hot flashes, and cramping,

LPH 11/11/2010

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WOMEN’S HEALTH CASE STUDIES – GUIDE

HISTORY

S: CC: Use pt’s words in quotation marks

HPI: Include onset, duration, progression, timing, amount, aggravating factors, alleviating factors, treatments already tried, previous h/o similar S&S? Fully describe, e.g. pelvic pain, noting relationship in time with menstrual cycle, association with sex, tampon use, or other factors. Describe any vaginal bleeding not associated with menses. Include pertinent negatives.

OB/Gyn History:

Menstrual history: LMP, age at menarche, length of cycle, average number of days of menses, characteristics of flow, regularity of cycles, descriptions of any irregularities and/or accompanying symptoms. (Normal cycle: 21 – 35 days, menses last 4 – 7 days)

Pregnancy history: GTPAL. Chronological order: year, duration, type of birth, sex, baby’s weight, complications, is the child alive and well? TABs, SABs, ectopics, molar pregnancies.

History of STIs: what type of infections, what tx, how frequently, complications? & screen for HIV risk. Number of current sexual partners and lifetime, condom use? Does she douche?

Gyn problems/procedures:

Breast biopsies?

Paps: Date of last, Abnormals?, if so – Follow ups? HPV results?

Colposcopy’s, LEEP, etc…

Contraceptive use: is she currently using a method? Is she satisfied with it or does she desire a change? Discuss her past methods if relevant for the visit.

Menopause or peri-menopause: if appropriate to age – HRT?, non-pharmacologic therapies?

Social History/Habits: Include use of tobacco, drugs, ETOH, Current living situation. Occupational, exposure to hazards. Relationships, recent sexual history/partners, monogamous?

Chart Review: Relevant information from chart, place either in S or O

General Medical History: Include any pertaining to the CC or that would affect treatment plan

Current illnesses or disease

Past hospitalizations or serious injuries

Prior surgical procedures

Immunization status Tdap? HPV? Etc…

Medications: OTC, herbal, prescriptions

Allergies: meds, environmental, latex, shellfish, iodine

FMH: Include any pertinent to the CC or that would affect treatment plan (alcoholism, cancer, endocrine, genetic/chromosomal, hematological, mental retardation, CVD, congenital anomalies, GI, lung, neuro, renal, multiple gestation, DV). Brief

Chart Review: Relevant information from chart, place either in S or O

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ROS – as per your prior case studies with emphasis on Breast and GU

For ex – Denies breast tenderness, nipple discharge or noted changes in breast, does not perform monthly BSE etc…

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PHYSICAL EXAM = BULLET FORMAT in head to toe order!

PE: Include only systems r/to CC. Organize by systems and list in head to toe order. Sometimes no exam is necessary, and this should be noted (e.g., “deferred, not examined”) however do not do a case study on a patient who does not require a reproductive health exam. A breast, pelvic, and or OB exam is REQUIRED.

O: Vital signs, weight, height, BMI

General: Observation of pt – is she anxious, nervous, in pain? If so, identify the behaviors she demonstrates. Does she look older than stated age? State of health (ex: malnourished, well-nourished, obese)? Can use NAD

HEENT: Normocephalic. EOMI. PERRLA. TMs pearly gray bilaterally. No nasal drainage or lesions. Mouth and throat without lesions or exudates, teeth in good repair, gums pink.

Neck: No lymphadenopathy or thyroid enlargement, no masses palpated

(thyroid dysfunction can cause irregular menses, anovulation, and infertility)

Cardiac: RRR, no murmur, S1S2

Chest/Lungs: CTAB No wheezes, rales, rhonchi

Breast exam: Size (if remarkable, e.g. small, large, pendulous), nipples, symmetry. Skin changes (rashes, lesions, dimpling, retraction). Note masses, lumps, or tenderness. Description of a mass: Location (can draw picture or describe location as on a clock face), size, shape, consistency, mobility distinctness, nipple, skin over lump, tenderness, lymphadenopathy.

(Ex: No masses, lumps, or tenderness palpated, symmetrical without nipple discharge. Axilla without palpated masses or lymphadenopathy etc)

Abdomen: Non-tender, no hepatosplenomegaly, scars, striae, if pregnant (or postpartum) fundal height etc..

Pelvic exam:

External Genitalia: Mons including hair distribution ( no lesions, shaved), labia majora and minora, clitoris, Bartholin’s and Skene’s glands (often grouped with urethra as BUS), hymen, introitus, perineum. Piercings?

Please do not state “intact” – not appropriate terminology here

Vagina: Color, rugation, odor, tone, discharge. (Cystocele, rectocele, discharge, inflammation, lesions, masses) (Ex: rugated, pink, no lesions or discharge, good tone)

Cervix: Color, os, position, texture, mobility. (Lesions, masses, inflammation, discharge, friability or bleeding, cervical motion tenderness/CMT) (Ex: No CMT, lesions, ectropion, discharge, patent os) Again, not “intact”

Uterus: Position, size, consistency, mobility. (Masses or tenderness) (Ex: Small, firm, midline, smooth and mobile, non-tender)

Adnexae: Size & shape. (Masses or tenderness) (Ex: bilaterally nontender, no masses palpated)

Extremities: FROM no varicosities, or edema

Diagnostics: List results that you already have available (lab, x-ray, urine dip, office pregnancy test, sono report etc..)

DIFFERENTIAL DIAGNOSES

WORKING DIAGNOSIS ALWAYS FIRST

A: #1 Diagnosis: (WORKING DIAGNOSIS) FOR EX:

Undesired fertility (for gyn/birth control visit)

Prenatal visit at 32 weeks gestation

Vulvovaginal Candidiasis etc….

Cervicitis

Pathophysiologic support for your working diagnosis WITH pertinent positives and negatives

#2,3 List and explain your differential’s (diagnosis’) – you should have 2 additional DD’s related to your working diagnosis - list pertinent positives and negatives

“what else could it be?” with brief patho here

(you may have other diagnoses as well just list them– for ex: )

• contraceptive management

• high risk sexual behaviors

• IUP @ 28 weeks etc….

• Whatever…

PLAN OF CARE

P: Diagnostic (lab, x-ray, cultures) that you plan to do for this patient for this pt (Ex: Pap smear, GC/CT)

Pharmacologic Treatment (including OTC, herbals, prescription) Correct dosing and directions as you would write a prescription –

(For ex: Diflucan 150mg po x1 dose today – dispense #1, no refills)

Education (Ex: nutrition, exercise, calcium intake; BSE)

Follow-up: Must state when the pt will be seen again. (Ex: RTC in 1 yr for annual exam and prn or Return to office in 3 months for contraceptive management)

Consultations, Collaborations, or Referrals

You must include one Research Article and 2 References