Woman Exam Flashcards
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?
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
_______ 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
Gravidity; parity
4 components of parity that are listed with Gs and Ps
Term (37-42 wks)
Preterm (20-36+6)
Abortion (all pregnancy losses before 20 wks including elective AB, spontaneous AB, ectopics, etc.)
Living
[TPAL]
The average age of menarche is ______. Primary amenorrhea means that the pt has not yet had a period by age ____
12-13; 16
Average interval cycle
21-35 days
2 Most common causes of amenorrhea
Pregnancy
Menopause
Components of gynecologic history
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
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
Cervical cancer
Endometrial/uterine cancer
What is Naegels rule?
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
ACOG recommendations regarding clinical breast exam
Every 1-3 years for women age 20-39
Every year with annual mammograms for women age 40+
ACOG recommendations regarding pelvic exams
Begin annual pelvic exams at age 21
[begin at ages 19-20 when indicated by medical history]
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
13-15; pelvic
[if hx includes vaginal discharge, menstrual d/o, pelvic pain, etc. proceed with pelvic exam]
Additional test that should be done at age 13-18 if pt is sexually active
Chlamydia and gonorrhea testing (via urine-based screening — does not require speculum exam)
HIV testing
Evaluation and counseling considerations for well woman exams age 13-18
Address high risk sexual behaviors (# of partners)
Contraception options
STD prevention — discuss barrier protection
Important components of evaluation and counseling during well woman exams in terms of psychosocial evaluation
Sexual abuse by family or partner
Age 19-39 should also be evaluated for intimate partner violence and counseled on acquaintance rape prevention
What vaccine should be given once between age 11-18?
Diphtheria and reduced tetanus toxoids and acellular pertussis (Tdap) booster
One series of ____ vaccines should be given for those who are not previously immunized between ages 9-45
HPV
[cervarix covers 16,18; gardasil covers 6, 11, 16, 18; gardasil 9 covers 6, 11, 16, 18, 31, 33, 45, 52, and 58]
Besides tdap and HPV, what additional vaccines are given at ages 13-18 if not previously immunized?
Hep B, influenza annually, MMR
[also varicella if no evidence of immunity]
ACOG recommendations regarding cervical cytology
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
Recommendations regarding STI testing for ages 19-39
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
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
35
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?
Pelvic prolapse hx
Menopausal sxs (avg age of menopause = 51)
ACOG recommendations regarding colorectal cancer screening
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]
Lipid profile screening guidelines (age and frequency)
Begin at age 45 and q5y
Mammography screening guidelines
Yearly after age 40
TSH screening guidelines
Begin at age 50 and q5y
Screening guidelines for diabetes
Begin at 45, then q3y
Preconception counseling in ages 40-64 should include ____ counseling
Genetic
Aspirin prophylaxis guidelines
Aspirin prophylaxis to reduce risk of stroke in ages 55-79
Varicella zoster vaccination is recommended at what age?
60+
When is it reasonable to discontinue the pelvic exam in ages 65+?
When a woman’s age or other health issues are such that she would choose not to intervene on conditions detected during routine exam
Cervical cytology guidelines in women age 65+
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
Ages 65+ typically requires bone mineral density screening. In the absence of new risk factors, this should NOT be screened more frequently than ______
q2y
Additional psychosocial counseling done at ages 65+ well woman exam
Advanced directive counseling
In addition to aspirin prophylaxis, breast self-awareness, and chemoprophylaxis for breast cancer in high risk women, health risk assessment in ages 65+ requires ….
Injury prevention (prevention of falls)
When is the pneumococcal vaccine recommended?
Once at age 65 or older
High-risk factors for all ages that require earlier bone mineral density screening
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)
High-risk factors for all ages that require earlier mammography
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)
High-risk factors for all ages that require earlier lipid profile assessment
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)
High-risk factors for all ages that require earlier colorectal cancer screening
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
High-risk factors for all ages that require earlier diabetes testing
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
High-risk factors for all ages that require earlier thyroid testing
Screen before 50 y/o if…
Strong family hx of thyroid disease
High-risk factors for all ages that require earlier STI testing
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
High-risk factors for all ages that require earlier meningococcal vaccination
Adults w/anatomic or functional asplenia
First-year college students living in dorms, military recruits
Pts that are traveling to hyperendemic or epidemic areas
_______ is pigmentation over the bridge of the nose and under the eyes and may be a sign of pregnancy noted during head/neck exam
Chloasma
Darkening of the ___ ___ in the midline of the abdomen can be a sign of pregnancy noted on abdominal exam
Linea nigra
2nd leading cause of cancer-related death in american women
Breast cancer
[1st is lung, 3rd is colorectal]
Describe breast exam with pt in upright sitting position
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
Describe breast exam with pt in supine position
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
If a mass or lump is identified on clinical breast exam, it should be characterized based on what 5 qualities?
Location Size Shape Mobility Retraction
Steps to set up for pelvic exam
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)
Steps of pelvic exam
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
Speculum with narrower blades that is more appropriate in nulliparous females
Pederson speculum
Speculum with wider blades that is more appropriate in multiparous females
Graves speculum
T/F: during pelvic exam, if cervix is not in view right away, the speculum should be pulled out
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
What is Chadwick’s sign?
Bluish hue to vagina and cervix that may indicate pregnancy
Yellowish green vaginal discharge and punctate hemorrhages on ectocervix (“strawberry cervix”)
Trichomonas vaginalis
Most common type of vaginal infection
Bacterial vaginosis — characterized by foul smelling thin grey homogenous discharge
White adherent vaginal discharge indicates ____ _____
Yeast vaginitis
What method is utilized for testing cervical discharge for gonorrhea/chlamydia?
Swab inserted into cervical os x45 seconds
Steps of cervical cytology (PAP)
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]
Steps of internal bimanual exam (IBE)
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
In pregnancy, the uterine consistency becomes softer and you may be able to palpate between the cervix and fundus, this is known as _______
Hegar’s sign
How would normal ovaries feel on bimanual exam
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
Describe rectovaginal exam
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
