GYNECOLOGIC HISTORY AND EXAMINATION doc

The last menstrual period LMP, previous menstrual 17 GYNECOLOGIC HISTORY AND EXAMINATION... BREASTS The size, shape, equality, masses, tenderness, scars, and nipple charge should be not

HISTORY

It is common practice to obtain much of the history by ical personnel, interactive computer activities, or a patient ques-tionnaire completed before seeing the physician Hence, the

paramed-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 amination

ex-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 HISTORYMENSTRUAL 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

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, mucousdischarge, and intermenstrual or postcoital spotting should berecorded

GYNECOLOGIC HISTORY

Record the following Gravida (G), the number of previous

preg-nancies; para (P), the number of previous term pregpreg-nancies; tions (Ab), the number of pregnancies terminated (spontaneously

abor-or electively) befabor-ore 20 weeks gestation abor-or 500 g; premature eries (Pre), the number of pregnancies terminated between 21–35 weeks gestation or 500–2499 g; living children (LC), the number

deliv-of children currently living, with twins noted in parenthesis at the

end of the sequence Often, this is recorded in a summary with justthe 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 livingchildren (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 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 currentstatus of living children should be noted also

du-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 mary of the patient’s childhood and later illnesses in chronologic

sum-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 degree relatives (often a brief pedigree is the best demonstration of

third-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 bemade about the duration of present marriage or living arrange-ment, patient’s assessment of the relationship, age and health ofspouse/partner, former marriages or relationships (when and howlong) and degree of compatibility, vaginal and pelvic infections, andsexually 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 tions to others may be assessed tangentially by questions relating

Reac-to successes, failures, and participation in social or religious ganizations

or-PERSONAL HISTORY (HABITS)

Sleep pattern, exercise habits, and alcohol, tobacco, and drug usageshould 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 asrubella and chicken pox (varicella)

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

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 stoolsshould be assessed

Urinary frequency, nocturia, oliguria, dysuria, hematuria, urethraldischarge, sores, swelling, and other urinary alterations should berecorded

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 NECKSkull size and shape, hair (amount, color, and texture), tumors, andtenderness may be useful

EYES

Prominence of the eyes or lids as well as the size, shape, pupillaryreaction to light, character of conjunctiva and sclera, fundi, and oc-ular movements should be assessed

EARS

The external ear, external auditory canal, and tympanic membraneshould be examined, and discharge, cerumen, tophi, tenderness, orother abnormalities must be noted

Any deformity, septal deviation, septal erosion, obstruction, derness, discharge, or tenderness over the sinuses requires comment NECK

ten-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

THORAXThe general size, shape, symmetry, and spinal integrity may bearnotation

BREASTS

The size, shape, equality, masses, tenderness, scars, and nipple charge should be noted (see next section for discussion).HEART

dis-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, diaphragmaticexclusions, and gastric tympany Auscultation reveals the quality andintensity 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 spleenand 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

BACKThe back should be checked for kyphosis or scoliosis Costoverte-bral angle tenderness should be noted

EXTREMITIESSize, shape, color, and movements of the hands should be visual-ized, and condition of the fingers and nails should be noted Thesize, color, condition, and movement of the legs should be assessed.The peripheral vascular system may be appraised by palpating theradial, femoral, distal pedal, posterior tibial, and popliteal arteriesfor thickness and resilience

NERVOUS SYSTEMCerebral function, cranial nerves, cerebellar function, motor andsensory 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)

and when she will be seen again Indicate any counseling or

in-structions given to the patient

SIGNATUREInclude time and date of notation

GYNECOLOGIC EXAMINATIONIncreasingly, 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 tailed For example, if the patient wishes to be seen for gynecologiccomplaints only and is already under the care of another primaryphysician, the gynecologic examination will be the focus of the visit

de-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 Anappraisal of other body systems should be done more frequentlythan the usual standards when indicated by the history or unusualphysical findings

BREAST EXAMINATION

The breast examination has three components: breast

self-exami-nation (BSE), physician examiself-exami-nation, 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 beavoided or delayed by early diagnosis and prompt therapy More-over, BSE is simple, costs nothing, and is painless Despite theseadvantages, only approximately one third of women perform BSEmonthly, 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 ient to choose a time when there is another monthly duty (e.g., pay-ing bills) to trigger remembering to do BSE

conven-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 tions, masses, nodes, or other abnormalities

examina-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 tomonth 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 ward from the erect position to reveal irregularities or dimplingwhen the breasts fall forward The health provider must look forthe same abnormalities as the patient (i.e., asymmetry, masses, nip-ple retraction, skin retraction, or other changes) Often, oblique light

for-is helpful to confirm surface dimpling

With the patient sitting, the patient is asked to extend her arms

60–90 Careful palpation of each axilla is performed using the

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.)

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

FIGURE 17-2. Palpation of axillary and supraclavicular regions for larged lymph nodes.

en-(From A.E Giuliano In: L.W Way, ed., Current Surgical Diagnosis & Treatment, 6th ed.

Lange, 1983.)

FIGURE 17-3. Palpation of breasts Palpation is performed with the patient supine and arm abducted

(From A.E Giuliano In: L.W Way, ed., Current Surgical Diagnosis & Treatment, 6th ed.

flat of the fingers Both side-to-side and upper-to-lower palpationmay be necessary depending on the configuration of the breasts.With the patient supine and arms above the head, the breastsare again inspected The axilla are reassessed with the patient’s arms

extended The breasts are palpated between the examining fingers.

Finally, with the woman’s arms relaxed at the sides, careful

palpa-tion of each breast quadrant is performed by compression against

the chest wall One breast at a time is palpated by holding the gers flat against the breast and carefully feeling with gentle pres-sure Gentle compression of the areas beneath the areola and nipplewith the thumb and index finger will detect masses and expressfluid Should a nipple discharge be present, it should be smeared

fin-on a slide and fixed for cytologic examinatifin-on.

The breasts are observed for consistency, thickened areas, regularities, areas with dissimilar consistency, cordlike duct struc-tures, as well as shotty or nodular masses It is determined whethermasses are fixed to the skin or chest wall

ir-When a breast mass is identified, the presumptive diagnosis is

usually established by mammography It may be necessary to

aspi-rate a cyst or biopsy to confirm the diagnosis.

● Baseline mammogram for all women age 35–40 years

● Mammography at 1–2 year intervals from age 40 to 49 years

● Annual mammograms for women 50 years

High-risk women (e.g., previous breast cancer, mothers or

sis-ters with bilateral or premenopausal breast cancer, and those withhistologic abnormalities associated with subsequent breast cancer—

Chapter 18) should have biannual examinations and annual

mam-mography Such a screening program will identify
6 cancers per

1000 asymptomatic women Moreover, the tumors will be detectedearlier (80% have negative axillary nodes vs 45% not screened).Approximately 40% of early breast cancers can be discovered only

by mammography, and ⬃40% can be detected only by palpation.Thus, both modalities are crucial

ABDOMINAL EXAMINATION

The abdomen is observed with the patient sitting, and then ine in the dorsal recumbent position with knees slightly flexed toimprove abdominal relaxation The contour is noted (flat, scaphoid,