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The Woman’s Health Examination

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  The Woman’s Health Examination   Obstetrics  was originally a separate branch of med icine, and gynecology  was a division of surgery.   Knowledge of the pathophysiology of the female reproductive tract led to a natural integration of these two areas, and obstetrics and gynecology merged into a single specialty. Obstetricians can now undergo further training in maternal fetal medicine, which deals with high-risk pregnancies and prenatal diagnosis.  Likewise, gynecology nowincludes general gynecology (which deals with nonmalignant dis-orders of the reproductive tract and associated organ systems, family planning, and preconception care), gynecologic oncology, reproductive endocrinology–infertility, and pelvic reconstructive surgery and urogynecology.  These areas constitute the major-ity of the requisite knowledge and skills expected of the fully trained  obstetrician–gynecologist  specialist.   Currently, many obstetrician–gynecologists also pro-vide complete care for women throughou
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The Doctor-Patient Relationship

  THE DOCTOR–PATIENT RELATIONSHIP   Starting with the first interaction with the patient, the physician strives to establish and develop a professional re-lationship of mutual trust and respect. At the same time, the patient usually decides if the physician is knowledgeable and trustworthy and whether she will accept recommenda-tions that are made. The process begins with an appropriate greeting, which may or may not include a handshake. Surnames should generally be used, because the patient–physician relation-ship, although friendly, is professional. “What brought you to the office today?” or “How may I help you today?” are neutral opening questions that allow the patient to frame a response that includes her problems, concerns, and reasons for the visit.   In the past, practitioners focused on finding the pa-tient’s problems and fixing them “for her.”  Modern healthcare of women involves the patient to a much greater extent in the care process.  This cooperative model is based on the
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Health Evaluation: History and Physical Examination

  HEALTH EVALUATION: HISTORY AND PHYSICAL EXAMINATION   Routine health care involves a detailed history and physical examination.  Routine visits are also a good time to counsel pa-tients about issues that affect health care and to perform routine screening tests based on age and risk factors. .   A comprehensive medical record should be kept and maintained for each patient and updated periodically. This record includes a medical history, physical examination, and laboratory and radiology results. Information from re-ferrals and other medical services outside the purview of the obstetrician–gynecologist should be integrated into the medical record. The American College of Obstetricians and Gynecologists (ACOG) offers a form called the  ACOGWomen’s Health Record  to assist health care providers intheir daily practice (Appendix A). It also includes screening recommendations and coding information. Medical History Information contained in the medical history includes dis-cussion of the ch
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Gynecologic History

  GYNECOLOGIC HISTORY   The gynecologic history focuses on the menstrual history, which begins with  menarche,  the age at which menses began. The basic menstrual history includes:   ·              Last menstrual period (LMP)   ·              Length of periods (number of days of bleeding)   ·              Number of days between periods   ·              Any recent changes in periods   Episodes of bleeding that are “light, but on time” should be noted as such, because they may have diagnostic signifi-cance. Estimation of the amount of menstrual flow can be made by asking whether the patient uses pads or tam-pons, how many are used during the heavy days of her flow, and whether they are soaked or just soiled when they are changed. It is normal for women to pass clots during menstruation, but normally they should not be larger than the size of a dime. Specific inquiry should be made about  irregular bleeding  (bleeding with no set pattern or duration),  intermenstrual bleeding  (bleeding b
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Obstetric History

  OBSTETRIC HISTORY   The basic obstetric history includes the patient’s  gravidity,  or number of pregnancies. A pregnancy can be a live birth, miscarriage, premature birth (less than 37 weeks of gestation), or an abortion. Details about each live birth are noted, including birthweight of the infant, sex, number of weeks at delivery, and type of delivery. The patient should be asked about any pregnancy complications, such as diabetes, hypertension, and preeclampsia, and whether she has a history of depression, either before or after a preg-nancy. A breastfeeding history is also useful information. If a patient has a history of  infertility  (generally de-fined as failure to conceive for 1 year with sufficiently frequent sexual encounters), questions concerning both partners should cover previous diseases or surgery that may affect fertility, previous fertility (previous children with the same or other partners), duration that preg-nancy has been attempted, and the frequency and timing
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Past History

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  PAST HISTORY   Past history includes information about any gynecologic disease and/or treatment that the patient has had, includ ing the diagnosis, the medical and/or surgical treatment, and the results.   Questions about previous gynecologic surgery should include the name of the procedure; indica-tion; when, where, and by whom the surgery was per-formed; and the results. Operative notes may contain useful information, for example, regarding pelvic adhe-sions, and should be obtained, if possible. The patient should be asked specifically about a history of sexually transmitted diseases (STDs), such as gonorrhea, herpes, chlamydia, genital warts (condylomata), hepatitis, ac-quired immune deficiency syndrome (AIDS), herpes, and syphilis.  To the extent possible, the patient’s immunization his-tory should be documented.  
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Family History

  FAMILY HISTORY   The  family history  should list illnesses occurring in first-degree relatives, such as diabetes, cancer, osteoporosis, and heart diseases.  Information gained from the family history mayindicate a genetic predisposition for a hereditary disease.  This in-formation may guide selection of specific tests or other in-terventions for the surveillance of the patient and perhaps other family members. Preconceptional counseling also may be offered.
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