Well Woman Exam PDF

WELL WOMAN Dr. Kelli Stephenson Certifi ed Nurse Midwife and Family Nurse Practitioner  ◦ Used interchangeably ◦ Pap smear: collection of cervical cells during a Pap smear & speculum exam well woman ◦ Well woman exam: a head-to-toe exam of a...

WELL WOMAN Dr. Kelli Stephenson Certifi ed Nurse Midwife and Family Nurse Practitioner  ◦ Used interchangeably ◦ Pap smear: collection of cervical cells during a Pap smear & speculum exam well woman ◦ Well woman exam: a head-to-toe exam of a woman; including a clinical breast exam (CBE), exam which may or may NOT include a pap smear; and/or additional testing Myths Facts Myths Facts ◦ Collection of cervical cells should ◦ Most women fall into the routine be done yearly on every woman. screening category for their age ◦ As soon as a woman becomes group sexually active, she should have a ◦ Regardless of age of sexual pap. intercourse, pap smears do not ◦ Well….women do not need to start until age 21. No exceptions! come in yearly at all anymore ◦ Most insurance companies cover an annual well woman exam Resources ◦ ASCCP ◦ https://www.asccp.org/mobile-app ◦ iOS devices and Google devices $9.99 ◦ Web based application is free (must enter email) ◦ US Prevention Task Force App ◦ Available for free for iOS and Google devices ◦ Hollier Text ◦ Dunphy Text Meet our first patient of the day ◦ Annie ◦ 21 years old ◦ CC: Well Woman Exam ◦ BP 120/80 P82 T98.2 ◦ Weight 120lb Height 5’5” ◦ Not sexually active & declines need for testing ◦ Declines birth control Clinical Breast Exam (CBE) Have patient lay flat with arms above head Looking at: Temperature -> unusually warm or Palpate both breasts & axillary cold? area using one of the three Tenderness -> any distinct areas different patterns, of tenderness? Circular or clockwise Size -> are the breasts Wedge approximately the same size? (it Vertical is normal for one breast to be slightly larger than the other) Tip: When charting abnormal Shape -> are they both breast results: think of the approximately the same shape breast as a clock Surface -> any rashes, wounds, open areas, peeling or cracking skin, dimples or divots, any unusual color changes ◦ Bimanual exam: ◦ Ovaries & Fallopian tubes -> tenderness or enlargement ◦ Uterus -> tenderness or enlargement & position ◦ Bladder -> tenderness or prolapse ◦ Cervix -> cervical motion tenderness ◦ Speculum exam: The GU exam ◦ Exterior -> any rashes, lesions, atrophy ◦ Vagina -> any foreign body; redness; irritation; excessive discharge; tenderness; prolapse. ◦ Cervix -> any discharge; redness; friability; bleeding; IUD strings ◦ Rectal exam -> note lesions; bleeding; irritation ANNIE’S PAP RESULTS ASC-US – Most common abnormal finding atypical Can be a sign of infection, such as squamous cells HPV or a vaginal infection of unknown May be a sign of inflammation significance Low hormones in postmenopausal women MOST OFTEN BENIGN LSIL – low grade Can also be called mild dysplasia squamous Usually caused by HPV Types of pap intraepithelial lesion May go away without any treatment but can sometimes lead to cancer smear results ASC-H – This may be a sign of high-grade abnormal lesions squamous cells This can become cervical cancer if cannot rule out left untreated high grade ◦ HPV 16 ◦ HPV 18 ◦ HPV HR (this usually includes at least 12 HPV known strains that has been linked to cervical cancer)  complete a pregnancy test Uterine Management Bleeding ◦ Regular cycle -> NSAIDs (AUB) ◦ LUS (Levonorgestrel Releasing System) ◦ Mirena ◦ OCPs ◦ Surgery: hysterectomy; ablation Amenorrhea Primary and Secondary: ◦ Most common reason is PCOS Treatment: ◦ Depends largely on cause ◦ May include: ◦ OCPS ◦ Medication such as Clomid for pregnancy ◦ Most common is lump in breast ◦ Age can vary ◦ Commonly found in women on HRT or OCPs ◦ May note one during certain points in Breast menstrual cycle concerns ◦ Most often they are benign in nature ◦ Fibrocystic or mammary dysplasia ◦ Women and family highly anxious  Tenderness Symptoms Rapid changes in size May see redness, dimpling, peeling ◦ Difficult to tell between cancer or cysts ◦ Testing is necessary ◦ Mammogram Testing ◦ Ultrasound ◦ Breast biopsy Treatment / self care Avoid Avoid trauma Wear Wear good fitting bras Eliminate Eliminate caffeine, HRT, OCPs, progesterone supplements Breast Stress importance of breast self awareness and CBE Awareness ◦ Painful cramping associated with at least one of the following ◦ Sweating; headaches; N/V/D; leg or back pain ◦ Can affect up to 90% of women in their lifetime ◦ Primary: teen’s – 20’s -> no underlining reason ◦ Secondary: 20’s – 30’s -> usually a pathology Dysmenorrhea Treatment: ◦ Primary -> NSAIDs, OCPs heating pad; TENS unit; reassurance ◦ Secondary -> treatment depends on cause ◦ Refer to specialist Menopause ◦ Spontaneous: no period for 12 months ◦ Perimenopause: menstrual cycle is abnormal, may have some s/s ◦ Premature menopause: risk for osteoporosis ◦ Primary ovarian insufficiency; risk for osteoporosis Treatment: ◦ Calcium and Vitamin D supplementation ◦ SSRIs ◦ HRT -> caution -> must use progesterone if patient has a uterus ◦ Cannot use with current, past or suspected breast cancer ◦ Estrogen sensitive malignancy ◦ Undiagnosed vaginal bleeding ◦ MenoPro Mobile App (Free) Common findings ◦ Vaginal / vulvar changes ◦ Dry, irritated, painful sex, spotting or bleeding after sex ◦ Vaginal atrophy ◦ Thin, pale, decreased elasticity ◦ Bladder issues ◦ Increase in frequency and urgency ◦ Common to get UTIs GSM ◦ Incontinence Treatment ◦ Nonhormonal treatments ◦ Hormonal treatments ◦ Local estrogen Deloris 53 years old, LMP 8 months ago BP 138/80; Weight 145lb No significant family history Hx of lipid disorder SH: negative Follow up to menopausal signs and symptoms Etiology is unknown ◦ Common feature is hypersecretion of androgens In adult women 2 of the 3 must be present for a diagnosis ◦ Hyperandrogenism ◦ Oligo—ovulation or anovulation ◦ Polycystic ovaries on ultrasound PCOS Treatment ◦ Depends on if pregnancy is desired Can be a lifelong disease LS ◦ Irretractable itching ◦ Unknown cause ◦ Often misdiagnoses for yeast infection, genital herpes ◦ Exam ◦ White wrinkle appearing plaques or patches, tissue is usually red around it Testing: punch biopsy; rule out coexisting vaginal infection Treatment: use ointment over cream Vulvodynia -> vulvar pain x3 months with no cause ◦ Etiology is unknown Many women have issues with sexual intercourse Vulvodynia Diagnosis ◦ Based on exam and history and ◦ Rule out any co-existing conditions Dyspareunia Treatment -> pelvic floor therapy & referral to GYN ◦ Hollier pg 790-791 Yeast Infection ◦ Most common cause of vaginal itching Exam: ◦ Thick discharge; thick white patches in vaginal mucosa; usually no odor Testing ◦ KOH-prep Treatment ◦ Topical is available OTC; oral and topical may also be prescribed References ◦ ASCCP Risk-Based management consensus guidelines. (n.d.). ASCCP. https://www.asccp.org/Default.aspx ◦ Dunphy, Winland-Brown, Porter, & Thomas. (2019). Primary Care: Art and Science of Advanced Practice Nursing - An Interprofessional Approach (5th ed.). F.A. Davis Company. ◦ Hollier, A. D. (2018). CLINICAL GUIDELINES IN PRIMARY CARE (3rd ed.). Advanced Practice Education Associates, Inc. ◦ Jordan, R. G., Engstrom, J., Marfell, J., & Farley, C. L. (2014). Prenatal and Postnatal Care (1st ed.). Wiley-Blackwell.