GYNECOLOGIC HISTORY AND EXAMINATION doc

505 HISTORY It is common practice to obtain much of the history by paramed- ical personnel, interactive computer activities, or a patient ques- tionnaire completed before seeing the physician. Hence, the patient–physician interaction can be focused with emphasis on the patient’s concerns. Additionally, important positive and negative findings may be reviewed with the patient before the physical ex- amination. AGE, MARITAL STATUS, GRAVIDITY, AND PARITY CHIEF COMPLAINT The patient’s main problem(s) in her own words listed in her order of seriousness comprise the chief complaint. PRESENT ILLNESS The patient’s health at the onset of illness and the symptoms in se- quence of development form the present illness. As much detail (e.g., facts, dates) as is possible is included, documenting what, where, when, why, how, and to what degree each complaint affects her. PAST HISTORY MENSTRUAL HISTORY The age and character of the menarche (or menopause) should be described. The last menstrual period (LMP), previous menstrual 17 GYNECOLOGIC HISTORY AND EXAMINATION CHAPTER Copyright 2001 The McGraw-Hill Companies. Click Here for Terms of Use. BENSON & PERNOLL’S 506 HANDBOOK OF OBSTETRICS AND GYNECOLOGY period (PMP), and last normal menstrual period (LNMP), if relevant, should be recorded. Also, the regularity, duration, amount of bleeding (number of perineal pads or tampons), pain, mucous discharge, and intermenstrual or postcoital spotting should be recorded. GYNECOLOGIC HISTORY Record the following. Gravida (G), the number of previous preg- nancies; para (P), the number of previous term pregnancies; abor- tions (Ab), the number of pregnancies terminated (spontaneously or electively) before 20 weeks gestation or 500 g; premature deliv- eries (Pre), the number of pregnancies terminated between 21–35 weeks gestation or 500–2499 g; living children (LC), the number of children currently living, with twins noted in parenthesis at the end of the sequence. Often, this is recorded in a summary with just the numbers in the sequence noted; [e.g., 4,2,1,2,4 (Twins 1 pr.) would mean the woman had been pregnant 4 times, had 2 term preg- nancies, had 1 abortion, had 2 premature births, and has 4 living children (here, the twins were premature but survived)]. In some patients, a more detailed obstetric history is indicated, including dates of all pregnancies; their duration, character, and du- ration of labor; and method of delivery (with type of uterine inci- sion if cesarean birth). Complications, weight and gender of in- fant(s), stillbirths, abortions, neonatal complications, and current status of living children should be noted also. MEDICAL AND SURGICAL HISTORY Record medical allergies (e.g., penicillin, iodine, horse serum) as well as important nonmedical allergies (e.g., shrimp). Record any excessive bleeding potentially indicative of a coagulopathy. A sum- mary of the patient’s childhood and later illnesses in chronologic order together with complications and the treatment prescribed for each is important. Record operations and injuries, with dates and outcome. Record all medications (prescription, proprietary) as well as alternative health care (medications, acupuncture, etc.). FAMILY HISTORY Age, health, and cause and date of death of first- through third- degree relatives (often a brief pedigree is the best demonstration of this material) should be recorded. Also note familial or hereditary abnormalities, diseases, bleeding tendencies, occurrence of cancer, tuberculosis, diabetes mellitus, heart disease, hypertension, and nervous or mental disorders. SEXUAL HISTORY Current and past contraception usage should be recorded, as well as libido and the frequency of coitus. Additional notes should be made about the duration of present marriage or living arrange- ment, patient’s assessment of the relationship, age and health of spouse/partner, former marriages or relationships (when and how long) and degree of compatibility, vaginal and pelvic infections, and sexually transmitted diseases (including HIV). SOCIAL HISTORY The patient’s occupation, avocation(s), and travel (especially abroad or in the tropics) should be appraised for hazards. Reac- tions to others may be assessed tangentially by questions relating to successes, failures, and participation in social or religious or- ganizations. PERSONAL HISTORY (HABITS) Sleep pattern, exercise habits, and alcohol, tobacco, and drug usage should be noted. Health maintenance parameters should be assessed: This in- cludes the status of age- and gender-specific screening (e.g., last mammography, last Pap smear, fecal occult hemoglobin screening, lipoprotein screening, Tay-Sachs screening). Additionally, the sta- tus of routine immunizations must be reviewed. This includes sta- tus of adult DT (diptheria, tetanus), “flu” immunizations, as well as rubella and chicken pox (varicella). SYSTEM REVIEW A positive or negative comment for each portion of this category will aid in health assessment. GENERAL Comment on the patient’s health, present weight, average weight, weight before present illness, reason for weight loss or gain, skin disorders, and change in hair pattern. CHAPTER 17 GYNECOLOGIC HISTORY AND EXAMINATION 507 BENSON & PERNOLL’S 508 HANDBOOK OF OBSTETRICS AND GYNECOLOGY HEAD AND NECK Pain, tenderness, swelling, restriction of neck, and trauma should be noted. EYES Vision with and without glasses, double vision, irritation, swelling of the lids, and prominence of eyes deserve comment. EARS Record pain, buzzing, discharge, and patient’s assessment of hear- ing. NOSE Obstruction to nasal passages, bleeding, discharge, and change in ability to smell require recording. MOUTH General condition of the teeth, gums, tongue, bleeding, and chew- ing difficulties should be noted. THROAT Speech difficulties, swallowing, or voice changes are notable. CARDIOVASCULAR Skin color (pale, ruddy, dusky), edema, precordial or substernal pain, irregular or labored heartbeat, and shortness of breath at rest or with exercise should be recorded. RESPIRATORY List any of the following: cough, wheezing, sputum, hemoptysis, chest pain with breathing, chills, fever, and night sweats. GASTROINTESTINAL The patient’s appetite, thirst, digestive difficulties (e.g., nausea, vomiting, preprandial or postprandial pain, hematemesis, food in- tolerance), jaundice, and frequency, character, and color of stools should be assessed. URINARY Urinary frequency, nocturia, oliguria, dysuria, hematuria, urethral discharge, sores, swelling, and other urinary alterations should be recorded. NEUROPSYCHIATRIC Strength, ability to work, skin sensations, ataxia, dizziness, tremor, headaches, “spells” or “fits,” acuity of memory, and strange occur- rences should be explored if warranted. PHYSICAL EXAMINATION VITAL SIGNS At the minimum, the patient’s weight, height, blood pressure, and pulse are recorded. The temperature and respirations are also use- ful, but more often recorded if related to the chief complaint. GENERAL The patient’s appearance, state of nutrition, ability to ambulate, at- titude, and color of skin (e.g., pallor, plethora) are often recorded. HEAD AND NECK Skull size and shape, hair (amount, color, and texture), tumors, and tenderness may be useful. EYES Prominence of the eyes or lids as well as the size, shape, pupillary reaction to light, character of conjunctiva and sclera, fundi, and oc- ular movements should be assessed. EARS The external ear, external auditory canal, and tympanic membrane should be examined, and discharge, cerumen, tophi, tenderness, or other abnormalities must be noted. CHAPTER 17 GYNECOLOGIC HISTORY AND EXAMINATION 509 BENSON & PERNOLL’S 510 HANDBOOK OF OBSTETRICS AND GYNECOLOGY NOSE Any deformity, septal deviation, septal erosion, obstruction, ten- derness, discharge, or tenderness over the sinuses requires comment. NECK Swelling, pulsations, tracheal deviations, thyroid, lymph nodes, retractions, and abnormal masses should be noted. MOUTH AND THROAT The lips, gums, tongue, dentition, tonsils, and oropharynx should be examined. THORAX The general size, shape, symmetry, and spinal integrity may bear notation. BREASTS The size, shape, equality, masses, tenderness, scars, and nipple dis- charge should be noted (see next section for discussion). HEART The point of maximal impulse at the apex, abnormal pulsations, retractions, or venous distention in the neck or in other veins should be noted. Auscultation of the heart should be accomplished. LUNGS Inspect the chest to reveal the equality of inspiration and expiration. Palpate to reveal muscle tone, tenderness, and tactile fremitus. Per- cussion should reveal resonance, cardiac silhouette, diaphragmatic exclusions, and gastric tympany. Auscultation reveals the quality and intensity of breath sound, rales, fremitus, and friction rubs. ABDOMEN Note the size, shape, and abdominal contour as well as masses, visible peristaltic waves, prominent veins, and herniation. Palpation may indicate the thickness of the abdominal wall, the liver edge, the spleen and any tenderness, rigidity, masses, hernias, and the presence or absence of a fluid wave. Percussion should confirm organ position or masses. Auscultation will reveal the presence of peristaltic tones. BACK The back should be checked for kyphosis or scoliosis. Costoverte- bral angle tenderness should be noted. EXTREMITIES Size, shape, color, and movements of the hands should be visual- ized, and condition of the fingers and nails should be noted. The size, color, condition, and movement of the legs should be assessed. The peripheral vascular system may be appraised by palpating the radial, femoral, distal pedal, posterior tibial, and popliteal arteries for thickness and resilience. NERVOUS SYSTEM Cerebral function, cranial nerves, cerebellar function, motor and sensory systems, and reflexes should be reported. PELVIC EXAMINATION A proper pelvic examination records visual inspection and palpa- tion of the external genitalia; Bartholin’s urethral, and Skene’s glands (BUS); introitus, vagina, and cervix. The bimanual exami- nation includes palpation of the uterus, ovaries, and uterine tubal areas. The rectovaginal examination must include palpation of vagina, rectum, and rectovaginal septum as high as the cul-de-sac (see next section for details). IMPRESSION (ANALYSIS) List probable diagnoses for each problem (in same order of chief complaint). PLAN Record a plan for each problem (i.e., diagnosis and therapy). Note any tests performed in the office (e.g., wet mount and Pap smear) and indicate other testing the patient is to have (e.g., mammography) CHAPTER 17 GYNECOLOGIC HISTORY AND EXAMINATION 511 BENSON & PERNOLL’S 512 HANDBOOK OF OBSTETRICS AND GYNECOLOGY and when she will be seen again. Indicate any counseling or in- structions given to the patient. SIGNATURE Include time and date of notation. GYNECOLOGIC EXAMINATION Increasingly, obstetrician–gynecologists, nurse practitioners, physi- cian assistants, and other health care professionals are providing the entire spectrum of primary health care for women, as well as taking care of their reproductive needs. Thus, it is proper to determine if the patient is being seen for a specific issue, or if she is expecting her entire health care to be met with this exchange. The depth of the gen- eral workup and health care advice may then be appropriately de- tailed. For example, if the patient wishes to be seen for gynecologic complaints only and is already under the care of another primary physician, the gynecologic examination will be the focus of the visit. The gynecologic evaluation devotes particular attention to ex- amination of the breasts, abdomen, and pelvis. The general exam- ination and appropriate laboratory studies should be performed. An appraisal of other body systems should be done more frequently than the usual standards when indicated by the history or unusual physical findings. BREAST EXAMINATION The breast examination has three components: breast self-exami- nation (BSE), physician examination, and mammography. BREAST SELF-EXAMINATION (BSE) After age 20 years, BSE is recommended on a monthly basis for all women. Women who do BSE as recommended discover breast dis- ease significantly earlier, and death from breast cancer can be avoided or delayed by early diagnosis and prompt therapy. More- over, BSE is simple, costs nothing, and is painless. Despite these advantages, only approximately one third of women perform BSE monthly, and of those, only about half do this correctly. Since BSE is more often and better performed if taught by a nurse or a physician, the time of examination is an ideal opportu- nity to teach BSE and discuss its significance. Most information will be gained in a menstruating woman im- mediately after menses when hormonal changes in the breast are at a minimum. In nonmenstruating women, it is often most conven- ient to choose a time when there is another monthly duty (e.g., pay- ing bills) to trigger remembering to do BSE. The examination is begun in the upright position with good direct light. Looking in a mirror, the patient inspects the breasts carefully, first with her arms at the sides, and then raised above her head. She is seeking abnormalities of contour or symmetry, skin changes, masses, retraction, or nipple alterations. Palpation of the supraclavicular and axillary regions is per- formed next. She is looking for changes from previous examina- tions, masses, nodes, or other abnormalities. Next, the patient reclines, with a towel or small pillow beneath the back on the side of the breast being examined (to rotate the chest so that the breast may be symmetrically flattened against the chest wall). Next, using the flat of her fingers, she systematically palpates each quadrant of the breast by pressing against the chest wall. Fi- nally, the areola and the area beneath the nipple should be palpated and the nipples compressed for evidence of secretion. Again, she is looking for changes from previous examinations, lumps (masses), and any other abnormalities. Should anything raise concern, the pa- tient should immediately consult her physician. Many women find keeping a simple sketch as a record of the findings from month to month to be a useful way to detect change. PHYSICIAN BREAST EXAMINATION A complete physician breast examination is recommended every 2–3 years for women age 20–40 (Figs. 17-1, 17-2, and 17-3). Women .40 should have at least annual examinations. The physician should proceed as follows. With the patient sitting in good light with her arms at the side, a visual inspection is performed. The patient is asked to press her hands on her hips (tensing the pectoralis muscles), and the inspec- tion continued. With her arms raised above her head, both breasts and axillae are examined. Finally, the patient is asked to bend for- ward from the erect position to reveal irregularities or dimpling when the breasts fall forward. The health provider must look for the same abnormalities as the patient (i.e., asymmetry, masses, nip- ple retraction, skin retraction, or other changes). Often, oblique light is helpful to confirm surface dimpling. With the patient sitting, the patient is asked to extend her arms 60Њ–90Њ. Careful palpation of each axilla is performed using the CHAPTER 17 GYNECOLOGIC HISTORY AND EXAMINATION 513 FIGURE 17-1. Inspection of breasts. Observe breasts with patient sitting, arms at sides and overhead, for presence of asymmetry and nipple or skin re- traction. These signs may be accentuated by having the patient raise her arms overhead. Skin retraction or dimpling may be demonstrated by having the patient press her hand on her hip in order to contract the pectoralis muscles. (From J.L. Wilson. In: J.E. Dunphy and L.W. Way, eds., Current Surgical Diagnosis & Treatment, 4th ed. Lange, 1979.) BENSON & PERNOLL’S 514 HANDBOOK OF OBSTETRICS AND GYNECOLOGY flat of the fingers of the right hand for the left axilla and the left hand for the axilla. Both the supraclavicular and infraclavicular areas are carefully palpated for masses. With the patient leaning forward, bimanual palpation of each breast is performed using the [...]... the fingers of the hand CHAPTER 17 GYNECOLOGIC HISTORY AND EXAMINATION 521 in the vagina are resting against the cervix and lower portion of the corpus Relaxation of the vaginal walls and fornices may permit palpation of much or all of the cul-de-sac and of the posterior aspect of the uterus A normally free uterus usually can be brought well downward and forward by the abdominal hand This makes possible... position and the examiner standing with one foot on a step or low 520 BENSON & PERNOLL’S HANDBOOK OF OBSTETRICS AND GYNECOLOGY stool and the elbow on that knee to brace the examining arm and hand The gloved, lubricated index finger is gently inserted into the vagina by applying slight downward pressure at the fourchette and asking the patient to relax After a pause to enhance relaxation, the middle and. .. only by mammography, and ϳ40% can be detected only by palpation Thus, both modalities are crucial ABDOMINAL EXAMINATION The abdomen is observed with the patient sitting, and then examine in the dorsal recumbent position with knees slightly flexed to improve abdominal relaxation The contour is noted (flat, scaphoid, CHAPTER 17 GYNECOLOGIC HISTORY AND EXAMINATION 517 or protuberant), and inspection of the...CHAPTER 17 GYNECOLOGIC HISTORY AND EXAMINATION 515 FIGURE 17-2 Palpation of axillary and supraclavicular regions for enlarged lymph nodes (From A.E Giuliano In: L.W Way, ed., Current Surgical Diagnosis & Treatment, 6th ed Lange, 1983.) flat of the fingers Both side-to-side and upper-to-lower palpation may be necessary depending on the configuration of the breasts With the patient supine and arms above... examining hand may be inserted into the vagina Palpation of Structures of Introitus Tenderness, masses, and thickening at the introitus may be palpated between the thumb and forefinger With the thumb external and the palm turned downward, enlargement and/ or sensitivity of Bartholin’s glands may be appreciated Direct palpation of the lower vaginal wall may detect abnormalities Similarly, the urethra and base... Slight tenderness and a suggestion of thickening over the normal ureter at or near its insertion into the bladder are normal Bimanual Examination The foregoing procedures require only one unaided hand In bimanual examination, the other hand is used on the abdomen to outline the deeper pelvic structures The abdominal hand is held palm down on the abdomen with the fingers together and slightly flexed,... cervix merits careful examination (i.e.: color, size, contour, surface characteristics, and the squamocolumnar junction) Lacerations; displacement; size and configuration of the external os; distortion or ulceration; type and amount of discharge, blood, or fluid present in the cervical canal; and the character of the endocervix (through a patulous os) are all notable Before digital examination, a clean... landmarks Rectovaginal Examination Rectovaginal examination should be performed routinely even though all of the internal genital structures have been palpated 522 BENSON & PERNOLL’S HANDBOOK OF OBSTETRICS AND GYNECOLOGY properly on vaginal evaluation Anal abnormalities, lesions of the rectovaginal septum, and even sacral masses may be felt only on rectovaginal examination This examination is invaluable... Fluid exudates may be obtained from the urethral meatus, Skene’s and Bartholin’s ducts, the vaginal walls, the posterior vaginal fornix, and the cervical os CHAPTER 17 GYNECOLOGIC HISTORY AND EXAMINATION 523 Using bacteriologic technique, the applicator is directly applied to the culture medium or to a transfer medium Avoid heating and drying the sample When gonorrhea is suspected, a sterile chocolate... 17-4 Vaginal specula and vaginoscope These come in various sizes CHAPTER 17 GYNECOLOGIC HISTORY AND EXAMINATION 519 vagina, to slightly depress the perineum while asking the patient to relax the muscles being pressed on, may also facilitate relaxation The speculum is most easily inserted by holding the blades slightly obliquely to the axis of the vagina while directing them downward and inward at approximately . gain, skin disorders, and change in hair pattern. CHAPTER 17 GYNECOLOGIC HISTORY AND EXAMINATION 507 BENSON & PERNOLL’S 508 HANDBOOK OF OBSTETRICS AND GYNECOLOGY HEAD AND NECK Pain, tenderness,. PAST HISTORY MENSTRUAL HISTORY The age and character of the menarche (or menopause) should be described. The last menstrual period (LMP), previous menstrual 17 GYNECOLOGIC HISTORY AND EXAMINATION CHAPTER Copyright. therapy. PALPATION Digital examination is easiest with the patient in the lithotomy po- sition and the examiner standing with one foot on a step or low CHAPTER 17 GYNECOLOGIC HISTORY AND EXAMINATION 519 BENSON