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Routine Gynecologic Care
Once a year, a full gynecologic exam is indicated in women of childbearing years.
This is an excellent opportunity for routine health screening and patient counseling. The amount of detail and the content of the exam will depend on many factors, but a typical, routine, examination is illustrated here.
Many health care providers find it useful to utilize a standard form for recording information about this exam. An example is shown here:
This is the reason for the visit.
It might be for a routine GYN visit, or to refill birth control pills, or because of a troublesome vaginal discharge. The Chief Complaint can almost always be stated in one sentence or less.
"What brings you to see me today?
Ask how the patient has been since her last examination.
This is an opportunity for you to get a current medical status report. You might ask:
"Have you had any problems?"
"How are you feeling today?"
For patients not previously seen or for whom you have no medical records, you should note any previous significant medical or surgical illness, and allergies.
"Have you every been hospitalized for any medical illness?"
"Have you ever had any surgery?
"Are you allergic to any medicine?
Ask her to identify medications she takes regularly.
This will provide additional insight into her current health status and may identify areas of her medical history she has forgotten.
"Are you taking any medication on a regular basis?"
Record menstrual data.
Age of onset of menses (menarche), the regularity (or irregularity) of menses, their frequency, duration, heaviness and any associated symptoms, such as cramps, bloating or headaches. Note the first day of the last menstrual period
LMP_________
Menarche age______
Menses are regular/irregular
Menses Q_____ days x ______ days.
Determine the number and nature of pregnancies.
Gravida (G) means the total number of pregnancies. Para (P) means the number of children born. Abortions (AB) means the number of spontaneous or induced abortions.
G_______
P_______
AB_____
Inquire as to the method currently used for contraception.
This may provoke an answer that opens the door to a discussion of sexual issues that may be troubling to her.
Contraception__________________________________
Assess the general nutritional status.
This can be done visually and with noting her height and weight. For women with a normal, balanced diet, nutritional supplements are probably not necessary, but most people have difficulty maintaining a normal balanced diet. For those, a daily multivitamin can be very helpful in making up for any nutritional deficiencies. Additional iron is particularly helpful for women in maintaining a positive iron balance. Otherwise, the steady loss of iron through menstruation can lead to some degree of anemia.
For women anticipating a pregnancy, Folic acid 400 mg PO daily is recommended by the Center for Disease Control to reduce the risk of birth defect related to the spine.
I sometimes will ask:
"Are you eating a normal, balanced diet ?"
"Do you normally take a vitamin pill?"
Regular exercise is important for physical and psychological reasons.
Women who exercise regularly will generally experience less trouble with cardiovascular disease, bone loss (osteoporosis), weight control, and depression.
To be most effective, the exercise should be strenuous enough to cause sweating, last at least 20 minutes, and occur several times a week. Lesser amounts of exercise may also be beneficial.
"Do you get a chance to exercise regularly?"
As a group, women are more likely to sustain minor athletic injuries, for reasons that may include level of training or fitness, degree of experience with exercise, architectural construction of the pelvis and lower limbs, and possibly hormonal effects.
It is important to try to avoid athletic injuries while continuing to exercise. Try not to perform the same exercise two days in a row...give the body 48 hours to recover.
If a certain exercise causes pain, either modify it or discontinue it so that the pain does not persist. Gradually increase the duration and intensity of training and avoid sudden large increases that may lead to overuse injuries.
Depression is a common clinical problem affecting twice as many women as men. Talking with the patient will give you a reasonable assessment of her mood.
Depression is diagnosed whenever a depressed mood or loss of interest/pleasure is associated with at least four other symptoms, consistently over a two-week period. (DSM-IV)
- Depressed mood most of the day, most days
- Marked loss of interest in normal activities most of the day, most days
- >5% change in body weight in 1 month when not intentionally trying to modify body weight
- Insomnia or too much sleep most nights
- Psychomotor agitation or depression most of the time
- Marked fatigue nearly every day
- Feeling worthless or inappropriately guilty most of the time
- Diminished ability to think or make decisions most days
- Recurring thoughts of death or suicide
While some physicians perform each of these evaluations at every routine gynecologic visit, some perform only those which focus on specific issues for the specific patient.
Weigh the patient.
Make an assessment of how her weight fits with standards for good health. Too much and too little weight are both problems.
Compare the weight with previous weights to assess the trend.
Measure the blood pressure.
Take the other vital signs.
Particularly among older women, elevated blood pressure is a common problem and one that may be effectively controlled or treated. Uncontrolled elevated blood pressure is associated with a number of serious medical consequences.
Look in her eyes.
Watch they eyes for symmetry, proportion, focus, white sclerae, and movement. Look for any facial muscle weakness appearing as a droop or asymmetry.
Eye movements should be coordinated. The ability to read a sentence with each eye suggests intact ophthalmic, neurologic and higher brain function.
Facial muscles should have symmetry.
Look in her ears.
While not always necessary, a quick look in the ears will confirm pearly-white drums, the absence of fluid behind the drum, clean canals and the absence of pain while pulling on the external ear to straighten the canal.
Check the thyroid gland.
Many gynecologists routinely feel the thyroid for enlargement, tenderness or lumps which might suggest a thyroid nodule.
Listen.
Listen for wheezes suggesting asthma, diminished breath sounds, or fine crackles, suggesting pneumonia or heart failure. Some apparently abnormal sounds will clear if the patient coughs.
Listen.
Note the regularity of the rhythm, and the presence of any abnormal sounds such as clicks or murmurs.
Check for any lumps, masses, tenderness, nipple discharge, or skin changes such as dimpling, retraction or crusting.
Palpate the abdomen.
It should be soft, and non-tender, with no masses. The liver may be just barely palpable below the rib cage and should not be tender.
Evaluate the pelvis systematically.
Visually inspect the vulva, vagina and cervix. Obtain specimens for a Pap smear and any cultures that may be indicated.
Then feel the pelvis by application of a "bimanual exam." For a normal examination:
- External genitalia are of normal appearance.There is no enlargement of the Bartholin or Skene glands.
- Urethra and bladder are non-tender.
- Vagina is clean, without lesions or discharge
- Cervix is smooth, without lesions. Motion of the cervix causes no pain.
- Uterus is normal size, shape, and contour. It is non-tender
- The adnexa (tubes and ovaries) are neither tender nor enlarged.
Click here to watch a video on how to perform a pelvic exam.
Click here to watch a video on how to perform a bimanual exam.
Obtain a Pap smear annually.
Sometimes, a Pap is repeated more often, particularly if there have been abnormalities on prior Pap smears.
Click here to watch a PowerPoint lecture on how to obtain a Pap smear.
Cultures can sometimes be helpful in determining the cause for vaginal or vulvar symptoms such as pain, burning or itching.
Bacterial cultures for Strept, E. coli and other pathogens may then indicate a course of treatment.
Some physicians routinely culture for gonorrhea and/or chlamydia on all of their patients at each routine visit. Whether this is wise for you depends on the frequency with which these STDs are found in your population.
While some physicians routinely perform a rectal exam on all patients, others perform a rectal only on selected individuals in certain clinical circumstances, such as after age 50.
Routine screening with sigmoidoscopy every 5 years after age 50 is recommended by many physicians.
After the rectal exam, the small particles of stool left on the examining glove can be evaluated for the presence of occult blood. This is most useful after the age of 50.
Some physicians routinely check the urine at each routine visit.
Others check the urine only for a specific indications. A clean urine specimen can be evaluated for the presence of:
- Color
- Character
- Leukocytes
- nitrite
- Urobilinogen
- Protein
- pH
- Blood
- Specific Gravity
- Ketones
- Bilirubin
- Glucose
Watch a video demonstrating testing the urine with a dipstick
Vaginal discharge can be evaluated using a "wet mount."
A small amount of discharge is mixed with 10% potassium hydroxide (KOH), placed on a glass slide and covered with a coverslip. The KOH dissolves cell membranes, making it easier to see yeast organisms under the microscope.
Another small amount of discharge is mixed with a drop of normal saline, placed on a glass slide and examined under the microscope. With saline, active trichomonad organisms can be seen moving and "clue cells," indicating bacterial vaginosis can be seen.
Read more about performing a wet mount.
Mammography is a useful method of evaluating the breasts for the possible presence of early malignancy.
While not 100% accurate, it is probably around 80% accurate, particularly in detecting the very small, early malignancies not appreciated by physical examination.
Recommendations for frequency of mammograms, but the following general guidelines can be followed:
- Women with a disquieting symptom (eg bloody nipple discharge) or physical finding may benefit from an indicated mammogram
- Women with no significant high risk factors will probably benefit from routine mammogram screening every other year, from age 40 to 50, and annually after age 50.
- Women with a strong family history of breast cancer or other significant high risk factor may benefit from more frequent mammogram screening, and starting at a younger age.
An important part of patient education is to see that she feels confident in her skills at self-breast examination. If not, you can teach her the proper techniques. I sometimes inquire:
"Are you examining your breasts regularly?"
Watch a video on self breast examination.
In the civilian population, adult immunizations generally include:
- dt (Tetanus) every 10 years
- Measles booster once if born in 1957 or thereafter
- Influenza for the high risk group (Yearly>65, those with significant medical risks and their close contacts)
- Pneumococcus once after age 65 or in any high risk group
- Hepatitis B for high risk groups
In military populations, immunizations are directed by the Armed Forces Immunizations Program, and augmented by the addition of anthrax immunization.
Counseling may be brief or lengthy.
It may be focused on the problems presented during the examination, or may be global, such as diet, exercise, or other healthy life-styles.
Patients often feel this is the most important part of the visit. Take your time and sit down while talking to the patient. You need not be a master of "bed side manner" for the patient to appreciate this time. Just be honest, direct, and pleasant.
Before leaving, the patient should understand any future plans.
Laboratory requisitions or consultation requests can be given. Patient hand-outs can be provided. Plans might include:
- Mammography
- Laboratory tests
- Consultations
- Patient information brochures
It is routine to indicate when the patient should return to the office (RTO) or return to the clinic (RTC).
"RTO in _______ months."
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Operational Obstetrics
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