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Guidelines for Nurse Practitioners in Gynecologic Settings, 13th Edition

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1: Well-Patient Initial/Annual Gynecologic Exam

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DOI:

10.1891/9780826173294.0001

Authors

  • Fantasia, Heidi Collins

Abstract

The initial visit to a gynecologic clinician encompasses preventive healthcare that includes a discussion of health topics relevant to age and risk factors, a full comprehensive health history, an exam, screening tests, and immunizations as appropriate. This chapter provides a comprehensive guide to a well-patient exam and can be adapted for specific practice settings and time constraints. It discusses medical history, recent changes in immediate family history, gynecologic history, urinary tract history, Pap smear history, sexual history, and social history. This chapter discusses physical exams, including vital signs and weight/height/body mass index, general exam, gynecologic exam, and internal pelvic exam. It also provides laboratory testing to consider, as well as treatment/intervention.

I. DEFINITION

The initial visit to a gynecologic clinician encompasses preventive healthcare that includes a discussion of health topics relevant to an individual’s age and risk factors, a full comprehensive health history, an exam, screening tests, and immunizations as appropriate. This chapter provides a comprehensive guide to a well-patient exam and can be adapted for specific practice settings and time constraints.

The Women’s Preventive Services Initiative (WPSI), the American College of Obstetricians and Gynecologists (ACOG), and the Health Resources and Services Administration (HRSA) provide guidance on recommended age-related health topics, exams, screening tests, and immunizations. These websites have been provided at the end of the chapter.

II. HISTORY

  1. Medical history

    1. General health status

    2. Recent changes in health status

    3. Allergies and sensitivities (medications, food, environmental, or latex)

    4. Surgeries

    5. Significant injuries not discussed with surgeries

    6. Current medications, including herbs, vitamins, minerals, supplements, and over-the-counter (OTC) medications

    7. Last Pap smear, colonoscopy, mammogram, and bone mineral density (BMD) screening as appropriate for age and history

    8. Vaccination status: Refer to the Centers for Disease Control and Prevention (CDC) vaccination guidelines for current age-based recommendations. These are updated yearly and can be found at www.cdc.gov/vaccines/hcp/index.html. The vaccine schedule is also available as a mobile application for smartphones. Federal law requires that each person receive a Vaccination Information Statement (VIS) prior to being given any immunization. A copy of the VIS can be found on the CDC site at www.cdc.gov/vaccines.

    9. Contraception history, past and present: Inquire if the patient is planning a pregnancy in the next year.

  2. Recent changes in immediate family history

  3. Gynecologic history

    1. Menstrual history

      1. Last menstrual period

      2. Menarche

      3. Interval

      4. Duration

      5. Flow, amount of bleeding

      6. Dysmenorrhea

      7. Recent changes in pattern/flow

  4. Urinary tract history

    1. History of past infections: how often, treatment, and approximate date of last infection

    2. Current problems (discomfort, pressure, or incontinence)

  5. Pap smear history

    1. Date of last Pap smear, human papillomavirus (HPV) vaccine or testing

    2. Age-appropriate abnormal Pap smear history, approximate dates, and any clinical intervention, including colposcopy, loop electrosurgical excision procedure (LEEP), cervical cryosurgery, and cold knife cone biopsy (conization)

  6. Sexual history

    1. Sexual orientation, gender identity, and preferred pronouns

    2. Age at first sexual experience/intercourse

    3. Number of sexual partners (lifetime and past year)

    4. Length of time with present partner

    5. Type of sexual activity (vaginal, oral, or anal)

    6. History of sexually transmitted infections (STIs), including treatment or current concerns

    7. HIV status and previous testing

    8. Issues related to sexual function

      1. Libido

      2. Dyspareunia

      3. Postcoital bleeding

  7. Social history

    1. Smoking history

      1. Age at first cigarette

      2. Total years of smoking

      3. Number of cigarettes/packs smoked each day

      4. Desire for smoking cessation

        1. Prior attempts

        2. Method(s) used

        3. Was it successful? If no success, would they like to try again?

    2. Alcohol use

      1. Age at first use

      2. Current use: How many drinks per day/week? How many drinks in a row? Any binge drinking?

      3. Alcohol type

      4. Has the individual, or any family member/friends, felt or expressed concern about their drinking? Does alcohol use cause issues/problems in the home or workplace? If so, discuss readiness to quit and appropriate treatment referrals.

    3. Recreational drug use

      1. Past use

      2. Present use

      3. Specific drug(s) used

      4. Has the use of substances caused difficulties with relationships or in the workplace? If so, discuss readiness to quit and appropriate treatment referrals.

    4. Exercise/physical activity history

      1. Does the individual exercise? What kind of exercise, for how long, and how often?

      2. Has this pattern changed from a previous pattern? In what way?

    5. Violence/abuse history

      1. Was the individual abused as a child (physical abuse, mental abuse, or sexual abuse)?

      2. Is there a history of intimate partner violence (IPV)? Does the person feel safe at home? Do they fear harm for themselves or their children?

      3. Have they ever been forced to have sex when they did not want to? Are they currently afraid of someone?

      4. If violence is current and the individual agrees, an action plan should be developed that includes a lethality assessment. If the individual is not ready to act, it would be appropriate to provide the names and phone numbers of local resources and strategize how they can safely keep these numbers where they can find them.

      5. Individuals at risk should be encouraged to develop a plan for a quick departure from their residence. This plan should include, but not be limited to, access to money, birth certificates/passports for self and children, transportation (or car keys), medications for self and children, and a safe shelter or residence (see abuse and violence guidelines in Chapter 6, “Guidelines for Assessing Individuals Who Have Experienced Abuse, Violence, and Sexual Assault”).

    6. Nutritional/dietary history

      1. Is the individual happy with their current weight?

      2. Do they consider their diet well-balanced?

      3. Have they actively attempted to lose or gain weight?

      4. If so, what plans or methods have they used? Have they taken any weight loss medication (prescription or OTC)? Has this been successful?

      5. Nutritional counseling may be offered if the individual is interested.

    7. Safer sex practices

      1. Use of condoms (past and present)

      2. Avoidance of unsafe situations involving use of alcohol or drugs and unprotected sex

      3. Awareness of partner history/testing for STIs

    8. Screening

      1. IPV

      2. Depression/anxiety

      3. Risk assessment for Breast Cancer genes 1 and 2 (BRCA 1 and 2), genetic disorders

III. PHYSICAL EXAM (AGE-APPROPRIATE)

  1. Vital signs

  2. Weight/height/body mass index (BMI)

  3. General exam

    1. Skin

    2. Head, eyes, ears, nose, and throat (HEENT)

    3. Thyroid

    4. Lymph nodes

    5. Breasts

    6. Heart

    7. Lungs

    8. Abdomen

    9. Extremities

  4. Gynecologic exam: includes an assessment of whether accommodations for positioning are needed based on any limitations posed by musculoskeletal conditions such as arthritis, paralysis, amputation, joint replacements, and aging joints and muscles that are less flexible; may consider a side-lying position versus on the back with feet in stirrups

    1. External genitalia

    2. Vagina

    3. Cervix

  5. Internal pelvic exam if indicated

    1. Uterus

    2. Adnexa

    3. Rectum

IV. LABORATORY TESTING TO CONSIDER

  1. Urine dipstick/culture as indicated; pregnancy testing as indicated/appropriate

  2. Pap smear as indicated based on history and national guidelines (see also Chapter 14, “HPV and Management of Cervical Abnormalities”)

  3. STI testing as indicated by age, history, and national guidelines

  4. Vaginal cultures if indicated

  5. Wet prep as indicated

  6. General hematologic screening as indicated by age, health history, and access to other routine healthcare (e.g., if the individual has no primary care provider and has not had a baseline lipid level, blood sugar assessment, and any other laboratory tests that seem to be indicated, then it would be appropriate to do the laboratory tests and refer as indicated if they cannot be managed in that setting)

V. TREATMENT/INTERVENTION

  1. Order mammogram/bone density testing or other appropriate screening as indicated by age and history.

  2. Teach and/or reinforce breast awareness or breast self-examination if appropriate for age and history.

  3. Order laboratory tests as indicated.

  4. Administer/refer for vaccines as appropriate to setting, age, and vaccine history.

  5. Teach as appropriate to history and physical findings, including, but not limited to, the importance of preventive healthcare and age-based screening tests, changes in Pap smear guidelines, importance of HPV vaccine if not vaccinated, other appropriate vaccines for age, weight management, diet, exercise, smoking cessation, alcohol use, safer sex, STI testing, IPV, healthy relationships, and general safety.

  6. Prescribe contraception if desired or any other treatment indicated by findings.

  7. Allow time for questions and concerns; make future appointment(s) for discussion or evaluation of specific problems or concerns raised during the visit.

  8. Refer to other care providers as appropriate.

Resources

www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/10/well-woman-visit

www.hrsa.gov/womens-guidelines/index.html

www.womenspreventivehealth.org/

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