1. Well woman exam a.

Goals: H&P, health maintenance (Screening cervical, breast, colon cancer, thyroid, CV panel, STD; Immunizations) b. H i. LMP. Age of menarche? Cycle length? Cycle duration? Age of menopause? ii. Obstetric hx G/P? any problems with pregnancies? iii. PMH iv. PSH ovaries and uterus still there? v. Fam Hx esp gyn malignancies vi. Social/Sexual Hx drug use/abuse. Relationship status in relationship, for how long? sexually active? how many partners? Contraception use? hx of stds? vii. Meds & Allergies c. P i. Breast exam 1. While doing exam, counsel pt on doing self checks a. check every month, after your period b. in the shower or lying flat on bed. c. put one arm under head, with the other arm feel for lesions as I am doing now. d. make sure to palpate the tail of Spence because cancers can be located here 2. there is some debate on how good self checks are. it can help to detect early cancer, but research shows that the practice of self checks doesn t lower overall mortality from cancer. a. it is up to you to decide if you want to do them, but make sure you get them checked every year at the clinic. ii. Abd exam bowel sounds. tender? feel for masses? iii. Pelvic exam come all the way to the edge of the table. 1. you re going to feel my hand. I m looking for any abnormal lesions that may hint at infection or cancer. 2. I m going to insert the speculum now. you will feel some pressure 3. I m going to take a pap smear. you may feel some pressure. 4. you may have some spotting afterwards. 5. pap results usually take a week to get back d. Plan i. schedule for tests. appt next year. 2. Cervical dysplasia a. LMP hx menarche? cycle length? cycle duration? b. sexual history? relationship? contraception? # of partners in last 6 mo? c. Cervical cancer risk factors i. ANY PREVIOUS ABNORMAL PAP RESULTS? ii. anyone said u have hpv?

iii. age of first sexual intercourse? iv. smoking? alcohol? MAKE SURE TO QUANTIFY! d. Counseling i. An abnormal pap means the appearance of cells that line your cervix have changed in some way to make us worried about transforming to cancer 1. That means it is not cancer yet 2. 65% of cervical dysplasia goes away on its own ii. Describe the histology of the cervical cancer to the pt. 1. Describe the follow up 3. Counseling menopausal pt a. LMP hx last period, cycle length, cycle duration? UNTIL WHEN WERE YOUR CYCLES STILL REGULAR b. Do you have menopausal sx? i. vasomotor hot flash = 90s increased temp, night sweat, sleep disturbance ii. vaginal atrophy? DYSPAREUNIA? iii. fracture? iv. mood changes? c. HRT RISK ASSESSMENT i. PMH liver disease OR JAUNDICE. coagulation disorder, stroke, CVD, DVT/PE? HTN!! DO YOU HAVE VAGINAL BLEEDING? HAVE YOU HAD CANCER BEFORE? ii. PSH do you have a uterus? iii. Family Hx breast cancer? iv. Social Hx DO YOU SMOKE d. Counseling i. HRT can help you with vasomotor sx and vaginal atrophy ii. WHI results: small increase in breast cancer risk, stroke, CVD. decrease in risk of colon cancer iii. If I put you on HRT, we will try to keep you on it for the minimum amount of time necessary to control your sx e. Plan mammogram, DEXA scan, LFT 4. Postop/postpartum a. Hx how did you sleep last night? eating? n/v? dysuria? obstipation? breast tenderness? uterine tenderness? chest pain? trouble breathing? fever? PAIN? mood/seen baby/depression? b. O heart, lungs, CVA, abd, breast tenderness, feel for uterine size (is it dec), perineal, Homan, incision c. Plan take out foley, advance diet, ambulation, pain control? d/c. 5. Third trimester bleeding a. FIRST ASSESS VITALS baby and mother b. PAINFUL? abruption, uterine rupture c. PAINLESS? vasa, previa d. risk factors

i. ii. iii. iv. e. plan i. ii. iii.

vasa multig, velamentous cord, accessory placental lobe previa hx of previa, multig, multip, AMA abruption HTN,drugs, trauma rupture overdistended uterus, previous surgery on uterus NO DIGITAL EXAM if stable do ultrasound if unstable . 1. if heavy bleeding, stabilize, do DIC panel and delivery 2. if light bleeding, then stabilize, incl position changes. a. if still unstable then deliver b. what s fetus doing? if not reassuring, then consider vasa and deliver i. if it s ok, can go and do ultrasound now 3. FOR STABILIZATION put in 2 wide bore IVs, draw blood for H&H & T&M

6. PIH visit a. PIH Sx HA, epigastric, visual change. Any swelling? b. Can be assoc w HELLP c. Plan get CBC, LFT, 24h urine. d. Mild we can just put on bedrest and deliver if mature at 36w. e. Severe, put on MgSO4 and deliver ASAP no matter what the age. i. put on labetalol and hydralzine. 7. Antenatal visit a. Hx Delivery date? GFM? Ctx? Fluid? Bleeding? Preeclampsia HA, epigastric, visual? UTI dysuria, frequency, urgency? i. if bleeding, rmr that postcoital bleeding is on the ddx ii. if fluid, need to have pooling in post fornix + nitrazine + ferning (all 3 needed) b. Ob Hx (if don t have) problems this preg? problems any preg? what were the other pregnancies i. PMH HTN, diabetes, thyroid ii. Sexual Hx STDs? c. Physical VITALS PLEASE i. compare weight with last time ii. fundal height & doppler d. Counseling i. Diet 1lb/wk after 20w. PNV ii. Kick count 10 kicks in 2 hrs iii. Come in if you have bleeding, gush of fluid, ctx more than q5min e. Labwork schedule i. First visit Bloodwork (CBC, T&S), Infection ( HIV, RPR, UC, GC/C), Pap, U/S if dates don t agree ii. 16w quad screen, U/S for anatomic survey,

iii. 26w 1hr GTT -> 3h (95,140,155,180), H/H (usually most anemic at this point), IDC/RhoGAM iv. 35w GBS, Can repeat Infection (HIV, RPR) v. Genetics workup if AMA f. Visits scheduling q4w before 28w. q2w until 36w. then q1w. g. Watch out for fetal acidosis if you have reaction or mod variability then there is no acidosis. Umbilical vein pH below 7.2, artery below 7.0 8. Preterm labor a. Risk factors multig, previous preterm, cervical surgery, abdominal surgery during preg, infection, abruption, uterine anomalies (incl short cervix) b. Trauma and hydration c. Can t do tocolytics if BAD CHU i. bleeding, abruption, death (fetal), chorioamniotis, HTN, unstable ii. mag, beta, indomethacin (don t do after 32w) iii. has an effect from 2-7d d. give steroids from w24-34 unless infection (lungs, reduces IVH, and NEC) e. trying to balance risk of infection vs risk of prematurity f. use fibronectin test to determine who is high risk for delivery i. give ab s for 10d for PPROM 9. UTI a. sx dysuria, frequency, urgency b. culture clean catch c. most pyelo is on the right side d. RMR to ask about stone hx, pyelo hx 10. Acute pelvic pain a. DDx appendicitis, salpingitis, ovarian abscess, ovarian torsion, ovarian cyst rupture, cholecystitis, ectopic b. Just work down the ddx rmr to ask about social hx c. workup vitals, CBC, BHCG, US, UA/UC d. rmr to do OLDCARTS on pain