OB-GYN - Standardized Patient Prep

8/13/2019 OB-GYN - Standardized Patient Prep

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( "he absolute numbers of patients getting diseases were small in both groups: for instance, 38 /

9, patients on hormone therapy got breast cancer, while 3 / 9, patients on placebo got

breast cancer;

( "he patients in this trial were older< many had already gone through menopause, so it=s not

eactly the same as how it=s used in clinical practice, but it=s the closest thing we=ve got right

now;

( 5f we decide to use +>", we=ll use the loweest dose possible for the shortest amount of time to

get you through the symptoms;

Osteoporosis ris+: consider getting %-?. / bisphosphonates )if pathologic f of hip or vertebrae, other f and "@

score @9; to @A;4, or " score B @A;4*; hould be ta#ing 9@94 mg $a daily no matter what< if osteoporotic,

8 5C vit% too;

et an en'o"etrial #iopsyif concerned )constant bleeding / lots of anovulatory cycles / etc*

PAPsmears:

7omen age 3 and older who have had three onseuti%e negati%e er%ial cytology test results may be

screened one e%ery three yearswith either the Pap or liquid@based cytology;

7omen with certain ris+ fators may need more frequent screening, including those who have +56, are

immunosuppressed, were eposed to diethylstilbestrol )%-* in utero, and have been treated for cervical

intraepithelial neoplasia )$51* A, $51 3, or cervical cancer;

Breast: "a""ogra" hould have yearly "a""ogra" starting at age -.and continuing as long as the woman is in good

health

5f strong D+ breast cancer )mother or sister*, "a""ogra" sreening / yrs earlier than youngest

fa"ily "e"#er0s 'iagnosisor 1. years if family member was premenopausal;


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Pu#ertal patient

History:

GYN+istory:

Menstrual: menarche, LMP, frequency, regularity, duration of periods, heavy / light* bleeding between

eneral 01:

( 6aginal discharge / itching / discomfort!

( Pain / itching / burning / discomfort when urinating!

( .bdominal / pelvic pain, masses, fullness;

.ny other 01 issues in the past!

Sexual history: seually active, with whom, pain with intercourse

.ny history of "5s!

'irth control! ometimes / always!

afe in relationship!

OB+istory: pregnancies, deliveries, miscarriages, abortions, ectopics, complications

PMHx:

.ny other medical conditions! %M, +"1, M5, lung dE, stro#e, cancer;

Medications! .llergies!

SurgHx: previous surgeries!

!a"ily Hx: previous h of cancer in family! #reast $ o%arian $ oloretalespecially; &ther dEs!

Soial Hx:

Lives with whom! afe at home!

"obacco / alcohol / drugs!

Physial exa":

6:

eneral appearance:

$6:

Pulm:

Pelvic:

&ounseling $ pre%entati%e:

Birth ontrol:

o from what she #nows / has been using

.s#: history of blood clots!

$ondoms: 94F failure rate, but protect against "%s

'irth control pills: 8F real life failure rate< decrease ovarian / endometrial cancer, etc; $an get nausea,

h/a, brea#through bleeding, wt gain( -strogen and progesterone; +ave to remember to ta#e every day

( Progesterone only: have to ta#e at same time every day, higher failure rate

( 'leeding every month, every 3 months, or continuous dosing )more brea#through bleeding*

( +ow to start:

Starting on 'ay 1 of cycle: least li#ely to ovulate during cycle

Sun'ay start: bac#up for G days, leaves net wee#end free;

Anyti"e start is actually fine: Hust bac#up method for G days


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%epo: Progesterone; hot in arm every 3 months; $an cause irregular bleeding, especially at beginning,

which bothers some people more than others; .lso decreased bone density )reversible*; can cause

depression, wt gain, hair loss, h/a; $an lead to amenorrhea; May ta#e I@98mo for fertility to return;

5mplanon: 3 years, progestin implant, most women have lighter periods )some none at all*, really

effective but can have irregular / unpredictable light bleeding

5C%s: Longer term, very effective

( Mirena:

; 4 years; Lighter or no periods;

( Paragard: copper; 9 years; $an cause irregular bleeding;

Less common stuff: patch )not if overwt or high thromboembolism ris#*, nuvaring )3 w#s in, 9 w# out, or

3mo in with changes, 9 w# out, ;8F failure rate*

-mergency contraception @ Plan ' )progestin only* within GAh; 1eed > if B 98, &"$ if 2 98;

ST2 testing:

onorrhea / chlamydia: swabs or urine if no pelvic eam

yphillis, +56: blood test

+6 swab if lesions

$onsider Gar'asilfor females 99@9A, or 93@AI who didn=t get doses previously )Jprotects against +P6;

ome types of +P6 cause genital warts, and some types can cause changes in your cervi that down the

road can lead to cancer; "his vaccine helps protect against both warts and cervical cancerK* PAPsmears:

tart at age 13 regar'less of sexual history* et4


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Breast exa"

Intro'ution: wash hands, get drape ready, as# about '-, everything can be done at home

Inspetion ) positions* @ epose both breasts, can use wall mirror at home

eated normally

+ands on hips, shrug shoulder forward

Leaning forward

.rms above head

Palpation @ seate'

Lymph nodes )supra/infraclavicular*

Palpate from clavicle to tail )ailla*, dont lose contact, wor# in strips, 3 degrees of pressure

upport breast with hand to palpate top of breast

1ipple / areola

.illary nodes @ deep central, lateral, medial, pectoral, subscapular

>epeat with other breast

Palpation @ laying, arm behind head

ame steps as above

5f discharge, identify quadrant by stripping / palpation towards nipple

$an have pt turn to side for lateral aspect of breast

)rap up: >egular, monthly sbe, use mirrors )wall / hand*;

1et sbe 9 mo, net clinical eam at annual yn visit

Pel%iexa"

5 6xternal exa"

7 Position, assist, drape, give s"all "irror, use light, wash hands / put on glo%es 8'ou#le glo%eon

dominant hand*, alert pt verbally

7 Palpate )*

9 Mons pu#is/ area of hairline

9 Inguinal nodes

9 a#ia "a;ora < "inora

9 $hec# S+ene0s N Bartholin0sglands

7 6isually eamine )*

9 >etract prepueN eamine litoris

9 Urethra

9 Introitus

9 Perineu"* anus

7 $hec# for prolapse @ as# pt to #ear 'o,n

5 Speulu"eam

7 5ntro: ,ar"speculum, show to pt, alert pt before each move

7 %o the speculum eam, tighten screw, Pap smear / swabs if indicated7 >emove slowly while holding bills open

5 Bi"anual exa"

7 .lert pt, use lubricant

7 Palpate %agina, then er%ix

7 Cse second hand to palpate fun'us, then a'nexa

5 (eto%aginal exa"

7 Ta+e off outer glo%e* use lu#e, alert pt, then "i''le fingerin rectum, forefinger in vagina;

7 (epeat #i"anual eam )uterus / adnea*

7 Palpate posterior retal ,all, then s,eeprectovaginal septum


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7 %o he"oulttest for blood

5 )rap up: as# pt to get dressed, will tal# in a bit;

OB-GYN - Standardized Patient Prep

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