Professional Documents
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History, PE, Prevention + Interaction of Diseases & Physiology
OUTLINE
History
A. Direct Observation
B. Components of Effective Communication
C. Essence of Gynecologic History
D. Essence of general Health History
II.
Physical Examination
A. Breast Examination
B. Abdominal Examination
C. Pelvic Examination
D. Annual Maintenance Visit
III.
Interaction of Diseases & Physiology
A. Pulmonary Disease
B. Inflammation
C. Gastrointestinal Disease
D. Hematologic and Thrombotic Disease
E. Mental Health issues
F. Antibiotics and OCPs
G. CNS
H. Cancer
I. Vascular and Hypertensive Disease
J. Renal Disease
K. Endocrine Disease
References:
1. Lecturers powerpoint.
2. Recording italicized
3. Comprehensive Gynecology 6th Edition [3]
HISTORY
DIRECT OBSERVATION (NONVERBAL CLUES)
DR. INGLES
NOV. 14 , 2014
Types of relationships
Individual(s) involved
Dyspareunia
Page 1 of 6
GYNECOLOGY 1.3
o
PHYSICAL EXAMINATION
BREAST EXAMINATION
Clinical breast examination done by a professional
o Should be done at least once a year, but women should do
their self-breast examination.
Examination of each breast with the patient sitting with arms raised,
and with the patient supine
Attention to the entire breast mound from midsternum to the posterior
axillary line and from the costal margin to the clavicle.
Inspection and palpation to assess (RED FLAGS):
o Skin flattening or dimpling, erythema and edema
o Nipple retraction, eczema, discharge
o Breast fixation breasts do not move because lymph nodes
are fixed to wall
o Tissue thickening
o Palpable masses not all masses are malignant, ex. of benign
changes: fibrocystic changes
Evaluation for axillary and supraclavicular lymphadenopathy
ABDOMINAL EXAMINATION
Do the abdominal examination in this order:
o Inspection if there is discoloration, asymmetry, scars,
Auscultation listen for bowel sounds
o Palpation palpated for organomegaly, masses, rigidity,
rebound
o Percussion differentiate fluid waves and outline sold organs
and masses
Not all abdominal enlargements are due to pregnancy, so examine
carefully.
Some questions to ask the patient: last menstrual period, last sexual
contact.
PELVIC EXAMINATION
The patient is lying supine on the examining table with her legs in
stirrups. (Dorsal lithotomy position)
SPECULUM EXAMINATION
Steps [3]:
o Warm the speculum with the use of a warming device or
warm water, and then touched to the patients leg to
determine that she feels the temperature is appropriate and
comfortable.
PAPSMEAR
Vaginal and cervical cytology as screening for cervical neoplasm.
To sample exfoliated cells in the endocervical canal and scrapes the
transformation zone (squamocolumnar junction).
Make sure to prepare everything you need before starting the
procedure.
Different types of materials used to get sample:
o Spatula
o Cotton tip
o Cytobrush
Prepare the following:
o Gloves
o Spatula/Cotton tip/Cytobrush
o Speculum
o Slide (if cotton tip)
o Fixing solution (if cytobrush)
Image 2. Materials used for Papsmear (L to R): spatula, cotton tip, gloves,
slide, fixing solution, speculum
Page 2 of 6
GYNECOLOGY 1.3
Visualize the cervix with the use of the speculum before using the
spatula to scrape the cervix.
Do not use KY jelly. You are getting epithelial cells.
Do not perform IE before pap smear. You will contaminate the area,
so do the papsmear before IE.
Image 3. Obtaining cells from endocervix using either: cytobrush (L) and
spatula (R).
BIMANUAL EXAMINATION
You use both hands one on the abdomen and the other inside the
vagina
Make sure you are gloved.
Use the flat of the fingers for palpation.
Dont forget the lateral areas to examine ovaries and fallopian tubes.
o To examine the adnexa (fallopian tubes & ovaries), the 1st two
fingers of the pelvic hand are moved to the right or left lateral
fornix and the abdominal hand is placed just medial to the
ASIS, then the two hands are brought together, allowing the
adnexa to be palpated between them
An index finger is placed into the vagina and the middle finger into the
rectum.
The rectovaginal septum is palpated between the 2 fingers.
The uterosacral ligaments (Extends from the posterior wall of the cervix
posteriorly and laterally toward the sacrum) is also identified.
Any thickening or beadiness of these structures may imply
inflammatory reaction or endometriosis.
Age
13-18
Page 3 of 6
GYNECOLOGY 1.3
19-39
40-69
PULMONARY DISEASE
Estrogen and progesterone increases both serotonin and histamine
release from granulocytes.
Increase risk of bronchial asthma attacks at the start of menstruation;
hormones affect smooth muscle bronchodilation[2]
Asthma[3]
o Before puberty: more common in boys
o After puberty: women are more prone up until menopause
Oral contraceptives[3]
o Mildly protective in decreasing the severity of asthma
Effects of asthma on female physiology[3]
o Later menarche
o Increased incidence of abnormal menstrual cycles with severe
asthma
o Inhaled glucocorticoids of postmenopausal women
B-cell enhancer
T cell inhibitor
o Low estrogen Immune response is stimulated. During
periods of estrogen withdrawal, late luteal phase,
menstruation, postpartum, and early menopause, there are
often clinical rebounds and an increase in disease flares with
the release of T-cell suppression.[3]
Page 4 of 6
GYNECOLOGY 1.3
GASTROINTESTINAL DISEASE
Estrogen and progesterone affect symptoms of irritable bowel
syndrome. Most women experience exacerbations of symptoms with
menses.
Progesterone produces mild constipation through smooth muscle
relaxation.
o Decreased levels before menstruation increased chance of
diarrhea.
o Luteal phase increase in systemic prostaglandins +
withdrawal of smooth muscle relaxation DIARRHEA
GnRH agonists[3]
o For women in whom menstrual affects become debilitating
Oral contraceptives[3]
o Continually used to minimize the number of periods.
Women with celiac disease have more problems with menstrual
hormone fluctuations. [3]
HEMATOLOGIC & THROMBOTIC DISEASE
Page 5 of 6
GYNECOLOGY 1.3
14% of all women with migraine have pure menstrual migraines and
46% have exacerbation of severity and frequency of their migraines
during menses.
o Menstrual migraine migraine headache without aura,
occurring within the last 2 days of the menstrual cycle and the
first 3 days of menses. Etiology is related to estrogen
withdrawal.[3]
Migraines with aura are more susceptible to stroke OCPs
contraindicated.
CANCER
Sexuality should be addressed from the beginning of cancer therapy. [3]
Radiation to the ovaries greater than or equal to 20 Gy may produce
ovarian failure
Antineoplastics and chemotherapeutic agents may produce ovarian
failure, sterility and premature menopause.
RENAL DISEASE
Women with end-stage renal disease have an increase in endometrial
hyperplasia, and increased incidence of cervical dysplasia.
Those undergoing hemodialysis, with chronic renal disease and those
who have renal transplants suffer from an increased incidence of sexual
dysfunction.
ENDOCRINE DISEASE
Endocrinopathies have higher incidence and severity in women. Its
interaction with hypothalamic-pituitary-ovarian axis is an inhibition of
normal function, producing anovulation.
Those with Type II DM, and obese women have increased anovulation,
infertility and potential problems with endometrial hyperplasia.
Estrogen and progesterone mildly promote insulin resistance and
worsen carbohydrate intolerance.
Thyroid disease affects the hypothalamic-pituitary-ovarian axis with an
increased risk of anovulation and infertility.
Page 6 of 6