Female Genitalia Exam: Bates Chapter 21 PDF

Female Genitalia Bates Chapter 21 Jessa Richards, MMS, PA-C 1 Instructional Objectives Describe the anatomy and physiology of the female genitalia Obtain a through patient history speci(cally regarding complaints of changes in menstruation, vaginal bleeding and/or discharge, o...

Female Genitalia Bates Chapter 21 Jessa Richards, MMS, PA-C 1 Instructional Objectives Describe the anatomy and physiology of the female genitalia Obtain a through patient history speci(cally regarding complaints of changes in menstruation, vaginal bleeding and/or discharge, or vulvovaginal lesions Describe the risk factors for cervical cancer, STD’s, and HIV Describe the principles of the pelvic examination Helpful De(nitions Menarche-onset of menses Dysmenorrhea-pain with menses, often with bearing down, aching, or cramping sensation in the lower abdomen or pelvis Premenstrual syndrome (PMS)-a cluster of emotional, behavioral, and physical symptoms occurring 5 days before menses for three consecutive cycles Abnormal uterine bleeding-bleeding between menses; includes infrequent, excessive, prolonged, or postmenopausal bleeding Menopause-absence of menses for 12 consecutive months, usually occurring between ages 48 and 55 years Postmenopausal bleeding-bleeding occurring after menopause Helpful De(nitions Menorrhagia-periods where the bleeding is quite heavier, or the duration is longer than usual Metrorrhagia-bleeding or spotting in between menstruation Menometrorrhagia-combination of moth menorrhagia and metrorrhagia Polymenorrhea-less than 21-day intervals between menses Oligomenorrhea-infrequent bleeding Amenorrhea-absence of menses Helpful De(nitions Gravidity- # of times a woman has been pregnant Primigravida-a woman who is pregnant now or has been pregnant once Multigravida-pregnant more than once Nulligravida-never been pregnant more than once Parity- # of times a woman has given birth to a baby of viable age (≥24 weeks) regardless of birth outcome Primipara (Primip)-pregnant for the (rst time (and has made it beyond viable age) OR has given birth to only 1 child Multipara (Multip)-Given birth 2 or more times Nullipara (Nullip)-a woman who has never given birth or who has never had a pregnancy progress beyond viability Miscarriage (spontaneous abortion)-fetal demise before the 20th week of gestation History: Chief Complaint CC: Yearly well-woman Menarche and menstruation Premenstrual syndrome (PMS)  Depression, angry outbursts, irritability, anxiety, confusion, crying spells, sleep disturbance, poor concentration, social withdrawal, bloating, weight gain, swelling of hands and feet, generalized aches and pains  Criteria: o 1. Must be present in the 5 days prior to menses for at least three consecutive cycles. o 2. Cessation of symptoms and signs within 4 days after onset of menses. o 3. Interfere with daily activities Amenorrhea  Primary-Absence of ever initiating periods  Secondary-Cessation of periods after they have been established Abnormal bleeding  Menorrhagia, metrorrhagia, and menometrorrhagia  Polymenorrhea, oligomenorrhea, post coital bleeding History: Chief Complaint CC: Dysmenorrhea  Abnormal when interfering with ADLs (activities of daily living)  Primary-Increased prostaglandin production during the luteal phase of the menstrual cycle, when estrogen and progesterone levels decline  Secondary-Endometriosis, adenomyosis (endometriosis in the muscular layers of the uterus), pelvic inBammatory disease (PID), and endometrial polyps History: Chief Complaint CC: Menopause and Postmenopausal bleeding Pelvic pain-acute and chronic  Dysmenorrhea, dyspareunia, etc Vulvovaginal symptoms  Discharge, pruritis, and rash/lesions STIs Sexual health Pregnancy Urinary symptoms  Dysuria, frequency, urgency, incontinence History HPI: OLDCARTS Pertinent positives/negatives PMH Reproductive health history/STI’s  Important to assess impact on fertility, risk for ectopic pregnancy, best contraceptive to prescribe, etc. History urinary tract infections, glomerulonephritis, etc Previous urinary catheterization/dilation History spina bi(da (risk factor for recurrent UTI) History of trauma/spinal cord injury Medications/form of birth control Surgical history Reproductive Health History Obstetric History Gyn History Ovarian cyst Onset of #Pregnancies Endometriosis Menarche #Losses/ Infertility/ Abortions treatments LNMP Delivery hx- Fibroids Salpingitis vaginal vs c- Tubo-ovarian section abscess PID Screenings Last pap Sexual smear History Last mammogra m Sexually transmitted infections STI/HIV screens  Reproductive Health History/Sexual History The 5 “Ps+” Partners Genders of sexual partners, recent sexual intercourse, # of partners in the last 6 months, 5 years, and lifetime, any new partners in the last 6 months Practices Types of sex (oral, vaginal, anal, etc) Protection from STIs Use of condoms Past history of STIs What kind, when, what treatment, last screening Pregnancy Plans Any plans or desire to have (more) children? Discuss concerns, birth control, etc Plus Encompasses an assessment of trauma, violence, sexual satisfaction, sexual health concerns/problems, and support for sexual orientation and gender identify (SOGI)  Reproductive Health History/OB History Gravidity and Parity Can be documented succinctly as G and P Ex: A woman who is gravida 2, para 2 (G2P2) has had two pregnancies and two deliveries after 24 weeks. Ex: A women who is gravida 2, para 0 (G2P0) has had two pregnancies, neither of which survived to a gestational age of 24 weeks  Reproductive Health History/OB History Parity can be broken down even further G,P(TPAL) Gravidity - # of pregnancies Parity T-Term- # of term pregnancies/deliveries 37-40 weeks P-Premature- # of premature pregnancies/deliveries 20-36 weeks A-Abortions/miscarriages Elective abortions and spontaneous abortions L-Living children Reproductive Health History/OB History Practice! Your patient: A woman with two spontaneous losses prior to 20 weeks gestation, 3 living children who were delivered at term, and currently pregnant Reproductive Health History/OB History How many times has she been pregnant? 2 spontaneous losses+3 living children at term+currently pregnant=6 G6 How many times has she had full term pregnancies? 3 children born at term T=3 How many times has she had pre-term pregnancies? 0 P=0 How many times has she had an abortion/miscarriage? Two spontaneous losses prior to 20 weeks A=2 How many living children does she have? 3 living children L=3 Reproductive Health History/OB History Practice! A woman with two spontaneous losses prior to 20 weeks gestation, 3 living children who were delivered at term, and currently pregnant G6P3023 Reproductive Health History/OB History Practice! What about twins? Important to note that for gravidity, it’s about number of pregnancies, not number of babies This also goes for T, P, and A (term/pre-term pregnancies and abortions/miscarriages) Try this one: A woman has only had one pregnancy, she had twins that were delivered at term. She has had no miscarriages or abortions Reproductive Health History/OB History How many times has she been pregnant? Once G1 How many times has she had full term pregnancies? 1 full term pregnancy T=1 How many times has she had pre-term pregnancies? 0 P=0 How many times has she had an abortion/miscarriage? 0 A=0 How many living children does she have? 2 living children L=2 Reproductive Health History/OB History Practice! What about twins? Important to note that for gravidity, it’s about number of pregnancies, not number of babies This also goes for T and P (term and pre-term pregnancies) Try this one: A woman has only had one pregnancy, she had twins that were delivered at term. She has had no miscarriages or abortions G1P1002 History FH History of renal disease Polycystic Kidney dz Renal failure Cancer SH Sexual history ROS General Skin Pulm Cardiac GI GU Physical Exam Vital signs General Skin Pulm Cardiac GI Rectal when indicated GU Pelvic exam Female Anatomy Female Anatomy Female Anatomy Female Anatomy Before preparing for the exam…  Is the patient younger than 21 years old? Pelvic exams should only be performed on patients under 21 years old if indicated by the medical history, such as menstrual disorders, pelvic pain, discharge, etc. NO EVIDENCE SUPPORTS THE ROUTINE INTERNAL EXAMINATION OF THE HEALTHY, ASYMPTOMATIC PATIENT BEFORE AGE 21 YEARS.  Male examiners should be accompanied by female chaperones, and female examiners should be accompanied by a chaperone as well. Tips for Successful Female Genitalia Exam Prep for the Pelvic Exam Assemble equipment Moveable light source Gloves Vaginal speculum of appropriate size Water-soluble lubricant Pap smear equipment (if indicated) Specimen/culture equipment (if indicated) Large cotton swabs Make Sure The Patient is Comfortable Positioning Assist the patient into lithotomy position She may be warmer and feel less exposed with socks on Ask her to slide all the way down the exam table until her buttocks extend slightly beyond the edge. Her hips should be Bexed, abducted, and externally rotated Make sure her head is supported with a pillow Touching the Patient Give patient power by your words: “This is the speculum I will use” “We will begin the examination now with your permission.” “You will feel the back of my hand”  GU Female Exam Inspection (and palpation if indicated) of the external genitalia  Mons pubis, labia majora and perineum  Labia minora, clitoris, urethral meatus, and introitus  Anus External Exam Mons pubis Inspect: Pubic hair pattern/distribution Labia majora Inspect: Color, symmetry, moisture, scarring, inBammation, swelling. Palpate for tenderness Labia minora Inspect: symmetry, moisture, inBammation, discharge, excoriations, lesions. Palpate for tenderness Clitoris Size, atrophy, inBammation, adhesions Urinary meatus Discharge, polyps, caruncles, inBammation Vaginal introitus Moisture, swelling, discoloration, discharge, lesions, (ssures Skene and Bartholin glands Inspect: Discharge and swelling Palpate: Bartholin glands for tenderness External Exam Bartholin glands Palpate each side at approximate the 4- o’clock and 8-o’clock position between your (nger and thumb Check for swelling or tenderness Note any discharge exuding from the duct opening of the gland Culture if present  Speculum Examination Understand mechanics of the speculum and make sure it’s in good working order Preferable to lubricate with warm water May use lubricant sparingly*** Can prevent accurate pap/culture results so use with caution!  Internal Exam-Speculum Exam Advise patient you will now place the speculum in the vagina Place 1-2 (ngers in the posterior introitus and press downward If needed, locate the position of the cervix with your (ngers to guide the direction of the speculum With speculum closed, insert at an oblique angle and gradually rotate to horizontal position Insert at a 30-degree downward angle towards the cervix Gradually open the speculum, bring cervix into view, and lock If having diRculty (nding the cervix, withdraw slightly and reposition on a diSerent slope  Internal Exam-Speculum Exam (cont) If discharge obscures the view, wipe away gently with a large cotton swab Note the color and symmetry of the cervix Note the surface characteristics Smooth, ectropion, Nabothian cysts, polyps, erythema Note the shape of the os Note the presence of any discharge Odor, consistency  Internal Exam-Speculum Exam (cont) Obtain pap smear and cultures if indicated Withdraw the speculum just until it clears the cervix, then inspect the vaginal walls Inspect for color, surface characteristics, lesions, secretions, or bleeding Have the patient bear down, and check for bulging in the vaginal wall or incontinence Ensuring the speculum has cleared the cervix, close the speculum and remove slowly at the same oblique angle The Speculum Exam Papanicolaou (Pap) Smear Once the cervix is clearly visualized: Obtain one specimen from the endocervix and another from the ectocervix If indicated/consented: Then take cultures from the cervical os TAKE CUTURES LAST!!!  GU Female Exam Bimanual Examination-Performed from standing position  Lubricate index and middle (ngers  Inform patient you will insert (ngers  Insert (ngers exerting pressure posteriorly, with the thumb abducted and 4th and 5th (ngers Bexed into the palm.  Note any lesions or tenderness in the vaginal wall, including the region of the urethra and bladder anteriorly  Palpate the cervix, noting the size, contour/consistency, and assess for cervical motion tenderness  Palpate the uterus  Place your other hand on the lower abdomen just above the symphysis pubis while you elevate the cervix and uterus with your pelvic hand. Press the abdominal hand in and down, capturing the uterus between your two hands. Note its position, size, shape, contour/consistency, any masses present, mobility and identify any tenderness.  Palpate each ovary  Place your abdominal hand on the right lower quadrant and your pelvic hand in the right lateral fornix, pushing your abdominal hand in and down.  Try to identify the right ovary or any adjacent adnexal masses  Note the size, shape, consistency, mobility, and tenderness  Repeat on left side DRE (Verbalize only that you will perform)   Note the sphincter tone and any scarring, (ssures, lesions, rectal wall masses, polyps, tenderness, uterus position/size/tenderness, stool color, and presence of any blood. The Bimanual Examination Special Techniques Milking the urethra To evaluate possible urethritis or inBammation of the paraurethral glands, insert your index (nger into the vagina and milk the urethra gently outward from the inside. Note any discharge from the urethral meatus. If discharge is present, culture it Common Abnormalities  Common Abnormalities Vulvar/Vaginal Lesions Herpes simplex Vesicles/ulcers Syphilis Cancer Bartholin cysts HPV Warts Common Abnormalities  Common Abnormalities Vaginal Pruritus/Pain Candidiasis Trichomoniasis Herpes simplex Vesicles  Common Abnormalities Vaginal discharge Urethritis/cervicitis Chlamydia/GC Mucopurulent discharge Bacterial Vaginosis Homogeneous white discharge which coats the vagina +clue cells Fishy odor, “whiS” test Candidiasis White clumped discharge Trichomoniasis Yellow/green, often malodorous discharge with vulvar itching Motile Bagellated organisms Common Abnormalities Urethrocele-When a prolapsed urethra protrudes into the anterior vaginal wall Cystocele-A bulge of the upper two-thirds of the anterior vaginal wall due to a prolapsed bladder Common Abnormalities Cystourethrocele-When the entire anterior vaginal wall, together with the bladder and urethra, produces the bulge. Rectocele-Herniation of the rectum into the posterior wall of the vagina, resulting from a weakness or defect in the endopelvic fascia. Common Abnormalities Urethral abnormalities Caruncle-Small red benign tumor visible at the posterior urethral meatus. Most common in postmenopausal women Typically asymptomatic Important to avoid confusing with carcinoma of the urethra  Common Abnormalities Cervical abnormalities Mucopurulent discharge  Mucopurulent cervicitis produces purulent yellow drainage from the cervical os, usually from C. trachomatis, N. gonorrhoeae, or herpes infection. Carcinoma of the cervix  Earliest stages-cannot be distinguished from a normal cervix.  Later stages-an extensive, irregular, cauliBower-like growth may develop.  Early frequent intercourse, multiple partners, smoking, and infection with human papillomavirus increase the risk for cervical cancer. Fetal exposure to DES  Daughters of women who took DES during pregnancy are at greatly increased risk for several abnormalities  Columnar epithelium that covers most or all of the cervix  Vaginal adenosis (i.e extension of this epithelium to the vaginal wall)  A circular collar or ridge of tissue, between the cervix and vagina  Rare carcinoma of the upper vagina. Nabothian cysts (AKA Mucinous retention cysts)  Common Abnormalities Uterine abnormalities Fibroids (Myomas) Very common, benign tumors Vary in number and size Firm, irregular nodules Prolapse Weakness of supporting structures of the pelvic Boor 1st degree-cervix is still well within the vagina 2nd degree-cervix is at the introitus 3rd degree-cervix and vagina are outside the introitus Common Abnormalities Adnexal masses and other causes of pelvic pain Ovarian cancer Ovarian cysts/tumors Cysts can be transient or suggestive of PCOS PCOS-Requires 2/3 factors to be present for diagnosis Androgen excess Ovulatory dysfunction Polycystic ovaries on U/S Ectopic pregnancy PID Dysmenorrhea Endometriosis Common Abnormalities Renal Conditions UTI and Pyelonephritis Nephrolithiasis Gross hematuria Glomerulonephritis Previous history of streptococcal infection Microscopic hematuria Nephrotic syndrome Facial edema/increased bp/> 3grams of protein in 24hours Documentation “External genitalia without erythema, lesions, or masses. Vaginal mucosa pink. Cervix parous, pink, and without discharge. Uterus anterior, midline, smooth, and not enlarged. No adnexal tenderness. Pap smear obtained. Rectovaginal wall intact. Rectal vault without masses. Stool brown and negative for fecal blood.” OR “External genitalia without erythema or lesions. Vaginal mucosa and cervix coated with white homogenous discharge with mild (shy odor. After swabbing cervix, no discharge visible in the cervical os. Uterus midline; no adnexal masses. Rectal vault without masses. Stool brown and negative for fecal blood.” Health Promotion and Education Question: Why should lubricant be used sparingly or not at all during a pap? A. Could cause an allergic reaction B. Could cause inaccurate results C. Could cause discomfort D. Could cause issues with the speculum Question: Which of the following is not an instrument used during a pelvic exam? A. Broom B. Spatula/Scrape C. Brush D. Cannula Question: Which of the following is the de(nition of metrorrhagia? A. Bleeding between menses B. Heavy bleeding C. Bleeding that occurs 1 year after cessation of periods D. Pain with menses Question: At what age should cervical cancer screening begin? A.18 B. 21 C. 30 D. When the patient becomes sexually active References Bates Guide to Physical Examination WRITING FOCUSED NOTES Physical Diagnosis II Spring 2025 Penn Mattox DMSC, MPAS, PA-C 2 pages  LEARNING OBJECTIVES 1. Understand the general principles of documentation 2. Define the components of a focused note 3. Organize pertinent positive and negatives in the HPI, ROS, and PE portion of note 4. Analyze information from the subjective and objective portion of notes to develop diagnosis 5. Develop differential diagnosis 6. Develop the Assessment (old problem list) 7. Document the Plan (patient management) 8. Organize and perform an oral case presentation  PRINCIPLES OF DOCUMENTATION To get paid you MUST document!!! “Not documented--Not done” Be clear and concise Make sure the medical records are complete and legible Patient encounters should include: Reason for visit (CC) Relevant history, physical exam findings, and resulted diagnostic test Clinical impression or diagnosis with differential diagnosis list Assessment to include current and pre-morbid problem list Medical care plan: medications, referral, resulted labs, diagnostics to be ordered, follow up, and patient education Date and legible identity of the provider  PRINCIPLES OF DOCUMENTATION Rational for diagnostics should be clear or easily inferred Health risk should be identified Patients progress, response to treatment should be documented, and revisions documented The diagnosis and treatment codes reported to the health insurance should be supported by your documentation  DETAILED FOCUS NOTE Identifying information (Subjective information first) CC } Primary complaint and duration in patient’s own words if possible (with quotes) in note HPI - Only complete , full paragraph PMH FH SH ROS  DETAILED FOCUS NOTE Objective information next PE Record of physical findings (must match the same systems in ROS) Labs/Diagnostics that are resulted at the time of the note (numbered) Assessment (numbered) I only if done by time of note. List your Ordered lab but no result yet In PLAN May list according to subjective material first followed by objective material Pre-morbid conditions, harmful habits (ETOH), pertinent family history (ETOH, mental illness) also included Plan (numbered) NumberedLabs/Diagnost is 3) Plan  IDENTIFYING INFORMATION Name: Age DOB (XX/XX/XXXX format) Sex  CHIEF COMPLAINT (CC) In patient’s words, if at all possible, the current problem, and should include duration If a direct quote, should be in quotes If paraphrasing—no quotes Complaints should be listed as single words or short phrases with the approximate length of time they have been present (if possible) CC is the starting place for making a differential diagnosis Example “I’ve been vomiting for 2 days”  SUBJECTIVE VERSUS OBJECTIVE Subjective Historical information (info from patient alone) Includes the CC through the ROS Example: Mrs. G is a 54-year-old female who reports pain and pressure over the left chest. “It feels like an elephant is sitting on my chest” (for approx 1 hr)  SUBJECTIVE VERSUS OBJECTIVE Objective Information you physically identified or concluded from testing--lab or diagnostic test info that has been resulted PE: Vitals T 97.5 HR 100 RR 28 BP 160/80 O2sat 99% Wt 180 Ht 5’10” Gen’l Appears older than stated age, obese, appears to be in mild distress Labs/Diagnostics 1. EKG:Sinus tachycardia 2. CBC normal (platelets 105)  SUBJECTIVE CC HPI (which is based on the CC--OLDCART) O-Onset: timing (progression, regressions or steady), frequency, L-Location (anatomic) and any radiation D-Duration C-Character A-Aggravated symptoms/Alleviating symptoms R-Relieving/remitting T-Timing S-Severity You also need to ask associated symptoms and list 3-5 pertinent positives and negatives  DOES THIS HPI MAKE THE GRADE?? How long has he had the pain? V Patient is a s 42-year-old male What is the character of the pain? Did he who presents with left knee hear a pop? X pain. He injured his knee while What is the quantity of the pain? X playing softball. The pain has Has he tried anything to relieve the pain?X gradually worsened over the past week. He denies any What pertinent positive and negatives are · documented? Should there be any other? swelling or numbness. He denies and prior knee surgery. Does the patient have any chronic medical problem? pain in joint Has the patient had any surgery? about below Any recent infections or injuries (puncture wounds)? Unprotected sex? If so it may need to go into HPI—otherwise not in HPI  DEVELOPING THE DIFFERENTIAL DIAGNOSIS After obtaining the CC Start thinking of a list of conditions As you obtain pertinent positives and negatives you should narrow the list As you conduct your vitals and physical exam, you narrow down your differentials more After you obtain Labs/Diagnostics you should select a primary or " presumptive diagnosis say"probable - can Dx... Followed by 4 differential diagnoses  DIAGNOSIS Differential Diagnosis Based on the CC Generate a list of at least five conditions Primary diagnosis is the one that is most likely and should be listed first on the list State a short explanation as to why you chose the primary diagnosis  A MNEMONIC FOR GENERATING DIFFERENTIAL DIAGNOSIS V – Vascular I – Infectious N – Neoplastic D – Degenerative I – Iatrogenic/intoxication C – Congenital A – Autoimmune T – Traumatic E – Endocrine/metabolic  SUBJECTIVE INFO PMH FH SH (always ask barriers to care and tobacco exposure) ROS General system Skin Pulm Cardiac (These 4 should be included with every CC—then add 2-4 more depending on the complaint)  OBJECTIVE INFO PE (These should be in a top-down fashion) Vital signs (linear fashion) PE (pertinent to the CC) ALWAYS perform Gen’l, Skin, Pulm, and Cardio exam (with pulses) Add additional systems according to the CC Labs/Diagnostics (numbered) Any lab/diagnostic that has been completed and RESULTED goes here Must be DATED  DIAGNOSIS Definitive diagnosis is made when you have all the information you need Use the information to establish a diagnosis based on the CC Differential Diagnosis Based on the CC Generate a list of at least five conditions Primary diagnosis is the one that is most likely and should be listed first on the list State a short explanation as to why you chose the primary diagnosis  NOTE PEARLS Always use the template format System heading format with abbreviations ONLY paragraph is in the HPI Try to document in a top-down fashion In the order you examine Head down—lungs before heart Inspect/palpate/ROM Labs/Diagnostics, Assessment, and Plan are numbered  PSYCH NOTE SUBJECTIVE INFO Psych questions for the HPI: Sig E CAPS S-Sleep I-Interest G-guilt E-Energy C-Concentration A-Appetite P-Psychomotor activity S-Suicidal Ideation Always include neuro as an additional system for ROS  PSYCH NOTE OBJECTIVE INFO PE for the psych exam for CSE’s Always include neuro as an additional system (MMSE, CN’s, gross sensory, gross motor, and reflexes) Psych (expected verbiage is as follows) Describe attitude Assess behaviors/ activity Describe affect Evaluates thought processes Evaluates thought content Assess patient perception Assess insight Assess judgment Level of consciousness Suicidal/ homicidal ideation Reliability  ASSESSMENT Declare your primary diagnosis with a short supportive statement Your old problem list becomes your Assessment Cluster information Signs and symptoms (HPI) Any premorbid conditions (PMH) Any relevant information obtained regarding family (FH) Any relevant social information (ETOH, tobacco, travel from SH) Involvement of various body systems (ROS) Physical exam findings (to include vitals) Lab/diagnostic results during encounter that are resulted  BULIDING AN ASSESSMENT 1. Patient’s signs and symptoms 2. Any pre-morbid conditions to include tobacco addiction or ETOH abuse 3. Any pertinent family history (eg. if patient has ETOH abuse and has a family history of ETOH abuse) 4. Any pertinent exposure (eg. travel with potential traveler’s diarrhea) 5. Any positive reporting on ROS (eg. patient is seeing you for fever and sore throat but tells you he has dyspnea on exertion) 6. Any abnormal physical findings to include abnormal vital signs/BMI 7. Any abnormal lab/diagnostic findings  ASSESSMENT PEARLS Do not forget to address pre-morbid conditions/FH/exposure/unrelated symptoms—anything that is reported to you—in your Plan It is imperative that if you discover something on exam or a condition is reported to you by the patient—you must address it—even if it’s just an infected toenail #1 Primary diagnosis with short supportive statement #2 as everything reported in the HPI (positives) #3 everything discovered in the PE/Labs &Diagnostics #4 pre-morbid conditions, unhealthy habits, exposures, pertinent family history related to illness  PLAN This is documentation of anything medical or nonmedical you have placed on your Assessment (that you discussed with the patient) Plan of care (numbered) 1. Patient disposition: Admit/Sent to ER/Discharged to home 2. Diagnostic test 3. Therapeutics: pharmacological and non-pharmacologic 4. Consultations / Referrals 5. Premorbid conditions 6. Patient education 7. Prevention 8. Follow up -- be specific 9. Don’t forget to address barriers to care if they exist  PLAN Diagnostics Includes any diagnostic tests/labs Therapeutics Medications, direction for use, and side effects Route, dosage, duration, indication, frequency Include nonpharmacologic advice Referral/ Consultation Pre-morbid conditions/relative FH, SH Continue Lisinopril for HTN Continue Prevacid for GERD Father with AAA 30-pack-year smoking hx  PLAN Education Anticipatory guidance Includes the expected prognosis Health promotion and disease prevention Prevention Discuss any diet needs, smoking cessation, illicit drug use counseling, obesity, blood sugar testing etc here Follow up -- be specific Don’t forget to address barriers to care if they exist  NOTE TEMPLATE Time/date Patient biographical data Name DOB: 10/XX/XXXX Sex: CC (in direct quotes; if possible include duration) HPI (paragraph form) OLDCARTS Associated symptoms Pertinent positives and negatives (3-5 each) PMH FH SH ROS  NOTE TEMPLATE PE VS in a linear fashion (eg. T 98.6, HR 66, RR 14, BP 130/72, O2 sat 97% room air, Ht 5’6”, Wt 160, BMI 30) Only the pertinent systems and examinations. (This is not a comprehensive PE; 4-8 in total) Organize from head ètoe Labs/Diagnostics The resulted diagnostic test should be listed here dated.  PA STUDENT NOTE TEMPLATE Assessment 1. Primary diagnosis with short supportive statement 2. Problem list (Signs, symptoms, vitals, physical findings, resulted labs/diagnostics, premorbid conditions, pertinent SH, pertinent FH Plan 1. Patient disposition 5. Diagnostics 6. Medications (be specific with medication) and non-pharmacologic 7. Referrals/consults 8. Pre-morbid conditions/relevant FH, SH 9. Patient education/disease prognosis 10. Prevention 11. Follow up 12. Barriers to care if any exist Sign note and date THE ORAL CASE PRESENTATION  THE ORAL CASE PRESENTATION This is a 5-7 minute orally summary of your patient encounter. Once you have completed your focused note you should then aggregate key components that can give the listener a visual of your patient encounter  ORAL CASE PRESENTATION: SUBJECTIVE State the CC: “Cough for 7 days” Present the HPI by starting with an introduction: MJ is a 35-year-old male teacher, who has a known history of asthma, presents with a cough for 7 days. Expand on OLD CARTS He experienced a cough like this two weeks ago which improved a little with robutussin. For 7 days it was intermittent but in the past 2 days it has been constant day and night. The cough is constant now and he his bringing up about a tablespoon of green/yellow mucous each time. The cough is affecting his sleep at night and there are no aggravating or alleviating factors. He also admits to associated fever, chills, and chest pain.  ORAL CASE PRESENTATION SUBJECTIVE PMH: significant for asthma as a teenager and a cold two weeks ago that he thought got better. Medication: took robutussin 2 days ago but did not help. NKDA, no known allergies to supplements or food Immunizations Not taken the flu shot because heard it makes you sick FH: Mother and Father unknown (adopted) Sister age 30 significant for asthma Sick contacts at his school (he teaches kindergarten) SH: Significant for smoking which started 3 months ago (pack/wk) Negative for smoking marijuana or use of illicit drugs  ORAL CASE PRESENTATION: SUBJECTIVE ROS General: significant for fever of 101. 5 for 2 days and chills Skin: negative for lesions, rashes, or erythema HEENT: Eyes, non-contributory; Nose denies any nasal congestion, or rhinorrhea Respiratory: denies wheezing or hemoptysis Cardiovascular: denies chest pan, palpitation, PND, or orthopnea  ORAL CASE PRESENTATION: OBJECTIVE PE is also brief, giving only pertinents. Vital signs :BP 146/90, T 103.7F, RR 28 bpm, HR 102 bpm Gen’l: WDWN male who appears ill and is in mild distress Skin: no pallor, cyanosis,s or diaphoresis. HEENT –non-contributory Respiratory: Good respiratory expansion with slight use of accessory muscles, anterior thorax tender to palpation in the mid sternal region. Tactile fremitus increased, dullness to percussion, and decreased breath sounds all noted in the left lung base. Egophony is present in the left lung base. Cardio: no lift or heaves noted and no thrills on palpation +S1 S2 Labs/Diagnostics: AP/Lat CXR: +consolidation LLL  ORAL PRESENTATION (CONT’D) DDX list 1. Diagnosis with rationale 2. Possible Differentials at least 5 total Assessment (optional with OCP) 1. Synopsis of his problem list in numerical fashion Plan: 1. What is your patient disposition 2. Diagnostic tests (to confirm or eliminate differentials) 3. Medications, treatments, referral 4. Patient education and follow-up plan  RUBRICS Focused Note Located in Modules for This Week Oral Case Presentation Located in Modules for This Week  APPROACH 2/5/25 TO THE Randi Beth Cooperman PULMONARY PATIENT DHSc, MCMSc, PA-C LEARNING OUTCOMES The student will be able to: Obtain a thorough patient history speci-cally regarding complaints of chest pain, shortness of breath, wheezing, cough, and hemoptysis Gather subjective and objective data for a problem-oriented case Provide health maintenance strategies for smoking cessation and proper adult immunizations against in3uenza and pneumonia Identify abnormal disease pattern characteristics during the examination of the thorax and lungs Utilize the problem list to generate a working di5erential diagnosis for common pulmonary complaints. PULMONARY ANATOMY ANATOMY OF THE CHEST WALL ANATOMY, CONTINUED Locating -ndings on the chest Describe abnormalities in two dimensions  Vertical axis  Circumference of the chest  To make vertical locations, count the ribs and interspaces; sternal angle is the best guide ANATOMY, CONTINUED To locate -ndings around the circumference of the chest, imagine a series of vertical lines ANATOMY, CONTINUED Lungs, -ssures, and lobes  Each lung is divided roughly in half by an oblique (major) ssure  The right lung is further divided by the horizontal (minor) ssure  These -ssures divide the lungs into lobes  The right lung is divided into upper, middle, and lower lobes  The left lung is divided into upper and lower lobes ANATOMY, CONTINUED The trachea and major bronchi  The trachea bifurcates into its main stem bronchi at the levels of the sternal angle anteriorly and the T4 spinous process posteriorly The pleurae  The pleurae are serous membranes that cover the outer surface of each lung (visceral pleura), and also the inner rib cage and upper surface of the diaphragm (parietal pleura) ANATOMY, CONTINUED Topographic markers  Nipples  Manubriosternal junction (angle of Louis)  Suprasternal notch  Costal angles  Vertebra prominens (C-7 spinous process)  Clavicles ANATOMY, CONTINUED Supraclavicular—above the clavicles Infraclavicular—below the clavicles Interscapular—between the scapulae Infrascapular—below the scapulae Apices of the lungs—the uppermost portions Bases of the lungs—the lowermost portions Upper, middle, and lower lung -elds  ANATOMY PEARLS Anatomy is always relevant! 2nd intercostal space for needle insertion for tension pneumothorax. 4th intercostal space for chest tube insertion. T4 for the lower margin of an endotracheal tube on a chest x-ray. Neurovascular structures run along the inferior margin of each rib, so needles and tubes should be placed just at the superior rib margins. COMMON PULMONARY CHIEF COMPLAINTS Chest Pain Dyspnea Cough Wheezing Hemoptysis CHEST PAIN Di5erential Diagnosis? HPI - CHEST PAIN  Initial questions should be as broad as possible, such as, “Do you have any discomfort or unpleasant feelings in your chest?”  Ask the patient to point to the location of the pain  Aside from lung conditions, chest pain may arise from cardiac, vascular, gastrointestinal, musculoskeletal, or skin pathology; it is also commonly associated with anxiety  HPI-CHEST PAIN Attempt to elicit all attributes of the patient’s symptom (PQRST or OLD CARTS) Table 15.3 Single location aggravated with inspiration usually sharp or stabbing Pleuritic pain, costochondritis Anterior chest radiating to shoulder, pressure or squeezing pain Angina pectoris or myocardial infarction Sharp pain with inspiration that is relieved with siting up and leaning forward Pericarditis Severe chest pain described as ripping or tearing Dissecting aortic aneurysm Retrosternal pain, described as burning after meals Gastrointestinal Re3ux Disease DYSPNEA Di5erential diagnosis? HPI-DYSPNEA  Dyspnea is a nonpainful but uncomfortable awareness of breathing that is inappropriate to the level of exertion  Begin assessment with a broad question, such as, “Have you had any diJculty breathing?”  Determine the severity of dyspnea based on the patient’s daily activities HPI-DYSPNEA Attempt to elicit all attributes of the patient’s symptom (PQRST or OLD CARTS) Table 15.1 Slow progression of SOB, worse when lying down Heart Failure Acute illness, often productive cough Pneumonia Sudden onset, pleuritic pain, often young healthy adult Pneumothorax Sudden onset, pleuritic pain, risk factors! Pulmonary embolism COUGH, WHEEZE, HEMOPTYSIS Di5erential Diagnosis? HPI – COUGH & WHEEZE  Ask whether the cough is dry or produces sputum, or phlegm  Ask the patient to describe the volume of any sputum and its color, odor, and consistency  “How much do you think you cough up in 24 hours: a teaspoon, tablespoon, quarter cup, half cup, cupful?”  If possible, ask the patient to cough into a tissue; inspect the phlegm, and note its characteristics.  Try to con-rm the source of the bleeding by history and examination before using the term “hemoptysis”; blood may also originate from the mouth, pharynx, or gastrointestinal tract HPI-COUGH & HEMOPTYSIS Attempt to elicit all attributes of the patient’s symptom (PQRST or OLD CARTS) Table 15.2 Episodic cough or wheeze, not always related to illness Asthma Cough, hemoptysis, fever, night sweats Tuberculosis Cough, hemoptysis, weight loss, tobacco use Lung cancer PAST MEDICAL HISTORY Thoracic trauma or surgery, dates of hospitalization for pulmonary disorders Use of O2/ventilation-assisting devices Chronic pulmonary diseases Chronic disorders (cardiac, CA, clotting) Childhood illness (asthma) Testing Immunizations (3u, pneumonia) FAMILY HISTORY TB Cystic -brosis Emphysema Allergy Asthma Malignancy Clotting disorders PERSONAL/SOCIAL HISTORY Employment Home environment Tobacco use Exposure to respiratory infections, 3u, TB Nutritional status Regional/travel exposures Hobbies (pigeons) Use of alcohol/drugs Exercise tolerance HIV risk factors PHYSICAL EXAMINATION IDENTIFY RESPIRATORY DISTRESS IDENTIFY RESPIRATORY DISTRESS Tachypnea Cyanosis Pallor Diaphoresis Accessory muscle use Breathing TYPES OF BREATHING PATTERNS  Pursed lip breathing  Obstructive lung disease  With lips pursed patient controls expiration slowly  No abdominal component  Acute abdomen  No thoracic component  Pleurisy  Chest wall pain USE OF ACCESSORY MUSCLES Intercostal  Used by patients with COPD  Signs of use include “Deeper” breathing & intercostal retractions Scalene  Used continuously in advanced COPD  Unable to see; use -ngers to palpate Sternocleidomastoid (SCM)  Signs: SCM retractions  Last to be recruited & patients tire quickly  Sign that patient will soon need to be intubated USE OF ACCESSORY MUSCLES INSPECTION Chest Shape/symmetry of chest Chest wall movement Super-cial venous patterns Prominence of ribs AP vs. transverse diameter Sternal protrusion Spinal deviation INSPECTION OF THORACIC INTEGRITY AP Diameter Thorax of healthy adult with AP diameter < transverse diameter Increased AP diameter in COPD (barrel chest) BARREL CHEST INSPECTION OF THORACIC INTEGRITY Deformity Pectus carinatum Pectus excavatum Kyphosis PECTUS CARINATUM Pectus Carinatum: sternum & costal cartilages project outwards. It can occur secondary to childhood asthma. PECTUS EXCAVATUM Hollow at lower part of chest Caused by backward displacement of xiphoid cartilage Funnel breast, funnel chest Poor posture, pot belly, & sunken chest PECTUS EXCAVATUM Congenital posterior displacement of lower aspect of sternum. This gives the chest a somewhat "hollowed-out" appearance.. Usually benign, requires no treatment PECTUS EXCAVATUM KYPHOSIS Increased curvature of thoracic spine causes patient to be bent forward THORACIC/CHEST EXPANSION  Normal Findings  Symmetrical  Asymmetric chest expansion  Always abnormal  Abnormal side expands less & lags behind normal side  Implies that air cannot enter a5ected side  Bilateral reduction: diJcult to detect clinically TACTILE FREMITUS  Consolidation  Lobar pneumonia  Heavy bronchial secretions  Segmental atelectasis  Pleural e5usion, -brosis or thickening  Massive pulmonary edema  Hemothorax ABNORMALITIES OF VOCAL RESONANCE Increased Decreased Bronchophony Bronchophony  Consolidation  Hyperin3ation  Segmental  Pneumothorax atelectasis  COPD  Pleural E5usion  Asthma REDUCED DIAPHRAGMATIC EXCURSION  Present in conditions which limit its descent  Pulmonary (COPD)  Abdominal (Massive ascites, tumor)  Super-cial pain (Fractured rib)  Tenderness, step o5  Diaphragm paralysis PERCUSSION Identify boundary between resonant lung tissue and dull structures (below diaphragm) Pathologic examples Large pleural e5usion Lobar pneumonia COPD Large pneumothorax ADVENTITIOUS BREATH SOUNDS  Snoring/ gurgling  Arise from disorders in nasopharynx  Hypertrophied tonsils (palatine)/ hypertrophied adenoids (pharyngeal tonsils)  Nasal polyps  Foreign body  Rhinitis  Pleural Friction Rub  Inspiratory or expiratory, disappears when holding breath  Raspy, dry, scratchy sound  Pleural irritation and in3ammation ADVENTITIOUS BREATH SOUNDS  Wheeze  FB  Bronchitis  Bronchiolitis  Asthma/COPD/Emphysema  Stridor  Epiglottitis  Laryngitis  Retropharyngeal abscess  FB ADVENTITIOUS BREATH SOUNDS Rales:  Inspiratory, doesn’t clear with cough  Etiology  Fibrosis  Atelectasis  Pneumonia  Fluid (CHF) Rhonchi:  Continuous, more pronounced during expiration  Can clear with cough BREATH SOUNDS: ILL VS. WELL PATIENT HEALTH PROMOTION AND COUNSELING Tobacco Cessation Lung Cancer Immunizations (RSV, in3uenza, strep pneumonia, COVID-19) TOBACCO CESSATION 19% of US adults smoke #1 preventable cause of premature death (1/5 deaths a year) Quitting smoking signi-cantly reduces disease risk of lung cancer and other. The facts below can be motivating when counseling smokers. Quitting tobacco reduces the cardiovascular risk of heart attack and death from coronary heart disease by half after just 1 year. Stroke risk is reduced within 2 to 5 years to the same level as a nonsmoker. Lung cancer risk is cut in half after 10 years. TOBACCO CESSATION HEALTH PROMOTION AND COUNSELING  Focus on prevention and cessation IMMUNIZATIONS Patient education, promote vaccination CDC Adult Immunization schedule, 2024: RSV COVID-19 Pneumococcal Vaccine In3uenza COVID-19 VACCINATION Unvaccinated:  1 dose of updated (2024–2025 Formula) Moderna or P-zer-BioNTech vaccine  2-dose series of updated (2024–2025 Formula) Novavax at 0, 3–8 weeks Previously vaccinated* with 1 or more doses of any COVID-19 vaccine: 1 dose of any updated (2024–2025 Formula) COVID-19 vaccine administered at least 8 weeks after the most recent COVID- 19 vaccine dose. COVID-19 VACCINATION RESPIRATORY SYNCYTIAL VIRUS (RSV) VACCINATION Pregnant at 32-36 weeks gestation from September through January in most of the continental United States*: 1 dose RSV vaccine (Abrysvo™). Administer RSV vaccine regardless of previous RSV infection. All other pregnant persons: RSV vaccine not recommended Age 60 years or older: Based on shared clinical decision-making, 1 dose RSV vaccine (Arexvy® or Abrysvo™). Persons most likely to bene-t from vaccination are those considered to be at increased risk for severe RSV disease.** Age >75 years PNEUMOCOCCAL VACCINE RECOMMENDATIONS INFLUENZA RECOMMENDATIONS PRACTICE A 21-year-old college senior presents to your clinic, complaining of shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory symptoms, chest pain, gastrointestinal symptoms, or urinary tract symptoms. Her past medical history is signi-cant only for seasonal allergies, for which she takes a nasal steroid spray but is otherwise on no other medications. She has had no surgeries. Her mother has allergies and eczema and her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. On examination she is in no acute distress and her temperature is 98.6. Her blood pressure is 120/80, her pulse is 80, and her respirations are 20. Her head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this best describe? A. Spontaneous Pneumothorax B. Chronic Obstructive Pulmonary Disease (COPD) C. Asthma D. Pneumonia E. Common Cold A 62-year-old construction worker presents to your clinic, complaining of almost a year of chronic cough and occasional shortness of breath. Although he has had worsening of symptoms occasionally with a cold, his symptoms have stayed about the same. The cough has occasional mucous drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is signi-cant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married and has two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. On examination you see a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Percussion notes are di5usely hyperresonant. What thorax or lung disorder is most likely causing his symptoms? A. Spontaneous Pneumothorax B. Chronic Obstructive Pulmonary Disease (COPD) C. Asthma D. Pneumonia E. Lung Cancer A 47-year-old vet-tech comes to your oJce, complaining of fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only gotten worse, despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. On examination you see a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated, at 101.1 F. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examinations are unremarkable except for edema of the nasal turbinates. On auscultation she has left sided decreased air movement, and coarse crackles are heard over the left lower lobe. There is left lower dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms? A. Spontaneous Pneumothorax B. Chronic Obstructive Pulmonary Disease (COPD) C. Asthma D. Pneumonia E. Upper respiratory infection A 17-year-old high school senior presents to your clinic in acute respiratory distress. Between shallow breaths he states he was at home -nishing his homework when he suddenly began having right-sided chest pain and severe shortness of breath. He denies any recent traumas or illnesses. His past medical history is unremarkable. He doesn't smoke but drinks several beers on the weekend. He has tried marijuana several times but denies any other illegal drugs. He is an honors student and is on the basketball team. His parents are both in good health. He denies any recent weight gain, weight loss, fever, or night sweats. On examination you see a tall, thin young man in obvious distress. He is diaphoretic and is breathing at a rate of 35 breaths per minute. On auscultation you hear no breath sounds on the right side of his superior chest wall. On percussion he is hyperresonant over the right upper lobe. With palpation he has decreased to absent fremitus over the right upper lobe. What disorder of the thorax or lung best describes his symptoms? A. Spontaneous Pneumothorax B. Chronic Obstructive Pulmonary Disease (COPD) C. Asthma D. Pneumonia E. Common Cold LEARNING OUTCOMES-DID YOU LEARN TO: Obtain a through patient history speci-cally regarding complaints of chest pain, shortness of breath, wheezing, cough, and hemoptysis Gather subjective and objective data for a problem-oriented case and develop a problem list. Provide health maintenance strategies for smoking cessation and proper adult immunizations against in3uenza and pneumonia Identify abnormal disease pattern characteristics during the examination of the thorax and lungs Utilize the problem list to generate a working di5erential diagnosis for common pulmonary complaints. REFERENCES https://www.cdc.gov/vaccines/hcp/imz-schedules/index.html Bickley LS, Szilagyi PS, Bates B. Bates' Guide to Physical Examination and History Taking. 13th ed. Philadelphia, PA. Lippincott Williams & Wilkins. 2020