History, Physical Examination and

Preventive Health Care

JEEZREEL M. ORQUINA, RN, LPT
 The annual well-woman visit is crucial part of general medical care.
During this visit, the healthcare provider can attend to current gynecologic
concerns, promote disease prevention, assess risks for potential disease,
and provide the indicated physical examination or tests. This annual health
encounter should include healthy lifestyle counseling, as well as screening
and immunizations as appropriate, based on the patient’s age and risks.
 Direct Observation

Four qualities in caring communication skills: comfort, acceptance, responsiveness, and empathy.
Components of Effective Nurse Communication
1. Be culturally sensitive
2. Establish rapport
3. Listen and respond to the woman’s concerns (empathy)
4. Be nonjudgmental
5. Include both verbal and nonverbal communication
6. Engage the woman in discussion and treatment options (partnership)
7. Convey comfort in discussing sensitive topics
8. Abandon stereotypes
9. Check for understanding of your explanations
10. Show support by helping the woman to overcome barriers to care and compliance with treatment
 History Outline

I. Observation VII.Occupational and avocational

II. Chief Complaint history
III.History of Gynecologic VIII.Social history
Problem(s) IX. Review of systems
IV.Significant health problems X. Physical abuse
V. Medications, habits and allergies
VI.Family history
 Examination, Screening, and Immunization Recommendation
for the Annual Health Maintenance Visit
AGE (Years)
 
19-39 40-64 65+
Vital Signs Ht, Wt, BMI, BP Ht, Wt, BMI, BP Ht, Wt, BMI, BP
Neck Adenopathy, thyroid Adenopathy, thyroid Adenopathy, thyroid
Clinical Every 3 years, beginning at 20yo Yearly Yearly
Breast Exam
Abdomen Yearly Yearly Yearly
Pelvic/ speculum 21+ periodically* Annually/ periodically* Annually/ periodically*

Additional Exams As indicated As indicated As indicated

Pap Smear 21+, every 3 years Every 5 with co-test (preferred) or Discontinue if negative adequate
every 3 Pap Smears screening and no hx of CIN2+
 Examination, Screening, and Immunization Recommendation
for the Annual Health Maintenance Visit
  AGE (Years)
19-39 40-64 65+
Chlamydia/ Gonorrhea <26 and sexually active, yearly As indicated As indicated

Colon cancer screening n/a 50+, colonoscopy every 10 years Colonoscopy every 10 years

Diabetes testing As indicated 45+, every 3 years Every 3 years

Mammogram If indicated Yearly Yearly
Lipids If indicated 45+, every 5 years every 5 years
Thyroid-stimulating If indicated 50+, every 5 years Every 5 years
hormone
Bone mineral density   If indicated Every 2+ years

Immunizations HPV, Tdap once, TD every 10 years, Tdap once, TD every 10 years; influenza Influenza yearly, Tdap once, TD every 10
influenza yearly yearly; herpes zoster once (>59) years, pneumococcus once

HIV Offered routinely Offered routinely Offered routinely

Breast Examination
 Pelvic Examination
A. Inspection

1. The vulva and introitus should be carefully inspected beginning with the
mons pubis.

2. The quality and pattern of the hair on the mons and the labia majora
should be noted. During the inspection of the pubic hair, the nurse should
look for evidence of body lice (pediculosis).
 Pelvic Examination
A. Inspection
3. The skin of the vulva/ perineum is inspected for erythema, excoriation,
discoloration, or loss of pigment and for the presence of vesicles,
ulcerations, pustules, warty growths, or neoplastic growths.
4. The clitoris should be noted and its size and shape described. (Normally,
it is 1 to 1.5cm in length).
 Pelvic Examination

A. Inspection
5. Any abnormalities of the labia majora and minora should be noted
and carefully described.
6. The introitus should be observed closely. Whether the hymen is
intact, imperforate, or open and whether the perineum gape or
remains closed in the usual lithotomy position should be noted.
 Pelvic Examination
B. Palpation
1. The labia minora are gently separated, and the urethra is inspected and the
length of the urethra is palpated and “milked” with the middle finger. In
this way, irregularities and inflammation of Skene glands (periurethral
glands), expressed pus or mucus, or a suburethral diverticulum can be
noted,
2. The area of the posterior third of the labia majora is palpated by placing the
finger inside the introitus and the thumb on the outside of the labium. In
this way, enlargements or cysts of Bartholin glands are noted.
 Pelvic Examination

B. Palpation
3. The opening of the vagina should be inspected. The presence of a cystocele or a
cystourethrocele should be noted. The presence of this abnormality may be
noted either by simply observing or by asking the patient to bear down.
Likewise, the posterior wall should be observed for a bulging upward, which
would represent a rectocele. A cystic bulge in the cul-de-sac may represent an
enterocele.
4. With the patient bearing down, the cervix may become visible, indicating
prolapse of the uterus.
 Speculum Examination

The vaginal canal is inspected during

the insertion of the speculum and upon
its removal. The vaginal epithelium
should be noted for evidence of
erythema or lesions. Vaginal lesions,
such as areas of adenosis, clear cystic
structures (Gartner cysts) or inclusion
cysts on the lines of scars or episiotomy
incisions, should be noted.
Papanicolaou Smear
Bimanual Examination
Rectovaginal Examination
GENITAL TRACT
INFECTIONS
Infections of Bartholin Glands
Pediculosis Pubis
Scabies
Molluscum Contagiosum
Genital Herpes
Granuloma Inguinale (Donovanosis)
Lymphogranuloma Venereum
Chancroid
 Syphilis

A. Primary Syphilis
B. Secondary Syphilis
C. Late or Tertiary Syphilis
 Typical Features of Vaginitis

  Bacterial Vaginosis Candidiasis Trichomoniasis

Signs and Increased discharge (white, thin), Increased discharge (white, thick), Increased discharge (yellow, frothy), increased
increased odor dysuria, pruritus, burning odor, dysuria, pruritus
Symptoms
Discharge Thin, whitish gray, homogenous Thick, curdy discharge, vaginal erythema Yellow, frothy discharge, with or without
discharge, cocci, sometimes frothy vaginal or cervical erythema

pH >4.5 <4.5 >4.5

Wet Mount Clue cells (>20%) shift in flora, amine Hyphae or spores Motile trichomonads, increased white cells
odor after adding potassium hydroxide
to wet mount

Treatment Metronidazole 500mg PO, bid for 7 Clotrimazole 100mg 2 vaginal tablets/ day Nitroimidazoles:
days; for 3 days; Miconazole 100mg vaginal Single dose Metronidazole 2g PO.
Clindamycin 300mg PO, bid for 7 days suppository/day for 7 days; Fluconazole Topical therapy for Trichomonas vaginitis is not
150mg 2 tablets PO, 72 hours apart; recommended because it does not eliminate
Metronidazole 500mg bid PO for 7 days disease reservoirs in Bartholin and Skene
glands.
Gonorrhea
Chlamydia
 Treatment for Pathogenic Cervical Bacteria
Gonorrhea
Ceftriaxone, 250mg IM, single dose
or if not an option
Cefixime, 400mg PO, single dose
plus
Azithromycin 1g orally in single doses
Chlamydia
Azithromycin 1g PO, single dose
or
Doxycycline, 100mg PO bid for 7 days
Alternative Treatment
Erythromycin base, 500mg PO qid for 7 days,
or
Ofloxacin, 300mg PO bid for 7 days, or
Levofloxacin, 500mg PO OD for 7 days