Medical brain notes 42

  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

  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

  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

  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

  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

  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.  

  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.

  SOCIAL HISTORY   Patients should be asked about behaviors and lifestyle is-sues that may potentially affect their health and increase their risk.  The outcome of this discussion provides a meaning-ful basis for counseling and interventions.  All patients shouldbe asked about the following issues:   ·    Tobacco use   ·    Alcohol use: amount and type   ·    Use of illegal drugs and misuse of prescription drugs   ·    Intimate-partner violence   ·    Sexual abuse   ·    Health hazards at work and at home; seatbelt use   ·    Nutrition, diet, and exercise, including folic acid and calcium intake   ·    Caffeine intake   Questions can also be asked about whether the patient has an advance directive and whether she is interested in organ donation.

  REVIEW OF SYSTEMS   Following the medical history, an overall assessment of a patient’s health history on a system-by-system basis should be conducted. This assessment provides an opportunity for a more focused evaluation of the patient. This review should encompass all body systems (Box 1.2).   Physical Examination   The physical examination encompasses an evaluation of a patient’s overall health as well as a breast and gyneco-logic examination.  The general physical examination servesto detect abnormalities suggested by the medical history as well as unsuspected problems.  Specific information the patientgives during the history should guide the practitioner to areas of physical examination that may not be sur-veyed in a routine screening. The extent of the exami-nation is based on the practitioner’s clinical relationship with the patient, what is being medically managed by other clinicians, and what is medically indicated. Areas that are included in this general examination are li

  POSITION OF THE PATIENT AND EXAMINER   The patient is asked to sit at the edge of the examination table and an opened draping sheet is placed over the patient’s knees. If a patient requests that a drape not be used, the request should be honored.   Positioning the patient for examination begins with the elevation of the head of the examining table to approx-imately 30 degrees from horizontal. The physician or an assistant should help the patient assume the  lithotomyposition  (Fig. 1.4). The patient should be asked to lieback, place her heels in the stirrups, and then slide down to the end of the table until her buttocks are flush with the edge of the table. After the patient is in the lithotomy po-sition, the drape is adjusted so that it does not obscure the clinician’s view of the perineum or obscure eye contact be-tween patient and physician. The physician should sit at the foot of the examining table, with the examination lamp adjusted to shine on the perineum. The lamp is optima

  INSPECTION AND EXAMINATION OF THE EXTERNAL GENITALIA   The pelvic examination begins with the inspection and exam-ination of the external genitalia.  Inspection should includethe mons pubis, labia majora and labia minora, per-ineum, and perianal area. Inspection continues as palpa-tion is performed in an orderly sequence, starting with the clitoral hood, which may be pulled back to inspect the glans proper. The labia are spread laterally to allow inspection of the introitus and outer vagina. The urethral meatus and the areas of the urethra and Skene glands should be inspected. The forefinger is placed an inch or so into the vagina to gently milk the urethra. A culture should be taken of any discharge from the urethral open-ing. The forefinger is then rotated posteriorly to palpate the area of the Bartholin glands between that finger and the thumb (Fig. 1.5).

  SPECULUM EXAMINATION   The next step is the  speculum examination. The parts of thespeculum are shown in Figure 1.6. There are two types of specula in common use for the examination of adults. The  Pederson speculum  has flat and narrow blades that barelycurve on the sides. The Pederson speculum works well for most nulliparous women and for postmenopausal women  with atrophic, narrowed vaginas. The Graves speculum  has blades that are wider, higher, and curved on the sides; it is more appropriate for most parous women. Its wider, curved blades keep the looser vaginal walls of multiparous women separated for visualization. A Pederson speculum with extra narrow blades may be used for visualizing the cervix in pubertal girls.   The speculum should be warmed either with warm water or by holding it in the examiner’s hand. Warming the speculum is done for the comfort of the patient and to aid with insertion. Insertion of the speculum  should take into account thenormal anatomic relations,