History, physical examination, and preventive health care

Key points

Strive to become a culturally sensitive and aware physician with a nonjudgmental approach to women regardless of race or ethnicity, age, faith, disabilities, profession, sexual orientation/identity, or activities.
Goals of preventive medicine include maintaining good health and function and promoting high-quality longevity.
A complete gynecologic evaluation should always include a review of menstruation, sexuality, contraception, pregnancies, gynecologic infections, gynecologic procedures, and any history of physical, emotional, or sexual abuse.
The specific examination components of the annual well-woman visit are based on patient age, health concerns, and risk factors. Whether to perform breast or pelvic examinations is a joint decision between individual providers and their patients.
Screenings, such as Papanicolaou smears, mammography, and sexually transmitted infection testing, should be in accordance with national recommendations.

The first contact a physician has with a patient is critical. It allows an initial bond of trust to be developed on which the future relationship may be built. The patient will share sensitive medical, reproductive, and psychosocial information. The physician will gain her confidence and establish rapport by the understanding and nonjudgmental manner in which he or she collects these data. Today’s obstetrician/gynecologist (OB/GYN) will care for women from around the globe with varying cultural, social, and religious beliefs and values. Women will be of differing socioeconomic status, may have physical or mental disabilities, and may identify as lesbian, bisexual, transgender, or queer. Open communication, with an awareness of and sensitivity to the vast diversity of our patient population, will help create a collaborative environment in which to explore health issues.

The annual well-woman visit is a crucial part of general medical care. The purpose of this visit includes the following:

Discussing healthy lifestyle and minimizing health risks
Promoting preventive health practices
Performing or providing age-specific screening, evaluation and counseling, and immunizations
Taking a comprehensive history and vital signs (including body mass index [BMI])
Performing indicated physical examinations

This chapter focuses on the appropriate manner that an OB/GYN should use to conduct a history and physical examination and discusses the appropriate ingredients of ongoing health maintenance.

Direct observations before speaking to the patient (nonverbal clues)

When meeting a patient, it is important to look at her even before speaking. Differing cultural backgrounds and belief systems may greatly affect the transfer of information and challenge effective communication. Addressing each patient by the patient’s preferred pronoun, she, he, or they, is crucial to demonstrate respect and understanding of each individual patient’s identity. The general demeanor of the patient should be evaluated. Many new patients are apprehensive about meeting a new physician and the potential for a pelvic examination. This apprehension may create barriers to an open and positive first encounter.

By observing nonverbal clues, such as eye contact, posture, facial expressions, and tone of voice, the physician can determine the appropriate approach for conducting the interview. The act of greeting the patient by name, making eye contact, and shaking hands is a formal but friendly start to the visit.

Four qualities have been recognized as potentially important in caring communication skills: comfort, acceptance, responsiveness, and empathy. Despite the busy demands of clinical practice, effective communication skills enhance patient satisfaction and patient safety and decrease the likelihood of medical liability litigation. Box 7.1 lists some components of effective physician communication.

BOX 7.1

Components of Effective Physician Communication

Be culturally sensitive.
Establish rapport.
Listen and respond to the woman’s concerns (empathy).
Be nonjudgmental.
Include both verbal and nonverbal communication.
Engage the woman in discussion and treatment options (partnership).
Convey comfort in discussing sensitive topics.
Abandon stereotypes.
Check for understanding of your explanations.
Show support by helping the woman to overcome barriers to care and compliance with treatment.

Essence of the gynecologic history

Chief complaint

The patient should be encouraged to tell the physician why she has sought care. The chief complaint is a concise statement describing the woman’s concerns in her words. Questions such as “What is the nature of the concern that brought you to me?” or “How may I help you?” are appropriate.

History of the present illness

The patient should be able to present her concern as she sees it, in her own words. During the interview the physician should ideally face the patient with direct eye contact and acknowledge important points of the history. This approach allows the physician to be involved in the problem and demonstrates a degree of caring to the patient. Now that electronic medical records (EMRs) are almost universally used, the ability to sit and just listen to the patient and provide that direct eye contact can be challenging because providers are often documenting while the patient is sharing her story. When the patient has completed the history of the present illness (HPI) or a review of her overall health, pertinent open-ended questions should be asked with respect to specific points. This process allows the physician to develop a more detailed database. Directed questions may be asked where pertinent to clarify points. A general outline for a gynecologic and general history is given in Box 7.2 .

BOX 7.2

History Outline

I.
Observation—nonverbal clues
II.
Chief complaint
III.
History of gynecologic issues/concerns(s)
- A.
  Menstrual history
- B.
  Pregnancy history
- C.
  Vaginal and pelvic infections
- D.
  Gynecologic surgical procedures
- E.
  Urologic history
- F.
  Pelvic pain
- G.
  Vaginal bleeding
- H.
  Sexual orientation, activity, concerns
- I.
  Contraceptive status
IV.
Significant health issues
- A.
  Systemic illnesses
- B.
  Surgical procedures
- C.
  Other hospitalizations
V.
Medications, habits, and allergies
- A.
  Medications
- B.
  Allergies
- C.
  Smoking history
- D.
  Alcohol usage
- E.
  Illicit drug usage
VI.
Family history
- A.
  Illnesses and causes of death of close family
- B.
  Congenital malformations, mental retardation, and reproductive loss
VII.
Occupational and avocational history
VIII.
Social history, including current safety and any history abuse (physical, verbal, emotional, sexual)
IX.
Review of systems
- A.
  Constitutional
- B.
  Head, eyes, ears, nose, mouth, throat
- C.
  Cardiovascular
- D.
  Respiratory
- E.
  Gastrointestinal
- F.
  Genitourinary
- G.
  Musculoskeletal
- H.
  Skin
- I.
  Neurologic
- J.
  Psychiatric—often using a depression questionnaire, such as the Patient Health Questionnaire (PHQ) 2 or PHQ-9
- K.
  Endocrine
- L.
  Hematologic
- M.
  Allergic/immunologic

Pertinent gynecologic history

A pertinent gynecologic history can be divided into several parts. These include menstrual history, pregnancy history, history of gynecologic infections; history of cervical cancer screenings, history of contraceptive use, history of gynecologic surgical procedures, sexual history, and history of pelvic pain.

Menstrual history

A menstrual history should include the following:

Age of menarche
Interval between cycles
Number of days bleeding
Regularity of menstrual cycles.
Intermenstrual or unexpected vaginal bleeding
Date of last menstrual period
Characteristics of the menstrual flow: the amount of flow, any clots, any accompanying symptoms, such as cramping, nausea, headache, or diarrhea

In general, menstruation that occurs monthly (range: 21 to 35 days), lasts 4 to 7 days, is bright red, and is often accompanied by cramping on the day preceding and the first day of the period is characteristic of an ovulatory cycle. Menstruation that is irregular, often dark colored, painless, and often short or very long may indicate lack of ovulation. Often adolescents or premenopausal women have anovulatory cycles with resultant irregular menstruation. For the postmenopausal woman, the age at last menses, history of hormone replacement therapy, and any postmenopausal bleeding should be noted.

Pregnancy history

A pregnancy history should include the following:

Chemical pregnancies
Abortions: miscarriages and terminations and method of resolution (medical or surgical)
Molar or ectopic pregnancies and how they were managed (medically and/or surgically)
Live births:
- Year of birth
- Gestational age at delivery
- Type of delivery
- Infant birth weight
- Complications of pregnancy or delivery
Infertility
Future family planning goals

Gynecologic infections

A history of gynecologic infections should include the following:

Specific infections, treatment received, and any complications
Risk factors for infections such as human immunodeficiency virus (HIV) and hepatitis C:
- Intravenous (IV) drug use or coitus with IV drug users
- Unprotected sex
- Sex with bisexual men
- Being a commercial sex worker
- History of blood transfusion between 1978 to 1985
Sexual activity with partner with known HIV or hepatitis C infection

The 2013 U.S. Preventive Services Task Force (USPSTF) report states with “high certainty that the net benefit of screening for HIV infection in adolescents, adults and pregnant women is substantial” ( ). Part of this rationale stems from the fact that 20% to 25% of individuals living with HIV infection are unaware they are infected ( Table 7.1 ).

TABLE 7.1

Initial HIV Screening Recommendations

CDC, 2006	ACP, 2009	IDSA, 2009	AAP, 2011	AAFP, 2013	USPSTF, 2013	ACOG, 2014
Initial screening age 13-64, regardless of risks	Initial screening age 13-64, regardless of risks	Screen all sexually active adults	Adolescents screened once by age 16-18	Screen all individuals aged 18-65	Initial screening age 15-65; however, optimum frequency of repeat screening unable to be determined	All women aged 13-64 screened at least once and annually based on risk factors

AAP , American Academy of Pediatrics; AAFP , American Academy of Family Physicians; ACP , American College of Physicians; ACOG , American College of Obstetricians and Gynecologists; CDC , Centers for Disease Control and Prevention; HIV , human immunodeficiency virus; IDSA , Infectious Diseases Society of America; USPSTF , U.S. Preventive Services Task Force.

Cervical cancer screening

The physician should obtain a Papanicolaou (Pap) test screening history:

Date of last Pap test
Result of last Pap test, including if human papilloma virus (HPV) was concurrently checked (cotest)
Frequency of screening
Any abnormal tests and subsequent follow-up or treatment
HPV vaccination status

Contraception

Contraceptive history should be investigated:

Specific methods used
Duration of use
Effectiveness of contraceptive method
Complications or significant side effects

You're Reading a Preview

Become a Clinical Tree membership for Full access and enjoy Unlimited articles

Become membership

If you are a member. Log in here