History, Physical Examination, & Preventative Health Care

1. History, Physical Examination, & Preventative Health Care by Ekaterina Tchmoutina, R1 8/6/2014

2. Outline • Direct Observation • Chief Complaint • Hx of Present Illness • Ob/GynHx • Past Medical Hx • Past Surgical Hx • Family Hx • Social Hx - including marital status, occupational and avocationalHx • Safety Practices • Review of Systems • Physical Exam • general • speculum • pap smear • bimanual • rectovaginal/rectal • Necessary Annual Screening • Preventative Health Care • Counseling

3. Direct Observation • non verbal clues • demeanor • address issues  improved pt safety, satisfaction & reduced litigation

4. Chief Complaint & HPI • encourage to tell own story • open ended inquiry • interrupt only for clarification

5. Menstrual Hx • LMP • cycle duration/regularity • menses duration/amount/color/accompanying symptoms • age of menarche

6. Pregnancy Hx • list with date, mode of delivery, size, complications, current condition of baby • molar pregnancies • elective/spontaneous abortion

7. Vaginal/Pelvic Infection Hx • type • treatment • test of cure • risk factors • Pap smear Hx • Contraceptive Hx

8. Sexual Hx • active vs inactive • number/type of partners • +/- orgasm • +/- dyspareunia • +/- sexual dysfunction (self/partner)

9. Pelvic Pain • location • timing • quality: throbbing/burning/colicky • radiation • intensity • duration • alleviating/aggravating factors • relationship to menses/intercourse/bladder/bowel symptoms

10. Urinary Symptoms • dysuria • urinary frequency • incontinence • nocturia • hematuria

11. PMHx & Rx • DM? • Hepatitis? • TB? • CV disease – HTN, CVA, TIA etc? • Thyroid disease? • Bleeding/clotting disorders? Hx of DVT/PE? • Asthma? • Bladder/Kidney infections, kidney stones? • Autoimmune diseases – SLE, MS, CD, UC etc? • Migranes? • All Rx including alternative/herbal remedies

12. PSHx • all pertinent non Ob/Gyn • all OB/Gyn procedures • dates • outcomes • inquire into path reports

13. Family Hx • cancer, especially breast (premenopausal), ovarian, colon • CV disease • genetic disorders

14. Social Hx • smoking • EtOH • recreational/prescription drug abuse • marital status • occupation • hobbies (pertinent to safety) • diet

15. Safety • seat belts • helmets • firearms • physical/sexual/verbal abuse

16. ROS

17. General Physical Exam • BMI • height especially for post-menopausal women (osteoporosis) • thyroid • pulmonary • CV • extremities

18. Breast Exam • 20-39 y/o - Q3yrs • >39 y/o – Q1yr • sitting & supine for assymetry • visual inspection for dimpling, erythema, nipple retraction, nipple eczema, discharge, breast fixation, tissue thickening, masses • systematic exam of entire breast for masses • vertical vs circular • variable pressure • finger pads • three middle fingers • axillary & supraclavicular lymphadenopathy • 7-10 ds after menses onset • self breast exam?

19. Abdominal Exam • scars • stria • escutcheon – triangle (female) vs diamond (male) • palpation – masses, organomegaly, fluid wave, tenderness, rebound, hernias, inguinal lymphadenopathy • percussion – masses, fluid wave • auscultation – bowel sounds, bruits

20. Pelvic Exam • +/- chaperone • inspection – nevi, pediculosis, clitoral size, warts, hemorroids • palpation – urethra, skene’s glands, bartholin’s glands, cystocele, cystourethrocele, rectocele, enterocele, uterine prolapse

21. Speculum Exam - 1 • Graves • small – young children, tight perineal repair, aged • medium • large – obese, multiparous • Pederson • not sexually active, nulliparous, tampon naïve

22. Speculum Exam - 2 • Vagina – erythema, lesions, vesicles, cysts (inclusion, Gartner’s duct cyst, Mullerian etc) • Vaginal swab – Trichomonas vaginalis (saline prep – flagellated), bacterial vaginosis (saline prep – clue cells), candidiasis (KOH prep) • Cervix – parity, lacerations, transformation zone, ectropion, Nabothian cysts, vesicles, warts, dysplasia • Endocervical cultures – N. gonorrhea, Chlamydia trachomatis (annual for sexually active </= 25 y/o)

23. Pap Smear • begin 21 y/o • 21-29 - Q1-2 yrs with reflex HPV • 30 – Q3 yrs + HPV co-testing • >65 – stop screening if no Hx CIN2 & 3 consecutive negatives cytology/co-test, or 2 consecuitive and last within last 5 yrs • high risk Q1yr and 1 yr after sexual activity onset – HIV, immunosuppressed, DES exposure in utero, Hx of treatment for cervical dysplasia/CA • no screening after hysterectomy for benign condition • Endocervical brush vs cotton swab – endocervical canal • Ayres spatula – transformation zone • immediate fixation on slide or Thin-prep

24. Pap Smear Results • squamous cells – ASC, LSIL, HGSIL, SCCA • glandular cells – AGC, AGC favor neoplastic, AIS (endocervical adenoCa in situ), adenoCa • reactive – inflammation, radiation, IUD, glandular cells s/p hysterectomy, atrophy • cellular changes of HSV • Actinomyces infection • Trichomonas vaginalis • Candida & other fungal organisms • BV associated shift in flora

25. Bimanual Exam • index & middle finger in posterior fornix against cervix • push uterus up to abdomen • uterine size/position/mobility • anteverted, mid position (1st degree retroverted), retroverted (2nd, 3rd degree) • cervical motion tenderness • adnexal masses/tenderness/mobility

26. Rectovaginal & Rectal Exam • thickness/masses, hemorroids, fissures, sphincter tone • uterosacral ligaments – thickening, beadiness, masses • retroverted uterus evaluation • rectovaginal membrane

27. Routine Annual Screening • rubella titer • TB test • HIV once 19-64 y/o • Hep C • TSH Q5ys ≥50 y/o • fasting lipid profile - Q5yrs 20-64 y/o, Q3-5 ≥65y/o • genetic testing with FHx breast Ca (premenopausal), ovarian Ca, colon Ca • mammography – ≥50 y/o Q1yr • colonoscopy ≥50 Q10 yr, ≥45 Q10 yr (AA), -10yrs from age of onset in first degree relative (if <60 y/o age of onset) • DEXA scan ≥65y/o Q2yrs (younger if steroids, FHx, fractures, physically inactive, tobacco/EtOH abuse, underweight, dementia, European/Asian ancestry, Hx of falls, E deficiency, poor nutrition) • hearing & visual acuity screening >65 y/o • atrophic vaginitis

28. Preventative Health Care • Influenza Q1 yr • HPV vaccine – Gardasil (6,8,16,18) 9-26 y/o, Cervarix (16, 18) 10-25 y/o • MMR vaccine • Tdap booster once + Td Q10 yrs • Zoster vaccine > 60 y/o • Hep A – travel • Hep B – health care professionals, high risk • Pneumonia vaccine

29. Counseling • diet • exercise • smoking cessation (Ask, Advise, Assess, Assist, Arrange) • excessive EtOH use • Ca & vit D (age dependent recommendations) • increasing bone strength – fall prevention, diet, weight bearing exercises • helmets, seatbealts • sun exposure prophylaxis

30. Appendix – Calcium from http://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/

31. Appendix – Vitamin D from http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/

32. References • Fletcher, SW. 2014. Screening for Breast Cancer. Up-to-Date, Jun 2014. • Lentz, GM. 2012. Comprehensive Gynecology. Sixth Edition. Chapter 7 – History, Physical Examination, and Preventative Health Care. Mosby, Elsevier Inc.; 113-128. • http://ods.od.nih.gov/factsheets/Calcium-HealthProfessional/ • http://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/ • Red Book