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The Female Physical Examination. by Donald G. Hudson, D.O.,FACEP/ACOEP. The female physical is frequently more complex than the male examination The history is absolutely important History has to explore changes over time
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The Female Physical Examination by Donald G. Hudson, D.O.,FACEP/ACOEP
The female physical is frequently more complex than the male examination • The history is absolutely important • History has to explore changes over time • Women tend to have more exams than men and have more detail concerning their health • Explore all self examinations done by the patient • Be sure to ask about all meds and surgeries • Ask about all Gyn issues, pregnancies, STD, number of sexual partners, pap smears, etc.
How to approach the problems • The patient will usually have a defined chief complaint that brought them to the office. • Initially limit your history to a directed history as related to the C/C. • As you develop some rapport with the patient you can expand your questions to include other systems, symptoms &/or issues
History • Family history of diabetes, ages of death, & other illness • Number of hospitalizations • Number and type of surgeries • Number of children, ages & health
What do you check? • All patients deserve a complete set of vital signs • Also a brief health history • It is important to look at the eyes, ears, mouth, develop an opinion concerning neuro status, listening to the heart & lungs, looking for edema of extremities • Weight & history of weight changes
When do you expand your history • Any positive findings requires a further investigation into them. • When, where, who, what made it worse or better • Did they seek medical care & what happened
Men & Women will have many of the same illnesses • While women will have their own set of diseases different from men it is important to look at the usual diseases that effect both. • HTN, Diabetes, Obesity, upper respiratory infections, pneumonia, dental disease, urinary tract infections, & musculoskeletal problems
Breast Examinations • While breast examinations are not necessary at every visit the incidence of breast cancers are too high to ignore the question. • Confirm that the patient does her own breast exams, how often and the procedure she uses. • The incidence of fatal breast cancer is decreasing mostly because good & frequent examinations
Breast Examinations • Frequent (2-4 times monthly) will allow the patient to feel important changes like: • The new nipple discharge, brown, bloody or milky • Changes in the skin, new dimples, areas looking like an orange peel. • Any lumps, especially those growing larger
The Breast Shape • The axilla can hide cancers quite easily • Many examiners forget that the breast is elliptical in shape with the smaller tip extending into the axilla. • Over 20% of the cancers (non-ductal) form initially high up in the axilla & are missed until they are large.
Breast Implants • These make breast examination very difficult • These are patients who need to do their own examinations but also need routine mammograms even at a young age • They do, however get a similar exam
Breast shape Examine Closely
Another area of concern is the reproductive tract • The incidence of cancer is high in the cervix • HPV is responsible for over 95% of the cervical & uterine cancers • The system is not easily visualized • The vaginal tract, cervix, labia & Bartholin glands can be a source for STD’s of many types • This area can be infected & infective for many years without the patients awareness
The Cervix Infected Cervix's
The Cervix Cervical Infection IUD String
HPV Vaccines • Currently the females aged 6-26 with 4 or less sexual partners are eligible for the vaccine. • The major study groups expect it to be available for all age groups of both females & males in less than 4 years. • Immunizations are expected to decrease the incidence of cervical cancers & condolomata by 98%
More concerns • Pregnancy, intrauterine & ectopic • Tubal & Ovarian abscess • Endometrial Abscess • Free pus in the abdomen • Acute Appendix, Diverticulosis & urinary tract disease
THIS IS A BI-MANUAL EXAM
Bi-Manual Examination • The purpose is to feel for painful areas or unusual structures, abscess or other unusual findings • The cervix should be located & moved upward checking for pain (a possible indicator of STD) • The vaginal & rectal openings are inspected for lesions, warts or other abnormal findings. • Describe them in your notes
Since Vaginas look so different you must take time to look because what you find inside maybe very different from outside
Don’t forget what you don’t expect to find may be found in either sex
While this is by no means a complete list or diagram of what to do for the female patient this is a guide for some of the usual items I see being missed far to often • This is designed to simply to raise your awareness of medical issues to watch for. • Remember you may be the first & last medical provider to see this patient before they develop a major problem