Wk 8: Women's health (5% of final)

Question 1

Describe the anatomy of the female breast

Answer 1

1) The female breast lies against the anterior thoracic wall, extending from the clavicle and second rib down to the sixth rib, and from the sternum across to the midaxillary line.
2) The breast overlies the pectoralis major and, at its inferior and lateral margins, the serratus anterior

Question 2

How should you describe clinical findings?

Answer 2

1) Can divide breast into 4 quadrants
-A fifth area, the axillary tail of breast (aka “tail of Spence”) extends laterally across the anterior axillary fold
2) Alternatively, findings can be localized as the time on the face of a clock (e.g., 3 o’clock) and the distance from the nipple (in cm).

Question 3

What are a few good general rules for the female exam?

Answer 3

1) Always interview the patient with her dressed (if possible), especially if this is your first time meeting her
2) Respect her privacy/modesty
3) Maintain your patient’s privacy (this includes where and how loudly you speak… many exam rooms have thin walls)

Question 4

Your patients will be evaluating you as they are deciding what to share with you; what 4 things are they looking for?

Answer 4

1) Interest: do you appear to really care?
2) Judgmental: can they safely share?
3) Rapport: have you “connected”?
4) Have you helped them understand why honesty is so important?

Question 5

Patient-provider partnership:
1) Define empathetic communication
2) Define motivational interviewing

Answer 5

1) Characterized by provider communicating with empathy & sympathy
2) “Reflective listening” replaces “advice giving”

Question 6

What nonverbal communication should you have during the female exam? (5 things)

Answer 6

1) Make eye contact when the patient is talking
2) Talk in layman’s terms
3) Make them feel like they have all the time they need to share with you… if you don’t have the time, schedule an appointment with them when you will have the time
4) Don’t DO other things while they are talking
5) Control your facial expressions

Question 7

What is the important past history for the female exam? (4 things)

Answer 7

1. GYN-menstrual, sexual
2. OB
3. Medical
4. Family
5. Social

Question 8

What are 4 important HPI questions to ask when pertinent to the CC?

Answer 8

1) Issues with menstrual/uterine bleeding? When did it start, how much, how long, clots?
2) Issues with pain? What hurts, when? what makes it better/worse. (Dyspareunia = pain with intercourse)
3) Issues with vaginal discharge? When did it start? Any odor? Itching? Different color/texture? Pain with intercourse?
4) STI concerns? Get details related to exposure, past hx of STIs and any current symptoms

Question 9

1) Menstrual history begins when?
2) Average amount of blood from a menstrual period is how many mL?
3) A daytime menstrual pad can hold how much blood?
4) A fully soaked overnight pad can hold how much blood?
5) A light tampon holds how many mL?
6) Fully soaked super tampon can hold how many mL?

Answer 9

1) Age of menarche
2) ~20-60 mL.
3) ~5 mL.
4) ~10-15 mL.
5) ~3 mL (fully soaked).
6) ~12 mL

Question 10

What are the 8 elements of menstrual history?

Answer 10

1) 1st day of Last menstrual period (LMP)
2) Length of periods (# of days of bleeding)
3) # of days between periods
4) Any recent change in periods
5) Estimation of amount of flow (including clots)
6) Irregular bleeding
7) Intermenstrual bleeding
8) Postcoital bleeding

Question 11

1) Define irregular bleeding
2) When does intermenstrual bleeding occur?
3) When does postcoital bleeding occur?

Answer 11

1) No set pattern or duration
2) Between menses
3) Immediate after coitus

Question 12

List 7 premenstrual symptoms

Answer 12

1) Anxiety
2) Fluid retention
3) Nervousness
4) Mood fluctuations
5) Food cravings
6) Variations in sexual feelings
7) Difficulty sleeping

Question 13

Are menstrual cramps & discomfort always abnormal? Explain

Answer 13

Can be normal or abnormal; dysmenorrhea is abnormally painful menstrual periods

Question 14

1) Define menopause
2) Define perimenopause. How long does it often last?
3) List the symptoms of perimenopause

Answer 14

1) Cessation of menses for >1 year
2) Transition from menstrual to non-menstrual life when ovarian function begins to wane (often 1-2 years)
3) Increasing menstrual irregularity; varying or decreased flow; hot flashes, nervousness, mood changes; decreased vaginal lubrication with sexual activity; altered libido

Question 15

List the gynecologic histories you should take (PMH) (3)

Answer 15

1) Illnesses & treatments
2) Surgeries (what, why, when, who)
3) Sexual hx

Question 16

What 5 sexual history questions do you need to ask?

Answer 16

1) “Have you ever been sexually active?”
2) “Please tell me about your sexual partner or partners.”
3) “Who are you sexually attracted to? Males, females, or both?”
4) Sexual & behavioral risks (STI screening)
5) Contraceptive history (current & past; desire for conception)

Question 17

What are the 5 Ps of sexual Hx? Explain each.

Answer 17

1) Partners (Number: ever/last 2 months, men/women/both?)
2) Practices (Oral, vaginal, anal)
3) Protection from STIs (How do you protect yourself; what % of the time)
4) Past history of STIs (Ever been tested/diagnosed? What, when, treated, current concerns?)
5) Pregnancy intention (and Contraception hx): current & past contraception; desire for contraception/pregnancy

Question 18

1) Define gravidity
2) Define parity

Answer 18

1) # of pregnancies, current and past, regardless of outcome (multiple gestation only counts once)
2) # of times a woman has given birth to an infant ≥20 weeks of gestation regardless of outcome
multiple gestation only counts once (except for living children)

Question 19

How do you document OB history?

Answer 19

GTPAL (ex, G2P1001): gravidity, term, preterm, abortion/(miscarriage), living

Question 20

1) Define term
2) Define preterm
3) Define abortion
4) Define living

Answer 20

1) Number of times a woman has given birth to an infant ≥37 weeks gestation
2) Number of times a woman has given birth to an infant between 20-36 6/7 weeks gestation
3) Number of losses before 20 weeks
4) Number of living children

Question 21

1) Define gravida
2) Define primigravida and multigravida
3) Define nulligravida

Answer 21

1) Is or has been pregnant
2) Is in or has had one pregnancy; has been pregnant more than once
3) Has never been pregnant

Question 22

1) Define primipara
2) Define multipara
3) Define nullipara

Answer 22

1) Has only birthed one child or is pregnant for the 1st time
2) Has given birth 2+ times
3) Has never given birth or had pregnancy go past gestational abortion age

Question 23

What does GTPAL stand for?

Answer 23

G = total pregnancies
T = # born ≥37 weeks (= term)
P = preterm
A = miscarriages/abortions
L = living children

Question 24

Pregnancy ends with one of what two things?

Answer 24

Birth (live or still) or abortion (spontaneous [miscarriage] or induced)

Question 25

Besides GTPAL, what 5 other Ob Hx elements do you need to get?

Answer 25

1) Live birth details
2) Pregnancy complications
3) Breastfeeding history
4) Genetic predisposition for hereditary disease
5) Infertility: failure to conceive for 1 year with sufficiently frequent sexual encounters

Question 26

Preconception counseling & care should include the discussion of what 5 things?

Answer 26

1) Family planning & pregnancy spacing
2) Immunization status
3) Genetic history (maternal & paternal)
4) Teratogens (environmental & occupational exposures)
5) Assessment of socioeconomic, educational, & cultural context

Question 27

List 4 teratogens and 3 positive factors for health in pregnancy

Answer 27

1) Drug, alcohol, tobacco use, and certain medications (antineoplastics, etc.)
2) Prenatal vitamins, diet, exercise

Question 28

1) Define “breast self-examination”
2) Is it generally currently recommended for average-risk women? Why or why not?

Answer 28

1) Self-inspection in a systematic way on a regular, repetitive basis (e.g., monthly) for detection of breast cancer.
2) No longer recommended for average-risk women, lack of evidence for benefits (beyond mammography) and potential harm from false-positives.

Question 29

Pt education on “Breast Self-Awareness” is recommended; what does this include?

Answer 29

1) Being aware of normal appearance and feel of one’s breasts
2) Be educated on signs/symptoms of breast cancer and notify health care provider if any changes (pain, mass, new nipple discharge, redness).

Question 30

1) True or false: Breast cancers are not frequently self-detected
2) True or false: Breast cancer is the most common female malignancy

Answer 30

1) False; they are frequently self-detected
2) True

Question 31

List 11 risk factors for breast cancer

Answer 31

1) Age (older)
2) Race
3) Breast cancer among first-degree relatives (sisters, mother, daughters)
4) Inherited genetic mutations (BRCA1, BRCA2)
5) Personal hx of atypical hyperplasia (ductal or lobular)
6) Younger age at menarche (first menstrual period <12 yo)
7) Older age at menopause (>55 yo)
8) High breast tissue density
9) No term pregnancies
10) Late age at first live birth (>30 yo)
11) Radiation exposure (chest)

Question 32

How does race affect chances of developing breast cancer?

Answer 32

1) White women have greater risk of developing breast cancer than Black women
2) However, Black women diagnosed with breast cancer are more likely to die of the disease b/c more likely to have aggressive types of the disease

Question 33

List 2 modifiable things that decrease risk of breast cancer

Answer 33

1) Women who have breastfed their infants for at least 1-2 years
2) 30 minutes of exercise 5 times per week

Question 34

List 2 modifiable things that increase risk of breast cancer

Answer 34

1) Drinking 2 to 3 alcoholic drinks per day
2) Smoking

Question 35

When should clinical breast exams (CBE) be recommended to each of the two age groups?

Answer 35

1) 25-39 yo: may be offered every 1-3 yrs based on shared decision-making*
2) ≥40 yo: may be offered annually based on shared decision-making*
*Uncertainty if CBE offers additional benefits beyond screening mammography, and there is possibility of false positives/harm.

Question 36

When should mammography be recommended to each of the two age groups?

Answer 36

1) 40-75 years old: screen every 1-2 yrs
2) Older than 75 years: shared decision-making process about whether to continue screening (dependent on health/life expectancy)