Medical brain notes 42

  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 th...

  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 peri...

  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...

  BIMANUAL EXAMINATION   The  bimanual examination  uses both a “vaginal” hand and an “abdominal” hand to entrap and palpate the pelvic organs. The bimanual examination begins by exerting gentle pres-sure on the abdomen approximately halfway between the umbilicus and the pubic hair line with the abdominal hand, while inserting the index and middle fingers of the vaginal hand into the vagina to approximately 2 inches and gently pushing downward, distending the vaginal canal. The pa-tient is asked to feel the muscles being pushed on and to relax them as much as possible. Then both the index and middle fingers are inserted into the vagina until they rest at the limit of the vaginal vault in the posterior fornix behind and below the cervix. A great deal of space may be created by posterior distension of the perineum. Occasionally, only the index finger of the vaginal hand can be comfort-ably inserted.   During the bimanual examination, the pelvic struc-tures are “ca...

  RECTOVAGINAL EXAMINATION   When indicated, a  rectovaginal examination  forms part of the complete pelvic examination on initial and annual examination, as well as at interval examinations whenever clinically indicated. The rectovaginal examination is begun by changing the glove on the vaginal hand and using a liberal supply of lub-ricant.  The examination may be comfortably performed if thenatural inclination of the rectal canal is followed: upward at a 45-degree angle for approximately 1 to 2 cm, then downward  (Fig. 1.10). This is accomplished by positioning the fingers of the vaginal hand as for the bimanual examination, except that the index finger is also flexed. The middle finger is then gently inserted through the rectal opening and inserted to the “bend” where the angle turns downward. The index (vaginal) finger is inserted into the vagina, and both fingers are inserted until the vaginal finger rests in the posterior fornix below the cervix, and ...

  FOLLOW-UP AND CONTINUITY OF CARE   Depending on the reason for the patient’s visit—either for a specific medical problem or for a preventive examination, further assessments and a management plan can be estab-lished. If the patient has consulted the physician for a spe-cific problem, a differential diagnosis may be formulated. Interventions can take the form of behavior modification, additional monitoring, treatment, or referral. If the patient has had a preventive health care examination, issues that arise during the history and physical examination and a long-term plan for addressing these issues should be discussed. Screening tests and immunizations that are appropriate for the patient should also be administered.